CHIEF COMPLAINT: Abdominal pain

PRESENT ILLNESS: 63 y/o male with hx of diffuse atherosclerotic disease and
aortic insufficiency (2+) transferred from OSH after cardiac
catheterization by Dr. [**Last Name (STitle) 8579**] where patient was found to have
multivessel disease: 99% stenosis RCA, 70% LAD, 70% left
circumflex.  Transferred to [**Hospital1 18**] to Dr.[**Name (NI) 5786**] service for
evaluation of multivessel PCI vs CABG/ AVR. Patient initially
admitted to OSH for evaluation and management of chronic
abdominal pain x 2 months.  Describes pain as a constant burning
pressure that radiates to back and up shoulder blades.
Occassional N/V with pain episodes. Pain comes on about 1 hour
after eating.  Relieved by vicodin only.  Patient notes
prolonged constipation, especially since initiation of vicodin.
EGD on [**9-23**] showed mild esophagitis and delayed gastric
emptying.  MRCP at OSH showed no evidence of biliary or
pancreatic obsrtuction.  KUB showed no signs of acute
obstruction.
Patient has also complained of nonradiating substernal chest
pressure with the abdominal pain for the 3 weeks.  No associated
SOB, diaphoresis, cough, or other related symptoms.
Nitroglycerin does not relieve pain.  Evaluated by nuclear scan
at [**State 792**]Hospital on [**2104-10-3**] which showed dilated RV,
scar in the RV territory and EF of 49%.
On transfer, vital signs were T= 98.1 HR = 66 BP = 131/75 RR =
18 SaO2 = 99% RA.  patient was comfortable without acute
complaints although he was concerned that pain would return once
morphine wore off.  Also citing concern that he has not had a
bowel movement in  7 days.
Review of Systems:
Pertinent positives: notes exertional calf pain, increased from
common iliac stenting [**4-16**] yeqars ago.  Denies any coldness,
ulcers, or paralysis in his lower extremities.  Complains of
orthopnea and paradoxical nocturnal dyspnea (uses [**5-18**] pilliows
at night).  Denies peripheral edema.
Pertinent negatives: he denies any prior history of stroke,
black stools or red stools, recent fevers, chills or rigors or
othersystemic symptoms.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: HTN, hyperlipidemia
2. CARDIAC HISTORY: CAD with diffuse multivessel disease s/p MI
(age unknown) followed by Dr. [**Last Name (STitle) 38001**]
3. PVD s/p bilateral iliac stents: approx 4 years ago by Dr.
[**Last Name (STitle) 41524**]
4. Abdominal Aortic Aneurysm stable at 3.9 cm by CT on [**10-11**]
5. Common iliac artery aneurysm at 2.5 cm by CT on [**10-11**]
6. Aortic insufficiency
7. Bladder cancer [**2101**] s/p resection
8. Hiatal hernia
9. Chronic kidney disease followed by Dr. [**Last Name (STitle) **]
10. GERD: EGD on [**2104-9-23**] showed mild esophagitis, gastritis,
delayed gastric emptying

MEDICATION ON ADMISSION: pravastatin 80', isosorbide 20"', diltiazem 180', plavix 75',
ranitidine 150", metoprolol 25', zetia 10', ASA 81'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T= 98.1  HR = 66   BP = 131/75   RR = 18   SaO2 = 99% RA
GENERAL: chronically ill, sallow gentleman, NAD
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink.  Dry
oral mucosa
NECK: Supple, no thyromegaly, normal JVP.  B/l carotid bruits
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. grade III/ VI diastolic blowing murmur
heard best at RSB. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. decreased breath sounds
at bases.
ABDOMEN: Soft, mild distention. + tenderness to palpation in
epigastrium. No guarding or rebound. No HSM. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. surgical dressing c/d/i on right groin.
No fluctuence or pain to palpitation.  + femoral bruits b/l
SKIN: no rashes, ulcers or lesions
PULSES: +2 DP, PT pulses bilaterally

FAMILY HISTORY: Extensive family history of heart disease
Father: died of MI at age 59
Mother: died of breast cancer
sisters: CAD

SOCIAL HISTORY: Divorced 2 times, lives with sister.  Currently employed
part-time in hotel laundry.  Multiple prior jobs in factories,
mechanics, etc.
-Tobacco history: Quit 3 months ago.  Heavy smoking history
since the age of 14
-ETOH:  quit 22 years ago
-Illicit drugs:  none
Coronary atherosclerosis of native coronary artery,Acute pancreatitis,Congenital insufficiency of aortic valve,Urinary tract infection, site not specified,Cardiac complications, not elsewhere classified,Dissection of other artery,Accidental puncture or laceration during a procedure, not elsewhere classified,Other specified cystic kidney disease,Aortic valve disorders,Other constipation,Retention of urine, unspecified,Atrial fibrillation,Other diseases of lung, not elsewhere classified,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Aneurysm of iliac artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other and unspecified hyperlipidemia,Abdominal aneurysm without mention of rupture,Personal history of malignant neoplasm of bladder,Chronic kidney disease, unspecified,Atherosclerosis of renal artery
Crnry athrscl natve vssl,Acute pancreatitis,Cong aorta valv insuffic,Urin tract infection NOS,Surg compl-heart,Dissection artery NEC,Accidental op laceration,Cystic kidney diseas NEC,Aortic valve disorder,Constipation NEC,Retention urine NOS,Atrial fibrillation,Other lung disease NEC,Abn react-cardiac cath,Iliac artery aneurysm,Hy kid NOS w cr kid I-IV,Hyperlipidemia NEC/NOS,Abdom aortic aneurysm,Hx of bladder malignancy,Chronic kidney dis NOS,Renal artery atheroscler
Admission Date:  [**2104-10-14**]              Discharge Date:   [**2104-11-4**]

Date of Birth:  [**2041-8-5**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Abdominal pain

Major Surgical or Invasive Procedure:
[**2104-10-24**] Aortic Valve Replacement(27mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic Tissue) and
Three Vessel Coronary Artery Bypass Grafting with Left internal
mammary graft to the left anterior descending artery and reverse
saphenous vein grafts to the posterior descending artery and
margianl branch


History of Present Illness:
63 y/o male with hx of diffuse atherosclerotic disease and
aortic insufficiency (2+) transferred from OSH after cardiac
catheterization by Dr. [**Last Name (STitle) 8579**] where patient was found to have
multivessel disease: 99% stenosis RCA, 70% LAD, 70% left
circumflex.  Transferred to [**Hospital1 18**] to Dr.[**Name (NI) 5786**] service for
evaluation of multivessel PCI vs CABG/ AVR. Patient initially
admitted to OSH for evaluation and management of chronic
abdominal pain x 2 months.  Describes pain as a constant burning
pressure that radiates to back and up shoulder blades.
Occassional N/V with pain episodes. Pain comes on about 1 hour
after eating.  Relieved by vicodin only.  Patient notes
prolonged constipation, especially since initiation of vicodin.
EGD on [**9-23**] showed mild esophagitis and delayed gastric
emptying.  MRCP at OSH showed no evidence of biliary or
pancreatic obsrtuction.  KUB showed no signs of acute
obstruction.
Patient has also complained of nonradiating substernal chest
pressure with the abdominal pain for the 3 weeks.  No associated
SOB, diaphoresis, cough, or other related symptoms.
Nitroglycerin does not relieve pain.  Evaluated by nuclear scan
at [**State 792**]Hospital on [**2104-10-3**] which showed dilated RV,
scar in the RV territory and EF of 49%.
On transfer, vital signs were T= 98.1 HR = 66 BP = 131/75 RR =
18 SaO2 = 99% RA.  patient was comfortable without acute
complaints although he was concerned that pain would return once
morphine wore off.  Also citing concern that he has not had a
bowel movement in  7 days.
Review of Systems:
Pertinent positives: notes exertional calf pain, increased from
common iliac stenting [**4-16**] yeqars ago.  Denies any coldness,
ulcers, or paralysis in his lower extremities.  Complains of
orthopnea and paradoxical nocturnal dyspnea (uses [**5-18**] pilliows
at night).  Denies peripheral edema.
Pertinent negatives: he denies any prior history of stroke,
black stools or red stools, recent fevers, chills or rigors or
othersystemic symptoms.



Past Medical History:
1. CARDIAC RISK FACTORS: HTN, hyperlipidemia
2. CARDIAC HISTORY: CAD with diffuse multivessel disease s/p MI
(age unknown) followed by Dr. [**Last Name (STitle) 38001**]
3. PVD s/p bilateral iliac stents: approx 4 years ago by Dr.
[**Last Name (STitle) 41524**]
4. Abdominal Aortic Aneurysm stable at 3.9 cm by CT on [**10-11**]
5. Common iliac artery aneurysm at 2.5 cm by CT on [**10-11**]
6. Aortic insufficiency
7. Bladder cancer [**2101**] s/p resection
8. Hiatal hernia
9. Chronic kidney disease followed by Dr. [**Last Name (STitle) **]
10. GERD: EGD on [**2104-9-23**] showed mild esophagitis, gastritis,
delayed gastric emptying


Social History:
Divorced 2 times, lives with sister.  Currently employed
part-time in hotel laundry.  Multiple prior jobs in factories,
mechanics, etc.
-Tobacco history: Quit 3 months ago.  Heavy smoking history
since the age of 14
-ETOH:  quit 22 years ago
-Illicit drugs:  none


Family History:
Extensive family history of heart disease
Father: died of MI at age 59
Mother: died of breast cancer
sisters: CAD


Physical Exam:
VS: T= 98.1  HR = 66   BP = 131/75   RR = 18   SaO2 = 99% RA
GENERAL: chronically ill, sallow gentleman, NAD
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink.  Dry
oral mucosa
NECK: Supple, no thyromegaly, normal JVP.  B/l carotid bruits
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. grade III/ VI diastolic blowing murmur
heard best at RSB. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. decreased breath sounds
at bases.
ABDOMEN: Soft, mild distention. + tenderness to palpation in
epigastrium. No guarding or rebound. No HSM. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. surgical dressing c/d/i on right groin.
No fluctuence or pain to palpitation.  + femoral bruits b/l
SKIN: no rashes, ulcers or lesions
PULSES: +2 DP, PT pulses bilaterally

Pertinent Results:
[**2104-10-15**] Carotid Series:
Right ICA stenosis <40%;  Left ICA stenosis <40%

[**2104-10-15**] Echocardiogram:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is mild regional left ventricular
systolic dysfunction with hypokinesis of the basal inferior
wall. The remaining segments contract normally and overall LVEF
is preserved (LVEF = 60 %). Right ventricular chamber size and
free wall motion are normal. The aortic root is moderately
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve is bicuspid (fused right and left
raphe) with mildly thickened/restricted leaflets. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). An eccentric jet
of moderate (2+) aortic regurgitation is seen, directed toward
the anterior mitral leaflet. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.

[**2104-10-17**] Chest CT Scan:
The ascending aorta measures 4.4 cm and there is mild
calcification of the posterior wall of the ascending aorta.
Diffuse paraseptal and centrilobular emphysematous changes of
the lungs. Asymmetric pulmonary fibrosis affecting the right
lung in subpleural and basilar distribution. 5-mm right lower
lobe pulmonary nodule for which followup is recommended in six
months. Right adrenal adenoma.

[**2104-10-21**] Abdominal Ultrasound:
Unremarkable appearance of the visualized portions of the
pancreas. Abdominal aortic aneurysm, measuring up to 3.9 cm.
Bilateral renal cysts. The largest cyst on the right contains
thin
septations inferiorly. Six-month followup study is recommended.

[**2104-10-24**] Intraop TEE:
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity is moderately dilated. There is mild global
left ventricular hypokinesis (LVEF = 40-45 %) with focal
hypokinesis of the inferior base. The remaining left ventricular
segments contract normally. Right ventricular chamber size and
free wall motion are normal. The aortic root is moderately
dilated at the sinus level (4.6-4.8cm). The ascending aorta is
mildly dilated. The descending thoracic aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta. The
aortic valve is bicuspid. There is systolic doming of the aortic
valve leaflets. Moderate to severe (3+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.

POSTBYPASS
There is a well seated, well functioning bioprostheis in the
aortic position. No aortic insufficiency is visualized.
Biventricular systolic function remain unchanged compared to
prebypass.

[**2104-11-2**] Chest X-ray(PA and Lat):
The right introducer sheath has been removed. There is no PTX.
The chronic changes in the upper lung fields are no different.
No new focal consolidations are seen. Pulmonary vascular
markings are within normal limits. The cardiac silhouette is
enlarged but no different than prior. Retrocardiac density has
largely resolved. The left CP angle is cut of from view.
IMPRESSION: Improved aeration in the retrocardiac area with no
new consolidations and no features of CHF.
             WBC/Hgb/Hct/Plt Ct
[**2104-11-3**]         26.5*
[**2104-11-3**] 7.7/7.9*/23.8*/293
[**2104-11-2**] 8.1/9.2*/27.8*/303
[**2104-11-2**]         25.3*

                        Glucose UreaN Creat Na   K  Cl HCO3
AnGap
[**2104-11-4**]                       31* 1.7*      4.3
[**2104-11-3**]                       26* 1.8* 133  4.6 98 25 15
[**2104-11-2**]                       27* 1.6*      4.4
[**2104-11-1**]                       28* 1.6* 133  4.6 97 27 14
[**2104-10-29**]                       27* 1.5* 132* 4.2 98 24 14
[**2104-10-27**]                       23* 1.4* 131* 4.3 93* 30 12




Brief Hospital Course:
63 yo male with hx CAD, aortic valve insufficiency transferred
from OSH after cardiac catheterization on [**2104-10-14**] showed native
three vessel disease: 99% RCA, 70% LAD, 70% Cx stenosis.
Cardiac surgery evaluated patient and felt he was an appropriate
candidate for CABG/ AVR. Preoperative issues included:
1. Abdominal Discomfort: Patient complaints of persistent
abdominal pain prompted initial admission to OSH.  Etiology
remained unclear despite extensive prior workup: unimpressive CT
abdoman (bilateral renal cysts), EGD with only mild gastritis.
Patient found to have elevated lipase/ amylase but had negative
MRCP for biliary/ pancreatic ductal dilitation, no evidence of
pancreatic inflammation or masses. Episode of abdominal pain
recurred on [**10-21**], and pancreatic enzymes were found to be mildly
elevated. GI consult felt presentation to be consistent with
acute pancreatitis.
2. Chronic Kidney Disease: According to outside records,
patient's baseline creatinine ranged from 1.4 - 1.7. Patient was
found to have renal artery stenosis > 90% by cardiac
catheterization, no acute intervention indicated.
3. Focal right femoral artery dissection s/p cardiac
catheterization on [**10-14**]: noted to have femoral bruit on physical
exam and found to have R CFA focal dissection by doppler.
Patient subjectively and clinically asymptomatic, distal pulses
intact.  Follow up with vascular surgery following discharge
from hospital.

On [**2104-10-24**] patient brought to the operating room at which time
he had aortic valve replacement and coronary bypass grafting
x3...please see operative report for details. He tolerated the
operation well and was transferred to the cardiac surgery ICU in
stable condition. He remained stable in the immediate post-op
period and was extubated on the morning of POD 1. He stayed in
the cardiac surgery ICU for aggressive pulmonary toilet. On POD
3 he was transferred to the stepdown floor. His chest tubes,
pacing wires and invasive monitoring lines were all discontinued
according to cardiac surgery protocol. He developed urination
retention after the foley was removed. He was started on Flomax
and had subsequent successful voiding trial. He was started on
beta blockers and diuretics and these were titrated to response.
On POD 6 he had a short burst of atrial fibrillation and was
treated with increased beta blockade and Amiodarone. Within 24
hours, he converted to sinus rhythm and no further episodes of
atrial fibrillation were noted. Given chronic renal
insufficiency, his creatinine was followed closely. Creatinine
ranged mostly between 1.4 to 1.6, peaking to 1.8 on POD 10.
Discharge creatinine was 1.7. He was also started on
Ciprofloxacin postoperatively for a positive urinalysis. Urine
culture revealed gram negative rods of greater than 100,000
organisms...final culture was pending at discharge. He continued
to make clinical improvements and was eventually cleared for
discharge to home on POD 11.



Medications on Admission:
pravastatin 80', isosorbide 20"', diltiazem 180', plavix 75',
ranitidine 150", metoprolol 25', zetia 10', ASA 81'


Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-19**]
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
10. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*0*
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
13. Megestrol 40 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
15. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home with Service

Facility:
tba

Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Aortic Insufficiency s/p AVR
Post operative atrial fibrillation
Hypertension
Peripheral Vascular Disease
Dyslipidemia
Chronic Renal Insufficiency
Postop Urinary Tract Infection
Acute Pancreatitis - preoperative
Femoral Artery Dissection - preoperative
Renal Artery Stenosis
Lung Nodule


Discharge Condition:
Good


Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]

Followup Instructions:
Please call to schedule appointments
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 8579**] in [**2-15**] weeks  [**Telephone/Fax (1) 23882**]
Dr. [**Last Name (STitle) **] in [**3-18**] weeks (needs 6 months followup of right renal
cyst)[**Telephone/Fax (1) 65924**]
Dr [**First Name (STitle) **] (thoracic surgery) [**Telephone/Fax (1) 170**] regarding lung nodule
follow up.
Dr. [**Last Name (STitle) **] for vascular surgery follow up appt



Completed by:[**2104-11-4**]
{'Coronary atherosclerosis of native coronary artery,Acute pancreatitis,Congenital insufficiency of aortic valve,Urinary tract infection, site not specified,Cardiac complications, not elsewhere classified,Dissection of other artery,Accidental puncture or laceration during a procedure, not elsewhere classified,Other specified cystic kidney disease,Aortic valve disorders,Other constipation,Retention of urine, unspecified,Atrial fibrillation,Other diseases of lung, not elsewhere classified,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Aneurysm of iliac artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other and unspecified hyperlipidemia,Abdominal aneurysm without mention of rupture,Personal history of malignant neoplasm of bladder,Chronic kidney disease, unspecified,Atherosclerosis of renal artery'}


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: 63 y/o male with hx of diffuse atherosclerotic disease and
aortic insufficiency (2+) transferred from OSH after cardiac
catheterization by Dr. [**Last Name (STitle) 8579**] where patient was found to have
multivessel disease: 99% stenosis RCA, 70% LAD, 70% left
circumflex.  Transferred to [**Hospital1 18**] to Dr.[**Name (NI) 5786**] service for
evaluation of multivessel PCI vs CABG/ AVR. Patient initially
admitted to OSH for evaluation and management of chronic
abdominal pain x 2 months.  Describes pain as a constant burning
pressure that radiates to back and up shoulder blades.
Occassional N/V with pain episodes. Pain comes on about 1 hour
after eating.  Relieved by vicodin only.  Patient notes
prolonged constipation, especially since initiation of vicodin.
EGD on [**9-23**] showed mild esophagitis and delayed gastric
emptying.  MRCP at OSH showed no evidence of biliary or
pancreatic obsrtuction.  KUB showed no signs of acute
obstruction.
Patient has also complained of nonradiating substernal chest
pressure with the abdominal pain for the 3 weeks.  No associated
SOB, diaphoresis, cough, or other related symptoms.
Nitroglycerin does not relieve pain.  Evaluated by nuclear scan
at [**State 792**]Hospital on [**2104-10-3**] which showed dilated RV,
scar in the RV territory and EF of 49%.
On transfer, vital signs were T= 98.1 HR = 66 BP = 131/75 RR =
18 SaO2 = 99% RA.  patient was comfortable without acute
complaints although he was concerned that pain would return once
morphine wore off.  Also citing concern that he has not had a
bowel movement in  7 days.
Review of Systems:
Pertinent positives: notes exertional calf pain, increased from
common iliac stenting [**4-16**] yeqars ago.  Denies any coldness,
ulcers, or paralysis in his lower extremities.  Complains of
orthopnea and paradoxical nocturnal dyspnea (uses [**5-18**] pilliows
at night).  Denies peripheral edema.
Pertinent negatives: he denies any prior history of stroke,
black stools or red stools, recent fevers, chills or rigors or
othersystemic symptoms.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: HTN, hyperlipidemia
2. CARDIAC HISTORY: CAD with diffuse multivessel disease s/p MI
(age unknown) followed by Dr. [**Last Name (STitle) 38001**]
3. PVD s/p bilateral iliac stents: approx 4 years ago by Dr.
[**Last Name (STitle) 41524**]
4. Abdominal Aortic Aneurysm stable at 3.9 cm by CT on [**10-11**]
5. Common iliac artery aneurysm at 2.5 cm by CT on [**10-11**]
6. Aortic insufficiency
7. Bladder cancer [**2101**] s/p resection
8. Hiatal hernia
9. Chronic kidney disease followed by Dr. [**Last Name (STitle) **]
10. GERD: EGD on [**2104-9-23**] showed mild esophagitis, gastritis,
delayed gastric emptying

MEDICATION ON ADMISSION: pravastatin 80', isosorbide 20"', diltiazem 180', plavix 75',
ranitidine 150", metoprolol 25', zetia 10', ASA 81'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T= 98.1  HR = 66   BP = 131/75   RR = 18   SaO2 = 99% RA
GENERAL: chronically ill, sallow gentleman, NAD
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink.  Dry
oral mucosa
NECK: Supple, no thyromegaly, normal JVP.  B/l carotid bruits
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. grade III/ VI diastolic blowing murmur
heard best at RSB. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. decreased breath sounds
at bases.
ABDOMEN: Soft, mild distention. + tenderness to palpation in
epigastrium. No guarding or rebound. No HSM. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. surgical dressing c/d/i on right groin.
No fluctuence or pain to palpitation.  + femoral bruits b/l
SKIN: no rashes, ulcers or lesions
PULSES: +2 DP, PT pulses bilaterally

FAMILY HISTORY: Extensive family history of heart disease
Father: died of MI at age 59
Mother: died of breast cancer
sisters: CAD

SOCIAL HISTORY: Divorced 2 times, lives with sister.  Currently employed
part-time in hotel laundry.  Multiple prior jobs in factories,
mechanics, etc.
-Tobacco history: Quit 3 months ago.  Heavy smoking history
since the age of 14
-ETOH:  quit 22 years ago
-Illicit drugs:  none 

### Response:
{'Coronary atherosclerosis of native coronary artery,Acute pancreatitis,Congenital insufficiency of aortic valve,Urinary tract infection, site not specified,Cardiac complications, not elsewhere classified,Dissection of other artery,Accidental puncture or laceration during a procedure, not elsewhere classified,Other specified cystic kidney disease,Aortic valve disorders,Other constipation,Retention of urine, unspecified,Atrial fibrillation,Other diseases of lung, not elsewhere classified,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Aneurysm of iliac artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other and unspecified hyperlipidemia,Abdominal aneurysm without mention of rupture,Personal history of malignant neoplasm of bladder,Chronic kidney disease, unspecified,Atherosclerosis of renal artery'}
