CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: Ms [**Known lastname 89417**] is a 22 year-old female with history of anxiety, s/p
recent rape (both vaginally and anally), which pt admitted to
multiple people was also with insertion of a baseball bat, with
subsequent pregnancy s/p abortion on [**4-7**] who presented to an OSH
with abdominal pain after the procedure. She went to went to
planned parenthood for the 2 day procedure; during second day
had desaturation to 78% and abdominal pain, and was sent to
[**Hospital1 **] for evaluation.  There she was found to have a Hct of
24 and SBPs in the 70's. She was also noted to have ?SVT to the
150's and was given metoprolol and adenosine and was eventually
electrically cardioverted to sinus rhythm. She was given 2 unit
PRBCs and 7 L IVF, and also got FFP. She underwent a CTA which
showed no PE and an abdominal CT with no hemorrhage. Prior to
this presentation in the OSH ED, she had been experience milder
abdominal pain for the past two weeks and had an episode of
BRBPR the day prior to presentation.
.
In the [**Hospital1 18**] ED she had SBPs in the 90s. She was given an
additional unit of PRBC, 2 units FFP, and rhogham. Gynecology
evaluated her and recommended starting zosyn and doxycycline.
She had a left IJ placed and was briefly on neo for pressure
support. On vaginal exam she was noted to have small clots.
Rectal showed trace guaiac stool. Of note she has recently
beeing taking large amounts of ibuprofen for pain. She was
started on an IV PPI.
.
She was initially in respiratory distress on arrival to the MICU
(thought to be due to flash pulmonary edema from the IVF) and
was given lasix. In the MICU her Hcts remained stable with no
further need for transfusion. Her acute anemia was thought to be
a combination of blood loss from her recent abortion and a slow
GI bleed possibly from NSAID-induced gastritis. She has had
significant anxiety and ?PTSD and psychiatry has been following
and making recommendations. She continues to have abdominal pain
and is on a dilaudid PCA. Social work is also following. GI was
consulted and are planning possible EGD/colonoscopy for Tuesday
(will likely need MAC) versus watchful waiting.
.
Additionally she had been placed on prednisone by her
pulmonologist (to be tapered). She was on 60 mg prior to
admission and has been tapered to 40 mg.
.
MICU attempted to call her out [**4-8**] but when the team evaluated
her she was found to have HR in the 150's with significant
anxiety. ? SVT. Sinus massage was attempted, but she was so
shaky, it was difficult to do. When she slowed down (when her
anxiety started to be controled), the rhythm looked like sinus
tach, not SVT, and she was kept in the ICU for 1 more night.
.
Patient continues to have abdominal pain, worst on the L, most
TTP over the CVA on the L. The abdominal pain has been requiring
a dilaudid PCA; ICU team felt she may have nonobstructive
nephrolithiasis vs an ovarian cyst but all imaging is with
contrast, so unclear.  GYN are following and does not think
there is any retained products but thinks may have had
endometritis so have continued course of abx, currently zosyn
and doxycycline.
 .
Upon transfer to the floor, patient is tearful and anxious, c/o
abdominal pain.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.

MEDICAL HISTORY: - ADHD
- asthma
- anxiety
- eating disorder
- h/o nephrolithiasis, always on left, last one 1 month ago
- h/o left ovarian cyst

MEDICATION ON ADMISSION: home meds:
- Adderall
- Vistaril (hydroxyzine

ALLERGIES: morphine / Codeine

PHYSICAL EXAM: On Admission:
Vitals: 110, 117/74, 17, 97% 6L facemask
General: anxious, in pain
HEENT: PERRLA, EOMI, OP clear, no LAD, neck veins flat, L CVL in
place
CV: S1S2, tachycardic, no m/r/g
Chest: limited exam due to shallow breathing, +wheezes,
decreased BS in bilateral bases
Abd: soft, moderate TTP diffusely, pain worst in LLQ, mildly
distended, +BS, no rebound/guarding
GU: (per Ob/gyn) no CMT, minimal blood, diffuse TTP, no discrete
adnexal or fundal TTP
Rectal: (per ED) faintly guiac positive
Ext: no e/c/c, 2+ peripheral pulses
Neuro: CN II-XII grossly intact, moving all 4 extremities
Psych: anxious

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: just quit smoking, denies alcohol and illicit drugs
Other specified complications following abortion or ectopic and molar pregnancy,Unspecified septicemia,Acute edema of lung, unspecified,Sepsis,Acute posthemorrhagic anemia,Hypopotassemia,Asthma, unspecified type, unspecified,Other specified cardiac dysrhythmias,Blood in stool,Abdominal pain, left lower quadrant,Other pain disorders related to psychological factors,Posttraumatic stress disorder,Attention deficit disorder with hyperactivity,History of physical abuse,Unspecified inflammatory disease of uterus,Duodenitis, without mention of hemorrhage,Unspecified analgesic and antipyretic causing adverse effects in therapeutic use,Home accidents,Other chronic pain,Panic disorder without agoraphobia,Personal history of colonic polyps,Headache,Fall from other slipping, tripping, or stumbling,History of fall,Internal hemorrhoids without mention of complication
Postabortion compl NEC,Septicemia NOS,Acute lung edema NOS,Sepsis,Ac posthemorrhag anemia,Hypopotassemia,Asthma NOS,Cardiac dysrhythmias NEC,Blood in stool,Abdmnal pain lt lwr quad,Psychogenic pain NEC,Posttraumatic stress dis,Attn deficit w hyperact,Hx of physical abuse,Uterine inflam dis NOS,Duodenitis w/o hmrhg,Adv eff analgesic NOS,Accident in home,Chronic pain NEC,Panic dis w/o agorphobia,Prsnl hst colonic polyps,Headache,Fall from slipping NEC,Personal history of fall,Int hemorrhoid w/o compl
Admission Date:  [**2164-4-7**]              Discharge Date:   [**2164-4-13**]

Date of Birth:  [**2142-1-26**]             Sex:   F

Service: MEDICINE

Allergies:
morphine / Codeine

Attending:[**First Name3 (LF) 800**]
Chief Complaint:
abdominal pain


Major Surgical or Invasive Procedure:
c-scope and EGD [**2164-4-13**]


History of Present Illness:
Ms [**Known lastname 89417**] is a 22 year-old female with history of anxiety, s/p
recent rape (both vaginally and anally), which pt admitted to
multiple people was also with insertion of a baseball bat, with
subsequent pregnancy s/p abortion on [**4-7**] who presented to an OSH
with abdominal pain after the procedure. She went to went to
planned parenthood for the 2 day procedure; during second day
had desaturation to 78% and abdominal pain, and was sent to
[**Hospital1 **] for evaluation.  There she was found to have a Hct of
24 and SBPs in the 70's. She was also noted to have ?SVT to the
150's and was given metoprolol and adenosine and was eventually
electrically cardioverted to sinus rhythm. She was given 2 unit
PRBCs and 7 L IVF, and also got FFP. She underwent a CTA which
showed no PE and an abdominal CT with no hemorrhage. Prior to
this presentation in the OSH ED, she had been experience milder
abdominal pain for the past two weeks and had an episode of
BRBPR the day prior to presentation.
.
In the [**Hospital1 18**] ED she had SBPs in the 90s. She was given an
additional unit of PRBC, 2 units FFP, and rhogham. Gynecology
evaluated her and recommended starting zosyn and doxycycline.
She had a left IJ placed and was briefly on neo for pressure
support. On vaginal exam she was noted to have small clots.
Rectal showed trace guaiac stool. Of note she has recently
beeing taking large amounts of ibuprofen for pain. She was
started on an IV PPI.
.
She was initially in respiratory distress on arrival to the MICU
(thought to be due to flash pulmonary edema from the IVF) and
was given lasix. In the MICU her Hcts remained stable with no
further need for transfusion. Her acute anemia was thought to be
a combination of blood loss from her recent abortion and a slow
GI bleed possibly from NSAID-induced gastritis. She has had
significant anxiety and ?PTSD and psychiatry has been following
and making recommendations. She continues to have abdominal pain
and is on a dilaudid PCA. Social work is also following. GI was
consulted and are planning possible EGD/colonoscopy for Tuesday
(will likely need MAC) versus watchful waiting.
.
Additionally she had been placed on prednisone by her
pulmonologist (to be tapered). She was on 60 mg prior to
admission and has been tapered to 40 mg.
.
MICU attempted to call her out [**4-8**] but when the team evaluated
her she was found to have HR in the 150's with significant
anxiety. ? SVT. Sinus massage was attempted, but she was so
shaky, it was difficult to do. When she slowed down (when her
anxiety started to be controled), the rhythm looked like sinus
tach, not SVT, and she was kept in the ICU for 1 more night.
.
Patient continues to have abdominal pain, worst on the L, most
TTP over the CVA on the L. The abdominal pain has been requiring
a dilaudid PCA; ICU team felt she may have nonobstructive
nephrolithiasis vs an ovarian cyst but all imaging is with
contrast, so unclear.  GYN are following and does not think
there is any retained products but thinks may have had
endometritis so have continued course of abx, currently zosyn
and doxycycline.
 .
Upon transfer to the floor, patient is tearful and anxious, c/o
abdominal pain.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.

Past Medical History:
- ADHD
- asthma
- anxiety
- eating disorder
- h/o nephrolithiasis, always on left, last one 1 month ago
- h/o left ovarian cyst

Social History:
just quit smoking, denies alcohol and illicit drugs

Family History:
Non-contributory

Physical Exam:
On Admission:
Vitals: 110, 117/74, 17, 97% 6L facemask
General: anxious, in pain
HEENT: PERRLA, EOMI, OP clear, no LAD, neck veins flat, L CVL in
place
CV: S1S2, tachycardic, no m/r/g
Chest: limited exam due to shallow breathing, +wheezes,
decreased BS in bilateral bases
Abd: soft, moderate TTP diffusely, pain worst in LLQ, mildly
distended, +BS, no rebound/guarding
GU: (per Ob/gyn) no CMT, minimal blood, diffuse TTP, no discrete
adnexal or fundal TTP
Rectal: (per ED) faintly guiac positive
Ext: no e/c/c, 2+ peripheral pulses
Neuro: CN II-XII grossly intact, moving all 4 extremities
Psych: anxious

On Discharge:
VS: Tm 98.1, Tc 98.0, BP 100/70 (100-110/68-82), HR 65 (65-93),
RR 15 (15-18), 96%RA (96-98%RA)
GENERAL - young female sitting in bed, alert, appropriate
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - hypoactive bowel sounds in all 4 quadrants.  L CVA
tenderness, L abdominal tenderness with voluntary guarding, no
rebound
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
GU: Full speculum vaginal exam showed bright red blood in the
vaginal vault, but otherwise normal vaginal mucosa, no lesions,
no scars no areas of obvious trauma
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-5**] throughout, sensation grossly intact throughout

Pertinent Results:
Admission labs:
===============
[**2164-4-7**] 01:50AM BLOOD WBC-12.5* RBC-3.02* Hgb-9.2* Hct-27.2*
MCV-90 MCH-30.4 MCHC-33.7 RDW-14.4 Plt Ct-252
[**2164-4-7**] 01:50AM BLOOD Neuts-91.7* Lymphs-5.5* Monos-2.5 Eos-0.2
Baso-0.1
[**2164-4-7**] 01:50AM BLOOD PT-13.5* PTT-25.5 INR(PT)-1.1
[**2164-4-7**] 01:50AM BLOOD Glucose-155* UreaN-6 Creat-0.4 Na-144
K-2.7* Cl-117* HCO3-15* AnGap-15
[**2164-4-7**] 01:50AM BLOOD Calcium-7.2* Phos-2.9 Mg-1.5*
.
Discharge labs:
===============
[**2164-4-13**] 08:20AM BLOOD WBC-8.3 RBC-4.73 Hgb-14.3 Hct-42.2 MCV-89
MCH-30.3 MCHC-34.0 RDW-14.9 Plt Ct-222
[**2164-4-13**] 08:20AM BLOOD Glucose-92 UreaN-8 Creat-0.7 Na-142 K-3.6
Cl-109* HCO3-22 AnGap-15
[**2164-4-13**] 08:20AM BLOOD Calcium-9.3 Phos-4.4 Mg-1.8
[**2164-4-11**] 05:45AM BLOOD HIV Ab-NEGATIVE
.
Imaging:
========
CXR: There is a left-sided IJ central venous catheter with the
distal lead tip at the cavoatrial junction. There has been
worsening of the airspace opacities bilaterally which causes
more opacification of the left retrocardiac area. Findings are
concerning for worsening pneumonia and/or aspiration.
.
Renal U/S:
1. No renal calculus identified; however, please note that CT is
more sensitive. No hydronephrosis.
2. Mild splenomegaly, small amount of ascites, suggestion of
splenorenal shunt and prominent splenic hilar vessels. Correlate
with any history of known liver disease/portal hypertension.
Possible small bilateral pleural effusions.
.
Pelvic U/S:
1. Enlarged uterus, compatible with recent TAB. Heterogeneously
echogenic material without internal vascularity in the
endometrial canal, most compatible with blood products. No
internal vascularity to definitively suggest presence of
retained products of conception.
2. Small free fluid.
3. Normal right ovary. Nonvisualization of the left ovary.
.
Repeat pelvic U/S:
Again seen, thickened, heterogeneous endometrium, measuring 2.7
cm in diameter, without internal vascularity.
.
CTA CHEST W&W/O C&RECONS, NON-; OUTSIDE FILMS READ ONLY; CT ABD
& PELVIS WITH CONTRAST; OUTSIDE FILMS READ ONLY
1. Enlarged heterogeneous uterus, likely reflecting TAB one day
prior. However, there is a large amount of heterogeneous fluid
and debris within the endometrial canal. This may reflect
hematometra, though retained products of conception cannot be
excluded by CT and ultrasound is recommended for further
evaluation. Superinfection also cannot be excluded by CT
imaging, and clinical correlation is advised.
2. No free fluid or free air in the abdomen or pelvis to suggest
uterine perforation.
3. No evidence of pulmonary embolus within the limits of this
study, which is limited by suboptimal bolus timing.
4. Heterogeneous enhancement of the kidneys may reflect phase of
contrast
timing, though correlation with urinalysis is recommended to
exclude pyelonephritis.

REPEAT CXR [**2164-4-9**]: IMPRESSION:
1. Improving mild pulmonary edema.
2. Possible tiny right pleural effusion, unchanged.

HEAD CT:
IMPRESSION: No acute intracranial hemorrhage or amss effect. If
there is
continued clinical concern given the abnormal neuro examn as
mentioned on the requisition, MRI can be considered if not CI.

EGD [**2164-4-13**]: Normal GE junction (biopsy)
Antral gastritis (biopsy)
Erythema and petechiae in the stomach fundus and cardia (biopsy)
Erythema with prominent vasculature and pigmentation in the
duodenum (biopsy, biopsy)
Small hiatal hernia
Otherwise normal EGD to ligament of Treitz
Recommendations: 	Will follow up biopsy report and inform
patient
Continue PPI therapy
Treat for H.pylori if positive
Return to hospital floor

C-Scope [**2164-4-13**]:
Impression: 	Normal mucosa in the whole colon and terminal ileum
Non-bleeding grade 2 internal hemorrhoids
Otherwise normal colonoscopy to cecum and terminal ileum
Recommendations: 	The findings do not account for the symptoms
Return to hospital floor
If rebleeding, suggest flexible sigmoidoscopy

MICROBIOLOGY:
[**2164-4-8**] [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB- NEGATIVE; [**Doctor Last Name **]-[**Doctor Last Name **]
VIRUS EBNA IgG AB-NEGATIVE; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM
AB-NEGATIVE
[**2164-4-8**] CMV IgG ANTIBODY-FINAL; CMV IgM ANTIBODY- NEGATIVE 	
[**2164-4-8**] MONOSPOT-NEGATIVE	
[**2164-4-7**] URINE CULTURE-NEGATIE
[**2164-4-7**] MRSA SCREEN-NEGATIVE
[**2164-4-7**] BLOOD CULTURE- NEGATIVE
[**2164-4-7**] BLOOD CULTURE- NEGATIVE

Per report from [**Hospital1 **]: Gonorrhea and Chlamydia screen -
NEGATIVE

Brief Hospital Course:
22 F G2P1 s/p TAB on [**4-6**] at 16 weeks, presented with
hypotension, vaginal bleeding, respiratory distress and
abdominal/pelvic pain.
.
#. Abdominal pain - patient admitted with abdominal pain after
TAB, she also had associated vaginal bleeding and pelvic pain
with no peritoneal signs on examination. Her abdominal pain has
been ongoing for several months with acute worsening of pain
over past several days prior to admission. No free
intra-abdominal air on CT. She received rhogam in the ED and
there was no abdominal free fluid visualized on ultrasound at
that time. She has a history of kidney stones though this is
unlikely at this time. PID, hemometria and splenomegaly also
consideration. Given splenomegaly and recent sexual assault HIV
testing was performed and returned negative. Patient was given
dilaudid PCA during MICU stay and continued on zosyn and
doxycycline per ObGyn recs for empiric coverage of endometritis.
Her cultures did not have any growth to date. GI was consulted
and felt that some of her pain may have been due to an ulcer or
gastritis in setting of heavy recent NSAID use. They recommended
an EGD/[**Last Name (un) **] once patient was stable. Of note, patient initially
reported that her pain has been ongoing for 2-4 weeks with
melena and occasional bloody stools prior to admission. On HD3
she reported prior assault with a small baseball bat in her
vagina and rectum and feels that the bleeding may be due to
this. We could not confirm whether this was the etiology.  After
she was transferred out of the MICU she had frequent
"flashbacks" to the assualt, all of which brought on [**9-10**]
abdominal pain, for which she was given dilaudid and ativan.  It
became clear that the pain was more somatic than anything as it
was relieved by just ativan at times, and the resolution of the
panic attacks.  She received an EGD and c-scope on [**4-13**], which
showed likely healed gastritis and some hemorrhoids.  She was
started on omeprazole at dispo (as an inpatient was on IV PPI)
and told to follow up with her new PCP to ensure resolution of
her sx.  She also was encouraged to attend an outpatient psych
partial hospitalization program (as below).  In addition she was
sent home with flagyl and doxycycline to complete a 14 day
course for PID per OB/GYN recs, although suspicion was low, and
gonorrhea and chlamydia were reported as negative at [**Hospital1 **].
She was sent home on a small amount of oral dilaudid for her
abdominal pain, although we felt that her pain would be more
likely improved with intensive psychotherapy to help decrease
the frequency of her flashbacks of the assault.
.
#. Acute respiratory distress - pulmonary edema likely from
large fluid bolus that patient received at OSH and ED. Improved
with IV lasix 10 mg x1. Patient with history of asthma, had been
on 60 mg of prednisone for the last 6 days prior to TAB. Also
with component of extreme anxiety. TRALI was also a
consideration given blood products given at OSH. Flash pulmonary
edema less likely given low BPs during episode. Aspiration and
ARDS [**1-4**] sepsis also on differential. We considered PE though
CTA was negative (poor study) and this is unlikely to cause
pulmonary edema. Repeat CXR prior to transfer to floor showed
improvement in pulmonary edema after receiving another dose of
lasix 10mg IV. She was continued on diuresis for 1-2L goal net
negative daily. Prednisone was tapered to 40mg for 2 days, and
20mg for 2 days then 10mg for 3 days, then stopped. She was
receviing ativan prn and standing to aid with anxiety. At time
of transfer out of the MICU, patient was on 4L NC, but quickly
it became apparent that she only needed the oxygen when she was
having a panic attack and was comfortable on RA otherwise.  She
was sent home on no prednisone after having completed a taper.
.
#. Anxiety - patient has severe anxiety per family, had been on
ativan prior to pregnancy. She is s/p recent sexual assault with
severe episodes of anxiety. Psychiatry was following patient and
recommending ativan initially standing and prn, but then
downtitrating to PRN only. She was started on zoloft 25mg daily.
She was also started on trazodone 100mg QHS PRN insomnia. Social
work was also consulted and was helping patient obtain a
restraining order against perpetrator, but she refused despite
multiple providers attempting to convince her to do so.  Patient
had frequent panic attacks during this hospitalization, with
tachycardia, hyperventilation and reported [**9-10**] abdominal pain.
 We had to give IV ativan numerous times during these panic
attacks initially, but eventually we would just sit with the
patient while they resolved, and then give PO ativan once she
was able to safely swallow pills.  Psychiatry started her on
zyprexa, initially at 1.25mg QD then at 2.5mg QD, which helped
decrease the frequency of pt's attacks.  She was cleared by
psych to go home with intensive outpatient psychiatric
follow-up, as they felt she did not meet sectionable criteria.
Patient was given information about partial hospitalization
programs in her area, all of which require her to call for an
intake meeting 24hrs prior to the start date.  She was
instructed of this, as were her parents, who would transport her
to the program, and reminded that this is an incredibly
important part of her healing process.  She was also set up with
a f/u appt with her outpatient psychiatrist.
.
# Sinus Tachycardia ?????? Patient with sinus tachycardia in setting
of her panic attacks only.  No evidence of acute blood loss or
fever. Tachycardia did not improve with fluid bolus, but did
improve with ativan, and resolution of panic attacks.
.
#. Hypotension - likely in setting of blood loss vs. sepsis
related to infection from TAB. Blood pressure improved with
fluid resuscitation, blood transfusion, and pressors which were
weaned quickly. There was also concern for infection given
abortion, with C. sordelli being the most concerning. She was
empirically started on zosyn and doxycycline for coverage of
endometirits. Her WBC trended down, and she was transitioned to
flagyl and doxy for a 14 day course for PID (although low
suspicion).
.
#. Anemia - in setting of acute GI bleed (likely has been having
chronic bleed in setting of NSAID use), only small amount of
blood loss during TAB.  Also received 7 L of fluid resuscitation
at OSH so component of dilution.  On pelvic exam, no active
bleeding.  No evidence of bleeding on imaging.  She is s/p a
total of 4 units pRBC given in the ICU.  Faintly guaiac positive
in ED. Per family she has a history of polyps in rectum. As
above, a few days into her hospitalization patient reported
prior assault in her vagina and rectum with a small baseball bat
which she believes may be contributing to the bleeding. On
admission initially, she reported black stools at home, then
BRBPR. GI was consulted and recommended EGD/colonoscopy for
further evaluation. She was continued on pantoprazole IV q12h.
EGD showed likely healing gastritis, but this was done after pt
on PPI x1 week, and c-scope showed hemmorhoids.  Patients HCT
stabilized to 42.2 at dispo.
.
#. Sexual assault - did not report this to authorities, does not
want her family to know. Family is aware that she's had the
abortion, but not the assualt. She was given rhogam on
admission. Psychiatry and social work are following patient. Her
HIV was negative here and G/C test at OSH negative.  Patient's
assailant is the father of her other child.  She reports that he
has been raping her many times over the last year.  He was
previously in jail, but when he got out he raped her numerous
times.  Per pt report this was both vaginally and anally, and
also with many painful objects including a broken off baseball
bat.  She also reported that his friends had raped her 3 weeks
prior to her abortion, which was why she decided to have one.
"They told me I must have wanted it, if I'd had a kid with him
(the assailant), so I was a whore and they could do what they
wanted with me."  She is very psychologically fragile and is
blaming herself for the assaults "if I'd just said yes, we could
have had normal sex".  She will need longterm intensive
psychotherapy for these issues.  One residual effect is that pt
has panic attacks around any male providers and should be
treated by female providers only if possible.  We attempted
numerous times to convince her to file a restraining order, but
she felt this would just anger her assailant.  Her mother
assures us that he was not allowed anywhere near the pt.
.
#. ADHD - held adderall per psychiatry both during the admission
and at dispo, as pt becomes tachycardic frequently with panic
attacks.

PENDING LABS:
None

TRANSITIONAL CARE ISSUES:
Pt set up with a new PCP, [**Name10 (NameIs) 1023**] has been contact[**Name (NI) **] to explain the
large amount of issues this pt will need followed up on.
Patient will need to start her partial hospitalization program
as soon as possible.  She will need frequent follow-up visits in
the future to ensure improvement of her symptoms.


Medications on Admission:
home meds:
- Adderall
- Vistaril (hydroxyzine


Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain: DO NOT EXCEED 4GRAMS IN 24
HOURS.
Disp:*30 Tablet(s)* Refills:*0*
4. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomina.
Disp:*14 Tablet(s)* Refills:*0*
6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): LAST DAY = [**2164-4-23**].
Disp:*30 Tablet(s)* Refills:*0*
7. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours): LAST DAY [**2164-4-20**].
Disp:*14 Capsule(s)* Refills:*0*
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*35 Tablet(s)* Refills:*0*
9. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
11. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary: Anxiety, Respiratory Distress, mild duodenitits
Secondary: Asthma


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


Discharge Instructions:
Dear Ms. [**Known lastname 89417**],
You were seen in the hospital for low blood pressure,
respiratory distress and bleeding.  This was improved after you
were in the ICU.  You got a colonoscopy and EGD that showed the
possibility of  a prior gastritis (irritation from likely
ibuprofen use).  You had biopsies taken and your PCP will be
able to follow-up on these as an outpatient.  We highly
recommend that you go to an outpatient psychiatric program, the
details of which were given to you at discharge.  We also highly
recommend you file a restraining order as previously discussed
with you.

We made the following changes to your medications:
1) We STARTED you on SENNA 8.6mg twice a day as needed for
constipation.
2) We STARTED you on DOCUSATE 100mg twice a day for
constipation.
3) We STARTED you on TYLENOL 500mg to 1000mg every 6 hours as
needed for fever/pain.
4) We STARTED you on SERTRALINE 25mg once daily
5) We STARTED you on TRAZODONE 100mg at bedtime as needed for
insomnia.
6) We STARTED you on METRONIDAZOLE 500mg every 8 hours with last
dose on [**2164-4-23**].
7) We STARTED you on DOXYCYCLINE 100mg every 12hours, last day
[**2164-4-20**].
8) We STARTED you on DILAUDID 2-4mg every 4-6 hours as needed
for pain.
9) We STARTED you on OLANZAPINE 2.5mg once a day for anxiety.
10) We STARTED you on ATIVAN 1-2mg every 4 hours as needed for
anxiety.
11) We STARTED you on OMEPRAZOLE 40mg once a day for your
gastritis.

If you experience any of the below listed Danger Signs, please
call your doctor or go to the nearest Emergency Room.

It was a pleasure taking care of you on this hospitalization.

Followup Instructions:
Department: [**State **]When: FRIDAY [**2164-4-20**] at 9:20 AM
With: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2205**]
Building: [**State 7478**] ([**Location (un) 86**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: On Street Parking
**Please contact your insurance company as soon as possible. You
will need to inform them of your new Primary Care Dr [**Last Name (STitle) 5001**] this
appointment. Your new Dr [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].**

You also have the following appt:
[**4-18**] Wednesday at 5:30 Dr. [**Last Name (STitle) 2645**]. Phone: [**Last Name (NamePattern1) 89418**]in [**Location (un) 47**] [**Numeric Identifier **]


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
{'Other specified complications following abortion or ectopic and molar pregnancy,Unspecified septicemia,Acute edema of lung, unspecified,Sepsis,Acute posthemorrhagic anemia,Hypopotassemia,Asthma, unspecified type, unspecified,Other specified cardiac dysrhythmias,Blood in stool,Abdominal pain, left lower quadrant,Other pain disorders related to psychological factors,Posttraumatic stress disorder,Attention deficit disorder with hyperactivity,History of physical abuse,Unspecified inflammatory disease of uterus,Duodenitis, without mention of hemorrhage,Unspecified analgesic and antipyretic causing adverse effects in therapeutic use,Home accidents,Other chronic pain,Panic disorder without agoraphobia,Personal history of colonic polyps,Headache,Fall from other slipping, tripping, or stumbling,History of fall,Internal hemorrhoids without mention of complication'}


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: Ms [**Known lastname 89417**] is a 22 year-old female with history of anxiety, s/p
recent rape (both vaginally and anally), which pt admitted to
multiple people was also with insertion of a baseball bat, with
subsequent pregnancy s/p abortion on [**4-7**] who presented to an OSH
with abdominal pain after the procedure. She went to went to
planned parenthood for the 2 day procedure; during second day
had desaturation to 78% and abdominal pain, and was sent to
[**Hospital1 **] for evaluation.  There she was found to have a Hct of
24 and SBPs in the 70's. She was also noted to have ?SVT to the
150's and was given metoprolol and adenosine and was eventually
electrically cardioverted to sinus rhythm. She was given 2 unit
PRBCs and 7 L IVF, and also got FFP. She underwent a CTA which
showed no PE and an abdominal CT with no hemorrhage. Prior to
this presentation in the OSH ED, she had been experience milder
abdominal pain for the past two weeks and had an episode of
BRBPR the day prior to presentation.
.
In the [**Hospital1 18**] ED she had SBPs in the 90s. She was given an
additional unit of PRBC, 2 units FFP, and rhogham. Gynecology
evaluated her and recommended starting zosyn and doxycycline.
She had a left IJ placed and was briefly on neo for pressure
support. On vaginal exam she was noted to have small clots.
Rectal showed trace guaiac stool. Of note she has recently
beeing taking large amounts of ibuprofen for pain. She was
started on an IV PPI.
.
She was initially in respiratory distress on arrival to the MICU
(thought to be due to flash pulmonary edema from the IVF) and
was given lasix. In the MICU her Hcts remained stable with no
further need for transfusion. Her acute anemia was thought to be
a combination of blood loss from her recent abortion and a slow
GI bleed possibly from NSAID-induced gastritis. She has had
significant anxiety and ?PTSD and psychiatry has been following
and making recommendations. She continues to have abdominal pain
and is on a dilaudid PCA. Social work is also following. GI was
consulted and are planning possible EGD/colonoscopy for Tuesday
(will likely need MAC) versus watchful waiting.
.
Additionally she had been placed on prednisone by her
pulmonologist (to be tapered). She was on 60 mg prior to
admission and has been tapered to 40 mg.
.
MICU attempted to call her out [**4-8**] but when the team evaluated
her she was found to have HR in the 150's with significant
anxiety. ? SVT. Sinus massage was attempted, but she was so
shaky, it was difficult to do. When she slowed down (when her
anxiety started to be controled), the rhythm looked like sinus
tach, not SVT, and she was kept in the ICU for 1 more night.
.
Patient continues to have abdominal pain, worst on the L, most
TTP over the CVA on the L. The abdominal pain has been requiring
a dilaudid PCA; ICU team felt she may have nonobstructive
nephrolithiasis vs an ovarian cyst but all imaging is with
contrast, so unclear.  GYN are following and does not think
there is any retained products but thinks may have had
endometritis so have continued course of abx, currently zosyn
and doxycycline.
 .
Upon transfer to the floor, patient is tearful and anxious, c/o
abdominal pain.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.

MEDICAL HISTORY: - ADHD
- asthma
- anxiety
- eating disorder
- h/o nephrolithiasis, always on left, last one 1 month ago
- h/o left ovarian cyst

MEDICATION ON ADMISSION: home meds:
- Adderall
- Vistaril (hydroxyzine

ALLERGIES: morphine / Codeine

PHYSICAL EXAM: On Admission:
Vitals: 110, 117/74, 17, 97% 6L facemask
General: anxious, in pain
HEENT: PERRLA, EOMI, OP clear, no LAD, neck veins flat, L CVL in
place
CV: S1S2, tachycardic, no m/r/g
Chest: limited exam due to shallow breathing, +wheezes,
decreased BS in bilateral bases
Abd: soft, moderate TTP diffusely, pain worst in LLQ, mildly
distended, +BS, no rebound/guarding
GU: (per Ob/gyn) no CMT, minimal blood, diffuse TTP, no discrete
adnexal or fundal TTP
Rectal: (per ED) faintly guiac positive
Ext: no e/c/c, 2+ peripheral pulses
Neuro: CN II-XII grossly intact, moving all 4 extremities
Psych: anxious

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: just quit smoking, denies alcohol and illicit drugs 

### Response:
{'Other specified complications following abortion or ectopic and molar pregnancy,Unspecified septicemia,Acute edema of lung, unspecified,Sepsis,Acute posthemorrhagic anemia,Hypopotassemia,Asthma, unspecified type, unspecified,Other specified cardiac dysrhythmias,Blood in stool,Abdominal pain, left lower quadrant,Other pain disorders related to psychological factors,Posttraumatic stress disorder,Attention deficit disorder with hyperactivity,History of physical abuse,Unspecified inflammatory disease of uterus,Duodenitis, without mention of hemorrhage,Unspecified analgesic and antipyretic causing adverse effects in therapeutic use,Home accidents,Other chronic pain,Panic disorder without agoraphobia,Personal history of colonic polyps,Headache,Fall from other slipping, tripping, or stumbling,History of fall,Internal hemorrhoids without mention of complication'}
