CHIEF COMPLAINT: Necrotizing pancreatitis

PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 89835**] is a 44 year old male transferred from an OSH
with a report of necrotizing pancreatitis.  He was in his usual
state of good health until three days ago when he developed
epigastric abdominal pain with radiation to the back.  Though he
denies nausea or vomiting, decreased po intake and bowel
activity accompanied this.  Last BM was PM [**3-13**] vs AM [**3-14**] with
decrease
in flatus over this time period.  Of note, he had an episode of
binge drinking ([**9-30**] drinks) approximately one week ago.  He
denies fever, chills, chest pain, blood per rectum at the time
of presentation to the outside hospital.  Given this pain,
patient sought care at an OSH this AM [**2130-3-17**].
  Patient was subsequently transferred to [**Hospital1 18**] with a question
of necrotizing pancreatitis following brief fluid resuscitation
and imaging at the OSH.  RUQ ultrasound and CT scan were
obtained as per below and patient was transferred for further
management when he became tachycardic (HR 120s) and hypotensive
(80s/50s) despite 4 liters of IVF.

MEDICAL HISTORY: PMH: Benign polyps removed on colonoscopy ([**2128**]), chronic lower
back pain [**1-18**] degenerative disc disease/? herniated disc

MEDICATION ON ADMISSION: Flonase prn seasonal allergies, MVI

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
VS: 98.0   122    88/60   24   90% 3L nasal cannula
GEN: WD, WN uncomfortable appearing male
HEENT: +scleral icterus, EOMI, oropharynx clear
NECK: no lymphadenopathy
CV: tachy, +S1S2 w no M/R/G
PULM: decreased breath sounds B/L bases;
ABD: soft, +epigastric tenderness, +distended, tympanitic upper
abdomen, no guarding/rebound, no hernias present
EXT: WWP, no pedal edema
NEURO: CN II-XII grossly intact; strength 5/5 at B/L UE and LE

FAMILY HISTORY: Mother: colon CA; father: CAD, DM, obesity; no fam hx of
pancreatic malignancy or chronic pancreatitis

SOCIAL HISTORY: Lives with wife and two children (6 and 11); owner of liquor
store; Denies tobacco other than occasional cigar; 3-5 drinks
per day with occasional binges of [**9-30**] drinks (last episode ~1
week ago); denies recreational drugs; exercises
3-4x/week
Acute pancreatitis,Acute respiratory failure,Portal vein thrombosis,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction,Hemoperitoneum (nontraumatic),Other diseases of spleen,Alcoholic fatty liver,Bacteremia,Unspecified pleural effusion,Other ascites,Acquired coagulation factor deficiency,Essential thrombocythemia,Thrombocytopenia, unspecified,Accidental puncture or laceration during a procedure, not elsewhere classified,Other and unspecified infection due to central venous catheter,Other and unspecified alcohol dependence, unspecified,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Acute pancreatitis,Acute respiratry failure,Portal vein thrombosis,SIRS-noninf w ac org dys,Hemoperitoneum,Spleen disease NEC,Alcoholic fatty liver,Bacteremia,Pleural effusion NOS,Ascites NEC,Acq coagul factor defic,Essntial thrombocythemia,Thrombocytopenia NOS,Accidental op laceration,Oth/uns inf-cen ven cath,Alcoh dep NEC/NOS-unspec,Abn reac-organ rem NEC,Abn react-procedure NEC
Admission Date:  [**2130-3-17**]              Discharge Date:   [**2130-4-13**]

Date of Birth:  [**2085-5-1**]             Sex:   M

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Necrotizing pancreatitis

Major Surgical or Invasive Procedure:
[**2130-3-21**]:  Exploratory laparotomy with splenectomy and repair of
small bowel serosal tear and placement of vacuum- assisted
closure dressing over 50 cm2.
[**2130-3-24**]:  Re-exploration of recent laparotomy, as intended,
with removal of packing and placement of V.A.C. dressing over 57
cm2.
[**2130-3-28**]:  Re-exploration, closure of abdomen with [**State 19827**]
patch and placement of negative pressure dressing.
[**2130-3-31**]: Tightening [**State 19827**] patch closure of abdomen.
[**2130-4-4**]: Bedside tightening [**State 19827**] patch closure of abdomen.
[**2130-4-10**]: 1. Reopening of recent laparotomy via removal of
[**State 19827**]
          patch and primary closure of abdomen.
          2. Also repositioning of drain into pancreatic fistula
          collection.


History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 89835**] is a 44 year old male transferred from an OSH
with a report of necrotizing pancreatitis.  He was in his usual
state of good health until three days ago when he developed
epigastric abdominal pain with radiation to the back.  Though he
denies nausea or vomiting, decreased po intake and bowel
activity accompanied this.  Last BM was PM [**3-13**] vs AM [**3-14**] with
decrease
in flatus over this time period.  Of note, he had an episode of
binge drinking ([**9-30**] drinks) approximately one week ago.  He
denies fever, chills, chest pain, blood per rectum at the time
of presentation to the outside hospital.  Given this pain,
patient sought care at an OSH this AM [**2130-3-17**].
  Patient was subsequently transferred to [**Hospital1 18**] with a question
of necrotizing pancreatitis following brief fluid resuscitation
and imaging at the OSH.  RUQ ultrasound and CT scan were
obtained as per below and patient was transferred for further
management when he became tachycardic (HR 120s) and hypotensive
(80s/50s) despite 4 liters of IVF.


Past Medical History:
PMH: Benign polyps removed on colonoscopy ([**2128**]), chronic lower
back pain [**1-18**] degenerative disc disease/? herniated disc

PSH: Repair torn R labrum x 2, benign neck cyst removal, repair
deviated septum


Social History:
Lives with wife and two children (6 and 11); owner of liquor
store; Denies tobacco other than occasional cigar; 3-5 drinks
per day with occasional binges of [**9-30**] drinks (last episode ~1
week ago); denies recreational drugs; exercises
3-4x/week


Family History:
Mother: colon CA; father: CAD, DM, obesity; no fam hx of
pancreatic malignancy or chronic pancreatitis


Physical Exam:
On Admission:
VS: 98.0   122    88/60   24   90% 3L nasal cannula
GEN: WD, WN uncomfortable appearing male
HEENT: +scleral icterus, EOMI, oropharynx clear
NECK: no lymphadenopathy
CV: tachy, +S1S2 w no M/R/G
PULM: decreased breath sounds B/L bases;
ABD: soft, +epigastric tenderness, +distended, tympanitic upper
abdomen, no guarding/rebound, no hernias present
EXT: WWP, no pedal edema
NEURO: CN II-XII grossly intact; strength 5/5 at B/L UE and LE

On Discharge:
VS: 98.6, 93, 98/54, 18, 96% RA
GEN: NAD, AAO x 3
CV: RRR, no m/r/g
LUNGS: Dininishe L base
ABD: Soft, flat, normal tenderness along midline incision.
Midline incision with staples, OTA and c/d/i. LUQ JP to bulb
suction, site with dry dressing and c/d/i
EXTR: Warm, no c/c/e


Pertinent Results:
[**2130-3-17**] 08:19PM   LACTATE-3.3*
[**2130-3-17**] 08:10PM   GLUCOSE-111* UREA N-23* CREAT-1.4* SODIUM-135
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-20* ANION GAP-14
[**2130-3-17**] 08:10PM   LIPASE-786*
[**2130-3-17**] 08:10PM   LIPASE-786*
[**2130-3-17**] 08:10PM   ALBUMIN-3.2* CALCIUM-7.3* PHOSPHATE-2.3*
MAGNESIUM-1.4*
[**2130-3-17**] 08:10PM   WBC-12.9* RBC-4.40* HGB-15.0 HCT-42.7 MCV-97
MCH-34.1* MCHC-35.2* RDW-13.7
[**2130-3-17**] 08:10PM   NEUTS-76* BANDS-2 LYMPHS-15* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2130-3-17**] 08:10PM   HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2130-3-17**] 08:10PM   PLT SMR-VERY LOW PLT COUNT-75*
[**2130-3-17**] 08:10PM   PT-15.9* PTT-30.3 INR(PT)-1.4*
[**2130-4-11**] 07:50AM BLOOD WBC-20.3* RBC-3.44* Hgb-10.0* Hct-31.9*
MCV-93 MCH-29.1 MCHC-31.4 RDW-14.8 Plt Ct-881*
[**2130-4-13**] 07:35AM BLOOD PT-21.1* INR(PT)-1.9*
[**2130-4-11**] 07:50AM BLOOD Glucose-91 UreaN-8 Creat-0.7 Na-140 K-4.2
Cl-101 HCO3-29 AnGap-14

[**2130-3-17**] EKG: Sinus tachycardia. No previous tracing available for
comparison.

[**2130-3-20**] CHEST PORT:
FINDINGS: Right subclavian vascular catheter remains in standard
position. Heart size is normal. Moderate left pleural effusion
is likely unchanged
allowing for positional differences and is accompanied by
adjacent atelectasis at the left base. Minor atelectasis at
right base has slightly worsened and is accompanied by a
possible new small right pleural effusion.

[**2130-3-21**] ABD CT:
IMPRESSION:
1. No pulmonary embolus.
2. Active extravasation of contrast coming from the spleen
with extensive hemoperitoneum.
3. Thrombosis in the splenic vein extending in the proximal main
portal vein and filling defect at the branching of the portal
vein extending in the left portal vein and proximal right portal
vein. SMV patent.
4. Bilateral pleural effusions with bibasilar opacities, could
be
atelectasis, cannot exclude superinfection. Scattered foci of
lung opacities in the upper lungs could be focal atelectasis;
however, cannot exclude superinfection or aspiration.
5. Necrosis within the pancreatic body and tail and focus of
necrosis in the pancreatic head.
6. Wall edema in the segment of ascending and descending colon,
nonspecific, could be related to third spacing, edema, local
inflammation; cannot exclude hypoperfusion, although less
likely.
7. Low liver density partially related to fatty infiltration and

hypoperfusion.

[**2130-3-25**]: CHEST PORT:
IMPRESSION:
Significant decrease in left pleural effusion after
thoracocentesis with no evidence of pneumothorax.

[**2130-3-28**] CHEST PORT:
IMPRESSION:
1. Moderately large left pleural effusion and left lower lobe
atelectasis,
the effusion appears to have enlarged since most recent
radiograph.
2. Satisfactory position of medical devices.

[**2130-3-29**] CARDIAC ECHO:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is mild symmetric left ventricular hypertrophy with normal
cavity size. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. No mass or vegetation is seen on the
mitral valve. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.

[**2130-4-8**] ABD CT:
1. Sequela of necrotizing pancreatitis with ill-defined fluid
collection /
phlegmon surrounding the pancreas and in the splenic resection
bed. There is no drainable fluid collection. Pancratic tail not
visualized, either resected or necrotic.
2. There is nonocclusive thrombus within the proximal portal
vein where the SMV makes its turn.

MICRO:
[**2130-3-20**] 8:53 pm BLOOD CULTURE      Source: Line-CVL.

                            **FINAL REPORT [**2130-3-29**]**

   Blood Culture, Routine (Final [**2130-3-29**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.
         Isolated from only one set in the previous five days.
         SENSITIVITIES REQUESTED BY DR. [**Last Name (STitle) **] [**Numeric Identifier 89836**] [**2130-3-27**].
         FINAL SENSITIVITIES.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPHYLOCOCCUS, COAGULASE NEGATIVE
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------  0.25 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE----------   <=1 S
VANCOMYCIN------------     1 S

   Anaerobic Bottle Gram Stain (Final [**2130-3-22**]):
      GRAM POSITIVE COCCI IN CLUSTERS.
      Reported to and read back by NEELISH [**Doctor Last Name 49170**] #[**Numeric Identifier 89837**] [**2130-3-22**]
3:00PM.
      Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN [**2130-3-22**]
2:55PM.

 [**2130-3-22**] 11:52 am SPUTUM     Site: ENDOTRACHEAL
      Source: Endotracheal.

                            **FINAL REPORT [**2130-3-26**]**

   GRAM STAIN (Final [**2130-3-22**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI IN
PAIRS.

   RESPIRATORY CULTURE (Final [**2130-3-26**]):
      MODERATE GROWTH Commensal Respiratory Flora.
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.
      HAEMOPHILUS SPECIES NOT INFLUENZAE.    MODERATE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------       R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------   0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S

[**2130-3-23**] 7:00 pm BRONCHOALVEOLAR LAVAGE

                            **FINAL REPORT [**2130-3-27**]**

   GRAM STAIN (Final [**2130-3-24**]):
      3+  (5-10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2130-3-27**]):
      Commensal Respiratory Flora Absent.
      STAPH AUREUS COAG +.    ~1000/ML.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------   0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S

[**2130-4-2**] 6:30 pm BLOOD CULTURE

                            **FINAL REPORT [**2130-4-8**]**

   Blood Culture, Routine (Final [**2130-4-8**]):    NO GROWTH.

[**2130-4-2**] 5:20 pm URINE      Source: CVS.

                            **FINAL REPORT [**2130-4-3**]**

   URINE CULTURE (Final [**2130-4-3**]):    NO GROWTH.







Brief Hospital Course:
Mr. [**Known lastname 89835**] was admitted to General Surgery Service in transfer
from an outside hospital.  Please see their discharge/transfer
summary for events prior to his admission to our facility.  He
was tachycardic and hypotensive on admission, central venous
access was maintained, and he was kept NPO and hydrated
aggressively.  Review of imaging from the outside hospital
disclosed thrombosis of the splenic and portal veins and he was
started on a heparin drip with goal 40-60 (he had a significant
percentage of non-enhancing pancreas on CT, presumed to be
necrotic, and so heparin was not bolused and the rate was up
titrated slowly to prevent hemorrhagic conversion).  Of note a
RUQ u/s showed no stones, CBD 6mm.  Hepatology was consulted.
By HD#3 he had stabilized hemodynamically and was transfered to
the floor.  On HD#5, despite never having a therapeutic PTT (it
was 28 that morning), the patient became acutely hypotensive,
diaphoretic, tachycardic, with a witnessed desaturation to 87%
on room air.  EKG was sinus tachycardia without ST/T changes.
He was emergently transferred to the ICU, intubated, and repeat
labs showed a significantly lower hematocrit.  He was taken
quickly to CT where a scan of the chest showed no PE.  Scan of
the abdomen showed active extravasation from a splenic injury.
There was no history of trauma. He was taken emergently to the
operating room for exploratory laparotomy, splenectomy, and
packing of the abdomen.  Please see separately dictated
operative note from Dr. [**First Name (STitle) **] for full details.  His abdomen was
left open and he was aggressively resuscitated with
approximately 20 units RBCs, fluid, and additional FFP and
platelets.  The following day (POD#1, HD#4) he spiked a fever
and blood cultures grew coag neg staph.  His CVC was removed and
replaced via fresh puncture and was started on vancomycin and
meropenem empirically to cover staph as well as empiric coverage
for necrotizing pancreatitis. On [**2130-3-24**] (HD # 8), the patient
was taken in OR for removal of packing and attempted closure.
Unable to do closure at this time, wound VAC was placed. On
[**2130-3-28**] (HD # 12), the patient was taken in OR, he underwent
closure of abdomen with [**State 19827**] patch and placement of negative
pressure dressing. The patient was extubated on [**3-29**] and
Dobbhoff tube was placed for tube feeding. On [**2130-3-31**] (HD # 15),
the patient back in OR, [**State 19827**] patch tightened as part of
staged abdominal closure. On [**2130-4-1**] (HD # 16), the patient was
transferred on the floor in stable condition. On the floor, the
patient was continued on PCA for pain control, Heparin gtt and
tube feed via Dobbhoff. The patient was hydrodynamically stable.
On [**2130-4-4**] (HD # 19), the patient underwent bedside [**State 19827**]
patch tightened as part of staged abdominal closure, negative
pressure dressing was continued as well. On [**2130-4-10**] (HD # 25),
the patient underwent Reopening of recent laparotomy via removal
of [**State 19827**] patch and primary closure of abdomen, also
repositioning of drain into pancreatic fistula collection, which
went well without complication (reader referred to the Operative
Note for details). Post operatively, all antibiotics were
discontinued, Dobbhoff was removed, diet was advanced to clears,
and patient had Dilaudid PCA for pain control.
Neuro: The patient received Dilaudid PCA with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Cardiac Echo
demonstrated  mild symmetric left ventricular hypertrophy with
normal cavity size, otherwise normal with LVEF > 55%.
Pulmonary: On admission chest xray, the patient was found to
have left pleural effusion with associated retrocardiac opacity.
On [**3-21**], the patient was required large amount of blood products
and fluid for resuscitation. Following chest xrays showed
increased left pleural effusion size. The patient sputum grew
Staph. aureus coag + and Haemophilus species on [**2130-3-22**], and
bronchoalveolar lavage grew Staph. aureus coag + on [**2130-3-23**]. The
patient was started on Meropenem/Vancomycin, and Ciprofloxacin
was added on [**3-26**]. On [**3-25**], the patient underwent bedside
thoracentesis with 600cc output. The patient was diuresed with
Lasix IV. The patient respiratory status gradually improved. He
was extubated on [**2130-3-28**], and was required supplemental O2 post
extubation to maintain O2 sat > 90%. Good pulmonary toilet,
early ambulation and incentive spirrometry were encouraged. The
patient was able to wean off supplemental O2. Antibiotics were
stopped on [**2130-4-10**]. The patient remained stable from pulmonary
standpoint prior discharge.
GI: The patient was made NPO on admission. Dobbhoff tube was
placed on [**2130-3-29**] and patient was started on TF on [**3-31**]. Diet
was advanced when appropriate, which was well tolerated.
Dobbhoff was removed on [**4-2**], the patient was tolerated fulls.
He was made NPO on [**2130-4-9**] for procedure. The patient's diet was
resumed on [**4-10**] and advanced to regular on [**4-11**]. Electrolytes
were routinely followed, and repleted when necessary.
ID: The patient's blood cultures from [**3-20**] and [**3-24**] grew
Staphylococcus coag negative. The patient was started on IV
Vancomycin. Sputum cultures from [**3-23**] and [**3-24**] was positive for
Staph. aureus coag +, Meropenem was added for abx regiment.
Ciprofloxacin was added on [**3-26**]. The patient was continued on
abx until [**4-10**], surveillance blood cultures were negative. The
patient continued to have leukocytosis, which thought to be [**1-18**]
splenectomy.
Vaccination: The patient was vaccinated on [**2130-4-13**] with
Pneumovax, Meningococcal vaccine and H. Flu Conjugate B. The
patient was instructed to follow up with his PCP in order to
adhere with current CDC recommendations for post splenectomy
patients.
Hematology: The patient has splenic vein thrombosis with
extension in the proximal main portal vein. The patient was
started on Heparin gtt on admission and Hematology was
consulted. Prior discharge, the patient was transferred on PO
Coumadin and SC Lovenox. His last INR was 1.9 (goal [**1-19**]), and he
was discharged home with instruction to follow up with PCP [**Last Name (NamePattern4) **]
[**2130-4-14**] at 11 am to recheck INR. The patient will continue to
follow with [**Hospital1 18**] Hepatology as outpatient.
The patient's HCT dropped on [**3-21**] to 17.9 [**1-18**] rupture of the
spleen. He received 23 units of RBC, 8 units of plasma and 1
unit of platelets. The patient's HCT improved and remained
stable during hospitalization, no further transfusions were
required. The patient developed post splenectomy thrombocytosis
and was treated with aspirin. Currently his platelets in 800s
and aspirin was stopped.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs.  The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.  The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. The patient was discharged
with VNA service for wound care and JP drain monitoring.


Medications on Admission:
Flonase prn seasonal allergies, MVI


Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please take at 4 PM. Follow with PCP to adjust dose as
instructed.
Disp:*30 Tablet(s)* Refills:*0*
8. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous [**Hospital1 **] (2 times a day) for 5 days.
Disp:*10 syringe* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
VNA Assoc. of [**Hospital3 **]

Discharge Diagnosis:
1. Necrotizing pancreatitis
2. Splenic vein thrombosis
3. Splenic rupture
4. Bacteremia
5. Open abdomen s/p splenectomy
6. Left pleural effusion
7. Thrombocytosis


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


Discharge Instructions:
You discharged on new medication - Coumadin. This medication
required weekly blood test to mesure your INR. You will be
followed by your PCP, [**Name10 (NameIs) **] PCP will monitor INR and adjust
Coumadin dose as necessary.
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 [**4-25**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical 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.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently.  Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.

You discharged home on Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin??????/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.

These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin??????/warfarin when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much Coumadin??????/warfarin you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin??????/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.


Followup Instructions:
Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) 177**], MD Phone:[**Telephone/Fax (1) 18696**], Date/Time:
[**2130-4-14**] 11:00 [**Street Address(2) 89838**], [**Location (un) 3320**], [**Numeric Identifier **] (for INR
check), Please see [**Name8 (MD) 16883**], RN
.
Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) 177**], MD Phone:[**Telephone/Fax (1) 18696**], Date/Time:
[**2130-4-19**] 13:15 [**Street Address(2) 89838**], [**Location (un) 3320**], [**Numeric Identifier **]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2130-4-26**]
3:00 [**Hospital1 **] [**Location (un) 620**], [**Street Address(2) 3001**], [**Location (un) 620**], [**Numeric Identifier 3002**]
You will have an abdominal CT scan prior your follow up with Dr.
[**First Name (STitle) **]. Dr.[**Name (NI) 5067**] office will notify your about time of the test
and will give you all instructions. If you have any questions
please call Dr. [**First Name (STitle) **] office @ [**Telephone/Fax (1) 2998**].
.
Provider: [**Name10 (NameIs) 89839**], [**Name11 (NameIs) 177**], MD (Hematology)
Phone:[**Telephone/Fax (1) 22**]
Date/Time: [**2130-5-26**] 10:00 [**Hospital Ward Name 23**] 9, [**Hospital Ward Name **]



Completed by:[**2130-4-13**]
{'Acute pancreatitis,Acute respiratory failure,Portal vein thrombosis,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction,Hemoperitoneum (nontraumatic),Other diseases of spleen,Alcoholic fatty liver,Bacteremia,Unspecified pleural effusion,Other ascites,Acquired coagulation factor deficiency,Essential thrombocythemia,Thrombocytopenia, unspecified,Accidental puncture or laceration during a procedure, not elsewhere classified,Other and unspecified infection due to central venous catheter,Other and unspecified alcohol dependence, unspecified,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: Necrotizing pancreatitis

PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 89835**] is a 44 year old male transferred from an OSH
with a report of necrotizing pancreatitis.  He was in his usual
state of good health until three days ago when he developed
epigastric abdominal pain with radiation to the back.  Though he
denies nausea or vomiting, decreased po intake and bowel
activity accompanied this.  Last BM was PM [**3-13**] vs AM [**3-14**] with
decrease
in flatus over this time period.  Of note, he had an episode of
binge drinking ([**9-30**] drinks) approximately one week ago.  He
denies fever, chills, chest pain, blood per rectum at the time
of presentation to the outside hospital.  Given this pain,
patient sought care at an OSH this AM [**2130-3-17**].
  Patient was subsequently transferred to [**Hospital1 18**] with a question
of necrotizing pancreatitis following brief fluid resuscitation
and imaging at the OSH.  RUQ ultrasound and CT scan were
obtained as per below and patient was transferred for further
management when he became tachycardic (HR 120s) and hypotensive
(80s/50s) despite 4 liters of IVF.

MEDICAL HISTORY: PMH: Benign polyps removed on colonoscopy ([**2128**]), chronic lower
back pain [**1-18**] degenerative disc disease/? herniated disc

MEDICATION ON ADMISSION: Flonase prn seasonal allergies, MVI

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
VS: 98.0   122    88/60   24   90% 3L nasal cannula
GEN: WD, WN uncomfortable appearing male
HEENT: +scleral icterus, EOMI, oropharynx clear
NECK: no lymphadenopathy
CV: tachy, +S1S2 w no M/R/G
PULM: decreased breath sounds B/L bases;
ABD: soft, +epigastric tenderness, +distended, tympanitic upper
abdomen, no guarding/rebound, no hernias present
EXT: WWP, no pedal edema
NEURO: CN II-XII grossly intact; strength 5/5 at B/L UE and LE

FAMILY HISTORY: Mother: colon CA; father: CAD, DM, obesity; no fam hx of
pancreatic malignancy or chronic pancreatitis

SOCIAL HISTORY: Lives with wife and two children (6 and 11); owner of liquor
store; Denies tobacco other than occasional cigar; 3-5 drinks
per day with occasional binges of [**9-30**] drinks (last episode ~1
week ago); denies recreational drugs; exercises
3-4x/week 

### Response:
{'Acute pancreatitis,Acute respiratory failure,Portal vein thrombosis,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction,Hemoperitoneum (nontraumatic),Other diseases of spleen,Alcoholic fatty liver,Bacteremia,Unspecified pleural effusion,Other ascites,Acquired coagulation factor deficiency,Essential thrombocythemia,Thrombocytopenia, unspecified,Accidental puncture or laceration during a procedure, not elsewhere classified,Other and unspecified infection due to central venous catheter,Other and unspecified alcohol dependence, unspecified,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
