CHIEF COMPLAINT: Pneumonia - bacterial, PCP
Pulmonary embolism
Abdominal abscess
Cardiac Thrombus
Bowel Obstruction
Anemia from GI bleeding

PRESENT ILLNESS: CC: SOB/Fevers
.
38 yo female w/ with crohns dz (recently on tapered prednisone,
now on mtx), recently in [**Hospital Unit Name 153**] for fevers and hypoxia thought [**2-4**]
aspiration PNA vs. [**Hospital 62799**] [**Name10 (NameIs) **] to floor overnight [**7-23**].
During this first [**Hospital Unit Name 153**] course, she was treated with zosyn,
levaquin, flagyl for the aspiration PNA, and also bactrim for
presumptive PCP despite induced [**Name9 (PRE) 97174**] negative x 2. She was
also treated with stress dose steroids briefly.

MEDICAL HISTORY: PMH:
Crohn??????s disease x 18 years
Bipolar disorder ?????? followed by Dr. [**Last Name (STitle) **] at
[**Location (un) **]([**Telephone/Fax (1) 97175**])
Asthma
ADHD
Abdominal interloop abscess with VRE colonization
.
PSH:
perirectal abscess drainage and fistulotomy ([**8-/2110**])
right ileal colectomy and repair bladder and ileosigmoid fistula
([**2-/2115**])
C-section ([**7-/2116**])
ileocolectomy and ileocolic anastamosis ([**8-3**])
ileocolectomy ([**11-5**])
stricture dilation ([**1-7**])

MEDICATION ON ADMISSION: Medications at home: Cipro 500 TID (pt takes TID), Flagyl 500
TID
Voriconazole 200 QD, methotrexate 25 mg injection Qweek,
klonopin
lasix, lexapro 20 daily, methadone 10 TID, buproprion 100 TID
.
.
Meds at transfer: Zosyn, bactrim 300 mg iv, prednsione 40 mg
caspofungin, vanc, methylphenidate, escitalopram, olanzapine,
bupropion, pantoprazole, IV heparin, methadone

ALLERGIES: Iodine; Iodine Containing / Mercaptopurine

PHYSICAL EXAM: VS: T 98.4 BP 100/62, P 92, RR 20, O2 94% on 2L nc
General: awake alert, AOx3, non-toxic appearing
HEENT: NC/AT, mmm, L neck line
Pulmonary: CTAB, no wheezes or rales
Cardiac: RRR, nl. S1S2, [**3-8**] SM -> RUSB
Abdomen: soft, NT/ND, normoactive bowel sounds, Mid-line ostomy
and JP drain in placed draining bile appearing fluid.
Extremities: No C/C/E bilaterally, 2+ DP bilat.
Skin: no rashes or lesions noted.
Neurologic: grossly non-focal

FAMILY HISTORY: Maternal ?????? breast CA at 69, CAD, colon CA - aunts/uncles lung
ca, kidney ca
Paternal ?????? DM II.

SOCIAL HISTORY: Pt is divorced. Lives with parents and 6 yo son.
Pneumonitis due to inhalation of food or vomitus,Other pulmonary embolism and infarction,Iron deficiency anemia secondary to blood loss (chronic),Hemorrhage of gastrointestinal tract, unspecified,Peritoneal abscess,Unspecified intestinal obstruction,Acute myocardial infarction of unspecified site, initial episode of care,Other pulmonary insufficiency, not elsewhere classified,Pneumocystosis,Regional enteritis of unspecified site,Intestinal bypass or anastomosis status,Bipolar disorder, unspecified,Fistula of intestine, excluding rectum and anus,Bacterial pneumonia, unspecified,Long-term (current) use of anticoagulants,Ileostomy status
Food/vomit pneumonitis,Pulm embol/infarct NEC,Chr blood loss anemia,Gastrointest hemorr NOS,Peritoneal abscess,Intestinal obstruct NOS,AMI NOS, initial,Other pulmonary insuff,Pneumocystosis,Regional enteritis NOS,Intestinal bypass status,Bipolar disorder NOS,Intestinal fistula,Bacterial pneumonia NOS,Long-term use anticoagul,Ileostomy status
Admission Date:  [**2123-7-20**]              Discharge Date:   [**2123-8-6**]

Date of Birth:  [**2084-9-18**]             Sex:   F

Service: MEDICINE

Allergies:
Iodine; Iodine Containing / Mercaptopurine

Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Pneumonia - bacterial, PCP
Pulmonary embolism
Abdominal abscess
Cardiac Thrombus
Bowel Obstruction
Anemia from GI bleeding

Major Surgical or Invasive Procedure:
None


History of Present Illness:
CC: SOB/Fevers
.
38 yo female w/ with crohns dz (recently on tapered prednisone,
now on mtx), recently in [**Hospital Unit Name 153**] for fevers and hypoxia thought [**2-4**]
aspiration PNA vs. [**Hospital 62799**] [**Name10 (NameIs) **] to floor overnight [**7-23**].
During this first [**Hospital Unit Name 153**] course, she was treated with zosyn,
levaquin, flagyl for the aspiration PNA, and also bactrim for
presumptive PCP despite induced [**Name9 (PRE) 97174**] negative x 2. She was
also treated with stress dose steroids briefly.

Transferred to the floor for further care

Past Medical History:
PMH:
Crohn??????s disease x 18 years
Bipolar disorder ?????? followed by Dr. [**Last Name (STitle) **] at
[**Location (un) **]([**Telephone/Fax (1) 97175**])
Asthma
ADHD
Abdominal interloop abscess with VRE colonization
.
PSH:
perirectal abscess drainage and fistulotomy ([**8-/2110**])
right ileal colectomy and repair bladder and ileosigmoid fistula
([**2-/2115**])
C-section ([**7-/2116**])
ileocolectomy and ileocolic anastamosis ([**8-3**])
ileocolectomy ([**11-5**])
stricture dilation ([**1-7**])


Social History:
Pt is divorced. Lives with parents and 6 yo son.


Family History:
Maternal ?????? breast CA at 69, CAD, colon CA - aunts/uncles lung
ca, kidney ca
Paternal ?????? DM II.

Physical Exam:
VS: T 98.4 BP 100/62, P 92, RR 20, O2 94% on 2L nc
General: awake alert, AOx3, non-toxic appearing
HEENT: NC/AT, mmm, L neck line
Pulmonary: CTAB, no wheezes or rales
Cardiac: RRR, nl. S1S2, [**3-8**] SM -> RUSB
Abdomen: soft, NT/ND, normoactive bowel sounds, Mid-line ostomy
and JP drain in placed draining bile appearing fluid.
Extremities: No C/C/E bilaterally, 2+ DP bilat.
Skin: no rashes or lesions noted.
Neurologic: grossly non-focal


Pertinent Results:
CHEST (PA & LAT)

Reason: pneumonia vs. Cardiac?

[**Hospital 93**] MEDICAL CONDITION:
38 year old woman with sob, decreased o2 saturation, fevers
REASON FOR THIS EXAMINATION:
pneumonia vs. Cardiac?
REASON FOR EXAMINATION: Shortness of breath, decreased
saturations, and fever.

PA and lateral upright chest radiograph compared to [**2123-5-2**].

There are bilateral widespread opacities, predominantly patchy
and some of them nodular involving mostly the right lower and
the entire left lung. They are completely new in comparison to
the previous chest x-ray. There is no sizable pleural effusion.
The heart size is grossly unchanged only related to lower lung
volumes.

IMPRESSION: New bibasilar patchy consolidations. Given the
patient's history of immunocompromising due to treatment with
methotrexate and steroids, the infection such as PCP, [**Name10 (NameIs) 1065**],
atypical viral infection should be suspected but
community-acquired pneumonia cannot be excluded. Close followup
with chest x-ray or CT is recommended

ECHO:
Cardiology Report ECHO Study Date of [**2123-7-21**]



PATIENT/TEST INFORMATION:
Indication: Chest pain. Pericardial effusion. /Fever.
Height: (in) 62
Weight (lb): 142
BSA (m2): 1.65 m2
BP (mm Hg): 100/56
HR (bpm): 120
Status: Inpatient
Date/Time: [**2123-7-21**] at 15:30
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006E043-1:13
Test Location: East MICU
Technical Quality: Suboptimal




REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]

MEASUREMENTS:
Left Atrium - Long Axis Dimension: 4.0 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.2 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.7 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 0.8 cm (nl 0.6 - 1.1 cm)

Left Ventricle - Inferolateral Thickness: 0.8 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.3 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.7 cm
Left Ventricle - Fractional Shortening: 0.37 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 60% to 70% (nl >=55%)
Aorta - Valve Level: 2.7 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.9 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *2.2 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 161 msec
TR Gradient (+ RA = PASP): 16 to 17 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: *1.4 m/sec (nl <= 1.0 m/s)

INTERPRETATION:

Findings:

LEFT ATRIUM: Normal LA size.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.

LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%). TVI E/e' < 8, suggesting normal PCWP (<12mmHg). No
resting LVOT
gradient. No LV mass/thrombus. No VSD.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.

AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.

MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. Normal
mitral valve supporting structures. Normal LV inflow pattern for
age.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal
tricuspid valve supporting structures. Normal PA systolic
pressure.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.

PERICARDIUM: Trivial/physiologic pericardial effusion.

GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal
image quality - poor parasternal views. Suboptimal image quality
- poor apical
views. Suboptimal image quality - poor subcostal views.
Suboptimal image
quality - bandages, defibrillator pads or electrodes. The
patient appears to
be in sinus rhythm. Resting tachycardia (HR>100bpm).

Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF 60-70%). Tissue
velocity imaging
demonstrates an E/e' <8 suggesting a normal left ventricular
filling pressure
(<12mmHg). No masses or thrombi are seen in the left ventricle.
There is no
ventricular septal defect. 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 estimated pulmonary artery systolic pressure
is normal.
There is a trivial/physiologic pericardial effusion.

An acoustic density measuring approximately 24 by 13 mm is
present abutting
the free wall of the right atrium. Although this finding could
represent an
artifact due to the technically suboptimal nature of this study,
a mass such a
thrombus cannot be excluded.

Compared with the findings of the prior study (images reviewed)
of [**2122-9-17**], a new acoustic density (mass vs artifact) is now
seen in the
right atrium. A transesophageal echocardiogram could better
define this
anomaly if clinically indicated.


CT CHEST W/CONTRAST  [**2123-7-22**] 8:53 AM

CT CHEST W/CONTRAST

Reason: Please eval for pneumonia/effusions/abscess.
Field of view: 31 Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
38 year old woman with Crohn's disease, now with fevers and CXR
suspicious for PCP vs aspiration pneumonia
REASON FOR THIS EXAMINATION:
Please eval for pneumonia/effusions/abscess.
CONTRAINDICATIONS for IV CONTRAST: None.

CT CHEST WITH CONTRAST, [**2123-7-22**]

INDICATION: Crohn's disease. Fever.

COMPARISON: Chest radiographs of [**2123-7-20**], [**2123-7-22**],
and [**2123-5-2**]. There are no prior CT scans of the chest for
comparison. Comparison is made to CT abdomen of [**2123-6-10**].

Multidetector CT of the chest was performed following
intravenous administration of 65 cc of Optiray. Images are
presented for display in the axial plane at 5-mm and 1.25-mm
collimation.

There are extensive abnormalities involving all lobes of both
lungs, including multifocal areas of consolidation, areas of
ground-glass attenuation, and centrilobular branching opacities
consistent with small airways disease (bronchiolitis). The areas
of consolidation are most severe in the right middle lobe and
right lower lobe. There are no centrally obstructing
endobronchial lesions.

There are mildly enlarged mediastinal and bilateral hilar lymph
nodes, likely reactive in the setting of a diffuse pneumonia.
The heart size is normal. There is no pericardial effusion.
There are trace bilateral dependent pleural effusions.

In the imaged portion of the upper abdomen, the adrenal glands
are incompletely imaged but are normal in their imaged portions.
The remaining imaged portion of the upper abdomen is
unremarkable.

There are no suspicious lytic or blastic skeletal lesions.

IMPRESSION: Severe multilobar pneumonia accompanied by extensive
bronchiolitis. The findings are not specific for a particular
organism, but the asymmetry and extensive bronchiolitis are not
typical for PCP.

CTA CHEST W&W/O C &RECONS

Reason: PE Protocol

[**Hospital 93**] MEDICAL CONDITION:
38 year old woman with Crohn's disease, now with fevers and CXR
suspicious for PCP vs aspiration pneumonia with persistent SOB
in setting of possible R atrial thrombus
REASON FOR THIS EXAMINATION:
PE Protocol
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATION: 38-year-old female with Crohn's disease, multifocal
pneumonia, now with shortness of breath in setting of possible
right atrial thrombus.

COMPARISON: [**2123-7-22**].

TECHNIQUE: Continuous axial images of the chest were obtained
following the administration of IV Optiray contrast. Multiplanar
reformatted images were also performed.

CTA CHEST: There is a filling defect in a right lower lobe
segmental pulmonary artery extending to several subsegmental
arterial branches. The heart and great vessels are unremarkable.
Again seen are mildly enlarged mediastinal and hilar lymph
nodes, likely reactive in the setting of diffuse pneumonia. The
airways are patent to the level of the subsegmental bronchi
bilaterally. Small bilateral pleural effusions have increased in
size.

Lung windows again demonstrate multifocal areas of consolidation
and ground- glass attenuation and centrilobular branching
opacities consistent with small airway disease. This is not
significantly changed in appearance compared to the prior
examination.

The osseous structures are unremarkable.

Multiplanar reformatted images confirm the above findings.

IMPRESSION:

1. Right lower lobe segmental and subsegmental pulmonary
embolus.

2. Extensive multilobular pneumonia and bronchiolitis.

BILATERAL LOWER EXTREMITY DVT STUDY: Grayscale and Doppler
son[**Name (NI) 1417**] of the bilateral common femoral, superficial femoral,
and popliteal veins were performed. There is normal flow,
compressibility and augmentation of these vessels. No
intraluminal thrombus was identified.

IMPRESSION: No evidence of DVT.

Cardiology Report ECHO Study Date of [**2123-7-27**]



PATIENT/TEST INFORMATION:
Indication: persistent  RA clot
Height: (in) 62
Weight (lb): 140
BSA (m2): 1.64 m2
BP (mm Hg): 96/53
HR (bpm): 73
Status: Inpatient
Date/Time: [**2123-7-27**] at 15:30
Test: Portable TTE (Focused views)
Doppler: Color Doppler only
Contrast: None
Tape Number: 2006E041-0:17
Test Location: East MICU
Technical Quality: Adequate




REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]

MEASUREMENTS:
Left Atrium - Four Chamber Length: *5.5 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 5.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 0.8 cm (nl 0.6 - 1.1 cm)

Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.4 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.0 cm
Left Ventricle - Fractional Shortening: 0.55 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 70% to 80% (nl >=55%)
TR Gradient (+ RA = PASP): 18 to 21 mm Hg (nl <= 25 mm Hg)

INTERPRETATION:

Findings:

LEFT ATRIUM: Elongated LA.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC is
normal in diameter
with appropriate phasic respirator variation.

LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Hyperdynamic
LVEF. No resting LVOT gradient.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA
systolic pressure.

PERICARDIUM: No pericardial effusion.

Conclusions:
The left atrium is elongated. Left ventricular wall thicknesses
are normal.
The left ventricular cavity size is normal. Left ventricular
systolic function
is hyperdynamic (EF 70-80%). Right ventricular chamber size and
free wall
motion are normal. The estimated pulmonary artery systolic
pressure is normal.
There is no pericardial effusion. Once again is seen an
echodensity measuring
approximately 25 by 15 mm abutting the free wall of the right
atrium.

Compared with the findings of the prior study (images reviewed)
of [**2123-7-21**], the appearance of the echodensity abutting the right atial
free wall is
unchanged.


 Cardiology Report ECG Study Date of [**2123-7-27**]  8:57:44 AM


Sinus bradycardia with sinus arrhythmia and atrial premature
complexes
Prolonged Q-Tc interval - clinical correlation is suggested
Since previous tracing of [**2123-7-25**], T wave amplitude improved


Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
52 120 86 [**Telephone/Fax (2) 97176**] 20 25


CHEST (PORTABLE AP)  [**2123-8-3**] 11:18 PM

CHEST (PORTABLE AP)

Reason: please assess infiltrates seen on AXR

[**Hospital 93**] MEDICAL CONDITION:
38 year old woman with Crohn's disease on immunosuppression,
recent bilobar pna, now with bibasilar patchy opacities seen on
AXR.
REASON FOR THIS EXAMINATION:
please assess infiltrates seen on AXR
INDICATION: Crohn's disease, on immunosuppression with bilobar
pneumonia.

COMPARISON: [**2123-7-24**].
AP UPRIGHT VIEW OF THE CHEST: Right PICC tip lies at the
confluence of brachiocephalic veins. Heart is normal size.
Mediastinal and hilar contours are unchanged. Previously noted
multifocal airspace opacities have improved with near complete
resolution within the right upper lobe. I doubt the presence of
a pleural effusion. Pulmonary vascularity is normal. No PTX.

IMPRESSION: Improving multifocal pneumonia.

PORTABLE ABDOMEN  [**2123-8-4**] 11:56 AM

PORTABLE ABDOMEN

Reason: obstruction

[**Hospital 93**] MEDICAL CONDITION:
38 year old woman with Crohn's disease, h/o abdominal abscess
with ostomy p/w increasing abd pain, decreased ostomy output,
distension.
REASON FOR THIS EXAMINATION:
obstruction
INDICATION: 38-year-old female with Crohn's disease presenting
with increased abdominal pain and decreased ostomy output.

COMPARISONS: Comparison is made to [**2123-8-3**].

TECHNIQUE: Supine and upright views of the abdomen.

FINDINGS: There is again noted a drain in the mid abdomen which
is draining an abscess. There is no evidence of free air. The
skeletal structures are unremarkable. There are again noted
multiple dilated loops of what appear to be small bowel. The
largest loop measures 7 cm. Overall, the degree of dilatation
appears to be similar to when compared to the prior study. There
are again noted bibasilar opacities which are unchanged when
compared to the prior study and consistent with a multifocal
pneumonia. There are surgical clips in the left flank.

IMPRESSION:
1. Dilated loops of small bowel similarly to prior study.
2. Multifocal pneumonia.

[**2123-7-20**] 12:00PM URINE  BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0 LEUK-SM
[**2123-7-20**] 12:00PM URINE  COLOR-Yellow APPEAR-SlHazy SP [**Last Name (un) 155**]-1.022
[**2123-7-20**] 12:39PM   LACTATE-2.0
[**2123-7-20**] 12:40PM   PLT SMR-NORMAL PLT COUNT-417
[**2123-7-20**] 12:40PM   HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL
[**2123-7-20**] 12:40PM   NEUTS-94.2* BANDS-0 LYMPHS-3.5* MONOS-1.6*
EOS-0.6 BASOS-0.2
[**2123-7-20**] 12:40PM   WBC-38.0*# RBC-3.09* HGB-8.2* HCT-25.3*
MCV-82 MCH-26.5* MCHC-32.4 RDW-21.3*
[**2123-7-20**] 12:40PM   LD(LDH)-382*
[**2123-7-20**] 12:40PM   GLUCOSE-90 UREA N-17 CREAT-0.9 SODIUM-137
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-21* ANION GAP-22*

Hematology
  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2123-8-6**] 06:30AM    11.9* 2.74* 7.5* 23.6* 86 27.4 31.8 22.9*
438
[**2123-8-5**] 06:04AM    14.5* 2.79* 7.4* 23.5* 84 26.6* 31.6
22.7* 426
[**2123-8-4**] 11:34AM    19.8* 3.26* 8.3* 26.9* 82 25.4* 30.8*
22.7* 557*
[**2123-8-4**] 09:33AM    15.1*     24.5*1         538*
1 SPUN HEMATOCRIT PERFORMED


[**2123-8-5**] 06:04AM
BASIC COAGULATION (PT, PTT, PLT, INR)
PT 11.7 sec 10.4 - 13.1
PTT 28.7 sec 22.0 - 35.0
INR(PT) 1.0   0.9 - 1.1

[**2123-8-6**] 06:30AM
Report Comment:
LIPEMIC SPECIMEN
RENAL & GLUCOSE
Glucose 70 mg/dL 70 - 105
Urea Nitrogen 19 mg/dL 6 - 20
Creatinine 0.8 mg/dL 0.4 - 1.1
Sodium 140 mEq/L 133 - 145
  VERIFIED BY ALTERNATE METHODOLOGY
Potassium 4.1 mEq/L 3.3 - 5.1
  VERIFIED BY ALTERNATE METHODOLOGY
Chloride 113* mEq/L 96 - 108
  VERIFIED BY ALTERNATE METHODOLOGY
Bicarbonate 22 mEq/L 22 - 32
  VERIFIED BY ALTERNATE METHODOLOGY
Anion Gap 9 mEq/L 8 - 20
ENZYMES & BILIRUBIN
Alanine Aminotransferase (ALT) 14 IU/L 0 - 40
Asparate Aminotransferase (AST) 16 IU/L 0 - 40
Alkaline Phosphatase 141* IU/L 39 - 117
Amylase 103* IU/L 0 - 100
Bilirubin, Total 0.1 mg/dL 0 - 1.5
OTHER ENZYMES & BILIRUBINS
Lipase 53 IU/L 0 - 60
CHEMISTRY
Calcium, Total 8.4 mg/dL 8.4 - 10.2
Phosphate 3.1 mg/dL 2.7 - 4.5
Magnesium 1.9 mg/dL 1.6 - 2.6




Brief Hospital Course:
#. Pneumonia- Treated with broad spectrum antibiotics - Zosyn
and vancomycin. Evaluated by ID. She was covered for bacterial
([**Year (4 digits) **] vs aspiration)pneumonia and PCP (emperically - sputum
negative) with bactrim and prednisone. Suspicion of PCP was high
given prolonged immunosupression and appearance of CXR. However,
chest CT was more consistent with multi-lobar pna than PCP.
[**Name10 (NameIs) 97177**] presumptively for PCP, [**Name10 (NameIs) **], and aspiration PNA.

-Initially on voriconazole/Zosyn/bactrim/vancomycin. -
Voriconazole was for anti-[**Name10 (NameIs) 1065**] proph and h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 563**]
infxn in her abd abscess.
- Bactrim and prednisone for PCP.

Pneumonia improved and the pt got better clinically. Pan
cultures were negative. Completed the course of zosyn and
vancomycin on [**2123-8-4**].  Bactrim-prednisone to be stopped on
[**2123-8-10**]

Other significant labs -
--Crypto ag negative
--legionella ag neg
.
# Pulmonary Embolism - During the hospitalization, she was found
to be hypoxic and CT chect done showed pulmonary embolism. She
was transferred to the ICU because of hypoxia; but did not need
mechanical ventilation. She was started on lovenox. Plan is to
hold coumadin till plan for surgery assessed. Doppler U/S of
Bilateral lower extremities negative was for DVT

# Cardiac Thrombus - official read pending. - Talked to
cardiology fellow ([**Doctor First Name **] Han) --> [**Last Name (un) **] read - 2 by 2 cm cardiac
thrombus in RA.
Cardiology recc: anticoagulation and follow up TTE in [**4-8**] months
to assess for resolution.
.
# Crohn's disease/ abdominal abscess s/p pigtail drainage -
Surgery and GI followed the patient while in house. Initially
covered with zosyn and vancomycin and thereafter, resumed flagyl
(Patient takes daily at home). The ostomy bag was replaced,no
leaking.

# Small bowel obstruction - 2 discrete episodes - Both managed
conservatively. Likely etiology of the SBO was initiation of
oral diet. Surgery plans to operate at a later date after
discharge and recommeded no acute intervention at this time.
Plan is to continue home TPN and restrict oral intake to ice
chips, clear liquids. At the time of discharge, the bowel
obstruction was partially resolved.

#Anemia- worked up before and iron deficient but not on iron
supplement. During the last 3 days of hospitalization , there
was a decrease in Hb. The patient had heme positive stool and
vomitus. GI reconsulted but recommended no endoscopy at this
time. I suspect that she has had chronic blood loss from the GI
tract for a long time (low baseline hb) but now this is beig
exacerbated by anti-coagulation. I discussed with the patient,
the need for maybe an IVC filter in the event that she starts
bleeding or hb continues to trend down. However, the patient did
not want to remain in the hospital. She stated that she wanted
to be with her son and that she felt good.

I explained in detail on multiple ocassions, the nature of her
illness - that she has severe anemia and her hb is further on
the decline and this is being worsened by the fact that she is
on anti-coagulation. Also discussed the possibility of an IVC
filter with her. I suspect that even if she does ge the IVC
filter at a later date, she will require anti-coagulation for
the cardiac thrombus. Also, informed her that in the event that
the clot gets bigger/new clot forms or that she has more
bleeding, she may get very sick and even die. [**Known firstname 553**] [**Last Name (NamePattern1) 97178**]
is alert and oriented and understands her prognosis and all the
complications of her wanting to leave against medical advice.
She could comprrehend the information I gave her. She signed the
AMA form after a detailed informed discussion with me.

Discharge services: TPN at home, to get IV flagyl at home.
Arrangements made by case manager, social work.
.
Apppointments provided for ID, surgery, primary MD, GI.
.
PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 97179**] in [**Location (un) 620**] informed of the above happenings.
.


Medications on Admission:
Medications at home: Cipro 500 TID (pt takes TID), Flagyl 500
TID
Voriconazole 200 QD, methotrexate 25 mg injection Qweek,
klonopin
lasix, lexapro 20 daily, methadone 10 TID, buproprion 100 TID
.
.
Meds at transfer: Zosyn, bactrim 300 mg iv, prednsione 40 mg
caspofungin, vanc, methylphenidate, escitalopram, olanzapine,
bupropion, pantoprazole, IV heparin, methadone


Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
5. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
6. Olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
10. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1)  Subcutaneous
Q12H (every 12 hours).
Disp:*60 * Refills:*2*
11. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*0*
12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QD () for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for insomnia.
15. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
16. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
17. Metronidazole 500 mg IV Q8H


Discharge Disposition:
Home With Service

Facility:
[**Hospital 2255**] [**Name (NI) 2256**]

Discharge Diagnosis:
Pneumonia - bacterial/ PCP
Abdominal abscess
[**Name9 (PRE) 4460**] bowel obstruction
Cardiac thrombus
Pulmonary embolism

Secondary diagnosis:
Crohns disease x 18 years
Bipolar disorder ; followed by Dr. [**Last Name (STitle) **] at
[**Location (un) **]([**Telephone/Fax (1) 97175**])
Asthma
ADHD
Abdominal interloop abscess with VRE colonization


Discharge Condition:
Poor. Signed out against medical advice.


Discharge Instructions:
1. Keep your appointments as instructed and mentioned in the
discharge summary.

2. Please check the blood work in the next week and follow up
with your provider.

3. Return to the emergency room if you develop abdominal pain,
nausea, vomiting, fevers, chest pain, dyspnea or any other
problems.

4. Continue to take the medications that you were taking prior
to your hospitalization (unless otherwise indicated)

5. Continue with the TPN and the IV flagyl.

6. After stopping the bactrim and prednisone on [**2123-8-10**], restart
ciprofloxacin as indicated on the prescription.

Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] INTERNAL MEDICINE Date/Time:[**2123-8-11**]
1:30

Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1954**]
Date/Time:[**2123-10-5**] 1:00

Dr [**Last Name (STitle) 1940**] - MAke an appointment in the next 2 weeks.

Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] - Friday [**2123-8-13**] at 11-30AM

[**Last Name (LF) **],[**First Name3 (LF) **] - Please call [**Telephone/Fax (1) 2981**] to make an
appointment in the next 1 week.
{'Pneumonitis due to inhalation of food or vomitus,Other pulmonary embolism and infarction,Iron deficiency anemia secondary to blood loss (chronic),Hemorrhage of gastrointestinal tract, unspecified,Peritoneal abscess,Unspecified intestinal obstruction,Acute myocardial infarction of unspecified site, initial episode of care,Other pulmonary insufficiency, not elsewhere classified,Pneumocystosis,Regional enteritis of unspecified site,Intestinal bypass or anastomosis status,Bipolar disorder, unspecified,Fistula of intestine, excluding rectum and anus,Bacterial pneumonia, unspecified,Long-term (current) use of anticoagulants,Ileostomy 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: Pneumonia - bacterial, PCP
Pulmonary embolism
Abdominal abscess
Cardiac Thrombus
Bowel Obstruction
Anemia from GI bleeding

PRESENT ILLNESS: CC: SOB/Fevers
.
38 yo female w/ with crohns dz (recently on tapered prednisone,
now on mtx), recently in [**Hospital Unit Name 153**] for fevers and hypoxia thought [**2-4**]
aspiration PNA vs. [**Hospital 62799**] [**Name10 (NameIs) **] to floor overnight [**7-23**].
During this first [**Hospital Unit Name 153**] course, she was treated with zosyn,
levaquin, flagyl for the aspiration PNA, and also bactrim for
presumptive PCP despite induced [**Name9 (PRE) 97174**] negative x 2. She was
also treated with stress dose steroids briefly.

MEDICAL HISTORY: PMH:
Crohn??????s disease x 18 years
Bipolar disorder ?????? followed by Dr. [**Last Name (STitle) **] at
[**Location (un) **]([**Telephone/Fax (1) 97175**])
Asthma
ADHD
Abdominal interloop abscess with VRE colonization
.
PSH:
perirectal abscess drainage and fistulotomy ([**8-/2110**])
right ileal colectomy and repair bladder and ileosigmoid fistula
([**2-/2115**])
C-section ([**7-/2116**])
ileocolectomy and ileocolic anastamosis ([**8-3**])
ileocolectomy ([**11-5**])
stricture dilation ([**1-7**])

MEDICATION ON ADMISSION: Medications at home: Cipro 500 TID (pt takes TID), Flagyl 500
TID
Voriconazole 200 QD, methotrexate 25 mg injection Qweek,
klonopin
lasix, lexapro 20 daily, methadone 10 TID, buproprion 100 TID
.
.
Meds at transfer: Zosyn, bactrim 300 mg iv, prednsione 40 mg
caspofungin, vanc, methylphenidate, escitalopram, olanzapine,
bupropion, pantoprazole, IV heparin, methadone

ALLERGIES: Iodine; Iodine Containing / Mercaptopurine

PHYSICAL EXAM: VS: T 98.4 BP 100/62, P 92, RR 20, O2 94% on 2L nc
General: awake alert, AOx3, non-toxic appearing
HEENT: NC/AT, mmm, L neck line
Pulmonary: CTAB, no wheezes or rales
Cardiac: RRR, nl. S1S2, [**3-8**] SM -> RUSB
Abdomen: soft, NT/ND, normoactive bowel sounds, Mid-line ostomy
and JP drain in placed draining bile appearing fluid.
Extremities: No C/C/E bilaterally, 2+ DP bilat.
Skin: no rashes or lesions noted.
Neurologic: grossly non-focal

FAMILY HISTORY: Maternal ?????? breast CA at 69, CAD, colon CA - aunts/uncles lung
ca, kidney ca
Paternal ?????? DM II.

SOCIAL HISTORY: Pt is divorced. Lives with parents and 6 yo son. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Other pulmonary embolism and infarction,Iron deficiency anemia secondary to blood loss (chronic),Hemorrhage of gastrointestinal tract, unspecified,Peritoneal abscess,Unspecified intestinal obstruction,Acute myocardial infarction of unspecified site, initial episode of care,Other pulmonary insufficiency, not elsewhere classified,Pneumocystosis,Regional enteritis of unspecified site,Intestinal bypass or anastomosis status,Bipolar disorder, unspecified,Fistula of intestine, excluding rectum and anus,Bacterial pneumonia, unspecified,Long-term (current) use of anticoagulants,Ileostomy status'}
