CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: Ms. [**Known lastname **] is a 54-year female with a history of diabetes,
coronary artery disease, hypertension, renal transplant and
significant peripheral [**Known lastname 1106**] disease who presented with a
several day history of abdominal discomfort and worsened over
the past 24 hours. She was seen in the emergency room and was
found to be in relative extremis condition. Although
hemodynamically stable, she had extensive peritonitis. She
underwent a CTA of the abdomen which demonstrated what appeared
to be a thrombosis of the SMA and thickening of the left and
right colon. She was taken to the operating room urgently for
exploration.

MEDICAL HISTORY: MI x2, CABG x2, DM1 with retinopathy/neuropathy/nephropathy. CRT
'[**43**] (Dr. [**Last Name (STitle) 15473**], PVD, LBKA [**6-/2147**], fem-[**Doctor Last Name **] '[**48**] w/ [**Doctor Last Name **]-DP bypass,
^chol, L eye prosth, b/l breast ca, chr anemia, CRI (baseline Cr
2.0)

MEDICATION ON ADMISSION: Allopurinol 100', ASA 81', Ativan 0.5 q8prn, CaCO3cVIT D
600-200", CATAPRES-TTS 2 0.2MG/24HR 2 patches qwk, Doxazosin 2',
Lisinopril 2.5', Fluoxetine 30', Lasix 40", Lantus 26hs, Novolog
SS, Imuran 25', Isosorbide mono 90qAM/30qPM, Lipitor 10',
Lopressor 75", Nifedipine 90', NTG 0.4' SL prn, Prednisone 7,
Prograf [**1-26**], Procrit 6000 qSu/W, Ranitidine 150"

ALLERGIES: Dilaudid / Codeine

PHYSICAL EXAM: on discharge:
Afebrile, BP 11/79-166/65, 74, 14, 100% Trach Mask
AOx3
CTA B/L
Trache in position
Abd soft, NT, ND
Resolving erythema over R knee
- edema

FAMILY HISTORY: 

SOCIAL HISTORY: 
Gout, unspecified,Other enthesopathy of knee,Hypercalcemia,Personal history of malignant neoplasm of breast,Chronic vascular insufficiency of intestine,Acute respiratory failure,Complications of transplanted kidney,Cardiac complications, not elsewhere classified,Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled,Hyperosmolality and/or hypernatremia,Urinary tract infection, site not specified,Unspecified essential hypertension,Peripheral vascular disease, unspecified
Gout NOS,Enthesopathy of knee NEC,Hypercalcemia,Hx of breast malignancy,Chr vasc insuff intest,Acute respiratry failure,Compl kidney transplant,Surg compl-heart,Subendo infarct, initial,Pneumonia, organism NOS,CHF NOS,DMI ophth nt st uncntrld,Hyperosmolality,Urin tract infection NOS,Hypertension NOS,Periph vascular dis NOS
Name:  [**Known lastname **],[**Known firstname 3473**] C                 Unit No:   [**Numeric Identifier 3474**]

Admission Date:  [**2158-4-27**]              Discharge Date:   [**2158-6-1**]

Date of Birth:  [**2103-6-1**]             Sex:   F

Service: SURGERY

Allergies:
Dilaudid / Codeine

Attending:[**First Name3 (LF) 2800**]
Addendum:
please see tacrolimus dose addendum

Discharge Medications:
31. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 49**] TCU - [**Location (un) 50**]

                             [**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**]

Completed by:[**2158-6-1**]

Admission Date:  [**2158-4-27**]              Discharge Date:   [**2158-6-1**]

Date of Birth:  [**2103-6-1**]             Sex:   F

Service: SURGERY

Allergies:
Dilaudid / Codeine

Attending:[**First Name3 (LF) 668**]
Chief Complaint:
abdominal pain

Major Surgical or Invasive Procedure:
percutaneous tracheostomy
Extended left hemicolectomy with
takedown of splenic flexure and ileostomy

History of Present Illness:
Ms. [**Known lastname **] is a 54-year female with a history of diabetes,
coronary artery disease, hypertension, renal transplant and
significant peripheral [**Known lastname 1106**] disease who presented with a
several day history of abdominal discomfort and worsened over
the past 24 hours. She was seen in the emergency room and was
found to be in relative extremis condition. Although
hemodynamically stable, she had extensive peritonitis. She
underwent a CTA of the abdomen which demonstrated what appeared
to be a thrombosis of the SMA and thickening of the left and
right colon. She was taken to the operating room urgently for
exploration.


Past Medical History:
MI x2, CABG x2, DM1 with retinopathy/neuropathy/nephropathy. CRT
'[**43**] (Dr. [**Last Name (STitle) 15473**], PVD, LBKA [**6-/2147**], fem-[**Doctor Last Name **] '[**48**] w/ [**Doctor Last Name **]-DP bypass,
^chol, L eye prosth, b/l breast ca, chr anemia, CRI (baseline Cr
2.0)

Physical Exam:
on discharge:
Afebrile, BP 11/79-166/65, 74, 14, 100% Trach Mask
AOx3
CTA B/L
Trache in position
Abd soft, NT, ND
Resolving erythema over R knee
- edema

Pertinent Results:
[**2158-4-27**] 05:30AM BLOOD WBC-5.7 RBC-4.01*# Hgb-13.8# Hct-40.1#
MCV-100* MCH-34.5* MCHC-34.5 RDW-18.5* Plt Ct-240
[**2158-4-30**] 02:54AM BLOOD WBC-18.1* RBC-3.18* Hgb-10.6* Hct-32.1*
MCV-101* MCH-33.4* MCHC-33.0 RDW-19.1* Plt Ct-178
[**2158-5-5**] 03:00AM BLOOD WBC-20.9* RBC-2.45* Hgb-8.2* Hct-24.2*
MCV-99* MCH-33.4* MCHC-33.8 RDW-19.3* Plt Ct-235
[**2158-5-8**] 03:13AM BLOOD WBC-8.7 RBC-2.46* Hgb-8.2* Hct-24.1*
MCV-98 MCH-33.1* MCHC-33.8 RDW-19.3* Plt Ct-162
[**2158-5-16**] 01:47AM BLOOD WBC-7.1 RBC-2.28* Hgb-7.4* Hct-21.9*
MCV-96 MCH-32.7* MCHC-34.1 RDW-18.6* Plt Ct-196
[**2158-5-20**] 03:20AM BLOOD WBC-7.3 RBC-3.10* Hgb-9.8* Hct-29.1*
MCV-94 MCH-31.7 MCHC-33.8 RDW-17.2* Plt Ct-262
[**2158-5-31**] 03:09AM BLOOD WBC-7.4 RBC-3.13* Hgb-10.0* Hct-29.3*
MCV-94 MCH-32.0 MCHC-34.2 RDW-16.9* Plt Ct-261
[**2158-5-26**] 04:08AM BLOOD PT-12.6 PTT-25.6 INR(PT)-1.1
[**2158-4-28**] 02:48AM BLOOD PT-17.9* PTT-34.7 INR(PT)-1.7*
[**2158-5-31**] 03:09AM BLOOD Glucose-205* UreaN-72* Creat-1.4* Na-140
K-4.1 Cl-112* HCO3-20* AnGap-12
[**2158-5-24**] 03:01AM BLOOD Glucose-117* UreaN-93* Creat-1.8* Na-146*
K-3.9 Cl-109* HCO3-27 AnGap-14
[**2158-5-19**] 02:25AM BLOOD Glucose-76 UreaN-94* Creat-1.9* Na-139
K-3.7 Cl-100 HCO3-27 AnGap-16
[**2158-5-12**] 05:11AM BLOOD Glucose-125* UreaN-90* Creat-2.0* Na-140
K-3.9 Cl-104 HCO3-23 AnGap-17
[**2158-5-4**] 05:09PM BLOOD Glucose-195* UreaN-86* Creat-2.6*# Na-135
K-3.8 Cl-105 HCO3-19* AnGap-15
[**2158-4-27**] 05:25PM BLOOD Glucose-219* UreaN-88* Creat-3.0* Na-143
K-3.6 Cl-110* HCO3-16* AnGap-21*
[**2158-5-29**] 02:34AM BLOOD ALT-32 AST-37 AlkPhos-214* Amylase-37
TotBili-0.8
[**2158-5-13**] 12:09PM BLOOD ALT-54* AST-50* CK(CPK)-25* AlkPhos-179*
Amylase-64 TotBili-0.5
[**2158-5-3**] 03:02AM BLOOD ALT-16 AST-26 LD(LDH)-348* AlkPhos-78
Amylase-148* TotBili-0.2
[**2158-5-3**] 05:43PM BLOOD Lipase-102*
[**2158-4-27**] 01:35PM BLOOD Lipase-113*
[**2158-5-31**] 03:09AM BLOOD Calcium-11.4* Phos-3.0 Mg-1.8
[**2158-5-28**] 02:27AM BLOOD Calcium-12.5* Phos-2.8 Mg-2.1
[**2158-5-25**] 03:00PM BLOOD Calcium-11.7* Phos-3.6 Mg-2.2
[**2158-5-18**] 02:34AM BLOOD Albumin-2.4* Calcium-9.2 Phos-4.2 Mg-1.9
[**2158-5-29**] 02:34AM BLOOD calTIBC-168* TRF-129*
[**2158-5-30**] 03:17AM BLOOD Ferritn-880*
[**2158-4-29**] 02:41AM BLOOD Triglyc-156* HDL-15 CHOL/HD-6.7
LDLcalc-55
[**2158-5-3**] 05:43PM BLOOD TSH-1.9
[**2158-5-28**] 02:27AM BLOOD PTH-21
[**2158-5-5**] 12:10PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2158-5-30**] 06:49AM BLOOD FK506-6.3
[**2158-5-29**] 06:54AM BLOOD FK506-5.9
[**2158-4-27**] 01:59PM BLOOD Glucose-459* Lactate-4.7*
[**2158-4-27**] 03:20PM BLOOD Glucose-352* Lactate-5.6* Na-140 K-3.7
Cl-108
[**2158-4-27**] 05:42PM BLOOD Glucose-203* Lactate-6.3*
[**2158-4-28**] 01:06PM BLOOD Glucose-147*
[**2158-4-28**] 06:37PM BLOOD Glucose-133* Lactate-1.2
[**2158-5-28**] 09:08AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2158-5-28**] 09:08AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2158-5-28**] 09:08AM URINE RBC-0-2 WBC-21-50* Bacteri-FEW Yeast-NONE
Epi-<1
[**2158-5-23**] 11:08AM URINE RBC->50 WBC-21-50* Bacteri-FEW Yeast-OCC
Epi-0 TransE-0-2
[**2158-5-23**] 11:08AM URINE CastHy-[**11-13**]*
[**2158-5-8**] 11:45 am URINE

                            **FINAL REPORT [**2158-5-9**]**

   URINE CULTURE (Final [**2158-5-9**]):
      YEAST.    >100,000 ORGANISMS/ML..

[**2158-5-28**] 9:08 am URINE

                            **FINAL REPORT [**2158-5-30**]**

   URINE CULTURE (Final [**2158-5-30**]):
      ESCHERICHIA COLI.
         >100,000 ORGANISMS/ML. PRESUMPTIVE IDENTIFICATION.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------    16 I
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
IMIPENEM--------------   <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----  =>16 R

CTA PELVIS W&W/O C & RECONS  [**2158-4-27**] 8:01 AM

CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS

Reason: NO IV CONTRAST, eval for divertic, aortic dz, mesenteric
isc
Contrast: VISAPAQUE

[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with severe ab pain
REASON FOR THIS EXAMINATION:
NO IV CONTRAST, eval for divertic, aortic dz, mesenteric
ischemia
CONTRAINDICATIONS for IV CONTRAST: Cr 3.3 today, renal
transplant pt

HISTORY: 54-year-old woman with severe abdominal pain. The
patient has history of end-stage renal disease, status post
renal transplant.

TECHNIQUE: Multidetector axial images of the abdomen and pelvis
were obtained without contrast. A mesenteric CTA was then
performed with 80 cc of Visipaque followed by delayed venous
sequence.

CT ABDOMEN: There is bibasilar atelectasis. The liver,
gallbladder, spleen, and adrenal glands are unremarkable. The
pancreas and native kidneys are atrophic. Stomach and small
bowel loops are unremarkable. There appears to be inflammatory
stranding and slight wall thickening of the transverse colon and
hepatic flexure. A small amount of free fluid is identified
tracking around the liver. There is no free air. No mesenteric
or retroperitoneal lymphadenopathy is identified. The ventral
hernia is noted in the epigastrium.

CT PELVIS: Foley catheter is noted in the bladder. The uterus,
adnexa, sigmoid colon, and rectum are unremarkable. There is a
small amount of pelvic free fluid. Moderate hydronephrosis is
again identified in the transplant kidney. This is not
significantly changed from the most recent renal ultrasound of
[**2156-11-27**]. A small cyst is noted in the transplant kidney
as well. There are no suspicious lytic or sclerotic osseous
lesions.

CTA IMAGES: There is severe atherosclerotic disease. Bilateral
iliac stents are noted. The mesenteric vessels are highly
calcified and there is significant amount of plaque within the
superior mesenteric artery. However, the mesenteric vessels
appear patent, and no [**Year (4 digits) 1106**] occlusion is identified. The 3D
reformats demonstrate patency and flow to the segments of
abnormal- appearing colon.

IMPRESSION:
1. Severe atherosclerotic disease especially involving the
superior mesenteric artery, but patent mesenteric vasculature.
2. Inflammatory stranding and slight wall thickening of the
transverse colon and splenic flexure consistent with colitis,
most likely infectious or related to a low flow state.
3. Small amount of free fluid in the abdomen and pelvis.
4. Moderate hydronephrosis in the transplant kidney which is not
significantly changed compared to [**2156-11-27**].
RENAL TRANSPLANT U.S.  [**2158-5-2**] 10:07 AM

RENAL TRANSPLANT U.S.

Reason: assess cadaveric renal transplant for clot/occlusion

[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with h/o cadaveric renal transplant, now
admitted w/ SMA occlusion s/p OR w/ R colectomy, now worsening
renal function
REASON FOR THIS EXAMINATION:
assess cadaveric renal transplant for clot/occlusion
INDICATION: History of cadaveric renal transplant, admitted with
SMA occlusion, status post colectomy, now with worsening renal
function. Please assess for clot or occlusion.

COMPARISON: [**2156-11-27**].

TECHNIQUE: Renal transplant ultrasound.

FINDINGS: A transplant kidney is again identified within the
left lower quadrant, measuring 11.6 cm in length. Moderate
hydronephrosis of the transplant kidney appears approximately
unchanged in degree since [**2156-11-27**]. There is ascites
throughout the abdomen, including within the left lower quadrant
adjacent to the transplant. Doppler examination of the
transplant kidney demonstrates visibly less venous flow in the
periphery of the renal cortex in comparison with the previous
examination. The diastolic flow on pulse Doppler waveforms
appears diminished. Resistive indices range from 0.63 to an
estimated upper value of 0.8. The main renal vein appears patent
and demonstrates a normal waveform. There is no echogenic
thrombus within the main renal artery or vein.

IMPRESSION:

1. Stable hydronephrosis of the transplant kidney.

2. Continued slight increase in resistive indices and visual
decrease in venous flow within the transplant kidney. No
evidence of thrombosis of the main renal artery or vein.

Conclusions:
1. The left atrium is moderately dilated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Regional left ventricular wall motion is
normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
5.The estimated pulmonary artery systolic pressure is normal.
6. There is no pericardial effusion.

Compared with the findings of the prior report (images
unavailable for review)
of [**2156-5-13**], the EF is slightly more vigorous then.

Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2158-5-5**]
17:14.
[**Location (un) **] PHYSICIAN:
[**Known lastname **],[**Known firstname 21022**]       [**2103-6-1**]    54 Female      [**Numeric Identifier 21023**]
[**Numeric Identifier 21024**]
Report to:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) 2093**] Description by:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 21025**]/dif



SPECIMEN SUBMITTED:  COLON (1).

Procedure date     Tissue received     Report Date    Diagnosed
by
[**2158-4-27**] [**2158-4-27**] [**2158-5-3**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma??????
Previous biopsies:    [**Numeric Identifier 21026**]  COMMON FEM ART. PLAQUE (RT.)
  [**Numeric Identifier 21027**]  EMC/jh/mf.
  [**Numeric Identifier 21028**]  SENTINEL, RT BREAST RE-EXC./bb.
  [**Numeric Identifier 21029**]  RT BREAST MICROCALCS/lb.
(and more)

DIAGNOSIS

Colon (A-Q):

1.  Colon with transmural infarction with ulceration and
serositis.

2.  Mucosal infarction present at distal resection margin.

3.  Proximal resection margin viable.

4.  Mesenteric vessels with mild focal medial calcification.

5. Ileum, cecum, ileocecal valve, and appendix, no diagnostic
abnormalities recognized..

7.  One lymph node, no malignancy identified.


Brief Hospital Course:
From the ED patient was taken to the SICU fairly quickly,
intubated, and then taken to the OR for a R extended colectomy &
ileostomy/[**Doctor Last Name **] for gangrenous R colon due to SMA thrombus.

#Neuro/Psych: when the patient was tolearting PO medications,
her home antidepressants were restarted. Ativan PRN was used to
tx her anxiety. Morphine was given for tracheostomy site pain.

#Pulm: Patient was intubated fairly immediately after being
admitted to the SICU from the ED and remained so after the OR.
She failed extubation multiple times. She was oringinally
extubated POD2 and remained extubated for over a week. She was
reintubated on [**5-14**] with NGT and swanz-ganz catheter placement
after being brought to unit the day before for shortness of
breath and a negative V/Q scan. Extubation was attempted a few
days later and she failed within minutes. Thoracic surgery
performed a fiberoptic bronchoscopy which did not show any
abnormalities. She continued to have a good cuff leak and stayed
on low ventilatory support. Extubation was again attempted on
[**5-23**] and the second time she failed within hours. A percutaneous
trachesotomy was eventually performed on [**5-26**] at the bedside, and
she has done well weaning to a trach mask since that time. It is
still unknown why patient continued to fail extubation.

#CV: cardiology was involved. Patient was in fluid overload with
pulmonary edema and cardiomegaly, underwent diuresis and
altering of blood pressure medications as her pressures were
running on the high end for a significant period of time. ECHO
showed mod [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **],LVEF 40-50%,3+MR,2+TR, mod PA HTN and on [**5-11**]
was WORSE vs [**5-5**].  She is discharged with stable BP controlled
on oral agents.

#GI: patient's ostomy has functioned well since the surgery
without any problems. She has been followed by the osteomy
nurses. Patient had multiple instances of repeat abdominal pain
with elevated white counts in the setting of immunosuppression
so KUBs and a few CTs were performed to rule out any
obstruciton, abscesses, or acute surgical complications. Diet
was advanced from sips to clears on POD4. She then went back and
forth from from cleras to NPO for the next week during
intermittent episodes of abdominal pain. Was eventually on a
regular diet for a few days before having to be reintubated gain
for respiratory failure. Elemental tube feeds were started slow
only [**5-27**], they were advanced on [**6-1**] when she had no abdominal
pain. On [**6-1**] her feeding tube became dislodged during a coughing
spell. It was replaced by interventional radiology.

#Renal/Electrolytes: Patient had post-op ATN in the setting of a
previous kidney transplant. A renal consult was obtained. Had
renal US which showed stable hydronephrosis of the transplant
kidney. Continued slight increase in resistive indices and
visual decrease in venous flow within the transplant kidney. No
evidence of thrombosis of the main renal artery or veinHad HD at
one point. Later developed hyponatremia and hypercalcemia. Was
started on calcitonin [**Hospital1 **] and diuresed and hydrated with some
normal saline. Her sodium normalized, though her calcium
remained elevated.On [**6-1**] the calcitonin was discontinued and
pamidronate was given (30mg IV x 1); it may be repeated in [**1-27**]
weeks. Patient continues on her immunosuppression for her
transplant.

#Endo: was followd by [**Last Name (un) 387**] for her DM-I. required an insulin
drip intermittently. Is discharged with stable blood glucose,
controlled with insulin.

#heme: Throughout her admission, patient received a total of 8
units of red cells for falling hematocrits.

#ID: was given a few doses of vancomycin peri- and post-op as
well as zosyn for 2 weeks post-op. She also received a course of
levo toward the end of her stay for E Coli in her urine which
will complete on [**2158-6-3**].

#Nutrition: Patient was maintained on TPN throughout her stay
and later was started on trophic TF via a dobhoff. Tube feeds
should be advanced and TPN decreased over time.

#Rheum: Early [**Month (only) **] patient complained of R knee pain - had a
gout flair with suprapatellar bursitis. Was started on cochicine
taper and calcitonin [**Hospital1 **].

Medications on Admission:
Allopurinol 100', ASA 81', Ativan 0.5 q8prn, CaCO3cVIT D
600-200", CATAPRES-TTS 2 0.2MG/24HR 2 patches qwk, Doxazosin 2',
Lisinopril 2.5', Fluoxetine 30', Lasix 40", Lantus 26hs, Novolog
SS, Imuran 25', Isosorbide mono 90qAM/30qPM, Lipitor 10',
Lopressor 75", Nifedipine 90', NTG 0.4' SL prn, Prednisone 7,
Prograf [**1-26**], Procrit 6000 qSu/W, Ranitidine 150"

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO once a day.
4. Azathioprine 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
11. Isosorbide Dinitrate 20 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
12. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
14. Nifedipine 10 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
15. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
16. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1)  Injection
QMOWEFR (Monday -Wednesday-Friday).
18. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q4H (every 4 hours) as needed for wheeze/sob.
19. Paroxetine HCl 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
20. Pantoprazole 40 mg IV Q24H
21. Lorazepam 2 mg/mL Syringe Sig: One (1) mg Injection Q6H
(every 6 hours) as needed for anxiety.
22. Morphine 2 mg/mL Syringe Sig: One (1)  Injection Q2H (every
2 hours) as needed for tracheostomy pain .
23. Metoclopramide 5 mg/mL Solution Sig: One (1)  Injection Q6H
(every 6 hours).
24. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1)
Intravenous  Q4-6H (every 4 to 6 hours) as needed: for sbp>150.

25. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
26. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding
scale  Subcutaneous ASDIR (AS DIRECTED): per provided sliding
scale.
27. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
28. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: Two Hundred
Fifty (250) mg Intravenous  Q24H (every 24 hours): through doses
on [**6-3**].
29. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
30. Tacrolimus 1 mg Capsule Sig: as directed Capsule PO twice a
31. Alendronate 5 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]

Discharge Diagnosis:
1. mesenteric ischemia
2. pancreatitis
3. respiratory failure
4. acute renal failure
5. R prepatellar bursitis
6. HTN
7. DM-I
8. anemia of chronic renal disease and chronic disease
9. hypercalcemia
10. hypernatremia


Discharge Condition:
Good


Discharge Instructions:
 please seek medical attention if you experience fever > 101.5,
severe nausea, vomitting, pain, shortness of breath

please take medications as directed

Followup Instructions:
1. Please call the transplant clinic [**Telephone/Fax (1) 673**] to schedule
appointments with both Dr. [**Last Name (STitle) **] and with one of the
transplant surgeons

2. Follow up with your Cardiologist within one month to have
your Lisinopril restarted.

3. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2158-6-6**]
11:00
[**Month/Day/Year **] NON-INVAS [**Month/Day/Year 3628**] [**Month/Day/Year **] [**Month/Day/Year 3628**] (NHB) Date/Time:[**2158-7-10**]
10:00Provider: [**Month/Day/Year **] NON-INVAS [**Month/Day/Year 3628**] [**Month/Day/Year **] [**Month/Day/Year 3628**] (NHB)
Date/Time:[**2158-7-10**] 10:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] (NHB)
Date/Time:[**2158-7-10**] 10:30
Provider: [**Name10 (NameIs) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2158-7-10**] 11:00
{'Gout, unspecified,Other enthesopathy of knee,Hypercalcemia,Personal history of malignant neoplasm of breast,Chronic vascular insufficiency of intestine,Acute respiratory failure,Complications of transplanted kidney,Cardiac complications, not elsewhere classified,Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled,Hyperosmolality and/or hypernatremia,Urinary tract infection, site not specified,Unspecified essential hypertension,Peripheral vascular disease, unspecified'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: Ms. [**Known lastname **] is a 54-year female with a history of diabetes,
coronary artery disease, hypertension, renal transplant and
significant peripheral [**Known lastname 1106**] disease who presented with a
several day history of abdominal discomfort and worsened over
the past 24 hours. She was seen in the emergency room and was
found to be in relative extremis condition. Although
hemodynamically stable, she had extensive peritonitis. She
underwent a CTA of the abdomen which demonstrated what appeared
to be a thrombosis of the SMA and thickening of the left and
right colon. She was taken to the operating room urgently for
exploration.

MEDICAL HISTORY: MI x2, CABG x2, DM1 with retinopathy/neuropathy/nephropathy. CRT
'[**43**] (Dr. [**Last Name (STitle) 15473**], PVD, LBKA [**6-/2147**], fem-[**Doctor Last Name **] '[**48**] w/ [**Doctor Last Name **]-DP bypass,
^chol, L eye prosth, b/l breast ca, chr anemia, CRI (baseline Cr
2.0)

MEDICATION ON ADMISSION: Allopurinol 100', ASA 81', Ativan 0.5 q8prn, CaCO3cVIT D
600-200", CATAPRES-TTS 2 0.2MG/24HR 2 patches qwk, Doxazosin 2',
Lisinopril 2.5', Fluoxetine 30', Lasix 40", Lantus 26hs, Novolog
SS, Imuran 25', Isosorbide mono 90qAM/30qPM, Lipitor 10',
Lopressor 75", Nifedipine 90', NTG 0.4' SL prn, Prednisone 7,
Prograf [**1-26**], Procrit 6000 qSu/W, Ranitidine 150"

ALLERGIES: Dilaudid / Codeine

PHYSICAL EXAM: on discharge:
Afebrile, BP 11/79-166/65, 74, 14, 100% Trach Mask
AOx3
CTA B/L
Trache in position
Abd soft, NT, ND
Resolving erythema over R knee
- edema

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Gout, unspecified,Other enthesopathy of knee,Hypercalcemia,Personal history of malignant neoplasm of breast,Chronic vascular insufficiency of intestine,Acute respiratory failure,Complications of transplanted kidney,Cardiac complications, not elsewhere classified,Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled,Hyperosmolality and/or hypernatremia,Urinary tract infection, site not specified,Unspecified essential hypertension,Peripheral vascular disease, unspecified'}
