CHIEF COMPLAINT: Decreased ileostomy output and abdominal pain

PRESENT ILLNESS: 26 y/o female with UC s/p single incision laparoscopic total
proctocolectomy with ileal pouch-anal anastamosis and diverting
loop ileostomy [**2195-8-27**], multiple admissions for partial SBO,
re-admitted with the same on [**2195-9-17**]. The patient reports that
after her last admission she was feeling well at home and
tolerating a regular diet when her ileostomy output decreased.
She was in touch with the outpatient colorectal nurse who
recommended full liquid diet. She reports decreased ileostomy
output for approximately 36 hours preceding admission with
increased "twisting, spastic" abdominal pain which waxes and
wanes. This pain is somewhat relieved with hot packs. She has
taken minimal POs to prevent nausea or vomiting. At time of
admission she denies nausea. She also reports dizziness with
standing and slight discomfort with urination. She has been
urinating in small amounts.

MEDICAL HISTORY: PMH: Ulcerative colitis s/p single incision laparoscopic total
proctocolectomy with ileal pouch-anal anastamosis and diverting
loop ileostomy [**2195-8-27**]; DVT of right superficial
femoral-popliteal vein [**8-14**]; Factor V Leiden heterozygous

MEDICATION ON ADMISSION: Prednisone Taper, currently taking 20mg daily, due to be
decreased by 5mg on [**2195-9-19**]. Lovenox 70mg SC every 12 hours,
80mg/0.8ml syringe

ALLERGIES: Cetacaine Anesthetic

PHYSICAL EXAM: On admission:
General: ill-appearing woman lying in bed in moderate discomfort
HEENT: NC/AT, PERRL/EOMI, sclerae anicteric
Neck: supple, no LAD
Lungs: CTA bilat, no r/rh/wh
Heart: RRR, nl S1-S2, no MRG
Abdomen: decreased BS, soft/ND, tympanic to percussion, tender
to
palpation diffusely without rebound / guarding
Extrem: WWP, no c/c/e

FAMILY HISTORY: Mother with [**Name2 (NI) **] s/p colectomy at age 33, brother with [**Name2 (NI) **]
relatively well-controlled. Maternal aunt with rheumatoid
arthritis. No colon ca.

SOCIAL HISTORY: Originally from [**State 33977**], recently an MBA grad student at BU.
Denies tobacco.  Social EtOH.
Mechanical complication of colostomy and enterostomy,Unspecified peritonitis,Other severe protein-calorie malnutrition,Paralytic ileus,Other specified forms of effusion, except tuberculous,Pulmonary collapse,Iatrogenic pneumothorax,Cytomegaloviral disease,Regional enteritis of unspecified site,Primary hypercoagulable state,Other ascites,Body Mass Index less than 19, adult,Dehydration,Personal history of venous thrombosis and embolism,Acquired absence of intestine (large) (small)
Colosty/enter comp-mech,Peritonitis NOS,Oth severe malnutrition,Paralytic ileus,Effusion NEC exc tb,Pulmonary collapse,Iatrogenic pneumothorax,Cytomegaloviral disease,Regional enteritis NOS,Prim hypercoagulable st,Ascites NEC,BMI less than 19,adult,Dehydration,Hx-ven thrombosis/embols,Acquire absnce intestine
Admission Date:  [**2195-9-17**]              Discharge Date:   [**2195-11-2**]

Date of Birth:  [**2169-8-12**]             Sex:   F

Service: SURGERY

Allergies:
Cetacaine Anesthetic

Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Decreased ileostomy output and abdominal pain

Major Surgical or Invasive Procedure:
[**2195-10-28**]: Left video assisted thoracoscopic decortication

[**2195-10-26**]: Ultrasound-guided placement of a Rocket 12-French
pleural drain in the left hemithorax; TPA infusions

[**2195-10-20**]: Placement of a left-sided 18-French pleural drain
under ultrasound guidance; TPA infusions

[**2195-10-12**]: Flexible sigmoidoscopy

[**2195-10-2**]: Laparotomy, lysis of adhesions, resection of portion
of the ileum with end ileostomy.

[**2195-9-24**]: Diagnostic laparoscopy, Flexible sigmoidoscopy with
biopsy

[**2195-9-23**]: Esophagogastroduodenoscopy

[**2195-9-18**]: Takedown of ileostomy with resection of ileostomy.


History of Present Illness:
26 y/o female with UC s/p single incision laparoscopic total
proctocolectomy with ileal pouch-anal anastamosis and diverting
loop ileostomy [**2195-8-27**], multiple admissions for partial SBO,
re-admitted with the same on [**2195-9-17**]. The patient reports that
after her last admission she was feeling well at home and
tolerating a regular diet when her ileostomy output decreased.
She was in touch with the outpatient colorectal nurse who
recommended full liquid diet. She reports decreased ileostomy
output for approximately 36 hours preceding admission with
increased "twisting, spastic" abdominal pain which waxes and
wanes. This pain is somewhat relieved with hot packs. She has
taken minimal POs to prevent nausea or vomiting. At time of
admission she denies nausea. She also reports dizziness with
standing and slight discomfort with urination. She has been
urinating in small amounts.


Past Medical History:
PMH: Ulcerative colitis s/p single incision laparoscopic total
proctocolectomy with ileal pouch-anal anastamosis and diverting
loop ileostomy [**2195-8-27**]; DVT of right superficial
femoral-popliteal vein [**8-14**]; Factor V Leiden heterozygous

PSH: as above; IVC filter placement [**8-14**]

Meds at Admission: Prednisone Taper, currently taking 20mg
daily, due to be decreased by 5mg on [**2195-9-19**]. Lovenox 70mg SC
every 12 hours, 80mg/0.8ml syringe

ALL: Cetacaine spray


Social History:
Originally from [**State 33977**], recently an MBA grad student at BU.
Denies tobacco.  Social EtOH.

Family History:
Mother with [**Name2 (NI) **] s/p colectomy at age 33, brother with [**Name2 (NI) **]
relatively well-controlled. Maternal aunt with rheumatoid
arthritis. No colon ca.


Physical Exam:
On admission:
General: ill-appearing woman lying in bed in moderate discomfort
HEENT: NC/AT, PERRL/EOMI, sclerae anicteric
Neck: supple, no LAD
Lungs: CTA bilat, no r/rh/wh
Heart: RRR, nl S1-S2, no MRG
Abdomen: decreased BS, soft/ND, tympanic to percussion, tender
to
palpation diffusely without rebound / guarding
Extrem: WWP, no c/c/e

At Discharge:
VS:  98.2   97.9   104(88-104)   114/66(97-118/55-76)   20
100%RA
GEN: thin, cachectic appearing female in no acute distress
HEENT: sclerae anicteric
Neck: supple, no LAD
CV: RRR/borderline tachycardic
PULM: No distress or accessory muscle use; chest tube dressing
sites C/D/I
ABD: S/NT/ND; RLQ old ostomy site w vac in place (approx
4x1x0.4cm); lower midline laparotomy [**Name2 (NI) **] C/D/I
EXT: no edema, warm, well perfused
NEURO: A&Ox3
PSYCH: normal affect

Pertinent Results:
LABORATORIES:
[**2195-9-17**] 03:30PM   GLUCOSE-91 UREA N-7 CREAT-0.8 SODIUM-138
POTASSIUM-5.4* CHLORIDE-100 TOTAL CO2-31 ANION GAP-12
[**2195-9-17**] 03:30PM   CALCIUM-9.5 PHOSPHATE-5.3*# MAGNESIUM-1.8
[**2195-9-17**] 03:30PM   WBC-12.4*# RBC-4.37# HGB-12.0 HCT-36.6#
MCV-84 MCH-27.4 MCHC-32.7 RDW-14.3
[**2195-9-17**] 03:30PM   PLT COUNT-323
[**2195-11-2**] 05:17AM BLOOD WBC-4.0 RBC-2.71* Hgb-7.2* Hct-22.8*
MCV-84 MCH-26.7* MCHC-31.7 RDW-15.9* Plt Ct-358
[**2195-10-28**] 04:59AM BLOOD PT-14.3* PTT-20.1* INR(PT)-1.2*
[**2195-9-18**] 06:30AM BLOOD PT-18.0* PTT-38.7* INR(PT)-1.6*
[**2195-11-2**] 05:17AM BLOOD Glucose-85 UreaN-7 Creat-0.4 Na-141 K-4.0
Cl-108 HCO3-25 AnGap-12
[**2195-9-17**] 03:30PM BLOOD Glucose-91 UreaN-7 Creat-0.8 Na-138
K-5.4* Cl-100 HCO3-31 AnGap-12
[**2195-11-2**] 05:17AM BLOOD Albumin-2.4* Calcium-7.9* Phos-4.8*
Mg-1.5* Iron-24*
[**2195-9-23**] 09:10AM BLOOD Albumin-2.4* Calcium-7.8* Phos-3.1 Mg-1.8

IMAGING:
POUCHOGRAM [**2195-9-17**]: No evidence of ileal pouch leak or ileal
pouch-anal anastomotic leak.

CT CHEST W/O CONTRAST [**2195-9-17**]: Incidental finding of posterior
pneumomediastinum likely secondary to subclinical esophageal
injury.

CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST [**2195-9-22**]: 1.
Interval development of non-specific enteritis involving the
long segment of distal small bowel including the ileoileal
anastomotic site and ileoanal
anastomotic sites. This is likely infectious or inflammatory
(question
Crohn's) in etiology. Underlying [**Month/Day/Year 1106**] ischemia is felt less
likely but
not completely excluded given lack of IV contrast on today's
exam. Increased adenopathy and fullness of the vasa recta
suggest active inflammation. 2. No findings of intra-abdominal
abscess or bowel leak. No findings of obstruction with moderate
small bowel ileus.

CT CHEST, ABDOMEN, PELVIS W/CONTRAST [**2195-9-29**]: 1. Interval
development of a large amount of intraabdominal and intrapelvic
fluid with enhancement of the peritoneum. These findings may be
consistent with peritonitis. 2. Interval development of
bilateral pleural effusions, moderate in size on
the right and moderate-to-large on the left with adjacent
airspace collapse.  3. Continued wall thickening of the distal
small bowel including the ileoileal anastomosis site and the
ileoanal pouch. These findings are likely infectious or
inflammatory or could reflect hypoalbumimemia. There is partial
small bowel obstruction with transition at the ileoileal
anastomosis (likely from edema) also unchanged. 4. Small
non-occlusive thrombus at the portal vein confluens

CT ABDOMEN, PELVIS W/CONTRAST [**2195-10-2**]: 1. Small amount of
hyperdense material in the right lower quadrant suspicious for
extraluminal contrast material within the ascites. 2. Large
amount of intra-abdominal and intrapelvic fluid with enhancement
of the peritoneum indicates peritonitis. The amount of fluid has
decreased in comparison to prior study, likely having exited at
the former ostomy site as suggested clinically. 3. Bilateral
pleural effusions, moderate in size on the right and
moderate-to-large on the left with adjacent atelectasis. 4.
Heterogeneous mural enhancement with wall thickening of the
small bowel
distal to the ligament of Treitz to the pouch, worse in the
pelvis, consistent with nonspecific inflammation. Pouch wall
shows equivocal thickening.

CTA CHEST W&W/O [**2195-10-19**]: 1. Substantial increase in large,
nonhemorrhagic left pleural effusion since [**9-29**]. No
pleural mass, abscess or blood clot, and no appreciable pleural
inflammation. Atelectasis in the left upper lobe has worsened,
left lower lobe collapse unchanged. 2. Small nonhemorrhagic
right pleural effusion and right basal atelectasis
unchanged.

CT CHEST W/CONTRAST [**2195-10-22**]: 1. Loculated foci of large left
hydropneumothoraces, with associated near complete collapse of
the left lower lobe. Though a basal chest tube is present, the
tube is bounded by the collapsed lower lobe and the
hemidiaphragm rather than being centered within the loculated
foci of hydropneumothoraces.  2. Moderate right pleural
effusion, associated with basilar atelectasis.

CT CHEST W/O CONTRAST [**2195-10-25**]: 1. Left pneumothorax improved
since prior.  2. Bilateral pleural effusion improved since
prior.

CXR [**2195-11-2**]:

PATHOLOGY:
Ileum, ileostomy takedown [**2195-9-18**]: Segment of small bowel with
unremarkable mucosa and focal serosal chronic inflammation,
granulation tissue, and fibrosis consistent with ileostomy site.


Small bowel biopsies x 4 [**2195-9-24**]: Mild active enteritis with
villous atrophy; Mild active pouchitis; No evidence of CMV

Ileo-ileo anastomosis [**2195-10-2**]: Severely active ileitis with
ulceration and deep submucosal inflammation; Acute serositis,
diffuse, with focal giant cell reaction to foreign body
material; Mucosal involvement by cytomegalovirus (CMV);

Ileal mucosal biopsy(anastomosis)/Neo terminal ileum biopsy
[**2195-10-12**]:
Ileal mucosa with focal active inflammation; Negative for CMV


Brief Hospital Course:
The patient was admitted to the Colorectal Surgery service on
[**2195-9-17**] for decreased ostomy output and abdominal pain.  In the
course of her admission, consults were obtained from infectious
disease, medicine, gastroenterology, acute pain service,
interventional pulmonology, thoracic surgery and psychiatry.

Neuro: The patient took po intake throughout the majority of her
admission though was made NPO intermittently, initially for
obstructive symptoms and then subsequently for procedures.
While NPO, the patient received Dilaudid IV/PCA with
good effect and adequate pain control.  When tolerating oral
intake, the patient was transitioned to oral pain medications.
Adjunctive medications were also used for analgesia including
tylenol, flexeril and lidocaine topical patch.  Ambien was used
to treat insomnia prn.

CV: The patient was stable from a cardiovascular standpoint; she
was tachycardic to low 100s-110s at baseline.  Propranolol was
given on recommendation from psychiatry for anxiety.  Vital
signs were routinely monitored.

Pulmonary: The patient was noted to have bilateral pleural
effusions L>R on CT scan [**2195-9-29**].  These were persistent on
intermittent CXR's and CT scans [**10-19**] with the primary
symptomatic manifestation being L shoulder/chest wall pain and
no manifestations of desaturation.  Interventional pulmonology
was consulted and a pleural drain was placed [**10-22**].  Upon
recommendation from thoracic surgery, TPA awas administered x 3
days with significant output.  As the L lung remained unexpanded
on serial CXRs, a second pleural drain was placed by
interventional pulmonology on [**10-26**] and TPA administered.  Given
a lack of improvement of her L pneumothorax, the patient was
taken for VATS decortication by thoracic surgery on [**10-28**].  On
[**11-1**], chest tubes were removed and post pull CXR showed
persistence of minimal L pneumothorax.  Plan was made for
patient to follow up with thoracic surgery in two weeks as an
outpatient following a CXR done on day of follow up appointment.
 Patient was otherwise stable from a pulmonary standpoint; vital
signs were routinely monitored.

GI/GU: Patient was admitted with obstructive symptoms of
decreased ostomy output/abdominal pain [**9-17**].  Given that there
may have been a mechanical aspect to obstructive symptoms
related to the loop ileostomy, patient was taken to the OR
[**2195-9-18**] for ileostomy takedown.  Following this procedure,
patient clinically deteriorated with tachycardia, severe
abdominal pain and new onset abdominal distension.  Because of
her clinical distress and these new findings, she was taken
urgently to the operating room for diagnostic laparoscopy and
flexible sigmoidoscopy [**9-24**] where she was found to have
significant ulcerations to the small bowel.  Continued
evaluation with radiological studies prompted by new enteric
drainage through her previous ileostomy site revealed a new tiny
perforation in
the small bowel in the right lower quadrant. The patient was
taken to the operating [****] for laparotomy, lysis of
adhesions, resection of portion of ileum with end ileostomy.
Patient did well from a GI standpoint following this procedure
and was advanced to regular diet.  Patient continued to have
intermittent episodes of small blood clots per rectum which will
continue to be evaluated on an outpatient basis.

Following resolution of her obstructive symptoms, patient
intermittently tolerated regular diet though she was unable to
sustain her caloric needs with po intake.  TPN was initiated on
[**9-23**] and continued until [**10-27**] when calorie counts noted that
she was taking in sufficient nutrition to sustain her recovery.


Patient's bowel regimen was titrated with metamucil wafers and
immodium to an output of between 1 and 1.5 liters.

Patient's RLQ previous ileostomy site was treated after takedown
with [**Month/Year (2) **] vac with favorable result.  Midline laparotomy [**Month/Year (2) **]
healed well and at time of discharge an area of superficial skin
dehiscence had healed well.

Patient required foley catheter for her operative procedures
which was discontinued as appropriate postoperatively.  Her
intake and output were closely monitored and she was
administered IV fluids as appropriate.

ID: Patient was given appropriate preoperative antibiotics for
her operative procedures.

Patient was noted to have an enteritis that was responsible for
the ulcerations of her small bowel.  She was initially started
on empiric antibiotic coverage for this with ciprofloxacin and
flagyl.  Ultimately a diagnosis of CMV enteritis was made based
upon positive stains seen on pathology from resected anastomosis
[**10-2**].  Patient was started on IV gancyclovir for CMV enteritis
and responded well.  She completed a 24 day course of IV
gancyclovir before being transitioned to a po prophylactic dose
based on recommendations from infectious disease.  Patient will
maintain this for three to six months time until her ileostomy
takedown is complete.

Heme: Patient was relatively anemic throughout admission and
patient was transfused as appropriate in setting of bleeding
related to CMV enteritis.  Patient was last transfused [**10-11**] and
remained stable thereafter.

Of note, patient was found to have methemoglobinemia prompting
admission to [**Hospital Ward Name 332**] ICU for hypoxia on [**9-23**].  This was likely
related to cetacaine spray received during EGD, as local
anesthetic agents are one of the more common causes of acquired
methemoglobinemia. Clinical suspicion of methemoglobinemia in
the setting of "cyanosis," in the presence of normal PaO2. On
laboratory diagnosis, initial MetHb level 47. Patient treated
with IV methylene blue with good response.

Prophylaxis: Patient has history of DVT in [**8-14**] and had an IVC
filter in place at time of admission.  She received subcutaneous
heparin during this stay, and was encouraged to get up and
ambulate as early as possible.

Psych: Patient was seen by psychiatry during this admission for
feelings of depressed mood and coping issues.  Per psychiatry
she was noted to have adjustmet disorder nos with anxiety and
medical comorbidities.  She was maintained on propranolol and
ativan per psychiatry for anxiety and remeron for depressive
symptoms.

At the time of discharge on HD46, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.


Medications on Admission:
Prednisone Taper, currently taking 20mg daily, due to be
decreased by 5mg on [**2195-9-19**]. Lovenox 70mg SC every 12 hours,
80mg/0.8ml syringe


Discharge Medications:
1. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. loperamide 1 mg/5 mL Liquid Sig: [**4-13**] mL PO TID (3 times a
day).
Disp:*500 mL* Refills:*5*
3. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for
heartburn.
Disp:*100 Tablet, Chewable(s)* Refills:*2*
4. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
5. propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
8. hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
1. Ulcerative Colitis status post laparoscopic total
proctocolectomy with ileal pouch-anal anastomosis and diverting
loop ileostomy
2. CMV Enteritis
3. Left pleural effusion from entrapped lung


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


Discharge Instructions:
You were admitted to the Colorectal Surgery service for
decreased ostomy output and abdominal pain.

Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.

General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication.  Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed.  You
may not drive or heavy machinery while taking narcotic analgesic
medications.  You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids.  Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions.  Please also
follow-up with your primary care physician.

Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water.  Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.

Monitoring Ostomy Output:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid drinking only plain water.  Include gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.

*If ostomy output exceeds 1 liter, take 4mg of Imodium, repeat
2mg with each episode of loose stool.  Do not exceed 16 mg in
one day.

Followup Instructions:
Surgery: Please call the colorectal surgery office at
[**Telephone/Fax (1) 160**] to make an appointment to see Dr. [**Last Name (STitle) 1120**] in 2 weeks.


Please call Dr. [**Last Name (STitle) 11482**] [**Name (STitle) **] with thoracic surgery for a
follow-up appointment in 2 weeks at ([**Telephone/Fax (1) 17398**].  Please have
a chest x-ray done the same day, before your appointment.
Radiology is on the [**Location (un) **] of the [**Hospital Ward Name 23**] building on [**Hospital Ward Name 5074**], or on the [**Location (un) **] of the Clinical Center on [**Hospital Ward Name 12837**].

Infectious Disease: Please follow-up in the infectious disease
clinic on [**2194-12-11**] @ 9:00 AM. You will need to have your complete
blood count and liver function tests every two weeks while
taking the valgangcyclovir.

GI: Please call for an appointment to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 38243**] for a follow-up appointment in [**1-7**] weeks.

Psych: Please call Dr. [**Last Name (STitle) 87475**] [**Name (STitle) **] at [**Telephone/Fax (1) 87476**] to
make an appointment for counseling in 2 weeks.



Completed by:[**2195-11-2**]
{'Mechanical complication of colostomy and enterostomy,Unspecified peritonitis,Other severe protein-calorie malnutrition,Paralytic ileus,Other specified forms of effusion, except tuberculous,Pulmonary collapse,Iatrogenic pneumothorax,Cytomegaloviral disease,Regional enteritis of unspecified site,Primary hypercoagulable state,Other ascites,Body Mass Index less than 19, adult,Dehydration,Personal history of venous thrombosis and embolism,Acquired absence of intestine (large) (small)'}


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: Decreased ileostomy output and abdominal pain

PRESENT ILLNESS: 26 y/o female with UC s/p single incision laparoscopic total
proctocolectomy with ileal pouch-anal anastamosis and diverting
loop ileostomy [**2195-8-27**], multiple admissions for partial SBO,
re-admitted with the same on [**2195-9-17**]. The patient reports that
after her last admission she was feeling well at home and
tolerating a regular diet when her ileostomy output decreased.
She was in touch with the outpatient colorectal nurse who
recommended full liquid diet. She reports decreased ileostomy
output for approximately 36 hours preceding admission with
increased "twisting, spastic" abdominal pain which waxes and
wanes. This pain is somewhat relieved with hot packs. She has
taken minimal POs to prevent nausea or vomiting. At time of
admission she denies nausea. She also reports dizziness with
standing and slight discomfort with urination. She has been
urinating in small amounts.

MEDICAL HISTORY: PMH: Ulcerative colitis s/p single incision laparoscopic total
proctocolectomy with ileal pouch-anal anastamosis and diverting
loop ileostomy [**2195-8-27**]; DVT of right superficial
femoral-popliteal vein [**8-14**]; Factor V Leiden heterozygous

MEDICATION ON ADMISSION: Prednisone Taper, currently taking 20mg daily, due to be
decreased by 5mg on [**2195-9-19**]. Lovenox 70mg SC every 12 hours,
80mg/0.8ml syringe

ALLERGIES: Cetacaine Anesthetic

PHYSICAL EXAM: On admission:
General: ill-appearing woman lying in bed in moderate discomfort
HEENT: NC/AT, PERRL/EOMI, sclerae anicteric
Neck: supple, no LAD
Lungs: CTA bilat, no r/rh/wh
Heart: RRR, nl S1-S2, no MRG
Abdomen: decreased BS, soft/ND, tympanic to percussion, tender
to
palpation diffusely without rebound / guarding
Extrem: WWP, no c/c/e

FAMILY HISTORY: Mother with [**Name2 (NI) **] s/p colectomy at age 33, brother with [**Name2 (NI) **]
relatively well-controlled. Maternal aunt with rheumatoid
arthritis. No colon ca.

SOCIAL HISTORY: Originally from [**State 33977**], recently an MBA grad student at BU.
Denies tobacco.  Social EtOH. 

### Response:
{'Mechanical complication of colostomy and enterostomy,Unspecified peritonitis,Other severe protein-calorie malnutrition,Paralytic ileus,Other specified forms of effusion, except tuberculous,Pulmonary collapse,Iatrogenic pneumothorax,Cytomegaloviral disease,Regional enteritis of unspecified site,Primary hypercoagulable state,Other ascites,Body Mass Index less than 19, adult,Dehydration,Personal history of venous thrombosis and embolism,Acquired absence of intestine (large) (small)'}
