CHIEF COMPLAINT: Left lower extremity pain

PRESENT ILLNESS: 26F w/ UC s/p single incision laparoscopic total
proctocolectomy with ileal pouch-anal anastamosis and diverting
loop ileostomy [**2195-8-27**] and multiple complications which resulted
in a prolonged (~3month) hospital stay presents with new L-sided
DVT.  We are consulted for management of the new DVT.  Of note
during her last hospitalization she was diagnosed with a RLE
DVT,
and due to upcoming surgery, an IVC filter was placed.  Since
that time she presented to an outpatient Hematologist to find
that she was a heterozygote for Factor V Leiden, and over this
past weekend she noted pain in her left anterior thigh.
Concerned over her hypercoagulable results and thigh pain, the
hematologist referred her for a BLE U/S, demonstrating a DVT
from
the L CFV to the calf.  Notably the patient is without
phlegmasia, has minimal pain, and is tolerating her ADL's
without
much pain.

MEDICAL HISTORY: PMH: Ulcerative colitis s/p single incision laparoscopic total
proctocolectomy with ileal pouch-anal anastamosis and diverting
loop ileostomy [**2195-8-27**]; DVT of right superficial
femoral-popliteal vein [**8-14**]; Factor V Leiden heterozygous

MEDICATION ON ADMISSION: CYCLOBENZAPRINE -  (Prescribed by Other Provider) - 10 mg Tablet
- 1 Tablet(s) by mouth once a day as needed for pain
HYDROCORTISONE ACETATE -  (Prescribed by Other Provider) - 30 mg
Suppository - 1 rectally at bedtime prn
LIDOCAINE [LIDODERM] -  (Prescribed by Other Provider) - 5 %
(700
mg/patch) Adhesive Patch, Medicated - 1 - 2 patches Topical once
a day applied to back Patch can stay in place for 12 hours and
should be removed for 12 hours
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for pain
PANTOPRAZOLE -  (Prescribed by Other Provider) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
PROPRANOLOL -  (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth 1 twice a day
VALGANCICLOVIR [VALCYTE] -  (Prescribed by Other Provider) - 450
mg Tablet - 2 Tablet(s) by mouth daily
ZOLPIDEM - 10 mg Tablet - One Tablet(s) by mouth at bedtime as
needed for sleep. (Fill if unable to fill prescription for
Ambien
CR)
ZOLPIDEM [AMBIEN CR] - 12.5 mg Tablet, Multiphasic Release - One
Tablet(s) by mouth at bedtime.

ALLERGIES: Cetacaine Anesthetic

PHYSICAL EXAM: Gen - tall, thin female in NAD
Pulm - CTAB
CV - Tachy rr, no m/g/r
Abd - +BS, soft, NTND, ostomy with flatus and stool
Extrem - RLE warm, +AT/PT, without swelling, LLE warm, +AT/PT,
without swelling, venopuncture site c/d/i

FAMILY HISTORY: Mother with [**Name2 (NI) **] s/p colectomy at age 33, brother with [**Name2 (NI) **]
relatively well-controlled. Maternal aunt with rheumatoid
arthritis. No colon ca.

SOCIAL HISTORY: Originally from [**State 33977**], recently an MBA grad student at BU.
Denies tobacco.  Social EtOH.
Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Primary hypercoagulable state,Precipitous drop in hematocrit,Ulcerative colitis, unspecified,Compression of vein,Attention to ileostomy,Other decreased white blood cell count,Antiviral drugs causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Hemorrhage complicating a procedure,Long-term (current) use of anticoagulants
Ac DVT/emb prox low ext,Prim hypercoagulable st,Drop, hematocrit, precip,Ulceratve colitis unspcf,Compression of vein,Atten to ileostomy,Decreased WBC count NEC,Adv eff antiviral drugs,Cardiac dysrhythmias NEC,Hemorrhage complic proc,Long-term use anticoagul
Admission Date:  [**2195-11-19**]              Discharge Date:   [**2195-11-25**]

Date of Birth:  [**2169-8-12**]             Sex:   F

Service: SURGERY

Allergies:
Cetacaine Anesthetic

Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Left lower extremity pain

Major Surgical or Invasive Procedure:
Thrombolysis of Left Lower Extremity Deep Vein Thrombosis

1. Ultrasound-guided puncture of left common femoral vein.
2. Advancement of catheter to inferior vena cava
    bifurcation.
3. Inferior venacavogram.
4. Serial venacavogram of left proximal lower extremity.
5. Stent placement at left common iliac vein, left external
    iliac vein.
6. AngioJet mechanical and tissue plasminogen activator-
    based thrombolysis of left common iliac vein, left
    external iliac vein and bifurcation of inferior vena
    cava.


History of Present Illness:
26F w/ UC s/p single incision laparoscopic total
proctocolectomy with ileal pouch-anal anastamosis and diverting
loop ileostomy [**2195-8-27**] and multiple complications which resulted
in a prolonged (~3month) hospital stay presents with new L-sided
DVT.  We are consulted for management of the new DVT.  Of note
during her last hospitalization she was diagnosed with a RLE
DVT,
and due to upcoming surgery, an IVC filter was placed.  Since
that time she presented to an outpatient Hematologist to find
that she was a heterozygote for Factor V Leiden, and over this
past weekend she noted pain in her left anterior thigh.
Concerned over her hypercoagulable results and thigh pain, the
hematologist referred her for a BLE U/S, demonstrating a DVT
from
the L CFV to the calf.  Notably the patient is without
phlegmasia, has minimal pain, and is tolerating her ADL's
without
much pain.


Past Medical History:
PMH: Ulcerative colitis s/p single incision laparoscopic total
proctocolectomy with ileal pouch-anal anastamosis and diverting
loop ileostomy [**2195-8-27**]; DVT of right superficial
femoral-popliteal vein [**8-14**]; Factor V Leiden heterozygous

PSH: as above; IVC filter placement [**8-14**]

Social History:
Originally from [**State 33977**], recently an MBA grad student at BU.
Denies tobacco.  Social EtOH.


Family History:
Mother with [**Name2 (NI) **] s/p colectomy at age 33, brother with [**Name2 (NI) **]
relatively well-controlled. Maternal aunt with rheumatoid
arthritis. No colon ca.


Physical Exam:
Gen - tall, thin female in NAD
Pulm - CTAB
CV - Tachy rr, no m/g/r
Abd - +BS, soft, NTND, ostomy with flatus and stool
Extrem - RLE warm, +AT/PT, without swelling, LLE warm, +AT/PT,
without swelling, venopuncture site c/d/i

Pertinent Results:
[**2195-11-19**] WBC-7.7  Hct-32.6*
[**2195-11-20**] WBC-5.8  Hct-24.0*
[**2195-11-21**] Hct-28.0*
[**2195-11-22**] WBC-4.0  Hct-27.0*
[**2195-11-23**] WBC-2.7* Hct-25.1*
[**2195-11-24**] WBC-2.9* Hct-26.1*

[**2195-11-24**] Immunology (CMV) CMV Viral Load-PENDING

[**2195-11-19**] Duplex of lower extremities
IMPRESSION:
1. Unremarkable venous Doppler right lower extremity.
2. Extensive deep vein thrombosis involving the entire left
lower extremity
to the level of the common femoral veins.


Brief Hospital Course:
The patient was admitted to the Colorectal surgery service on
[**2195-11-19**] with an extensive left lower extremity DVT. She was
transferred to the [**Date Range **] service on HD 2 and underwent stent
placement and thrombolysis of the clot. The patient tolerated
the procedure well. Post operatively she continued thrombolysis
with TPA for 6 hours and was placed on a heparin drip for
further anticoagulation. Because of a Hct drop during the
procedure the patient was transfused two units of PRBC's and had
an apropriate rise in Hct. On POD 1 she was switched to lovenox
and transferred back to the Colorectal service because of mild
bleeding from her ostomy site.

Neuro: Post-operatively, the patient received Dilaudid PO, and a
lidocaine patch with good effect and adequate pain control.

CV: The patient was tachycardic throughout her hospitalization.
She was in the 110's to 120's when lying down and could go up to
the 150's with ambulation. A cardiology consult was placed and
an Echo was recommended to evaluate for a PE or any congenital
abnormalities. The Echo was unremarkable and the cardiologist
mentioned that her tachycardia is likely in response to her
prolonged illness, acute issues and deconditioning and that this
requiress further treatment of her underlying illness.

Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.

GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced on POD 1, which
was tolerated well. She was briefly made NPO during POD 2 when
she had mild bleeding from her ostomy, which resolved on its
own. She was made NPO for a possible scope by GI. Because the
bleeding resolved, GI decided not to scope her and instead
follow her Hct, and trend her LFT's which trended down
throughout this admission. Intake and output were closely
monitored.

ID: Post-operatively, the patient did not require antibiotics.
The patient's temperature was closely watched for signs of
infection. She did have a decreased WBC count this admission and
an ID consult was obtained. Dr [**Last Name (STitle) 2148**] thought that her
decreasing WBC count may be due to prolonged administration of
Valsyte. On POD 3, the Valsyte was stopped and her WBC was
monitored for 48 hours. Her WBC count [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 87477**]. Because
she had been treated for over a month with the medicaiton it was
though that she had an adequate duration of treatment. A CMV
viral load was obtained during this hospitalization. It was not
back at the time of discharge.

Prophylaxis: The patient received Plavix and Lovenox post
operatively. Given her history of Factor V Leiden, and multiple
DVT's, she will likely need long term anticoagulation. She will
continue these medications for the duration recommended by the
[**Last Name (NamePattern1) 1106**] surgery team and will follow up with them in one
month's time. She was encouraged to get up and ambulate as early
as possible.

At the time of discharge on POD 5, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.

Medications on Admission:
CYCLOBENZAPRINE -  (Prescribed by Other Provider) - 10 mg Tablet
- 1 Tablet(s) by mouth once a day as needed for pain
HYDROCORTISONE ACETATE -  (Prescribed by Other Provider) - 30 mg
Suppository - 1 rectally at bedtime prn
LIDOCAINE [LIDODERM] -  (Prescribed by Other Provider) - 5 %
(700
mg/patch) Adhesive Patch, Medicated - 1 - 2 patches Topical once
a day applied to back Patch can stay in place for 12 hours and
should be removed for 12 hours
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for pain
PANTOPRAZOLE -  (Prescribed by Other Provider) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
PROPRANOLOL -  (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth 1 twice a day
VALGANCICLOVIR [VALCYTE] -  (Prescribed by Other Provider) - 450
mg Tablet - 2 Tablet(s) by mouth daily
ZOLPIDEM - 10 mg Tablet - One Tablet(s) by mouth at bedtime as
needed for sleep. (Fill if unable to fill prescription for
Ambien
CR)
ZOLPIDEM [AMBIEN CR] - 12.5 mg Tablet, Multiphasic Release - One
Tablet(s) by mouth at bedtime.

Medications - OTC
ACETAMINOPHEN -  (Prescribed by Other Provider) - 500 mg Tablet
-
2 Tablet(s) by mouth every 8 hours as needed for pain
CALCIUM CARBONATE -  (Prescribed by Other Provider) - Dosage
uncertain
LOPERAMIDE -  (Prescribed by Other Provider) - 1 mg/5 mL Liquid
-
5 - 10 ml by mouth 3 times a day


Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for Pain for 5 days: Please do not drive or
drink alcohol while taking this medication.
Disp:*40 Tablet(s)* Refills:*0*
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for Pain for 2 weeks.
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0*
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please take for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
4. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1)  Subcutaneous
Q12H (every 12 hours) for 1 months.
Disp:*21 * Refills:*0*
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*0*
6. trazodone 50 mg Tablet Sig: .[**4-4**] Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
7. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO
every eight (8) hours as needed for pain for 2 weeks.
Disp:*0 Tablet(s)* Refills:*0*
8. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO once a
day as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
9. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO four times a
day.
10. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (TU) for 2 months.
Disp:*8 Capsule(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Left common iliac vein deep venous thrombosis.


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted to the hospital with a large vein thrombosis.
You required thrombolysis on this clot while admitted. You will
need to continue anticoagulation to prevent a recurrent clot.
You have follow-up appointments with Dr. [**Last Name (STitle) 3407**] made as written
below. You will need to continue your plavix and lovenox for 30
more days. Please monitor the puncture site on his leg for
bleeding or increased bruising, call Dr. [**Last Name (STitle) 3407**] or Dr. [**Last Name (STitle) 4488**]
office if you have any concerns or questions or go to the
emergency room if the following symptoms are severe: increased
swelling, increased pain, numbness in the leg, bluish/purple
coloring in the leg, or decreased sensation. You should keep
your left leg ace wrapped from foot to thigh or wear a thigh
high compression stalking until your follow-up appointment with
Dr. [**Last Name (STitle) 3407**]. Please avoid lifting anything greater than 10 lbs
for the next 5 days. You will need to be on anticoagulation for
the next year, this will be either be lovenox on coumadin with a
baby aspirin and will be decided with Dr. [**Last Name (STitle) 87478**] and [**Doctor Last Name 2148**]. If
you develop any rectal spotting of blood please call Dr. [**Last Name (STitle) 4488**]
office for advice, if the bleeding is severe go to the emergency
room. You have a supply of lovenox at home from previous
prescriptions, as  the medication is so expensive you may use
these syringes but you are now taking 60mg and you will need to
waste the lovenox to the 0.6 line. I am giving you an
prescription to make up for the 10 days you are short, with this
prescription you will not need to waste. If you have any
problems with this please call the office for a new
prescription. Please check the expiration date on the lovenox
syringes you are using at home prior to use.

You no longer need to that the valgancyclovir for CMV treatment.
You developed a low white blood cell count from this medication.
Your most recent count is 2.8. You will see Dr. [**Last Name (STitle) 2148**] in
clinic next thursday for a lab draw to check your white blood
cell count. Please see the appointment time listed below. He
will also monitor the lab values for your blood while on the
lovenox. You will also be seeing him for your hematology needs.

While you were here you were also seen by cardiology to evaluate
your tachycaardia you have developed since your surgery. You had
an echocardiogram which was normal expcept for a small amount of
fluis around your heart which the cardiology department thinks
is not [**Last Name **] problem and that your tachycardia will improve as you
become more conditioned. They believe the tachycardia is related
to deconditioning. Please call the office if you feel as though
you have worsening shortness of breath, chest pain, worsening
fast heart rate that does not return to normal with rest.
Continue to Monitor

Please continue to monitor your ileostomy output and take
immmodium as needed. Call the office with any issues with your
ileostomy. Please continue to change the dressing on your
abdomen daily, apply a dry sterile gauze to the [**Last Name **].

Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication.  Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.  Avoid lifting
weights greater than [**4-13**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.

You should follow the directions from your GI doctor about the
vitamin D, you only need to take the capsule 1 time a week for 8
weeks and then preceed as you were instructed by Dr. [**Last Name (STitle) 6925**].

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2195-12-3**] 11:00, infectious disease/hematology, lab
(white blood cell count and PT check) at this appointment.

Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2195-12-25**]
8:00

Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2195-12-25**]
8:30

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2195-12-25**] 9:00

Please call Dr[**Doctor Last Name **] office for a follow up appointment
following your visits with the [**Doctor Last Name 1106**] surgeons.



Completed by:[**2195-11-25**]
{'Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Primary hypercoagulable state,Precipitous drop in hematocrit,Ulcerative colitis, unspecified,Compression of vein,Attention to ileostomy,Other decreased white blood cell count,Antiviral drugs causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Hemorrhage complicating a procedure,Long-term (current) use of anticoagulants'}


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: Left lower extremity pain

PRESENT ILLNESS: 26F w/ UC s/p single incision laparoscopic total
proctocolectomy with ileal pouch-anal anastamosis and diverting
loop ileostomy [**2195-8-27**] and multiple complications which resulted
in a prolonged (~3month) hospital stay presents with new L-sided
DVT.  We are consulted for management of the new DVT.  Of note
during her last hospitalization she was diagnosed with a RLE
DVT,
and due to upcoming surgery, an IVC filter was placed.  Since
that time she presented to an outpatient Hematologist to find
that she was a heterozygote for Factor V Leiden, and over this
past weekend she noted pain in her left anterior thigh.
Concerned over her hypercoagulable results and thigh pain, the
hematologist referred her for a BLE U/S, demonstrating a DVT
from
the L CFV to the calf.  Notably the patient is without
phlegmasia, has minimal pain, and is tolerating her ADL's
without
much pain.

MEDICAL HISTORY: PMH: Ulcerative colitis s/p single incision laparoscopic total
proctocolectomy with ileal pouch-anal anastamosis and diverting
loop ileostomy [**2195-8-27**]; DVT of right superficial
femoral-popliteal vein [**8-14**]; Factor V Leiden heterozygous

MEDICATION ON ADMISSION: CYCLOBENZAPRINE -  (Prescribed by Other Provider) - 10 mg Tablet
- 1 Tablet(s) by mouth once a day as needed for pain
HYDROCORTISONE ACETATE -  (Prescribed by Other Provider) - 30 mg
Suppository - 1 rectally at bedtime prn
LIDOCAINE [LIDODERM] -  (Prescribed by Other Provider) - 5 %
(700
mg/patch) Adhesive Patch, Medicated - 1 - 2 patches Topical once
a day applied to back Patch can stay in place for 12 hours and
should be removed for 12 hours
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for pain
PANTOPRAZOLE -  (Prescribed by Other Provider) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
PROPRANOLOL -  (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth 1 twice a day
VALGANCICLOVIR [VALCYTE] -  (Prescribed by Other Provider) - 450
mg Tablet - 2 Tablet(s) by mouth daily
ZOLPIDEM - 10 mg Tablet - One Tablet(s) by mouth at bedtime as
needed for sleep. (Fill if unable to fill prescription for
Ambien
CR)
ZOLPIDEM [AMBIEN CR] - 12.5 mg Tablet, Multiphasic Release - One
Tablet(s) by mouth at bedtime.

ALLERGIES: Cetacaine Anesthetic

PHYSICAL EXAM: Gen - tall, thin female in NAD
Pulm - CTAB
CV - Tachy rr, no m/g/r
Abd - +BS, soft, NTND, ostomy with flatus and stool
Extrem - RLE warm, +AT/PT, without swelling, LLE warm, +AT/PT,
without swelling, venopuncture site c/d/i

FAMILY HISTORY: Mother with [**Name2 (NI) **] s/p colectomy at age 33, brother with [**Name2 (NI) **]
relatively well-controlled. Maternal aunt with rheumatoid
arthritis. No colon ca.

SOCIAL HISTORY: Originally from [**State 33977**], recently an MBA grad student at BU.
Denies tobacco.  Social EtOH. 

### Response:
{'Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Primary hypercoagulable state,Precipitous drop in hematocrit,Ulcerative colitis, unspecified,Compression of vein,Attention to ileostomy,Other decreased white blood cell count,Antiviral drugs causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Hemorrhage complicating a procedure,Long-term (current) use of anticoagulants'}
