CHIEF COMPLAINT: Somnolence/weakness

PRESENT ILLNESS: [**Age over 90 **] year old female with history of HTN and HL who presents after
being found down by her husband.
.
She reports not eating well for the past several weeks.  Then, 3
days ago experienced the onset of nausea which has since
improved.  Over the last day, she became more and more weak.
She was sitting in a chair and slumped down to the ground
yesterday.  She slept there last night but refused to go to the
ED.  Her husband finally called EMS this morning.
.
Per EMS, she was alert and oriented, hypotensive to 80's and
tachy to 130's.  She was found down on her right side in the
bathroom.  In the ED, initial vitals were 97.2 128 100/54 22 98%
RA.  O2 Sats were reportedly 60's with good pleth.  ABG was
7.37/29/474 on NRB.  She was also found to have black, tarry
stool on rectal exam.  Had NG lavage which is negative.  She was
started on an IV protonix gtt, given vanc/cefepime, got 5L of
NS, and 1 unit of blood.  Right IJ cordis was placed under
sterile conditions. GI and surgery were consulted.  Vitals on
transfer were HR 127 BP 81/42, unable to obtain O2 sat.  She
continued to be awake and talking.

MEDICAL HISTORY: HTN
HL

MEDICATION ON ADMISSION: Pravastatin 40mg po daily
HCTZ 25mg po daily
Lisinopril 10mg po daily

ALLERGIES: Codeine

PHYSICAL EXAM: VS: 95.0 127 91/67 22 92%RA
GEN: Awake, but slightly lethargic, communicates appropriately
HEENT: PERRL, anicteric, dry MM, OP without lesions, has right
sided IJ cordis, no LAD, JVD elevated to lower jawline on left,
difficult to assess on the right
RESP: Rales bilaterally anteriorly
CV: RRR with dynamic heart sounds, no MRG
ABD: Soft, nontender, nondistended, no masses or
hepatosplenomegaly
EXT: 3+ pitting peripheral edema to thighs, cold extremitites.
Pulses thready and weak throughout.
NEURO: AAOx2. Cn II-XII grossly intact. 2+ DTRs throughout.
RECTAL: Black sticky stool on finger, guaiac positive

FAMILY HISTORY: No family history of bleeding or clotting disorders.

SOCIAL HISTORY: Lives at home with husband.  Denies tobacco, EtOH or other drug
use.  Reports that at baseline she walks around without
difficulty.
Blood in stool,Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Cardiogenic shock,Anemia, unspecified,Thrombocytopenia, unspecified,Unspecified essential hypertension,Personal history of malignant neoplasm of breast
Blood in stool,Acute kidney failure NOS,Acute necrosis of liver,Cardiogenic shock,Anemia NOS,Thrombocytopenia NOS,Hypertension NOS,Hx of breast malignancy
Admission Date:  [**2109-10-26**]              Discharge Date:   [**2109-10-28**]


Service: MEDICINE

Allergies:
Codeine

Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Somnolence/weakness

Major Surgical or Invasive Procedure:
None

History of Present Illness:
[**Age over 90 **] year old female with history of HTN and HL who presents after
being found down by her husband.
.
She reports not eating well for the past several weeks.  Then, 3
days ago experienced the onset of nausea which has since
improved.  Over the last day, she became more and more weak.
She was sitting in a chair and slumped down to the ground
yesterday.  She slept there last night but refused to go to the
ED.  Her husband finally called EMS this morning.
.
Per EMS, she was alert and oriented, hypotensive to 80's and
tachy to 130's.  She was found down on her right side in the
bathroom.  In the ED, initial vitals were 97.2 128 100/54 22 98%
RA.  O2 Sats were reportedly 60's with good pleth.  ABG was
7.37/29/474 on NRB.  She was also found to have black, tarry
stool on rectal exam.  Had NG lavage which is negative.  She was
started on an IV protonix gtt, given vanc/cefepime, got 5L of
NS, and 1 unit of blood.  Right IJ cordis was placed under
sterile conditions. GI and surgery were consulted.  Vitals on
transfer were HR 127 BP 81/42, unable to obtain O2 sat.  She
continued to be awake and talking.

Past Medical History:
HTN
HL

Social History:
Lives at home with husband.  Denies tobacco, EtOH or other drug
use.  Reports that at baseline she walks around without
difficulty.

Family History:
No family history of bleeding or clotting disorders.

Physical Exam:
VS: 95.0 127 91/67 22 92%RA
GEN: Awake, but slightly lethargic, communicates appropriately
HEENT: PERRL, anicteric, dry MM, OP without lesions, has right
sided IJ cordis, no LAD, JVD elevated to lower jawline on left,
difficult to assess on the right
RESP: Rales bilaterally anteriorly
CV: RRR with dynamic heart sounds, no MRG
ABD: Soft, nontender, nondistended, no masses or
hepatosplenomegaly
EXT: 3+ pitting peripheral edema to thighs, cold extremitites.
Pulses thready and weak throughout.
NEURO: AAOx2. Cn II-XII grossly intact. 2+ DTRs throughout.
RECTAL: Black sticky stool on finger, guaiac positive

Pertinent Results:
Admission Labs:
[**2109-10-26**] 09:04AM   GLUCOSE-133* LACTATE-2.5* NA+-133* K+-5.6*
CL--101 TCO2-20*
[**2109-10-26**] 09:10AM   GLUCOSE-87 UREA N-107* CREAT-2.3* SODIUM-130*
POTASSIUM-6.8* CHLORIDE-99 TOTAL CO2-17* ANION GAP-21*
[**2109-10-26**] 09:16AM   TYPE-ART O2-100 PO2-474* PCO2-29* PH-7.37
TOTAL CO2-17* BASE XS--6 AADO2-226 REQ O2-45 COMMENTS-NRB
[**2109-10-26**] 10:04AM   HGB-12.5 calcHCT-38
[**2109-10-26**] 10:10AM   WBC-9.4 RBC-2.95* HGB-9.5* HCT-29.6* MCV-100*
MCH-32.4* MCHC-32.3 RDW-20.4*
[**2109-10-26**] 10:10AM   NEUTS-87* BANDS-2 LYMPHS-5* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-2*
[**2109-10-26**] 10:10AM   CALCIUM-7.3* PHOSPHATE-3.2 MAGNESIUM-2.1
[**2109-10-26**] 10:10AM   CK-MB-14* MB INDX-2.7 cTropnT-0.06*
[**2109-10-26**] 10:10AM   LIPASE-56
[**2109-10-26**] 10:10AM   ALT(SGPT)-56* AST(SGOT)-74* CK(CPK)-510* ALK
PHOS-83 TOT BILI-1.3
[**2109-10-26**] 10:10AM   GLUCOSE-64* UREA N-86* CREAT-1.7* SODIUM-138
POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-16* ANION GAP-20
[**2109-10-26**] 02:28PM   HAPTOGLOB-31
[**2109-10-26**] 02:28PM   TSH-1.7

[**2109-10-26**] CXR: 1. Severe cardiomegaly is of unclear chronicity.
Comparison to prior study when available would be helpful.
Globular shape of the cardiac contour raises question of
pericardial effusion vs cardiomyopathy.
2. Hilar haziness and mild cephalization, suggestive of early
pulmonary
vascular congestion without frank edema. Small bilateral pleural
effusions.
3. Right middle lobe and lower lobe opacity may represent
atelectasis, but
concurrent infection cannot be excluded.
4. When the patient is able to tolerate, PA and lateral
examination may be
beneficial.


Brief Hospital Course:
[**Age over 90 **] year old female with history of HTN and HL who presents after
being found down by her husband with anemia, thrombocytopenia,
hypotension and tachycardia.

# GOALS OF CARE:  Despite maximal doses of 2 pressors, patient
was unable to maintain a perfusing blood pressure, though she
appeared to be mentating and was able to make her wishes know.
In concert with her husband [**Name (NI) 382**], son and daughter, decision
was made for no further escalation of care.

#. CARDIOGENIC SHOCK: She was admitted with hypotension, cold
extremities, significant lower extremity edema, Q waves on ECG
and was not responsive to IV fluids.  She had a central venous
O2 sat of 44% on admission and a diagnosis of cardiogenic shock
was made.  A stat TTE showed global left ventricular hypokinesis
with an LVEF = 25-30% and Moderate to severe 3+ mitral
regurgitation.  LENIs showed no evidence of DVT.  She was
started on neosynephrine with some response in her blood
pressure.  She was also started on dobutamine for inotropic
support but did not tolerate this due to tachycardia.  Her heart
rhythm was atrial flutter with HR in the 140's.  Milrinone was
also attempted with mild worsening in her tachycardia and no
obvious effect on her cardiac output.  In order to attempt
rhythm control, she was started on an amiodarone drip. Patient
declined electrical cardioversion. Rate was not able to be
controlled.

#. ANEMIA/GI BLEED: Hct initially in the ED 38 and dropped to
29.6.  Her stool was consistent with melena on rectal exam.  It
was felt that she most likely had gut ischemia in the setting of
cardiogenic shock.  She was given 2 units PRBCs in the ED and
had a right IJ cordis placed for resuscitation. She did not
require further blood transfusions.

#. THROMBOCYTOPENIA: Platelets 10 on admission, increased to
150's with 1 platelet transfusion.  Unclear etiology.  Per
review of smear by hematology, there was no evidence of TTP and
no schistocytes.  Not likely DIC given only mildly elevated
coags.  No recent heparin exposure that is known.  Her platelets
remained stable.

#. ACUTE RENAL FAILURE: Likely due to cardiogenic shock and poor
perfusion.  Improved mildly to IV fluids initially but her urine
output decline to 0 by the time of admission.

# Code Status:  DNR/DNI, confirmed with patient and family

Medications on Admission:
Pravastatin 40mg po daily
HCTZ 25mg po daily
Lisinopril 10mg po daily

Discharge Medications:
EXPIRED

Discharge Disposition:
Expired

Discharge Diagnosis:
Cardiogenic Shock

Discharge Condition:
EXPIRED

Discharge Instructions:
EXPIRED

Followup Instructions:
EXPIRED
{'Blood in stool,Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Cardiogenic shock,Anemia, unspecified,Thrombocytopenia, unspecified,Unspecified essential hypertension,Personal history of malignant neoplasm of breast'}


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: Somnolence/weakness

PRESENT ILLNESS: [**Age over 90 **] year old female with history of HTN and HL who presents after
being found down by her husband.
.
She reports not eating well for the past several weeks.  Then, 3
days ago experienced the onset of nausea which has since
improved.  Over the last day, she became more and more weak.
She was sitting in a chair and slumped down to the ground
yesterday.  She slept there last night but refused to go to the
ED.  Her husband finally called EMS this morning.
.
Per EMS, she was alert and oriented, hypotensive to 80's and
tachy to 130's.  She was found down on her right side in the
bathroom.  In the ED, initial vitals were 97.2 128 100/54 22 98%
RA.  O2 Sats were reportedly 60's with good pleth.  ABG was
7.37/29/474 on NRB.  She was also found to have black, tarry
stool on rectal exam.  Had NG lavage which is negative.  She was
started on an IV protonix gtt, given vanc/cefepime, got 5L of
NS, and 1 unit of blood.  Right IJ cordis was placed under
sterile conditions. GI and surgery were consulted.  Vitals on
transfer were HR 127 BP 81/42, unable to obtain O2 sat.  She
continued to be awake and talking.

MEDICAL HISTORY: HTN
HL

MEDICATION ON ADMISSION: Pravastatin 40mg po daily
HCTZ 25mg po daily
Lisinopril 10mg po daily

ALLERGIES: Codeine

PHYSICAL EXAM: VS: 95.0 127 91/67 22 92%RA
GEN: Awake, but slightly lethargic, communicates appropriately
HEENT: PERRL, anicteric, dry MM, OP without lesions, has right
sided IJ cordis, no LAD, JVD elevated to lower jawline on left,
difficult to assess on the right
RESP: Rales bilaterally anteriorly
CV: RRR with dynamic heart sounds, no MRG
ABD: Soft, nontender, nondistended, no masses or
hepatosplenomegaly
EXT: 3+ pitting peripheral edema to thighs, cold extremitites.
Pulses thready and weak throughout.
NEURO: AAOx2. Cn II-XII grossly intact. 2+ DTRs throughout.
RECTAL: Black sticky stool on finger, guaiac positive

FAMILY HISTORY: No family history of bleeding or clotting disorders.

SOCIAL HISTORY: Lives at home with husband.  Denies tobacco, EtOH or other drug
use.  Reports that at baseline she walks around without
difficulty. 

### Response:
{'Blood in stool,Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Cardiogenic shock,Anemia, unspecified,Thrombocytopenia, unspecified,Unspecified essential hypertension,Personal history of malignant neoplasm of breast'}
