CHIEF COMPLAINT: Hypotension, nausea, vomiting.

PRESENT ILLNESS: The pt. is an 86 year-old male with history of
panhypopituitarism (s/p resection for pituitary adenoma in [**2158**])
who presented with hypotension, nausea and vomiting.  He was
recently discharged from [**Hospital1 18**] to [**Hospital3 **] on two days
PTA after a two and a half week stay for an inferior STEMI on
[**2167-1-28**] complicated by cardiogenic shock, ventilator-associated
pneumonia, and a small retroperitoneal bleed. Per his daughter,
his [**Name2 (NI) **] pressure was in the 70s to 90s systolic while at
[**Hospital1 **]. He was transferred to [**Hospital1 18**] ED for evaluation of
hypotension.

MEDICAL HISTORY: -inferior STEMI [**1-17**] with cath, stent placement x 4 (2LCMA,
1LCx, 1 -LAD), c/b cardiogenic shock. CK peak 4000, Tp peak 12
-ventilator associated pneumonia (serratia marascens) [**1-17**]
-CHF, EF 40-45% on echo [**1-17**]
-hyperlipidemia
-HTN
-Pan-hypopituitarism s/p pituitary adenoma resection [**2158**]
-H/O Tachy-Brady syndrome s/p pacemaker placement in [**2154**]
-SIADH
-gastroesophageal reflux disease

MEDICATION ON ADMISSION: Aspirin EC 325 mg PO DAILY
Clopidogrel Bisulfate 75 mg PO DAILY
Atorvastatin Calcium 80 PO DAILY
Levothyroxine Sodium 75 mcg PO DAILY
Senna 8.6 mg PO BID prn
Acetaminophen 325 mg Tablet PO Q4-6H
Docusate Sodium 100 mg PO BID
Milk of Magnesia 311 mg Tablet PO Q6H as needed for heartburn.
Atacand 4 mg PO QD
Spironolactone 25 mg PO DAILY
Lactulose 30 ML PO TID PRN constipation
Amiodarone HCl 300 mg PO DAILY for 9 days: then start 200 mg per
day for 3 more weeks, then off.
Toprol XL 12.5 mg PO DAILY
Prednisone 20 mg PO DAILY for 5 days: Then 10 mg for 7 days then
5 mg ongoing.
Potassium Chloride 30 mEq PO DAILY
Furosemide 40 mg PO DAILY
Guaifenesin 5-10 MLs PO Q6H as needed for cough for 7 days

ALLERGIES: Norvasc

PHYSICAL EXAM: Vitals: T: 97.8F BP: 130/70 (90/50-170/110) P: 80 R: 14 SaO2:
97% on 4L O2 NC
Gen: Lying in bed, NAD, talkative and cooperative
HEENT: PERRL, OP clear, MMM, small white areas on tongue, soft
palate
Neck: no JVD
CV: RRR, nl S1s2 distant, soft II/VI HSM at LSB without apparent
radiation
Resp: CTA bilaterally
Abd: slight tenderness to palpation in suprapubic area. No
rebound, no guarding. Nondistended. Normoactive bowel sounds. No
massess or HSM appreciated.
Ext: 2+ bilateral UE edema, 1+ bilateral LE edema, warm, well
perfused bilaterally
Skin: scattered ecchymoses over extremities and trunk

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The pt. lived at home with his wife before last admission in
[**Month (only) 956**] at which time he was discharged to rehab.  He denied
h/o tobacco, alcohol or illicit drug use.
Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve insufficiency,Candidiasis of mouth,Other disorders of neurohypophysis,Unspecified essential hypertension,Other abnormal blood chemistry,Coronary atherosclerosis of native coronary artery,Esophageal reflux,Other and unspecified hyperlipidemia,Acute myocardial infarction of other inferior wall, subsequent episode of care,Adrenal cortical steroids causing adverse effects in therapeutic use
Rheumatic heart failure,Mitral/aortic val insuff,Thrush,Neurohypophysis dis NEC,Hypertension NOS,Abn blood chemistry NEC,Crnry athrscl natve vssl,Esophageal reflux,Hyperlipidemia NEC/NOS,AMI inferior wall,subseq,Adv eff corticosteroids
Admission Date:  [**2167-2-15**]              Discharge Date:   [**2167-2-20**]


Service: MEDICINE

Allergies:
Norvasc

Attending:[**First Name3 (LF) 317**]
Chief Complaint:
Hypotension, nausea, vomiting.

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
The pt. is an 86 year-old male with history of
panhypopituitarism (s/p resection for pituitary adenoma in [**2158**])
who presented with hypotension, nausea and vomiting.  He was
recently discharged from [**Hospital1 18**] to [**Hospital3 **] on two days
PTA after a two and a half week stay for an inferior STEMI on
[**2167-1-28**] complicated by cardiogenic shock, ventilator-associated
pneumonia, and a small retroperitoneal bleed. Per his daughter,
his [**Name2 (NI) **] pressure was in the 70s to 90s systolic while at
[**Hospital1 **]. He was transferred to [**Hospital1 18**] ED for evaluation of
hypotension.

On arrival, the pt. complained only of slight abdominal pain and
nausea, and said he had a poor appetite over the few days PTA.
He denied [**Hospital1 5162**], chills, respiratory problems, diarrhea. [**Name2 (NI) **] has
had constipation recently but no BRBPR.

In the ED, he had a nadir BP of 72/48 but averaged 90/60. He
received 3.5 liters of fluid.  A CXR was performed which was not
suggestive of cardiac failure, an abdominal CT was normal. The
surgery service was consulted and recommended no intervention
for abdominal pain. He was given zosyn, vanco, dexamethasone,
and hydrocortisone. His troponins were elevated. He had ST
segment changes on an EKG, but cardiology was consulted and not
concerned. He was transferred to the MICU for hypotension.
During his one day MICU stay, the pt. was hydrated with 4 liters
of normal saline and placed on stress-dose steroids.

Past Medical History:
-inferior STEMI [**1-17**] with cath, stent placement x 4 (2LCMA,
1LCx, 1 -LAD), c/b cardiogenic shock. CK peak 4000, Tp peak 12
-ventilator associated pneumonia (serratia marascens) [**1-17**]
-CHF, EF 40-45% on echo [**1-17**]
-hyperlipidemia
-HTN
-Pan-hypopituitarism s/p pituitary adenoma resection [**2158**]
-H/O Tachy-Brady syndrome s/p pacemaker placement in [**2154**]
-SIADH
-gastroesophageal reflux disease

Social History:
The pt. lived at home with his wife before last admission in
[**Month (only) 956**] at which time he was discharged to rehab.  He denied
h/o tobacco, alcohol or illicit drug use.

Family History:
Noncontributory.

Physical Exam:
Vitals: T: 97.8F BP: 130/70 (90/50-170/110) P: 80 R: 14 SaO2:
97% on 4L O2 NC
Gen: Lying in bed, NAD, talkative and cooperative
HEENT: PERRL, OP clear, MMM, small white areas on tongue, soft
palate
Neck: no JVD
CV: RRR, nl S1s2 distant, soft II/VI HSM at LSB without apparent
radiation
Resp: CTA bilaterally
Abd: slight tenderness to palpation in suprapubic area. No
rebound, no guarding. Nondistended. Normoactive bowel sounds. No
massess or HSM appreciated.
Ext: 2+ bilateral UE edema, 1+ bilateral LE edema, warm, well
perfused bilaterally
Skin: scattered ecchymoses over extremities and trunk


Pertinent Results:
[**2167-2-15**] Radiology CT ABDOMEN W/CONTRAST
IMPRESSION:
1) No definite reason for patient's pain identified.
2) Interval resolution of right pleural effusion and interval
decrease of the left pleural effusion.
3) Interval decrease of the intramuscular hematomas.
4) Duodenum diverticulum containing fecalized material is
unchanged when com compared to previous study.

[**2167-2-14**] Radiology CHEST (PORTABLE AP)
IMPRESSION: Left retrocardiac opacity was seen previously and
could represent atelectasis or pneumonia.

TTE [**2167-2-16**]:
Conclusions:
Technically difficult study.
1. The left atrium is normal in size. The left atrium is
elongated.
2.The right atrium is moderately dilated.
3.There is mild symmetric left ventricular hypertrophy. The left
ventricular  cavity size is normal. There is mild regional left
ventricular systolic  dysfunction. Overall left ventricular
systolic function is mildly depressed  (LVEF=45-50%). Resting
regional wall motion abnormalities include inferior and  basal
inferolateral hypokinesis.
4.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
5.The aortic root is mildly dilated. The ascending aorta is
mildly dilated.
6.The aortic valve leaflets (3) appear structurally normal with
good leaflet  excursion. Mild (1+) aortic regurgitation is seen.

7.The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-14**]+)
mitral regurgitation is seen.
8.The estimated pulmonary artery systolic pressure is normal.
9.There is no pericardial effusion.
10. There is an echogenic density in the right ventricle
consistent with a  central line.

Compared with the findings of the prior report (tape unavailable
for review)  of [**2167-2-10**], by description in the limited views
obtained in this study, suspect  the whole inferior wall is now
hypokinetic.

Labs on admission:

[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] WBC-12.1* RBC-4.22* Hgb-12.7* Hct-37.4*
MCV-89 MCH-30.1 MCHC-34.0 RDW-14.0 Plt Ct-303
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] Neuts-92.2* Bands-0 Lymphs-5.5* Monos-2.3
Eos-0 Baso-0
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] PT-12.8 PTT-26.2 INR(PT)-1.0
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] Glucose-125* UreaN-35* Creat-1.0 Na-129*
K-4.8 Cl-95* HCO3-25 AnGap-14
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] ALT-37 AST-36 CK(CPK)-67 AlkPhos-63
Amylase-75 TotBili-1.5
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] Lipase-68*
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] cTropnT-1.16*
[**2167-2-14**] 10:30AM [**Year/Month/Day 3143**] TotProt-6.0* Calcium-9.4 Phos-3.3 Mg-2.3
[**2167-2-16**] 06:38AM [**Year/Month/Day 3143**] TSH-1.3

Labs on discharge:

[**2167-2-20**] 05:25AM [**Year/Month/Day 3143**] WBC-13.2* RBC-3.79* Hgb-11.6* Hct-34.6*
MCV-91 MCH-30.6 MCHC-33.6 RDW-15.0 Plt Ct-265
[**2167-2-20**] 05:25AM [**Year/Month/Day 3143**] Glucose-78 UreaN-15 Creat-0.7 Na-127*
K-3.9 Cl-91* HCO3-29 AnGap-11
[**2167-2-20**] 05:25AM [**Year/Month/Day 3143**] Albumin-3.0* Calcium-8.6 Phos-1.9* Mg-1.8

Brief Hospital Course:
1. Hypotension: The cause of the pt's hypotension was felt to be
multifactorial and related to hypovolemia and a degree of
adrenal insufficiency.  He was given approximately five liters
of normal saline over the course of the first 24 hours of
admission in the ED and MICU to which his [**Year/Month/Day **] pressure
responded to 110-120's.  He was also started on IV
hydrocortisone and oral fludricortisone.  This was eventually
changed to oral prednisone on hospital day three.  As his [**Year/Month/Day **]
pressure had remained stable in the 110-130's systolic, his beta
blocker and [**Last Name (un) **] were re-introduced on the third hospital day.
He will be discharged on a prednisone taper, his maintainence
dose should remain 10mg daily once the taper is complete.

2. CHF: The pt. is known to have low EF 40-45% after his MI in
[**Month (only) 956**]. A repeat TTE was performed on hospital day two, the
results of which are noted in the "Pertinent Results" section of
this report.
As part of treatment for hypotension, the pt. was aggressively
hydrated.  This resulted in the pt. becoming fluid over-loaded
both on physical exam and also evident with a serum sodium of
127.  This was felt to reflect a hypervolemic hyponatremia and
chronic SIADH and was stable with gentle diuresis before
discharge.  His [**Last Name (un) **] was re-introduced on hospital day four.
Furosemide was also re-introduced on hospital day five with
effective diuresis.  Subsequently, the pt. was maintained on
20mg of oral furosemide daily.

3. Cardiac Rhythm/Pacemaker: The pt. is status-post pacemaker
placement for a history of tachy-brady syndrome. In the MICU, he
was noted to have episodes of wide and narrow compled paced
rhythm on telemetry. The pt remained asymptomatic. The
electrophysiology service was consulted and reprogrammed his
pacemaker.  During his last admission in [**Month (only) 956**], he
experienced peri-myocardial infarction atrial fibrillation and
the pt. was continued on the month-long amiodarone taper during
this admission.

4. Hypopituitarism: The pt. was treated with levothyroxine and a
steroid regimen as above. He was also re-started on a
testosterone patch.

5. Thrush: This was felt to be due chronic prednisone
immunosuppression, and was treated with nystatin swish and
swallow.

6. CAD: The pt. had one episode of left shoulder pain while
working with physical therapy on hospital day four.  This
spontaneously abated.  He had no further episodes.  He was
maintained on aspirin, plavix and atorvastatin.  Once his [**Month (only) **]
pressure stabilized, metoprolol and atacand were reintroduced on
hospital day four.

7. Steroid-induced hyperglycemia: The pt was maintained on a
sliding scale of regular insulin while on steroids.


Medications on Admission:
Aspirin EC 325 mg PO DAILY
Clopidogrel Bisulfate 75 mg PO DAILY
Atorvastatin Calcium 80 PO DAILY
Levothyroxine Sodium 75 mcg PO DAILY
Senna 8.6 mg PO BID prn
Acetaminophen 325 mg Tablet PO Q4-6H
Docusate Sodium 100 mg PO BID
Milk of Magnesia 311 mg Tablet PO Q6H as needed for heartburn.
Atacand 4 mg PO QD
Spironolactone 25 mg PO DAILY
Lactulose 30 ML PO TID PRN constipation
Amiodarone HCl 300 mg PO DAILY for 9 days: then start 200 mg per
day for 3 more weeks, then off.
Toprol XL 12.5 mg PO DAILY
Prednisone 20 mg PO DAILY for 5 days: Then 10 mg for 7 days then
5 mg ongoing.
Potassium Chloride 30 mEq PO DAILY
Furosemide 40 mg PO DAILY
Guaifenesin 5-10 MLs PO Q6H as needed for cough for 7 days

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed.
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

8. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
10. Testosterone 2.5 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal Q24H (every 24 hours).
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: 0.5 Tablet Sustained Release 24HR PO DAILY (Daily).
12. Candesartan Cilexetil 4 mg Tablet Sig: One (1) Tablet PO
daily ().
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Amiodarone HCl 200 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily) for 2 days.
Disp:*3 Tablet(s)* Refills:*0*
16. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a
day for 21 days.
Disp:*21 Tablet(s)* Refills:*0*
17. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO daily () for
5 doses.
Disp:*20 Tablet(s)* Refills:*0*
18. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO daily () for
5 doses.
Disp:*10 Tablet(s)* Refills:*0*
19. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily (): To
continue as maintainence dose after taper.
Disp:*30 Tablet(s)* Refills:*2*
20. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 1 days: To be given on [**2-21**], followed by taper as
written.
Disp:*3 Tablet(s)* Refills:*0*
21. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - Acute Rehab

Discharge Diagnosis:
-hypotension related to dehydration
-congestive heart failure with EF 40-45%
-SIADH
-coronary artery disease
-pan-hypopituitarism s/p pituitary resection
-hypertension, by history

Discharge Condition:
Stable.

Discharge Instructions:
Please continue to take all medications as prescribed.  If you
experience any chest pain, shoulder pain, shortness of breath,
nausea, vomiting or abdominal pain or any other symptom that is
concerning to you, please call your primary care doctor or come
to the emergency department for evaluation.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6719**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2167-2-24**] 2:15

Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow-up
appointment within the next week.
{'Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve insufficiency,Candidiasis of mouth,Other disorders of neurohypophysis,Unspecified essential hypertension,Other abnormal blood chemistry,Coronary atherosclerosis of native coronary artery,Esophageal reflux,Other and unspecified hyperlipidemia,Acute myocardial infarction of other inferior wall, subsequent episode of care,Adrenal cortical steroids causing adverse effects in therapeutic use'}


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, vomiting.

PRESENT ILLNESS: The pt. is an 86 year-old male with history of
panhypopituitarism (s/p resection for pituitary adenoma in [**2158**])
who presented with hypotension, nausea and vomiting.  He was
recently discharged from [**Hospital1 18**] to [**Hospital3 **] on two days
PTA after a two and a half week stay for an inferior STEMI on
[**2167-1-28**] complicated by cardiogenic shock, ventilator-associated
pneumonia, and a small retroperitoneal bleed. Per his daughter,
his [**Name2 (NI) **] pressure was in the 70s to 90s systolic while at
[**Hospital1 **]. He was transferred to [**Hospital1 18**] ED for evaluation of
hypotension.

MEDICAL HISTORY: -inferior STEMI [**1-17**] with cath, stent placement x 4 (2LCMA,
1LCx, 1 -LAD), c/b cardiogenic shock. CK peak 4000, Tp peak 12
-ventilator associated pneumonia (serratia marascens) [**1-17**]
-CHF, EF 40-45% on echo [**1-17**]
-hyperlipidemia
-HTN
-Pan-hypopituitarism s/p pituitary adenoma resection [**2158**]
-H/O Tachy-Brady syndrome s/p pacemaker placement in [**2154**]
-SIADH
-gastroesophageal reflux disease

MEDICATION ON ADMISSION: Aspirin EC 325 mg PO DAILY
Clopidogrel Bisulfate 75 mg PO DAILY
Atorvastatin Calcium 80 PO DAILY
Levothyroxine Sodium 75 mcg PO DAILY
Senna 8.6 mg PO BID prn
Acetaminophen 325 mg Tablet PO Q4-6H
Docusate Sodium 100 mg PO BID
Milk of Magnesia 311 mg Tablet PO Q6H as needed for heartburn.
Atacand 4 mg PO QD
Spironolactone 25 mg PO DAILY
Lactulose 30 ML PO TID PRN constipation
Amiodarone HCl 300 mg PO DAILY for 9 days: then start 200 mg per
day for 3 more weeks, then off.
Toprol XL 12.5 mg PO DAILY
Prednisone 20 mg PO DAILY for 5 days: Then 10 mg for 7 days then
5 mg ongoing.
Potassium Chloride 30 mEq PO DAILY
Furosemide 40 mg PO DAILY
Guaifenesin 5-10 MLs PO Q6H as needed for cough for 7 days

ALLERGIES: Norvasc

PHYSICAL EXAM: Vitals: T: 97.8F BP: 130/70 (90/50-170/110) P: 80 R: 14 SaO2:
97% on 4L O2 NC
Gen: Lying in bed, NAD, talkative and cooperative
HEENT: PERRL, OP clear, MMM, small white areas on tongue, soft
palate
Neck: no JVD
CV: RRR, nl S1s2 distant, soft II/VI HSM at LSB without apparent
radiation
Resp: CTA bilaterally
Abd: slight tenderness to palpation in suprapubic area. No
rebound, no guarding. Nondistended. Normoactive bowel sounds. No
massess or HSM appreciated.
Ext: 2+ bilateral UE edema, 1+ bilateral LE edema, warm, well
perfused bilaterally
Skin: scattered ecchymoses over extremities and trunk

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The pt. lived at home with his wife before last admission in
[**Month (only) 956**] at which time he was discharged to rehab.  He denied
h/o tobacco, alcohol or illicit drug use. 

### Response:
{'Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve insufficiency,Candidiasis of mouth,Other disorders of neurohypophysis,Unspecified essential hypertension,Other abnormal blood chemistry,Coronary atherosclerosis of native coronary artery,Esophageal reflux,Other and unspecified hyperlipidemia,Acute myocardial infarction of other inferior wall, subsequent episode of care,Adrenal cortical steroids causing adverse effects in therapeutic use'}
