CHIEF COMPLAINT: Abdominal pain, Hypotension

PRESENT ILLNESS: History of Present Illness:   57 yo female with ESRD on HD
(MWF), HTN, HCV cirrhosis, Hypothyroidism, Anxiety, chronic back
pain on methadone, called in to [**Company 191**] complaining of lower right
abdominal pain, and referred to the ED.  Of note, she was
recently admitted to the hospitalist service for hypotension.
During that admission she was thought to be over medicated,
taking nitroglycerin daily instead of PRN, over beta-blocked.
The patient was found to also be very hypothyroid, with TSH >
assay.  Adrenal insufficiency was ruled out.  She was determined
to have a dry weight of 74kg.  Today, she reported to the [**Company 191**]
nurse that her pain started on Sunday and radiates to the right
side of the umbilicus.  She feels this pain was similar to
ovarian and renal cysts she had in the past.  The pain limits
ambulation and po intake.  She reports nausea and vomiting X1
today.  Denies diarrhea, melena, hematochezia, urinary symptoms.
 Last HD yesterday, and per her report her BP dropped to 70/p,
HD had to be stopped early.
.
In the ED, initial vs were: 97.8 87 74/55 18 98% RA.   Triggered
for hypotension on arrival, denies taking any antihypertensives,
took methadone at 7am.  On exam, she was found to be somnolent,
right sided CVA tenderness.  Her labs were significant for
lipase of 118, AP 199, ALT 47, AST 52, Tbili wnl, no
leukocytosis, mild thrombocytopenia, INR 1.4, AG of 16, lactate
of 2.5 initially and corrected to 1.5 with fluids.  CXR showed
mild bibasilar atelectasis.  CT of the abd showed no acute abd
pathology, fibroid uterus, 4-cm R adnexal complex cyst (old),
atrophic right kidney, right hemicolectomy, new splenomegaly.
Received a total of 1.2L NS with only mild improvement in BP to
89 systolic.  She then had a R IJ placed, with improvement in BP
to 104/69 without pressors.  She also received vanc/zosyn for ?
infection, although unclear source.  On transfer to the floor,
77 104/69 12 98% on 2L.
.
On the floor, the patient continues to complain of right lower
abdominal pain that radiates to her right flank and right leg.
She reports mental slowing and "not feeling well."

MEDICAL HISTORY: -HTN
-ESRD on hemodialysis
-HCV cirrhosis
-spinal stenosis with back pain
-seizure disorder
-depression
-hypothyroidism
-substance abuse
-Lumbar laminectomy
-status post failed renal transplant
-cholecystectomy
-thyroidectomy

MEDICATION ON ADMISSION: levetiracetam 250 mg PO BID
fluticasone-salmeterol 250-50 mcg/dose Disk [**Hospital1 **]
levothyroxine 100 mcg + 88mcg once a day
gabapentin 300 mg PO QHD
clonazepam 0.5 mg PO BID
methadone 10 mg/mL Concentrate 44 mg PO DAILY
fluoxetine 60 mg PO DAILY
calcium acetate 667 mg PO TID with meals
aspirin 81 mg PO once a day.
simvastatin 20 mg PO once a day.
Sensipar 30 mg PO once a day.
omeprazole 20 mg PO once a day.
folic acid 1 mg PO once a day.
trazodone 50 mg PO at bedtime.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Alert, with mildly slow to answer questions, oriented,
no acute distress
HEENT: Sclera anicteric, mm mildly dry, oropharynx clear
Neck: RIJ in place, supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV:  [**2-20**] murmur radiates to the graft on the left, no rubs,
gallops
Abdomen: mild TTP of RLQ, RUQ, distended, soft, +BS
GU: no foley
Ext:  RLE first two missing large portion of the toenail,
granulation tissue present, no purulence.

FAMILY HISTORY: Father: ESRD and hypertension
Mother: lung cancer

SOCIAL HISTORY: Retired special education teacher. Widowed, lives at home with
sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy.
# Tobacco: 3 packs per week since teenager
# Alcohol: Denies
# Drugs: Past IVDU, but not in several years
Hypotension of hemodialysis,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Complications of transplanted kidney,Opioid type dependence, continuous,Acquired coagulation factor deficiency,Acidosis,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Neoplasm of unspecified nature of other genitourinary organs,Renal dialysis status,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anemia in chronic kidney disease,Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Coronary atherosclerosis of native coronary artery,Spinal stenosis, unspecified region,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified acquired hypothyroidism,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Abdominal pain, left lower quadrant,Dysthymic disorder,Thrombocytopenia, unspecified
Hemododialysis hypotensn,End stage renal disease,Hyp kid NOS w cr kid V,Compl kidney transplant,Opioid dependence-contin,Acq coagul factor defic,Acidosis,Abn react-renal dialysis,Other gu neoplasm NOS,Renal dialysis status,Abn react-org transplant,Anemia in chr kidney dis,Hpt C w/o hepat coma NOS,Cirrhosis of liver NOS,Crnry athrscl natve vssl,Spinal stenosis NOS,Epilep NOS w/o intr epil,Hypothyroidism NOS,Migrne unsp wo ntrc mgrn,Abdmnal pain lt lwr quad,Dysthymic disorder,Thrombocytopenia NOS
Admission Date:  [**2129-5-12**]              Discharge Date:   [**2129-5-17**]

Date of Birth:  [**2072-5-1**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Abdominal pain, Hypotension

Major Surgical or Invasive Procedure:
None

History of Present Illness:
History of Present Illness:   57 yo female with ESRD on HD
(MWF), HTN, HCV cirrhosis, Hypothyroidism, Anxiety, chronic back
pain on methadone, called in to [**Company 191**] complaining of lower right
abdominal pain, and referred to the ED.  Of note, she was
recently admitted to the hospitalist service for hypotension.
During that admission she was thought to be over medicated,
taking nitroglycerin daily instead of PRN, over beta-blocked.
The patient was found to also be very hypothyroid, with TSH >
assay.  Adrenal insufficiency was ruled out.  She was determined
to have a dry weight of 74kg.  Today, she reported to the [**Company 191**]
nurse that her pain started on Sunday and radiates to the right
side of the umbilicus.  She feels this pain was similar to
ovarian and renal cysts she had in the past.  The pain limits
ambulation and po intake.  She reports nausea and vomiting X1
today.  Denies diarrhea, melena, hematochezia, urinary symptoms.
 Last HD yesterday, and per her report her BP dropped to 70/p,
HD had to be stopped early.
.
In the ED, initial vs were: 97.8 87 74/55 18 98% RA.   Triggered
for hypotension on arrival, denies taking any antihypertensives,
took methadone at 7am.  On exam, she was found to be somnolent,
right sided CVA tenderness.  Her labs were significant for
lipase of 118, AP 199, ALT 47, AST 52, Tbili wnl, no
leukocytosis, mild thrombocytopenia, INR 1.4, AG of 16, lactate
of 2.5 initially and corrected to 1.5 with fluids.  CXR showed
mild bibasilar atelectasis.  CT of the abd showed no acute abd
pathology, fibroid uterus, 4-cm R adnexal complex cyst (old),
atrophic right kidney, right hemicolectomy, new splenomegaly.
Received a total of 1.2L NS with only mild improvement in BP to
89 systolic.  She then had a R IJ placed, with improvement in BP
to 104/69 without pressors.  She also received vanc/zosyn for ?
infection, although unclear source.  On transfer to the floor,
77 104/69 12 98% on 2L.
.
On the floor, the patient continues to complain of right lower
abdominal pain that radiates to her right flank and right leg.
She reports mental slowing and "not feeling well."


Past Medical History:
-HTN
-ESRD on hemodialysis
-HCV cirrhosis
-spinal stenosis with back pain
-seizure disorder
-depression
-hypothyroidism
-substance abuse
-Lumbar laminectomy
-status post failed renal transplant
-cholecystectomy
-thyroidectomy


Social History:
Retired special education teacher. Widowed, lives at home with
sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy.
# Tobacco: 3 packs per week since teenager
# Alcohol: Denies
# Drugs: Past IVDU, but not in several years


Family History:
Father: ESRD and hypertension
Mother: lung cancer


Physical Exam:
General: Alert, with mildly slow to answer questions, oriented,
no acute distress
HEENT: Sclera anicteric, mm mildly dry, oropharynx clear
Neck: RIJ in place, supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV:  [**2-20**] murmur radiates to the graft on the left, no rubs,
gallops
Abdomen: mild TTP of RLQ, RUQ, distended, soft, +BS
GU: no foley
Ext:  RLE first two missing large portion of the toenail,
granulation tissue present, no purulence.


Pertinent Results:
[**2129-5-12**] 07:31PM   LACTATE-1.5
[**2129-5-12**] 06:48PM   LACTATE-1.7
[**2129-5-12**] 03:33PM   LACTATE-2.5*
[**2129-5-12**] 03:33PM   HGB-11.7* calcHCT-35
[**2129-5-12**] 03:20PM   GLUCOSE-151* UREA N-37* CREAT-6.5* SODIUM-140
POTASSIUM-5.1 CHLORIDE-97 TOTAL CO2-27 ANION GAP-21*
[**2129-5-12**] 03:20PM   estGFR-Using this
[**2129-5-12**] 03:20PM   ALT(SGPT)-47* AST(SGOT)-52* ALK PHOS-199* TOT
BILI-0.3
[**2129-5-12**] 03:20PM   LIPASE-118*
[**2129-5-12**] 03:20PM   ALBUMIN-4.3 CALCIUM-7.9* PHOSPHATE-5.3*
MAGNESIUM-1.8
[**2129-5-12**] 03:20PM   WBC-5.9# RBC-3.76* HGB-11.4* HCT-34.2* MCV-91
MCH-30.3 MCHC-33.3 RDW-18.1*
[**2129-5-12**] 03:20PM   NEUTS-61.2 LYMPHS-29.2 MONOS-6.0 EOS-2.8
BASOS-0.7
[**2129-5-12**] 03:20PM   PLT COUNT-119*
[**2129-5-12**] 03:20PM   PT-16.3* PTT-27.1 INR(PT)-1.4*
,
Imaging:
CT Abdomen:
INDICATION: 57-year-old female with right abdominal and flank
pain x few
days.

COMPARISON: CT from [**2129-4-20**] and MR from [**2129-4-22**].

TECHNIQUE: Helical MDCT images were acquired from the lung bases
through the
greater trochanters without and with intravenous contrast, per
the CT urogram
protocol. The patient is scheduled for dialysis within the next
24 hours, per
discussion with the referring physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2093**]. 5-mm
axial,
coronal, and sagittal multiplanar reformats were generated.

FINDINGS:

Mild atelectasis is noted at the lung bases. There are no
pleural effusions.
The heart is normal in size, without pericardial effusion. Note
is made of a
moderate sliding hiatal hernia.

ABDOMEN:

The liver is mildly heterogeneous with a slightly irregular
contour,
consistent with known cirrhosis. Note is made of a recanalized
umbilical vein
and mild gastrohepatic varices. The gallbladder is surgically
absent. The
pancreas is normal. There is no intra- or extra-hepatic biliary
ductal
dilatation.

The spleen is enlarged at 19 cm, previously 15 cm. Accessory
splenule is
noted posterior to the main splenic body.

The adrenals are normal. The kidneys are atrophic, but enhance
symmetrically.
Multiple bilateral renal cysts are present. There are no renal
stones,
masses, or hydronephrosis.

Stomach is distended with retained oral contents. Note is made
of a
diverticulum arising from the second portion of the duodenum.
The small bowel
demonstrates a slightly unusual configuration, likely
post-surgical.

PELVIS:

Slightly atrophic transplant kidney measuring 6 cm in length is
noted in the
right iliac fossa, without significant contrast enhancement.

Changes of right hemicolectomy are present, with intact
anastomotic suture
line in the right abdomen. There is a moderate amount of
retained fecal
material throughout the transverse and sigmoid colon.

Multiple calcified fibroids are again noted in the uterus. There
is a 4 x 4
cm right adnexal cystic lesion with single internal septation,
which
previously measured 4.3 x 3.5 cm. The bladder is partially
collapsed. Small
bilateral fat-containing inguinal hernias are present, left
greater than
right.

Scattered calcifications are noted in the abdominal aorta and
iliac arteries,
with patent branch vessel origins. Scattered retroperitoneal and
mesenteric
lymph nodes measure up to 6 mm in short axis. There is no free
intraperitoneal fluid or air.

Mild degenerative changes are noted in the thoracolumbar spine,
with grade 1
anterolisthesis at L4-L5. Moderate diffuse disc bulges are noted
at L3-L4
through L5-S1, with impingement of the thecal sac outline;
please note that CT
cannot visualize intrathecal detail. Moderate facet hypertrophy
and
ligamentum flavum thickening are also present.

IMPRESSION:
1. Fibroid uterus, with 4-cm right adnexal hypodense structure
that should be
evaluated by non-emergent pelvic ultrasound.
2. Acutely increased splenomegaly, may reflect infection or
lymphoproliferative process. Please correlate clinically.
3. Cirrhosis
4. Atrophic native and transplant kidneys
5. Moderate hiatal hernia.
The study and the report were reviewed by the staff radiologist.
.
US:
The transabdominal ultrasound did not allow visualization of the
uterus or the
ovaries; therefore, we proceeded to a transvaginal examination.
The uterus is
enlarged and contains multiple fibroids. Overall, the uterus
measures
approximately 7.6 x 5.5 x 6 cm. Multiple, partially calcified
fibroids
distort the endometrial cavity. The largest fibroid lies
posteriorly in the
uterine body and measures approximately 4.5 x 4.3 x 3.9 cm. The
endometrium
is distorted by the multiple fibroids and difficult to visualize
throughout
its length, this measures approximately 3 mm in thickness. There
is a large
predominantly cystic mass in the right ovary. This measures 4 x
5 x 3 cm and
contains multiple internal septations, several of which
demonstrate internal
blood flow. The left ovary measures 2.6 x 2 x 2 cm and contains
multiple
small cysts as well as a small calcified lesion measuring 0.7 x
0.6 x 0.6 cm.
No free fluid seen in the pelvis.
.
IMPRESSION:
1. Bulky fibroid uterus as described.
2. The large cystic mass in the right ovary has some complex
features, with
multiple internal septations, some of which demonstrate
vascularity and
concerning for neoplasm. Recommend referral to OB/GYN for
further assessment.
3. Multiple small cysts seen in the left ovary are also atypical
in a
postmenopausal woman and this should also be evaluated by
OB/GYN.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was informed of the findings by telephone at
2pm [**2129-5-13**].
.
MRI
FINDINGS:
Arising from the right ovary is a multiseptated lobular
well-circumscribed T2
hyperintense lesion measuring 4.2 x 3.7 x 5.0 cm. Multiple
internal
septations are seen some with slight thickening. No nodular
components are
present. No surrounding inflammatory changes.
The left ovary measures 2.8 x 1.5 cm and contains many
physiologic follicles
The uterus is anteverted with multiple T1 and T2 hypoattenuating
masses
demonstrating significant enhancement. The largest is in the
posterior
myometrium and measures 4.0 x 4.4 x 4.4 cm. It demonstrates
progressive
enhancement. An avidly enhancing exophytic anterior fibroid is
also present
measuring 2.2 x 2.4 cm. Additional smaller myometrial and
subserosal fibroids
are seen. There is trace fluid in the endometrial canal.
Adjacent to the right external iliac vessels, a 1.0 x 0.8 cm
ovoid soft tissue
density is seen, perhaps a lymph node. No significant free fluid
is present
within the pelvis. No significant pelvic sidewall or inguinal
adenopathy.
Subcentimeter inguinal lymph nodes are present. Fat-containing
left inguinal
hernia without bowel content. The rectosigmoid contains a large
amount of
stool. No pericolonic stranding. Presacral fat is preserved.
Within the right iliac fossa is an atrophic, abnormally
appearing right renal
transplant measuring 5.6 x 2.6 cm with diffuse irregular
enhancement. No
surrounding inflammatory changes.
Visualized bone marrow signal is preserved. Multilevel lower
lumbar
degenerative disease. Post-surgical changes in the anterior
hypogastrium are
seen. No abnormal fluid collections.

IMPRESSION:
1. Well-circumscribed multiseptated right adnexal lesion is
present
containing fluid content. Septations appear smooth throughout
though some of
the septations are mildly thickened. Though enhancement cannot
be assessed
without contrast, no definite nodular components or adjacent
inflammatory
changes are present. It appears stable in size since [**Month (only) 404**]
[**2129**] but is new
since the examination of [**2125**].
This lesion has features suggesting mucinous cystadenoma of the
ovary. If no
surgical intervention is planned, consider follow up imaging
with MR or US to
assess for continued stability.
2. Multiple uterine fibroids as previously described. Most
demonstrate avid
enhancement.
3. Left ovary with multiple physiologic follicles. No free
fluid.
4. Atrophic, deformed right iliac fossa renal transplant.

Discharge labs
[**2129-5-17**] 05:34AM BLOOD WBC-4.0 RBC-3.52* Hgb-10.7* Hct-31.9*
MCV-91 MCH-30.4 MCHC-33.6 RDW-17.4* Plt Ct-106*
[**2129-5-17**] 05:34AM BLOOD Glucose-95 UreaN-42* Creat-6.1*# Na-138
K-5.0 Cl-91* HCO3-35* AnGap-17
[**2129-5-13**] 03:03AM BLOOD ALT-43* AST-44* CK(CPK)-79 AlkPhos-175*
TotBili-0.3
[**2129-5-17**] 05:34AM BLOOD Calcium-7.9* Phos-4.9*# Mg-2.0
[**2129-5-12**] 03:20PM BLOOD TSH-5.6*
[**2129-5-14**] 11:42AM BLOOD Cortsol-32.1*

Brief Hospital Course:
Ms. [**Known lastname 3671**] is a 57 year old female with HCV cirrhosis, ESRD s/p
failed renal transplant, htn, CAD, hypothyroidism, and chronic
back pain requiring methadone who presented to the ED with right
lower quadrant pain in the context of a right adnexal complex
mass. She became hypotensive in the ED and required fluid
rescusitation in MICU overnight with an unclear cause of her
hypotension.

# Hypotension: The differential diganosis for her hypotension
was broad, but it was felt that she had been taking her
anti-hypertensives incorrectly and her hypotension corrected
with volume.  Additional causes of hypotension including adrenal
insufficieny, hypothyroidism, and sepsis were all entertained.
Upon arrival to the floor she was continued on HD for her ESRD,
and her anti-hypertension medications were held.  She will need
to have her anti-hypertensive medications restarted as an
outpatient.
.
# R ovarian mass:  She presented with focal RLQ abdominal pain
that was concerning for malignancy, but after consultation with
Gyn/Onc, it was felt that the mass was not cancer and should be
followed with serial imaging.

# Chronic Pain:  She has been on methadone for chronic pain.
She was started on dilaudid PRN for addtional right lower
quadrant pain.
.
# ESRD: Due to her hypocalcemia when she presented, there was
concern that it may have caused her hypotension.  Cinacalcet was
discontinued, and she was started on vitamin D and calcium.
.
#Cirrhosis and splenomegaly: Secondary to HCV.  Her LT's were
mildly elevated during this admission, but otherwise stable.
She has tender splenomegaly and portal or mesenteric vein
thrombosis could be considered.
.
# CAD:  Her last Cath showed that she did not have significant
Coronary artery disease.  Nevertheless, due to her hypotension,
she was ruled out during this admission.  She was continued on
asa 81 mg and simvastatin 20 mg PO daily.
.
# Hypothyroidism: She was continued on her home levothyroxine
188mcg.
.
# Coagulopathy: She had a mildly elevated INR which was thought
to be secondary to underlying poor synthetic liver function
.
# Thrombocytopenia: Her thrombocytopenia was thought to be
secondary to her cirrhosis and was stable during this admission.

.
# Anemia of CKD: She receives erythropoietin as an outpatient.
Her anemia was stable during this admission.
.
# Seizure Disorder: She was continued on her levetiracetam
.
# Depression/Anxiety: She was continued on her clonazepam and
fluoxetine.
.
Discharge:
Home with services
Transition of care:  The patient will need help with her
medication regiment, she will also need to have her medications,
including her hypertensive medication regiment adjusted.

Medications on Admission:
levetiracetam 250 mg PO BID
fluticasone-salmeterol 250-50 mcg/dose Disk [**Hospital1 **]
levothyroxine 100 mcg + 88mcg once a day
gabapentin 300 mg PO QHD
clonazepam 0.5 mg PO BID
methadone 10 mg/mL Concentrate 44 mg PO DAILY
fluoxetine 60 mg PO DAILY
calcium acetate 667 mg PO TID with meals
aspirin 81 mg PO once a day.
simvastatin 20 mg PO once a day.
Sensipar 30 mg PO once a day.
omeprazole 20 mg PO once a day.
folic acid 1 mg PO once a day.
trazodone 50 mg PO at bedtime.


Discharge Medications:
1. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
4. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
5. methadone 10 mg/mL Concentrate Sig: Forty Four (44) mg PO
DAILY (Daily).
6. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
13. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. levothyroxine 100 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
15. levothyroxine 88 mcg Capsule Sig: One (1) Capsule PO once a
day.
16. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
17. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
18. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Hypotension
Right ovarian mass

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

Discharge Instructions:
Dear Ms. [**Known lastname 3671**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
to the hospital for treatment of low blood pressure and a right
ovarian mass. You were in the medical intensive care unit for
one night, where you were given intravenous fluids. Your blood
pressure improved. On the regular medical floor, the
gynecologists evaluated your right ovarian mass. After doing an
ultrasound and MRI, we determined that the right ovarian mass is
unlikely to be cancer. We will follow it with an ultrasound in
[**Month (only) **].

Please make the following changes to your home medications:
- Take Dilaudid 2-4 mg up to four times per day as needed for
pain for the next few days
- STOP Sensipar
- START calcium carbonate 500 mg twice daily
- START vitamin D 1000 units daily

Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2129-5-26**] at 3:20 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: GASTROENTEROLOGY
When: THURSDAY [**2129-6-2**] at 4:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: RADIOLOGY
When: THURSDAY [**2129-6-16**] at 10:00 AM [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: GYN SPECIALTY
When: THURSDAY [**2129-6-23**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 5777**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


Completed by:[**2129-6-16**]
{'Hypotension of hemodialysis,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Complications of transplanted kidney,Opioid type dependence, continuous,Acquired coagulation factor deficiency,Acidosis,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Neoplasm of unspecified nature of other genitourinary organs,Renal dialysis status,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anemia in chronic kidney disease,Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Coronary atherosclerosis of native coronary artery,Spinal stenosis, unspecified region,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified acquired hypothyroidism,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Abdominal pain, left lower quadrant,Dysthymic disorder,Thrombocytopenia, 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, Hypotension

PRESENT ILLNESS: History of Present Illness:   57 yo female with ESRD on HD
(MWF), HTN, HCV cirrhosis, Hypothyroidism, Anxiety, chronic back
pain on methadone, called in to [**Company 191**] complaining of lower right
abdominal pain, and referred to the ED.  Of note, she was
recently admitted to the hospitalist service for hypotension.
During that admission she was thought to be over medicated,
taking nitroglycerin daily instead of PRN, over beta-blocked.
The patient was found to also be very hypothyroid, with TSH >
assay.  Adrenal insufficiency was ruled out.  She was determined
to have a dry weight of 74kg.  Today, she reported to the [**Company 191**]
nurse that her pain started on Sunday and radiates to the right
side of the umbilicus.  She feels this pain was similar to
ovarian and renal cysts she had in the past.  The pain limits
ambulation and po intake.  She reports nausea and vomiting X1
today.  Denies diarrhea, melena, hematochezia, urinary symptoms.
 Last HD yesterday, and per her report her BP dropped to 70/p,
HD had to be stopped early.
.
In the ED, initial vs were: 97.8 87 74/55 18 98% RA.   Triggered
for hypotension on arrival, denies taking any antihypertensives,
took methadone at 7am.  On exam, she was found to be somnolent,
right sided CVA tenderness.  Her labs were significant for
lipase of 118, AP 199, ALT 47, AST 52, Tbili wnl, no
leukocytosis, mild thrombocytopenia, INR 1.4, AG of 16, lactate
of 2.5 initially and corrected to 1.5 with fluids.  CXR showed
mild bibasilar atelectasis.  CT of the abd showed no acute abd
pathology, fibroid uterus, 4-cm R adnexal complex cyst (old),
atrophic right kidney, right hemicolectomy, new splenomegaly.
Received a total of 1.2L NS with only mild improvement in BP to
89 systolic.  She then had a R IJ placed, with improvement in BP
to 104/69 without pressors.  She also received vanc/zosyn for ?
infection, although unclear source.  On transfer to the floor,
77 104/69 12 98% on 2L.
.
On the floor, the patient continues to complain of right lower
abdominal pain that radiates to her right flank and right leg.
She reports mental slowing and "not feeling well."

MEDICAL HISTORY: -HTN
-ESRD on hemodialysis
-HCV cirrhosis
-spinal stenosis with back pain
-seizure disorder
-depression
-hypothyroidism
-substance abuse
-Lumbar laminectomy
-status post failed renal transplant
-cholecystectomy
-thyroidectomy

MEDICATION ON ADMISSION: levetiracetam 250 mg PO BID
fluticasone-salmeterol 250-50 mcg/dose Disk [**Hospital1 **]
levothyroxine 100 mcg + 88mcg once a day
gabapentin 300 mg PO QHD
clonazepam 0.5 mg PO BID
methadone 10 mg/mL Concentrate 44 mg PO DAILY
fluoxetine 60 mg PO DAILY
calcium acetate 667 mg PO TID with meals
aspirin 81 mg PO once a day.
simvastatin 20 mg PO once a day.
Sensipar 30 mg PO once a day.
omeprazole 20 mg PO once a day.
folic acid 1 mg PO once a day.
trazodone 50 mg PO at bedtime.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Alert, with mildly slow to answer questions, oriented,
no acute distress
HEENT: Sclera anicteric, mm mildly dry, oropharynx clear
Neck: RIJ in place, supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV:  [**2-20**] murmur radiates to the graft on the left, no rubs,
gallops
Abdomen: mild TTP of RLQ, RUQ, distended, soft, +BS
GU: no foley
Ext:  RLE first two missing large portion of the toenail,
granulation tissue present, no purulence.

FAMILY HISTORY: Father: ESRD and hypertension
Mother: lung cancer

SOCIAL HISTORY: Retired special education teacher. Widowed, lives at home with
sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy.
# Tobacco: 3 packs per week since teenager
# Alcohol: Denies
# Drugs: Past IVDU, but not in several years 

### Response:
{'Hypotension of hemodialysis,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Complications of transplanted kidney,Opioid type dependence, continuous,Acquired coagulation factor deficiency,Acidosis,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Neoplasm of unspecified nature of other genitourinary organs,Renal dialysis status,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anemia in chronic kidney disease,Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Coronary atherosclerosis of native coronary artery,Spinal stenosis, unspecified region,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified acquired hypothyroidism,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Abdominal pain, left lower quadrant,Dysthymic disorder,Thrombocytopenia, unspecified'}
