CHIEF COMPLAINT: Chest pain and RUQ/back pain

PRESENT ILLNESS: History obtained with Russian translation from daughter.
85F Russian-speaking, HTN, HLD, T2DM, mild CHF EF>55% likely
NYHA II, AF with PPM insertion, no hx of CAD who presents from
[**Hospital3 1196**] with chest pain and elevated TnT in
the context of an admission with acute cholecystitis.
.
Patient had 1 week history of RUQ pain whcih was severe and
intermittent. This began on [**5-28**] when she had RUQ pain for 2
days and this spontaneously resolved. Patient then had no pain
until [**6-2**] when RUQ pain into back returned. Pain waxed and
waned until becoming progressively severe over the last 48 hrs.
She complained of nausea but denied vomiting, fever, chills, or
diarrhea. She then presented to NWH on [**6-3**] for her pain.
Patient denies any fevers of N/V. Only vomited in the context of
having morphine at NWH. She states that she has felt pain after
eating for many years. She has no past surgical history, however
she has had a significant umbilical hernia for over 5 yrs.
.
At NWH, the patient was admitted on [**6-3**] to the surgical service
for acute cholecystitis discovered on U/S with gallstones,
sludge (ultrasonographic [**Doctor Last Name 515**]) and no significant bile duct
dilatation. Patient was started on Pip/Tazo, IVF and had pain
control with Dilaudid. Overnight the patient did well but had
chest pressure at roughly 0500 (per daughter) this morning
([**6-4**]) with no ECG changes. Chest pressure was without radiation
and this was in the context of feeling hot, there was no SOB,
sweating or radiation. Labs drawn at the time of chest pain
showed a troponin increase from 0.01 to 0.78 (Troponin I: 0.01
-> 0.78 -> 0.59). The chest pain resolved with dilaudid and
patient continued to have no ECG changes. An urgent cards
consult was obtained and they requested a cath procedure prior
any intervention for the cholecystitis. The patient remained
chest pain free for the entire morning and received a full dose
Aspirin this AM.
.
Currently, she compained of [**8-17**] RUQ pain radiating into the
back. No N/V but feels dry.
.
Cardiac review of systems is notable for absence of current
chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
.
RS - No pleuritic CP, no sputum, cough, hemoptysis or wheeze.
GIS - No recent weight loss, no BRBPR, melena, heartburn.
CNS - No vertigo. No numbness. No weakness.
US - No dysuria, frquency, hematuria.
ES - No fevers, sweats, chills, tremors. Flet hot during chest
pain.
HS - No bleeding or bruising
DS - No rashes, pruritis

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- Diastolic heart failure - likely NYHA II
-Atrial Fibrillation s/p AVJ ablation
- s/p Biotronik biventricular pacemaker placement at CSEMC [**8-13**]

MEDICATION ON ADMISSION: MEDICATIONS (home): Per recent OMR note
Medications - Prescription
CICLOPIROX - 0.77 % Suspension - apply twice a day to the R
thumbnail and between fingers as needed for fungal infection
CYCLOBENZAPRINE - 5 mg Tablet - 1 Tablet(s) by mouth daily as
needed for muscle stiffness
GLIPIZIDE - 5 mg Tablet - 1 Tablet(s) by mouth twice a day
HYDROCORTISONE [PROCTOZONE-HC] - 2.5 % Cream - apply Cream(s)
rectally 1-2 times a day for symptoms
LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch,
Medicated - apply one patch topically for 12 hr qd as needed
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day
LOSARTAN - 50 mg Tablet - 1 Tablet(s) by mouth twice a day
MECLIZINE - 12.5 mg Tablet - 1 Tablet(s) by mouth daily as
needed
for dizziness
METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth three times a
day
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually q5min as needed for chest pain Call 911 if chest
pain not resolving in 5 minutes.
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam at Admission:
VS: T=98.3 BP=150/63 HR=79 RR=24 O2 sat=89-93% on RA 97-97 on 2L
O2
GENERAL: C/O RUQ and back pain - obviously in pain. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Mother - died 79 ? cause
Father - died of old age
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: She lives alone with some assistance from nurses who come to her
home. She does not speak fluent English, her daughter has served
as a translator in past interactions.
Patient was a former technician doing mechanical drawings.
Lives alone. Patient walks with cane and also has walker.
-Tobacco history: Never smoked
-ETOH: None
-Illicit drugs: None
-Herbal Medications: None
Acute cholecystitis,Subendocardial infarction, initial episode of care,Primary pulmonary hypertension,Chronic diastolic heart failure,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Esophageal reflux,Anemia, unspecified
Acute cholecystitis,Subendo infarct, initial,Prim pulm hypertension,Chr diastolic hrt fail,Obstructive sleep apnea,Hypertension NOS,DMII wo cmp nt st uncntr,Atrial fibrillation,Esophageal reflux,Anemia NOS
Admission Date:  [**2112-6-4**]              Discharge Date:   [**2112-6-10**]

Date of Birth:  [**2027-5-16**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3991**]
Chief Complaint:
Chest pain and RUQ/back pain

Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy tube placement
PICC placement by IR, removal by IV team


History of Present Illness:
History obtained with Russian translation from daughter.
85F Russian-speaking, HTN, HLD, T2DM, mild CHF EF>55% likely
NYHA II, AF with PPM insertion, no hx of CAD who presents from
[**Hospital3 1196**] with chest pain and elevated TnT in
the context of an admission with acute cholecystitis.
.
Patient had 1 week history of RUQ pain whcih was severe and
intermittent. This began on [**5-28**] when she had RUQ pain for 2
days and this spontaneously resolved. Patient then had no pain
until [**6-2**] when RUQ pain into back returned. Pain waxed and
waned until becoming progressively severe over the last 48 hrs.
She complained of nausea but denied vomiting, fever, chills, or
diarrhea. She then presented to NWH on [**6-3**] for her pain.
Patient denies any fevers of N/V. Only vomited in the context of
having morphine at NWH. She states that she has felt pain after
eating for many years. She has no past surgical history, however
she has had a significant umbilical hernia for over 5 yrs.
.
At NWH, the patient was admitted on [**6-3**] to the surgical service
for acute cholecystitis discovered on U/S with gallstones,
sludge (ultrasonographic [**Doctor Last Name 515**]) and no significant bile duct
dilatation. Patient was started on Pip/Tazo, IVF and had pain
control with Dilaudid. Overnight the patient did well but had
chest pressure at roughly 0500 (per daughter) this morning
([**6-4**]) with no ECG changes. Chest pressure was without radiation
and this was in the context of feeling hot, there was no SOB,
sweating or radiation. Labs drawn at the time of chest pain
showed a troponin increase from 0.01 to 0.78 (Troponin I: 0.01
-> 0.78 -> 0.59). The chest pain resolved with dilaudid and
patient continued to have no ECG changes. An urgent cards
consult was obtained and they requested a cath procedure prior
any intervention for the cholecystitis. The patient remained
chest pain free for the entire morning and received a full dose
Aspirin this AM.
.
Currently, she compained of [**8-17**] RUQ pain radiating into the
back. No N/V but feels dry.
.
Cardiac review of systems is notable for absence of current
chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
.
RS - No pleuritic CP, no sputum, cough, hemoptysis or wheeze.
GIS - No recent weight loss, no BRBPR, melena, heartburn.
CNS - No vertigo. No numbness. No weakness.
US - No dysuria, frquency, hematuria.
ES - No fevers, sweats, chills, tremors. Flet hot during chest
pain.
HS - No bleeding or bruising
DS - No rashes, pruritis

Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- Diastolic heart failure - likely NYHA II
-Atrial Fibrillation s/p AVJ ablation
- s/p Biotronik biventricular pacemaker placement at CSEMC [**8-13**]

- not on warfarin because of life-threatening LGIB
3. OTHER PAST MEDICAL HISTORY:
-GERD
-Anxiety
-Anemia


Social History:
She lives alone with some assistance from nurses who come to her
home. She does not speak fluent English, her daughter has served
as a translator in past interactions.
Patient was a former technician doing mechanical drawings.
Lives alone. Patient walks with cane and also has walker.
-Tobacco history: Never smoked
-ETOH: None
-Illicit drugs: None
-Herbal Medications: None


Family History:
Mother - died 79 ? cause
Father - died of old age
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

Physical Exam:
Physical Exam at Admission:
VS: T=98.3 BP=150/63 HR=79 RR=24 O2 sat=89-93% on RA 97-97 on 2L
O2
GENERAL: C/O RUQ and back pain - obviously in pain. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP 4-5cm above sternal angle.
CARDIAC: HS 1+2+0 no MRG RRR.
LUNGS: Bibasal crackles R>L (to midzones on R)
ABDOMEN: Soft, tender + in RUQ with guarding. BS reduced but
present. Unable to assess for hepatomegaly due to pain. No
splenomegaly.
EXTREMITIES: No c/c. Pitting edema to knees bilaterally. No
femoral bruits. Good femoral pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+
Left: Carotid 2+ Femoral 2+ DP 2+
CNS: UL and LL exam unremarkable with good power. CN 2-12
normal. No fields or fundi assessed. Plantars flexor
bilaterally.

Physical exam on day of Discharge:
VS: T=97.8 BP=110/85 HR=70 RR=18 O2 sat=97 on RA
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP 4-5cm above sternal angle.
CARDIAC: No MRG RRR.
LUNGS: Bibasal crackles R>L (to midzones on R)
ABDOMEN: Soft, nontender, nondistended. + BS.
EXTREMITIES: Pitting edema to knees bilaterally. No femoral
bruits. Good femoral pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
CNS: UL and LL exam unremarkable with good power. CN 2-12
normal. No fields or fundi assessed. Plantars flexor
bilaterally.


Pertinent Results:
Laboratory investigations:
Admission labs:
[**2112-6-4**] 09:03PM BLOOD WBC-16.2*# RBC-3.97* Hgb-11.8* Hct-34.5*
MCV-87 MCH-29.8 MCHC-34.3 RDW-15.0 Plt Ct-185
[**2112-6-4**] 09:03PM BLOOD PT-15.0* PTT-28.1 INR(PT)-1.3*
[**2112-6-4**] 09:03PM BLOOD Glucose-197* UreaN-14 Creat-1.1 Na-134
K-3.7 Cl-98 HCO3-25 AnGap-15
[**2112-6-4**] 09:03PM BLOOD ALT-66* AST-25 CK(CPK)-46 AlkPhos-158*
Amylase-19 TotBili-1.3
[**2112-6-4**] 09:03PM BLOOD Lipase-11
[**2112-6-4**] 09:03PM BLOOD CK-MB-3 cTropnT-0.03*
[**2112-6-4**] 09:03PM   ALBUMIN-3.2* CALCIUM-8.5 PHOSPHATE-4.1
MAGNESIUM-1.2* CHOLEST-130
.
Discharge labs:
[**2112-6-10**] 05:35AM BLOOD WBC-6.8 RBC-4.09* Hgb-11.9* Hct-36.4
MCV-89 MCH-29.1 MCHC-32.7 RDW-14.8 Plt Ct-274
[**2112-6-10**] 05:35AM BLOOD Glucose-137* UreaN-11 Creat-1.0 Na-147*
K-3.5 Cl-107 HCO3-28 AnGap-16
.
Radiology:
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2112-6-4**]
7:01 PM
FINDINGS:
There are no focal hepatic lesions and the liver echotexture is
normal. The portal vein is patent with normal hepatopetal flow.
There is no intra- or extra-hepatic biliary dilation with the
common bile duct measuring 5 mm. The gallbladder is distended
and contains a large shadowing gallstone with moderate wall
edema. A son[**Name (NI) 493**] [**Name2 (NI) 515**] sign was positive. No right upper
quadrant ascites. The spleen measures 10.6 cm.
IMPRESSION: Acute cholecystitis. No biliary dilatation.
.
XR CHEST (PA & LAT) Study Date of [**2112-6-4**] 7:46 PM
COMPARISON: [**2110-11-7**].
FRONTAL AND LATERAL CHEST RADIOGRAPHS: Left-sided pacemaker is
again noted.  Cardiomegaly is mild in extent and there is mild
vascular congestion.  Plate-like atelectasis is seen at the
right lung base. Mild elevation of the right hemidiaphragm
persists. No pleural effusions or pneumothorax.
.
[**2112-6-5**] Percutaneous cholecystostomy tube placement: IMPRESSION:

Successful placement of an 8 French [**Last Name (un) 2823**] catheter into the
gallbladder.
Specimen was sent to laboratory for analysis, as specified by
the referring team.
.
ECHO Study Date of [**2112-6-8**]
 Suboptimal image quality. Moderate symmetric left ventricular
hypertrophy with preserved regional and global biventricular
systolic fucntion. Elevated PCWP. Mild mitral regurgitation.
Severe pulmonary hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2109-7-22**]
.
PICC placement [**2112-6-8**]
Uncomplicated ultrasound and fluoroscopically guided double
lumen
PICC line placement via the right basilic venous approach. Final
internal
length is 43 cm, with the tip positioned in SVC. The line is
ready to use.


Brief Hospital Course:
Ms. [**Known lastname 28613**] is an 85 yo Russian-speaking F w/ h/o HTN, HLD, T2DM,
mild dCHF, AF s/p AV node ablation and PPM insertion, no hx of
CAD who presents from [**Hospital3 1196**] with chest pain
and elevated troponin in the context of an admission with acute
cholecystitis. Troponin I levels peaked at 0.78 and downtrending
from OSH.
.
# Acute cholecystitis: Patient was admitted to OSH with
stuttering biliary colic and then has had persistent RUQ pain.
U/S revealed a large 3cm gallstone, sludge, gallbladder wall
thickening and mildly dilated CBD at 8mm with ultrasonographic
[**Doctor Last Name 515**]. Patient was treated with IVF, IV dilaudid and IV
pip/tazo at OSH and plan was for perc chole. However, when she
developed at Troponin leak to troponin I peak at OSH of 0.78,
she was transferred to [**Hospital1 18**] for further management. On
transfer, she had persistent pain in RUQ ++ with guarding. LFTs
showed elevated ALT 94 AST 44 Alk P 209 neg amylase and lipase.
WBC was mildly elevated at 13.3 and has had no fevers. Patient
was started on IV Amp/Sulbactam Q6 (was on Pip/Tazo at OSH).
Stat U/S showed acute cholecystitis. She was given IV dilaudid
for pain. Surgery and IR were consulted. Given tender + abdomen
and rising WBC patient was transferred to MICU very early in the
morning on [**6-5**] for conscious sedation fo  perc chole drainage
which was done that night but IR.  She had some desaturations
during the procedure with sedation but otherwise tolerated the
procedure well and following procedure remained hemodynamically
stable.  Patient was continued on unasyn. She was transition to
PO metronidazole and PO ciprofloxacin after transfer to the
floor. Bile culture grew streptococcus anginosus. Perc chole
tube continued to drain serosanguinous fluid. As her diet was
advanced, she experienced some abdominal pain so she was made
NPO and a PICC was placed due to poor peripheral access on [**6-8**].
She was slowly advanced to regular diet and tolerated it well.
Her PICC was pulled on her day of discharge. She was sent home
with VNA services for help with flushing the perc chole drain
each day. She will continue the antibiotics for 10 more days (14
days total) and she is scheduled to follow up with Surgery in 2
weeks, at which time they will decide when she might have the
perc chole tube removed and cholecystectomy.
.
# Coronary Artery disease: Patient with no previous CAD and no
cath on our system but has risk factors of HTN, HLD and T2DM.
Patient had CP at rest at OSH with no ECG changes and TnI peaked
at 0.78 at OSH. This was felt to be demand especially given
precipitous drop in TnI to 0.03. We continued aspirin 325mg,
metoprolol (was started at OSH) and started Atorvastatin 80mg.
We also restarted her losartan at 12.5mg and titrated up to
25mg. She did not require her home dose of losartan 50mg daily
for BP control in house. She had one episode of chest pain while
walking on the floor, but no troponin leak nor changes on
telemetry. She had no further episodes of chest pain and was
ambulating well at time of d/c. She will follow up with her
outpatient cardiologist who was aware of this admission.
.
# Diastolic CHF: Most recent echo [**2109**] showed normal global and
regional biventricular systolic function EF>55% with mild MR and
mild-moderate TR. Stigmata of CHF on admission exam with
bilateral pitting edema and bibasal crackles likely pulmonary
edema in setting of fluid resuscitation at OSH. Also sats 89-93%
on RA. CXR showed pulmonary edema and patient received 20mg IV
furosemide while in the MICU. IV fluids were held as was her
home torsemide and losartan given acute cholecystitis and
borderline BPs during her MICU course. Upon transfer to the
general medicine floor, she was started on metoprolol and
afterwards restarted  on low-dose losartan 12.5mg. Her torsemide
continued to be held, as she was not fluid overloaded on exam.
She did not have an oxygen requirement nor SOB. An ECHO
performed on [**6-8**] revealed:  EF>55%, elevated PCWP, Mild MR,
Severe pulmonary HTN. Her losartan was titrated up to 25mg and
her torsemide restarted prior to d/c.
.
# Atrial Fibrillation: AF with biventricular PPM and not on
warfarin because of previous life-threatening LGIB. She was
discharged on an ASA and metoprolol.
.
# T2DM: Last HbA1c 7.9% on 2/[**2112**]. On Metformin and glipizide at
home. GLc was 229 at OSH. Metformin and glipizide were held in
house and HISS was given. Both metformin and glipizide were
restarted on d/c.
.
# HTN: On torsemide, verapamil and losartan at home. Was started
on metoprolol at OSH. Due to her hypotension and sepsis on
admission, all blood pressure medications were held. She was
restarted on metoprolol and losartan on the floor with good
control of BPs. Her home torsemide was restarted prior to d/c
and verapamil was discontinued.
.
# HLD: Last lipids in [**2111**] with LDL 110. Lipid profile this
admission revealed: LDL 70, Tcholesterol 130, HDL 47,
triglycerides 66. Pt was started on atorvastatin 80mg daily this
admission

Medications on Admission:
MEDICATIONS (home): Per recent OMR note
Medications - Prescription
CICLOPIROX - 0.77 % Suspension - apply twice a day to the R
thumbnail and between fingers as needed for fungal infection
CYCLOBENZAPRINE - 5 mg Tablet - 1 Tablet(s) by mouth daily as
needed for muscle stiffness
GLIPIZIDE - 5 mg Tablet - 1 Tablet(s) by mouth twice a day
HYDROCORTISONE [PROCTOZONE-HC] - 2.5 % Cream - apply Cream(s)
rectally 1-2 times a day for symptoms
LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch,
Medicated - apply one patch topically for 12 hr qd as needed
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day
LOSARTAN - 50 mg Tablet - 1 Tablet(s) by mouth twice a day
MECLIZINE - 12.5 mg Tablet - 1 Tablet(s) by mouth daily as
needed
for dizziness
METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth three times a
day
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually q5min as needed for chest pain Call 911 if chest
pain not resolving in 5 minutes.
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)

by mouth daily
TORSEMIDE - (Not Taking as Prescribed: Taking [**1-10**] tab qod) - 10

mg Tablet - 1 Tablet(s) by mouth once a day
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for pain
VERAPAMIL - 240 mg Cap,Ext Release Pellets 24 hr - 1 Cap(s) by
mouth twice a day

Medications - OTC
ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by

mouth once a day
BLOOD SUGAR DIAGNOSTIC [CONTOUR TEST STRIPS] - Strip - as
directed to monitor blood sugar tid and prn
CYANOCOBALAMIN (VITAMIN B-12) - (Prescribed by Other Provider) -

Dosage uncertain
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg Tablet Extended
Release
- 1 Tablet(s) by mouth daily
FERROUS SULFATE - 325 mg (65 mg Iron) Tablet - 1 Tablet(s) by
mouth daily as needed
LANCETS [LANCETS,THIN] - Misc - as directed tid and prn
.
Medication on transfer:
Aspirin 325mg qd
Heparin s/c 5000 units tid
HISS
Pantoprazole 40mg IV qd
Metoprolol 12.5mg [**Hospital1 **]
Simvastatin 20mg qd
Verapamil SR 240mg qd
Furosemide 20mg IV qd
IV pip/Tazo 3.375g tid
IV ondansetron 4mg PRN
IV hydromorphone Q4H PRN

Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*20 Tablet(s)* Refills:*0*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
Disp:*30 Tablet(s)* Refills:*0*
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
9. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. metformin 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.

12. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
13. cyclobenzaprine 5 mg Tablet Sig: One (1) Tablet PO once a
day as needed for muscle stiffness.
14. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1)  Topical every twelve (12) hours as needed for pain.
15. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO once a day
as needed for dizziness.
16. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
17. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Extended
Release Sig: One (1) Tablet Extended Release PO once a day.
18. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual q5min.
19. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) cc Injection
once a day: Please flush cholecystostomy tube daily.
Disp:*30 flushes* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
CityWide Home Care Inc

Discharge Diagnosis:
Primary diagnosis:
Acute cholecystitis
Secondary diagnoses:
Non ST elevated myocardial infarction
chronic diastolic congestive heart failure
Hypertension
Atrial fibrillation
Diabetes mellitus


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:
You were admitted with an acute infection of your gall bladder
call cholecystitis. To treat this, your gall bladder was drained
with a tube placed through your skin. You will complete 2 weeks
of antibiotics for your infection and then follow up with the
surgeons to discuss possibly removing the tube in your gall
bladder and removing your gall bladder all together with a
cholecystectomy.

While you were here, we also became concerned about your heart
as it seemed to be showing signs of stress from your infection.
We did an ultrasound of your heart and it looks basically
unchanged. You will follow up with your cardiologist as below.

Please keep all your follow up appointments as below.

The follow changes were made to your medications:

START ciprofloxacin and metronidazole for 10 more days.
START atorvastatin, for cholesterol.
DECREASE losartan, for blood pressure, from 50mg to 25mg.
We gave you a prescription for losartan at 25mg, but please ask
your pharmacist if you can split your home losartan pills in
half.
STOP verapamil and START metoprolol, for blood pressure/heart
rate control.

Followup Instructions:
Please follow up with your cardiologist as follows:
Department: CARDIAC SERVICES
When: MONDAY [**2112-6-27**] at 3:00 PM
With:  DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Please follow up with the surgeons as follows:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2112-6-23**] at 3:00 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Please follow up with your primary care physician as follows:
Department: [**Hospital3 249**]
When: THURSDAY [**2112-6-23**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**] DO 12-BJM

Completed by:[**2112-6-13**]
{'Acute cholecystitis,Subendocardial infarction, initial episode of care,Primary pulmonary hypertension,Chronic diastolic heart failure,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Esophageal reflux,Anemia, 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: Chest pain and RUQ/back pain

PRESENT ILLNESS: History obtained with Russian translation from daughter.
85F Russian-speaking, HTN, HLD, T2DM, mild CHF EF>55% likely
NYHA II, AF with PPM insertion, no hx of CAD who presents from
[**Hospital3 1196**] with chest pain and elevated TnT in
the context of an admission with acute cholecystitis.
.
Patient had 1 week history of RUQ pain whcih was severe and
intermittent. This began on [**5-28**] when she had RUQ pain for 2
days and this spontaneously resolved. Patient then had no pain
until [**6-2**] when RUQ pain into back returned. Pain waxed and
waned until becoming progressively severe over the last 48 hrs.
She complained of nausea but denied vomiting, fever, chills, or
diarrhea. She then presented to NWH on [**6-3**] for her pain.
Patient denies any fevers of N/V. Only vomited in the context of
having morphine at NWH. She states that she has felt pain after
eating for many years. She has no past surgical history, however
she has had a significant umbilical hernia for over 5 yrs.
.
At NWH, the patient was admitted on [**6-3**] to the surgical service
for acute cholecystitis discovered on U/S with gallstones,
sludge (ultrasonographic [**Doctor Last Name 515**]) and no significant bile duct
dilatation. Patient was started on Pip/Tazo, IVF and had pain
control with Dilaudid. Overnight the patient did well but had
chest pressure at roughly 0500 (per daughter) this morning
([**6-4**]) with no ECG changes. Chest pressure was without radiation
and this was in the context of feeling hot, there was no SOB,
sweating or radiation. Labs drawn at the time of chest pain
showed a troponin increase from 0.01 to 0.78 (Troponin I: 0.01
-> 0.78 -> 0.59). The chest pain resolved with dilaudid and
patient continued to have no ECG changes. An urgent cards
consult was obtained and they requested a cath procedure prior
any intervention for the cholecystitis. The patient remained
chest pain free for the entire morning and received a full dose
Aspirin this AM.
.
Currently, she compained of [**8-17**] RUQ pain radiating into the
back. No N/V but feels dry.
.
Cardiac review of systems is notable for absence of current
chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
.
RS - No pleuritic CP, no sputum, cough, hemoptysis or wheeze.
GIS - No recent weight loss, no BRBPR, melena, heartburn.
CNS - No vertigo. No numbness. No weakness.
US - No dysuria, frquency, hematuria.
ES - No fevers, sweats, chills, tremors. Flet hot during chest
pain.
HS - No bleeding or bruising
DS - No rashes, pruritis

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- Diastolic heart failure - likely NYHA II
-Atrial Fibrillation s/p AVJ ablation
- s/p Biotronik biventricular pacemaker placement at CSEMC [**8-13**]

MEDICATION ON ADMISSION: MEDICATIONS (home): Per recent OMR note
Medications - Prescription
CICLOPIROX - 0.77 % Suspension - apply twice a day to the R
thumbnail and between fingers as needed for fungal infection
CYCLOBENZAPRINE - 5 mg Tablet - 1 Tablet(s) by mouth daily as
needed for muscle stiffness
GLIPIZIDE - 5 mg Tablet - 1 Tablet(s) by mouth twice a day
HYDROCORTISONE [PROCTOZONE-HC] - 2.5 % Cream - apply Cream(s)
rectally 1-2 times a day for symptoms
LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch,
Medicated - apply one patch topically for 12 hr qd as needed
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day
LOSARTAN - 50 mg Tablet - 1 Tablet(s) by mouth twice a day
MECLIZINE - 12.5 mg Tablet - 1 Tablet(s) by mouth daily as
needed
for dizziness
METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth three times a
day
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually q5min as needed for chest pain Call 911 if chest
pain not resolving in 5 minutes.
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam at Admission:
VS: T=98.3 BP=150/63 HR=79 RR=24 O2 sat=89-93% on RA 97-97 on 2L
O2
GENERAL: C/O RUQ and back pain - obviously in pain. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Mother - died 79 ? cause
Father - died of old age
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: She lives alone with some assistance from nurses who come to her
home. She does not speak fluent English, her daughter has served
as a translator in past interactions.
Patient was a former technician doing mechanical drawings.
Lives alone. Patient walks with cane and also has walker.
-Tobacco history: Never smoked
-ETOH: None
-Illicit drugs: None
-Herbal Medications: None 

### Response:
{'Acute cholecystitis,Subendocardial infarction, initial episode of care,Primary pulmonary hypertension,Chronic diastolic heart failure,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Esophageal reflux,Anemia, unspecified'}
