CHIEF COMPLAINT: hypoglycemia and hypotension

PRESENT ILLNESS: 87 year old female with ESRD on HD Tu/Th/Sat, CAD s/p PCI LAD,
OM1 '[**91**], NSTEMI [**7-18**], DM2, RAS who presented to OSH from nursing
home with confusion and diaphoresis. Glucose noted to be in the
30's and given D50 with improvement in mental status. At OSH she
had abdominal pain and a CT Abd/Pelvis without contrast was
performed which showed no evidence of obstruction, free air, or
AAA but had significant bandemia. She was given Ceftriaxone and
flagyl and transferred to [**Hospital1 18**].
.
On transfer to [**Hospital1 18**] ED, SBP in 60's, hypoglycemic to 40's with
abdominal pain. She was guaiac (+) with dark flecks of material
on rectal. An NG lavage was done with bilious material which
cleared with 700cc NS (no blood). Surgery was consulted,
reviewed her CT scans from OSH and felt there was no acute
surgical issue. She was given Vanco x1. U/A was positive, and
patient was given 2 L NS with SBP into 120s and HR 60's. Blood
sugars improved to 140's with 1 amp D50. Blood and urine
cultures drawn. Patient was due for dialysis on the day of
admission. Renal was contact[**Name (NI) **] about missing her HD but felt no
acute need for HD. On admission, patient was unable to recall
preceding events. Does not remember why she was sent in from NH.
Denied fevers, chills, nausea, vomiting, diarrhea. Did complain
of some left-sided abdominal pain.

MEDICAL HISTORY: CAD
PCI LAD, OM1 '[**91**]
NSTEMI [**8-11**]
ESRD
Chronic HD
DM2
HTN
Dyslipidemia
Hypothyroidism
RAS
Dementia
Depression
RBBB/LAFB/Bradycardia
Staph Epidermis infection dialysis catheter [**7-18**]
OA

MEDICATION ON ADMISSION: ASA 325
Plavix
Labetalol 200 [**Hospital1 **]
clonidine 0.3mg po bid
sucralfate 1g qid
nephrocaps
FeSO4 325 qday
glyburide 5mg qday
isosorbide Mononitrate 60 qday
levothyroxine 100 qday
lipitor 80
norvasc 10 qday
sertraline 50 qday
colace/senna/dulcolax
protonix 40 qday
razadyne 4mg qhs
ativan 0.5mg qday prn
prochlorperazine 25 mg pr prn nausea
tylenol/benadryl prn
sl NTG prn
percocetq4 prn pain

ALLERGIES: Morphine / Shellfish

PHYSICAL EXAM: PHYSICAL EXAM:
VS: T: 98.0; HR: 70; BP: 130/87; RR 18; O2 95% RA
GEN: awake, alert, oriented to self and year. Thought she was @
[**Hospital1 112**].
HEENT: EOMI. MMM. OP clear. 3 cm diameter soft, mobile,
nontender mass over R occiput (?lipoma). Pt states has been
present for x4mos.
NECK: supple, no JVD.
CV: RRR. Nl S1, S2. [**3-20**] sys murmur at LUSB.
PULM: bibasilar crackles.
ABD: (+) BS. soft, ND. Minimal epigastic tenderness. No rebound
or guarding.
BACK: No CVA tenderness
EXT: Lower extremities warm, well-perfused. 1+ DP pules bilat.
No edema.

FAMILY HISTORY: NC

SOCIAL HISTORY: Widowed. Lives at Pine Manor Nursing Center. STM loss.
Has 2 grown sons. [**Name (NI) **], [**Name (NI) 122**] is power of attorney and health
care proxy for patient.
Nonsmoker. Denies alcohol use.
Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Hypotension, unspecified,Depressive disorder, not elsewhere classified,Other persistent mental disorders due to conditions classified elsewhere,Nausea with vomiting,Unspecified acquired hypothyroidism,Cardiac pacemaker in situ,Anemia of other chronic disease
Urin tract infection NOS,Hyp kid NOS w cr kid V,End stage renal disease,DMII oth nt st uncntrld,Hypotension NOS,Depressive disorder NEC,Mental disor NEC oth dis,Nausea with vomiting,Hypothyroidism NOS,Status cardiac pacemaker,Anemia-other chronic dis
Admission Date:  [**2197-11-14**]              Discharge Date:   [**2197-11-19**]


Service: MEDICINE

Allergies:
Morphine / Shellfish

Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
hypoglycemia and hypotension

Major Surgical or Invasive Procedure:
None


History of Present Illness:
87 year old female with ESRD on HD Tu/Th/Sat, CAD s/p PCI LAD,
OM1 '[**91**], NSTEMI [**7-18**], DM2, RAS who presented to OSH from nursing
home with confusion and diaphoresis. Glucose noted to be in the
30's and given D50 with improvement in mental status. At OSH she
had abdominal pain and a CT Abd/Pelvis without contrast was
performed which showed no evidence of obstruction, free air, or
AAA but had significant bandemia. She was given Ceftriaxone and
flagyl and transferred to [**Hospital1 18**].
.
On transfer to [**Hospital1 18**] ED, SBP in 60's, hypoglycemic to 40's with
abdominal pain. She was guaiac (+) with dark flecks of material
on rectal. An NG lavage was done with bilious material which
cleared with 700cc NS (no blood). Surgery was consulted,
reviewed her CT scans from OSH and felt there was no acute
surgical issue. She was given Vanco x1. U/A was positive, and
patient was given 2 L NS with SBP into 120s and HR 60's. Blood
sugars improved to 140's with 1 amp D50. Blood and urine
cultures drawn. Patient was due for dialysis on the day of
admission. Renal was contact[**Name (NI) **] about missing her HD but felt no
acute need for HD. On admission, patient was unable to recall
preceding events. Does not remember why she was sent in from NH.
Denied fevers, chills, nausea, vomiting, diarrhea. Did complain
of some left-sided abdominal pain.


Past Medical History:
CAD
PCI LAD, OM1 '[**91**]
NSTEMI [**8-11**]
ESRD
Chronic HD
DM2
HTN
Dyslipidemia
Hypothyroidism
RAS
Dementia
Depression
RBBB/LAFB/Bradycardia
Staph Epidermis infection dialysis catheter [**7-18**]
OA


Social History:
Widowed. Lives at Pine Manor Nursing Center. STM loss.
Has 2 grown sons. [**Name (NI) **], [**Name (NI) 122**] is power of attorney and health
care proxy for patient.
Nonsmoker. Denies alcohol use.


Family History:
NC

Physical Exam:

PHYSICAL EXAM:
VS: T: 98.0; HR: 70; BP: 130/87; RR 18; O2 95% RA
GEN: awake, alert, oriented to self and year. Thought she was @
[**Hospital1 112**].
HEENT: EOMI. MMM. OP clear. 3 cm diameter soft, mobile,
nontender mass over R occiput (?lipoma). Pt states has been
present for x4mos.
NECK: supple, no JVD.
CV: RRR. Nl S1, S2. [**3-20**] sys murmur at LUSB.
PULM: bibasilar crackles.
ABD: (+) BS. soft, ND. Minimal epigastic tenderness. No rebound
or guarding.
BACK: No CVA tenderness
EXT: Lower extremities warm, well-perfused. 1+ DP pules bilat.
No edema.


Pertinent Results:
[**2197-11-14**] 02:50PM   PT-15.4* PTT-68.3* INR(PT)-1.4*
[**2197-11-14**] 02:50PM   PLT SMR-NORMAL PLT COUNT-163
[**2197-11-14**] 02:50PM   HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL BURR-1+
[**2197-11-14**] 02:50PM   NEUTS-78.0* BANDS-0 LYMPHS-16.9* MONOS-3.9
EOS-1.1 BASOS-0.1
[**2197-11-14**] 02:50PM   WBC-4.9# RBC-3.20* HGB-11.0* HCT-33.6*
MCV-105* MCH-34.4* MCHC-32.8 RDW-18.0*
[**2197-11-14**] 02:50PM   CALCIUM-6.7* PHOSPHATE-7.1*# MAGNESIUM-1.4*
[**2197-11-14**] 02:50PM   CK-MB-NotDone cTropnT-0.03*
[**2197-11-14**] 02:50PM   LIPASE-12
[**2197-11-14**] 02:50PM   ALT(SGPT)-18 AST(SGOT)-22 CK(CPK)-23* ALK
PHOS-91 TOT BILI-0.2
[**2197-11-14**] 02:50PM   GLUCOSE-42* UREA N-60* CREAT-5.3*# SODIUM-139
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-19* ANION GAP-24*
[**2197-11-14**] 09:30PM   CK-MB-NotDone cTropnT-0.05*
[**2197-11-17**] 06:55AM BLOOD CK-MB-NotDone cTropnT-0.21*
[**2197-11-17**] 07:19PM BLOOD CK-MB-NotDone cTropnT-0.31*
[**2197-11-19**] 06:55AM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2197-11-19**] 06:55AM BLOOD WBC-5.1 RBC-3.76* Hgb-12.7 Hct-39.4
MCV-105* MCH-33.9* MCHC-32.3 RDW-17.5* Plt Ct-219
[**2197-11-19**] 06:55AM BLOOD Plt Ct-219
[**2197-11-19**] 06:55AM BLOOD Glucose-73 UreaN-26* Creat-5.1*# Na-140
K-3.9 Cl-100 HCO3-28 AnGap-16
[**2197-11-19**] 06:55AM BLOOD CK(CPK)-38
[**2197-11-19**] 06:55AM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2197-11-19**] 06:55AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.3
KUB: IMPRESSION: Nonspecific bowel gas pattern without evidence
of obstruction.

Brief Hospital Course:
87 year old female with ESRD on HD, CAD s/p MI and PCI, DM2, RAS
presented from OSH with hypoglycemia, hypotension, abdominal
pain, UTI, now normotensive with new epigastic pain and
persistent intermittent hypoglycemia.
--In the MICU, patient treated for UTI and question of urosepsis
with Cipro. Pyelonephritis was considered possible source of
abdominal pain. Urine cultures came back positive for
pansensitive E. coli and patient was continued on Cipro. There
was no growth in blood cultures. She was ruled out for MI with
mild troponin elevation in the setting of renal failure but flat
CKs. Patient was restarted on HD the day following admission.
Her labetolol, norvasc, clonidine, and isosorbide were held. She
had no further hypotension following initial volume
recessitation. However, she continued to be hypoglycemic at
times, thought most likely secondary to persistent blood levels
of glipizide in the setting of renal insufficiency as well as
poor po intake. Patient's po intake began to improve and prior
to transfer to the floor, BGs had improved to 70-140 [**11-16**]. MICU
stay also complicated by epigastric abdominal pain and emesis,
bilious and non-bloody. Pancreatic enzymes and LFTs were normal.
PTT and INR elevated in MICU. Heparin sc stopped. Both trended
down on repeat checks.
.
The morning after transfer, the patient was found to have
increasing nausea and vomiting that was poorly responsive to
anti-nausea meds.  As there was concern for cardiac ischemia, an
EKG was done that showed new T-wave inversions in the lateral
leads. Pt had significan troponin elevation and cardiology was
consulted.  Though the patient was likely having  mild episode
of cardiac ischemia, given the patient's significant
comorbidities and resolvation of symptoms as well as no
hemodynamic compromise, the patient was treated medically with
aspirin, plavix, beta blocker and oxygen.  The patient was
asymptomatic and had downtrending troponins.  For the remainder
of the hospital, the patient has stable vital signs and no other
complaints of chest pressure.
.
# UTI: Urine culture positive for pansensitive E coli. Was
initially treated with cipro, but with the patient's nausea and
vomiting, it was changed to levofloxacin QHD.  Pt now on day 6
of appropriate abx. Currently afebrile. CVA tenderness noted on
admission now resolved. Pyelonephritis possible cause of initial
abdominal pain but no clear evidence of that on CT abdomen from
OSH.
.
# ESRD on HD (Tues/Thurs/Sat)  Pt now on MWF schedule,
nephrology following.
- next session due [**11-20**]
- monitor electrolytes
- continue nephrocaps
.
# EPIGASTRIC TENDERNESS/VOMITING: minimal epigastric tenderness
on exam, +N/V. Unclear etiology. LFTs, pancreatic enzymes
normal. [**Month (only) 116**] be [**3-16**] to gastroparesis given h/o DM and patient
reports chronic N/V prior to admission.  Now asymptomatic, if
persists, nay need gastric emptying study.
.
# DMII: patient p/w hypoglycemia, now resolved. Was likely [**3-16**]
oral hypoglycemics in setting of worsened renal function due to
infection.  Stable finger sticks on day of discharge, pt on
insulin sliding scale
- monitor QID finger sticks
- cont to hold glyburide as was hypoglycemic
- RISS if needed
.
# HTN: Labetalol, clonidine, and norvasc held on admission to
MICU given hypotension. Restarted prior to discharge.
.
# CAD: stable, denies CP. slight troponin elevation likely [**3-16**]
renal failure, but slight elevation likely due to mild ischemic
event, managed medically as pt has multiple comorbities. CK/MB
negative.
- continue ASA, Plavix, statin
.
# Right hip pain- pt given history of falling prior to
admission. X ray on admission showed no signs of occult fracture
though small linear lucency on x ray.  Pt with large hematoma on
hip that precludes anticoagulation.
.
# HYPOTHYROIDISM: continue levothyroxine
.
# DEPRESSION: continue sertraline
.
# CODE: DNR/DNI confirmed with patient at the time of transfer


Medications on Admission:
ASA 325
Plavix
Labetalol 200 [**Hospital1 **]
clonidine 0.3mg po bid
sucralfate 1g qid
nephrocaps
FeSO4 325 qday
glyburide 5mg qday
isosorbide Mononitrate 60 qday
levothyroxine 100 qday
lipitor 80
norvasc 10 qday
sertraline 50 qday
colace/senna/dulcolax
protonix 40 qday
razadyne 4mg qhs
ativan 0.5mg qday prn
prochlorperazine 25 mg pr prn nausea
tylenol/benadryl prn
sl NTG prn
percocetq4 prn pain


Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: Two Hundred
Fifty (250) mg Intravenous  Q48H (every 48 hours): please give
at dialysis.
15. Imdur 60 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
16. Razadyne 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
18. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
19. Labetalol 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
20. Insulin Regular Human 100 unit/mL Solution Sig: see sliding
scale  Injection ASDIR (AS DIRECTED): Check glucose QID, if < 70
give [**2-13**] amp D 50 and [**Name8 (MD) 138**] MD, if 70-150 no insulin, if 151-200
give 2 U, if 201-250 give 4 U, if 300-350 give 6 U, if 351-400
give 8 U, if >400, give 10 U and [**Name8 (MD) 138**] MD.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 25499**] Manor - [**Location (un) 47**]

Discharge Diagnosis:
Urinary tract infection, hypoglycemia


Discharge Condition:
Stable; tolerating PO intake and afebrile


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Please take your medications as directed
Please keep your follow-up appointments


Followup Instructions:
Please make an appointment with [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 69239**] for
the next 7-10 days.
Please return to your normal hemodialysis schedule
{'Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Hypotension, unspecified,Depressive disorder, not elsewhere classified,Other persistent mental disorders due to conditions classified elsewhere,Nausea with vomiting,Unspecified acquired hypothyroidism,Cardiac pacemaker in situ,Anemia of other chronic disease'}


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: hypoglycemia and hypotension

PRESENT ILLNESS: 87 year old female with ESRD on HD Tu/Th/Sat, CAD s/p PCI LAD,
OM1 '[**91**], NSTEMI [**7-18**], DM2, RAS who presented to OSH from nursing
home with confusion and diaphoresis. Glucose noted to be in the
30's and given D50 with improvement in mental status. At OSH she
had abdominal pain and a CT Abd/Pelvis without contrast was
performed which showed no evidence of obstruction, free air, or
AAA but had significant bandemia. She was given Ceftriaxone and
flagyl and transferred to [**Hospital1 18**].
.
On transfer to [**Hospital1 18**] ED, SBP in 60's, hypoglycemic to 40's with
abdominal pain. She was guaiac (+) with dark flecks of material
on rectal. An NG lavage was done with bilious material which
cleared with 700cc NS (no blood). Surgery was consulted,
reviewed her CT scans from OSH and felt there was no acute
surgical issue. She was given Vanco x1. U/A was positive, and
patient was given 2 L NS with SBP into 120s and HR 60's. Blood
sugars improved to 140's with 1 amp D50. Blood and urine
cultures drawn. Patient was due for dialysis on the day of
admission. Renal was contact[**Name (NI) **] about missing her HD but felt no
acute need for HD. On admission, patient was unable to recall
preceding events. Does not remember why she was sent in from NH.
Denied fevers, chills, nausea, vomiting, diarrhea. Did complain
of some left-sided abdominal pain.

MEDICAL HISTORY: CAD
PCI LAD, OM1 '[**91**]
NSTEMI [**8-11**]
ESRD
Chronic HD
DM2
HTN
Dyslipidemia
Hypothyroidism
RAS
Dementia
Depression
RBBB/LAFB/Bradycardia
Staph Epidermis infection dialysis catheter [**7-18**]
OA

MEDICATION ON ADMISSION: ASA 325
Plavix
Labetalol 200 [**Hospital1 **]
clonidine 0.3mg po bid
sucralfate 1g qid
nephrocaps
FeSO4 325 qday
glyburide 5mg qday
isosorbide Mononitrate 60 qday
levothyroxine 100 qday
lipitor 80
norvasc 10 qday
sertraline 50 qday
colace/senna/dulcolax
protonix 40 qday
razadyne 4mg qhs
ativan 0.5mg qday prn
prochlorperazine 25 mg pr prn nausea
tylenol/benadryl prn
sl NTG prn
percocetq4 prn pain

ALLERGIES: Morphine / Shellfish

PHYSICAL EXAM: PHYSICAL EXAM:
VS: T: 98.0; HR: 70; BP: 130/87; RR 18; O2 95% RA
GEN: awake, alert, oriented to self and year. Thought she was @
[**Hospital1 112**].
HEENT: EOMI. MMM. OP clear. 3 cm diameter soft, mobile,
nontender mass over R occiput (?lipoma). Pt states has been
present for x4mos.
NECK: supple, no JVD.
CV: RRR. Nl S1, S2. [**3-20**] sys murmur at LUSB.
PULM: bibasilar crackles.
ABD: (+) BS. soft, ND. Minimal epigastic tenderness. No rebound
or guarding.
BACK: No CVA tenderness
EXT: Lower extremities warm, well-perfused. 1+ DP pules bilat.
No edema.

FAMILY HISTORY: NC

SOCIAL HISTORY: Widowed. Lives at Pine Manor Nursing Center. STM loss.
Has 2 grown sons. [**Name (NI) **], [**Name (NI) 122**] is power of attorney and health
care proxy for patient.
Nonsmoker. Denies alcohol use. 

### Response:
{'Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Hypotension, unspecified,Depressive disorder, not elsewhere classified,Other persistent mental disorders due to conditions classified elsewhere,Nausea with vomiting,Unspecified acquired hypothyroidism,Cardiac pacemaker in situ,Anemia of other chronic disease'}
