CHIEF COMPLAINT: Abdominal pain

PRESENT ILLNESS: Mr. [**Known lastname 78764**] is a [**Age over 90 **]M with history of atrial fibrillation c/b
iliac thrombus and chronic GIB who was admitted with right-sided
abdominal pain, swelling, and dyspnea.  On admission, he was
found to have Hct of 16 and a rectus sheath hematoma. He had
been on levonox 60BID following recent admission for left iliac
thrombus. He was initially admitted to the vascular service and
required transfusion of 4 units PRBCs and 2 units FFP. He had an
angiography showing no evidence of active bleeding.

MEDICAL HISTORY: CHF systolic
--EF 40-45% [**2199-4-26**] mild global HK, 2+MR, 3+TR, RA moderately
dilated, mild LVH, mod-severe pulm HTN
--repeat echo [**2199-5-2**] with EF 60%
Hypertension
Hypercholesterolemia
Atrial fibrillation, on warfarin
Iliac thrombus s/p embolectomy
Chronic GIB
-negative colonoscopy [**2199-5-6**]
-negative EGD [**2199-4-26**]
-negative enteroscopy [**2199-4-30**]
-had capsule study [**5-7**] delayed transit from esophagus, capsule
did not reach esophagus
Duodenal ulcer
CAD
Colon CA s/p resection [**2171**]'s
Pleural effusion
Back Surgery

MEDICATION ON ADMISSION: Enoxaparin 60 mg SC bid, lisinopril 5, omeprazole 20,
simvastatin 40, Lopressor 25 [**Hospital1 **], aspirin 81, Lasix 20 daily,
Colace, oxycodone, Tylenol

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 96.8 P 81 BP 128/54 RR 19 O2 97% on RA
General Pale elderly man in no acute distress
HEENT sclera white, conjunctiva pink, MMM
Neck +JVD
Pulm Lungs with few wheezes, no rales
CV Regular S1 S2 II/VI HSM LLSB increased with inspiration
Abd Soft L side with hematoma palpable R side of abdomen, tender
on right, no rigidity guarding or rebound
Extrem LE with 2+ bilateral edema, feet cool but 1+ palpable DP
and PT pulses
Foley in place

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Retired [**Location (un) 86**] policeman.  Daughter lives upstairs.  Non-smoker.
 Rare EtOH (1-2 drinks/week).  Wife currently lives at [**Hospital 100**]
Rehab.
Other disorders of muscle, ligament, and fascia,Acute on chronic diastolic heart failure,Embolism and thrombosis of iliac artery,Acute posthemorrhagic anemia,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary tract infection, site not specified,Long-term (current) use of anticoagulants,Anticoagulants causing adverse effects in therapeutic use,Atrial fibrillation,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Epistaxis,Unspecified essential hypertension,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Personal history of malignant neoplasm of large intestine
Muscle/ligament dis NEC,Ac on chr diast hrt fail,Iliac artery embolism,Ac posthemorrhag anemia,React-indwell urin cath,Urin tract infection NOS,Long-term use anticoagul,Adv eff anticoagulants,Atrial fibrillation,Abn react-urinary cath,Epistaxis,Hypertension NOS,Pure hypercholesterolem,Crnry athrscl natve vssl,Hx of colonic malignancy
Admission Date:  [**2199-5-20**]              Discharge Date:   [**2199-6-11**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Abdominal pain

Major Surgical or Invasive Procedure:
Angiography


History of Present Illness:
Mr. [**Known lastname 78764**] is a [**Age over 90 **]M with history of atrial fibrillation c/b
iliac thrombus and chronic GIB who was admitted with right-sided
abdominal pain, swelling, and dyspnea.  On admission, he was
found to have Hct of 16 and a rectus sheath hematoma. He had
been on levonox 60BID following recent admission for left iliac
thrombus. He was initially admitted to the vascular service and
required transfusion of 4 units PRBCs and 2 units FFP. He had an
angiography showing no evidence of active bleeding.

His hospital course was complicated by a troponin leak to 0.14
(in the setting of Cr elevation to 1.5). Cardiology consult was
called and recommended medical management.  Upon transfer to the
medicine service, he had no complaints, denying CP, SOB,
abdominal pain, lightheadedness/dizziness, recent bleeding.

Past Medical History:
CHF systolic
--EF 40-45% [**2199-4-26**] mild global HK, 2+MR, 3+TR, RA moderately
dilated, mild LVH, mod-severe pulm HTN
--repeat echo [**2199-5-2**] with EF 60%
Hypertension
Hypercholesterolemia
Atrial fibrillation, on warfarin
Iliac thrombus s/p embolectomy
Chronic GIB
-negative colonoscopy [**2199-5-6**]
-negative EGD [**2199-4-26**]
-negative enteroscopy [**2199-4-30**]
-had capsule study [**5-7**] delayed transit from esophagus, capsule
did not reach esophagus
Duodenal ulcer
CAD
Colon CA s/p resection [**2171**]'s
Pleural effusion
Back Surgery

Social History:
Retired [**Location (un) 86**] policeman.  Daughter lives upstairs.  Non-smoker.
 Rare EtOH (1-2 drinks/week).  Wife currently lives at [**Hospital 100**]
Rehab.


Family History:
Non-contributory

Physical Exam:
T 96.8 P 81 BP 128/54 RR 19 O2 97% on RA
General Pale elderly man in no acute distress
HEENT sclera white, conjunctiva pink, MMM
Neck +JVD
Pulm Lungs with few wheezes, no rales
CV Regular S1 S2 II/VI HSM LLSB increased with inspiration
Abd Soft L side with hematoma palpable R side of abdomen, tender
on right, no rigidity guarding or rebound
Extrem LE with 2+ bilateral edema, feet cool but 1+ palpable DP
and PT pulses
Foley in place

Pertinent Results:
ADMISSION LABS:
[**2199-5-20**] 12:05PM   WBC-11.6*# RBC-2.76* HGB-8.3* HCT-25.9*
MCV-94 MCH-30.3 MCHC-32.2 RDW-15.4
[**2199-5-20**] 12:05PM   PLT COUNT-342
[**2199-5-20**] 12:05PM   NEUTS-86.3* LYMPHS-7.4* MONOS-5.6 EOS-0.2
BASOS-0.4
[**2199-5-20**] 12:05PM   PT-13.8* PTT-33.1 INR(PT)-1.2*
[**2199-5-20**] 12:05PM   GLUCOSE-160* UREA N-25* CREAT-1.2 SODIUM-139
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-21* ANION GAP-18
[**2199-5-20**] 12:47PM   LACTATE-2.8*
[**2199-5-20**] 04:20PM   HGB-5.3*# HCT-16.3*#
[**2199-5-20**] 10:57PM   FIBRINOGE-459*

LABS AT TIME OF DISCHARGE:
[**2199-6-10**] 06:55AM BLOOD WBC-6.1# RBC-4.17* Hgb-12.8* Hct-37.9*
MCV-91 MCH-30.6 MCHC-33.6 RDW-15.4 Plt Ct-346
[**2199-6-10**] 06:55AM BLOOD Glucose-95 UreaN-16 Creat-1.2 Na-142
K-3.5 Cl-103 HCO3-27 AnGap-16
[**2199-6-10**] 06:55AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.6

[**2199-5-20**] EKG:
Atrial fibrillation. Ventricular premature beats. Consider prior
anteroseptal myocardial infarction. Baseline artifact. Low QRS
voltage in the limb leads. Compared to the previous tracing of
[**2199-5-2**] the ventricular premature beats and artifact are new.

[**2199-5-20**] CXR IMPRESSION: Layering right pleural effusion.

[**2199-5-20**] CT ABD/PELVIS:
1. Large right rectus sheath hematoma as described with
posterior extension into the extraperitoneal and intraperitoneal
portions of the anterior pelvis. CT with contrast may be
performed to evaluate for active extravasation.
2. Large right pleural effusion with right lower lobe
compressive atelectasis.
3. Small amount of abdominal ascites.
4. Pancreatic calcifications, raising the possibility of chronic
pancreatitis.
5. Right renal hypodensities, likely represent cysts.

[**2199-5-22**] LE ULTRASOUNDS:
No evidence of DVT in either lower extremity.

[**2199-5-28**] TRANSTHORACIC ECHOCARDIOGRAM:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2199-5-2**],
left ventricular function appears similar.

Brief Hospital Course:
1. Rectus sheath hematoma
Mr. [**Name14 (STitle) 78765**] presented with abdominal pain and swelling and was
found to have a large right sided rectus sheath hematoma and
significant drop in his hematocrit. He underwent angiography
that showed no active bleeding. The vascular surgery service
evaluated the patient and felt that no operative intervention
was required and conservative management was most appropriate.
His abdominal discomfort and hematoma size were improved at time
of discharge.

2. Atrial fibrillation
Mr. [**Name14 (STitle) 78765**] on metoprolol 25 mg [**Hospital1 **] on admission for rate
control; it was titrated to 37.5 mg [**Hospital1 **] with HR in the 50 -
60's.  He was changed to metoprolol XL 50 mg QD prior to
discharge with stable HR and BP.  The risks vs. benefits were
discussed at length with the patient, and he decided to restart
warfarin given the stroke risk.  A lower INR goal of 2.0 - 2.5
was chosen given his history of bleeding, and he was discharged
on warfarin 2 mg QHS.

3. Congestive heart failure, systolic, acute on chronic
Mr. [**Name14 (STitle) 78765**] was total body volume overloaded in the setting of
receiving blood products for his anemia. An echocardiogram was
obtained which showed a preserved ejection fraction with
moderate TR and MR as seen in prior studies. He was diuresed
with lasix with good effect. He was discharged on metoprolol and
lisinopril, as well as standing lasix 40 mg PO QD.  He was
euvolemic upon discharge.

4. Coronary artery disease with demand ischemia
His troponin was mildly elevated to peak of 0.14, likely demand
ischemia due to anemia and poor rate control early in admission.
He will continue metoprolol, simvastatin, and lisinopril.  He
was on aspirin prior to admission for a history of NSTEMI,
although this was held in house while the patient was bleeding
into his rectus shealth.  Aspirin 81 mg should be restarted once
INR is stabilized and the rectus sheath hematoma is stable at
the therapeutic INR.

5. Hypertension
Mr. [**Name14 (STitle) 78765**] was started on lisinopril, metoprolol, and
amlodipine for blood pressure control with good effect; BP was
in the 110-120's/50-60's upon discharge.

INSTRUCTIONS GIVEN TO REHAB FACILITY FOR FOLLOW-UP:
(1) Mr. [**Known lastname 78764**] should have his INR measured for a goal of 2.0 -
2.5 (lower goal range given patient's history of bleeding).
Please measure on [**2199-6-12**] and adjust warfarin dose appropriately
(he was discharged on warfarin). Please check INR every two days
until stable.
(2) Please weigh patient daily and adjust lasix as appropriate
to keep weight stable.
(3) The patient was on aspirin prior to this hospital admission.
Please restart aspirin 81 mg QD by the end of the week once INR
is stable in range 2.0-2.5 and there is no evidence of worsening
of the rectus sheath hematoma with anticoagulation.

Medications on Admission:
Enoxaparin 60 mg SC bid, lisinopril 5, omeprazole 20,
simvastatin 40, Lopressor 25 [**Hospital1 **], aspirin 81, Lasix 20 daily,
Colace, oxycodone, Tylenol

Discharge Medications:
1. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed: to groin rash.
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-9**] Sprays Nasal
TID (3 times a day).
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Please adjust as needed for INR 2.0 - 2.5.
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day:
PLEASE DO NOT START UNTIL INR IS STABLE AND NO EVIDENCE OF
ONGOING BLEEDING IN RECTUS SHEATH.


Discharge Disposition:
Extended Care

Facility:
[**Doctor First Name 533**] Centre for Extended Care

Discharge Diagnosis:
Primary
1. Rectus sheath hematoma
2. Coronary artery disease with demand ischemia
3. Atrial fibrillation
4. Hypertension
5. Congestive heart failure, acute on chronic, diastolic


Discharge Condition:
Fair, hemodynamically stable with no gross bleeding, pain under
control.


Discharge Instructions:
You came into the hospital because of bleeding in your abdominal
muscles (rectus sheath hematoma). This was likely due to the
blood thinners (lovenox) you were taking. You were evaluated by
the vascular surgeons who felt that this should be followed
closely but you did not need a surgical procedure.

Call your doctors and [**Name5 (PTitle) **] medical attention if you develop:
bloody or black tarry stools, nosebleeds or other bleeding,
chest discomfort, shortness of breath, weakness, numbness,
confusion, slurred speech, or any other symptoms that worry you
or your family.

Followup Instructions:
Please follow up with Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Hospital3 **] [**7-25**] at 3pm. The office is on the
[**Hospital Ward Name 516**] of [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] on the [**Location (un) **].  The
phone number is [**Telephone/Fax (1) 250**].

Your coumadin levels will now be followed at the [**Hospital **] at [**Hospital1 **] Hospital.  They will call you to
set up your first appointment for checking your coumadin levels
after you leave [**Hospital 100**] Rehab.
{'Other disorders of muscle, ligament, and fascia,Acute on chronic diastolic heart failure,Embolism and thrombosis of iliac artery,Acute posthemorrhagic anemia,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary tract infection, site not specified,Long-term (current) use of anticoagulants,Anticoagulants causing adverse effects in therapeutic use,Atrial fibrillation,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Epistaxis,Unspecified essential hypertension,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Personal history of malignant neoplasm of large intestine'}


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: Mr. [**Known lastname 78764**] is a [**Age over 90 **]M with history of atrial fibrillation c/b
iliac thrombus and chronic GIB who was admitted with right-sided
abdominal pain, swelling, and dyspnea.  On admission, he was
found to have Hct of 16 and a rectus sheath hematoma. He had
been on levonox 60BID following recent admission for left iliac
thrombus. He was initially admitted to the vascular service and
required transfusion of 4 units PRBCs and 2 units FFP. He had an
angiography showing no evidence of active bleeding.

MEDICAL HISTORY: CHF systolic
--EF 40-45% [**2199-4-26**] mild global HK, 2+MR, 3+TR, RA moderately
dilated, mild LVH, mod-severe pulm HTN
--repeat echo [**2199-5-2**] with EF 60%
Hypertension
Hypercholesterolemia
Atrial fibrillation, on warfarin
Iliac thrombus s/p embolectomy
Chronic GIB
-negative colonoscopy [**2199-5-6**]
-negative EGD [**2199-4-26**]
-negative enteroscopy [**2199-4-30**]
-had capsule study [**5-7**] delayed transit from esophagus, capsule
did not reach esophagus
Duodenal ulcer
CAD
Colon CA s/p resection [**2171**]'s
Pleural effusion
Back Surgery

MEDICATION ON ADMISSION: Enoxaparin 60 mg SC bid, lisinopril 5, omeprazole 20,
simvastatin 40, Lopressor 25 [**Hospital1 **], aspirin 81, Lasix 20 daily,
Colace, oxycodone, Tylenol

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 96.8 P 81 BP 128/54 RR 19 O2 97% on RA
General Pale elderly man in no acute distress
HEENT sclera white, conjunctiva pink, MMM
Neck +JVD
Pulm Lungs with few wheezes, no rales
CV Regular S1 S2 II/VI HSM LLSB increased with inspiration
Abd Soft L side with hematoma palpable R side of abdomen, tender
on right, no rigidity guarding or rebound
Extrem LE with 2+ bilateral edema, feet cool but 1+ palpable DP
and PT pulses
Foley in place

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Retired [**Location (un) 86**] policeman.  Daughter lives upstairs.  Non-smoker.
 Rare EtOH (1-2 drinks/week).  Wife currently lives at [**Hospital 100**]
Rehab. 

### Response:
{'Other disorders of muscle, ligament, and fascia,Acute on chronic diastolic heart failure,Embolism and thrombosis of iliac artery,Acute posthemorrhagic anemia,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary tract infection, site not specified,Long-term (current) use of anticoagulants,Anticoagulants causing adverse effects in therapeutic use,Atrial fibrillation,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Epistaxis,Unspecified essential hypertension,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Personal history of malignant neoplasm of large intestine'}
