CHIEF COMPLAINT: Increasing Abdominal Pain, Decreased PO Intake

PRESENT ILLNESS: This is a [**Age over 90 **] year old male with PMH of Alzheimer's disease,
bilateral inguinal hernias, BPH, constipation, bilateral heel
ulcers, s/p 3 documented falls since [**2195-2-13**] presenting
with increasing abdominal pain and decreased PO intake over the
past week. The patient started developing abdominal pain 6 days
ago. The pain has become increasingly severe and is diffuse in
nature. He stopped taking solid foods PO 5 days prior to
presentation and stopped taking fluids 3 days prior to
presentation. Prior to this past week he was described as having
a robust appetite. He saw his PCP yesterday and was started on
enemas and magnesium citrate PO as well as cipro/flagyl to
empirically cover for a GI source of infection. According to the
patient's family he has been having bowel movements as they
report that the nursing home has been changing his
undergarments.
.
The patient has been in severe pain from his bilateral heel
ulcers and is on an aggressive opiate pain regimen with a
minimal bowel regimen. He is seen by a wound specialist and gets
debrided once weekly with dressing changes of his wounds twice
daily. He has fallen three times in [**2195**] and has a residual
hematoma on his left forehead from one of his falls.
.
In the ED, initial vs were: T=98.4, P=97, BP=130/70, R=18 O2
sat=94% RA. He was noted to have a rigid abdomen and
non-reducible >6 cm, hard bilateral inguinal hernias with
concern for strangulation in the right scrotum. He also had a
leukocytosis to 26.4 and a Cr=1.9. CXR and KUB showed no
evidence of free air under diaphragm. Non contract CT of abdomen
and pelvis preliminariy showed fecal loading, large inguinal
hernias without evidence of obstruction or strangulation or
volvulus. Surgery was consulted and recommended no surgical
intervention. A Foley was placed and drained 1.5L of urine.
Blood cultures were drawn. Patient was given ciprofloxacin and
flagyl, 2L of NS boluses, and morphine 4mg IV.
.
On the floor, the patient was somnolent, but briefly arousable.
He would not answer questions appropriately but was noted to be
in severe pain secondary to his heels and his abdomen.
.
Review of sytems:
Unable to obtain as patient is too somnolent

MEDICAL HISTORY: -Bradycardia - never worked up; asymptomatic per son. Noted on
physical exam
-BPH
-constipation
-post-herpetic neuralgia
-he denies CAD, DM, cancer

MEDICATION ON ADMISSION: (Per Nursing Home Records)
- Ciprofloxacin 500mg PO BID (started [**6-19**])
- Flagyl 500mg PO TID (started [**6-19**])
- Oxycodone IR 2.5mg-10mg PO q4 PRN pain
- Oxycodone IR 2.5mg daily at 7AM
- Morphine 4mg PO hourly PRN
- Lorazepam 0.5mg PO q4 PRN
- Artificial tears 1gtt OU [**Hospital1 **]
- Milk of Magnesia 30cc PO daily PRN
- Bisacodyl 10mg PR PRN
- Doxazosin 2mg PO HS
- Simethicone 40mg TID PRN
- EMLA cream PRN to heels prior to debridement
- Hyoscyamine sulfate 0.25mg q6 PRN
- Prochlorperazine 25mg PR q12 PRN
- Senna 17.2mg PO HS
- Lactulose 10gm daily

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission Exam:
Vitals: T: 98 BP: 139/46 P: 110s-130s R: 18 O2: 94% RA
General: Elderly male, somnolent, but will respond to his name
HEENT: Sclera anicteric, dry MM, oropharynx clear, hematoma
noted on the left side of his forehead
Neck: supple, JVP flat
Lungs: Clear to auscultation anteriorly
CV: Irregularly irregular, tachycardic
Abdomen: firm, diffusely tender, distended, hypoactive bowel
sounds, no rebound tenderness or guarding
GU: Foley in place
Ext: warm, well perfused; Dopplerable pulses; no clubbing,
cyanosis or edema; bilateral necrotic heel ulcers noted

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives at [**Location 19168**] on the [**Doctor Last Name **]. Denies history of tobacco
use. Occassional alcohol use.
Other constipation,Acute kidney failure, unspecified,Inguinal hernia, with obstruction, without mention of gangrene, bilateral (not specified as recurrent),Urinary tract infection, site not specified,Retention of urine, unspecified,Atrial fibrillation,Hypopotassemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Pressure ulcer, heel,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance
Constipation NEC,Acute kidney failure NOS,Bilat ing hernia w obst,Urin tract infection NOS,Retention urine NOS,Atrial fibrillation,Hypopotassemia,BPH w/o urinary obs/LUTS,Pressure ulcer, heel,Alzheimer's disease,Dementia w/o behav dist
Admission Date:  [**2195-6-20**]              Discharge Date:   [**2195-6-25**]


Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Increasing Abdominal Pain, Decreased PO Intake

Major Surgical or Invasive Procedure:
none.


History of Present Illness:
This is a [**Age over 90 **] year old male with PMH of Alzheimer's disease,
bilateral inguinal hernias, BPH, constipation, bilateral heel
ulcers, s/p 3 documented falls since [**2195-2-13**] presenting
with increasing abdominal pain and decreased PO intake over the
past week. The patient started developing abdominal pain 6 days
ago. The pain has become increasingly severe and is diffuse in
nature. He stopped taking solid foods PO 5 days prior to
presentation and stopped taking fluids 3 days prior to
presentation. Prior to this past week he was described as having
a robust appetite. He saw his PCP yesterday and was started on
enemas and magnesium citrate PO as well as cipro/flagyl to
empirically cover for a GI source of infection. According to the
patient's family he has been having bowel movements as they
report that the nursing home has been changing his
undergarments.
.
The patient has been in severe pain from his bilateral heel
ulcers and is on an aggressive opiate pain regimen with a
minimal bowel regimen. He is seen by a wound specialist and gets
debrided once weekly with dressing changes of his wounds twice
daily. He has fallen three times in [**2195**] and has a residual
hematoma on his left forehead from one of his falls.
.
In the ED, initial vs were: T=98.4, P=97, BP=130/70, R=18 O2
sat=94% RA. He was noted to have a rigid abdomen and
non-reducible >6 cm, hard bilateral inguinal hernias with
concern for strangulation in the right scrotum. He also had a
leukocytosis to 26.4 and a Cr=1.9. CXR and KUB showed no
evidence of free air under diaphragm. Non contract CT of abdomen
and pelvis preliminariy showed fecal loading, large inguinal
hernias without evidence of obstruction or strangulation or
volvulus. Surgery was consulted and recommended no surgical
intervention. A Foley was placed and drained 1.5L of urine.
Blood cultures were drawn. Patient was given ciprofloxacin and
flagyl, 2L of NS boluses, and morphine 4mg IV.
.
On the floor, the patient was somnolent, but briefly arousable.
He would not answer questions appropriately but was noted to be
in severe pain secondary to his heels and his abdomen.
.
Review of sytems:
Unable to obtain as patient is too somnolent

Past Medical History:
-Bradycardia - never worked up; asymptomatic per son. Noted on
physical exam
-BPH
-constipation
-post-herpetic neuralgia
-he denies CAD, DM, cancer


Social History:
Lives at [**Location 19168**] on the [**Doctor Last Name **]. Denies history of tobacco
use. Occassional alcohol use.

Family History:
Non-contributory

Physical Exam:
Admission Exam:
Vitals: T: 98 BP: 139/46 P: 110s-130s R: 18 O2: 94% RA
General: Elderly male, somnolent, but will respond to his name
HEENT: Sclera anicteric, dry MM, oropharynx clear, hematoma
noted on the left side of his forehead
Neck: supple, JVP flat
Lungs: Clear to auscultation anteriorly
CV: Irregularly irregular, tachycardic
Abdomen: firm, diffusely tender, distended, hypoactive bowel
sounds, no rebound tenderness or guarding
GU: Foley in place
Ext: warm, well perfused; Dopplerable pulses; no clubbing,
cyanosis or edema; bilateral necrotic heel ulcers noted


Pertinent Results:
STUDIES:
CXR ([**2195-6-20**]) - IMPRESSION:
1. No evidence of free intra-abdominal air.
2. Small right pleural effusion.
.
KUB ([**2195-6-20**]) - IMPRESSION:
1. Massive amount of stool within mildly dilated large bowel.
2. herniated loops of bowel at the right inguinal region.
3. Dilated loops of small bowel seen on the lateral decubitus
views, could be due to a focal ileus or early obstruction.
4. No evidence of free air.
.
CT A/P ([**2195-6-20**]) - IMPRESSION:
1. Massive bowel-containing inguinal hernias without definite
evidence for
obstruction or ischemia although the right hernia in particular
is probably at risk for torsion potentially in the future.
2. Marked fecal impaction in the rectal vault.
3. Porceline gallbladder with cholelithiasis, generally
considered to
represent a substantial risk of developing gallbladder cancer.
4. Small right pleural effusion with asymmetric right pulmonary
interlobular septal thickening which could represent asymmetric
edema or an inflammatory process in the right lung, although if
patient has history of primary malignancy, differential
consideration includes lymphangiocarcinomatosis. If acute
pulmonary symptoms are clinically present, a PA/Lateral chest
radiograph is recommended. A chest CT should also be considered
for further evaluation when clinically appropriate.
5. Mild bilateral hydronephrosis with hydroureter on the left
without
definite source. One possibility is that the degree of fecal
impaction is so great as to induce extrinsic compression. Renal
ultrasound following fecal disimpaction may be potentially
helpful to see if the renal findings improve.
6. Diffuse severe atherosclerotic disease.
.
.
[**2195-6-22**] TTE:
Conclusions
The left atrium is moderately dilated. There is mild
(non-obstructive) focal hypertrophy of the basal septum. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets are
mildly thickened (?#). There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. There is mild functional
mitral stenosis (mean gradient 3 mmHg) due to mitral annular
calcification. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2195-2-17**], the
rhythm still appears to be atrial fibrillation. Left ventricular
function is less dynamic (but still normal). Estimated pulmonary
artery pressures are higher. There is no longer a gradient
across the outflow tract.
.
.
[**2195-6-21**] FOOT XRAY:
IMPRESSION:
1. Soft tissue swelling involving both right and left feet.
.
2. Right calcaneus -- relative [**Name (NI) **] in posterior calcaneus --
ddx include reactive osteopenia, vs usbtle osteomyelitis. No
cortical interruption of discrete lytic lesion detected.
.
3. Left calcaneus -- No obvious calcaneal bone destruction is
detected to
confirm the presence of osteomyelitis, but the ulcer does lie in
close
proximity of the bone.
.
4. Right 5th proximal phalanx -- focal ostepenia, ? lytic
lesion. In the
absence of overlying soft tissue infection, this would most
likely represent an enchondroma. Clinical correlation requested.

.
.
LABS:
[**2195-6-20**] 12:30PM BLOOD WBC-26.4*# RBC-4.33* Hgb-11.6* Hct-35.9*
MCV-83 MCH-26.8* MCHC-32.3 RDW-15.4 Plt Ct-236
[**2195-6-20**] 07:05PM BLOOD WBC-18.4* RBC-3.57* Hgb-9.6* Hct-30.2*
MCV-85 MCH-26.8* MCHC-31.7 RDW-15.1 Plt Ct-207
[**2195-6-21**] 04:48AM BLOOD WBC-15.3* RBC-3.65* Hgb-10.0* Hct-31.1*
MCV-85 MCH-27.4 MCHC-32.2 RDW-14.9 Plt Ct-202
[**2195-6-22**] 06:15AM BLOOD WBC-11.8* RBC-3.62* Hgb-9.8* Hct-30.8*
MCV-85 MCH-27.1 MCHC-31.9 RDW-14.5 Plt Ct-188
[**2195-6-23**] 07:16AM BLOOD WBC-10.6 RBC-3.71* Hgb-10.2* Hct-31.7*
MCV-86 MCH-27.6 MCHC-32.2 RDW-14.8 Plt Ct-197
[**2195-6-24**] 03:15PM BLOOD WBC-12.0* RBC-4.16* Hgb-10.7* Hct-34.6*
MCV-83 MCH-25.8* MCHC-31.0 RDW-14.2 Plt Ct-246
[**2195-6-25**] 07:25AM BLOOD WBC-11.0 RBC-4.30* Hgb-11.1* Hct-35.5*
MCV-83 MCH-25.7* MCHC-31.2 RDW-14.5 Plt Ct-236
[**2195-6-20**] 12:30PM BLOOD Neuts-92* Bands-0 Lymphs-2* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2195-6-20**] 07:05PM BLOOD Neuts-92.3* Lymphs-2.9* Monos-4.4 Eos-0.4
Baso-0
[**2195-6-20**] 12:30PM BLOOD PT-13.2 PTT-24.8 INR(PT)-1.1
[**2195-6-21**] 04:48AM BLOOD PT-13.8* PTT-26.6 INR(PT)-1.2*
[**2195-6-22**] 06:15AM BLOOD PT-15.2* PTT-29.4 INR(PT)-1.3*
[**2195-6-23**] 07:16AM BLOOD ESR-17*
[**2195-6-20**] 12:30PM BLOOD Glucose-233* UreaN-50* Creat-1.9*# Na-144
K-3.9 Cl-103 HCO3-31 AnGap-14
[**2195-6-21**] 04:48AM BLOOD Glucose-197* UreaN-37* Creat-0.9 Na-149*
K-3.6 Cl-111* HCO3-33* AnGap-9
[**2195-6-22**] 06:15AM BLOOD Glucose-183* UreaN-24* Creat-0.6 Na-147*
K-3.1* Cl-109* HCO3-32 AnGap-9
[**2195-6-23**] 07:16AM BLOOD Glucose-130* UreaN-14 Creat-0.5 Na-140
K-3.5 Cl-105 HCO3-29 AnGap-10
[**2195-6-24**] 03:15PM BLOOD Glucose-135* UreaN-10 Creat-0.5 Na-136
K-3.2* Cl-101 HCO3-24 AnGap-14
[**2195-6-25**] 07:25AM BLOOD Glucose-128* UreaN-8 Creat-0.5 Na-137
K-3.0* Cl-100 HCO3-28 AnGap-12
[**2195-6-21**] 04:48AM BLOOD CK(CPK)-23*
[**2195-6-25**] 07:25AM BLOOD ALT-19 AST-28 AlkPhos-100 TotBili-0.4
[**2195-6-20**] 12:30PM BLOOD ALT-18 AST-15 AlkPhos-129 TotBili-0.5
[**2195-6-20**] 12:30PM BLOOD Lipase-8
[**2195-6-20**] 07:05PM BLOOD CK-MB-2 cTropnT-0.03*
[**2195-6-21**] 04:48AM BLOOD CK-MB-3 cTropnT-0.03*
[**2195-6-20**] 07:05PM BLOOD Calcium-7.8* Phos-3.5 Mg-2.5
[**2195-6-22**] 06:00PM BLOOD Mg-1.9
[**2195-6-24**] 03:15PM BLOOD Calcium-8.0* Phos-2.6* Mg-1.8
[**2195-6-25**] 07:25AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.9
[**2195-6-21**] 04:48AM BLOOD %HbA1c-6.8* eAG-148*
[**2195-6-23**] 07:16AM BLOOD CRP-85.9*
[**2195-6-21**] 04:48AM BLOOD TSH-1.2
[**2195-6-20**] 07:05PM BLOOD Osmolal-309
[**2195-6-20**] 12:40PM BLOOD Lactate-1.9
[**2195-6-20**] 12:55PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.022
[**2195-6-21**] 04:48AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018
[**2195-6-24**] 04:43PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2195-6-20**] 12:55PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-5.0 Leuks-SM
[**2195-6-21**] 04:48AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-LG
[**2195-6-24**] 04:43PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-6.5 Leuks-TR
[**2195-6-20**] 12:55PM URINE RBC-0-2 WBC-[**7-23**]* Bacteri-MANY Yeast-NONE
Epi-0
[**2195-6-21**] 04:48AM URINE RBC-158* WBC-65* Bacteri-NONE Yeast-NONE
Epi-0
[**2195-6-24**] 04:43PM URINE RBC-29* WBC-5 Bacteri-FEW Yeast-NONE
Epi-<1
[**2195-6-21**] 04:48AM URINE CastHy-8*
[**2195-6-20**] 12:55PM URINE Mucous-MANY
[**2195-6-21**] 04:48AM URINE Mucous-MOD
[**2195-6-24**] 04:43PM URINE Mucous-FEW
[**2195-6-20**] 12:55PM URINE CaOxalX-MOD
.
.
MICROBIOLOGY:
[**2195-6-20**] 12:30 pm BLOOD CULTURE

   Blood Culture, Routine (Pending):
.
.
[**2195-6-21**] 4:48 am STOOL     CONSISTENCY: SOFT

                            **FINAL REPORT [**2195-6-22**]**

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2195-6-22**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).
.
.
[**2195-6-21**] 4:48 am URINE     Site: CATHETER

                            **FINAL REPORT [**2195-6-22**]**

   URINE CULTURE (Final [**2195-6-22**]):    NO GROWTH.

.
.
[**2195-6-21**] 4:48 am SWAB     Site: RECTAL

                            **FINAL REPORT [**2195-6-24**]**

   R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2195-6-24**]):
      ENTEROCOCCUS SP..    Sensitivity testing performed by
Etest.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
VANCOMYCIN------------  >256 R
.
.


Brief Hospital Course:
[**Age over 90 **]M h/o alzheimer's dementia and BPH admitted with 1 week of
increasing abdominal pain and found to have severe diffuse fecal
loading with massive inguinal hernias containing loops of colon
as well as acute kidney injury.
.
# abdominal pain / constipation / impaction -  pt's abdominal
pain was felt to likely be secondary to constipation, given his
imaging with severe diffuse fecal loading and massive inguinal
hernias containing loops of colon. On arrival to the ICU, the
patient was noted to aspirate oral medications and was therefore
made NPO. He was treated with aggressive bowel regimen,
including senna, colace, bisacodyl,  lactulose enemas.  He also
underwent manual disimpaction, which revealed hard trace guaiaic
positive stools.
.
Given loops of bowel in scrotum, and concern for incarceration,
surgical service was consulted, who recommended conservative
management.  After disimpaction his bowel began moving, and he
was called out to the medical floor.
.
Upon arrival to the medical floor, he was continued on
aggressive bowel regimen including daily tap water and/or
mineral oil enemas, disimpaction x1.  He continued to have daily
bowel movements, his abdomen became soft, and the loops of bowel
in the scrotum became notable soft.  Surgical service signed
off, and pt was discharged back to rehab with instructions to
continue aggressive daily bowel regimen with goal of 2 soft BMs
per day.  Given ongoing bowel movements, his diet was advanced
back to regular diet without difficulty.
.
.
# acute kidney injury / urinary retention - Patient was noted to
have a creatinine of 1.9 from a baseline of 0.5. The etiology
was felt to be both prerenal and postrenal. Upon arrival to the
ED, a Foley was placed and drained 1.5 Liters of urine. It was
felt that the patient's diffuse fecal loading was causing an
element of obstruction and that his decreased PO intake was
leading to a component of prerenal azotemia.  His creatinine
resolved with IVF.
.
His urinary retention was felt possible [**3-17**] narcotic use and
constipation.  Voiding trial was attempted x2 and was
unsucessful, despite restarting his doxazosin.  He was
discharged to Rehab with foley catheter in place.  Repeat
voiding trial should be attempted within 7d of discharge, should
he fail again, he should follow-up with urology clinic.
.
.
# leukocytosis - etiology was initially felt possibly [**3-17**] UTI
versus heel ulcers.  After discussion with podiatry, heel
infection was felt less likely, and vancomycin was discontinued.
 His leukocytosis resolved with treatment of UTI and
constipation.
.
.
# bilateral heel ulcers - The patient had necrotic areas
overlying both heels which were draining fibrinous material
initially concerning for infection.  He had a documented history
of MRSA at his nursing facility from a heel swab on [**5-31**] and was
reporedly undergoing weekly debridements there. IV vancomycin
was started empirically on admission, and podiatry service was
consulted, who felt there was no evidence of infection.  Foot
XRAY was obtained which raised concern for possible
osteomyeletis, however, after discussion with podiatry, this was
felt unlikely.  ESR was 17, and CRP was 85, however felt there
was contribution from UTI and constipation.
.
Podiatry made wound care recommendations as below, including
treatment with enzymatic debridement:
-offloading with multipodus boots bilaterally
-daily wet to dry dressing changes
-santyl enzymatic dressing changes on the right heel.
.
.
Pt instructed to follow-up with podiatry within [**2-14**] month of
discharge.
.
.
# altered mental status - the patient has Alzheimer's disease at
baseline and the family had noted a marked decrease in his
functional status since [**2195-2-13**] when he was hospitalized
for a fall.  His initial delerium was felt multifactorial with
contribution from narcotic administration,
anticholinergics/benzo's at his nursing home, constipation,
urinary tract infection.  With treatment of his constipation,
and UTI, his mental status slowly improved, though he remained
A&Ox2, his son's corroborated that he was approaching his
baseline.
.
.
# atrial fibrillation - pt has no previous record of atrial
fibrillation.  TSH was 1.2.  He was treated with iv metoprolol
prn in ICU, however did not require additional rate control
medications upon arrival to the floor.  He was intermittently
back in NSR.  His CHADs score is [**2-14**] (not clearly diabetic),
therefore he should be covered with aspirin daily.  This was
started at the time of his discharge.   Should he have elevated
heart rates, he can be started on low dose metoprolol, which can
be uptitrated as needed.   TTE was performed which showed
preserved EF.
.
.
# BPH - Home doxazosin was held on admission given hypotension,
and resumed prior to discharge.
.
.
# hypokalemia - pt with K=3.0 prior to discharge, this was
repleted without difficulty.  he should have repeat potassium
checked on 1d after discharge, and repleted as needed, for goal
K>3.7 given atrial fibrillation above.
.
.
# hyperglycemia - no h/o diabetes, mildly elevated FSBS in ICU,
A1c 6.8.  not requiring insulin on floor.  he was discharged to
rehab without starting insulin, and instructed to follow-up with
his PCP.
.
.
# CODE - DNR/DNI.
.
.
# COMM - Patient; [**Name (NI) 32851**] [**Name (NI) **] (son/HCP/retired ENT physician)
[**Telephone/Fax (1) 77596**] (home) + [**Telephone/Fax (1) 77597**] (cell); [**Name (NI) 122**] [**Name (NI) 77598**]
(son) [**Telephone/Fax (1) 77599**]; Newbridge on the [**Doctor Last Name **] nursing facility
[**Telephone/Fax (1) 77600**]

Medications on Admission:
(Per Nursing Home Records)
- Ciprofloxacin 500mg PO BID (started [**6-19**])
- Flagyl 500mg PO TID (started [**6-19**])
- Oxycodone IR 2.5mg-10mg PO q4 PRN pain
- Oxycodone IR 2.5mg daily at 7AM
- Morphine 4mg PO hourly PRN
- Lorazepam 0.5mg PO q4 PRN
- Artificial tears 1gtt OU [**Hospital1 **]
- Milk of Magnesia 30cc PO daily PRN
- Bisacodyl 10mg PR PRN
- Doxazosin 2mg PO HS
- Simethicone 40mg TID PRN
- EMLA cream PRN to heels prior to debridement
- Hyoscyamine sulfate 0.25mg q6 PRN
- Prochlorperazine 25mg PR q12 PRN
- Senna 17.2mg PO HS
- Lactulose 10gm daily


Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain: please try tylenol first, use
oxycodone only if pain is severe.
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-14**]
Drops Ophthalmic [**Hospital1 **] (2 times a day).
4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)  PO
BID (2 times a day) as needed for constipation: titrate to 2
soft bowel movements daily.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation: titrate to 2
soft bowel movements daily.
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): titrate to 2 soft bowel movements daily.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): titrate to 2 soft bowel movements daily.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
12. Collagenase Clostridium hist. 250 unit/g Ointment Sig: One
(1) Appl Topical DAILY (Daily): apply to right heel.
13. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]

Discharge Diagnosis:
severe constipation/impaction
inguinal hernia
urinary tract infection, bacterial
delerium
bilateral heel ulcers


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
you were admitted to the hospital with severe constipation,
confusion, and urinary tract infection.  you were seen by the
surgical service given your inguinal hernias, who felt that no
surgical intervention was required.
.
you were treated with aggressive bowel regimen, enemas, and
disimpaction, and your constipation resolved.
.
you were treated with an antibiotic for your UTI.
.
your mental status was felt to be back to baseline per your
sons.
.
your heel ulcers were evaluated by the podiatry service, and not
felt to be infected.  wound care recommendations were made.
.
the following changes were made to your medication regimen:
1. you were started on an aggressive bowel regimen including
daily senna, colace, bisacodyl, lactulose, miralax, and tap
water/mineral oil enemas daily as needed to facilitate 2 soft
bowel movements per day.
2. you were started/continued on ciprofloxacin to complete a 5
day course for your UTI.

Followup Instructions:
upon arriving home, please contact your primary care physician,
[**Name10 (NameIs) **] arrange to be seen within 1-2 weeks of your discharge for
routine follow-up.
.
upon arriving home, please contact your podiatrist, and arrange
to have routine follow-up of your heel ulcers as needed.
{"Other constipation,Acute kidney failure, unspecified,Inguinal hernia, with obstruction, without mention of gangrene, bilateral (not specified as recurrent),Urinary tract infection, site not specified,Retention of urine, unspecified,Atrial fibrillation,Hypopotassemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Pressure ulcer, heel,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance"}


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: Increasing Abdominal Pain, Decreased PO Intake

PRESENT ILLNESS: This is a [**Age over 90 **] year old male with PMH of Alzheimer's disease,
bilateral inguinal hernias, BPH, constipation, bilateral heel
ulcers, s/p 3 documented falls since [**2195-2-13**] presenting
with increasing abdominal pain and decreased PO intake over the
past week. The patient started developing abdominal pain 6 days
ago. The pain has become increasingly severe and is diffuse in
nature. He stopped taking solid foods PO 5 days prior to
presentation and stopped taking fluids 3 days prior to
presentation. Prior to this past week he was described as having
a robust appetite. He saw his PCP yesterday and was started on
enemas and magnesium citrate PO as well as cipro/flagyl to
empirically cover for a GI source of infection. According to the
patient's family he has been having bowel movements as they
report that the nursing home has been changing his
undergarments.
.
The patient has been in severe pain from his bilateral heel
ulcers and is on an aggressive opiate pain regimen with a
minimal bowel regimen. He is seen by a wound specialist and gets
debrided once weekly with dressing changes of his wounds twice
daily. He has fallen three times in [**2195**] and has a residual
hematoma on his left forehead from one of his falls.
.
In the ED, initial vs were: T=98.4, P=97, BP=130/70, R=18 O2
sat=94% RA. He was noted to have a rigid abdomen and
non-reducible >6 cm, hard bilateral inguinal hernias with
concern for strangulation in the right scrotum. He also had a
leukocytosis to 26.4 and a Cr=1.9. CXR and KUB showed no
evidence of free air under diaphragm. Non contract CT of abdomen
and pelvis preliminariy showed fecal loading, large inguinal
hernias without evidence of obstruction or strangulation or
volvulus. Surgery was consulted and recommended no surgical
intervention. A Foley was placed and drained 1.5L of urine.
Blood cultures were drawn. Patient was given ciprofloxacin and
flagyl, 2L of NS boluses, and morphine 4mg IV.
.
On the floor, the patient was somnolent, but briefly arousable.
He would not answer questions appropriately but was noted to be
in severe pain secondary to his heels and his abdomen.
.
Review of sytems:
Unable to obtain as patient is too somnolent

MEDICAL HISTORY: -Bradycardia - never worked up; asymptomatic per son. Noted on
physical exam
-BPH
-constipation
-post-herpetic neuralgia
-he denies CAD, DM, cancer

MEDICATION ON ADMISSION: (Per Nursing Home Records)
- Ciprofloxacin 500mg PO BID (started [**6-19**])
- Flagyl 500mg PO TID (started [**6-19**])
- Oxycodone IR 2.5mg-10mg PO q4 PRN pain
- Oxycodone IR 2.5mg daily at 7AM
- Morphine 4mg PO hourly PRN
- Lorazepam 0.5mg PO q4 PRN
- Artificial tears 1gtt OU [**Hospital1 **]
- Milk of Magnesia 30cc PO daily PRN
- Bisacodyl 10mg PR PRN
- Doxazosin 2mg PO HS
- Simethicone 40mg TID PRN
- EMLA cream PRN to heels prior to debridement
- Hyoscyamine sulfate 0.25mg q6 PRN
- Prochlorperazine 25mg PR q12 PRN
- Senna 17.2mg PO HS
- Lactulose 10gm daily

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission Exam:
Vitals: T: 98 BP: 139/46 P: 110s-130s R: 18 O2: 94% RA
General: Elderly male, somnolent, but will respond to his name
HEENT: Sclera anicteric, dry MM, oropharynx clear, hematoma
noted on the left side of his forehead
Neck: supple, JVP flat
Lungs: Clear to auscultation anteriorly
CV: Irregularly irregular, tachycardic
Abdomen: firm, diffusely tender, distended, hypoactive bowel
sounds, no rebound tenderness or guarding
GU: Foley in place
Ext: warm, well perfused; Dopplerable pulses; no clubbing,
cyanosis or edema; bilateral necrotic heel ulcers noted

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives at [**Location 19168**] on the [**Doctor Last Name **]. Denies history of tobacco
use. Occassional alcohol use. 

### Response:
{"Other constipation,Acute kidney failure, unspecified,Inguinal hernia, with obstruction, without mention of gangrene, bilateral (not specified as recurrent),Urinary tract infection, site not specified,Retention of urine, unspecified,Atrial fibrillation,Hypopotassemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Pressure ulcer, heel,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance"}
