CHIEF COMPLAINT: hypotension and altered mental status

PRESENT ILLNESS: Ms. [**Known lastname 37559**] is a 54 yo female with ESRD on HD, PVD s/p L BKA,
h/o L stump osteomyelitis s/p Vanco/[**Last Name (un) **] for 6 weeks completed
in [**5-6**], DM, OSA, admitted with hypotension of 64/42 at
dialysis. She was given 1L NS at dialysis and her BP improved to
140/doppler.
.
In the ED, her initial vitals were 149/72, RR 18, HR 59, 94% on
2LNC.  She was hypotensive to 90/D in the [**Last Name (LF) **], [**First Name3 (LF) **] she was given
another L of IVF.  CXR showed possible PNA, so she was given
vancomycin and levaquin.  She was also noted to be somnolent and
patient was found to have two fentanyl patches on her body, one
of which was removed.  A head CT was performed which was
unchanged. Given her history of OSA, an ABG was performed with
showed a pCO2 of 49.
.
She remained hypotensive with SBP in the 70s, and she was
transferred to the MICU.
.
She reports fatigue over the past three days and increased
sleepiness.  She is tearful intermittently though denies home
stressors or depressed mood.  She denies cough, shortness of
breath, chest pain, fevers, chills, dysuria, skin rash, or any
other symptoms.

MEDICAL HISTORY: - Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]

MEDICATION ON ADMISSION: Lactulose 30 mg prn
Seroquel 25 mg q 12 hour
Sensipar 60 mg daily
Renagel 2400 TIDWF
Zemplar 4 mcg MWF IV
Nitropaste prn
Novolog sliding scale
HSQ
Senokot 1  [**Hospital1 **]
Reglan 5 mg TID
Nexium 20 mg daily
Colace 100 mg daily
Zocor 10 mg daily
Lopressor 12.5 q 12 hours
Lovenox 40 mg daily
Aranesp 100 Mo
Remeron 15 mg qhs
Duralgesic 75 mcq q3day
Aspirin 81 daily
Nephrocaps 1 daily
Ambien 5 mg
Ultram 50 [**Hospital1 **]
Perocet 2 tabs 1 6 hours neuronitn 300 prn
Novolog sliding scale

ALLERGIES: Lisinopril

PHYSICAL EXAM: VS: T 97.5, HR 61, BP 114/34, 96% on 3LNC, RR 8
Gen: alert and oriented x 2 (did not know date), conversant
HEENT: PERRL, EOMI, o/p clear
CV: RRR, systolic murmur at LUSB
Pulm: Clear anteriorly, though poor inspiratory effort,
unlabored, decreased respiratory rate
Abd: obese, soft, NT, ND
Ext: peripheral edema present, left AKA
Neuro: alert and oriented x 2, moving all extremities, CNs [**1-10**]
intact

FAMILY HISTORY: Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

SOCIAL HISTORY: Admitted from rehab. Has two sisters, one daughter.  [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago.
Poisoning by unspecified sedative or hypnotic,Acute respiratory failure,Pressure ulcer, buttock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Accidental poisoning by unspecified sedative or hypnotic,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Personal history of malignant neoplasm of kidney,Above knee amputation status
Pois-sedative/hypnot NOS,Acute respiratry failure,Pressure ulcer, buttock,Hyp kid NOS w cr kid V,End stage renal disease,Acc poison-sedatives NOS,Hyperpotassemia,DMII wo cmp nt st uncntr,Chr airway obstruct NEC,Obstructive sleep apnea,Hx of kidney malignancy,Status amput above knee
Admission Date:  [**2192-8-15**]              Discharge Date:   [**2192-8-25**]

Date of Birth:  [**2138-3-6**]             Sex:   F

Service: MEDICINE

Allergies:
Lisinopril

Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
hypotension and altered mental status

Major Surgical or Invasive Procedure:
ICU admission for observation
Hemodialysis

History of Present Illness:
Ms. [**Known lastname 37559**] is a 54 yo female with ESRD on HD, PVD s/p L BKA,
h/o L stump osteomyelitis s/p Vanco/[**Last Name (un) **] for 6 weeks completed
in [**5-6**], DM, OSA, admitted with hypotension of 64/42 at
dialysis. She was given 1L NS at dialysis and her BP improved to
140/doppler.
.
In the ED, her initial vitals were 149/72, RR 18, HR 59, 94% on
2LNC.  She was hypotensive to 90/D in the [**Last Name (LF) **], [**First Name3 (LF) **] she was given
another L of IVF.  CXR showed possible PNA, so she was given
vancomycin and levaquin.  She was also noted to be somnolent and
patient was found to have two fentanyl patches on her body, one
of which was removed.  A head CT was performed which was
unchanged. Given her history of OSA, an ABG was performed with
showed a pCO2 of 49.
.
She remained hypotensive with SBP in the 70s, and she was
transferred to the MICU.
.
She reports fatigue over the past three days and increased
sleepiness.  She is tearful intermittently though denies home
stressors or depressed mood.  She denies cough, shortness of
breath, chest pain, fevers, chills, dysuria, skin rash, or any
other symptoms.


Past Medical History:
- Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]

- Likely left AKA stump osteomyelitis requiring admission in
[**3-/2192**], on IV antibiotics, VAC dressing in place
- ESRD on HD. Last HD yesterday. Usually MWF schedule.
- HTN
- Diabetes Mellitus
- Renal Cell Carcinoma s/p right nephrectomy
- Obesity
- Depression
- s/p CCY
- Gastric Ulcer
- Obstructive Sleep Apnea. The patient reports that she used to
use a CPAP however her machine broke and she no longer uses it.

- Gastroparesis
- COPD on 3-4L NC baseline
- h/o ischemic colitis
- left adrenal adenoma


Social History:
Admitted from rehab. Has two sisters, one daughter.  [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago.

Family History:
Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

Physical Exam:
VS: T 97.5, HR 61, BP 114/34, 96% on 3LNC, RR 8
Gen: alert and oriented x 2 (did not know date), conversant
HEENT: PERRL, EOMI, o/p clear
CV: RRR, systolic murmur at LUSB
Pulm: Clear anteriorly, though poor inspiratory effort,
unlabored, decreased respiratory rate
Abd: obese, soft, NT, ND
Ext: peripheral edema present, left AKA
Neuro: alert and oriented x 2, moving all extremities, CNs [**1-10**]
intact

Pertinent Results:
Admission Labs:
.
142 | 105 | 43 /
--------------- 114
5.5 | 24 | 7.6 \
.
Ca 9.6
Mg 2.5
P 5.7
.
.. \ 10.4 /
7.8 ------ 109
.. / 33.7 \
.
ABG 7.31/51/75/27
.
Lactate 1.1
.

[**2192-8-17**]
WBC RBC   Hgb   Hct   MCV MCH  MCHC RDW   Plt Ct
5.7 3.24* 10.0* 30.8* 95  30.7 32.3 18.1* 107
.
Glu  BUN Creat Na   K   Cl  HCO3 AnGap
197* 26* 5.6*  141 4.0  102  28   15
.
[**2192-8-20**]
WBC RBC   Hgb   Hct   MCV  MCH   MCHC  RDW  Plt Ct
7.0 3.54* 10.8* 33.7* 95   30.6  32.0  17.2*  133
.
Glu  BUN  Creat Na   K   Cl  HCO3 AnGap
159* 28*  6.0*  136 4.4  99  25    16
.
[**2192-8-22**]
WBC RBC   Hgb   Hct   MCV MCH  MCHC RDW   Plt Ct
7.0 3.54* 10.9* 33.1* 94  30.7 32.8 17.8* 157
.
Glu  BUN Creat Na   K   Cl  HCO3 AnGap
231* 29* 6.6*# 134 4.5  101 22    16
.
.
Imaging:
[**2192-8-15**].  CT Head. No acute process seen.
.
[**2192-8-15**].  CXR.  Wet read:  linear opacity right mid lung
concerning for evolving pneumonia, ddx includes atelectasis.
FINAL FINDINGS: Central venous catheter is stable. The study is
extremely limited by patient body
habitus. The right-sided layering pleural effusion is no longer
present.
Linear opacity of the right mid lung may represent evolving
pneumonia or
atelectasis.
.
[**2192-8-16**]  CXR: Linear opacity in the right middle lung is most
likely atelectasis and is unchanged. Allowing the difference in
position of the patient, there is now more clearly visualized
moderate right pleural effusion. There is mild fluid overload.
Main central pulmonary arteries are prominent unchanged from
prior CT from [**2192-6-7**]. Cardiomegaly is mild. Right
subclavian catheter remains in place with tip in the SVC.

[**2192-8-19**] Plain film ABD: Vasculopathy. Paucity of bowel gas is
non-specific. No dilalated loops of small bowel or air fluid
levels to suggest obstruction.


Brief Hospital Course:
1.  Hypotension.  Patient noted to be hypotensive at dialysis
with ongoing blood pressure readings with systolics of 90s
though patient is entirely asymptomatic.  As outpatient, patient
is noted to have SBPs of 130s and 140s.  Most likely dehydration
versus med effect secondary to over-sedation with narcotics.
Patient received 2L IVF and is on HD. Accurate blood pressures
are difficult to attain given patients obesity.  No evidence to
suggest sepsis in spite of concern for pneumonia in ED; patient
denies symptoms of pneumonia, is afebrile and does not have an
elevated WBC.  Also with normal lactate. Antiobiotics were
stopped on admission to the floor. No evidence of blood loss or
EKG changes.  Her antihypertensives and narcotics were held
initailly, and patient's BP remained stable in the ICU, on the
floor and during HD. Home meds were restarted slowly, with no
further drops in BP.
.
2.  Altered mental status.  Patient reportedly somnolent in the
ED, though on admission, per daughter, patient is at her
baseline, though has slept more frequently during the day than
normal. [**Month (only) 116**] be secondary to OSA (and lack of consistent BIPAP
use), depression (patient tearful on exam), or overmedication
with opioids. Head CT in ED unchanged.  Patient noted to have
PCO2 of 51 on admission, which is increased from the past.
Patient back at basline by transfer from ICU and rest of
hospital stay. Patient restarted on home psych meds.
.
3.  Diabetes.  Continued standing humalog and HISS. Serum
glucose remained in the 100s to 200s throughout the
hospitalization.
.
4.  OSA.  Patient noted to have elevated CO2 on admission.  This
may have contributed to patient's somnolence in ED.  Patient
reports she ws not using bipap every night. Continued on BIPAP
at night without difficulty, although the patient will take off
the BiPAP after only a few hours use per night due to
discomfort.
.
5.  Hyperkalemia.  No evidence of EKG changes on admission.
Given kayexelate x 1. Received HD x2 with resolution of
hyperkalemia. No further episodes during hospital stay.
.
6.  CAD.  Unclear why patient is on plavix; patient does not
report history of stent placement. Continued aspirin, statin,
plavix during hospital stay.
.
7.  ESRD on HD. Continued phos binders, nephrocaps, and dialysis
MWF. Received dialysis on [**8-20**], [**8-20**] and [**8-22**]. Spoke with
transplant surgery team, and it was decided to evaluate the
patient as an outpatient for an AV graft.
.
8.  Nausea/vomiting. The patient developed nausea and vomiting
on [**2192-8-19**]. After one day of ice chips and around the clock
anti-emetics, the N/V subsided. The patient was taking po
without problems the rest of the hospital stay.
.
9.  Dispo. Patient was ready to go back to Rehab on Friday
([**8-17**]), but needed to be rescreened by the Rehab facility.
Stayed through the weekend, as this did not take place until
Monday [**8-20**]. She was rejected by her previous Rehab, and got a
bed at a new Rehab. Unfortunately, the patient's HD slot was
lost, and she was re-placed, which took an additional week in
the hospital to coordinate.

Medications on Admission:
Lactulose 30 mg prn
Seroquel 25 mg q 12 hour
Sensipar 60 mg daily
Renagel 2400 TIDWF
Zemplar 4 mcg MWF IV
Nitropaste prn
Novolog sliding scale
HSQ
Senokot 1  [**Hospital1 **]
Reglan 5 mg TID
Nexium 20 mg daily
Colace 100 mg daily
Zocor 10 mg daily
Lopressor 12.5 q 12 hours
Lovenox 40 mg daily
Aranesp 100 Mo
Remeron 15 mg qhs
Duralgesic 75 mcq q3day
Aspirin 81 daily
Nephrocaps 1 daily
Ambien 5 mg
Ultram 50 [**Hospital1 **]
Perocet 2 tabs 1 6 hours neuronitn 300 prn
Novolog sliding scale

Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
9. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

10. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*60 Tablet(s)* Refills:*2*
13. Paricalcitol 5 mcg/mL Solution Sig: One (1)  Intravenous
3X/WEEK (MO,WE,FR).
14. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
17. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)) as needed for nausea.

18. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for stump pain.


Discharge Disposition:
Extended Care

Facility:
[**First Name8 (NamePattern2) 1495**] [**Hospital 11042**] Nursing Care Center

Discharge Diagnosis:
Primary diagnoses:
Altered mental status, likely secondary to narcotic overdose
Hypotension, likely secondary to dehydration and narcotic
overdose

Secondary diagnoses:
ESRD with HD
HTN
DM
OSA


Discharge Condition:
Good, tolerating diabetic/renal diet, using BiPAP, VSS, good
mentation


Discharge Instructions:
You were admitted to the hospital for your low blood pressure at
dialysis and also a low level of consciousness. We found two
pain patches on your back and arm, which is most likely why you
were so sleepy and why your blood pressure was low. In the
future, you should only use one pain patch at a time, if you
even need them at all. We have started Tylenol for your pain.
You do not need to be on antibiotics.

You may resume your medications that you were on before you came
to the hospital. Your blood pressure medication (Lopressor
12.5mg [**Hospital1 **]) was restarted.

You will also need to make an appointment for evaluation to get
an arteriovenous fistula in order to have better dialysis
access.

Call your doctor [**First Name (Titles) **] [**Last Name (Titles) 101900**] the Emergency Department right away
if any of the following problems develop:

* You have recurrent loss of consciousness in the next 6 months.
* You are not getting better in 24 hours, or you are getting
worse in any way.
* You experience new chest pain, pressure, squeezing,
tightness, a rapid heartbeat or palpitations.
* You have shaking chills, or a fever greater than 102 degrees
(F).
* You have new or worsening difficulty breathing.
* You develop abdominal (belly) pain, vomiting, black or bloody
stool.
* You develop severe headache, dizziness, confusion or change in
behavior.
* Any serious change in your symptoms, or any new symptoms that
concern you.


Followup Instructions:
Please make an appointment with your PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] by calling
[**Telephone/Fax (1) 250**]. You should follow up within 1-2 weeks to assess
your recovery.

You will also need to call [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**], who is the Surgery
Transplant Coordinator at ([**Telephone/Fax (1) 20193**]. She will help you set
up a time to be evaluated for an ateriovenous fistula for better
hemodialysis access.



Completed by:[**2192-8-25**]
{'Poisoning by unspecified sedative or hypnotic,Acute respiratory failure,Pressure ulcer, buttock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Accidental poisoning by unspecified sedative or hypnotic,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Personal history of malignant neoplasm of kidney,Above knee amputation status'}


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 and altered mental status

PRESENT ILLNESS: Ms. [**Known lastname 37559**] is a 54 yo female with ESRD on HD, PVD s/p L BKA,
h/o L stump osteomyelitis s/p Vanco/[**Last Name (un) **] for 6 weeks completed
in [**5-6**], DM, OSA, admitted with hypotension of 64/42 at
dialysis. She was given 1L NS at dialysis and her BP improved to
140/doppler.
.
In the ED, her initial vitals were 149/72, RR 18, HR 59, 94% on
2LNC.  She was hypotensive to 90/D in the [**Last Name (LF) **], [**First Name3 (LF) **] she was given
another L of IVF.  CXR showed possible PNA, so she was given
vancomycin and levaquin.  She was also noted to be somnolent and
patient was found to have two fentanyl patches on her body, one
of which was removed.  A head CT was performed which was
unchanged. Given her history of OSA, an ABG was performed with
showed a pCO2 of 49.
.
She remained hypotensive with SBP in the 70s, and she was
transferred to the MICU.
.
She reports fatigue over the past three days and increased
sleepiness.  She is tearful intermittently though denies home
stressors or depressed mood.  She denies cough, shortness of
breath, chest pain, fevers, chills, dysuria, skin rash, or any
other symptoms.

MEDICAL HISTORY: - Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]

MEDICATION ON ADMISSION: Lactulose 30 mg prn
Seroquel 25 mg q 12 hour
Sensipar 60 mg daily
Renagel 2400 TIDWF
Zemplar 4 mcg MWF IV
Nitropaste prn
Novolog sliding scale
HSQ
Senokot 1  [**Hospital1 **]
Reglan 5 mg TID
Nexium 20 mg daily
Colace 100 mg daily
Zocor 10 mg daily
Lopressor 12.5 q 12 hours
Lovenox 40 mg daily
Aranesp 100 Mo
Remeron 15 mg qhs
Duralgesic 75 mcq q3day
Aspirin 81 daily
Nephrocaps 1 daily
Ambien 5 mg
Ultram 50 [**Hospital1 **]
Perocet 2 tabs 1 6 hours neuronitn 300 prn
Novolog sliding scale

ALLERGIES: Lisinopril

PHYSICAL EXAM: VS: T 97.5, HR 61, BP 114/34, 96% on 3LNC, RR 8
Gen: alert and oriented x 2 (did not know date), conversant
HEENT: PERRL, EOMI, o/p clear
CV: RRR, systolic murmur at LUSB
Pulm: Clear anteriorly, though poor inspiratory effort,
unlabored, decreased respiratory rate
Abd: obese, soft, NT, ND
Ext: peripheral edema present, left AKA
Neuro: alert and oriented x 2, moving all extremities, CNs [**1-10**]
intact

FAMILY HISTORY: Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

SOCIAL HISTORY: Admitted from rehab. Has two sisters, one daughter.  [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago. 

### Response:
{'Poisoning by unspecified sedative or hypnotic,Acute respiratory failure,Pressure ulcer, buttock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Accidental poisoning by unspecified sedative or hypnotic,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Personal history of malignant neoplasm of kidney,Above knee amputation status'}
