CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: 42 yo with DM II and HTN who presents with 2 days of abdominal
pain. THe patient reports that on Wednesday after eating a
[**Last Name (un) **] he developed abdominal pain, nausea, vomiting and
diarrhea. He states that the abdominal pain is located
predominantly in the LLQ, was mostly crampy and intermittently
sharp in character, non-radiating. Over the next two days the
pain got progressivley worsening abdominal pain. He was only
able to take minimal po intake. Nothing appeared to make the
pain worse or better. He does not recall any aspiration however
he noted his breathing started to became more laboured on
Thursday. He reports mild pleuritic chest pain associated with
deep breaths, non positional. He also noted a fever for the
first time on Friday as well as worsening respiratory
secretions. Because of the worsening respiratory status and his
abdominal pain he decided to go to the [**Location (un) 620**] [**Hospital1 **] on Friday.
There he was found to have an elevated WBC, Lipase and Amylase
and a CT abdomen was consisted with pancreatitis. The patient
was transfered to [**Hospital1 18**] for further care after receiving 2L NS,
levofloxacin and Flagyl.
.
ED course: On arrival to the [**Hospital1 18**] ED the patient was
tachycardic to 136, febrile to 101, normotensive to 129/79 with
a RR of 19 and O2sat of 80RA. THe patient was started on O2 by
nasal canula which was uptitrated over the next hours ultimately
requiring a NRB. The patient was given a total of 5L of NS as
fluid resuscitation. A CTA was done as well as a CT abdomen and
pelvis which was negative for PE, but comfirmed a b/l lower lobe
pneumonia and acute pancreatitis without necrosis. He was given
Levofloxacin and Dilaudid 4mg for pain and Lorazepam 2mg iv for
anxiety.
.
On admission to the ICU the patient complaint of LLQ pain, [**4-7**],
non-radiating. He confirmed respiratory distress but rated that
stable over the last several hours. He denied any nausea
currently and did not have any further diarrhea. Pt denies any
recent travel, excessive ETOH or yellow discoloration of skin.
pt reports recent food excess during attendance of a symposium.
.
ROS: negative for rash, dysuria, changes in the color of the
urine or stool.

MEDICAL HISTORY: Polycythemia
Impaired fasting glucose-on metformin
Obesity
Depression
Pre-hypertension

MEDICATION ON ADMISSION: Metformin 500mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 100.4 BP 125/71 HR 130 RR 28 O2Sat 95 NRB
Gen: NAD, AAOx3, talking in full sentences
HEENT: NC/AT, PERRLA, mmm
NECK: no LAD, no JVD
COR: S1S2, regular rhythm, no m/r/g
PULM: decreased breath sounds in b/l bases, positive egophony,
no wheezing or rhonchi
ABD: + bowel sounds, soft, nd, obese, tender in LLQ and L flank,
no rebound or guarding
Skin: warm extremities, no rash
EXT: 2+ DP, no edema/c/c, no CVA tenderness
Neuro: moving all extremities, 5/5 strength, following commands,
PERRLA, reflexes 2+ b/l

FAMILY HISTORY: Father with valve replacement at age 72

SOCIAL HISTORY: ETOH: occ social, no recent binge drinking
Tobacco: none
Occupation: chemistry researcher working with Iridium
Living situation: lives with wife and 2 children, age 16 and 4
[**11-30**]
Acute pancreatitis,Pneumonia, organism unspecified,Unspecified pleural effusion,Congestive heart failure, unspecified,Paralytic ileus,Other chronic nonalcoholic liver disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Depressive disorder, not elsewhere classified
Acute pancreatitis,Pneumonia, organism NOS,Pleural effusion NOS,CHF NOS,Paralytic ileus,Chronic liver dis NEC,DMII wo cmp nt st uncntr,Hypertension NOS,Depressive disorder NEC
Admission Date:  [**2174-7-22**]              Discharge Date:   [**2174-7-29**]

Date of Birth:  [**2132-3-7**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
abdominal pain

Major Surgical or Invasive Procedure:
none


History of Present Illness:
42 yo with DM II and HTN who presents with 2 days of abdominal
pain. THe patient reports that on Wednesday after eating a
[**Last Name (un) **] he developed abdominal pain, nausea, vomiting and
diarrhea. He states that the abdominal pain is located
predominantly in the LLQ, was mostly crampy and intermittently
sharp in character, non-radiating. Over the next two days the
pain got progressivley worsening abdominal pain. He was only
able to take minimal po intake. Nothing appeared to make the
pain worse or better. He does not recall any aspiration however
he noted his breathing started to became more laboured on
Thursday. He reports mild pleuritic chest pain associated with
deep breaths, non positional. He also noted a fever for the
first time on Friday as well as worsening respiratory
secretions. Because of the worsening respiratory status and his
abdominal pain he decided to go to the [**Location (un) 620**] [**Hospital1 **] on Friday.
There he was found to have an elevated WBC, Lipase and Amylase
and a CT abdomen was consisted with pancreatitis. The patient
was transfered to [**Hospital1 18**] for further care after receiving 2L NS,
levofloxacin and Flagyl.
.
ED course: On arrival to the [**Hospital1 18**] ED the patient was
tachycardic to 136, febrile to 101, normotensive to 129/79 with
a RR of 19 and O2sat of 80RA. THe patient was started on O2 by
nasal canula which was uptitrated over the next hours ultimately
requiring a NRB. The patient was given a total of 5L of NS as
fluid resuscitation. A CTA was done as well as a CT abdomen and
pelvis which was negative for PE, but comfirmed a b/l lower lobe
pneumonia and acute pancreatitis without necrosis. He was given
Levofloxacin and Dilaudid 4mg for pain and Lorazepam 2mg iv for
anxiety.
.
On admission to the ICU the patient complaint of LLQ pain, [**4-7**],
non-radiating. He confirmed respiratory distress but rated that
stable over the last several hours. He denied any nausea
currently and did not have any further diarrhea. Pt denies any
recent travel, excessive ETOH or yellow discoloration of skin.
pt reports recent food excess during attendance of a symposium.
.
ROS: negative for rash, dysuria, changes in the color of the
urine or stool.

Past Medical History:
Polycythemia
Impaired fasting glucose-on metformin
Obesity
Depression
Pre-hypertension

Social History:
ETOH: occ social, no recent binge drinking
Tobacco: none
Occupation: chemistry researcher working with Iridium
Living situation: lives with wife and 2 children, age 16 and 4
[**11-30**]

Family History:
Father with valve replacement at age 72

Physical Exam:
VS T 100.4 BP 125/71 HR 130 RR 28 O2Sat 95 NRB
Gen: NAD, AAOx3, talking in full sentences
HEENT: NC/AT, PERRLA, mmm
NECK: no LAD, no JVD
COR: S1S2, regular rhythm, no m/r/g
PULM: decreased breath sounds in b/l bases, positive egophony,
no wheezing or rhonchi
ABD: + bowel sounds, soft, nd, obese, tender in LLQ and L flank,
no rebound or guarding
Skin: warm extremities, no rash
EXT: 2+ DP, no edema/c/c, no CVA tenderness
Neuro: moving all extremities, 5/5 strength, following commands,
PERRLA, reflexes 2+ b/l

Pertinent Results:
EKG: SR, tachycardia, rate 120, NA, NI, no ST or TW changes
.
CTA/ CT abdomen: [**2174-7-22**]
1. No evidence of pulmonary embolism.
2. Bilateral lower lobe airspace consolidation, likely
pneumonia, with small bilateral pleural effusions.
3. Acute pancreatitis, without evidence of acute complication.
4. Fatty liver.
5. Bilateral renal hypodensities, likely small cysts

US liver - FINDINGS: The bedside ultrasound examination is
markedly limited by patient body habitus, and inability to
cooperate due to pain and respiratory distress. Limited images
of the liver demonstrate increased echogenicity, likely
representing fatty liver. Gallbladder was unable to be
identified.

IMPRESSION:

Markedly limited portable study. Nonvisualization of the
gallbladder. Echogenic liver.

[**2174-7-26**]
CTA CHEST W&W/O C&RECONS, NON-; CT ABDOMEN W/CONTRAST

Reason: Evaluate for pseudocyst formation, abscess, or interval
[**Doctor Last Name **]

[**Hospital 93**] MEDICAL CONDITION:
42 year old man with pancreatitis and rising WBC, and SOB with
tachycardia.
REASON FOR THIS EXAMINATION:
Evaluate for pseudocyst formation, abscess, or interval change
in pancreatitis. R/o PE for persistent tachycardia and SOB.
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATION: 30-year-old man with pancreatitis and shortness of
breath.

Comparison is made to the CTA of the chest performed on [**7-22**], [**2173**].

TECHNIQUE: Axial MDCT images were obtained from thoracic inlet
to pubic symphysis. The CTA of the chest was performed based on
pulmonary embolism protocol; nontheless, there is suboptimal
contrast timing for assessing pulmonary embolism. The CT of the
abdomen and pelvis portion is performed with CTE protocol. Two
separate injections of contrast were administered, with the
chest covered with both injections.

CT OF CHEST WITH AND WITHOUT IV CONTRAST: The heart and great
vessels appear unremarkable. No pathologically enlarged hilar,
mediastinal or axillary nodes are noted. Severe degree of
atelectatic changes is noted within the anterior [**Doctor First Name **] segment
of right lower lobe and base of the right middle lobe. Moderate
degree of atelectasis is also noted at the left lung base. Given
the presence of air bronchograms particularly at the left lower
lobe, there is likely superimposed consolidation. Trace
bilateral pleural effusion is seen, which is more prominent on
the left side.

Although the pulmonary artery contrast bolus appears suboptimal
(probably due to patient habitus and slower injection rate due
to IV size) on both scans of the chest, there is no evidence of
pulmonary embolus within the limits of the study.

CT OF THE ABDOMEN WITH IV CONTRAST: The pre-pancreatic
fluid/phlegmon in the anterior pararenal space appears slightly
larger, especially inferiorly-- there is increased fluid along
the left lateroconal fascia. A small amount of fluid now tracks
down the left anterior pararenal space to the pelvis. A trace of
fluid is also seen within the right anterior pararenal space.
The pancreas enhances homogeneously and there is no site of
necrosis. No definite fluid collection is shown in the pancreas.
No loculated pseudoaneurysm is visualized. No evidence of SMV or
portal vein thrombosis.

There is hepatic steatosis. A 1.8 cm hypodense structure is
again noted within the dome of the liver, with fluid density
likely representing a cyst. Small amount of ascitic fluid has
developed adjacent to the liver and spleen. The gallbladder and
intra- and extra- hepatic bile ducts are unremarkable. This
spleen, adrenal glands and kidneys have normal appearance. No
pathologically enlarged retroperitoneal or mesenteric node is
noted. No free air is noted within the abdomen.

CT OF THE PELVIS WITH IV CONTRAST: The rectum has a normal
appearance. The sigmoid colon contains multiple diverticula,
with no evidence of diverticulitis. The urinary bladder and
distal ureters appear unremarkable. No pathologically enlarged
pelvic or inguinal nodes are visualized. No free air is noted
within the pelvis. As noted above, a small amount of fluid
tracks into the pelvis.

BONE WINDOWS: No concerning lytic or sclerotic lesions are
identified.

IMPRESSION:

1. Overall similar appearance of peripancreatic inflammation;
however, anterior pararenal fluid and phlegmon is minimally
increased. No pancreatic necrosis, pseudocyst, or abscess is
visualized.

2. No evidence of pulmonary embolism.

3. Atelectatic with superimposed consolidation at both lung
bases.

4. Small amount of ascites is noted within the abdomen and
pelvis.

5. Small hypodense lesion of the dome of the liver, which are
too small to characterize, likely a cyst.

CHEST (PORTABLE AP)  [**2174-7-26**] 6:16 AM

CHEST (PORTABLE AP)

Reason: ? interval change

[**Hospital 93**] MEDICAL CONDITION:
42 year old man with DM2 presents with acute pancreatitis and ?
aspiration pneumonia, please assess for interval change
REASON FOR THIS EXAMINATION:
? interval change
CHEST

HISTORY: Aspiration pneumonia.

COMPARISON: [**2174-7-24**].

The patient has taken a poor inspiratory effort. Compared to the
prior study there is increased pulmonary vascular
re-distribution. There is blunting of both costophrenic angles
left greater than right consistent with pleural effusions. There
is persistent retrocardiac opacity.

IMPRESSION: Bilateral pleural effusions and persistent left
retrocardiac opacity.

Increased pulmonary vascular re-distribution consistent with
mild CHF.

[**2174-7-28**] - CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: The
visualized portion of the lung bases demonstrates small left
pleural effusion which is unchanged. Linear atelectatic
changes/pulmonic infiltrate of the left lower lobe and right
lower lobe appear unchanged. The heart and great vessels appear
unremarkable. A small axial hiatal hernia is unchanged.

The pancreas and peripancreatic inflammation are unchanged. No
definite fluid collection is noted. No area of pancreatic
necrosis is identified. No definite gas is noted within the
peripancreatic tissue.

The liver has faaty infiltration. The gallbladder, intra- and
extrahepatic bile ducts, spleen, and adrenal glands appear
unremarkable. The small hypodense lesion of the dome of the
liver appears unchanged. The right kidney contains a small
hypodense lesion which is too small to characterize and appears
relatively unchanged compared to the prior study. The stomach,
duodenum, and small bowel loops are unremarkable. There is ileus
of the transverse colon adjacent to the site of inflammation.
The remainder of the colon appear unremarkable. Small amount of
ascites is noted within the abdomen. No free air is identified.
No pathologically enlarged retroperitoneal or mesenteric nodes
are noted.

CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon,
urinary bladder, and distal ureters are unremarkable. Small
amount of ascites noted within the pelvis. No pathologically
enlarged pelvic or inguinal nodes are noted. No free air is
noted within the pelvis.

BONE WINDOWS: No concerning lytic or sclerotic lesions are
identified.

IMPRESSION:

1. Similar appearance of peripancreatic inflammation with no
necrosis, pseudocyst or abscess formation. The anterior
pararenal fluid and the phlegmon are stable.

2. Transverse colon ileus is unchanged compared to the prior
study.

3. Unchanged appearance of small bilateral pleural effusion with
atelectatic changes. Small ascites unchanged.

4. Stable appearance of a small hypodense lesion of the dome of
the liver.

5. Fatty liver.

Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%) Transmitral
and tissue Doppler imaging suggests normal diastolic function,
and a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation.
The mitral valve appears structurally normal with trivial mitral

regurgitation. There is no mitral valve prolapse. The pulmonary
artery
systolic pressure could not be determined. There is no
pericardial effusion.

IMPRESSION: Normal (for BSA) biventricular cavity sizes with
preserved global
and regional biventricular systolic function.


[**2174-7-29**] 05:45AM BLOOD WBC-16.3* RBC-4.27* Hgb-13.2* Hct-37.9*
MCV-89 MCH-31.0 MCHC-35.0 RDW-14.1 Plt Ct-206
[**2174-7-28**] 06:00AM BLOOD WBC-17.1* RBC-4.48* Hgb-14.0 Hct-39.8*
MCV-89 MCH-31.4 MCHC-35.3* RDW-14.5 Plt Ct-237
[**2174-7-27**] 05:55AM BLOOD WBC-19.4* RBC-4.70 Hgb-14.3 Hct-42.3
MCV-90 MCH-30.3 MCHC-33.7 RDW-13.6 Plt Ct-212
[**2174-7-22**] 03:00PM BLOOD WBC-19.6*# RBC-5.21 Hgb-16.3 Hct-45.5
MCV-87 MCH-31.3 MCHC-35.9* RDW-14.6 Plt Ct-188
[**2174-7-26**] 05:28AM BLOOD WBC-24.5* RBC-5.07 Hgb-15.7 Hct-45.2
MCV-89 MCH-31.0 MCHC-34.7 RDW-13.8 Plt Ct-235
[**2174-7-29**] 05:45AM BLOOD Neuts-74* Bands-0 Lymphs-9* Monos-10
Eos-1 Baso-0 Atyps-1* Metas-1* Myelos-3* Promyel-1*
[**2174-7-22**] 03:00PM BLOOD Neuts-87.8* Lymphs-8.0* Monos-3.7 Eos-0.4
Baso-0.2
[**2174-7-26**] 05:28AM BLOOD Neuts-84* Bands-2 Lymphs-3* Monos-6 Eos-0
Baso-0 Atyps-2* Metas-0 Myelos-1* Promyel-2*
[**2174-7-29**] 05:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2174-7-26**] 05:28AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Burr-1+ Tear
Dr[**Last Name (STitle) **]1+
[**2174-7-23**] 04:42AM BLOOD PT-13.8* PTT-23.5 INR(PT)-1.2*
[**2174-7-29**] 05:45AM BLOOD UreaN-5* Creat-0.7 Na-134 K-3.9 Cl-95*
HCO3-32 AnGap-11
[**2174-7-22**] 03:00PM BLOOD Glucose-284* UreaN-12 Creat-0.8 Na-137
K-4.0 Cl-105 HCO3-27 AnGap-9
[**2174-7-28**] 06:00AM BLOOD ALT-15 AST-19 AlkPhos-59 TotBili-0.5
[**2174-7-22**] 03:00PM BLOOD ALT-42* AST-24 CK(CPK)-54 AlkPhos-59
Amylase-141* TotBili-1.0
[**2174-7-27**] 05:55AM BLOOD Lipase-47
[**2174-7-24**] 04:16AM BLOOD Lipase-78*
[**2174-7-23**] 04:42AM BLOOD Lipase-140*
[**2174-7-22**] 03:00PM BLOOD Lipase-220*
[**2174-7-22**] 03:00PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2174-7-23**] 04:42AM BLOOD Albumin-2.7* Calcium-7.3* Phos-1.2*
Mg-1.8
[**2174-7-29**] 05:45AM BLOOD Mg-2.0
[**2174-7-28**] 06:00AM BLOOD Triglyc-318*
[**2174-7-22**] 03:00PM BLOOD Triglyc-832*
[**2174-7-27**] 05:55AM BLOOD Osmolal-287
[**2174-7-26**] 05:28AM BLOOD TSH-2.4
[**2174-7-24**] 01:51AM BLOOD Type-ART PEEP-8 FiO2-60 pO2-86 pCO2-43
pH-7.45 calTCO2-31* Base XS-4 Intubat-NOT INTUBA
[**2174-7-22**] 03:14PM BLOOD Comment-GREEN TOP
[**2174-7-22**] 03:14PM BLOOD Lactate-1.4
[**2174-7-26**] 08:02PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2174-7-26**] 08:02PM URINE Blood-LGE Nitrite-NEG Protein-TR
Glucose-100 Ketone-150 Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG
[**2174-7-26**] 03:34AM URINE RBC->1000* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2174-7-26**] 03:34AM URINE AmorphX-MOD
[**2174-7-22**] 11:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]->1.035
[**2174-7-26**] 03:34AM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-250 Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
[**2174-7-26**] 03:34AM URINE RBC->1000* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0

[**2174-7-26**] 3:34 am URINE     Site: CATHETER

                            **FINAL REPORT [**2174-7-27**]**

   URINE CULTURE (Final [**2174-7-27**]):    NO GROWTH.

[**2174-7-28**] 6:27 am STOOL     CONSISTENCY: LOOSE      Source: Stool.


                            **FINAL REPORT [**2174-7-28**]**

   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2174-7-28**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
           (Reference Range-Negative).

[**2174-7-25**] 4:03 am BLOOD CULTURE     Site: ARM

   AEROBIC BOTTLE (Pending):

   ANAEROBIC BOTTLE (Pending):

[**2174-7-22**] 7:20 pm BLOOD CULTURE     Site: ARM

                            **FINAL REPORT [**2174-7-28**]**

   AEROBIC BOTTLE (Final [**2174-7-28**]):    NO GROWTH.

   ANAEROBIC BOTTLE (Final [**2174-7-28**]):    NO GROWTH.

Brief Hospital Course:
Acute pancreatitis - likely from hyperlipidemia/
hypertriglyceridemia. Started on niacin (pre Rx with EcASA).
Pancreatitis treated with NPO, IVF, analgesics and bowel rest.
Improved remarkably and tolerating low fat diet well at
discharge.
For a few days prior to discharge reported 'bloating' CT abdomen
showed transverse colon ileus, likely from the pancreatitis in
the neighbouring area. No colitis noted. GI consulted and hey
did not recommend any neostigmine, decompression etc. Avoiding
narcotics. The patient did not have much discomfort or pain and
was eating well on the day of discharge. Advised to follow up
with PCP.

Hyperlipidemia - Niacin as above with EcASA. Dietary consulted
to educate on a low fat diet. Patient advised weight loss as
well as low fat diet. To get LFT, lipids checked next week with
PCP.

Bilateral pneumonia - treated initially with IV zosyn and
improved with decreasing WBC. Was weaned off oxygen.
Transitioned to levofloxacin and flagyl. To complete a 14 days
course (total). CT chest neg for PE. Patient has symptoms of
OSA. Again advised to follow up with PCP for arranging [**Name Initial (PRE) **]
pulmonary sleep study.

Transverse colon ileus - as above

Abnormal CBC differential - heme consulted and they saw toxic
granulations of smear. Advised to get another CBC with diff with
PCP after active infection issues resolve.

Liver lesion on CT (incidental finding) - Advised to get a
follow up US/CT in 6 months.  I shall defer to PCP for arranging
this.
Abnormal UA  - repeat testing should be done with PCP [**Last Name (NamePattern4) **] [**11-30**]
weeks and if blood persists, patient will need more testing and
work-up. Will defer to PCP.

Depression - meds continued.
DM type 2 - metformin stopped and to be restarted at home (day
after discharge)

Medications on Admission:
Metformin 500mg [**Hospital1 **]

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
Disp:*30 Tablet, Chewable(s)* Refills:*0*
3. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. 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:*0*
5. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for insomnia.
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
9. Niacin 250 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: take 30-60
mins before niacin.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Acute pancreatitis
Bilateral pneumonia
Transverse colon ileus
Abnormal CBC differential
Liver lesion on CT (incidental finding)
Abnormal urinanalysis
Hyperlipidemia / hypertriglyceridemia
Hypertension
Depression


Discharge Condition:
stable


Discharge Instructions:
Return to the hospital if you notice worsening abdominal pain,
nausea, vomiting, fevers, chills or any other symptoms of
concern to you.

Keep your appointments.

Take medicines as indicated.
Complete the course of antibiotics.

Avoid alcohol use; avoid use around niacin dose. Take the
aspirin 30 - 60 mins prior to the niacin dose.

See your doctor next week to check a blood tests.

Strictly adhere to a low fat diet.

Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 4775**] on Friday [**2174-8-5**] at 1330 hours.
Please go there 15 mins prior to the appointment.
(Fax: 1-[**Telephone/Fax (1) 4776**])
Please follow up with your doctor for a repeat blood count (CBC,
renal function, liver tests as well as a lipid panel, UA)
{'Acute pancreatitis,Pneumonia, organism unspecified,Unspecified pleural effusion,Congestive heart failure, unspecified,Paralytic ileus,Other chronic nonalcoholic liver disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Depressive disorder, not elsewhere classified'}


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: 42 yo with DM II and HTN who presents with 2 days of abdominal
pain. THe patient reports that on Wednesday after eating a
[**Last Name (un) **] he developed abdominal pain, nausea, vomiting and
diarrhea. He states that the abdominal pain is located
predominantly in the LLQ, was mostly crampy and intermittently
sharp in character, non-radiating. Over the next two days the
pain got progressivley worsening abdominal pain. He was only
able to take minimal po intake. Nothing appeared to make the
pain worse or better. He does not recall any aspiration however
he noted his breathing started to became more laboured on
Thursday. He reports mild pleuritic chest pain associated with
deep breaths, non positional. He also noted a fever for the
first time on Friday as well as worsening respiratory
secretions. Because of the worsening respiratory status and his
abdominal pain he decided to go to the [**Location (un) 620**] [**Hospital1 **] on Friday.
There he was found to have an elevated WBC, Lipase and Amylase
and a CT abdomen was consisted with pancreatitis. The patient
was transfered to [**Hospital1 18**] for further care after receiving 2L NS,
levofloxacin and Flagyl.
.
ED course: On arrival to the [**Hospital1 18**] ED the patient was
tachycardic to 136, febrile to 101, normotensive to 129/79 with
a RR of 19 and O2sat of 80RA. THe patient was started on O2 by
nasal canula which was uptitrated over the next hours ultimately
requiring a NRB. The patient was given a total of 5L of NS as
fluid resuscitation. A CTA was done as well as a CT abdomen and
pelvis which was negative for PE, but comfirmed a b/l lower lobe
pneumonia and acute pancreatitis without necrosis. He was given
Levofloxacin and Dilaudid 4mg for pain and Lorazepam 2mg iv for
anxiety.
.
On admission to the ICU the patient complaint of LLQ pain, [**4-7**],
non-radiating. He confirmed respiratory distress but rated that
stable over the last several hours. He denied any nausea
currently and did not have any further diarrhea. Pt denies any
recent travel, excessive ETOH or yellow discoloration of skin.
pt reports recent food excess during attendance of a symposium.
.
ROS: negative for rash, dysuria, changes in the color of the
urine or stool.

MEDICAL HISTORY: Polycythemia
Impaired fasting glucose-on metformin
Obesity
Depression
Pre-hypertension

MEDICATION ON ADMISSION: Metformin 500mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 100.4 BP 125/71 HR 130 RR 28 O2Sat 95 NRB
Gen: NAD, AAOx3, talking in full sentences
HEENT: NC/AT, PERRLA, mmm
NECK: no LAD, no JVD
COR: S1S2, regular rhythm, no m/r/g
PULM: decreased breath sounds in b/l bases, positive egophony,
no wheezing or rhonchi
ABD: + bowel sounds, soft, nd, obese, tender in LLQ and L flank,
no rebound or guarding
Skin: warm extremities, no rash
EXT: 2+ DP, no edema/c/c, no CVA tenderness
Neuro: moving all extremities, 5/5 strength, following commands,
PERRLA, reflexes 2+ b/l

FAMILY HISTORY: Father with valve replacement at age 72

SOCIAL HISTORY: ETOH: occ social, no recent binge drinking
Tobacco: none
Occupation: chemistry researcher working with Iridium
Living situation: lives with wife and 2 children, age 16 and 4
[**11-30**] 

### Response:
{'Acute pancreatitis,Pneumonia, organism unspecified,Unspecified pleural effusion,Congestive heart failure, unspecified,Paralytic ileus,Other chronic nonalcoholic liver disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Depressive disorder, not elsewhere classified'}
