CHIEF COMPLAINT: Abdominal pain, persistent portal vein thrombosis.

PRESENT ILLNESS: Mr. [**Known lastname 73394**] is a 51 year-old male with a history of Crohn's
disease who was seen in the emergency room at [**Hospital1 18**] on [**2107-7-31**] with right upper quadrant abdominal pain.  A CT of the
abdomen and pelvis was performed, which demonstrated moderate
colonic fecal load as well as a partially obstructing thrombus
in the right posterior portal vein, main portal vein, and SMV
before the portal vein confluence.  He was discharged home by
the ED and returned again to the ED on [**2107-8-10**].  He once
again was complaining of right upper quadrant abdominal pain and
an ultrasound demonstrated complete portal vein thrombosis.

MEDICAL HISTORY: -Crohn's disease
-Non-alcoholic steatohepatitis with transaminemia
-Glucocorticoid associated osteopenia
-Peri-anal fistula
-Nephrolithiasis requiring lithotripsy
-Osteoporosis (spine T-score -3.0)
-Hypogonadotrophic hypogonadism: treated with clomiphene since
[**1-/2105**] and had been taking testosterone supplementation prior
-Toe fracture and spinal compression fracture
-Ileocolectomy (at least 20cm of small bowel and possibly equal
length of colon) [**2103**] after presenting with an obstruction two
years after stopping 6-MP in effort to conceive

MEDICATION ON ADMISSION: Humira 40mg every other week, clomiphene citrate 50mg qd,
vitamin D2 50,000 U tablet once a week, Lunesta 3mg qhs, Viagra
100mg prn, teriparatide 20mcg sq qhs, tumeric, ursodiol 1500mg
once a day, Align, MVI, omega-3 fatty acids

ALLERGIES: Erythromycin Base / adhesive tape / Tegaderm

PHYSICAL EXAM: Physical Exam on Admission:
Vitals: T 98, HR 105, BP 123/64, RR 16, O2 100RA
Gen: alert and oriented x3, NAD, lying comfortably on gurney;
skin and sclerae anicteric
CV: RRR, no murmur, neck veins flat
Resp: cta bilaterally, no respiratory distress
Abd: well-healed incision c/w previous surgery; soft, ND, +BS;
mildly TTP in RUQ; negative [**Doctor Last Name **] sign; no fluid wave; liver
and spleen not palpable
Extr: warm, 2+ peripheral pulses bilaterally; calves soft,
[**Last Name (un) 5813**] sign negative

FAMILY HISTORY: No clotting/bleeding disorders.  No DVT or PE.

SOCIAL HISTORY: No EtOH, tobacco, or other drug use.
Portal vein thrombosis,Acute vascular insufficiency of intestine,Regional enteritis of small intestine with large intestine,Accidental puncture or laceration during a procedure, not elsewhere classified,Precipitous drop in hematocrit,Abdominal pain, right upper quadrant,Other chronic nonalcoholic liver disease,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Other iatrogenic hypotension,Long-term (current) use of steroids,Disorder of bone and cartilage, unspecified,Constipation, unspecified,Other anterior pituitary disorders,Personal history of pathologic fracture,Anal fistula
Portal vein thrombosis,Ac vasc insuff intestine,Reg enterit sm/lg intest,Accidental op laceration,Drop, hematocrit, precip,Abdmnal pain rt upr quad,Chronic liver dis NEC,Acc cut in med care NEC,Iatrogenc hypotnsion NEC,Long-term use steroids,Bone & cartilage dis NOS,Constipation NOS,Anter pituitary dis NEC,Hx pathological fracture,Anal fistula
Admission Date:  [**2107-8-10**]              Discharge Date:   [**2107-8-18**]

Date of Birth:  [**2056-7-31**]             Sex:   M

Service: SURGERY

Allergies:
Erythromycin Base / adhesive tape / Tegaderm

Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Abdominal pain, persistent portal vein thrombosis.

Major Surgical or Invasive Procedure:
[**2107-8-10**]: Portal venography and thrombolysis.
[**2107-8-11**]: Portal venography, mechanical portal vein thrombolysis.
[**2107-8-12**]: Gelfoam embolization of right hepatic artery branch.
[**2107-8-12**]: Cholecystectomy and attempted portal vein thrombectomy.


History of Present Illness:
Mr. [**Known lastname 73394**] is a 51 year-old male with a history of Crohn's
disease who was seen in the emergency room at [**Hospital1 18**] on [**2107-7-31**] with right upper quadrant abdominal pain.  A CT of the
abdomen and pelvis was performed, which demonstrated moderate
colonic fecal load as well as a partially obstructing thrombus
in the right posterior portal vein, main portal vein, and SMV
before the portal vein confluence.  He was discharged home by
the ED and returned again to the ED on [**2107-8-10**].  He once
again was complaining of right upper quadrant abdominal pain and
an ultrasound demonstrated complete portal vein thrombosis.

Past Medical History:
-Crohn's disease
-Non-alcoholic steatohepatitis with transaminemia
-Glucocorticoid associated osteopenia
-Peri-anal fistula
-Nephrolithiasis requiring lithotripsy
-Osteoporosis (spine T-score -3.0)
-Hypogonadotrophic hypogonadism: treated with clomiphene since
[**1-/2105**] and had been taking testosterone supplementation prior
-Toe fracture and spinal compression fracture
-Ileocolectomy (at least 20cm of small bowel and possibly equal
length of colon) [**2103**] after presenting with an obstruction two
years after stopping 6-MP in effort to conceive

Social History:
No EtOH, tobacco, or other drug use.

Family History:
No clotting/bleeding disorders.  No DVT or PE.

Physical Exam:
Physical Exam on Admission:
Vitals: T 98, HR 105, BP 123/64, RR 16, O2 100RA
Gen: alert and oriented x3, NAD, lying comfortably on gurney;
skin and sclerae anicteric
CV: RRR, no murmur, neck veins flat
Resp: cta bilaterally, no respiratory distress
Abd: well-healed incision c/w previous surgery; soft, ND, +BS;
mildly TTP in RUQ; negative [**Doctor Last Name **] sign; no fluid wave; liver
and spleen not palpable
Extr: warm, 2+ peripheral pulses bilaterally; calves soft,
[**Last Name (un) 5813**] sign negative

Physical Exam on Discharge:
Vitals: T 97.8, HR 90, BP 134/76, RR 18, 99% O2 on RA.
Gen: Alert, oriented, in NAD.
CV: RRR, no m/r/g.
Resp: CTA bilaterally.
Abd: Soft, non tender, mildly distended throughout. Abdominal
incision clean/dry/intact with steri-strips in place. Resolving
right flank ecchymosis.
Ext: 1+ peripheral edema bilateral lower extremities, TEDs in
place. 2+ peripheral pulses throughout.

Pertinent Results:
[**2107-8-9**] 08:30PM BLOOD WBC-11.6* RBC-4.82 Hgb-14.5 Hct-42.5
MCV-88 MCH-30.1 MCHC-34.1 RDW-13.3 Plt Ct-235
[**2107-8-11**] 05:15PM BLOOD Hct-31.6*
[**2107-8-11**] 07:59PM BLOOD Hct-29.4*
[**2107-8-12**] 02:07AM BLOOD WBC-18.1*# RBC-3.85* Hgb-11.3* Hct-32.3*
MCV-84 MCH-29.5 MCHC-35.1* RDW-13.6 Plt Ct-163
[**2107-8-12**] 02:00PM BLOOD WBC-13.9* RBC-3.08* Hgb-9.3* Hct-25.7*
MCV-84 MCH-30.3 MCHC-36.3* RDW-14.1 Plt Ct-194
[**2107-8-12**] 07:18PM BLOOD Hct-29.2*
[**2107-8-13**] 11:59PM BLOOD Hct-29.0* Plt Ct-112*
[**2107-8-14**] 11:37AM BLOOD Hct-31.0*
[**2107-8-16**] 05:54AM BLOOD WBC-10.0 RBC-3.84* Hgb-11.5* Hct-31.9*
MCV-83 MCH-29.9 MCHC-35.9* RDW-15.2 Plt Ct-154
[**2107-8-17**] 05:03AM BLOOD WBC-9.5 RBC-3.89* Hgb-11.4* Hct-32.7*
MCV-84 MCH-29.3 MCHC-34.9 RDW-15.4 Plt Ct-197
[**2107-8-10**] 03:00AM BLOOD PT-13.5* PTT-22.0 INR(PT)-1.2*
[**2107-8-12**] 02:07AM BLOOD PT-15.7* PTT-21.6* INR(PT)-1.4*
[**2107-8-11**] 02:16PM BLOOD PTT-47.9*
[**2107-8-11**] 07:59PM BLOOD PTT-79.3*
[**2107-8-12**] 02:07AM BLOOD PT-15.7* PTT-21.6* INR(PT)-1.4*
[**2107-8-12**] 11:25AM BLOOD PT-14.3* PTT-22.0 INR(PT)-1.2*
[**2107-8-13**] 07:36PM BLOOD PT-13.6* PTT-25.1 INR(PT)-1.2*
[**2107-8-16**] 05:54AM BLOOD PT-12.6 PTT-26.9 INR(PT)-1.1
[**2107-8-17**] 05:03AM BLOOD PT-15.2* PTT-31.7 INR(PT)-1.3*
.
[**2107-8-18**] 05:30AM BLOOD PT-28.2* INR(PT)-2.7* = ***INR ON
DISCHARGE***
.

[**2107-8-10**] 03:00AM BLOOD Fibrino-533*
[**2107-8-11**] 02:11AM BLOOD Fibrino-559*
[**2107-8-13**] 11:59PM BLOOD Fibrino-556*#
.
Hematologic clotting workup laboratory values:
[**2107-8-10**] 03:00AM BLOOD Fact V-100
[**2107-8-10**] 03:00AM BLOOD ProtCFn-85 ProtSAg-92
[**2107-8-10**] 03:00AM BLOOD ACA IgG-3.9 ACA IgM-2.8
[**2107-8-10**] 03:00AM BLOOD PROTHROMBIN MUTATION ANALYSIS-Test:
Negative
.
[**2107-8-9**] 08:30PM BLOOD Glucose-186* UreaN-15 Creat-1.0 Na-135
K-4.4 Cl-99 HCO3-27 AnGap-13
[**2107-8-12**] 03:12PM BLOOD Glucose-133* UreaN-20 Creat-1.3* Na-141
K-5.3* Cl-110* HCO3-25 AnGap-11
[**2107-8-17**] 05:03AM BLOOD Glucose-107* UreaN-12 Creat-0.7 Na-139
K-3.7 Cl-106 HCO3-25 AnGap-12
[**2107-8-9**] 08:30PM BLOOD ALT-25 AST-19 LD(LDH)-167 AlkPhos-85
TotBili-0.3
[**2107-8-12**] 03:12PM BLOOD ALT-145* AST-120* CK(CPK)-194 AlkPhos-41
TotBili-1.8*
[**2107-8-13**] 02:20AM BLOOD ALT-283* AST-225* AlkPhos-60 TotBili-0.9
[**2107-8-14**] 03:20AM BLOOD ALT-209* AST-125* LD(LDH)-281* AlkPhos-68
TotBili-1.3
[**2107-8-17**] 05:03AM BLOOD ALT-97* AST-44* AlkPhos-81 TotBili-0.6
[**2107-8-12**] 03:12PM BLOOD CK-MB-3 cTropnT-<0.01
[**2107-8-12**] 11:10PM BLOOD CK-MB-6 cTropnT-<0.01
[**2107-8-13**] 06:14AM BLOOD CK-MB-5 cTropnT-<0.01
[**2107-8-10**] 07:35AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.0
[**2107-8-12**] 03:12PM BLOOD Albumin-2.3* Calcium-7.9* Phos-4.8*#
Mg-1.8
[**2107-8-17**] 05:03AM BLOOD Albumin-2.5* Calcium-7.7* Phos-2.6*
Mg-2.0
[**2107-8-13**] 11:59PM BLOOD Hapto-97
[**2107-8-13**] 11:59PM BLOOD D-Dimer-6140*
.
Imaging and Interventional Radiology:
.
[**2107-8-9**] Abdominal US:
IMPRESSION:
1. No flow demonstrated in the main or left portal veins,
compatible with
thrombosis. Right portal vein not visualized and is also likely
occluded.
2. Echogenic liver, compatible with fatty infiltration; other
forms of
hepatic cirrhosis/fibrosis cannot be excluded.
3. Focal area of fatty sparing adjacent to the gallbladder in
the right lobe.
3. No gallstones or evidence of acute cholecystitis.
.
[**2107-8-10**] CTA abdomen/pelvis:
IMPRESSION:
1. Thrombosis within the splanchnic venous circulation is more
extensive with
thrombus now seen within the main portal vein, left main portal
vein,
anterior/posterior branches of the right main portal vein, and
throughout much
of the SMV. The splenic vein, IVC, and hepatic veins remain
patent.
2. Enhancing soft tissue lesion within the gallbladder fundus
could be a
polyp or adenomyomatosis.
3. Bilateral small renal hypodensities are too small to
characterize but
statistically are simple cysts.
.
[**2107-8-10**] Portal venography:
FINDINGS:
1. Extensive thrombotic occlusion involving the upper SMV, main
portal vein
and right portal vein.
2. Partial cavernous transformation of the portal vein.
3. Patent splenic vein and inferior mesenteric vein.
4. Prominent coronary vein.
IMPRESSION:
Successful percutaneous transhepatic portal venography and
placement of [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 73395**]-[**Doctor Last Name 6632**] 5 French infusion catheter for TPA infusion.
PLAN:
The patient will return to interventional radiology for repeat
venogram and
potential mechanical thrombectomy/thrombolysis on the following
day.
.
[**2107-8-11**] Portal venography:
1. Initial portal venography demonstrated substantial lysis of
thrombus
burden in the main portal vein and in the distal superior
mesenteric vein
relative to the initial procedure performed on [**2107-8-10**].
2. Mechanical thrombectomy and pulse-spray tPA infusion was
performed in the
main portal vein and distal superior mesenteric vein followed by
mechanical
thrombectomy in the left portal vein.
3. Successful recanalization of the left portal vein by
mechanical
thrombectomy alone.
4. Persistent occlusion of the right portal vein at the
conclusion of the
procedure.
.
[**2107-8-12**] CTA abdomen/pelvis:
IMPRESSION:
1. New large volume of complex fluid within the abdomen is
highly concerning for hemoperitoneum given the patient's history
of recent mechanical portal venous/SMV thrombolysis. There is
evidence of several sites of active extravasation involving
hepatic segment V. Small regions of hyperdense fluid and an
associated locule of air within hepatic segment V also reflect
hepatic injury.
2. Persistent thrombosis of the main portal vein, left main
portal vein, and anterior/posterior branches of the right main
portal vein. Partial occlusion of the SMV is also again noted.
The splenic vein remains patent.
3. New bilateral pleural effusions with associated compressive
atelectasis,
right greater than left.
4. Unchanged enhancing lesion in the gallbladder fundus
measuring 9 x 5 mm
could be a polyp or adenomyomatosis, as previously described on
recent CT.
5. Non-obstructive right renal calculi.
.
[**2107-8-12**] Transcatheter embolization:
IMPRESSION: Identification of a region of active extravasation
at the lateral periphery of segment VI of a branch of the right
hepatic artery. Successful embolization with Gelfoam.
.
[**2107-8-13**] CTA abdomen/pelvis:
IMPRESSION:
1. Interval extension of a portal venous clot now extending
three-fourths of the way to the splenic hilum within the splenic
vein. Interval re
canalization of a small branch of the left portal vein.
2. New areas of heterogeneous enhancement in the segment VI and
inferior
portion of segment VII concerning for early infarction.
3. Moderately high-density fluid around the liver could be
postoperative. No areas of active extravasation noted.

Brief Hospital Course:
On presentation to [**Hospital1 18**] on [**2107-8-10**], the patient was once again
complaining of right upper quadrant abdominal pain, and an
ultrasound demonstrated complete portal vein thrombosis (a
progression from the thrombosis of the right posterior portal
vein and a short segment of the SMV seen on his [**2107-8-1**] CT
abdomen during his recent presentation to the ED for abdominal
pain). On [**2107-8-10**] CT scan demonstrated a thrombosed portal vein
including the main, right and left portal veins and extension of
the clot into the superior mesenteric vein.  He was
anticoagulated and underwent placement of a transhepatic
catheter in the portal vein by interventional radiology on
[**2107-8-10**] with infusion of TPA.  On [**2107-8-11**] he underwent successful
transhepatic percutaneous thrombectomy by interventional
radiology with the AngioJet and additional TPA.  Flow was able
to be reestablished in the main portal vein, superior mesenteric
vein and left portal vein.  The right portal vein could not be
thrombectomized. Postoperatively, he developed hypotension and
was found on CT scan to be bleeding from a branch of the right
hepatic artery that had been injured at the time of the
percutaneous procedure.  He was taken again to interventional
radiology the morning of [**2107-8-12**], where he underwent embolization
of a branch of the right hepatic artery. A CT scan showed a
large amount of blood and clot in the abdomen.  The CT further
demonstrated that the right, left and main portal veins were
once again thrombosed with thrombosis of the superior mesenteric
vein as well.  Therefore the patient was brought to the
operating room for evacuation of the intra-abdominal blood and
hematoma with attempt at open portal vein thrombectomy on
[**2107-8-12**]. A large amount of old blood and clots were then removed.
Since the porta was quite deep and foreshortened, the
gallbladder was removed for better exposure. A dissection to
identify the portal vein was attempted, however due to extensive
collaterals and few viable planes, the attempt at portal vein
thrombectomy was abandoned due to the risk of proceeding.
Hemostasis was obtained, and Surgicel was used superiorly and
inferiorly. The patient returned to the ICU postoperatively, off
his heparin drip and intubated. While in the ICU his hematocrit
was stabilized with multiple units of blood products. A
postoperative CTA abdomen showed no areas of active
extravasation. His heparin drip was restarted on [**2107-8-15**], he was
successfully extubated, and transferred to the floor. Warfarin
was begun on [**2107-8-16**], for a goal INR of [**3-10**]. His heparin drip
was discontinued [**2107-8-17**], and he was begun on enoxaparin 80 mg
twice a day. Enoxaparin teaching was provided, which the patient
received well. On discharge his INR was therapeutic at 2.7. He
was discharged home on warfarin and enoxaparin. His enoxaparin
and warfarin dosages on discharge were appropriately titrated,
and follow up labs were arranged, which the patient will fax to
Dr.[**Name (NI) 1369**] office for further titration and management of his
anticoagulation regimen going forward. His pain medications were
transitioned from IV to oral when the patient was tolerating a
regular diet. On discharge he was in minimal pain, and was
ambulating independently, tolerating a regular diet.
.
While inpatient, the patient was followed by the
gastroenterology service given his history of Crohn's disease,
and also was seen by the hematology service to asses the cause
of his portal vein thrombosis. His home clomiphene and forteo
were held given their association with clotting, and a
hypercoagulability workup was sent, which was entirely negative
at the time of discharge (see labs above). He will follow up
with hematology as an outpatient for potential further
hematologic testing to determine the underlying cause of his
clotting.

Medications on Admission:
Humira 40mg every other week, clomiphene citrate 50mg qd,
vitamin D2 50,000 U tablet once a week, Lunesta 3mg qhs, Viagra
100mg prn, teriparatide 20mcg sq qhs, tumeric, ursodiol 1500mg
once a day, Align, MVI, omega-3 fatty acids

Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
2. Humira 40 mg/0.8 mL Kit Sig: One (1) dose Subcutaneous every
2 weeks: Resume on Sunday [**8-21**].
3. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
4. ursodiol 500 mg Tablet Sig: Three (3) Tablet PO at bedtime.
5. Lunesta 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for insomnia.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
8. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous [**Hospital1 **] (2 times a day): Use evening of [**8-18**] only.
Disp:*10 syringes* Refills:*0*
9. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day: Take
at same time in early evening.
Disp:*150 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Portal Vein Thrombus with extension to the SMV.


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


Discharge Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever, chills,
increased abdominal pain. Monitor for signs of elevated INR from
coumadin to include nosebleed, rectal bleeding, dark/tarry
stool, easy bruising, bleeding that won't stop.
.
Have labs drawn on Monday [**8-22**]. Have results faxed to Dr
[**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 22248**]. Dr [**Last Name (STitle) 4727**] office will follow up
with you regarding any dosage changes and time for next blood
draw.
.
No heavy lifting greater than 10 pounds until notified you may
do so. For now, walking is your best exercise. Timeline for
increasing intensity of exercise is dependent on your progress.
Walking is an excellent exercise for now and is highly
encouraged.
.
No driving if taking narcotic pain medication
You may shower, allow water to run over incision and pat area
dry. No lotions or creams to incision area.
Avoid green/leafy [**Last Name (LF) 73396**], [**First Name3 (LF) 691**] multi-vitamin with Vitamin K
in it. These foods and Vitamin K can alter and bind your
coumadin leaving you with a lower INR and increased risk of clot
extension.

Followup Instructions:
Labs at [**Hospital Ward Name 23**] Building Outpatient Lab Friday [**8-19**]
Labs at [**Hospital Ward Name 1826**] Building [**Location (un) 436**] Saturday [**8-20**] at 8 AM
....
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Last Name (Titles) 23**], [**Location (un) **];
Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2107-8-23**] 10:20
...
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PhD [**Hospital Unit Name **], [**Last Name (NamePattern1) **], [**Location (un) 86**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2107-8-24**] 2:00
...
[**2107-10-5**]  11:00a   [**Last Name (LF) **],[**First Name3 (LF) **] I.
  SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
  HEMATOLOGY/ONCOLOGY-SC
...
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2107-9-27**]
1:20


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]

Completed by:[**2107-8-18**]
{'Portal vein thrombosis,Acute vascular insufficiency of intestine,Regional enteritis of small intestine with large intestine,Accidental puncture or laceration during a procedure, not elsewhere classified,Precipitous drop in hematocrit,Abdominal pain, right upper quadrant,Other chronic nonalcoholic liver disease,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Other iatrogenic hypotension,Long-term (current) use of steroids,Disorder of bone and cartilage, unspecified,Constipation, unspecified,Other anterior pituitary disorders,Personal history of pathologic fracture,Anal fistula'}


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, persistent portal vein thrombosis.

PRESENT ILLNESS: Mr. [**Known lastname 73394**] is a 51 year-old male with a history of Crohn's
disease who was seen in the emergency room at [**Hospital1 18**] on [**2107-7-31**] with right upper quadrant abdominal pain.  A CT of the
abdomen and pelvis was performed, which demonstrated moderate
colonic fecal load as well as a partially obstructing thrombus
in the right posterior portal vein, main portal vein, and SMV
before the portal vein confluence.  He was discharged home by
the ED and returned again to the ED on [**2107-8-10**].  He once
again was complaining of right upper quadrant abdominal pain and
an ultrasound demonstrated complete portal vein thrombosis.

MEDICAL HISTORY: -Crohn's disease
-Non-alcoholic steatohepatitis with transaminemia
-Glucocorticoid associated osteopenia
-Peri-anal fistula
-Nephrolithiasis requiring lithotripsy
-Osteoporosis (spine T-score -3.0)
-Hypogonadotrophic hypogonadism: treated with clomiphene since
[**1-/2105**] and had been taking testosterone supplementation prior
-Toe fracture and spinal compression fracture
-Ileocolectomy (at least 20cm of small bowel and possibly equal
length of colon) [**2103**] after presenting with an obstruction two
years after stopping 6-MP in effort to conceive

MEDICATION ON ADMISSION: Humira 40mg every other week, clomiphene citrate 50mg qd,
vitamin D2 50,000 U tablet once a week, Lunesta 3mg qhs, Viagra
100mg prn, teriparatide 20mcg sq qhs, tumeric, ursodiol 1500mg
once a day, Align, MVI, omega-3 fatty acids

ALLERGIES: Erythromycin Base / adhesive tape / Tegaderm

PHYSICAL EXAM: Physical Exam on Admission:
Vitals: T 98, HR 105, BP 123/64, RR 16, O2 100RA
Gen: alert and oriented x3, NAD, lying comfortably on gurney;
skin and sclerae anicteric
CV: RRR, no murmur, neck veins flat
Resp: cta bilaterally, no respiratory distress
Abd: well-healed incision c/w previous surgery; soft, ND, +BS;
mildly TTP in RUQ; negative [**Doctor Last Name **] sign; no fluid wave; liver
and spleen not palpable
Extr: warm, 2+ peripheral pulses bilaterally; calves soft,
[**Last Name (un) 5813**] sign negative

FAMILY HISTORY: No clotting/bleeding disorders.  No DVT or PE.

SOCIAL HISTORY: No EtOH, tobacco, or other drug use. 

### Response:
{'Portal vein thrombosis,Acute vascular insufficiency of intestine,Regional enteritis of small intestine with large intestine,Accidental puncture or laceration during a procedure, not elsewhere classified,Precipitous drop in hematocrit,Abdominal pain, right upper quadrant,Other chronic nonalcoholic liver disease,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Other iatrogenic hypotension,Long-term (current) use of steroids,Disorder of bone and cartilage, unspecified,Constipation, unspecified,Other anterior pituitary disorders,Personal history of pathologic fracture,Anal fistula'}
