CHIEF COMPLAINT: 77M s/p sigmoid colectomy for recurrent diverticulitis presented
10 days post operatively with shortness of breath, abdominal
distention, bloating, diarrhea, and abdominal pain

PRESENT ILLNESS: 77 year old male with multiple medical problems admitted with
abdominal pain, leukocytosis and fever s/p sigmoid resection [**5-25**]
for recurrent diverticulitis. His postoperative course was
complicated by NSTEMI post-operatively, as well as concern
regarding possible anastamotic leak. He had a CT scan of the
abdomen and pelvis on [**5-28**] without evidence of leak. He was
treated with Zosyn from [**Date range (1) 57306**] empirically. He was discharged
on [**6-2**] to home off of antibiotics.

MEDICAL HISTORY: Prostate CA, CAD/CABG '[**13**], Aortic stenosis

MEDICATION ON ADMISSION: Avapro 150', Lipitor 40', Triamterene, ASA, Omega 3

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On day of admission:

FAMILY HISTORY: Positive for early CAD, father had MI before 55, 2 brothers d
from MI

SOCIAL HISTORY: married, quit smoking [**2088**], denies EtOH
Intestinal infection due to Clostridium difficile,Cardiac complications, not elsewhere classified,Congestive heart failure, unspecified,Other iatrogenic hypotension,Other abnormal glucose,Aortic valve disorders,Subendocardial infarction, subsequent episode of care,Depressive disorder, not elsewhere classified,Retention of urine, unspecified,Aortocoronary bypass status,Personal history of malignant neoplasm of prostate,Family history of ischemic heart disease,Personal history of irradiation, presenting hazards to health,Personal history of tobacco use
Int inf clstrdium dfcile,Surg compl-heart,CHF NOS,Iatrogenc hypotnsion NEC,Abnormal glucose NEC,Aortic valve disorder,Subendo infarct, subseq,Depressive disorder NEC,Retention urine NOS,Aortocoronary bypass,Hx-prostatic malignancy,Fam hx-ischem heart dis,Hx of irradiation,History of tobacco use
Admission Date:  [**2125-6-4**]              Discharge Date:   [**2125-6-29**]

Date of Birth:  [**2048-1-16**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1**]
Chief Complaint:
77M s/p sigmoid colectomy for recurrent diverticulitis presented
10 days post operatively with shortness of breath, abdominal
distention, bloating, diarrhea, and abdominal pain

Major Surgical or Invasive Procedure:
[**2125-6-16**] Total abdominal colectomy, end-ileostomy.


History of Present Illness:
77 year old male with multiple medical problems admitted with
abdominal pain, leukocytosis and fever s/p sigmoid resection [**5-25**]
for recurrent diverticulitis. His postoperative course was
complicated by NSTEMI post-operatively, as well as concern
regarding possible anastamotic leak. He had a CT scan of the
abdomen and pelvis on [**5-28**] without evidence of leak. He was
treated with Zosyn from [**Date range (1) 57306**] empirically. He was discharged
on [**6-2**] to home off of antibiotics.

The patient recently [**Month/Year (2) 1834**] the above operation, he presented
to [**Hospital 77429**] medical center complaining of fairly acute onset of
abdominal pain after having a bowel movement on [**6-4**]. In the ER,
he was noted to be afebrile with abdominal pain and tenderness.
At that time, he was complaining of frequent loose liquid stools
and progressive abdominal distension. He had a WBC of 18.5, 79 %
polys, 12 % bands with minor derangements in his chemistries and
liver function testing, normal amylase and lipase. He was sent
to radiology to have a CT scan and apparently rigored in the
radiology department at [**Hospital3 **] so he was given empiric
antibiotics with vancomycin, Zosyn and flagyl.

Arrangements were made for transfer to [**Hospital1 **] and he was transferred
here for ongoing care.

Past Medical History:
Prostate CA, CAD/CABG '[**13**], Aortic stenosis

Social History:
married, quit smoking [**2088**], denies EtOH


Family History:
Positive for early CAD, father had MI before 55, 2 brothers d
from MI

Physical Exam:
On day of admission:

T 98.9 HR 88  BP 110/84  RR 18 97% on 3L
Gen - alert and oriented
Pulm - clear to auscultation bilaterally
CVS - RRR
Abd - moderately firm, distended, tympanitic, diffuse pain to
palpaption, no guarding
Abdominal wound - intact, no erythema, no drainage
Penis very swollen
.
At Discharge:
Vitals:T-98.5,HR-68,BP-148/80,RR-18,O2 sat-94% on RA
GEN: NAD, A/Ox3
CV: RRR
RESP: CTAB
ABD- +BS, soft, NT/ND, stoma beefy red & viable with liquid
brown stool
Incision: midline OTA with steri strips, CDI. No erythema
Extrem: RUE with 1-2+ edema r/t PICC, LUE no edema, Lower
extremities with 0-1+ edema, CSM's intact

Pertinent Results:
[**2125-6-26**] 05:13AM BLOOD WBC-8.1 RBC-3.81* Hgb-11.1* Hct-32.3*
MCV-85 MCH-29.1 MCHC-34.3 RDW-14.3 Plt Ct-452*
[**2125-6-18**] 02:40AM BLOOD WBC-17.1* RBC-2.56* Hgb-7.6* Hct-23.0*
MCV-86 MCH-29.8 MCHC-34.6 RDW-14.8 Plt Ct-308
[**2125-6-16**] 04:18PM BLOOD WBC-22.6*# RBC-4.06* Hgb-12.0* Hct-35.1*
MCV-86 MCH-29.5 MCHC-34.1 RDW-14.7 Plt Ct-514*
[**2125-6-5**] 12:39AM BLOOD WBC-26.7*# RBC-4.05* Hgb-11.9* Hct-35.4*
MCV-88 MCH-29.4 MCHC-33.6 RDW-14.2 Plt Ct-370
[**2125-6-22**] 04:25AM BLOOD PT-14.3* PTT-29.9 INR(PT)-1.2*
[**2125-6-20**] 05:50AM BLOOD PT-13.7* PTT-28.8 INR(PT)-1.2*
[**2125-6-5**] 12:39AM BLOOD PT-14.3* PTT-27.7 INR(PT)-1.2*
[**2125-6-27**] 05:16AM BLOOD Glucose-99 UreaN-20 Creat-0.8 Na-136
K-3.3 Cl-99 HCO3-32 AnGap-8
[**2125-6-21**] 04:20AM BLOOD Glucose-150* UreaN-19 Creat-0.7 Na-135
K-4.1 Cl-99 HCO3-32 AnGap-8
[**2125-6-25**] 01:10PM BLOOD cTropnT-<0.01
[**2125-6-24**] 07:49AM BLOOD CK-MB-2 cTropnT-<0.01
[**2125-6-18**] 08:18PM BLOOD CK-MB-3 cTropnT-<0.01
[**2125-6-18**] 02:40AM BLOOD CK-MB-3 cTropnT-<0.01
[**2125-6-5**] 05:20PM BLOOD CK-MB-3 cTropnT-0.05*
[**2125-6-5**] 07:35AM BLOOD CK-MB-3 cTropnT-0.06*
[**2125-6-5**] 12:39AM BLOOD CK-MB-2
[**2125-6-27**] 05:16AM BLOOD Calcium-7.9* Phos-3.7 Mg-1.7
[**2125-6-21**] 09:52AM BLOOD Albumin-1.7*
[**2125-6-20**] 11:51AM BLOOD Albumin-1.6* Calcium-7.2* Phos-3.5 Mg-1.9
[**2125-6-11**] 06:27AM BLOOD Albumin-1.9* Calcium-7.4* Phos-3.9 Mg-1.7
Iron-22*
[**2125-6-7**] 06:50AM BLOOD Calcium-7.4* Phos-2.9 Mg-2.5
[**2125-6-6**] 06:30AM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.7 Mg-2.4
[**2125-6-5**] 07:35AM BLOOD Albumin-2.3* Calcium-7.7* Phos-3.9 Mg-2.4
[**2125-6-11**] 06:27AM BLOOD calTIBC-95* Ferritn-694* TRF-73*
[**2125-6-19**] 03:13PM BLOOD Triglyc-97
[**2125-6-11**] 06:27AM BLOOD Triglyc-126
[**2125-6-17**] 03:42AM BLOOD Cortsol-23.1*
.
[**2125-6-5**] 2:44 am STOOL     CONSISTENCY: SOFT      Source: Stool.

                            **FINAL REPORT [**2125-6-5**]**
   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2125-6-5**]):
      REPORTED BY PHONE TO [**First Name5 (NamePattern1) 24448**] [**Last Name (NamePattern1) 24449**] ON [**2125-6-5**] AT NOON.
      CLOSTRIDIUM DIFFICILE.
         FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
           (Reference Range-Negative).
         A positive result in a recently treated patient is of
uncertain
         significance unless the patient is currently
symptomatic
.
STUDIES:
[**6-5**]: CT with rectal contrast: no leak, pancolitis
[**6-14**] KUB: distended colon (~9cm), no distension of small bowel
[**6-15**] KUB: No [**Month/Year (2) 65**] change in gaseous distention of colon. Diffuse
distention of small-bowel loops that may reflect adynamic ileus.
.
  Pathology Examination
Procedure date    [**2125-6-16**]
DIAGNOSIS:
Colon and omentum, subtotal colectomy:
1.  Severe pseudomembranous colitis with marked colonic
dilation; see note.
2.  Proximal ileal and distal colonic margins, uninvolved.
3.  Appendix with fibrous obliteration.
4.  One unremarkable lymph node.
5.  Previous colocolonic anastomosis intact.
Note:  The findings are consistent with C. difficile colitis in
the appropriate clinical setting.
Clinical:  Colitis.


Brief Hospital Course:
The patient was admitted to the surgical floor for continued
monitoring.  He was started empirically on cipro/flagyl, started
on IVF and a foley catheter was placed.  CT scan on admission
showed pan colitis associated with an elevated white count.

[**6-5**] - started on sips, continued on PO vancomycin and flagyl,
cipro discontinued.  GI consult obtained, agreed with antibiotic
plan.

[**6-6**] advanced to clears as the patient looked to be improving

[**6-7**] - WCC increasing, but patient clinically improving.  KUB
showed dilated transverse colon.  Diet changed to NPO

[**6-8**] - PICC line placed, TPN started

[**6-9**] TPN, antibiotics continued
[**6-10**] - sips started, cont TPN, antibiotics
[**6-11**] - [**6-13**] - advanced to clears, gentle diuresis started, cont
TPN, antibiotics
[**6-14**] - flagyl discontinued
[**6-15**] - abdominal pain increasing, KUB showed [**Last Name (un) **] increase in
colonic distention, no flatus/BM x 48 hours
[**6-16**] - increasing pain, no improvement, patient taken to the
operating room for subtotal colectomy, end ileostomy.  Following
the procedure the patient was transferred intubated to the [**Hospital Unit Name 153**],
required minimal pressor support for transient hypotensive,
started on zosyn / vanc / flagyl

[**6-17**] - fluid resuscitated for low CVP, pressor support as needed

[**6-18**] - Patient fluid overloaded, in heart failure - cardiology
consulted - recommended lasix drip and diuresis of 1 liter per
day, pressors as needed, transfused one unit RBC for hct of
23.0, TPN resumed after being held for 2 days for fluid overload

[**6-19**] - continued on minimal pressors, lasix drip, TPN,
antibiotics, transfused 2 units RBC

[**6-20**] - [**6-21**] - continued ventilator support, minimal pressors,
lasix drip, TPN, antibiotics, discontinued zosyn, continued on
vanc / flagyl

[**6-22**] - patient extubated without difficulty, vancomycin
discontinued, continued on antibiotics, TPN, lasix drip

[**6-23**] - continued diuresis, TPN, antibiotics, started on clear
liquid diet, discontinued central line, a line

[**6-24**] - started on a regular diet, transferred to the floor,
started on PO meds, continued flagyl, started on PO lasix [**Hospital1 **],
continued TPN

[**6-25**] - evaluated by speech and swallow for difficulty swallowing
- no deficit noticed. Discomfort swallowing likely related to
endotracheal tube from prolonged intubation in ICU. Managed with
Chlorasceptic spray PRN and Oxymetazoline for 3 days.
Medications given with applesauce. Tolerating well. No s/s of
aspiration.

[**6-26**] - cont ambulation and gentle diuresis, foley traumatically
removed during dressing change. Patient reported frequent
urination with dribbling due to PO Lasix. Foley reinserted.
Urology consulted-recommended starting Flomax, and keeping Foley
in place for 5 day. Foley will be removed in REHAB, with
post-void bladder scans. Goal residual <200cc. Abdominal staples
removed. Steri strips applied.

[**Date range (1) 77430**] -PO lasix discontinued. Foley in place with decrease in
urine output. 500cc normal saline bolus given with increase in
urine output. Urine output has remained adequate for past 20
hours. PICC line removed. Continue elevation of RUE to decrease
swelling. Pain well controlled with oral medication. Abdominal
incision OTA with steris, CDI. Stoma beefy red & viable with
liquid brown stool. Ostomy appliance changed [**Name6 (MD) **] Ostomy RN on
[**2125-6-29**] prior to transfer to REHAB. Continue checking daily
weights.

Plan to follow-up with Dr. [**Last Name (STitle) **] 2 weeks, and with Urology
as needed.

Medications on Admission:
Avapro 150', Lipitor 40', Triamterene, ASA, Omega 3

Discharge Medications:
1. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Last Name (STitle) **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Multivitamin,Tx-Minerals     Tablet [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
4. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for Anxiety/insomnia.
5. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day): Crush & give with applesauce.
6. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID
(4 times a day) as needed for groin for 2 weeks.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Hydromorphone 2 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
9. Phenol-Phenolate Sodium     Mouthwash [**Last Name (STitle) **]: One (1) Spray
Mucous membrane Q6H (every 6 hours) as needed for sore throat.
10. Oxymetazoline 0.05 % Aerosol, Spray [**Last Name (STitle) **]: One (1) Spray Nasal
[**Hospital1 **] (2 times a day) as needed for 3 days.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 49880**] Nursing Facility

Discharge Diagnosis:
Primary:
Toxic megacolon from Clostridium difficile colitis
Post-op fluid overload
Post-op pulmonary edema requiring prolonged intubation
Post-op urinary retention
.
Secondary:
recurrent diverticulitis, Prostate CA, CAD/CABG, moderate AS

Discharge Condition:
Stable
Tolerating a regular diet with supplements
Adequate pain control with oral medication

Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
Incision Care:
*You may shower. Pat incision dry.
*Avoid swimming and baths until further instruction at your
followup appointment.
*Leave the steri-strips on. They will fall off on their own, or
be removed during your followup.
*Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Monitoring Ostomy Output / Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.

*If Ostomy output exceeds 1 liter, take 4mg of Imodium, repeat
2mg with each episode of loose stool. Do not exceed 16mg in 24
hours.
.
Foley/Flomax:
-Please continue PO Flomax until follow-up appointment with Dr.
[**Last Name (STitle) **].
-Remove Foley on [**2125-7-1**]. Scan bladder after voiding to assess
for retention.
-Please contact Urology Department at [**Hospital3 **] with any
Urologic concerns ([**Telephone/Fax (1) 772**], pager: [**Numeric Identifier 42293**].


Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] for a follow up
appointment within 2-3 weeks [**Telephone/Fax (1) 9**].
.
Follow-up with Urology Department at [**Hospital1 827**] as needed ([**Telephone/Fax (1) 772**].
.
Follow-up with your PCP--[**Last Name (NamePattern4) **]. [**Last Name (STitle) 14206**] K. AGIOMAVRITIS,
[**Telephone/Fax (1) 71705**] in [**1-24**] weeks and as needed.



Completed by:[**2125-6-29**]
{'Intestinal infection due to Clostridium difficile,Cardiac complications, not elsewhere classified,Congestive heart failure, unspecified,Other iatrogenic hypotension,Other abnormal glucose,Aortic valve disorders,Subendocardial infarction, subsequent episode of care,Depressive disorder, not elsewhere classified,Retention of urine, unspecified,Aortocoronary bypass status,Personal history of malignant neoplasm of prostate,Family history of ischemic heart disease,Personal history of irradiation, presenting hazards to health,Personal history of tobacco use'}


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: 77M s/p sigmoid colectomy for recurrent diverticulitis presented
10 days post operatively with shortness of breath, abdominal
distention, bloating, diarrhea, and abdominal pain

PRESENT ILLNESS: 77 year old male with multiple medical problems admitted with
abdominal pain, leukocytosis and fever s/p sigmoid resection [**5-25**]
for recurrent diverticulitis. His postoperative course was
complicated by NSTEMI post-operatively, as well as concern
regarding possible anastamotic leak. He had a CT scan of the
abdomen and pelvis on [**5-28**] without evidence of leak. He was
treated with Zosyn from [**Date range (1) 57306**] empirically. He was discharged
on [**6-2**] to home off of antibiotics.

MEDICAL HISTORY: Prostate CA, CAD/CABG '[**13**], Aortic stenosis

MEDICATION ON ADMISSION: Avapro 150', Lipitor 40', Triamterene, ASA, Omega 3

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On day of admission:

FAMILY HISTORY: Positive for early CAD, father had MI before 55, 2 brothers d
from MI

SOCIAL HISTORY: married, quit smoking [**2088**], denies EtOH 

### Response:
{'Intestinal infection due to Clostridium difficile,Cardiac complications, not elsewhere classified,Congestive heart failure, unspecified,Other iatrogenic hypotension,Other abnormal glucose,Aortic valve disorders,Subendocardial infarction, subsequent episode of care,Depressive disorder, not elsewhere classified,Retention of urine, unspecified,Aortocoronary bypass status,Personal history of malignant neoplasm of prostate,Family history of ischemic heart disease,Personal history of irradiation, presenting hazards to health,Personal history of tobacco use'}
