CHIEF COMPLAINT: abdominal pain, acute renal failure, hypotension

PRESENT ILLNESS: Ms. [**Known lastname 4886**] is a 74 year old woman with a history of CHF, chronic
renal insufficiency, peptic ulcer disease, CAD, HTN, who is
admitted to the MICU for management of acute renal failure,
abdominal pain, and hypotension. She was brought in to the
[**Hospital6 10353**] ED yesterday after reportedly having
several days of poor PO intake and abdominal pain at her
[**Hospital3 **] facility, per her daughter. The patient gives a
vague history of recent URI symptoms, and she reports a
mechanical fall yesterday, without any head trauma or loss of
consciousness.
.
At the [**Hospital3 **] ED, she was noted to be in
acute-on-chronic renal failure with a creatinine of 4.9 and a
serum HCO3 of 6. She had a SBP in the mid-80s and was reportedly
hypothermic to 95.8, with a leukocytosis to [**Numeric Identifier 2686**]. An ABG showed
a metabolic acidosis (7.22/22/175 on 2L n.c.). She was noted to
vomit 200cc of "blood-tinged mucous". She underwent an abdominal
CT with PO (no IV) contrastwhich showed no acute process. She
was given a dose of metronidazole and moxifloxacin for empiric
antibiotics. She was also given a dose of IV ondansetron, a
1000cc NS bolus, and 150 mEq of NaHCO3. A left-sided subclavian
central line was placed and she was transferred to [**Hospital1 18**].
.
Upon arrival to the [**Hospital1 18**] ED, she was afebrile with a
temperature of 98.2, BP 91/59, HR 84. She was given 1000cc NS
bolus and 1000cc D5W with 150 mEq HCO3. She reportedly had a
decrease in her BP to 56/44 which improved to 102/58 with a
250cc NS bolus and low dose of norepinephrine. She was also
given 10 mg of IV dexamethasone for unclear reasons. She had a
CT which showed no acute process and an abdominal ultrasound
which showed a mildly dilated (1.1cm) CBD; no gallbladder was
identified. Per the [**Hospital1 18**] ED resident, she was noted on two
separate rectal examinations to have black tarry stool which was
Guaiac negative.
.
Upon arrival to the MICU, she had a dry black stool which was
Guaiac positive. Her norepinephrine was weaned off upon arrival
to the MICU.
.
Of note, she had a similar presentation to [**Hospital 882**] Hospital in
[**9-/2144**] when she presented with acute-on-chronic renal failure,
decreased PO intake, and left-sided abdominal pain. An EGD on
that admission showed a nonbleeding gastric ulcer, and her ppi
was changed from pantoprazole to omeprazole and increased [**Hospital1 **].
She also had a question of antral thickening on a CT scan, and
antral biopsies were taken, the results of which are unavailable
to us at the time of this note.

MEDICAL HISTORY: Past Medical History:
- congestive heart failure (by report, LVEF 50% om [**4-/2144**])
- CAD with ?MI
- peptic ulcer disease with ? bleeding ulcer in distant past;
EGD in [**11/2143**] showed nonbleeding gsatritis; EGD in [**9-/2144**]
showed nonbleeding erythematous gastritis and nonbleeding
gastric ulcer
- short-term memory loss
- ?CVA vs TIA
- chronic renal insufficiency (baseline creatinine 1.6) with
multiple recent episodes of acute exacerbations
- HTN
- hx C2 fracture with hardware in place
- "moderate" right-sided RAS
- s/p appendectomy
- s/p cholecystectomy
- s/p partial colectomy for diverticulitis
- osteoporosis
- hyperlipidemia
- COPD
.

MEDICATION ON ADMISSION: Home Medications:
ferrous sulfate 325 mg daily
lisinopril 10 mg daily
aspirin 81 mg daily
multivitamin 1 tab daily
calcium carbonate/vitamin D 1 tab daily
docusate 100 mg [**Hospital1 **]
ipratropium/albuterol MDI 2 puffs [**Hospital1 **]
mirtazapine 7.5 mg qhs
atorvastatin 80 mg daily
acetaminophen 500 mg tid
omeprazole 20 mg daily

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: T 97.8 BP 121/58 HR 93 RR 23 Sat 100% on 2L n.c.
CVP 4cm
General: uncomfortable, but in no acute distress
HEENT: no scleral icterus, MM moderately dry
Neck: JVP 6cm, no thyromegaly
Chest: clear to auscultation throughout, no w/r/r
CV: regular rate/rhythm, normal S1S2, no m/r/g
Abdomen: soft, mild voluntary guarding esp. in LLQ; tenderness
to moderate palpation mostly in LLQ; no rebound
Extremities: no edema, 2+ PT pulses
Skin: no rashes
Neuro: alert, oriented to self, "[**2142-1-3**]" and "River Bay
Club".

FAMILY HISTORY: Family History:
Per daughter, the patient's father died at an early age from an
MI.

SOCIAL HISTORY: Social History:
Quit smoking >15 yrs ago. No alcohol or drugs. Lives in River
Bay Club [**Hospital3 **] facility.
Acute kidney failure, unspecified,Chronic systolic heart failure,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Infection and inflammatory reaction due to indwelling urinary catheter,Chronic airway obstruction, not elsewhere classified,Hypotension, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Constipation, unspecified,Disorders of phosphorus metabolism,Other and unspecified noninfectious gastroenteritis and colitis,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Acute kidney failure NOS,Chr systolic hrt failure,Urin tract infection NOS,Hyperosmolality,React-indwell urin cath,Chr airway obstruct NEC,Hypotension NOS,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Gstr/ddnts NOS w/o hmrhg,Duodenal ulcer NOS,Constipation NOS,Dis phosphorus metabol,Noninf gastroenterit NEC,Abn react-urinary cath
Admission Date:  [**2145-1-17**]              Discharge Date:   [**2145-1-25**]

Date of Birth:  [**2070-3-24**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
abdominal pain, acute renal failure, hypotension

Major Surgical or Invasive Procedure:
left subclavian central line
Upper endoscopy
Transfusion of packed red blood cells


History of Present Illness:
Ms. [**Known lastname 4886**] is a 74 year old woman with a history of CHF, chronic
renal insufficiency, peptic ulcer disease, CAD, HTN, who is
admitted to the MICU for management of acute renal failure,
abdominal pain, and hypotension. She was brought in to the
[**Hospital6 10353**] ED yesterday after reportedly having
several days of poor PO intake and abdominal pain at her
[**Hospital3 **] facility, per her daughter. The patient gives a
vague history of recent URI symptoms, and she reports a
mechanical fall yesterday, without any head trauma or loss of
consciousness.
.
At the [**Hospital3 **] ED, she was noted to be in
acute-on-chronic renal failure with a creatinine of 4.9 and a
serum HCO3 of 6. She had a SBP in the mid-80s and was reportedly
hypothermic to 95.8, with a leukocytosis to [**Numeric Identifier 2686**]. An ABG showed
a metabolic acidosis (7.22/22/175 on 2L n.c.). She was noted to
vomit 200cc of "blood-tinged mucous". She underwent an abdominal
CT with PO (no IV) contrastwhich showed no acute process. She
was given a dose of metronidazole and moxifloxacin for empiric
antibiotics. She was also given a dose of IV ondansetron, a
1000cc NS bolus, and 150 mEq of NaHCO3. A left-sided subclavian
central line was placed and she was transferred to [**Hospital1 18**].
.
Upon arrival to the [**Hospital1 18**] ED, she was afebrile with a
temperature of 98.2, BP 91/59, HR 84. She was given 1000cc NS
bolus and 1000cc D5W with 150 mEq HCO3. She reportedly had a
decrease in her BP to 56/44 which improved to 102/58 with a
250cc NS bolus and low dose of norepinephrine. She was also
given 10 mg of IV dexamethasone for unclear reasons. She had a
CT which showed no acute process and an abdominal ultrasound
which showed a mildly dilated (1.1cm) CBD; no gallbladder was
identified. Per the [**Hospital1 18**] ED resident, she was noted on two
separate rectal examinations to have black tarry stool which was
Guaiac negative.
.
Upon arrival to the MICU, she had a dry black stool which was
Guaiac positive. Her norepinephrine was weaned off upon arrival
to the MICU.
.
Of note, she had a similar presentation to [**Hospital 882**] Hospital in
[**9-/2144**] when she presented with acute-on-chronic renal failure,
decreased PO intake, and left-sided abdominal pain. An EGD on
that admission showed a nonbleeding gastric ulcer, and her ppi
was changed from pantoprazole to omeprazole and increased [**Hospital1 **].
She also had a question of antral thickening on a CT scan, and
antral biopsies were taken, the results of which are unavailable
to us at the time of this note.


Past Medical History:
Past Medical History:
- congestive heart failure (by report, LVEF 50% om [**4-/2144**])
- CAD with ?MI
- peptic ulcer disease with ? bleeding ulcer in distant past;
EGD in [**11/2143**] showed nonbleeding gsatritis; EGD in [**9-/2144**]
showed nonbleeding erythematous gastritis and nonbleeding
gastric ulcer
- short-term memory loss
- ?CVA vs TIA
- chronic renal insufficiency (baseline creatinine 1.6) with
multiple recent episodes of acute exacerbations
- HTN
- hx C2 fracture with hardware in place
- "moderate" right-sided RAS
- s/p appendectomy
- s/p cholecystectomy
- s/p partial colectomy for diverticulitis
- osteoporosis
- hyperlipidemia
- COPD
.

Social History:
Social History:
Quit smoking >15 yrs ago. No alcohol or drugs. Lives in River
Bay Club [**Hospital3 **] facility.


Family History:
Family History:
Per daughter, the patient's father died at an early age from an
MI.


Physical Exam:
T 97.8 BP 121/58 HR 93 RR 23 Sat 100% on 2L n.c.
CVP 4cm
General: uncomfortable, but in no acute distress
HEENT: no scleral icterus, MM moderately dry
Neck: JVP 6cm, no thyromegaly
Chest: clear to auscultation throughout, no w/r/r
CV: regular rate/rhythm, normal S1S2, no m/r/g
Abdomen: soft, mild voluntary guarding esp. in LLQ; tenderness
to moderate palpation mostly in LLQ; no rebound
Extremities: no edema, 2+ PT pulses
Skin: no rashes
Neuro: alert, oriented to self, "[**2142-1-3**]" and "River Bay
Club".


Pertinent Results:
From [**Hospital3 **] Ctr:
ABG (9:45pm)
7.22/22/175 on 2L n.c.
.
Labs on admission:
[**2145-1-17**] 12:30AM BLOOD WBC-16.2* RBC-3.56* Hgb-11.1* Hct-32.5*
MCV-91 MCH-31.3 MCHC-34.3 RDW-14.1 Plt Ct-253
[**2145-1-17**] 12:30AM BLOOD Neuts-95.9* Bands-0 Lymphs-2.8*
Monos-1.2* Eos-0.1 Baso-0
[**2145-1-17**] 12:30AM BLOOD PT-13.2 PTT-26.0 INR(PT)-1.1
[**2145-1-18**] 06:09AM BLOOD Ret Aut-0.7*
[**2145-1-17**] 12:30AM BLOOD Glucose-196* UreaN-119* Creat-4.0* Na-137
K-4.7 Cl-110* HCO3-13* AnGap-19
[**2145-1-17**] 12:30AM BLOOD ALT-14 AST-25 CK(CPK)-164* AlkPhos-143*
Amylase-68 TotBili-0.2
[**2145-1-17**] 12:30AM BLOOD Lipase-80*
[**2145-1-17**] 12:30AM BLOOD CK-MB-8 cTropnT-0.01
[**2145-1-17**] 12:30AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.3
[**2145-1-18**] 06:09AM BLOOD calTIBC-148* Ferritn-397* TRF-114*
[**2145-1-19**] 06:05AM BLOOD Osmolal-307
[**2145-1-21**] 06:15AM BLOOD PEP-NO SPECIFI
[**2145-1-17**] 06:02AM BLOOD Type-ART pO2-123* pCO2-22* pH-7.36
calTCO2-13* Base XS--10
[**2145-1-17**] 12:31AM BLOOD Lactate-1.3
[**2145-1-17**] 06:02AM BLOOD freeCa-1.28
.
Labs on discharge:
[**2145-1-24**] 11:00AM BLOOD WBC-9.5 RBC-2.75* Hgb-9.1* Hct-26.0*
MCV-95 MCH-33.2* MCHC-35.1* RDW-14.5 Plt Ct-266
[**2145-1-25**] 06:04AM BLOOD Glucose-83 UreaN-8 Creat-1.2* Na-140
K-4.0 Cl-108 HCO3-22 AnGap-14
[**2145-1-25**] 06:04AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.5*
.
Microbiology:
[**2145-1-17**] blood culture - negative
[**2145-1-17**] Urine culture - negative
[**2145-1-17**] c diff - negative
[**2145-1-18**] blood culture - negative
[**2145-1-19**] h pyloi - negative
.
Other Studies:
Abd CT ([**2145-1-16**]- from [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) **]):
Appendix is not identified. Atrophic kidneys. Gallbladder is not
visualized. Atherosclerotic aorta. Old healed deformity of left
anterior and superior pubic rami.
.
Head CT ([**2145-1-17**]):
Examination is mildly limited by motion artifact. There is no
hemorrhage, mass effect, shift of the normally midline
structures, or vascular territorial infarct. Mild
periventricular white matter hypodensity is consistent with
chronic microvascular ischemia. There is no hydrocephalus. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. Orthopedic
hardware is seen within the dens. The visualized paranasal
sinuses and mastoid air cells are well aerated.
.
Abd US ([**2145-1-17**]):
The liver is unremarkable without focal or textural abnormality.
The portal vein is patent with appropriate hepatopedal flow.
There is no intrahepatic biliary dilatation. The common bile
duct is dilated measuring 1.1 cm. The gallbladder is not
definitively identified. The structure interrogated on multiple
views located near the gallbladder fossa most likely represents
bowel/stomach with gallstone-filled gallbladder.
.
ECG ([**2145-1-17**]):
NSR at 93 bpm. Normal axis, normal intervals. Poor baseline.
Biphasic T waves noted in I, aVL, II, aVF, and V5-V6.
.
CT Abd/Pelvis ([**2145-1-17**]):
IMPRESSION:
1. Mild colonic wall thickening extending from the splenic
flexure to the distal sigmoid, suggestive of infectious or less
likely, ischemic etiology. No perforation or fluid collection.
No abscess. Following recuperation of renal function, a CT
angiogram of the mesenteric vessels could be performed if
clinically indicated.
2. Likely subacute fracture of the left symphysis pubis and
rami. Correlation with prior outside imaging studies may be of
assistance.
3. LLL 6 mm pulmonary nodule. 6 month fllow-up exam advised.
.
CT Abd/Pelvis, repeat ([**2145-1-24**]):
IMPRESSION:
1. Resolution of mild colonic wall thickening seen on prior
study.
2. No additional evidence to explain patient's symptoms.


Brief Hospital Course:
74 year old woman with abdominal pain, Guaiac-positive black
stool, and acute-on-chronic renal failure.
.
1) Guaiac-positive black stool: Patient was initially admitted
to the ICU for management.  GI consulted and recommended
endoscopy, [**Hospital1 **] PPI, and C. Diff studies.  Endoscopy was
performed demonstrating a non-bleeding duodenal ulcer w/o
exposed vessels, and gastritis.  Continued on [**Hospital1 **] PPI with
stable Hct thereafter.  H. Pylori negative.
.
2) Abdominal Pain: Certainly could be due to PUD, though the
location of her pain is not classic for PUD. Abdominal CT scan
report from OSH unrevealing (status post cholecystectomy and
appendectomy). Pancreatic/hepatic labs within normal limits.
Abdominal CT without contrast here with mild distal colonic
thickening - unclear if infectious vs. inflammatory vs. ischemic
(less likely). GI consulted for guiac + stool.  Recommended C.
Diff studies (negative x1).  On transfer to the floor abdominal
pain remained mild, but persisted over several days.  Patient
had unimpressive abdominal exam, but with definite tenderness to
palpation in the LLQ and RLQ.  Repeat CT of the abdomen was
performed demonstrating clearance of the colonic thickening.
Her abdominal pain was ultimately attributed to constipation, as
she had not had a bowel movement in 7 days.  Bowel regimen was
uptitrated resulting in multiple bowel movements (and some
diarrhea) with some resolution of abdominal discomfot.
.
3) Acute renal failure: Likely due to hypovolemia/prerenal
azotemia given CVP of 4 on initial presentation to ICU, poor PO
intake, known renal artery stenosis.  Creatinine improved with
IV hydration and reached nadir of 1.1 - 1.2, patient's baseline.

.
4) Metabolic Acidosis/hypophosphatemia:  Patient was noted to
have metabolic acidosis in setting of renal failure. Renal
consulted.  They felt this was likely due to the patients renal
failure, and did not recomend chronic bicarbonate repletion.
Unable to clearly diagnose type I or type II RTA in setting of
acute renal failure.  Upon resolution of renal failure, acidemia
resolved.
.
5) Hyphophatemia:  Floor course complicated by severe
hypophosphatemia requiring aggressive repletion and thought due
to chronic poor PO intake and refeeding syndrome.  Resolved by
time of discharge.
.
6) Tachypnea: Patient notably tachypneic throughout most of her
ICU course, but without SOB, cough or other pulmonary
complaints.  All pulmonary work up was negative and this was
felt due to her metabolic acidosis with respiratory
compensation.  Resolved with resolution of metabolic acidosis.
.
7) Hypotension: Patients SBP improved with IV hydration.
Cultures were negative.  Was orthostatic on transfer to the
floor, but resolved with further hydration.  Felt all to be due
to dehydration/GI bleed.  Completely resolved at time of
discharge.
.
8) Leukocytosis: Patient with prominent leukocytosis on
admission.  C. Diff negative, cultures NGTD.  Steadily improved
over hospitalization and thought to be due to low level GI bleed
and UTI.  Urine culture was negative, but treated for UTI as
below.
.
9) Urinay tract infection:  During work up for leukocytosis
above, urinalysis was sent, which was borderline positive.  She
was treated with 7 day course of levofloxacin, as this was felt
to be a foley catheter related UTI.  Urine culture returned
negative.
.
10) Pulmonary Nodule: Patient had right lower lobe lung nodule
noted incidentally on abdominal CT scan.  This will require
follow up with repeat chest CT in 6 months


Medications on Admission:
Home Medications:
ferrous sulfate 325 mg daily
lisinopril 10 mg daily
aspirin 81 mg daily
multivitamin 1 tab daily
calcium carbonate/vitamin D 1 tab daily
docusate 100 mg [**Hospital1 **]
ipratropium/albuterol MDI 2 puffs [**Hospital1 **]
mirtazapine 7.5 mg qhs
atorvastatin 80 mg daily
acetaminophen 500 mg tid
omeprazole 20 mg daily


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): [**Month (only) 116**] take an extra 2 tablets per day as needed for
constipation.
Disp:*60 Tablet(s)* Refills:*2*
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
12. Multivitamins     Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
13. CALCIUM 500+D 500 (1,250)-400 mg-unit Tablet, Chewable Sig:
One (1) Tablet, Chewable PO twice a day.
14. Mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO once a day.



Discharge Disposition:
Home With Service

Facility:
Elder Services Plan

Discharge Diagnosis:
Primary:
Acute renal failure
Hypotension-Dehydration
Mixed metabolic acidosis
Left sided colitis NOS
Hypophosphatemia
Duodenal ulcer
Left lower lobe 6 mm pulmonary nodule
Constipation

Secondary:
Osteoporosis
Subacute fracture - left symphysis pubis and rami
CKD Stage III
COPD
C2 fracture s/p instrumentation
Hyperlipidemia
CAD NOS
Diastolic heart failure NOS
Depression
s/p appendectomy
s/p cholecystectomy
s/p partial colectomy for diverticulitis


Discharge Condition:
Good.  Patient ambulating, symptoms improved.


Discharge Instructions:
You were admitted to the hospital for evaluation of a mechanical
fall, and treatment of low blood pressure, acute renal failure
and abdominal pain.  During your hospital course, your low blood
pressure and acute renal failure resolved with fluid hydration.
You were also evaluated for a low blood level with an endoscopy
that demonstrated an ulcer, and inflammation of your stomach.
You were started on pantoprazole 40mg twice daily.  Your
abdominal pain was evaluated with a CT scan, repeat was normal.
However it did incidentally note a small left sided pulmonary
nodule which will need to be followed up in 6 months time.
Otherwise your abdominal pain was treated with  giving you
medications to help you have a bowel movement.
.
Please take all medications as directed.
.
Please follow up with all appointments as directed.
.
Please contact physician if develop worsening abdominal pain,
diarrhea, blood in stool, weakness/dizziness, black colored
stools, any other questions or concerns.

Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 724**] ([**Telephone/Fax (1) 76456**] in [**2-4**] weeks time.
.
Of note, you had a left lower lobe lung nodule that was 6mm in
size that was noted on a CT scan during your hospital course.
You will need a 6 month follow-up CT scan that should be
scheduled by your primary care physician.
.
Please have your primary care physician set you up with follow
up with gastroenterology, for follow up of your duodenal ulcer.
{'Acute kidney failure, unspecified,Chronic systolic heart failure,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Infection and inflammatory reaction due to indwelling urinary catheter,Chronic airway obstruction, not elsewhere classified,Hypotension, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Constipation, unspecified,Disorders of phosphorus metabolism,Other and unspecified noninfectious gastroenteritis and colitis,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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, acute renal failure, hypotension

PRESENT ILLNESS: Ms. [**Known lastname 4886**] is a 74 year old woman with a history of CHF, chronic
renal insufficiency, peptic ulcer disease, CAD, HTN, who is
admitted to the MICU for management of acute renal failure,
abdominal pain, and hypotension. She was brought in to the
[**Hospital6 10353**] ED yesterday after reportedly having
several days of poor PO intake and abdominal pain at her
[**Hospital3 **] facility, per her daughter. The patient gives a
vague history of recent URI symptoms, and she reports a
mechanical fall yesterday, without any head trauma or loss of
consciousness.
.
At the [**Hospital3 **] ED, she was noted to be in
acute-on-chronic renal failure with a creatinine of 4.9 and a
serum HCO3 of 6. She had a SBP in the mid-80s and was reportedly
hypothermic to 95.8, with a leukocytosis to [**Numeric Identifier 2686**]. An ABG showed
a metabolic acidosis (7.22/22/175 on 2L n.c.). She was noted to
vomit 200cc of "blood-tinged mucous". She underwent an abdominal
CT with PO (no IV) contrastwhich showed no acute process. She
was given a dose of metronidazole and moxifloxacin for empiric
antibiotics. She was also given a dose of IV ondansetron, a
1000cc NS bolus, and 150 mEq of NaHCO3. A left-sided subclavian
central line was placed and she was transferred to [**Hospital1 18**].
.
Upon arrival to the [**Hospital1 18**] ED, she was afebrile with a
temperature of 98.2, BP 91/59, HR 84. She was given 1000cc NS
bolus and 1000cc D5W with 150 mEq HCO3. She reportedly had a
decrease in her BP to 56/44 which improved to 102/58 with a
250cc NS bolus and low dose of norepinephrine. She was also
given 10 mg of IV dexamethasone for unclear reasons. She had a
CT which showed no acute process and an abdominal ultrasound
which showed a mildly dilated (1.1cm) CBD; no gallbladder was
identified. Per the [**Hospital1 18**] ED resident, she was noted on two
separate rectal examinations to have black tarry stool which was
Guaiac negative.
.
Upon arrival to the MICU, she had a dry black stool which was
Guaiac positive. Her norepinephrine was weaned off upon arrival
to the MICU.
.
Of note, she had a similar presentation to [**Hospital 882**] Hospital in
[**9-/2144**] when she presented with acute-on-chronic renal failure,
decreased PO intake, and left-sided abdominal pain. An EGD on
that admission showed a nonbleeding gastric ulcer, and her ppi
was changed from pantoprazole to omeprazole and increased [**Hospital1 **].
She also had a question of antral thickening on a CT scan, and
antral biopsies were taken, the results of which are unavailable
to us at the time of this note.

MEDICAL HISTORY: Past Medical History:
- congestive heart failure (by report, LVEF 50% om [**4-/2144**])
- CAD with ?MI
- peptic ulcer disease with ? bleeding ulcer in distant past;
EGD in [**11/2143**] showed nonbleeding gsatritis; EGD in [**9-/2144**]
showed nonbleeding erythematous gastritis and nonbleeding
gastric ulcer
- short-term memory loss
- ?CVA vs TIA
- chronic renal insufficiency (baseline creatinine 1.6) with
multiple recent episodes of acute exacerbations
- HTN
- hx C2 fracture with hardware in place
- "moderate" right-sided RAS
- s/p appendectomy
- s/p cholecystectomy
- s/p partial colectomy for diverticulitis
- osteoporosis
- hyperlipidemia
- COPD
.

MEDICATION ON ADMISSION: Home Medications:
ferrous sulfate 325 mg daily
lisinopril 10 mg daily
aspirin 81 mg daily
multivitamin 1 tab daily
calcium carbonate/vitamin D 1 tab daily
docusate 100 mg [**Hospital1 **]
ipratropium/albuterol MDI 2 puffs [**Hospital1 **]
mirtazapine 7.5 mg qhs
atorvastatin 80 mg daily
acetaminophen 500 mg tid
omeprazole 20 mg daily

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: T 97.8 BP 121/58 HR 93 RR 23 Sat 100% on 2L n.c.
CVP 4cm
General: uncomfortable, but in no acute distress
HEENT: no scleral icterus, MM moderately dry
Neck: JVP 6cm, no thyromegaly
Chest: clear to auscultation throughout, no w/r/r
CV: regular rate/rhythm, normal S1S2, no m/r/g
Abdomen: soft, mild voluntary guarding esp. in LLQ; tenderness
to moderate palpation mostly in LLQ; no rebound
Extremities: no edema, 2+ PT pulses
Skin: no rashes
Neuro: alert, oriented to self, "[**2142-1-3**]" and "River Bay
Club".

FAMILY HISTORY: Family History:
Per daughter, the patient's father died at an early age from an
MI.

SOCIAL HISTORY: Social History:
Quit smoking >15 yrs ago. No alcohol or drugs. Lives in River
Bay Club [**Hospital3 **] facility. 

### Response:
{'Acute kidney failure, unspecified,Chronic systolic heart failure,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Infection and inflammatory reaction due to indwelling urinary catheter,Chronic airway obstruction, not elsewhere classified,Hypotension, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Constipation, unspecified,Disorders of phosphorus metabolism,Other and unspecified noninfectious gastroenteritis and colitis,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
