CHIEF COMPLAINT: Abd pain

PRESENT ILLNESS: 88-year-old man, with diabetes, CAD, status post MI over a
decade ago, hypertension, hyperlipidemia, peripheral vascular
disease p/w abdominal tightness. It started around 730 pm when
the pt was sitting watching TV. It resolved by itself within 5
mins. However it reappeared when the pt was in the ER and this
time lasted abt 10 minutes. No SOB/dizzy/palps.

MEDICAL HISTORY: CAD, status post MI over a decade ago
hypertension
hyperlipidemia
peripheral vascular disease with bilateral carotid
endarterectomies
BCC
Systolic HF, EF 25-30% in 04 w/ severe AK/HK (on coumadin)

MEDICATION ON ADMISSION: At home
EZETIMIBE [ZETIA] - 10 mg qd
GLYBURIDE 5 mg one Tablet(s) by mouth qam, 0.5 tab po qpm
HYDROCHLOROTHIAZIDE - 12.5 mg qd
ISOSORBIDE MONONITRATE - 30 mg Sustained Release qd
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg qd
PRAVASTATIN [PRAVACHOL] - 40 mg qd
QUINAPRIL - 40 mg qd
WARFARIN [COUMADIN] - 5 mg Tablet - 1/2-1 Tablet(s) by mouth
daily take one tab 4 days a week and [**1-6**] taab on Tue, Th and Sat

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.6 BP:108/57 P:87 R: 20 O2: 97% on 2L NC
General: Alert, mentating well, does not appear acutely ill,
appears younger than stated age
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: NC

SOCIAL HISTORY: He is a retired fireman, lives in [**Location (un) 538**] with his wife.
Married 55 years. Grown children. No smoking. No alcohol
consumption.
Hemorrhage of gastrointestinal tract, unspecified,Acute and subacute necrosis of liver,Acute kidney failure with lesion of tubular necrosis,Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Encephalopathy, unspecified,Other primary cardiomyopathies,Injury to bladder and urethra, without mention of open wound into cavity,Cardiogenic shock,Renal sclerosis, unspecified,Atrial fibrillation,Hypovolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified accident,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Peripheral vascular disease, unspecified,Other left bundle branch block,Unspecified vitamin D deficiency,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Long-term (current) use of anticoagulants,Other postprocedural status
Gastrointest hemorr NOS,Acute necrosis of liver,Ac kidny fail, tubr necr,Subendo infarct, initial,Ac on chr syst hrt fail,Encephalopathy NOS,Prim cardiomyopathy NEC,Bladder/urethra inj-clos,Cardiogenic shock,Renal sclerosis NOS,Atrial fibrillation,Hypovolemia,DMII wo cmp nt st uncntr,Crnry athrscl natve vssl,Old myocardial infarct,Accident NOS,Hypertension NOS,Hyperlipidemia NEC/NOS,Periph vascular dis NOS,Left bb block NEC,Vitamin D deficiency NOS,Cholelithiasis NOS,Long-term use anticoagul,Post-proc states NEC
Admission Date:  [**2102-6-17**]              Discharge Date:   [**2102-6-30**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Abd pain

Major Surgical or Invasive Procedure:
Hemodialysis catheter
Continuous Venous Venous hemodialysis
Arterial line
triple lumen catheter
Nasogastric tube
PICC
Foley Catheter


History of Present Illness:
88-year-old man, with diabetes, CAD, status post MI over a
decade ago, hypertension, hyperlipidemia, peripheral vascular
disease p/w abdominal tightness. It started around 730 pm when
the pt was sitting watching TV. It resolved by itself within 5
mins. However it reappeared when the pt was in the ER and this
time lasted abt 10 minutes. No SOB/dizzy/palps.

In the emergency department, initial vitals:98.2 66 132/80 18
100/ra. In the ED he recd ASA 325, SL NTG x 1, zofran x 1.
Dropped SBP to 80s after SL NTG. Recd 2L IVF and SBP back to
110s. First set of enzymes was neg. CXR was WNL.

On the general medicine floor this am, he was found to have SBP
78/palp, felt nausea, vomited 400cc dark brown mixed w/ food.
Gastoccult positive, guiac positive w. rectal exam of dark brown
stool. Started PPI bolus and gtt. AM labs returned with HCT of
31.7 down from 33.7 after IVF, INR 3.1. GI aware. He also
received 10mg po Vit K. VS at time of transfer BP 80-100
systolic, HR 70, afebrile, 98% on Ra.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

Past Medical History:
CAD, status post MI over a decade ago
hypertension
hyperlipidemia
peripheral vascular disease with bilateral carotid
endarterectomies
BCC
Systolic HF, EF 25-30% in 04 w/ severe AK/HK (on coumadin)

Social History:
He is a retired fireman, lives in [**Location (un) 538**] with his wife.
Married 55 years. Grown children. No smoking. No alcohol
consumption.


Family History:
NC

Physical Exam:
Vitals: T: 98.6 BP:108/57 P:87 R: 20 O2: 97% on 2L NC
General: Alert, mentating well, does not appear acutely ill,
appears younger than stated age
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
[**2102-6-17**] 08:50PM   GLUCOSE-161* UREA N-48* CREAT-2.4* SODIUM-139
POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15
[**2102-6-17**] 08:50PM   CK(CPK)-50
[**2102-6-17**] 08:50PM   cTropnT-<0.01
[**2102-6-17**] 08:50PM   CK-MB-3
[**2102-6-17**] 08:50PM   WBC-6.2 RBC-3.88* HGB-11.2* HCT-33.1* MCV-85
MCH-29.0 MCHC-33.9 RDW-14.2
[**2102-6-17**] 08:50PM   NEUTS-60.5 LYMPHS-27.2 MONOS-7.5 EOS-4.3*
BASOS-0.5
[**2102-6-17**] 08:50PM   PLT COUNT-243
[**2102-6-17**] 08:50PM   PT-26.2* PTT-27.9 INR(PT)-2.5*
.
[**2102-6-17**] ECG: Sinus rhythm. Left bundle-branch block. Compared to
the previous tracing of [**2098-6-3**] no diagnostic change.
.
[**2102-6-21**] ECG: Sinus rhythm with atrial ectopic activity versus
atrial fibrillation with rapid ventricular response. Left bundle
branch block
Possible inferior infarct - age undetermined. Lateral ST
elevation, CONSIDER ACUTE INFARCT. Since previous tracing of
[**2102-6-20**], the heart rate is faster, irregular rhythm, atrial
ectopic activity or atrial fibrillation now present.
Clinical correlation is suggested.
.
[**2102-6-22**] ECG: Sinus rhythm. Left bundle-branch block. Compared
to the previous tracing of [**2102-6-22**] the rhythm is now sinus.
.
[**2102-6-17**] CXR: No acute pulmonary process.
.
[**2102-6-19**] CXR: Bilateral infrahilar opacification, left greater
than right, which has worsened since [**6-17**] is stable since
[**6-18**], probably atelectasis, conceivably aspiration. Upper
lungs clear. Heart size normal. No pulmonary edema. No
appreciable pleural effusion or pneumothorax. Left jugular line
tip projects over the junction of the brachiocephalic veins.
Nasogastric tube ends in the upper stomach. Heart size top
normal.
.
[**2102-6-22**] CXR: Lung volumes are lower. Cardiomediastinal
silhouette is unchanged. Bilateral bibasal opacities greater on
the left side have increased on the left probably due to
atelectasis and or aspiration. There is no pneumothorax. The
left IJ catheter remains in place. NG tube has been removed.
.
[**2102-6-22**] CXR: Right PICC terminates in the mid SVC. Minimally
increased right upper lung opacity may represent evolving
infectious process or increasing atelectasis. Otherwise little
change since [**05**] hours prior.
.
[**2102-6-19**] TTE: The left atrium is mildly dilated. The interatrial
septum is aneurysmal. Left ventricular wall thicknesses and
cavity size are normal. There is moderate to severe regional
left ventricular systolic dysfunction with near akinesis of the
distal 2/3rds of the ventricle (LVEF 25%). No aneurysm or
thrombus is seen. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left vevntricular
cavity size with extensive regional systolic dysfunction c/w
multivessel CAD. Moderate mitral regurgitation. Mild pulmonary
artery systolic hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2097-1-7**], the severity of mitral regurgitation
and the estimated pulmonary artery systolic pressure have
increased. Left ventricular systolic function is similar.
.
[**2102-6-18**] Liver/Gallbladder U/S: 1. Gallbladder filled with
sludge and stones with moderate wall thickening. The findings
are equivocal for acute cholecystitis and if there is continued
concern, consider HIDA scan for further evaluation. 2. Echogenic
liver consistent with fatty infiltration. However, other forms
of liver disease and more advanced liver disease (ie hepatic
fibrosis/cirrhosis) are not excluded.
.
[**2102-6-20**] Liver/Gallbladder U/S: 1. Mildly improved appearance of
the gallbladder, containing sludge, with mild wall thickening.
No specific sign of cholecystitis or biliary dilatation.
2. Increased hepatic echogenicity as previously seen.
3. Right pleural effusion.
.
LFT TREND:


Brief Hospital Course:
This is a 88 yo M admitted for abdominal pain and hypotension,
transferred to the unit for evaluation of new UGI bleed in
setting of anticoagulation.

# Hypotension/Shock. Felt initially to be hypovolemia in setting
of GIB and poor po intake. He received IVF and blood (4 units
total) and hcts remained stable. Patient also with poor CO (EF
25%) and some concern for cardiogenic shock so IVF given
conservatively after initial boluses in ED. Patient then
developed rapid AF and had MAPs in 40s. He was started on
neosynephrine with good result. Digoxin was started as below and
when patient remained in NSR BPs were in 110s/60s and the neo
was turned off.  In the setting of the hypotension he did
develop ARF and ALF as noted below. After initiation of CVVH,
hypotension continued and mental status deteriorated. Goals of
care were transitioned to comfort measures after discussion with
his family and he died less than 24 hours after CVVH was
discontinued. Family and PCP were notified. Family declined
autopsy.

# Coffee ground emesis - Thought likely upper GI source in
setting of therapeutic INR, ddx included PUD, ASA-induced
gastritis, malignancy. Gi was consulted and wanted to perform
EGD when INR< 2. He was given FFP and INR decreased however Hct
remained stable after 2units pRBCs and he did not have further
emesis so scope was deferred. Hct continued to remain stable and
GI eventually decided to have EGD as o/p. He was on PPI gtt X 72
hours then transitioned to IV and later PO BID. His diet was
advanced slowly. Coumadin and ASA were held.

# Afib with RVR: Patient developed AF with RVR after a few days
of hospitalization. With this arrhythmia he developed
hypotension. Given his ARF and ALF medication options were
limited. His cardiologist was consulted and recommended a
digoxin load with close follow up of digoxin levels. He was
started on digoxin with good effect and remained mostly in NSR.
Eventually metoprolol was introduced and titrated up to help
control rate.  The AFib again became difficult to treat after
patient initiated CVVH.

# Shock Liver: Patient noted to have supratherapeutic INR on
admission. LFTs rose steadily. RUQ U/S showed patent vessels.
Patient was treated for hypotension as above. Liver team was
consulted and felt it was consistent with shock liver. Hepatitis
serologies were negative. He devleoped ~1 day of encephalopathy
treated with lactulose. This resolved. His LFTs began to trend
down, however the t-bili continue to rise throughout his stay.

# Acute Renal Failure: Baseline Cr around 2.0 however rose
steadily to 4.8 in setting of hypotension. Renal felt likely [**2-6**]
hypoperfusion. IVF did not improve the creatinine. Renal
discussed with son the potential need for hemodialysis and given
his rising BUN to 155 on [**6-26**], the decision was made to intiate
CVVH. On CVVH he required vasopressors and his mental status
continued to deteriorate. As above, decision was made to
transition to comfort measures and CVVH was discontinued.

# Heart Failure: most recent EF 25% with severe hypokinesis.
Has been anticoagulated with coumadin to prevent
intra-ventricular thrombus formation.  Coumadin was held on
admission given GIB and supratherapeutic INR. Cardiology was
consulted for AF with RVR and suggested starting dig and
metoprolol for this. TTE showed stable EF with slightly worse MR
and PAH. He tolerated modest amounts of IV fluids.

#DM: Held home glyburide and was kept on ISS while hospitalized.


Medications on Admission:
At home
EZETIMIBE [ZETIA] - 10 mg qd
GLYBURIDE 5 mg one Tablet(s) by mouth qam, 0.5 tab po qpm
HYDROCHLOROTHIAZIDE - 12.5 mg qd
ISOSORBIDE MONONITRATE - 30 mg Sustained Release qd
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg qd
PRAVASTATIN [PRAVACHOL] - 40 mg qd
QUINAPRIL - 40 mg qd
WARFARIN [COUMADIN] - 5 mg Tablet - 1/2-1 Tablet(s) by mouth
daily take one tab 4 days a week and [**1-6**] taab on Tue, Th and Sat

ASPIRIN - (OTC) - 81 mg qd
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) - Dosage uncertain

On transfer:
Ezetimibe 10 mg PO DAILY
Insulin SC  (per Insulin Flowsheet) Sliding Scale
Ondansetron 4 mg IV ONCE
Pantoprazole 80 mg IV BOLUS plus 8 mg/hr IV DRIP
Phytonadione 10 mg PO ONCE
Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR
Pravastatin 40 mg PO DAILY


Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
Systolic Heart Failure
Gastrointestinal Bleed
Acute hemorrhagic shock
Cardiogenic shock
renal failure
shock liver
atrial fibrillation with rapid ventricular rate


Discharge Condition:
Deceased


Discharge Instructions:
None

Followup Instructions:
none
{'Hemorrhage of gastrointestinal tract, unspecified,Acute and subacute necrosis of liver,Acute kidney failure with lesion of tubular necrosis,Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Encephalopathy, unspecified,Other primary cardiomyopathies,Injury to bladder and urethra, without mention of open wound into cavity,Cardiogenic shock,Renal sclerosis, unspecified,Atrial fibrillation,Hypovolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified accident,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Peripheral vascular disease, unspecified,Other left bundle branch block,Unspecified vitamin D deficiency,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Long-term (current) use of anticoagulants,Other postprocedural status'}


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: Abd pain

PRESENT ILLNESS: 88-year-old man, with diabetes, CAD, status post MI over a
decade ago, hypertension, hyperlipidemia, peripheral vascular
disease p/w abdominal tightness. It started around 730 pm when
the pt was sitting watching TV. It resolved by itself within 5
mins. However it reappeared when the pt was in the ER and this
time lasted abt 10 minutes. No SOB/dizzy/palps.

MEDICAL HISTORY: CAD, status post MI over a decade ago
hypertension
hyperlipidemia
peripheral vascular disease with bilateral carotid
endarterectomies
BCC
Systolic HF, EF 25-30% in 04 w/ severe AK/HK (on coumadin)

MEDICATION ON ADMISSION: At home
EZETIMIBE [ZETIA] - 10 mg qd
GLYBURIDE 5 mg one Tablet(s) by mouth qam, 0.5 tab po qpm
HYDROCHLOROTHIAZIDE - 12.5 mg qd
ISOSORBIDE MONONITRATE - 30 mg Sustained Release qd
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg qd
PRAVASTATIN [PRAVACHOL] - 40 mg qd
QUINAPRIL - 40 mg qd
WARFARIN [COUMADIN] - 5 mg Tablet - 1/2-1 Tablet(s) by mouth
daily take one tab 4 days a week and [**1-6**] taab on Tue, Th and Sat

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.6 BP:108/57 P:87 R: 20 O2: 97% on 2L NC
General: Alert, mentating well, does not appear acutely ill,
appears younger than stated age
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: NC

SOCIAL HISTORY: He is a retired fireman, lives in [**Location (un) 538**] with his wife.
Married 55 years. Grown children. No smoking. No alcohol
consumption. 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,Acute and subacute necrosis of liver,Acute kidney failure with lesion of tubular necrosis,Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Encephalopathy, unspecified,Other primary cardiomyopathies,Injury to bladder and urethra, without mention of open wound into cavity,Cardiogenic shock,Renal sclerosis, unspecified,Atrial fibrillation,Hypovolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified accident,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Peripheral vascular disease, unspecified,Other left bundle branch block,Unspecified vitamin D deficiency,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Long-term (current) use of anticoagulants,Other postprocedural status'}
