CHIEF COMPLAINT: Abdominal pain

PRESENT ILLNESS: 85 yo male with abdominal pain, distention and diarrhea for 1
week prior to admission. Was seen in [**State 108**] and diagnosed with
?hernia. He and his wife came back to [**State 350**] for further
workup. He was admitted to [**Hospital1 18**] with an obstructing splenic
mass.

MEDICAL HISTORY: HTN
Hiatal hernia
TIA (on Plavix)
Asthma
Spinal stenosis
AR and MR (requires SBE prophylaxis)

MEDICATION ON ADMISSION: Plavix 75'
Flomax 0.4'
Cozaar 50'
Lipitor 10'
Lopressor 25''

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: on discharge:
vitals: 98.9 81  148/74 20 94 (RA)
Chest: CTAB
CV: RRR
Abdomen: large midline granulating incision. Dressing C/D/I,
abdomen soft, NT, ND, large girth. Right sided colostomy bag.
Ext: No C/C/E, warm.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Married and lives with wife
[**Name (NI) **] in [**Name (NI) 108**] during winter months
Malignant neoplasm of descending colon,Other specified intestinal obstruction,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Accidental puncture or laceration during a procedure, not elsewhere classified,Perforation of intestine,Mitral valve insufficiency and aortic valve insufficiency,Iatrogenic pneumothorax,Acute posthemorrhagic anemia,Atrial fibrillation,Acute kidney failure, unspecified,Unspecified essential hypertension,Obesity, unspecified,Other specified disorders of peritoneum,Foreign body in trachea,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation
Mal neo descend colon,Intestinal obstruct NEC,Mal neo lymph intra-abd,Accidental op laceration,Perforation of intestine,Mitral/aortic val insuff,Iatrogenic pneumothorax,Ac posthemorrhag anemia,Atrial fibrillation,Acute kidney failure NOS,Hypertension NOS,Obesity NOS,Peritoneal disorder NEC,Foreign body in trachea,Resp obstr-inhal obj NEC
Admission Date:  [**2135-12-5**]              Discharge Date:   [**2136-1-5**]


Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Abdominal pain

Major Surgical or Invasive Procedure:
[**12-16**] Exploratory lap with diverting ileostomy; G-J tube
placement; appendectomy; washout and VAC placment


History of Present Illness:
85 yo male with abdominal pain, distention and diarrhea for 1
week prior to admission. Was seen in [**State 108**] and diagnosed with
?hernia. He and his wife came back to [**State 350**] for further
workup. He was admitted to [**Hospital1 18**] with an obstructing splenic
mass.

Past Medical History:
HTN
Hiatal hernia
TIA (on Plavix)
Asthma
Spinal stenosis
AR and MR (requires SBE prophylaxis)

Social History:
Married and lives with wife
[**Name (NI) **] in [**Name (NI) 108**] during winter months

Family History:
Noncontributory

Physical Exam:
on discharge:
vitals: 98.9 81  148/74 20 94 (RA)
Chest: CTAB
CV: RRR
Abdomen: large midline granulating incision. Dressing C/D/I,
abdomen soft, NT, ND, large girth. Right sided colostomy bag.
Ext: No C/C/E, warm.


Pertinent Results:
   Blood    Urine    CSF    Other Fluid    Microbiology
Recent

 Last Day  Last Week  Last 30 Days  All Results   Hide Comments
  From Date   To Date

Hematology
  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2136-1-3**] 05:25AM    13.4* 3.39* 10.4* 31.6* 93 30.7 32.9
15.7* 440
  DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2135-12-25**] 02:12AM    79* 2 11* 5 1 0 2* 0 0
  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2136-1-3**] 05:25AM        440
  BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
FDP
[**2135-12-18**] 04:04AM    611*
ART

Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2136-1-3**] 05:25AM    141* 22* 0.9 131* 4.2 95* 31 9
  ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2136-1-3**] 05:25AM    Using this1
1 Using this patient's age, gender, and serum creatinine value
of 0.9,
Estimated GFR = >75 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
  ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2135-12-28**] 01:27AM          36*
  OTHER ENZYMES & BILIRUBINS Lipase
[**2135-12-18**] 04:04AM    35
ART
  CPK ISOENZYMES CK-MB cTropnT
[**2135-12-28**] 01:27AM    NotDone1 0.03*2
1 NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100

2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
  CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron

[**2136-1-3**] 05:25AM      2.5*   8.1* 2.0* 1.7   PND
HEMATOLOGIC TRF
[**2136-1-3**] 05:25AM    PND
LIPID/CHOLESTEROL Cholest Triglyc
[**2135-12-10**] 03:08PM      1021
CK CPIS TNT ADDED 7:50P [**2135-12-10**]
1 LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE
IMMUNOLOGY CEA
[**2135-12-6**] 06:15AM    <1.01
1 <1.0
MEASURED BY [**Doctor Last Name 8721**] ELECSYS (ECLIA)
  LAB USE ONLY GreenHd HoldBLu
[**2135-12-28**] 01:27AM    HOLD1
1 HOLD
DISCARD GREATER THAN 4 HOURS OLD

Blood Gas
  BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS AADO2 REQ O2 Intubat Vent Comment
[**2135-12-31**] 12:38PM    [**Last Name (un) **]                 7.45
[**2135-12-31**] 03:43AM    [**Last Name (un) **]             99 46* 7.49* 36* 10
  GREEN TOP1
1 GREEN TOP
L. SC CVL

  WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
[**2135-12-27**] 08:49AM    102     4.1
  HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT O2 Sat COHgb
MetHgb
[**2135-12-23**] 12:54PM        96
  CALCIUM freeCa
[**2135-12-31**] 12:38PM    1.20
[**2135-12-31**] 03:43AM    1.10*

Sinus rhythm
Left axis deviation - anterior fascicular block
Poor R wave progression - could be secondary to left anterior
fascicular block
Since previous tracing, right bundle branch block absent



  Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 192 84 420/442.14 23 -57 41

  CHEST (PORTABLE AP)

Reason: sob, eval for effusion or chf

[**Hospital 93**] MEDICAL CONDITION:
84 year old man s/p diverting ileostomy w/ new line
REASON FOR THIS EXAMINATION:
sob, eval for effusion or chf
AP CHEST 9:23 A.M. ON [**12-27**].

HISTORY: Ileostomy. New central line. Suspect pleural effusion.

IMPRESSION: AP chest compared to [**12-23**] through 22:

Moderate bilateral pleural effusions, not changed appreciably
since [**12-26**]. Persistent severe left lower lobe atelectasis
and at least moderate cardiomegaly. Pulmonary vascular
congestion has worsened. Tip of the left subclavian line
projects over the left brachiocephalic vein. No pneumothorax.

PATHOLOGY REPORT:

Name Birthdate    Age     Sex Pathology #     [**Hospital1 18**] [**Known lastname 102113**],[**Known firstname 1955**]       [**2050-12-24**]    84 Male      [**Numeric Identifier 102114**]
[**Numeric Identifier 102115**]
Report to:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **], DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif


SPECIMEN SUBMITTED: LEFT COLECTOMY AND OMENTUM, PROXIMAL BOWEL,
OMENTUM OF TRANSVERSE COLON & SPLEEN.

Procedure date     Tissue received     Report Date    Diagnosed
by
[**2135-12-8**] [**2135-12-8**] [**2135-12-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 18795**]/kg

DIAGNOSIS:

I. Specimen designated "proximal bowel" (A,B):

Segment of colon; no diagnostic abnormalities recognized.

II. Omentum of transverse colon (C,D):

No diagnostic abnormalities recognized.

III. Spleen (80 grams) (E,F):

Capsular fibrosis; fresh hemorrhage in the hilar area.

IV. Segmental resection of left colon (G-AC):

1. Adenocarcinoma; see synoptic report.



2. Diverticulosis.

V. Omentum (AD-AF):

No diagnostic abnormalities recognized.



Colon and Rectum: Resection Synopsis

MACROSCOPIC

Specimen Type:  Colonic resection.  Location:  Transverse/left
colon.

Specimen Size
    Greatest dimension:  86.5 cm.

Tumor Site:  Splenic flexure.

Tumor configuration:  Annular.

Tumor Size
    Greatest dimension:  6.0 cm.  Additional dimensions:  2.0
cm.

MICROSCOPIC

Histologic Type:  Adenocarcinoma.

Histologic Grade:  Low-grade  (moderately differentiated).

EXTENT OF INVASION

Primary Tumor:  pT3:  Tumor invades through the muscularis
propria into the subserosa.

Regional Lymph Nodes:  pN1; (see comments):  Metastasis in 1 to
3 lymph nodes.

Lymph Nodes
    Number examined:  23.
    Number involved:  2.

Distant metastasis:  pMX:  Cannot be assessed.

Margins
    Proximal margin:
        Uninvolved by invasive carcinoma:  Distance of tumor
from closest margin:  180 mm.
    Distal margin:
        Uninvolved by invasive carcinoma:  Distance of tumor
from closest margin:  170 mm.
    Circumferential (radial) margin:
        Uninvolved by invasive carcinoma:  Distance of tumor
from closest margin:  55 mm.

Lymphatic Small Vessel Invasion:  Present.  Intramural.

Venous (large vessel) invasion:  Absent.

Perineural invasion:  Absent.

Tumor border configuration:  Infiltrating.

Comments:  One of the two positive lymph nodes is directly
beneath the colonic cancer. The second positive lymph node is
the apex mesenteric lymph node designated with a suture by the
surgeon.

Clinical:  Obstructing colonic mass near splenic flexure.
Gross:



The specimen is received fresh in five parts, all labeled with
"[**Known firstname **] [**Known lastname **]" and the medical record number.



Part 1 is additionally labeled "proximal bowel" and consists of
a segment of bowel measuring 4.2 cm long x 5.4 cm in greatest
diameter, stapled at both ends.  The specimen is inked and
opened to reveal mucosa that appears unremarkable, with no
evidence of masses, or areas of hemorrhage or ulceration.  The
specimen is represented as follows: A = margins, B = remainder
of the representative sections through the mucosa.



Part 2 is additionally labeled "omentum of transverse colon" and
consists of a fragment of grossly unremarkable fatty tissue
measuring 7 x 4.4 x 1.6 cm.  No nodules or tumors are
identified.  It is serially sectioned to reveal unremarkable
fibrofatty cut surfaces.  The specimen is represented in C-D.



Part 3 is additionally labeled "spleen" and consists of a spleen
weighing 80 grams and measuring 8.0 x 5.6 x 3.8 cm. On the
capsule are diffusely scattered fibrous patches.  The specimen
is serially sectioned to reveal red cut surfaces without any
evidence of masses or nodules.   The specimen is represented as
follows; E = multiple sections taken through the spleen and
capsule demonstrating the exudate.  F = sections taken through
splenic hilum.



Part 4 is additionally labeled "left colectomy" and consists of
a segment of colon measuring 86.5 cm in length by 7 cm in
maximum diameter. It is stapled at both ends. It is inked and
opened to reveal a circumferential mass measuring 2.0 cm in
length, 17 cm from the distal end and 18 cm from the proximal
end.  The circumference of the mass is 6.0 cm.  The proximal end
of the colon is mildly dilated with respect to the distal end.
The serosa subjacent to the mass is not adherent or puckered.
The distance from the mass to the radial margin is 5.5 cm,
grossly. No other masses and no polyps are noted.   The specimen
is represented as follows: G=proximal margin, H=distal margin,
I-M=sections through the mass, N=sections through grossly
unremarkable colon distal to mass, O=sections through grossly
unremarkable colon proximal to the mass, P=the bisected apex
mesenteric lymph node, which is indicated by the surgeon with a
suture. Q-AC=possible lymph nodes. Gross diagnosis by Dr. [**Last Name (STitle) 7108**]
is, "Annular carcinoma of the colon; final diagnosis pending
microscopic examination."



Part 5 is additionally labeled "omentum". It consists of a sheet
of fibroadipose tissue measuring 20.1 x 8.3 x 2.1 cm. It is
sectioned to reveal grossly unremarkable tissue, with no masses
or nodules present. It is represented in AD-AF.








Brief Hospital Course:
He was admitted to the Surgical service under the care of Dr.
[**Last Name (STitle) **]. He underwent abdominal CT imaging which revealed an
obstructing colonic mass. He was taken to the operating room on
[**12-7**] for left colectomy and splenectomy. Pathology showed a T3N1
colonic adenocarcinoma. Postoperatively he did fairly well until
[**12-16**] when he began to show signs of an anastomotic leak
(abdominal distention, pain, decreased UOP). He was taken back
to the operating room where an ex-lap with G-J tube placement,
appendectomy, and diverting ileostomy was performed.
Post-operatively, the patient required large amounts of volume
to support his hemodynamics. On POD 0, he also had an episode of
low oxygen saturations, hypos tension. He was bronched, and
chest was needled. A L SCL was placed and a swan floated. A
chest tube was also placed for a small pneumothorax.  He was
also started on pressors. Three days later he began to improve,
diuresis was begun, and pressors were weaned. He tolerated his
tube feeds, chest tube d/c'd on [**12-23**], and he was successfully
extubated on [**12-24**]. He was subsequently transferred to the floor,
where he did well. Diuresis was continued, he began to tolerate
oral intake, and calorie counts were started. He was discharged
on post-operative days 26/20 in good condition, to rehab
facility where calorie counts will continue, and his nutritional
status will continue to be worked on. Appropriate follow-up was
arranged. His primary care doctor, Dr. [**Last Name (STitle) **], was notified, via
e-mail, that the patient will need follow-up with an oncologist
as an outpatient.

Medications on Admission:
Plavix 75'
Flomax 0.4'
Cozaar 50'
Lipitor 10'
Lopressor 25''

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) ML
Injection TID (3 times a day).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR [**Last Name (STitle) **]: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
4. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime.

5. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) Neb
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
6. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Neb
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
7. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID
(3 times a day): hold for HR <60; SBP <110.
8. Losartan 50 mg Tablet [**Last Name (STitle) **]: 1 [**12-6**] Tablet PO DAILY (Daily):
hold fro SBP <110.
9. Polyvinyl Alcohol 1.4 % Drops [**Month/Day (2) **]: 1-2 Drops Ophthalmic Q4-6H
(every 4 to 6 hours) as needed for dry eyes.
10. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet [**Telephone/Fax (3) **]: Two
(2) Packet PO TID (3 times a day).
11. Oxycodone-Acetaminophen 5-325 mg Tablet [**Telephone/Fax (3) **]: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
12. Furosemide 20 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO BID (2 times
a day).
13. Insulin Regular Human 100 unit/mL Solution [**Telephone/Fax (3) **]: One (1) dose
Injection four times a day as needed for per sliding scale.
14. Impact/Fiber     Liquid [**Telephone/Fax (3) **]: 80 cc/hr bag PO cycle over 12h
from 1800 to 0600 every night: Tubefeeding: Impact w/ fiber Full
strength;
Goal rate: 80 ml/hr
Cycle?: Yes, starting now Cycle start: 1800 Cycle end: 600
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 30 ml water qd.
Disp:*20 bags* Refills:*2*


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]

Discharge Diagnosis:
Obstructing splenic mass


Discharge Condition:
Stable


Discharge Instructions:
- continue to eat a regular diet, please take a nutrient
enriched shake (like ensure) with each meal.
- you are being discharged on your tube feeds. You will need to
continue your tube feeds until the amount of calories you take
by mouth improves. A nutritionist at the your new facility will
help guide this process.
- you may shower, but please keep your abdominal wound dry.
- the wound on your abdomen is open, you will need to continue
twice a day wet to dry dressing changes to help the wound heal.
- return to the emergency room should you experience any
increased drainage or redness from your abdominal wound, or
increased abdominal distention, decreased oral intake, recurrent
fever spikes, intractable nausea, or vomiting.
- you have a list of follow-up appointments below, please make
sure you call each office to confirm your scheduled date/time,
or to book an appointment if one has not already been done.

Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 1 week, call [**Telephone/Fax (1) 6439**] for an
appointment.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Date/Time:[**2136-1-24**] 12:15
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2136-5-8**] 10:30
Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**]
Date/Time:[**2136-7-6**] 10:00
Please call Dr.[**Name (NI) 3588**] office for a follow-up appointment. The
number to call is [**Telephone/Fax (1) 3393**]. You will also need follow-up
with an oncologist. Your PCP is aware of this.



Completed by:[**2136-1-5**]
{'Malignant neoplasm of descending colon,Other specified intestinal obstruction,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Accidental puncture or laceration during a procedure, not elsewhere classified,Perforation of intestine,Mitral valve insufficiency and aortic valve insufficiency,Iatrogenic pneumothorax,Acute posthemorrhagic anemia,Atrial fibrillation,Acute kidney failure, unspecified,Unspecified essential hypertension,Obesity, unspecified,Other specified disorders of peritoneum,Foreign body in trachea,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation'}


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: Abdominal pain

PRESENT ILLNESS: 85 yo male with abdominal pain, distention and diarrhea for 1
week prior to admission. Was seen in [**State 108**] and diagnosed with
?hernia. He and his wife came back to [**State 350**] for further
workup. He was admitted to [**Hospital1 18**] with an obstructing splenic
mass.

MEDICAL HISTORY: HTN
Hiatal hernia
TIA (on Plavix)
Asthma
Spinal stenosis
AR and MR (requires SBE prophylaxis)

MEDICATION ON ADMISSION: Plavix 75'
Flomax 0.4'
Cozaar 50'
Lipitor 10'
Lopressor 25''

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: on discharge:
vitals: 98.9 81  148/74 20 94 (RA)
Chest: CTAB
CV: RRR
Abdomen: large midline granulating incision. Dressing C/D/I,
abdomen soft, NT, ND, large girth. Right sided colostomy bag.
Ext: No C/C/E, warm.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Married and lives with wife
[**Name (NI) **] in [**Name (NI) 108**] during winter months 

### Response:
{'Malignant neoplasm of descending colon,Other specified intestinal obstruction,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Accidental puncture or laceration during a procedure, not elsewhere classified,Perforation of intestine,Mitral valve insufficiency and aortic valve insufficiency,Iatrogenic pneumothorax,Acute posthemorrhagic anemia,Atrial fibrillation,Acute kidney failure, unspecified,Unspecified essential hypertension,Obesity, unspecified,Other specified disorders of peritoneum,Foreign body in trachea,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation'}
