CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: This is a 62 year old woman with atrial fibrillation and end
stage renal disease presenting with epigastric pain and
bradycardia from dialysis suite.  Our patient was at home in her
usual state of health while she developed epigastric pain while
straining during a bowel movement.  She then came into dialyis,
and while in the suite, she was noted to be bradycardic in the
30s and hypotensive in 90s/40s and refered to the ED.  In the ED
he presenting vitals were VS 97.4, HR 30s, 107/61 18, 97% RA.
Her ECG showed second degree AVB and peaked t waves. Her K was
7.0.
Of note she has a history of a similar admission with
hyperkalemia and bradycardia in [**9-28**], which was treated with
dialysis. On arrival to floor, patient states that abdominal
pain has improved.

MEDICAL HISTORY: 1. Atrial fibrillation/flutter: first diagnosed in [**Month (only) **]
[**2195**]. She has not been on Coumadin until very recently due to
history of upper GI bleeding. On [**Month (only) 404**] of this year, she was
admitted to [**Hospital1 18**] with chest pain and shortness of breath in the

MEDICATION ON ADMISSION: AMIODARONE - (Prescribed by Other Provider: [**Name10 (NameIs) **] [**Name Initial (NameIs) **]/c from hosp) -

ALLERGIES: Dilantin

PHYSICAL EXAM: GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or

SOCIAL HISTORY: She is single, lives by herself in [**Location (un) 686**], and has no
children. She quit smoking 25 years ago (10-pack-years). She
rarely drinks alcohol, and denies illicit drug use. She used to
First degree atrioventricular block,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic diastolic heart failure,Hyperpotassemia,Atrial flutter,Abdominal pain, epigastric,Depressive disorder, not elsewhere classified,Personal history of peptic ulcer disease,Renal dialysis status,Personal history of noncompliance with medical treatment, presenting hazards to health,Long-term (current) use of anticoagulants,Other antihypertensive agents causing adverse effects in therapeutic use
Atriovent block-1st degr,End stage renal disease,Hyp kid NOS w cr kid V,Chr diastolic hrt fail,Hyperpotassemia,Atrial flutter,Abdmnal pain epigastric,Depressive disorder NEC,Prsnl hst peptic ulcr ds,Renal dialysis status,Hx of past noncompliance,Long-term use anticoagul,Adv eff antihyperten agt
Admission Date:  [**2196-12-17**]              Discharge Date:   [**2196-12-19**]

Date of Birth:  [**2134-9-9**]             Sex:   F

Service: MEDICINE

Allergies:
Dilantin

Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
abdominal pain

Major Surgical or Invasive Procedure:
none


History of Present Illness:
This is a 62 year old woman with atrial fibrillation and end
stage renal disease presenting with epigastric pain and
bradycardia from dialysis suite.  Our patient was at home in her
usual state of health while she developed epigastric pain while
straining during a bowel movement.  She then came into dialyis,
and while in the suite, she was noted to be bradycardic in the
30s and hypotensive in 90s/40s and refered to the ED.  In the ED
he presenting vitals were VS 97.4, HR 30s, 107/61 18, 97% RA.
Her ECG showed second degree AVB and peaked t waves. Her K was
7.0.
Of note she has a history of a similar admission with
hyperkalemia and bradycardia in [**9-28**], which was treated with
dialysis. On arrival to floor, patient states that abdominal
pain has improved.

Past Medical History:
1. Atrial fibrillation/flutter: first diagnosed in [**Month (only) **]
[**2195**]. She has not been on Coumadin until very recently due to
history of upper GI bleeding. On [**Month (only) 404**] of this year, she was
admitted to [**Hospital1 18**] with chest pain and shortness of breath in the

setting of atrial flutter with rapid ventricular response and
hyperkalemia. She was treated for hyperkalemia and subsequently

her atrial flutter was converted to sinus rhythm. Myocardial
infarction was [**Hospital1 20003**] out based EKG and biomarkers. Thereafter,
she underwent right-sided isthmus ablation of clockwise atrial
flutter, and was started on quinidine and Coumadin.
2. End-stage renal disease on hemodialysis secondary to IgA
nephropathy. She underwent cadaveric kidney transplant in [**2173**]
which has eventually failed, and started on hemodialysis in
[**2193**].
3. History of upper GI bleeding on [**2195-2-20**] with evidence
of esophagitis, gastric ulcer, and bleeding duodenal vessel. She

was treated by clipping, cauterization and PPI. Repeated
endoscopy in [**2195-4-21**] revealed mild inflammation and healing
ulcer. She has not had any recurrent episodes of GI bleeding
since then.
4. Diastolic heart failure supported by an echocardiography from

[**2195-12-21**]. Clinically, she is stable and fairly asymptomatic

on her current medical regimen.
5. History of malignant hypertension, which was complicated by
seizure on [**2193-5-20**]. Not on antiepileptic meds. Denies h/o CVA.

6. Depression.
7. Rheumatic fever in childhood
.


Social History:
She is single, lives by herself in [**Location (un) 686**], and has no
children. She quit smoking 25 years ago (10-pack-years). She
rarely drinks alcohol, and denies illicit drug use. She used to

work part-time in a coffee shop, but currently does not work.


Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or

sudden cardiac death; otherwise non-contributory. Her father
died at the age of 80. Her mother died at the age of 64 from
lung CA. She has a sister with breast CA. MI in uncle in his 60s



Physical Exam:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP of 6cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. II/VI at apex. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Thrill over LUE AV
Fistula.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+


Pertinent Results:
ADMISSION LABS

[**2196-12-17**] 07:30AM   PT-16.1* PTT-26.8 INR(PT)-1.4*
[**2196-12-17**] 07:30AM   WBC-7.8 RBC-3.78* HGB-12.3 HCT-36.6 MCV-97
MCH-32.6* MCHC-33.6 RDW-14.6
[**2196-12-17**] 07:30AM   PLT COUNT-206
[**2196-12-17**] 07:30AM   NEUTS-73.5* LYMPHS-18.7 MONOS-4.4 EOS-2.4
BASOS-1.0
[**2196-12-17**] 07:30AM   GLUCOSE-94 UREA N-92* CREAT-11.8*# SODIUM-135
POTASSIUM-7.6* CHLORIDE-91* TOTAL CO2-27 ANION GAP-25*
[**2196-12-17**] 07:30AM   CALCIUM-10.7* PHOSPHATE-5.7*# MAGNESIUM-2.8*
[**2196-12-17**] 07:30AM   CK-MB-3
[**2196-12-17**] 07:30AM   CK(CPK)-39
[**2196-12-17**] 07:30AM   cTropnT-0.07*
[**2196-12-17**] 05:22PM   ALT(SGPT)-55* AST(SGOT)-44* LD(LDH)-199
CK(CPK)-31 ALK PHOS-96 AMYLASE-90 TOT BILI-0.4
[**2196-12-17**] 05:22PM   LIPASE-42

CXR:  No active pulmonary disease.

EKG:Sinus bradycardia with pauses and junctional escape beats.
Possible blocked premature atrial contractions. Also, evidence
for retrograde conduction in lead V1. Tall T waves suggesting
hyperkalemia. Probable anteroseptal myocardial infarction.
Compared to the previous tracing of [**2196-10-4**] sinus bradycardia,
first degree A-V block, junctional beats and tall peaked T waves
are new.

DISCHARGE LABS

134 | 90 | 67
--------------
5.6 | 32 | 9.7 &#8710;

Ca: 10.9 Mg: 2.8 P: 3.0
TSH:3.3

WBC: 8.5  Hgb: 11.8  HCT: 34.8  Plt: 264

PT: 20.6  PTT: 28.7  INR: 1.9


Brief Hospital Course:
62 year old woman with atrial fibrillation and end stage renal
disease status post failed transplant and currently on HD who
presented with epigastric pain, hyperkalemia, and sinus
bradycardia.
 .
# Hyperkalemia: Secondary to ESRD. She has a history of
hyperkalemic episodes in the past, that required MICU admission
and emergent dialysis. Her baseline K is in the 5-6 range. K was
7.6 at admission and EKG showed peaked T waves and first-second
degree AV block with junctional escape rhythm. She received
calcium gluconate, bicarb and 10 units insulin in the ED. She
was urgently dialyzed and K came down to 4.0. K increased
gradually over following 24 hours and requiring 2 hours HD prior
to discharge. This was due to diet in the setting of oliguria,
and less likely due to ACEi. Patient was taking both captopril
and lisinopril at home. She will be discharged on lisinopril at
half her prior dose.
.
# Bradycardia: Sinus bradycardia with 1st degree AV delay with
junctional escape beats. The most likely cause was beta-blocker
toxicity in setting of worsening CRI. Metoprolol was D/Ced. TSH
was WNL.
.
# Atrial fibrillation: Pt in sinus rhythm. Continued amiodarone
and warfarin. INR at D/C was 1.9, which was trending up from 1.4
on home dose of 4 mg warfarin daily. This dose was continued and
she will f/u in [**Hospital **] clinic.
.
# Epigastric pain: Ddx included anginal equivalent/CAD vs viral
gastroenteritis vs renal failure vs gastritis. Troponins were
flat at prior baseline 0.05-0.07. EKG with no ischemic changes.
No diarrhea. Pain improved spontaneously. Continued
pantoprazole.
.
# ESRD on HD: secondary to IgA nephropathy, s/p failed
transplant. Underwent HD on [**12-17**] and [**12-19**].
.
# HTN:  Normotensive. Continued lisinopril at half home dose and
D/Ced captopril. Continued norvasc. D/Ced metoprolol for
toxicity with ESRD that caused bradycardia.


Medications on Admission:
AMIODARONE - (Prescribed by Other Provider: [**Name10 (NameIs) **] [**Name Initial (NameIs) **]/c from hosp) -

200 mg Tablet - 1 Tablet(s) by mouth daily
AMLODIPINE - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
Hold on dialysis days
CALCIUM ACETATE - 667 mg Capsule - 3 Capsule(s) by mouth three
times a day
CAPTOPRIL - 12.5 mg Tablet - 1 Tablet(s) by mouth at bedtime
CINACALCET [SENSIPAR] - 60 mg Tablet - 2 Tablet(s) by mouth
DAILY
(Daily)
CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth qam
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
pt
holds on dialysis days
METOPROLOL SUCCINATE - 50 mg Tablet Sustained Release 24 hr - 1

Tablet(s) by mouth DAILY (Daily)
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth once a day Name Brand Only, No Substitutions - No
Substitution
SEVELAMER CARBONATE [RENVELA] - 800 mg Tablet - 3 Tablet(s) by
mouth three times a day
SODIUM POLYSTYRENE SULFONATE - Powder - 15grams Powder(s) by
mouth daily
WARFARIN - 1 mg Tablet - Take up to 4 tablets (4mgs) a day or as

directed by [**Hospital 191**] [**Hospital 197**] Clinic


Discharge Medications:
1. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO QMWFSUN (): do
not take on dialysis days.
8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
primary:
hyperkalemia
bradycardia secondary to beta-blockers

secondary:
atrial fibrillation
chronic diastolic CHF


Discharge Condition:
good condition post-hemodialysis with stable vital signs


Discharge Instructions:
It was a pleasure taking care of you. You were admitted for
hyperkalemia (elevated potassium) due to your kidney disease.
You were treated with dialysis and your heart was monitored. You
also had low heart rate and blood rate due to metoprolol, which
does not get cleared as well by your kidneys. You should stop
taking metoprolol as well as captopril.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Adhere to 2 gm sodium diet

Please seek medical attention if you experience shortness of
breath, chest pain, or any new symptoms.

Followup Instructions:
[**Name6 (MD) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2197-1-27**] 1:00
{'First degree atrioventricular block,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic diastolic heart failure,Hyperpotassemia,Atrial flutter,Abdominal pain, epigastric,Depressive disorder, not elsewhere classified,Personal history of peptic ulcer disease,Renal dialysis status,Personal history of noncompliance with medical treatment, presenting hazards to health,Long-term (current) use of anticoagulants,Other antihypertensive agents causing adverse effects in therapeutic use'}


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 62 year old woman with atrial fibrillation and end
stage renal disease presenting with epigastric pain and
bradycardia from dialysis suite.  Our patient was at home in her
usual state of health while she developed epigastric pain while
straining during a bowel movement.  She then came into dialyis,
and while in the suite, she was noted to be bradycardic in the
30s and hypotensive in 90s/40s and refered to the ED.  In the ED
he presenting vitals were VS 97.4, HR 30s, 107/61 18, 97% RA.
Her ECG showed second degree AVB and peaked t waves. Her K was
7.0.
Of note she has a history of a similar admission with
hyperkalemia and bradycardia in [**9-28**], which was treated with
dialysis. On arrival to floor, patient states that abdominal
pain has improved.

MEDICAL HISTORY: 1. Atrial fibrillation/flutter: first diagnosed in [**Month (only) **]
[**2195**]. She has not been on Coumadin until very recently due to
history of upper GI bleeding. On [**Month (only) 404**] of this year, she was
admitted to [**Hospital1 18**] with chest pain and shortness of breath in the

MEDICATION ON ADMISSION: AMIODARONE - (Prescribed by Other Provider: [**Name10 (NameIs) **] [**Name Initial (NameIs) **]/c from hosp) -

ALLERGIES: Dilantin

PHYSICAL EXAM: GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or

SOCIAL HISTORY: She is single, lives by herself in [**Location (un) 686**], and has no
children. She quit smoking 25 years ago (10-pack-years). She
rarely drinks alcohol, and denies illicit drug use. She used to 

### Response:
{'First degree atrioventricular block,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic diastolic heart failure,Hyperpotassemia,Atrial flutter,Abdominal pain, epigastric,Depressive disorder, not elsewhere classified,Personal history of peptic ulcer disease,Renal dialysis status,Personal history of noncompliance with medical treatment, presenting hazards to health,Long-term (current) use of anticoagulants,Other antihypertensive agents causing adverse effects in therapeutic use'}
