CHIEF COMPLAINT: Left Arm Pain

PRESENT ILLNESS: Mr [**Known lastname 1313**] was recently in our ICU for urosepsis secondary to
nephrolithiasis.  He also has a history of type II DM and
hypertension, as well as recent diagnosis of atrial fibrillation
with RVR and acute kidney injury in the setting of his
infection.

MEDICAL HISTORY: nephrolithiasis
class III obesity
DM2
HTN
gout
atrial fibrillation

MEDICATION ON ADMISSION: 1. insulin glargine 100 unit/mL Solution Sig: Ten (10)
Subcutaneous at bedtime.
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. ceftriaxone 1 gram Recon Soln Sig: One (1)  Intravenous once
a day for 2 days: Day 1 = [**5-5**], LAST DAY= [**2121-5-18**].
5. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: Hold
for HR<60, SBP<100.
6. miconazole nitrate 2 % Powder Sig: One (1)  Topical once a
day.
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO at bedtime: Hold for SBP<100.
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please titrate warfarin dosing for goal INR of [**2-14**].
9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP<100.
10. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam
VS: HR 80, BP 90/45, SpO2 100% RA, RR 12
Gen: Caucasian male, in no apparent distress
Cardiac: Nl s1/s2 irregular rhythm, no murmurs appreciable
pulm: clear bilaterally in anterior lung fields
abd: soft, nontender,nondistended, +BS
Ext: no edema noted, nephrostomy tube in place, Foley in place

FAMILY HISTORY: Father lost kidney due to stones

SOCIAL HISTORY: retired dry cleaning machine manufacturerer
no ETOH
no tobacco
no illicits
Iron deficiency anemia secondary to blood loss (chronic),Acute kidney failure, unspecified,Chronic systolic heart failure,Urinary tract infection, site not specified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Subendocardial infarction, subsequent episode of care,Calculus of kidney,Other artificial opening of urinary tract status,Gout, unspecified,Unspecified essential hypertension,Long-term (current) use of insulin,Do not resuscitate status,Obesity, unspecified,Pain in limb
Chr blood loss anemia,Acute kidney failure NOS,Chr systolic hrt failure,Urin tract infection NOS,DMII wo cmp nt st uncntr,Atrial fibrillation,Subendo infarct, subseq,Calculus of kidney,Urinostomy status NEC,Gout NOS,Hypertension NOS,Long-term use of insulin,Do not resusctate status,Obesity NOS,Pain in limb
Admission Date:  [**2121-5-15**]              Discharge Date:   [**2121-5-19**]

Date of Birth:  [**2045-7-26**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Doctor First Name 2080**]
Chief Complaint:
Left Arm Pain

Major Surgical or Invasive Procedure:
Blood transfusion


History of Present Illness:
Mr [**Known lastname 1313**] was recently in our ICU for urosepsis secondary to
nephrolithiasis.  He also has a history of type II DM and
hypertension, as well as recent diagnosis of atrial fibrillation
with RVR and acute kidney injury in the setting of his
infection.

He is currently presenting secondary to having intermittent left
arm pain while at rehab.  A troponin was checked at the rehab
which was 0.4 and he was sent to our ED.  He denied chest pain,
dyspnea, diaphoresis, nausea.  He said the pain in his arm was
an "ache" rather than radiating pain.  His troponins during his
hospitalization last week have been trending downward; the
troponin checked in the ED is lower than his baseline and
continues his downward trend (it was 0.82 down from 1.1).

In the ED, his hematocrit was noted to be 25.6 compared to a
baseline of 31 at the start of his prior admission; during his
last ICU stay last week, his hematocrits have hovered around
25.6.  He has heme-positive stool in the ED, but he denies any
history of GI bleeding.  He does take NSAIDS sporadically.  He
states he has never had a colonoscopy.  Denies weakness,
dizziness, lightheadedness.  At baseline, he was ambulatory and
feeling well; since urosepsis, he has been less functional and
is very weak at the rehab, able to do minimal walking with
physical therapy.

During his last hospitalization, he was treated for urosepsis
that resulted secondary to an obstructing calculus above the UVJ
- urine cultures from OSH were reported to be greater than
100,000 colonies of E Coli resistant to Levofloxacin, Bactrim
and sensitive to all
other agents. He was planned for a two week antibiotic course.
Percutaneous nephrostomy tube was placed by IR (pt was kept
intubated for the procedure) on [**2121-5-6**].  This was complicated
by bleeding from nephrostomy tube when pt was started on heparin

gtt for afib.  IR reassessed the tube and found it to be in
calyx instead of kidney; this was replaced ON [**5-9**] and bleeding
from nephrostomy tube resolved. Creatinine > 4 on admission from

obstructive [**Last Name (un) **], now trending down to 1.4 after nephrostomy tube

placement.  Urology recommended initiation of tamsulosin and
placement of Foley after failed voiding trial, with plan to keep
Foley in place until Urology outpatient followup.  He was
discharged on IV ceftriaxone, last day = [**5-18**] for total 2 week
course.  During this hospitalization he also had significant
atrial fibrillation, new-onset, which required trial of
metoprolol, diltiazem, and esmolol drip. However, he became
hypotensive on these agents.  He was then
started on an amiodarone drip.  Given his CHADS of 3 and
increased risk of stroke with potential cardioversion on
amiodarione drip, he was started on heparin gtt. This was
complicated by bleeding from foley as well as nephrostomy tube.

He was eventually rate controlled on 50 QID metoprolol tartrate,
tansitioned to 200 metoprolol succinate on discharge.  He was
continued on heparin gtt and was initiated on coumadin the day
prior to discharge.  On discharge, he was well rate controlled
in the
90s-110s with bursts into the 130s-140s when eating breakfast or

lunch.  These rates would only last for several minutes and
patient remained stable and asymptomatic until resolution.  A
TTE was obtained that revealed EF of 35%, left ventricular
aneurysm, and possibly hypokinetic right ventricle, mild aortic
stenosis.  Cardiology recommended that he undergo non urgent
cardiac catheterization when stable.  He was started on a baby
aspirin.  His troponins were down-trending at time of his last
discharge.

At time of transfer to the MICU, he had no active complaints.
He denies active chest pain, arm pain, shortness of breath,
diaphoresis, nausea. His vitals were HR 80, BP 103/48, 100% RA,
afebrile.


Past Medical History:
nephrolithiasis
class III obesity
DM2
HTN
gout
atrial fibrillation


Social History:
retired dry cleaning machine manufacturerer
no ETOH
no tobacco
no illicits


Family History:
Father lost kidney due to stones


Physical Exam:
Admission Exam
VS: HR 80, BP 90/45, SpO2 100% RA, RR 12
Gen: Caucasian male, in no apparent distress
Cardiac: Nl s1/s2 irregular rhythm, no murmurs appreciable
pulm: clear bilaterally in anterior lung fields
abd: soft, nontender,nondistended, +BS
Ext: no edema noted, nephrostomy tube in place, Foley in place

Discharge Exam
VS: 98.7, BP 108/56, HR 88(70-88) SpO2 100% 2L of O2, RR 20
Gen: NAD
Cardiac: Nl s1/s2 irregular rhythm, no murmurs appreciable
pulm: clear bilaterally in anterior lung fields, no rales or
wheezes
abd: soft, nontender,nondistended, +BS
Ext: no edema noted, nephrostomy tube in place, Foley in place

Pertinent Results:
Admission Labs

[**2121-5-14**] 06:25AM BLOOD WBC-10.2 RBC-2.76* Hgb-8.4* Hct-27.2*
MCV-99* MCH-30.5 MCHC-31.0 RDW-15.4 Plt Ct-327
[**2121-5-15**] 08:55PM BLOOD Neuts-74.5* Lymphs-18.5 Monos-2.7 Eos-4.0
Baso-0.3
[**2121-5-14**] 06:25AM BLOOD PT-13.7* PTT-50.1* INR(PT)-1.3*
[**2121-5-14**] 06:25AM BLOOD Glucose-132* UreaN-22* Creat-1.4* Na-132*
K-4.1 Cl-102 HCO3-24 AnGap-10
[**2121-5-14**] 06:25AM BLOOD ALT-117* AST-80* AlkPhos-70 TotBili-0.4
[**2121-5-15**] 08:55PM BLOOD cTropnT-0.82*
[**2121-5-14**] 06:25AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.7
[**2121-5-15**] 09:22PM BLOOD Lactate-1.6

CXR [**2121-5-15**]
FINDINGS: Single portable view of the chest is compared to
previous exam from [**2121-5-10**]. The coil previously seen in
the right-sided PICC line is no longer visualized. The right
PICC tip is now seen with tip in the upper SVC.  Otherwise,
there has been no change given differences in positioning and
technique. There is no new confluent consolidation.
Cardiomediastinal silhouette is unchanged.

IMPRESSION: Right PICC now seen without coil and tip in the
upper SVC.
Otherwise, no change. No evidence of consolidation.

Additional Labs

[**2121-5-19**] 06:18AM BLOOD WBC-6.6 RBC-2.84* Hgb-8.6* Hct-27.9*
MCV-98 MCH-30.2 MCHC-30.7* RDW-16.2* Plt Ct-273
[**2121-5-18**] 05:37AM BLOOD WBC-7.0 RBC-2.84* Hgb-8.5* Hct-27.6*
MCV-97 MCH-29.9 MCHC-30.7* RDW-16.7* Plt Ct-266
[**2121-5-17**] 05:48PM BLOOD WBC-6.9 RBC-2.69* Hgb-8.1* Hct-25.7*
MCV-96 MCH-30.1 MCHC-31.5 RDW-16.4* Plt Ct-261
[**2121-5-15**] 08:55PM BLOOD Neuts-74.5* Lymphs-18.5 Monos-2.7 Eos-4.0
Baso-0.3
[**2121-5-19**] 06:18AM BLOOD Plt Ct-273
[**2121-5-19**] 06:18AM BLOOD PT-25.7* PTT-36.6* INR(PT)-2.5*
[**2121-5-18**] 05:37AM BLOOD Plt Ct-266
[**2121-5-19**] 06:18AM BLOOD
[**2121-5-18**] 05:37AM BLOOD
[**2121-5-19**] 06:18AM BLOOD Glucose-103* UreaN-24* Creat-1.3* Na-135
K-5.4* Cl-102 HCO3-24 AnGap-14
[**2121-5-18**] 05:37AM BLOOD Glucose-110* UreaN-23* Creat-1.3* Na-133
K-4.5 Cl-100 HCO3-25 AnGap-13
[**2121-5-17**] 05:44AM BLOOD Glucose-110* UreaN-20 Creat-1.3* Na-136
K-4.4 Cl-103 HCO3-25 AnGap-12
[**2121-5-19**] 06:18AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.6
[**2121-5-18**] 05:37AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.5*

Brief Hospital Course:
# Arm pain: Patient states his arm pain was a constant ache and
began after working with weights while at rehab.  The character
of the pain was not cardiac in nature, there were no ECG
changes, and his cardiac enzymes continued to downtrend from his
demand NSTEMI several weeks ago.  He is being discharged on
tramadol as needed for his pain.

# Anemia, chronic blood loss - Hct 25 upon admission; baseline
has been in the mid-20s since his first admission at the end of
[**Month (only) 547**].  Most likely this reflects anticoagulation, hematuria,
and repeated phlebotomy.  He was transfused one unit with
appropriate increase in Hct to 27/28.  He was initially guiac
positive brown stool, was guiac negative on discharge.  At this
point, he will likely need an outpatient colonoscopy.

# Recent urosepsis - Ceftriaxone was completed on [**5-18**] and
patient remained afebrile during his hospitali course. The
nephrostomy tube and foley remain in place with plans for
reevaluation by urology as an outpatient.

# [**Last Name (un) **] - Was resolving during the hospital stay and was likely in
setting of recent urosepsis and bladder outlet obstruction. Cr
1.3 on discharge, at baseline.

#. AFib - rate controlled on home regimen and transitioned to
coumadin for outpatient anticoagulation.  INR became therapeutic
and heparin drip was discontinued.

# Positive troponins - downtrending from NSTEMI that occurred
during prior hospitalization.  Troponins peaked at 1.10 on [**5-10**],
was .81 on [**5-16**].  No new EKG changes. EF of 35%, left ventricular
aneurysm, and possibly hypokinetic right ventricle, mild aortic
stenosis seen on last echo.  He will follow up with cradiology
in two weeks for likely outpatient cath.

#. DM2: Patient was stable and continued on home lantus and HISS
with appropiate blood sugars during his hospital stay.


Medications on Admission:
1. insulin glargine 100 unit/mL Solution Sig: Ten (10)
Subcutaneous at bedtime.
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. ceftriaxone 1 gram Recon Soln Sig: One (1)  Intravenous once
a day for 2 days: Day 1 = [**5-5**], LAST DAY= [**2121-5-18**].
5. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: Hold
for HR<60, SBP<100.
6. miconazole nitrate 2 % Powder Sig: One (1)  Topical once a
day.
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO at bedtime: Hold for SBP<100.
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please titrate warfarin dosing for goal INR of [**2-14**].
9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP<100.
10. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.

11. simethicone 80 mg Tablet Sig: One (1) Tablet PO every [**6-20**]
hours as needed for Gas.
12. insulin aspart 100 unit/mL Cartridge Sig: SSI  Subcutaneous
every six (6) hours: Use in conjunction with patient's sliding
scale.


Discharge Medications:
1. insulin glargine 100 unit/mL Solution Sig: Ten (10)
Subcutaneous at bedtime.
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. ceftriaxone 1 gram Recon Soln Sig: One (1)  Intravenous once
a day for 2 days: Day 1 = [**5-5**], LAST DAY= [**2121-5-18**].
5. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: Hold
for HR<60, SBP<100.
6. miconazole nitrate 2 % Powder Sig: One (1)  Topical once a
day.
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO at bedtime: Hold for SBP<100.
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please titrate warfarin dosing for goal INR of [**2-14**].
9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP<100.
10. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.

11. simethicone 80 mg Tablet Sig: One (1) Tablet PO every [**6-20**]
hours as needed for Gas.
12. insulin aspart 100 unit/mL Cartridge Sig: SSI  Subcutaneous
every six (6) hours: Use in conjunction with patient's sliding
scale.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Anemia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Mr. [**Known lastname 1313**],
  You came from rehab because you were having left arm pain.
You had multiple tests that were negative for a cardiac process.
 Your ekg was reassuring.  Your blood counts were slightly low,
but close to your baseline.  We gave you a blood transfusion to
help boost your red blood cell count.  After close observation
over the weekend, you were deemed safe enough to go back to
rehab.
.
We made the following changes to your medications:
STOP Ceftriaxone
STOP heparin drip
.
For your heart failure, make sure you weigh yourself every
.
We have rescheduled your follow up appoints at [**Hospital1 18**] to see both
a urologist and cardiologist. You will have your nephrostoty
tubes and foley in place until evaluation by urology.

Thanks for the opportuntiy to participate in your care.

Followup Instructions:
Department: SURGICAL SPECIALTIES
Specialty: Urology
When: FRIDAY [**2121-5-23**] at 11:15 AM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

We are working on a follow up appt with Dr.[**Last Name (STitle) 696**] in the [**9-27**]
days. You will be called at home with the appointment.   If you
have not heard or have questions, please call([**Telephone/Fax (1) 2037**].

*Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] R.
Address: [**Last Name (un) 92517**], [**Hospital1 **],[**Numeric Identifier 27861**]
Phone: [**Telephone/Fax (1) 31293**]



Completed by:[**2121-5-21**]
{'Iron deficiency anemia secondary to blood loss (chronic),Acute kidney failure, unspecified,Chronic systolic heart failure,Urinary tract infection, site not specified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Subendocardial infarction, subsequent episode of care,Calculus of kidney,Other artificial opening of urinary tract status,Gout, unspecified,Unspecified essential hypertension,Long-term (current) use of insulin,Do not resuscitate status,Obesity, unspecified,Pain in limb'}


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 Arm Pain

PRESENT ILLNESS: Mr [**Known lastname 1313**] was recently in our ICU for urosepsis secondary to
nephrolithiasis.  He also has a history of type II DM and
hypertension, as well as recent diagnosis of atrial fibrillation
with RVR and acute kidney injury in the setting of his
infection.

MEDICAL HISTORY: nephrolithiasis
class III obesity
DM2
HTN
gout
atrial fibrillation

MEDICATION ON ADMISSION: 1. insulin glargine 100 unit/mL Solution Sig: Ten (10)
Subcutaneous at bedtime.
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. ceftriaxone 1 gram Recon Soln Sig: One (1)  Intravenous once
a day for 2 days: Day 1 = [**5-5**], LAST DAY= [**2121-5-18**].
5. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: Hold
for HR<60, SBP<100.
6. miconazole nitrate 2 % Powder Sig: One (1)  Topical once a
day.
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO at bedtime: Hold for SBP<100.
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please titrate warfarin dosing for goal INR of [**2-14**].
9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP<100.
10. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam
VS: HR 80, BP 90/45, SpO2 100% RA, RR 12
Gen: Caucasian male, in no apparent distress
Cardiac: Nl s1/s2 irregular rhythm, no murmurs appreciable
pulm: clear bilaterally in anterior lung fields
abd: soft, nontender,nondistended, +BS
Ext: no edema noted, nephrostomy tube in place, Foley in place

FAMILY HISTORY: Father lost kidney due to stones

SOCIAL HISTORY: retired dry cleaning machine manufacturerer
no ETOH
no tobacco
no illicits 

### Response:
{'Iron deficiency anemia secondary to blood loss (chronic),Acute kidney failure, unspecified,Chronic systolic heart failure,Urinary tract infection, site not specified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Subendocardial infarction, subsequent episode of care,Calculus of kidney,Other artificial opening of urinary tract status,Gout, unspecified,Unspecified essential hypertension,Long-term (current) use of insulin,Do not resuscitate status,Obesity, unspecified,Pain in limb'}
