CHIEF COMPLAINT: 

PRESENT ILLNESS: A [**Age over 90 **]-year-old male with a
history of right cecal adenocarcinoma resected in [**2169-7-21**].  On follow-up colonoscopy, a lesion was noted at the
anastomosis with a patch of mucinous adenocarcinoma and
necrosis.  The patient noted no change in bowel habits, no
bright red blood per rectum, no abdominal pain, or nausea or
vomiting.

MEDICAL HISTORY: 1. Status post myocardial infarction in [**2134**], status post
percutaneous transluminal angiography in [**2160**] to left
anterior descending artery and diagonal I.
2. Angina.
3. Insulin dependent-diabetes mellitus.
4. Diabetic neuropathy.
5. Colon cancer as above.
6. Benign prostatic hypertrophy.

MEDICATION ON ADMISSION: Captopril 12.5 [**Hospital1 **], atenolol 50 q
day, isosorbide dinitrate 20 [**Hospital1 **], Senna [**Hospital1 **], Betoptic one
drop OD [**Hospital1 **], Humulin N 30 units q am and 5 units q pm.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: Tobacco 50 pack year history, quit in [**2133**],
35 year cigar history, smokes 2-3 per day from age 65 to
present, rare ethanol use.  No IV drug use.  The patient is
widowed and lives alone.  Is a former owner of a upholstery
shop.
Malignant neoplasm of ascending colon,Congestive heart failure, unspecified,Malignant neoplasm of liver, secondary,Acute myocardial infarction of unspecified site, initial episode of care,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Acute respiratory failure,Acidosis,Polyneuropathy in diabetes,Personal history of malignant neoplasm of large intestine
Malig neo ascend colon,CHF NOS,Second malig neo liver,AMI NOS, initial,DMI neuro nt st uncntrld,Acute respiratry failure,Acidosis,Neuropathy in diabetes,Hx of colonic malignancy
Admission Date:  [**2171-8-12**]     Discharge Date:  [**2171-8-23**]


Service:  Blue Surgery

REASON FOR ADMISSION:  Recurrent colon adenocarcinoma.

CAUSE OF DEATH:  Respiratory and circulatory arrest.

HISTORY OF PRESENT ILLNESS:  A [**Age over 90 **]-year-old male with a
history of right cecal adenocarcinoma resected in [**2169-7-21**].  On follow-up colonoscopy, a lesion was noted at the
anastomosis with a patch of mucinous adenocarcinoma and
necrosis.  The patient noted no change in bowel habits, no
bright red blood per rectum, no abdominal pain, or nausea or
vomiting.

A preoperative stress echocardiogram on [**7-18**] showed a
reversible moderate inferior wall perfusion defect, mild
apical perfusion defect, ejection fraction of 48%, no wall
motion abnormalities.

Review of systems reveals occasional dyspnea, questionable
angina with exertion.  No chest pain at rest.  No shortness
of breath at rest.  No dysuria.

PAST MEDICAL HISTORY:
1. Status post myocardial infarction in [**2134**], status post
percutaneous transluminal angiography in [**2160**] to left
anterior descending artery and diagonal I.
2. Angina.
3. Insulin dependent-diabetes mellitus.
4. Diabetic neuropathy.
5. Colon cancer as above.
6. Benign prostatic hypertrophy.

MEDICATIONS ON ADMISSION:  Captopril 12.5 [**Hospital1 **], atenolol 50 q
day, isosorbide dinitrate 20 [**Hospital1 **], Senna [**Hospital1 **], Betoptic one
drop OD [**Hospital1 **], Humulin N 30 units q am and 5 units q pm.

Allergies to aspirin which causes bleeding.

PAST SURGICAL HISTORY:  Right ileocolectomy in [**2168**] and TURP.

SOCIAL HISTORY:  Tobacco 50 pack year history, quit in [**2133**],
35 year cigar history, smokes 2-3 per day from age 65 to
present, rare ethanol use.  No IV drug use.  The patient is
widowed and lives alone.  Is a former owner of a upholstery
shop.

EXAMINATION ON ADMISSION:  Vitals:  Temperature 97.5, heart
rate 60, blood pressure 142/80, respirations 16.  Sat 95% on
room air.  General:  Pleasant-elderly male in no acute
distress.  HEENT:  Pupils are equal, round, and reactive to
light.  Sclerae are anicteric.  Oropharynx is clear.  Mucous
membranes are moist.  Neck is supple without lymphadenopathy.
There is no carotid bruit.  Pulmonary:  Crackles at the bases
bilaterally.  Heart is regular, rate, and rhythm, no murmur.
Abdomen is soft, nontender, nondistended, bowel sounds are
present.  There is a faded right perimedial incision scar and
a right lateral hernia without hepatosplenomegaly.
Extremities are without edema.  There is a dorsalis pedis and
PT pulses are 2+ bilaterally.

Chest x-ray from the [**7-12**] showed a small right
pleural effusion, a nodular opacity in the right upper field,
bibasilar interstitial opacities, no evidence of congestive
heart failure.

Electrocardiogram shows sinus bradycardia at 49.  ST
depression in I, II, and V6, ST elevation in V1 and V2.
Echocardiogram shows ejection fraction of 48% per the history
of present illness.

Admit laboratories:  ALT 25, AST 10, alkaline phosphatase
113, amylase 51, lipase 49, total bilirubin 0.3, uric acid
5.9.  White count 6.4, hematocrit 31.2, platelets of 138.  PT
of 13.0, PTT 27.0, INR 1.2.  Sodium 145, potassium 4.3,
chloride 110, CO2 28, BUN 29, creatinine 1.6, and glucose
125, albumin 3.4, calcium 9.0, phosphorus 3.2, and magnesium
2.0.  Urinalysis negative.

ASSESSMENT:  This is a [**Age over 90 **]-year-old male with recurrent colon
cancer presenting for resection.  He was admitted for
preoperative and typed and crossed 2 units, made NPO past
midnight, except medications, and Hibiclens scrub to his
abdomen.  He was seen by Dr. [**Last Name (STitle) 957**].

HOSPITAL COURSE:  The patient was taken to the operating room
and underwent exploratory laparotomy and ileocolectomy at the
ileocolonic anastomosis as well as a small bowel resection.
His blood loss is 300.  There are no complications.  This was
done under epidural and local anesthesia, and required no
transfusions.  Was given 3100 cc of Crystalloid and sent to
Recovery Room in stable condition.  Refer to operative
dictation for details.

Postoperatively, the patient had a nasogastric tube with a
pO2 of 73.  His hypertension which was controlled with
Nipride, plan was to take his nasogastric tube out the
following morning.  Postoperative, the patient's temperature
is 95 po, his heart rate was 50-60, blood pressure 187/70,
respirations 15 and again he was given IV Lopressor,
nitropaste.  He was transferred to the SICU for postoperative
monitoring.  He was continued on his captopril and isosorbide
and plan was to begin a nitroglycerin drip if his systolic
blood pressure increased over 150.

Respiratory he was diuresed with Lasix and supplemental
oxygen was continued.  Aggressive pulmonary toilet was
instituted.  He was on perioperative antibiotics at this
time.  Patient's epidural was left in postoperatively for
perioperative pain control.  Narcotic was taken out of the
mixture.

Patient on overnight postoperatively became agitated, and
combative, and was given some Ativan for sedation.  He was
hemodynamically stable making urine.  He had no chest pain.

Postoperative day one, the patient was continued on
Lopressor, Captopril, and Isordil for blood pressure control.
Pulmonary toilet was continued.  He is still on IV fluids, no
feedings.  He was also given prn Lasix for diuresis.  His
hematocrit was stable.

On postoperative day one, approximately 4 pm in the
afternoon, patient had desaturation into the 50s, which
increased to the 90s with bagging.  His blood pressure is in
the 170s sinus tachycardia, ST depression in V3 through V5.
He had no complaint of chest pain.  He had faint rales on
examination with rhonchi throughout.  Plan was to check
laboratories, give Lasix IV, and Lopressor for rate control
to rule out for myocardial infarction, given pulmonary
toilet, and contact Cardiology for consultation.

Cardiology saw the patient and recommendations were to cycle
cardiac enzymes to rule out ischemia and to recommend aspirin
from a cardiac perspective, to proceed with diuresis to
control heart rate and blood pressure with beta blocker and
ACE, nitroglycerin, and Morphine.

Postoperative day three, the patient's Lopressor was
continued.  CK was 974 with a MB of 12 and troponin of less
than 0.3.  Patient was also diuresed prn.  Patient did rule
in for myocardial infarction by troponin, however, the CKs
remained relatively flat and his electrocardiogram changes
resolved.  He did remain tachycardic and hypertensive.  My
recommendation is to continue aspirin, to increase beta
blocker for rate control.  Check his echocardiogram to
evaluate for systolic function, diurese to goal of [**11-21**] liters
negative for the day, follow CKs.  Hold on the Heparin drip.

On the [**7-16**] in the afternoon, the patient had
been suffering from progressive respiratory distress due to
the complications of his heart condition as well as
congestive heart failure, and had developed increasing
acidosis and hypertension and decreasing renal function.  He
was placed on mechanical ventilation and a PA catheter was
also placed to guide fluid therapy as well as pressors if
needed.  Echocardiogram obtained today showed an ejection
fraction of 40%, 2+ mitral regurgitation, and anteroseptal
hyperkinesis.

At that time, his picture appeared to be consistent with
sepsis in the setting of perioperative ischemia, and plan was
to start Levophed to support blood pressure, to begin Heparin
drip, to broaden his antibiotic coverage to attempt further
diuresis.  He is placed on amp of levo and Flagyl.

After discussion with family after these events, it was
decided to make the patient DNR with no chest compressions,
shock.  He did begin to respond to a Lasix boluses and was
finally put on a Lasix drip for which he diuresed well.
Pressors were able to be weaned, however, the patient did at
one point require Dobutamine for support as his Levophed was
weaned off.

On the [**6-21**], the patient was able to be extubated
to a shovel mask.  Additionally, his dobutamine was weaned to
off.  He had been restarted on trophic tube feeds and showed
some bowel activity with a small bowel movement.  Patient did
not show any signs of regaining his mental status, however,
after extubation, this is felt possibly due to prolonged
sedative effect as he had been given Ativan earlier in his
hospital course.  Additionally, the patient developed
progressive uremia up to as high as 105-108.  This is thought
secondary to progressive renal failure earlier in his
hospital course with cardiogenic shock with myocardial
infarction as well as a possible sepsis picture.  However,
the patient's cultures never grew out any organisms.

Patient's nutrition while he was intubated was supported with
TPN, and this could also have effected his blood-nitrogen
levels.  At any rate after the patient was extubated two days
ago, he did not regain his mental function, remained
unresponsive.  On examination the patient can only open his
eyes to deep pain and would only withdraw slightly to deep
pain.  Additionally, he had no verbal response.

Per the patient's family request, he is made a DNI as well as
kept DNR.  His Lasix drip was able to be stopped and the
patient continued to make urine well on his own over the last
couple of days.  His tube feeds were kept the same and his
TPN was stopped yesterday.  He continued to require
supplemental oxygen which the requirements have increased
overnight.

This morning he was on 60% and his saturations dropped to the
low 90s throughout the morning.  Around 9 am, the patient
desaturated markedly to 60s and became bradycardic.  He
quickly progressed to asystole, and on examination he had no
heart sounds and no breath sounds.  The family was notified
as well as the attending, and the time of death is declared
at 9:20.  Cause of death is likely secondary to respiratory
failure.

PROCEDURES DURING THIS ADMISSION:
1. Ileocolectomy and small bowel resection.
2. Oral intubation.
3. PA catheter placement.
4. Arterial catheter placement.
5. Echocardiography.


                          [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 4007**]

Dictated By:[**Last Name (STitle) 45848**]

MEDQUIST36

D:  [**2171-8-23**]  09:57
T:  [**2171-8-28**]  05:48
JOB#:  [**Job Number **]
{'Malignant neoplasm of ascending colon,Congestive heart failure, unspecified,Malignant neoplasm of liver, secondary,Acute myocardial infarction of unspecified site, initial episode of care,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Acute respiratory failure,Acidosis,Polyneuropathy in diabetes,Personal history of malignant neoplasm of large intestine'}


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: A [**Age over 90 **]-year-old male with a
history of right cecal adenocarcinoma resected in [**2169-7-21**].  On follow-up colonoscopy, a lesion was noted at the
anastomosis with a patch of mucinous adenocarcinoma and
necrosis.  The patient noted no change in bowel habits, no
bright red blood per rectum, no abdominal pain, or nausea or
vomiting.

MEDICAL HISTORY: 1. Status post myocardial infarction in [**2134**], status post
percutaneous transluminal angiography in [**2160**] to left
anterior descending artery and diagonal I.
2. Angina.
3. Insulin dependent-diabetes mellitus.
4. Diabetic neuropathy.
5. Colon cancer as above.
6. Benign prostatic hypertrophy.

MEDICATION ON ADMISSION: Captopril 12.5 [**Hospital1 **], atenolol 50 q
day, isosorbide dinitrate 20 [**Hospital1 **], Senna [**Hospital1 **], Betoptic one
drop OD [**Hospital1 **], Humulin N 30 units q am and 5 units q pm.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: Tobacco 50 pack year history, quit in [**2133**],
35 year cigar history, smokes 2-3 per day from age 65 to
present, rare ethanol use.  No IV drug use.  The patient is
widowed and lives alone.  Is a former owner of a upholstery
shop. 

### Response:
{'Malignant neoplasm of ascending colon,Congestive heart failure, unspecified,Malignant neoplasm of liver, secondary,Acute myocardial infarction of unspecified site, initial episode of care,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Acute respiratory failure,Acidosis,Polyneuropathy in diabetes,Personal history of malignant neoplasm of large intestine'}
