CHIEF COMPLAINT: Hypotension and hypothermia

PRESENT ILLNESS: HPI: 59 year old homeless gentleman with h/o EtOH abuse and s/p
PEG and h/o tach (retained stoma) found down by police, and
taken to the ED. He has a h/o several ED visit in the past for
etOH intoxication (administers vodka and listerine via PEG). No
vital signs were recorded at the scene, but pt was noted to be
wet. On arrival to ED, he was found to be hypotensive with SBP
60s-70s, and hypothermic to 92.3F. ECG with suggestion of mild
[**Doctor Last Name **] waves. ABG 7.28/63/46/31 with lactate 2.7. A Bare hugger
was placed, and temp rose to 95.0F. He was given 4L NS, which
did not raise his BP significantly. A R femoral TLC was placed,
and he was started on dopamine, which was switched to levophed
after continued hypotension to 80s/40s. He was also hypoxic with
SaO2 70-80% on RA. His trach stoma was recannulated, and was
placed on AC ventilation via trach. He was given vanc/CTX for
presumed sepsis. Urine/serum tox were notable only for EtOH 311.
Mr. [**Known lastname 5621**] did not have a leukocytosis, with wbc 4.8. No
severe electrolyte abnormalities, amylase 12. CXR demonstrated
an old clavicular fracture that, on exam, had eroded through
skin with visible bone, but no acute pulmonary process. UA was
normal. CT head demonstrated areas of low attenuation in
anterior frontal lobes c/w contusion vs subacute infarct vs
edema [**2-21**] possible mass effect. This is similar to CT head read
from [**9-24**]. FAST scan was negative, and CT c-spine was negative
for fracture. CT torso demonstrated no intrathoracic or solid
organ injury, with confirmation of R clavicular fracture and old
rib fractures. He was admitted to [**Hospital Unit Name 153**] for further management.
.
Of note, previous records note several episodes of ED visits for
EtOH intoxication and hypotension to SBP 80s, responding with
IVF to 90s-100s before d/c, which appears to be his BP baseline.

MEDICAL HISTORY: 1) EtOH Abuse: Several ED notes describe visits for EtOH
intoxication. Pt apparently administers vodka and listerine via
PEG.
.
2) s/p PEG and trach placement: unclear etiology
.
3) Evidence on previous ED labs of macrocytic anemia. No work-up
here.

MEDICATION ON ADMISSION: None

ALLERGIES: Aspirin

PHYSICAL EXAM: VS: T: 97.9F BP: 106/71 HR: 67 RR: 17 SaO2: 100% wt 67kg
Vent: AC 450 x 14/5/100%
Gen: Sedated, dissheveled Caucasian gentleman.
HEENT: PERRL, sclerae anicteric, subconjunctival hemmorrhage R
eye, MMM
Neck: Supple, no LAD,
CV: RRR, nl S1 and S2, no m/r/g
Chest: CTAB, no w/r/r
Abd: Soft, PEG site nonerythematous
Extr: R TLC femoral catheter in place, no LE edema, 1+ DPs
bilaterally, extremities cool, but good cap refill
Neuro: tached, sedated

FAMILY HISTORY: unknown

SOCIAL HISTORY: +EtOH abuse, homeless.
Acute respiratory failure,Dehydration,Unspecified protein-calorie malnutrition,Acute alcoholic intoxication in alcoholism, continuous,Open fracture of clavicle, unspecified part,Fracture, cause unspecified
Acute respiratry failure,Dehydration,Protein-cal malnutr NOS,Ac alcohol intox-contin,Fx clavicle NOS-open,Fracture, cause NOS
Admission Date:  [**2137-8-24**]              Discharge Date:   [**2137-8-31**]

Date of Birth:  [**2078-8-10**]             Sex:   M

Service: MEDICINE

Allergies:
Aspirin

Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Hypotension and hypothermia

Major Surgical or Invasive Procedure:
Date:  [**2137-8-27**]
PROCEDURE:
1.  Debridement of open fracture to bone.
2.  Partial excision, right clavicle.


History of Present Illness:
HPI: 59 year old homeless gentleman with h/o EtOH abuse and s/p
PEG and h/o tach (retained stoma) found down by police, and
taken to the ED. He has a h/o several ED visit in the past for
etOH intoxication (administers vodka and listerine via PEG). No
vital signs were recorded at the scene, but pt was noted to be
wet. On arrival to ED, he was found to be hypotensive with SBP
60s-70s, and hypothermic to 92.3F. ECG with suggestion of mild
[**Doctor Last Name **] waves. ABG 7.28/63/46/31 with lactate 2.7. A Bare hugger
was placed, and temp rose to 95.0F. He was given 4L NS, which
did not raise his BP significantly. A R femoral TLC was placed,
and he was started on dopamine, which was switched to levophed
after continued hypotension to 80s/40s. He was also hypoxic with
SaO2 70-80% on RA. His trach stoma was recannulated, and was
placed on AC ventilation via trach. He was given vanc/CTX for
presumed sepsis. Urine/serum tox were notable only for EtOH 311.
Mr. [**Known lastname 5621**] did not have a leukocytosis, with wbc 4.8. No
severe electrolyte abnormalities, amylase 12. CXR demonstrated
an old clavicular fracture that, on exam, had eroded through
skin with visible bone, but no acute pulmonary process. UA was
normal. CT head demonstrated areas of low attenuation in
anterior frontal lobes c/w contusion vs subacute infarct vs
edema [**2-21**] possible mass effect. This is similar to CT head read
from [**9-24**]. FAST scan was negative, and CT c-spine was negative
for fracture. CT torso demonstrated no intrathoracic or solid
organ injury, with confirmation of R clavicular fracture and old
rib fractures. He was admitted to [**Hospital Unit Name 153**] for further management.
.
Of note, previous records note several episodes of ED visits for
EtOH intoxication and hypotension to SBP 80s, responding with
IVF to 90s-100s before d/c, which appears to be his BP baseline.



Past Medical History:
1) EtOH Abuse: Several ED notes describe visits for EtOH
intoxication. Pt apparently administers vodka and listerine via
PEG.
.
2) s/p PEG and trach placement: unclear etiology
.
3) Evidence on previous ED labs of macrocytic anemia. No work-up
here.


Social History:
+EtOH abuse, homeless.

Family History:
unknown

Physical Exam:
VS: T: 97.9F BP: 106/71 HR: 67 RR: 17 SaO2: 100% wt 67kg
Vent: AC 450 x 14/5/100%
Gen: Sedated, dissheveled Caucasian gentleman.
HEENT: PERRL, sclerae anicteric, subconjunctival hemmorrhage R
eye, MMM
Neck: Supple, no LAD,
CV: RRR, nl S1 and S2, no m/r/g
Chest: CTAB, no w/r/r
Abd: Soft, PEG site nonerythematous
Extr: R TLC femoral catheter in place, no LE edema, 1+ DPs
bilaterally, extremities cool, but good cap refill
Neuro: tached, sedated


Pertinent Results:
[**2137-8-24**] 02:40AM   WBC-4.8 RBC-4.10* HGB-11.7* HCT-35.2* MCV-86
MCH-28.5 MCHC-33.2 RDW-17.7*
[**2137-8-24**] 02:40AM   ASA-NEG ETHANOL-311* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2137-8-24**] 02:40AM   CK-MB-17* MB INDX-6.7* cTropnT-<0.01
[**2137-8-24**] 02:40AM   CK(CPK)-252* AMYLASE-12
[**2137-8-24**] 02:46AM   GLUCOSE-72 LACTATE-2.7* NA+-134* K+-3.5
CL--97*
[**2137-8-24**] 02:50AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2137-8-24**] 02:50AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2137-8-24**] 09:45AM   CORTISOL-3.6
[**2137-8-24**] 09:45AM   TSH-2.1
[**2137-8-24**] 09:45AM   VIT B12-694 FOLATE-12.5
[**2137-8-24**] 09:45AM   ALBUMIN-3.6 CALCIUM-9.5 PHOSPHATE-3.9
MAGNESIUM-2.7*
[**2137-8-24**] 10:20AM   CORTISOL-31.7*
.
AEROBIC BOTTLE (Final [**2137-8-30**]):    NO GROWTH.
ANAEROBIC BOTTLE (Final [**2137-8-30**]):    NO GROWTH.
.
[**2137-8-24**] 2:40 pm SWAB     Site: SHOULDER      R SHOULDER.

   GRAM STAIN (Final [**2137-8-24**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.

   WOUND CULTURE (Preliminary):
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup is performed appropriate to the isolates recovered
from the
      site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
      aureus and beta streptococcus).
      DR [**First Name (STitle) **] [**Doctor Last Name **] ([**Numeric Identifier 67543**]) REQUESTED FURTHER WORK-UP [**2137-8-31**].

      STAPH AUREUS COAG +.    MODERATE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         Please contact the Microbiology Laboratory ([**7-/2437**])
immediately if
         sensitivity to clindamycin is required on this
patient's isolate.
         BEING ISOLATED FOR SENSITIVITIES.
      CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).    MODERATE
GROWTH.
         OF TWO COLONIAL MORPHOLOGIES.  BEING ISOLATED.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------       PND
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------     4 R
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA----       PND
VANCOMYCIN------------   <=1 S

   ANAEROBIC CULTURE (Final [**2137-8-28**]):    NO ANAEROBES ISOLATED.

.
.
CT CHEST W/CONTRAST  [**2137-8-24**] 2:36 AM
IMPRESSION:
1. No evidence of intrathoracic or soft organ injury.
2. Right clavicle fracture.
3. Old right rib fractures (numbers IV-VII).
.
CT C-SPINE W/O CONTRAST  [**2137-8-24**] 2:35 AM
IMPRESSION: No definite fracture or subluxation. Soft tissue
swelling is noted above the tracheostomy site.
5mm lucency is noted in the dens of uncertain etiology. If
clinically warranted an MRI may be performed on a non-emergent
basis for further evaluation.
.
CT HEAD W/O CONTRAST  [**2137-8-24**] 2:35 AM
IMPRESSION:
1. No intracranial hemorrhage.
2. Areas of low attenuation in the anterior frontal lobes
bilaterally suggestive of old contusions, unchanged from prior
study.
3. Opacification of the left mastoid air cells with possible
bone destruction are seen, raising a suspicion of mastoiditis.
Please correlate clinically.
.
CHEST (PORTABLE AP)  [**2137-8-24**] 2:38 AM
IMPRESSION: Right clavicle fracture. No other acute traumatic
injuries.
.
SCROTAL U.S.  [**2137-8-28**] 6:09 PM
CONCLUSION:

1. No evidence of focal penile or scrotal of collection, but
diffuse penoscrotal and lower limb subcutaneous edema.

2. The urethra is not evaluated.
.
RETRO UROGRAM ([**Numeric Identifier 73261**],[**Numeric Identifier 69615**])  [**2137-8-29**] 10:40 AM
IMPRESSION: Normal retrograde urethrogram.
.


Brief Hospital Course:
59 year old homeless gentleman found down, intoxicated,
hypotensive and hypothermic requiring a brief ICU course who was
being treated for an infected right clavicular fracture.  This
fracture grew out corynebacterium and the patient was undergoing
treatment with Vancomycin.  Given that the surgery was a
debridgement and not a full resection there was concern that
there was still bacteria within the bone.  Thus, the patient
would need clean-margin resection of the infected bone with
subsequent long-term antibiotic therapy at another facility.
The patient was not in agreement with these plans and after
comprehensive discussion about the risks of not completing
appropriate therapy, he exited against medical advice.
.
.
Plan:
.
#1) ID: Patient has growth of cornybacterium from open R
clavicular wound. Patient received 4 days of treatment with
Vancomycin.
.
#2) Scrotal swelling - patient had scrotal/penile swelling
following catheter removal. The patient had both a penile US and
an RUG, both showed no acute process. The patient reports that
this reaction also happened after removal of a foley at another
hospital recently and it was self-limiting.  On the day of
discharge the patient was exhibiting no signs of any penile
and/or scrotal problems.
.
#3) Hypotension: Appears to be [**2-21**] hypovolemia as a result of
decreased PO intake and EtOH induced diuresis as patient
responded well to aggressive IV hydration. Currently has SBPs
110's/50 6L IVF boluses yesterday with response in BP. Now
110's/50's-70, likely represents combination of hypothermia,
hypovolemia from poor PO intake with EtOH/hypothermia-induced
diuresis. This did not appear to be due to sepsis or adrenal
insufficiency.  The patient had stable vital aigns upon
discharge.
.
#4) Hypoxia: Patient initially on a ventilator while in the ICU.
 he was weaned promptly from the ventilator and did not require
any respiratory support during the stay on the floor.  The
patient was admitted with a tracheostomy and this was still in
place upon discharge.
.
#5) EtOH abuse: EtOH level 311 on admission. Concern for DTs-no
signs or symptoms thus far.  The patient did not exhibit any
signs of withdrawal during the hospital course.  He was
monitored via the CIWA scale and did not require any Ativan.
.
#6) Clavicle fracture:
- On the day of discharge the patient Day 4 s/p debridgement and
partial resection of the right clavicle.  He had been seen by PT
while in house and was instructed on movement such as to not
aggrevate the fracture.

Medications on Admission:
None

Discharge Medications:
None

Discharge Disposition:
Home

Discharge Diagnosis:
Dehydration
Alcohol intoxication
R clavicular fracture s/p debridement and partial excision


Discharge Condition:
poor


Discharge Instructions:
Patient left AMA

Followup Instructions:
Patient encouraged to seek medical care



Completed by:[**2137-8-31**]
{'Acute respiratory failure,Dehydration,Unspecified protein-calorie malnutrition,Acute alcoholic intoxication in alcoholism, continuous,Open fracture of clavicle, unspecified part,Fracture, cause unspecified'}


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 hypothermia

PRESENT ILLNESS: HPI: 59 year old homeless gentleman with h/o EtOH abuse and s/p
PEG and h/o tach (retained stoma) found down by police, and
taken to the ED. He has a h/o several ED visit in the past for
etOH intoxication (administers vodka and listerine via PEG). No
vital signs were recorded at the scene, but pt was noted to be
wet. On arrival to ED, he was found to be hypotensive with SBP
60s-70s, and hypothermic to 92.3F. ECG with suggestion of mild
[**Doctor Last Name **] waves. ABG 7.28/63/46/31 with lactate 2.7. A Bare hugger
was placed, and temp rose to 95.0F. He was given 4L NS, which
did not raise his BP significantly. A R femoral TLC was placed,
and he was started on dopamine, which was switched to levophed
after continued hypotension to 80s/40s. He was also hypoxic with
SaO2 70-80% on RA. His trach stoma was recannulated, and was
placed on AC ventilation via trach. He was given vanc/CTX for
presumed sepsis. Urine/serum tox were notable only for EtOH 311.
Mr. [**Known lastname 5621**] did not have a leukocytosis, with wbc 4.8. No
severe electrolyte abnormalities, amylase 12. CXR demonstrated
an old clavicular fracture that, on exam, had eroded through
skin with visible bone, but no acute pulmonary process. UA was
normal. CT head demonstrated areas of low attenuation in
anterior frontal lobes c/w contusion vs subacute infarct vs
edema [**2-21**] possible mass effect. This is similar to CT head read
from [**9-24**]. FAST scan was negative, and CT c-spine was negative
for fracture. CT torso demonstrated no intrathoracic or solid
organ injury, with confirmation of R clavicular fracture and old
rib fractures. He was admitted to [**Hospital Unit Name 153**] for further management.
.
Of note, previous records note several episodes of ED visits for
EtOH intoxication and hypotension to SBP 80s, responding with
IVF to 90s-100s before d/c, which appears to be his BP baseline.

MEDICAL HISTORY: 1) EtOH Abuse: Several ED notes describe visits for EtOH
intoxication. Pt apparently administers vodka and listerine via
PEG.
.
2) s/p PEG and trach placement: unclear etiology
.
3) Evidence on previous ED labs of macrocytic anemia. No work-up
here.

MEDICATION ON ADMISSION: None

ALLERGIES: Aspirin

PHYSICAL EXAM: VS: T: 97.9F BP: 106/71 HR: 67 RR: 17 SaO2: 100% wt 67kg
Vent: AC 450 x 14/5/100%
Gen: Sedated, dissheveled Caucasian gentleman.
HEENT: PERRL, sclerae anicteric, subconjunctival hemmorrhage R
eye, MMM
Neck: Supple, no LAD,
CV: RRR, nl S1 and S2, no m/r/g
Chest: CTAB, no w/r/r
Abd: Soft, PEG site nonerythematous
Extr: R TLC femoral catheter in place, no LE edema, 1+ DPs
bilaterally, extremities cool, but good cap refill
Neuro: tached, sedated

FAMILY HISTORY: unknown

SOCIAL HISTORY: +EtOH abuse, homeless. 

### Response:
{'Acute respiratory failure,Dehydration,Unspecified protein-calorie malnutrition,Acute alcoholic intoxication in alcoholism, continuous,Open fracture of clavicle, unspecified part,Fracture, cause unspecified'}
