CHIEF COMPLAINT: Toxic megacolon, Sepsis

PRESENT ILLNESS: Pt is a 73M well known to Dr. [**Last Name (STitle) **] who was transferred
to his care tonight from [**Hospital3 35813**] Center in RI.  He
presented there on on [**2131-2-18**] with weakness and lower abdominal
pain.  By report CT scan showed evidence of colitis.  Stool was
positive for C Diff. WBC was 44,000.  He was admitted, hydrated,
and started on PO vanco.

MEDICAL HISTORY: 1. HTN
2. perforated Diverticulitis [**6-/2125**] c/b sepsis, respiratory
failure, ARF, A Fib [**Hospital **] transferred from OSH to Dr.[**Name (NI) 1482**]
care after initial colectomy/[**Doctor Last Name 3379**].
3. s/p colectomy/Hartmann for perforated diverticulitis [**6-/2125**]
at
an OSH c/b intra-abdominal abscess treated by IR drain
4. s/p colostomy takedown/[**Doctor Last Name 3379**] reversal [**12/2125**] ([**Doctor Last Name **])
5. ?recurrent diverticulitis [**2128**]
6. SBO [**11/2129**] - managed non-operatively
7. ex-lap, small bowel resection and lysis of adhesions. [**4-/2130**]
([**Doctor Last Name **]) for recurrent SBO caused by an inflammatory mass
8. s/p left inguinal hernia repair
9. Prostate Ca
[**31**]. COPD
11. h/o CVA
hernia repair

MEDICATION ON ADMISSION: advair 500'', atenolol 25', ASA 325', Flomax 0.4'

ALLERGIES: Zosyn

PHYSICAL EXAM: Upon Admission:

FAMILY HISTORY: emphysema in his father and brain cancer in his mother

SOCIAL HISTORY: Lives with wife in [**Name (NI) **]. quit smoking 40+ years
Septicemia due to anaerobes,Acute respiratory failure,Intestinal infection due to Clostridium difficile,Septic shock,Acute kidney failure, unspecified,Acute vascular insufficiency of intestine,Acute posthemorrhagic anemia,Disruption of internal operation (surgical) wound,Candidiasis of mouth,Chronic airway obstruction, not elsewhere classified,Severe sepsis,Unspecified essential hypertension,Personal history of tobacco use,Atrial fibrillation,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Retention of urine, unspecified,Edema,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Peritoneal adhesions (postoperative) (postinfection)
Anaerobic septicemia,Acute respiratry failure,Int inf clstrdium dfcile,Septic shock,Acute kidney failure NOS,Ac vasc insuff intestine,Ac posthemorrhag anemia,Disrup internal op wound,Thrush,Chr airway obstruct NEC,Severe sepsis,Hypertension NOS,History of tobacco use,Atrial fibrillation,Abn react-external stoma,Retention urine NOS,Edema,Hx TIA/stroke w/o resid,Peritoneal adhesions
Admission Date:  [**2131-2-21**]              Discharge Date:   [**2131-3-8**]

Date of Birth:  [**2057-12-10**]             Sex:   M

Service: SURGERY

Allergies:
Zosyn

Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Toxic megacolon, Sepsis

Major Surgical or Invasive Procedure:
[**2-22**] Total abdominal colectomy, lysis of adhesions, and
ileostomy
PICC placement


History of Present Illness:
Pt is a 73M well known to Dr. [**Last Name (STitle) **] who was transferred
to his care tonight from [**Hospital3 35813**] Center in RI.  He
presented there on on [**2131-2-18**] with weakness and lower abdominal
pain.  By report CT scan showed evidence of colitis.  Stool was
positive for C Diff. WBC was 44,000.  He was admitted, hydrated,
and started on PO vanco.

No discharge summary was sent with him.  In speaking with the
outside physician, [**Name10 (NameIs) **] had improved after starting PO vanco.  His
WBC & diarrhea decreased.  He was tolerating diet and had
minimal
abdominal pain.  However, last night developed ARF and was
making
minimal urine with Cr newly elevated to 3.5.  Then today he
developed significant abdominal distension and SOB.  Over a
short
periord this afternoon he quickly decompensated becoming
hypotensive with respiratory distress.  He was transfered to the
ICU, intubated, had a central line placed, started on
vasopressors, and was given 3L IVF and meropenem/flagyl IV.
Arrangements were then made for transfer here.

Of note patient was also admitted to [**Hospital3 **] center w/
a
COPD exacerbation & PNA approx 2 weeks prior to this
presentation.  He has failed outpatient treatmend with
augmentin;
then received levofloxacin an as inpatient. It is unclear, but
he
may have been discharged home to complete a 14-day course of
Ampicillin.


Past Medical History:
1. HTN
2. perforated Diverticulitis [**6-/2125**] c/b sepsis, respiratory
failure, ARF, A Fib [**Hospital **] transferred from OSH to Dr.[**Name (NI) 1482**]
care after initial colectomy/[**Doctor Last Name 3379**].
3. s/p colectomy/Hartmann for perforated diverticulitis [**6-/2125**]
at
an OSH c/b intra-abdominal abscess treated by IR drain
4. s/p colostomy takedown/[**Doctor Last Name 3379**] reversal [**12/2125**] ([**Doctor Last Name **])
5. ?recurrent diverticulitis [**2128**]
6. SBO [**11/2129**] - managed non-operatively
7. ex-lap, small bowel resection and lysis of adhesions. [**4-/2130**]
([**Doctor Last Name **]) for recurrent SBO caused by an inflammatory mass
8. s/p left inguinal hernia repair
9. Prostate Ca
[**31**]. COPD
11. h/o CVA
hernia repair

Social History:
Lives with wife in [**Name (NI) **]. quit smoking 40+ years


Family History:
emphysema in his father and brain cancer in his mother

Physical Exam:
Upon Admission:

PE: Currently on Propofol and Levophed
VS: 97.8 101 95/48 19 97% CMV 0.5 500x16 +5
Intubated, sedated.  Upon arrival with sedation off, moved all
extremities, did not follow commands
No jaundice or icterus
breath sounds diminished B/L
Abd: healed midline scar. massively distended. tympanitic.
grimaces to light palpation
No LE edema

Upon Discharge:
VS: 99.9, 78, 128/62, 16, 93% RA
NAD
NCAT
RRR, S1S2
CTAB, minor wheezes
Soft, NTND, Ostomy is C/D/I. Staples are still in place and are
C/D/I.
There is a small defect at the inferior portion of the incision
site that is packed with saline soaked gauze. There is mild
erythema, but no induration. There is minor serous drainage. No
purulence.


Pertinent Results:
[**2131-2-21**] 08:19PM BLOOD WBC-10.1# RBC-4.49* Hgb-14.7 Hct-42.9
MCV-96 MCH-32.6* MCHC-34.2 RDW-13.2 Plt Ct-161
[**2131-2-22**] 02:03AM BLOOD WBC-10.8 RBC-4.15* Hgb-13.3* Hct-39.2*
MCV-95 MCH-32.2* MCHC-34.0 RDW-13.8 Plt Ct-180
[**2131-2-22**] 10:57AM BLOOD WBC-12.4* RBC-3.57* Hgb-11.7* Hct-34.8*
MCV-98 MCH-32.9* MCHC-33.8 RDW-13.2 Plt Ct-179
[**2131-2-22**] 04:19PM BLOOD WBC-7.4 RBC-3.22* Hgb-10.7* Hct-30.7*
MCV-96 MCH-33.4* MCHC-34.9 RDW-13.3 Plt Ct-136*
[**2131-2-22**] 09:33PM BLOOD WBC-8.6 RBC-2.82* Hgb-9.2* Hct-26.5*
MCV-94 MCH-32.6* MCHC-34.7 RDW-13.7 Plt Ct-139*
[**2131-2-23**] 02:07AM BLOOD WBC-10.0 RBC-2.89* Hgb-9.6* Hct-27.2*
MCV-94 MCH-33.2* MCHC-35.2* RDW-13.3 Plt Ct-151
[**2131-2-23**] 02:36PM BLOOD WBC-11.3* RBC-3.15* Hgb-10.2* Hct-29.0*
MCV-92 MCH-32.3* MCHC-35.2* RDW-14.0 Plt Ct-157
[**2131-2-24**] 01:59AM BLOOD WBC-11.2* RBC-2.95* Hgb-9.6* Hct-26.9*
MCV-91 MCH-32.6* MCHC-35.8* RDW-14.6 Plt Ct-141*
[**2131-2-25**] 01:22AM BLOOD WBC-14.3* RBC-3.04* Hgb-10.1* Hct-27.8*
MCV-91 MCH-33.2* MCHC-36.3* RDW-13.5 Plt Ct-200
[**2131-2-26**] 02:01AM BLOOD WBC-12.1* RBC-2.86* Hgb-9.7* Hct-26.6*
MCV-93 MCH-33.7* MCHC-36.3* RDW-13.6 Plt Ct-232
[**2131-2-27**] 01:57AM BLOOD WBC-14.0* RBC-3.00* Hgb-10.0* Hct-28.2*
MCV-94 MCH-33.2* MCHC-35.4* RDW-13.8 Plt Ct-262
[**2131-2-28**] 05:21AM BLOOD WBC-12.1* RBC-2.99* Hgb-9.4* Hct-28.5*
MCV-95 MCH-31.4 MCHC-33.0 RDW-13.8 Plt Ct-329
[**2131-3-1**] 06:25AM BLOOD WBC-12.3* RBC-2.90* Hgb-9.5* Hct-27.8*
MCV-96 MCH-32.6* MCHC-34.1 RDW-13.2 Plt Ct-342
[**2131-3-2**] 07:00AM BLOOD WBC-13.1* RBC-3.05* Hgb-9.6* Hct-29.2*
MCV-96 MCH-31.6 MCHC-32.9 RDW-13.3 Plt Ct-466*
[**2131-3-3**] 04:15AM BLOOD WBC-9.7 RBC-2.73* Hgb-8.5* Hct-25.7*
MCV-94 MCH-31.2 MCHC-33.2 RDW-13.4 Plt Ct-414
[**2131-3-4**] 04:38AM BLOOD WBC-8.0 RBC-2.52* Hgb-8.3* Hct-23.8*
MCV-95 MCH-32.8* MCHC-34.7 RDW-13.2 Plt Ct-425
[**2131-3-5**] 05:21AM BLOOD WBC-6.6 RBC-2.65* Hgb-8.6* Hct-25.2*
MCV-95 MCH-32.6* MCHC-34.4 RDW-13.4 Plt Ct-497*
[**2131-3-6**] 06:18AM BLOOD WBC-7.3 RBC-2.71* Hgb-8.7* Hct-25.6*
MCV-94 MCH-32.2* MCHC-34.1 RDW-13.2 Plt Ct-566*
[**2131-3-7**] 04:41AM BLOOD WBC-6.2 RBC-2.75* Hgb-8.7* Hct-25.7*
MCV-93 MCH-31.5 MCHC-33.8 RDW-13.3 Plt Ct-509*
[**2131-3-2**] 07:00AM BLOOD Neuts-89.6* Lymphs-8.0* Monos-1.4*
Eos-0.8 Baso-0.2
[**2131-3-5**] 05:21AM BLOOD Neuts-78.8* Lymphs-13.7* Monos-5.2
Eos-2.0 Baso-0.3
[**2131-2-21**] 08:19PM BLOOD PT-13.69* PTT-25.9 INR(PT)-1.2*
[**2131-2-22**] 02:03AM BLOOD PT-14.6* PTT-29.4 INR(PT)-1.3*
[**2131-2-22**] 10:57AM BLOOD PT-15.8* PTT-32.0 INR(PT)-1.4*
[**2131-2-22**] 04:19PM BLOOD Plt Ct-136*
[**2131-2-23**] 02:07AM BLOOD PT-15.9* PTT-34.4 INR(PT)-1.4*
[**2131-2-24**] 01:59AM BLOOD PT-15.5* PTT-33.7 INR(PT)-1.4*
[**2131-2-25**] 01:22AM BLOOD PT-16.5* PTT-34.1 INR(PT)-1.5*
[**2131-2-27**] 01:57AM BLOOD PT-20.1* PTT-51.8* INR(PT)-1.9*
[**2131-2-28**] 05:21AM BLOOD PT-19.1* PTT-35.3* INR(PT)-1.8*
[**2131-2-21**] 08:19PM BLOOD Glucose-128* UreaN-70* Creat-4.8*#
Na-131* K-4.3 Cl-99 HCO3-20* AnGap-16
[**2131-2-22**] 02:03AM BLOOD Glucose-119* UreaN-70* Creat-4.5* Na-131*
K-4.3 Cl-100 HCO3-18* AnGap-17
[**2131-2-22**] 10:57AM BLOOD Glucose-139* UreaN-61* Creat-4.1* Na-133
K-4.5 Cl-108 HCO3-18* AnGap-12
[**2131-2-22**] 04:19PM BLOOD Glucose-131* UreaN-63* Creat-4.1* Na-133
K-4.8 Cl-106 HCO3-17* AnGap-15
[**2131-2-22**] 11:29PM BLOOD Glucose-114* UreaN-60* Creat-3.8* Na-135
K-4.6 Cl-107 HCO3-19* AnGap-14
[**2131-2-23**] 02:07AM BLOOD Glucose-124* UreaN-63* Creat-3.8* Na-133
K-4.5 Cl-106 HCO3-18* AnGap-14
[**2131-2-23**] 02:36PM BLOOD Glucose-108* UreaN-60* Creat-3.2* Na-134
K-4.5 Cl-107 HCO3-17* AnGap-15
[**2131-2-24**] 01:59AM BLOOD Glucose-104 UreaN-63* Creat-2.9* Na-136
K-4.4 Cl-106 HCO3-20* AnGap-14
[**2131-2-24**] 03:07PM BLOOD Glucose-92 UreaN-57* Creat-2.1* Na-139
K-4.0 Cl-108 HCO3-21* AnGap-14
[**2131-2-25**] 05:52PM BLOOD Glucose-101 UreaN-45* Creat-1.2 Na-145
K-4.2 Cl-109* HCO3-27 AnGap-13
[**2131-2-26**] 02:01AM BLOOD Glucose-126* UreaN-41* Creat-1.1 Na-147*
K-4.1 Cl-113* HCO3-30 AnGap-8
[**2131-2-28**] 05:21AM BLOOD Glucose-132* UreaN-28* Creat-0.8 Na-143
K-4.3 Cl-107 HCO3-33* AnGap-7*
[**2131-3-1**] 06:25AM BLOOD Glucose-90 UreaN-26* Creat-0.9 Na-144
K-5.0 Cl-107 HCO3-31 AnGap-11
[**2131-3-2**] 07:00AM BLOOD Glucose-108* UreaN-28* Creat-1.0 Na-141
K-4.9 Cl-105 HCO3-28 AnGap-13
[**2131-3-3**] 04:15AM BLOOD Glucose-132* UreaN-25* Creat-0.9 Na-141
K-3.8 Cl-107 HCO3-29 AnGap-9
[**2131-3-4**] 04:38AM BLOOD Glucose-113* UreaN-23* Creat-0.8 Na-140
K-4.0 Cl-108 HCO3-29 AnGap-7*
[**2131-3-5**] 05:21AM BLOOD Glucose-114* UreaN-20 Creat-0.7 Na-138
K-4.0 Cl-107 HCO3-28 AnGap-7*
[**2131-3-6**] 06:18AM BLOOD Glucose-111* UreaN-17 Creat-0.8 Na-142
K-3.8 Cl-107 HCO3-28 AnGap-11
[**2131-3-7**] 04:41AM BLOOD Glucose-96 UreaN-16 Creat-0.7 Na-142
K-3.7 Cl-108 HCO3-26 AnGap-12
[**2131-2-21**] 08:19PM BLOOD ALT-26 AST-37 CK(CPK)-645* AlkPhos-73
TotBili-0.6
[**2131-2-22**] 02:03AM BLOOD ALT-30 AST-37 AlkPhos-75 TotBili-0.6
[**2131-2-22**] 11:29PM BLOOD CK(CPK)-274*
[**2131-2-23**] 08:03AM BLOOD CK(CPK)-329*
[**2131-2-23**] 05:21PM BLOOD CK(CPK)-265*
[**2131-2-27**] 01:57AM BLOOD ALT-29 AST-21 AlkPhos-54 TotBili-0.5
[**2131-2-21**] 08:19PM BLOOD CK-MB-32* MB Indx-5.0 cTropnT-0.02*
[**2131-2-22**] 11:29PM BLOOD CK-MB-10 MB Indx-3.6 cTropnT-0.04*
[**2131-2-23**] 08:03AM BLOOD CK-MB-7 cTropnT-0.03*
[**2131-2-23**] 05:21PM BLOOD CK-MB-5 cTropnT-0.03*
[**2131-2-21**] 08:19PM BLOOD Albumin-2.4* Calcium-7.4* Phos-7.1*#
Mg-3.2*
[**2131-2-22**] 10:57AM BLOOD Calcium-5.8* Phos-6.8* Mg-2.5
[**2131-2-22**] 11:29PM BLOOD Calcium-7.5* Phos-6.3* Mg-2.4
[**2131-2-24**] 01:59AM BLOOD Calcium-8.1* Phos-5.8* Mg-2.5
[**2131-2-25**] 01:22AM BLOOD Calcium-7.8* Phos-4.4 Mg-2.1
[**2131-2-26**] 02:01AM BLOOD Albumin-1.9* Calcium-7.5* Phos-3.9 Mg-1.9
[**2131-2-27**] 01:57AM BLOOD Albumin-1.9* Calcium-7.6* Phos-2.8 Mg-1.7
[**2131-3-1**] 06:25AM BLOOD Calcium-7.3* Phos-3.7 Mg-1.7
[**2131-3-4**] 04:38AM BLOOD Calcium-7.1* Phos-3.7 Mg-1.8
[**2131-3-5**] 05:21AM BLOOD Calcium-7.1* Phos-3.6 Mg-2.2
[**2131-3-6**] 06:18AM BLOOD Calcium-7.3* Phos-3.9 Mg-1.8
[**2131-3-7**] 04:41AM BLOOD Calcium-6.9* Phos-3.5 Mg-1.9
[**2131-2-24**] 07:59AM BLOOD Vanco-6.1*
[**2131-2-22**] 10:57AM BLOOD Cortsol-40.6*
[**2131-2-25**] 10:33AM BLOOD freeCa-1.09*

CT abd/pelvis [**2131-2-21**]:
1. High-grade bowel obstruction with transition point at the
descending
colon/sigmoid junction secondary to stricture at site of prior
inflammation.
2. Right lower lung ground-glass opacity is stable since [**2124**]
and does not
require followup.

CXR [**2-22**]:
No pulmonary edema. Bibasilar atelectasis and moderate left
pleural effusion.

CXR [**2-24**]:
FINDINGS: As compared to the previous radiograph, the monitoring
and support devices are in unchanged position, except for the
nasogastric tube that hasbeen slightly pulled back and could be
advanced by several centimeters. The extent of the pre-existing
left-sided pleural effusion is unchanged. Also unchanged is the
left retrocardiac atelectasis. On the right, the pre-existing
small pleural effusion has cleared, a small discoid atelectasis
persists at the right lung base. There is no evidence of focal
parenchymal opacities suggestive of pneumonia, no evidence of
overhydration.

CXR [**2-26**]:
The cardiomediastinal silhouette and hilar contours are normal,
the
lungs are clear. The elevated left hemidiaphragm is unchanged
since [**2124**].
Previously mentioned possible effusion and consolidation within
the left lung base are related to the elevated left
hemidiaphragm. There has been interval removal of endotracheal
tube, NG tube. The left subclavian central line is unchanged.


Brief Hospital Course:
The patient was transferred from an OSH. He arrived at [**Hospital1 18**] and
after a short period of supportive care with pressors and
antibiotics it was decided that he was clinically deteriorating
and was taken to the OR for total colectomy and end ileostomy.
He tolerated the procedure well and was taken to the SICU. He
remained in the ICU with supportive care. Major events and there
dates in the ICU:

[**2-21**]: resuscitation, intubation, Levophed, CT abd
[**2-22**]: OR, vasopressin added, [**Last Name (un) **], resuscitation, bicarb,
albumin, amio for RVR
[**2-23**]: Off Levo, esophageal balloon placed
[**2-24**]: Off vasopressin, esophageal balloon d/c'd, Lasix,
restarted amio for AF w/RVR, CPAP/PSV, ileostomy matured
[**2-25**]: extubated, Dilaudid PCA, Lasix gtt, started sips, started
PO Lopressor & amio, amio gtt d/c'd, [**Last Name (un) **] d/c'd
[**2-26**]: Nystatin S&S for thrush, d/c'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2830**], started cipro for
wound infection

The patient was then transferred to the floor on [**2131-2-27**]. On the
floor, he started tolerating a regular diet and PO pain
medications. However, on [**2-28**] his abdomen became more distended
and the patient became nauseous. He was reverted back to NPO
status. He was also noted to have some drainage from the lower
portion of his abdominal wound.

A PICC line was placed for TPN use and TPN was started on
[**2131-3-2**]. He began tolerating clear liquids again on [**3-4**], and then
a regular diet on [**3-5**]. TPN was discontinued on [**3-6**] as he was
tolerating a full regular diet. A nutrition consult was also
initiated for the use of yogurt/probiotics, which he began
eating in the evening of [**3-6**]. His PICC was removed prior to
discharge.

Urinary Retention:
The patient had his foley catheter removed on [**3-4**]. However, he
failed to void appropriately and was straigh-catheterized. After
failing to void a second time, the foley was replaced and
remained in place upon discharge. He was also restarted on his
home flomax dose.

Peripheral Edema:
The patient was noted to have peripheral edema on the post-op
state and was started on IV and then PO lasix. He actively
diuresed significantally and began to return to his pre-op
weight. However, he was still requiring PO lasix at dishcarge.

Ostomy: His ostomy remained clean, dry and intact.

Wound care: The inferior portion of his wound was draining
serosanguinous fluid and was opened and probed. It did not
appear infected, but cultures grew out yeast and he was started
on Fluconazole. He completed a 7 day course. Small amounts of
feculent drainage appeared in the wound , treated with dry
packing.

C. Diff colitis: after the operation, the patient remained on IV
flagyl until [**3-7**] when it was stopped. He completed a 14 days
course of antibiotics.

A-fib: The patient was found to be in afib postoperatively on
POD 1. He was started on an amio drip and converted to NSR. He
was transitioned to PO amio when tolerating PO. Daily EKG's were
checked to ensure that his QT interval was not lengthening.

The patient was discharged to a rehab facility on [**2131-3-7**] with
his staples, foley, and ostomy all in place. He was ambulatory
and tolerating PO. His pain was well controlled.

Medications on Admission:
advair 500'', atenolol 25', ASA 325', Flomax 0.4'

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed.
3. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1)  Inhalation B ID ().
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

12. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).


Discharge Disposition:
Extended Care

Facility:
Rehab Hospital Of [**Doctor Last Name **]

Discharge Diagnosis:
Toxic Megacolon secondary to Clostridium dificile colitis
Septic Shock secondary to above
Enterocutaneous fistula- low output
Wound seroma
Postoperative Atrial Fibrillation
Peripheral edema - started lasix as inpatient


Discharge Condition:
Good


Discharge Instructions:
1.  Take your medicines as prescribed.
2.  Diet:  Regular, as tolerated, with ensure supplements at all
meals, and Yogurt supplementation at all meals
3.  Activity:  as tolerated
4.  Wound care:  The ostomy should be changed as instructed by
ostomy care nursing.  The midline abdominal wound should be
packed with wet-to-dry dressings twice a day.
5.  If you develop any fever, chills, shortness of breath,
abdominal distension, redness or swelling around your wound,
abdominal pain, foul-smelling output from your wound, then
please call our office or come to the Emergency Room.
6.  The Foley catheter may be removed at rehab and the patient
followed with bladder scans as deemed necessary.

Followup Instructions:
1. Urology:  You need to follow-up with your urologist given
your difficulties urinating
2. Primary Care:  You need to follow-up with your primary care
doctor to determine whether to continue the amiodarone (started
for postop AFib).
3. Dr. [**Last Name (STitle) **]:  Please call his office to schedule a
follow-up appointment.



Completed by:[**2131-3-7**]

Name:  [**Known lastname 9663**],[**Known firstname **] J                  Unit No:   [**Numeric Identifier 9664**]

Admission Date:  [**2131-2-21**]              Discharge Date:   [**2131-3-8**]

Date of Birth:  [**2057-12-10**]             Sex:   M

Service: SURGERY

Allergies:
Zosyn

Attending:[**First Name3 (LF) 203**]
Addendum:
Mr. [**Known lastname **] did not get discharged until [**2131-3-8**]. He remained at
[**Hospital1 8**] for an additional day because there was feculent material
leaking from his wound. It is believed that he has a fistula
draining into his wound.

His wound was observed and cared for as previously described in
his discharge summary. His PICC line was removed prior to
discharge.

He was also continued on Flagyl 500mg PO q8hrs, which should be
continued for a total of 7 more days.

Discharge Disposition:
Extended Care

Facility:
Rehab Hospital Of [**Doctor Last Name 5041**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**]

Completed by:[**2131-3-8**]
{'Septicemia due to anaerobes,Acute respiratory failure,Intestinal infection due to Clostridium difficile,Septic shock,Acute kidney failure, unspecified,Acute vascular insufficiency of intestine,Acute posthemorrhagic anemia,Disruption of internal operation (surgical) wound,Candidiasis of mouth,Chronic airway obstruction, not elsewhere classified,Severe sepsis,Unspecified essential hypertension,Personal history of tobacco use,Atrial fibrillation,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Retention of urine, unspecified,Edema,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Peritoneal adhesions (postoperative) (postinfection)'}


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: Toxic megacolon, Sepsis

PRESENT ILLNESS: Pt is a 73M well known to Dr. [**Last Name (STitle) **] who was transferred
to his care tonight from [**Hospital3 35813**] Center in RI.  He
presented there on on [**2131-2-18**] with weakness and lower abdominal
pain.  By report CT scan showed evidence of colitis.  Stool was
positive for C Diff. WBC was 44,000.  He was admitted, hydrated,
and started on PO vanco.

MEDICAL HISTORY: 1. HTN
2. perforated Diverticulitis [**6-/2125**] c/b sepsis, respiratory
failure, ARF, A Fib [**Hospital **] transferred from OSH to Dr.[**Name (NI) 1482**]
care after initial colectomy/[**Doctor Last Name 3379**].
3. s/p colectomy/Hartmann for perforated diverticulitis [**6-/2125**]
at
an OSH c/b intra-abdominal abscess treated by IR drain
4. s/p colostomy takedown/[**Doctor Last Name 3379**] reversal [**12/2125**] ([**Doctor Last Name **])
5. ?recurrent diverticulitis [**2128**]
6. SBO [**11/2129**] - managed non-operatively
7. ex-lap, small bowel resection and lysis of adhesions. [**4-/2130**]
([**Doctor Last Name **]) for recurrent SBO caused by an inflammatory mass
8. s/p left inguinal hernia repair
9. Prostate Ca
[**31**]. COPD
11. h/o CVA
hernia repair

MEDICATION ON ADMISSION: advair 500'', atenolol 25', ASA 325', Flomax 0.4'

ALLERGIES: Zosyn

PHYSICAL EXAM: Upon Admission:

FAMILY HISTORY: emphysema in his father and brain cancer in his mother

SOCIAL HISTORY: Lives with wife in [**Name (NI) **]. quit smoking 40+ years 

### Response:
{'Septicemia due to anaerobes,Acute respiratory failure,Intestinal infection due to Clostridium difficile,Septic shock,Acute kidney failure, unspecified,Acute vascular insufficiency of intestine,Acute posthemorrhagic anemia,Disruption of internal operation (surgical) wound,Candidiasis of mouth,Chronic airway obstruction, not elsewhere classified,Severe sepsis,Unspecified essential hypertension,Personal history of tobacco use,Atrial fibrillation,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Retention of urine, unspecified,Edema,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Peritoneal adhesions (postoperative) (postinfection)'}
