CHIEF COMPLAINT: Back/Abdominal Pain

PRESENT ILLNESS: (Russian interpreter requested for the AM) 72 M w/ pmh of HTN,
CAD, Nonischemic cardiomyopathy (EF 40%) CKD, chronic abdominal
pain admitted on [**12-15**] with left sided abdominal pain, that
started acutely 4 hours prior to presentation and associated
with nausea. Patient has been most tender on the left side and
periumbilical region. Denied fevers, chills, new foods, sick
contacts. Different from his chronic abdominal pain.
.
In the ED, initial VS: 85 131/61 19 94% on RA. Exam noted for
tenderness on the left side. CT ABD/Pelvis showed Left sided
nephrolithiasis with mild left renal edema, perinephric
stranding, no other abdominal process. U/A showed blood but no
leukocytosis. Got 16 IV morphine, 8IV Zofran. Urology was
reportedly consulted in ED, though no note in chart or OMR.
.
On the floor the patient continued to have abdominal pain and
nausea only partly relieved by morphine.  Of note, patient has
been getting 125cc/hr of IV fluids for the last 1.5 day, and did
not receive his home lasix dose.
.
Patient was noted to be hypoxic to 85% while on 3L while
sleeping this evening. Exam notable for bilateral crackles. He
complained of some shortness of breath.  He received 40mg IV
lasix x1 with good urine output of 300cc+.  ABG was 7.36/36/72
while on 100% NRB. CXR notable for bilateral pulm edema. Patient
had persistent O2 sats of 85%-90% on 6L nc. He was transferred
to the MICU for relative hypoxia and nursing concern.

MEDICAL HISTORY: HTN
Smoking
Polycythemia [**1-20**] OSA?
OSA refractory to CPAP
hx iron deficiency anemia
CrI with bl CR 1.3-1.5 [**1-20**] HTN
CAD: last cath [**6-21**] documenting mild to mod diffuse CAD, but no
obstructing lesions, MI x 2; EF 50% most recently, 2+ MR, 2+ AR

MEDICATION ON ADMISSION: AMLODIPINE - 10 mg po qhs
ATORVASTATIN [LIPITOR] - 80 mg po daily
BIPAP - 12/8 CM H2O - NIGHTLY.
CALCITRIOL - (dc med) - 0.25 mcg Capsule - 2 Capsule(s) by mouth
twice a day
FINASTERIDE - 5 mg po daily
FLUOXETINE [PROZAC] - 20 mg po daily
FUROSEMIDE - 20 mg po daily
LEVOTHYROXINE - 200 mcg po daily
LISINOPRIL - 40 mg po daily
METOPROLOL SUCCINATE - 50 mg po daily
PANTOPRAZOLE [PROTONIX] - 40 mg po bid
TRAZODONE - 50 mg po qhs PRN insomnia
WARFARIN - 2.5-5 mg po daily
Aspirin 81 mg po daily
ASCORBIC ACID - 500 mg po daily
CALCIUM CARBONATE [CALCIUM 600] - 600 mg (1,500 mg) po tid
CYANOCOBALAMIN - 2,000 mcg po daily
DOCUSATE SODIUM [COLACE] - 100 mg po bid
FERROUS SULFATE - 324 mg (65 mg Iron) po daily
SENNA - 8.6 mg po bid PRN constipation
SIMETHICONE - 80 mg po qid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T:97.8 BP: 152/60 P: 76 R: 18 O2:  95% on Bipap
General: Alert, oriented, tachypnic
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated though body habitus is quite
large, so this is difficult to assess, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregularly irregular, no murmurs
Abdomen:  soft, mildly tender to deep palpation over R side,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU:  foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: No h/o premature CAD, no family hx of Medullary thyorid CA

SOCIAL HISTORY: 
Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Urinary tract infection, site not specified,Other primary cardiomyopathies,Paralytic ileus,Calculus of kidney,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Iron deficiency anemia, unspecified,Obstructive sleep apnea (adult)(pediatric),Atrial fibrillation,Polycythemia vera,Long-term (current) use of anticoagulants
Acute kidney failure NOS,Ac on chr syst hrt fail,Urin tract infection NOS,Prim cardiomyopathy NEC,Paralytic ileus,Calculus of kidney,Hypertension NOS,Crnry athrscl natve vssl,Iron defic anemia NOS,Obstructive sleep apnea,Atrial fibrillation,Polycythemia vera,Long-term use anticoagul
Admission Date:  [**2200-12-15**]              Discharge Date:   [**2200-12-23**]

Date of Birth:  [**2128-5-23**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
Back/Abdominal Pain

Major Surgical or Invasive Procedure:
None

History of Present Illness:
(Russian interpreter requested for the AM) 72 M w/ pmh of HTN,
CAD, Nonischemic cardiomyopathy (EF 40%) CKD, chronic abdominal
pain admitted on [**12-15**] with left sided abdominal pain, that
started acutely 4 hours prior to presentation and associated
with nausea. Patient has been most tender on the left side and
periumbilical region. Denied fevers, chills, new foods, sick
contacts. Different from his chronic abdominal pain.
.
In the ED, initial VS: 85 131/61 19 94% on RA. Exam noted for
tenderness on the left side. CT ABD/Pelvis showed Left sided
nephrolithiasis with mild left renal edema, perinephric
stranding, no other abdominal process. U/A showed blood but no
leukocytosis. Got 16 IV morphine, 8IV Zofran. Urology was
reportedly consulted in ED, though no note in chart or OMR.
.
On the floor the patient continued to have abdominal pain and
nausea only partly relieved by morphine.  Of note, patient has
been getting 125cc/hr of IV fluids for the last 1.5 day, and did
not receive his home lasix dose.
.
Patient was noted to be hypoxic to 85% while on 3L while
sleeping this evening. Exam notable for bilateral crackles. He
complained of some shortness of breath.  He received 40mg IV
lasix x1 with good urine output of 300cc+.  ABG was 7.36/36/72
while on 100% NRB. CXR notable for bilateral pulm edema. Patient
had persistent O2 sats of 85%-90% on 6L nc. He was transferred
to the MICU for relative hypoxia and nursing concern.

.
.
On MICU eval patient complained more of abdominal pain, though
did not feel comfortable with breathing. This was confirmed with
a Russian interpreter. A trial of Bipap at his usual OSA
overnight settings was attempted, with sats still 90%.
.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies diarrhea, or changes
in bowel habits.

Past Medical History:
HTN
Smoking
Polycythemia [**1-20**] OSA?
OSA refractory to CPAP
hx iron deficiency anemia
CrI with bl CR 1.3-1.5 [**1-20**] HTN
CAD: last cath [**6-21**] documenting mild to mod diffuse CAD, but no
obstructing lesions, MI x 2; EF 50% most recently, 2+ MR, 2+ AR

Atrial fibrillation on coumadin
Medullary thyorid CA s/p thyroidectomy
Parathyroid adenoma s/p partial parathyroidectomy
TURP [**9-/2191**]
BPH
PUD s/p gastrectomy/Billroth II [**2172**]
[**Doctor First Name **] [**Doctor Last Name **] tear in [**2195**] p/w BRBPR
s/p CCY
ventral hernia
Raynaud's
hematuria with hx epidymitis
depression


Family History:
No h/o premature CAD, no family hx of Medullary thyorid CA

Physical Exam:
Vitals: T:97.8 BP: 152/60 P: 76 R: 18 O2:  95% on Bipap
General: Alert, oriented, tachypnic
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated though body habitus is quite
large, so this is difficult to assess, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregularly irregular, no murmurs
Abdomen:  soft, mildly tender to deep palpation over R side,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU:  foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
[**2200-12-18**] KUB: prelim read: Gas distended small bowel may
represent ileus vs early/partial obstruction.
.
[**2200-12-17**] Portable CXR: FINDINGS: Since the previous chest
radiograph, bilateral pleural effusions and pulmonary vascular
congestion have improved and are now minimal. No new
consolidation, left lower lobe atelectasis also improved with
partial reappearance of the left hemidiaphragm. Cardiomegaly is
unchanged. IMPRESSION: Overall improvement in pleural effusions,
pulmonary vascular congestion and
left lower lobe atelectasis.
.
[**2200-12-16**] Renal US: FINDINGS: Note is made that this is a limited
portable study. The right kidney measures 10.3 cm and the left
kidney measures 12.7 cm. There is a borderline pelvocaliectasis
seen in the left kidney which appears unchanged from the CT of
yesterday. No renal stone can be identified. No hydronephrosis
is seen in the right kidney. IMPRESSION: Mild fullness of the
left kidney, unchanged from the CT of [**2200-12-15**].
.
[**2200-12-15**] CT abd/pelvis without IV contrast: There is bibasilar
subsegmental dependent atelectasis at the lung bases. The heart
is enlarged as before. Coronary artery atherosclerotic
calcification is noted. Evaluation of the abdominal organs is
limited without IV contrast. Within this limitation, the liver
is unremarkable. The common bile duct measures up to 11 mm,
which is unchanged from prior. Gallbladder is not seen. The
pancreas demonstrates mild fatty atrophy. The spleen and adrenal
glands are unremarkable. The opacified stomach and
intra-abdominal loops of bowel are unremarkable. The left kidney
appears slightly edematous compared to the right and there is
mild left perinephric stranding. In addition, there is slight
engorgement of the left renal pelvis. There is a 2.5-mm
radiodensity along the expected course of the left mid ureter
(2:38) which likely represents a ureteral calculus. No other
calculi are identified. There is extensive atherosclerosis of
the abdominal aorta and several branches. A saccular infrarenal
aortic aneurysm is again noted measuring 3.0 (TRV) x 2.9 (AP) x
2.5 (CCN) is not significantly increased from prior when it
measured 2.9 x 2.8 x 2.5 cm. No free air or fluid is noted in
the abdomen. No mesenteric or retroperitoneal lymphadenopathy
meeting CT criteria for pathologic enlargement is noted. The
patient is status post partial gastrectomy with
gastrojejunostomy. The urinary bladder, distal ureters, seminal

vesicles, prostate, sigmoid colon and rectum are unremarkable.
There is no free fluid or pelvic or inguinal lymphadenopathy
noted. BONE WINDOWS: No suspicious lytic or sclerotic osseous
lesions identified.
IMPRESSION: 1. Left mid ureteral 2.5-mm stone with associated
left perinephric stranding and mild renal edema. 2. No evidence
of mesenteric ischemia, diverticulitis or acute aortic
pathology, although evaluation is somewhat limited on this
non-contrast-enhanced CT. 3. No significant change in the
saccular infrarenal abdominal aortic aneurysm compared to
[**2200-2-27**]. 4. Cardiomegaly.
.
[**2200-12-16**] EKG: "Fine" atrial fibrillation with ventricuilar
premature beats. Left ventricular hypertrophy. Intraventricular
conduction delay with left axis deviation may be due to left
ventricular hypertrophy and left anterior fascicular block. ST-T
wave abnormalities may be due to left ventricular hypertrophy,
intraventricular conduction delay and/or possible ischemia.
Since the previous tracing of [**2200-12-14**] no significant change.
.
[**2200-12-14**] 09:40PM   PT-26.5* PTT-31.5 INR(PT)-2.6*
[**2200-12-14**] 09:40PM   PLT COUNT-200
[**2200-12-14**] 09:40PM   NEUTS-81.1* LYMPHS-13.2* MONOS-4.5 EOS-0.5
BASOS-0.7
[**2200-12-14**] 09:40PM   WBC-10.0# RBC-4.80 HGB-13.3* HCT-40.4 MCV-84#
MCH-27.7 MCHC-32.9 RDW-15.6*
[**2200-12-14**] 09:40PM   LIPASE-28
[**2200-12-14**] 09:40PM   ALT(SGPT)-21 AST(SGOT)-24 ALK PHOS-76 TOT
BILI-0.6
[**2200-12-14**] 09:40PM   estGFR-Using this
[**2200-12-14**] 09:40PM   GLUCOSE-142* UREA N-38* CREAT-2.3* SODIUM-142
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-22 ANION GAP-16
[**2200-12-14**] 10:37PM   LACTATE-1.1
[**2200-12-15**] 01:50AM URINE  HYALINE-[**2-20**]*
[**2200-12-15**] 01:50AM URINE  RBC-[**11-7**]* WBC-[**2-20**] BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2200-12-15**] 01:50AM URINE  BLOOD-LGE NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2200-12-15**] 01:50AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2200-12-15**] 01:50AM URINE  GR HOLD-HOLD
[**2200-12-15**] 01:50AM URINE  HOURS-RANDOM
[**2200-12-15**] 01:50AM URINE  HOURS-RANDOM CREAT-176 SODIUM-48
POTASSIUM-72 CHLORIDE-40

Brief Hospital Course:
72 year old male with ephysema, OSA, cardiomyopathy (EF 40%),
CAD, CKD presents with nephrolithiasis, acute on chronic kidney
disease whose course has been complicated by pulmonary edema and
hypoxia requiring diuresis and now ileus vs partial obstruction.

.
#. Nephrolithiasis: This was the patient's first kidney stone. A
CT scan done initially showed perinephric stranding and a stone
in the left ureter.  Urology evaluated the patient.  He was
started on tamsulosin and restarted on flomax.  The patient
developed ARF secondary to obstructive uropathy (see below), but
maintained good urine output.  He was initially treated with iv
dilaudid (which was switched to tylenol and oxycodone secondary
to ileus) and ivfs, which was stopped secondary to volume
overload (see below).  He was also treated with a course of
ceftriaxone for suspected pyelonephritis.  He passed several
stones on this admission, and one was sent for analysis.  A
repeat CT scan was done that showed an obstructive stone in the
UV junction with hydronephrosis and urology recommended
observation.  Patient subsequently passed stone with improvement
of creatine, pain, and large quantity of diuresis.
.
#. Hypoxia: On presentation patient received fluid hydration for
nephrolithiasis and subsequently, developed hypoxia.  He was
then transferred to the MICU.  Patient was ruled out for
myocardial damage and CXR did not show evidence of
consolidation. His hypoxia was thought to be secondary to fluid
overload from cardiomyopathy and acute on chronic kidney disease
(see below). He was aggressively diuresed approximately 5 L in
the MICU with improvement of SaO2.  Upon transfer back to the
floors, he was weaned onto room air keeping his SaO2 above 90%.
He was continued on his home CPAP overnight for OSA and lasix
was restarted at his home dose po.
.
#. Acute on chronic kidney disease: Baseline Cr 1.4-1.7.
Throughout hospitalization Cr peaked to 3.2 and subsequently
trended down after passing of multiple stones.  Nephrology was
consulted and initially, the team suspected a pre-renal vs
vascular disease as possible etiology of his ARF.  However, a
repeat CT abdomen was done that showed worsening hydronephrosis
and a ~4mm stone at the UV junction.  Urology was then consulted
regarding surgery and advised monitoring the patient clinically
given his comorbidities and risk of anesthesia.  Patient passed
a stone [**12-22**] and subsequent to this Creatine improved to
baseline and began putting out large amounts of urine.  It was
ultimately felt that his ARF was likely secondary to obstructive
uropathy with resolution of passing of stone and
post-obstructive diuresis.  Patient was discharged with follow
up with his outpatient nephrologist.  Throughout this time his
lisinopril was held and not restarted on discharge.
.
#. Ileus: Patient developed ileus secondary to large quantity of
narcotics and was treated with an aggressive bowel regimen with
resolution of his symptoms.
.
#. Atrial fibrillation: On admission patient was
supratherapeutic. His coumadin dose was initially held and then
restarted at 2mg daily.  INR remained therapeutic throughout.
Patient was continued on metoprolol for rate control.
.
#. Obstructive sleep apnea: He was continued on CPAP overnight
on home settings
.
#. Hypertension: His lisinopril was held in the setting of acute
on chronic renal desease.  He was continued on his home regimen
of amlodipine and metoprolol.
.
#. Acute on chronic systolic heart failure: Patient had
pulmonary edema (see above) secondary to fluid overload and was
diuresed in the MICU.  He was further managed with his home beta
blocker, lasix, and ACEi held due to kidney issues.
.
#. H/o PUD/gastritis: continued on home [**Hospital1 **] PPI
.
#. S/p thyroidectomy: continued on home levothyroxine
.
#. S/p parathyroidectomy: continued on calcitriol

Medications on Admission:
AMLODIPINE - 10 mg po qhs
ATORVASTATIN [LIPITOR] - 80 mg po daily
BIPAP - 12/8 CM H2O - NIGHTLY.
CALCITRIOL - (dc med) - 0.25 mcg Capsule - 2 Capsule(s) by mouth
twice a day
FINASTERIDE - 5 mg po daily
FLUOXETINE [PROZAC] - 20 mg po daily
FUROSEMIDE - 20 mg po daily
LEVOTHYROXINE - 200 mcg po daily
LISINOPRIL - 40 mg po daily
METOPROLOL SUCCINATE - 50 mg po daily
PANTOPRAZOLE [PROTONIX] - 40 mg po bid
TRAZODONE - 50 mg po qhs PRN insomnia
WARFARIN - 2.5-5 mg po daily
Aspirin 81 mg po daily
ASCORBIC ACID - 500 mg po daily
CALCIUM CARBONATE [CALCIUM 600] - 600 mg (1,500 mg) po tid
CYANOCOBALAMIN - 2,000 mcg po daily
DOCUSATE SODIUM [COLACE] - 100 mg po bid
FERROUS SULFATE - 324 mg (65 mg Iron) po daily
SENNA - 8.6 mg po bid PRN constipation
SIMETHICONE - 80 mg po qid

Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
15. Cyanocobalamin 1,000 mcg Tablet Sig: Two (2) Tablet PO once
a day.
16. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO four times a day.
18. Calcium Carbonate 600 mg (1,500 mg) Tablet Sig: One (1)
Tablet PO three times a day.
19. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
20. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
21. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain: not to exceed more than 4mg per day.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Nephrolithiasis
Obstructive Uropathy
Urinary Tract Infection
Pulmonary Edema


Discharge Condition:
A&O x 3
Independent Ambulation


Discharge Instructions:
Dear Mr. [**Last Name (Titles) 27530**],
We had the pleasure of taking care of you at [**Hospital1 18**].  You were
admitted to the hospital because you had abdominal pain from
kidney stones.  While you were here we treated you with iv
fluids.  However, because of your kidney dysfunction and heart
failure you developed difficulty breathing because of volume
overload, and so you were treated with lasix.  Your kidney
stones passed on their own, and your kidney function has since
improved.

We have made the following changes to your medications:
1. We have stopped your Lisinopril because of your kidney
function, please see your PCP before restarting this medication.
2. We have discharged you on Coumadin 2mg daily.  Please follow
up in [**Hospital3 271**] to have your INR checked.
3. We have started you on tamsulosin, please continue this
4. We have restarted your flomax, please continue this.  Your
PCP will decide if you should stay on this medication.
5. We have started you on tylenol for pain.  Do not exceed 4mg
per day.

Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.

Please make sure you follow up with your PCP and Nephrologist
(kidney doctor); see below.

Followup Instructions:
Follow up with PCP:
[**Name10 (NameIs) 357**] follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2200-12-26**] at 02:20p.  His
office is in the [**Hospital Ward Name **] CENTER, [**Location (un) **] [**Hospital 191**] MEDICAL UNIT
(SB).

Follow up with Nephrology:
Someone from Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office will call you to schedule
an appointment time for you.  You will need to follow up with
him regarding your kidney function and kidney stones.  He may
decide to get an US of your kidney for further assessment.

Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2201-1-27**] 3:30

Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2201-2-11**] 3:00

Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2201-2-11**] 3:00



Completed by:[**2200-12-24**]
{'Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Urinary tract infection, site not specified,Other primary cardiomyopathies,Paralytic ileus,Calculus of kidney,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Iron deficiency anemia, unspecified,Obstructive sleep apnea (adult)(pediatric),Atrial fibrillation,Polycythemia vera,Long-term (current) use of anticoagulants'}


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: Back/Abdominal Pain

PRESENT ILLNESS: (Russian interpreter requested for the AM) 72 M w/ pmh of HTN,
CAD, Nonischemic cardiomyopathy (EF 40%) CKD, chronic abdominal
pain admitted on [**12-15**] with left sided abdominal pain, that
started acutely 4 hours prior to presentation and associated
with nausea. Patient has been most tender on the left side and
periumbilical region. Denied fevers, chills, new foods, sick
contacts. Different from his chronic abdominal pain.
.
In the ED, initial VS: 85 131/61 19 94% on RA. Exam noted for
tenderness on the left side. CT ABD/Pelvis showed Left sided
nephrolithiasis with mild left renal edema, perinephric
stranding, no other abdominal process. U/A showed blood but no
leukocytosis. Got 16 IV morphine, 8IV Zofran. Urology was
reportedly consulted in ED, though no note in chart or OMR.
.
On the floor the patient continued to have abdominal pain and
nausea only partly relieved by morphine.  Of note, patient has
been getting 125cc/hr of IV fluids for the last 1.5 day, and did
not receive his home lasix dose.
.
Patient was noted to be hypoxic to 85% while on 3L while
sleeping this evening. Exam notable for bilateral crackles. He
complained of some shortness of breath.  He received 40mg IV
lasix x1 with good urine output of 300cc+.  ABG was 7.36/36/72
while on 100% NRB. CXR notable for bilateral pulm edema. Patient
had persistent O2 sats of 85%-90% on 6L nc. He was transferred
to the MICU for relative hypoxia and nursing concern.

MEDICAL HISTORY: HTN
Smoking
Polycythemia [**1-20**] OSA?
OSA refractory to CPAP
hx iron deficiency anemia
CrI with bl CR 1.3-1.5 [**1-20**] HTN
CAD: last cath [**6-21**] documenting mild to mod diffuse CAD, but no
obstructing lesions, MI x 2; EF 50% most recently, 2+ MR, 2+ AR

MEDICATION ON ADMISSION: AMLODIPINE - 10 mg po qhs
ATORVASTATIN [LIPITOR] - 80 mg po daily
BIPAP - 12/8 CM H2O - NIGHTLY.
CALCITRIOL - (dc med) - 0.25 mcg Capsule - 2 Capsule(s) by mouth
twice a day
FINASTERIDE - 5 mg po daily
FLUOXETINE [PROZAC] - 20 mg po daily
FUROSEMIDE - 20 mg po daily
LEVOTHYROXINE - 200 mcg po daily
LISINOPRIL - 40 mg po daily
METOPROLOL SUCCINATE - 50 mg po daily
PANTOPRAZOLE [PROTONIX] - 40 mg po bid
TRAZODONE - 50 mg po qhs PRN insomnia
WARFARIN - 2.5-5 mg po daily
Aspirin 81 mg po daily
ASCORBIC ACID - 500 mg po daily
CALCIUM CARBONATE [CALCIUM 600] - 600 mg (1,500 mg) po tid
CYANOCOBALAMIN - 2,000 mcg po daily
DOCUSATE SODIUM [COLACE] - 100 mg po bid
FERROUS SULFATE - 324 mg (65 mg Iron) po daily
SENNA - 8.6 mg po bid PRN constipation
SIMETHICONE - 80 mg po qid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T:97.8 BP: 152/60 P: 76 R: 18 O2:  95% on Bipap
General: Alert, oriented, tachypnic
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated though body habitus is quite
large, so this is difficult to assess, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregularly irregular, no murmurs
Abdomen:  soft, mildly tender to deep palpation over R side,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU:  foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: No h/o premature CAD, no family hx of Medullary thyorid CA

SOCIAL HISTORY:  

### Response:
{'Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Urinary tract infection, site not specified,Other primary cardiomyopathies,Paralytic ileus,Calculus of kidney,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Iron deficiency anemia, unspecified,Obstructive sleep apnea (adult)(pediatric),Atrial fibrillation,Polycythemia vera,Long-term (current) use of anticoagulants'}
