CHIEF COMPLAINT: hypotension, nausea, vomitting

PRESENT ILLNESS: This is a [**Age over 90 **] yo male with HTN, CHF, CAD, advanced dementia, who
initially presented on [**2-6**] with a 2 day hx of diarrhea,
vomiting, and cough while at [**Hospital 100**] Rehab. Pt is non-verbal thus
history per records. Multiple others wsere sick at [**Hospital 100**] rehab.
Pt was noted to be hypotensive 80/60 at [**Hospital1 100**] and transferred
to [**Hospital1 18**].
.
In the [**Name (NI) **], pt was febrile to 101.8, had BP of 80/60, HR 110's,
and RR 40 on arrival. His BP improved after 4L NS. He was found
to have dirty UA, possible infiltrate on CXR, and was given
vanc/levo/flagyl.
.
In the MICU he was given fluids and continued on above
antibiotics. He did not require intubation or pressors(He is
DNR/DNI). Of note he was also found to have a creatinine of 4.6.
He had a Hct drop from 37.5 to 21.8, but then on recheck was 31.
However does have guaiac + brown stool.

MEDICAL HISTORY: Anemia (baseline hct 33 in '[**00**])
CHF (unkwnon EF)
CAD
h/o MRSA UTI
h/o DVT LLE (was on coumadin, stopped [**11-14**])
advanced dementia (per son, pt opens eyes but mostly non-verbal)

MEDICATION ON ADMISSION: Acetaminophen 325-650 mg PO/PR Q4-6H:PRN
Levofloxacin 250 mg IV DAILY
Albuterol 0.083% Neb Q6H:PRN
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Or
Artificial Tears PRN
Protonix 40mg qday
Erythromycin 0.5% Ophth Oint OD QID
Heparin 5000 UNIT SC TID
Vanco 1gm IV Q48hrs
Ipratropium Bromide Neb Q6H

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 99 BP 118/77 HR 86 RR 20 O2sat 99% 5L NC
Gen: non-verbal, but responsive to painful stimuli, mouth open
HEENT: PERRL. OP dry.
Neck: No visible JVD
Cardio: distant heart sounds, RRR
Resp: decreased BS throughout, scattered rhonchi
Abd: soft, nt, nd, +BS
Ext: no edema. Severe contractures of bilateral upper ext.
Neuro: non-verbal. Respons to painful stimuli. Does not open
eyes to commands.

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at [**Hospital 100**] Rehab. No smoking or EtOH. Family very involved
with care.
Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Pressure ulcer, lower back,Acute on chronic systolic heart failure,Hyperosmolality and/or hypernatremia,Chronic kidney disease, unspecified,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Severe sepsis,Rheumatoid arthritis,Iron deficiency anemia, unspecified,Other and unspecified noninfectious gastroenteritis and colitis,Other persistent mental disorders due to conditions classified elsewhere,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Conjunctivitis, unspecified
Septicemia NOS,Food/vomit pneumonitis,Subendo infarct, initial,Pressure ulcer, low back,Ac on chr syst hrt fail,Hyperosmolality,Chronic kidney dis NOS,Acute kidney failure NOS,Urin tract infection NOS,Severe sepsis,Rheumatoid arthritis,Iron defic anemia NOS,Noninf gastroenterit NEC,Mental disor NEC oth dis,Hy kid NOS w cr kid I-IV,Conjunctivitis NOS
Admission Date:  [**2103-2-6**]              Discharge Date:   [**2103-2-14**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypotension, nausea, vomitting

Major Surgical or Invasive Procedure:
none.

History of Present Illness:
This is a [**Age over 90 **] yo male with HTN, CHF, CAD, advanced dementia, who
initially presented on [**2-6**] with a 2 day hx of diarrhea,
vomiting, and cough while at [**Hospital 100**] Rehab. Pt is non-verbal thus
history per records. Multiple others wsere sick at [**Hospital 100**] rehab.
Pt was noted to be hypotensive 80/60 at [**Hospital1 100**] and transferred
to [**Hospital1 18**].
.
In the [**Name (NI) **], pt was febrile to 101.8, had BP of 80/60, HR 110's,
and RR 40 on arrival. His BP improved after 4L NS. He was found
to have dirty UA, possible infiltrate on CXR, and was given
vanc/levo/flagyl.
.
In the MICU he was given fluids and continued on above
antibiotics. He did not require intubation or pressors(He is
DNR/DNI). Of note he was also found to have a creatinine of 4.6.
He had a Hct drop from 37.5 to 21.8, but then on recheck was 31.
However does have guaiac + brown stool.

Past Medical History:
Anemia (baseline hct 33 in '[**00**])
CHF (unkwnon EF)
CAD
h/o MRSA UTI
h/o DVT LLE (was on coumadin, stopped [**11-14**])
advanced dementia (per son, pt opens eyes but mostly non-verbal)

RA
CRI (creat 2.0 on [**10-15**])
Psoriasis


Social History:
Lives at [**Hospital 100**] Rehab. No smoking or EtOH. Family very involved
with care.

Family History:
NC

Physical Exam:
Vitals: T 99 BP 118/77 HR 86 RR 20 O2sat 99% 5L NC
Gen: non-verbal, but responsive to painful stimuli, mouth open
HEENT: PERRL. OP dry.
Neck: No visible JVD
Cardio: distant heart sounds, RRR
Resp: decreased BS throughout, scattered rhonchi
Abd: soft, nt, nd, +BS
Ext: no edema. Severe contractures of bilateral upper ext.
Neuro: non-verbal. Respons to painful stimuli. Does not open
eyes to commands.


Pertinent Results:
[**2103-2-6**] 06:09AM   PLT SMR-NORMAL PLT COUNT-319
[**2103-2-6**] 06:09AM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ELLIPTOCY-1+
[**2103-2-6**] 06:09AM   WBC-16.6*# RBC-4.38* HGB-12.1* HCT-37.5*
MCV-86 MCH-27.6 MCHC-32.3 RDW-14.4
[**2103-2-6**] 06:09AM   ALBUMIN-3.1* CALCIUM-8.7 PHOSPHATE-4.3
MAGNESIUM-2.5
[**2103-2-6**] 06:09AM   CK-MB-5 cTropnT-0.26*
[**2103-2-6**] 06:09AM   LIPASE-14
[**2103-2-6**] 06:09AM   ALT(SGPT)-14 AST(SGOT)-23 LD(LDH)-297*
CK(CPK)-428* ALK PHOS-84 AMYLASE-301* TOT BILI-0.3
[**2103-2-6**] 06:09AM   estGFR-Using this
[**2103-2-6**] 06:09AM   GLUCOSE-152* UREA N-84* CREAT-4.4*#
SODIUM-150* POTASSIUM-5.7* CHLORIDE-114* TOTAL CO2-18* ANION
GAP-24*
[**2103-2-6**] 06:19AM   LACTATE-2.4*
[**2103-2-6**] 06:30AM URINE  RBC-[**5-20**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2103-2-6**] 06:30AM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2103-2-6**] 06:30AM URINE  COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015
[**2103-2-6**] 07:00PM   PLT COUNT-163
[**2103-2-6**] 07:00PM   WBC-7.1# RBC-2.51*# HGB-7.0*# HCT-21.8*#
MCV-87 MCH-28.0 MCHC-32.2 RDW-14.5
[**2103-2-6**] 07:00PM   CK-MB-5 cTropnT-0.13*
[**2103-2-6**] 07:00PM   LIPASE-8
[**2103-2-6**] 07:00PM   ALT(SGPT)-8 AST(SGOT)-15 CK(CPK)-259* ALK
PHOS-44 AMYLASE-183* TOT BILI-0.2
[**2103-2-6**] 08:08PM   LACTATE-1.6
[**2103-2-6**] 09:24PM   FIBRINOGE-598*
[**2103-2-6**] 09:24PM   PLT SMR-NORMAL PLT COUNT-193
[**2103-2-6**] 09:24PM   PLT SMR-NORMAL PLT COUNT-202
[**2103-2-6**] 09:24PM   HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
ELLIPTOCY-1+
[**2103-2-6**] 09:24PM   HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2103-2-6**] 09:24PM   NEUTS-64 BANDS-25* LYMPHS-8* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2103-2-6**] 09:24PM   WBC-10.0 RBC-3.66*# HGB-10.5*# HCT-31.0*#
MCV-85 MCH-28.7 MCHC-33.9 RDW-14.4
[**2103-2-6**] 09:24PM   WBC-8.8 RBC-3.49*# HGB-9.8*# HCT-30.1*#
MCV-86 MCH-28.2 MCHC-32.6 RDW-14.5
[**2103-2-6**] 09:24PM URINE  OSMOLAL-438
[**2103-2-6**] 09:24PM   ALT(SGPT)-12 AST(SGOT)-20 LD(LDH)-243
CK(CPK)-559* ALK PHOS-67 AMYLASE-240* TOT BILI-0.2
[**2103-2-6**] 09:24PM   GLUCOSE-115* UREA N-92* CREAT-4.3*#
SODIUM-152* POTASSIUM-5.1 CHLORIDE-119* TOTAL CO2-18* ANION
GAP-20
.
CXR:
1. Possible early left lower lung zone infiltrate.

2. Cardiomegaly.
[**2103-2-8**] 03:00AM BLOOD WBC-5.9 RBC-3.04* Hgb-8.6* Hct-25.8*
MCV-85 MCH-28.1 MCHC-33.1 RDW-14.5 Plt Ct-189
[**2103-2-6**] 09:24PM BLOOD Neuts-57 Bands-31* Lymphs-11* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2103-2-8**] 03:00AM BLOOD Glucose-177* UreaN-96* Creat-4.6* Na-150*
K-3.9 Cl-118* HCO3-19* AnGap-17
[**2103-2-7**] 02:24AM BLOOD ALT-13 AST-24 LD(LDH)-228 AlkPhos-64
Amylase-187* TotBili-0.2
[**2103-2-7**] 02:24AM BLOOD Lipase-11
[**2103-2-8**] 03:00AM BLOOD Calcium-7.5* Phos-3.2 Mg-2.1
[**2103-2-6**] 09:24PM BLOOD calTIBC-157* Hapto-328* Ferritn-351
TRF-121*

Brief Hospital Course:
This is a [**Age over 90 **] yo m with HTN, CHF, CAD, p/w N/V/D found to be
septic.
.
1) Sepsis: The patient was admitted with leukoctyosis, lactate
elevation to 2.4 and fever. Initially there was question of PNA,
thought to be aspiration given his h/o vomiting and the patient
had a dirty urine with > 50 leukocytes. The patient was found to
be profoundly volume depleted and was resuscitated with IVF.
He was empirically started on Vanc/levo/flagyl for broad
coverage, including MRSA given pt's history, aspiration
pneumonia, and likely UTI. Legionella antigen was negative.
Blood, sputum, and urine cultures were sent. After the
aforementioned interventions, the patient's BP normalized and
the patient quicklyl defervesced. After 48 hrs, blood and sputum
cultures were negative but urine culture grew out coag positive
staph aureus. Sensitivities are pending. Given the patient has
not spiked in house, and has no other clinical signs of PNA,
coverage for asp PNA was stopped. We will continue the
vancomycin for possible MRSA in his urine. This should be
continued for ten days or until sensitivities suggest otherwise.
C.diff is also pending upon discharge. This will also need to be
followed up and flagyl restarted if positive.
.
2) conjunctivitis: The patient was noted to have erythemetous
conjunctiva L>R and was started on erythromycin eye drops. This
should be continued for a seven day course.
.
3) Anemia: The patient has a normocytic anemia with a HCT today
of 25.8. The patient was found to have guaiac + stools. However,
the family does not with to pursue any diagnostic procedures and
would like to minimize any interventions. Therefore, we did not
work the anemia up any further.
.
4) CAD/CHF: After aggressive fluid resuscitation the patient
briefly experienced pulmonary edema and was put on a NRB with
sats in the mid 90's. He was given lasix and was taken of the
NRB mask and transitioned to 6L 02 via NC with SaO2 100%. The
patient's aspirin was discontinued as his stool was found to be
guaiac positive and his HCT was 25.8 with a baseline crit in
high 20s low 30s.
.
5) HTN: Initially the pt's Toprol and amlodapine were stopped
given his hypotension. However, the patient was given 5mg Toprol
IV prn for hypertension as he was unable to take PO medications
and the family did not want an NGT placed. The amlodapine was
not continued. The patient was discharged on no BP meds.
However, metoprolol IV may be needed in the future for blood
pressure control as the patient continues to recover from his
infections.
.
6) Elevated trop: The patient's CK's and Trops were elevated
upon admission, but MBs were negative. EKG did not show evidence
of ischemia. Therefore, the elevated trops were likely secondary
to increased demand in the setting of renal failure and severe
hypotension.
.
7) Acute on chronic renal failure: The patient's most recent Cr
prior to admission was 1.3 in [**2092**]. He was initially thought to
be pre-renal in setting of sepsis with FENa<1%. However, his cr
did not improve s/p aggressive hydration. Renal USN neg for
hydronephrosis. Therefore, it was thought that the pt may be at
a new baseline.
.
8) Hypernatremia: The patient came in with elevated Na level
which was attributed to a free water deficit in the setting of
N/V and diarrhea and decreased PO intake. He had a 3.9L water
deficit on admission. He was volume resuscitated with normal
saline and then started on D5W at 150cc/hr for about 12 hrs. The
family refused an NGT to deliver free water boluses. Therefore,
the patient was continued on D5W with the rate increased to
200cc/hr.
.
Code: DNR/DNI


Medications on Admission:
Acetaminophen 325-650 mg PO/PR Q4-6H:PRN
Levofloxacin 250 mg IV DAILY
Albuterol 0.083% Neb Q6H:PRN
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Or
Artificial Tears PRN
Protonix 40mg qday
Erythromycin 0.5% Ophth Oint OD QID
Heparin 5000 UNIT SC TID
Vanco 1gm IV Q48hrs
Ipratropium Bromide Neb Q6H


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-12**] Tablet,
Delayed Release (E.C.)s PO once a day as needed for
constipation.
3. CALCIUM 500+D 500-125 mg-unit Tablet Sig: One (1) Tablet PO
three times a day.
4. topical creams
please take the following creams as previously prescribed:
Sebulex topical
lac-hydrin topical [**Hospital1 **] prn
5. Senna 8.6 mg Capsule Sig: [**12-12**] Capsules PO at bedtime.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
8. Erythromycin 5 mg/g Ointment Sig: Two (2) drops Ophthalmic
QID (4 times a day) for 7 days.
9. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous Q48hr for 7 days.
10. 5% dextrose in water  Sig: 200 ml/hour  continuous: continue
for goal sodium <143, may adjust rate prn.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 **] Center

Discharge Diagnosis:
UTI
gastroenteritis
conjunctivitis
severe dehydration secondary to gastroenteritis


Discharge Condition:
Good.


Discharge Instructions:
Please return to the ER if you experience increasing fevers,
difficulty breathing or any symptoms that concern you.
.
Please follow up on blood and stool cultures and sensitivities
of urine culture results.

Followup Instructions:
Please follow up with your PCP upon discharge. Please have him
follow up on all culture data.





Name:  [**Known lastname 2549**],[**Known firstname **]                 Unit No:   [**Numeric Identifier 2550**]

Admission Date:  [**2103-2-6**]              Discharge Date:   [**2103-2-14**]

Date of Birth:  [**2011-4-11**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2551**]
Addendum:
the pt. was transferred from the ICU to the floor for further
treatment of hypernatremia and PNA. Pt. was treated with free
water repletion, his sodium improved somewhat with free water.
We continued vancomycin, flagyl, and levaquin. His fever and WBC
count improved. Speech and swallow eval deemed pt. to be an
aspiration risk, however, the family wanted the patient fed for
comfort reasons. They understood and accepted the risks of
aspiration. With feeding, the pt. did seem to aspirate and had
copious secretions and cough. on [**2103-2-13**] he again became febrile.
A subsequent CXR showed increased infiltrates in the LLL,
probably [**1-12**] to aspiration. After discussions between the
attending and family, it was determined that goals of care for
the patient would be made comfort measures. The pt. was
transferred back to [**Hospital **] rehab for continued care. The current
levaquin treatment was to be continued per the families wishes.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 **] Center

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2552**] MD [**MD Number(2) 2553**]

Completed by:[**2103-2-14**]
{'Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Pressure ulcer, lower back,Acute on chronic systolic heart failure,Hyperosmolality and/or hypernatremia,Chronic kidney disease, unspecified,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Severe sepsis,Rheumatoid arthritis,Iron deficiency anemia, unspecified,Other and unspecified noninfectious gastroenteritis and colitis,Other persistent mental disorders due to conditions classified elsewhere,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Conjunctivitis, 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, nausea, vomitting

PRESENT ILLNESS: This is a [**Age over 90 **] yo male with HTN, CHF, CAD, advanced dementia, who
initially presented on [**2-6**] with a 2 day hx of diarrhea,
vomiting, and cough while at [**Hospital 100**] Rehab. Pt is non-verbal thus
history per records. Multiple others wsere sick at [**Hospital 100**] rehab.
Pt was noted to be hypotensive 80/60 at [**Hospital1 100**] and transferred
to [**Hospital1 18**].
.
In the [**Name (NI) **], pt was febrile to 101.8, had BP of 80/60, HR 110's,
and RR 40 on arrival. His BP improved after 4L NS. He was found
to have dirty UA, possible infiltrate on CXR, and was given
vanc/levo/flagyl.
.
In the MICU he was given fluids and continued on above
antibiotics. He did not require intubation or pressors(He is
DNR/DNI). Of note he was also found to have a creatinine of 4.6.
He had a Hct drop from 37.5 to 21.8, but then on recheck was 31.
However does have guaiac + brown stool.

MEDICAL HISTORY: Anemia (baseline hct 33 in '[**00**])
CHF (unkwnon EF)
CAD
h/o MRSA UTI
h/o DVT LLE (was on coumadin, stopped [**11-14**])
advanced dementia (per son, pt opens eyes but mostly non-verbal)

MEDICATION ON ADMISSION: Acetaminophen 325-650 mg PO/PR Q4-6H:PRN
Levofloxacin 250 mg IV DAILY
Albuterol 0.083% Neb Q6H:PRN
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Or
Artificial Tears PRN
Protonix 40mg qday
Erythromycin 0.5% Ophth Oint OD QID
Heparin 5000 UNIT SC TID
Vanco 1gm IV Q48hrs
Ipratropium Bromide Neb Q6H

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 99 BP 118/77 HR 86 RR 20 O2sat 99% 5L NC
Gen: non-verbal, but responsive to painful stimuli, mouth open
HEENT: PERRL. OP dry.
Neck: No visible JVD
Cardio: distant heart sounds, RRR
Resp: decreased BS throughout, scattered rhonchi
Abd: soft, nt, nd, +BS
Ext: no edema. Severe contractures of bilateral upper ext.
Neuro: non-verbal. Respons to painful stimuli. Does not open
eyes to commands.

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at [**Hospital 100**] Rehab. No smoking or EtOH. Family very involved
with care. 

### Response:
{'Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Subendocardial infarction, initial episode of care,Pressure ulcer, lower back,Acute on chronic systolic heart failure,Hyperosmolality and/or hypernatremia,Chronic kidney disease, unspecified,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Severe sepsis,Rheumatoid arthritis,Iron deficiency anemia, unspecified,Other and unspecified noninfectious gastroenteritis and colitis,Other persistent mental disorders due to conditions classified elsewhere,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Conjunctivitis, unspecified'}
