CHIEF COMPLAINT: cc:[**CC Contact Info 69648**]
Major Surgical or Invasive Procedure:
[**2137-7-25**]: Irrigation and debridement of bilateral ischiorectal
abscess.
[**2137-8-2**]: Cardiac Catheterization
[**2137-8-6**]: Exploratory laparotomy; Lysis of adhesions; Creation of
end ileostomy.

PRESENT ILLNESS: This is a 32 yo man w/ severe crohn's disease on prednisone who
was transferred to [**Hospital1 18**] from a referring facility for a gluteal
abscess.  The abscess was present for ~3 months prior to
admission; he failed outpatient therapy of antibiotics.  CT at
referring facility demonstrated large loculated
perianal/peri-rectal abscess; transferred to [**Hospital1 18**] for surgical
evaluation.

MEDICAL HISTORY: Crohn's disease x 20 years
Gluteal abscess x 3 months
s/p colonic resection x 2 (last [**2131**])

MEDICATION ON ADMISSION: Prednisone 30 mg po daily
Augmentin/Cipro x 2 months
Percocet

ALLERGIES: Quinolones / Reglan / Fluconazole

PHYSICAL EXAM: Admission Exam
97.7  106   121/85  22  100% RA
NAD, A&Ox3
RRR
CTAB
Abd: soft, mildly distended, mild non-localized tenderness
Rectal: R peri-anal induration and tenderness
Ext: WWP, no edema

FAMILY HISTORY: +FH crohn's disease

SOCIAL HISTORY: Denies smoking, moderate EtOH, no drug use
Abscess of anal and rectal regions,Pneumonitis due to inhalation of food or vomitus,Acidosis,Cardiac arrest,Regional enteritis of unspecified site,Other specified disorders of rectum and anus,Anal fistula,Anemia, unspecified
Anal & rectal abscess,Food/vomit pneumonitis,Acidosis,Cardiac arrest,Regional enteritis NOS,Rectal & anal dis NEC,Anal fistula,Anemia NOS
Admission Date:  [**2137-7-24**]              Discharge Date:   [**2137-8-10**]

Date of Birth:  [**2105-1-4**]             Sex:   M

Service: SURGERY

Allergies:
Quinolones / Reglan / Fluconazole

Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
cc:[**CC Contact Info 69648**]
Major Surgical or Invasive Procedure:
[**2137-7-25**]: Irrigation and debridement of bilateral ischiorectal
abscess.
[**2137-8-2**]: Cardiac Catheterization
[**2137-8-6**]: Exploratory laparotomy; Lysis of adhesions; Creation of
end ileostomy.


History of Present Illness:
This is a 32 yo man w/ severe crohn's disease on prednisone who
was transferred to [**Hospital1 18**] from a referring facility for a gluteal
abscess.  The abscess was present for ~3 months prior to
admission; he failed outpatient therapy of antibiotics.  CT at
referring facility demonstrated large loculated
perianal/peri-rectal abscess; transferred to [**Hospital1 18**] for surgical
evaluation.

On arrival c/o gluteal pain, denies fevers/chills, N/V,
abdominal pain, CP, SOB.

Past Medical History:
Crohn's disease x 20 years
Gluteal abscess x 3 months
s/p colonic resection x 2 (last [**2131**])

Social History:
Denies smoking, moderate EtOH, no drug use

Family History:
+FH crohn's disease

Physical Exam:
Admission Exam
97.7  106   121/85  22  100% RA
NAD, A&Ox3
RRR
CTAB
Abd: soft, mildly distended, mild non-localized tenderness
Rectal: R peri-anal induration and tenderness
Ext: WWP, no edema

Pertinent Results:
Admission Labs
[**2137-7-25**] 05:40AM BLOOD WBC-24.4* RBC-3.27* Hgb-8.1* Hct-24.4*
MCV-75* MCH-24.6* MCHC-32.9 RDW-24.7* Plt Ct-934*
[**2137-7-28**] 06:45AM BLOOD Neuts-96.5* Bands-0 Lymphs-1.7*
Monos-1.6* Eos-0.2 Baso-0
[**2137-7-25**] 05:40AM BLOOD Glucose-94 UreaN-5* Creat-0.3* Na-140
K-4.1 Cl-105 HCO3-19* AnGap-20
[**2137-7-25**] 05:40AM BLOOD ALT-12 AST-16 LD(LDH)-218 AlkPhos-120*
TotBili-0.4
[**2137-7-25**] 05:40AM BLOOD Albumin-2.4* Calcium-7.4* Phos-2.5*
Mg-2.7*
[**2137-7-25**] 02:09PM BLOOD Type-ART Rates-/34 O2 Flow-6 pO2-44*
pCO2-42 pH-7.30* calTCO2-21 Base XS--5 Intubat-NOT INTUBA
[**2137-7-25**] 03:06PM BLOOD Lactate-1.4

Post-Code labs results:
Culture Results
[**2137-7-25**] 10:30 am ABSCESS     Site: RECTAL      PERI-RECTAL.
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.    MODERATE
GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).    SPARSE GROWTH.
PROTEUS SPECIES.    RARE GROWTH.

[**2137-7-29**] 7:31 pm  URINE CULTURE (Final [**2137-7-30**]):    NO GROWTH.

[**2137-7-30**] 1:04 am SPUTUM     Site: ENDOTRACHEAL RESPIRATORY
CULTURE (Final [**2137-8-1**]): RARE GROWTH OROPHARYNGEAL FLORA.
YEAST.    SPARSE GROWTH.

Imaging:
Pre-Op EKG:Sinus tachycardia @ 103. Normal ECG except for rate

Post Op CXR [**7-25**]: Substantial opacification LLL and RML raises
concern for recent aspiration and developing pneumonia. No
pneumothorax or appreciable pleural effusion is present.

Post Op EKG: Wandering baseline. Sinus tachycardia @140. ST-T
wave changes may likely be due to wandering baseline. Cannot
exclude ischemia. Compared to the previous tracing of [**2137-7-25**] the
rate is faster.

CTA CHEST W&W/O C &RECONS  [**2137-7-26**] 8:38 AM:
1) No evidence of pulmonary embolism.
2) Severe bilateral opacities mostly in the dependent portions
of the lungs likely related to aspiration/aspiration pneumonia.
Clinical correlation recommended.
3) Fatty liver.

CHEST PORT. LINE PLACEMENT  [**2137-7-29**] 9:24 PM
SUPINE AP VIEW OF THE CHEST: The left subclavian central venous
catheter has been withdrawn with the tip now lying at the
cavoatrial junction. Endotracheal tube and nasogastric tube
remain in unchanged positions. There is improved aeration in the
left lower lobe. Persistent bibasilar opacities likely reflect
aspiration or pneumonia. Mild pulmonary edema persists. There is
no pneumothorax. Probable small left pleural effusion is
unchanged.

ECHO Study Date of [**2137-8-1**] : LA normal size.  LV normal wall
thickness, cavity size, LVEF (>60%).  There may be mild inferior
hypokinesis. RV  chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery  systolic
hypertension. There is a very small pericardial effusion.

Excerpts of Operative Reports/Procedures:
[**2137-7-25**]
PREOPERATIVE DIAGNOSIS: Perirectal abscess.
POSTOPERATIVE DIAGNOSIS: Bilateral ischiorectal abscess.
PROCEDURE: Irrigation and debridement of bilateral
ischiorectal abscess.
INCISION: Bilateral circumanal incisions were made outside the
sphincter on both lateral aspects.
FINDINGS: There was a large amount of pus in the rectum which
went up the ischiorectal fossa on both sides and communicated
posteriorly across the coccyx.

Cardiac Catheterization [**2137-8-2**]:
1. No angiographically apparent coronary artery disease.
2. Normal systemic pressure.

[**2137-8-6**] Colonoscopy
Findings:
Mucosa: Friability, pesudopolyps and cobblestoning with contact
bleeding were noted in the rectum. These findings are compatible
with Colitis.
Other Normal ileum above the ileo-rectal anastomosis
Impression: Friability, pesudopolyps and cobblestoning in the
rectum compatible with Colitis. Normal ileum above the
ileo-rectal anastomosis

[**2137-8-6**]
PREOPERATIVE DIAGNOSES: Proctitis from Crohn's disease and
rectal fistula.
POSTOPERATIVE DIAGNOSES: Proctitis from Crohn's disease and
rectal fistula.
PROCEDURE:
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Creation of end ileostomy.
DESCRIPTION OF PROCEDURE: The abdomen was opened without
injuring any underlying bowel. There were noted to be some
adhesions to the side walls.
These were taken down sharply and with the [**Last Name (un) 4161**], again there
were no injuries to the bowel. The distal end of the ileum was
localized and the ileorectal anastomosis was also localized.
Approximately 20 cm proximal to the ileorectal anastomosis the
ileum was divided. The distal segment was left as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3379**]
pouch and the proximal segment was brought out as the end of the
[**Last Name (NamePattern4) 9341**] in the right lower quadrant. This [**Last Name (NamePattern4) 9341**] site was
previously marked by the stomal therapy nurse. [**First Name (Titles) **] [**Last Name (Titles) 69649**]s was achieved. There were no injuries to the small
bowel.

Next the stoma was opened with electrocautery. Hemostasis was
achieved along the wound edges. A [**Doctor Last Name **] ileostomy was fashioned
in a standard 2 layer [**Doctor Last Name **] ileostomy fashion. Vicryl sutures
were used to evert the edges. A stoma appliance was applied. The
patient was awakened in the operating room. He tolerated the
procedure well without any complications. All sponge counts,
needle counts were correct at the end of the case times

Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2137-7-24**] and underwent an
incision and drainage on [**2137-7-25**].  He subsequently
underwent a colonoscopy and diverting end ileostomy on [**8-6**], [**2136**].  During his hospitalization he was cared for by the
surgical, gastroenterology, endocrine and electrophysiology
teams.

Respiratory:
In the PACU he was tachycardic to the 140s and had increased
oxygen requirements with rapid shallow breathing.  He was
treated with lopressor, EKG changes resolved.  CXR was
suggestive of an aspiration event.  CTA was obtained which was
negative for PE. Respiratory problems resolved by POD #2; though
patient remained persistently tachycardic through most of his
hospital course.

Cardiovascular:
On HD 6 ([**2137-7-29**]) @ 6:30 PM Mr. [**Known lastname **] was found unresponsive in
cardiac arrest. He was defibrillated for a wide-complex VF
resembling torsades then compressions were started.  Patient was
intubated and transferred to the ICU.  Cardiac enzymes were
obtained and were negative for an ischemic event.  He was
extubated on [**7-30**] and transferred to the floor on [**7-31**].
The cardiology/electrophysiology team was consulted.  The
etiology of cardiac arrest is believed to be acquired prolonged
QT syndrome; possibly due to use of quinolone antibiotics,
Reglan, and/or fluconazole.  A cardiac catheterization was
performed and was negative for coronary artery disease.
Electrolytes were aggressively repleted, all QT prolonging drugs
were discontinued.  Mr. [**Known lastname **] was monitored on telemetry for
the remainder of his hospitalization; notable only for sinus
tachycardia, improved after treatment with BB and resolved after
diverting ileostomy.

GI:
Ischiorectal abscess was drained.  As he continued to drain
large amounts of fecal and purulent discharge from his abscess,
a diverting end-ileostomy was performed to help with wound
healing.  Initially prednisone was continued at 30 mg/day.  GI
was consulted who performed a colonscopy which revealed only a
small amount of colon remained (rectum), friability,
pseudopolyps and cobblestoning of remaining rectum consistent
with colitis; and normal ileum above the competent ileo-rectal
anastomosis.  GI recommended decreasing prednisone by 5 mg/week.
 He will follow-up with Dr. [**First Name4 (NamePattern1) 1939**] [**Last Name (NamePattern1) 1940**] for further care of
his Crohn's Disease.

ID: abscess drained; cultures grew [**Female First Name (un) **], cornybacterium and
proteus. Patient initially treated with unasyn and fluconazole;
these were discontinued after the cardiac arrest.  After
diverting ileostomy, patient was afebrile and without
leukocytosis.

Endocrine: given long term steroid use, Mr. [**Known lastname **] was seen by
endocrine, started on calcium and Vit D supplementation and will
follow-up as an outpatient with Endocrinology and have a BMD
scan performed.

Neuro/Pysch: patient was continued on prn ativan for anxiety,
percocet for pain control.

Medications on Admission:
Prednisone 30 mg po daily
Augmentin/Cipro x 2 months
Percocet

Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*1*
3. Potassium Chloride 20 mEq Packet Sig: One (1)  PO DAILY
(Daily).
Disp:*30 * Refills:*1*
4. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*1*
5. Prednisone 5 mg Tablet Sig: see steroid taper instructions
Tablet PO once a day: You are being started on a steroid taper.
You will take 25 mg (five tablets) through [**8-14**].  From [**8-14**]
through [**8-21**] take 20 mg (4 tabs). [**8-23**] through [**8-29**] take 15 mg (3
tabs). [**8-30**] through [**9-5**] take 10 mg (2 tabs). [**9-6**] through [**9-12**]
take 1 tab. .
Disp:*95 Tablet(s)* Refills:*0*
6. CALCIUM 500+D 500-200 mg-unit Tablet Sig: Three (3) Tablet PO
once a day. Tablet(s)
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Caregroup VNA

Discharge Diagnosis:
Primary Diagnosis:
Bilateral ischiorectal abscess
Crohn's Disease
s/p diverting end ileostomy
.
Secondary Diagnoses:
Acquired QT Prologation (now resolved)
s/p cardiac arrest


Discharge Condition:
Good.  Afebrile.  Decreased drainage from abscess.  Normal
cardiac function.


Discharge Instructions:
You were hospitalized at the [**Hospital1 18**] for an ischiorectal abscess
(infection with a pus collection) that fistulized (communicated)
with your bowel.  The abscess was surgically drained, however
because of the fistula, a diverting ileostomy was performed to
drain your stool into a bag in order to help the abscess heal.

Your hospital stay was complicated by a cardiac arrest where
your heart stopped functioning properly for a short period of
time(minutes).  Because of this episode, you were intubated and
then watched in the ICU for several days.  From reviewing the
records, it appears your heart when into an abnormal rhythm
called "torsades de pointes." We believe this was due to
'acquired QT prolongation' where some medications you were
prescribed lengthened a particular part of the cardiac cycle.
It is very important you avoid these medications in the future:
these include quinolone antibiotics (levofloxacin/Levaquin,
ciprofloxacin, moxifloxacin, gatifloxcin), reglan, and
fluconazole.  Please inform all your current and future
healthcare providers (doctors, nurses, emergency personnel) that
you had this problem and should NOT prescribed medications with
a side effect of prolonging the QT interval.  As a part of the
evaluation of your cardiac arrest, you underwent a cardiac
catheterization to look at the arteries in your heart - the
arteries were normal (no clogged arteries).

You should follow-up as detailed below with: the surgeons that
drained your abscess and performed your ileostomy operation; the
GI physicians to manage your Crohn's Disease; and endocrine.  We
have also scheduled you with an appointment with a primary care
physician in [**Hospital6 733**].

Take all medications as prescribed.  You have been started on a
steroid taper.  You need to decrease your prednisone by 5 mg
each week (you are currently taking 25 mg; you will then taper
to one week of 20 mg a day; then you'll taper to one week of 15
mg daily, etc).  The GI physcians and the endocrine physicians
will re-evaluate you after the taper is complete/near complete.
You have been started on a betablocker for heart rate control
(your primary care physician and you can decide whether to
continue this).  You have been prescribed ativan as needed for
anxiety and percocet as need for pain.  Percocet may make you
drowsy and can make you constipated.  You should not drive or
operate heavy machinery when taking percocet. If you become
constipated, you can take a stool softner.  If your pain is
mild, you can take acetaminophen (tylenol) or ibuprofen (motrin)
instead.

You should take calcium and vitamin D supplementation to
increase the strength of your bones, as prednisone decreases
[**Hospital6 500**] strength.  This can either be through pills (like vitamins)
or liquid supplements (like Boost or Ensure).  You should take
1200-1500 mg of elemental calcium each day and 800 units of
vitamin D each day.

It is extremely important that you keep well hydrated and take
in as much fluids as your put out in your urine and stool.  You
can advance your diet as tolerated, starting with softer foods
and eventually eating normal food.  If you have a limited
appetite, you should take BOOST shakes to ensure you get enough
nutrition, as good nutrition is essential to healing.

You can take [**Last Name (un) **] baths up to twice daily to help with wound
healing.  (Fill up the bath tub with warm water and sit in it
for 15-20 mins.)

Follow the instructions of the [**Last Name (un) 9341**] nurse [**First Name (Titles) 4120**] [**Last Name (Titles) 9341**]
care.

You should be seen by your doctor or return to the hospital for:
*increased discharge from your abscess/wound
*increased pain at the site of your abscess/wound
*redness around or red streaks extending from your abscess/wound
or your stoma
*persistent fever >102
*nausea, vomiting, no output from your stoma, bloody stools
*lightheadedness/feeling like you might pass out
*chest pain/shortness of breath
*if you lose consciousness
*other symptoms that concern you.

Followup Instructions:
You should follow-up in 1 week with either Dr. [**Last Name (STitle) **] in Surgery.
 Please call the Trauma Clinic at [**Telephone/Fax (1) 6439**] to make an
appointment.

Primary Care Appointment: Provider: [**Name10 (NameIs) 8741**] [**Name8 (MD) 9529**], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2137-8-21**] 1:30
-Please call [**Hospital3 **] ([**Doctor First Name **]) at [**Telephone/Fax (1) 250**] to
update your insurance information.

Endocrine followup: Provider:  [**Name10 (NameIs) **] DENSITY TESTING
Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2137-8-23**] 8:40; Provider: [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 16051**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2137-8-23**] 9:30.  [**Hospital Ward Name 23**]
Clinical Center, [**Location (un) 436**].

Gastroenterology: Dr. [**First Name4 (NamePattern1) 1939**] [**Last Name (NamePattern1) 1940**] on Friday, [**2137-9-6**] at 3PM.
-Please contact the GI office at [**Telephone/Fax (1) 1983**] to update
registration information and obtain directions. Please bring
your insurance card and copay to the appointment.



Completed by:[**2137-8-13**]
{'Abscess of anal and rectal regions,Pneumonitis due to inhalation of food or vomitus,Acidosis,Cardiac arrest,Regional enteritis of unspecified site,Other specified disorders of rectum and anus,Anal fistula,Anemia, unspecified'}


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: cc:[**CC Contact Info 69648**]
Major Surgical or Invasive Procedure:
[**2137-7-25**]: Irrigation and debridement of bilateral ischiorectal
abscess.
[**2137-8-2**]: Cardiac Catheterization
[**2137-8-6**]: Exploratory laparotomy; Lysis of adhesions; Creation of
end ileostomy.

PRESENT ILLNESS: This is a 32 yo man w/ severe crohn's disease on prednisone who
was transferred to [**Hospital1 18**] from a referring facility for a gluteal
abscess.  The abscess was present for ~3 months prior to
admission; he failed outpatient therapy of antibiotics.  CT at
referring facility demonstrated large loculated
perianal/peri-rectal abscess; transferred to [**Hospital1 18**] for surgical
evaluation.

MEDICAL HISTORY: Crohn's disease x 20 years
Gluteal abscess x 3 months
s/p colonic resection x 2 (last [**2131**])

MEDICATION ON ADMISSION: Prednisone 30 mg po daily
Augmentin/Cipro x 2 months
Percocet

ALLERGIES: Quinolones / Reglan / Fluconazole

PHYSICAL EXAM: Admission Exam
97.7  106   121/85  22  100% RA
NAD, A&Ox3
RRR
CTAB
Abd: soft, mildly distended, mild non-localized tenderness
Rectal: R peri-anal induration and tenderness
Ext: WWP, no edema

FAMILY HISTORY: +FH crohn's disease

SOCIAL HISTORY: Denies smoking, moderate EtOH, no drug use 

### Response:
{'Abscess of anal and rectal regions,Pneumonitis due to inhalation of food or vomitus,Acidosis,Cardiac arrest,Regional enteritis of unspecified site,Other specified disorders of rectum and anus,Anal fistula,Anemia, unspecified'}
