CHIEF COMPLAINT: 

PRESENT ILLNESS: Briefly, this is a 63 year old
male who has a history of metastatic rectal carcinoma who had
been seen by Dr. [**Last Name (STitle) **] in [**Location (un) 4121**] where he had a resection
of his primary tumor as well as a liver resection.  He
returns now to [**Hospital1 69**] on
[**2107-5-9**], for an elective caudate lobe resection for
recurrence as well as radiofrequency ablation of the lateral
segmental mass as well as insertion of an infusion pump into
his hepatic artery.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Malignant neoplasm of liver, secondary,Other postoperative infection,Other candidiasis of other specified sites,Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Unspecified pleural effusion,Personal history of malignant neoplasm of large intestine,Unspecified essential hypertension,Unspecified late effects of cerebrovascular disease
Second malig neo liver,Other postop infection,Candidiasis site NEC,Intestinal adhes w obstr,Pleural effusion NOS,Hx of colonic malignancy,Hypertension NOS,Late effect CV dis NOS
Admission Date:  [**2107-5-9**]       Discharge Date:  [**2107-6-5**]

Date of Birth:   [**2043-12-24**]       Sex:  M

Service:  HEPATOBILIARY SURGERY

HISTORY OF PRESENT ILLNESS:   Briefly, this is a 63 year old
male who has a history of metastatic rectal carcinoma who had
been seen by Dr. [**Last Name (STitle) **] in [**Location (un) 4121**] where he had a resection
of his primary tumor as well as a liver resection.  He
returns now to [**Hospital1 69**] on
[**2107-5-9**], for an elective caudate lobe resection for
recurrence as well as radiofrequency ablation of the lateral
segmental mass as well as insertion of an infusion pump into
his hepatic artery.

The patient has a past medical history significant for his
rectal cancer, hypertension, hernia repair. rheumatic fever
as a child and high cholesterol.  He has had cerebrovascular
accidents in the past with multiple infarctions in his
lacunar area.

The patient was taken to the Operating Room on [**2107-5-9**],
where a caudate lobe resection, radiofrequency ablation of
lateral segment mass and infusion pump procedure was
performed.  The patient tolerated the procedure.  Please see
Operating Report for further details of that operation.  The
patient was transferred to the floor postoperatively.

The Acute Pain Service was consulted for management of his
epidural.  He tolerated the procedure well and was continued
on antibiotics, Unasyn, for prophylaxis.

He slowly began having difficulty with oxygenation on
[**2107-5-11**], where he dropped his O2 saturation to 86% and his
respiratory rate rise to 40.  It was decided that the patient
would be transferred to the Intensive Care Unit on
[**2107-5-11**], and he was transferred there.

MEDICATIONS UPON ADMISSION:
1.  Lopressor 100 mg p.o. twice a day.
2.  Cardizem 120 p.o. q. day.
3.  Pravachol 40 mg p.o. q. day.
4.  Zestril 15 mg p.o. q. day.

The patient also has a colostomy from his primary rectal
cancer resection.

HOSPITAL COURSE:   During his hospital course, as noted
before, he had pulmonary respiratory desaturations on
[**2107-5-11**], and was transferred to the Intensive Care Unit.
At that time, his white blood cell count rose to 15.5.  His
physical examination was unremarkable. He was awake, alert
and oriented.  His lungs were clear.  His heart was regular.
His abdomen was soft and nontender.

He had multiple blood cultures drawn at that time for the
respiratory difficulty which ended up being negative
throughout.

The patient was having agitation at that time and continued
to be monitored for this agitation.  He had a CT scan which
ultimately showed no new infarctions or lesions.  It was felt
that the confusion was secondary to the radiofrequency
ablation and chemotherapy agents that were given, and he was
continued to be monitored for this.

Neurology was consulted for this confusion.  Neurology felt
that limiting his medications would be one step in helping to
clear his confusion.  It was felt that while it could
represent an infectious encephalopathy, it was more likely
due to the toxic effects of his radiofrequency ablation.

He began having fevers on [**2107-5-14**], and there was a
question of whether his wound was infected.  CT scan two days
earlier was negative.  His white blood cell count continued
to be elevated during this time, reaching a high of 37.5.  He
was continued on his Unasyn for this elevated white count as
well as his temperatures.

His confusion remained throughout his hospital course and on
[**2107-5-15**], AmBisome was started for a question of Candidal
infection.  Ultimately, this Candidal infection was
determined to be [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] and it was decided that
upon further work-up that he would require a 28 day course of
AmBisome.  It was decided at that time that he would
ultimately need removal of his infusion port, however,
because of his status, it was felt that it could be postponed
until later.

On [**2107-5-18**], it was decided that he would be taken back to
the Operating Room for a re-exploration and for removal of
his infusion pump.  It was found that on [**2107-5-18**], during
exploration, he had a large abscess that ultimately grew out
[**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**].  He was washed out and continued on his
AmBisome for this reason; please see Operating Report for
further details.

He was continued on his Unasyn and AmBisome for that time,
however, postoperatively, in order to broaden coverage, his
Unasyn was changed to Zosyn.  The patient was continued on
total parenteral nutrition throughout his hospital course and
originally a central line was placed, however, as his
infection cleared a PICC line was placed.

His white count rose as stated previously, to a high of 37.6
on postoperative day ten and one, and after the washout it
continued to be elevated, however, slowly trended down . At
the time of discharge, his white blood count was 14.0 and he
had multiple blood cultures, port cultures and PICC line
cultures, which were all negative for anything.

He also had an echocardiogram which revealed no vegetations
on his valves and an Ophthalmology examination which was also
negative for embolic events.

The patient stayed in the Intensive Care Unit after the
second operation.  The patient was transferred out of the
Intensive Care Unit on [**5-23**]/3004, on postoperative day
number 14 and 5, after being afebrile for over five days.
His white count had decreased down to 18 at this time and he
was started on a clear liquid diet as well as continuing on
his total parenteral nutrition.  His [**Location (un) 1661**]-[**Location (un) 1662**] drains,
which were placed at the time of the second operation, had
slow output throughout his hospital course and were removed,
the first one removed on postoperative day, [**5-31**],
postoperative days number 22 and 13; and the second one being
removed on postoperative day number 25 and 11 on [**6-3**].

The patient continues to improve.  His mental status slowly
began to clear, however, he was not back to his baseline
levels even upon time of discharge.

The patient was kept on sitters until [**2107-5-29**], for
agitation and for monitoring.  After that, he was able to be
maintained without any sitters and was much more appropriate
at that time.

Blood cultures, urine cultures, port cultures, were all
negative after the original blood and Operating Room culture
were positive for [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**].

On [**2107-5-26**], after multiple cultures were negative and no
bacteria were discovered, the Zosyn was stopped and he was
continued only on his [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**].  He was kept on
morphine intermittently for pain control, Haldol for
confusion, Lopressor, Protonix, and Regular insulin for his
total parenteral nutrition.  The patient was also transfused
two units of blood on [**2107-5-28**], postoperative days 19 and
10, for a low hematocrit of 25.6.

His wound, which was left open after the second operation,
was packed with normal saline wet-to-dry dressing.
Granulation slowly improved the wound site, therefore a VAC
drain was placed.

The VAC drain put out low amounts and continued wound healing
and was removed just prior to discharge to the rehabilitation
facility.  Instructions were given for assessment of the
wound upon arrival to the rehabilitation facility with the
decision of whether wet-to-dry dressing or VAC dressing could
be used.

The patient slowly improved mentally and Physical Therapy was
consulted for ambulation on [**2107-5-31**].  The patient began
ambulating with Physical Therapy and he did well.  Nutrition
was also following and calorie counts were started on
[**2107-5-31**].

Over the next three days, it was found that the patient was
taking more and more of his nutritional requirements by
mouth.  Two days prior to discharge, he was able to take 75
percent of his caloric needs and 75 percent of his protein
needs p.o., tolerating a regular diet with Boost
supplementation and his total parenteral nutrition was
continued in order to help him with wound care and to boost
his immune status.

He was also started on Marinol 5 mg p.o. twice a day to
enhance his appetite.

The patient was discharged on [**2107-6-5**], while tolerating a
regular diet.  His wound was clean, dry and intact.  He
continued to have an elevated respiratory rate up into the
20s and 30s, even at time of discharge, and a heart rate that
was tachycardic to the low 100s; however, his O2 saturations
were normal at 98% and the patient was able to ambulate and
tolerate exercise.

The patient's pulmonary status was good, however,there was a
small right pleural effusion noted on chest x-ray which was
decreasing in size.  His port was in good position.  He had a
PICC line placed in his left arm which was used for total
parenteral nutrition and antibiotics.  His Foley catheter was
removed.  He did have some hematuria after the Foley
insertion which he had noted before as in the past history,
It fully resolved, however, the patient was incontinent of
urine.  Urine cultures were negative and the patient was
watched carefully for this.

His abdominal drains were removed and sites were dressed.
There was some slight fibrinous serous drainage from those
[**Location (un) 1661**]-[**Location (un) 1662**] sites upon discharge, however, the output had
decreased.  The wound itself was clean, dry and intact and
granulating well when the VAC drain was removed.

Mentally, his confusion had improved, however, he was still
not oriented to place but was able to be interactive and
cooperative both with the staff and with family who were
present throughout his hospital course.

His total parenteral nutrition had been stabilized for
approximately two weeks prior to discharge with only minor
modifications of electrolytes.  His white blood cell count as
noted before, was returning to normal with the last one being
14.7.  His hematocrit after his transfusions stabilized at
approximately 30.0 and his platelet count was normal at 230.
His electrolytes were all within normal limits.  His
creatinine was watched carefully for the long duration of his
AmBisome treatment.  His discharging creatinine was 1.2, up
ever so slightly from his baseline of 1.0.

His liver function tests were all within normal limits.  His
alkaline phosphatase was 218 and his ALT and AST were normal.
His total bilirubin was also normal at 0.3.

Infectious Disease was consulted and it was planned that the
patient would have a 28 day course AmBisome.  Upon time of
discharge, he would have completed 22 days, therefore, six
more days were needed and he would complete his course of
AmBisome on [**2107-6-11**].  He was going to be continued on
Protonix 40 mg p.o. q. day.

DISCHARGE MEDICATIONS:
1.  Lopressor 100 mg p.o. twice a day.
2.  Cardizem 120 p.o. q. day.
3.  Pravachol 40 p.o. q. day.
4.  Zoloft 15 mg p.o. q. day p.r.n.
5.  Protonix 40 mg p.o. q. day.
6.  Regular insulin sliding scale.

His morphine and Haldol were held due to somnolence and he
was only treated intermittently with pain medications,
specifically with dressing changes.  He also had Marinol
added to his regimen, 5 mg p.o. four times a day as well as
Boost supplementation for his diet.

The patient was discharged to a rehabilitation facility on
[**2107-6-5**], [**Hospital 10680**] Rehabilitation Facility in [**Location (un) 4121**],
[**State 4260**].

FOLLOW-UP INSTRUCTIONS:   He was instructed to follow-up with
Dr. [**Last Name (STitle) 49614**], Dr. [**Last Name (STitle) 49615**], and Dr. [**Last Name (STitle) 49616**], all at the
[**Location (un) **] Hospital and at [**Hospital 10680**] Rehabilitation facility for
further care.

DISCHARGE DIAGNOSES:
1.  Rectal cancer, status post resection and colostomy.
2.  Status post right hepatectomy for metastases.
3.  Now status post caudate lobe resection, radiofrequency
ablation and infusion pump insertion.
4.  Status post exploratory laparotomy washout and removal of
infusion port.
5.  Depression.
6.  Hypertension.
7.  High cholesterol.
8.  Cerebrovascular accidents in the past.

DISPOSITION:   The patient is discharged to the
rehabilitation facility as planned and he will have an
ambulance ride.

DISCHARGE INSTRUCTIONS:
1.  He will be continued on his total parenteral nutrition
throughout the ambulance ride as well as continue at the
rehabilitation facility.
2.  To continue his Physical Therapy.
3.  Continue with wound care at that time.

CONDITION ON DISCHARGE:   Stable.

NOTE:  A copy of the patient's chart as well as copy of all
radiologic reports and culture data will be included in his
discharge packet.  If there are any questions, the receiving
facility is instructed to contact myself or Dr. [**Last Name (STitle) **] for
further information.



                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D.
02-366

Dictated By:[**First Name (STitle) **]
MEDQUIST36

D:  [**2107-6-4**]  17:53
T:  [**2107-6-4**]  18:13
JOB#:  [**Job Number 49617**]

cc:[**Last Name (un) 49618**]
{'Malignant neoplasm of liver, secondary,Other postoperative infection,Other candidiasis of other specified sites,Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Unspecified pleural effusion,Personal history of malignant neoplasm of large intestine,Unspecified essential hypertension,Unspecified late effects of cerebrovascular disease'}


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: 

PRESENT ILLNESS: Briefly, this is a 63 year old
male who has a history of metastatic rectal carcinoma who had
been seen by Dr. [**Last Name (STitle) **] in [**Location (un) 4121**] where he had a resection
of his primary tumor as well as a liver resection.  He
returns now to [**Hospital1 69**] on
[**2107-5-9**], for an elective caudate lobe resection for
recurrence as well as radiofrequency ablation of the lateral
segmental mass as well as insertion of an infusion pump into
his hepatic artery.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Malignant neoplasm of liver, secondary,Other postoperative infection,Other candidiasis of other specified sites,Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Unspecified pleural effusion,Personal history of malignant neoplasm of large intestine,Unspecified essential hypertension,Unspecified late effects of cerebrovascular disease'}
