CHIEF COMPLAINT: Abdominal pain & distention

PRESENT ILLNESS: 78M h/o CAD s/p CABG, CHF (EF 35%), chronic GI bleed s/p
Portacath placement [**2153**] for delivery of blood products, CKD,
cardiac cirrhosis, presented to the ED with abdominal pain and
distention, vomiting x1, as well as poor PO intake, x3 days
after leaving AMA from nursing home and stopping his typical
regimen of paracentesis every ~14 days.  Noted to have N/V and
increased protrusion of umbilical hernia.
.
In the ED, T 97, HR 62, BP 95/43, RR 16, O2sat 100% 2L.  SBP
90-110s.  Exam notable for ascites, positive guaiac, hct 18.8,
Cr 3.3 (baseline 1.7), lactact 2.4.  Received 4mg IV morphine,
40mg IV protonix, 20mg IV furosemide, 2units PRBC.  Paracentesis
with 3L removed, negative for SBp.  CXR demonstrated
incompletely evaluated opactiy in LL base, but considered
atelectasis and effusion.  CT abdomen/pelvis limited with no IV
contrast and nearly no oral contrast, nondiagnostic for
diverticulitis or "infection"; no discrete transition point or
prox SB dilatation.  Massive ascites on CT despite 3L
paracentesis prior to study.  Admitted to ICU for anemia,
massive ascites, and acute renal failure.
.
ROS difficult to complete given limited verbal communication.
Denied current f/c, n/v, dysuria/hematuria, increased
melena/BRBPR, lightheadedness/dizziness.  C/o itchiness.

MEDICAL HISTORY: # HTN
# CAD: Reports CABG x3, first age 22(?), CABG [**2140**], cath [**2151**]
with patent lima-lad, occluded svg-om, near occluded svg-rca
# CHF: TTE [**7-6**] with EF 35%, mild LVH and LV-HK, 2+MR, 4+TR;
cardiac cath [**3-7**] to determine volume status with elevated
biventricular filling pressures, moderate pulmonary
hypertension, ventricularization of RA pressure consistent with
severe tricuspid
regurgitation.
# Afib: previously on coumadin but no longer secondary to GIB in

MEDICATION ON ADMISSION: Meds per [**2153-11-27**] OMR
Albuterol MDI QID PRN
Albuterol nebs PRN
Mylanta PRN
Ca carbonate 500mg PO TID
Digoxin 125mcg QOD
Ferrous sulfate 325mg Po daily
Ipratropium MDI QID PRN
Lactulose 15ml [**Hospital1 **]
Levoxyl 150mcg daily
Ativan 0.25mg TID PRn
Metolazone 5mg daily
Mirtazapine 15mg HS
MVI
Oxycodone-acetaminophen 5-325mg Q4H PRN
KCl 20mEq daily
.
Meds [**First Name8 (NamePattern2) **] [**Location (un) 1468**] [**Location (un) 269**] ([**2154-1-9**])
Tylenol PRN
Digoxin 125mcg QOD
Senekot [**Hospital1 **]
Ativan 0.5mg PO TID
Colace 100mg [**Hospital1 **]
Lasix 120mg [**Hospital1 **]
Potassium 10mEq daily
Levothyroxine 175mcg daily
metolazone 5mg daily
Mirtazapine 15mg daily
MVI
Ferrous sulfate 325mg daily
Lactulose 15ml [**Hospital1 **] PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: 96.6, 124/56, 70, 20, 97% RA
HEENT: NCAT, PERRL, neck supple
Cardiac: RRR, nl S1 and S2, no MRGs
Lungs: CTAB anteriorly, too agitated and restless to listen post

FAMILY HISTORY: Reported previously: Mother- HTN, ?died of MI; Father-83 yo and

SOCIAL HISTORY: Originally from [**Country 3397**]. Living with wife in [**Name (NI) 3146**] but states
has difficulty getting around and she has difficulty moving him,
Diseases of tricuspid valve,Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Subendocardial infarction, initial episode of care,Other ascites,Angiodysplasia of intestine with hemorrhage,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Other encephalopathy,Iron deficiency anemia secondary to blood loss (chronic),Umbilical hernia without mention of obstruction or gangrene,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified acquired hypothyroidism,Atrial fibrillation,Aortocoronary bypass status,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Chronic airway obstruction, not elsewhere classified
Tricuspid valve disease,Acute kidney failure NOS,Ac on chr syst hrt fail,Subendo infarct, initial,Ascites NEC,Angio intes w hmrhg,Hpt B chrn wo cm wo dlta,Hyposmolality,Urin tract infection NOS,Encephalopathy NEC,Chr blood loss anemia,Umbilical hernia,Abn react-procedure NEC,Hypothyroidism NOS,Atrial fibrillation,Aortocoronary bypass,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,Proteus infection NOS,Thrombocytopenia NOS,Chr airway obstruct NEC
Admission Date:  [**2154-1-30**]              Discharge Date:   [**2154-2-12**]

Date of Birth:  [**2075-5-19**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Abdominal pain & distention

Major Surgical or Invasive Procedure:
Paracentesis x 4

History of Present Illness:
78M h/o CAD s/p CABG, CHF (EF 35%), chronic GI bleed s/p
Portacath placement [**2153**] for delivery of blood products, CKD,
cardiac cirrhosis, presented to the ED with abdominal pain and
distention, vomiting x1, as well as poor PO intake, x3 days
after leaving AMA from nursing home and stopping his typical
regimen of paracentesis every ~14 days.  Noted to have N/V and
increased protrusion of umbilical hernia.
.
In the ED, T 97, HR 62, BP 95/43, RR 16, O2sat 100% 2L.  SBP
90-110s.  Exam notable for ascites, positive guaiac, hct 18.8,
Cr 3.3 (baseline 1.7), lactact 2.4.  Received 4mg IV morphine,
40mg IV protonix, 20mg IV furosemide, 2units PRBC.  Paracentesis
with 3L removed, negative for SBp.  CXR demonstrated
incompletely evaluated opactiy in LL base, but considered
atelectasis and effusion.  CT abdomen/pelvis limited with no IV
contrast and nearly no oral contrast, nondiagnostic for
diverticulitis or "infection"; no discrete transition point or
prox SB dilatation.  Massive ascites on CT despite 3L
paracentesis prior to study.  Admitted to ICU for anemia,
massive ascites, and acute renal failure.
.
ROS difficult to complete given limited verbal communication.
Denied current f/c, n/v, dysuria/hematuria, increased
melena/BRBPR, lightheadedness/dizziness.  C/o itchiness.

Past Medical History:
# HTN
# CAD: Reports CABG x3, first age 22(?), CABG [**2140**], cath [**2151**]
with patent lima-lad, occluded svg-om, near occluded svg-rca
# CHF: TTE [**7-6**] with EF 35%, mild LVH and LV-HK, 2+MR, 4+TR;
cardiac cath [**3-7**] to determine volume status with elevated
biventricular filling pressures, moderate pulmonary
hypertension, ventricularization of RA pressure consistent with
severe tricuspid
regurgitation.
# Afib: previously on coumadin but no longer secondary to GIB in

past
# Cardiac cirrhosis: Requiring repeat sx paracenteses
# Chronic GIB [**3-2**] AVMs
# Colon polyps
# HBV
# CRI: cr 1.5-1.8
# Hypothyroidism
# OA


Social History:
Originally from [**Country 3397**]. Living with wife in [**Name (NI) 3146**] but states
has difficulty getting around and she has difficulty moving him,

recently in rehab. Previously stated quit smoking 15 years ago,

smoked 1 ppd x 40 years. No EtOH. Retired, but used to work as a
machinist. Unable to walk. Needs wheelchair/walker to get around
his house.


Family History:
Reported previously: Mother- HTN, ?died of MI; Father-83 yo and

died of "old age" but unable to verify this tonight, states "I
don't remember."


Physical Exam:
Vitals: 96.6, 124/56, 70, 20, 97% RA
HEENT: NCAT, PERRL, neck supple
Cardiac: RRR, nl S1 and S2, no MRGs
Lungs: CTAB anteriorly, too agitated and restless to listen post

Abd: protruburant abd/umbilicus, +dullness to persussion, caput
medusa, +BS
Ext: in waffle boots, legs wrapped in gauze
Skin: ecchymosis throughout
Neuro: Alert but not able to assess orientation. MAE,
uncooperative with further exam


Pertinent Results:
COMPLETE BLOOD COUNT   WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2154-2-12**] 05:09AM    6.4 3.37* 9.3* 29.7* 88 27.6 31.3 18.3*
151
[**2154-2-11**] 06:26AM    5.9 3.26* 9.0* 29.0* 89 27.6 31.0 18.0*
125*
[**2154-2-10**] 05:37AM    7.1 3.29* 9.1* 29.3* 89 27.6 31.0 18.0*
127*
.
[**2154-2-4**] 06:07AM    7.3 3.52* 9.9* 30.0* 85 28.2 33.1 18.9*
112*
[**2154-2-3**] 02:20AM    6.2 3.46* 9.9* 29.0* 84 28.7 34.2 17.0*
125*
[**2154-2-2**] 03:22AM    5.5 2.91* 8.0* 24.6* 84 27.5 32.7 18.4*
127*
[**2154-2-1**] 02:50AM    5.6 2.89* 7.8* 24.3* 84 26.9* 32.0 16.8*
110*
[**2154-1-31**] 04:07AM    7.6 2.94* 7.9* 24.7* 84 26.8* 31.8 16.5*
163
[**2154-1-30**] 02:25AM    5.0 2.29* 5.7* 18.8*1 82 24.9* 30.4*
19.1* 291
.
BASIC COAGULATION       PT    PTT    INR(PT)
[**2154-2-12**] 05:09AM    14.1* 54.2*     1.2*
[**2154-2-11**] 06:26AM    14.2* 57.4*     1.2*
.
[**2154-1-30**] 02:25AM    16.8* 51.3*     1.5*
.
RENAL & GLUCOSE      Glucose UreaN Creat  Na  K   Cl HCO3
[**2154-2-12**] 05:09AM    93     52*   1.0  138 4.2 103  28
[**2154-2-11**] 06:26AM    77     55*   1.1  141 4.1 103  27
[**2154-2-10**] 05:37AM    107*   58*   1.2  145 4.8 109* 26
.
[**2154-2-5**] 05:10AM    151*  121*   1.6* 143 3.3 103 29
[**2154-2-4**] 06:07AM    141*  141*   2.0* 141 3.3 98 28
[**2154-2-3**] 02:20AM    93    161*   2.7* 133 3.6 90* 22
.
[**2154-1-31**] 04:07AM    76    169    3.2* 125* 4.4 86* 24
[**2154-1-30**] 08:11PM    80    171    3.1* 126* 4.6 85* 24
[**2154-1-30**] 02:25AM    82    179*   3.3* 125* 4.9 85* 21*
.
CPK ISOENZYMES        CK-MB MB Indx cTropnT
[**2154-1-31**] 04:07AM    23*   13.0*   0.60*
[**2154-1-30**] 03:44PM    25    16.0*   0.57*
[**2154-1-30**] 08:00AM                  0.53*
[**2154-1-30**] 02:25AM    20*   17.9*
.
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
[**2154-2-5**] 05:10AM    92 781 37 2.5 39
.
PITUITARY              TSH
[**2154-1-30**] 08:00AM    13*
.
THYROID              Free T4
[**2154-1-31**] 04:07AM    1.1
.
OTHER ENDOCRINE        Cortsol
[**2154-1-30**] 08:00AM    26.3
.
CARDIAC/PULMONARY     Digoxin
[**2154-2-12**] 05:09AM    1.0
[**2154-1-30**] 08:00AM    3.2*
.
.
CT Abdomen/pelvis [**2154-1-30**]
1. Severely limited examination. Given the lack of intravenous
contrast and near absence of oral contrast, the study is
nondiagnostic for infection or diverticulitis as requested.
2. There is a large umbilical hernia which should be apparent on
clinical exam (though not provided in the given history). A gas-
distended loop of small bowel appears to enter and exit the
hernia sac without definite transition point. No proximal small
bowel dilatation, to CT criteria, is noted.
.
CXR [**2154-2-4**]
In comparison with the study of [**1-31**], there is again substantial
left pleural effusion. It is difficult to compare this upright
film with the previous semi-upright study, in which the effusion
layers out along the posterior chest wall.
Enlargement of the cardiac silhouette persists. The degree of
pulmonary vascularity is essentially unchanged


Brief Hospital Course:
ASSESSEMENT/PLAN: 78 yo M with h/o CAD, CHF (EF 35-40%), cardiac
cirrhosis, CRI, chronic GIB and anemia who presented with
abdominal pain, found to have acute on chronic renal failure and
worsened anemia thus admitted initially to the ICU then
transferred to the floor after stabilization.
.
# Acute on chronic renal failure: Baseline creatinine 1.3-1.8,
3.3 on admission. Further investigation revealed that pt had
pre-renal failure due to dehydration and not hepatorenal
syndrome. Fluid rehydration with IVF as well [**Date Range 61990**] was done
with improvement in creatinine levels daily. Renal failure
resolved prior to discharge.
.
# Hypotension:  Pt was noromotensive on admission, however
developed hypotension after aggressive diuresis in the intensive
care unit. Hepatology and renal were consulted for the potential
of hepatorenal syndrome. However, pt was found to be mostly
dehydrated and IVF resusitation and [**Date Range 61990**] was aggressively
engaged. Pt did not have hepatorenal syndrome, hence midodrine
and octreotide that was initially started was stopped. His BP
improved and IVF, [**Date Range 61990**] was eventally discontinued. Pt has
remained normotensive since transfer from the unit.
.
# Anemia:  Chronic anemia with baseline hematocrit ~20-30's. Per
daughter, pt requires frequent blood transfusions ~q2weeks in
the setting of chronic GIB r/t AVM's. Pt received 5units PRBC
during this admission.
.
# CAD/NSTEMI: Pt developed NSTEMI during ICU stay in the setting
of renal failure, pt with known hx of CAD. There were no changes
on EKG. Pt not on aspirin due to h/o GIB, not started during
this admission. Lipids were at goal, hence statin was not
initiated.
.
# Atrial Fibrillation: Rate controlled on digoxin. Dig level 3.2
on admission, however held dose and redosed for dig levels < 1.
Pt's dig level 1.0 at discharge.
.
# CHF: LVEF 35-40% and massive ascites [**3-2**] cardiac cirrhosis.
Although with L pleural effusion, did not have evidence of fluid
overload on admission. During ICU stay developed new crackles on
examination, with evidence on CXR, however was post blood
transfusion and thought to be TRALI. We dosed digoxin as above,
rehydrated pt with IVF & [**Month/Day (2) 61990**] for renal failure.
.
# Abdominal pain: Had been a presenting complaint, however
improved after paracentesis. LFTs, amylase normal, lipase only
mildly elevated and unlikely etiology of previous symptoms.
There was no evidence of infectious etiology per physical
examination, labs or imaging. CT abdomen/pelvis unrevealing for
SBO, but study lacked oral contrast thus limited. Has large
umbilical hernia filled mainly with ascites on exam, however
hernia is reducible and nontender. Abdominal pain resolved
during hospitalization and has been attributed to abdominal
distention.
.
# Hypoxia: Developed hypoxia in the intensive care unit where he
was somnolent but with a low resp rate; however had only
received minimal narcotics in the ED. Received narcan in the
unit with some improvement. Evidence of atelectasis vs. L
infiltrate, also with progresive crackles worrisome for a
pneumonia, hence he received levofloxacin & ceftriaxone
initially, however did not worsen hence the levaquin was
discontinued. There was also ? of TRALI as pt had received 2U
PRBC in the ED, this could not be completely ruled out. Pt was
continued on ceftriaxone for a 7 day course to treat his UTI.
.
# Thrombocytopenia: Developed during admission, no clear
etiology thus ?sequestration. +cardiac cirrhosis, negative HIT
antibodies, no evidence of schitocytes on smear and negative DIC
labs. Did not require transfusion and improved prior to
discharge
.
# Hypernatremia: Initially hyponatremic during admission with
intravascular depletion, this resolved. However developed
hypernatremia after one episode of paracentesis, resolved with
D5W bolus and encouraging pt to drink. No seizure activity or
mental status changes. Max sodium level was 151.
.
# Cardiac cirrhosis: Known hx of frequent paracentesis for
diuretic refractory acites. Liver function appears stable
currently, however mild thrombocytopenia. s/p paracentesis
[**2154-2-5**], received paracentesis on day of discharge with
removal of ~5L ascitic fluid. Pt is scheduled for paracentesis
at [**Hospital1 18**] on [**2153-2-26**] at 930am.
We discontinued his Metolazone & furosemide daily as pt did not
appear to be fluid overloaded, would recommend diuresis with
evidence of overload while closely monitoring renal function.
.
# Complicated UTI: +UA noted on admission, urine culture with
pansensitive P. mirabilis. Completed 7 day course of Ceftriaxone
[**2154-2-7**]
.
# Senile Purpura/ecchymosis: [**Doctor Last Name 61997**] purpura [**3-2**] thin skin,
trauma & coagulopathy. Applied mitts to prevent pt from
scratching. Did not worsen during admission.
.
# Coagulopathy: INR 1.5 on admission, remained close to that
baseline. Known cardiac cirrhosis, received vitamin K po x 3
days in ICU.
.
# ?COPD: Reportedly on 2L at home, however daughter was unsure
if he had actually been using it. Remote tobacco use; had not
need for oxygen after transfer to the floor. We provided
albuterol, atrovent MDI's prn.
.
# Hypothyroidism: TSH on admission elevated to 13. Continued pt
on levothyroxine 175mg po daily.
.
# Encephalopathy: Resolved during admission. Thought to be due
to cardiac cirrhosis and also uremia with pt.renal failure. Pt
was somewhat agitated, calling out at baseline. We avoided
sedating meds and benzos. Pt refused lactulose during admission.

.
Pt had reached maximal hospital benefit and was transferred to a
rehab facility.

Medications on Admission:
Meds per [**2153-11-27**] OMR
Albuterol MDI QID PRN
Albuterol nebs PRN
Mylanta PRN
Ca carbonate 500mg PO TID
Digoxin 125mcg QOD
Ferrous sulfate 325mg Po daily
Ipratropium MDI QID PRN
Lactulose 15ml [**Hospital1 **]
Levoxyl 150mcg daily
Ativan 0.25mg TID PRn
Metolazone 5mg daily
Mirtazapine 15mg HS
MVI
Oxycodone-acetaminophen 5-325mg Q4H PRN
KCl 20mEq daily
.
Meds [**First Name8 (NamePattern2) **] [**Location (un) 1468**] [**Location (un) 269**] ([**2154-1-9**])
Tylenol PRN
Digoxin 125mcg QOD
Senekot [**Hospital1 **]
Ativan 0.5mg PO TID
Colace 100mg [**Hospital1 **]
Lasix 120mg [**Hospital1 **]
Potassium 10mEq daily
Levothyroxine 175mcg daily
metolazone 5mg daily
Mirtazapine 15mg daily
MVI
Ferrous sulfate 325mg daily
Lactulose 15ml [**Hospital1 **] PRN

Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
5. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for Anxiety/insomnia.
6. Atrovent HFA 17 mcg/Actuation Aerosol Sig: [**1-30**] puff
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
8. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Mylanta 200-200-20 mg/5 mL Suspension Sig: Five (5) ml PO
every eight (8) hours as needed for indigestion.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2857**] - [**Location (un) 1121**] - [**Location (un) 4310**]

Discharge Diagnosis:
Acute on chronic renal failure
Anemia
Cardiac cirrhosis [**3-2**] CHF
Hypothyroidism
Atrial fibrillation


Discharge Condition:
Stable, Cr.1.0


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L
.
We have held your Metolazone & furosemide for now. Please
continue to take your other medications as prescribed.

Followup Instructions:
Provider: [**Name10 (NameIs) 703**] WEST INTERVENTIONAL/PROSTATE US RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2154-2-26**] 11:00 - If with worsening
abdominal pain and distension prior to [**2154-2-26**], please call
to schedule the patient for a sooner appointment.
.
Please make an appointment to follow up with your PCP [**Name Initial (PRE) 151**]
1-2weeks of discharge or when your leave rehab. PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **]
[**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1144**]
{'Diseases of tricuspid valve,Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Subendocardial infarction, initial episode of care,Other ascites,Angiodysplasia of intestine with hemorrhage,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Other encephalopathy,Iron deficiency anemia secondary to blood loss (chronic),Umbilical hernia without mention of obstruction or gangrene,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified acquired hypothyroidism,Atrial fibrillation,Aortocoronary bypass status,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Chronic airway obstruction, not elsewhere classified'}


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 & distention

PRESENT ILLNESS: 78M h/o CAD s/p CABG, CHF (EF 35%), chronic GI bleed s/p
Portacath placement [**2153**] for delivery of blood products, CKD,
cardiac cirrhosis, presented to the ED with abdominal pain and
distention, vomiting x1, as well as poor PO intake, x3 days
after leaving AMA from nursing home and stopping his typical
regimen of paracentesis every ~14 days.  Noted to have N/V and
increased protrusion of umbilical hernia.
.
In the ED, T 97, HR 62, BP 95/43, RR 16, O2sat 100% 2L.  SBP
90-110s.  Exam notable for ascites, positive guaiac, hct 18.8,
Cr 3.3 (baseline 1.7), lactact 2.4.  Received 4mg IV morphine,
40mg IV protonix, 20mg IV furosemide, 2units PRBC.  Paracentesis
with 3L removed, negative for SBp.  CXR demonstrated
incompletely evaluated opactiy in LL base, but considered
atelectasis and effusion.  CT abdomen/pelvis limited with no IV
contrast and nearly no oral contrast, nondiagnostic for
diverticulitis or "infection"; no discrete transition point or
prox SB dilatation.  Massive ascites on CT despite 3L
paracentesis prior to study.  Admitted to ICU for anemia,
massive ascites, and acute renal failure.
.
ROS difficult to complete given limited verbal communication.
Denied current f/c, n/v, dysuria/hematuria, increased
melena/BRBPR, lightheadedness/dizziness.  C/o itchiness.

MEDICAL HISTORY: # HTN
# CAD: Reports CABG x3, first age 22(?), CABG [**2140**], cath [**2151**]
with patent lima-lad, occluded svg-om, near occluded svg-rca
# CHF: TTE [**7-6**] with EF 35%, mild LVH and LV-HK, 2+MR, 4+TR;
cardiac cath [**3-7**] to determine volume status with elevated
biventricular filling pressures, moderate pulmonary
hypertension, ventricularization of RA pressure consistent with
severe tricuspid
regurgitation.
# Afib: previously on coumadin but no longer secondary to GIB in

MEDICATION ON ADMISSION: Meds per [**2153-11-27**] OMR
Albuterol MDI QID PRN
Albuterol nebs PRN
Mylanta PRN
Ca carbonate 500mg PO TID
Digoxin 125mcg QOD
Ferrous sulfate 325mg Po daily
Ipratropium MDI QID PRN
Lactulose 15ml [**Hospital1 **]
Levoxyl 150mcg daily
Ativan 0.25mg TID PRn
Metolazone 5mg daily
Mirtazapine 15mg HS
MVI
Oxycodone-acetaminophen 5-325mg Q4H PRN
KCl 20mEq daily
.
Meds [**First Name8 (NamePattern2) **] [**Location (un) 1468**] [**Location (un) 269**] ([**2154-1-9**])
Tylenol PRN
Digoxin 125mcg QOD
Senekot [**Hospital1 **]
Ativan 0.5mg PO TID
Colace 100mg [**Hospital1 **]
Lasix 120mg [**Hospital1 **]
Potassium 10mEq daily
Levothyroxine 175mcg daily
metolazone 5mg daily
Mirtazapine 15mg daily
MVI
Ferrous sulfate 325mg daily
Lactulose 15ml [**Hospital1 **] PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: 96.6, 124/56, 70, 20, 97% RA
HEENT: NCAT, PERRL, neck supple
Cardiac: RRR, nl S1 and S2, no MRGs
Lungs: CTAB anteriorly, too agitated and restless to listen post

FAMILY HISTORY: Reported previously: Mother- HTN, ?died of MI; Father-83 yo and

SOCIAL HISTORY: Originally from [**Country 3397**]. Living with wife in [**Name (NI) 3146**] but states
has difficulty getting around and she has difficulty moving him, 

### Response:
{'Diseases of tricuspid valve,Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Subendocardial infarction, initial episode of care,Other ascites,Angiodysplasia of intestine with hemorrhage,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Other encephalopathy,Iron deficiency anemia secondary to blood loss (chronic),Umbilical hernia without mention of obstruction or gangrene,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified acquired hypothyroidism,Atrial fibrillation,Aortocoronary bypass status,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Chronic airway obstruction, not elsewhere classified'}
