CHIEF COMPLAINT: CC: Low Blood Pressure

PRESENT ILLNESS: 57 y.o. Female with HCV cirrhosis, ESRD on HD s/p failed renal
transplant, seizure, HTN, recently dx ovarian mass,
hypothyroidism s/p thyroidectomy referred to the ED from HD for
hypotension. Admitted to ICU for hypotension.
.
Ms. [**Known lastname 3671**] states over the past few days she has noted
intermittent episodes of lightheadedness particularly
orthostasis symptoms, she denies any episodes of syncope. She
was in dialysis today with a reported (per pt) systolic BP 108
laying down and mid 90s sitting she thinks she fell asleep
during dialysis. She woke up at the end of dialysis and not her
dialysis run was finished, the HD RNs were also next to her
telling her her BP was low. Per report from the ED her BPs in
dialysis were in ther 70s after her run, she was given 1L of NS
with no improvement with her BPs which is why she was referred
to the ED. She denies any consitutional symptoms such as nausea,
vomiting, fevers, chills. She does endorse a 5 day history of
sore throat, rhinorrhea which has now improved. She has also had
a dry cough x 3 days. She denies any SOB or DOE. She states that
she has been under a lot of stress over the passt few days, she
lives at home with her sister who is 'unstable' and lead to them
having to move out. She has been trying to move out of her place
for the past few days. Due to the stress she states she is not
eating or drinking as much but denies feeling dehydrated.
.
In the ED initial VS were noted to be T97.8, HR 87, BP 102/47,
RR 16, Sat 96% RA. In the room however she was noted to be
'[**Name6 (MD) 98153**] [**Name8 (MD) **] RN note and triggered for a BP 78/47, HR 82, RR
12, Sat 100% on RA. Per ED signout pt was noted to have foggy
thinking but no evidence of chest pain, lightheadedness. Given
the level of hypotension which trended down to systolic of 69 a
rt femoral line was placed. Pt was given 1gm of Vancomycin, 2L
NS with a BP improvement to 89-93 systolic. An EKG showed SR 74
bpm, STD V3-V4, TWI V3-V6. Pt received and additional 2 L of NS
in the ED with BPs remaining 92/48, BP improved to 92/48 after 2
more litres of NS her BP was noted to be 101. In total pt
received 1L NS at HD and an extra 4L NS in the ED.
.
CXR in the ED showed linear scarring in lung bases that was
unchanged from priors. His initial labwork was notable for WBC
5.9, Hgb/Hct 12.1/35.4, plt 146. chem panel was notable for K of
6.2, BUN/Cr 13/3.3. Repear K was then 3.6 and then 2.9, lactate
1.7. Pt also 750mg Levofloxacin in addition to Vancomycin for
empiric coverage.
.
Of note she has been admitted twice over the past 2 months for
hypotension pre and post dialysis. Her first admission was
[**2129-4-23**] and was thought to be [**2-16**] aggressive BP regimen as
well as the pt inappropriately taking her medications. She was
taking nitroglycerin every day as opposed to PRN. She was also
noted to be hypothyroid, likely not adherent to her snythroid
medication. She was ruled out for adrenal insufficiency. Outpt
Nephrologist reports dry weight as 74kg. On [**5-12**] she was
referred to the ED for abdominal pain and triggered in the ED
for a BP in the 70s. Again her hypotension was easily corrected
with fluid and thought to be [**2-16**] BP regimen.

MEDICAL HISTORY: -HTN
-ESRD on hemodialysis
-HCV cirrhosis
-spinal stenosis with back pain
-seizure disorder
-depression
-hypothyroidism
-substance abuse
-Lumbar laminectomy
-status post failed renal transplant
-cholecystectomy
-thyroidectomy
-Rt ovarian mass

MEDICATION ON ADMISSION: 1. Levetiracetam 250 mg [**Hospital1 **]
2. Fluticasone-salmeterol 250-50 mcg/dose INH [**Hospital1 **]
3. Gabapentin 300 mg qHD
4. Clonazepam 0.5 mg [**Hospital1 **] PRN
5. Methadone 44mg daily
6. Fluoxetine 60 mg daily
7. ASA 81 mg daily
8. Simvastatin 20 mg daily
9. Omeprazole 20 mg daily
10. Folic acid 1 mg daily
11. Trazodone 50 mg qHS PRN
12. B complex-vitamin C-folic acid 1 mg Daily
13. Calcium acetate 667 mg 2 Capsule TID W/MEALS
14. Levothyroxine 188 mcg daily
15. calcium carbonate 200 mg calcium (500 mg) PO BID
17. Vitamin D 1,000 unit daily
18. Hydromorphone 4-8 mg q4hrs PRN

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: GEN: African American Female laying down in bed tearful,
comfortable, NAD
HEENT: PERRL, EOMI, anicteric, mildly dry MM
Neck: No thyroid palpated, no cervical LAD
RESP: Bibasilar inspiratory crackles otherwise CTA
CV: S1, S2,  II/VI murmur referred from the graft
ABD: Soft, mild tenderness over RLQ, tympanetic to percussion,
old surgical scars noted midline
EXT: No edema, no asterixis. Left arm fistula +bruits/+thrills
SKIN: no rashes/no jaundice/dry skin
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout.

FAMILY HISTORY: Father: ESRD and hypertension
Mother: lung cancer

SOCIAL HISTORY: Retired special education teacher. Widowed, lives at home with
sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy.
# Tobacco: 3 packs per week since teenager
# Alcohol: Denies
# Drugs: Past IVDU, but not in several years
Other iatrogenic hypotension,End stage renal disease,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other drugs and medicinal substances causing adverse effects in therapeutic use,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Renal dialysis status,Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Postsurgical hypothyroidism,Epilepsy, unspecified, without mention of intractable epilepsy,Cocaine abuse, in remission,Coronary atherosclerosis of native coronary artery,Backache, unspecified,Other chronic pain,Asthma, unspecified type, unspecified,Depressive disorder, not elsewhere classified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Anemia in chronic kidney disease,Personal history of noncompliance with medical treatment, presenting hazards to health,Other secondary thrombocytopenia,Benign neoplasm of ovary,Nonspecific abnormal electrocardiogram [ECG] [EKG],Hypopotassemia
Iatrogenc hypotnsion NEC,End stage renal disease,Compl kidney transplant,Hyp kid NOS w cr kid V,Abn react-renal dialysis,Adv eff medicinal NEC,Abn react-org transplant,Renal dialysis status,Hpt C w/o hepat coma NOS,Cirrhosis of liver NOS,Postsurgical hypothyroid,Epilep NOS w/o intr epil,Cocaine abuse-in remiss,Crnry athrscl natve vssl,Backache NOS,Chronic pain NEC,Asthma NOS,Depressive disorder NEC,Migrne unsp wo ntrc mgrn,Anemia in chr kidney dis,Hx of past noncompliance,Sec thrombocytpenia NEC,Benign neoplasm ovary,Abnorm electrocardiogram,Hypopotassemia
Admission Date:  [**2129-6-22**]              Discharge Date:   [**2129-6-23**]

Date of Birth:  [**2072-5-1**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 8404**]
Chief Complaint:
CC: Low Blood Pressure


Major Surgical or Invasive Procedure:
None.


History of Present Illness:
57 y.o. Female with HCV cirrhosis, ESRD on HD s/p failed renal
transplant, seizure, HTN, recently dx ovarian mass,
hypothyroidism s/p thyroidectomy referred to the ED from HD for
hypotension. Admitted to ICU for hypotension.
.
Ms. [**Known lastname 3671**] states over the past few days she has noted
intermittent episodes of lightheadedness particularly
orthostasis symptoms, she denies any episodes of syncope. She
was in dialysis today with a reported (per pt) systolic BP 108
laying down and mid 90s sitting she thinks she fell asleep
during dialysis. She woke up at the end of dialysis and not her
dialysis run was finished, the HD RNs were also next to her
telling her her BP was low. Per report from the ED her BPs in
dialysis were in ther 70s after her run, she was given 1L of NS
with no improvement with her BPs which is why she was referred
to the ED. She denies any consitutional symptoms such as nausea,
vomiting, fevers, chills. She does endorse a 5 day history of
sore throat, rhinorrhea which has now improved. She has also had
a dry cough x 3 days. She denies any SOB or DOE. She states that
she has been under a lot of stress over the passt few days, she
lives at home with her sister who is 'unstable' and lead to them
having to move out. She has been trying to move out of her place
for the past few days. Due to the stress she states she is not
eating or drinking as much but denies feeling dehydrated.
.
In the ED initial VS were noted to be T97.8, HR 87, BP 102/47,
RR 16, Sat 96% RA. In the room however she was noted to be
'[**Name6 (MD) 98153**] [**Name8 (MD) **] RN note and triggered for a BP 78/47, HR 82, RR
12, Sat 100% on RA. Per ED signout pt was noted to have foggy
thinking but no evidence of chest pain, lightheadedness. Given
the level of hypotension which trended down to systolic of 69 a
rt femoral line was placed. Pt was given 1gm of Vancomycin, 2L
NS with a BP improvement to 89-93 systolic. An EKG showed SR 74
bpm, STD V3-V4, TWI V3-V6. Pt received and additional 2 L of NS
in the ED with BPs remaining 92/48, BP improved to 92/48 after 2
more litres of NS her BP was noted to be 101. In total pt
received 1L NS at HD and an extra 4L NS in the ED.
.
CXR in the ED showed linear scarring in lung bases that was
unchanged from priors. His initial labwork was notable for WBC
5.9, Hgb/Hct 12.1/35.4, plt 146. chem panel was notable for K of
6.2, BUN/Cr 13/3.3. Repear K was then 3.6 and then 2.9, lactate
1.7. Pt also 750mg Levofloxacin in addition to Vancomycin for
empiric coverage.
.
Of note she has been admitted twice over the past 2 months for
hypotension pre and post dialysis. Her first admission was
[**2129-4-23**] and was thought to be [**2-16**] aggressive BP regimen as
well as the pt inappropriately taking her medications. She was
taking nitroglycerin every day as opposed to PRN. She was also
noted to be hypothyroid, likely not adherent to her snythroid
medication. She was ruled out for adrenal insufficiency. Outpt
Nephrologist reports dry weight as 74kg. On [**5-12**] she was
referred to the ED for abdominal pain and triggered in the ED
for a BP in the 70s. Again her hypotension was easily corrected
with fluid and thought to be [**2-16**] BP regimen.

Past Medical History:
-HTN
-ESRD on hemodialysis
-HCV cirrhosis
-spinal stenosis with back pain
-seizure disorder
-depression
-hypothyroidism
-substance abuse
-Lumbar laminectomy
-status post failed renal transplant
-cholecystectomy
-thyroidectomy
-Rt ovarian mass

Social History:
Retired special education teacher. Widowed, lives at home with
sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy.
# Tobacco: 3 packs per week since teenager
# Alcohol: Denies
# Drugs: Past IVDU, but not in several years


Family History:
Father: ESRD and hypertension
Mother: lung cancer


Physical Exam:
GEN: African American Female laying down in bed tearful,
comfortable, NAD
HEENT: PERRL, EOMI, anicteric, mildly dry MM
Neck: No thyroid palpated, no cervical LAD
RESP: Bibasilar inspiratory crackles otherwise CTA
CV: S1, S2,  II/VI murmur referred from the graft
ABD: Soft, mild tenderness over RLQ, tympanetic to percussion,
old surgical scars noted midline
EXT: No edema, no asterixis. Left arm fistula +bruits/+thrills
SKIN: no rashes/no jaundice/dry skin
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout.


Pertinent Results:
[**2129-6-22**] 11:20PM   SODIUM-142 POTASSIUM-4.6 CHLORIDE-106
[**2129-6-22**] 11:20PM   CK(CPK)-59
[**2129-6-22**] 11:20PM   CK-MB-3 cTropnT-0.05*
[**2129-6-22**] 07:01PM   PT-16.4* PTT-28.1 INR(PT)-1.4*
[**2129-6-22**] 05:58PM   LACTATE-1.7
[**2129-6-22**] 05:52PM   GLUCOSE-109* UREA N-10 CREAT-3.0* SODIUM-144
POTASSIUM-2.9* CHLORIDE-106 TOTAL CO2-28 ANION GAP-13
[**2129-6-22**] 05:52PM   TSH-0.45
[**2129-6-22**] 05:04PM   GLUCOSE-130* K+-3.6
[**2129-6-22**] 05:00PM   GLUCOSE-130* UREA N-13 CREAT-3.3*# SODIUM-137
POTASSIUM-6.2* CHLORIDE-95* TOTAL CO2-31 ANION GAP-17
[**2129-6-22**] 05:00PM   estGFR-Using this
[**2129-6-22**] 05:00PM   WBC-5.9 RBC-3.86* HGB-12.1 HCT-35.4* MCV-92
MCH-31.4 MCHC-34.3 RDW-17.0*
[**2129-6-22**] 05:00PM   NEUTS-66.4 LYMPHS-24.6 MONOS-5.9 EOS-2.6
BASOS-0.5
[**2129-6-22**] 05:00PM   PLT COUNT-146*

CXR [**2129-6-22**]:  Stable scarring of bilateral lower lungs. No acute
process.

EKG [**2129-6-22**]:  Sinus rhythm. Extensive ST-T wave changes are
non-specific although cannot exclude myocardial ischemia.
Compared to the previous tracing of [**2129-5-20**] the ST-T wave changes
are slightly more prominent in the precordial leads. The other
findings are similar.

EKG [**2129-6-23**]:  Sinus rhythm. Non-specific inferior and anterior T
wave changes. Cannot exclude ischemia. Compared to the previous
tracing of [**2129-6-22**] no diagnostic interim change.

TTE [**2129-6-23**]:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.

IMPRESSION: Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. No clinically significant valvular
regurgitation or stenosis. Normal pulmonary artery systolic
pressure.

Compared with the prior study (images reviewed) of [**2128-2-20**],
mild mitral regurgitation is no longer present and the pulmonary
artery systolic pressure has normalized.


Brief Hospital Course:
57 y.o. Female with a history of HTN, HCV cirrhosis, ESRD on HD
s/p failed renal transplant, seizure d.o., depression,
hypothyroidism, substance abuse referred to the ED for
hypotension at dialysis. Admitted to the ICU for hypotension.
.
# Hypotension:  Pt admitted with systolic BPs in the 70s with
improvement to 100s after 5L of NS. On review of Ms. [**Known lastname 21913**]
history in OMR this is the 3rd time she has presented to the ED
with BPs in the mid 70s requiring ICU care. On review of the
discharge summaries, her prior work ups have included infectious
(with neg cx), adrenal insufficiency ([**4-/2129**] [**Last Name (un) 104**] stim to 32.1
from 7.8). She has been noted to have TSH >100 and 5.6 in the
past; however most recent TSH was improved. There concerns that
this may be medication-related given she is taking multiple
medications for pain which may cause hypotension, but the
patient reports compliance with her medication regimen.  During
this admission, the patient's episode occurred during HD and she
was given fluid back which was initially removed but still
became hypotensive to the 70's following HD.  It is believed
that the fluid shifts and hypoveolemia [**2-16**] dialysis. She
endorsed decreased PO intake, orthostatic symptoms and her BP
and symptoms improved with IVF.  She was placed on Levo/Vanc to
cover for possible HAP vs CAP initially, but antibiotics were
subsequently discontinued as she had no infectious symptoms, was
afebrile, and had no leukocytosis.  Renal felt her hypotension
was again related to overuse of pain medications, and the
patient was informed the that strict medication compliance is
essential.  Her blood pressures remained stable in the MICU back
at her baseline and she was discharged the following day.
.
# EKG Changes/CAD: Pt had acute on chronic non-specific ST
changes on EKG in the ED.  She denied any chest pain or
tightness and her prior cath in [**2128-12-15**] showed non
obstructive CAD. Repeat EKG was unchanged, CE's were negative,
and the patient underwent a TTE which showed no wall motion
abnormalities.  She was continued on ASA 81mg, Simvastatin and
was closely monitored without incident.
.
# Hypokalemia: Unclear as to the etiology, pt had dialysis but
her K bath is unlikely to have been as low as 2.9. The pt
received K in the ED, and her K+ was rechecked.
.
# Hypothyroidism: Continued levothyroxine 188mcg.  TSH was wnl.
.
# ESRD on HD: Will notify renal of admission, continue on home
regimen of Calcium Acetate
.
# HCV Cirrhosis: Last liver bx [**2121**] grade 1 fibrosis. No
evidence of asterixis, hepatic decompensation on examination. Pt
has underlying mild coagulopathy with INR 1.4-1.5, thought [**2-16**]
depressed hepatic synthetic function.
.
# Thrombocytopenia: Pt has chronic thrombocytopenia likely [**2-16**]
cirrhosis, splenomegaly.
.
# Seizure Disorder: Continued on Keppra 250 mg [**Hospital1 **].
.
# Depression/Anxiety: Continued on fluoxetine 60 mg daily.
.
# Rt Ovarian Mass: Pt recently diagnosed with rt ovarian mass
which was thought to be benign, pt on Dilaudid PRN for RLQ pain.
 Home Dilaudid PRN was continued.
.
# Methadone: Called Habit OpCo and confirmed Methadone dose was
54mg daily, and she was given a dose at 2pm the day of
discharge.  Unclear if this is for her IVDU history vs chronic
pain.  Was contact[**Name (NI) **] by the [**Hospital 228**] [**Hospital 2514**] Clinic following
her discharge and informed them of the hospital course.
.
## Code status: FULL CODE

Medications on Admission:
1. Levetiracetam 250 mg [**Hospital1 **]
2. Fluticasone-salmeterol 250-50 mcg/dose INH [**Hospital1 **]
3. Gabapentin 300 mg qHD
4. Clonazepam 0.5 mg [**Hospital1 **] PRN
5. Methadone 44mg daily
6. Fluoxetine 60 mg daily
7. ASA 81 mg daily
8. Simvastatin 20 mg daily
9. Omeprazole 20 mg daily
10. Folic acid 1 mg daily
11. Trazodone 50 mg qHS PRN
12. B complex-vitamin C-folic acid 1 mg Daily
13. Calcium acetate 667 mg 2 Capsule TID W/MEALS
14. Levothyroxine 188 mcg daily
15. calcium carbonate 200 mg calcium (500 mg) PO BID
17. Vitamin D 1,000 unit daily
18. Hydromorphone 4-8 mg q4hrs PRN

Discharge Medications:
1. methadone 10 mg/5 mL Solution Sig: Fifty Four (54) mg PO
DAILY (Daily).
2. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
[**1-16**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
6. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
13. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Total of 188mcg daily.
15. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a
day: Total of 188mcg daily.
16. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
17. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
18. hydromorphone 2 mg Tablet Sig: 2-4 Tablets PO every four (4)
hours as needed for pain.


Discharge Disposition:
Home

Discharge Diagnosis:
Hypotension (low blood pressure)


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.


Discharge Instructions:
You presented to the hospital for low blood pressures during
your hemodialysis sessions.  Your electrocardiogram tracings of
your heart rhythm showed changes which were concerning for
insufficient blood supply to your heart when your blood
pressures were low.  You underwent an echocardiogram which did
not show any concerning abnormalities, and a repeat
electrocardiogram showed improvement of the abnormalities in the
setting of improved blood pressures.  Your low blood pressures
may be due to decreased fluid content in your body following
dialysis, or from some of your medications.  You were seen by
the kidney specialists in the ICU and you will resume dialysis
according to your usual schedule when you leave the hospital.

No changes were made to your home medications.  Please discuss
your medications, particularly your pain medications, with your
primary care physician to determine whether they may be causing
low blood pressure.

Followup Instructions:
Department: ENDO SUITES
When: FRIDAY [**2129-7-1**] at 3:00 PM

Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2129-7-1**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST     Best Parking: Main Garage

Department: ADVANCED VASC. CARE CNT
When: TUESDAY [**2129-9-6**] at 2:00 PM
With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]
{'Other iatrogenic hypotension,End stage renal disease,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other drugs and medicinal substances causing adverse effects in therapeutic use,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Renal dialysis status,Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Postsurgical hypothyroidism,Epilepsy, unspecified, without mention of intractable epilepsy,Cocaine abuse, in remission,Coronary atherosclerosis of native coronary artery,Backache, unspecified,Other chronic pain,Asthma, unspecified type, unspecified,Depressive disorder, not elsewhere classified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Anemia in chronic kidney disease,Personal history of noncompliance with medical treatment, presenting hazards to health,Other secondary thrombocytopenia,Benign neoplasm of ovary,Nonspecific abnormal electrocardiogram [ECG] [EKG],Hypopotassemia'}


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: CC: Low Blood Pressure

PRESENT ILLNESS: 57 y.o. Female with HCV cirrhosis, ESRD on HD s/p failed renal
transplant, seizure, HTN, recently dx ovarian mass,
hypothyroidism s/p thyroidectomy referred to the ED from HD for
hypotension. Admitted to ICU for hypotension.
.
Ms. [**Known lastname 3671**] states over the past few days she has noted
intermittent episodes of lightheadedness particularly
orthostasis symptoms, she denies any episodes of syncope. She
was in dialysis today with a reported (per pt) systolic BP 108
laying down and mid 90s sitting she thinks she fell asleep
during dialysis. She woke up at the end of dialysis and not her
dialysis run was finished, the HD RNs were also next to her
telling her her BP was low. Per report from the ED her BPs in
dialysis were in ther 70s after her run, she was given 1L of NS
with no improvement with her BPs which is why she was referred
to the ED. She denies any consitutional symptoms such as nausea,
vomiting, fevers, chills. She does endorse a 5 day history of
sore throat, rhinorrhea which has now improved. She has also had
a dry cough x 3 days. She denies any SOB or DOE. She states that
she has been under a lot of stress over the passt few days, she
lives at home with her sister who is 'unstable' and lead to them
having to move out. She has been trying to move out of her place
for the past few days. Due to the stress she states she is not
eating or drinking as much but denies feeling dehydrated.
.
In the ED initial VS were noted to be T97.8, HR 87, BP 102/47,
RR 16, Sat 96% RA. In the room however she was noted to be
'[**Name6 (MD) 98153**] [**Name8 (MD) **] RN note and triggered for a BP 78/47, HR 82, RR
12, Sat 100% on RA. Per ED signout pt was noted to have foggy
thinking but no evidence of chest pain, lightheadedness. Given
the level of hypotension which trended down to systolic of 69 a
rt femoral line was placed. Pt was given 1gm of Vancomycin, 2L
NS with a BP improvement to 89-93 systolic. An EKG showed SR 74
bpm, STD V3-V4, TWI V3-V6. Pt received and additional 2 L of NS
in the ED with BPs remaining 92/48, BP improved to 92/48 after 2
more litres of NS her BP was noted to be 101. In total pt
received 1L NS at HD and an extra 4L NS in the ED.
.
CXR in the ED showed linear scarring in lung bases that was
unchanged from priors. His initial labwork was notable for WBC
5.9, Hgb/Hct 12.1/35.4, plt 146. chem panel was notable for K of
6.2, BUN/Cr 13/3.3. Repear K was then 3.6 and then 2.9, lactate
1.7. Pt also 750mg Levofloxacin in addition to Vancomycin for
empiric coverage.
.
Of note she has been admitted twice over the past 2 months for
hypotension pre and post dialysis. Her first admission was
[**2129-4-23**] and was thought to be [**2-16**] aggressive BP regimen as
well as the pt inappropriately taking her medications. She was
taking nitroglycerin every day as opposed to PRN. She was also
noted to be hypothyroid, likely not adherent to her snythroid
medication. She was ruled out for adrenal insufficiency. Outpt
Nephrologist reports dry weight as 74kg. On [**5-12**] she was
referred to the ED for abdominal pain and triggered in the ED
for a BP in the 70s. Again her hypotension was easily corrected
with fluid and thought to be [**2-16**] BP regimen.

MEDICAL HISTORY: -HTN
-ESRD on hemodialysis
-HCV cirrhosis
-spinal stenosis with back pain
-seizure disorder
-depression
-hypothyroidism
-substance abuse
-Lumbar laminectomy
-status post failed renal transplant
-cholecystectomy
-thyroidectomy
-Rt ovarian mass

MEDICATION ON ADMISSION: 1. Levetiracetam 250 mg [**Hospital1 **]
2. Fluticasone-salmeterol 250-50 mcg/dose INH [**Hospital1 **]
3. Gabapentin 300 mg qHD
4. Clonazepam 0.5 mg [**Hospital1 **] PRN
5. Methadone 44mg daily
6. Fluoxetine 60 mg daily
7. ASA 81 mg daily
8. Simvastatin 20 mg daily
9. Omeprazole 20 mg daily
10. Folic acid 1 mg daily
11. Trazodone 50 mg qHS PRN
12. B complex-vitamin C-folic acid 1 mg Daily
13. Calcium acetate 667 mg 2 Capsule TID W/MEALS
14. Levothyroxine 188 mcg daily
15. calcium carbonate 200 mg calcium (500 mg) PO BID
17. Vitamin D 1,000 unit daily
18. Hydromorphone 4-8 mg q4hrs PRN

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: GEN: African American Female laying down in bed tearful,
comfortable, NAD
HEENT: PERRL, EOMI, anicteric, mildly dry MM
Neck: No thyroid palpated, no cervical LAD
RESP: Bibasilar inspiratory crackles otherwise CTA
CV: S1, S2,  II/VI murmur referred from the graft
ABD: Soft, mild tenderness over RLQ, tympanetic to percussion,
old surgical scars noted midline
EXT: No edema, no asterixis. Left arm fistula +bruits/+thrills
SKIN: no rashes/no jaundice/dry skin
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout.

FAMILY HISTORY: Father: ESRD and hypertension
Mother: lung cancer

SOCIAL HISTORY: Retired special education teacher. Widowed, lives at home with
sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy.
# Tobacco: 3 packs per week since teenager
# Alcohol: Denies
# Drugs: Past IVDU, but not in several years 

### Response:
{'Other iatrogenic hypotension,End stage renal disease,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other drugs and medicinal substances causing adverse effects in therapeutic use,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Renal dialysis status,Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Postsurgical hypothyroidism,Epilepsy, unspecified, without mention of intractable epilepsy,Cocaine abuse, in remission,Coronary atherosclerosis of native coronary artery,Backache, unspecified,Other chronic pain,Asthma, unspecified type, unspecified,Depressive disorder, not elsewhere classified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Anemia in chronic kidney disease,Personal history of noncompliance with medical treatment, presenting hazards to health,Other secondary thrombocytopenia,Benign neoplasm of ovary,Nonspecific abnormal electrocardiogram [ECG] [EKG],Hypopotassemia'}
