CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: Ms. [**Known lastname 94952**] is a [**Age over 90 **] yo female with ESRD on HD who comes in with
3 days of intermittent RUQ pain (chronic), + nausea, no
vomiting.  She visited her PCP, [**Name10 (NameIs) 1023**] documented a T about 100 and
was concerned about abd pain on exam.  He sent her to the ED
where she denied current abd pain.  She was noted to have a
slight leukocytosis, and had a CXR showing chronic effusions but
better than usual.  KUB was negative.  UA with epi's.  During
her stay, she then spiked a fever to 102 and her pressure
dropped down to 80 systolic.  Got .5L fluid x 2 with no
improvement in her pressures.  A right femoral line was placed
after failure to place a right IJ. She received a dose of vanc
and cipro.  An abdominal CT was largely unremarkable.

MEDICAL HISTORY: AFib
Tachy-brady s/p PPM [**3-9**]
CKD stage IV b/l ~Cr 2.2
SCC leg and neck s/p radiation [**1-9**]
4+ TR
2+ MR
[**First Name (Titles) **] [**Last Name (Titles) **] HTN
Hypothyroidism
HTN
IBS
Anemia b/l Hct ~34%
Diverticulosis

MEDICATION ON ADMISSION: 1. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] to each eye ().
2. Citalopram 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Lactaid 3,000 unit Tablet Sig: One (1) Tablet PO QAC ().
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Polyethylene Glycol 3350 100 % Powder Sig: One (1) tablespoon

ALLERGIES: Penicillins / Sulfonamides / Tetracyclines

PHYSICAL EXAM: vitals: T 95.4 BP 92/D P 64 R 24 98%2L
gen: pleasant, NAD
heent: Anicteric. OP clear. MM dry.
neck: supple, no elevated jvp. L subclavian catheter c/d/i.
[**Location (un) **]: CTAB
cv: RRR, 2/6 SEM at LLSB
abd: soft NT/ND +BS
extr: 2+ LE edema. Fragile skin with some tears on R forearm. R
1st MTP with erythema and swelling although no TTP. Ostomy bag
over former site of femoral line with small amt serous fluid.
PICC in L antecub.
neuro: Alert, oriented to [**Hospital1 18**], [**Month (only) **]. CN II-XII grossly
intact. Moving all extremities.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Retired. No current alcohol or tobacco use. Dtrs very active in
her care. Lives in house in [**Location (un) 10059**] with live-in aide.
Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin resistant Staphylococcus aureus septicemia,Severe sepsis,Septic shock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Herpes zoster with other nervous system complications,Unspecified pleural effusion,Other and unspecified coagulation defects,Acute on chronic diastolic heart failure,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Gout, unspecified,Cardiac pacemaker in situ,Atrial fibrillation,Unspecified disease of respiratory system,Unspecified acquired hypothyroidism,Other chronic pulmonary heart diseases,Thrombocytopenia, unspecified,Pressure ulcer, lower back,Hyperpotassemia
React-oth vasc dev/graft,MRSA septicemia,Severe sepsis,Septic shock,Hyp kid NOS w cr kid V,End stage renal disease,H zoster nerv syst NEC,Pleural effusion NOS,Coagulat defect NEC/NOS,Ac on chr diast hrt fail,Abn react-renal dialysis,Gout NOS,Status cardiac pacemaker,Atrial fibrillation,Resp system disease NOS,Hypothyroidism NOS,Chr pulmon heart dis NEC,Thrombocytopenia NOS,Pressure ulcer, low back,Hyperpotassemia
Admission Date:  [**2184-10-19**]              Discharge Date:   [**2184-11-2**]


Service: MEDICINE

Allergies:
Penicillins / Sulfonamides / Tetracyclines

Attending:[**First Name3 (LF) 23347**]
Chief Complaint:
Hypotension

Major Surgical or Invasive Procedure:
Hemodialysis
Right IJ central venous catheter placement attempt
Right femoral central venous catheter placement
Left IJ hemodialysis catheter removal, temporary catheter
placement, and permanent catheter placement
Left arm PICC placement

History of Present Illness:
Ms. [**Known lastname 94952**] is a [**Age over 90 **] yo female with ESRD on HD who comes in with
3 days of intermittent RUQ pain (chronic), + nausea, no
vomiting.  She visited her PCP, [**Name10 (NameIs) 1023**] documented a T about 100 and
was concerned about abd pain on exam.  He sent her to the ED
where she denied current abd pain.  She was noted to have a
slight leukocytosis, and had a CXR showing chronic effusions but
better than usual.  KUB was negative.  UA with epi's.  During
her stay, she then spiked a fever to 102 and her pressure
dropped down to 80 systolic.  Got .5L fluid x 2 with no
improvement in her pressures.  A right femoral line was placed
after failure to place a right IJ. She received a dose of vanc
and cipro.  An abdominal CT was largely unremarkable.

Of note, she was recently started on dialysis in the middle of
[**Month (only) 359**] with a HD catheter placed.  She was also seen 2 weeks
ago for LE cellulitis in the ED.  She was given a 10 day course
of levofloxacin.

Vitals in ED: T 102  HR 65  BP 84/36  97% on 4LNC  RR 24

On the floor, she is comfortable and pleasant.  She denies SOB,
f/c, chest pain, cough, HA.  She reports urinary frequency with
incomplete voiding, but denies dysuria.

Past Medical History:
AFib
Tachy-brady s/p PPM [**3-9**]
CKD stage IV b/l ~Cr 2.2
SCC leg and neck s/p radiation [**1-9**]
4+ TR
2+ MR
[**First Name (Titles) **] [**Last Name (Titles) **] HTN
Hypothyroidism
HTN
IBS
Anemia b/l Hct ~34%
Diverticulosis

Social History:
Retired. No current alcohol or tobacco use. Dtrs very active in
her care. Lives in house in [**Location (un) 10059**] with live-in aide.

Family History:
Noncontributory

Physical Exam:
vitals: T 95.4 BP 92/D P 64 R 24 98%2L
gen: pleasant, NAD
heent: Anicteric. OP clear. MM dry.
neck: supple, no elevated jvp. L subclavian catheter c/d/i.
[**Location (un) **]: CTAB
cv: RRR, 2/6 SEM at LLSB
abd: soft NT/ND +BS
extr: 2+ LE edema. Fragile skin with some tears on R forearm. R
1st MTP with erythema and swelling although no TTP. Ostomy bag
over former site of femoral line with small amt serous fluid.
PICC in L antecub.
neuro: Alert, oriented to [**Hospital1 18**], [**Month (only) **]. CN II-XII grossly
intact. Moving all extremities.

Pertinent Results:
Admission Labs:
[**2184-10-19**] 01:40PM BLOOD WBC-12.3*# RBC-3.09* Hgb-11.4* Hct-35.8*
MCV-116* MCH-36.8* MCHC-31.8 RDW-20.2* Plt Ct-131*
[**2184-10-19**] 01:40PM BLOOD Neuts-89.4* Lymphs-5.6* Monos-4.6 Eos-0.2
Baso-0.1
[**2184-10-19**] 06:50PM BLOOD PT-26.7* PTT-38.8* INR(PT)-2.7*
[**2184-10-19**] 06:50PM BLOOD Glucose-108* UreaN-24* Creat-2.2* Na-144
K-3.9 Cl-100 HCO3-29 AnGap-19
[**2184-10-19**] 06:50PM BLOOD ALT-17 AST-34 AlkPhos-197* TotBili-1.2
[**2184-10-19**] 06:50PM BLOOD Lipase-25
[**2184-10-19**] 06:50PM BLOOD Albumin-3.6 Calcium-9.0 Phos-2.4* Mg-1.5*

Interval Labs:
[**2184-10-19**] 11:28PM BLOOD WBC-11.4* RBC-2.46* Hgb-9.0* Hct-27.9*
MCV-114* MCH-36.6* MCHC-32.2 RDW-21.3* Plt Ct-113*
[**2184-10-26**] 05:56AM BLOOD WBC-6.3 RBC-2.34* Hgb-8.5* Hct-26.1*
MCV-112* MCH-36.2* MCHC-32.4 RDW-20.4* Plt Ct-112*
[**2184-10-31**] 05:20AM BLOOD WBC-7.3 RBC-2.20* Hgb-8.1* Hct-25.2*
MCV-115* MCH-36.7* MCHC-31.9 RDW-20.0* Plt Ct-184
[**2184-10-21**] 05:34AM BLOOD PT-40.2* PTT-45.3* INR(PT)-4.4*
[**2184-10-25**] 04:08AM BLOOD PT-16.0* PTT-37.1* INR(PT)-1.4*
[**2184-10-20**] 10:40AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.024
[**2184-10-20**] 10:40AM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-SM
[**2184-10-20**] 10:40AM URINE RBC-[**10-21**]* WBC-[**10-21**]* Bacteri-MANY
Yeast-NONE Epi-011/25/08 05:56AM BLOOD VitB12-1392* Folate-11.9

Discharge Labs:
******

Micro Data:
[**2184-10-19**] blood cultures: 4/4 bottles positive for MRSA
[**2184-10-20**] blood cultures: 2/4 bottles positive for MRSA
[**2184-10-20**] catheter tip: positive for MRSA
[**2184-10-20**] urine culture: GRAM POSITIVE BACTERIA. 10,000-100,000
Alpha hemolytic colonies consistent with alpha streptococcus or
Lactobacillus sp.
Blood cultures 11/20, [**10-21**], [**10-22**], [**10-23**], [**10-25**]: no growth

Imaging:
CXR [**2184-10-19**]: 1. Cardiomegaly with mild pulmonary edema and
moderate-sized bilateral pleural effusions, right greater than
left.
2. Interval placement of left-sided hemodialysis catheter with
the tip within the right atrium.
3. Unchanged right-sided dual-chamber pacemaker.

CT Abd/Pelvis [**2184-10-19**]:
1. No evidence of abcess or acute abdominal process.
2. Bilateral pleural effusion, right greater than left,
measuring simple
fluid attenuation. Trace pericardial effusion and small amount
of abdominal / pelvic ascites.
3. Possible sludge or stone in the gallbladder without evidence
of
cholelithiasis.
4. Sigmoid diverticulosis without evidence of diverticulitis.

Echo [**2184-10-25**]: Right atrial pressure is 10-15mmHg. LVEF>55%.
Increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular cavity is moderately dilated with mild global
free wall hypokinesis. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid regurgitation.] There is abnormal septal motion c/w
right ventricular pressure and volume overload. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
to severe pulmonary artery systolic hypertension. Significant
pulmonic regurgitation is seen. No vegetations seen.

Right foot plain films ([**10-25**]): No acute fracture. Soft tissue
swelling along the medial aspect of the foot centered at the
first MTP joint.

CXR ([**10-25**]): Moderate bilateral pleural effusion, right greater
than left, continues to increase.

Brief Hospital Course:
1) Septic shock: Secondary to MRSA infection of HD catheter. The
catheter was removed and subsequent blood cultures were all
negative. TTE showed no vegetations. She initially required
levophed for hypotension and was treated with vancomycin and
cefepime, but the cefepime was stopped after cultures showed
MRSA in the blood. She had a temporary IJ HD line placed, which
was later changed to a permanent line. A PICC was also placed
for access and antibiotics. She was weaned off the levophed and
transferred out of the ICU, where she remained afebrile and
hemodynamically stable, with SBP improved to 110s. Due to the
fluids received for resuscitation, she was significantly
hypervolemic, with pleural effusions and anasarca. She was
weaned off supplemental O2 and continued on HD, where some of
the excess fluid was removed. The vancomycin will continue at HD
for two weeks after the first negative blood culture, ie, until
[**11-4**]. Her PICC was removed at discharge.

2) Gout: Painful and swollen right 1st MTP noted and podiatry
was consulted. Steroids were avoided due to her recent septic
shock. She responded well to a 4 day course of indomethacin.

3) Macrocytic anemia: Initial hematocrit drop in setting of IV
fluid resuscitation. Patient was guaiac negative. She remained
stable in the mid to upper 20s, although this was below her
prior baseline. B12 and folate were normal. She was given epo at
HD, and later iron was added.

4) Afib with tachy-brady: Metoprolol was held throughout the
admission as the patient had no hypertension or tachycardia. Her
INR was initially supratherapeutic and vitamin K was given. It
later became subtherapeutic and her warfarin was restarted.

5) Post-herpetic neuralgia: Patient had intermittent pain under
L breast that responded well to capsaicin cream, tylenol and
warm compresses. As an outpatient, she can be evaluated for
long-term therapy, such as with gabapentin or venlafaxine.

6) Abdominal pain: Noted intermittently and often not
reproducible on exam. Thought to be related to IBS or
constipation, or possibly fluid shifts from HD. She was kept on
an aggressive bowel regimen to relieve constipation.

[**Hospital 100**] Rehab to do:
[ ] blood transfusion (2 u pRBCs) with hemodialysis on [**11-5**]
[ ] hemodialysis [**11-5**]
[ ] follow INR

Medications on Admission:
1. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] to each eye ().
2. Citalopram 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Lactaid 3,000 unit Tablet Sig: One (1) Tablet PO QAC ().
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Polyethylene Glycol 3350 100 % Powder Sig: One (1) tablespoon

powder PO once daily as directed.
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap

PO DAILY (Daily).
7. Warfarin 2.5 mg
8. Nystatin 100,000 unit/g Cream Sig: One (1) application
Topical twice a day as needed for itching.
9. Metoprolol Tartrate 12.5 [**Hospital1 **]
10. Citracal + D 315-200 mg-unit Tablet two [**Hospital1 **]
11. Senna 8.6 mg qhs

Discharge Medications:
1. Cyclosporine 0.05 % Dropperette Sig: One (1)  Ophthalmic [**Hospital1 **]
(2 times a day): to each eye.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Polyethylene Glycol 3350 100 % Powder Sig: One (1) tablespoon
PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Lactaid 3,000 unit Tablet Sig: One (1) Tablet PO before
meals.
9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
11. Citracal + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO
twice a day.
12. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for shoulder pain.
13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

14. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q4H (every 4 hours) as
needed.
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours.
18. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed.
19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
20. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous HD PROTOCOL (HD Protochol) for 1 doses: Give at HD
on [**11-5**].
21. Capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3
times a day).
22. Trazodone 50 mg Tablet Sig: 0.75 Tablet PO HS (at bedtime)
as needed for insomnia.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Primary:
Septicemia from Methicillin Resistant Staphylococcus Aureus

Secondary:
End stage renal disease
Atrial fibrillation
Irritable bowel syndrome
Post-herpetic neuralgia
Chronic anemia


Discharge Condition:
Hemodynamically stable, afebrile


Discharge Instructions:
You were admitted to [**Hospital1 18**] due to an infection called MRSA in
your bloodstream, that initially was treated in the ICU. You
received IV fluids and an antibiotic called vancomycin, which
controlled this infection. We were able to remove some of your
excess fluid build up with dialysis, and this will continue as
an outpatient.

Please take all medications as prescribed and go to all follow
up appointments. We have made the following medication changes:
- Increased your citalopram (Celexa) dose.
- Restarted your atorvastatin (for high cholesterol) and
pantoprazole (stomach acid blocker).
- Stopped your metoprolol as your blood pressure and heart rate
were not elevated.
- You will receive a dose of vancomycin at your next dialysis
session ([**11-5**]).
- You have been started on tylenol, capsaicin cream for pain
control
- You have been started on trazodone for sleep
- You have been started on simethicone for gas

If you experience fevers, chills, difficulty breathing,
confusion, chest pain, vomiting, diarrhea, or any other
concerning symptoms, please seek medical attention or come to
the ER immediately.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.

Followup Instructions:
Please call your PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 719**] to schedule
a follow up appointment.

Continue your dialysis Monday, Wednesday and Friday at [**Hospital 100**]
Rehab.
Your INR will be followed at [**Hospital 100**] Rehab.


                             [**Name6 (MD) **] [**Last Name (NamePattern4) 23348**] MD, [**MD Number(3) 23349**]
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin resistant Staphylococcus aureus septicemia,Severe sepsis,Septic shock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Herpes zoster with other nervous system complications,Unspecified pleural effusion,Other and unspecified coagulation defects,Acute on chronic diastolic heart failure,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Gout, unspecified,Cardiac pacemaker in situ,Atrial fibrillation,Unspecified disease of respiratory system,Unspecified acquired hypothyroidism,Other chronic pulmonary heart diseases,Thrombocytopenia, unspecified,Pressure ulcer, lower back,Hyperpotassemia'}


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: Ms. [**Known lastname 94952**] is a [**Age over 90 **] yo female with ESRD on HD who comes in with
3 days of intermittent RUQ pain (chronic), + nausea, no
vomiting.  She visited her PCP, [**Name10 (NameIs) 1023**] documented a T about 100 and
was concerned about abd pain on exam.  He sent her to the ED
where she denied current abd pain.  She was noted to have a
slight leukocytosis, and had a CXR showing chronic effusions but
better than usual.  KUB was negative.  UA with epi's.  During
her stay, she then spiked a fever to 102 and her pressure
dropped down to 80 systolic.  Got .5L fluid x 2 with no
improvement in her pressures.  A right femoral line was placed
after failure to place a right IJ. She received a dose of vanc
and cipro.  An abdominal CT was largely unremarkable.

MEDICAL HISTORY: AFib
Tachy-brady s/p PPM [**3-9**]
CKD stage IV b/l ~Cr 2.2
SCC leg and neck s/p radiation [**1-9**]
4+ TR
2+ MR
[**First Name (Titles) **] [**Last Name (Titles) **] HTN
Hypothyroidism
HTN
IBS
Anemia b/l Hct ~34%
Diverticulosis

MEDICATION ON ADMISSION: 1. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] to each eye ().
2. Citalopram 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Lactaid 3,000 unit Tablet Sig: One (1) Tablet PO QAC ().
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Polyethylene Glycol 3350 100 % Powder Sig: One (1) tablespoon

ALLERGIES: Penicillins / Sulfonamides / Tetracyclines

PHYSICAL EXAM: vitals: T 95.4 BP 92/D P 64 R 24 98%2L
gen: pleasant, NAD
heent: Anicteric. OP clear. MM dry.
neck: supple, no elevated jvp. L subclavian catheter c/d/i.
[**Location (un) **]: CTAB
cv: RRR, 2/6 SEM at LLSB
abd: soft NT/ND +BS
extr: 2+ LE edema. Fragile skin with some tears on R forearm. R
1st MTP with erythema and swelling although no TTP. Ostomy bag
over former site of femoral line with small amt serous fluid.
PICC in L antecub.
neuro: Alert, oriented to [**Hospital1 18**], [**Month (only) **]. CN II-XII grossly
intact. Moving all extremities.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Retired. No current alcohol or tobacco use. Dtrs very active in
her care. Lives in house in [**Location (un) 10059**] with live-in aide. 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin resistant Staphylococcus aureus septicemia,Severe sepsis,Septic shock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Herpes zoster with other nervous system complications,Unspecified pleural effusion,Other and unspecified coagulation defects,Acute on chronic diastolic heart failure,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Gout, unspecified,Cardiac pacemaker in situ,Atrial fibrillation,Unspecified disease of respiratory system,Unspecified acquired hypothyroidism,Other chronic pulmonary heart diseases,Thrombocytopenia, unspecified,Pressure ulcer, lower back,Hyperpotassemia'}
