CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: 73F h/o DM, PVD s/p bilateral BKA, ESRD Afib and diastolic CHF
with multiple admissions for hypotension and CHF now admitted
with hypotension. Of note, the patient has had two recent
admissions for chest pain on [**2-2**] followed by respiratory
distress on [**3-25**]. At this time she was admitted to the [**Hospital Unit Name 153**]
and treated for pulmonary edema with ntg gtt. She also received
HD and had 3.5L taken off. She briefly required bipap. She was
quickly transferred to medical floor and received HD as
scheduled on Saturday.
.
The pt presented from HD today after being found to be
hypotensive with BP to 80s. She was given 1.5L NS but remained
hypotensive in the 80s and was sent to the ER for evaluation.
Per EMS the pt remained alert and oriented X3. BP 68/36 HR 104.
On arrival to ED the pt was A&Ox3 with no complaints of pain,
denied fever/chills, no CP/SOB. She complained of fatigue. IV
access was difficult to obtain, failed attempt at RIJ. Pt had EJ
placed followed by a R femoral line. Initial vitals: T 98.0, HR
98, BP 62/34, RR 18 O2 100% on 4L. She was given vancomycin 1gm
IVX1 and zosyn 3.375g IV X1. BP improved to 99/34 following 1L
NS. CXR with no evidence of infiltrate. ECG with no change from
prior. Lactate 1.5.
.
On arrival to the MICU, the pt is resting comfortably, denies
lightheadedness. Denies CP/SOB.

MEDICAL HISTORY: ESRD on HD since [**12-29**]; qMWF schedule at [**Location (un) **] [**Location (un) **]
IDDM
Chronic diastolic CHF (LVEF >75%)
PAF s/p failed ablation, on warfarin
HTN c/b LVH & LVOT
Hyperlipidemia
PVD s/p bilateral BKAs
Left eye blindness
GERD
h/o VRE UTI

MEDICATION ON ADMISSION: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
Vitals: afebrile, BP 105/40, HR 98, RR 17, 91% RA
GENERAL: chronically ill-appearing woman in NAD, appropriate and
pleasant
HEENT: EOMI, MMM
NECK: Supple with no elevation of JVP
CARDIAC: irregular, normal S1, S2, II/VI crescedno-decrescendo
murmur
heard best at RUSB
LUNGS: no accessory muscle use. CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness
Ext: b/l BKA

FAMILY HISTORY: Her father died in his 90s of complications of DM2 and mother at
the age of 102 of a stroke. Patient had a sister who died in her
70s of cancer (unknown type and site) and 2 brothers that died
stroke and brain cancer. She has 7 children who are healthy. Her
family history is significant for coronary artery disease,
cancer, and diabetes.

SOCIAL HISTORY: The patient denies alcohol and IV drug use. She states that she
smokes approximately 3 cigarettes daily and has history of ~30
pack-year. She lives in a senior citizen center; her daughter
lives with her.
Other iatrogenic hypotension,Chronic diastolic heart failure,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Secondary hyperparathyroidism (of renal origin),Atrial fibrillation,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Other and unspecified hyperlipidemia,Long-term (current) use of insulin,Peripheral vascular disease, unspecified,Below knee amputation status
Iatrogenc hypotnsion NEC,Chr diastolic hrt fail,End stage renal disease,Hyp kid NOS w cr kid V,Sec hyperparathyrd-renal,Atrial fibrillation,DMII oth nt st uncntrld,Esophageal reflux,Hyperlipidemia NEC/NOS,Long-term use of insulin,Periph vascular dis NOS,Status amput below knee
Admission Date:  [**2164-2-6**]              Discharge Date:   [**2164-2-11**]

Date of Birth:  [**2090-1-9**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 30201**]
Chief Complaint:
Hypotension

Major Surgical or Invasive Procedure:
Femoral central venous catheter placement
Hemodialysis


History of Present Illness:
73F h/o DM, PVD s/p bilateral BKA, ESRD Afib and diastolic CHF
with multiple admissions for hypotension and CHF now admitted
with hypotension. Of note, the patient has had two recent
admissions for chest pain on [**2-2**] followed by respiratory
distress on [**3-25**]. At this time she was admitted to the [**Hospital Unit Name 153**]
and treated for pulmonary edema with ntg gtt. She also received
HD and had 3.5L taken off. She briefly required bipap. She was
quickly transferred to medical floor and received HD as
scheduled on Saturday.
.
The pt presented from HD today after being found to be
hypotensive with BP to 80s. She was given 1.5L NS but remained
hypotensive in the 80s and was sent to the ER for evaluation.
Per EMS the pt remained alert and oriented X3. BP 68/36 HR 104.
On arrival to ED the pt was A&Ox3 with no complaints of pain,
denied fever/chills, no CP/SOB. She complained of fatigue. IV
access was difficult to obtain, failed attempt at RIJ. Pt had EJ
placed followed by a R femoral line. Initial vitals: T 98.0, HR
98, BP 62/34, RR 18 O2 100% on 4L. She was given vancomycin 1gm
IVX1 and zosyn 3.375g IV X1. BP improved to 99/34 following 1L
NS. CXR with no evidence of infiltrate. ECG with no change from
prior. Lactate 1.5.
.
On arrival to the MICU, the pt is resting comfortably, denies
lightheadedness. Denies CP/SOB.


Past Medical History:
ESRD on HD since [**12-29**]; qMWF schedule at [**Location (un) **] [**Location (un) **]
IDDM
Chronic diastolic CHF (LVEF >75%)
PAF s/p failed ablation, on warfarin
HTN c/b LVH & LVOT
Hyperlipidemia
PVD s/p bilateral BKAs
Left eye blindness
GERD
h/o VRE UTI

Social History:
The patient denies alcohol and IV drug use. She states that she
smokes approximately 3 cigarettes daily and has history of ~30
pack-year. She lives in a senior citizen center; her daughter
lives with her.

Family History:
Her father died in his 90s of complications of DM2 and mother at
the age of 102 of a stroke. Patient had a sister who died in her
70s of cancer (unknown type and site) and 2 brothers that died
stroke and brain cancer. She has 7 children who are healthy. Her
family history is significant for coronary artery disease,
cancer, and diabetes.

Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: afebrile, BP 105/40, HR 98, RR 17, 91% RA
GENERAL: chronically ill-appearing woman in NAD, appropriate and
pleasant
HEENT: EOMI, MMM
NECK: Supple with no elevation of JVP
CARDIAC: irregular, normal S1, S2, II/VI crescedno-decrescendo
murmur
heard best at RUSB
LUNGS: no accessory muscle use. CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness
Ext: b/l BKA

Pertinent Results:
[**2164-2-5**] 07:10AM BLOOD WBC-11.6* RBC-3.68* Hgb-11.1* Hct-35.7*
MCV-97 MCH-30.1 MCHC-31.1 RDW-20.3* Plt Ct-299
[**2164-2-6**] 11:25AM BLOOD WBC-8.3 RBC-3.24* Hgb-9.6* Hct-30.3*
MCV-94 MCH-29.5 MCHC-31.5 RDW-19.5* Plt Ct-266
[**2164-2-6**] 11:25AM BLOOD Neuts-88.6* Lymphs-8.6* Monos-2.4 Eos-0.3
Baso-0.1
[**2164-2-7**] 03:55AM BLOOD WBC-8.1 RBC-2.91* Hgb-8.8* Hct-27.3*
MCV-94 MCH-30.2 MCHC-32.2 RDW-19.9* Plt Ct-258
[**2164-2-8**] 08:15AM BLOOD WBC-6.8 RBC-3.23* Hgb-9.5* Hct-30.6*
MCV-95 MCH-29.5 MCHC-31.2 RDW-19.8* Plt Ct-281
[**2164-2-9**] 07:55AM BLOOD WBC-6.1 RBC-3.50* Hgb-10.2* Hct-33.3*
MCV-95 MCH-29.2 MCHC-30.6* RDW-19.1* Plt Ct-286
[**2164-2-11**] 06:15AM BLOOD WBC-7.1 RBC-3.42* Hgb-9.9* Hct-33.1*
MCV-97 MCH-29.1 MCHC-30.0* RDW-19.7* Plt Ct-329
[**2164-2-5**] 07:10AM BLOOD PT-19.6* PTT-29.6 INR(PT)-1.8*
[**2164-2-6**] 06:30AM BLOOD PT-19.7* INR(PT)-1.8*
[**2164-2-6**] 11:25AM BLOOD PT-20.8* PTT-34.6 INR(PT)-2.0*
[**2164-2-7**] 03:55AM BLOOD PT-22.7* PTT-34.1 INR(PT)-2.2*
[**2164-2-8**] 08:15AM BLOOD PT-21.7* PTT-27.7 INR(PT)-2.1*
[**2164-2-9**] 07:55AM BLOOD PT-22.3* PTT-27.7 INR(PT)-2.1*
[**2164-2-5**] 07:10AM BLOOD Glucose-113* UreaN-49* Creat-6.6*# Na-135
K-4.9 Cl-98 HCO3-21* AnGap-21*
[**2164-2-6**] 11:25AM BLOOD Glucose-64* UreaN-23* Creat-3.4*# Na-145
K-3.6 Cl-101 HCO3-28 AnGap-20
[**2164-2-7**] 03:55AM BLOOD Glucose-77 UreaN-34* Creat-5.3*# Na-144
K-3.8 Cl-104 HCO3-30 AnGap-14
[**2164-2-8**] 08:15AM BLOOD Glucose-92 UreaN-17 Creat-4.2*# Na-143
K-4.2 Cl-102 HCO3-36* AnGap-9
[**2164-2-9**] 07:55AM BLOOD Glucose-103 UreaN-12 Creat-3.4* Na-141
K-3.9 Cl-99 HCO3-35* AnGap-11
[**2164-2-11**] 06:15AM BLOOD Glucose-96 UreaN-18 Creat-3.9* Na-139
K-4.7 Cl-100 HCO3-30 AnGap-14
[**2164-2-6**] 11:25AM BLOOD ALT-50* AST-42* CK(CPK)-21* AlkPhos-59
TotBili-0.4
[**2164-2-7**] 03:55AM BLOOD ALT-72* AST-113* LD(LDH)-255*
CK(CPK)-223* AlkPhos-58 TotBili-0.3
[**2164-2-7**] 11:38AM BLOOD CK(CPK)-184*
[**2164-2-8**] 08:15AM BLOOD ALT-61* AST-82* LD(LDH)-305* CK(CPK)-75
AlkPhos-62 TotBili-0.2
[**2164-2-9**] 07:55AM BLOOD ALT-54* AST-60* LD(LDH)-314* CK(CPK)-50
AlkPhos-69 TotBili-0.3
[**2164-2-6**] 11:25AM BLOOD cTropnT-0.09*
[**2164-2-7**] 03:55AM BLOOD CK-MB-36* MB Indx-16.1* cTropnT-2.56*
[**2164-2-7**] 11:38AM BLOOD CK-MB-28* MB Indx-15.2* cTropnT-2.88*
[**2164-2-8**] 08:15AM BLOOD CK-MB-NotDone cTropnT-3.34*
[**2164-2-9**] 07:55AM BLOOD CK-MB-NotDone cTropnT-5.13*
.
[**2164-2-6**] 11:35 am BLOOD CULTURE      #2.

                            **FINAL REPORT [**2164-2-12**]**

   Blood Culture, Routine (Final [**2164-2-12**]):    NO GROWTH.
.
Cardiology Report	ECG	Study Date of [**2164-2-6**]  10:35:26 AM

Atrial fibrillation with a variable but most likely rapid
ventricular response.
Consider left ventricular hypertrophy. ST-T wave abnormalities.
Since the
previous tracing of [**2164-2-3**] atrial fibrillation is new.
.
[**2164-2-7**] TTE
The left atrium is elongated. There is severe symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Overall left ventricular systolic function is
normal (LVEF>55%). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). There is a mild
resting left ventricular outflow tract obstruction. A
mid-cavitary gradient (peak >=26 mmHg) is identified. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2163-7-13**],
findings are similar.
.

Brief Hospital Course:
#Hypotension - Attributed to a combination of antihypertensive
medications and a recent increase in the target dry weight for
hemodialysis. Resolved with fluid resuscitation.
Antihypertensive medications were gradually added and blood
pressure and heart rate were well-controlled with metoprolol
12.5 [**Hospital1 **] (reduced from an outpatient dose of Toprol XL 100 mg)
and verapamil 40 mg TID (reduced from an outpatient dose of 80
mg TID) upon discharge. Lisinopril, valsartan, and isosorbide
mononitrate were discontinued.
.
#Chronic diastolic heart failure - Positive cardiac biomarkers
were attributed to subendocardial ischemia in the setting of
hypotension and atrial fibrillation with rapid ventricular rate
given the patient's known LVH and LVOT. Acute coronary syndrome
was felt to be unlikely given a normal cardiac catheterization 1
year prior to admission and the absence of a new wall motion
abnormality on TTE. She was seen in consultation by cardiology
who agreed with this assessment and recommended continuing
medical management with blood pressure and rate control,
aspirin, and statin therapy.  She will be seen in close follow
up by her cardiologist the week after discharge.
.
#Chronic kidney disease stage V - Hemodialysis was continued,
without recurrent episodes of hypotension. Calcium acetate was
discontinued due to hypophosphatemia.
.
#Atrial fibrillation - Rate was well-controlled despite reduced
doses of metoprolol and verapamil. Continued amiodarone.
.
#Insulin-dependent diabetes mellitus - Blood sugars were
well-controlled with basal and sliding scale insulin.
.
#Dyslipidemia - Continued simvastatin.


Medications on Admission:
1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Warfarin 1 mg Tablet Sig: 1-2 Tablets PO once a day: Take 1
tablet every other day and take 2 tablets on the other days.
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap

PO DAILY (Daily).
14. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
16. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2

times a day).
19. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation

Q4H (every 4 hours) as needed.
20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Four
(4) units Subcutaneous twice a day.
21. Insulin Lispro 100 unit/mL Solution Sig: As DIR
Subcutaneous QACHS: Per sliding scale.


Discharge Medications:
1. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Warfarin 1 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
16. Novolin N 100 unit/mL Suspension Sig: Four (4) units
Subcutaneous twice a day.
17. Insulin Lispro 100 unit/mL Solution Sig: ASDIR INJ
Subcutaneous QIDACHS: per sliding scale with meals & at bedtime.



Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] [**Location (un) 269**]

Discharge Diagnosis:
Primary
1) Hypotension
2) Chronic diastolic heart failure
3) Chronic kidney disease stage V

Secondary
1) Atrial fibrillation
2) Insulin-dependent diabetes mellitus
3) Dyslipidemia


Discharge Condition:
Asymptomatic with stable vital signs.


Discharge Instructions:
You were admitted to the hospital with low blood pressure,
likely due to a combination of medications and overdialysis.

The following medication changes were therefore recommended:
1) Metoprolol was decreased from Toprol XL 100 mg daily to
Lopressor 12.5 mg twice daily.
2) Verapamil was decreased from 80 mg three times daily to 40 mg
three times daily.
3) Lisinopril was discontinued.
4) Valsartan was discontinued.
5) Isosorbide mononitrate (imdur) was discontinued.
6) Calcium acetate was discontinued due to low phosphorus.

Please discuss adjustments in your blood pressure regimen with
your primary care physician and cardiologist.

Please record your weight daily and call your physician if your
weight increases by more than 3 pounds. Please adhere to a diet
containing less than 2 grams of sodium, 2 grams of potassium,
and 1 gram of phosphorus.

Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] on Wednesday, [**2-15**] at 2:40 PM. The phone number is [**Telephone/Fax (1) 62**] if you wish to
reschedule.

Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Thursday, [**2-16**] at 2:40 PM. Please call [**Telephone/Fax (1) 250**] if you wish to
reschedule.

Please call your physician or return to the Emergency Department
if you experience headache, vision changes, dizziness,
lightheadedness, chest pain, palpitations, cough, or shortness
of breath.

Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] on Wednesday, [**2-15**] at 2:40 PM. The phone number is [**Telephone/Fax (1) 62**] if you wish to
reschedule.

Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Thursday, [**2-16**] at 2:40 PM. Please call [**Telephone/Fax (1) 250**] if you wish to
reschedule.

Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2164-3-28**]
11:00



Completed by:[**2164-2-12**]
{'Other iatrogenic hypotension,Chronic diastolic heart failure,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Secondary hyperparathyroidism (of renal origin),Atrial fibrillation,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Other and unspecified hyperlipidemia,Long-term (current) use of insulin,Peripheral vascular disease, unspecified,Below 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

PRESENT ILLNESS: 73F h/o DM, PVD s/p bilateral BKA, ESRD Afib and diastolic CHF
with multiple admissions for hypotension and CHF now admitted
with hypotension. Of note, the patient has had two recent
admissions for chest pain on [**2-2**] followed by respiratory
distress on [**3-25**]. At this time she was admitted to the [**Hospital Unit Name 153**]
and treated for pulmonary edema with ntg gtt. She also received
HD and had 3.5L taken off. She briefly required bipap. She was
quickly transferred to medical floor and received HD as
scheduled on Saturday.
.
The pt presented from HD today after being found to be
hypotensive with BP to 80s. She was given 1.5L NS but remained
hypotensive in the 80s and was sent to the ER for evaluation.
Per EMS the pt remained alert and oriented X3. BP 68/36 HR 104.
On arrival to ED the pt was A&Ox3 with no complaints of pain,
denied fever/chills, no CP/SOB. She complained of fatigue. IV
access was difficult to obtain, failed attempt at RIJ. Pt had EJ
placed followed by a R femoral line. Initial vitals: T 98.0, HR
98, BP 62/34, RR 18 O2 100% on 4L. She was given vancomycin 1gm
IVX1 and zosyn 3.375g IV X1. BP improved to 99/34 following 1L
NS. CXR with no evidence of infiltrate. ECG with no change from
prior. Lactate 1.5.
.
On arrival to the MICU, the pt is resting comfortably, denies
lightheadedness. Denies CP/SOB.

MEDICAL HISTORY: ESRD on HD since [**12-29**]; qMWF schedule at [**Location (un) **] [**Location (un) **]
IDDM
Chronic diastolic CHF (LVEF >75%)
PAF s/p failed ablation, on warfarin
HTN c/b LVH & LVOT
Hyperlipidemia
PVD s/p bilateral BKAs
Left eye blindness
GERD
h/o VRE UTI

MEDICATION ON ADMISSION: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
Vitals: afebrile, BP 105/40, HR 98, RR 17, 91% RA
GENERAL: chronically ill-appearing woman in NAD, appropriate and
pleasant
HEENT: EOMI, MMM
NECK: Supple with no elevation of JVP
CARDIAC: irregular, normal S1, S2, II/VI crescedno-decrescendo
murmur
heard best at RUSB
LUNGS: no accessory muscle use. CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness
Ext: b/l BKA

FAMILY HISTORY: Her father died in his 90s of complications of DM2 and mother at
the age of 102 of a stroke. Patient had a sister who died in her
70s of cancer (unknown type and site) and 2 brothers that died
stroke and brain cancer. She has 7 children who are healthy. Her
family history is significant for coronary artery disease,
cancer, and diabetes.

SOCIAL HISTORY: The patient denies alcohol and IV drug use. She states that she
smokes approximately 3 cigarettes daily and has history of ~30
pack-year. She lives in a senior citizen center; her daughter
lives with her. 

### Response:
{'Other iatrogenic hypotension,Chronic diastolic heart failure,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Secondary hyperparathyroidism (of renal origin),Atrial fibrillation,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Other and unspecified hyperlipidemia,Long-term (current) use of insulin,Peripheral vascular disease, unspecified,Below knee amputation status'}
