CHIEF COMPLAINT: Abdominal pain

PRESENT ILLNESS: Patient is a 62 year old female with a history of obstipation
since last Tuesday. She had some increasing abdominal pain and
nausea. Patient had a fusion of her left ankle about a week ago.
 She was having trouble moving her bowels and progressively
worsening abdominal pain over the past 24 hours, which brought
her to the Emergency Department. A CT scan revealed
pneumoperitoneum, and she was admitted.

MEDICAL HISTORY: 1. DM
2. HTN
3. IBS
4. Rectal fistula
5. Hyperlipidemia
6. Psoriasis- rash distribution scalp, elbows, thighs, chest.
7. Osteoarthritis of ankles, knees, Right shoulder. Left ankle
end stage tibiotalar osteoarthritis s/p Left ankle fusion
[**2151-10-8**]
8. Fibromyalgia
9. Right meniscal injury
10. Bilateral hip trochanteric bursitis.
11. (L) index finger gout

MEDICATION ON ADMISSION: AMITRIPTYLINE - 75 mg hs
ATORVASTATIN CALCIUM - 10 MG qday
HYDROCHLOROTHIAZIDE - 12.5mg day
KETOPROFEN - 75 mg tid
LISINOPRIL - 20MG qday
METFORMIN - 500 MG [**Hospital1 **]
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1-2 tabs q4h prn
TEMAZEPAM - 15MG hs

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
Vitals: 98.9F 108 119/92 mmHg  22  94
GEN: Looks uncomfortable
LUNGS: Clear bilateral
COR: RRR
ABD: Distended. Tenderness generalized but more in RLQ. Rebound
tenderness present.
RECTAL: Empty. Occult blood negative.
EXTREM: Warm to touch, well perfused.
MS: (L)ankle splint in place.
.
On Discharge:
VS: 98.9   102  106/60  18  96RA
GEN: A+Ox3. In NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B)
COR: RRR
ABD:
-(R)LQ Ileostomy:stoma is located at the RLQ, oval, [**Male First Name (un) 239**],
measuring, approx. 1 [**1-22**]" x 1 [**3-24**]", stoma is pink, and moist
with Os at 2 o'clock. Mucocutaneous Junction is intact,.
Peristomal skin is intact. Effluent: green semi-formed stool.
-Colostomy: (mucous fistula) is located in the LLQ, measuring 2"
round. The stoma is flushed against abdomen, primarily necrotic
with yellow tissue sloughing off. Pink area's of flush stoma
noted under slough. Os is in the center. Mucocutaneous Junction
separated at 7 o'clock to 12 o'clock and at 2 o'clock to 4
o'clock, sutures present, intact where mucocutaneous junction is
still intact. Peristomal skin is clean and intact, no breakdown.
-Midline incisional wound: Approximately 12cm x 3cm x 2cm
granulating, clean, intact without exudate. Improved. No
undermining or tunneling. VAC dressing with black foam
continuous pressure at 125mm Hg.
-BSx4. Appropriately tender to palpation, otherwise soft/NT/ND.
EXTREM: WWP. No c/c/e on the right.
MS: (L) LE in ankle splint. Non-weight bearing. (L) lower
extremity in the splint mildly swollen.
NEURO: A+Ox3. Pleasant. Non-focal/grossly intact.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Works as administrative coordinator. Drinks 12 drinks every
week, wine or vodka. Ex-smoker quit 20 years ago.
Perforation of intestine,Unspecified peritonitis,Sepsis,Streptococcal septicemia,Acute appendicitis with peritoneal abscess,Paralytic ileus,Pulmonary collapse,Other specified disorders of peritoneum,Other and unspecified ovarian cyst,Unspecified essential hypertension,Irritable bowel syndrome,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Arthropathy, unspecified, ankle and foot,Acute gouty arthropathy,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Tachycardia, unspecified
Perforation of intestine,Peritonitis NOS,Sepsis,Streptococcal septicemia,Abscess of appendix,Paralytic ileus,Pulmonary collapse,Peritoneal disorder NEC,Ovarian cyst NEC/NOS,Hypertension NOS,Irritable bowel syndrome,DMII wo cmp nt st uncntr,Arthropathy NOS-ankle,Acute gouty arthropathy,Abn react-anastom/graft,Accid in resident instit,Tachycardia NOS
Admission Date:  [**2151-10-11**]              Discharge Date:   [**2151-10-30**]

Date of Birth:  [**2089-1-27**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal pain

Major Surgical or Invasive Procedure:
[**2151-10-11**]:
1. Right hemicolectomy with ileocolostomy
2. Right salpingo-oophorectomy
.
[**2151-10-18**]:
1. Exploratory laparotomy.
2. Resection of ileocolic anastomosis.
3. [**Doctor Last Name **] ileostomy.
4. Transverse end-colostomy.
5. Debridement of fascial edges.


History of Present Illness:
Patient is a 62 year old female with a history of obstipation
since last Tuesday. She had some increasing abdominal pain and
nausea. Patient had a fusion of her left ankle about a week ago.
 She was having trouble moving her bowels and progressively
worsening abdominal pain over the past 24 hours, which brought
her to the Emergency Department. A CT scan revealed
pneumoperitoneum, and she was admitted.

Past Medical History:
1. DM
2. HTN
3. IBS
4. Rectal fistula
5. Hyperlipidemia
6. Psoriasis- rash distribution scalp, elbows, thighs, chest.
7. Osteoarthritis of ankles, knees, Right shoulder. Left ankle
end stage tibiotalar osteoarthritis s/p Left ankle fusion
[**2151-10-8**]
8. Fibromyalgia
9. Right meniscal injury
10. Bilateral hip trochanteric bursitis.
11. (L) index finger gout


Social History:
Works as administrative coordinator. Drinks 12 drinks every
week, wine or vodka. Ex-smoker quit 20 years ago.

Family History:
Non-contributory.

Physical Exam:
On Admission:
Vitals: 98.9F 108 119/92 mmHg  22  94
GEN: Looks uncomfortable
LUNGS: Clear bilateral
COR: RRR
ABD: Distended. Tenderness generalized but more in RLQ. Rebound
tenderness present.
RECTAL: Empty. Occult blood negative.
EXTREM: Warm to touch, well perfused.
MS: (L)ankle splint in place.
.
On Discharge:
VS: 98.9   102  106/60  18  96RA
GEN: A+Ox3. In NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B)
COR: RRR
ABD:
-(R)LQ Ileostomy:stoma is located at the RLQ, oval, [**Male First Name (un) 239**],
measuring, approx. 1 [**1-22**]" x 1 [**3-24**]", stoma is pink, and moist
with Os at 2 o'clock. Mucocutaneous Junction is intact,.
Peristomal skin is intact. Effluent: green semi-formed stool.
-Colostomy: (mucous fistula) is located in the LLQ, measuring 2"
round. The stoma is flushed against abdomen, primarily necrotic
with yellow tissue sloughing off. Pink area's of flush stoma
noted under slough. Os is in the center. Mucocutaneous Junction
separated at 7 o'clock to 12 o'clock and at 2 o'clock to 4
o'clock, sutures present, intact where mucocutaneous junction is
still intact. Peristomal skin is clean and intact, no breakdown.
-Midline incisional wound: Approximately 12cm x 3cm x 2cm
granulating, clean, intact without exudate. Improved. No
undermining or tunneling. VAC dressing with black foam
continuous pressure at 125mm Hg.
-BSx4. Appropriately tender to palpation, otherwise soft/NT/ND.
EXTREM: WWP. No c/c/e on the right.
MS: (L) LE in ankle splint. Non-weight bearing. (L) lower
extremity in the splint mildly swollen.
NEURO: A+Ox3. Pleasant. Non-focal/grossly intact.

Pertinent Results:
On Admission:
[**2151-10-11**] 07:17PM   TYPE-ART PO2-127* PCO2-43 PH-7.34* TOTAL
CO2-24 BASE XS--2
[**2151-10-11**] 07:17PM   freeCa-1.02*
[**2151-10-11**] 07:04PM   GLUCOSE-183* UREA N-30* CREAT-0.9 SODIUM-140
POTASSIUM-2.8* CHLORIDE-105 TOTAL CO2-22 ANION GAP-16
[**2151-10-11**] 07:04PM   CALCIUM-7.4* PHOSPHATE-3.3 MAGNESIUM-1.5*
[**2151-10-11**] 07:04PM   WBC-7.9 RBC-3.01* HGB-9.3* HCT-26.8* MCV-89
MCH-30.9 MCHC-34.7 RDW-13.4
.
On discharge:
[**2151-10-27**]  WBC 10.5 RBC 3.36* HGB 9.9 HCT 29.1 PLT 143
[**2151-10-27**]  GLU 111  BUN 8  CRT 0.5  NA 138  K 4.4 CL 103 HCO3 29
[**2151-10-27**]  CA 7.7 [**Doctor Last Name **] 2.3 MG 1.6

Imaging:
.
[**2151-10-11**] ABDOMEN (SUPINE & ERECT):
Large amount of pneumoperitoneum suggesting viscus perforation.
Dilated colon. See concurrent abdomen/pelvis CT for further
details.
.
[**2151-10-11**] CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST:
1. Large pneumoperitoneum suggesting hollow viscus perforation
without definitive source identified, although foci of gas
tracking along the right abdomen and pelvis along with
irregularity of the cecum make the right colon/cecum suspect.
Distended cecum, ascending colon, and transverse colon with
large air-fluid levels.
2. Small amount of perihepatic and perisplenic fluid. Small
amount of pelvic free fluid.
3. Hypodense right adnexal structure, likely arising from the
right ovary, increased in size since the prior CT examination.
Given that the patient is postmenopausal, findings are of
concern and a non-emergent pelvic ultrasound for further
evaluation is advised.
.
[**2151-10-13**] HAND (AP, LAT & OBLIQUE) BILAT:
1. Degenerative changes consistent with osteoarthritis.
2. Possible changes consistent with psoriatic arthritis in the
right index
finger. Uncertain finding.
.
[**2151-10-17**] ABD/PELVIC CT W/CONTRAST:
1. Dilated loops of small bowel with decreased mucosal
enhancement and the
presence of portal venous air are concerning for ischemic bowel.

2. One week status post ileocolic resection for perforated colon
with pneumoperitoneum that it is more than expected for the
postoperative period. In addition, there is a large amount of
free fluid, stranding of the mesentery, and a defect adjacent to
the ileocolic anastomosis consistent with a leak. No evidence of
discrete fluid collection.
3. Interval removal hypodense right adnexal structure which was
confirmed to be a simple right ovarian cyst by pathology.
4. Minimal bilateral pleural effusions and atelectasis.
.
[**2151-10-19**] CXR (Portable AP):
Improving left lower lobe atelectasis with stable small left
pleural effusion. No new consolidation.
.
[**2151-10-20**] CXR (Portable AP):
As compared to the previous examination, the monitoring and
support devices are in unchanged position. Unchanged size of the
cardiac silhouette. Increase in extent of the pre-existing
retrocardiac opacity, slight increase in extent of the
pre-existing left pleural effusion. No evidence of newly
occurred focal parenchymal opacities. The size of the cardiac
silhouette is unchanged.
.
[**2151-10-21**] CXR (Portable AP):
As compared to the previous radiograph, there is now intubation
of the right main bronchus. The endotracheal tube should be
pulled back by 3-4 cm. The responsible nurse [**First Name (Titles) **] [**Name (NI) 653**] by
telephone at the time of dictation.

The nasogastric tube is in unchanged position. Also unchanged is
the size of the cardiac silhouette, the pre-existing
retrocardiac atelectasis and the potential presence of a small
left pleural effusion. No evidence of newly appeared focal
parenchymal opacities in the right lung. Unchanged position of
the right central venous access line.
.
[**2151-10-23**] ECHO:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion.

IMPRESSION: Normal biventricular systolic function. No
vegetations identified. If clinically suggested, the absence of
a vegetation by 2D echocardiography does not exclude
endocarditis.
.
FINDINGS: Comparison is made to the intraoperative study from
[**2151-10-6**].
.
ANKLE (AP, MORTISE & LA:
The patient is status post tibiotalar fusion via two screws. The
joint space is still faintly visualized. There has been
resection of distal fibula. Overall, the hardware is unchanged.
There are no signs for complications. Fine bony detail is
somewhat limited due to the overlying cast material.
.
Microbiology:

[**2151-10-26**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2151-10-26**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2151-10-22**] BLOOD CULTURE, no growth final
[**2151-10-22**] CATHETER TIP-IV WOUND CULTURE-FINAL-No growth
[**2151-10-22**] URINE URINE CULTURE-FINAL; ANAEROBIC CULTURE-FINAL-No
growth
[**2151-10-22**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL; ANAEROBIC
CULTURE-FINAL-PMLs, GNR.
[**2151-10-20**] BLOOD CULTURE Blood Culture, FINAL-No growth
[**2151-10-20**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ENTEROCOCCUS FAECIUM}; Anaerobic Bottle Gram Stain-FINAL
.
Blood Culture, Routine (Final [**2151-10-26**]):
      ENTEROCOCCUS FAECIUM.    FINAL SENSITIVITIES.
         HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml
of
         gentamicin. Screen predicts NO synergy with penicillins
or
         vancomycin. Consult ID for treatment options HIGH LEVEL
         STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml of
streptomycin.
         Screen predicts NO synergy with penicillins or
vancomycin.
         Consult ID for treatment options.  .  Daptomycin = 3
MCG/ML.
         Daptomycin Sensitivity testing performed by Etest.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS FAECIUM
                             |
AMPICILLIN------------  =>32 R
DAPTOMYCIN------------       S
LINEZOLID-------------     2 S
PENICILLIN G----------  =>64 R
VANCOMYCIN------------  =>32 R
.
[**2151-10-20**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{ESCHERICHIA COLI}; FUNGAL CULTURE-PRELIMINARY
.
[**2151-10-20**] 1:24 am SPUTUM      Source: Endotracheal.

   GRAM STAIN (Final [**2151-10-20**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      SMEAR REVIEWED; RESULTS CONFIRMED.

   RESPIRATORY CULTURE (Final [**2151-10-23**]):
      Commensal Respiratory Flora Absent.
      ESCHERICHIA COLI.    MODERATE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--    16 I
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------    16 I
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------  =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN----------    32 I
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------     4 S
TRIMETHOPRIM/SULFA----   <=1 S

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED
.
[**2151-10-19**] BLOOD CULTURE Blood Culture, Routine-FINAL-No growth
[**2151-10-19**] BLOOD CULTURE Blood Culture, Routine-FINAL-No growth
[**2151-10-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2151-10-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2151-10-19**] URINE URINE CULTURE-FINAL-No growth
[**2151-10-18**] MRSA SCREEN MRSA SCREEN-FINAL-Negative
[**2151-10-17**] BLOOD CULTURE Blood Culture, Routine-FINAL-No growth
[**2151-10-17**] BLOOD CULTURE Blood Culture, Routine-FINAL-No growth
[**2151-10-17**] URINE URINE CULTURE-FINAL-No growth
[**2151-10-16**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL
{ESCHERICHIA COLI, LACTOBACILLUS SPECIES}; ANAEROBIC
CULTURE-FINAL
.
Time Taken Not Noted     Log-In Date/Time: [**2151-10-16**] 7:59 am
      SWAB      Source: Abdominal.

                            **FINAL REPORT [**2151-10-20**]**

   GRAM STAIN (Final [**2151-10-16**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   WOUND CULTURE (Final [**2151-10-19**]):
      ESCHERICHIA COLI.    SPARSE GROWTH.
      LACTOBACILLUS SPECIES.    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--    16 I
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     8 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------  =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN----------    32 I
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------     4 S
TRIMETHOPRIM/SULFA----   <=1 S

   ANAEROBIC CULTURE (Final [**2151-10-20**]):    NO ANAEROBES ISOLATED.

.
[**2151-10-15**] BLOOD CULTURE Blood Culture, Routine-FINAL-No growth
[**2151-10-15**] BLOOD CULTURE Blood Culture, Routine-FINAL-No growth
[**2151-10-13**] BLOOD CULTURE Blood Culture, Routine-FINAL-No growth
[**2151-10-11**] MRSA SCREEN MRSA SCREEN-FINAL-Negative
[**2151-10-11**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-PMLs, No growth.
[**2151-10-11**] BLOOD CULTURE Blood Culture, Routine-FINAL-No Growth
[**2151-10-11**] URINE URINE CULTURE-FINAL-No growth

Brief Hospital Course:
The patient was admitted to the General Surgical Service on
[**2151-10-11**] for evaluation and treatment of abdominal pain. An
abdominal/pelvic CT revealed a large pneumoperitoneum. The
patient was brought to the Operating Room emergently, where she
underwent right hemicolectomy with ileocolostomy primary
anastomosis for a finding of peritonitis and ischemic right
hemicolon and right colonic perforation.
.
The patient was taken to the surgical intensive care unit
intubated in guarded condition. In the SICU pain control was
adequate with a Dilaudid PCA. Propofol and fentanyl infusion
given during intubation. The patient was extubated without
problem, and placed on supplemental oxygen by nasal cannula. She
exhibited adequate ventilatory efforts. She was NPO on IV
fluids, an NG tube and foley catheter were in place. She was
continued on IV Flagyl and Cipro for the perforated bowel. While
in the SICU, the patient experienced (L) index finger swellin,
pain , mild erythema. Rheumatology was consulted. An x-ray was
perfomed of both hands, which showed degenerative changes
consistent with osteoarthritis, and possible changes consistent
with psoriatic arthritis in the right index  finger, although
this finding was uncertain. Given the patient's bowel surgery,
it was determined NSAIDS should be avoided, and the pain be
treated with opioid pain medications.

On POD#2, the patient was transferred to the floor NPO, on IV
fluids and antibiotics, with a foley catheter, and a Dilaudid
PCA for pain control. The patient was hemodynamically stable at
the time. Her recovery initially progressed uneventfully. The NG
Tube, IV antibiotics and foley were discontinued, and the
patient was started on sips on POD#3. Diet was advanced to
clears on POD#4.
.
Early on POD#6, however, the patient began experiencing
intermittent fevers, and a small incisional opening, which was
being packed. House staff notified at approximately 9:00 p.m.
that the patient was now tachycardiac but no frank peritonitis.
In consultation with Dr. [**Last Name (STitle) 468**], proceeded with CAT scan which
demonstrated portal venous air, intra-abdominal fluid, dilated
small bowel, concern for vascular compromise of small bowel, no
frank extravasation of contrast. These findings nevertheless
were consistent with perforation and the patient was consented
and brought back to the OR for urgent exploratory laparotomy and
probable ileostomy, colostomy and resection.
.
Early on [**2151-10-18**], the patient underwent exploratory laparotomy,
resection of ileocolic anastomosis, [**Doctor Last Name **] ileostomy, transverse
end-colostomy, and debridement of fascial edges for identified
perforation ileocolic anastomosis, which went well (see
Operative Note). Post-operatively, the patient was transferred
to the SICU NPO on IV fluids, back on IV Flagyl and Cipro, with
a foley and NG Tube in place, intubated on mechanical
ventialtion.  POD#7/0, she was febrile and tachy. Required
Neomycin, IVF, and albumin. The (L) ankle cast was valved.
POD#[**8-21**], checked CDiff from both mucous fistula/colostomy &
ileostomy, rectal tube placed. Anemic with a HCT of 22; given 2
units PRBCs, Albumin, and lasix. Bladder P 17. Cipro off,
cefepime on for resistant E.coli from wound. Alkalosis improved
despite lasix. Fever 101.9; Pan cultured. POD#[**9-22**], NGT output
continues to be high, tip in stomach; RSB 50 however still fluid
avid, remained intubated. Febrile to 101.7, restarted cipro for
extended gram neg coverage. Albumin 25% 12.5g [**Hospital1 **]. POD#[**10-23**],
extubated and well tolerated. PRBC per primary team. NGT losses
replaced. Patient refusing confirmation film. Agitated. GPC in
BCx. POD#[**11-24**], refused CXR this am. Spiked temp, ID consulted.
Recommended repeat BCx. Wound cx sent. Continued on current dose
of Vanco. New subclavian placed. A-line removed. Started HCTZ.
TTE ordered. C/o pain, PCA started. POD#[**12-25**], started on regular
diabetic diet and home medications. POD#13/6, started on IV
Daptomycin for VRE (ENTEROCOCCUS FAECIUM) from blood culture
dated [**2151-10-20**]. IV Vancomycin discontinued. VAC dressing placed.
The patient was transferred back to the inpatient floor.
.
The patient arrived on the floor on a diabetic regular diet,
home medications, oral pain medications, and on a comprehensive
antibiotics regimen, which consisted of IV Daptomycin and
cefepime and oral Flagyl and Ciprofloxacin. She had a VAC
dressing with black foam at 125mmHg applied to her mid-abdominal
incisional wound, an ileostomy and colostomy. Physical Therapy,
Occupational Therapy, and Ostomy Nurse consults were continued.
She was given repletement for her ostomy output with IV Lactated
Ringer's. She was followed by Orthopedics regarding for the left
ankle; she remained non-weight bearing on the left with an ankle
splint in place. An x-ray of the left ankle demonstrated that
the hardware is unchanged, and that there were no signs for
complications.
.
The patient tolerated her diabetic regular diet with fair
intake, but no nausea. She was also started on nutritional
supplements. Pain was well controlled on oral pain medications.
Midline abdominal incisional wound improved with continued use
of the VAC dressing system. Colostomy and ileostomy remained
patent. Ostomy output was repleted cc:cc with LR IV Q4Hours. The
patient got out of bed with Nursing or Physcial Therapy to a
chair. Mobility was restricted due to non-weight bearing status
on the left foot. She was adherent with respiratory toilet and
incentive spirrometry. Oral Cipro and Flagyl were discontinued
on [**2151-10-25**]. IV Cefepime was discontinued on [**2151-10-26**]. IV
Daptomycin will be continued until [**2151-10-31**]. She experienced
episodic left index finger swelling and pain; she was ultimately
started on a short course of Indocin with symptomatic
improvement. Her blood sugar was monitored closely and covered
when indicated by an insulin sliding scale. Labwork was
routinely monitored; electrolytes were repleted when indicated.
VAC dressing was last changed on [**2151-10-27**].
.
On [**2151-10-28**], she was given a 500mL NS fluid bolus to catch up on
fluid losses from the ileostomy. Ileostomy output started to
decrease at approximately 1Liter per day. Imodium PRN was
started to maintain an ileosotmy output around the 1L/day
volume. Subsequently, imodium was discontinued on [**2151-10-29**]. The
ileostomy output decreased and was approximately 600cc during
the 24 hours on [**2151-10-29**], the day prior to discharge.
.
At the time of discharge on [**2151-10-30**], the patient is doing well,
afebrile with stable vital signs.  The patient is tolerating a
regular diet, ileostomy and colostomy are functioning properly,
and pain is well controlled.  She is discharged to an extended
care facility. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.

Medications on Admission:
AMITRIPTYLINE - 75 mg hs
ATORVASTATIN CALCIUM - 10 MG qday
HYDROCHLOROTHIAZIDE - 12.5mg day
KETOPROFEN - 75 mg tid
LISINOPRIL - 20MG qday
METFORMIN - 500 MG [**Hospital1 **]
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1-2 tabs q4h prn
TEMAZEPAM - 15MG hs


Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation, anxiety.
7. Amitriptyline 75 mg Tablet Sig: One (1) Tablet PO at bedtime.

8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
10. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. Daptomycin 600 mg IV Q24H
Discontinue after AM dose on [**2151-10-31**].
12. Insulin Lispro 100 unit/mL Solution Sig: 2-12 units
Subcutaneous As directed per Humalog Insulin Sliding Scale.
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itchy skin.
14. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for for ileostomy output > 40mL/Hr (1L/day).
15. Medication:
HYDROmorphone (Dilaudid) 1 mg IV Q3H:PRN breakthrough pain or
before VAC dressing change


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary:
1. Peritonitis.
2. Ischemic right hemicolon and right colonic perforation.
3. Simple right ovarian cyst
4. Perforation ileocolic anastomosis
Secondary:
1. Type II DM
2. HTN
3. s/p Left ankle fusion and left tendoachilles lengthening for
ankle arthritis [**2151-10-6**] (Prior hospitalization) - ankle splint
in place. Non-weight bearing.

Discharge Condition:
Good


Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency  Department for any of the following:

*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons.  Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours.  Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.

Please resume all regular home medications , unless specifically
advised not to take a particular medication.  Also, please take
any new medications as prescribed.

Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.  Avoid lifting
weights greater than [**5-30**] lbs until you follow-up with your
surgeon.
.
Monitoring Ileostomy output/Prevention of Dehydration:

*Keep well hydrated.
*Replace fluid loss from ileostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ileostomy output between 1000mL to 1500mL per
day.
*If Ileostomy output >1 liter, take 4mg of Imodium, repeat 2mg
with each episode of loose stool. Do not exceed 16mg/24 hours.


Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2028**], MD [**First Name (Titles) **] [**Last Name (Titles) **]. Please
call([**Telephone/Fax (1) 26840**] to schedule your appointment.
.
Please follow up with Dr. [**Last Name (STitle) 468**] (Surgery) in three weeks.
Please call ([**Telephone/Fax (1) 471**] to schedule a follow-up appointment in
[**2-23**] weeks.
.
Please call ([**Telephone/Fax (1) 28786**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) **] (Surgery) in [**2-23**] weeks.
.
Provider: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2151-11-2**] 9:45



Completed by:[**2151-10-30**]
{'Perforation of intestine,Unspecified peritonitis,Sepsis,Streptococcal septicemia,Acute appendicitis with peritoneal abscess,Paralytic ileus,Pulmonary collapse,Other specified disorders of peritoneum,Other and unspecified ovarian cyst,Unspecified essential hypertension,Irritable bowel syndrome,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Arthropathy, unspecified, ankle and foot,Acute gouty arthropathy,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Tachycardia, unspecified'}


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: Patient is a 62 year old female with a history of obstipation
since last Tuesday. She had some increasing abdominal pain and
nausea. Patient had a fusion of her left ankle about a week ago.
 She was having trouble moving her bowels and progressively
worsening abdominal pain over the past 24 hours, which brought
her to the Emergency Department. A CT scan revealed
pneumoperitoneum, and she was admitted.

MEDICAL HISTORY: 1. DM
2. HTN
3. IBS
4. Rectal fistula
5. Hyperlipidemia
6. Psoriasis- rash distribution scalp, elbows, thighs, chest.
7. Osteoarthritis of ankles, knees, Right shoulder. Left ankle
end stage tibiotalar osteoarthritis s/p Left ankle fusion
[**2151-10-8**]
8. Fibromyalgia
9. Right meniscal injury
10. Bilateral hip trochanteric bursitis.
11. (L) index finger gout

MEDICATION ON ADMISSION: AMITRIPTYLINE - 75 mg hs
ATORVASTATIN CALCIUM - 10 MG qday
HYDROCHLOROTHIAZIDE - 12.5mg day
KETOPROFEN - 75 mg tid
LISINOPRIL - 20MG qday
METFORMIN - 500 MG [**Hospital1 **]
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1-2 tabs q4h prn
TEMAZEPAM - 15MG hs

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
Vitals: 98.9F 108 119/92 mmHg  22  94
GEN: Looks uncomfortable
LUNGS: Clear bilateral
COR: RRR
ABD: Distended. Tenderness generalized but more in RLQ. Rebound
tenderness present.
RECTAL: Empty. Occult blood negative.
EXTREM: Warm to touch, well perfused.
MS: (L)ankle splint in place.
.
On Discharge:
VS: 98.9   102  106/60  18  96RA
GEN: A+Ox3. In NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B)
COR: RRR
ABD:
-(R)LQ Ileostomy:stoma is located at the RLQ, oval, [**Male First Name (un) 239**],
measuring, approx. 1 [**1-22**]" x 1 [**3-24**]", stoma is pink, and moist
with Os at 2 o'clock. Mucocutaneous Junction is intact,.
Peristomal skin is intact. Effluent: green semi-formed stool.
-Colostomy: (mucous fistula) is located in the LLQ, measuring 2"
round. The stoma is flushed against abdomen, primarily necrotic
with yellow tissue sloughing off. Pink area's of flush stoma
noted under slough. Os is in the center. Mucocutaneous Junction
separated at 7 o'clock to 12 o'clock and at 2 o'clock to 4
o'clock, sutures present, intact where mucocutaneous junction is
still intact. Peristomal skin is clean and intact, no breakdown.
-Midline incisional wound: Approximately 12cm x 3cm x 2cm
granulating, clean, intact without exudate. Improved. No
undermining or tunneling. VAC dressing with black foam
continuous pressure at 125mm Hg.
-BSx4. Appropriately tender to palpation, otherwise soft/NT/ND.
EXTREM: WWP. No c/c/e on the right.
MS: (L) LE in ankle splint. Non-weight bearing. (L) lower
extremity in the splint mildly swollen.
NEURO: A+Ox3. Pleasant. Non-focal/grossly intact.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Works as administrative coordinator. Drinks 12 drinks every
week, wine or vodka. Ex-smoker quit 20 years ago. 

### Response:
{'Perforation of intestine,Unspecified peritonitis,Sepsis,Streptococcal septicemia,Acute appendicitis with peritoneal abscess,Paralytic ileus,Pulmonary collapse,Other specified disorders of peritoneum,Other and unspecified ovarian cyst,Unspecified essential hypertension,Irritable bowel syndrome,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Arthropathy, unspecified, ankle and foot,Acute gouty arthropathy,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Tachycardia, unspecified'}
