CHIEF COMPLAINT: Fever, Abdominal Pain, Hypotension

PRESENT ILLNESS: 22-year-old female with history of gastroparesis with
intermittently occuring ileus/obstruction, multiple ex-laps for
obstructions who now presents to the floor from the ICU
following transfer from OSH with hypotension, fevers and
abdominal pain.
.
Over the last few months, the patient has noted an increased in
the frequency of "ileus and SBO" episodes, which are generally
preceded by nausea, vomiting and abdominal pain. She typically
is admitted and decompressed and then generally feels better.
This most recent episode also began on the night of [**1-24**]
with LUQ pain which is present at baseline as a dull ache, but
now had a "sharp, gnawing quality" and occasionally traveled to
the right. She denies any changes in the pain with position. She
also began to experience nausea and vomiting, which was
non-bloody, non bilious.
.
She presented to [**Hospital1 **] on [**1-25**], where she was initially
imaged for evidence of intususception. She was then given 1g of
erythromycin IV. When this failed to provide relief, an NG tube
was placed for decompression. On [**1-30**], a PICC line was placed and
the patient was started on TPN as well as octreotride. Over the
next few days, the patient began to feel much better from a pain
and N/V standpoint and asked to start clears on [**2-2**]. However, on
[**2-3**], the patient spiked a low grade temperature to 100.9 and
worsening abdominal pain, nausea and vomiting. She was made NPO
once again. On [**3-22**] overnight she spiked a temperature to
105.6. She then became hypotensive and was given 2L of IVF and
was started on Vanc/Gent/Zosyn. Her PICC was pulled and tip was
cultured. A subclavian CVL was placed. She was started on
norepinephrine drip and was then transferred to [**Hospital1 18**] for
further evaluation.
.
On arrival to [**Hospital1 18**], vitals were: T 102.5, HR 108, BP 108/51, RR
18, SaO2 100% RA. She was briefly taken off Levophed but
systolic blood pressure dropped and levophed restarted. She was
given 3L IVF. A CT Torso was ordered and was unrevealing. Gen
[**Doctor First Name **] consulted and ID were consulted. She was continued on
Vanc/Zosyn/Micafungin for concerns of line infection.
.
While in the ICU, labs drawn demonstrated a marked pancytopenia,
abnormal diff (elevated monocytes, atypical cells) a
transaminitis with elevated alkaline phosphatase, coagulopathy
(high INR, PT and PTT), low AM cortisol (2.4) and modestly
elevated lipase (73). Cosyntropin stimulation test revealed
appropriate response.  Fibrinogen was also checked and found to
be 260. HIV, HSV, EBV, CMV PCR were sent.
.

MEDICAL HISTORY: PMHx: GERD, Dumping Syndrome, pancreatitis, gastroparesis
(failed Domperidon), bile reflux.
.
PSHx:
[**7-28**] Nissen fundoplication & pyloroplasty
[**8-29**] repeat Nissen fundoplication & hiatal hernia repair
[**10-29**] ERCP
[**11-28**] J-tube, G-tube placement
[**12-30**] Exploratory laparotomy ("kinked bowel")
[**6-29**] ERCP, sphincterotomy, stent placement (removed 10 days
later)
[**2101-3-7**] Roux-en-Y ([**Hospital1 2025**])
[**2102-1-10**] Esophagogastroduodenoscopy and dilatation to a #44.
[**2102-1-10**] Feeding jejunostomy, open, and placement of a left
subclavian for venous access.
[**2102-6-6**] Exploratory lap, lysis of adhesions, takedown of
Roux-en-Y, Billroth I reconstruction, removal of obstructing
gastrostomy tube, gastrojejunostomy and enteroenterostomy and
placement of gastrostomy and change jejunostomy tube.

MEDICATION ON ADMISSION: Transfer Medications
- Esomeprazole 40mg IV BID
- Dilaudid 1mg IV q4H
- Ketorolac 30mg IV x3 doses
- Piperacillin/tazobactam 3.375g IV q6H
- Vancomycin 1g IV x1
- Phengran 25mg rectal q6H
- Acetaminophen 650mg PO q4H prn
- Cepacol PO prn
- Diphenhydramin 12.5mg IV TID prn
- Magnesium sulfate 1g IV daily prn
- Fleet enema 133ml Rectal q24h prn
- Ondansetron 4mg IV q4H prn
- Promethazine 25mg IV q6h prn
- dilaudid 1mg IV q4H prn
.
Home Medications
Erythromycin 500 mg TID
Zofran 4 mg PO Q6H prn

ALLERGIES: Prochlorperazine / Reglan

PHYSICAL EXAM: Admission Exam (ICU):
VS: 102.5 108/51  108  18  100RA
GEN: pleasant, apepars uncomfortable
HEENT: PERRL, pale, sclerae anicteric, neck supple, MMM, no
ulcers/lesions/thrush
CV: RRR, tachycardic, normal S1, S2, no M/G/R
PULM: CTA bilat w/o wheezes/rhonchi/rales
BACK: no focal tenderness, no CVAT
GI: tender primarily in left periumbilical and LLQ area, no
rebound or guarding, normoactive bowel sounds, not distended
MSK: no joint swelling or erythema
EXT: warm and well perfused, no edema, 2+ DP pulses palpable b/l
LYMPH: no cervical, or inguinal lymphadenopathy
SKIN: no rashes, no jaundice
NEURO: AAOx3, PSYCH: anxious, normal affect
Access: L SCL catheter
.
Discharge Exam:
T- 97.3 BP- 96/60 HR- 73 RR- 16 99% on RA
Persistently tender to palpation in ~4 cm lateral to the
umbilicus on the left.

FAMILY HISTORY: Mom has asthma and father is healthy. One sister developed
reflex sympathetic dystrophy but her other two sisters are
healthy. Her grandparents on the mother's side had cancer and
hypertension and her paternal grandmother also had some kind of
[**Last Name 499**] problem probably [**Name2 (NI) 499**] cancer.

SOCIAL HISTORY: Nursing student, works [**Hospital1 **]. Has very supportive friends
and family (mom, dad, sisters). Denies tobacco and ETOH use.
Unspecified septicemia,Septic shock,Other and unspecified coagulation defects,Unspecified protein-calorie malnutrition,Gastroparesis,Severe sepsis,Constipation, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Peritoneal adhesions (postoperative) (postinfection)
Septicemia NOS,Septic shock,Coagulat defect NEC/NOS,Protein-cal malnutr NOS,Gastroparesis,Severe sepsis,Constipation NOS,Elev transaminase/ldh,Peritoneal adhesions
Admission Date:  [**2106-2-5**]              Discharge Date:   [**2106-2-9**]

Date of Birth:  [**2083-2-27**]             Sex:   F

Service: [**Year (4 digits) 662**]

Allergies:
Prochlorperazine / Reglan

Attending:[**First Name3 (LF) 5134**]
Chief Complaint:
Fever, Abdominal Pain, Hypotension

Major Surgical or Invasive Procedure:
Arterial line
Central line
Pressor support


History of Present Illness:
22-year-old female with history of gastroparesis with
intermittently occuring ileus/obstruction, multiple ex-laps for
obstructions who now presents to the floor from the ICU
following transfer from OSH with hypotension, fevers and
abdominal pain.
.
Over the last few months, the patient has noted an increased in
the frequency of "ileus and SBO" episodes, which are generally
preceded by nausea, vomiting and abdominal pain. She typically
is admitted and decompressed and then generally feels better.
This most recent episode also began on the night of [**1-24**]
with LUQ pain which is present at baseline as a dull ache, but
now had a "sharp, gnawing quality" and occasionally traveled to
the right. She denies any changes in the pain with position. She
also began to experience nausea and vomiting, which was
non-bloody, non bilious.
.
She presented to [**Hospital1 **] on [**1-25**], where she was initially
imaged for evidence of intususception. She was then given 1g of
erythromycin IV. When this failed to provide relief, an NG tube
was placed for decompression. On [**1-30**], a PICC line was placed and
the patient was started on TPN as well as octreotride. Over the
next few days, the patient began to feel much better from a pain
and N/V standpoint and asked to start clears on [**2-2**]. However, on
[**2-3**], the patient spiked a low grade temperature to 100.9 and
worsening abdominal pain, nausea and vomiting. She was made NPO
once again. On [**3-22**] overnight she spiked a temperature to
105.6. She then became hypotensive and was given 2L of IVF and
was started on Vanc/Gent/Zosyn. Her PICC was pulled and tip was
cultured. A subclavian CVL was placed. She was started on
norepinephrine drip and was then transferred to [**Hospital1 18**] for
further evaluation.
.
On arrival to [**Hospital1 18**], vitals were: T 102.5, HR 108, BP 108/51, RR
18, SaO2 100% RA. She was briefly taken off Levophed but
systolic blood pressure dropped and levophed restarted. She was
given 3L IVF. A CT Torso was ordered and was unrevealing. Gen
[**Doctor First Name **] consulted and ID were consulted. She was continued on
Vanc/Zosyn/Micafungin for concerns of line infection.
.
While in the ICU, labs drawn demonstrated a marked pancytopenia,
abnormal diff (elevated monocytes, atypical cells) a
transaminitis with elevated alkaline phosphatase, coagulopathy
(high INR, PT and PTT), low AM cortisol (2.4) and modestly
elevated lipase (73). Cosyntropin stimulation test revealed
appropriate response.  Fibrinogen was also checked and found to
be 260. HIV, HSV, EBV, CMV PCR were sent.
.

Past Medical History:
PMHx: GERD, Dumping Syndrome, pancreatitis, gastroparesis
(failed Domperidon), bile reflux.
.
PSHx:
[**7-28**] Nissen fundoplication & pyloroplasty
[**8-29**] repeat Nissen fundoplication & hiatal hernia repair
[**10-29**] ERCP
[**11-28**] J-tube, G-tube placement
[**12-30**] Exploratory laparotomy ("kinked bowel")
[**6-29**] ERCP, sphincterotomy, stent placement (removed 10 days
later)
[**2101-3-7**] Roux-en-Y ([**Hospital1 2025**])
[**2102-1-10**] Esophagogastroduodenoscopy and dilatation to a #44.
[**2102-1-10**] Feeding jejunostomy, open, and placement of a left
subclavian for venous access.
[**2102-6-6**] Exploratory lap, lysis of adhesions, takedown of
Roux-en-Y, Billroth I reconstruction, removal of obstructing
gastrostomy tube, gastrojejunostomy and enteroenterostomy and
placement of gastrostomy and change jejunostomy tube.


Social History:
Nursing student, works [**Hospital1 **]. Has very supportive friends
and family (mom, dad, sisters). Denies tobacco and ETOH use.


Family History:
Mom has asthma and father is healthy. One sister developed
reflex sympathetic dystrophy but her other two sisters are
healthy. Her grandparents on the mother's side had cancer and
hypertension and her paternal grandmother also had some kind of
[**Last Name 499**] problem probably [**Name2 (NI) 499**] cancer.

Physical Exam:
Admission Exam (ICU):
VS: 102.5 108/51  108  18  100RA
GEN: pleasant, apepars uncomfortable
HEENT: PERRL, pale, sclerae anicteric, neck supple, MMM, no
ulcers/lesions/thrush
CV: RRR, tachycardic, normal S1, S2, no M/G/R
PULM: CTA bilat w/o wheezes/rhonchi/rales
BACK: no focal tenderness, no CVAT
GI: tender primarily in left periumbilical and LLQ area, no
rebound or guarding, normoactive bowel sounds, not distended
MSK: no joint swelling or erythema
EXT: warm and well perfused, no edema, 2+ DP pulses palpable b/l
LYMPH: no cervical, or inguinal lymphadenopathy
SKIN: no rashes, no jaundice
NEURO: AAOx3, PSYCH: anxious, normal affect
Access: L SCL catheter
.
Discharge Exam:
T- 97.3 BP- 96/60 HR- 73 RR- 16 99% on RA
Persistently tender to palpation in ~4 cm lateral to the
umbilicus on the left.

Pertinent Results:
Labs on transfer to [**Hospital1 18**]:
[**2106-2-5**] 04:23PM   LACTATE-0.6
[**2106-2-5**] 12:06PM BLOOD WBC-1.6*# RBC-2.71* Hgb-7.6* Hct-21.8*
MCV-80* MCH-28.0 MCHC-34.9 RDW-13.2 Plt Ct-60*#
[**2106-2-5**] 12:06PM BLOOD Neuts-62.8 Lymphs-26.9 Monos-7.6 Eos-2.1
Baso-0.5
[**2106-2-5**] 12:06PM BLOOD PT-17.6* PTT-34.1 INR(PT)-1.6*
[**2106-2-5**] 12:06PM BLOOD Glucose-97 UreaN-6 Creat-0.6 Na-135 K-3.5
Cl-110* HCO3-20* AnGap-9
[**2106-2-5**] 12:06PM BLOOD ALT-121* AST-246* LD(LDH)-304*
AlkPhos-144* TotBili-0.2
.
Notable labs:
Blood, urine, and catheter tip cultures all NGTD on day of
discharge
.
HSV 1 and 2 Ab: negative
.
[**Last Name (un) **] stim test:
[**2106-2-6**] 04:44PM BLOOD Cortsol-11.9
[**2106-2-6**] 04:44PM BLOOD Cortsol-25.5*
[**2106-2-6**] 05:48PM BLOOD Cortsol-29.1*
.
[**2106-2-6**] 05:23PM BLOOD HIV Ab-NEGATIVE
.
CT Torso:
IMPRESSION:

1. No acute intra-abdominal abnormality to explain the patient's
symptoms.
Trace intra-abdominal simple free fluid which is of uncertain
significance.

2. Small right and trace left pleural effusions with associated
compressive
atelectasis.

3. Nonspecific simple free fluid in the abdomen.
.
On discharge:
[**2106-2-9**] 06:02AM BLOOD WBC-3.0* RBC-3.62* Hgb-9.8* Hct-29.2*
MCV-81* MCH-27.1 MCHC-33.6 RDW-13.4 Plt Ct-124*
[**2106-2-7**] 05:56AM BLOOD PT-14.5* PTT-31.1 INR(PT)-1.3*
[**2106-2-9**] 06:02AM BLOOD ALT-74* AST-42* AlkPhos-150* TotBili-0.2
.


Brief Hospital Course:
22-year-old female with gastroparesis and multiple GI surgeries
who presents from OSH with hypotension, fevers and abdominal
pain concerning for sepsis. No source for sepsis was discovered.

.
#Sepsis: The patient was transferred from [**Hospital1 **]-[**Location (un) 620**] where she
was admitted for gastroparesis exacerbation/decompression. Later
in her admission, after the initiation of TPN via PICC, the
patient developed high fevers, hypotension and tachycardia
concerning for infection with septic physiology. Her
hemodynamics and fever curve improved rapidly with 3L IVF on
arrival to ICU and broad antimicrobials (Vanc/Zosyn/Micafungin).
She transiently required pressors. CXR was without evidence of
consolidation. Her abdominal exam was initially concerning
although no evidence of free air was found on imaging and CT
torso without evidence of acute infectious process. Given her
pancytopenia, there was also concern for viral or atypical
infection. ID was consulted and recommended checking CMV VL,
HSV, EBV and HIV serologies which were sent. Her monospot test
was negative, and EBV serology was consistent with past EBV
infection but no acute infection. HIV and CMV testing were
negative. On transfer to the floor, she remained hemodynamically
stable with SBPs in the 90s-100s. Following discussion with ID,
micafungin was d/c'd. She was taken off IVF fluids when her diet
was advanced to clear liquids, and she remained hemodynamically
stable. At the time of discharge, blood, urine, and mycolytic
cultures were all negative. The patient was discharged to
complete a 10-day course of ciprofloxacin/flagyl at the
recommendation of ID. Parvovirus and herpes virus studies were
pending at the time of discharge. The patient also had a
cortisol-stim test, which was normal.
.
# Abdominal pain: On arrival to the ICU, the patient described
both a LUQ pain that represented an exacerbation of baseline
pain as well as a crampy periumbilical pain that was new. Her
LUQ pain was thought to be secondary to adhesions/dysmotility,
whereas her new periumblical pain was thought to be due to
constipation. CT Torso did not reveal any other significant
pathology. She was given methylnaltrexone x1 in the ICU and then
was given a bowel regimen on the floor with enemas, but she did
not produce any stool. She passed regular flatus. She tolerated
a regular diet prior to discharge, though still required
intermittent dilaudid and zofran.
.
# Pancytopenia:
The patient initially demonstrated pancytopenia with WBC count
of 1.0, Hct of 21.2 and ANC of 400-600. She was transfused 2 U
of PRBC and continued on broad spectrum antibiotics. Her WBC
count slowly improved. ANC was > 1500 on the day of discharge.
This was felt to be most likely due to an underlying viral
infection or potentially related to sepsis of unknown source.
.
# Transaminitis:
Liver enzymes, including AST, ALT, and AlkP were elevated on
transfer. As her sepsis resolved these values all trended down,
suggesting that the initial rise was likely due to shock liver
in the setting of sepsis.
.
# Nutrition: The patient was malnourished with a low serum
albumin of 2.7, as well as coaguloapathy (elevated PT/PTT/INR)
that responded to Vitamin K administration. She did not receive
TPN after transfer and instead was advanced to sips/clears on
arrival to the floor, which she tolerated without any problems.
She was tolerating a regular diet on the day of discharge.
.
The patient was discharged with PCP [**Last Name (NamePattern4) 702**]. She had plans to
see Dr. [**Last Name (STitle) **] at [**Hospital1 2025**] to have a feeding tube placed to help manage
her chronic symptoms. Communication was with the patient and her
mother.


Medications on Admission:
Transfer Medications
- Esomeprazole 40mg IV BID
- Dilaudid 1mg IV q4H
- Ketorolac 30mg IV x3 doses
- Piperacillin/tazobactam 3.375g IV q6H
- Vancomycin 1g IV x1
- Phengran 25mg rectal q6H
- Acetaminophen 650mg PO q4H prn
- Cepacol PO prn
- Diphenhydramin 12.5mg IV TID prn
- Magnesium sulfate 1g IV daily prn
- Fleet enema 133ml Rectal q24h prn
- Ondansetron 4mg IV q4H prn
- Promethazine 25mg IV q6h prn
- dilaudid 1mg IV q4H prn
.
Home Medications
Erythromycin 500 mg TID
Zofran 4 mg PO Q6H prn

Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
4. Miralax 17 gram Powder in Packet Sig: Seventeen (17) grams PO
once a day as needed for constipation.
5. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
6. erythromycin 500 mg Tablet Sig: One (1) Tablet PO TID w/
meals: to stimulate intestinal motility.
7. Zofran 4 mg Tablet Sig: One (1) Tablet PO every six (6) hours
as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
8. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Sepsis with unknown source
Hypotension
Neutropenia

Primary:
Sepsis with unknown source
Hypotension
Neutropenia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were transferred from [**Hospital3 67383**]
Center for sepsis. You required a brief stay in the ICU and you
were briefly on medications to help support your blood pressure.
We have not determined a cause of your infection, but we presume
that the source was from the gastrointestinal tract given your
complex surgical history or possibly from the PICC line and TPN.
You will complete a 10-day course of antibiotics. Also, your
blood counts were transiently low, but they appear to be
recovering.
.
We made the following changes to your medications:
We STARTED Ciprofloxacin
We STARTED Metronidazole
Last day of antibiotics is [**2-14**]
.
Your follow-up information is listed below.

Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) 8826**] [**Last Name (NamePattern1) 19115**]
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**] CENTER
Address: [**Street Address(2) 3861**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 3858**]
Appt: Thursday [**2-11**] at 11:45am

You should also follow-up with your Gastroenterologists with the
already scheduled appointments.
{'Unspecified septicemia,Septic shock,Other and unspecified coagulation defects,Unspecified protein-calorie malnutrition,Gastroparesis,Severe sepsis,Constipation, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],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: Fever, Abdominal Pain, Hypotension

PRESENT ILLNESS: 22-year-old female with history of gastroparesis with
intermittently occuring ileus/obstruction, multiple ex-laps for
obstructions who now presents to the floor from the ICU
following transfer from OSH with hypotension, fevers and
abdominal pain.
.
Over the last few months, the patient has noted an increased in
the frequency of "ileus and SBO" episodes, which are generally
preceded by nausea, vomiting and abdominal pain. She typically
is admitted and decompressed and then generally feels better.
This most recent episode also began on the night of [**1-24**]
with LUQ pain which is present at baseline as a dull ache, but
now had a "sharp, gnawing quality" and occasionally traveled to
the right. She denies any changes in the pain with position. She
also began to experience nausea and vomiting, which was
non-bloody, non bilious.
.
She presented to [**Hospital1 **] on [**1-25**], where she was initially
imaged for evidence of intususception. She was then given 1g of
erythromycin IV. When this failed to provide relief, an NG tube
was placed for decompression. On [**1-30**], a PICC line was placed and
the patient was started on TPN as well as octreotride. Over the
next few days, the patient began to feel much better from a pain
and N/V standpoint and asked to start clears on [**2-2**]. However, on
[**2-3**], the patient spiked a low grade temperature to 100.9 and
worsening abdominal pain, nausea and vomiting. She was made NPO
once again. On [**3-22**] overnight she spiked a temperature to
105.6. She then became hypotensive and was given 2L of IVF and
was started on Vanc/Gent/Zosyn. Her PICC was pulled and tip was
cultured. A subclavian CVL was placed. She was started on
norepinephrine drip and was then transferred to [**Hospital1 18**] for
further evaluation.
.
On arrival to [**Hospital1 18**], vitals were: T 102.5, HR 108, BP 108/51, RR
18, SaO2 100% RA. She was briefly taken off Levophed but
systolic blood pressure dropped and levophed restarted. She was
given 3L IVF. A CT Torso was ordered and was unrevealing. Gen
[**Doctor First Name **] consulted and ID were consulted. She was continued on
Vanc/Zosyn/Micafungin for concerns of line infection.
.
While in the ICU, labs drawn demonstrated a marked pancytopenia,
abnormal diff (elevated monocytes, atypical cells) a
transaminitis with elevated alkaline phosphatase, coagulopathy
(high INR, PT and PTT), low AM cortisol (2.4) and modestly
elevated lipase (73). Cosyntropin stimulation test revealed
appropriate response.  Fibrinogen was also checked and found to
be 260. HIV, HSV, EBV, CMV PCR were sent.
.

MEDICAL HISTORY: PMHx: GERD, Dumping Syndrome, pancreatitis, gastroparesis
(failed Domperidon), bile reflux.
.
PSHx:
[**7-28**] Nissen fundoplication & pyloroplasty
[**8-29**] repeat Nissen fundoplication & hiatal hernia repair
[**10-29**] ERCP
[**11-28**] J-tube, G-tube placement
[**12-30**] Exploratory laparotomy ("kinked bowel")
[**6-29**] ERCP, sphincterotomy, stent placement (removed 10 days
later)
[**2101-3-7**] Roux-en-Y ([**Hospital1 2025**])
[**2102-1-10**] Esophagogastroduodenoscopy and dilatation to a #44.
[**2102-1-10**] Feeding jejunostomy, open, and placement of a left
subclavian for venous access.
[**2102-6-6**] Exploratory lap, lysis of adhesions, takedown of
Roux-en-Y, Billroth I reconstruction, removal of obstructing
gastrostomy tube, gastrojejunostomy and enteroenterostomy and
placement of gastrostomy and change jejunostomy tube.

MEDICATION ON ADMISSION: Transfer Medications
- Esomeprazole 40mg IV BID
- Dilaudid 1mg IV q4H
- Ketorolac 30mg IV x3 doses
- Piperacillin/tazobactam 3.375g IV q6H
- Vancomycin 1g IV x1
- Phengran 25mg rectal q6H
- Acetaminophen 650mg PO q4H prn
- Cepacol PO prn
- Diphenhydramin 12.5mg IV TID prn
- Magnesium sulfate 1g IV daily prn
- Fleet enema 133ml Rectal q24h prn
- Ondansetron 4mg IV q4H prn
- Promethazine 25mg IV q6h prn
- dilaudid 1mg IV q4H prn
.
Home Medications
Erythromycin 500 mg TID
Zofran 4 mg PO Q6H prn

ALLERGIES: Prochlorperazine / Reglan

PHYSICAL EXAM: Admission Exam (ICU):
VS: 102.5 108/51  108  18  100RA
GEN: pleasant, apepars uncomfortable
HEENT: PERRL, pale, sclerae anicteric, neck supple, MMM, no
ulcers/lesions/thrush
CV: RRR, tachycardic, normal S1, S2, no M/G/R
PULM: CTA bilat w/o wheezes/rhonchi/rales
BACK: no focal tenderness, no CVAT
GI: tender primarily in left periumbilical and LLQ area, no
rebound or guarding, normoactive bowel sounds, not distended
MSK: no joint swelling or erythema
EXT: warm and well perfused, no edema, 2+ DP pulses palpable b/l
LYMPH: no cervical, or inguinal lymphadenopathy
SKIN: no rashes, no jaundice
NEURO: AAOx3, PSYCH: anxious, normal affect
Access: L SCL catheter
.
Discharge Exam:
T- 97.3 BP- 96/60 HR- 73 RR- 16 99% on RA
Persistently tender to palpation in ~4 cm lateral to the
umbilicus on the left.

FAMILY HISTORY: Mom has asthma and father is healthy. One sister developed
reflex sympathetic dystrophy but her other two sisters are
healthy. Her grandparents on the mother's side had cancer and
hypertension and her paternal grandmother also had some kind of
[**Last Name 499**] problem probably [**Name2 (NI) 499**] cancer.

SOCIAL HISTORY: Nursing student, works [**Hospital1 **]. Has very supportive friends
and family (mom, dad, sisters). Denies tobacco and ETOH use. 

### Response:
{'Unspecified septicemia,Septic shock,Other and unspecified coagulation defects,Unspecified protein-calorie malnutrition,Gastroparesis,Severe sepsis,Constipation, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Peritoneal adhesions (postoperative) (postinfection)'}
