CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: The patient is a 56 year old male with a history of DM, hep C,
idiopathic cardiomyopathy w/ EF 50%, and chronic pain presents
with 1 week of presyncope and found to be hypotensive at his
cardiologist's office today.  The patient states that he was
started on diovan 40mg daily 1 month ago and for the past 1 week
has been symptomatically orthostatic.  No fatigue, no CP, no
SOB, no orthopnea, no pedal edema or weight changes.  No PND.
No fevers, chills or night sweats.  No pain anywhere beyond his
baseline.  No increase in baseline hip pain, no change in
baseline spinal stenosis pain.  No diarrhea, good PO intake,
nausea x 3 days, good appetite.  Rest of ROS is negative.

MEDICAL HISTORY: DM2, proteinuria
PE x2 on lifelong coumadin
Congenital hip dysplasia s/p reconstruction at age 10, multiple
hip replacement over the years; most recently [**1-/2111**] (R hip
revision)
Hypertension
Hepatitis C (fibrosis on biopsy; followed by Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2643**])
Chronic Pain syndrome
Cardiomyopathy (normal cath [**2-/2111**]): EF 50-60%
s/p Laminectomy

MEDICATION ON ADMISSION: MS contin 30mg po bid
Oxycodone 5mg po bid prn
Amlactin cream
Coreg 12.5mg po bid
Neurontin 400mg po tid
Folate 2mg po daily
HCTZ 12.5mg po daily (not taking)
Humalog sliding scale
Insulin 70/30 22 units in a.m., 15 units prior to dinner
Lisinopril 40mg daily
Nortriptyline 75mg po daily
polyethylene glycol daily prn
Viagra 50mg po prn (last used 1 month ago)
Simvastatin 80mg daily
Bactrim DS 2 tabs [**Hospital1 **] for prosthetic joint infection prophylaxis
Coumadin 5mg daily
Diovan 40mg daily
ASA 81mg daily
Colace and senna prn

ALLERGIES: Anti-Inflam/Antiarth Agents Misc. Classf

PHYSICAL EXAM: VITAL SIGNS: T 98.0  HR 70  BP 120/81   RR 10  O2 100% on 3L
GEN: NAD, AOX3
HEENT: JVP 7cm, OP clear, MM slightly dry
CHEST: CTAB
CV: RRR, no m/r/g, soft heart sounds
ABD: moderate distension, BS+, NT, no masses or organogealy.
moderate distension. No fluid wave or shifting dullness.
EXT: wwp, no c/c/e, DP and PT 2+ bilaterally

FAMILY HISTORY: There is a family history of diabetes.  His mother and maternal
grandmother both had heart disease.

SOCIAL HISTORY: Pt currently unemployed, lives alone and uses a cane. Denies
current tobacco use, quit years ago. No recent EtoH use, quit
~10yrs ago. Denies IVDU.
Acute kidney failure, unspecified,Other primary cardiomyopathies,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Orthostatic hypotension,Long-term (current) use of anticoagulants,Unspecified viral hepatitis C without hepatic coma,Chronic pain syndrome,Unemployment,Dehydration,Other left bundle branch block,Spinal stenosis, unspecified region
Acute kidney failure NOS,Prim cardiomyopathy NEC,DMII wo cmp nt st uncntr,Orthostatic hypotension,Long-term use anticoagul,Hpt C w/o hepat coma NOS,Chronic pain syndrome,Unemployment,Dehydration,Left bb block NEC,Spinal stenosis NOS
Admission Date:  [**2113-5-3**]              Discharge Date:   [**2113-5-7**]

Date of Birth:  [**2056-10-3**]             Sex:   M

Service: MEDICINE

Allergies:
Anti-Inflam/Antiarth Agents Misc. Classf

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Hypotension

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is a 56 year old male with a history of DM, hep C,
idiopathic cardiomyopathy w/ EF 50%, and chronic pain presents
with 1 week of presyncope and found to be hypotensive at his
cardiologist's office today.  The patient states that he was
started on diovan 40mg daily 1 month ago and for the past 1 week
has been symptomatically orthostatic.  No fatigue, no CP, no
SOB, no orthopnea, no pedal edema or weight changes.  No PND.
No fevers, chills or night sweats.  No pain anywhere beyond his
baseline.  No increase in baseline hip pain, no change in
baseline spinal stenosis pain.  No diarrhea, good PO intake,
nausea x 3 days, good appetite.  Rest of ROS is negative.

He was recently started on diovan 40mg daily and had been on
lisinopril 40mg daily.  He also is on coreg 12.5mg po bid which
had not been changed recently.  In addition he was prescribed
HCTZ 12.5mg daily but had not been taking this.

Initial VS were: T 98.3 HR 84 BP 81/54  RR 20 O2 sat 100% RA

The patient was noted to be in acute renal failure and was
symptomatically orthostatic.  Access was obtained with 2 PIV 18g
and he was given 4L IVF (bedside ultrasound suggested that his
IVC was collapsable).  His SBP nadir was 76 and following IVF
improved to 90.  He was noted to have a K of 5.9 with slight QRS
widening.  Toxicology was called and suggested calcium gluconate
2g given that the patient is on a beta blocker, as well as an
amp of bicarb to see if his QRS narrows (as the patient is on a
TCA).  In addition the patient has had recurrent prosthetic hip
infections, currently w/o pain, fever or leukocytosis- a CRP and
ESR was sent to follow the course of this.  Given that the
patient had a low sodium and elevated K a dose of decadron was
given for possibility of adrenal insufficiency.

Prior to transfer to the floor his VS were: BP 90/63, HR 72, sat
100% on 3L NC


Past Medical History:
DM2, proteinuria
PE x2 on lifelong coumadin
Congenital hip dysplasia s/p reconstruction at age 10, multiple
hip replacement over the years; most recently [**1-/2111**] (R hip
revision)
Hypertension
Hepatitis C (fibrosis on biopsy; followed by Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2643**])
Chronic Pain syndrome
Cardiomyopathy (normal cath [**2-/2111**]): EF 50-60%
s/p Laminectomy

Social History:
Pt currently unemployed, lives alone and uses a cane. Denies
current tobacco use, quit years ago. No recent EtoH use, quit
~10yrs ago. Denies IVDU.


Family History:
There is a family history of diabetes.  His mother and maternal
grandmother both had heart disease.

Physical Exam:
VITAL SIGNS: T 98.0  HR 70  BP 120/81   RR 10  O2 100% on 3L
GEN: NAD, AOX3
HEENT: JVP 7cm, OP clear, MM slightly dry
CHEST: CTAB
CV: RRR, no m/r/g, soft heart sounds
ABD: moderate distension, BS+, NT, no masses or organogealy.
moderate distension. No fluid wave or shifting dullness.
EXT: wwp, no c/c/e, DP and PT 2+ bilaterally

Pertinent Results:
Admission:

[**2113-5-3**] 01:45PM   WBC-8.1 RBC-4.52* HGB-13.8* HCT-39.8* MCV-88
MCH-30.5 MCHC-34.6 RDW-13.6
[**2113-5-3**] 01:45PM   NEUTS-71.4* LYMPHS-23.2 MONOS-3.8 EOS-1.2
BASOS-0.4
[**2113-5-3**] 01:45PM   PLT COUNT-332
[**2113-5-3**] 01:45PM   PT-48.4* PTT-43.9* INR(PT)-5.3*
[**2113-5-3**] 01:45PM   SED RATE-50*
[**2113-5-3**] 01:45PM   ALT(SGPT)-21 AST(SGOT)-33 CK(CPK)-412* ALK
PHOS-113 TOT BILI-0.3
[**2113-5-3**] 01:45PM   cTropnT-0.02*
[**2113-5-3**] 01:45PM   CK-MB-5 proBNP-50
[**2113-5-3**] 01:45PM   ALBUMIN-3.7 CALCIUM-9.2 PHOSPHATE-5.5*#
MAGNESIUM-2.2
[**2113-5-3**] 01:45PM   GLUCOSE-212* UREA N-57* CREAT-4.4*#
SODIUM-128* POTASSIUM-5.9* CHLORIDE-93* TOTAL CO2-26 ANION
GAP-15

Abd Ultrasound: Limited study with right kidney not visualized.
Left kidney grossly within normal limits with no hydro and good
main renal artery arterial waveform. Trace ascites.

pCXR :Increased linear opacity in the left lung base, for which
atelectasis is favored; however PA and lateral chest radiographs
are
recommended to exclude pneumonia.

Echo [**4-25**]:
 The left atrium is normal in size. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Overall left ventricular systolic function is low
normal (LVEF 50-55%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is an anterior space which
most likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2112-11-4**],
the findings are similar with low normal left ventricular
systolic function.


Brief Hospital Course:
1. Hypotension: most likely medication effect with component of
dehydration.  All medications held at admission and BP
normalized. Received 4 L of fluid initially and tolerated well.
Echocardiogram repeated and results were similar to prior.
Cortisol and TSH WNL. Thought to be due to aggressive
anti-hypertensive regimen. BP returned to hypertensive range
with withholding of all medications and the meds were restarted
one-by-one with careful monitoring of BPs. Pt's PCP and
cardiologist were consulted by email. Metoprolol was not
restarted due to concern of masking hypoglycemic symptoms. Also
there was a question of whether pt is compliant in taking meds
at home, leading to continued up-titration of medications. Pt
was discharged home on Lisinopril, Diovan (to improve
proteinuria per renal), and amlodipine.

2. ARF: presented with creatinine of 4.4 from 1.2 in the setting
of ACE/[**Last Name (un) **] combination and dehydration.  Received 4L NS with
improvement to 2.7. FENa was >1%, in the setting of hydration.
Held ace and [**Last Name (un) **]. No evidence of RAS on doppler on left kidney,
right kidney not visualized. ACEI and [**Last Name (un) **] were restarted. Pt was
followed by renal service.

3.  Hyponatremia: Improved with hydration.

4. Hyperkalemia: in setting of ARF, ACE and [**Last Name (un) **] use, and
hyperglycemia.  Treated initially with insulin, bicarb and
improved.  Was given Kayexelate. Should be monitored as
outpatient, since pt on two K-sparing agents.

5. Wide QRS: with LBBB, QRS 130. Per tox recs in the ED, given 1
amp of bicarb without change in QRS, so bicarb gtt not started.
Unlikely tricyclic (on nortriptyline at home) toxicity since it
didn't improve with bicarb. Remained stable.

6. Slightly elevated troponin: in the setting of ARF. Resolved.

7. h/O PE: INR was supratherapeutic for most of hospital stay -
warfarin was held.

8. DM/Hyperglycemia: initially received lower dose of insulin in
the setting of renal failure and was hyperglycemic. Restarted
home dose of insulin with Humalog SS. AM and PM doses of his
home 70/30 were increased prior to discharge as pt's AM finger
sticks remained high.

9. Chronic pain: held nortriptyline 75mg daily briefly while in
renal failure with wide QRS.

FULL CODE

Medications on Admission:
MS contin 30mg po bid
Oxycodone 5mg po bid prn
Amlactin cream
Coreg 12.5mg po bid
Neurontin 400mg po tid
Folate 2mg po daily
HCTZ 12.5mg po daily (not taking)
Humalog sliding scale
Insulin 70/30 22 units in a.m., 15 units prior to dinner
Lisinopril 40mg daily
Nortriptyline 75mg po daily
polyethylene glycol daily prn
Viagra 50mg po prn (last used 1 month ago)
Simvastatin 80mg daily
Bactrim DS 2 tabs [**Hospital1 **] for prosthetic joint infection prophylaxis
Coumadin 5mg daily
Diovan 40mg daily
ASA 81mg daily
Colace and senna prn

Discharge Medications:
1. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
3. AmLactin     Cream Sig: One (1) application Topical once a
day.
4. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

5. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Bactrim DS 160-800 mg Tablet Sig: Two (2) Tablet PO twice a
day.
11. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: as
directed.
12. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO
DAILY (Daily) as needed for constipation.
13. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Insulin NPH & Regular Human 100 unit/mL (70-30) Insulin Pen
Sig: as directed  Subcutaneous twice a day: 24 units in the
morning, 18 units in the evening. .
15. Insulin Lispro 100 unit/mL Insulin Pen Sig: as directed
Subcutaneous twice a day: use the sliding scale provided by
primary care doctor.
16. Outpatient Lab Work
INR and Chem 7 panel on [**Last Name (LF) 766**], [**2113-5-8**]
17. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
18. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
19. Diovan 40 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Primary:
Hypotension
Acute renal failure
Electrolyte abnormalities


Discharge Condition:
Improved


Discharge Instructions:
You were admitted to the hospital because you were found to be
hypotensive during your visit with your cardiologist. You were
given intravenous fluids which brought your blood pressure back
to normal. All of your blood pressure medications were withheld
initially; and Lisinopril and Valsartan were restarted and a new
medication called Amlodipine was added.

Lab tests showed that your kidneys were not functioning well
when you were admitted. It has since improved back to the
previous level of function.

It's not clear why your blood pressure has been fluctuating
recently. It's important that you take all of your medications
as directed.

Changes were made to your medication regimen:
1) Stopped Carvedilol (also called Coreg)
2) Stopped Hydrochlorothiazide
3) Increased Aspirin to 325 mg once a day
4) Started Amlodipine 5mg daily for blood pressure control
5) Changed insulin regimen to 24 units in the morning, 18 units
in the evening

Your INR (Coumadin level) was initially high during your
hospital stay so coumadin was withheld for 3 days. Please have
your INR measured on [**Last Name (LF) 766**], [**5-8**]. Your doctor will give
you further instructions on how much Coumadin to take based on
that INR result.

If you experience more lightheadedness, dizziness, loss of
consciousness, chest pain, palpitations, or any other symptoms
concerning to you, please call Dr.[**Name (NI) 11945**] office at [**Telephone/Fax (1) 250**]
or return to the emergency room.

Followup Instructions:
Appointment #1
MD: Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **]
Specialty: internal medicine/ pcp
Date and time: Thursday, [**5-16**]  9:20am
Location: [**Location (un) **], [**Location (un) 86**]  [**Hospital Ward Name 23**] Bldg, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 250**]

Appointment #2
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP
Specialty: cardiology
Date and time: Tuesday, [**5-9**]  2:30pm
Location: [**Location (un) **], [**Location (un) 86**]  [**Hospital Ward Name 23**] Bldg, [**Location (un) 436**]
Phone number: [**Telephone/Fax (1) 62**]


                             [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

Completed by:[**2113-5-10**]
{'Acute kidney failure, unspecified,Other primary cardiomyopathies,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Orthostatic hypotension,Long-term (current) use of anticoagulants,Unspecified viral hepatitis C without hepatic coma,Chronic pain syndrome,Unemployment,Dehydration,Other left bundle branch block,Spinal stenosis, unspecified region'}


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: The patient is a 56 year old male with a history of DM, hep C,
idiopathic cardiomyopathy w/ EF 50%, and chronic pain presents
with 1 week of presyncope and found to be hypotensive at his
cardiologist's office today.  The patient states that he was
started on diovan 40mg daily 1 month ago and for the past 1 week
has been symptomatically orthostatic.  No fatigue, no CP, no
SOB, no orthopnea, no pedal edema or weight changes.  No PND.
No fevers, chills or night sweats.  No pain anywhere beyond his
baseline.  No increase in baseline hip pain, no change in
baseline spinal stenosis pain.  No diarrhea, good PO intake,
nausea x 3 days, good appetite.  Rest of ROS is negative.

MEDICAL HISTORY: DM2, proteinuria
PE x2 on lifelong coumadin
Congenital hip dysplasia s/p reconstruction at age 10, multiple
hip replacement over the years; most recently [**1-/2111**] (R hip
revision)
Hypertension
Hepatitis C (fibrosis on biopsy; followed by Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2643**])
Chronic Pain syndrome
Cardiomyopathy (normal cath [**2-/2111**]): EF 50-60%
s/p Laminectomy

MEDICATION ON ADMISSION: MS contin 30mg po bid
Oxycodone 5mg po bid prn
Amlactin cream
Coreg 12.5mg po bid
Neurontin 400mg po tid
Folate 2mg po daily
HCTZ 12.5mg po daily (not taking)
Humalog sliding scale
Insulin 70/30 22 units in a.m., 15 units prior to dinner
Lisinopril 40mg daily
Nortriptyline 75mg po daily
polyethylene glycol daily prn
Viagra 50mg po prn (last used 1 month ago)
Simvastatin 80mg daily
Bactrim DS 2 tabs [**Hospital1 **] for prosthetic joint infection prophylaxis
Coumadin 5mg daily
Diovan 40mg daily
ASA 81mg daily
Colace and senna prn

ALLERGIES: Anti-Inflam/Antiarth Agents Misc. Classf

PHYSICAL EXAM: VITAL SIGNS: T 98.0  HR 70  BP 120/81   RR 10  O2 100% on 3L
GEN: NAD, AOX3
HEENT: JVP 7cm, OP clear, MM slightly dry
CHEST: CTAB
CV: RRR, no m/r/g, soft heart sounds
ABD: moderate distension, BS+, NT, no masses or organogealy.
moderate distension. No fluid wave or shifting dullness.
EXT: wwp, no c/c/e, DP and PT 2+ bilaterally

FAMILY HISTORY: There is a family history of diabetes.  His mother and maternal
grandmother both had heart disease.

SOCIAL HISTORY: Pt currently unemployed, lives alone and uses a cane. Denies
current tobacco use, quit years ago. No recent EtoH use, quit
~10yrs ago. Denies IVDU. 

### Response:
{'Acute kidney failure, unspecified,Other primary cardiomyopathies,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Orthostatic hypotension,Long-term (current) use of anticoagulants,Unspecified viral hepatitis C without hepatic coma,Chronic pain syndrome,Unemployment,Dehydration,Other left bundle branch block,Spinal stenosis, unspecified region'}
