CHIEF COMPLAINT: Left flank pain

PRESENT ILLNESS: 76 yo man with PMH significant for afib and recent
subtherapuetic INR, who presented to PCP's office on [**2135-10-26**]
with left flank pain.  The pain started suddenly on [**2135-10-25**],
was described as sharp "like a knife", and was located in left
flank region without radiation.  Mr. [**Known lastname 62631**] also had significant
nausea, concommitant with the flank pain, which he attempted and
failed to relieve through self-induced vomiting. He had no
hematuria, fever, or diarrhea.  No recent trauma.

MEDICAL HISTORY: Coronary artery disease status post angioplasty ~ 15 yrs ago
Atrial fibrillation
Prostate condition - unspecified
Hypertension
Hypercholesterolemia
Asthma - pt unaware of PFTs in past

MEDICATION ON ADMISSION: [**Last Name (un) **] 180 mg po qd
Furosemide 40 mg po qd
Zocor 40 mg po qd
Coumadin 5 mg po qd

ALLERGIES: Opioid Analgesics

PHYSICAL EXAM: VS: T 98.6 HR 99 BP 161/94 RR 15 O2sat 96%RA
Genl: NAD
HEENT: PERRLA, EOMI
Neck: no carotid bruits, no LAD, no JVD
CV: Irregularly irregular, nl s1s2, no mrg
Pulm: Lungs clear
Abdomen: soft, tender at left flank, nondistended, normoactive
bowel sounds, no abdominal bruit, no pulsating mass to suggest
AAA
Back: left CVa tenderness, no ecchymosis
Ext: LE without edema, 1+DP pulses/ 1+[**Doctor Last Name **] pulses, no cyanosis

FAMILY HISTORY: Father with unknown type cancer
Mother with MI

SOCIAL HISTORY: 60 pack yr smoking hx, quit 30 yrs ago
Alcohol occasionally
No drug use
Lives with wife
retired, former [**Name (NI) 62632**] worker
Vascular disorders of kidney,Atrial fibrillation,Unspecified essential hypertension,Calculus of kidney,Percutaneous transluminal coronary angioplasty status,Pure hypercholesterolemia,Asthma, unspecified type, unspecified,Long-term (current) use of anticoagulants,Backache, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)
Renal vascular disorder,Atrial fibrillation,Hypertension NOS,Calculus of kidney,Status-post ptca,Pure hypercholesterolem,Asthma NOS,Long-term use anticoagul,Backache NOS,BPH w/o urinary obs/LUTS
Admission Date:  [**2135-10-26**]              Discharge Date:   [**2135-11-3**]

Date of Birth:  [**2059-10-6**]             Sex:   M

Service: MEDICINE

Allergies:
Opioid Analgesics

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Left flank pain

Major Surgical or Invasive Procedure:
s/p catheterization and tpa thrombolysis


History of Present Illness:
76 yo man with PMH significant for afib and recent
subtherapuetic INR, who presented to PCP's office on [**2135-10-26**]
with left flank pain.  The pain started suddenly on [**2135-10-25**],
was described as sharp "like a knife", and was located in left
flank region without radiation.  Mr. [**Known lastname 62631**] also had significant
nausea, concommitant with the flank pain, which he attempted and
failed to relieve through self-induced vomiting. He had no
hematuria, fever, or diarrhea.  No recent trauma.

The pain persisted, constant in intensity at 10/10, and he saw
his PCP [**Last Name (NamePattern4) **] [**10-26**] where he was found to have microscopic
hematuria by UA and was referred to the [**Hospital 1474**] Hospital ED. CT
there showed a left renal artery obstruction c/w thrombosis vs.
thromboembolism. He was transferred to [**Hospital1 18**].

Past Medical History:
Coronary artery disease status post angioplasty ~ 15 yrs ago
Atrial fibrillation
Prostate condition - unspecified
Hypertension
Hypercholesterolemia
Asthma - pt unaware of PFTs in past



Social History:
60 pack yr smoking hx, quit 30 yrs ago
Alcohol occasionally
No drug use
Lives with wife
retired, former [**Name (NI) 62632**] worker


Family History:
Father with unknown type cancer
Mother with MI


Physical Exam:
VS: T 98.6 HR 99 BP 161/94 RR 15 O2sat 96%RA
Genl: NAD
HEENT: PERRLA, EOMI
Neck: no carotid bruits, no LAD, no JVD
CV: Irregularly irregular, nl s1s2, no mrg
Pulm: Lungs clear
Abdomen: soft, tender at left flank, nondistended, normoactive
bowel sounds, no abdominal bruit, no pulsating mass to suggest
AAA
Back: left CVa tenderness, no ecchymosis
Ext: LE without edema, 1+DP pulses/ 1+[**Doctor Last Name **] pulses, no cyanosis


Pertinent Results:
Admission labs:
CBC: WBC-9.4 RBC-5.07 Hgb-12.5* Hct-37.8* Plt Ct-164
Diff: Neuts-85.0* Bands-0 Lymphs-10.8* Monos-3.8 Eos-0.1
Baso-0.3
Coags: PT-14.0* INR(PT)-1.3
Chem10: Glucose-118* UreaN-20 Creat-1.5* Na-137 K-4.8 Cl-96
HCO3-28
Calcium-8.7 Phos-2.8 Mg-1.8
Fe studies: Iron-21* calTIBC-365 Ferritn-54 TRF-281
Anemia studies: VitB12-496 Folate-15.8 Ret Aut-1.3 Fibrino-667*

Discharge labs:
Chem10: Glucose-157* UreaN-13 Creat-1.3* Na-140 K-4.6 Cl-106
HCO3-23
Calcium-8.8 Phos-3.3 Mg-2.2
CBC: WBC-4.8 RBC-4.03* Hgb-10.2* Hct-30.7* Plt Ct-232
Coags: PT-18.8* PTT-115.7* INR(PT)-2.5

Micro:
Blood cx x 2 - negative
Urine cx - negative

Studies:
.
UA at OSH with 0-2 rbc, 0-2 wbc, creat 1.3
Stool guaiac negative
.
CT abd/pelvis at OSH with essentially complete absence of flow
to the left kidney other than min flow to some portions of ant
mid pole and lower pole, contrast in prox left renal aa with
lack beyong that point suggests in situ thrombus or embolism;
cysts in both kidneys, aorta diffusely calcified but nl in
caliber, no aortic dissection, prostate enlarged, no LAD,
diverticuli, enlarged heart; otherwise nl
.
EKG at [**Hospital1 18**] with afib, normal axis, no LVH, q in III, no ST/T
wave abnormalities.

ECHO ([**10-27**]):
Left Atrium - Long Axis Dimension: *5.0 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *7.5 cm (nl <= 5.2 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)

Left Ventricle - Inferolateral Thickness: 0.8 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.2 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 45% (nl >=55%)
Aorta - Valve Level: 2.9 cm (nl <= 3.6 cm)
Aorta - Ascending: *4.1 cm (nl <= 3.4 cm)
Aorta - Arch: *3.1 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - E Wave Deceleration Time: 181 msec
TR Gradient (+ RA = PASP): *22 to 30 mm Hg (nl <= 25 mm Hg)

INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Normal LV cavity size. Mildly depressed LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity. RV function
depressed.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
(1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild [1+]TR.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is moderately dilated. The right atrium is
moderately
dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is mildly depressed. Inferior hypokinesis is
present.
3. The right ventricular cavity is mildly dilated. Right
ventricular systolic function appears depressed.
4. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.

Cath [**10-27**]: Selective renal angiography demonstrated a large
blood clot present within the left main renal artery extending
into the peripheral branches. Perfusion of the left renal
parenchyma was significantly reduced. Catheter-directed
intrathrombus pulse spray infusion of 10 mg of TPA was performed
via a multisidehole infusion catheter. The multisidehole
infusion catheter positioned within the thrombosed was connected
to a continuous drip of TPA at 1 mg per hour during the first
hours of the infusion and 0.5 mg per hour continuous infusion of
TPA thereafter. Followup angiogram was planned to be performed
in approximately 15 hours.

Cath [**10-28**]: Followup left renal angiography demonstrated
significantly reduced amount of thrombus within the left renal
artery. Perfusion to the left renal parenchyma has significantly
improved. Areas of the left renal parenchyma in its lower
lateral pole demonstrated persistent hypoperfusion. Pulse spray
catheter-directed infusion of 6 mg of TPA into the left renal
artery was performed. The catheter was connected to the
continuous infusion of TPA at 1 mg per hour for 4 hours. A
followup left renal angiography will be then performed.

Follow-up 10/28: Marked improvement of the left renal artery
thrombus with only small residual filling defects, predominantly
in the lower renal artery branch. Overall, improved parenchymal
perfusion compared with the prior study with still some areas of
hypoperfusion in the interpolar region and lower pole.

Arterial duplex, right lower extremity, [**11-3**]: No evidence of
right inguinal pseudoaneurysm or AV fistula.


Brief Hospital Course:
76yo man with afib, CAD, HTN, BPH, w/ left renal artery
occlusion, renal failure, s/p catheter guided TPA lysis to
restore flow.
.
History is detailed below by problem:
.
1) Left renal artery occlusion: The patient was found to have a
left renal artery thrombus [**1-2**] cms distal to origin of aorta
with occlusion of the tributaries extending into renal pelvis.
Renal arteriography was performed with injection of TPA x 3.
Adequate flow was restored and patient received heparin bridging
to coumadin over 5 days. On the night following his TPA therapy,
He had bleeding from a hematoma at the right groin catheter
site. Bleeding was stopped with pressure and the hematoma was
monitored closely; it resolved throughout his hospital course.

2) Renal insufficiency: Mr. [**Known lastname 62633**] creatinine was 1.5 on
admission, up from baseline of 1.0, believed secondary to renal
artery occlusion. With restoration of arterial perfusion, his
creatinine trended down to 1.3 at discharge. Per the
interventional radiology service, this would be analagous to
slow recovery from ATN and would expect for it to continue to
fall.

3) Anemia: Pt has Fe deficiency anemia. His hematocrit dropped
from 37 on admission to 29 to a low of 27.1 on [**10-28**]. Guaiac
exams were negative, and no active sources of bleeding were
idenitified. His hematocrit stabilized in the low 30s prior to
discharge.

4) Hypertension: he was normotensive throughout his course,
received lasix home med dose of 40 mg po qd and continued on
verapamil SR 240 mg PO Q24H. [**Last Name (un) **] was held given the ACE
inhibitor component.

Medications on Admission:
[**Last Name (un) **] 180 mg po qd
Furosemide 40 mg po qd
Zocor 40 mg po qd
Coumadin 5 mg po qd

Discharge Medications:
1. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*10 Tablet(s)* Refills:*0*
7. Atrovent 18 mcg/Actuation Aerosol Sig: One (1) INH Inhalation
twice a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Renal artery embolus and renal infarct s/p thrombolysis


Discharge Condition:
good


Discharge Instructions:
Please call your primary care doctor if you have fevers > 101.5,
severe chest pain, shortness of breath, worsening back pain,
blood in your urine or if your symptoms worsen.

Take your coumadin as prescribed and have your INR checked by
your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] at clinic.

Followup Instructions:
Follow up appointment w/ PCP on [**Name9 (PRE) 766**], [**11-7**], at 215pm

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2135-11-29**] 10:00

Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2135-11-17**] 2:00
{'Vascular disorders of kidney,Atrial fibrillation,Unspecified essential hypertension,Calculus of kidney,Percutaneous transluminal coronary angioplasty status,Pure hypercholesterolemia,Asthma, unspecified type, unspecified,Long-term (current) use of anticoagulants,Backache, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)'}


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: Left flank pain

PRESENT ILLNESS: 76 yo man with PMH significant for afib and recent
subtherapuetic INR, who presented to PCP's office on [**2135-10-26**]
with left flank pain.  The pain started suddenly on [**2135-10-25**],
was described as sharp "like a knife", and was located in left
flank region without radiation.  Mr. [**Known lastname 62631**] also had significant
nausea, concommitant with the flank pain, which he attempted and
failed to relieve through self-induced vomiting. He had no
hematuria, fever, or diarrhea.  No recent trauma.

MEDICAL HISTORY: Coronary artery disease status post angioplasty ~ 15 yrs ago
Atrial fibrillation
Prostate condition - unspecified
Hypertension
Hypercholesterolemia
Asthma - pt unaware of PFTs in past

MEDICATION ON ADMISSION: [**Last Name (un) **] 180 mg po qd
Furosemide 40 mg po qd
Zocor 40 mg po qd
Coumadin 5 mg po qd

ALLERGIES: Opioid Analgesics

PHYSICAL EXAM: VS: T 98.6 HR 99 BP 161/94 RR 15 O2sat 96%RA
Genl: NAD
HEENT: PERRLA, EOMI
Neck: no carotid bruits, no LAD, no JVD
CV: Irregularly irregular, nl s1s2, no mrg
Pulm: Lungs clear
Abdomen: soft, tender at left flank, nondistended, normoactive
bowel sounds, no abdominal bruit, no pulsating mass to suggest
AAA
Back: left CVa tenderness, no ecchymosis
Ext: LE without edema, 1+DP pulses/ 1+[**Doctor Last Name **] pulses, no cyanosis

FAMILY HISTORY: Father with unknown type cancer
Mother with MI

SOCIAL HISTORY: 60 pack yr smoking hx, quit 30 yrs ago
Alcohol occasionally
No drug use
Lives with wife
retired, former [**Name (NI) 62632**] worker 

### Response:
{'Vascular disorders of kidney,Atrial fibrillation,Unspecified essential hypertension,Calculus of kidney,Percutaneous transluminal coronary angioplasty status,Pure hypercholesterolemia,Asthma, unspecified type, unspecified,Long-term (current) use of anticoagulants,Backache, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)'}
