CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 77-year-old male who
recently had an episode of diverticulitis with an abscess and
fistula to involve penile prosthesis.  The patient had the
penile prosthetic devise removed.  He was left a colonic
fistula from the colon to the scrotum.  There was a
significant amount of stool drainage every day, approximately
less than 100 cc, but persistent.  The patient was seen by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1888**] and was counseled regarding surgery.

MEDICAL HISTORY: 1.  Hypertension.  2.  Hyperlipidemia.
3.  History of prostate carcinoma.

MEDICATION ON ADMISSION: Celebrex 100 mg p.o. b.i.d.,
Verapamil 240 mg p.o. q.d., Prilosec 20 mg p.o. q.d., Lipitor
10 mg  p.o. q.d., Aspirin 325 mg p.o. q.d., Ziac, Celexa 20
mg p.o. q.d.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Fistula of intestine, excluding rectum and anus,Unspecified septicemia,Severe sepsis,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Subendocardial infarction, initial episode of care,Paralytic ileus
Intestinal fistula,Septicemia NOS,Severe sepsis,Acute kidney failure NOS,CHF NOS,Subendo infarct, initial,Paralytic ileus
Admission Date:  [**2106-2-11**]       Discharge Date:[**2106-3-2**]

Date of Birth:   [**2028-2-20**]       Sex:  M

Service:

HISTORY OF PRESENT ILLNESS:  This is a 77-year-old male who
recently had an episode of diverticulitis with an abscess and
fistula to involve penile prosthesis.  The patient had the
penile prosthetic devise removed.  He was left a colonic
fistula from the colon to the scrotum.  There was a
significant amount of stool drainage every day, approximately
less than 100 cc, but persistent.  The patient was seen by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1888**] and was counseled regarding surgery.

PAST MEDICAL HISTORY:  1.  Hypertension.  2.  Hyperlipidemia.
3.  History of prostate carcinoma.

PAST SURGICAL HISTORY:  1.  Status post appendectomy.  2.
Status post prostatectomy.  3.  Status post cervical disk
surgery.  4.  Penile implant placement.

MEDICATIONS ON ADMISSION:  Celebrex 100 mg p.o. b.i.d.,
Verapamil 240 mg p.o. q.d., Prilosec 20 mg p.o. q.d., Lipitor
10 mg  p.o. q.d., Aspirin 325 mg p.o. q.d., Ziac, Celexa 20
mg p.o. q.d.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAMINATION:  Vital signs:  On initial evaluation,
the patient was afebrile, and his vital signs were stable.
General:  He was a well-appearing male in no acute distress.
HEENT:  He had no carotid bruits on neck exam.  The remainder
of his head and neck exam was within normal limits.  Lungs:
Clear to auscultation bilaterally.  Heart:  Regular rhythm.
Normal S1 and S2.  Abdomen:  Soft and nontender.  On the left
anterior portion of the scrotal area, the patient had a
longitudinal wound that was dry and intact.  Extremities:
Lower extremities did not have any edema.

HOSPITAL COURSE:  On [**2106-2-11**], the patient underwent a
low anterior resection, splenic flexure immobilization,
ileostomy placement, and drainage of pelvic abscess.  There
were no complications during the surgery.  Please see the
dictated operative notes for details of this surgery.

Over the first several postoperative days, the patient did
well.  His pain was initially controlled on a PCA, and then
he was transitioned to p.o. pain medications.  He was
initially made NPO, and then his diet was advanced as
tolerated.

He was placed on a regular diet on postoperative day #4.  His
JP drain was discontinued.  He was ambulating with assistance
from Physical Therapy.

By hospital day #4, the patient's ostomy had
................... in it.  His abdomen had bowel sounds and
was nontender but slightly distended.

On hospital day #6, the patient had some emesis.  He
complained of slight abdominal pain and increased distention.
CT scan of the abdomen was done which only showed a
developing ileus.  The patient was made NPO.

Serial abdominal exams were performed as well.  By
postoperative day #7, the patient's ileus was improving.  He
was restarted on a regular diet.  The patient continued to
have output from his ostomy, as well as gas in his ostomy
bag.

On postoperative day #8, the patient began to complain of
slight disorientation.  He was not oriented with regards to
time or place.  Electrolytes were drawn that morning which
were within normal limits.

The patient's ostomy output significantly increased over the
course of the day.  Another set of electrolytes were drawn.
His creatinine had significantly increased to 4.1.  His white
blood cell count had also significantly increased to 19.7.

The patient was afebrile however.  He continued to be
increasingly disoriented and appeared to be septic.  At that
time, a subclavian central line was immediately.  The Foley,
which had been previously discontinued, was reinserted with
the help of Urology.  He was started on intravenous fluids.

An ABG was done which was within normal limits.  Chest x-ray
was performed as well.  The patient's blood pressure, which
had decreased that evening, was closely monitored.  He was
transferred to the Surgical Intensive Care Unit.

Another set of laboratories were sent.  Blood cultures and
urine cultures from earlier that day were followed up.  His
antibiotics were changed to Zosyn and Clindamycin.

While in the Intensive Care Unit, his Clindamycin was then
switched to Flagyl, given that the patient may have been
infected with Clostridium difficile.

It was unclear as to the exact source of the patient's septic
picture.  His blood cultures had no growth to date.  His
urine cultures were negative.  CT scan was done of the
abdomen as well.  There were no signs of an abscess.  Stool
cultures were negative.

Given that the patient's white blood cell count continued to
be elevated, he was then started on Fluconazole empirically,
given that he may have some sort of fungemia.

While in the Surgical Intensive Care Unit, the patient
remained afebrile, and his vital signs improved.  His blood
pressure normalized with fluids.  Chest x-ray revealed
bibasilar opacities.

Over the next several days, the patient's renal function
significantly improved as well.  Throughout the rest of his
hospital stay, the creatinine trended downward and eventually
reached normal range.

Given that the patient was stable in the Surgical Intensive
Care Unit, he was transferred to the floor after several
days.

The patient's ostomy output continued to be large.  He was
continued on cc/cc of replacement.  His electrolytes were
repleted, and he was started on total parenteral nutrition.

The patient's orientation had significantly improved in the
latter part of his Intensive Care Unit stay.  While on the
floor, the patient remained oriented times three, and his
mental status was well within normal range.

The patient's diet was gradually advanced while he remained
on the TPN.  His labs were closely monitored daily.  He was
continued on Zosyn, Flagyl, and Fluconazole.

The Renal Service continued to follow the patient after he
had been transferred to the floor.

The patient's NG tube was pulled several days after he had
been transferred back to the floor, given that the output had
decreased.  His staples were removed, and Steri-Strips were
placed over his incision, which was clean, dry, and intact.

On postoperative day #15, the patient was placed on Imodium
to slow down his ostomy output, to which responded.

By postoperative day #18, the patient remained stable, and it
was felt that the patient could be discharged to a
rehabilitation facility within the next few days.  The
patient was tolerating a regular diet.  He was ambulating
without much discomfort.  His ostomy output had been within
normal range after being placed on Imodium.  He was afebrile,
and his vital signs were stable.  He had adequate urine
output, and his renal function had normalized.

His Zosyn and Flagyl were discontinued on postoperative day
#18.  He was continued on the Fluconazole.

Any additions to the [**Hospital 228**] hospital course after this
discharge summary has been dictated, will be added at a later
time.

DISCHARGE STATUS:  Rehabilitation facility.

CONDITION ON DISCHARGE:  Stable.

DISCHARGE DIAGNOSIS:
1.  Status post low anterior resection with ileostomy
placement for colonic fistula.
2.  Acute renal failure.
3.  Sepsis.
4.  Empiric treatment for fungemias.

DISCHARGE INSTRUCTIONS:  The patient was instructed to call
his doctor or return to the Emergency Room for any increased
pain, vomiting, fevers, chills, pus or drainage from the
incision site, malfunctioning ostomy, or other worrisome
symptoms.

FOLLOW-UP:  He was told to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1888**]
within two weeks after his discharge.

DISCHARGE MEDICATIONS:  Pantoprazole 40 mg p.o. q.d., Vicodin
5/500 mg [**12-4**] tab p.o. q.4-6 hours p.r.n. pain, Fluconazole
200 mg p.o. q.d., the patient was told to resume all of his
prehospitalization medications.




                            [**Last Name (NamePattern4) 1889**], M.D.  [**MD Number(1) 1890**]

Dictated By:[**Name8 (MD) 4955**]
MEDQUIST36

D:  [**2106-3-1**]  11:55
T:  [**2106-3-1**]  12:18
JOB#:  [**Job Number **]


Name:  [**Known lastname **], [**Known firstname 17790**]                       Unit No:  [**Numeric Identifier 17791**]

Admission Date:  [**2106-2-11**]     Discharge Date:  [**2106-3-5**]

Date of Birth:   [**2028-2-20**]     Sex:  M

Service:

ADDENDUM:  This is an Addendum to a prior dictated Discharge
Summary with job number [**Job Number **].

From the prior dictated Discharge Summary, the patient was
discharged on [**2106-3-5**].  The patient's event included a
slightly elevated white blood cell count around 15 to 17.
Given the patient's elevated white blood cell count, the
patient was not discharged to a rehabilitation facility at
that time.  Instead, he was monitored in the hospital for a
few more days.  The patient was pan-cultured, and all
cultures were negative.

A computed tomography scan of his abdomen was repeated.  The
computed tomography scan was negative for any abscess or
obstruction.

The patient's white blood cell count was monitored daily.
His white blood cell count slowly normalized over a period of
three days.  The patient remained asymptomatic and had
adequate ostomy output.

Given that the patient was afebrile and his vital signs were
stable and was asymptomatic, it was thought that the patient
could be discharged home on postoperative day 22.  The
patient refused to be sent to a rehabilitation facility;
although that had been highly recommended.  He was seen by
Physical Therapy who cleared him for discharge on the day of
his discharge.  He was set up to have home physical therapy
as well as visiting nurses to check his wound and ostomy.
The patient was discharged to home in good condition.

The patient was not discharged home on fluconazole given that
he had finished his course.  He was only sent out on
pantoprazole and Vicodin.  He was told to resume his pre
hospitalization medications.  The patient was also instructed
to follow up with Dr. [**First Name4 (NamePattern1) 255**] [**Last Name (NamePattern1) **] in two to three weeks.





                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 17792**], M.D.

Dictated By:[**Name8 (MD) **]

MEDQUIST36

D:  [**2106-3-5**]  16:34
T:  [**2106-3-6**]  04:19
JOB#:  [**Job Number 17793**]
{'Fistula of intestine, excluding rectum and anus,Unspecified septicemia,Severe sepsis,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Subendocardial infarction, initial episode of care,Paralytic ileus'}


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: This is a 77-year-old male who
recently had an episode of diverticulitis with an abscess and
fistula to involve penile prosthesis.  The patient had the
penile prosthetic devise removed.  He was left a colonic
fistula from the colon to the scrotum.  There was a
significant amount of stool drainage every day, approximately
less than 100 cc, but persistent.  The patient was seen by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1888**] and was counseled regarding surgery.

MEDICAL HISTORY: 1.  Hypertension.  2.  Hyperlipidemia.
3.  History of prostate carcinoma.

MEDICATION ON ADMISSION: Celebrex 100 mg p.o. b.i.d.,
Verapamil 240 mg p.o. q.d., Prilosec 20 mg p.o. q.d., Lipitor
10 mg  p.o. q.d., Aspirin 325 mg p.o. q.d., Ziac, Celexa 20
mg p.o. q.d.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Fistula of intestine, excluding rectum and anus,Unspecified septicemia,Severe sepsis,Acute kidney failure, unspecified,Congestive heart failure, unspecified,Subendocardial infarction, initial episode of care,Paralytic ileus'}
