CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 51 year old
male with metastatic colon cancer status post chemotherapy
and radiation at [**Hospital 4068**] Hospital, who presents with weakness,
fatigue, nausea, vomiting and back pain at site of former
x-ray therapy.  Positive fever, positive chills.  He fell
three weeks ago and complained of back pain since then.  The
patient denied drainage or redness from the wound until
today, now draining foul smelling material.  The patient was
admitted to [**Hospital 4068**] Hospital last week with dehydration and
hyponatremia.

MEDICAL HISTORY: 1.  Subtotal colectomy with ileorectal anastomosis in [**2157**].
2.  Metastases to liver and pelvis.
3.  Right ureteral stent placement.
4.  Small bowel obstruction with lysis of adhesions.
5.  Non-insulin dependent diabetes mellitus.
6.  X-ray therapy in [**2157**].

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: No alcohol.  Quit tobacco.
Fistula of intestine, excluding rectum and anus,Unspecified septicemia,Hyposmolality and/or hyponatremia,Malignant neoplasm of liver, secondary,Nutritional marasmus,Personal history of malignant neoplasm of large intestine,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Intestinal fistula,Septicemia NOS,Hyposmolality,Second malig neo liver,Nutritional marasmus,Hx of colonic malignancy,DMII wo cmp nt st uncntr
Admission Date:  [**2161-1-30**]     Discharge Date:  [**2161-2-19**]

Date of Birth:   [**2109-7-8**]     Sex:  M

Service:

HISTORY OF PRESENT ILLNESS:  The patient is a 51 year old
male with metastatic colon cancer status post chemotherapy
and radiation at [**Hospital 4068**] Hospital, who presents with weakness,
fatigue, nausea, vomiting and back pain at site of former
x-ray therapy.  Positive fever, positive chills.  He fell
three weeks ago and complained of back pain since then.  The
patient denied drainage or redness from the wound until
today, now draining foul smelling material.  The patient was
admitted to [**Hospital 4068**] Hospital last week with dehydration and
hyponatremia.

PAST MEDICAL HISTORY:
1.  Subtotal colectomy with ileorectal anastomosis in [**2157**].
2.  Metastases to liver and pelvis.
3.  Right ureteral stent placement.
4.  Small bowel obstruction with lysis of adhesions.
5.  Non-insulin dependent diabetes mellitus.
6.  X-ray therapy in [**2157**].

SOCIAL HISTORY:  No alcohol.  Quit tobacco.

MEDICATIONS:
1.  Prilosec.
2.  Celebrex.
3.  Glucotrol.
4.  Roxicontin.

PHYSICAL EXAMINATION:  Temperature 96.9 F.; 82; 138/80; 21;
100% on room air.  In general, he is an ill appearing white
male.  Regular rate and rhythm.  Lungs are clear.  Abdomen
soft, flat, nontender.  Back:  Indurated fluctuant right
flank with foul-smelling purulent drainage.  Positive
erythema.  Rectal is heme positive brown stool.

LABORATORY:  His sodium was 126, potassium 4.8, 88, 29, 18,
1.4 and 90.  His white blood cell count was 10.5, hematocrit
32, platelets 480.

HOSPITAL COURSE:  The patient was admitted on [**2161-1-30**], and
the patient had his back abscess drained.  After CT scan
showed distal small bowel leak to the well drained
retroperitoneal abscess, it was clear that the patient had an
enterocutaneous fistula.  The patient was started on total
parenteral nutrition through a right IJ line for nutrition
preoperatively.  The patient was started on Levofloxacin and
Flagyl intravenously.  Duplex ultrasound was obtained for his
right lower extremity swelling, which was negative.

The patient was taken to the Operating Room on [**2161-2-4**],
for resection of enterocutaneous fistula and ileostomy and
incision and drainage of the flank wound.  Postoperatively,
the patient was started on Levofloxacin, Flagyl and Kefzol.
Immediately postoperatively, the patient was admitted to the
Intensive Care Unit for septic shock.  The patient's blood
pressure had dipped into the 80's systolic.  The patient was
also febrile.  The patient was given intravenous fluids and
was started on pressure support of Levophed.  The patient
stayed three days in the Intensive Care Unit, was weaned off
the Levophed and was transferred to the Floor.

The patient was continued on his Levofloxacin and Flagyl and
was continued on total parenteral nutrition.   The patient's
diet was advanced on [**2161-2-8**] with a regular diet and Boost
supplements.  On [**2161-2-9**], on postoperative day number
five, the patient's PCA was discontinued.  The patient was
started on Percocet and breakthrough morphine for pain.  The
patient was seen by Physical Therapy and Occupational Therapy
as well.

On [**2161-2-10**], it was noted that the patient's ostomy output
was increased to 4500 cc.  At that time, the patient was
started on motility slowing [**Doctor Last Name 360**] Lomotil.  The patient was
hyponatremic and this was supplemented with cc per cc normal
saline replacements from his ostomy as well as in his TPN.
Part of this problem was the high ostomy output.  A GI
consultation was obtained because of this high output and the
patient was started on Questran per their recommendations, 4
grams p.o. twice a day.  The patient was also started on
Octreotide 100 micrograms per hour intravenous q. eight
hours.

On [**2161-2-13**], postoperative day number nine, it was noted
that the patient's ileostomy drainage had decreased slightly.
A VAC dressing had been placed to his back wound on
postoperative day number eight and this was changed on
[**2161-2-13**].  The patient was taken off the Levofloxacin and
Flagyl on postoperative day number eight.  The patient was
started on tincture of opium as well as a motility slowing
[**Doctor Last Name 360**].  On postoperative day number 12, the patient's
Somatostatin dose was increased and rehabilitation options
were looked in to as the hyponatremia seemed to be under
control with the TPN and the replacements.

On postoperative day number 13, it was noted that the patient
had Methicillin resistant Staphylococcus aureus growing from
his abdominal wounds which had been draining some purulent
material.  The patient was started on Vancomycin for this
reason.  On postoperative day number 14, the patient's
ileostomy replacement was changed to 1/2 cc per cc
replacement.  Also, on postoperative day number 14, it was
decided that the patient should have a CT scan to see why the
abdominal and back wounds continued to drain.  The CT scan
showed extensive undrained infection in the abdomen, right
lower quadrant, extending to the right flank, hip and
buttock.

At this point, Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 916**] discussed with the
patient options for intervention as well as Hospice.  The
patient had decided that he wished to return home with
Hospice care and saw no need for further intervention.  On
postoperative day number 15, these measures for Hospice were
set in place.  The patient did not want a VAC dressing as he
felt this was uncomfortable.  The patient was put on
dry-to-dry dressing changes on his abdomen and back wound
three times a day and p.r.n.  The patient wished not to have
an intravenous for intravenous antibiotics or for intravenous
fluids.  The PICC line was removed and the patient was taken
off of the Vancomycin intravenously as well as the TPN.

The patient was sent home with Hospice on the following
medications.

DISCHARGE MEDICATIONS:
1.  Levofloxacin 500 mg p.o. q. day.
2.  Flagyl 500 mg p.o. three times a day.
3.  Lopressor 25 mg p.o. twice a day.
4.  Lomotil two tablets p.o. four times a day.
5.  Questran 4 grams p.o. twice a day.
6.  Nystatin 5 cc swish and spit four times a day.
7.  Oxy-Contin 40 mg p.o. twice a day.
8.  Tylenol 650 mg p.o. q. four to six hours p.r.n.
9.  Compazine 5 to 10 mg p.o. q. six hours p.r.n.
10. Ativan Elixir 0.25 mg.

DISCHARGE INSTRUCTIONS:
1.  The patient was discharged on a regular diet.

DISCHARGE DIAGNOSES:
1.  Status post enterocutaneous fistula resection and
ileostomy, now with abscesses in abdomen and hip.

CONDITION AT DISCHARGE:   Guarded.

The patient and family understand the patient's prognosis and
the patient made the decision to have Hospice involved in his
care.


                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D.  [**MD Number(1) 2214**]

Dictated By:[**Last Name (NamePattern1) 6067**]

MEDQUIST36

D:  [**2161-2-19**]  12:25
T:  [**2161-2-19**]  12:56
JOB#:  [**Job Number 28155**]
{'Fistula of intestine, excluding rectum and anus,Unspecified septicemia,Hyposmolality and/or hyponatremia,Malignant neoplasm of liver, secondary,Nutritional marasmus,Personal history of malignant neoplasm of large intestine,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: The patient is a 51 year old
male with metastatic colon cancer status post chemotherapy
and radiation at [**Hospital 4068**] Hospital, who presents with weakness,
fatigue, nausea, vomiting and back pain at site of former
x-ray therapy.  Positive fever, positive chills.  He fell
three weeks ago and complained of back pain since then.  The
patient denied drainage or redness from the wound until
today, now draining foul smelling material.  The patient was
admitted to [**Hospital 4068**] Hospital last week with dehydration and
hyponatremia.

MEDICAL HISTORY: 1.  Subtotal colectomy with ileorectal anastomosis in [**2157**].
2.  Metastases to liver and pelvis.
3.  Right ureteral stent placement.
4.  Small bowel obstruction with lysis of adhesions.
5.  Non-insulin dependent diabetes mellitus.
6.  X-ray therapy in [**2157**].

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: No alcohol.  Quit tobacco. 

### Response:
{'Fistula of intestine, excluding rectum and anus,Unspecified septicemia,Hyposmolality and/or hyponatremia,Malignant neoplasm of liver, secondary,Nutritional marasmus,Personal history of malignant neoplasm of large intestine,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
