CHIEF COMPLAINT: Abdominal pain

PRESENT ILLNESS: This is a 65 year old woman with hisotry of Myasthenia [**Last Name (un) **]
who presents with progressive abdominal pain and possible MG
flare.
.
The pain started two weeks ago as diffuse pain which then moved
to the mid pelvis region. It was described as sharp and crampy,
worse when lying to her sides and after defecation. Denied
n/v/d/fever/chills/hematochez/melena. She has never had
abdominal surgery or hernias. She was recently admitted to ETS
service with abdominal pain. CT abdomen at the time was reported
as mild diverticulitis. Initally treated with cipro/flagyl and
then switched to cefpodoxime/flagyl. Called PCP today with
[**Name9 (PRE) 95371**] abd pain and told to come to ED.
.
In the ED initial vitals were: T:98 HR:100 BP:174/93 RR:40.
Looked in respiratory distress. NIF was -20 and VC 1.6. ABG:
7.42/48/87/32. She was thought to be having a myasthenia [**Last Name (un) 2902**]
flare. She was given Vanc/flagyl/zosyn for presumed
intra-abdominal infection leading to the MG flare. In CT scan
could not lay flat and she had to be intubated in ED. CT Torso
revealed no saddle embolus but poor scan so started heparin
empirically. Also with evidence of lll PNA (not on CT Abd a few
days ago). Also has worsening diverticulitis so surgery asked to
eval in ED. Neuro was consulted and said hold on tx for MG for
now given possible infection currently, Staffed with Dr [**Last Name (STitle) **].
[**Doctor Last Name 18530**]. recommended MICU admit, check NIFs & VCs q6h - neuro
will follow as consult. Cdiff was sent as thought infection
might have precipitated this flare. NIF was -20. Received
Vanc/Zosyn/Flagyl. Intubated using etomidate and recuronium and
versed/fentanyl. Started on hep gtt. Also got KCl for K of 2.9.
Surgery was called and said no changes in antibiotics and NPO.
Prior to transfer to the floor CT Chest read as ETT too low.
Pulled back by ED and repeat CXR ok per ED report on arrival to
the floor patient was intubated and sedated.

MEDICAL HISTORY: 1. Myasthenia [**Last Name (un) **]-first diagnosed in [**2163**], followed by Dr.
[**Last Name (STitle) **] at [**Hospital1 18**]
2. multiple spinal compression fractures s/p steroid use for MG

MEDICATION ON ADMISSION: Hydrochlorothiazide 25 mg PO QAM, Lidocaine 5% patch apply dialy
for 12 hours, Metoprolol 25 mg PO BID,
Percocet 10-325 mg PO QID prn pain, Pyridostigmine Bromide 60 mg

ALLERGIES: Prempro / Fiorinal / Erythromycin Base / Aleve

PHYSICAL EXAM: Vitals: T: 98.1 HR 77 BP 106/54 ABG: 7.42/45/266/30 on AC at
450X16, 5, 99%FIO2
General: Sedated, intubated.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, dry MM
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: TTP pelvic area, soft, ND, normoactive bowel sounds, no
masses or organomegaly noted. No [**Doctor Last Name 515**] sign, no rebound
Extremities: No edema, 2+ radial, DP pulses b/l
Skin: no rashes or lesions noted.

FAMILY HISTORY: Mother: [**Name (NI) 77552**], first age 55, also CHF, deceased age 77; father
with rheumatic heart disease, deceased age 83 CVA; sister died
at age 5 of insulin dependent diabetes mellitus w/PNA.
.

SOCIAL HISTORY: Patient is single, lives alone. She is currently on disability.
She used to work as a histology tech a [**Hospital1 18**]. She denies
tobacco, illicit drugs, occ EToH but none since starting
narcotic medications.
Diverticulosis of colon (without mention of hemorrhage),Acute respiratory failure,Pneumonia, organism unspecified,Alkalosis,Myasthenia gravis without (acute) exacerbation,Benign essential hypertension,Other and unspecified hyperlipidemia,Anemia, unspecified,Osteoporosis, unspecified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Personal history of pathologic fracture
Dvrtclo colon w/o hmrhg,Acute respiratry failure,Pneumonia, organism NOS,Alkalosis,Mysthna grvs w/o ac exac,Benign hypertension,Hyperlipidemia NEC/NOS,Anemia NOS,Osteoporosis NOS,Migrne unsp wo ntrc mgrn,Hx pathological fracture
Admission Date:  [**2176-5-2**]              Discharge Date:   [**2176-5-11**]

Date of Birth:  [**2110-10-7**]             Sex:   F

Service: MEDICINE

Allergies:
Prempro / Fiorinal / Erythromycin Base / Aleve

Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
Abdominal pain

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is a 65 year old woman with hisotry of Myasthenia [**Last Name (un) **]
who presents with progressive abdominal pain and possible MG
flare.
.
The pain started two weeks ago as diffuse pain which then moved
to the mid pelvis region. It was described as sharp and crampy,
worse when lying to her sides and after defecation. Denied
n/v/d/fever/chills/hematochez/melena. She has never had
abdominal surgery or hernias. She was recently admitted to ETS
service with abdominal pain. CT abdomen at the time was reported
as mild diverticulitis. Initally treated with cipro/flagyl and
then switched to cefpodoxime/flagyl. Called PCP today with
[**Name9 (PRE) 95371**] abd pain and told to come to ED.
.
In the ED initial vitals were: T:98 HR:100 BP:174/93 RR:40.
Looked in respiratory distress. NIF was -20 and VC 1.6. ABG:
7.42/48/87/32. She was thought to be having a myasthenia [**Last Name (un) 2902**]
flare. She was given Vanc/flagyl/zosyn for presumed
intra-abdominal infection leading to the MG flare. In CT scan
could not lay flat and she had to be intubated in ED. CT Torso
revealed no saddle embolus but poor scan so started heparin
empirically. Also with evidence of lll PNA (not on CT Abd a few
days ago). Also has worsening diverticulitis so surgery asked to
eval in ED. Neuro was consulted and said hold on tx for MG for
now given possible infection currently, Staffed with Dr [**Last Name (STitle) **].
[**Doctor Last Name 18530**]. recommended MICU admit, check NIFs & VCs q6h - neuro
will follow as consult. Cdiff was sent as thought infection
might have precipitated this flare. NIF was -20. Received
Vanc/Zosyn/Flagyl. Intubated using etomidate and recuronium and
versed/fentanyl. Started on hep gtt. Also got KCl for K of 2.9.
Surgery was called and said no changes in antibiotics and NPO.
Prior to transfer to the floor CT Chest read as ETT too low.
Pulled back by ED and repeat CXR ok per ED report on arrival to
the floor patient was intubated and sedated.

Past Medical History:
1. Myasthenia [**Last Name (un) **]-first diagnosed in [**2163**], followed by Dr.
[**Last Name (STitle) **] at [**Hospital1 18**]
2. multiple spinal compression fractures s/p steroid use for MG

3. hypercholesterolemia
4. h/o migraines
5. seasonal allergies
6. HTN
7. osteoporosis

Social History:
Patient is single, lives alone. She is currently on disability.
She used to work as a histology tech a [**Hospital1 18**]. She denies
tobacco, illicit drugs, occ EToH but none since starting
narcotic medications.


Family History:
Mother: [**Name (NI) 77552**], first age 55, also CHF, deceased age 77; father
with rheumatic heart disease, deceased age 83 CVA; sister died
at age 5 of insulin dependent diabetes mellitus w/PNA.
.

Physical Exam:
Vitals: T: 98.1 HR 77 BP 106/54 ABG: 7.42/45/266/30 on AC at
450X16, 5, 99%FIO2
General: Sedated, intubated.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, dry MM
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: TTP pelvic area, soft, ND, normoactive bowel sounds, no
masses or organomegaly noted. No [**Doctor Last Name 515**] sign, no rebound
Extremities: No edema, 2+ radial, DP pulses b/l
Skin: no rashes or lesions noted.


Pertinent Results:
At admission:
[**2176-5-1**] 07:35PM BLOOD WBC-12.7* RBC-4.28 Hgb-14.2 Hct-42.4
MCV-99* MCH-33.1* MCHC-33.5 RDW-12.5 Plt Ct-206
[**2176-5-1**] 07:35PM BLOOD Neuts-86.1* Lymphs-8.2* Monos-4.6 Eos-0.6
Baso-0.5
[**2176-5-2**] 05:43AM BLOOD PT-16.0* PTT->150* INR(PT)-1.4*
[**2176-5-1**] 07:35PM BLOOD Glucose-113* UreaN-16 Creat-0.8 Na-143
K-2.9* Cl-100 HCO3-31 AnGap-15
[**2176-5-1**] 07:35PM BLOOD ALT-10 AST-17 CK(CPK)-87 AlkPhos-44
TotBili-0.5
[**2176-5-1**] 07:35PM BLOOD cTropnT-<0.01
[**2176-5-1**] 07:35PM BLOOD Albumin-4.2
[**2176-5-2**] 04:30AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.2
[**2176-5-1**] 10:02PM BLOOD Type-ART pO2-87 pCO2-48* pH-7.42
calTCO2-32* Base XS-5 Intubat-NOT INTUBA
[**2176-5-1**] 08:01PM BLOOD Lactate-1.8

CXR:
FINDINGS: In comparison with the study of earlier in this date,
the tip of the endotracheal tube now measures approximately 2.6
cm above the carina.  Nasogastric tube again extends well into
the stomach. Extensive opacification is seen at the left base
consistent with volume loss and pleural effusion. There is
apparent opacification in the left perihilar region. This could
represent an area of developing aspiration or volume loss
related to mucus plugging.

CTA torso [**5-2**]: 1. Sigmoid diverticulitis with adjacent punctate
foci of air compatible with focal perforation, mildly worsened
in appearance from prior study. No drainable fluid collection.
2. New left lower lobe collapse secondary to mucus
plugging/aspiration. 3. Nondiagnostic study for evaluation of
pulmonary embolism. No central thrombus. In case of continued
clinical concern for pulmonary embolism, a repeat study can be
obtained.

CTA chest [**5-3**]:
IMPRESSION:
1. No pulmonary embolism or aortic pathology.
2. Near-complete LLL collapse and partial RLL collapse,
unchanged. Small
focal superimposed infection cannot be excluded.
3. Marked left hemithorax volume loss, with leftward shift of
mediastinal
structures, also unchanged. No pneumothorax.
4. Small left-sided pleural effusion tracks along the major
fissure.

Most Recent Labs:
[**2176-5-11**] 03:41AM BLOOD WBC-8.7 RBC-3.84* Hgb-12.7 Hct-38.7
MCV-101* MCH-33.1* MCHC-32.8 RDW-12.3 Plt Ct-209
[**2176-5-11**] 03:41AM BLOOD Glucose-94 UreaN-14 Creat-0.8 Na-140
K-3.1* Cl-96 HCO3-35* AnGap-12
[**2176-5-10**] 06:18AM BLOOD Glucose-86 UreaN-13 Creat-0.9 Na-140
K-3.8 Cl-95* HCO3-35* AnGap-14
[**2176-5-5**] 02:56AM BLOOD ALT-7 AST-16 LD(LDH)-195 AlkPhos-24*
TotBili-0.3
[**2176-5-1**] 07:35PM BLOOD Lipase-21
[**2176-5-1**] 07:35PM BLOOD cTropnT-<0.01
[**2176-5-11**] 03:41AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.2
[**2176-5-5**] 05:43PM BLOOD Hapto-259*
[**2176-5-2**] 04:30AM BLOOD Triglyc-58
[**2176-5-6**] 03:21AM BLOOD TSH-4.2
[**2176-5-8**] 02:47PM BLOOD Type-ART Temp-37 pO2-77* pCO2-52*
pH-7.46* calTCO2-38* Base XS-10

Brief Hospital Course:
Ms. [**Known lastname **] is a 65 year old woman with history of myasthenia
[**Last Name (un) 2902**] who was admitted to the [**Hospital Unit Name 153**] on [**5-2**] with progressive
abdominal pain, respiratory distress requiring intubation, and
possible MG flare. She has known diverticular disease and
imaging at admission was consistent with diverticulitis flare
with microperforation. Surgery was consulted and she was treated
with bowel rest with improvement; she was  cleared from a
surgical standpoint given resolution of her abdominal pain and
ability to tolerate po diet. She is to complete a 14 day course
of Zosyn.
.
Her respiratory distress was initially thought to be
multifactorial: diaphragm weakness from MG flare and splinting
from abd pain, but imaging was suggestive of PNA and this was
thought to be the main cause of her respiratory failure. There
was also initial concern for PE, but this was ruled out on CTA
chest. She was noted to improve on antibiotics (Vancomycin and
Zosyn). Barriers to extubation were weak NIF (-20), fluid
overload and copious secretions. She was diuresed to contraction
alkalosis. We held her mestinon, her secretions subsided and her
NIF improved to -60. She was successfully extubated on [**5-7**] and progressively weaned from face tent at 50% to nasal
cannula. Her mestinon was restarted 6 hours after extubation. An
ABG on [**5-8**] showed mild alkalosis with appropriate
respiratory compensation. Her respiratory status continued to
improve, and she completed an 8 day course of vancomycin and
Zosyn for hospital acquired pneumonia (still has  4 days of
Zosyn left at the time of discharge for the diverticulitis). She
remains on 3l/min od O2 via NC, but her supplemental O2 needs
continue to decrease.
.
For her MG, the patient was on pyridostigmine at home. Neuro was
consulted and they recommended continuing this medication as an
inpatient. She did not require steroids or IVIG treatment as it
was not felt that she was having a flare. (No weakening off of
mestinon)
.
Of note, on prior CT abdomen ([**2176-4-28**]) the patient was noted to
have a heterogeneous endometrium measuring up to 1.5 cm,
abnormal in a post-menopausal patient.  Patient will need
further evaluation with pelvic ultrasound as an outpatient.

On [**5-10**] she developed diarrhea. Stool was sent for C.Diff and was
negative. Her diarrhea abated. Her potassium also dropped to 3.1
on [**2176-5-11**]. SHE WAS STARTED ON POTASSIUM REPLETION AND WILL
NEED TO HAVE HER POTASSIUM (and, possibly, Magnesium) FOLLOWED
AT [**Hospital1 **]-[**Hospital1 **] - NEXT LEVEL RECCOMENDED TO BE DRAWN ON
[**2176-5-12**].

At the time of discharge from [**Hospital1 18**] the patient was clinically
and hemodynamically stable. She will be discharge to [**First Name9 (NamePattern2) **]
[**Hospital1 **]-[**Hospital1 8**].
.
Ms. [**Known lastname 61693**] code status was confirmed as FULL CODE this
admission.

Medications on Admission:
Hydrochlorothiazide 25 mg PO QAM, Lidocaine 5% patch apply dialy
for 12 hours, Metoprolol 25 mg PO BID,
Percocet 10-325 mg PO QID prn pain, Pyridostigmine Bromide 60 mg

PO TTID, Evista 60 mg PO Daily, Simvastatin 40 mg PO Daily


Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation every four (4) hours as
needed for SOB.
5. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours).
6. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily). Capsule(s)
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold if sbp < 95 or HR < 60.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO TID (3 times a
day) for 2 days.
11. Zosyn 4.5 gram Recon Soln Sig: One (1)  Intravenous every
eight (8) hours for 4 days.
12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center

Discharge Diagnosis:
Diverticulosis with microperforation
Nosocomial LLL pneumonia and atelectasis
Acute respiratory failure requiring intubation and mechanical
ventilation
Volume overload
Myasthenia [**Last Name (un) 2902**] diagnosed in [**2163**]
Spinal compression fractures
Hyperlipidemia
Migraine headaches
Hypertension
Osteoporosis


Discharge Condition:
Stable

Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair


Discharge Instructions:
You were admitted with abdominal pain and difficulty breathing.
You were diagnosed with diverticulitis and pneumonia. You were
treated for a period of time in the intensive care unit, but
with antibiotics and supportive care you improved. You are now
ready for rehabilitation in a specialized rehabilitation
hospital.

Followup Instructions:
Patient needs to see her primary care physician in [**Name9 (PRE) 702**]
within 2 weeks of discharge from [**Hospital1 **]-[**Hospital1 8**].

Department: [**Hospital3 249**]
When: MONDAY [**2176-5-20**] at 9:40 AM
With: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ADULT SPECIALTIES
When: MONDAY [**2176-7-15**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],M [**Telephone/Fax (1) 9407**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site
{'Diverticulosis of colon (without mention of hemorrhage),Acute respiratory failure,Pneumonia, organism unspecified,Alkalosis,Myasthenia gravis without (acute) exacerbation,Benign essential hypertension,Other and unspecified hyperlipidemia,Anemia, unspecified,Osteoporosis, unspecified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Personal history of pathologic fracture'}


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: This is a 65 year old woman with hisotry of Myasthenia [**Last Name (un) **]
who presents with progressive abdominal pain and possible MG
flare.
.
The pain started two weeks ago as diffuse pain which then moved
to the mid pelvis region. It was described as sharp and crampy,
worse when lying to her sides and after defecation. Denied
n/v/d/fever/chills/hematochez/melena. She has never had
abdominal surgery or hernias. She was recently admitted to ETS
service with abdominal pain. CT abdomen at the time was reported
as mild diverticulitis. Initally treated with cipro/flagyl and
then switched to cefpodoxime/flagyl. Called PCP today with
[**Name9 (PRE) 95371**] abd pain and told to come to ED.
.
In the ED initial vitals were: T:98 HR:100 BP:174/93 RR:40.
Looked in respiratory distress. NIF was -20 and VC 1.6. ABG:
7.42/48/87/32. She was thought to be having a myasthenia [**Last Name (un) 2902**]
flare. She was given Vanc/flagyl/zosyn for presumed
intra-abdominal infection leading to the MG flare. In CT scan
could not lay flat and she had to be intubated in ED. CT Torso
revealed no saddle embolus but poor scan so started heparin
empirically. Also with evidence of lll PNA (not on CT Abd a few
days ago). Also has worsening diverticulitis so surgery asked to
eval in ED. Neuro was consulted and said hold on tx for MG for
now given possible infection currently, Staffed with Dr [**Last Name (STitle) **].
[**Doctor Last Name 18530**]. recommended MICU admit, check NIFs & VCs q6h - neuro
will follow as consult. Cdiff was sent as thought infection
might have precipitated this flare. NIF was -20. Received
Vanc/Zosyn/Flagyl. Intubated using etomidate and recuronium and
versed/fentanyl. Started on hep gtt. Also got KCl for K of 2.9.
Surgery was called and said no changes in antibiotics and NPO.
Prior to transfer to the floor CT Chest read as ETT too low.
Pulled back by ED and repeat CXR ok per ED report on arrival to
the floor patient was intubated and sedated.

MEDICAL HISTORY: 1. Myasthenia [**Last Name (un) **]-first diagnosed in [**2163**], followed by Dr.
[**Last Name (STitle) **] at [**Hospital1 18**]
2. multiple spinal compression fractures s/p steroid use for MG

MEDICATION ON ADMISSION: Hydrochlorothiazide 25 mg PO QAM, Lidocaine 5% patch apply dialy
for 12 hours, Metoprolol 25 mg PO BID,
Percocet 10-325 mg PO QID prn pain, Pyridostigmine Bromide 60 mg

ALLERGIES: Prempro / Fiorinal / Erythromycin Base / Aleve

PHYSICAL EXAM: Vitals: T: 98.1 HR 77 BP 106/54 ABG: 7.42/45/266/30 on AC at
450X16, 5, 99%FIO2
General: Sedated, intubated.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, dry MM
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: TTP pelvic area, soft, ND, normoactive bowel sounds, no
masses or organomegaly noted. No [**Doctor Last Name 515**] sign, no rebound
Extremities: No edema, 2+ radial, DP pulses b/l
Skin: no rashes or lesions noted.

FAMILY HISTORY: Mother: [**Name (NI) 77552**], first age 55, also CHF, deceased age 77; father
with rheumatic heart disease, deceased age 83 CVA; sister died
at age 5 of insulin dependent diabetes mellitus w/PNA.
.

SOCIAL HISTORY: Patient is single, lives alone. She is currently on disability.
She used to work as a histology tech a [**Hospital1 18**]. She denies
tobacco, illicit drugs, occ EToH but none since starting
narcotic medications. 

### Response:
{'Diverticulosis of colon (without mention of hemorrhage),Acute respiratory failure,Pneumonia, organism unspecified,Alkalosis,Myasthenia gravis without (acute) exacerbation,Benign essential hypertension,Other and unspecified hyperlipidemia,Anemia, unspecified,Osteoporosis, unspecified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Personal history of pathologic fracture'}
