CHIEF COMPLAINT: SBO with ischemic bowel

PRESENT ILLNESS: 83M presented to his PCP's office on the morning of [**6-24**]
complaining
of one day of worsening abdominal pain and a firm abdomen.  He
was sent to the ED where he was noted to be of altered mental
status (AAOx1), had a lactate of 8.3 and was increasingly
tachypneic prompting intubation.  At time of this exam, he is
intubated, sedated and on norepinephrine to support his blood
pressure.

MEDICAL HISTORY: PMH: GERD, HTN, HLD, rectal/colon ca s/p resection, mitral
insufficiency, mild aortic stenosis, right inguinal hernia

MEDICATION ON ADMISSION: Preadmissions medications listed are incomplete and require
futher investigation.  Information was obtained from  Admission
Note.
1. Atorvastatin 80 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Aspirin 81 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Metoprolol Succinate XL 12.5 mg PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
Vitals:  103  88  90/73  20  100% 2LNC
Gen: Intubated sedated, pupils 2mm->1mm
Card: RRR
Pulm: Vented respirations
Abdomen: well-healed midline surgical scar, firm, distended
nonincarcerated right inguinal hernia
Ext: No edema

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: Lives with wife (accompanying him today), 2 children
(daughter lives locally, son in [**Name (NI) **])
Unspecified septicemia,Acute vascular insufficiency of intestine,Acute respiratory failure,Acidosis,Acute systolic heart failure,Septic shock,Ventilator associated pneumonia,Hernia of other specified sites, with gangrene,Unspecified pleural effusion,Other ascites,Intestinal infection due to Clostridium difficile,Bloodstream infection due to central venous catheter,Aortic valve disorders,Thrombocytopenia, unspecified,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Atrial fibrillation,Foreign body in larynx,Foreign body accidentally entering other orifice,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Examination of participant in clinical trial,Intestinal bypass or anastomosis status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Severe sepsis
Septicemia NOS,Ac vasc insuff intestine,Acute respiratry failure,Acidosis,Ac systolic hrt failure,Septic shock,Ventltr assoc pneumonia,Hernia, site NEC w gangr,Pleural effusion NOS,Ascites NEC,Int inf clstrdium dfcile,Blood inf dt cen ven cth,Aortic valve disorder,Thrombocytopenia NOS,Hyperlipidemia NEC/NOS,Hypertension NOS,Abn react-procedure NEC,Atrial fibrillation,Foreign body in larynx,FB entering oth orifice,Hx-rectal & anal malign,Exam-clincal trial,Intestinal bypass status,DMII wo cmp nt st uncntr,Severe sepsis
Admission Date:  [**2200-6-24**]              Discharge Date:   [**2200-7-22**]

Date of Birth:  [**2116-12-10**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
SBO with ischemic bowel

Major Surgical or Invasive Procedure:
[**6-24**]: Exploratory laparotomy with lysis of
adhesions, resection of small bowel, and temporary closure of
abdomen.
[**6-27**]: Small-bowel resection with primary anastomosis
and abdominal closure.


History of Present Illness:
83M presented to his PCP's office on the morning of [**6-24**]
complaining
of one day of worsening abdominal pain and a firm abdomen.  He
was sent to the ED where he was noted to be of altered mental
status (AAOx1), had a lactate of 8.3 and was increasingly
tachypneic prompting intubation.  At time of this exam, he is
intubated, sedated and on norepinephrine to support his blood
pressure.

Per his wife, he was doing pretty well up until this morning
except for mild complaints of abdominal pain the last day.  No
fevers or chills, nausea or vomiting at home.

Past Medical History:
PMH: GERD, HTN, HLD, rectal/colon ca s/p resection, mitral
insufficiency, mild aortic stenosis, right inguinal hernia

PSH: colonic resection (for colon/rectal CA) via lower midline
laparotomy [**2169**], TURP [**2191**]


Social History:
Lives with wife (accompanying him today), 2 children
(daughter lives locally, son in [**Name (NI) **])


Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

Physical Exam:
On Admission:
Vitals:  103  88  90/73  20  100% 2LNC
Gen: Intubated sedated, pupils 2mm->1mm
Card: RRR
Pulm: Vented respirations
Abdomen: well-healed midline surgical scar, firm, distended
nonincarcerated right inguinal hernia
Ext: No edema

On Discharge:


Pertinent Results:
Admission Labs:
[**2200-6-24**] 10:30AM BLOOD WBC-13.1* RBC-5.08 Hgb-15.4 Hct-47.0
MCV-93 MCH-30.4 MCHC-32.8 RDW-14.0 Plt Ct-227
[**2200-6-24**] 10:30AM BLOOD Neuts-67 Bands-20* Lymphs-10* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2200-6-24**] 04:30PM BLOOD PT-17.6* PTT-34.6 INR(PT)-1.7*
[**2200-6-24**] 10:30AM BLOOD Glucose-179* UreaN-34* Creat-1.5* Na-137
K-5.0 Cl-94* HCO3-19* AnGap-29*
[**2200-6-24**] 10:30AM BLOOD ALT-15 AST-43* AlkPhos-78 TotBili-1.5
[**2200-6-24**] 10:30AM BLOOD cTropnT-<0.01
[**2200-6-24**] 10:30AM BLOOD Lipase-22
[**2200-6-24**] 04:30PM BLOOD Calcium-6.7* Phos-2.0* Mg-1.3*
[**2200-6-24**] 10:44AM BLOOD Lactate-8.3*
[**2200-6-24**] 11:30AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
[**2200-6-24**] 11:30AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2200-6-24**] 11:30AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025
[**2200-7-9**] 08:17PM URINE RBC-60* WBC-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2200-7-9**] 08:17PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2200-7-9**] 08:17PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2200-7-10**] 07:20PM PLEURAL TotProt-1.0 Glucose-139 LD(LDH)-121
Cholest-8
[**2200-7-10**] 07:20PM PLEURAL WBC-41* RBC-14* Polys-5* Lymphs-54*
Monos-0 Meso-4* Macro-33* Other-4*

PERTINENT MICRO
[**2200-7-4**] 4:45 pm BLOOD CULTURE      Source: Line-cvl.

                            **FINAL REPORT [**2200-7-7**]**

   Blood Culture, Routine (Final [**2200-7-7**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.
         Isolated from only one set in the previous five days.
         SENSITIVITIES PERFORMED ON REQUEST..
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    SECOND MORPHOLOGY.
         Isolated from only one set in the previous five days.
         SENSITIVITIES PERFORMED ON REQUEST..
[**2200-7-4**] 6:57 pm STOOL     CONSISTENCY: SOFT      Source: Stool.


                            **FINAL REPORT [**2200-7-5**]**

   C. difficile DNA amplification assay (Final [**2200-7-5**]):
      Reported to and read back by DR [**First Name8 (NamePattern2) 488**] [**Last Name (NamePattern1) **] [**2200-7-5**] AT
14:07.
      CLOSTRIDIUM DIFFICILE.
         Positive for toxigenic C. difficile by the Illumigene
DNA
         amplification.            (Reference Range-Negative).

PERTINENT REPORTS:
TTE [**2200-6-24**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size is normal. Tricuspid annular plane
systolic excursion is depressed (12 mm) consistent with right
ventricular systolic dysfunction. The aortic valve leaflets are
moderately thickened. There is moderate aortic valve stenosis
(valve area 1.0-1.2cm2). No aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is
moderate/severe posterior leaflet mitral valve prolapse. An
eccentric, anteriorly-directed jet of Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Hyperdynamic left ventricle. Moderate aortic
stenosis with estimated valve area of 1.1 cm2. Depressed right
ventricular systolic function. Prolapsed posterior mitral valve
leaflet.

CT Torso with Contrast [**2200-6-24**]
Closed loop obstruction in the right lower quadrant with
hypoenhancing loops of bowel and free fluid throughout the
abdomen and pelvis, concerning for bowel ischemia.

CT Head [**2200-6-24**]
1.  No acute intracranial process.
2.  Chronic left maxillary sinus mucosal disease.

TEE [**2200-6-25**]
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta. The abdominal aorta is mildly
dilated. There are complex (>4mm) atheroma in the abdominal
aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Moderate to severe (3+) aortic
regurgitation is seen. There is severe posterior leaflet mitral
valve prolapse. There is at least moderate and probably severe
mitral regurgitation(3+ to 4+) . Due to the eccentric nature of
the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Moderate [2+] tricuspid
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.

CT Torso [**2200-7-4**]
1.  No evidence of an anastomotic leak.
2.  Thickening of the sigmoid colon and rectal wall suggestive
for
proctitis/colitis.
3.  Large bilateral pleural effusions with associated
atelectasis.
4.  2.5 x 1.9 cm hypodense hepatic lesion at the junction of
segment II and [**Doctor First Name 690**] is incompletely characterized and requires an
ultrasound or MRI for further characterization.

TTE [**2200-7-9**]
Focused, limited views due to the patient's inability to
cooperate:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). There is moderate aortic
valve stenosis (valve area 1.0-1.2cm2). Aortic regurgitation is
present, but cannot be quantified. The mitral valve leaflets are
mildly thickened. There is moderate/severe posterior leaflet
mitral valve prolapse. Moderate to severe (3+) mitral
regurgitation is seen.
Compared with the prior, complete study dated [**2200-6-24**] (images
reviewed), based on transvalvular gradients and velocity only
([**Location (un) 109**] cannot be calculated currently as a parasternal long axis
view is not available for reliable LVOT measurement), the degree
of aortic stenosis is moderate and possibly underestimated given
limited echocardiographic views.

CT Torso [**7-12**]
1.  Bilateral upper and middle lobe pulmonary opacities,
compatible with
infection.
2.  Volume overload with pulmonary edema, pleural effusions,
periportal edema,
ascites, and anasarca.
3.  Small left pneumothorax.
4.  No evidence of bowel obstruction, abscess or fluid
collection in abdomen or pelvis.

CXR [**7-17**]: FINDINGS:  In comparison with the study of [**7-15**], the
endotracheal tube and nasogastric tubes have been removed.
Right pleural catheter remains in place and there is no
pneumothorax.  Central catheters are in good position.
Cardiac silhouette appears to be more prominent than on the
previous study and there is further fullness of indistinct
pulmonary vessels consistent with worsening pulmonary venous
pressure.

Brief Hospital Course:
Mr. [**Known lastname 7324**] was brought to the ED by ambulance from his PCP's
office where his abdominal pain was worsening and his mental
status was noted to be of mild confusion.  On arrival to the ED
he was AAOx1 and tachypneic.  He was intubated for airway
protection.  A CT scan was consistent with a closed loop bowel
obstruction.  He was noted to be hypotensive and placed on
pressors.  A central line was placed in the ED and he was rushed
to the operating room for emergent abdominal exploration.

In the OR, he was noted to have a sharply demarcated segment of
ischemic small bowel due to compression from adhesions.  This
was resected.  Prior to creating an anastamosis, however, his
pressor requirement started to increase, to triple pressors
(levo, neo and vaso).  Due to this instability, the abdomen was
packed and the procedure was aborted.

He was volume resuscitated in the ICU post-operatively and
placed on broad spectrum antibiotic (zosyn).  He remained on
triple pressors.  An echocardiogram (TTE) revealed a 0.6mm2
aortic valve prompting a consult to cardiology for potential
valvuloplasty.  He was deemed not a candidate due to his
concommitant aortic insufficiency.  His pressors gradually
weaned down to a single pressor, levophed, and he returned to
the OR on [**2200-6-27**] for re-anastamosis and abdominal closure.

Post operatively, his pressor was weaned further and he was
started on a lasix drip to remove excess fluid (noted to be 20
liters positive, though this number is probably in excess as it
does not account for insensible losses). He was extubated on
[**2200-6-29**] only to be reintubated the same night for respiratory
distress.  His pressors were weaned off, he was further diuresed
with a lasix drip and 25% albumin, and was successfully
extubated on [**2200-6-30**].

The remainder of his hospital course by problem:

Aortic stenosis and insufficiency:  TEE showing a 0.6mm2 valve
area but deemed insuitable for a valvuloplasty due to his aortic
insufficiency.  After his surgeries, he had been on the surgical
floor, but had increasing respiratory distress due to volume
overload. He was transferred to the medicine service, and for
several days diuresis was attempted but was limited by SBP's in
the 80-90's, so he was transferred to the CCU. He was on
multiple pressors initially levo/neo/vaso which were weaned as
tolerated.  In total, he required pressors for about a week.
His cardic output was calculated with a Swann-Ganz catheter and
found to be high, even when he was hypotensive (CI >6).  Thus,
there was no concern that his AS was a cause of his hypotension
and inability to maintain his pressures.  His EF was greater
than 55% and a TTE showed severe mitral regurgitation, but a
valve area of 1.0-1.2 consistent with moderate aortic stenosis.
Per cardiology, TTE more sensitive than TEE, and valvuloplasty
not pursued as would not improve valvular surface area. .  His
lisinopril and metoprolol were held due to low blood pressures.
LOS fluid balance at time of transfer was -8.7L.

Recurrent Shock:  Patient with multiple episodes of hypotension
requiring pressor support with levophed.  Unclear etiology of
shock.  Swan Ganz catheter placed on [**2200-7-11**].  PAP 64/24 and
PAPm was 39.  CO on Levophed was 6.8, and CI was 3.6 with SVR of
1381.  Levophed was temporarily disocntinued and CO increased to
12.1 with CI of 6.4 and SVR of 444.  Hemodynamics were
suggestive of a non cardiac etiology of his shock, and concern
for sepsis was rasied.  An abdominal scan was pursued with
contrast to look for occult abscess or infection, but was
negative.  Treated with meropenem empirically (after prior HCAP
treatment with Cefepime/Vancomycin) for possible HCAP sepsis.
The patient continued to have equivocal blood pressures for the
next week, with PRN pressors including Levophed and Vasopressin.
 Meropenem course to be completed on [**2200-7-21**].

Recurrent respiratory failure: Intubated on arrival to ED,
extubated post-op on [**2200-6-29**], reintubated 3 times during the
hospital stay for respiratory distress.  Eventually
self-extubated and did well after gentle diuresis with lasix
drip.  He did have a CT chest which showed bilateral pleural
effusions.  He underwent a right thoracentesis with pigtail
catheter placement to help his respiratory status since diuresis
was limited by blood pressures.  Ultimate etiology is unclear,
but he did have a presumed HCAP and was treated with
cefepime/vanc but continued to spike fevers until the abx were
changed to meropenem.  However, a bronchoscopy did not find any
evidence of infection, only pulmonary edema so it is also
possible that all his respiratory failure was volume related.
Likely worse due to severe mitral regurgitation.  On the evening
of [**7-20**], patient's respiratory status acutely worsened after
attempt at NGT was made.  Became hypercarboic with rapid shallow
breathing, requiring reintubation.  Chest XRAY at that time
showed worsening diffuse bilateral infiltrates concerning for
flash pulmonary edema vs. ARDS vs aspiration pneumonitis.
Pulmonary consult at that time placed for questionable
superimposed ARDS on top of cardiogenic edema.

Neuro: Initially sedated with fentanyl/versed while intubated.
Even once extubated, he remained delirious, and required
frequent re-orientation.  While extubated, had episodes of
recurrent delirium/waxing/[**Doctor Last Name 688**].

Small bowel obstruction with ischemic bowel: Taken to the OR on
admission on [**2200-6-24**].  An ischemic portion of small bowel was
resected and his abdomen was left open and bowel in
discontinuity due to HD instability.  He returned to the OR on
[**2200-6-27**] for reanastamosis and abdominal closure.  Tube feeds were
started on [**2200-7-1**] when he was off pressors but the dobhoff was
"self-dc'd" on [**2200-7-1**].  At this point he was assessed with a
bedside swallow eval in which he did well.  He was advanced to a
regular diet.  Surgery continued to follow, and per above for
questionable sepsis requested a second CT torso to look for
infectious etiology of his shock.  CT torso was unrevealing for
any infectious nidus...

C. diff: He developed diarrhea post-op and C. diff PCR in stool
was positive.  He was treated with PO vancomycin 125 mg q6h, his
course should continue for 14 days after finishing the meropenem
for HCAP.

Heme: He was initially placed on heparin SQ but his platelets
(in the 200s on admission) dropped to <100 by HD [**3-30**].  Due to
concern for HIT, this was dc'd and a HIT panel was negative for
heparin-PF4 antibodies.  His heparin SQ was restarted at this
point but the next day his platelets dropped further to 60.  The
heparin SQ was dc'd again at this point and a serotonin release
assay was sent, it was negative.  SQH was restarted on [**2200-7-2**]
and continued throughout the hospital stay.  His platelets
recovered to > 200s.  It was thought that he was septic causing
the thrombocytopenia.

Metabolic Alkalosis:  Duration of hospitalization had worsening
alkalosis due to ongoing diuresis.  Had correction with
acetazolamide, potassium supplementation, vasopressin, and
spironolactone.

Hypernatremia:  With increased diuresis became increasingly
hypernatremic.  Free water flushes instituted with Tube Feeds.

Hyperlipidemia: Continued atorvastatin.

On Hospital Day 28 through 29, multiple family meetings were
held about the patient's goals of care.  Ultimately, it was
decided that his care should be focused on comfort instead of
aggressive measures.  His care was withdrawn on the evening of
[**7-22**] and he shortly passed thereafter with his family at the
bedside.

Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation.  Information was obtained from  Admission
Note.
1. Atorvastatin 80 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Aspirin 81 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Metoprolol Succinate XL 12.5 mg PO DAILY


Discharge Disposition:
Expired

Discharge Diagnosis:
Heart Failure
Cardiopulmonary arrest
Cariogenic and septic shock

Discharge Condition:
Diseased

Discharge Instructions:
x

Followup Instructions:
x

                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Unspecified septicemia,Acute vascular insufficiency of intestine,Acute respiratory failure,Acidosis,Acute systolic heart failure,Septic shock,Ventilator associated pneumonia,Hernia of other specified sites, with gangrene,Unspecified pleural effusion,Other ascites,Intestinal infection due to Clostridium difficile,Bloodstream infection due to central venous catheter,Aortic valve disorders,Thrombocytopenia, unspecified,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Atrial fibrillation,Foreign body in larynx,Foreign body accidentally entering other orifice,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Examination of participant in clinical trial,Intestinal bypass or anastomosis status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Severe sepsis'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: SBO with ischemic bowel

PRESENT ILLNESS: 83M presented to his PCP's office on the morning of [**6-24**]
complaining
of one day of worsening abdominal pain and a firm abdomen.  He
was sent to the ED where he was noted to be of altered mental
status (AAOx1), had a lactate of 8.3 and was increasingly
tachypneic prompting intubation.  At time of this exam, he is
intubated, sedated and on norepinephrine to support his blood
pressure.

MEDICAL HISTORY: PMH: GERD, HTN, HLD, rectal/colon ca s/p resection, mitral
insufficiency, mild aortic stenosis, right inguinal hernia

MEDICATION ON ADMISSION: Preadmissions medications listed are incomplete and require
futher investigation.  Information was obtained from  Admission
Note.
1. Atorvastatin 80 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Aspirin 81 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Metoprolol Succinate XL 12.5 mg PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
Vitals:  103  88  90/73  20  100% 2LNC
Gen: Intubated sedated, pupils 2mm->1mm
Card: RRR
Pulm: Vented respirations
Abdomen: well-healed midline surgical scar, firm, distended
nonincarcerated right inguinal hernia
Ext: No edema

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: Lives with wife (accompanying him today), 2 children
(daughter lives locally, son in [**Name (NI) **]) 

### Response:
{'Unspecified septicemia,Acute vascular insufficiency of intestine,Acute respiratory failure,Acidosis,Acute systolic heart failure,Septic shock,Ventilator associated pneumonia,Hernia of other specified sites, with gangrene,Unspecified pleural effusion,Other ascites,Intestinal infection due to Clostridium difficile,Bloodstream infection due to central venous catheter,Aortic valve disorders,Thrombocytopenia, unspecified,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Atrial fibrillation,Foreign body in larynx,Foreign body accidentally entering other orifice,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Examination of participant in clinical trial,Intestinal bypass or anastomosis status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Severe sepsis'}
