CHIEF COMPLAINT: Transfer from OSH for BRBPR and abdominal pain

PRESENT ILLNESS: This is a 56 yo man with hx of Diverticulitis s/p partial
colectomy x 2, hx of multiple herniorraphy's, recent diagnosis
of Crohn's disease who was transferred from OSH for BRBPR and
abdominal pain. Patient states he has had chronic abdominal pain
for "years". One month ago he went for routine colonoscopy and
was diagnosed with Crohn's disease. Last week he began to
experience chills, sweats and BRBPR. He was seen at [**Hospital 1562**]
Hospital and had a workup done including CT scan of the ABD
which was negative. Over the past week, diarrhea has continued
with 4-6 bloody BMs per day. He states he is passing only clots
and blood for the past 4 days. Also had temp to 102 one day last
week. He has history of bloody diarrhea in the past with
aspirin. He was seen at [**Hospital6 **] and he was
noted to have a HCT drop from 40 to 33 over the past week. He
was transferred to [**Hospital1 18**] for further management. Of note,
patient also with right groin fistula.
.
In the emergency department, initial vitals: Temp 97.8, BP
137/92, HR 93, RR 20 100% RA. Patient was given Cipro 400mg IV x
1, Flagyl 500mg IV once, Pantoprazole 40mg IV x 1, morphine 4mg
IV x 2. GI notified and will see in AM, recommended to hold
steroids for now, start cipro/flagyl. CT abd/pelvis with no
abscess or evidence of other acute intra-abdominal pathology.
Initially, the plan was for the patient to be admitted to the
medical floor, however while in the ED the patient became
hypotensive to 70-80s and tachycardic to 120s. R IJ was placed.
SBP improved to 100-110s after IVF resuscitation with ~1.5L NS.
Admitted to the MICU for close monitoring.
.
On arrival the ICU, the patient complains of dry mouth,
exhaustion, HA, sore back, and nausea (no vomiting). Had large
bloody bowel movement shortly afterward.

MEDICAL HISTORY: Crohn's disease
DM2
Arthritis
HTN
Diverticulitis s/p Partial Colectomy x 2
s/p Multiple Herniorraphy's

MEDICATION ON ADMISSION: Naproxen 400mg [**Hospital1 **]
Lantus 30 units qHS
Tramadol 50mg PO daily
Lisinopril unknown dose
Glyburide unknown dose
Actos unknown dose
Prednisone 30mg daily with plan for slow taper, started last
week

ALLERGIES: Azithromycin / Metformin

PHYSICAL EXAM: 99.8; 92; 117/80; 95% RA
General - Resting comfortably in bed, no acute distress
HEENT - Sclera anicteric, MMM
Neck - Supple
Pulm - CTA bilaterally; no wheezes, rales, or rhonchi
CV - Quiet heart sounds ([**1-26**] body habitus); RRR, normal S1/S2;
no murmurs
Abdomen - Obese; midline hernia appreciated; normoactive bowel
sounds; soft; diffuse TTP
Ext - Warm, well perfused, radial and DP pulses 2+; trace lower
extremity edema to knees
Neuro - Moving all extremities
GU - Right of scrotum a small (2-3mm) perforation with
clear/yellowish serous drainage

FAMILY HISTORY: No family hx of Crohn's disease. Mother passed away from PNA,
also had HTN.

SOCIAL HISTORY: Occasional EtOH use, prior hx of Alcohol Abuse over 15 years
ago. Denies tobacco or illicit drug use. Lives in [**Location 7453**], has a significant other x 19 years. On disability [**1-26**]
L hand crush injury, former mechanic.
Regional enteritis of large intestine,Acute kidney failure, unspecified,Blood in stool,Diverticulosis of colon (without mention of hemorrhage),Unspecified essential hypertension,Orthostatic hypotension,Tachycardia, unspecified,Hypovolemia,Fever, unspecified,Benign neoplasm of skin of trunk, except scrotum,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pain in limb,Edema,Arthropathy, unspecified, site unspecified,Long-term (current) use of insulin,Other drugs and medicinal substances causing adverse effects in therapeutic use,Adrenal cortical steroids causing adverse effects in therapeutic use
Reg enteritis, lg intest,Acute kidney failure NOS,Blood in stool,Dvrtclo colon w/o hmrhg,Hypertension NOS,Orthostatic hypotension,Tachycardia NOS,Hypovolemia,Fever NOS,Benign neo skin trunk,DMII wo cmp nt st uncntr,Pain in limb,Edema,Arthropathy NOS-unspec,Long-term use of insulin,Adv eff medicinal NEC,Adv eff corticosteroids
Admission Date:  [**2195-4-27**]              Discharge Date:   [**2195-5-4**]

Date of Birth:  [**2139-1-6**]             Sex:   M

Service: MEDICINE

Allergies:
Azithromycin / Metformin

Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Transfer from OSH for BRBPR and abdominal pain

Major Surgical or Invasive Procedure:
Colonoscopy
Insertion of right internal jugular central venous line


History of Present Illness:
This is a 56 yo man with hx of Diverticulitis s/p partial
colectomy x 2, hx of multiple herniorraphy's, recent diagnosis
of Crohn's disease who was transferred from OSH for BRBPR and
abdominal pain. Patient states he has had chronic abdominal pain
for "years". One month ago he went for routine colonoscopy and
was diagnosed with Crohn's disease. Last week he began to
experience chills, sweats and BRBPR. He was seen at [**Hospital 1562**]
Hospital and had a workup done including CT scan of the ABD
which was negative. Over the past week, diarrhea has continued
with 4-6 bloody BMs per day. He states he is passing only clots
and blood for the past 4 days. Also had temp to 102 one day last
week. He has history of bloody diarrhea in the past with
aspirin. He was seen at [**Hospital6 **] and he was
noted to have a HCT drop from 40 to 33 over the past week. He
was transferred to [**Hospital1 18**] for further management. Of note,
patient also with right groin fistula.
.
In the emergency department, initial vitals: Temp 97.8, BP
137/92, HR 93, RR 20 100% RA. Patient was given Cipro 400mg IV x
1, Flagyl 500mg IV once, Pantoprazole 40mg IV x 1, morphine 4mg
IV x 2. GI notified and will see in AM, recommended to hold
steroids for now, start cipro/flagyl. CT abd/pelvis with no
abscess or evidence of other acute intra-abdominal pathology.
Initially, the plan was for the patient to be admitted to the
medical floor, however while in the ED the patient became
hypotensive to 70-80s and tachycardic to 120s. R IJ was placed.
SBP improved to 100-110s after IVF resuscitation with ~1.5L NS.
Admitted to the MICU for close monitoring.
.
On arrival the ICU, the patient complains of dry mouth,
exhaustion, HA, sore back, and nausea (no vomiting). Had large
bloody bowel movement shortly afterward.


Past Medical History:
Crohn's disease
DM2
Arthritis
HTN
Diverticulitis s/p Partial Colectomy x 2
s/p Multiple Herniorraphy's


Social History:
Occasional EtOH use, prior hx of Alcohol Abuse over 15 years
ago. Denies tobacco or illicit drug use. Lives in [**Location 7453**], has a significant other x 19 years. On disability [**1-26**]
L hand crush injury, former mechanic.

Family History:
No family hx of Crohn's disease. Mother passed away from PNA,
also had HTN.

Physical Exam:
99.8; 92; 117/80; 95% RA
General - Resting comfortably in bed, no acute distress
HEENT - Sclera anicteric, MMM
Neck - Supple
Pulm - CTA bilaterally; no wheezes, rales, or rhonchi
CV - Quiet heart sounds ([**1-26**] body habitus); RRR, normal S1/S2;
no murmurs
Abdomen - Obese; midline hernia appreciated; normoactive bowel
sounds; soft; diffuse TTP
Ext - Warm, well perfused, radial and DP pulses 2+; trace lower
extremity edema to knees
Neuro - Moving all extremities
GU - Right of scrotum a small (2-3mm) perforation with
clear/yellowish serous drainage


Pertinent Results:
[**2195-4-27**] 09:45PM BLOOD WBC-11.1* RBC-4.13* Hgb-11.5* Hct-34.3*
MCV-83 MCH-27.8 MCHC-33.5 RDW-13.9 Plt Ct-563*
[**2195-4-27**] 09:45PM BLOOD Neuts-84.0* Lymphs-10.2* Monos-5.6 Eos-0
Baso-0.1
[**2195-4-27**] 09:45PM BLOOD PT-13.5* PTT-24.7 INR(PT)-1.2*
[**2195-4-30**] 03:20AM BLOOD ESR-87*
[**2195-4-27**] 09:45PM BLOOD Glucose-175* UreaN-49* Creat-1.3* Na-135
K-4.3 Cl-102 HCO3-24 AnGap-13
[**2195-4-27**] 09:45PM BLOOD ALT-12 AST-10 CK(CPK)-89 AlkPhos-64
TotBili-0.3
[**2195-4-27**] 09:45PM BLOOD Lipase-16
[**2195-4-27**] 09:45PM BLOOD CK-MB-NotDone
[**2195-4-27**] 09:45PM BLOOD cTropnT-<0.01
[**2195-4-28**] 09:22AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.0
[**2195-5-3**] 10:26AM BLOOD %HbA1c-6.9*
[**2195-4-30**] 03:20AM BLOOD CRP-181.6*
[**2195-5-4**] 05:30AM BLOOD WBC-11.6* RBC-3.43* Hgb-9.8* Hct-28.8*
MCV-84 MCH-28.5 MCHC-33.9 RDW-14.2 Plt Ct-513*
[**2195-5-4**] 05:30AM BLOOD Glucose-142* UreaN-32* Creat-2.0* Na-142
K-3.8 Cl-107 HCO3-26 AnGap-13
[**2195-5-4**] 05:30AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.2

[**2195-4-27**] 09:45PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2195-4-27**] 09:45PM   PT-13.5* PTT-24.7 INR(PT)-1.2*
[**2195-4-27**] 09:45PM   WBC-11.1* RBC-4.13* HGB-11.5* HCT-34.3*
MCV-83 MCH-27.8 MCHC-33.5 RDW-13.9
[**2195-4-27**] 09:45PM   PLT COUNT-563*
[**2195-4-27**] 09:45PM   LIPASE-16

Blood Cx:
Blood Culture, Routine (Final [**2195-5-5**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.
         ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
[**4-28**], [**4-29**], [**4-29**], [**4-29**], [**4-29**] NO GROWTH

Urine Cx: [**4-28**], [**4-29**], [**4-30**] NO GROWTH

FECAL CULTURE (Final [**2195-4-29**]):    NO SALMONELLA OR SHIGELLA
FOUND.
   CAMPYLOBACTER CULTURE (Final [**2195-4-30**]):    NO CAMPYLOBACTER
FOUND.
   OVA + PARASITES (Final [**2195-4-29**]):
      NO OVA AND PARASITES SEEN.
      This test does not reliably detect Cryptosporidium,
Cyclospora or
      Microsporidium. While most cases of Giardia are detected
by routine
      O+P, the Giardia antigen test may enhance detection when
organisms
      are rare.                                .
      MANY RBC'S.                                .
      MODERATE POLYMORPHONUCLEAR LEUKOCYTES.
   FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2195-4-30**]):
      NO E.COLI 0157:H7 FOUND.
   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2195-4-29**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).

FECAL CULTURE (Final [**2195-5-2**]):    NO SALMONELLA OR SHIGELLA
FOUND.
   CAMPYLOBACTER CULTURE (Final [**2195-5-2**]):    NO CAMPYLOBACTER
FOUND.
   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2195-4-30**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).
   OVA + PARASITES (Final [**2195-4-30**]):
      NO OVA AND PARASITES SEEN.
      This test does not reliably detect Cryptosporidium,
Cyclospora or
      Microsporidium. While most cases of Giardia are detected
by routine
      O+P, the Giardia antigen test may enhance detection when
organisms
      are rare.                     .
      MANY RBC'S.                        .
      MANY POLYMORPHONUCLEAR LEUKOCYTES.

CT ABDOMEN W/CONTRAST Study Date of [**2195-4-28**] 12:32 AM:
IMPRESSION:
1. No evidence of colitis or intra-abdominal abscess.
2. Multiple abdominal wall hernias, containing loops of small
and large bowel
as detailed above, without evidence of obstruction.
3. Right adrenal nodule, incompletely characterized, but likely
reflects an
adrenal adenoma. Recommend comparison with outside studies to
assess for
interval changes in size.
4. Left renal cyst.
5. Diverticulosis, without evidence of diverticulitis.

Colonoscopy Wednesday, [**2195-4-29**]:
Impression: Ulceration, granularity, exudate and erythema in the
cecum, ascending colon, transverse colon, descending colon and
sigmoid colon compatible with Crohn's disease, Diverticulosis of
the sigmoid colon and descending colon, Otherwise normal
colonoscopy to cecum
Recommendations: Please obtain MRI to evaluate for
abscess/fistula. If this does not show evidence of abscess, will
proceed to treatment with IV steroids +/- remicaid.
Monitor HCT.
Please resend stool x 2 for c.diff.
Send ESR/CRP.

CT abd/pelvis: [**4-28**]
IMPRESSION:
1. No evidence of colitis or intra-abdominal abscess.
2. Multiple abdominal wall hernias, containing loops of small
and large bowel
as detailed above, without evidence of obstruction.
3. Right adrenal nodule, incompletely characterized, but likely
reflects an
adrenal adenoma. Recommend comparison with outside studies to
assess for
interval changes in size.
4. Left renal cyst.
5. Diverticulosis, without evidence of diverticulitis.

MRI: Pelvis
IMPRESSION: Small track, measuring 14 mm in depth, extending
from the skin of
the right thigh to the fascia abutting the gracilis, with no
evidence of
deeper extension and no evidence of fistula or abscess, as
questioned. Trace
bilateral hydroceles.

X-ray Foot:
FINDINGS: There is general soft tissue swelling. The
mineralization of the
bones appears normal. Mild-to-moderate degenerative disease at
the tibiotalar
joint and talonavicular joint. Small plantar spur. There is no
secure sign
of cortical disruption indicative of fracture.




Brief Hospital Course:
56 year-old male with diverticulitis s/p partial colectomy x 2,
history of multiple herniorraphies, recent diagnosis of Crohn's
disease transferred from OSH for BRBPR and abdominal pain on
[**2195-4-27**]. In the ED, he was hypotensive and tachycardia and
required a brief stay in the MICU, after which he was
transferred to the medicine service.

MICU COURSE
===========
# Crohn's Disease:  Patient found to have severe crohn's dz on
colonoscopy.  An MRI was done showing no fistulas or abscesses.
Patient was started on solumedrol along with Cipro and Flagyl
prior to transfer to the floor per GI recommendations.  In
addition, stool O&P along with C. Diff toxin sent. C. difficile
was negative.

# Hypotension/Sinus tachycardia: Likely secondary to hypovolemia
in the context of bleeding, decreased PO intake, fever.
Hypotension resolved with fluid boluses.

# BRBPR: Pt with significant bleeding causing hemodynamic
instability. Hct drop 40-->33, was been stable in MICU despite
multiple bloody BM's in ED. Likely lower GI bleed given
description of BRB with clots. Differential would include
Crohn's disease, diverticulosis, AVM, infectious. Also uses
chronic NSAIDS so could represent a brisk UGI bleed.  Patient
started on IV protonix and Hct observed Q6H.

# Fever: Pt had fever to 102 at home and now with low-grade
temp. No leukocytosis. Raised concern for infectious or
inflammatory process-- especially given history of
diverticulitis and Crohn's-- however no signs of abscess,
colitis, or pericolic fat stranding on CT.

# Elevated creatinine: No history of chronic kidney disease.
Most likely represents prerenal acute renal failure in the
setting of BRBPR.  Cr increased to 1.7 from 1.4, received a
contrast dye load and is also prerenal given low FeNa.  Unclear
etiology, possibly a component of both ATN and pre-renal
azotemia.  Continued to monitor and adminstered fluid.

MEDICINE COURSE
===============
On transfer to the medicine service, patient was transitioned to
prednisone for Crohn's flare. He did not have any episodes of
BRBPR. He remained hemodynamically stable and did not require
blood transfusions. PPD was checked for possible initiation of
Remicade as outpatient; PPD was negative. TMPT, checked to
assess for ability to tolerate azathiprione therapy, was pending
on discharge. On discharge, patient was scheduled for
appointment with outpatient gastroenterologist. He was sent out
with a steroid taper and PPI. His antibiotics were 10 day course
of ciprofloxacin and flagyl.
     As his blood glucose was not well-controlled with steroid
therapy, [**Last Name (un) **] was consulted. He was maintained on his home
dose of Lantus and started on an aggressive Humalog sliding
scale insulin regimen which should be titrated concurrently with
steroids on an outpatient basis.
     Patient's creatinine improved after transfer from ICU.
Acute kidney injury was likely secondary to contrast-induced
nephropathy. His creatinine should be rechecked within one week
of discharge.
     On MRI patient was also noted to have a 14mm track
extending from is right thigh to the underlying muscle. He
report serous drainage. There was no fecal output. This was
dressed daily, and the wound team was consulted for further
recommendations (given risk of infection based on location). He
was sent home with VNA and wound care.
     On day prior to discharge patient also complained of right
foot pain. He injured the right ankle approximately 1.5 years
ago; did not seek medical attention, and pain improved.
Worsening pain on plantar surface, medially of right foot
throughout hospital course. Also with ?small effusion inferior
to lateral malleolus. Most likely pain from soft tissue edema
secondary to steroid use. Plain film of the film showed no
evidence of fracture. The patient should have outpatient
follow-up with the pain persists.

Medications on Admission:
Naproxen 400mg [**Hospital1 **]
Lantus 30 units qHS
Tramadol 50mg PO daily
Lisinopril unknown dose
Glyburide unknown dose
Actos unknown dose
Prednisone 30mg daily with plan for slow taper, started last
week


Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO once a day.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: generic for tylenol.
7. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Four (24) units Subcutaneous daily at breakfast time: will be
tapered based on prednisone dosing.
Disp:*QS 1 month* Refills:*2*
9. Insulin Lispro 100 unit/mL Solution Sig: AS DIR units
Subcutaneous four times a day: see attached sliding scale for
dosing based on fingerstick before meals and at bedtime.
Disp:*QS 1 month* Refills:*2*
10. Dressing Care
Commercial wound cleanser or normal saline to irrigate/cleanse
right groin wound.
 Pat the tissue dry with dry gauze.
 Pack loosely with [**Doctor Last Name 12536**] AMD [**12-26**]" packing strip moistened with
normal saline.
 Cover with dry gauze
 Change dressing daily.
 Secure dressing in underclothes or minimal softcloth tape


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **] Nursing Association

Discharge Diagnosis:
Primary:
- Crohn's flare
- Acute kidney injury, likely secondary to contrast exposure

Secondary:
- Epidermal retention cyst with draining tract in groin
- Diabetes mellitus, type II
- Right foot


Discharge Condition:
Hemodynamically stable; without blood in stools; ambulating
without problem; afebrile


Discharge Instructions:
You were admitted to [**Hospital1 69**] on
[**2195-4-27**] due to blood in your stools due to a flare of your
Crohn's disease. You had a brief stay in the ICU, and then were
transferred to the medical [**Hospital1 **] for further care; you did not
require any blood transfusions. The gastroenterology service was
involved in your care. You were treated with steroids and
antibiotics. You were also noted to have a worsening of your
kidney function; this is likely related to contrast which your
received for a CT scan, and should improve over time.

Your medication regimen has changed. Please review your
medication list closely. Note that we have stopped your diabetic
pills, because of the acute renal failure (resolving) and the
increased blood sugars due to prednisone. Discuss restarting the
pills (Actos and glyburide) with Dr [**Last Name (STitle) **] when your kidneys have
fully recovered and you are off of prednisone. We also stopped
your lisinopril. You should continue to drink fluid and maintain
good hydration.

In the meantime, you are on two new forms of insulin in addition
to lantus. One is called NPH, which is intermediate-acting. You
will take this at breakfast time to counter-act prednisone. If
any changes are made in your prednisone dosing, you need to
discuss with your doctor how to change the insulin-NPH dosing,
because with less prednisone, you will need less NPH.

The other new insulin is insulin-lispro, or Humalog. You will
take doses of this based on your fingerstick value at meal time
to adjust the blood sugar. Attached is a copy of the sliding
scale of doses, based on pre-meal blood sugar, that we recommend
for now; discuss this with Dr [**Last Name (STitle) **], as it will need to be
refined going forward, especially if you are able to restart the
pills for blood sugar control.

It is important that you follow up with your physicians as
listed below.

Please call your physician or return to the emergency department
for increasing abdominal pain, blood in your stools, dark tarry
stools, fever, or for any other symptoms which are concerning to
you.

Followup Instructions:
You have an appointment with your PCP, [**Name10 (NameIs) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 29822**]), to make sure the kidneys are functioning
normally and diabetes care follow-up.
Date and time: [**5-8**] at 11am
Location: [**Location (un) **]
Phone number: [**Telephone/Fax (1) 29822**]

You have an appointment with Dr [**Last Name (STitle) **], your gastroenterologist,
to discuss starting either remicade or other medications to
achieve remission of the Crohn's disease.
MD: Dr [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]
Specialty: GI
Date and time: [**5-11**] at 3pm
Location: [**Hospital1 1562**]
Phone number: [**Telephone/Fax (1) 82746**]


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]

Completed by:[**2195-5-13**]
{'Regional enteritis of large intestine,Acute kidney failure, unspecified,Blood in stool,Diverticulosis of colon (without mention of hemorrhage),Unspecified essential hypertension,Orthostatic hypotension,Tachycardia, unspecified,Hypovolemia,Fever, unspecified,Benign neoplasm of skin of trunk, except scrotum,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pain in limb,Edema,Arthropathy, unspecified, site unspecified,Long-term (current) use of insulin,Other drugs and medicinal substances causing adverse effects in therapeutic use,Adrenal cortical steroids causing adverse effects in therapeutic use'}


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: Transfer from OSH for BRBPR and abdominal pain

PRESENT ILLNESS: This is a 56 yo man with hx of Diverticulitis s/p partial
colectomy x 2, hx of multiple herniorraphy's, recent diagnosis
of Crohn's disease who was transferred from OSH for BRBPR and
abdominal pain. Patient states he has had chronic abdominal pain
for "years". One month ago he went for routine colonoscopy and
was diagnosed with Crohn's disease. Last week he began to
experience chills, sweats and BRBPR. He was seen at [**Hospital 1562**]
Hospital and had a workup done including CT scan of the ABD
which was negative. Over the past week, diarrhea has continued
with 4-6 bloody BMs per day. He states he is passing only clots
and blood for the past 4 days. Also had temp to 102 one day last
week. He has history of bloody diarrhea in the past with
aspirin. He was seen at [**Hospital6 **] and he was
noted to have a HCT drop from 40 to 33 over the past week. He
was transferred to [**Hospital1 18**] for further management. Of note,
patient also with right groin fistula.
.
In the emergency department, initial vitals: Temp 97.8, BP
137/92, HR 93, RR 20 100% RA. Patient was given Cipro 400mg IV x
1, Flagyl 500mg IV once, Pantoprazole 40mg IV x 1, morphine 4mg
IV x 2. GI notified and will see in AM, recommended to hold
steroids for now, start cipro/flagyl. CT abd/pelvis with no
abscess or evidence of other acute intra-abdominal pathology.
Initially, the plan was for the patient to be admitted to the
medical floor, however while in the ED the patient became
hypotensive to 70-80s and tachycardic to 120s. R IJ was placed.
SBP improved to 100-110s after IVF resuscitation with ~1.5L NS.
Admitted to the MICU for close monitoring.
.
On arrival the ICU, the patient complains of dry mouth,
exhaustion, HA, sore back, and nausea (no vomiting). Had large
bloody bowel movement shortly afterward.

MEDICAL HISTORY: Crohn's disease
DM2
Arthritis
HTN
Diverticulitis s/p Partial Colectomy x 2
s/p Multiple Herniorraphy's

MEDICATION ON ADMISSION: Naproxen 400mg [**Hospital1 **]
Lantus 30 units qHS
Tramadol 50mg PO daily
Lisinopril unknown dose
Glyburide unknown dose
Actos unknown dose
Prednisone 30mg daily with plan for slow taper, started last
week

ALLERGIES: Azithromycin / Metformin

PHYSICAL EXAM: 99.8; 92; 117/80; 95% RA
General - Resting comfortably in bed, no acute distress
HEENT - Sclera anicteric, MMM
Neck - Supple
Pulm - CTA bilaterally; no wheezes, rales, or rhonchi
CV - Quiet heart sounds ([**1-26**] body habitus); RRR, normal S1/S2;
no murmurs
Abdomen - Obese; midline hernia appreciated; normoactive bowel
sounds; soft; diffuse TTP
Ext - Warm, well perfused, radial and DP pulses 2+; trace lower
extremity edema to knees
Neuro - Moving all extremities
GU - Right of scrotum a small (2-3mm) perforation with
clear/yellowish serous drainage

FAMILY HISTORY: No family hx of Crohn's disease. Mother passed away from PNA,
also had HTN.

SOCIAL HISTORY: Occasional EtOH use, prior hx of Alcohol Abuse over 15 years
ago. Denies tobacco or illicit drug use. Lives in [**Location 7453**], has a significant other x 19 years. On disability [**1-26**]
L hand crush injury, former mechanic. 

### Response:
{'Regional enteritis of large intestine,Acute kidney failure, unspecified,Blood in stool,Diverticulosis of colon (without mention of hemorrhage),Unspecified essential hypertension,Orthostatic hypotension,Tachycardia, unspecified,Hypovolemia,Fever, unspecified,Benign neoplasm of skin of trunk, except scrotum,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pain in limb,Edema,Arthropathy, unspecified, site unspecified,Long-term (current) use of insulin,Other drugs and medicinal substances causing adverse effects in therapeutic use,Adrenal cortical steroids causing adverse effects in therapeutic use'}
