CHIEF COMPLAINT: right colonic mass

PRESENT ILLNESS: 86F initially presentig with fatigue and anemia, and found to
have right-sided colon mass concerning for colonic
adenocarcinoma. She presented this admission for resection.

MEDICAL HISTORY: HTN, hypercholesterolemia, diverticulits, atrial fibrillation

MEDICATION ON ADMISSION: Atenolol 50', MVI

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: 97.7  97.3  65  119/70  20  97RA

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Noncontributory
Malignant neoplasm of ascending colon,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Secondary malignant neoplasm of skin,Other acute and subacute forms of ischemic heart disease, other,Acute posthemorrhagic anemia,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Transfusion associated circulatory overload,Unspecified essential hypertension,Pure hypercholesterolemia,Umbilical hernia without mention of obstruction or gangrene,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other iatrogenic hypotension
Malig neo ascend colon,Ot pul insuf fol trm/srg,Secondary malig neo skin,Ac ischemic hrt dis NEC,Ac posthemorrhag anemia,Streptococcus group b,Atrial fibrillation,DMII wo cmp nt st uncntr,Transfsn w circ overload,Hypertension NOS,Pure hypercholesterolem,Umbilical hernia,Abn reac-organ rem NEC,Iatrogenc hypotnsion NEC
Admission Date:  [**2127-2-24**]              Discharge Date:   [**2127-3-2**]

Date of Birth:  [**2040-3-29**]             Sex:   F

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
right colonic mass

Major Surgical or Invasive Procedure:
1. Open right colectomy.
2. Excision of tumor in sidewall.
3. Repair of umbilical hernia.


History of Present Illness:
86F initially presentig with fatigue and anemia, and found to
have right-sided colon mass concerning for colonic
adenocarcinoma. She presented this admission for resection.

Past Medical History:
HTN, hypercholesterolemia, diverticulits, atrial fibrillation

Social History:
Noncontributory


Family History:
Noncontributory

Physical Exam:
97.7  97.3  65  119/70  20  97RA

GEN: NAD, A&Ox3
CV: irregular rate, no mumurs appreciated
PULM: CTAB
ABD: soft, mild peri-incisional tenderness to palpation,
non-distended
Incision: clean, dry, intact, no evidence of infection
EXT: WWP, no edema
Neuro: grossly intact

Pertinent Results:
[**2127-2-27**] 06:30AM BLOOD WBC-14.1* RBC-3.99* Hgb-9.2* Hct-29.8*
MCV-75* MCH-23.0* MCHC-30.7* RDW-18.4* Plt Ct-524*
[**2127-2-28**] 11:40AM BLOOD WBC-11.6*
[**2127-3-1**] 05:30AM BLOOD Glucose-112* UreaN-11 Creat-0.7 Na-134
K-4.4 Cl-100 HCO3-26 AnGap-12
[**2127-3-1**] 05:30AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1

Pathology, surgical specimen:
Colonic adenocarcinoma, pT3N0Mx.  See synoptic report in OMR.

CHEST (PORTABLE AP) Study Date of [**2127-2-25**] 5:28 PM
FINDINGS: As compared to the previous radiograph, there is newly
occurred
mild-to-moderate interstitial edema. No large effusions are
visualized.
Borderline size of the cardiac silhouette. Moderate perihilar
haze.

CHEST (PORTABLE AP) Study Date of [**2127-2-26**] 4:36 AM
FINDINGS: As compared to the previous radiograph, there is a
decrease in
extent of the pre-existing parenchymal opacity. Otherwise, the
radiograph is unchanged. Other monitoring and support devices
are in constant position.

Brief Hospital Course:
The patient had an open right colectomy for her colon mass. For
details, see the separately-dictated operative note.

RESPIRATORY DISTRESS: By POD#1, the patient continued to have
marginal UOP since the OR. The patient was baseline anemic from
her colon cancer, and she had an expected drop in her Hct with
the addition of IVF resuscitation. She received 2uPRBC. Several
hours later, she developed acute shortness of breath with
desaturation. Her O2 saturation failed to improve with
supplemental O2, and a trigger was called. She was found on CXR
to have pulmonary edema. She received nebulized ipratropium and
xopenex, with little improvement. Diuresis was initiated with
lasix, and she put out about 450cc in about the first hour.
Nonetheless, she began to tire from her tachypnea, and it was
decided to transfer her to the ICU for intubation. She was
continued on diuresis, and by the next morning, she was able to
extubate and actually looked and felt much better. She was
transferred back to the floor the afternoon of POD#2, breathing
comforably.

NEURO/PAIN: Immediately post-operatively, the patient had an
auto-infusing bupivicaine pump at her incision. She was also was
maintained on IV pain medication until she was able to tolerate
PO pain medication. By discharge, she was well-controlled on
just PO tylenol. While intubated during her overnight stay in
the ICU, she received appropriate sedation. She was otheriwise
A&Ox3.

CARDIOVASCULAR: At the time when she developed pulmonary edema,
the patient was noted to have an elevated troponin (0.1). She
was given aspirin. Troponins were drawn serially, and during her
stay in the ICU they trended downward to 0.03. It was thought
that she was not having an MI, and that this was likely demand
ischemia. For a short period of time after intubation on POD#1,
the patient required phenylephrine for blood pressure support,
but this was discontinued the same night. An echocardiogram in
the ICU showed normal ventricular function and normal ejection
fraction. On POD#2, as she was being transferred back to the
floor, she developed atrial fibrillation with RVR. She was
rate-controlled with metoprolol. Medicine consulted, and she was
eventually well-rate-controlled (HR 70s-90s, with only
occasional few-second periods of tachycardia) on PO metoprolol
and diltiazem. Medicine continued to follow the patient and
assist through the day of discharge. The decision was made not
to anticoagulate her, with a CHADS score of 2, for now. The
patient should follow up with her PCP regarding future
management of her metoprolol and diltiazem, as well as for
further consideration of anticoagulation.

RESPIRATORY: The patient was extubated in the immediate post-op
period successfully. She was re-intubated as above. Following
her second extubation, she had no further respiratory issues and
saturated adequately on room air.

GASTROINTESTINAL/FEN: The patient was NPO following her
procedure, and advanced to sips on POD#1. After being NPO during
her ICU stay, she was gradually advanced as her bowel function
returned. By POD#4, she was tolerating a regular diet with PO
medications. At the time of her flash pulmonary edema, her IVF
were held. She received electrolyte repletion as needed.

GENITOURINARY: The patient's urine output was monitored. She had
low urine output immediately post-operatively, and actually
triggered for it; this was initially treated with albumin. A
Foley catheter had been placed intra-operatively and removed on
POD#4, and she voided well.

HEME: The patient had baseline anemia (Hct about 27) associated
with her colon cancer. The patient received 2uPRBC on POD#1, as
above, for a Hct of 21. Her Hct increased appropriately, and she
required no further transfusions.

ID: Intraoperativley, the patient was found to have had a
perforated colon cancer. She was started on cefazolin and
flagyl. As her cultures were found to grow back group B
beta-hemolytic streptococcus, her antibiotics were changed to
unasyn on POD#3, and then to augmentin on POD#4 when she was
taking PO medications. She will complete a 7-day course of
augmentin (5 more days). She was not febrile, and her WBC
trended downward from 24.4 on POD#1 to 11.6 on POD#4. Her wound
remained without signs of infection.

ENDOCRINE: The patient's blood glucose was monitored, and she
had no active endocrine issues.

PROPHYLAXIS: This was maintained with subcutaneous heparin,
aspirin when she developed elevated troponin, pneumatic boots,
and ambulation when safe and cleared by PT. She was given
omeprazole. She was encouraged to use incentive spirometry.

On the day of discharge, the patient was discharged to a rehab
facility, as recommended by PT. She needs follow-up by her PCP
for management of her atrial fibrillation and potential
anticoagulation. She should also call to make a follow-up
appointment with colorectal surgery. She was ambulating well
with assistance, her bowel function had returned, her heart rate
was controlled, and her pain was controlled by tylenol.

______________________________________________________________
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] atrial fibrillation with RVR
[x] flash pulmonary edema requiring intubation and ICU stay
[ ] None

Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of VNA services
[ ] Difficulty finding appropriate rehabilitation hospital
disposition.
[ ] Lack of insurance coverage for VNA/ Rehab services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
discharge.
[x] No social factors contributing in delay of discharge.

Medications on Admission:
Atenolol 50', MVI

Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain: No more than 4000mg in a day.
Each tab has 325mg.
Disp:*90 Tablet(s)* Refills:*2*
3. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **] (2
times a day) for 2 days: Apply NU [**Hospital1 **] for 2 days.
Disp:*QS * Refills:*0*
4. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours).
Disp:*180 Tablet(s)* Refills:*2*

Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Health Care Center - [**Location (un) **]

Discharge Diagnosis:
colonic adenocarcinoma, umbilical hernia, atrial fibrillation


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance as needed.


Discharge Instructions:
You were admitted to the hospital after an open Right-Sided
Colectomy for surgical management of your colon lesion. You have
recovered from this procedure well and you are now ready to
return home. Samples from your colon were taken and this tissue
has been sent to the pathology department for analysis. You will
receive these pathology results at your follow-up appointment.
If there is an urgent need for the surgeon to contact you
regarding these results they will contact you before this time.
You have tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.

Please monitor your bowel function closely. It is important that
you have  a bowel movement in the next 3-4 days. After
anesthesia it is not uncommon for patients to have some decrease
in bowel function but you should not have prolonged
constipation. Some loose stool and passing of small amounts of
dark, old-appearing blood are expected; however, if you notice
that you are passing bright red blood with bowel movments or
having loose stool without improvement please call the office or
go to the emergency room. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms does not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or constipation.

You have a long vertical incision on your abdomen. This incision
can be left open to air or covered with a dry sterile gauze
dressing if that is more comfortable for you. Please monitor the
incision for signs and symptoms of infection including:
increasing redness at the incision, opening of the incision,
increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe.  You may
shower, let the warm water run over the incision line and pat
the area dry with a towel; do not rub.

No heavy lifting for at least 6 weeks after surgery. You may
gradually increase your activity as tolerated. You should
continue to walk as tolerated.

You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking Tylenol.

Stop taking your atenolol, and instead take the medications as
prescribed from this hospital stay. Your PCP will give you
firther instructions about your medications.

You developed a heart condition called atrial fibrillation. This
makes your heart beat too quickly and irregularly. We started
you on two new medications called diltiazem and metoprolol. You
should follow up with your primary doctor about your atrial
fibrillation, and they may make adjustments in your medications.

Followup Instructions:
Call the colorectal surgery office to make a follow-up
appointment. Please call [**Telephone/Fax (1) 160**] to make this appointment.

Call your PCP for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment for about 1 week.
Please discuss your atrial fibrillation, and ask if there should
be any adjustments to your medications



Completed by:[**2127-3-2**]
{'Malignant neoplasm of ascending colon,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Secondary malignant neoplasm of skin,Other acute and subacute forms of ischemic heart disease, other,Acute posthemorrhagic anemia,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Transfusion associated circulatory overload,Unspecified essential hypertension,Pure hypercholesterolemia,Umbilical hernia without mention of obstruction or gangrene,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other iatrogenic hypotension'}


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: right colonic mass

PRESENT ILLNESS: 86F initially presentig with fatigue and anemia, and found to
have right-sided colon mass concerning for colonic
adenocarcinoma. She presented this admission for resection.

MEDICAL HISTORY: HTN, hypercholesterolemia, diverticulits, atrial fibrillation

MEDICATION ON ADMISSION: Atenolol 50', MVI

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: 97.7  97.3  65  119/70  20  97RA

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Noncontributory 

### Response:
{'Malignant neoplasm of ascending colon,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Secondary malignant neoplasm of skin,Other acute and subacute forms of ischemic heart disease, other,Acute posthemorrhagic anemia,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Transfusion associated circulatory overload,Unspecified essential hypertension,Pure hypercholesterolemia,Umbilical hernia without mention of obstruction or gangrene,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other iatrogenic hypotension'}
