CHIEF COMPLAINT: Diarrhea and bowel perforation

PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname **] is a 75 year old man with history of Crohn's s/p
small bowel resections x 3, s/p ileocectomy, h/o
post-colonoscopy jejunal diverticular perforation s/p small
bowel resection [**2174**], perianal fistula, diverticulitis, colon
polyps, and h/o GI bleeding who presented on [**2181-1-22**] to an OSH
from home with increased diarrhea and concern for dehydation. Of
note, he has three recent hospital admission for GI symptoms
ranging from diarrhea to constipation.  Per the patient he
believes his change in pain medications and bowel regimens were
responsible for these admission. At the OSH, a CT abdomen/pelvis
was performed demonstrating a contained bowel perforation. He
was transferred [**Hospital1 18**] on [**2181-1-23**] and admitted to the surgical
service for further management. He was treated conservatively
with bowel rest, cipro IV and flagyl IV. Patient remained
hemodynamically stable without concerning physical exam.
Surgical team decided patient did not warrant surgical
intervention at this time and could be conservatively managed.
Patient was started on a clear diet which the patient did not
accept as he did not want to contribute to his continuous
diarrhea. TPN was ordered given patient's report of recent
weightloss and inability to tolerate pos. Patient was then
transferred to the medical service for further management.
.
At the time of transfer, the patient's only concern is the
extreme pain in his bilateraly hips.  He reports having chronic
pain that is managed by long acting morphine 15 mg up to 4 times
per day and a fentanyl patch 75 mcg. He reports he has not
received any pain medications today.  This pain is the same
character as his chronic hip pain just much more severe as he is
lying on his side/hip because of the diarrhea. He is concerned
to start his home regimen as he fears it may cause his diarrhea
to completely stop and make his perforation worse. The patient
denies abdominal pain, nausea or vomiting. He has no blood in
his stool. He has no current fevers or chills. He does report an
episode of chills yesterday and intermittent episodes of chills
and diaphoresis over the last 10 days at home. He describes
continuous diarrhea throughout the day today that is nonbloody
and causing anal and scrotal pain.

MEDICAL HISTORY: 1) Crohn's disease s/p SB rections x3 managed on chronic
prednisone, azathioprine, mesalamine
2) Perianal fistula
3) Diverticulitis
4) Colon polyp
5) Bowel perforation secondary to colonscopy
6) GI bleed on coumadin [**2-/2180**]
7) Afib rate controlled and on coumadin
8) h/o DVT RUE [**2175**]
9) HTN
10) CRI unknown baseline creatinine
11) h/o PNA
12) Avascular necrosis of bilateral hips R > L
13) Chronic back pain
14) Gout
15) h/o MRSA and VRE
16) s/p appendectomy

MEDICATION ON ADMISSION: Pentasa 1000mg daily
mag Oxide 3 tabs daily
Azathioprine 50mg daily
Paxil 20mg daily
Prednisone 5mg daily
Dulcolax 10mg daily
Coumadin 3mg daily
Lopressor 12.5 mg daily

ALLERGIES: oxycodone-acetaminophen / hydrocodone-acetaminophen

PHYSICAL EXAM: VS T 98.4 120/66 78 20 98% RA.
General: Alert, oriented x3, uncomfortable, restless
HEENT: Sclera anicteric, MMM, R eye strabismus
Neck: supple, JVP not elevated, no LAD, R IJ CVL in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and irregular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen:  soft, nontender, + bs, no masses, no rebound, no
guarding, no CVA or suprapubic tenderness, + anal pain and skin
break down from chronic diarrhea
Ext: R dorsal surface of foot swollen, erythematous, and warm
2+ distal pulses in all four extremities

FAMILY HISTORY: Denies family history of IBD.

SOCIAL HISTORY: Patient is retired, widowed with five children and living with
his second wife. [**Name (NI) **] ambulates with the assistance of a walker at
home. His wife [**Name (NI) **] assists him with most ADLs prior to coming
to the hospital.  He denies use of tobacco, alcohol, illicit
drugs, or herbal medications.
Regional enteritis of unspecified site,Perforation of intestine,Acute kidney failure, unspecified,Bacteremia,Unspecified protein-calorie malnutrition,Aseptic necrosis of head and neck of femur,Other and unspecified infection due to central venous catheter,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia of other chronic disease,Atrial fibrillation,Backache, unspecified,Gout, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Long-term (current) use of anticoagulants,Do not resuscitate status
Regional enteritis NOS,Perforation of intestine,Acute kidney failure NOS,Bacteremia,Protein-cal malnutr NOS,Aseptic necrosis femur,Oth/uns inf-cen ven cath,Mth sus Stph aur els/NOS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Anemia-other chronic dis,Atrial fibrillation,Backache NOS,Gout NOS,Abn react-surg proc NEC,Long-term use anticoagul,Do not resusctate status
Admission Date:  [**2181-1-22**]              Discharge Date:   [**2181-2-7**]

Date of Birth:  [**2105-12-29**]             Sex:   M

Service: MEDICINE

Allergies:
oxycodone-acetaminophen / hydrocodone-acetaminophen

Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Diarrhea and bowel perforation

Major Surgical or Invasive Procedure:
[**2181-1-22**] Central venous Line placed in right internal jugular vein
[**2181-1-28**] PICC line placed
[**2181-2-1**] Transesophageal echocardiography performed
[**2181-2-2**] PICC line placed


History of Present Illness:
Mr. [**Known firstname **] [**Known lastname **] is a 75 year old man with history of Crohn's s/p
small bowel resections x 3, s/p ileocectomy, h/o
post-colonoscopy jejunal diverticular perforation s/p small
bowel resection [**2174**], perianal fistula, diverticulitis, colon
polyps, and h/o GI bleeding who presented on [**2181-1-22**] to an OSH
from home with increased diarrhea and concern for dehydation. Of
note, he has three recent hospital admission for GI symptoms
ranging from diarrhea to constipation.  Per the patient he
believes his change in pain medications and bowel regimens were
responsible for these admission. At the OSH, a CT abdomen/pelvis
was performed demonstrating a contained bowel perforation. He
was transferred [**Hospital1 18**] on [**2181-1-23**] and admitted to the surgical
service for further management. He was treated conservatively
with bowel rest, cipro IV and flagyl IV. Patient remained
hemodynamically stable without concerning physical exam.
Surgical team decided patient did not warrant surgical
intervention at this time and could be conservatively managed.
Patient was started on a clear diet which the patient did not
accept as he did not want to contribute to his continuous
diarrhea. TPN was ordered given patient's report of recent
weightloss and inability to tolerate pos. Patient was then
transferred to the medical service for further management.
.
At the time of transfer, the patient's only concern is the
extreme pain in his bilateraly hips.  He reports having chronic
pain that is managed by long acting morphine 15 mg up to 4 times
per day and a fentanyl patch 75 mcg. He reports he has not
received any pain medications today.  This pain is the same
character as his chronic hip pain just much more severe as he is
lying on his side/hip because of the diarrhea. He is concerned
to start his home regimen as he fears it may cause his diarrhea
to completely stop and make his perforation worse. The patient
denies abdominal pain, nausea or vomiting. He has no blood in
his stool. He has no current fevers or chills. He does report an
episode of chills yesterday and intermittent episodes of chills
and diaphoresis over the last 10 days at home. He describes
continuous diarrhea throughout the day today that is nonbloody
and causing anal and scrotal pain.


Past Medical History:
1) Crohn's disease s/p SB rections x3 managed on chronic
prednisone, azathioprine, mesalamine
2) Perianal fistula
3) Diverticulitis
4) Colon polyp
5) Bowel perforation secondary to colonscopy
6) GI bleed on coumadin [**2-/2180**]
7) Afib rate controlled and on coumadin
8) h/o DVT RUE [**2175**]
9) HTN
10) CRI unknown baseline creatinine
11) h/o PNA
12) Avascular necrosis of bilateral hips R > L
13) Chronic back pain
14) Gout
15) h/o MRSA and VRE
16) s/p appendectomy


Social History:
Patient is retired, widowed with five children and living with
his second wife. [**Name (NI) **] ambulates with the assistance of a walker at
home. His wife [**Name (NI) **] assists him with most ADLs prior to coming
to the hospital.  He denies use of tobacco, alcohol, illicit
drugs, or herbal medications.

Family History:
Denies family history of IBD.

Physical Exam:
VS T 98.4 120/66 78 20 98% RA.
General: Alert, oriented x3, uncomfortable, restless
HEENT: Sclera anicteric, MMM, R eye strabismus
Neck: supple, JVP not elevated, no LAD, R IJ CVL in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and irregular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen:  soft, nontender, + bs, no masses, no rebound, no
guarding, no CVA or suprapubic tenderness, + anal pain and skin
break down from chronic diarrhea
Ext: R dorsal surface of foot swollen, erythematous, and warm
2+ distal pulses in all four extremities


Pertinent Results:
MICRO:
.
STOOL STUDIES:
[**2181-1-24**] C. diff toxin negative
[**2181-1-24**] Ova & Parasites negative
[**2181-1-25**] C. diff toxin negative
[**2181-1-25**] Ova & Parasites negative
[**2181-1-25**] Stool culture negative
[**2181-1-26**] Ova & Parasites negative
[**2181-1-30**]: C. diff toxin negative
.
BLOOD CULTURES:
[**2181-1-26**] STAPH AUREUS COAG +.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
[**2181-1-27**] MSSA (sensitivities as above)
[**2181-1-28**] MSSA (sensitivities as above)
[**2181-1-29**] No growth to date
[**2181-1-30**] No growth to date
[**2181-1-31**] No growth to date
[**2181-2-1**] No growth to date
[**2181-2-2**] No growth to date
.
[**2181-1-26**] CVL catheter tip: MSSA (sensitivities as above)
.
[**2181-1-28**] Urine cx: No growth
.
IMAGING:
.
[**2181-1-23**] outside film CT read:
Free air along the ascending colon and at the greater omentum
anterior to a wall thickened distal ileum bowel loop (3, 52;
201, 69), consistent with bowel perforation, likely in the
setting of active Crohn's flare.
.
[**2181-1-23**] CXR: In comparison with study of [**2174-9-2**], there is little
change and no evidence of acute cardiopulmonary disease. No
evidence of free intraperitoneal gas, though this may well not
represent a true upright image.  If perforation is a serious
clinical concern, CT could be considered for further evaluation.

.
[**2181-1-26**] CT Abdomen/Pelvis w/o contrast:
1. In this patient with history of Crohn's disease, and recent
microperforation, there is no significant interval change in the
amount of free intraperitoneal air. No intra-abdominal abscesses
or fluid collections are seen.
2. Interval improvement in the bibasilar tree-in-[**Male First Name (un) 239**] opacities,
likely
related to infection or aspiration. New trace pleural effusions.

3. Cholelithiasis, without evidence of acute cholecystitis.
4. AVN of bilateral femoral head.
.
[**2181-1-29**] CXR PA and Lateral:
As compared to the previous radiograph from [**2181-1-29**],
the
PICC line is in unchanged position. At the right lung base, the
pre-described opacities are more subtle than on the previous
image. As noted in the previous report, they could correspond to
early pneumonia or a small amount of intrafissural fluid. No new
opacities are seen in the lung parenchyma. The left lung is
unremarkable.
.
[**2181-1-29**] Neck Ultrasound:
1. Heterogeneous hypoechoic track in the right neck,
corresponding with the location of the recent central line
removal, likely represents fluid and/or clot within this tract.
2. Nonocclusive thrombus seen within the right internal jugular
vein.
.
[**2181-1-29**] CT neck with contrast:
1. Heterogeneous hypoechoic track in the right neck,
corresponding with the location of the recent central line
removal, likely represents fluid and/or clot within this tract.
2. Nonocclusive thrombus seen within the right internal jugular
vein.
.
[**2181-1-31**] Transthoracic Echo:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. No mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. No masses or vegetations are seen on the tricuspid
valve, but cannot be fully excluded due to suboptimal image
quality. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.

IMPRESSION: Suboptimal image quality. No echocardiographic
evidence of endocarditis. If clinically suggested, the absence
of a vegetation by 2D echocardiography does not exclude
endocarditis. Normal global biventricular systolic function.
.
[**2181-2-1**] Transesophageal Echo:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Overall left ventricular
systolic function is normal (LVEF>55%). with normal free wall
contractility. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on the aortic
valve. No aortic valve abscess is seen. No aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. No mass or vegetation is seen on
the mitral valve. No vegetation/mass is seen on the pulmonic
valve. There is no pericardial effusion.

IMPRESSION: No echocardiographic signs of endocarditis. Normal
global biventricular systolic function. Mild tricuspid
regurgitation. No other significant valvular regurgitation seen.

.


Brief Hospital Course:
75 year old man with a history of afib, Crohn's, and avascular
necrosis who is transferred to [**Hospital1 18**] after imaging suggestive of
bowel perforation. [**Hospital **] medical management of bowel
perforation was complicated by CVL-associated infection with
MSSA bacteremia and septic thrombus.
.
1) MSSA Bacteremia: Secondary to CVL-associated infection.  Last
fever on [**2181-1-28**].  Last positive blood culture [**2181-1-28**].  Patient
started on Vancomycin on and switched to Nafcillin on [**2181-1-29**]
based on culture results.  Patient's TEE and TTE were negative
for evidence of endocarditis.  New PICC line placed on [**2181-2-2**]
after > 72 hours of negative blood cultures. Given patient's
concurrent nonocclusive thrombus his antibiotic course will be
extended to four weeks (last dose on [**2181-2-27**]). Patient will
follow up with the [**Hospital1 18**] Infectious disease clinic on [**2181-3-1**].
Patient should continue to have weekly CBC, BUN/Cr and LFTs
monitored while on naficillin and the results faxed to
Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions
regarding outpatient antibiotics should be directed to the
clinic is closed.
.
.
2) Nonocclusive Thrombus: Located in right IJ at site of prior
CVL.  Given patient's concurrent MSSA bacteremia, thrombus is
presumed septic.  CT scan and ultrasound show no evidence of
surrounding abscess or involvement of carotid artery. Patient
was started on coumadin and bridged with a heparin gtt. He will
continue Nafcillin regimen as above.
.
3) Bowel microperforation: Patient with no history of acute
abdomen or indication for surgical intervention on presentation.
 Patient was medically managed with cipro/flagyl x 14 days (last
dose on [**2181-2-4**]). His abdominal exam remained benign throughout
his admission.
.
4) Diarrhea: Patient presents with watery, nonbloody diarrhea of
several days. Quantity of stools declined during his admission
but watery consistency persists.  Stool studies negative for
infection (C. diff, ova & parasites, and negative cultures).
Aggressive treatment of possible Crohn's flare (with steroids or
immune modulators) was avoided given patient's recent bowel
perforation and systemic infection.  He was continued on home
regimen of prednisone 5 mg and azathioprine 50 mg daily.  His
mesalamine was initially held on admission but ultimately
restarted at a higher dose. Just prior to discharge patient was
started on a trial of cholestyramine as this would help treat
bile salt wasting if it is contibuting to his diarrhea.  If
patient's stools remain watery over the next 48 hours his dose
may be increased.  If no improvement is seen within 2 days of
increasing his dose of cholestyramine his diarrhea is likely not
due to bile salt wasting and the cholestyramine can be
discontinued. Patient requested use of a Flexiseal fecal
containment system for comfort. Flexiseal was kept in place
during the majority of his admission to prevent skin break down
and treat skin irritation. Patient is to continue current
medical regimen and follow up with [**Hospital 18**] [**Hospital **] clinic
within two weeks of discharge.
.
Given patient's decreased mobility and increased narcotic use,
close attention should be paid to the frequency and quantity of
patient's bowel movements as constipation may contribute to poor
appetite or complicate patient's recent bowel perforation.
Patient and family are rightfully very anxious about the
management of his pain and the affect it may have on his bowels.
.
5) Malnutrition: Patient describes 20 lbs weight loss in 2
months with increased diarrhea and poor po intake.  He was
started on TPN during his admission.  Initially, patient's bowel
microperforation was managed with bowel rest and antibiotics.
Given his persistent benign abdominal exam and clinical
stability he was instructed to start a regular diet.  Due to
patient's loose stools, high pill burden, hip pain he continued
to have poor po intake.  Strongly recommend that patient
continue to followed closely by a nutritional team after
discharge to optimize patient's diet as he is able to increase
his po intake.  The nutrition team cautioned patient that tube
feeds may be warranted if no improvement in his caloric intake
is seen.
.
5) Avascular necrosis of bilateral hips: Patient with severe
bilateral hip pain R > L that is exacerbated by his immobility
during this admission.  His pain was extremely difficult to
manage during his admission as his pain requirements varied
widely from day to day.  On transfer to the medicine service he
was restarted on his home fentanyl patch 75 mcg q72h which was
titrate up to 100 mcg q72h, and started on standing
acetaminophen 1 g TID, lidocaine 5% patch to right hip daily. He
required additional dilaudid IV which ranged from 1 mg q4h prn
to 1.5 mg q3h standing.  He was ultimately transitioned to a
dilaudid PCA to help determine his narcotic requirements.
Patient will likely require PCA adjustments when his physical
activity increases.
.
Patient's greatest concern during his admission was his pain
regimen and his bowel regimen as he believes his recent GI
issues (constipation, diarrhea, and bowel perforation) were due
to an imbalance in his pain medications and bowel regimen. He
also would frequently decline physical therapy due to fear of
pain which only  worsened his already impressive deconditioned
state. He was counseled that there are medications available to
help manage his pain and that his recovery is dependent on his
participation. He was also counseled that his narcotic regimen
may continue to change with increased activity at rehabilitation
and that his health care providers at rehab would be able to
adjust his current pain regimen to accommodate to his pain
levels.
.
6) Atrial fibrillation: Patient has required no rate control for
afib throughout hospitalization.  He remained on heparing gtt
and coumadin for anticoagulation. Patient's INR was not
consistently above 2.0 during his admission on coumadin 4 mg
daily.  His coumadin dose was increased to 5 mg daily on day of
discharge. Patient should continue heparin drip until INR is
consistently > 2.0 for > 24 hours. Recommend increased
monitoring of INR after discharge as his diet and antibiotic
regimen will be changing.  Patient's goal INR remains [**2-22**] as he
has atrial fibrillation, history of RUE DVT ([**2175**]), and new
diagnosis of R IJ thrombus.
.
7) CRI: Patient with unclear baseline. Creatinine 2.6 on
presentation with decrease to as low as 1.2 during his
admission. Creatinine 1.3 on day of discharge.
.
8) GOUT: Patient presented with mild right ankle and dorsal foot
erythema and edema consistent with prior gout.  This exam
remained stable throughout admission.  However, on [**2181-2-5**]
patient reported some mild right wrist swelling and signficant
pain.  Overnight he had a fever and the following morning his
right wrist was considerably more swollen, erythematous, and
tender to palpation. His exam was consistent with gout.  He was
started on prednisone 30 mg po on [**2181-2-6**].  He received an
additional 30 mg po on [**2181-2-7**].  Recommend tapering prednisone
to 20 mg daily on discharge and tapering the patient down to
home dose of 5 mg po daily over the next two weeks as his gout
symptoms allow.  Caution should be taken with excessive
prednisone use as prednisone make abdominal exams less reliable.

.
NUTRITON: Patient encouraged to eat regular diet; continue TPN
pending ability to maintain adequate caloric intake by mouth.
Strongly recommend close monitoring by Nutrition services.
.
IV ACCESS: 1 PIV, PICC placed [**2181-2-2**] by IR
.
EMERGENCY CONTACT: [**Name (NI) **] (wife)[**Telephone/Fax (1) 58550**]; and
[**Doctor Last Name **](son)[**Telephone/Fax (1) 58551**]
.
CODE STATUS: DNR/DNI
.
DISPO: Rehab

Medications on Admission:
Pentasa 1000mg daily
mag Oxide 3 tabs daily
Azathioprine 50mg daily
Paxil 20mg daily
Prednisone 5mg daily
Dulcolax 10mg daily
Coumadin 3mg daily
Lopressor 12.5 mg daily


Discharge Medications:
1. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical every
eight (8) hours as needed for rectal irritation.
3. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily):
Please taper prednisone dose back to home dose of 5 mg daily
over the next two weeks as gout flare allows. Tablet(s)
4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. mesalamine 250 mg Capsule, Sustained Release Sig: Four (4)
Capsule, Sustained Release PO QID (4 times a day).
8. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. hydromorphone (PF) 4 mg/mL Solution Sig: SEE PCA dosing
below.  Injection ASDIR (AS DIRECTED): Patient currently on
dilaudid 0.10 mg/hr basal rate with boluses of 0.1 q6min with a
lock out of 6 minutes and total 1.10 mg/hr.
10. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
11. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day): This medication may be titrated up. If no
affect on diarrhea in 2 days can be discontinued completely. Do
not give this medication with other oral medications as it will
decrease their absorption.
12. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gram
Intravenous Q4H (every 4 hours). gram
13. heparin flush (porcine) in NS 100 unit/mL Kit Sig: sliding
scale heparin  Intravenous continuous: Please continue heparin
drip with goal PTT 60-100 until INR is > 2.0 for over 24 hours.

14. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Eight (8) mg
Injection Q8H (every 8 hours) as needed for nausea.
15. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]

Discharge Diagnosis:
Bowel perforation
Crohn's disease
Diarrhea
Avascular necrosis of bilateral hips
Atrial fibrillation
Gout: Right wrist and R foot
MSSA Bacteremia
Septic thrombus
Anemia of chronic disease
Acute renal failure
Malnutrition


Discharge Condition:
Afebrile, hemodynamically stable, alert and oriented to person,
place and day of the week.  Dependent for all ambulation and
transfers.


Discharge Instructions:
You were transferred to [**Hospital1 69**]
after you were found to have a perforation of your colon on CT
imaging at an outside hospital.  On presentation you were found
to have no clinical indications for surgical repair. You were
medically managed with antibiotics.  You tolerated the
antibiotics well and completed a 14 day course of antibiotics
(ciprofloxacin and flagyl) on [**2181-2-4**].  Your diarrhea persisted
throughout your admission. The frequency of diarrhea improved
with treatment of your bowel perforation but the consistency
remained unchanged.  The stool studies showed no evidence of
infection as the cause of your diarrhea.  Your diarrhea may be
due to your bowel perforation, your Crohn's disease, or your
malnutrition.  You were continued on your home Crohn's
medications including low dose prednisone and imuran.  These
medication could not be increased as they could cause your bowel
perforation and infections to get worse. Your mesalamine dose
was able to be increased.  Your malnutrition was treated with
TPN.  Your diet was advanced and you were encouraged to eat
frequently throughout the day.  You should continue to use TPN
until you have reliable oral intake.  You should be followed
closely by a dietician after your discharge.
.
Your hospital admission was complicated by an infection and
blood clot from your IV.  The IV allowed bacteria to enter your
blood and grow.  The infection is being treated with IV
antibiotics and the blood clot is being treated with IV heparin
until your coumadin could reach appropriate levels.  It is very
important that you continue to take your coumadin to prevent the
blood clot from expanding and to prevent future clots.  You will
need to continue to have your INR monitored closely while your
antibiotics and diet are changing.  You will continue your IV
antibiotics for your blood infection until [**2181-2-27**].  You will
need to follow up with the infectious disease clinic to ensure
that your infection has completely resolved.
.
A great challenge during your admission was your pain control.
You experienced severe hip pain that was likely worsened by your
immobility.  You required widely varying amounts of IV pain
medications to keep your pain controlled.  The amount of pain
medications that you will need in the future is likely going to
change as you increase your activity and work with physical
therapy to get stonger.  Your physician at your rehab will be
able to adjust these medications to make sure that your pain is
controlled.
.
The following changes were made to your home medications:
1) STOP metoprolol
2) STOP Doculax
3) START Nafcillin IV 2 gram every 4 hours for MSSA bacteremia.
Last dose on [**2181-2-27**].
4) START Acetaminophen 1 gram by mouth three times a day for
pain control.
5) START Lidocaine 5% patch apply to right hip daily for pain
control
6) START Dilaudid PCA
7) START Cholestyramine (for bile acid sequestration as a trial
to slow diarrhea) 4 grams po bid.
7) INCREASE Mesalamine 1000 mg by mouth four times a day for
diarrhea.
8) INCREASE Coumadin to 5 mg daily
9) INCREASE Fentanyl patch to 100 mcg patch q72 hours
10) INCREASE Prednisone to 20 mg daily and taper as gout allows
over the next week to your home prednisone dose of 5 mg daily.

.
Please continue to take all other medications as previously
directed.

.
It is very important that you continue to have your INR and
electrolytes monitored closely after discharge.  You will also
need to follow up with a gastroenterologist and the infectious
disease specialists as listed below.


Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: FRIDAY [**2181-2-16**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21795**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage
.

Department: INFECTIOUS DISEASE
When: THURSDAY [**2181-3-1**] at 9:50 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
.
Department: RHEUMATOLOGY
When: THURSDAY [**2181-3-8**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
{'Regional enteritis of unspecified site,Perforation of intestine,Acute kidney failure, unspecified,Bacteremia,Unspecified protein-calorie malnutrition,Aseptic necrosis of head and neck of femur,Other and unspecified infection due to central venous catheter,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia of other chronic disease,Atrial fibrillation,Backache, unspecified,Gout, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Long-term (current) use of anticoagulants,Do not resuscitate status'}


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: Diarrhea and bowel perforation

PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname **] is a 75 year old man with history of Crohn's s/p
small bowel resections x 3, s/p ileocectomy, h/o
post-colonoscopy jejunal diverticular perforation s/p small
bowel resection [**2174**], perianal fistula, diverticulitis, colon
polyps, and h/o GI bleeding who presented on [**2181-1-22**] to an OSH
from home with increased diarrhea and concern for dehydation. Of
note, he has three recent hospital admission for GI symptoms
ranging from diarrhea to constipation.  Per the patient he
believes his change in pain medications and bowel regimens were
responsible for these admission. At the OSH, a CT abdomen/pelvis
was performed demonstrating a contained bowel perforation. He
was transferred [**Hospital1 18**] on [**2181-1-23**] and admitted to the surgical
service for further management. He was treated conservatively
with bowel rest, cipro IV and flagyl IV. Patient remained
hemodynamically stable without concerning physical exam.
Surgical team decided patient did not warrant surgical
intervention at this time and could be conservatively managed.
Patient was started on a clear diet which the patient did not
accept as he did not want to contribute to his continuous
diarrhea. TPN was ordered given patient's report of recent
weightloss and inability to tolerate pos. Patient was then
transferred to the medical service for further management.
.
At the time of transfer, the patient's only concern is the
extreme pain in his bilateraly hips.  He reports having chronic
pain that is managed by long acting morphine 15 mg up to 4 times
per day and a fentanyl patch 75 mcg. He reports he has not
received any pain medications today.  This pain is the same
character as his chronic hip pain just much more severe as he is
lying on his side/hip because of the diarrhea. He is concerned
to start his home regimen as he fears it may cause his diarrhea
to completely stop and make his perforation worse. The patient
denies abdominal pain, nausea or vomiting. He has no blood in
his stool. He has no current fevers or chills. He does report an
episode of chills yesterday and intermittent episodes of chills
and diaphoresis over the last 10 days at home. He describes
continuous diarrhea throughout the day today that is nonbloody
and causing anal and scrotal pain.

MEDICAL HISTORY: 1) Crohn's disease s/p SB rections x3 managed on chronic
prednisone, azathioprine, mesalamine
2) Perianal fistula
3) Diverticulitis
4) Colon polyp
5) Bowel perforation secondary to colonscopy
6) GI bleed on coumadin [**2-/2180**]
7) Afib rate controlled and on coumadin
8) h/o DVT RUE [**2175**]
9) HTN
10) CRI unknown baseline creatinine
11) h/o PNA
12) Avascular necrosis of bilateral hips R > L
13) Chronic back pain
14) Gout
15) h/o MRSA and VRE
16) s/p appendectomy

MEDICATION ON ADMISSION: Pentasa 1000mg daily
mag Oxide 3 tabs daily
Azathioprine 50mg daily
Paxil 20mg daily
Prednisone 5mg daily
Dulcolax 10mg daily
Coumadin 3mg daily
Lopressor 12.5 mg daily

ALLERGIES: oxycodone-acetaminophen / hydrocodone-acetaminophen

PHYSICAL EXAM: VS T 98.4 120/66 78 20 98% RA.
General: Alert, oriented x3, uncomfortable, restless
HEENT: Sclera anicteric, MMM, R eye strabismus
Neck: supple, JVP not elevated, no LAD, R IJ CVL in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and irregular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen:  soft, nontender, + bs, no masses, no rebound, no
guarding, no CVA or suprapubic tenderness, + anal pain and skin
break down from chronic diarrhea
Ext: R dorsal surface of foot swollen, erythematous, and warm
2+ distal pulses in all four extremities

FAMILY HISTORY: Denies family history of IBD.

SOCIAL HISTORY: Patient is retired, widowed with five children and living with
his second wife. [**Name (NI) **] ambulates with the assistance of a walker at
home. His wife [**Name (NI) **] assists him with most ADLs prior to coming
to the hospital.  He denies use of tobacco, alcohol, illicit
drugs, or herbal medications. 

### Response:
{'Regional enteritis of unspecified site,Perforation of intestine,Acute kidney failure, unspecified,Bacteremia,Unspecified protein-calorie malnutrition,Aseptic necrosis of head and neck of femur,Other and unspecified infection due to central venous catheter,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia of other chronic disease,Atrial fibrillation,Backache, unspecified,Gout, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Long-term (current) use of anticoagulants,Do not resuscitate status'}
