CHIEF COMPLAINT: Abdominal Pain

PRESENT ILLNESS: 66F with h/o RA, s/p cholecystectomy and appendectomy, who
presents with acute abdominal pain and nausea and subacute
malaise/weakness. The patient reports that she has had
epigastric and R sided abdominal pain for the last 24-36 hours,
with radiation to the back. She has had only mildly decreased PO
intake but poor appetite. She also reports malaise since [**Month (only) 958**],
with significant workup by PCP including EBV, HIV, Monospot etc.
She also reports that her BP runs low at baseline, 90s-100s
systolic. She also reports that in the setting of past
infections, she has not mounted a significant leukocytosis or
fevers. Finally, she reports an episode of severe sore throat in
[**Month (only) 116**], which took approx. 10 days to improve. She did receive a
course of Augmentin prior to that episode of pharyngitis for a
sinus infection.
.
In the ED, initial VS were 99.2 103 104/58 16 99% RA.  UA was
grossly positive. CT abdomen/pelvis was done which showed
findings consistent with early pyelonephritis. She was given
morphine 4mg IV for pain around midnight, Unasyn
(sulfa/quinolone allergies), and ondansetron, along with Toradol
early this morning. She received 3L IVF with no improvement in
BP, and decision was made to admit the patient to the MICU given
persistent hypotension. She was never on vasopressors and has
mentated well throughout her ED course. BP from last clinic note
reported as 105/75 so does not seem to be far from baseline. VS
at time of transfer: 85/61 69 16 99%RA.

MEDICAL HISTORY: Rheumatoid Arthritis-on prednisone x 15 yrs, stopped 10yrs ago
s/p appendectomy [**2141**]
s/p cholecystectomy [**2161**]
h/o breast cancer s/p mastectomy, chemo - [**2147**]
h/o UTI, pyelonephritis [**2164**]
Diverticulitis - [**2162**]
h/o C. jejuni gastroenteritis
Hypothyroidism
Paresthesias
Sinusitis

MEDICATION ON ADMISSION: Levothyroxine 100mcg PO 6x/week (not on Sunday)
Zolpidem 5mg PO QHS prn

ALLERGIES: Methotrexate / Sulfa (Sulfonamide Antibiotics) / levofloxacin in
D5W

PHYSICAL EXAM: ON ADMISSION:
Vitals: T: 97.3 BP: 80/54 P: 61 R: 12 O2: 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly, tender in epigastric,
RUQ, RLQ regions
GU: no foley, +R sided CVAT
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Grandmother died of renal cancer at 79yo, grandfather had
melanoma. Mother with recurrent UTIs later in life

SOCIAL HISTORY: - Tobacco: former 10 pack year smoker, quit 30 yrs ago
- Alcohol: endorses 1 drink per day at dinner, none for the last
2 weeks
- Illicits: denies
Works as exec. director of Stoeckle Center for Primary Care at
[**Hospital1 2025**]
Acute pyelonephritis without lesion of renal medullary necrosis,Hypotension, unspecified,Rheumatoid arthritis,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of breast,Dehydration
Ac pyelonephritis NOS,Hypotension NOS,Rheumatoid arthritis,Hypothyroidism NOS,Hx of breast malignancy,Dehydration
Admission Date:  [**2169-6-28**]              Discharge Date:   [**2169-7-2**]

Date of Birth:  [**2108-1-9**]             Sex:   F

Service: MEDICINE

Allergies:
Methotrexate / Sulfa (Sulfonamide Antibiotics) / levofloxacin in
D5W

Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Abdominal Pain


Major Surgical or Invasive Procedure:
none


History of Present Illness:
66F with h/o RA, s/p cholecystectomy and appendectomy, who
presents with acute abdominal pain and nausea and subacute
malaise/weakness. The patient reports that she has had
epigastric and R sided abdominal pain for the last 24-36 hours,
with radiation to the back. She has had only mildly decreased PO
intake but poor appetite. She also reports malaise since [**Month (only) 958**],
with significant workup by PCP including EBV, HIV, Monospot etc.
She also reports that her BP runs low at baseline, 90s-100s
systolic. She also reports that in the setting of past
infections, she has not mounted a significant leukocytosis or
fevers. Finally, she reports an episode of severe sore throat in
[**Month (only) 116**], which took approx. 10 days to improve. She did receive a
course of Augmentin prior to that episode of pharyngitis for a
sinus infection.
.
In the ED, initial VS were 99.2 103 104/58 16 99% RA.  UA was
grossly positive. CT abdomen/pelvis was done which showed
findings consistent with early pyelonephritis. She was given
morphine 4mg IV for pain around midnight, Unasyn
(sulfa/quinolone allergies), and ondansetron, along with Toradol
early this morning. She received 3L IVF with no improvement in
BP, and decision was made to admit the patient to the MICU given
persistent hypotension. She was never on vasopressors and has
mentated well throughout her ED course. BP from last clinic note
reported as 105/75 so does not seem to be far from baseline. VS
at time of transfer: 85/61 69 16 99%RA.




Past Medical History:
Rheumatoid Arthritis-on prednisone x 15 yrs, stopped 10yrs ago
s/p appendectomy [**2141**]
s/p cholecystectomy [**2161**]
h/o breast cancer s/p mastectomy, chemo - [**2147**]
h/o UTI, pyelonephritis [**2164**]
Diverticulitis - [**2162**]
h/o C. jejuni gastroenteritis
Hypothyroidism
Paresthesias
Sinusitis

Rheumatoid arthritis
h/o breast cancer

Social History:
- Tobacco: former 10 pack year smoker, quit 30 yrs ago
- Alcohol: endorses 1 drink per day at dinner, none for the last
2 weeks
- Illicits: denies
Works as exec. director of Stoeckle Center for Primary Care at
[**Hospital1 2025**]


Family History:
Grandmother died of renal cancer at 79yo, grandfather had
melanoma. Mother with recurrent UTIs later in life

Physical Exam:
ON ADMISSION:
Vitals: T: 97.3 BP: 80/54 P: 61 R: 12 O2: 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly, tender in epigastric,
RUQ, RLQ regions
GU: no foley, +R sided CVAT
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

On Discharge:

Vitals: T: 98.4 BP: 110/64 P: 64 R: 16 O2: 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly, abdomen nontender to
deep palpation
GU: no foley, no CVAT
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, + rheumatoid arthritic changes to fingers b/l


Pertinent Results:
ON ADMISSION:
WBC-9.2# RBC-4.47 Hgb-13.2 Hct-37.3 Plt Ct-216
Neuts-70.5* Lymphs-24.2 Monos-3.7 Eos-1.2 Baso-0.4
PT-12.9 PTT-27.2 INR(PT)-1.1
Glucose-105* UreaN-17 Creat-0.8 Na-141 K-4.1 Cl-105 HCO3-23
AnGap-17
ALT-22 AST-26 AlkPhos-124* TotBili-0.6
Calcium-9.5
TSH-1.5
Cortsol-28.4*
LACTATE-0.8
URINE  RBC->182* WBC->182* BACTERIA-FEW YEAST-NONE EPI-0
BLOOD-LG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-LG
CK-MB-1 cTropnT-<0.01

CT ABD & PELVIS W & W/O CONTRAST [**2169-6-28**]
IMPRESSION:
1. Mild prominence of the right ureter, likely reflecting
urothelial
thickening, with mild diffuse periureteral inflammation. Given
the clinical history, findings are most compatible with early
ascending infectious process (ie ureteritis). The renal
parenchyma enhances homogeneously, and there is no
hydronephrosis or nephrolithiasis. There is no renal or
perinephric abscess is identified.
2. Status post cholecystectomy. No biliary ductal dilation.
3. Left L5 spondylolysis. Normal spinal alignment. Diffuse facet

arthropathy in the lower lumbar spine


RUQ US [**2169-6-28**] IMPRESSION: Unremarkable right upper quadrant
ultrasound.

[**2169-7-2**] 05:40AM BLOOD WBC-4.9 RBC-4.03* Hgb-12.1 Hct-34.5*
MCV-86 MCH-30.1 MCHC-35.1* RDW-13.6 Plt Ct-200
[**2169-7-1**] 05:06AM BLOOD Neuts-61.6 Lymphs-30.0 Monos-3.6 Eos-3.8
Baso-1.0
[**2169-6-30**] 03:03AM BLOOD PT-11.7 INR(PT)-1.0
[**2169-7-2**] 05:40AM BLOOD Glucose-101* UreaN-15 Creat-0.7 Na-142
K-3.9 Cl-108 HCO3-26 AnGap-12
[**2169-7-2**] 05:40AM BLOOD AlkPhos-135* TotBili-0.3
[**2169-6-30**] 03:03AM BLOOD ALT-42* AST-46* LD(LDH)-149 AlkPhos-149*
TotBili-0.4

Brief Hospital Course:
Ms. [**Known lastname 111263**] [**Known lastname 18920**] is a 61 woman with past medical history
significant for cholecystectomy, appendectomy, and rheumatoid
arthritis who presented with subacute abdominal pain and
hypotension unresponsive to IVF.

# Hypotension: Patient remained persistently hypotensive despite
IV fluid resuscitation. The concern of septic shock was present,
however, she had no signs of organ hypoperfusion and no elevated
lactate. She was started on broad antibiotic coverage with
Vancomycin and Zosyn. She was ruled out for a MI. In MICU, pt
was diagnosed with a urinary tract infection, and was
transitioned to augmentin. BP responded to fluid bolus therapy.
Pt responded well, and was normotensive, with SBPs in 100s to
110s upon transfer to floor. Pt was monitored for one additional
day on the floor.

# Abdominal Pain:CT findings and urinalysis were consistent with
pyelonephritis. We considered the pain to be most likely related
to this. However, the chronicity of her pain was less consistent
with this. CXR and exam were not consistent with a pneumonia.
She was started on broad antibiotic coverage. Urine and blood
cultures were obtained, and pt was transitioned to augmentin
upon diagnosis of UTI.

# Hypothyroidism: Patient was stable. She was continued on home
levothyroxine.


Medications on Admission:
Levothyroxine 100mcg PO 6x/week (not on Sunday)
Zolpidem 5mg PO QHS prn


Discharge Medications:
1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
EXCEPT SUNDAY ().
2. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 10 days: start date: [**6-30**];
end date [**7-9**].
Disp:*20 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Urinary Tract Infection


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Ms [**Known lastname 111263**] it was a pleasure taking care of you.

You were admitted for treatment of hypotension. Work-up revealed
a urinary tract infection as well as a potential kidney
infection. You were started on antibiotics and given IV
hydration. Prior to discharge you were tolerating a regular diet
with stable blood pressures.
.
CHANGES TO YOUR MEDICATIONS:
To treat infection:
Continue taking AUGMENTIN 875mg tablets. Take one tablet twice
daily for the next 10 days.
.
Take all other medications as prescribed.
.
Again it was a pleasure taking care of you. Please contact with
any questions or concerns


Followup Instructions:
Please arrange follow-up with your PCP [**Last Name (NamePattern4) **] 1 week.
.
Department: GASTROENTEROLOGY
When: TUESDAY [**2169-7-4**] at 10:20 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage



Completed by:[**2169-7-4**]
{'Acute pyelonephritis without lesion of renal medullary necrosis,Hypotension, unspecified,Rheumatoid arthritis,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of breast,Dehydration'}


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: 66F with h/o RA, s/p cholecystectomy and appendectomy, who
presents with acute abdominal pain and nausea and subacute
malaise/weakness. The patient reports that she has had
epigastric and R sided abdominal pain for the last 24-36 hours,
with radiation to the back. She has had only mildly decreased PO
intake but poor appetite. She also reports malaise since [**Month (only) 958**],
with significant workup by PCP including EBV, HIV, Monospot etc.
She also reports that her BP runs low at baseline, 90s-100s
systolic. She also reports that in the setting of past
infections, she has not mounted a significant leukocytosis or
fevers. Finally, she reports an episode of severe sore throat in
[**Month (only) 116**], which took approx. 10 days to improve. She did receive a
course of Augmentin prior to that episode of pharyngitis for a
sinus infection.
.
In the ED, initial VS were 99.2 103 104/58 16 99% RA.  UA was
grossly positive. CT abdomen/pelvis was done which showed
findings consistent with early pyelonephritis. She was given
morphine 4mg IV for pain around midnight, Unasyn
(sulfa/quinolone allergies), and ondansetron, along with Toradol
early this morning. She received 3L IVF with no improvement in
BP, and decision was made to admit the patient to the MICU given
persistent hypotension. She was never on vasopressors and has
mentated well throughout her ED course. BP from last clinic note
reported as 105/75 so does not seem to be far from baseline. VS
at time of transfer: 85/61 69 16 99%RA.

MEDICAL HISTORY: Rheumatoid Arthritis-on prednisone x 15 yrs, stopped 10yrs ago
s/p appendectomy [**2141**]
s/p cholecystectomy [**2161**]
h/o breast cancer s/p mastectomy, chemo - [**2147**]
h/o UTI, pyelonephritis [**2164**]
Diverticulitis - [**2162**]
h/o C. jejuni gastroenteritis
Hypothyroidism
Paresthesias
Sinusitis

MEDICATION ON ADMISSION: Levothyroxine 100mcg PO 6x/week (not on Sunday)
Zolpidem 5mg PO QHS prn

ALLERGIES: Methotrexate / Sulfa (Sulfonamide Antibiotics) / levofloxacin in
D5W

PHYSICAL EXAM: ON ADMISSION:
Vitals: T: 97.3 BP: 80/54 P: 61 R: 12 O2: 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly, tender in epigastric,
RUQ, RLQ regions
GU: no foley, +R sided CVAT
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Grandmother died of renal cancer at 79yo, grandfather had
melanoma. Mother with recurrent UTIs later in life

SOCIAL HISTORY: - Tobacco: former 10 pack year smoker, quit 30 yrs ago
- Alcohol: endorses 1 drink per day at dinner, none for the last
2 weeks
- Illicits: denies
Works as exec. director of Stoeckle Center for Primary Care at
[**Hospital1 2025**] 

### Response:
{'Acute pyelonephritis without lesion of renal medullary necrosis,Hypotension, unspecified,Rheumatoid arthritis,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of breast,Dehydration'}
