CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: This is a 68M t4 level paraplejia, CAD, CHF EF , severe sacral
debub, multiple UTIs, PE with IVC filter who is sent from rehab
with Hypotension. Of note, recently discharged from [**Hospital1 18**] after
and admission for code stroke [**4-21**]--[**4-27**] which at the end, it
was thought to be a seizure episode. Prior to that, admitted
[**2106-4-6**]- [**2106-4-15**] for fever and hypotension treated for UTI and
wound infection with Vanc/Zosyn compleatted on [**4-21**].
.
Sent to the ED, after he was noted hypotensive today into the
60's.Per referal, he was noted with BO into the 60's that did
not repond to fluid boluses.  Per report, his baseline BP
80-90's. He had also been currently treated with antibiotics for
a UTI. He completely his Vancomycin/Zosyn treatment course for
enterococi UTI and decub/ulcer swab infection on [**4-21**].
.
In the ED, VS:   He was hypotensive into the 60's, good mental
status. A IJ line was placed and levophed was started.  Levophed
was also started. ID was curvesided and agreed with Vanc/Zosyn
for empiric coverage

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: Ipratropium q8h
Levetiracetam 500 [**Hospital1 **]
levofloxacine 250 daily [**2106-5-5**] [**2106-5-19**]
Megace 400 mg once daily
Metronidazol 500 mg TID [**2106-5-5**] / [**2106-5-19**] -- apparently after
debridment.
Omeprazole 20 mg daily
Ondansetron 4 mg q8h
Oxycodone 5 mg TID
potassium 20 meq
Senna 1 tab
ursodiol 300 mg [**Hospital1 **]
warfarin [**5-12**] 0.5 mg INR [**2106-5-12**] 2.3
albuterol 2 puff q6h
aspirin 81 daily
Baclofen 10 mg TID
Bisacodyl 10 mg once daily
Calcium carbonate 650 TID
Carvedilol 3.125 [**Hospital1 **]
Citalopram 30 mg qd
fluticasone/salmeterol Advair 250/50
Gabapentin 300 [**Hospital1 **]
Insulin sliding scale
PRN
Tylenol 650 q4h
MAALOx
Prochlorperazine 25 mg q12 rectall

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: No stroke, aneurysm, no seizure, no AAA.

SOCIAL HISTORY: He moved here from [**Country 3594**] (after living in many different
countries) in the [**2068**].  He is retired from a job in the
maritime industry.  Divorced 24 years ago.  Three children.
Quit smoking [**2076**].  Quit drinking [**2080**].  No history of illicit
drug use or abuse.
Unspecified septicemia,Septic shock,Acute systolic heart failure,Paraplegia,Pressure ulcer, buttock,Severe sepsis,Chronic airway obstruction, not elsewhere classified,Esophageal reflux,Personal history of venous thrombosis and embolism
Septicemia NOS,Septic shock,Ac systolic hrt failure,Paraplegia NOS,Pressure ulcer, buttock,Severe sepsis,Chr airway obstruct NEC,Esophageal reflux,Hx-ven thrombosis/embols
Admission Date:  [**2106-5-13**]              Discharge Date:   [**2106-5-20**]

Date of Birth:  [**2038-4-1**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
Hypotension

Major Surgical or Invasive Procedure:
Central Veinous line placement
PICC placement

History of Present Illness:
This is a 68M t4 level paraplejia, CAD, CHF EF , severe sacral
debub, multiple UTIs, PE with IVC filter who is sent from rehab
with Hypotension. Of note, recently discharged from [**Hospital1 18**] after
and admission for code stroke [**4-21**]--[**4-27**] which at the end, it
was thought to be a seizure episode. Prior to that, admitted
[**2106-4-6**]- [**2106-4-15**] for fever and hypotension treated for UTI and
wound infection with Vanc/Zosyn compleatted on [**4-21**].
.
Sent to the ED, after he was noted hypotensive today into the
60's.Per referal, he was noted with BO into the 60's that did
not repond to fluid boluses.  Per report, his baseline BP
80-90's. He had also been currently treated with antibiotics for
a UTI. He completely his Vancomycin/Zosyn treatment course for
enterococi UTI and decub/ulcer swab infection on [**4-21**].
.
In the ED, VS:   He was hypotensive into the 60's, good mental
status. A IJ line was placed and levophed was started.  Levophed
was also started. ID was curvesided and agreed with Vanc/Zosyn
for empiric coverage

.
ROS: Denied fever, chills, SOB, cough, chest pain, abdominal
pain, blood in stools, weight gain or weight loss


Social History:
He moved here from [**Country 3594**] (after living in many different
countries) in the [**2068**].  He is retired from a job in the
maritime industry.  Divorced 24 years ago.  Three children.
Quit smoking [**2076**].  Quit drinking [**2080**].  No history of illicit
drug use or abuse.


Family History:
No stroke, aneurysm, no seizure, no AAA.

Pertinent Results:
Admit labs:

[**2106-5-13**] 01:25PM BLOOD WBC-9.4# RBC-3.52* Hgb-8.7* Hct-28.1*
MCV-80* MCH-24.8* MCHC-31.1 RDW-17.0*
[**2106-5-13**] 01:25PM BLOOD PT-26.6* PTT-38.4* INR(PT)-2.7*
[**2106-5-13**] 01:25PM BLOOD Glucose-101 UreaN-15 Creat-1.1 Na-139
K-4.7 Cl-104 HCO3-24 AnGap-16
[**2106-5-13**] 01:25PM BLOOD ALT-5 AST-10 LD(LDH)-124 CK(CPK)-50
AlkPhos-89 TotBili-0.2
[**2106-5-13**] 01:25PM BLOOD Albumin-2.8* Calcium-8.6 Phos-2.3* Mg-1.6
[**2106-5-14**] 04:00AM BLOOD Cortsol-14.0
=================================================
Discharge labs:

[**2106-5-19**] 03:19AM BLOOD WBC-6.3 RBC-3.17* Hgb-7.7* Hct-25.5*
MCV-81* MCH-24.2* MCHC-30.1* RDW-17.6* Plt Ct-146*
[**2106-5-19**] 03:19AM BLOOD Plt Ct-146*
[**2106-5-19**] 03:19AM BLOOD PT-29.5* PTT-37.4* INR(PT)-3.0*
[**2106-5-19**] 03:19AM BLOOD Glucose-79 UreaN-5* Creat-0.5 Na-140
K-3.9 Cl-109* HCO3-24 AnGap-11
[**2106-5-18**] 05:50AM BLOOD ALT-6 AST-9 AlkPhos-78 Amylase-46
TotBili-0.2
[**2106-5-19**] 03:19AM BLOOD Mg-1.7
Cholesterol:

[**2106-5-17**] 05:40AM BLOOD Triglyc-79 HDL-18 CHOL/HD-3.1 LDLcalc-21
[**2106-5-17**] 05:40AM BLOOD  Cholest-55
==========================================================
ECG:Sinus rhythm. Prior inferior myocardial infarction. Diffuse
non-specific
ST-T wave changes. Compared to the previous tracing of [**2106-4-22**]
there is
diffuse ST segment and T wave flattening. Otherwise, no
diagnostic interim
change.
==========================================================

CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN

Reason: infiltrate? pneumothorax?

[**Hospital 93**] MEDICAL CONDITION:
68 year old man with urosepsis, s/p hypoxia and coughing,
increased o2 requirement
REASON FOR THIS EXAMINATION:
infiltrate? pneumothorax?
AP CHEST 8:45 P.M. [**5-13**]

HISTORY: Hypoxia and coughing. Possible pneumothorax.

IMPRESSION: AP chest compared to [**4-21**] through [**5-13**]:

Lungs are clear. Heart size normal. No pneumothorax or pleural
effusion. The patient has had median sternotomy. Tip of the
right jugular line projects over the upper SVC. No pneumothorax.
==============================================================
MR [**Name13 (STitle) 6452**] W & W/O CONTRAST  [**2106-5-17**] 8:23 AM

MR [**Name13 (STitle) 6452**] W & W/O CONTRAST

Reason: Please evalaute L-spine/coccyx--patient with multiple
sacral
Contrast: MAGNEVIST

[**Hospital 93**] MEDICAL CONDITION:
68 year old man with T4 paraplegia, multiple sacral decub
include probe to bone- admit with sepsis-unclear source
REASON FOR THIS EXAMINATION:
Please evalaute L-spine/coccyx--patient with multiple sacral
decubitus ulcers, sepsis unclear source--?osteomyelitis
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATION: T4 paraplegia with multiple sacral decubitus ulcers
probing to bone. Admitted with sepsis of unclear source. Please
evaluate for osteomyelitis.

TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained
through the lumbar spine without and with intravenous contrast.

COMPARISON: MR lumbar spine images of [**2105-2-20**].

MR LUMBAR SPINE WITHOUT AND WITH CONTRAST: Sagittal images were
obtained through the lumbosacral spine; however, axial images go
through S1-S2. There is no evidence of lumbar spine fracture or
malalignment. At L2-L3 and L3-L4, there is no evidence of
significant canal stenosis or neural foraminal narrowing. At
L4-L5, there are degenerative endplate changes consistent with
type 2 [**Last Name (un) 13425**] changes. There is mild loss of disc height with
mild-to-moderate left and moderate right neural foraminal
narrowing without significant canal stenosis.

At L5-S1, there are type 2 [**Last Name (un) 13425**] degenerative changes of the
endplates with mild loss of the vertebral body and disc space
height. A mild central disc bulge is again noted along with mild
bilateral facet hypertrophy causing moderate left and
mild-to-moderate right neural foraminal narrowing.

There has been no change in the signal intensity within the
lumbosacral spine since the prior exam. There is no abnormal
enhancement. There is no evidence of osteomyelitis. There is
marked atrophy of the conus of the spinal cord as well as the
paraspinal musculature consistent with the patient's history of
paraplegia.

IMPRESSION:
1. No evidence of osteomyelitis within the lumbar spine and
visualized portion of the sacrum.
2. Multilevel degenerative changes as described above without
high-grade spinal canal stenosis.
3. Atrophy of the conus of the spinal cord and paraspinal
muscles consistent with paraplegia
=============================================================

Brief Hospital Course:
68M T4 paraplegia, CAD, systolic CHF, sacral decubitus ulcers,
multiple UTIs, PE with IVC filter on anticoagulation admitted
with hypotension.
.
# Hypotension/Septicemia: Pt (chronic nursing home pt) was
considered to have multiple possible sources of infection
including lines, urosepsis, and decubitus ulcers.  Pt was
started on vancomycin for MRSA, meropenem for pseudomonas,
ciprofloxacin for double GNR coverage, and metronidazole for
anaerobic coverage.  Of note, had been on levoquin and flagyl
for unclear reasons at [**Hospital 100**] Rehab for sometime before
admission to [**Hospital1 18**].  Aggressive fluid rescucitation and pressors
in ICU.  Pt was taken off pressors two days after admission, and
remained afebrile throughout.  PICC line removed, foley catheter
changed.  Blood, urine, and midline cultures remained no growth
throughout but were of little value given antibiotic therapy
preceding cultures.   Plastic surgery evaluated sacral decubs
and did not feel they were likely source of sepsis.  MRI of
sacral decubs without evidence of sepsis. C. diff considered, no
samples sent in ICU and then on floor, no stool for sample.
Influenza negative.   Appropriate adrenal response on [**Last Name (un) 104**] stim
testing.
Patient to receive two week course of vancomycin/meropenem given
septicemia without source.  He should receive flagyl for one
week after completion of these given high risk for c. diff and
possible c. diff as cause of septicemia.   Needs safety labs
including CBC, chem-10, lft's [**5-24**].  7more days vanc/meropenm
and 14 days flagyl.
********Please note, after this course, patient should have
serial blood cultures, urine cultures  and evaluation/wound
culture by plastic surgery as he has had multiple admissions for
septicemia of unclear etiology.  He should not be treated
empirically with antibiotics unless these cultures are performed
or unless he is critically ill, precluding the ability to obtain
these cultures.  It is strongly suspected that his decubitus
ulcers may be leading to these episodes, but almost chronic
institution of antibiotics without culture data precludes
definitive treatment.
Furthermore, patient has baseline low blood pressure from
chronic systolic heart failure and possible autonomic
dysregulation.  On discharge, BP 80's to 100's on low dose
lisinopril and carvedilol
.
# Decubitus ulcer:  Pt was noted to have extensive decubitus
ulcers, and plastics as well as wound care were consulted.
Wound care recs were followed; plastics did not feel further
imaging or tissue sampling was warranted.  MRI was obtained and
did not demonstrate osteomyelitis.
.
Chronic Systolic Heart Failure: EF 25%.  With aggressive
fluids/pressors, no pulmonary edema.  Low dose lisinopril and
carvedilol re-started by [**5-18**].  BP's generally 80's to 100's.
.
Coronary Artery Disease: No specific ischemic changes on ECG.
Maintained on aspirin.  Beta blocker and ace inhibitor added by
discharge.  Statin discontinued as cholesterol very low (total
of 55).
.
# PE s/p IVC filter: Pt's warfarin was initially held given INR
3.5; anticoagulation dosing was per INR with goal between 2 and
3.  On day of d/c, [**5-20**] INR of 2.9, plan 1mg coumadin today.
Should have INR check on [**5-21**] and then week of [**5-23**].
.
# Depression:  Continued citalopram
.
# h/o seizures: Continued Keppra
.
# h/o cholelitiasis/abdominal pain/GERD: Patient with
intermittent complaints of RUQ and epigastric abdominal pain,
also left sided chest..  PPI changed to [**Hospital1 **], tums and maalox
added.  LFT's within normal limits on serial measurements.  RUQ
U/S showed large stone in gallbladder which has been seen
previously, no evidence choleycystitis
Continued ursodiol throughout.  If ongoing pain, patietn should
be evaluated by surgery once he has completed his antibioitic
course for consideration of choleycystectomy
.


Medications on Admission:
Ipratropium q8h
Levetiracetam 500 [**Hospital1 **]
levofloxacine 250 daily [**2106-5-5**] [**2106-5-19**]
Megace 400 mg once daily
Metronidazol 500 mg TID [**2106-5-5**] / [**2106-5-19**] -- apparently after
debridment.
Omeprazole 20 mg daily
Ondansetron 4 mg q8h
Oxycodone 5 mg TID
potassium 20 meq
Senna 1 tab
ursodiol 300 mg [**Hospital1 **]
warfarin [**5-12**] 0.5 mg INR [**2106-5-12**] 2.3
albuterol 2 puff q6h
aspirin 81 daily
Baclofen 10 mg TID
Bisacodyl 10 mg once daily
Calcium carbonate 650 TID
Carvedilol 3.125 [**Hospital1 **]
Citalopram 30 mg qd
fluticasone/salmeterol Advair 250/50
Gabapentin 300 [**Hospital1 **]
Insulin sliding scale
PRN
Tylenol 650 q4h
MAALOx
Prochlorperazine 25 mg q12 rectall

Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).

5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours).
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

17. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
18. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once for 1
doses: on [**5-20**].
19. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: must
have INR check on [**5-21**] and [**5-23**] Goal INR is [**3-14**].
20. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Recon
Soln Intravenous Q6H (every 6 hours) for 7 days.
21. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 7 days.
22. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 14 days.
23. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for gas.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
1. Septicemia, NOS
2. Chronic Systolic Heart Failure
3. Coronary Artery Disease
4. Pulmonary Embolism
5. Paraplegia
6. Sacral Decubitus Ulcer
7. GERD
8. choledocholithiasis without obstruction
9. Anemia
10. Seizure history

Discharge Condition:
Afebrile, stable, tolerating PO intake, systolic bp 80-100

Discharge Instructions:
Adhere to 2 gm sodium diet
Fluid Restriction:2 liters
.
All medications as prescribed.  We have made a number of
changes.  Please note patient to receive coumadin 1mg on [**2106-5-20**]
for INR of 2.9 and then to resume coumadin therapy on [**2106-5-20**].
Should have INR checked on [**2106-5-21**] to guide further therapy (had
been getting 2mg daily but now on multiple antibiotics).  Goal
INR is between 2 and 3.  Usual dose will likely need to be
altered given concurrent vancomycin/meropenem/flagyl therapy.

Patient's systolic blood pressure generally between 80 and 100.
Patient should receive lisinopril and carvedilol unless bp drops
below eighty given his heart failure.

Once patient completes antibiotic course, should have blood
cultures sent and be seen by plastic surgery.  He has had a
number of admissions for sepsis of unclear etiology.  He should
not be treated with empiric antibiotics before having blood,
urine and wound cultures sent unless he is critically ill.

Patient should have INR checked on [**5-21**] and then during week of
[**5-23**] to guide coumadin therapy.

Patient should have full set of safety labs checked [**5-24**]
including CBC, Chem-10, alt, ast, total bilirubin.

Patient has ongoing right upper quadrant/right sided chest pain.
 It has been extesnively worked up.  he does have gallstones but
no evidence of choleycystitis.  If this is ongoing, he should be
evaluated by a surgeon once he has finished his antibiotic
course.
Follow up as below.

Followup Instructions:
Patient should follow up with primary care doctor within two
weeks of discharge from  [**Hospital **] Rehab.  You will be followed by
doctors there in the meantime.

You should follow up with plastic surgery here at [**Hospital3 **]
after  completing your antibiotic course.

You also have the previously scheduled appointments:
Neurology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD Phone:[**Telephone/Fax (1) 5434**]
Date/Time:[**2106-7-16**] 9:30

Cardiology:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) 3947**]. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2106-11-3**] 9:40
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2106-11-3**]
11:00
{'Unspecified septicemia,Septic shock,Acute systolic heart failure,Paraplegia,Pressure ulcer, buttock,Severe sepsis,Chronic airway obstruction, not elsewhere classified,Esophageal reflux,Personal history of venous thrombosis and embolism'}


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: This is a 68M t4 level paraplejia, CAD, CHF EF , severe sacral
debub, multiple UTIs, PE with IVC filter who is sent from rehab
with Hypotension. Of note, recently discharged from [**Hospital1 18**] after
and admission for code stroke [**4-21**]--[**4-27**] which at the end, it
was thought to be a seizure episode. Prior to that, admitted
[**2106-4-6**]- [**2106-4-15**] for fever and hypotension treated for UTI and
wound infection with Vanc/Zosyn compleatted on [**4-21**].
.
Sent to the ED, after he was noted hypotensive today into the
60's.Per referal, he was noted with BO into the 60's that did
not repond to fluid boluses.  Per report, his baseline BP
80-90's. He had also been currently treated with antibiotics for
a UTI. He completely his Vancomycin/Zosyn treatment course for
enterococi UTI and decub/ulcer swab infection on [**4-21**].
.
In the ED, VS:   He was hypotensive into the 60's, good mental
status. A IJ line was placed and levophed was started.  Levophed
was also started. ID was curvesided and agreed with Vanc/Zosyn
for empiric coverage

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: Ipratropium q8h
Levetiracetam 500 [**Hospital1 **]
levofloxacine 250 daily [**2106-5-5**] [**2106-5-19**]
Megace 400 mg once daily
Metronidazol 500 mg TID [**2106-5-5**] / [**2106-5-19**] -- apparently after
debridment.
Omeprazole 20 mg daily
Ondansetron 4 mg q8h
Oxycodone 5 mg TID
potassium 20 meq
Senna 1 tab
ursodiol 300 mg [**Hospital1 **]
warfarin [**5-12**] 0.5 mg INR [**2106-5-12**] 2.3
albuterol 2 puff q6h
aspirin 81 daily
Baclofen 10 mg TID
Bisacodyl 10 mg once daily
Calcium carbonate 650 TID
Carvedilol 3.125 [**Hospital1 **]
Citalopram 30 mg qd
fluticasone/salmeterol Advair 250/50
Gabapentin 300 [**Hospital1 **]
Insulin sliding scale
PRN
Tylenol 650 q4h
MAALOx
Prochlorperazine 25 mg q12 rectall

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: No stroke, aneurysm, no seizure, no AAA.

SOCIAL HISTORY: He moved here from [**Country 3594**] (after living in many different
countries) in the [**2068**].  He is retired from a job in the
maritime industry.  Divorced 24 years ago.  Three children.
Quit smoking [**2076**].  Quit drinking [**2080**].  No history of illicit
drug use or abuse. 

### Response:
{'Unspecified septicemia,Septic shock,Acute systolic heart failure,Paraplegia,Pressure ulcer, buttock,Severe sepsis,Chronic airway obstruction, not elsewhere classified,Esophageal reflux,Personal history of venous thrombosis and embolism'}
