CHIEF COMPLAINT: hypotension

PRESENT ILLNESS: 75 yo M with Crohn's disease on chronic daily Prednisone and
Azathioprine, s/p small bowel resections X 4, perianal fistula,
diverticulitis, GI bleeding, CAD, AFib on Coumadin, esophageal
stricture and recent catheter-associated MSSA bacteremia
currently at Rehab presenting with weakness, fever, and
hypotension.
.
The patient was admitted from [**Date range (3) 58552**] for a contained
bowel perforation, which was medically managed with
Cipro/Flagyl. He developed a septic thrombus at the site of RIJ
CVC placed for TPN. Blood cultures grew MSSA, TTE & TEE were
negative for endocarditis, and the patient was d/c on 6 weeks of
Nafcillin (only completed 4).
Yesterday ([**2181-4-27**]) he spiked a fever to 104 at his rehab
facility
He was started on Vancomycin, Zosyn, and Levaquin.
.
In the ED, initial vs were: 96.6, 116, 75/47, 98% 2L NC. Labs
were notable for Na 130, Cr 1.7 (BL 1.3). White count was 7.7
and lactate 1.6. L PICC line was pulled with tip sent for cx.
Blood and urine cultures also sent. Left IJ was placed and Pt
was given IVF (4L) and started on Levophed (0.1). CXR showed
bibasilar opacities, likely atelectasis. CT C/A/P revealed focal
free air (similar to prior scan). ACS was consulted and
recommended admission to MICU, serial abd exams, trending of lab
markers, and strict NPO given that the Pt's abdominal exam was
unremarkable. He was given 100 mg of IV Hydrocortisone (out of
concern for AI), Micofungin (out of concern for fungal pathogens
[**2-21**] TPN), and Vanco/Levaquin/Zosyn.
.
On admission to the [**Hospital Unit Name 153**], he was sleepy, but arousable and
answering questions appropriately. He denied any localizing
symptoms of infection (no HA, dyspnea, cough, N/V, abd pain,
dysuria, rash) or cardiac disease. His CVP was 4 and he was
given an additional 2L NS bolus with improvement to 12.
.
Review of sytems: as above
(+) Per HPI, + diarrhea (chronic)
(-) HA, seizure, sore throat, chest pain, palpitations, dyspnea,
cough, nausea, vomiting, dysuria, rash, leg swelling

MEDICAL HISTORY: -Crohns disease s/p 3 small bowel resections
-Hx of ileocectomy
-Hx of diverticular perforation vs jejunal perforation likely
r/t
Crohns flare s/p ex-lap complicated by MI (in past)
-CAD
-Perianal Fistulas
-Diverticulitis
-Colonic polyp
-Afib rate controlled, on Coumadin
-HTN
-CRI
-Hx of GIB [**2-21**] Coumadin ([**2-/2180**])
-Hx of DVT in RUE [**2175**]
-Hx of PNA
-Chronic hip and back pain d/t bilateral AVN of femoral head
-Gout
-Hx of MRSA and VRE

MEDICATION ON ADMISSION: Azathioprine 50 mg Tab Oral 1 Tablet(s) Once Daily
-Prednisone 20 mg Tab Oral 1 Tablet(s) Once Daily (to be tapered
to 10 on [**5-2**])
-Pantoprazole 40 mg Tab, Delayed Release Oral 1 Tablet Once
Daily
-Mesalamine Powder Misc 1 Powder(s) Four times daily, 1,00 mg
-Lidocaine- Unknown Strength 1 Patch, Medicated(s) Every 6-8 hr

ALLERGIES: oxycodone-acetaminophen / hydrocodone-acetaminophen

PHYSICAL EXAM: Vitals: 97.5, 115, 157/100, 17, 99% on RA
General: elderly, well-nourished, sleepy, arousable,
appropriate, oriented, no acute distress
HEENT: sclera anicteric, no conjunctival hemorrhage, dry MM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: tachycardic, irregular rhythm, S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: + foley
Ext: cool, no edema, + [**Male First Name (un) **] hose, distal pulses present and
symmetric, crusted ulceration with surrounding blue macule on R
foot 3rd toe, distal hyperpigmented macule on tip of R hallux

FAMILY HISTORY: Denies family history of IBD.

SOCIAL HISTORY: Patient is retired, widowed with five children and living with
his second wife. [**Name (NI) **] ambulates with the assistance of a walker at
home. His wife [**Name (NI) **] assists him with most ADLs prior to coming
to the hospital.  He denies use of tobacco, alcohol, illicit
drugs, or herbal medications.
Pt currently lives at [**Hospital3 **] since [**Month (only) 404**]. He denies
any current EtOH, tobacco or recreational drug use. Prior hx of
tobacco. He is able to ambulate with a walker.
Unspecified septicemia,Septic shock,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Regional enteritis of unspecified site,Aseptic necrosis of head and neck of femur,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Severe sepsis,Cardiac arrest,Anemia, unspecified,Long-term (current) use of steroids,Chronic kidney disease, unspecified,Gout, unspecified
Septicemia NOS,Septic shock,Acute kidney failure NOS,Hyposmolality,Regional enteritis NOS,Aseptic necrosis femur,Hy kid NOS w cr kid I-IV,Severe sepsis,Cardiac arrest,Anemia NOS,Long-term use steroids,Chronic kidney dis NOS,Gout NOS
Admission Date:  [**2181-4-28**]              Discharge Date:   [**2181-4-30**]

Date of Birth:  [**2105-12-29**]             Sex:   M

Service: MEDICINE

Allergies:
oxycodone-acetaminophen / hydrocodone-acetaminophen

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hypotension

Major Surgical or Invasive Procedure:
None

History of Present Illness:
75 yo M with Crohn's disease on chronic daily Prednisone and
Azathioprine, s/p small bowel resections X 4, perianal fistula,
diverticulitis, GI bleeding, CAD, AFib on Coumadin, esophageal
stricture and recent catheter-associated MSSA bacteremia
currently at Rehab presenting with weakness, fever, and
hypotension.
.
The patient was admitted from [**Date range (3) 58552**] for a contained
bowel perforation, which was medically managed with
Cipro/Flagyl. He developed a septic thrombus at the site of RIJ
CVC placed for TPN. Blood cultures grew MSSA, TTE & TEE were
negative for endocarditis, and the patient was d/c on 6 weeks of
Nafcillin (only completed 4).
Yesterday ([**2181-4-27**]) he spiked a fever to 104 at his rehab
facility
He was started on Vancomycin, Zosyn, and Levaquin.
.
In the ED, initial vs were: 96.6, 116, 75/47, 98% 2L NC. Labs
were notable for Na 130, Cr 1.7 (BL 1.3). White count was 7.7
and lactate 1.6. L PICC line was pulled with tip sent for cx.
Blood and urine cultures also sent. Left IJ was placed and Pt
was given IVF (4L) and started on Levophed (0.1). CXR showed
bibasilar opacities, likely atelectasis. CT C/A/P revealed focal
free air (similar to prior scan). ACS was consulted and
recommended admission to MICU, serial abd exams, trending of lab
markers, and strict NPO given that the Pt's abdominal exam was
unremarkable. He was given 100 mg of IV Hydrocortisone (out of
concern for AI), Micofungin (out of concern for fungal pathogens
[**2-21**] TPN), and Vanco/Levaquin/Zosyn.
.
On admission to the [**Hospital Unit Name 153**], he was sleepy, but arousable and
answering questions appropriately. He denied any localizing
symptoms of infection (no HA, dyspnea, cough, N/V, abd pain,
dysuria, rash) or cardiac disease. His CVP was 4 and he was
given an additional 2L NS bolus with improvement to 12.
.
Review of sytems: as above
(+) Per HPI, + diarrhea (chronic)
(-) HA, seizure, sore throat, chest pain, palpitations, dyspnea,
cough, nausea, vomiting, dysuria, rash, leg swelling


Past Medical History:
-Crohns disease s/p 3 small bowel resections
-Hx of ileocectomy
-Hx of diverticular perforation vs jejunal perforation likely
r/t
Crohns flare s/p ex-lap complicated by MI (in past)
-CAD
-Perianal Fistulas
-Diverticulitis
-Colonic polyp
-Afib rate controlled, on Coumadin
-HTN
-CRI
-Hx of GIB [**2-21**] Coumadin ([**2-/2180**])
-Hx of DVT in RUE [**2175**]
-Hx of PNA
-Chronic hip and back pain d/t bilateral AVN of femoral head
-Gout
-Hx of MRSA and VRE


Social History:
Patient is retired, widowed with five children and living with
his second wife. [**Name (NI) **] ambulates with the assistance of a walker at
home. His wife [**Name (NI) **] assists him with most ADLs prior to coming
to the hospital.  He denies use of tobacco, alcohol, illicit
drugs, or herbal medications.
Pt currently lives at [**Hospital3 **] since [**Month (only) 404**]. He denies
any current EtOH, tobacco or recreational drug use. Prior hx of
tobacco. He is able to ambulate with a walker.


Family History:
Denies family history of IBD.

Physical Exam:
Vitals: 97.5, 115, 157/100, 17, 99% on RA
General: elderly, well-nourished, sleepy, arousable,
appropriate, oriented, no acute distress
HEENT: sclera anicteric, no conjunctival hemorrhage, dry MM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: tachycardic, irregular rhythm, S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: + foley
Ext: cool, no edema, + [**Male First Name (un) **] hose, distal pulses present and
symmetric, crusted ulceration with surrounding blue macule on R
foot 3rd toe, distal hyperpigmented macule on tip of R hallux


Pertinent Results:
[**2181-4-28**] 06:50PM BLOOD WBC-7.7 RBC-3.09* Hgb-10.0* Hct-28.9*
MCV-93 MCH-32.3*# MCHC-34.6 RDW-16.4* Plt Ct-158#
[**2181-4-29**] 04:07AM BLOOD WBC-9.8 RBC-3.11* Hgb-9.5* Hct-29.9*
MCV-96 MCH-30.5 MCHC-31.7 RDW-16.4* Plt Ct-230
[**2181-4-29**] 09:47AM BLOOD WBC-13.1* RBC-2.99* Hgb-9.2* Hct-28.8*
MCV-96 MCH-30.8 MCHC-32.0 RDW-16.4* Plt Ct-270
[**2181-4-29**] 03:20PM BLOOD WBC-10.2 RBC-3.12* Hgb-9.5* Hct-31.2*
MCV-100* MCH-30.5 MCHC-30.5* RDW-16.3* Plt Ct-225
[**2181-4-28**] 06:50PM BLOOD Neuts-93.8* Lymphs-3.0* Monos-2.9 Eos-0.1
Baso-0.2
.
[**2181-4-28**] 06:50PM BLOOD PT-15.5* PTT-38.4* INR(PT)-1.4*
[**2181-4-29**] 04:07AM BLOOD PT-14.8* PTT-51.9* INR(PT)-1.3*
[**2181-4-29**] 06:30PM BLOOD PT-21.9* PTT-150* INR(PT)-2.1*
.
[**2181-4-28**] 06:50PM BLOOD Glucose-138* UreaN-55* Creat-1.7* Na-130*
K-4.8 Cl-94* HCO3-30 AnGap-11
[**2181-4-29**] 04:07AM BLOOD Glucose-250* UreaN-42* Creat-1.4* Na-131*
K-4.2 Cl-103 HCO3-18* AnGap-14
[**2181-4-29**] 06:30PM BLOOD Glucose-380* UreaN-43* Creat-1.5* Na-131*
K-4.8 Cl-105 HCO3-13* AnGap-18
.
[**2181-4-28**] 06:50PM BLOOD ALT-18 AST-16 LD(LDH)-214 AlkPhos-67
TotBili-0.2
[**2181-4-29**] 06:30PM BLOOD ALT-1122* AST-2277* AlkPhos-94 Amylase-57
TotBili-0.3
[**2181-4-29**] 08:35PM BLOOD ALT-2043* AST-4983* AlkPhos-112
TotBili-0.3
[**2181-4-29**] 06:30PM BLOOD Lipase-77*
[**2181-4-28**] 06:50PM BLOOD cTropnT-0.04*
[**2181-4-29**] 04:07AM BLOOD CK-MB-7 cTropnT-0.12*
[**2181-4-28**] 06:50PM BLOOD Albumin-2.0* Calcium-7.5* Phos-2.7 Mg-2.2
[**2181-4-29**] 04:07AM BLOOD Calcium-6.5* Phos-2.9 Mg-1.9
[**2181-4-29**] 06:30PM BLOOD Calcium-6.7* Phos-4.5# Mg-1.8
.
[**2181-4-29**] 12:25PM BLOOD Type-MIX pH-7.25*
[**2181-4-29**] 03:32PM BLOOD Type-ART pO2-72* pCO2-19* pH-7.25*
calTCO2-9* Base XS--16 Intubat-NOT INTUBA
[**2181-4-29**] 06:40PM BLOOD Type-ART Temp-35.8 O2 Flow-2 pO2-75*
pCO2-23* pH-7.42 calTCO2-15* Base XS--6 Intubat-NOT INTUBA
[**2181-4-30**] 01:00AM BLOOD Type-ART Temp-36.7 pO2-88 pCO2-28*
pH-7.06* calTCO2-8* Base XS--21
[**2181-4-28**] 06:59PM BLOOD Lactate-1.6
[**2181-4-29**] 06:10AM BLOOD Lactate-1.9
[**2181-4-29**] 03:32PM BLOOD Glucose-152* Lactate-6.6* Na-131* K-4.8
Cl-113*
[**2181-4-29**] 08:39PM BLOOD Lactate-6.0*
[**2181-4-29**] 06:40PM BLOOD freeCa-0.98*
.
[**2181-4-28**] 08:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018
[**2181-4-28**] 08:30PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2181-4-28**] 08:30PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
[**2181-4-29**] 12:04AM URINE Hours-RANDOM UreaN-863 Creat-51 Na-98
K-39 Cl-34
[**2181-4-29**] 12:04AM URINE Osmolal-561

IMAGING
CT abd/pelvis [**4-29**]
PENDING

CT chest/abd/pelvis [**4-28**]
IMPRESSION:
1. Extensive pneumatosis which was noted on [**2181-1-26**] has
worsened
since that and the most recent prior examination of [**2181-3-7**]. No
portal venous gas seen. Small associated foci of free air are
seen adjacent to the regions of pneumatosis.  Etiology is
uncertain but may include both those of ischemic bowel, as well
as benign including connective tissue disorder, infectious
enteritis, and in association with steroid use.
2. No intra-abdominal abscesses or fluid collections are noted.

3. Bibasilar tree-in-[**Male First Name (un) 239**] opacities and trace bilateral pleural
effusions.
Findings may represent infection or aspiration, less likely
atelectasis.
4. Cholelithiasis without evidence of cholecystitis.
5. Avascular necrosis and collapse of bilateral femoral heads.

Findings were initially discussed with Dr. [**First Name4 (NamePattern1) 14552**] [**Last Name (NamePattern1) 17597**] at 11:40
p.m. on [**2181-4-28**] in person. Updated findings were then
discussed with Dr. [**Last Name (STitle) 3450**] at 1:00 a.m. on [**2181-4-29**], and Dr.
[**Last Name (STitle) **] at 3:30pm on [**2181-4-29**].

CHest xray [**4-28**]
IMPRESSION: PICC line appears to be in appropriate position.
Basilar
atelectasis on the left. No acute intrathoracic process


Brief Hospital Course:
75 yo M with Hx of Crohn's complicated by multiple surgeries and
medically-managed perforation in [**1-30**], as well as septic RIJ
thrombus and MSSA bacteremia s/p 4 weeks of Nafcillin presenting
with fever to 104, weakness, and hypotension
.
# Hypotension: Patient presented to ED with BPs in the 70s, for
which a L IJ CVC was placed and he received resuscitation with
IVFs and was started on Levophed. Likely etiology was sepsis,
given high fever. He did not have a leukocytosis, but was on
chronic immunosuppressants. Possible sources included his
indwelling PICC, which was removed and tip sent for culture.
Also, pulmonary, given that his chest CT revealed ground glass
opacities. However, the most likely source was intra-abdominal.
CT A/P revealed intra-abdominal free air, concerning for
perforation. General Surgery was consulted in the ED and
recommended no surgical management, serial exams, and monitoring
of his lactate and WBC. He was admitted to the [**Hospital Unit Name 153**] and started
on broad antimicrobials, including double coverage for GNR and
fungal pathogens. He was also started on stress dosed steroids
for possible adrenal insufficiency. His pressures continued to
fall and he was bolused additional liters of IVFs to maintain
CVP >10 without improvement in urine output, which was minimal.
His lactate rose from normal value and peaked at 6. His liver
enzymes reflected shock liver. A bladder pressure was 13.
General Surgery was made aware, and recommended repeat CT A/P,
which showed unchanged pneumatosis of the small bowel.
Exploratory laparotomy was denied by the family, given the
patient's wishes. After further discussion with the family he
was made DNR/DNI, started on a morphine gtt for pain control,
and expired at 0134 with family at the bedside.
.
# Free Air on Abdominal Imaging: As described above. Likely a
chronic finding related to his multiple abdominal surgeries and
prior perforation. His exam was not initially consistent with
acute new perforation; however, he was on chronic steroids.
GSurgery consulted in ED who felt no surgical treatment was
warranted and provided the recs as stated above. He was kept
strict NPO. The rest of the details are as above under
"hypotension."
.
# Acute Kidney Injury: Likely pre-renal in etiology secondary to
febrile illness and hypotension. Urinalysis with small protein.
FeNa of 2%; however, repeat Cr after fluids showed improvement
to recent baseline (1.4). Slowly uptrending creatinine and
oliguria that evolved throughout the day was attributed to ATN
and hypotension.
.
# Hyponatremia: Given clinical history, likely hypovolemic
hyponatremia. However, urine electrolytes supported SIADH.
Repeat Na mildly improved with IV hydration.
.
# A Fib with RVR: Patient has a hx of chronic A Fib on
anticoagulation. Initial rapid rate to 130s was likely related
to volume depletion. IV Lopressor 5 mg was given once with
subsequent drop in BP, requiring the addition of Neo-Synephrine
for pressure support. Blood pressure was never stable enough for
additional attempt at nodal [**Doctor Last Name 360**] control. Troponins were
elevated at 0.04, likely secondary to demand ischemia. See above
for the progression of illness.
.
# Anticoagulation: The patient has a hx of septic thrombus and A
fib, for which he was anticoagulated (usually on Coumadin,
presented on Lovenox bridge given potential upcoming GI
endoscopy to evaluate esophageal stricture). He was continued on
heparin gtt with goal PTT 60-100. Hct remained stable.
.
# Anemia: Chronic, normocytic. Currently above baseline on
presentation, likely reflecting hemoconcentration. No signs of
active bleeding. Hct was trended. He did not require any blood
transfusions.
.
# Crohn's Disease:  He was continued on stress dose steroids and
IV azathioprine dose adjusted to his current creatinine
clearance. Mesalamine was held.
.
# Chronic Pain secondary to B/L AVN: He was continued on his
outpatient fentanyl patch and lidocaine, and started on Dilaudid
for breakthrough pain. Toward the end of his course, he was
changed to a morphine gtt for comfort prior to expiration.

Medications on Admission:
Azathioprine 50 mg Tab Oral 1 Tablet(s) Once Daily
-Prednisone 20 mg Tab Oral 1 Tablet(s) Once Daily (to be tapered
to 10 on [**5-2**])
-Pantoprazole 40 mg Tab, Delayed Release Oral 1 Tablet Once
Daily
-Mesalamine Powder Misc 1 Powder(s) Four times daily, 1,00 mg
-Lidocaine- Unknown Strength 1 Patch, Medicated(s) Every 6-8 hr

-Fentanyl 150 mcg/hr Transderm Patch Transdermal 1 Patch 72
hr(s) every 3 days
-Lovenox 80 mg subcut [**Hospital1 **] (Coumadin held for upcoming GI
endoscopy to evaluate esophageal stricture)
-Ultram 50 mg Tab Oral 2 Tablet(s) Every 4-6 hrs, as needed
-Ambien 5 mg Tab Oral 1 Tablet(s) Once Daily, as needed
-Levofloxacin - 1 Solution(s) 500mg iv every 24 hours
-Vancomycin 1,000 mg Intravenous 1 Recon Soln(s) Once Daily
-Zosyn 4.5 gram IV Solution Intravenous 1 Recon Soln(s) every
6-8 hrs


Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
Cardiac Arrest
Septic shock

Discharge Condition:
deceased

Discharge Instructions:
None

Followup Instructions:
None

                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Unspecified septicemia,Septic shock,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Regional enteritis of unspecified site,Aseptic necrosis of head and neck of femur,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Severe sepsis,Cardiac arrest,Anemia, unspecified,Long-term (current) use of steroids,Chronic kidney disease, unspecified,Gout, 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: hypotension

PRESENT ILLNESS: 75 yo M with Crohn's disease on chronic daily Prednisone and
Azathioprine, s/p small bowel resections X 4, perianal fistula,
diverticulitis, GI bleeding, CAD, AFib on Coumadin, esophageal
stricture and recent catheter-associated MSSA bacteremia
currently at Rehab presenting with weakness, fever, and
hypotension.
.
The patient was admitted from [**Date range (3) 58552**] for a contained
bowel perforation, which was medically managed with
Cipro/Flagyl. He developed a septic thrombus at the site of RIJ
CVC placed for TPN. Blood cultures grew MSSA, TTE & TEE were
negative for endocarditis, and the patient was d/c on 6 weeks of
Nafcillin (only completed 4).
Yesterday ([**2181-4-27**]) he spiked a fever to 104 at his rehab
facility
He was started on Vancomycin, Zosyn, and Levaquin.
.
In the ED, initial vs were: 96.6, 116, 75/47, 98% 2L NC. Labs
were notable for Na 130, Cr 1.7 (BL 1.3). White count was 7.7
and lactate 1.6. L PICC line was pulled with tip sent for cx.
Blood and urine cultures also sent. Left IJ was placed and Pt
was given IVF (4L) and started on Levophed (0.1). CXR showed
bibasilar opacities, likely atelectasis. CT C/A/P revealed focal
free air (similar to prior scan). ACS was consulted and
recommended admission to MICU, serial abd exams, trending of lab
markers, and strict NPO given that the Pt's abdominal exam was
unremarkable. He was given 100 mg of IV Hydrocortisone (out of
concern for AI), Micofungin (out of concern for fungal pathogens
[**2-21**] TPN), and Vanco/Levaquin/Zosyn.
.
On admission to the [**Hospital Unit Name 153**], he was sleepy, but arousable and
answering questions appropriately. He denied any localizing
symptoms of infection (no HA, dyspnea, cough, N/V, abd pain,
dysuria, rash) or cardiac disease. His CVP was 4 and he was
given an additional 2L NS bolus with improvement to 12.
.
Review of sytems: as above
(+) Per HPI, + diarrhea (chronic)
(-) HA, seizure, sore throat, chest pain, palpitations, dyspnea,
cough, nausea, vomiting, dysuria, rash, leg swelling

MEDICAL HISTORY: -Crohns disease s/p 3 small bowel resections
-Hx of ileocectomy
-Hx of diverticular perforation vs jejunal perforation likely
r/t
Crohns flare s/p ex-lap complicated by MI (in past)
-CAD
-Perianal Fistulas
-Diverticulitis
-Colonic polyp
-Afib rate controlled, on Coumadin
-HTN
-CRI
-Hx of GIB [**2-21**] Coumadin ([**2-/2180**])
-Hx of DVT in RUE [**2175**]
-Hx of PNA
-Chronic hip and back pain d/t bilateral AVN of femoral head
-Gout
-Hx of MRSA and VRE

MEDICATION ON ADMISSION: Azathioprine 50 mg Tab Oral 1 Tablet(s) Once Daily
-Prednisone 20 mg Tab Oral 1 Tablet(s) Once Daily (to be tapered
to 10 on [**5-2**])
-Pantoprazole 40 mg Tab, Delayed Release Oral 1 Tablet Once
Daily
-Mesalamine Powder Misc 1 Powder(s) Four times daily, 1,00 mg
-Lidocaine- Unknown Strength 1 Patch, Medicated(s) Every 6-8 hr

ALLERGIES: oxycodone-acetaminophen / hydrocodone-acetaminophen

PHYSICAL EXAM: Vitals: 97.5, 115, 157/100, 17, 99% on RA
General: elderly, well-nourished, sleepy, arousable,
appropriate, oriented, no acute distress
HEENT: sclera anicteric, no conjunctival hemorrhage, dry MM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: tachycardic, irregular rhythm, S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: + foley
Ext: cool, no edema, + [**Male First Name (un) **] hose, distal pulses present and
symmetric, crusted ulceration with surrounding blue macule on R
foot 3rd toe, distal hyperpigmented macule on tip of R hallux

FAMILY HISTORY: Denies family history of IBD.

SOCIAL HISTORY: Patient is retired, widowed with five children and living with
his second wife. [**Name (NI) **] ambulates with the assistance of a walker at
home. His wife [**Name (NI) **] assists him with most ADLs prior to coming
to the hospital.  He denies use of tobacco, alcohol, illicit
drugs, or herbal medications.
Pt currently lives at [**Hospital3 **] since [**Month (only) 404**]. He denies
any current EtOH, tobacco or recreational drug use. Prior hx of
tobacco. He is able to ambulate with a walker. 

### Response:
{'Unspecified septicemia,Septic shock,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Regional enteritis of unspecified site,Aseptic necrosis of head and neck of femur,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Severe sepsis,Cardiac arrest,Anemia, unspecified,Long-term (current) use of steroids,Chronic kidney disease, unspecified,Gout, unspecified'}
