CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: 59 year old man with PMH significant for CAD s/p CABG and
stents; atrial fibrillation; ETOH abuse; and pancreatitis.
Presented to ED w/ severe [**9-4**] epigastric pain radiating to
back.  Admitted to ED with suspected severe pancreatitis
recurrence.
.
In the ED, VS were 98.8 73 [**Telephone/Fax (2) 51055**]% RA. Labs were
significant for a lipase of 4276 and an amylase of 761. He also
had an anion gap of 28. A surgery consult was obtained but did
not feel that pt had current surgical needs.  Imaging revealed
uncomplicated pancreatitis.
.
He was initially planned to be admitted to the floor, but then
CXR showed new pulmonary edema, and there was concern over
giving iv fluids on the floor and so Mr. [**Known lastname 51051**] was admitted
to the [**Hospital Unit Name 153**] for further monitoring and treatment. [**Hospital Unit Name 153**] course
included:
-Aggresive IVF and dilaudid PCA for pain control
-Increasing abdominal distension, pt passing flatus, NGT was
placed for decompression which he self-dc'd c/o severe
discomfort.
- TTE showed mild LVH, preserved biventricular systolic function
- He was placed on a CIWA scale for DT but did not need any
valium
- Electrolytes were aggresively repleted
.
He was called out to the floor on [**11-8**] but did not receive a
bed until [**11-10**] at 11pm.
.
On [**11-11**] in a.m. of admission to main team on floor, he c/o very
little abd pain ([**1-4**] epigastric), was able to ambulate w/o
difficulty and Foley to d/c'ed; requesting PO intake.

MEDICAL HISTORY: 1. Atrial fibrillation- Pt developed atrial fibrillation
approximately twelve years ago. He reports that he was
anticoagulated on coumadin for several years. He was then placed
on amiodarone following his CABG in [**2120**] and converted to sinus
rhythm. He was then taken off the anticoagulation and has
remained in sinus rhythem per his report.
2. Coronary artery disease- Pt is s/p one vessel CABG from the
LIMA to the LAD on [**2121-10-17**]. He then went to cardiac cath on
[**2121-10-20**] at which time three stents were placed to the RCA and
one to the distal circumflex. He has not had any further stress
tests since that time. His cardiologist is Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **].

MEDICATION ON ADMISSION: Meds on transfer to floor:
Heparin 5000 UNIT SC TID
Hydromorphone 0.1 mg
Insulin SC Sliding Scale
Amiodarone HCl 200 mg PO DAILY
Metoprolol 12.5 mg PO TID
Aspirin 300 mg PR DAILY
Quinapril 5 mg PO DAILY
Bisacodyl 10 mg PR DAILY
Senna 1 TAB PO BID
Diazepam 10 mg IV Q2H:PRN
Docusate Sodium 100 mg PO BID

ALLERGIES: Iodine / Ativan / Lipitor

PHYSICAL EXAM: VS 99.5 90  154/94 24  93% RA  UOP 775 cc on morning of [**11-11**],
substantial increase over ED
Gen/psych- AOX3.  He is alert and ambulating.  He has some
insight into his illness though seems confused into thinking
that some of our interventions are causing the problems which
they are actually treating.  Seems intermittently agitated, not
at staff but very frustrated about his general health, observed
in one case to rip shirt cuff off arm when having difficulty
undoing a button.
HEENT- NC/AT. EOMI. Anicteric sclera. Moist mucous membranes.
NECK: JVP at 2 cm above sternal notch
Cardiac- RRR nl S1 S2. No m,r,g.
Pulm- Decreased bibasilar breath sounds with faint wheezes at R
base. No rales or rhonchi.
Abdomen- Soft but visibly distended. Mildly tender to palpation
in epigastric region while not complaining of significant pain.
No rebound tenderness or guarding. Positive bowel sounds.
Extremities- Warm. No c/c/e.
Genital: Diminished penile and scrotal edema from before
Neuro- CN II-XII intact. 5/5 strength in the upper and lower
extremities bilaterally.

FAMILY HISTORY: Significant for hypertriglyceridemia though no FH of early-onset
CAD

SOCIAL HISTORY: 5 pack-year smoking hx, quit 30 years ago.  Longstanding hx of
EtOH consumption, three double-EtOH drinks/day.  Works as
insurance salesman.
Acute pancreatitis,Alcohol withdrawal,Atrial fibrillation,Other and unspecified alcohol dependence, continuous,Congestive heart failure, unspecified,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Pure hyperglyceridemia,Gout, unspecified,Hypopotassemia,Anemia, unspecified,Other abnormal blood chemistry,Spinal stenosis, unspecified region,Personal history of tobacco use,Aortocoronary bypass status
Acute pancreatitis,Alcohol withdrawal,Atrial fibrillation,Alcoh dep NEC/NOS-contin,CHF NOS,Hypertension NOS,Crnry athrscl natve vssl,Pure hyperglyceridemia,Gout NOS,Hypopotassemia,Anemia NOS,Abn blood chemistry NEC,Spinal stenosis NOS,History of tobacco use,Aortocoronary bypass
Admission Date:  [**2123-11-7**]              Discharge Date:   [**2123-11-12**]

Date of Birth:  [**2064-9-16**]             Sex:   M

Service: MEDICINE

Allergies:
Iodine / Ativan / Lipitor

Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
abdominal pain

Major Surgical or Invasive Procedure:
Echocardiography
Foley catheter


History of Present Illness:
59 year old man with PMH significant for CAD s/p CABG and
stents; atrial fibrillation; ETOH abuse; and pancreatitis.
Presented to ED w/ severe [**9-4**] epigastric pain radiating to
back.  Admitted to ED with suspected severe pancreatitis
recurrence.
.
In the ED, VS were 98.8 73 [**Telephone/Fax (2) 51055**]% RA. Labs were
significant for a lipase of 4276 and an amylase of 761. He also
had an anion gap of 28. A surgery consult was obtained but did
not feel that pt had current surgical needs.  Imaging revealed
uncomplicated pancreatitis.
.
He was initially planned to be admitted to the floor, but then
CXR showed new pulmonary edema, and there was concern over
giving iv fluids on the floor and so Mr. [**Known lastname 51051**] was admitted
to the [**Hospital Unit Name 153**] for further monitoring and treatment. [**Hospital Unit Name 153**] course
included:
-Aggresive IVF and dilaudid PCA for pain control
-Increasing abdominal distension, pt passing flatus, NGT was
placed for decompression which he self-dc'd c/o severe
discomfort.
- TTE showed mild LVH, preserved biventricular systolic function
- He was placed on a CIWA scale for DT but did not need any
valium
- Electrolytes were aggresively repleted
.
He was called out to the floor on [**11-8**] but did not receive a
bed until [**11-10**] at 11pm.
.
On [**11-11**] in a.m. of admission to main team on floor, he c/o very
little abd pain ([**1-4**] epigastric), was able to ambulate w/o
difficulty and Foley to d/c'ed; requesting PO intake.


Past Medical History:
1. Atrial fibrillation- Pt developed atrial fibrillation
approximately twelve years ago. He reports that he was
anticoagulated on coumadin for several years. He was then placed
on amiodarone following his CABG in [**2120**] and converted to sinus
rhythm. He was then taken off the anticoagulation and has
remained in sinus rhythem per his report.
2. Coronary artery disease- Pt is s/p one vessel CABG from the
LIMA to the LAD on [**2121-10-17**]. He then went to cardiac cath on
[**2121-10-20**] at which time three stents were placed to the RCA and
one to the distal circumflex. He has not had any further stress
tests since that time. His cardiologist is Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **].

3. Pancreatitis- First episode of pancreatitis was in [**2103**]. He
has had approximately 10 flares since that time. He reports that
his current pain is epigastric when in the past his
"pancreatitis" pain was more localized to his left lower
abdomen/flank.
4. Ethanol abuse- Pt denies any history of DTS. He reports that
he normally quits drinking for a couple of months each winter
with [**Last Name **] problem. However, there is a record of an episode of DTs
at an OSH in [**2119**]. He attributes these symtpoms to receiving too
much ativan.
5. Hypertriglyceridemia
6. Hypertension
7. Gout
8. Spinal stenosis
9. MRSA infection- Pt had a MRSA PNA at an OSH when he was
intubated during an episode of pancreatitis. He had a sputum
positive for MRSA here at [**Hospital1 18**] in [**2120**].

Social History:
5 pack-year smoking hx, quit 30 years ago.  Longstanding hx of
EtOH consumption, three double-EtOH drinks/day.  Works as
insurance salesman.

Family History:
Significant for hypertriglyceridemia though no FH of early-onset
CAD


Physical Exam:
VS 99.5 90  154/94 24  93% RA  UOP 775 cc on morning of [**11-11**],
substantial increase over ED
Gen/psych- AOX3.  He is alert and ambulating.  He has some
insight into his illness though seems confused into thinking
that some of our interventions are causing the problems which
they are actually treating.  Seems intermittently agitated, not
at staff but very frustrated about his general health, observed
in one case to rip shirt cuff off arm when having difficulty
undoing a button.
HEENT- NC/AT. EOMI. Anicteric sclera. Moist mucous membranes.
NECK: JVP at 2 cm above sternal notch
Cardiac- RRR nl S1 S2. No m,r,g.
Pulm- Decreased bibasilar breath sounds with faint wheezes at R
base. No rales or rhonchi.
Abdomen- Soft but visibly distended. Mildly tender to palpation
in epigastric region while not complaining of significant pain.
No rebound tenderness or guarding. Positive bowel sounds.
Extremities- Warm. No c/c/e.
Genital: Diminished penile and scrotal edema from before
Neuro- CN II-XII intact. 5/5 strength in the upper and lower
extremities bilaterally.


Pertinent Results:
[**2123-11-7**] 08:30PM   GLUCOSE-147* UREA N-12 CREAT-0.5 SODIUM-145
POTASSIUM-3.2* CHLORIDE-96 TOTAL CO2-21* ANION GAP-31*
[**2123-11-7**] 08:30PM   ALT(SGPT)-21 AST(SGOT)-30 CK(CPK)-45 ALK
PHOS-93 AMYLASE-761* TOT BILI-0.5
[**2123-11-7**] 08:30PM   LIPASE-4276*
[**2123-11-7**] 08:30PM   CK-MB-2 cTropnT-<0.01
[**2123-11-7**] 08:30PM   CALCIUM-9.7 PHOSPHATE-2.7 MAGNESIUM-1.7
[**2123-11-7**] 08:30PM   WBC-11.7* RBC-4.37*# HGB-14.7# HCT-40.5#
MCV-93 MCH-33.6* MCHC-36.2*# RDW-13.3
[**2123-11-7**] 08:30PM   NEUTS-89.2* BANDS-0 LYMPHS-7.1* MONOS-1.8*
EOS-1.5 BASOS-0.3
[**2123-11-7**] 08:30PM   HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2123-11-7**] 08:30PM   PLT COUNT-234
[**2123-11-7**] 08:30PM   PT-12.5 PTT-27.4 INR(PT)-1.0

Brief Hospital Course:
59 year old man with PMH significant for CAD s/p CABG and
stents; atrial fibrillation; ETOH abuse; and recurrent
pancreatitis admitted with active severe pancreatitis.
.
## GI
.
#. Pancreatitis: Due to EtOH. Amylase and lipase steadily
improved since admission to nearly normal levels.  No
complication seen on abdominal CT. He initially had prerenal
azotemia and was bolused, urine output fully recovered by day of
discharge.
- Able to tolerate PO clears by day prior to discharge, no
epigastric pain reported on discharge on [**11-12**], able to ambulate
well.
- dilaudid PCA initially, d/c'ed on [**11-11**].
- Had some minor non-bloody diarrhea night before discharge
perhaps s/p stool softeners and laxatives; K repleted and bowel
regimen d/c'ed.

## Pulmonary
.
# Low Grade Fever:
- Initial suspicion of ? aspiration pneumonia based on CXR w/
RUL infiltrates but CXR gradually resolved over course of stay.

- Continued w/ some low grades temps and fever until day prior
to admission when temp fully normalized.

# Pulmonary edema:
- Found to be volume overloaded on exam and by CXR early in
stay, perhaps s/p aggressive initial rehydration in wake of
prerenal azotemia on admission.
- TTE showed normal EF and no sign of diastolic dysfunction but
sub-optimal windows.
- Excellent urine output by day before discharge w/o need for
diuresis.
.
# Wheezes on Lung Exam:
- No prior hx of such wheezes. No h/o COPD. Improved with
albuterol nebs.
- Could be due to volume overload, but could also be from
metoprolol.
- Received nebs prn.
- Consider pulmonary function tests as an outpatient
.
##Neuro/psych/tox
.
# EtOH abuse- Mr. [**Known lastname 51051**] has a history of ETOH withdrawal per
records and required prolonged intubation for this at an OSH. He
has a reported history of allergy to ativan, but this actually
seems to have been a result of oversedation from too much ativan
administered.
- He was maintained on a diazepam CIWA scale for ETOH withdrawal
throughout hospitalization. Given hypertension and tachycardia
on admission, treated with diazepam 10iv x 1 and monitored
throughout.
- On [**11-11**] he had a ? withdrawal picture pulling out IV and
becoming somewhat agitated in late afternoon, mildly
diaphoretic.
- On morning of [**11-12**] he vigorously expressed desire to leave
hospital, became somewhat agitated.  However, though
hypertensive in both cases of agitation, he had no tachycardia.
Seemed frustrated with situation but aware and no indication of
MS changes or confusion.  No indication of DT.
- Placed on fall precautions.
- Given thiamine and folate qd
.
##Renal
.
#. Anion gap- He initially p/w a significant anion gap of 28 on
his admission labs. Likely from saline repletion; gap resolved
by end of admission w/ no indication of acidosis.
.
#. Hypokalemia- Potassium of 3.0 early on day of discharge as
noted above, probably s/p diarrhea night before.  K normalized
on PO, IV repletion.
.
## Cardio
.
#. CAD/HTN- He has a history of one vessel CABG and multiple
stents in [**2120**].
- Ruled out for MI x three sets of cardiac enzymes.
- Continued on ASA.
- Restarted fenofibrate and quinapril.
- Was started on Metoprolol in the [**Hospital Unit Name 153**] for hypertension.  HTN
continued to be a problem during stay and he spiked to 170s on
[**11-11**] afternoon and up to 180 on [**11-12**] midnight.  His quinapril
dose increased to 10 mg PO DAILY and discharged on 20 mg.  Sent
home on the metoprolol.
- Recommend follow-up and adjustment of BP meds as needed.
.
#. Atrial fibrillation- He has a long history of atrial fib but
is not anticoagulated.
- Continued on amiodarone.
## Heme
.
# Low Hct:  Apparently hemodilution, stable throughout
hospitalization to baseline for him, though may benefit from
further work-up.
.
## Endocrine
.
# Glucose control
- No known h/o diabetes, but continued with a sliding scale
during hospitalization, QID FS.
- Glucose stabilized on [**11-11**]; outpt. follow-up and Rx of
presumed DMII if high HbA1c
.
## FEN/PPx summary- SC heparin; MRSA precautions; Fall
precautions, withdrawal precautions/CIWA scale.
.
# Communication- With Mr. [**Known lastname 51051**] and family members.
.
# Code status- Full code.


Medications on Admission:
Meds on transfer to floor:
Heparin 5000 UNIT SC TID
Hydromorphone 0.1 mg
Insulin SC Sliding Scale
Amiodarone HCl 200 mg PO DAILY
Metoprolol 12.5 mg PO TID
Aspirin 300 mg PR DAILY
Quinapril 5 mg PO DAILY
Bisacodyl 10 mg PR DAILY
Senna 1 TAB PO BID
Diazepam 10 mg IV Q2H:PRN
Docusate Sodium 100 mg PO BID

Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Recurrence of acute pancreatitis in the setting of labile blood
pressure, apparent EtOH withdrawal w/o frank DT (on CIWA
protocol)


Discharge Condition:
Stable


Discharge Instructions:
Please call a physician if you experience sudden chest pain,
shortness of breath, high fever, seizures, severe headache,
fainting, severe and prolonged confusion, or rapid and
substantial weight loss.

Followup Instructions:
Please see Dr. [**Last Name (STitle) 51052**] at your already scheduled time on Monday
[**2123-11-15**]; please mention that your blood pressure became high
late in your hospitalization (to 180/100) and this is why we
have increased your Accupril dose to 20 milligrams per day.
Please mention also that your potassium became low (to 3.0) on
your day of discharge after you'd had some diarrhea the night
before, and that we repleted your potassium.

Please schedule an appointment with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] within
two weeks and mention the same issues to him, especially your
blood pressure.

To PCP:  [**Name10 (NameIs) 357**] consider ordering pulmonary function tests for
Mr. [**Known lastname 51051**] as PE and CXR both seem to indicate substantial
difficulty in deep inhalation.  No indication of pulmonary
fibrosis from amiodarone but ? other restrictive process.
Follow-up anemia work-up if necessary.
{'Acute pancreatitis,Alcohol withdrawal,Atrial fibrillation,Other and unspecified alcohol dependence, continuous,Congestive heart failure, unspecified,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Pure hyperglyceridemia,Gout, unspecified,Hypopotassemia,Anemia, unspecified,Other abnormal blood chemistry,Spinal stenosis, unspecified region,Personal history of tobacco use,Aortocoronary bypass status'}


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: 59 year old man with PMH significant for CAD s/p CABG and
stents; atrial fibrillation; ETOH abuse; and pancreatitis.
Presented to ED w/ severe [**9-4**] epigastric pain radiating to
back.  Admitted to ED with suspected severe pancreatitis
recurrence.
.
In the ED, VS were 98.8 73 [**Telephone/Fax (2) 51055**]% RA. Labs were
significant for a lipase of 4276 and an amylase of 761. He also
had an anion gap of 28. A surgery consult was obtained but did
not feel that pt had current surgical needs.  Imaging revealed
uncomplicated pancreatitis.
.
He was initially planned to be admitted to the floor, but then
CXR showed new pulmonary edema, and there was concern over
giving iv fluids on the floor and so Mr. [**Known lastname 51051**] was admitted
to the [**Hospital Unit Name 153**] for further monitoring and treatment. [**Hospital Unit Name 153**] course
included:
-Aggresive IVF and dilaudid PCA for pain control
-Increasing abdominal distension, pt passing flatus, NGT was
placed for decompression which he self-dc'd c/o severe
discomfort.
- TTE showed mild LVH, preserved biventricular systolic function
- He was placed on a CIWA scale for DT but did not need any
valium
- Electrolytes were aggresively repleted
.
He was called out to the floor on [**11-8**] but did not receive a
bed until [**11-10**] at 11pm.
.
On [**11-11**] in a.m. of admission to main team on floor, he c/o very
little abd pain ([**1-4**] epigastric), was able to ambulate w/o
difficulty and Foley to d/c'ed; requesting PO intake.

MEDICAL HISTORY: 1. Atrial fibrillation- Pt developed atrial fibrillation
approximately twelve years ago. He reports that he was
anticoagulated on coumadin for several years. He was then placed
on amiodarone following his CABG in [**2120**] and converted to sinus
rhythm. He was then taken off the anticoagulation and has
remained in sinus rhythem per his report.
2. Coronary artery disease- Pt is s/p one vessel CABG from the
LIMA to the LAD on [**2121-10-17**]. He then went to cardiac cath on
[**2121-10-20**] at which time three stents were placed to the RCA and
one to the distal circumflex. He has not had any further stress
tests since that time. His cardiologist is Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **].

MEDICATION ON ADMISSION: Meds on transfer to floor:
Heparin 5000 UNIT SC TID
Hydromorphone 0.1 mg
Insulin SC Sliding Scale
Amiodarone HCl 200 mg PO DAILY
Metoprolol 12.5 mg PO TID
Aspirin 300 mg PR DAILY
Quinapril 5 mg PO DAILY
Bisacodyl 10 mg PR DAILY
Senna 1 TAB PO BID
Diazepam 10 mg IV Q2H:PRN
Docusate Sodium 100 mg PO BID

ALLERGIES: Iodine / Ativan / Lipitor

PHYSICAL EXAM: VS 99.5 90  154/94 24  93% RA  UOP 775 cc on morning of [**11-11**],
substantial increase over ED
Gen/psych- AOX3.  He is alert and ambulating.  He has some
insight into his illness though seems confused into thinking
that some of our interventions are causing the problems which
they are actually treating.  Seems intermittently agitated, not
at staff but very frustrated about his general health, observed
in one case to rip shirt cuff off arm when having difficulty
undoing a button.
HEENT- NC/AT. EOMI. Anicteric sclera. Moist mucous membranes.
NECK: JVP at 2 cm above sternal notch
Cardiac- RRR nl S1 S2. No m,r,g.
Pulm- Decreased bibasilar breath sounds with faint wheezes at R
base. No rales or rhonchi.
Abdomen- Soft but visibly distended. Mildly tender to palpation
in epigastric region while not complaining of significant pain.
No rebound tenderness or guarding. Positive bowel sounds.
Extremities- Warm. No c/c/e.
Genital: Diminished penile and scrotal edema from before
Neuro- CN II-XII intact. 5/5 strength in the upper and lower
extremities bilaterally.

FAMILY HISTORY: Significant for hypertriglyceridemia though no FH of early-onset
CAD

SOCIAL HISTORY: 5 pack-year smoking hx, quit 30 years ago.  Longstanding hx of
EtOH consumption, three double-EtOH drinks/day.  Works as
insurance salesman. 

### Response:
{'Acute pancreatitis,Alcohol withdrawal,Atrial fibrillation,Other and unspecified alcohol dependence, continuous,Congestive heart failure, unspecified,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Pure hyperglyceridemia,Gout, unspecified,Hypopotassemia,Anemia, unspecified,Other abnormal blood chemistry,Spinal stenosis, unspecified region,Personal history of tobacco use,Aortocoronary bypass status'}
