CHIEF COMPLAINT: Abdominal Pain

PRESENT ILLNESS: 62 year old female with history of severe bilateral PVD, s/p
bilateral lower extremity angio with occluded fem-PT bypasses
bilaterally, now presenting
to the ED w/abdominal pain of 5 days duration. We are consulted
for an evaluation of mesenteric ischemia. Patient reports sudden
onset of severe abdominal 5 days ago. The pain has remained high
in intensity and constant. Patient has been unable to tolerate
food. She had no episodes of frank emesis, but reports retching
and some "yellow secretion". The pain is located in the
mid-abdomen radiates to substernal region and to flanks and
lower back. Patient denies fevers, but reports chills over the
past few days. She denies diarrhea. Her stools are formed and
regular. She denies any hematochezia or melena. She denies ever
having this type of abdominal pain in the past. She stopped
taking majority of her medications a few days ago as she was
concerned it may contribute to her pain.

MEDICAL HISTORY: PAD, Hypertension, Hyperlipideia, Thalasemia, Gout

MEDICATION ON ADMISSION: Hydroxyurea 1000mg daily
Valsartan/HCTZ 320/25 daily
Crestor 10mg daily
KCL 10mEq daily
Metoprolol ER 50mg po daily
Folic Acid 1mg po daily
Neurontin 600mg po TID
[**Name10 (NameIs) **] 81mg po daily
Pletal 100mg po BID
Coumadin 5mg po Daily

ALLERGIES: Heparin Agents

PHYSICAL EXAM: Admission Physical Exam:
VS: 97.7 100 131/78 18 100% RA
CV: RRR, no murmur
pulm: CTA b/l
abd: obese, + BS, tender especially in the RLQ, also reports
subjective pain in the mid abdomen, but not fully evident on
exam

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Currently smokes [**11-26**] ppd, former 1 ppd for last 50 years,
denies EtOH or illicit drugs
Acute vascular insufficiency of intestine,Other specified gastritis, with hemorrhage,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Acute kidney failure with other specified pathological lesion in kidney,Arterial embolism and thrombosis of upper extremity,Precipitous drop in hematocrit,Anticoagulants causing adverse effects in therapeutic use,Atherosclerosis of autologous vein bypass graft of the extremities,Abdominal pain, periumbilic,Heparin-induced thrombocytopenia (HIT),Other and unspecified hyperlipidemia,Gout, unspecified,Thalassemia, unspecified,Tobacco use disorder,Long-term (current) use of anticoagulants,Angiodysplasia of stomach and duodenum without mention of hemorrhage,Benign neoplasm of colon,Diverticulosis of colon (without mention of hemorrhage),Other iatrogenic hypotension,Hypoxemia,Esophagitis, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other drugs and medicinal substances causing adverse effects in therapeutic use
Ac vasc insuff intestine,Oth spf gastrt w hmrhg,Chr duoden ulcer w hem,Acute kidney failure NEC,Upper extremity embolism,Drop, hematocrit, precip,Adv eff anticoagulants,Ath ext autologs bps gft,Abdmnal pain periumbilic,Heparin-indu thrombocyto,Hyperlipidemia NEC/NOS,Gout NOS,Thalassemia, unspecified,Tobacco use disorder,Long-term use anticoagul,Angio stm/dudn w/o hmrhg,Benign neoplasm lg bowel,Dvrtclo colon w/o hmrhg,Iatrogenc hypotnsion NEC,Hypoxemia,Esophagitis, unspecified,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Adv eff medicinal NEC
Admission Date:  [**2192-11-20**]              Discharge Date:   [**2192-12-27**]

Date of Birth:  [**2130-8-8**]             Sex:   F

Service: SURGERY

Allergies:
Heparin Agents

Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Abdominal Pain

Major Surgical or Invasive Procedure:
OPERATIONS PERFORMED [**2192-11-23**]:
1. Ultrasound-guided puncture of left brachial artery.
2. Catheterization of aorta.
3. Abdominal aortogram with mesenteric angiography.
4. Selective catheterization of superior mesenteric artery.
5. Balloon angioplasty and stent of proximal superior
    mesenteric artery.
6. Brachial artery cutdown with primary repair

[**2192-11-23**]: Exploratory Laparoscopy

[**2192-12-5**]: EGD
[**2192-12-6**]: Colonoscopy
[**2192-12-15**]: EGD
[**2192-12-20**]: EGD and Sigmoidoscopy


History of Present Illness:
62 year old female with history of severe bilateral PVD, s/p
bilateral lower extremity angio with occluded fem-PT bypasses
bilaterally, now presenting
to the ED w/abdominal pain of 5 days duration. We are consulted
for an evaluation of mesenteric ischemia. Patient reports sudden
onset of severe abdominal 5 days ago. The pain has remained high
in intensity and constant. Patient has been unable to tolerate
food. She had no episodes of frank emesis, but reports retching
and some "yellow secretion". The pain is located in the
mid-abdomen radiates to substernal region and to flanks and
lower back. Patient denies fevers, but reports chills over the
past few days. She denies diarrhea. Her stools are formed and
regular. She denies any hematochezia or melena. She denies ever
having this type of abdominal pain in the past. She stopped
taking majority of her medications a few days ago as she was
concerned it may contribute to her pain.


Past Medical History:
PAD, Hypertension, Hyperlipideia, Thalasemia, Gout

PSH:
Left Lower Extremity Bypass [**2180**](appears to be fem-PT), revision
in [**2187**];  Right Lower Extremity Bypass [**2185**] (appears to be
fem-AT);  BLE angio - [**2192-10-17**];  cholecystectomy;  hysterectomy


Social History:
Currently smokes [**11-26**] ppd, former 1 ppd for last 50 years,
denies EtOH or illicit drugs


Family History:
non-contributory

Physical Exam:
Admission Physical Exam:
VS: 97.7 100 131/78 18 100% RA
CV: RRR, no murmur
pulm: CTA b/l
abd: obese, + BS, tender especially in the RLQ, also reports
subjective pain in the mid abdomen, but not fully evident on
exam

guaiac positive
extremities: minimal lower extremity edema

Pulses:
     Fem  [**Doctor Last Name **]  AT   DP         PT
R    palp dop  dop  faint dop  dop
L    palp dop  dop  NS         dop

Discharge Exam:
(per progress note)
VS: 100.1  98  88  151/76  20  99% ra
Gen: Obese female, alert and oriented x 3,
Card: RRR
Lungs: CTA bilat
Abd: obese, soft, no m/t/o
Extremities: warm, mild lower extremity edema
Pulses:   Rad   Fem  DP  PT

   right  p      p    d   d
   left   p      p    d   d

Pertinent Results:
Admission:
[**2192-11-20**] 12:35PM BLOOD WBC-8.4 RBC-2.41* Hgb-9.7* Hct-29.4*
MCV-122* MCH-40.2* MCHC-33.0 RDW-16.9* Plt Ct-347
[**2192-11-20**] 12:35PM BLOOD PT-31.5* PTT-43.7* INR(PT)-3.1*
[**2192-11-20**] 12:35PM BLOOD Glucose-143* UreaN-38* Creat-1.9* Na-141
K-3.6 Cl-103 HCO3-26 AnGap-16
[**2192-11-20**] 12:35PM BLOOD ALT-13 AST-12 AlkPhos-65 TotBili-0.2
[**2192-11-21**] 04:23AM BLOOD Calcium-8.2* Phos-4.2 Mg-1.9

Discharge:
[**2192-12-27**] 06:46AM BLOOD WBC-7.3 RBC-3.25* Hgb-10.2* Hct-30.0*
MCV-92 MCH-31.4 MCHC-34.0 RDW-19.9* Plt Ct-304
[**2192-12-27**] 06:46AM BLOOD PT-33.5* PTT-45.6* INR(PT)-3.3*
[**2192-12-27**] 06:46AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9

Other pertinent labs:
[**2192-11-23**] 4:59 pm MRSA SCREEN      SOURCE:NASAL SWAB.

                            **FINAL REPORT [**2192-11-26**]**

   MRSA SCREEN (Final [**2192-11-26**]):    No MRSA isolated.

[**2192-12-6**] 5:25 am SEROLOGY/BLOOD      CHEM # 60812J [**12-6**] 5:25AM.


                            **FINAL REPORT [**2192-12-7**]**

   HELICOBACTER PYLORI ANTIBODY TEST (Final [**2192-12-7**]):
      NEGATIVE BY EIA.
           (Reference Range-Negative).

[**2192-12-9**] 11:15 am URINE      Source: CVS.

                            **FINAL REPORT [**2192-12-10**]**

   URINE CULTURE (Final [**2192-12-10**]):
      MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
      AND/OR GENITAL CONTAMINATION.

[**2192-12-20**] EGD: A single superficial non-bleeding 5 mm ulcer was
found in the duodenal bulb. This ulcer had a clean base and was
not bleeding. There were two adherent clots adjacent to the
ulcer, one proximal and one distal. The distal clot was removed
with aggressive washing and suctioning, and no underlying lesion
could be identified. The proximal clot remained adherent despite
aggressive washing. One endoclip was successfully applied to the
proximal adherent clot for the purpose of hemostasis.

[**2192-12-20**] Flexible Sigmoidoscopy: The previously seen single
pedunculated 2 cm polyp was found in the distal sigmoid colon at
20cm. The polyp was not bleeding.
Poor bowel prep

[**2192-12-16**] 08:43AM HEPARIN DEPENDENT ANTIBODIES    POSITIVE
-
[**2192-11-23**] 09:42PM   HEPARIN DEPENDENT ANTIBODIES       Negative


Brief Hospital Course:
Ms. [**Known lastname 6515**] was admitted with abdominal pain and non occlusive
SMA thrombus. She was put on a heparin gtt, plavix and aspirin
325mg.  SHe was transfused for a low hct. Her pain resolved and
she was started on sips with close monitoring.  On [**11-24**] her
pain increased and she had a stat CTA which showed an unchanged
appearance of SMA thrombus and no direct or indirect evidence of
mesenteric ischemia. She was then pre-op'd and consented and
taken to the angio suite where she had:
1. Ultrasound-guided puncture of left brachial artery.
2. Catheterization of aorta.
3. Abdominal aortogram with mesenteric angiography.
4. Selective catheterization of superior mesenteric artery.
5. Balloon angioplasty and stent of proximal superior
    mesenteric artery.

At completion of the procedure, upon  removal of the wire, it
was noted there was extensive clot seen on the wire.  The
patient had been receiving full heparin drip and was fully
anticoagulated as well as having a therapeutic INR on Coumadin,
as well as being on full-dose aspirin and Plavix prior to the
presentation in the operating room.  This led to our decision to
not rebolus her with more heparin.  However, due to the nature
of the clot that was seen on the wire upon exchange to the
5-French short sheath, and then upon attempt to flush the short
sheath we were not able to draw back, there was significant
concern for a clot in the brachial
artery.  We therefore did a: Brachial artery cutdown with
thrombectomy and primary repair.  ACS then did an exploratory
laparoscopy and found no evidence of bowel ischemia. Their ports
were closed and the patient was monitored closely.  She had
respiratory distress and was re-intubated and taken to the
CVICU. Given her hypercoaguable state, heme was involved and she
was started on an argatroban gtt. She was extubated on [**11-25**] and
did well. She was transfused again for a falling hct. She
remained hemodynamicaly stable and was transfered to the VICU
and [**Month/Day (4) 8337**] a clear diet on [**11-25**].  She continued to make steady
progress , tolerating a regular diet, ambulating and voiding
when her foley was removed. Her coumadin was restarted with an
INR goal of 3.0-3.5 .  She continued to make progress but on [**12-2**]
reported seeing blood on her toilet paper, after a bowel
movement and was found to be guiac positive. Her h/h had fallen
and she was transfused for a hct of 25 on [**12-3**]. She responded
appropriately but on [**12-4**] her hct was down to 25.1.  She
received 1 unit prbc without much of a response and got another
1 unit. By this point she was having melena and her hct
continued to fall. GI was consulted on [**12-4**]. She was prepped
appropriately and had an EGD on [**12-5**] which showed erosive
gastritis in the stomach body and antrum. Then on [**12-6**] she had
colonoscopy which showed a 20 mm polyp which was treated with an
endoloop. Her h/h was stable for several days, and her INR was
therapeutic and discharge planning was initiated.  On [**12-11**], her
hct was drifting down. She was transfused appropriately but
didn't respond appropriately. She was still having melena.  GI
was monitoring the patient.  Her surgical issues were stable and
the decision was made to transfer the patient to the medicine
team for further monitoring and treatment.

On [**12-14**], we were called to the bedside by night merit team for
persistent hypotension to the 70s. Reviewing vitals flowsheets
places her BP in the 100 systolic range, though she repeatedly
dropped into the upper 80s throughout the day.  As of 2300, her
BP slipped into the 70s, though she continued to mentate
normally without lightheadedness, chest pain or pressure. She
has been having daily melenotic stools for the past few days.
Her bp meds were stopped and she received a liter of NS and her
fourth pRBC transfusion of the day with improvement of her SBP
to 100-105.  After consulting with GI, decision made to transfer
to MICU6 for endoscopy in the AM.  She has undergone 18 red cell
transfusions this admission. Her current INR was 4.3. In the
MICU, the patient continued to have melena, but otherwise
hemodynamically stable. An EGD was performed that showed
friability and erythema of the esophagus, stomach and duodenum.
Cautery was used to stop bleeding from the duodenal bulb. After
EGD, the patient cotninued to have melena. She was maintained on
her coumadin, plavix, aspirin, and heparin. The patient was then
transfered to the VICU for further management.

Ms. [**Known lastname 6515**] remained hemodynamically stable following transfer to
the VICU. Her hematocrit was routinely monitored and she was
transfused as needed for Hcts in the low - mid 20s.  Given the
persistence of her melena, however, she underwent flexible
sigmoidoscopy and EGD on [**2192-12-20**], the results of which were
notable only for a nonbleeding polyp in the sigmoid colon
(previously seen on prior [**Last Name (un) **]) as well as some friability of
the duodenum which was clipped and injected with epinephrine.
Following this procedure, Ms. [**Known lastname 6515**] [**Last Name (Titles) 8337**] her diet well.

She was transfered to the [**Last Name (Titles) 1106**] floor where she was monitored
for another week. She remained on an argatroban gtt until her
true INR was >3.0 . On [**2192-12-27**] she was stable from a medical and
surgical standpoint. Her true INR wasd 3.3 and she was not
having any melena or other GI symptoms.

At the time of discharge, Ms. [**Known lastname 6515**] was hemodynamically stable,
mentating and ambulating at baseline, and with a stable
hematocrit. Her INR is therapeutic and she is scheduled for very
close monitoring of her h/h and INR with her PCP. [**Name10 (NameIs) **] will also
have her BP monitored, and discuss restarting meds with her PCP.
[**Name10 (NameIs) **] will be followed by her PCP, [**Name10 (NameIs) 1106**] surgery, hematology
and GI. She has been instructed regarding her post-discharge
plans and verbally expressed understanding and agreement with
these plans.


Medications on Admission:
Hydroxyurea 1000mg daily
Valsartan/HCTZ 320/25 daily
Crestor 10mg daily
KCL 10mEq daily
Metoprolol ER 50mg po daily
Folic Acid 1mg po daily
Neurontin 600mg po TID
[**Name10 (NameIs) **] 81mg po daily
Pletal 100mg po BID
Coumadin 5mg po Daily

Discharge Medications:
1. hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
5. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
6. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day:
call PCP for refills.
Disp:*30 Tablet(s)* Refills:*0*
7. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.

8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for pain.
13. BLOOD PRESSURE MONITORING
We stopped all of your BP meds (valsartan/hctz and toprol xl).
Please have your blood pressure checked several times per week.
Follow up with PCP regarding restarting your blood pressure meds


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
-Abdominal pain/ Mesenteric ischemia
-Left Brachial artery emboli
-GI bleed/ Erosive gastritis
-Heparin Induced Thrombocytopenia

Secondary:
Bilateral Lower extremity ischemia with pain
HTN
Hyperlipidemia


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


Discharge Instructions:
Division of [**Name10 (NameIs) **] and Endovascular Surgery
Endovascular Discharge Instructions

You were admitted with abdominal pain and had a complicated
hospital course.  You had mesenteric ischemia and had a stent
placed in your superior mesenteric artery through a brachial
(arm) sheath. After the procedure you were found to have a blood
clot in your brachial artery, and had to have that surgically
removed. You then had an exploratory laparoscopy to evaluate for
dead bowel. You had no evidence of this.  You remained in the
hospital and were carefully anticoagulated.  You had concern for
GI bleeding and had an endoscopy and colonoscopy by the GI team.
The egd (upper scope) showed erosive esophagitis which was
thought to be the cause of bleeding. The colonoscopy showed a
polyp in the sigmoid colon which was removed, and diverticulosis
in the sigmoid colon. You were started on several new
medications including carafate and omeprazole.

Your INR will continue to be followed by the Atrius anti-coag
team. You will follow up with Gastroenterology, [**Name10 (NameIs) **] surgery
and hematology.

Medications:
??????	Take Aspirin 325mg daily
??????	Take Plavix 75mg once daily.
        Take Coumadin daily as directed - your INR goal is now
3.0 - 3.5
Do not stop Aspirin/Plavix/or Coumadin unless your [**Name10 (NameIs) **]
Surgeon instructs you to do so.
??????	Continue all other medications you were taking before surgery,
unless otherwise directed
??????	You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort

What to expect when you go home:
It is normal to have slight swelling of the legs:
??????	Elevate your leg above the level of your heart (use [**12-28**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
??????	Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
??????	Drink plenty of fluids and eat small frequent meals
??????	It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
??????	To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication

What activities you can and cannot do:
??????	When you go home, you may walk and go up and down stairs
??????	You may shower (let the soapy water run over groin incision,
rinse and pat dry)
??????	Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
??????	No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
??????	After 1 week, you may resume sexual activity
??????	After 1 week, gradually increase your activities and distance
walked as you can tolerate
??????	No driving until you are no longer taking pain medications
??????	Call and schedule an appointment to be seen in [**3-1**] weeks for
post procedure check and CTA

What to report to office:
??????	Numbness, coldness or pain in lower extremities
??????	Temperature greater than 101.5F for 24 hours
??????	New or increased drainage from incision or white, yellow or
green drainage from incisions
??????	Bleeding from groin puncture site

SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
??????	Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Date Range 1106**] office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.


Followup Instructions:
HEMATOLOGY:
[**2193-1-18**] 1030am
[**Telephone/Fax (1) 91089**]
[**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], MD
[**First Name8 (NamePattern2) **] [**Last Name (Titles) **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC

PCP/INR FOLLOW UP:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Fax: [**Telephone/Fax (1) 6808**]
She will follow your INR and your CBC 2 x week for your GI
bleed. Please go to get your labs drawn tomorrow, [**2192-12-28**].
Your goal INR is 3-3.5

[**Month/Day/Year **] SURGERY:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2193-1-22**]
8:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2193-1-22**] 9:15

GASTROENTEROLOGY:
[**1-22**] 11am
[**Hospital Unit Name 1825**] - [**Hospital Ward Name 516**] [**Location (un) 453**]
([**Telephone/Fax (1) 2233**]



Completed by:[**2192-12-27**]
{'Acute vascular insufficiency of intestine,Other specified gastritis, with hemorrhage,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Acute kidney failure with other specified pathological lesion in kidney,Arterial embolism and thrombosis of upper extremity,Precipitous drop in hematocrit,Anticoagulants causing adverse effects in therapeutic use,Atherosclerosis of autologous vein bypass graft of the extremities,Abdominal pain, periumbilic,Heparin-induced thrombocytopenia (HIT),Other and unspecified hyperlipidemia,Gout, unspecified,Thalassemia, unspecified,Tobacco use disorder,Long-term (current) use of anticoagulants,Angiodysplasia of stomach and duodenum without mention of hemorrhage,Benign neoplasm of colon,Diverticulosis of colon (without mention of hemorrhage),Other iatrogenic hypotension,Hypoxemia,Esophagitis, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other drugs and medicinal substances causing adverse effects in therapeutic use'}


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: 62 year old female with history of severe bilateral PVD, s/p
bilateral lower extremity angio with occluded fem-PT bypasses
bilaterally, now presenting
to the ED w/abdominal pain of 5 days duration. We are consulted
for an evaluation of mesenteric ischemia. Patient reports sudden
onset of severe abdominal 5 days ago. The pain has remained high
in intensity and constant. Patient has been unable to tolerate
food. She had no episodes of frank emesis, but reports retching
and some "yellow secretion". The pain is located in the
mid-abdomen radiates to substernal region and to flanks and
lower back. Patient denies fevers, but reports chills over the
past few days. She denies diarrhea. Her stools are formed and
regular. She denies any hematochezia or melena. She denies ever
having this type of abdominal pain in the past. She stopped
taking majority of her medications a few days ago as she was
concerned it may contribute to her pain.

MEDICAL HISTORY: PAD, Hypertension, Hyperlipideia, Thalasemia, Gout

MEDICATION ON ADMISSION: Hydroxyurea 1000mg daily
Valsartan/HCTZ 320/25 daily
Crestor 10mg daily
KCL 10mEq daily
Metoprolol ER 50mg po daily
Folic Acid 1mg po daily
Neurontin 600mg po TID
[**Name10 (NameIs) **] 81mg po daily
Pletal 100mg po BID
Coumadin 5mg po Daily

ALLERGIES: Heparin Agents

PHYSICAL EXAM: Admission Physical Exam:
VS: 97.7 100 131/78 18 100% RA
CV: RRR, no murmur
pulm: CTA b/l
abd: obese, + BS, tender especially in the RLQ, also reports
subjective pain in the mid abdomen, but not fully evident on
exam

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Currently smokes [**11-26**] ppd, former 1 ppd for last 50 years,
denies EtOH or illicit drugs 

### Response:
{'Acute vascular insufficiency of intestine,Other specified gastritis, with hemorrhage,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Acute kidney failure with other specified pathological lesion in kidney,Arterial embolism and thrombosis of upper extremity,Precipitous drop in hematocrit,Anticoagulants causing adverse effects in therapeutic use,Atherosclerosis of autologous vein bypass graft of the extremities,Abdominal pain, periumbilic,Heparin-induced thrombocytopenia (HIT),Other and unspecified hyperlipidemia,Gout, unspecified,Thalassemia, unspecified,Tobacco use disorder,Long-term (current) use of anticoagulants,Angiodysplasia of stomach and duodenum without mention of hemorrhage,Benign neoplasm of colon,Diverticulosis of colon (without mention of hemorrhage),Other iatrogenic hypotension,Hypoxemia,Esophagitis, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other drugs and medicinal substances causing adverse effects in therapeutic use'}
