CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: 82F with h/o HTN, HLD, chronic 2yr h/o paroxysmal abdominal pain
of unclear etiology, discharged from [**Hospital1 18**] 2d ago. She has
experienced chronic abdominal pain since [**2154**] but in past few
year or so has been in and out of EDs without any specific
etiology found. In the past 6 months she has had increased
severity and frequency in pain.
.
During her most recent admission last week, the patient was
transferred from OSH with tearing abdominal pain. Vascular
Surgery admitted her out of concern for ischemic entero-colitis
of terminal ileum and cecum.  Imaging was nonconcerning for
significant vascular impairment of the mesenteric system. She
was transferred to the Medicine service for further GI workup.
Stool studies were negative for infectious etiology. Colonoscopy
done [**11-27**] and [**11-28**] showed no significant findings, Bx results
benign hyperplastic polyp. Pt was asymptomatic during her stay
and tolerated PO well, so d/c with close GI outpatient follow-up
planned. On review of CT scan after colonoscopy, there was a
concern for ventral hernia possibly causing paroxysmal attacks
of abdominal pain.
.
She returned home and ate soft foods out of concern for
recurrent GI pain.  Early this morning she noted recurrent
abdominal pain and presented to [**Hospital3 **].  She was
transferred here for continued GI workup.
.
In the ED, vitals: 98.1  62  112/57  16  94%. Pain described as
"cutting" in the epigastric region, associated with nausea and
sweats, but no changes in BM, SOB, CP, back pain. Belly was felt
to be soft, distended, tender throughout, with positive BS's.
She denied any obstructive symptoms. CT abd/pelvis with contrast
obtained with wet read showing: "terminal ileitis and colitis in
similar distribution to CT on [**2158-11-24**]. Now causing small bowel
obstruction proximal to 6 cm narrowed segment of terminal ileum.
Appendix is dilated and fluid-filled, similar to [**2158-11-24**]." CXR
showed L basilar atelectasis only.
.
Surgery was consulted, and per verbal discussion concluded that
the patient had no obstructive symptoms. She has been recently
at her [**Month/Day/Year 5348**] of 2 loose BM's per day. She takes iron
supplements, so stool is dark at [**Month/Day/Year 5348**]. No surgical
intervention planned, conservative [**Month/Day/Year **].  Pt was given 1L
NS, 2 doses IV Dilaudid and one IV Zofran. Vitals before
transfer: 98.2  66  16  142/68.
.
On the floor, she denies nausea or abdominal pain.

MEDICAL HISTORY: PE in [**2147**]
Polymyalgia rheumatica
Chronic abdominal pain of presently unclear etiology
PVD
[**Name (NI) 2091**] with [**Name (NI) 5348**] Cr 1.3 in [**11/2158**]
Hypertension
Hypothyroidism
Hypercholesterolemia
GERD
Osteoarthritis
Glaucoma
Chronic abdominal pain
H/o diverticulitis treated with antibiotics
.
SURGICAL HISTORY:
L fem-[**Doctor Last Name **] bypass [**2147**] at [**Hospital1 336**]
tubal ligation
hysterectomy
back surgery
hemorrhoid surgery
cataracts b/l

MEDICATION ON ADMISSION: simvastatin 20 mg DAILY
aspirin 81 mg DAILY
levothyroxine 25 mcg Tablet DAILY
prednisone 5 mg EVERY OTHER DAY
ferrous sulfate 300  mg DAILY
omeprazole 40 mg Capsule DAILY
triamterene-hydrochlorothiazide 37.5-25 mg DAILY
atenolol 100 mg DAILY
dicyclomine 10 mg four times a day as needed for abdominal pain.

ALLERGIES: morphine / Penicillins / Cipro

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: 96.1  BP: 118/64  P: 75  R: 24  O2:  96% RA
General: Alert, oriented, no acute distress
HEENT: EOMI, PE non responsive [**1-18**] cataract surgery, Sclera
anicteric, dry MM, OP clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, mildly distended, hypoactive bowel
sounds, no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, strength 5/5 throughout, motor function
grossly normal
Psych:  drifts off during conversation, but oriented and able to
narrate her history well

FAMILY HISTORY: Denies family history of IBD or chronic abdominal pain.  Mother
had borderline DM and died of a heart attack. Father with heart
disease, 1 son with heart disease. Denies family history of
vascular disease.

SOCIAL HISTORY: Lives in her own apartment in NH. Independent in her ADL's. Has
2 sons and 1 daughter. Denies tobacco use, EtOH consumption, and
illicits
Neoplasm of unspecified nature of digestive system,Perforation of intestine,Acute kidney failure with lesion of tubular necrosis,Other specified intestinal obstruction,Regional enteritis of small intestine,Hyposmolality and/or hyponatremia,Laparoscopic surgical procedure converted to open procedure,Other and unspecified hyperlipidemia,Other chronic pain,Polymyalgia rheumatica,Peripheral vascular disease, unspecified,Unspecified acquired hypothyroidism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Personal history of pulmonary embolism,Esophageal reflux,Other drugs and medicinal substances causing adverse effects in therapeutic use
Digestive neoplasm NOS,Perforation of intestine,Ac kidny fail, tubr necr,Intestinal obstruct NEC,Reg enteritis, sm intest,Hyposmolality,Lap surg convert to open,Hyperlipidemia NEC/NOS,Chronic pain NEC,Polymyalgia rheumatica,Periph vascular dis NOS,Hypothyroidism NOS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Hx pulmonary embolism,Esophageal reflux,Adv eff medicinal NEC
Admission Date:  [**2158-12-1**]              Discharge Date:   [**2158-12-14**]

Date of Birth:  [**2076-4-1**]             Sex:   F

Service: SURGERY

Allergies:
morphine / Penicillins / Cipro

Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
abdominal pain

Major Surgical or Invasive Procedure:
[**2158-12-8**]: Right hemicolectomy with end-ileostomy.


History of Present Illness:
82F with h/o HTN, HLD, chronic 2yr h/o paroxysmal abdominal pain
of unclear etiology, discharged from [**Hospital1 18**] 2d ago. She has
experienced chronic abdominal pain since [**2154**] but in past few
year or so has been in and out of EDs without any specific
etiology found. In the past 6 months she has had increased
severity and frequency in pain.
.
During her most recent admission last week, the patient was
transferred from OSH with tearing abdominal pain. Vascular
Surgery admitted her out of concern for ischemic entero-colitis
of terminal ileum and cecum.  Imaging was nonconcerning for
significant vascular impairment of the mesenteric system. She
was transferred to the Medicine service for further GI workup.
Stool studies were negative for infectious etiology. Colonoscopy
done [**11-27**] and [**11-28**] showed no significant findings, Bx results
benign hyperplastic polyp. Pt was asymptomatic during her stay
and tolerated PO well, so d/c with close GI outpatient follow-up
planned. On review of CT scan after colonoscopy, there was a
concern for ventral hernia possibly causing paroxysmal attacks
of abdominal pain.
.
She returned home and ate soft foods out of concern for
recurrent GI pain.  Early this morning she noted recurrent
abdominal pain and presented to [**Hospital3 **].  She was
transferred here for continued GI workup.
.
In the ED, vitals: 98.1  62  112/57  16  94%. Pain described as
"cutting" in the epigastric region, associated with nausea and
sweats, but no changes in BM, SOB, CP, back pain. Belly was felt
to be soft, distended, tender throughout, with positive BS's.
She denied any obstructive symptoms. CT abd/pelvis with contrast
obtained with wet read showing: "terminal ileitis and colitis in
similar distribution to CT on [**2158-11-24**]. Now causing small bowel
obstruction proximal to 6 cm narrowed segment of terminal ileum.
Appendix is dilated and fluid-filled, similar to [**2158-11-24**]." CXR
showed L basilar atelectasis only.
.
Surgery was consulted, and per verbal discussion concluded that
the patient had no obstructive symptoms. She has been recently
at her [**Month/Day/Year 5348**] of 2 loose BM's per day. She takes iron
supplements, so stool is dark at [**Month/Day/Year 5348**]. No surgical
intervention planned, conservative [**Month/Day/Year **].  Pt was given 1L
NS, 2 doses IV Dilaudid and one IV Zofran. Vitals before
transfer: 98.2  66  16  142/68.
.
On the floor, she denies nausea or abdominal pain.

Past Medical History:
PE in [**2147**]
Polymyalgia rheumatica
Chronic abdominal pain of presently unclear etiology
PVD
[**Name (NI) 2091**] with [**Name (NI) 5348**] Cr 1.3 in [**11/2158**]
Hypertension
Hypothyroidism
Hypercholesterolemia
GERD
Osteoarthritis
Glaucoma
Chronic abdominal pain
H/o diverticulitis treated with antibiotics
.
SURGICAL HISTORY:
L fem-[**Doctor Last Name **] bypass [**2147**] at [**Hospital1 336**]
tubal ligation
hysterectomy
back surgery
hemorrhoid surgery
cataracts b/l

Social History:
Lives in her own apartment in NH. Independent in her ADL's. Has
2 sons and 1 daughter. Denies tobacco use, EtOH consumption, and
illicits

Family History:
Denies family history of IBD or chronic abdominal pain.  Mother
had borderline DM and died of a heart attack. Father with heart
disease, 1 son with heart disease. Denies family history of
vascular disease.

Physical Exam:
Admission Physical Exam:
Vitals: T: 96.1  BP: 118/64  P: 75  R: 24  O2:  96% RA
General: Alert, oriented, no acute distress
HEENT: EOMI, PE non responsive [**1-18**] cataract surgery, Sclera
anicteric, dry MM, OP clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, mildly distended, hypoactive bowel
sounds, no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, strength 5/5 throughout, motor function
grossly normal
Psych:  drifts off during conversation, but oriented and able to
narrate her history well

Pertinent Results:
Admission Labs:
[**2158-12-1**] 10:00AM BLOOD WBC-10.8# RBC-4.33 Hgb-11.9* Hct-37.5
MCV-87 MCH-27.4 MCHC-31.7 RDW-14.2 Plt Ct-326#
[**2158-12-1**] 10:00AM BLOOD Neuts-88.6* Lymphs-8.1* Monos-3.2 Eos-0.1
Baso-0
[**2158-12-1**] 10:00AM BLOOD PT-10.6 PTT-27.2 INR(PT)-1.0
[**2158-12-1**] 10:00AM BLOOD Glucose-123* UreaN-19 Creat-1.6* Na-138
K-4.8 Cl-104 HCO3-24 AnGap-15
[**2158-12-1**] 10:00AM BLOOD ALT-12 AST-19 AlkPhos-33* TotBili-0.2
[**2158-12-1**] 10:00AM BLOOD Lipase-52
[**2158-12-1**] 11:13AM BLOOD Lactate-1.5
.
[**Hospital3 **]:
[**2158-12-2**] 06:50AM BLOOD WBC-9.5 RBC-3.65* Hgb-10.0* Hct-32.0*
MCV-88 MCH-27.3 MCHC-31.2 RDW-14.4 Plt Ct-252
[**2158-12-2**] 09:10PM BLOOD WBC-7.0 RBC-3.55* Hgb-9.7* Hct-31.0*
MCV-87 MCH-27.3 MCHC-31.3 RDW-14.4 Plt Ct-217
[**2158-12-3**] 05:27AM BLOOD WBC-6.0 RBC-3.36* Hgb-9.2* Hct-29.0*
MCV-86 MCH-27.5 MCHC-31.8 RDW-14.5 Plt Ct-218
[**2158-12-4**] 07:00AM BLOOD WBC-9.1# RBC-3.82* Hgb-10.3* Hct-33.1*
MCV-87 MCH-26.9* MCHC-31.0 RDW-14.6 Plt Ct-323
[**2158-12-5**] 07:45AM BLOOD WBC-8.5 RBC-3.80* Hgb-10.3* Hct-31.7*
MCV-83 MCH-27.1 MCHC-32.5 RDW-14.7 Plt Ct-328
[**2158-12-6**] 07:05AM BLOOD WBC-8.1 RBC-3.88* Hgb-10.5* Hct-33.1*
MCV-85 MCH-27.1 MCHC-31.8 RDW-14.6 Plt Ct-301
[**2158-12-2**] 06:50AM BLOOD Glucose-92 UreaN-24* Creat-1.6* Na-137
K-5.2* Cl-108 HCO3-21* AnGap-13
[**2158-12-3**] 05:27AM BLOOD Glucose-85 UreaN-22* Creat-1.2* Na-139
K-4.6 Cl-108 HCO3-23 AnGap-13
[**2158-12-4**] 07:00AM BLOOD Glucose-81 UreaN-21* Creat-1.1 Na-140
K-4.5 Cl-108 HCO3-20* AnGap-17
[**2158-12-5**] 07:45AM BLOOD Glucose-71 UreaN-24* Creat-1.2* Na-138
K-4.6 Cl-107 HCO3-18* AnGap-18
[**2158-12-6**] 07:05AM BLOOD Glucose-68* UreaN-25* Creat-1.1 Na-141
K-4.4 Cl-106 HCO3-21* AnGap-18
[**2158-12-2**] 06:50AM BLOOD Albumin-3.0* Calcium-8.3* Phos-4.7*#
Mg-2.0
[**2158-12-3**] 05:27AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0
[**2158-12-4**] 07:00AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0
[**2158-12-5**] 07:45AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.9
[**2158-12-6**] 07:05AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.9
[**2158-12-4**] 07:00AM BLOOD ESR-33*
[**2158-12-4**] 07:00AM BLOOD CRP-23.2*
[**2158-12-2**] 06:50AM BLOOD tTG-IgA-2 (negative)
[**2158-12-3**] 10:01AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.018
[**2158-12-3**] 10:01AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2158-12-3**] 10:01AM URINE RBC-1 WBC-18* Bacteri-NONE Yeast-NONE
Epi-2 TransE-<1
[**2158-12-3**] 10:01AM URINE CastHy-1*
[**2158-12-3**] 10:01AM URINE Mucous-RARE
.
Discharge Labs:

.
Microbiology:
[**2158-12-5**]	STOOL	Cryptosporidium/Giardia (DFA) - NEGATIVE
[**2158-12-5**]	CMV Viral Load - none detected
[**2158-12-3**]	URINE CULTURE - no growth
[**2158-12-2**]	BLOOD CULTURE - PENDING
[**2158-12-1**]	BLOOD CULTURE - PENDING
.
Imaging:
CXR ([**12-1**]):
PA AND LATERAL VIEWS OF THE CHEST: Cardiac silhouette size is
normal. The aortic knob is mildly calcified. Mediastinal and
hilar contours are unremarkable. The pulmonary vascularity is
normal. Minimal atelectasis is noted in the left lung base. No
focal consolidation, pleural effusion or pneumothorax is
present. There are no acute osseous abnormalities.
IMPRESSION: Mild left basilar atelectasis.
.
CT abdomen and pelvis ([**12-1**]):
FINDINGS:
CT OF THE ABDOMEN: There is dependent bibasilar atelectasis.
Coronary artery calcifications are mild. The liver enhances
homogenously and there are no focal liver lesions. There is mild
prominence of the intrahepatic biliary ducts, unchanged, with no
extrahepatic biliary duct dilatation. The hepatic and portal
veins are patent. The gallbladder, pancreas, spleen, and adrenal
glands are unremarkable. A heterogeneous mass in the interpolar
region of the right kidney is again noted, measuring 3.4 x 3.4
cm (601B:49) as seen on recent CT of the abdomen and pelvis. A
second lesion measuring 6-mm is noted in the upper pole of the
right kidney (601b:49), which is not completely characterized.
The distal esophagus is filled with fluid and a small hiatal
hernia is noted. The stomach and proximal small bowel is
otherwise unremarkable. Small amount of perihepatic fluid is
present. No free air. No pathologically enlarged mesenteric or
retroperitoneal lymph nodes. A fat-containing ventral abdominal
hernia is noted.
CT OF THE PELVIS: A 6-cm segment of terminal ileum with mural
edema, mucosal hyperenhancement, surrounding fat stranding and
mild luminal narrowing is present, which appears similar when
compared to the prior study. Proximal to this finding are
multiple distended fluid filled loops of small bowel measuring
up to 3-cm with transition point noted at the inflamed terminal
ileum (2:70). A focal area of narrowing with mural enhancing and
thickening is also noted at the junction between the cecum and
the ascending colon (2:64), similar to [**2158-11-24**]. Other areas of
small bowel wall thickening seen on the prior CT from [**11-23**], [**2157**] are not present on the current exam. The appendix is
again diffusely dilated to 12-mm, which is not significantly
changed in the interval, and is fluid filled, though, no
secondary signs of inflammation are present to indicate acute
appendicitis. There is a small amount of free fluid in the right
lower quadrant and cul-de-sac. The distal portions of the colon
are collapsed from the hepatic flexure to the rectum. There is
sigmoid diverticulosis without evidence of diverticulitis. The
urinary bladder is unremarkable. The uterus and adnexa are not
visualized. There is no pelvic or inguinal lymphadenopathy.
There are bilateral fat-containing inguinal hernias. Surgical
clips are seen in the left inguinal region.
VASCULATURE: There are diffuse atherosclerotic changes
throughout the descending aorta with stenosis of the celiac and
SMA.
OSSEOUS STRUCTURES: There are multilevel degenerative changes of
the thoracic and lumbar spine. No suspicious osseous lytic or
blastic lesions are identified.
IMPRESSION:
1. Terminal ileitis and focal colitis, not significantly changed
from the prior CT from [**2158-11-24**] now causing upstream small-bowel
obstruction. Findings may be due to an inflammatory or
infectious process. Other previously noted areas of small bowel
wall thickening have resolved.
2. Unchanged right interpolar renal mass concerning for
neoplasm. A possible second smaller right upper pole lesion
measuring 6-mm is also noted. Again, urological consultation is
recommended, and an MRI can be obtained for further evaluation.
.
KUB ([**12-3**]):
There is diffuse distention of small bowel loops measuring up to
4.2 cm. There are a few air-fluid levels. There is no free air
within the abdomen. There is a small amount of air in the
rectum. There are no pathological intraabdominal calcifications.
IMPRESSION: stable small bowel obstruction compared to prior CT
from [**12-1**].
.
MR Enterography ([**12-6**]):
FINDINGS: There is a small bowel obstruction with dilated loops
of small bowel measuring up to 3.5 cm, little changed in extent
since the prior CT from [**2158-12-1**]. In addition, there is a
fluid-dilated cecum. There is an abrupt transition demonstrated
within the ascending colon (1001:59) where mild inflammatory
change is still demonstrated. No eccentric wall thickening is
appreciated in this level. No endoluminal mass is identified in
this region. There is a small-to-moderate intra-abdominal
ascites and free fluid layering to the pelvis. Previously noted
area of terminal ileitis is improved with no inflammatory change
demonstrated within the region. The appendix is dilated, likely
secondary inflammatory changes related to known focal ascending
colitis. The extent of ascending colitis is little changed since
[**2158-12-1**]. No adenopathy is identified. Demonstrated within the
interpolar region of the right kidney extending to the hilum,
there is a 4.0 x 3.3 heterogeneously enhancing solid mass highly
concerning for renal cell carcinoma. This is partially evaluated
on this examination. The liver, gallbladder, spleen, pancreas,
left kidney, both adrenal glands are unremarkable. Incidentally
noted is a left paramedian fat-containing ventral hernia (6:62).
The rectum and sigmoid colon, demonstrating diverticulosis, are
decompressed.
The bladder and adnexa are unremarkable. There is no pelvic or
inguinal lymphadenopathy.
IMPRESSION:
1. Small bowel obstruction and obstruction of the cecum
secondary to a focal segment of persistent ascending colitis,
little changed from [**2158-12-1**].
2. Heterogeneously enhancing 3.4 x 3.4 cm mass centered within
the interpolar region of the right kidney extending to the renal
hilum highly concerning for renal cell carcinoma, partially
evaluated on this MR enterography.
3. Mild-to-moderate intra-abdominal ascites.
4. 4.2-cm fat-containing paramedian abdominal ventral wall
hernia.
.

Brief Hospital Course:
82F with h/o HTN, HLD, chronic 2yr h/o paroxysmal abdominal pain
of unclear etiology p/w recurrent abdominal pain and CT evidence
of SBO.
.
# Bowel Obstruction:  The patient on admission had CT evidence
of obstruction with recent nausea and vomiting, current burping,
and no recent flatus.  Her abdominal exam was benign with some
mild distension.  Patient preferred to try to manage
conservatively, but this was not successful.  An NGT was placed
for abdominal decompression.  She continued to have nausea with
any intake.  MR Enterography performed for diagnostic purposes
[**12-6**] revealed continued obstruction due to persistent cecal
inflammation.  Due to the prolonged course of her obstruction,
PPN was started to provide some nutritional support and aid
healing, however, this was discontinued on [**12-7**].
.
# Ileitis and enterocolitis:  Recent workup was concerning for
ventral hernia, chronic mesenteric ischemia, inflammatory bowel
disease, infectious colitis, and malignancy.  As the patient had
a recent extensive workup, there was no need to repeat stool
studies, colonoscopy, imaging.   TTG-IgA for possible celiac was
negative, as was CMV viral load and cryptococcus and Giardia
antigens.  The Gastroenterology team was consulted and
recommended MR enterography to further investigate her symptoms.
 This showed that the ileitis had resolved, but that the colitis
at the cecum persisted.  There was no clear evidence by imaging
or prior colonoscopy as to the etiology of this finding.  On
discussion with Gastroenterology and Surgery, she underwent a
right hemicolectomy with end-ileostomy on [**12-8**].

# Leukocytosis:  WBC on admission 10.8, up from 4.2 [**11-27**].
There was some element of concentration, but insufficient to
explain this difference.  Patient was afebrile, and her only
localizing symptom was abdominal pain.  [**Month (only) 116**] be [**1-18**] SBO, may be a
sign of infection.  Blood and urine cultures were unrevealing.
Leukocytosis resolved.
.
# [**Last Name (un) **]:  Cr 1.6 on admission up from [**Last Name (un) 5348**] 1.2-1.3.  Likely
due to contrast load from CT [**11-24**].  This resolved to [**Month/Day (4) 5348**]
with IV hydration.
.
# Renal mass:  Discovered incidentally on last admission.
Concerning for RCC.   Previously recommended MR renal and
Urology consultation for characterization, was planned for
outpatient follow-up.  On this admission, we continued to
recommend outpatient follow-up, as this is not likely associated
with current symptoms.  Set up appointment with Dr [**Last Name (STitle) 3748**] of
Urology for consultation.
.
#Rehab: The patient was evaluated by physical therapy on [**12-12**]
who felt Inactive Issues:
# Hypertension:  held anti-hypertensives, ASA, statin, restarted
when patient could tolerate PO intake
# Hypothyroid:  Levothyroxine was provided in IV form when the
patient could not tolerate PO
# PMR:  held prednisone until able to take PO.
Transitional Issues:
- Continue follow-up of renal mass with Urology as outpatient
(appt with Dr [**Last Name (STitle) 3748**]
- Continue follow-up with Gastroenterology (appt in early [**Month (only) **])
- Blood and urine cultures pending

Following above hospital course, surgical consultation was
obtained [**12-8**] for [**Month/Year (2) **] of terminal ileal stricture/small
bowel obstruction demonstrated both clinically and on MR
enterography.  Patient was taken to OR on [**12-8**] for right
hemicolectomy with end-ileostomy.  Intra-operative findings were
notable for perforated cecal tumor with narrowing of the
terminal ileum.  Following the procedure the patient was
extubated and brought to the TSICU for further [**Month/Year (2) **]. Right
IJ CVL and radial a-line were placed for improved access.

Neuro: Post-operatively, the patient was received intermittent
IV narcotic analgesics with good effect and adequate pain
control.  Initially postop patient demonstrated altered mental
status and this improved significantly [**2073-12-9**] with return of
mental status to [**Month/Day/Year 5348**].  When tolerating oral intake, the
patient was transitioned to oral pain medications.

CV: Patient was hypotensive postop with requirement of neo
vasopressor support.  Fluid resuscitation was pursued with
crystalloid/colloid fluid.  TTE postop demonstrated hypovolemia
and goal directed resuscitation was pursued.  [**12-9**] patient
weaned pressors and patient remained normotensive.  Home
medications were resumed [**12-12**].  Vital signs were routinely
monitored.

Pulmonary: Patient was extubated at end of procedure [**12-8**] and
patient was placed on supplemental oxygen by nasal cannula.
Pulmonary toilet including incentive spirometry and early
ambulation were encouraged.  The patient was stable from a
pulmonary standpoint; vital signs were routinely monitored.

GI/GU: Post-operatively, the patient was kept NPO w IVF
resuscitation. Her diet was advanced to regular [**12-10**], which was
tolerated well but intake remained suboptimal.  Nutrition
assessed the patient and recommended high protein supplements
with each meal. Ostomy function returned with production
stool/gas [**2074-12-10**]; the patient received ostomy care teaching
from the Ostomy/Wound nurse.  She was also started on a bowel
regimen to encourage ostomy output. Patient was oliguric
postoperatively.  Crystalloid IVF boluses were administered in
conjunction with colloid bolus.  Found to have [**Last Name (un) **] w Cr 1.1
preop to 1.3 postop.  Resuscitation was continued.  [**12-9**] urine
output improved and subsequently creatinine returned to
[**Month/Year (2) 5348**].  [**12-11**] patient received boluses of crystalloid/
colloid in conjunction with lasix to support urine output with
good effect.  Postop Foley was removed on [**12-12**] at midnight; the
patient was subsequently able to void. Intake and output were
closely monitored.

ID: Post-operatively, the patient was started on meropenem for
gastrointestinal contamination intra-operatively.  This was
transitioned to CTX/flagyl.  Intravenous Flagyl was completed on
[**12-12**] and IV ceftriaxone was completed on [**12-14**].  The patient's
temperature was closely watched for signs of infection.

ENDO: Patient maintained on insulin sliding scale per ICU
protocol. Received IV equivalent levothyroxine.  These were
transitioned to po medications per home regimen when tolerating
regular diet.  Also resumed home dose steroids [**12-12**].

Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.

DISPO: Patient admitted to TSICU postoperatively for hypotension
and oliguria.  These recovered with IVF/colloid resuscitation
with pressor wean and improvement in urine output.  Patient
stable for transfer to floor [**12-10**]. She was re-evaluated by
physical therapy who felt the patient was experiencing worsening
functional status related to her recent surgical procedure and
would require discharge to a rehab facility.

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


Medications on Admission:
simvastatin 20 mg DAILY
aspirin 81 mg DAILY
levothyroxine 25 mcg Tablet DAILY
prednisone 5 mg EVERY OTHER DAY
ferrous sulfate 300  mg DAILY
omeprazole 40 mg Capsule DAILY
triamterene-hydrochlorothiazide 37.5-25 mg DAILY
atenolol 100 mg DAILY
dicyclomine 10 mg four times a day as needed for abdominal pain.

Citrucel  Oral

Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 **]

Discharge Diagnosis:
bowel obstruction


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:
It was a pleasure taking care of you at [**Hospital1 827**].  You came to the hospital with abdominal pain.
This has been a chronic problem for you, worsening in the last
few months.  You had been recently discharged from our facility
with planned outpatient follow-up, however you felt your
symptoms were worsening.  You were found to have a bowel
obstruction, a condition in which inflamed bowel becomes tangled
and does not allow passage of stomach contents.   This caused
nausea, vomiting, and pain.

You were treated conservatively with bowel rest and IV fluids.
A nasogastric tube was placed to help decompress your stomach to
allow the obstruction to resolve.  Our Gastroenterology team
evaluated your case and obstruction during your stay.  They
recommended several tests to continue the workup of your
abdominal pain, including an MR enterography of the small bowel.
 This revealed significant inflammation of the cecum, the
initial section of the colon.  The gastroenterology team, in
conjuction with the surgical team, recommended proceeding with
an operation, which you underwent on [**2158-12-8**] as mentioned
above.

While recovering from your surgery, you received teaching from
the Ostomy/ Wound Nurse [**First Name (Titles) **] [**Last Name (Titles) **] of your ostomy appliance.
 You were also evaluated by the Physical Therapist felt you
would benefit from discharge to a rehabilitation facility
following discharge.  You are now preparing for discharge to a
rehabiliation facility.

Followup Instructions:
You will need to follow-up with the Acute Care Service within 2
weeks from discharge.  Please call [**Telephone/Fax (1) 600**] to schedule your
appointment. Other follow-up appointments include:

Department:  UROLOGY
When:  Thursday, [**2158-12-21**] at 11:00 AM
With:  Dr [**Last Name (STitle) 3748**], ([**Telephone/Fax (1) 8791**]
Building:  [**Hospital Ward Name 23**] building, [**Location (un) 470**]
Campus:  East    Best Parking:  [**Hospital Ward Name 23**]

Department: GASTROENTEROLOGY
When: WEDNESDAY [**2158-12-20**] at 12:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2158-12-14**]
{'Neoplasm of unspecified nature of digestive system,Perforation of intestine,Acute kidney failure with lesion of tubular necrosis,Other specified intestinal obstruction,Regional enteritis of small intestine,Hyposmolality and/or hyponatremia,Laparoscopic surgical procedure converted to open procedure,Other and unspecified hyperlipidemia,Other chronic pain,Polymyalgia rheumatica,Peripheral vascular disease, unspecified,Unspecified acquired hypothyroidism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Personal history of pulmonary embolism,Esophageal reflux,Other drugs and medicinal substances 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: abdominal pain

PRESENT ILLNESS: 82F with h/o HTN, HLD, chronic 2yr h/o paroxysmal abdominal pain
of unclear etiology, discharged from [**Hospital1 18**] 2d ago. She has
experienced chronic abdominal pain since [**2154**] but in past few
year or so has been in and out of EDs without any specific
etiology found. In the past 6 months she has had increased
severity and frequency in pain.
.
During her most recent admission last week, the patient was
transferred from OSH with tearing abdominal pain. Vascular
Surgery admitted her out of concern for ischemic entero-colitis
of terminal ileum and cecum.  Imaging was nonconcerning for
significant vascular impairment of the mesenteric system. She
was transferred to the Medicine service for further GI workup.
Stool studies were negative for infectious etiology. Colonoscopy
done [**11-27**] and [**11-28**] showed no significant findings, Bx results
benign hyperplastic polyp. Pt was asymptomatic during her stay
and tolerated PO well, so d/c with close GI outpatient follow-up
planned. On review of CT scan after colonoscopy, there was a
concern for ventral hernia possibly causing paroxysmal attacks
of abdominal pain.
.
She returned home and ate soft foods out of concern for
recurrent GI pain.  Early this morning she noted recurrent
abdominal pain and presented to [**Hospital3 **].  She was
transferred here for continued GI workup.
.
In the ED, vitals: 98.1  62  112/57  16  94%. Pain described as
"cutting" in the epigastric region, associated with nausea and
sweats, but no changes in BM, SOB, CP, back pain. Belly was felt
to be soft, distended, tender throughout, with positive BS's.
She denied any obstructive symptoms. CT abd/pelvis with contrast
obtained with wet read showing: "terminal ileitis and colitis in
similar distribution to CT on [**2158-11-24**]. Now causing small bowel
obstruction proximal to 6 cm narrowed segment of terminal ileum.
Appendix is dilated and fluid-filled, similar to [**2158-11-24**]." CXR
showed L basilar atelectasis only.
.
Surgery was consulted, and per verbal discussion concluded that
the patient had no obstructive symptoms. She has been recently
at her [**Month/Day/Year 5348**] of 2 loose BM's per day. She takes iron
supplements, so stool is dark at [**Month/Day/Year 5348**]. No surgical
intervention planned, conservative [**Month/Day/Year **].  Pt was given 1L
NS, 2 doses IV Dilaudid and one IV Zofran. Vitals before
transfer: 98.2  66  16  142/68.
.
On the floor, she denies nausea or abdominal pain.

MEDICAL HISTORY: PE in [**2147**]
Polymyalgia rheumatica
Chronic abdominal pain of presently unclear etiology
PVD
[**Name (NI) 2091**] with [**Name (NI) 5348**] Cr 1.3 in [**11/2158**]
Hypertension
Hypothyroidism
Hypercholesterolemia
GERD
Osteoarthritis
Glaucoma
Chronic abdominal pain
H/o diverticulitis treated with antibiotics
.
SURGICAL HISTORY:
L fem-[**Doctor Last Name **] bypass [**2147**] at [**Hospital1 336**]
tubal ligation
hysterectomy
back surgery
hemorrhoid surgery
cataracts b/l

MEDICATION ON ADMISSION: simvastatin 20 mg DAILY
aspirin 81 mg DAILY
levothyroxine 25 mcg Tablet DAILY
prednisone 5 mg EVERY OTHER DAY
ferrous sulfate 300  mg DAILY
omeprazole 40 mg Capsule DAILY
triamterene-hydrochlorothiazide 37.5-25 mg DAILY
atenolol 100 mg DAILY
dicyclomine 10 mg four times a day as needed for abdominal pain.

ALLERGIES: morphine / Penicillins / Cipro

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: 96.1  BP: 118/64  P: 75  R: 24  O2:  96% RA
General: Alert, oriented, no acute distress
HEENT: EOMI, PE non responsive [**1-18**] cataract surgery, Sclera
anicteric, dry MM, OP clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, mildly distended, hypoactive bowel
sounds, no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, strength 5/5 throughout, motor function
grossly normal
Psych:  drifts off during conversation, but oriented and able to
narrate her history well

FAMILY HISTORY: Denies family history of IBD or chronic abdominal pain.  Mother
had borderline DM and died of a heart attack. Father with heart
disease, 1 son with heart disease. Denies family history of
vascular disease.

SOCIAL HISTORY: Lives in her own apartment in NH. Independent in her ADL's. Has
2 sons and 1 daughter. Denies tobacco use, EtOH consumption, and
illicits 

### Response:
{'Neoplasm of unspecified nature of digestive system,Perforation of intestine,Acute kidney failure with lesion of tubular necrosis,Other specified intestinal obstruction,Regional enteritis of small intestine,Hyposmolality and/or hyponatremia,Laparoscopic surgical procedure converted to open procedure,Other and unspecified hyperlipidemia,Other chronic pain,Polymyalgia rheumatica,Peripheral vascular disease, unspecified,Unspecified acquired hypothyroidism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Personal history of pulmonary embolism,Esophageal reflux,Other drugs and medicinal substances causing adverse effects in therapeutic use'}
