CHIEF COMPLAINT: abdominal pain, diarrhea

PRESENT ILLNESS: This is a 87 year old man with multiple medical problesm
including coronary artery disease status post coronary artery
bypass graft, congestive heart failure with ejection fraction of
20-30%, status post pacemaker for sick sinus syndrome, atrial
fibrillation on coumadin, chronic lower back pain who was
transferred from [**Hospital3 7571**]Hospital to the vascular service
with concern for aortic dissection.
.
The patient reports that he began to develop diarrhea several
weeks prior to admission. This diarrhea is only during the day,
not related to eating. Per the nurse, the patient's stool is
liquid, brown, no bright red blood per rectum. The patient also
developed nausea and epigastric pain one week prior to
admission. The epigastric pain is sharp, constant, unrelated to
eating and without exacerbating or alleviating factors. The
patient denies emesis, recent travel, or recent antibiotic use.
.
The pt presented to [**Location (un) **] emergency department on [**2184-2-15**] for
these symptoms, and was noted to have an abdominal aorta
aneurysm at the level of the renal artery as well as a short
aortic dissection on CT. Repeat CT here revealed a 2 cm aortic
dissection at level of renal arteries, with possible chronicity.
The patient is transferred to medicine for blood pressure
management given patient's systolic blood pressure was up to 198
on day of admission.
.
On review of systems, patient denies fever, decreased appetite.
He complains of worsened sciatica down his right leg.

MEDICAL HISTORY: 1. coronary artery disease
2. pacemaker for sick sinus syndrome, right bundle branch block
3. cardiomyopathy with ejection fraction 20-30%
4. congestive heart failure
5. osteoarthritis
6. severe low back pain
7. gastroespophageal reflux disease
8. orthostatic hypotension
9. atrial fibrillation with cardioversion
10.peripheral neuropathy
11.degenerative joint disease
12.chronic pain
13.pulmonary embolus x2
[**92**].atrial appendage clot
15.depression
16.hypercholesterolemia
17.history of campylobacter
PSH: CABG x2 [**66**] / 98, Left subclavian [**Name (NI) **], PTCA [**69**], anterior
scalenectomy, lap CCY, b/l carpal tunnel, multiple hernia repair

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: midodrine 7.5 tid, digoxin 0.125 qod, lasix 40, coumadin
2.5, mevacor 20, prevacid 30, norvasc 2.5, nuerontin 200 "',
xanax prn, nitroquick 0.4, oxycontin 20 ", oxycodone 5 prn,
colchicine 0.6
.
Meds on Transfer:
Xanax 0.5 mg po TID prn, amlodipine 2.5 mg po qd, atorvastatin
20 mg po qd, bisacodyl prn, colchicine 0.6 qd, dig 0.125 mg qod,
colace, anzemet prn, Lasix 40 mg po qd, nuerontin 200 mg TID,
dilaudid prn, hydral 20 mg IV q6 hr, Lansoprazole 30 mg po qd,
levothyroxine 88 ug, day, midodrine 7.5 mg po tid, NTG patch,
senna, percocet

ALLERGIES: Sulfa (Sulfonamides) / Penicillins / Clindamycin / Tetracycline
/ Cozaar / Zestril / Coreg / Toprol Xl

PHYSICAL EXAM: Vitals: Tm 99.1 Tc 98.1 P 45-77 BP 118-198/50-85 Sat 95-96%RA
General: thin man laying flat in bed, NAD
HEENT: PERRL, NCAT, conjunctivae anicteric and noninjected, dry
MM, scale and erythema noted in nasolabial folds
Neck: no JVD, supple
CV: mostly RRR but occasional PVCs per monitor, Grade 2/6 SEM
LUSB, PCM palpable in L chest wall, median sternotomy scar well
healed
Lungs: bibasilar rales, decreased breath sounds, hyperresonant
to percussion
Abd: soft, NABS, tender to palp in epigastric region without
rebound tenderness
Extrem: no c/c/e, full dp/pt pulses
Neuro: a and ox 3, CNII-XII grossly intact

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives in a room in a monastery. Drinks one alcoholic beverage
every couple of weeks. Quit smoking 30 years ago. No illicit
drug use.
Dissection of aorta, abdominal,Congestive heart failure, unspecified,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonitis due to inhalation of food or vomitus,Candidiasis of mouth,Acute kidney failure, unspecified,Paralytic ileus,Unspecified protein-calorie malnutrition,Hypovolemia,Sciatica,Incisional hernia without mention of obstruction or gangrene,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Other chest pain,Orthostatic hypotension,Adult failure to thrive,Long-term (current) use of anticoagulants
Dsct of abdominal aorta,CHF NOS,Atrial fibrillation,Hyp kid NOS w cr kid V,Food/vomit pneumonitis,Thrush,Acute kidney failure NOS,Paralytic ileus,Protein-cal malnutr NOS,Hypovolemia,Sciatica,Incisional hernia,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Chest pain NEC,Orthostatic hypotension,Failure to thrive-adult,Long-term use anticoagul
Admission Date:  [**2184-2-20**]              Discharge Date:   [**2184-3-17**]


Service: MEDICINE

Allergies:
Sulfa (Sulfonamides) / Penicillins / Clindamycin / Tetracycline
/ Cozaar / Zestril / Coreg / Toprol Xl

Attending:[**First Name3 (LF) 7202**]
Chief Complaint:
abdominal pain, diarrhea

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is a 87 year old man with multiple medical problesm
including coronary artery disease status post coronary artery
bypass graft, congestive heart failure with ejection fraction of
20-30%, status post pacemaker for sick sinus syndrome, atrial
fibrillation on coumadin, chronic lower back pain who was
transferred from [**Hospital3 7571**]Hospital to the vascular service
with concern for aortic dissection.
.
The patient reports that he began to develop diarrhea several
weeks prior to admission. This diarrhea is only during the day,
not related to eating. Per the nurse, the patient's stool is
liquid, brown, no bright red blood per rectum. The patient also
developed nausea and epigastric pain one week prior to
admission. The epigastric pain is sharp, constant, unrelated to
eating and without exacerbating or alleviating factors. The
patient denies emesis, recent travel, or recent antibiotic use.
.
The pt presented to [**Location (un) **] emergency department on [**2184-2-15**] for
these symptoms, and was noted to have an abdominal aorta
aneurysm at the level of the renal artery as well as a short
aortic dissection on CT. Repeat CT here revealed a 2 cm aortic
dissection at level of renal arteries, with possible chronicity.
The patient is transferred to medicine for blood pressure
management given patient's systolic blood pressure was up to 198
on day of admission.
.
On review of systems, patient denies fever, decreased appetite.
He complains of worsened sciatica down his right leg.

Past Medical History:
1. coronary artery disease
2. pacemaker for sick sinus syndrome, right bundle branch block
3. cardiomyopathy with ejection fraction 20-30%
4. congestive heart failure
5. osteoarthritis
6. severe low back pain
7. gastroespophageal reflux disease
8. orthostatic hypotension
9. atrial fibrillation with cardioversion
10.peripheral neuropathy
11.degenerative joint disease
12.chronic pain
13.pulmonary embolus x2
[**92**].atrial appendage clot
15.depression
16.hypercholesterolemia
17.history of campylobacter
PSH: CABG x2 [**66**] / 98, Left subclavian [**Name (NI) **], PTCA [**69**], anterior
scalenectomy, lap CCY, b/l carpal tunnel, multiple hernia repair



Social History:
Lives in a room in a monastery. Drinks one alcoholic beverage
every couple of weeks. Quit smoking 30 years ago. No illicit
drug use.


Family History:
NC

Physical Exam:
Vitals: Tm 99.1 Tc 98.1 P 45-77 BP 118-198/50-85 Sat 95-96%RA
General: thin man laying flat in bed, NAD
HEENT: PERRL, NCAT, conjunctivae anicteric and noninjected, dry
MM, scale and erythema noted in nasolabial folds
Neck: no JVD, supple
CV: mostly RRR but occasional PVCs per monitor, Grade 2/6 SEM
LUSB, PCM palpable in L chest wall, median sternotomy scar well
healed
Lungs: bibasilar rales, decreased breath sounds, hyperresonant
to percussion
Abd: soft, NABS, tender to palp in epigastric region without
rebound tenderness
Extrem: no c/c/e, full dp/pt pulses
Neuro: a and ox 3, CNII-XII grossly intact


Pertinent Results:
[**2178**] cath:
COMMENTS:
1. Coronary angiography in this right dominants system revealed
severe left main and three vessel CAD. The left main coronary
artery was diffusely diseased with a 70% distal stenosis. The
LAD was totally occluded proximally. The left circumflex artery
had a 70% mid-vessel stenosis and the first obtuse marginal
branch was totally occluded. The RCA was occluded immediately
distal to its origin.
2. Graft angiography revealed patent SVGs. The SVG to the LAD
was widely patent. The skip SVG to the first and second diagonal
branchs had moderate luminal irregularities throughout its
course. The SVG to the obtuse marginal branch was patent. The
SVG to the rPDA was patent and the native posterolateral branch
beyond the anastamosis was diffusely diseased.
3. Resting hemodynamic studies revealed normal right and left
sided
filling pressure. The mean RA pressure was 3 mmHg, teh mean PCWP
was 5 mmHg, and the LVEDP was 6 mmHg. The cardiac index was
marginally
depressed at 2.4 L/min/m2.
4. Left ventriculography revealed global hypokinesis with more
severe apical hypokinesis and inferior wall akinesis. The
estimated LVEF was 30-35%.
FINAL DIAGNOSIS:
1. Severe left main and native three vessel coronary artery
disease.
2. Patent SVGs to the LAD, skip diagonals, obtuse marginal and
rPDA.
3. Severe systolic ventricular dysfunction.

Labs on admission:
WBC 7.1 Hct 39.5* MCV 81* Plt Ct 206
Neuts 66.9 Lymphs 23.7 Monos 6.2 Eos 2.5 Baso 0.7
.
Glucose 103 UreaN 10 Creat 1.6* Na 141 K 3.5 Cl 104 HCO3 26
AnGap 15 Albumin 4.1 Calcium 9.0 Phos 2.9 Mg 1.8
.
ALT 8 AST 20 LD(LDH) 191 47 AlkPhos 59 Amylase 42 Lipase 24
TotBili 0.7
PT 39.1* PTT 38.4* INR(PT) 4.4*
.
Lactate 1.2 TSH 0.42 Digoxin 0.5*
.
UA negative
.
Additional Labs:
[**2184-2-27**] 02:40PM CK(CPK) 73 cTropnT <0.01
[**2184-2-27**] 09:00PM CK(CPK) 49 cTropnT <0.01
[**2184-2-28**] 06:40AM CK(CPK) 43 cTropnT <0.01
.
[**2184-2-29**] 08:33AM BLOOD Cortsol 27.1*
.
[**2184-2-27**] 06:49AM URINE Color Yellow Appear Clear Sp [**Last Name (un) **] 1.013
Blood NEG Nitrite NEG Protein NEG Glucose NEG Ketone NEG Bilirub
NEG Urobiln NEG pH 5.0 Leuks NEG RBC 0 WBC [**3-28**] Bacteri FEW Yeast
NONE Epi 0
CastHy [**3-28**]* Mucous OCC Eos NEGATIVE
.
[**2184-2-22**] 12:55PM URINE Osmolal 356 UreaN 433 Creat 159 Na 33
.
STOOL CULTURE x2: neg
C diff: neg
OVP x2: negative
URINE CULTURE x2: neg
BLOOD CULTURE x2: neg
.
C diff: PENDING
OVP x2: PENDING
.
Studies:
.
CXR [**2184-2-20**]:
1. Cardiac pacer leads terminate in the right atrium and the
right ventricle.
2. Elevated left hemidiaphragm.
.
CT abdomen [**2-21**]: 1.  No evidence of thoracic aortic dissection.
2. Emphysema. 3.  A 13 mm vague nodular density in the right
middle lobe, which should be evaluated further within three
months (as well as a 7 mm nodular density at the left base as
well, which can be re-evaluated at he same time). 4.  Severe
stenosis at the origin of the left renal artery with relative
atrophy of the left kidney compared to the right. 5.  Short 2cm
dissection of the aorta at the level of the renal arteries.
Although of uncertain chronicity, the appearance may be chronic.
6. Small abdominal aortic aneurysm. 7.  Right common iliac
aneurysm. 8. Compression fracture of T12, probably chronic.
.
EKG [**2184-2-25**]: A-V sequential pacemaker pacemaker rhythm
  Intervals Axes
Rate PR QRS QT/QTc  P QRS T
60   0  168 450/450 0 -73 103
.
CHEST (PORTABLE AP) [**2184-2-28**]: The portable erect AP radiograph
of the chest is reviewed, and compared with the previous study
of yesterday.
.
The patient has prior CABG and median sternotomy. Pacemaker
leads remain in place. There is increase in mild congestive
heart failure with cardiomegaly with small right pleural
effusion. There is increase in bibasilar patchy atelectasis.
.
Again, note is made of marked tortuosity of the thoracic aorta
with calcification. No pneumothorax is identified.
[**2184-3-4**] Echo:
Conclusions:
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is difficult to assess but is moderately
depressed. Overall
left ventricular EF cannot be reliably assessed.
3. The aortic valve leaflets are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.

INDICATION: 87-year-old male with throat pain, equivocal bedside
evaluation.

Video oropharyngeal swallow.

FINDINGS: Note is made of moderate amount of pharyngeal residue
after multiple swallowing attempts. Note is made of penetration
at thin barium swallow, more with straw than cup sip. No
evidence of aspiration is seen.

Please also refer to the official report by speech and lung
pathologist available on CareWeb.
[**2184-3-10**] Echo
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left
ventricular systolic function is low normal (LVEF 50%); the apex
appears
hypokinetic. Due to suboptimal technical quality, another focal
wall motion
abnormality cannot be fully excluded. Right ventricular
contracrtile function
appears normal; there is abnormal septal activation suggestive
of
intraventricular conduction delay. No masses or thrombi are seen
in the left
ventricle. There is no ventricular septal defect. The aortic
root is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial
mitral regurgitation is seen. The left ventricular inflow
pattern suggests
impaired relaxation. There is no pericardial effusion.

Compared with the findings of the prior study (images reviewed)
of [**2184-3-4**], no major change is evident.

[**2184-3-13**] AXR
Oral contrast is present within the distal rectosigmoid region,
possibly related to contrast administered during a video swallow
study of [**2184-3-9**], unless a more recent contrast study has
been performed elsewhere in the interval. Again demonstrated are
numerous air filled loops of small and bowel, likely related to
an ileus. If there is strong clinical suspicion for an
obstructive process, additional upright view may be considered
for more complete assessment if warranted clinically.
CXR [**3-8**]:
COMMENTS:  Portable erect AP radiograph of the chest is
reviewed, and compared with the previous study of [**2184-3-6**].
There is continued mild-to-moderate congestive heart failure
with
cardiomegaly, which is superimposed on patient's underlying
severe emphysema.  There is increased opacity in the right lower
lobe indicating superimposed pneumonia or aspiration.
The patient has prior CABG and median sternotomy.  Uppermost
cerclage wires of the sternum has been broken.  Pacemaker leads
remain in place.  There is continued tortuosity of the thoracic
aorta with calcification.  No pneumothorax is identified.
.
CT ABD:
IMPRESSION:
1.  No evidence of thoracic aortic dissection.
2.  Emphysema.
3.  A 13 mm vague nodular density in the right middle lobe,
which should be evaluated further within three months (as well
as a 7 mm nodular density at the left base as well, which can be
re-evaluated at the same time).
4.  Severe stenosis at the origin of the left renal artery with
relative atrophy of the left kidney compared to the right.
5.  Short 2cm dissection of the aorta at the level of the renal
arteries. Although of uncertain chronicity, the appearance may
be chronic.
6.  Small abdominal aortic aneurysm.
7.  Right common iliac aneurysm.
8.  Compression fracture of T12, probably chronic

Brief Hospital Course:
This 87 yo man with history of CAD s/p CABG, CHF EF 20-30%, s/p
PCM for SSS, A fib on coumadin, chronic [**Hospital 16825**] transferred from
[**Hospital3 **]hospital [**2184-2-20**] initially to Vascular service
with concern for aortic dissection now having hypoxia. The pt
presented to [**Location (un) **] ER with diarrhea and cramping and was noted
to have an AAA at the level of the renal artery as well as a
short aortic dissection on CT. Repeat CT here 2 cm aortic
dissection at level of renal arteries, with possible chronicity.
Surgery had no plan to intervene on him so pt was transferred to
medicine for BP management given pts SBP up to 198. His BP was
controlled with hydral and imdur then his BP dropped so these
were held. His cardiologist advised conversion from atrial
fibrillation. He was electrically cardioverted and treated with
Amiodarone and Digoxin. He remained in NSR.
.
On the night of [**2184-3-2**] a "trigger" was called as he was found to
be hypoxic, 78% on 5L NC. ABG 7.39/44/78 on NRB, lactate 1.6. He
was treated with Lasix and his hypoxia resolved. Later that
evening he was having chest pain, NTG given and BP dropped to
78/p, improved with fluid. Today was sent down for V/Q scan.
Upon return from V/Q scan he was hypoxic to the 80s. He was
placed on NRB and his sats went to 94%. MICU was called to
evaluate him given the need for closer monitoring.
.
MICU course: For his hypoxia, he was treated for pulmonary edema
by diuresis with IV lasix, as well as cont treatment for his
CAP. V/q scan was low prob for PE. Started on lasix gtt MICU d
#3, placed on vancomycin for nosocomial PNA, pt to recieve 7
more days. Changed to lasix 60 mg IV on [**3-8**]. Pt complained of
chest pain on [**3-8**], relieved with 1 SL NTG, became hypoxic with
sats 86%, placed on NRB. Increased lasix to 100 mg tid, d/c
afterload reduction. Speech and swallow [**Month/Year (2) **] without aspiration,
? silent asp. Began txt for thrush. Narcotics held [**2-26**] low BP.
Pt was transferred to [**Hospital Unit Name 196**] service for further CHF mgmt.
.

Pt has had a long history of ischemic heart disease with h/o
cath + CABG.  During the [**Hospital 228**] hospital course, he was
having several episodes of L sided pleuritic chest pain which
was alleviated with a lidocaine patch.  There were no ekg
changes during the episodes of the chest pain.  Several sets of
cardiac enzymes were taken during the chest pain episodes and
were negative each time.  Due to the patient's high risk
profile, the patient was resterted on aspirin 325. No further
coronary intervention was undertaken during his hospital stay.
..
PUMP: BNP 1301 on transfer to [**Hospital Unit Name 196**]. systolic function is low
normal (LVEF 50%) by recent echo; the apex appeared hypokinetic.
In the MICU, the patient was unresponsive to lasix gtt and
standing dose of lasix.  Patient was gently diuresed with HCTZ
and PO lasix once on the floor with limited efficacy.  When
BUN/Cr contined to climb, a decision was made to scale back the
diuretic dosing.  While at rehab, volume status should be
At rehab, please hold the captopril dosing for SBP < 90.  Pt
always runs higher blood pressures on the R arm, since has a h/o
subclavian stenosis on the L side.  Also, pt tends to run low
blood pressures while sitting up although he is asymptomatic.
The blood pressure returns up to 100 once the patient is back in
bed.
.
Hypoxia: [**2-26**] CHF and potential nosocomial PNA. Patient has
bibasilar infiltrates on CXR.  Was treated empirically in the
MICU for aspiration pneumonia, completed 7 days of vancoomycin.
While on the floor, WBC count was trending down.  PNA appears
resolving, WBC trending down, pt afebrile. ID consulted and
recommended d/c abx. The patient has passed his speech and
swallow [**Last Name (LF) **], [**First Name3 (LF) **] aspiration events were less likely.  CXR done
on [**3-15**] did not show any change from previous while the
patient's oxygen dramatically improved.  When the patient left
the MICU, he was on a high flow O2 mask.  While on the floor, he
was weaned down to 4L by NC, sating 93-94%.
-cont CHF mgmt as above
.
AF: Pacer, s/p DCCV in past, on amiodarone and anticoagulation.
Patient had paced rhythm on his EKG w/o any changes with chest
pain epidoses.  He was continued on amiodarone.  The patient was
anti-coagulated with coumadin.  During the last few days of his
hospitalization, coumadin was held due to elevated INR.  While
at rehab, the patient's INR should be carefully monitored,
checked at least 3 times per week and as needed, and coumadin
dosing should be adjusted as necessary.
.
CRI: patient has had a chronic h/o CRI with  baseline Cr
1.6-1.7. His Cr bumped with aggressive IV diuresis, so diuretics
were switched to PO and decreased dosing.  On discharge, the
patient's Cr was 2.2 (close to baseline).  It was recommended
that the patient follows up with his PCP or his nephrologist for
his renal issues.
.
Abdominal Pain: patient was found to be full of stool on AXR/vs
contrast from prior speech/swallow study.  Pt given enemas and
felt better, responding with lots of stool. More aggressive
bowel regimen was started.  Abdominal pain was monitored
carefully since the patient does have an infrarenal AAA.  Should
the patient have more severe abdominal or back pain or drop in
his Hct, an urgent evaluation for progression of AAA or
dissection should be considered.
.
AAA: patient was originally admitted to the surgical service to
evalute his AAA and abdominal aortic disection. After thorough
evaluation, he was deemend not a surgical candidate and optimal
BP control was recommended.  The patient was also started on a
statin.  While on the medical service, the blood pressure
remained well controlled.  Surgical service recommends
re-imaging CT scan of the abdomen to document the progression or
stability of his disease.
.


Medications on Admission:
[**Last Name (un) 1724**]: midodrine 7.5 tid, digoxin 0.125 qod, lasix 40, coumadin
2.5, mevacor 20, prevacid 30, norvasc 2.5, nuerontin 200 "',
xanax prn, nitroquick 0.4, oxycontin 20 ", oxycodone 5 prn,
colchicine 0.6
.
Meds on Transfer:
Xanax 0.5 mg po TID prn, amlodipine 2.5 mg po qd, atorvastatin
20 mg po qd, bisacodyl prn, colchicine 0.6 qd, dig 0.125 mg qod,
colace, anzemet prn, Lasix 40 mg po qd, nuerontin 200 mg TID,
dilaudid prn, hydral 20 mg IV q6 hr, Lansoprazole 30 mg po qd,
levothyroxine 88 ug, day, midodrine 7.5 mg po tid, NTG patch,
senna, percocet


Discharge Medications:
1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
6. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed).
7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Ten (10) ML
Mucous membrane  QID (4 times a day) as needed.
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) inj
Subcutaneous ASDIR (AS DIRECTED): please refer to the attached
sliding scale.
14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical  DAILY (Daily) as
needed for chronic pain: apply to Left upper chest as needed for
chest pain/pressure.
18. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  QID
(4 times a day) as needed.
20. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
22. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
23. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
please hold [**2184-3-17**] and [**2184-3-18**] dosing.
24. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
25. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).


Discharge Disposition:
Extended Care

Facility:
Life Care Centers of [**Location (un) **]

Discharge Diagnosis:
primary diagnosis:
1. chronic type III aortic dissection
2. paroxysmal atrial fibrillation s/p cardioversion
3. epigastric hiatal hernia
4. Congestive heart failure
5. failure to thrive
.
secondary diagnosis:


Discharge Condition:
stable, ambulatory, satting 100% on 3L O2 by nasal cannula


Discharge Instructions:
Please take medications as prescribed.
.
Please keep follow-up appointments.
.
If you have acute worsening abdominal or back pain,
lightheadedness, fever/chills or any other concerning symptoms
please call your primary care physician or return to the
emergency room.
.
Staff: please follow patient's INR.  Patient is anti-coagulated
with coumadin for afib and SSS.  INR level should be [**2-27**].
Patient will need his INR checked daily.  Please hold [**3-17**] and
[**3-18**] dosing of coumadin.  Re-check INR on [**3-19**].  Restart
warfarin as needed to keep INR [**2-27**].
.
Please check pt's blood pressures.  Please do not administer
captopril if SBP < 90
.
please ambulate the patient and get the patient out of bed as
tolerated.

Followup Instructions:
You must ask your primary care physician to order [**Name Initial (PRE) **] noncontrast
cat scan of your chest within 3-6 months to follow-up on a
nodule in the right middle lobe of your lung that was
incidentally found on your cat scan.
.
call your PCP [**Name9 (PRE) 16826**],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 16827**] to make a follow up
appointment to discuass your heart condition
.
Please call your primary care physician to arrange [**Name9 (PRE) 702**] in
coumadin clinic for managment of your INR and proper dosing of
your coumadin.



Completed by:[**2184-3-17**]
{'Dissection of aorta, abdominal,Congestive heart failure, unspecified,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonitis due to inhalation of food or vomitus,Candidiasis of mouth,Acute kidney failure, unspecified,Paralytic ileus,Unspecified protein-calorie malnutrition,Hypovolemia,Sciatica,Incisional hernia without mention of obstruction or gangrene,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Other chest pain,Orthostatic hypotension,Adult failure to thrive,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: abdominal pain, diarrhea

PRESENT ILLNESS: This is a 87 year old man with multiple medical problesm
including coronary artery disease status post coronary artery
bypass graft, congestive heart failure with ejection fraction of
20-30%, status post pacemaker for sick sinus syndrome, atrial
fibrillation on coumadin, chronic lower back pain who was
transferred from [**Hospital3 7571**]Hospital to the vascular service
with concern for aortic dissection.
.
The patient reports that he began to develop diarrhea several
weeks prior to admission. This diarrhea is only during the day,
not related to eating. Per the nurse, the patient's stool is
liquid, brown, no bright red blood per rectum. The patient also
developed nausea and epigastric pain one week prior to
admission. The epigastric pain is sharp, constant, unrelated to
eating and without exacerbating or alleviating factors. The
patient denies emesis, recent travel, or recent antibiotic use.
.
The pt presented to [**Location (un) **] emergency department on [**2184-2-15**] for
these symptoms, and was noted to have an abdominal aorta
aneurysm at the level of the renal artery as well as a short
aortic dissection on CT. Repeat CT here revealed a 2 cm aortic
dissection at level of renal arteries, with possible chronicity.
The patient is transferred to medicine for blood pressure
management given patient's systolic blood pressure was up to 198
on day of admission.
.
On review of systems, patient denies fever, decreased appetite.
He complains of worsened sciatica down his right leg.

MEDICAL HISTORY: 1. coronary artery disease
2. pacemaker for sick sinus syndrome, right bundle branch block
3. cardiomyopathy with ejection fraction 20-30%
4. congestive heart failure
5. osteoarthritis
6. severe low back pain
7. gastroespophageal reflux disease
8. orthostatic hypotension
9. atrial fibrillation with cardioversion
10.peripheral neuropathy
11.degenerative joint disease
12.chronic pain
13.pulmonary embolus x2
[**92**].atrial appendage clot
15.depression
16.hypercholesterolemia
17.history of campylobacter
PSH: CABG x2 [**66**] / 98, Left subclavian [**Name (NI) **], PTCA [**69**], anterior
scalenectomy, lap CCY, b/l carpal tunnel, multiple hernia repair

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: midodrine 7.5 tid, digoxin 0.125 qod, lasix 40, coumadin
2.5, mevacor 20, prevacid 30, norvasc 2.5, nuerontin 200 "',
xanax prn, nitroquick 0.4, oxycontin 20 ", oxycodone 5 prn,
colchicine 0.6
.
Meds on Transfer:
Xanax 0.5 mg po TID prn, amlodipine 2.5 mg po qd, atorvastatin
20 mg po qd, bisacodyl prn, colchicine 0.6 qd, dig 0.125 mg qod,
colace, anzemet prn, Lasix 40 mg po qd, nuerontin 200 mg TID,
dilaudid prn, hydral 20 mg IV q6 hr, Lansoprazole 30 mg po qd,
levothyroxine 88 ug, day, midodrine 7.5 mg po tid, NTG patch,
senna, percocet

ALLERGIES: Sulfa (Sulfonamides) / Penicillins / Clindamycin / Tetracycline
/ Cozaar / Zestril / Coreg / Toprol Xl

PHYSICAL EXAM: Vitals: Tm 99.1 Tc 98.1 P 45-77 BP 118-198/50-85 Sat 95-96%RA
General: thin man laying flat in bed, NAD
HEENT: PERRL, NCAT, conjunctivae anicteric and noninjected, dry
MM, scale and erythema noted in nasolabial folds
Neck: no JVD, supple
CV: mostly RRR but occasional PVCs per monitor, Grade 2/6 SEM
LUSB, PCM palpable in L chest wall, median sternotomy scar well
healed
Lungs: bibasilar rales, decreased breath sounds, hyperresonant
to percussion
Abd: soft, NABS, tender to palp in epigastric region without
rebound tenderness
Extrem: no c/c/e, full dp/pt pulses
Neuro: a and ox 3, CNII-XII grossly intact

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives in a room in a monastery. Drinks one alcoholic beverage
every couple of weeks. Quit smoking 30 years ago. No illicit
drug use. 

### Response:
{'Dissection of aorta, abdominal,Congestive heart failure, unspecified,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonitis due to inhalation of food or vomitus,Candidiasis of mouth,Acute kidney failure, unspecified,Paralytic ileus,Unspecified protein-calorie malnutrition,Hypovolemia,Sciatica,Incisional hernia without mention of obstruction or gangrene,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Other chest pain,Orthostatic hypotension,Adult failure to thrive,Long-term (current) use of anticoagulants'}
