CHIEF COMPLAINT: Abdominal pain

PRESENT ILLNESS: Ms [**Known lastname 12130**] is a 71 year old woman with history of silent MI
([**2103**]) that was complicated with left ventricular aneurysm (s/p
repair) and mural thrombus, STEMI ([**9-16**]), CAD s/p CABG x 4
(LIMA to LAD, SVG to OM1, OM2 and RCA) [**10-17**], recent NSTEMI
([**12-18**]), insulin dependent diabetes, peripheral [**Month/Year (2) 1106**] disease,
and hyperthyroidism.

MEDICAL HISTORY: PAST CARDIAC HISTORY:
- Silent MI in [**2103**] c/b ventricular aneurysm and apical thrombus
- CABG: in [**2116-10-31**] x4
LIMA to LAD, SVG to OM1, SVG to OM2, SVG to RCA, LCx
endarterectomy
- s/p left ventricular aneurysm repair (Dor procedure?)
- NSTEMI [**2116-12-31**] s/p PCI with PTCA and stenting of the left main
- proximal left circumflex with a Xience drug eluting stent and
PTCA of the proximal left anterior descending artery.
- ICD placement: [**4-/2117**] [**Company 1543**] Virtuoso DR D1548WG, AAI<->DDD
.
PAST MEDICAL HISTORY:
-- PAD s/p left SFA angioplasty and stent ([**2114**])
-- DM2, well-controlled
-- HTN
-- OA
-- spinal stenosis
-- Hyperthyroidism
-- s/p cholecystectomy
-- s/p appendectomy
-- s/p TAH
.
CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia,
(+)Hypertension

MEDICATION ON ADMISSION: ASA 325mg daily
Lipitor 80mg daily
Lisinopril 20mg daily
Metoprolol Succinate 75mg daily
Plavix 75mg daily
Protonix 40mg daily
Tapazole 10mg daily
Insulin
-- Detemir 34 units at night
-- Lispro 6 with breakfast, 14 with dinner.
Clorazepate 3.75 mg qday
KCl 20mEq daily
Furosemide 40mg daily (took 80mg day PTA)
MVI daily
APAP PRN

ALLERGIES: Bactrim

PHYSICAL EXAM: VS: T 98 HR 82 BP 82/36 (114/50 manually) RR 16 O2sat 96% on 2L
General - NAD, AAO
HEENT - JVD to angle of jaw, MMM, no scleral icterus
CVS - irreg. irreg, S1 and S2 present, no m/r/g
Pulm - bibasilar crackles, no wheezes
Abdomen - soft, NT, ND, b.s. present, no bruits
Extremities - no c/c/e. 2+ PT pulses b/l.

FAMILY HISTORY: Brother died of MI at age 59.

SOCIAL HISTORY: Lives with her husband in [**Name (NI) 392**], [**Name6 (MD) **] is NP and is very
involved in her care. Denies EtOH. Quit tobacco 12 yrs ago
(smoked 1/2ppd x 20+ yrs).
Acute on chronic systolic heart failure,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Peripheral vascular disease, unspecified,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Hypotension, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Spinal stenosis, unspecified region,Old myocardial infarction,Long-term (current) use of insulin,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ
Ac on chr syst hrt fail,Crnry athrscl natve vssl,Hypertension NOS,DMII wo cmp nt st uncntr,Periph vascular dis NOS,Thyrotox NOS no crisis,Hypotension NOS,Osteoarthros NOS-unspec,Spinal stenosis NOS,Old myocardial infarct,Long-term use of insulin,Aortocoronary bypass,Status autm crd dfbrltr
Admission Date:  [**2117-8-10**]              Discharge Date:   [**2117-8-12**]

Date of Birth:  [**2045-10-30**]             Sex:   F

Service: MEDICINE

Allergies:
Bactrim

Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Abdominal pain

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Ms [**Known lastname 12130**] is a 71 year old woman with history of silent MI
([**2103**]) that was complicated with left ventricular aneurysm (s/p
repair) and mural thrombus, STEMI ([**9-16**]), CAD s/p CABG x 4
(LIMA to LAD, SVG to OM1, OM2 and RCA) [**10-17**], recent NSTEMI
([**12-18**]), insulin dependent diabetes, peripheral [**Month/Year (2) 1106**] disease,
and hyperthyroidism.

She is presenting with  bloating and abdominal pain that started
1-2 weeks ago. Her abdominal pain is diffuse, crampy in nature,
not increased with exertion, and relieved by Gas-X or flatus.
She denies vomiting but has some mild nausea today. She had
loose stools secondary to Miralax for constipation but denies
melena or hematochezia.

Patient has noticed feeling increasingly more weak with
exertion. She has increased dyspnea when on exercise bike during
cardiac rehab or when climbing flight of [**9-23**] stairs recently
at her grandson's wedding. She has orthopnea at baseline that
has not worsened recently. Patient also has a mild cough with
whitish-pink sputum.

Denies fevers/chills, sweats, flushing, syncope, dizziness,
lightheadedness, chest pain, palpitations, shoulder pain (except
baseline pain in R shoulder secondary to OA) or defibrillator
firing.

Patient presented initially to her PCP with these symptoms. Her
PCP thought they could be related to fluid overload and
increased her Lasix dose to 80mg and, because she presented with
similar symptoms during her NSTEMI in [**12-18**], her PCP checked
troponin. Today the troponin I level came back at 0.14 (previous
troponin T <0.01 in [**3-18**]). Her PCP called her and told her to
come to the ED.

In ED initial VS were: 98.3 96 117/64 99. She complained of mild
abdominal pain which improved after placement of a foley. On
exam no evidence of fluid overload with only 1+ edema, no JVD,
and no crackles. EKG showed no changes but patient has ICD.
Heparin was not started because she has h/o spontaneous bleed
when she was placed on heparin previously. Initially the plan
was for her to be admitted to the [**Hospital Unit Name 196**] floor but then in the ED
she had a transient drop in her BP (nadir = 76/45). She was
bolused 250mL NS X2 and BP came up to 109/35. She remained
asymptomatic throughout this episode.

Past Medical History:
PAST CARDIAC HISTORY:
- Silent MI in [**2103**] c/b ventricular aneurysm and apical thrombus
- CABG: in [**2116-10-31**] x4
LIMA to LAD, SVG to OM1, SVG to OM2, SVG to RCA, LCx
endarterectomy
- s/p left ventricular aneurysm repair (Dor procedure?)
- NSTEMI [**2116-12-31**] s/p PCI with PTCA and stenting of the left main
- proximal left circumflex with a Xience drug eluting stent and
PTCA of the proximal left anterior descending artery.
- ICD placement: [**4-/2117**] [**Company 1543**] Virtuoso DR D1548WG, AAI<->DDD
.
PAST MEDICAL HISTORY:
-- PAD s/p left SFA angioplasty and stent ([**2114**])
-- DM2, well-controlled
-- HTN
-- OA
-- spinal stenosis
-- Hyperthyroidism
-- s/p cholecystectomy
-- s/p appendectomy
-- s/p TAH
.
CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia,
(+)Hypertension


Social History:
Lives with her husband in [**Name (NI) 392**], [**Name6 (MD) **] is NP and is very
involved in her care. Denies EtOH. Quit tobacco 12 yrs ago
(smoked 1/2ppd x 20+ yrs).


Family History:
Brother died of MI at age 59.


Physical Exam:
VS: T 98 HR 82 BP 82/36 (114/50 manually) RR 16 O2sat 96% on 2L
General - NAD, AAO
HEENT - JVD to angle of jaw, MMM, no scleral icterus
CVS - irreg. irreg, S1 and S2 present, no m/r/g
Pulm - bibasilar crackles, no wheezes
Abdomen - soft, NT, ND, b.s. present, no bruits
Extremities - no c/c/e. 2+ PT pulses b/l.

On discharge:
97.4  66  18  103/56   97% RA
General - NAD, AAO
HEENT - JVD non elevated, MMM, no scleral icterus
CVS - irreg. irreg, S1 and S2 present, no m/r/g
Pulm - CTA bilat, with rare rales right base
Abdomen - soft, NT, ND, b.s. present, no bruits
Extremities - no c/c/e. 2+ PT pulses bilaterally


Pertinent Results:
labs upon discharge:
WBC  RBC    Hgb   Hct MCV  MCH  MCHC RDW  Plt Ct
7.1  4.09* 11.6* 36.3  89  28.3 31.8 13.7 202

Glucose UreaN Creat  Na  K   Cl HCO3 AnGap
  147*   22*   0.9  142 4.3 104  26   16

trop T 0.03

Mg 2

TTE on admission ([**2117-8-10**])
The left atrium is dilated. The right atrial pressure is
indeterminate. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. There is moderate
regional left ventricular systolic dysfunction with apical
aneurysm which is dyskinetic. A left ventricular mass/thrombus
cannot be excluded. Right ventricular chamber size is normal.
with normal free wall contractility. The aortic root is mildly
dilated at the sinus level. The aortic arch is mildly dilated.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is a
small pericardial effusion.

Compared with the prior study (images reviewed) of [**2117-5-14**],
mitral regurgitation and tricuspid regurgitation are now more
prominent and the estimated pulmonary artery systolic pressure
is now higher.

Brief Hospital Course:
71 year old woman with insulin dependent diabetes, 3 vessel CAD
s/p CABG, presenting with abdominal pain and increase in
troponins, admitted to CCU for exacerbation of systolic heart
failure
.
# Acute on Chronic SYSTOLIC HEART FAILURE: Dyspnea and abdominal
discomfort could be secondary to CHF exacerbation.  Etiology
ACS/NSTEMI versus dietary indiscretion. Patient was continued on
ASA, Plavix, Lipitor, metoprolol, ACE-I. Serial troponins/CK-MB
were followed and were never elevated.  Etiology thought to be
due to dietary indiscretion.  ECG showed NSR with many PVCs.
TTE showed similar finding to prior (see above) consistent with
mild systolic failure.  Patient was dosed with short-acting
metoprolol in setting of mild hypotension, which was reason for
admission to CCU.  Persantine Thallium test was scheduled for 2
weeks after discharge to evaluate for ischemia.  Patient
responded well to additional doses of lasix, with increased
urine output and net (-) fluid balance of [**12-11**] liters/day.
Patient was transferred from unit to floor and continued to do
well.  The addition of spironolactone to her regimen was
deferred in the setting of systolic blood pressure in the 100s.
The patient was discharged on [**2117-8-12**] in improved and stable
condition.
.
# RHYTHM: PVC's present but ICD in place.  Rate was
well-controlled during admission on metoprolol.
.
# HYPOTENSION: Manual cuff BP of 115/50. Automated BP
measurements were thought to be artifically low secondary to
multiple premature ventricular contractions.  The patient was
converted to short-acting metoprolol and ACE inhibitor for
improved control, and was discharged on her home regimen of
toprol XL and lisinopril at decreased dose of 10 mg.
.
# DIABETES: Patient was continued  on home insulin regimen with
Lantus and Novolog with good glycemic control.
.
# HYPERTHYROIDISM:  Methimazole was continued.
.
# CODE: full (confirmed)




Medications on Admission:
ASA 325mg daily
Lipitor 80mg daily
Lisinopril 20mg daily
Metoprolol Succinate 75mg daily
Plavix 75mg daily
Protonix 40mg daily
Tapazole 10mg daily
Insulin
-- Detemir 34 units at night
-- Lispro 6 with breakfast, 14 with dinner.
Clorazepate 3.75 mg qday
KCl 20mEq daily
Furosemide 40mg daily (took 80mg day PTA)
MVI daily
APAP PRN


Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not stop taking unless Dr. [**Last Name (STitle) **] tells you to. .
5. Methimazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses.
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO once a day.
12. Tranxene T-Tab 3.75 mg Tablet Sig: One (1) Tablet PO once a
day.
13. Insulin Detemir 100 unit/mL Solution Sig: Thirty Four (34)
units Subcutaneous at bedtime.
14. Insulin Lispro 100 unit/mL Solution Sig: Six (6) units
Subcutaneous once a day: 14 units at night.
15. Multivitamin     Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
Acute on Chronic Systolic Heart Failure

Secondary Diagnoses:
- Coronary Artery Disease
- Peripheral Artery Disease
- Diabetes Mellitus
- Hypertension
- Osteoarthritis
- Spinal stenosis
- Hyperthyroidism


Discharge Condition:
stable and improved


Discharge Instructions:
You came to the hospital with abdominal pain.  While you were
evaluated in the ED, you developed low blood pressure, and you
were then admitted to the ICU for further monitoring.  You had
received extra doses of lasix before coming to the hospital and
some additional Lasix here. We feel that your congestive heart
failure was because you ate some high salt foods. You will need
to avoid these in the future.
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight > 3 lbs
in 1 day of 6 pounds in 3 days.
Adhere to 2 gm sodium diet, information about this was discussed
with you at discharge.
,
Medication changes:
1. Your Lisinopril was decreased to 10 mg daily because of low
blood pressure
2. Your Protonix was changed to Famotidine because the Protonix
interferes with the Plavix.

Please see below for follow up appointments. You will be
scheduled for a stress test in 2 weeks.

Please call your PCP [**Last Name (NamePattern4) **] 911 if you develop chest pain, shortness
of breath, abdominal pain, a dry cough, dizziness with standing
or any other unusual symptoms.

Followup Instructions:
[**Last Name (NamePattern4) **] Surgery:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2118-7-4**]
10:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2118-7-4**] 11:20
.
Cardiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 4105**] Date/time: [**9-15**] at
11;30am
You have an appt for a stress test at [**Hospital1 **] on Thursday
[**9-2**] at 9:00am.
.
Primary Care:
Dr. [**Last Name (STitle) **] [**Name (STitle) 75782**] Phone: [**Telephone/Fax (1) 7164**] Date/Time: Tuesday [**8-17**]
at 2:15pm.
{'Acute on chronic systolic heart failure,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Peripheral vascular disease, unspecified,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Hypotension, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Spinal stenosis, unspecified region,Old myocardial infarction,Long-term (current) use of insulin,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ'}


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

PRESENT ILLNESS: Ms [**Known lastname 12130**] is a 71 year old woman with history of silent MI
([**2103**]) that was complicated with left ventricular aneurysm (s/p
repair) and mural thrombus, STEMI ([**9-16**]), CAD s/p CABG x 4
(LIMA to LAD, SVG to OM1, OM2 and RCA) [**10-17**], recent NSTEMI
([**12-18**]), insulin dependent diabetes, peripheral [**Month/Year (2) 1106**] disease,
and hyperthyroidism.

MEDICAL HISTORY: PAST CARDIAC HISTORY:
- Silent MI in [**2103**] c/b ventricular aneurysm and apical thrombus
- CABG: in [**2116-10-31**] x4
LIMA to LAD, SVG to OM1, SVG to OM2, SVG to RCA, LCx
endarterectomy
- s/p left ventricular aneurysm repair (Dor procedure?)
- NSTEMI [**2116-12-31**] s/p PCI with PTCA and stenting of the left main
- proximal left circumflex with a Xience drug eluting stent and
PTCA of the proximal left anterior descending artery.
- ICD placement: [**4-/2117**] [**Company 1543**] Virtuoso DR D1548WG, AAI<->DDD
.
PAST MEDICAL HISTORY:
-- PAD s/p left SFA angioplasty and stent ([**2114**])
-- DM2, well-controlled
-- HTN
-- OA
-- spinal stenosis
-- Hyperthyroidism
-- s/p cholecystectomy
-- s/p appendectomy
-- s/p TAH
.
CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia,
(+)Hypertension

MEDICATION ON ADMISSION: ASA 325mg daily
Lipitor 80mg daily
Lisinopril 20mg daily
Metoprolol Succinate 75mg daily
Plavix 75mg daily
Protonix 40mg daily
Tapazole 10mg daily
Insulin
-- Detemir 34 units at night
-- Lispro 6 with breakfast, 14 with dinner.
Clorazepate 3.75 mg qday
KCl 20mEq daily
Furosemide 40mg daily (took 80mg day PTA)
MVI daily
APAP PRN

ALLERGIES: Bactrim

PHYSICAL EXAM: VS: T 98 HR 82 BP 82/36 (114/50 manually) RR 16 O2sat 96% on 2L
General - NAD, AAO
HEENT - JVD to angle of jaw, MMM, no scleral icterus
CVS - irreg. irreg, S1 and S2 present, no m/r/g
Pulm - bibasilar crackles, no wheezes
Abdomen - soft, NT, ND, b.s. present, no bruits
Extremities - no c/c/e. 2+ PT pulses b/l.

FAMILY HISTORY: Brother died of MI at age 59.

SOCIAL HISTORY: Lives with her husband in [**Name (NI) 392**], [**Name6 (MD) **] is NP and is very
involved in her care. Denies EtOH. Quit tobacco 12 yrs ago
(smoked 1/2ppd x 20+ yrs). 

### Response:
{'Acute on chronic systolic heart failure,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Peripheral vascular disease, unspecified,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Hypotension, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Spinal stenosis, unspecified region,Old myocardial infarction,Long-term (current) use of insulin,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ'}
