CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: 51 YO F w ESLD [**1-8**] HCV and septic hip who presented to an
outpatient appt for reclast at which time she was noted to have
a BP in the 70s. The patient was feeling well until the night
prior to presentation when she had several loose bowel movements
without blood. She slept last night and awoke this am feeling
nauseous. She ate 1 bite of breakfast and vomited nonbloody
gastric contents. She denied any fever, chills, or shortness of
breath. She was scheduled for an outpatient Reclast infusion so
was picked up by an ambulance for transport at which time EMTs
noted her SBP to be in the 70s. The patient insisted on going to
her appt rather than the ED. At her appt she was again noted to
have SBPs in the 70s so was transported to the ED.
.
In the ED, patient was triggered for an initial BP of 73/43. She
was given 2L NS without effect. A femoral CVL was placed and she
was given vanc, zosyn, hydrocort, and norepi with improvement in
her SBPs to the 100s-120s. Her labs returned notable for WBCs
7.8 with 23% bands, creat 1.5, K 6.6 and lactate 3.7. U/A was
negative for evidence of UTI. Blood and urine cultures were
drawn. EKG revealed peaked T waves so she was given insulin,
dextrose, bicarb, and Ca gluconate. K went from 6.6 to 5.5. She
is was noted to be very sleepy but arousable and able to protect
her airway. CXR was c/w a retrocardiac opacity. VS prior to
transfer were: 101/65 85-90 16 93% RA.
.
On the floor, the patient reports feeling better. She does
complain of bilateral lower abdominal pain. Her mother says she
is still not at her baseline but is much improved since arriving
at the ED; most specifically, she is much less lethargic.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting,
constipation. No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: 1. HCV Cirrhosis, diagnosed [**2151**], nonresponder to interferon /
ribavirin, s/p TIPS [**11-8**] for ascites. Course has been
complicated by encephalopathy, thrombocytopenia, ascites, and
hydrothorax. Was on [**Month/Year (2) **] list but inactivated due to
recurrent infections.
2. Hyponatremia baseline 128-133
3. Secondary adrenal insufficiency
4. Asthma
5. Diabetes mellitus
6. GERD
7. Anxiety
8. History of urinary tract infections
9. s/p hip fracture and ORIF in [**11/2157**], which was
complicated by polymicrobial septic hip (E. Coli, enterococcus,
coag neg Staph, Klebisiella) s/p washout [**6-/2158**],  hardware
removal [**9-/2158**], with wound vac in place at home.
10. History of LE Cellulitis
11. Possible prolactinoma suggestion of microadenoma [**5-12**]
12. Hypercalcemia thought due to aggressive vitamin D repletion

MEDICATION ON ADMISSION: Albuterol Sulfate 90 mcg 2 PUFFS [**Hospital1 **]
Amoxicillin 2g PRN Dental work
Calcitriol 0.25 mcg Capsule QOD
Clotrimazole 10 mg Troche QID
Doxycycline Hyclate 100mg PO BID
Effexor 75mg PO BID
Ergocalciferol (Vitamin D2) [Vitamin D] 50,000 units QMWF
Fluticasone-Salmeterol 250 mcg-50 mcg/Dose INH [**Hospital1 **]
Folic Acid 1 mg PO daily
Furosemide [Lasix] 80mg PO BID
Gabapentin 100mg PO BID
Insulin Glargine [Lantus] 22 units QPM
Insulin Lispro [Humalog] Sliding Scale
Ipratropium Bromide [Atrovent HFA] 1-2puff [**Hospital1 **] PRN
Ketoconazole 2% Cream [**Hospital1 **]
Lactulose 45mL TID ([**2-7**] BM/Day)
Montelukast [Singulair] 10mg PO daily
Oxycodone 5mg [**12-8**] PO Daily
Oxycodone [OxyContin] 10mg PO BID
Prednisone 5mg PO daily
Rifaximin [Xifaxan] 500mg PO BID
Spironolactone 100mg PO daily
Calcium Carbonate 1g PO TID
Magnesium Oxide 400mg PO BID/TID
Multivitamin 1 tab Daily
Sodium Chloride 0.65 % Nasal [**12-8**] PRN

ALLERGIES: Shellfish / Flexeril / Tricyclic Compounds

PHYSICAL EXAM: On admission:
Vitals: 85, 101/65, 16, 93% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Father - COPD, alcohol cirrhosis
Mother - diabetes, HTN, HL
Daughter - congenital heart dz

SOCIAL HISTORY: Lives with her mother. [**Name (NI) **] 1 daughter and a granddaughter.
Stopped smoking in [**2154**], previously smoked [**12-8**] ppd for several
years, unclear how long. Sober since [**2148**], drank an unclear
amount of drinks per day before that. H/o IV heroin, stopped in
[**2148**]. No other drugs used. No sick contacts or recent travel.
Septicemia due to pseudomonas,Acute kidney failure, unspecified,Septic shock,Chronic hepatitis C with hepatic coma,Hyposmolality and/or hyponatremia,Glucocorticoid deficiency,Non-healing surgical wound,Other ascites,Other and unspecified coagulation defects,Severe sepsis,Cirrhosis of liver without mention of alcohol,Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Anxiety state, unspecified,Thrombocytopenia, unspecified,Diarrhea,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other specified disorders of rectum and anus
Pseudomonas septicemia,Acute kidney failure NOS,Septic shock,Chrnc hpt C w hepat Coma,Hyposmolality,Glucocorticoid deficient,Non-healing surgcl wound,Ascites NEC,Coagulat defect NEC/NOS,Severe sepsis,Cirrhosis of liver NOS,Asthma NOS,DMII wo cmp nt st uncntr,Esophageal reflux,Anxiety state NOS,Thrombocytopenia NOS,Diarrhea,Abn react-surg proc NEC,Rectal & anal dis NEC
Admission Date:  [**2160-7-2**]              Discharge Date:   [**2160-7-11**]

Date of Birth:  [**2109-1-23**]             Sex:   F

Service: MEDICINE

Allergies:
Shellfish / Flexeril / Tricyclic Compounds

Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Hypotension

Major Surgical or Invasive Procedure:
PICC line placement

History of Present Illness:
51 YO F w ESLD [**1-8**] HCV and septic hip who presented to an
outpatient appt for reclast at which time she was noted to have
a BP in the 70s. The patient was feeling well until the night
prior to presentation when she had several loose bowel movements
without blood. She slept last night and awoke this am feeling
nauseous. She ate 1 bite of breakfast and vomited nonbloody
gastric contents. She denied any fever, chills, or shortness of
breath. She was scheduled for an outpatient Reclast infusion so
was picked up by an ambulance for transport at which time EMTs
noted her SBP to be in the 70s. The patient insisted on going to
her appt rather than the ED. At her appt she was again noted to
have SBPs in the 70s so was transported to the ED.
.
In the ED, patient was triggered for an initial BP of 73/43. She
was given 2L NS without effect. A femoral CVL was placed and she
was given vanc, zosyn, hydrocort, and norepi with improvement in
her SBPs to the 100s-120s. Her labs returned notable for WBCs
7.8 with 23% bands, creat 1.5, K 6.6 and lactate 3.7. U/A was
negative for evidence of UTI. Blood and urine cultures were
drawn. EKG revealed peaked T waves so she was given insulin,
dextrose, bicarb, and Ca gluconate. K went from 6.6 to 5.5. She
is was noted to be very sleepy but arousable and able to protect
her airway. CXR was c/w a retrocardiac opacity. VS prior to
transfer were: 101/65 85-90 16 93% RA.
.
On the floor, the patient reports feeling better. She does
complain of bilateral lower abdominal pain. Her mother says she
is still not at her baseline but is much improved since arriving
at the ED; most specifically, she is much less lethargic.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting,
constipation. No dysuria. Denied arthralgias or myalgias.

Past Medical History:
1. HCV Cirrhosis, diagnosed [**2151**], nonresponder to interferon /
ribavirin, s/p TIPS [**11-8**] for ascites. Course has been
complicated by encephalopathy, thrombocytopenia, ascites, and
hydrothorax. Was on [**Month/Year (2) **] list but inactivated due to
recurrent infections.
2. Hyponatremia baseline 128-133
3. Secondary adrenal insufficiency
4. Asthma
5. Diabetes mellitus
6. GERD
7. Anxiety
8. History of urinary tract infections
9. s/p hip fracture and ORIF in [**11/2157**], which was
complicated by polymicrobial septic hip (E. Coli, enterococcus,
coag neg Staph, Klebisiella) s/p washout [**6-/2158**],  hardware
removal [**9-/2158**], with wound vac in place at home.
10. History of LE Cellulitis
11. Possible prolactinoma suggestion of microadenoma [**5-12**]
12. Hypercalcemia thought due to aggressive vitamin D repletion




Social History:
Lives with her mother. [**Name (NI) **] 1 daughter and a granddaughter.
Stopped smoking in [**2154**], previously smoked [**12-8**] ppd for several
years, unclear how long. Sober since [**2148**], drank an unclear
amount of drinks per day before that. H/o IV heroin, stopped in
[**2148**]. No other drugs used. No sick contacts or recent travel.


Family History:
Father - COPD, alcohol cirrhosis
Mother - diabetes, HTN, HL
Daughter - congenital heart dz


Physical Exam:
On admission:
Vitals: 85, 101/65, 16, 93% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
ON ADMISSION ([**2160-7-2**]):
WBC-7.8 RBC-3.15* Hgb-9.9* Hct-30.3* MCV-96 MCH-31.4 MCHC-32.6
RDW-18.2* Plt Ct-61*
Neuts-66 Bands-23* Lymphs-7* Monos-1* Eos-1 Baso-0 Atyps-0
Metas-2* Myelos-0
Hypochr-2+ Anisocy-2+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL
Polychr-1+ Ovalocy-1+ Schisto-1+
PT-17.8* PTT-36.2* INR(PT)-1.6*
Glucose-93 UreaN-48* Creat-1.5* Na-121* K-6.6* Cl-91* HCO3-22
AnGap-15
ALT-22 AST-50* AlkPhos-273*
cTropnT-0.06*
Calcium-8.2* Phos-5.1*# Mg-2.0
Lactate-3.7*
.
UPON DISCHARGE ([**2160-7-10**]):
WBC-8.8 RBC-2.45* Hgb-7.5* Hct-23.1* MCV-94 MCH-30.4 MCHC-32.2
RDW-20.1* Plt Ct-62*
PT-21.8* PTT-38.3* INR(PT)-2.0*
Glucose-166* UreaN-35* Creat-0.6 Na-137 K-4.1 Cl-107 HCO3-23
AnGap-11
ALT-27 AST-37 AlkPhos-204* TotBili-2.4*
Albumin-2.8* Calcium-8.4 Phos-2.4* Mg-1.7
.
MICRO:
Blood Cx ([**7-2**]): Pseudomonas aeurginosa
Urine Cx ([**7-2**]): no growth
Stool Cx ([**7-2**]): no C. diff, Salmonella, Shigella, or
Campylobacter
Blood Cx ([**7-4**], [**7-5**], [**7-6**], [**7-7**]): no growth
Stool Cx ([**7-6**]): no C. diff
CMV viral load ([**7-8**]): not detected
Stool Cx ([**7-8**]): no C. diff, Cryptosporidium, or Giardia
.
IMAGING:
Portable CXR ([**7-2**]): 1. LLL consolidation, worrisome for PNA
with possible superimposed atelectasis. 2. Right pleural
effusion and increased interstitial markings reflecting mild
pulmonary edema.
.
Abdominal U/S ([**7-3**]): Minimal amount of intra-abdominal ascites.
The amount of fluid within the abdominal quadrants would be a
high-risk procedure even for a diagnostic aspiration and we
would recommend deferral of attempting sampling at this time.
.
PA&LAT CXR ([**7-3**]): Chronic bilateral pleural effusions and
bibasilar opacities/atelectasis, possibly due to chronic
aspiration. Increased left retrocardiac consolidation is again
worrisome for pneumonia.
.
RUQ U/S ([**7-3**]): 1. Unchanged cirrhotic-appearing liver, without
suspicious hepatic lesion or intrahepatic fluid collection to
suggest abscess. 2. Contracted gallbladder related to recent
meal. Biliary sludge and stable cholelithiasis but no findings
of acute cholecystitis.
.
CT abdomen/pelvis w/ contrast ([**7-4**]): 1. Patchy opacity in the
right lung base may represent aspiration or infection. 2. Small
bilateral pleural effusions with associated compressive
atelectasis, underlying infection not excluded. 3. Findings
compatible with cirrhosis and portal HTN. 4. Wall edema in the
distal rectum suggestive of proctitis.
.
Mandible XR ([**7-9**]): Patchy osteopenia of the mandible. Multiple
erosions.

Brief Hospital Course:
51 year old woman with HCV cirrhosis s/p TIPS in [**2153**], which has
been c/b encephalopathy, thrombocytopenia, ascites, hydrothorax,
and multiple infections, and septic right hip who presented to
an outpatient appointment for reclast at which time she was was
noted to be hypotensive and confused, and was sent to the ED.
Please see admission note for further details. Brief hospital
course by problem:
.
# Sepsis: The pt presented with vomiting, hypotension, and
altered mental status and was found to have 7.8 WBCs with 23%
bands. U/A was negative and urine culutures showed no growth. A
CXR revealed a LLL consolidation suspicious for PNA, however the
pt denied respiratory symptoms and was not hypoxic. An abdominal
U/S revealed an unchanged cirrhotic-appearing liver, w/o
evidence of abscess or ascites. An abdominal CT revealed wall
edema in the distal rectum suggestive of proctitis. She was
empirically treated for SBP with vanco, zosyn, and ciprofloxacin
and received albumin. Blood cultures came back positive for
Pseudomonas aeruginosa, however no source was identified.
Antibiotics were narrowed to cefepime to cover Pseudomonas and
flagyl for potential GI source considering proctitis seen on CT.
A PICC line was placed. The patient's mental status improved
with lactulose, rifaximin, and antibiotics and her vitals
remained stable. Several repeat blood cultures were all
negative. The pt was discharged home with VNA to help with
antibiotic administration and PICC care. Cefepime was continued
for a 14-day course.
.
# ARF: On admission the pt was noted to have a Cr of 1.5 which
was felt to be prerenal secondary to hypotension. She was
treated with fluids and her creatinine normalized. Cr was 0.6
upon discharge.
.
# [**Year (4 digits) **]: On admission the pt was noted to have a K of
6.6. An EKG revealed peaked T waves so she was given insulin,
dextrose, bicarb, and calcium gluconate and her potassium
normalized.
.
# Diarrhea: Pt reported several loose BMs prior to admission and
experienced several days of watery diarrhea during this
admission. A flexiseal was placed. Stool cultures were negative
for C. diff, Salmonella, Shigella, Campylobacter,
Cryptosporidium, or Giardia, and CMV viral load was
undetectable. An abdominal CT revealed wall edema in the distal
rectum suggestive of proctitis, however this was felt to be
unlikely to explain her watery diarrhea. Unclear etiology.
Flagyl 500 mg q8 was continued for a 14-day course.
.
# Poor dentition: There was concern that her dentition may be a
source of infection so dental x-rays were done and dentistry was
consulted. There are two teeth that will need to be extracted so
an OP appt was made with oral surgery on [**7-17**].
.
# HCV cirrhosis: S/p TIPS in [**2153**], has been c/b encephalopathy,
thrombocytopenia, ascites, hydrothorax, and multiple infections.
LFTs were stable during this admission. Continued home meds plus
increased lasix to 120mg QD and increased spironolactone to
150mg QD.
.
# S/p hip fracture and ORIF in [**11-11**], c/b polymicrobial septic
hip s/p washout [**6-/2158**], hardware removal [**9-12**], with wound vac
in place at home. A wound care consult was placed and
.
# Secondary adrenal insufficiency: Stable. Continued prednisone
5mg daily.
.
# Diabetes: Stable. Continued home meds.
.
# Asthma: Stable. Continued home meds.
.
# GERD: Stable.

Medications on Admission:
Albuterol Sulfate 90 mcg 2 PUFFS [**Hospital1 **]
Amoxicillin 2g PRN Dental work
Calcitriol 0.25 mcg Capsule QOD
Clotrimazole 10 mg Troche QID
Doxycycline Hyclate 100mg PO BID
Effexor 75mg PO BID
Ergocalciferol (Vitamin D2) [Vitamin D] 50,000 units QMWF
Fluticasone-Salmeterol 250 mcg-50 mcg/Dose INH [**Hospital1 **]
Folic Acid 1 mg PO daily
Furosemide [Lasix] 80mg PO BID
Gabapentin 100mg PO BID
Insulin Glargine [Lantus] 22 units QPM
Insulin Lispro [Humalog] Sliding Scale
Ipratropium Bromide [Atrovent HFA] 1-2puff [**Hospital1 **] PRN
Ketoconazole 2% Cream [**Hospital1 **]
Lactulose 45mL TID ([**2-7**] BM/Day)
Montelukast [Singulair] 10mg PO daily
Oxycodone 5mg [**12-8**] PO Daily
Oxycodone [OxyContin] 10mg PO BID
Prednisone 5mg PO daily
Rifaximin [Xifaxan] 500mg PO BID
Spironolactone 100mg PO daily
Calcium Carbonate 1g PO TID
Magnesium Oxide 400mg PO BID/TID
Multivitamin 1 tab Daily
Sodium Chloride 0.65 % Nasal [**12-8**] PRN

Discharge Medications:
1. Cefepime 2 gram Recon Soln Sig: Two (2) gram Injection Q12H
(every 12 hours) for 8 days.
Disp:*32 gram* Refills:*0*
2. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
3. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) cc Injection
every eight (8) hours: For duration of PICC line.
Disp:*30 * Refills:*0*
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation [**Hospital1 **] (2 times a day).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
6. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO every Mon/Wed/Fri.
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
11. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
Disp:*45 Tablet(s)* Refills:*0*
12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
13. Lantus 100 unit/mL Solution Sig: Twenty Two (22) units
Subcutaneous every evening.
14. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day.
15. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: 1-2 Puffs Inhalation [**Hospital1 **] (2 times a day) as needed for
wheezing.
16. Ketoconazole 2 % Cream Sig: One (1)  Topical twice a day.
17. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO
three times a day: Titrate to [**2-7**] bowel movements daily.
18. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for pain.
20. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
21. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
22. Rifaximin 550 mg Tablet Sig: One (1) Tablet PO twice a day.

23. Calcium Carbonate 1,000 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
24. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
25. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
26. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-8**]  Nasal as
needed.
27. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
28. Clotrimazole 10 mg Troche Sig: One (1)  Mucous membrane four
times a day.
29. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
30. Outpatient Lab Work
On Monday [**2160-7-14**] and weekly thereafter: CBC, Chem7, LFTs, with
results to be faxed to [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] ([**Last Name (NamePattern1) 1326**] Coordinator),
[**Hospital1 18**] Liver Center at [**Telephone/Fax (1) 697**]


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] Home Care Services

Discharge Diagnosis:
Primary:
- Sepsis secondary to pseudomonas infection
.
Secondary:
- HCV cirrhosis
- Adrenal insufficiency
- Diabetes
- Acute renal failure
- Right hip wound


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Ms. [**Known lastname 68459**],
You were admitted to the hospital because you had vomiting with
low blood pressure. You were found to have an infection in your
blood which we are treating with antibiotics. Your kidneys were
sick, but have gotten better. You were seen by a dentist, who
recommended to see an oral surgeon to discuss teeth extraction.
.
Please continue to take your home medications. We have made the
following changes:
- STARTED cefepime 2g IV twice daily, last doses on [**7-18**]
- STARTED metronidazole 500 mg orally every eight hours, last
doses on [**7-18**]
- INCREASED lasix to 120mg by mouth daily
- INCREASED spironolactone to 150mg by mouth daily
- HOLDING amoxicillin while you are taking cefepime. Please talk
to the oral surgeons about this when you see them next week.
.
Please keep your appointments and take your medications as
directed below.

Followup Instructions:
ORAL SURGERY CLINIC at [**Hospital6 **]. [**Location (un) 68462**], [**Location (un) **] Yawkey Ambulatory Center. Date/Time:[**2160-7-17**]
2:00 pm. Phone: [**Telephone/Fax (1) 68463**]. Your oral surgeon will be
requesting further information about how long you have been
taking Reclast.
.
[**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2160-7-30**] 10:50
.
[**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 6742**] Date/Time:[**2160-8-1**] 1:30
.
[**Month/Day/Year **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2160-8-6**] 9:00
.
[**Month/Day/Year **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2160-8-21**] 9:20



Completed by:[**2160-7-17**]
{'Septicemia due to pseudomonas,Acute kidney failure, unspecified,Septic shock,Chronic hepatitis C with hepatic coma,Hyposmolality and/or hyponatremia,Glucocorticoid deficiency,Non-healing surgical wound,Other ascites,Other and unspecified coagulation defects,Severe sepsis,Cirrhosis of liver without mention of alcohol,Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Anxiety state, unspecified,Thrombocytopenia, unspecified,Diarrhea,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other specified disorders of rectum and anus'}


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: 51 YO F w ESLD [**1-8**] HCV and septic hip who presented to an
outpatient appt for reclast at which time she was noted to have
a BP in the 70s. The patient was feeling well until the night
prior to presentation when she had several loose bowel movements
without blood. She slept last night and awoke this am feeling
nauseous. She ate 1 bite of breakfast and vomited nonbloody
gastric contents. She denied any fever, chills, or shortness of
breath. She was scheduled for an outpatient Reclast infusion so
was picked up by an ambulance for transport at which time EMTs
noted her SBP to be in the 70s. The patient insisted on going to
her appt rather than the ED. At her appt she was again noted to
have SBPs in the 70s so was transported to the ED.
.
In the ED, patient was triggered for an initial BP of 73/43. She
was given 2L NS without effect. A femoral CVL was placed and she
was given vanc, zosyn, hydrocort, and norepi with improvement in
her SBPs to the 100s-120s. Her labs returned notable for WBCs
7.8 with 23% bands, creat 1.5, K 6.6 and lactate 3.7. U/A was
negative for evidence of UTI. Blood and urine cultures were
drawn. EKG revealed peaked T waves so she was given insulin,
dextrose, bicarb, and Ca gluconate. K went from 6.6 to 5.5. She
is was noted to be very sleepy but arousable and able to protect
her airway. CXR was c/w a retrocardiac opacity. VS prior to
transfer were: 101/65 85-90 16 93% RA.
.
On the floor, the patient reports feeling better. She does
complain of bilateral lower abdominal pain. Her mother says she
is still not at her baseline but is much improved since arriving
at the ED; most specifically, she is much less lethargic.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting,
constipation. No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: 1. HCV Cirrhosis, diagnosed [**2151**], nonresponder to interferon /
ribavirin, s/p TIPS [**11-8**] for ascites. Course has been
complicated by encephalopathy, thrombocytopenia, ascites, and
hydrothorax. Was on [**Month/Year (2) **] list but inactivated due to
recurrent infections.
2. Hyponatremia baseline 128-133
3. Secondary adrenal insufficiency
4. Asthma
5. Diabetes mellitus
6. GERD
7. Anxiety
8. History of urinary tract infections
9. s/p hip fracture and ORIF in [**11/2157**], which was
complicated by polymicrobial septic hip (E. Coli, enterococcus,
coag neg Staph, Klebisiella) s/p washout [**6-/2158**],  hardware
removal [**9-/2158**], with wound vac in place at home.
10. History of LE Cellulitis
11. Possible prolactinoma suggestion of microadenoma [**5-12**]
12. Hypercalcemia thought due to aggressive vitamin D repletion

MEDICATION ON ADMISSION: Albuterol Sulfate 90 mcg 2 PUFFS [**Hospital1 **]
Amoxicillin 2g PRN Dental work
Calcitriol 0.25 mcg Capsule QOD
Clotrimazole 10 mg Troche QID
Doxycycline Hyclate 100mg PO BID
Effexor 75mg PO BID
Ergocalciferol (Vitamin D2) [Vitamin D] 50,000 units QMWF
Fluticasone-Salmeterol 250 mcg-50 mcg/Dose INH [**Hospital1 **]
Folic Acid 1 mg PO daily
Furosemide [Lasix] 80mg PO BID
Gabapentin 100mg PO BID
Insulin Glargine [Lantus] 22 units QPM
Insulin Lispro [Humalog] Sliding Scale
Ipratropium Bromide [Atrovent HFA] 1-2puff [**Hospital1 **] PRN
Ketoconazole 2% Cream [**Hospital1 **]
Lactulose 45mL TID ([**2-7**] BM/Day)
Montelukast [Singulair] 10mg PO daily
Oxycodone 5mg [**12-8**] PO Daily
Oxycodone [OxyContin] 10mg PO BID
Prednisone 5mg PO daily
Rifaximin [Xifaxan] 500mg PO BID
Spironolactone 100mg PO daily
Calcium Carbonate 1g PO TID
Magnesium Oxide 400mg PO BID/TID
Multivitamin 1 tab Daily
Sodium Chloride 0.65 % Nasal [**12-8**] PRN

ALLERGIES: Shellfish / Flexeril / Tricyclic Compounds

PHYSICAL EXAM: On admission:
Vitals: 85, 101/65, 16, 93% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Father - COPD, alcohol cirrhosis
Mother - diabetes, HTN, HL
Daughter - congenital heart dz

SOCIAL HISTORY: Lives with her mother. [**Name (NI) **] 1 daughter and a granddaughter.
Stopped smoking in [**2154**], previously smoked [**12-8**] ppd for several
years, unclear how long. Sober since [**2148**], drank an unclear
amount of drinks per day before that. H/o IV heroin, stopped in
[**2148**]. No other drugs used. No sick contacts or recent travel. 

### Response:
{'Septicemia due to pseudomonas,Acute kidney failure, unspecified,Septic shock,Chronic hepatitis C with hepatic coma,Hyposmolality and/or hyponatremia,Glucocorticoid deficiency,Non-healing surgical wound,Other ascites,Other and unspecified coagulation defects,Severe sepsis,Cirrhosis of liver without mention of alcohol,Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Anxiety state, unspecified,Thrombocytopenia, unspecified,Diarrhea,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other specified disorders of rectum and anus'}
