CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: 85 yo F with h/o CAD s/p CABG, chronic CHF and recent bowel
surgery presents with hypotension now tx from [**Hospital1 882**] (orig
from [**Hospital **] rehab). Per [**Hospital 100**] rehab, BP has been low for several
days, now not responsive to fluids. She was found overnight to
systolics reportedly as low as 50s; ? still mentating.
Thereafter, she was transferred to [**Hospital 882**] Hospital where she
received 4L IVFs as well as IV zosyn. Patient was alert and
oriented x3, code status was discussed with patient who stated
DNR/DNI and that she doesnt want central line even if
lifesaving. This was confirmed with her niece who is HCP, who
states that her aunt discussed with her DNR and confirms. Thus,
she was started on levophed through right PICC (placed prior to
presentation, but unclear when) and was transferred to [**Hospital1 18**] ED
for further management.
.
Of note, she has a hx of recent rectocolectomy for rectal perf
with small bowel prolapse (2 feet of bowel resected) at [**Hospital1 **] and has ostomy and choleostomy bag (placed for acalculus
cholecystitis). Post op course was complicated by wound
infection, pneumonia, c. diff and right hip cellulitis. She was
treated periop with levofloxacin, flagyl and keflex. Discharge
summary from [**Hospital3 **] recommends course of keflex to end on
[**12-2**], levofloxacin to end on [**12-4**] and flagyl to be continued
through [**12-9**]. Her transfer record only lists flagyl as
antibiotic so it is unclear whether she received full courses of
these meds.
.
In the ED here, initial vitals were T: 95.4 BP: 116/88 HR: 100
RR: 26 O2 sat: 100% (unclear amount supplemental O2). Labs were
notable for creatinine of 2.7 (CRI, but unclear baseline),
bicarb of 10, and initial venous pH of 7.08 which improved
slightly to 7.11 prior to transfer. Lactate was normal at 1.4.
Initial glucose drawn from her PICC was 546 however this was
thought d/t dextrose delivered through her PICC at [**Hospital3 **]
for hypoglycemia as repeats without intervention normalized.
Arterial line placement was attempted in ? left wrist (with
doppler) however pt extremely edemetous so attempt was
unsuccessful. UA was not sent. CXR demonstrated hiatal hernia,
cardiomegaly and inadequately characterized retrocardiac
opacity. CT abdomen/pelvis was obtained which demonstrated
transverse colon herniation into chest and small amount of free
fluid within pelvis and perisplenic; viability of tissue in
hernia could not be evaluated per radiology prelim read, however
surgery evaluated imaging and suspect source is most likely
intraabdominal, but patient adamantly refused surgical
intervention. She received 1g IV vanco and 500mg flagyl as well
as 25mcg fentanyl for back pain (it does not appear by
documentation that she received any additional IVFs) and is now
being admitted to the ICU for further management of hypotension.

MEDICAL HISTORY: -Rectal prolapse s/p rectocolectomy at [**Hospital3 **] now with
colostomy and choleostomy after complicated postop course
-C. diff
-Hypertension
-Hyperlipidemia
-CAD S/P 3-vessel CABG in [**2187**] (LIMA to LAD,SVG to OMI, SVG to
PDA); Myocardial Infarction in [**2194**]
-Chronic Heart Failure with preserved EF 55% with Inf HK (Echo
[**12-22**])
-Paroxismal Atrial fibrillation (not on coumadin b/c of elevated
K)
-Hypothyroidism
-Anemia
-Chronic Kidney Disease (Baseline Cr 1.8-2.2)
-Osteorathritis
-Rotator cuff arthropathy

MEDICATION ON ADMISSION: 1. Amlodipine 5 mg a day.
2. Atenolol 12.5 mg a day.
3. Atorvastatin 20 mg a day.
4. Calcitriol 0.25 mcg PO daily.
5. Furosemide 20 mg a day.
6. Levothyroxine 150 mcg.
7. Lisinopril 10 mg.
8. Aspirin 81 mg.
9. [**Doctor First Name **] 60mg PO bid.
10. Procrit [**2188**] units (? frequency)
11. Sodium bicarb 50meq IV bid (per [**Hospital **] rehab transfer log)
12. Flagyl 500mg PO tid
13. SC heparin tid
14. Tylenol prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS  Afebrile  140/86  P59  R20  99%RA
GEN: pleasant elderly female, comfortable, nontoxic. Generalized
anasarca, gradually improving.
HEENT: eomi
Neck: R IJ pulled ([**12-15**]), no evidence of infection
RESP: CTA B.
CV: RRR. no mrg.
Abd: +BS. ostomy viable, brown stool. Biliary drain in place.
Abd wound bandaged.
EXT: generalized anasarca.
NEURO: intact.

FAMILY HISTORY: Father died from pancreatic cancer and mother died from lung
cancer.

SOCIAL HISTORY: Most recently living at [**Hospital 100**] Rehab. Prior to to that, she
lived alone in [**Location 4288**] and performed all of her activities of
daily living independently. Former smoker of 1ppd for 10 years,
quit over 30years ago. No alcohol.
Other staphylococcal septicemia,Disseminated candidiasis,Septic shock,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Chronic diastolic heart failure,Acidosis,Severe sepsis,Aortocoronary bypass status,Unspecified acquired hypothyroidism,Atrial fibrillation,Old myocardial infarction,Other and unspecified hyperlipidemia,Colostomy status,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified
Staphylcocc septicem NEC,Disseminated candidiasis,Septic shock,Int inf clstrdium dfcile,Acute kidney failure NOS,Chr diastolic hrt fail,Acidosis,Severe sepsis,Aortocoronary bypass,Hypothyroidism NOS,Atrial fibrillation,Old myocardial infarct,Hyperlipidemia NEC/NOS,Colostomy status,Chronic kidney dis NOS,Anemia in chr kidney dis,Hy kid NOS w cr kid I-IV
Name:  [**Known lastname 4392**],[**Known firstname 1911**] S.                  Unit No:   [**Numeric Identifier 4393**]

Admission Date:  [**2196-12-4**]              Discharge Date:   [**2196-12-15**]

Date of Birth:  [**2111-10-16**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 128**]
Addendum:
Pt discharged to [**Hospital **] Rehab MACU.
.
Note clarification of Lasix dosing:
      40 mg po qam; 20 mg po qpm  (changed from 20mg po BID)

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 609**] for the Aged - MACU

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 131**] MD [**Last Name (un) 132**]

Completed by:[**2196-12-15**]

Admission Date:  [**2196-12-4**]              Discharge Date:   [**2196-12-15**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Hypotension

Major Surgical or Invasive Procedure:
none

History of Present Illness:
85 yo F with h/o CAD s/p CABG, chronic CHF and recent bowel
surgery presents with hypotension now tx from [**Hospital1 882**] (orig
from [**Hospital **] rehab). Per [**Hospital 100**] rehab, BP has been low for several
days, now not responsive to fluids. She was found overnight to
systolics reportedly as low as 50s; ? still mentating.
Thereafter, she was transferred to [**Hospital 882**] Hospital where she
received 4L IVFs as well as IV zosyn. Patient was alert and
oriented x3, code status was discussed with patient who stated
DNR/DNI and that she doesnt want central line even if
lifesaving. This was confirmed with her niece who is HCP, who
states that her aunt discussed with her DNR and confirms. Thus,
she was started on levophed through right PICC (placed prior to
presentation, but unclear when) and was transferred to [**Hospital1 18**] ED
for further management.
.
Of note, she has a hx of recent rectocolectomy for rectal perf
with small bowel prolapse (2 feet of bowel resected) at [**Hospital1 **] and has ostomy and choleostomy bag (placed for acalculus
cholecystitis). Post op course was complicated by wound
infection, pneumonia, c. diff and right hip cellulitis. She was
treated periop with levofloxacin, flagyl and keflex. Discharge
summary from [**Hospital3 **] recommends course of keflex to end on
[**12-2**], levofloxacin to end on [**12-4**] and flagyl to be continued
through [**12-9**]. Her transfer record only lists flagyl as
antibiotic so it is unclear whether she received full courses of
these meds.
.
In the ED here, initial vitals were T: 95.4 BP: 116/88 HR: 100
RR: 26 O2 sat: 100% (unclear amount supplemental O2). Labs were
notable for creatinine of 2.7 (CRI, but unclear baseline),
bicarb of 10, and initial venous pH of 7.08 which improved
slightly to 7.11 prior to transfer. Lactate was normal at 1.4.
Initial glucose drawn from her PICC was 546 however this was
thought d/t dextrose delivered through her PICC at [**Hospital3 **]
for hypoglycemia as repeats without intervention normalized.
Arterial line placement was attempted in ? left wrist (with
doppler) however pt extremely edemetous so attempt was
unsuccessful. UA was not sent. CXR demonstrated hiatal hernia,
cardiomegaly and inadequately characterized retrocardiac
opacity. CT abdomen/pelvis was obtained which demonstrated
transverse colon herniation into chest and small amount of free
fluid within pelvis and perisplenic; viability of tissue in
hernia could not be evaluated per radiology prelim read, however
surgery evaluated imaging and suspect source is most likely
intraabdominal, but patient adamantly refused surgical
intervention. She received 1g IV vanco and 500mg flagyl as well
as 25mcg fentanyl for back pain (it does not appear by
documentation that she received any additional IVFs) and is now
being admitted to the ICU for further management of hypotension.

.
Currently she reports generally feeling unwell, fatigued and
complains of extremely dry mouth. She endorses productive cough.
She denies significant SOB. She has no CP/palps. She endorses
low back pain which she says is chronic. She denies abdominal
pain and is unsure if her ostomy output has changed. She denies
dysuria or urinary urgency. She denies rashes. She denies focal
numbness, tingling, weakness (just marked generalized weakness).



Past Medical History:
-Rectal prolapse s/p rectocolectomy at [**Hospital3 **] now with
colostomy and choleostomy after complicated postop course
-C. diff
-Hypertension
-Hyperlipidemia
-CAD S/P 3-vessel CABG in [**2187**] (LIMA to LAD,SVG to OMI, SVG to
PDA); Myocardial Infarction in [**2194**]
-Chronic Heart Failure with preserved EF 55% with Inf HK (Echo
[**12-22**])
-Paroxismal Atrial fibrillation (not on coumadin b/c of elevated
K)
-Hypothyroidism
-Anemia
-Chronic Kidney Disease (Baseline Cr 1.8-2.2)
-Osteorathritis
-Rotator cuff arthropathy


Social History:
Most recently living at [**Hospital 100**] Rehab. Prior to to that, she
lived alone in [**Location 4288**] and performed all of her activities of
daily living independently. Former smoker of 1ppd for 10 years,
quit over 30years ago. No alcohol.

Family History:
Father died from pancreatic cancer and mother died from lung
cancer.

Physical Exam:
VS  Afebrile  140/86  P59  R20  99%RA
GEN: pleasant elderly female, comfortable, nontoxic. Generalized
anasarca, gradually improving.
HEENT: eomi
Neck: R IJ pulled ([**12-15**]), no evidence of infection
RESP: CTA B.
CV: RRR. no mrg.
Abd: +BS. ostomy viable, brown stool. Biliary drain in place.
Abd wound bandaged.
EXT: generalized anasarca.
NEURO: intact.

Pertinent Results:
On admission:

[**2196-12-4**] 06:00AM BLOOD WBC-12.8* RBC-3.08* Hgb-9.5* Hct-30.3*
MCV-99* MCH-30.8 MCHC-31.2 RDW-15.5 Plt Ct-347
[**2196-12-4**] 06:00AM BLOOD PT-37.8* PTT-46.0* INR(PT)-4.1*
[**2196-12-4**] 10:40AM BLOOD Fibrino-662* D-Dimer-1741*
[**2196-12-4**] 10:40AM BLOOD FDP-10-40*
[**2196-12-4**] 06:00AM BLOOD Glucose-546* UreaN-42* Creat-2.4* Na-124*
K-3.8 Cl-105 HCO3-9* AnGap-14
[**2196-12-4**] 06:00AM BLOOD ALT-7 AST-25 AlkPhos-61 TotBili-0.2
[**2196-12-4**] 06:00AM BLOOD Calcium-5.9* Phos-5.3* Mg-1.9
[**2196-12-4**] 10:40AM BLOOD TSH-23*
[**2196-12-4**] 01:07PM BLOOD T4-3.3* T3-54* Free T4-0.48*
[**2196-12-5**] 05:45AM BLOOD Vanco-22.3*
.
On transfer to floor:

[**2196-12-12**] 04:42AM BLOOD WBC-10.6 RBC-3.33* Hgb-10.2* Hct-30.7*
MCV-92 MCH-30.7 MCHC-33.2 RDW-15.9* Plt Ct-200
[**2196-12-12**] 04:42AM BLOOD Glucose-86 UreaN-37* Creat-1.2* Na-140
K-4.2 Cl-116* HCO3-16* AnGap-12
[**2196-12-12**] 04:42AM BLOOD Calcium-7.1* Phos-3.9 Mg-2.1
.
[**2196-12-4**] CT abd/ pelvis without contrast: IMPRESSION:
1. A long segment of transverse colon herniates through a large
diaphragmatic defect into the chest. There is no pneumatosis,
although further evaluation of the bowel for ischemic changes is
limited without the use of contrast.
2. Small amount of pelvic free fluid. Without oral contrast, it
is difficult to differentiate free fluid from decompressed colon
and small bowel.
3. Suture line with small pocket of gas and fluid adjacent that
may be post- surgical (2:58).
4. The gallbladder is not well seen, which may be contracted
around the
drain.
.
[**2196-12-11**] CXR: The patient has a right-sided central line,
unchanged in position. Portable AP film is of suboptimal
quality. There is a degree of rotation also. The patient has
prominence of the right hilum, likely vascular. Cardiomegaly,
cardiac calcifications, and probable left retrocardiac
atelectasis is unchanged. There is a degree of respiratory
unsharpness on this radiograph also. No florid evidence of
pulmonary failure.
CONCLUSION
Little change from prior radiograph.
.
.
Discharge:
[**2196-12-14**] 09:34AM BLOOD WBC-7.9 RBC-3.21* Hgb-10.0* Hct-30.5*
MCV-95 MCH-31.3 MCHC-33.0 RDW-16.5* Plt Ct-182
[**2196-12-15**] 05:55AM BLOOD PT-21.5* PTT-30.1 INR(PT)-2.0*
[**2196-12-15**] 05:55AM BLOOD Glucose-77 UreaN-30* Creat-1.1 Na-142
K-4.3 Cl-118* HCO3-17* AnGap-11
[**2196-12-14**] 09:34AM BLOOD Calcium-6.8* Phos-3.2 Mg-1.9

Brief Hospital Course:
Mrs. [**Known lastname 25588**] is an 85 year old female with a PMH significant for
CAD s/p CABG and recent hospitalization for rectal perforation
and small bowel prolapse complicated by necrosis now s/p
rectocolectomy and percutaneous chole with course complicated by
pneumonia and C.diff transferred from OSH on [**12-4**] for septic
shock secondary to fungemia and bacteremia.

# Sepsis: Patient with blood cultures from [**12-4**] positive for
coag negative Staph and [**Female First Name (un) 564**] parapsilosis.  Also with
positive C.diff from OSH in prior week and possible
intraabdominal infectious process.
- Continued PO vanco and IV flagyl for C. diff coverage
- Continued caspofungin for fungemia. Continue for 14 days from
first negative blood culture ([**2196-12-5**]).
After transfer to floor, patient remained hemodynamically stable
with gradually increasing blood pressure. No fevers, WBC
normalized.
.
# Coagulopathy:  Likely combination of nutritional deficiency in
conjunction with antimicrobial therapy altering gut flora.
Improves with intermittent po Vitamin K
.
# Acute on chronic renal failure:  Improved to baseline by time
of discharge.
.
# Anemia: stable and did not require any transfusions
.
# Rectocolectomy: Patient evaluated by surgery and wound care.
Wound care recommendations provided for abdominal wound and
ostomy.
- Fentaynl patch
- oxycodone prn dressing changes
.
# Biliary drain: scheduled to be removed in 3 weeks.
.
# PAF: Continues to appear to be in afib/flutter on telemetry.
Pt was started on metoprolol 12.5 [**Hospital1 **] for rate control and
tolerating.
.
# History of CAD s/p CABG with MI in [**2194**]. Stable, although
period of elevated biomarkers during hospitalization thought due
to demand ischemia.
- Aspirin continues to be held due to complicated recent
surgical history.  Please consider restarting Aspirin 81 mg in
approx 1 week.
.
# CHRONIC CHF: In [**11-22**], LVEF>55% without evidence of diastolic
dysfunction.
Resumed on po lasix, tolerating well.  Lasix dose increased
prior to discharge to 40 mg po q am, 20 mg po qpm.  Titrate prn
according to volume status, blood pressure, and renal function.
.
# HYPERLIPIDEMIA: Hold statin for now.  Restart in future
.

# HYPOTHYROIDISM: TSH elevated to 23. T3/T4 low.  Levothyroxine
dose was increased [**12-5**]. Recommend rechecking TSH/thyroid panel
in approx 4 weeks and titrate synthroid as needed.
.
# Code:  DNR/DNI
.
.
Per Geriatrics consult:
<br>
<b>A. Potemtial for Delirium</b>
--no evidence of delirium at this pint; 0/4 CAM criteria
   REC:  cont. non-pharm measures, avoidance of
anticholinergic/sedating Rx, daily CAM re-assesment; as per
previous recs.
<br>
<b>C. Wound </b>
--closure by secondary intention, no new Recs.
(T-tube out in 3 weeks)
<br>
<b>D. Insomnia </b>
--pt denies somnolenc w/ 25mg of trazadone
--consider trazadone 25mg PO q 8PM; re-assess at 9PM if not
somnolent give additional 25mg PRN.
<br>




Medications on Admission:
1. Amlodipine 5 mg a day.
2. Atenolol 12.5 mg a day.
3. Atorvastatin 20 mg a day.
4. Calcitriol 0.25 mcg PO daily.
5. Furosemide 20 mg a day.
6. Levothyroxine 150 mcg.
7. Lisinopril 10 mg.
8. Aspirin 81 mg.
9. [**Doctor First Name **] 60mg PO bid.
10. Procrit [**2188**] units (? frequency)
11. Sodium bicarb 50meq IV bid (per [**Hospital **] rehab transfer log)
12. Flagyl 500mg PO tid
13. SC heparin tid
14. Tylenol prn

Discharge Medications:
1. Caspofungin 70 mg Recon Soln Sig: 50 mg Recon Solns
Intravenous Q24H (every 24 hours) for through [**2196-12-20**] days.
2. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for through [**2196-12-20**] days.
3. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for
through [**2196-12-20**] days.
4. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for dressing changes.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
# Fungemia; [**Female First Name (un) **] parapsilosis
# Sepsis
# Coagulopathy
# Acute on chronic renal failure
# Anemia of chronic disease
# History of rectocolectomy; abdominal wound healing by second
intention
# History of paroxysmal afib
# Generalized anasarca
# Hypothyroidism; TSH 23, synthroid increased
# Hyperlipidemia


Discharge Condition:
Stable


Discharge Instructions:
Continue antibiotics as prescribed.
Please discontinue foley as soon as possible.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2197-3-10**] 3:40
.
Per Surgery service: discontinue biliary drain in 3 weeks.
.
Wound care as per instructions provided in "Page 1".
.
Please monitor fluid balance, renal function, and blood
pressure. Titrate lasix as needed.
{'Other staphylococcal septicemia,Disseminated candidiasis,Septic shock,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Chronic diastolic heart failure,Acidosis,Severe sepsis,Aortocoronary bypass status,Unspecified acquired hypothyroidism,Atrial fibrillation,Old myocardial infarction,Other and unspecified hyperlipidemia,Colostomy status,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}


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: Hypotension

PRESENT ILLNESS: 85 yo F with h/o CAD s/p CABG, chronic CHF and recent bowel
surgery presents with hypotension now tx from [**Hospital1 882**] (orig
from [**Hospital **] rehab). Per [**Hospital 100**] rehab, BP has been low for several
days, now not responsive to fluids. She was found overnight to
systolics reportedly as low as 50s; ? still mentating.
Thereafter, she was transferred to [**Hospital 882**] Hospital where she
received 4L IVFs as well as IV zosyn. Patient was alert and
oriented x3, code status was discussed with patient who stated
DNR/DNI and that she doesnt want central line even if
lifesaving. This was confirmed with her niece who is HCP, who
states that her aunt discussed with her DNR and confirms. Thus,
she was started on levophed through right PICC (placed prior to
presentation, but unclear when) and was transferred to [**Hospital1 18**] ED
for further management.
.
Of note, she has a hx of recent rectocolectomy for rectal perf
with small bowel prolapse (2 feet of bowel resected) at [**Hospital1 **] and has ostomy and choleostomy bag (placed for acalculus
cholecystitis). Post op course was complicated by wound
infection, pneumonia, c. diff and right hip cellulitis. She was
treated periop with levofloxacin, flagyl and keflex. Discharge
summary from [**Hospital3 **] recommends course of keflex to end on
[**12-2**], levofloxacin to end on [**12-4**] and flagyl to be continued
through [**12-9**]. Her transfer record only lists flagyl as
antibiotic so it is unclear whether she received full courses of
these meds.
.
In the ED here, initial vitals were T: 95.4 BP: 116/88 HR: 100
RR: 26 O2 sat: 100% (unclear amount supplemental O2). Labs were
notable for creatinine of 2.7 (CRI, but unclear baseline),
bicarb of 10, and initial venous pH of 7.08 which improved
slightly to 7.11 prior to transfer. Lactate was normal at 1.4.
Initial glucose drawn from her PICC was 546 however this was
thought d/t dextrose delivered through her PICC at [**Hospital3 **]
for hypoglycemia as repeats without intervention normalized.
Arterial line placement was attempted in ? left wrist (with
doppler) however pt extremely edemetous so attempt was
unsuccessful. UA was not sent. CXR demonstrated hiatal hernia,
cardiomegaly and inadequately characterized retrocardiac
opacity. CT abdomen/pelvis was obtained which demonstrated
transverse colon herniation into chest and small amount of free
fluid within pelvis and perisplenic; viability of tissue in
hernia could not be evaluated per radiology prelim read, however
surgery evaluated imaging and suspect source is most likely
intraabdominal, but patient adamantly refused surgical
intervention. She received 1g IV vanco and 500mg flagyl as well
as 25mcg fentanyl for back pain (it does not appear by
documentation that she received any additional IVFs) and is now
being admitted to the ICU for further management of hypotension.

MEDICAL HISTORY: -Rectal prolapse s/p rectocolectomy at [**Hospital3 **] now with
colostomy and choleostomy after complicated postop course
-C. diff
-Hypertension
-Hyperlipidemia
-CAD S/P 3-vessel CABG in [**2187**] (LIMA to LAD,SVG to OMI, SVG to
PDA); Myocardial Infarction in [**2194**]
-Chronic Heart Failure with preserved EF 55% with Inf HK (Echo
[**12-22**])
-Paroxismal Atrial fibrillation (not on coumadin b/c of elevated
K)
-Hypothyroidism
-Anemia
-Chronic Kidney Disease (Baseline Cr 1.8-2.2)
-Osteorathritis
-Rotator cuff arthropathy

MEDICATION ON ADMISSION: 1. Amlodipine 5 mg a day.
2. Atenolol 12.5 mg a day.
3. Atorvastatin 20 mg a day.
4. Calcitriol 0.25 mcg PO daily.
5. Furosemide 20 mg a day.
6. Levothyroxine 150 mcg.
7. Lisinopril 10 mg.
8. Aspirin 81 mg.
9. [**Doctor First Name **] 60mg PO bid.
10. Procrit [**2188**] units (? frequency)
11. Sodium bicarb 50meq IV bid (per [**Hospital **] rehab transfer log)
12. Flagyl 500mg PO tid
13. SC heparin tid
14. Tylenol prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS  Afebrile  140/86  P59  R20  99%RA
GEN: pleasant elderly female, comfortable, nontoxic. Generalized
anasarca, gradually improving.
HEENT: eomi
Neck: R IJ pulled ([**12-15**]), no evidence of infection
RESP: CTA B.
CV: RRR. no mrg.
Abd: +BS. ostomy viable, brown stool. Biliary drain in place.
Abd wound bandaged.
EXT: generalized anasarca.
NEURO: intact.

FAMILY HISTORY: Father died from pancreatic cancer and mother died from lung
cancer.

SOCIAL HISTORY: Most recently living at [**Hospital 100**] Rehab. Prior to to that, she
lived alone in [**Location 4288**] and performed all of her activities of
daily living independently. Former smoker of 1ppd for 10 years,
quit over 30years ago. No alcohol. 

### Response:
{'Other staphylococcal septicemia,Disseminated candidiasis,Septic shock,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Chronic diastolic heart failure,Acidosis,Severe sepsis,Aortocoronary bypass status,Unspecified acquired hypothyroidism,Atrial fibrillation,Old myocardial infarction,Other and unspecified hyperlipidemia,Colostomy status,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}
