CHIEF COMPLAINT: Retroperitoneal bleed

PRESENT ILLNESS: 53 year old Hatian Creole spaaeking woman s/p percutaneous PFO
repair by Dr. [**Last Name (STitle) **] on [**8-7**] complicated by retroperitoneal bleed
and new onset A-fib.

MEDICAL HISTORY: - Prior CVA [**2132**] p/w with L arm weakness now resolved.  though
[**2-27**] from PFO.
- H/o PFO now s/p percutaneous repair, for hope to come off
warfarin
- HTN
- hypercholesterolemia
- Vitreal bleed secondary to Coumadin therapy
- H/o Colonic polyp
- Mild diverticulosis
- GERD
- Cataract surgery [**7-/2136**]
- ? Hysterectomy

MEDICATION ON ADMISSION: Medications prior to admission:
clopidogrel 75 mg
enoxaparin 80 mg [**Hospital1 **]
olmesartan-hydrochlorothiazide 20/12.5 mg
potassium chloride 40 mEq
simvastatin 40 mg
aspirin 325 mg

ALLERGIES: Hydralazine

PHYSICAL EXAM: ADMISION EXAM
T99.3 HR 94 (NSR), BP 166/66, RR 30 O2SAT 98% on 3L O2.
Gen: Hatian Creole (no english) speaking woman in NAD.
HEENT: EOMI PERRL MMM
Neck: JVD at 10 cm
Pulm: Diminished lung sounds from bases to mid lung fields R>L,
No obvious wheezing
CV: RRR 2/6 SEM RUSB, no R/G
ABD: Obese, soft, 5-8 cm ecchymoses over R flank, Large
ecchymosis over R groin
EXT: no CCE
Pulses: 2+ DP pulses
.
DISCHARGE EXAM
VS: T 97-100.3 BP 100-125/60-81 HR 60-85 RR 20-30 O2 Sat 94% 2L
I/O: -1100cc/24 hours
GEN: NAD, sitting up in bed
HEENT: MMM, midline tongue, PERRL, EOMI
HEART: RRR, grade 2 systolic murmur heard best at 2ICS, no
radiation
LUNG: decreased breath sound on the right, fine crackles at
right lung base, no wheeze or rhonchi
ABD: soft, nontender, distended, +BS, no mass palpated
EXT: warm, nontender, no pitting edema, peripheral pulse 2+
bilaterally
NEURO: A/Ox3, Non focal

FAMILY HISTORY: 

SOCIAL HISTORY: Absence of tobacco, alcohol, illicit drug use.
She is a homemaker.
Hemorrhage complicating a procedure,Acute kidney failure, unspecified,Ostium secundum type atrial septal defect,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Atrial fibrillation,Leukocytosis, unspecified
Hemorrhage complic proc,Acute kidney failure NOS,Secundum atrial sept def,Abn react-surg proc NEC,Hypertension NOS,Hyperlipidemia NEC/NOS,Esophageal reflux,Atrial fibrillation,Leukocytosis NOS
Admission Date:  [**2137-8-9**]              Discharge Date:   [**2137-8-18**]

Date of Birth:  [**2080-8-19**]             Sex:   F

Service: MEDICINE

Allergies:
Hydralazine

Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Retroperitoneal bleed

Major Surgical or Invasive Procedure:
PFO repair


History of Present Illness:
53 year old Hatian Creole spaaeking woman s/p percutaneous PFO
repair by Dr. [**Last Name (STitle) **] on [**8-7**] complicated by retroperitoneal bleed
and new onset A-fib.

For a full HPI please see H&P from vascualr surgery [**2137-8-9**].
Briefly Mrs. [**Known lastname 4597**] underwent percutaneous PFO closure on
[**2137-8-7**] and was discharged on therapeutic lovenox and plavix.
The morning of [**8-9**] she felt lightheaded and weak and presented
to an OSH where she was noted to have a HCT of 16 and evidence
of an RP bleed. She was transfused 1 unit PRBCs and transferred
to [**Hospital1 18**]. She was admitted to the CVICU where she was stabilized
with IVF, 8 units PRBC and 6 u plts. Her hematocrit responded
appropriately and stabilized around 26-27. He lovenox and plavix
has been DC'd. She is currently on ASA.

On [**2137-8-11**] she was noted to be in A-Fib which is new for her.
She was seen by cardiology who recommended Amiodarone which
converted her rhythm back to NSR. She has been in NSR since 2am
on [**8-12**].

On transfer to [**Hospital1 1516**] her vitals were: T99.3 HR 94 (NSR), BP
166/66, RR 30 O2SAT 98% on 3L O2. Her I/O status is +2.3L from
admission. She curently denies any CP, abd pain, LE edema or
pain. She says that her breathing has improved.

Past Medical History:
- Prior CVA [**2132**] p/w with L arm weakness now resolved.  though
[**2-27**] from PFO.
- H/o PFO now s/p percutaneous repair, for hope to come off
warfarin
- HTN
- hypercholesterolemia
- Vitreal bleed secondary to Coumadin therapy
- H/o Colonic polyp
- Mild diverticulosis
- GERD
- Cataract surgery [**7-/2136**]
- ? Hysterectomy

Social History:
Absence of tobacco, alcohol, illicit drug use.
She is a homemaker.

Physical Exam:
ADMISION EXAM
T99.3 HR 94 (NSR), BP 166/66, RR 30 O2SAT 98% on 3L O2.
Gen: Hatian Creole (no english) speaking woman in NAD.
HEENT: EOMI PERRL MMM
Neck: JVD at 10 cm
Pulm: Diminished lung sounds from bases to mid lung fields R>L,
No obvious wheezing
CV: RRR 2/6 SEM RUSB, no R/G
ABD: Obese, soft, 5-8 cm ecchymoses over R flank, Large
ecchymosis over R groin
EXT: no CCE
Pulses: 2+ DP pulses
.
DISCHARGE EXAM
VS: T 97-100.3 BP 100-125/60-81 HR 60-85 RR 20-30 O2 Sat 94% 2L
I/O: -1100cc/24 hours
GEN: NAD, sitting up in bed
HEENT: MMM, midline tongue, PERRL, EOMI
HEART: RRR, grade 2 systolic murmur heard best at 2ICS, no
radiation
LUNG: decreased breath sound on the right, fine crackles at
right lung base, no wheeze or rhonchi
ABD: soft, nontender, distended, +BS, no mass palpated
EXT: warm, nontender, no pitting edema, peripheral pulse 2+
bilaterally
NEURO: A/Ox3, Non focal


Pertinent Results:
ADMISSION LABS

[**2137-8-9**] 05:40PM   WBC-18.1* RBC-2.63* HGB-7.6* HCT-21.3*#
MCV-81* MCH-28.9 MCHC-35.8* RDW-16.1*
[**2137-8-9**] 05:40PM   NEUTS-87.2* LYMPHS-10.6* MONOS-1.9* EOS-0.1
BASOS-0.2
[**2137-8-9**] 05:40PM   PLT COUNT-157
[**2137-8-9**] 05:40PM   PT-12.5 PTT-45.8* INR(PT)-1.1
[**2137-8-8**] 06:05AM   UREA N-14 CREAT-0.7 SODIUM-141 POTASSIUM-3.4
CHLORIDE-106
[**2137-8-8**] 06:05AM   CK-MB-4
.
DISCHARGE LABS

[**2137-8-18**] 10:30AM BLOOD WBC-16.3* RBC-3.28* Hgb-9.7* Hct-28.9*
MCV-88 MCH-29.4 MCHC-33.4 RDW-17.0* Plt Ct-445*
[**2137-8-18**] 10:30AM BLOOD Plt Ct-445*
[**2137-8-15**] 06:14AM BLOOD Ret Aut-4.8*
[**2137-8-18**] 10:30AM BLOOD Glucose-136* UreaN-29* Creat-1.1 Na-137
K-3.7 Cl-95* HCO3-34* AnGap-12
[**2137-8-18**] 10:30AM BLOOD Calcium-10.1 Phos-2.3* Mg-2.1
.
RELEVANT STUDIES
CXR ([**2137-8-15**]): Cardiomediastinal contours are unchanged with
stable cardiomegaly. Vascular
congestion has resolved. Small right pleural effusion is
unchanged. Right
lower lobe collapse has improved. The left lung is clear. There
is no
pneumothorax.
.
TTE ([**2137-8-11**]): A septal occluder device is seen across the
interatrial septum. Left ventricular wall thicknesses and cavity
size are normal. Left ventricular systolic function is
hyperdynamic (EF>75%). Right ventricular chamber size and free
wall motion are normal. There is moderate pulmonary artery
systolic hypertension. There is a very small circumferential
pericardial effusion.

Compared with the prior study (images reviewed) of [**2137-8-8**],
biventricular systolic function is now more dynamic and the
heart rate is higher. The pericardial effusion is similar. A
right pleural effusion is now seen (not specifically examined
for in the prior study).
.
CT ABDOMEN ([**2137-8-9**]):
1. 16.7-cm right retroperitoneal hematoma with hematocrit level
and layering hyperdensity suggests active extravasation with
peripheral stranding superiorly adjacent to the right kidney and
extending into the right groin without direct relationship to
the right iliac/femoral vessels. Trace fluid is also seen
adjacent to the duodenum in the retroperitoneal space.
2. Small pericardial effusion, right greater than left small
pleural
effusions, small free pelvic fluid and trace perihepatic fluid.
3. Stranding in the left lower pelvis/groin soft tissues could
reflect small hematoma.
.
CT PELVIS ([**2137-8-9**]):
1. 16.7-cm right retroperitoneal hematoma with hematocrit level
and layering hyperdensity suggests active extravasation with
peripheral stranding superiorly adjacent to the right kidney and
extending into the right groin without direct relationship to
the right iliac/femoral vessels. Trace fluid is also seen
adjacent to the duodenum in the retroperitoneal space.
2. Small pericardial effusion, right greater than left small
pleural
effusions, small free pelvic fluid and trace perihepatic fluid.
3. Stranding in the left lower pelvis/groin soft tissues could
reflect small hematoma.


Brief Hospital Course:
PRIMARY REASON FOR ADMISSION: This is a 56 yo Haitian Creole
speaking female s/p percutaneous PFO repair, presented 2 days
post-op with dizziness and was found to have a retroperitoneal
bleed likely a complication from the procedure.
.
ACTIVE ISSUES
# Retroperitoneal Bleed
This is likely a complication of percutaneous PFO repair on
[**8-7**].  Patient presented with a Hct of 15.4, hypotension and
dizziness.  Patient was admitted to CVICU.  Initially, patient's
Hct responded to the transfusion but not as robust as expected,
suggesting persistent slow bleeding.  Patient was seen by
cardiology and surgery, and decision was made to treat
medically.  Antiplatelet treatments were held initially except
for aspirin, which was started at 81 mg, but later increased to
162 mg daily.  Patient received a total of 8 units of RBC and 15
units of platelets.  Her Hct was steadily slowing trending up
during the last 72 hours prior to discharge.
OUTPATIENT ISSUES:
- Discontinued clopidogrel, enoxaparin
- Please STOP taking olmesartan-hydrochlorothiazide until
further discussion with Dr. [**Last Name (STitle) **].
.
# A-Fib.
Patient was found to have new onset atrial fibrillation while in
the CVICU.  She was initiated on amiodarone and converted
successfully.  Cardiology was consulted.  Patient remained in
normal sinus rhythm throughout the rest of hospitalization.
OUTPATIENT ISSUES:
- STARTED amiodarone 200 mg qd.
- STARTED metoprolol XL 100 mg qd
.
# Pulmonary edema
After transfer out of the CVICU, patient was found to have
increased respiratory distress and tachypnea.  She was found to
be pulmonary edema based on physical exam and chest X-ray
findings.  She was transferred to CCU, and received lasix drip
for diuresis.  Patient improved shortly after the initiation of
diuresis and was able to maintain O2 saturation in high 90s
during ambulation. Her drip was weaned and she was maintained on
IV lasix with good UOP and transitioned to PO for discharge.
OUTPATIENT ISSUES:
- STARTED furosemide 40 mg po daily
- STARTED spirolactone 12.5 mg po daily
.
# Acute renal failure
Patient's baseline Cr was normal.  During this hospitalization,
increase of Cr to ~1.5 was seen twice, like a result of prerenal
hypovolemia in the setting of active bleed.  Her acute renal
insufficiency resolved with adequate transfusion.
.
# Hypotension/hypertension
Patient has a documented history of hypertension.  On admission
she was found to be hypotensive given significant Hct drop
secondary to RP bleed.  We held her blood pressure medication
initially.  After active bleeding resolved, her blood pressure
improved.  We started her on Losartan before discharge, but
continued to hold hydrochlorothiazide given active diuresis.
OUTPATIENT ISSUES:
- Discontinued olmesartan, HCTZ; and started losartan 25 mg
daily.
.
# Leukocytosis.
Patient's WBC was elevated throughout this hospitalization,
although she remained afebrile throughout this admission. The
leukocytosis was felt most like secondary to the RP bleed, but
urine culture later grew enterobacter cloace and klebsiella
pneumoniae.  She was treated with ciproflaxacin for 7 days in
the setting of complicated UTI (foley associated).  Her chest
x-ray did not show evidence of pneumonia, and her blood culture
remained negative to date.
OUTPATIENT ISSUES
- STARTED Ciprofloxacin 500 mg [**Hospital1 **] for a total of 7 days
.
CHRONIC ISSUES
Patient has a documented history of GERD and
hypercholesterolemia, both of which remained stable during this
admission.
.
TRANSITIONAL ISSUES
- Patient maintained a full code during this admission.
- Patient has followup appointment with Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) 7047**].
- Patient was instructed to get CBC and CHEM10 prior to her
followup appointment.

Medications on Admission:
Medications prior to admission:
clopidogrel 75 mg
enoxaparin 80 mg [**Hospital1 **]
olmesartan-hydrochlorothiazide 20/12.5 mg
potassium chloride 40 mEq
simvastatin 40 mg
aspirin 325 mg

Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*9 Tablet(s)* Refills:*0*
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
7. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please obtain CBC and CHEM10


Discharge Disposition:
Home

Discharge Diagnosis:
Primary diagnosis
patent foramum ovale
retroperitoneal bleed
pulmonary edema

Secondary diagnosis
Hypertension
Hyperlipidemia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Ms [**Known lastname 4597**],

You came to our hospital for an elective repair of a defect in
your heart.  You surgery was successfully performed.  However,
later there was evidence that you had a bleed into the back of
your belly from the procedure.  Because of that, you received a
total of 8 units of red blood cells and 15 units of platelets.
The multiple transfusion also lead to accumulation of fluid in
your lung.  You were treated in our cardiac critical care unit
for diuresis.  You blood count was finally stable, and your
breathing improved significantly as well.  At this point, we
thought that you are stable enough to go home to continue your
recovery.

Please note that the following medications have been changed.
- Please STOP taking clopidogrel until further discussion with
Dr. [**Last Name (STitle) **].
- Please STOP taking olmesartan-hydrochlorothiazide until
further discussion with Dr. [**Last Name (STitle) **].
- Please STOP taking enoxaparin until further discussion with
Dr. [**Last Name (STitle) **].
- Please STOP taking potassium chloride until further discussion
with Dr. [**Last Name (STitle) **].
- Please START taking amiodarone 200 mg orally daily
- Please START taking furosemide 40 mg orally daily
- Please START taking losartan 25 mg orally daily
- Please START taking metoprolol 100 mg orally daily
- Please START taking ciprofloxacin 500 mg orally twice day for
another 4 days (finish on [**8-22**])

You will need follow up appointments with Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) 7047**].  Unfortunately, we could not get the appointments for
you on the weekend.  We will set up the appointment for you on
Monday, and let you know early this week.  In the meantime, it
will be helpful for your doctor if you could measure your daily
weight and blood pressure, document them and bring them to your
doctor's appointment.

It has been a privilege to take care of you here at [**Hospital1 18**].  We
wish you have a speedy recovery.

Followup Instructions:
Patient will need follow up appointment with Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) 7047**].  Appointments will be set up on Monday.  Patient should
receive phone call early next week about her appointment.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
{'Hemorrhage complicating a procedure,Acute kidney failure, unspecified,Ostium secundum type atrial septal defect,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Atrial fibrillation,Leukocytosis, unspecified'}


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: Retroperitoneal bleed

PRESENT ILLNESS: 53 year old Hatian Creole spaaeking woman s/p percutaneous PFO
repair by Dr. [**Last Name (STitle) **] on [**8-7**] complicated by retroperitoneal bleed
and new onset A-fib.

MEDICAL HISTORY: - Prior CVA [**2132**] p/w with L arm weakness now resolved.  though
[**2-27**] from PFO.
- H/o PFO now s/p percutaneous repair, for hope to come off
warfarin
- HTN
- hypercholesterolemia
- Vitreal bleed secondary to Coumadin therapy
- H/o Colonic polyp
- Mild diverticulosis
- GERD
- Cataract surgery [**7-/2136**]
- ? Hysterectomy

MEDICATION ON ADMISSION: Medications prior to admission:
clopidogrel 75 mg
enoxaparin 80 mg [**Hospital1 **]
olmesartan-hydrochlorothiazide 20/12.5 mg
potassium chloride 40 mEq
simvastatin 40 mg
aspirin 325 mg

ALLERGIES: Hydralazine

PHYSICAL EXAM: ADMISION EXAM
T99.3 HR 94 (NSR), BP 166/66, RR 30 O2SAT 98% on 3L O2.
Gen: Hatian Creole (no english) speaking woman in NAD.
HEENT: EOMI PERRL MMM
Neck: JVD at 10 cm
Pulm: Diminished lung sounds from bases to mid lung fields R>L,
No obvious wheezing
CV: RRR 2/6 SEM RUSB, no R/G
ABD: Obese, soft, 5-8 cm ecchymoses over R flank, Large
ecchymosis over R groin
EXT: no CCE
Pulses: 2+ DP pulses
.
DISCHARGE EXAM
VS: T 97-100.3 BP 100-125/60-81 HR 60-85 RR 20-30 O2 Sat 94% 2L
I/O: -1100cc/24 hours
GEN: NAD, sitting up in bed
HEENT: MMM, midline tongue, PERRL, EOMI
HEART: RRR, grade 2 systolic murmur heard best at 2ICS, no
radiation
LUNG: decreased breath sound on the right, fine crackles at
right lung base, no wheeze or rhonchi
ABD: soft, nontender, distended, +BS, no mass palpated
EXT: warm, nontender, no pitting edema, peripheral pulse 2+
bilaterally
NEURO: A/Ox3, Non focal

FAMILY HISTORY: 

SOCIAL HISTORY: Absence of tobacco, alcohol, illicit drug use.
She is a homemaker. 

### Response:
{'Hemorrhage complicating a procedure,Acute kidney failure, unspecified,Ostium secundum type atrial septal defect,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Atrial fibrillation,Leukocytosis, unspecified'}
