CHIEF COMPLAINT: Abdominal pain x 2-3 weeks

PRESENT ILLNESS: 78 y/o Cantonese speaking man with history of CAD s/p CABG
([**2118**]), HTN, HLD, and emphysema who presented on [**2124-6-17**] to the
medical floor with 2 weeks epigastric pain. CT abdomen showed
severe duodenitis; surgery and GI were consulted. His original
abdominal exam was consistent with guarding and surgery was
concerned about a perforation but a repeat CT and abdominal
X-ray were not consistent with free air. However, gallbladder
wall thickening with pericholecystic fluid were noted, and his
LFTs were consistent with obstruction, leading to concern for
cholecystittis/cholangitis, and the patient was started on
meropenem and vancomycin. Shortly after his repeat CT scan, he
developed SOB and was tachycardic to the 140s with 3mm ST
elevations in the lateral leads but troponins were negative and
he did not complain of chest pain. There was a concern for
demand ischemia and he was started on heparin gtt. The patient
became hypotensive to an SBP in the 80s after he received
metoprolol, and was transferred to the ICU. He was bolused with
IV fluids and his metoprolol and lisinopril were held; he
received a percutaneous chole drain and he continued to receive
meropenem and vancomycin pending results of blood cultures.  His
vital signs stabilized nicely and he was transferred to medicine
for further management.

MEDICAL HISTORY: - Coronary artery disease s/p CABG [**3-/2119**] (LIMA to the LAD and
-separate SVGs to the PDA and an OM)
- HLD
- HTN
- BPH
- Emphysema per ct scan
- TB many years ago, treated for 2 years

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Doxazosin 4 mg PO DAILY
2. Ropinirole 1 mg PO TID
3. Omeprazole 40 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY

ALLERGIES: Penicillins / simvastatin

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VITALS:  98.5 74 137/54 18 96%5L.
GENERAL:  Elderly chinese man, alert oriented, uncomfortable
with movement in bed, ambulatory
HEENT: PERRL, EOMI +arcus senilis
NECK: no carotid bruits, JVD
LUNGS: CTA b/l no wrc
HEART: RRR, normal S1 S2, no MRG.  Sternal scar c/w CABG
ABDOMEN: Tense abdomen with guarding diffusely.  TTP diffusely,
more so in epigastrium.  Moderate distension.  +BS. No palpable
masses.
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3

FAMILY HISTORY: Mother had hypertension and history of cancer.
Coronary artery disease in the family.

SOCIAL HISTORY: 20-pack-year smoker, discontinued 20 years ago.
Occupation, retired machine operator. Lives with his family.
Alcohol, none. Exposure, none.
Acute cholecystitis,Unspecified septicemia,Septic shock,Severe sepsis,Obstruction of bile duct,Methicillin resistant pneumonia due to Staphylococcus aureus,Paralytic ileus,Other acute and subacute forms of ischemic heart disease, other,Duodenitis, without mention of hemorrhage,Helicobacter pylori [H. pylori],Leukocytosis, unspecified,Unspecified essential hypertension,Other emphysema,Restless legs syndrome (RLS),Other and unspecified hyperlipidemia,Hypoxemia,Constipation, unspecified,Anemia, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Aortocoronary bypass status,Personal history of tuberculosis,Personal history of tobacco use
Acute cholecystitis,Septicemia NOS,Septic shock,Severe sepsis,Obstruction of bile duct,Meth res pneu d/t Staph,Paralytic ileus,Ac ischemic hrt dis NEC,Duodenitis w/o hmrhg,Helicobacter pylori,Leukocytosis NOS,Hypertension NOS,Emphysema NEC,Restless legs syndrome,Hyperlipidemia NEC/NOS,Hypoxemia,Constipation NOS,Anemia NOS,BPH w/o urinary obs/LUTS,Aortocoronary bypass,Prsnl hst tuberculosis,History of tobacco use
Admission Date:  [**2124-6-17**]              Discharge Date:   [**2124-6-27**]

Date of Birth:  [**2045-8-27**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / simvastatin

Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Abdominal pain x 2-3 weeks


Major Surgical or Invasive Procedure:
Placement of percutatenous chole drain

History of Present Illness:
78 y/o Cantonese speaking man with history of CAD s/p CABG
([**2118**]), HTN, HLD, and emphysema who presented on [**2124-6-17**] to the
medical floor with 2 weeks epigastric pain. CT abdomen showed
severe duodenitis; surgery and GI were consulted. His original
abdominal exam was consistent with guarding and surgery was
concerned about a perforation but a repeat CT and abdominal
X-ray were not consistent with free air. However, gallbladder
wall thickening with pericholecystic fluid were noted, and his
LFTs were consistent with obstruction, leading to concern for
cholecystittis/cholangitis, and the patient was started on
meropenem and vancomycin. Shortly after his repeat CT scan, he
developed SOB and was tachycardic to the 140s with 3mm ST
elevations in the lateral leads but troponins were negative and
he did not complain of chest pain. There was a concern for
demand ischemia and he was started on heparin gtt. The patient
became hypotensive to an SBP in the 80s after he received
metoprolol, and was transferred to the ICU. He was bolused with
IV fluids and his metoprolol and lisinopril were held; he
received a percutaneous chole drain and he continued to receive
meropenem and vancomycin pending results of blood cultures.  His
vital signs stabilized nicely and he was transferred to medicine
for further management.

On arrival to the medicine floor, his vitals were T99 BP 101/47
HR 75 94% 4L. He complains of RUQ pain. He denies SOB or chest
pain.

Past Medical History:
- Coronary artery disease s/p CABG [**3-/2119**] (LIMA to the LAD and
-separate SVGs to the PDA and an OM)
- HLD
- HTN
- BPH
- Emphysema per ct scan
- TB many years ago, treated for 2 years


Social History:
20-pack-year smoker, discontinued 20 years ago.
Occupation, retired machine operator. Lives with his family.
Alcohol, none. Exposure, none.


Family History:
Mother had hypertension and history of cancer.
Coronary artery disease in the family.


Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS:  98.5 74 137/54 18 96%5L.
GENERAL:  Elderly chinese man, alert oriented, uncomfortable
with movement in bed, ambulatory
HEENT: PERRL, EOMI +arcus senilis
NECK: no carotid bruits, JVD
LUNGS: CTA b/l no wrc
HEART: RRR, normal S1 S2, no MRG.  Sternal scar c/w CABG
ABDOMEN: Tense abdomen with guarding diffusely.  TTP diffusely,
more so in epigastrium.  Moderate distension.  +BS. No palpable
masses.
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3

Discharge exam:


Pertinent Results:
Admission Labs:
[**2124-6-16**] 06:00PM BLOOD WBC-10.2# RBC-4.79 Hgb-15.3 Hct-44.4
MCV-93 MCH-31.8 MCHC-34.4 RDW-13.5 Plt Ct-294
[**2124-6-16**] 06:00PM BLOOD Neuts-88.6* Lymphs-7.8* Monos-2.8 Eos-0.7
Baso-0.1
[**2124-6-16**] 06:00PM BLOOD Plt Ct-294
[**2124-6-16**] 06:00PM BLOOD Glucose-126* UreaN-15 Creat-0.9 Na-137
K-3.9 Cl-101 HCO3-26 AnGap-14
[**2124-6-16**] 06:00PM BLOOD ALT-31 AST-26 AlkPhos-99 TotBili-0.4
[**2124-6-16**] 06:00PM BLOOD cTropnT-<0.01
[**2124-6-16**] 06:00PM BLOOD cTropnT-<0.01
[**2124-6-16**] 06:00PM BLOOD Albumin-4.2
[**2124-6-17**] 10:15AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.7
[**2124-6-16**] 08:09PM BLOOD Lactate-2.9*

CT AP ([**2124-6-17**])
========================
INDICATION:  Abdominal pain for two to three weeks.

Comparison chest CT available from [**2121-11-20**].

TECHNIQUE:  MDCT-acquired 5-mm axial images through the abdomen
and pelvis
were obtained following the uneventful administration of 130 ml
of Omnipaque
intravenous contrast.  Coronal and sagittal reformations were
performed at
5-mm slice thickness.

CT OF THE ABDOMEN WITH IV CONTRAST:
Included views of the lung bases demonstrate moderate-to-severe
emphysema with
superimposed bibasilar fibrosis which has progressed since the
most recent
chest CT examination from [**2121-11-20**].  There is no
pericardial or
pleural effusion.  The heart size is top normal.

Extensive stranding surrounds the proximal duodenum (2:26, 27).
No focal
fluid collections are identified.  There is no free air.
Perihepatic free
fluid is present.  A short segment of the proximal jejunum is
mildly distended
(2:48), with neighboring loops demonstrating mild fecalization
(2:31).  No
transition point is seen.  The remaining loops of small and
large bowel are
within normal limits.

The stomach, spleen, pancreas, adrenal glands, kidneys, and
gallbladder are
normal.  A well-circumscribed hypodense hepatic lesion within
segment [**Doctor First Name 690**]
(2:11) is minimally enlarged since [**2120**], likely representing a
small cyst or
biliary hamartoma. A 15 mm partially exophytic cyst arising from
the
interpolar region of the right kidney  (2:35) is slightly
enlarged since [**2120**].


There are moderate atherosclerotic calcifications throughout the
abdominal
aorta and iliac branches.  The celiac trunk, SMA, and [**Female First Name (un) 899**] are
patent and
normal in caliber.

There is no mesenteric or retroperitoneal lymphadenopathy.

CT OF THE PELVIS WITH IV CONTRAST:
The rectum, sigmoid colon, urinary bladder, intrapelvic loops of
small and
large bowel are normal.  The prostate is moderately enlarged
(2:83).  There is
no intrapelvic free fluid or lymphadenopathy.

OSSEOUS STRUCTURES:
The patient is post-median sternotomy.  No acute fracture is
detected.  There
are no bony lesions concerning for malignancy or infection.

IMPRESSION:
1.  Severe duodenitis.  No secondary signs of perforation.  EGD
is recommended
to assess for further evaluation.
2.  Mild dilatation of a short segment of jejunum, with
fecalization of
contents without transition point. Findings may represent a
focal ileus.
3.  Progression of moderate to severe emphysema and bibasilar
interstitial
fibrosis compared to the [**2120**] CT chest examination.
4.  Small amount of perihepatic ascites. No drainable fluid
collections.
5.  Moderately enlarged prostate.

The study and the report were reviewed by the staff radiologist.


DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]

KUB [**2124-6-17**]
======================
ABDOMEN

INDICATION:  Duodenitis, evaluation for free air.

COMPARISON:  No comparison available at the time of dictation.

FINDINGS:  Documentation is provided by two radiographic images.
 No free
intra-abdominal air.  Several small air-fluid levels projecting
over
nondistended bowel loops in the mid abdomen.  Colonic air
filling and stool
filling of the ascending and descending colon.  Contrast
material in the
bladder.  Diffuse gas feeling of small bowel loops without
evidence of wall
thickening.  No pathologic calcifications.  No foreign bodies.

CT AP [**2124-6-18**]
==========================
INDICATION:  Duodenitis with increasing abdominal tenderness.

COMPARISON:  CT available from [**2123-12-17**].

TECHNIQUE:  MDCT-acquired 5-mm axial images of the abdomen and
pelvis were
obtained following the uneventful administration of Gastrografin
and 130 ml of
Omnipaque intravenous contrast.  Coronal and sagittal
reformations were
performed at 5-mm slice thickness.

DLP: 363 mGy-cm

CT OF THE ABDOMEN WITH IV CONTRAST:
Moderate right basilar atelectasis is new since the [**2123-12-17**]
examination (2:5).  Again seen is moderate-to-severe bibasilar
emphysema with
superimposed peripheral fibrosis.  There is no pericardial or
pleural
effusion.  The heart size is normal.

Mild heterogenous liver perfusion is noted, predominantly in the
right
anterior and left medial lobes (2:19).  A well-circumscribed
subcentimeter
hypodense hepatic lesion within segment [**Doctor First Name 690**] (2:11) likely
represents a small
cyst or biliary hamartoma.  The portal and hepatic veins remain
patent.

Again seen is moderate stranding around the proximal duodenum
(2:27),
minimally changed since [**2124-6-16**], now with new mild
stranding about the
proximal CBD and gallbladder.  The gallbladder and CBD remain
non-distended
though gallbladder is mimially hyperemic.

The pancreas, adrenal glands, kidneys, and intraabdominal loops
of small and
large bowel are normal.  A 15 mm partially exophytic cyst
arising from the
interpolar region of the right kidney (300B:40) is unchanged.
There is no
free air or free fluid.  There is no mesenteric or
retroperitoneal
lymphadenopathy.

CT OF THE PELVIS WITH IV CONTRAST:
A small amount of intrapelvic free fluid (2:83) is new since
[**2124-6-16**].
The rectum and bladder are normal.  Moderate prostate
hypertrophy is again
seen (2:86).  There is no intrapelvic lymphadenopathy.

Small fat-containing bilateral inguinal hernias are again seen
(2:81).

OSSEOUS STRUCTURES:  There is no fracture.  There are no bony
lesions
concerning for malignancy or infection.  The patient is
post-median
sternotomy.

IMPRESSION:
1. Moderate stranding about the proximal duodenum appears
minimally changed
since [**2124-6-16**], but hyperemia and minimal stranding about
the gallbladder
and proximal CBD appears new. Cholecystitis would be somewhat
unusual given
the non-distended appearance of the gallbladder. Nonethelesse,
correlate with
clinical presentation and consider US examination for further
evaluation.
2.  Small amount of intrapelvic free fluid is new since [**2124-6-16**].
3.  Slight hyperenhancement of the right anterior and left
medial liver of
uncertain significance.  It is unclear if this is related to the
adjacent
gallbladder.
4.  No free air.
5.  Moderate prostate hypertrophy.

The study and the report were reviewed by the staff radiologist.


CXR ([**2124-6-18**])
=======================
CHEST RADIOGRAPH

INDICATION:  Hypoxemia, evaluation for pulmonary edema.

COMPARISON:  [**2123-12-17**].

FINDINGS:  As compared to the previous radiograph, the lung
volumes have
decreased, likely reflecting a lesser inspiratory effort.
Widespread
bilateral interstitial opacities, better characterized on
previous CT
examinations.  No additional or secondary parenchymal opacities.
 Sternal
wires, moderate cardiomegaly, no larger pleural effusions.  No
pneumothorax.

DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]

[**2124-6-19**] - CXR

FINDINGS:  Compared to the previous radiograph, there are new
focal
parenchymal opacities that have occurred in both the left lung
and at the
right lung base.  The distribution and morphology of these
opacities are
highly suspicious for pneumonia.  Unchanged borderline size of
the cardiac
silhouette without overt pulmonary edema.  No pleural effusions.
 No
pneumothorax.  Unchanged mild right apical pleural thickening.

EKG [**2124-6-21**]:
Sinus rhythm. Non-specific anterior T wave changes. Compared to
the previous
tracing of [**2124-6-18**] anterior T wave changes are new. Clinical
correlation is
suggested.

Rate PR QRS QT/QTc P QRS T
66 148 82 [**Telephone/Fax (2) 46125**] 32


Brief Hospital Course:
78 yo Cantonese-speaking male w/ PMH HTN, BPH, CAD s/p CABG [**2118**]
p/w 2-3 weeks abdominal pain, found to have cholecystitis.

ACTIVE ISSUES:
#Acute cholecystitis with Septic Shock: Patient presented
complaining of new RUQ pain and was found to have leukocytosis
(15-17) with fever (T101) while on medicine floor.  Repeat CT
done on [**6-18**] showed gallbladder wall thickening and
pericholecystic fluid and LFTs were drawn and found to be
elevated. Shortly after repeat CT the patient triggered for low
oxygen saturation, tachycardia, and hypotension and was found
with ST changes on EKG. He was transferred to the ICU.
In the ICU, the patient was put on meropenem and vancomycin, and
had a percutaneous chole drain placed with IR with bile cultures
positive for E. coli. He drained serosanguinous fluid until
[**2124-6-24**] until he started to drain bile. He stabilized nicely
in the ICU with fluid boluses and did not require pressor
support. He was transferred back to the floor and switched to
cefepime once E. coli sensitivities returned. He will need
cefepime until [**7-5**] and he is planned to have a
cholecystectomy on [**2124-7-6**].

#Ileus: On the evening of [**2124-6-23**], patient complained of
epigastric pain. KUB showed ileus.  Bowel regimen was started
and his pain resolved and bowel movements became regular.

# Duodenitis: Patient reported 2-3 weeks of intermittent
epigastric abdominal pain and nausea, with no noted melena,
hematemesis, hematochezia.  On abdominal CT, the patient was
noted to have severe duodenitis although no free air/fluid and
surgery and GI were consulted.  Surgery felt no intervention
necessary at that time, and GI plans to do EGD on [**2124-6-29**]. An
abdominal plain film was done to evaluate for free air which was
negative.  A repeat CT was also obtained which showed no signs
of perforation, minimal change in duodenitis from prior study,
no free air/fluid. H. pylori serology was sent and was positive,
but stool antigen remains pending.

# Myocardial strain: Patient triggered on [**6-18**] - nursing found
patient did not look well after returning to floor from CT,
found with oxygen saturation in 60s and HR 150s; patient
reported shortness of breath but not chest pain. EKG showed
ST-depressions in V3-V6, I, aVL, II.  Nebulizers, aspirin,
morphine, and Metoprolol were given, and repeat EKG was improved
but still with ST-changes, and the patient had troponins of 0.05
x2. These changes resolved on his next EKG. Troponins 0.05 x 2.
Cardiology was consulted felt that the EKG changes were
secondary to demand ischemia. The patient was started on heparin
gtt in addition to his regimen. His heparin was drip was
discontinued after transfer to medicine and the patient has not
complained of shortness or chest pain and was stable on tele and
repeat EKGs were unchanged.

# PNA: The patient was diagnosed with bilateral pneumonia on
hospital day 2 and developed hemoptysis. Because of his history
of TB, the patient was placed in respiratory isolation and ruled
out for TB with 4 negative sputums. Because of concern for MRSA
pneumonia, pt was started on vancomycin, which was continued
until [**6-26**].  He has no respiratory symptoms on discharge.

CHRONIC ISSUES:
# Coronary artery disease s/p CABG.
# HLD - On atorvastation per cardio reccs.
# HTN - cont lisinopril, metoprolol
# BPH - held doxazosin given hypotension.
# Restless leg syndrome - held Requip.

TRANSITIONAL ISSUES:
He will need to obtain a follow up appointment with cardiology
EGD on [**2124-6-29**]
Cholecystectomy on [**2124-7-6**]
Cefepime to continue until [**2124-7-5**] (total 14 day course)

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Doxazosin 4 mg PO DAILY
2. Ropinirole 1 mg PO TID
3. Omeprazole 40 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY


Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Lisinopril 2.5 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Doxazosin 4 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Ropinirole 1 mg PO TID
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheezing
8. Atorvastatin 10 mg PO DAILY
9. CefePIME 2 g IV Q12H Duration: 9 Days
10. Docusate Sodium 100 mg PO BID:PRN constipation
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
12. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB/wheeze
13. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain
RX *Oxecta 5 mg 1 tablet(s) by mouth q6H PRN pain Disp #*15
Tablet Refills:*0
RX *oxycodone 5 mg 1 tablet(s) by mouth q6H PRN pain Disp #*15
Tablet Refills:*0
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 1 TAB PO BID:PRN constipation
16. Pantoprazole 40 mg PO Q24H


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]

Discharge Diagnosis:
Cholecystitis
Pneumonia
Demand myocardial ischemia


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


Discharge Instructions:
Dear Mr. [**Known lastname **],

It was a pleasure taking care of you during your stay at the
[**Hospital1 18**]. You were admitted for evaluation of abdominal pain. You
were found to have an infection in your gallbladder which was
treated with placement of a drain and use of antibiotics. You
were also found to have developed pneumonia and were treated for
antibiotics.  You tested negative for tuberculosis.  The stress
associated with your gallbladder and infection caused your blood
pressure to decrease during your stay and may have lead to minor
damage to your heart.

Please follow up with surgery for evaluation for surgery to
remove your gallbladder on [**2124-7-6**], at 3:15 PM. In
addition, please make an appointment to follow up with
cardiology in the future.

Followup Instructions:
Department: WEST PROCEDURAL CENTER
When: THURSDAY [**2124-6-29**] at 1:15 PM
With: WPC ROOM THREE [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: GI-WEST PROCEDURAL CENTER
When: THURSDAY [**2124-6-29**] at 1:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7937**], MD [**Telephone/Fax (1) 463**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2124-7-6**] at 3:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2124-6-28**]
{'Acute cholecystitis,Unspecified septicemia,Septic shock,Severe sepsis,Obstruction of bile duct,Methicillin resistant pneumonia due to Staphylococcus aureus,Paralytic ileus,Other acute and subacute forms of ischemic heart disease, other,Duodenitis, without mention of hemorrhage,Helicobacter pylori [H. pylori],Leukocytosis, unspecified,Unspecified essential hypertension,Other emphysema,Restless legs syndrome (RLS),Other and unspecified hyperlipidemia,Hypoxemia,Constipation, unspecified,Anemia, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Aortocoronary bypass status,Personal history of tuberculosis,Personal history of tobacco 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 x 2-3 weeks

PRESENT ILLNESS: 78 y/o Cantonese speaking man with history of CAD s/p CABG
([**2118**]), HTN, HLD, and emphysema who presented on [**2124-6-17**] to the
medical floor with 2 weeks epigastric pain. CT abdomen showed
severe duodenitis; surgery and GI were consulted. His original
abdominal exam was consistent with guarding and surgery was
concerned about a perforation but a repeat CT and abdominal
X-ray were not consistent with free air. However, gallbladder
wall thickening with pericholecystic fluid were noted, and his
LFTs were consistent with obstruction, leading to concern for
cholecystittis/cholangitis, and the patient was started on
meropenem and vancomycin. Shortly after his repeat CT scan, he
developed SOB and was tachycardic to the 140s with 3mm ST
elevations in the lateral leads but troponins were negative and
he did not complain of chest pain. There was a concern for
demand ischemia and he was started on heparin gtt. The patient
became hypotensive to an SBP in the 80s after he received
metoprolol, and was transferred to the ICU. He was bolused with
IV fluids and his metoprolol and lisinopril were held; he
received a percutaneous chole drain and he continued to receive
meropenem and vancomycin pending results of blood cultures.  His
vital signs stabilized nicely and he was transferred to medicine
for further management.

MEDICAL HISTORY: - Coronary artery disease s/p CABG [**3-/2119**] (LIMA to the LAD and
-separate SVGs to the PDA and an OM)
- HLD
- HTN
- BPH
- Emphysema per ct scan
- TB many years ago, treated for 2 years

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Doxazosin 4 mg PO DAILY
2. Ropinirole 1 mg PO TID
3. Omeprazole 40 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY

ALLERGIES: Penicillins / simvastatin

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VITALS:  98.5 74 137/54 18 96%5L.
GENERAL:  Elderly chinese man, alert oriented, uncomfortable
with movement in bed, ambulatory
HEENT: PERRL, EOMI +arcus senilis
NECK: no carotid bruits, JVD
LUNGS: CTA b/l no wrc
HEART: RRR, normal S1 S2, no MRG.  Sternal scar c/w CABG
ABDOMEN: Tense abdomen with guarding diffusely.  TTP diffusely,
more so in epigastrium.  Moderate distension.  +BS. No palpable
masses.
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3

FAMILY HISTORY: Mother had hypertension and history of cancer.
Coronary artery disease in the family.

SOCIAL HISTORY: 20-pack-year smoker, discontinued 20 years ago.
Occupation, retired machine operator. Lives with his family.
Alcohol, none. Exposure, none. 

### Response:
{'Acute cholecystitis,Unspecified septicemia,Septic shock,Severe sepsis,Obstruction of bile duct,Methicillin resistant pneumonia due to Staphylococcus aureus,Paralytic ileus,Other acute and subacute forms of ischemic heart disease, other,Duodenitis, without mention of hemorrhage,Helicobacter pylori [H. pylori],Leukocytosis, unspecified,Unspecified essential hypertension,Other emphysema,Restless legs syndrome (RLS),Other and unspecified hyperlipidemia,Hypoxemia,Constipation, unspecified,Anemia, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Aortocoronary bypass status,Personal history of tuberculosis,Personal history of tobacco use'}
