CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: This is an 89 y/o Cantonese-speaking female with h/o
constipation s/p negative c-scope [**3-25**], distant ovarian CA
w/positive peritoneal washings refusing to f/u since [**2132**],
NIDDM, who presented on [**2143-6-26**] to the ED with diffuse, colicky
abdominal pain x 24 hours, non-radiating w/o
aggravating/alleviating factors, with nausea but no vomiting.
Last BM 3 days PTA, but pt was able to pass gas earlier on the
day of admit. No dysuria, urinary c/o on admission. She was
noted to be febrile to 102 in the ED, lactate of 5.5, elevated
LFTs, wbc 7.6, with negative imaging and benign abdominal exam.
Given labs, Code Sepsis was initiated and the patient was
started on early goal-directed therapy, receiving a CVL, IVF
resuscitation, foley, broad-spectrum abx (levo, flagyl, amp),
and transferred to the MICU for further management.
.
In the MICU, general surgery consulted on the pt, and thought
her clinical picture to be more c/w with hepatitis than
cholecystitis. Hep panel was negative for Hep A/B/C. No acute
infection with EBV, CMV, and HSV. RUQ u/s [**6-26**] showed
non-specific GB wall thickening (either related to edema or
known ovarian CA). CT abd/pelvis [**6-26**] demonstrated a small amount
of ascites, slightly heterogenous appearance of the liver
raising the possibility of hepatitis, and slight GB wall edema
likely [**2-21**] hepatitis. A HIDA scan on [**6-27**] demonstrated normal GB
filling. Patient's abdominal pain improved with a standing bowel
regimen and now is tolerating a regular diet. In the MICU, blood
cx drawn on admission grew out [**1-23**] GNR, specifically
pan-sensitive E.coli. Pt was switched from broad-spectrum abx to
po Levoflox. She has remained afebrile with a normal wbc. Source
of infection is unknown, with negative u/a's, no further
positive blood cx, and negative abdominal imaging. LFTs have
been trending down during her course.

MEDICAL HISTORY: 1. Tachybrady syndrome, status post DDD implant [**2136-5-19**].
2. Moderate MR [**First Name (Titles) **] [**Last Name (Titles) 113**] in [**2135-9-20**], with left atrium 4 x 1
cm and normal LV at that time.
3. ETT thallium [**2136-4-19**], at which time she went three minutes
on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol and reached 75% of maximum predicted heart
rate and did not have any wall-motion abnormalities or
reversible defects.
4. Ovarian cancer diagnosed in [**2128**]. Status post TAH/BSO.
Papillary serous type status post oral melphalan treatment. The
patient had positive peritoneal washing. The patient refused
follow up since [**2132**].
5. Adult-onset diabetes mellitus which is insulin requiring.
6. Constipation.
7. Peptic ulcer disease, status post H. pylori treatment [**Month (only) 404**]
[**2135**].
8. Peripheral neuropathy secondary to diabetes mellitus.
9. Chronic headaches.
10. Mild lower extremity edema/venous insufficiency.
11. Concentric LVH, h/o flash pulmonary edema
12. Hypothyroid [**2-21**] Amiodarone

MEDICATION ON ADMISSION: MEDS (at home) -
1. Amiodarone 200 mg qd
2. ASA 325 mg qd
3. Atenolol 50 mg qd
4. Nortriptyline 10 mg qd
5. NPH 25/16, regular 8 units [**Hospital1 **]
6. Synthroid 50 mcg qd
7. Losartan 50 mg qd
8. Zantac 150 mg [**Hospital1 **]
.
MEDS (on transfer) -
1. Amiodarone 200 mg qd
2. ASA 325 mg qd
3. Atenolol 50 mg qd
4. Nortriptyline 10 mg qd
5. Insulin NPH 12 units/8 units w/RISS
6. Synthroid 50 mcg qd
7. Levofloxacin 250 mg qd
8. Losartan 50 mg qd
9. Bowel regimen
10. Hep SC

ALLERGIES: Vasotec / Iodine; Iodine Containing / Nifedipine / Lipitor /
Norvasc / Ranitidine / Lovastatin / Protonix

PHYSICAL EXAM: Vitals: T 97.3, BP 144/72, HR 74, RR 18, SaO2 94%/RA
Gen: Elderly well-appearing asian woman lying in bed, NAD,
pleasant
HEENT: NC/AT, PERRL, EOMI, MMM, OP clear
Neck: supple, no LAD or JVD noted
CV: RRR, s1 s2 normal, [**2-25**] syst murmur at apex
Lungs: CTA-B, no w/r/r
Abd: mildly distended, soft, NT, NABS, no HSM, no [**Doctor Last Name 515**]
Rectal: guaiac neg per ED resident exam
Ext: no edema, 2+ DP pulses bilaterally
Skin: warm and dry

FAMILY HISTORY: NC

SOCIAL HISTORY: SH - Lives at home with family. No tobacco/EtoH/illicits.
Septicemia due to escherichia coli [E. coli],Acute and subacute necrosis of liver,Mitral valve disorders,Thrombocytopenia, unspecified,Sepsis,Personal history of other malignant neoplasm of skin,Other iatrogenic hypothyroidism,Cardiac rhythm regulators causing adverse effects in therapeutic use,Sinoatrial node dysfunction,Cardiac pacemaker in situ,Iron deficiency anemia, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Long-term (current) use of insulin
E coli septicemia,Acute necrosis of liver,Mitral valve disorder,Thrombocytopenia NOS,Sepsis,Hx-skin malignancy NEC,Iatrogen hypothyroid NEC,Adv eff card rhyth regul,Sinoatrial node dysfunct,Status cardiac pacemaker,Iron defic anemia NOS,DMII neuro nt st uncntrl,Neuropathy in diabetes,Long-term use of insulin
Admission Date:  [**2143-6-26**]              Discharge Date:   [**2143-7-1**]


Service: MEDICINE

Allergies:
Vasotec / Iodine; Iodine Containing / Nifedipine / Lipitor /
Norvasc / Ranitidine / Lovastatin / Protonix

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
abdominal pain

Major Surgical or Invasive Procedure:
Central line placement


History of Present Illness:
This is an 89 y/o Cantonese-speaking female with h/o
constipation s/p negative c-scope [**3-25**], distant ovarian CA
w/positive peritoneal washings refusing to f/u since [**2132**],
NIDDM, who presented on [**2143-6-26**] to the ED with diffuse, colicky
abdominal pain x 24 hours, non-radiating w/o
aggravating/alleviating factors, with nausea but no vomiting.
Last BM 3 days PTA, but pt was able to pass gas earlier on the
day of admit. No dysuria, urinary c/o on admission. She was
noted to be febrile to 102 in the ED, lactate of 5.5, elevated
LFTs, wbc 7.6, with negative imaging and benign abdominal exam.
Given labs, Code Sepsis was initiated and the patient was
started on early goal-directed therapy, receiving a CVL, IVF
resuscitation, foley, broad-spectrum abx (levo, flagyl, amp),
and transferred to the MICU for further management.
.
In the MICU, general surgery consulted on the pt, and thought
her clinical picture to be more c/w with hepatitis than
cholecystitis. Hep panel was negative for Hep A/B/C. No acute
infection with EBV, CMV, and HSV. RUQ u/s [**6-26**] showed
non-specific GB wall thickening (either related to edema or
known ovarian CA). CT abd/pelvis [**6-26**] demonstrated a small amount
of ascites, slightly heterogenous appearance of the liver
raising the possibility of hepatitis, and slight GB wall edema
likely [**2-21**] hepatitis. A HIDA scan on [**6-27**] demonstrated normal GB
filling. Patient's abdominal pain improved with a standing bowel
regimen and now is tolerating a regular diet. In the MICU, blood
cx drawn on admission grew out [**1-23**] GNR, specifically
pan-sensitive E.coli. Pt was switched from broad-spectrum abx to
po Levoflox. She has remained afebrile with a normal wbc. Source
of infection is unknown, with negative u/a's, no further
positive blood cx, and negative abdominal imaging. LFTs have
been trending down during her course.


Past Medical History:
1. Tachybrady syndrome, status post DDD implant [**2136-5-19**].
2. Moderate MR [**First Name (Titles) **] [**Last Name (Titles) 113**] in [**2135-9-20**], with left atrium 4 x 1
cm and normal LV at that time.
3. ETT thallium [**2136-4-19**], at which time she went three minutes
on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol and reached 75% of maximum predicted heart
rate and did not have any wall-motion abnormalities or
reversible defects.
4. Ovarian cancer diagnosed in [**2128**]. Status post TAH/BSO.
Papillary serous type status post oral melphalan treatment. The
patient had positive peritoneal washing. The patient refused
follow up since [**2132**].
5. Adult-onset diabetes mellitus which is insulin requiring.
6. Constipation.
7. Peptic ulcer disease, status post H. pylori treatment [**Month (only) 404**]
[**2135**].
8. Peripheral neuropathy secondary to diabetes mellitus.
9. Chronic headaches.
10. Mild lower extremity edema/venous insufficiency.
11. Concentric LVH, h/o flash pulmonary edema
12. Hypothyroid [**2-21**] Amiodarone


Social History:
SH - Lives at home with family. No tobacco/EtoH/illicits.

Family History:
NC

Physical Exam:

Vitals: T 97.3, BP 144/72, HR 74, RR 18, SaO2 94%/RA
Gen: Elderly well-appearing asian woman lying in bed, NAD,
pleasant
HEENT: NC/AT, PERRL, EOMI, MMM, OP clear
Neck: supple, no LAD or JVD noted
CV: RRR, s1 s2 normal, [**2-25**] syst murmur at apex
Lungs: CTA-B, no w/r/r
Abd: mildly distended, soft, NT, NABS, no HSM, no [**Doctor Last Name 515**]
Rectal: guaiac neg per ED resident exam
Ext: no edema, 2+ DP pulses bilaterally
Skin: warm and dry


Pertinent Results:
[**2143-6-26**] 12:20PM BLOOD ALT-188* AST-400* AlkPhos-270* Amylase-56
TotBili-2.1*
[**2143-6-26**] 04:30PM BLOOD LD(LDH)-256* CK(CPK)-26 DirBili-1.2*
[**2143-6-27**] 02:21AM BLOOD ALT-140* AST-170* AlkPhos-206*
TotBili-1.2
[**2143-6-28**] 04:08AM BLOOD ALT-78* AST-64* LD(LDH)-118 CK(CPK)-26
AlkPhos-153* TotBili-0.8
[**2143-6-29**] 07:49AM BLOOD ALT-61* AST-55* AlkPhos-171*
[**2143-6-30**] 03:09AM BLOOD ALT-45* AST-43* LD(LDH)-153 AlkPhos-159*
TotBili-0.6
[**2143-7-1**] 06:05AM BLOOD ALT-38 AST-46* LD(LDH)-153 AlkPhos-152*
Amylase-47 TotBili-0.6

TTE [**7-1**] - Regional left ventricular systolic dysfunction c/w
multivessel
CAD. Mild aortic regurgititation. Mild mitral regurgitation.
Compared with the prior report (images unavailable for review),
regional left
ventricular systolic function is more extensive.

Based on [**2134**] AHA endocarditis prophylaxis recommendations, the
[**Year (4 digits) 113**] findings
indicate a moderate risk (prophylaxis recommended). Clinical
decisions
regarding the need for prophylaxis should be based on clinical
and
echocardiographic data.
.
HIDA scan [**6-27**] - Normal gallbladder filling with no evidence of
biliary obstruction. A rim of
decreased tracer uptake surrounding the gallbladder is
suggestive of gallbladder
wall thickening. If consistent with clinical findings, this
could be
suggestive of gallbladder wall necrosis, but more likely
reflects the effects of
ascites and generalized tissue edema in this patient.
.
Liver u/s [**6-26**] - 1. No biliary ductal dilatation.

2. Nonspecific gallbladder wall edema, which may be related to
known ovarian cancer or liver disease.

Brief Hospital Course:

This is an 89 y/o Cantanese-speaking woman with h/o
constipation, neg cspy [**3-25**], distant ovarian CA, p/w abd pain x
24h, found to have elevated lactate and fever, elevated LFTs,
now with 1/4 E. coli bacteremia.
.
1. E coli bacteremia - No clear source. Likely GI related given
abdominal pain and pathogen. Given elevated LFTs, possible that
patient passed a stone and subsequent transient bacteremia. [**1-23**]
bottles [**2143-6-26**]. Ucx negative. HIDA negative. Pan sensitive.
Being treated with levofloxacin for 14-day course. Afebrile and
normal wbc throughout course. Given pt has a pacer, a TTE was
done to evaluate the pacer and wires for vegetation though
unlikely as it was a low-grade bacteria and rare pathogen to
affect heart valves. The TTE was negative for any vegetations,
however, it did show further decline of her LV function, for
which she should f/u with her cardiologist. No acute ischemic
symptoms. Surveillance cultures were sent on [**2143-7-1**], which were
pending on the day of discharhe.
.
2. Hepatitis - Hep serologies negative. [**Month (only) 116**] have been [**2-21**] to
shock though no documented hypotensive event. LFTs normalized by
the time of discharge. No symptoms, including abdominal pain,
n/v/diarrhea.
.
3. Abd pain - likely [**2-21**] constipation vs. hepatitis NOS. All
abdominal imaging negative for any acute process. Resolved with
standing bowel regimen and pt was tolerating full diet for last
several days of her stay.
.
4. Elevated lactate on admission - normalized with IVF. Likely
[**2-21**] E.coli bacteremia and septicemia.
.
5. CV
a) Tachybrady syndrome s/p DDD pacer; stable
b) Moderate MR, LVH with h/o flash PE; gently with IVF if needed

c) Coronaries: no known CAD with ETT (-) in 4/99; continue amio,
atenolol, aspirin, losartan.
.
6. Ovarian cancer - no acute issues, outpt f/u
.
7. NIDDM - continue insulin regimen, titrate as needed
.
8. PUD - continue zanatc
.
9. Hypothyroidism - continue synthroid
.
10. Anemia - stable Hct, baseline in-house 30-33; iron studies
c/w iron-deficiency anemia
-hold on Fe supplements given h/o constipation and current
abdominal pain
-recent c-scope w/ small adenoma otherwise wnl, may need a
repeat given new baseline
.


Medications on Admission:
MEDS (at home) -
1. Amiodarone 200 mg qd
2. ASA 325 mg qd
3. Atenolol 50 mg qd
4. Nortriptyline 10 mg qd
5. NPH 25/16, regular 8 units [**Hospital1 **]
6. Synthroid 50 mcg qd
7. Losartan 50 mg qd
8. Zantac 150 mg [**Hospital1 **]
.
MEDS (on transfer) -
1. Amiodarone 200 mg qd
2. ASA 325 mg qd
3. Atenolol 50 mg qd
4. Nortriptyline 10 mg qd
5. Insulin NPH 12 units/8 units w/RISS
6. Synthroid 50 mcg qd
7. Levofloxacin 250 mg qd
8. Losartan 50 mg qd
9. Bowel regimen
10. Hep SC


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
13. Insulin Regimen
Continue with 12 units of NPH at breakfast and 8 units of NPH at
dinner. Cover with regular insulin as needed per sliding scale.
Please see attached sheet. You may titrate up to prior home
regimen slowly.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary - low-grade E.coli bacteremia, abdominal pain, hepatitis
NOS

Secondary - NIDDM (insulin requiring), PUD, peripheral
neuropathy, hypothyroidism, chronic constipation, h/o ovarian CA


Discharge Condition:
Good, afebrile with stable VS, asymptomatic


Discharge Instructions:
-continue with all medications as prescribed
-you will need to complete a total of 14 days of antibiotics,
you currently are on day # 5
-please follow-up with appointments as listed below
-if you have any symptoms of fevers, chills, sweats, chest pain,
increasing abdominal pain, or any other concerning symptoms
please seek medical attention immediately

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Date/Time:[**2143-7-17**] 8:00
Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2143-9-24**]
10:30
Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2144-3-31**]
1:00



Completed by:[**2143-7-3**]
{'Septicemia due to escherichia coli [E. coli],Acute and subacute necrosis of liver,Mitral valve disorders,Thrombocytopenia, unspecified,Sepsis,Personal history of other malignant neoplasm of skin,Other iatrogenic hypothyroidism,Cardiac rhythm regulators causing adverse effects in therapeutic use,Sinoatrial node dysfunction,Cardiac pacemaker in situ,Iron deficiency anemia, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Long-term (current) use of insulin'}


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: This is an 89 y/o Cantonese-speaking female with h/o
constipation s/p negative c-scope [**3-25**], distant ovarian CA
w/positive peritoneal washings refusing to f/u since [**2132**],
NIDDM, who presented on [**2143-6-26**] to the ED with diffuse, colicky
abdominal pain x 24 hours, non-radiating w/o
aggravating/alleviating factors, with nausea but no vomiting.
Last BM 3 days PTA, but pt was able to pass gas earlier on the
day of admit. No dysuria, urinary c/o on admission. She was
noted to be febrile to 102 in the ED, lactate of 5.5, elevated
LFTs, wbc 7.6, with negative imaging and benign abdominal exam.
Given labs, Code Sepsis was initiated and the patient was
started on early goal-directed therapy, receiving a CVL, IVF
resuscitation, foley, broad-spectrum abx (levo, flagyl, amp),
and transferred to the MICU for further management.
.
In the MICU, general surgery consulted on the pt, and thought
her clinical picture to be more c/w with hepatitis than
cholecystitis. Hep panel was negative for Hep A/B/C. No acute
infection with EBV, CMV, and HSV. RUQ u/s [**6-26**] showed
non-specific GB wall thickening (either related to edema or
known ovarian CA). CT abd/pelvis [**6-26**] demonstrated a small amount
of ascites, slightly heterogenous appearance of the liver
raising the possibility of hepatitis, and slight GB wall edema
likely [**2-21**] hepatitis. A HIDA scan on [**6-27**] demonstrated normal GB
filling. Patient's abdominal pain improved with a standing bowel
regimen and now is tolerating a regular diet. In the MICU, blood
cx drawn on admission grew out [**1-23**] GNR, specifically
pan-sensitive E.coli. Pt was switched from broad-spectrum abx to
po Levoflox. She has remained afebrile with a normal wbc. Source
of infection is unknown, with negative u/a's, no further
positive blood cx, and negative abdominal imaging. LFTs have
been trending down during her course.

MEDICAL HISTORY: 1. Tachybrady syndrome, status post DDD implant [**2136-5-19**].
2. Moderate MR [**First Name (Titles) **] [**Last Name (Titles) 113**] in [**2135-9-20**], with left atrium 4 x 1
cm and normal LV at that time.
3. ETT thallium [**2136-4-19**], at which time she went three minutes
on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol and reached 75% of maximum predicted heart
rate and did not have any wall-motion abnormalities or
reversible defects.
4. Ovarian cancer diagnosed in [**2128**]. Status post TAH/BSO.
Papillary serous type status post oral melphalan treatment. The
patient had positive peritoneal washing. The patient refused
follow up since [**2132**].
5. Adult-onset diabetes mellitus which is insulin requiring.
6. Constipation.
7. Peptic ulcer disease, status post H. pylori treatment [**Month (only) 404**]
[**2135**].
8. Peripheral neuropathy secondary to diabetes mellitus.
9. Chronic headaches.
10. Mild lower extremity edema/venous insufficiency.
11. Concentric LVH, h/o flash pulmonary edema
12. Hypothyroid [**2-21**] Amiodarone

MEDICATION ON ADMISSION: MEDS (at home) -
1. Amiodarone 200 mg qd
2. ASA 325 mg qd
3. Atenolol 50 mg qd
4. Nortriptyline 10 mg qd
5. NPH 25/16, regular 8 units [**Hospital1 **]
6. Synthroid 50 mcg qd
7. Losartan 50 mg qd
8. Zantac 150 mg [**Hospital1 **]
.
MEDS (on transfer) -
1. Amiodarone 200 mg qd
2. ASA 325 mg qd
3. Atenolol 50 mg qd
4. Nortriptyline 10 mg qd
5. Insulin NPH 12 units/8 units w/RISS
6. Synthroid 50 mcg qd
7. Levofloxacin 250 mg qd
8. Losartan 50 mg qd
9. Bowel regimen
10. Hep SC

ALLERGIES: Vasotec / Iodine; Iodine Containing / Nifedipine / Lipitor /
Norvasc / Ranitidine / Lovastatin / Protonix

PHYSICAL EXAM: Vitals: T 97.3, BP 144/72, HR 74, RR 18, SaO2 94%/RA
Gen: Elderly well-appearing asian woman lying in bed, NAD,
pleasant
HEENT: NC/AT, PERRL, EOMI, MMM, OP clear
Neck: supple, no LAD or JVD noted
CV: RRR, s1 s2 normal, [**2-25**] syst murmur at apex
Lungs: CTA-B, no w/r/r
Abd: mildly distended, soft, NT, NABS, no HSM, no [**Doctor Last Name 515**]
Rectal: guaiac neg per ED resident exam
Ext: no edema, 2+ DP pulses bilaterally
Skin: warm and dry

FAMILY HISTORY: NC

SOCIAL HISTORY: SH - Lives at home with family. No tobacco/EtoH/illicits. 

### Response:
{'Septicemia due to escherichia coli [E. coli],Acute and subacute necrosis of liver,Mitral valve disorders,Thrombocytopenia, unspecified,Sepsis,Personal history of other malignant neoplasm of skin,Other iatrogenic hypothyroidism,Cardiac rhythm regulators causing adverse effects in therapeutic use,Sinoatrial node dysfunction,Cardiac pacemaker in situ,Iron deficiency anemia, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Long-term (current) use of insulin'}
