CHIEF COMPLAINT: Weakness, hypotension

PRESENT ILLNESS: Mr. [**Known lastname 1726**] is an 83M with hx parosysmal Afib not on coumadin,
CAD s/p CABG in [**2135**] with LIMA to LAD which is totally occluded
after D1, SVG-D1 (stent in graft), SVG-OM (chronically
occluded), with most recent PCI in [**5-26**] with stenting Lcx, s/p
hip replacement, with hx chronic c.diff infection x 5 years. Pt
was in USOH until the night prior to admission when he noted
that he was unable to get up out of bed secondary to weakness,
which he noted was worse in his legs than in his arms. He
struggled to get OOB for a while, eventually becoming SOB, with
subsequent mid sternal sharp non radiating chest pain
experienced, similar to his anginal episodes. The pain was not
associated with diaphoresis or nausea, p.o intake, there was no
positional or pleuritic component. He took SLNTG x1 and the CP
resolved. He continued to experience this weakness on the day of
admission, called life line, with EMS sent to his home. On
arrival he was noted to have ? NSVT on monitor. Of note, he has
experienced several days of diarrhea with 10 or more loose
stools a day. Increased from baseline.
.
In the ER, initial VS were T97.1, HR 150, BP 73/54 -> 86/59, RR
36, O2 100% NRB. EKG showed wide complex tachycardia afib with
aberancy. Having CP. Labs notable for WBC 26, Cr 1.9 from
baseline 1.3. Underwent cardioversion for A. Fib with
hypotension and subsequently converted to sinus rhythm with
resolution of his chest pain. CXR negative for PNA. Overall
impression was for sepsis [**2-24**] C. diff and patient given
metronidazole for his diarrhea and 2L of IVF. Prior to transfer
had been making urine >800cc.
.
Vitals prior to transfer HR72 113/70 17 100%2L.
.
ROS is notable for chronic fatigue. He denies recent URIs,
cough, hemoptysis, fever, chills, rigors, diaphoresis, abdominal
pain, sick contacts, travel, prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, black stools or red
stools. He denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
On arrival to the CCU he was seen to be in slow A.fib on EKG,
and hypotensive to the high 80s. IVF boluses were initiated with
subsequent improvement in pressure.  He was found to have GNR on
blood culture and was started on IV vanc/flagyll. He was started
on amniodorone drip .

MEDICAL HISTORY: -CAD with stable angina, s/p CABG '[**35**], multiple stents (last
cath report [**5-26**]: Two vessel CAD. Patent LIMA-LAD. Patent
SVG-D1. SVG-OM is known to be chronically occluded. The LCx had

MEDICATION ON ADMISSION: aspirin 81 mg daily
nigtroglycerin SR 2.5 mg
metoprolol 25mg q24
sertraline 100mg [**Hospital1 **]
vanco 125 [**Hospital1 **]
folic acid 400mg
avicor 20mg [**Hospital1 **]
multivitamin

ALLERGIES: Ticlid / Lipitor

PHYSICAL EXAM: VS - T: HR: 80 BP: 93/55 (64) RR: 13 SPO2: 99%
Gen: Notable pallor. Poor cap refill. Poor skin turgor.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 7 cm.
CV:mostly regular rymth. PMI located in 5th intercostal space,
midclavicular line. RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits. Cool lower extremities. [**5-26**]
muscle strength BUE, BLE.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
DP/PT: dopperable bilaterally.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Denies tobacco and ETOH use.
Bacteremia,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Acidosis,Coronary atherosclerosis of autologous vein bypass graft,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Atrial fibrillation,Other chronic pulmonary heart diseases,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Anemia, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Personal history of malignant neoplasm of prostate,Hip joint replacement
Bacteremia,Acute kidney failure NOS,Urin tract infection NOS,Int inf clstrdium dfcile,Acidosis,Crn ath atlg vn bps grft,Oth gram negatv bacteria,Atrial fibrillation,Chr pulmon heart dis NEC,Status-post ptca,Old myocardial infarct,Hypertension NOS,Hyperlipidemia NEC/NOS,Anemia NOS,Osteoarthros NOS-unspec,Hx-prostatic malignancy,Joint replaced hip
Admission Date:  [**2156-3-23**]              Discharge Date:   [**2156-3-29**]

Date of Birth:  [**2072-5-20**]             Sex:   M

Service: MEDICINE

Allergies:
Ticlid / Lipitor

Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
Weakness, hypotension

Major Surgical or Invasive Procedure:
Cardioversion


History of Present Illness:
Mr. [**Known lastname 1726**] is an 83M with hx parosysmal Afib not on coumadin,
CAD s/p CABG in [**2135**] with LIMA to LAD which is totally occluded
after D1, SVG-D1 (stent in graft), SVG-OM (chronically
occluded), with most recent PCI in [**5-26**] with stenting Lcx, s/p
hip replacement, with hx chronic c.diff infection x 5 years. Pt
was in USOH until the night prior to admission when he noted
that he was unable to get up out of bed secondary to weakness,
which he noted was worse in his legs than in his arms. He
struggled to get OOB for a while, eventually becoming SOB, with
subsequent mid sternal sharp non radiating chest pain
experienced, similar to his anginal episodes. The pain was not
associated with diaphoresis or nausea, p.o intake, there was no
positional or pleuritic component. He took SLNTG x1 and the CP
resolved. He continued to experience this weakness on the day of
admission, called life line, with EMS sent to his home. On
arrival he was noted to have ? NSVT on monitor. Of note, he has
experienced several days of diarrhea with 10 or more loose
stools a day. Increased from baseline.
.
In the ER, initial VS were T97.1, HR 150, BP 73/54 -> 86/59, RR
36, O2 100% NRB. EKG showed wide complex tachycardia afib with
aberancy. Having CP. Labs notable for WBC 26, Cr 1.9 from
baseline 1.3. Underwent cardioversion for A. Fib with
hypotension and subsequently converted to sinus rhythm with
resolution of his chest pain. CXR negative for PNA. Overall
impression was for sepsis [**2-24**] C. diff and patient given
metronidazole for his diarrhea and 2L of IVF. Prior to transfer
had been making urine >800cc.
.
Vitals prior to transfer HR72 113/70 17 100%2L.
.
ROS is notable for chronic fatigue. He denies recent URIs,
cough, hemoptysis, fever, chills, rigors, diaphoresis, abdominal
pain, sick contacts, travel, prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, black stools or red
stools. He denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
On arrival to the CCU he was seen to be in slow A.fib on EKG,
and hypotensive to the high 80s. IVF boluses were initiated with
subsequent improvement in pressure.  He was found to have GNR on
blood culture and was started on IV vanc/flagyll. He was started
on amniodorone drip .


Past Medical History:
-CAD with stable angina, s/p CABG '[**35**], multiple stents (last
cath report [**5-26**]: Two vessel CAD. Patent LIMA-LAD. Patent
SVG-D1. SVG-OM is known to be chronically occluded. The LCx had

70% in-stent stenosis in the proximal stent. There was a 70%
lesion just distal to the stent. Successful PTCA of the LCX.)
-Moderate systolic CHF - LVEF of 35%-40% on echo in [**5-30**]
-Moderate pulmonary artery systolic hypertension - TR gradient
of 49 mmHg on echo in [**5-30**]
-A-fib (paroxysmal)previously on coumadin but not currently
taking
-hemoperitoneum around the liver and in the pelvis along with
two splenic artery pseudoaneurysms s/p IR embolization of both
in [**11/2155**]
-NSTEMI in the setting of acute blood loss anemia during
hospitalization in [**11/2155**]
- H/o C Diff - found in [**2152**], on chronic PO vanco at home; when

taken off vanco, has frequent diarrhea and dehydration
-HTN
-Hyperlipidemia
-Anemia
-Prostate CA s/p XRT (over 10 years ago), s/p TURP [**1-11**]
-s/p discectomy [**9-25**]
-Left hip arthroplasty [**12-26**]
-Severe osteoarthritis
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
.
Cardiac History: CABG, in [**2135**] anatomy as follows:
-LIMA to LAD, SVG-D1 (stent in graft), SVG-OM (chronically
occluded)


Social History:
Denies tobacco and ETOH use.


Family History:
Noncontributory

Physical Exam:
VS - T: HR: 80 BP: 93/55 (64) RR: 13 SPO2: 99%
Gen: Notable pallor. Poor cap refill. Poor skin turgor.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 7 cm.
CV:mostly regular rymth. PMI located in 5th intercostal space,
midclavicular line. RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits. Cool lower extremities. [**5-26**]
muscle strength BUE, BLE.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
DP/PT: dopperable bilaterally.

Pertinent Results:
[**2156-3-23**] 10:56PM   HCT-30.0*
[**2156-3-23**] 07:56PM   LACTATE-2.6*
[**2156-3-23**] 07:45PM   GLUCOSE-250* UREA N-37* CREAT-1.9* SODIUM-139
POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-18* ANION GAP-17
[**2156-3-23**] 07:45PM   CK(CPK)-597*
[**2156-3-23**] 07:45PM   cTropnT-2.85*
[**2156-3-23**] 07:45PM   CK-MB-58* MB INDX-9.7*
[**2156-3-23**] 02:00PM   GLUCOSE-281* UREA N-37* CREAT-1.9* SODIUM-139
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-14* ANION GAP-25*
[**2156-3-23**] 02:00PM   CK(CPK)-39*
[**2156-3-23**] 02:00PM   cTropnT-0.05*
[**2156-3-23**] 02:00PM   CALCIUM-9.1 PHOSPHATE-4.1 MAGNESIUM-2.0
[**2156-3-23**] 02:00PM   WBC-26.4*# RBC-3.40* HGB-10.2* HCT-31.2*
MCV-92# MCH-30.0 MCHC-32.7 RDW-15.8*
[**2156-3-23**] 02:00PM   NEUTS-93.8* LYMPHS-4.5* MONOS-1.3* EOS-0.2
BASOS-0.2
[**2156-3-23**] 02:00PM   PLT COUNT-292#
[**2156-3-23**] 02:00PM   PT-13.8* PTT-22.9 INR(PT)-1.2*
.
CXR [**2156-3-23**]
FINDINGS: Overlying EKG leads slightly obscures film. There is
moderate
cardiomegaly, unchanged. There is a tortuous aorta. Patient is
status post
CABG. Sternotomy wires are intact. There is no focal
consolidation, pleural
effusion or pneumothorax.

IMPRESSION: No focal consolidation.

[**2156-3-27**] 05:58AM BLOOD WBC-12.5* RBC-3.14* Hgb-9.4* Hct-28.9*
MCV-92 MCH-30.0 MCHC-32.6 RDW-15.9* Plt Ct-169
[**2156-3-28**] 05:04AM BLOOD WBC-10.5 RBC-3.20* Hgb-9.3* Hct-28.2*
MCV-88 MCH-29.0 MCHC-32.8 RDW-16.4* Plt Ct-167
[**2156-3-29**] 06:54AM BLOOD WBC-13.2* RBC-2.91* Hgb-8.6* Hct-25.8*
MCV-89 MCH-29.4 MCHC-33.2 RDW-16.9* Plt Ct-155
[**2156-3-24**] 04:54AM BLOOD PT-15.0* PTT-26.5 INR(PT)-1.3*
[**2156-3-25**] 04:29AM BLOOD PT-15.0* PTT-28.3 INR(PT)-1.3*
[**2156-3-25**] 03:44PM BLOOD Glucose-110* UreaN-42* Creat-1.5* Na-138
K-3.6 Cl-111* HCO3-17* AnGap-14
[**2156-3-26**] 06:15AM BLOOD Glucose-133* UreaN-43* Creat-1.4* Na-140
K-3.8 Cl-112* HCO3-15* AnGap-17
[**2156-3-27**] 05:58AM BLOOD Glucose-110* UreaN-39* Creat-1.2 Na-140
K-3.6 Cl-112* HCO3-17* AnGap-15
[**2156-3-28**] 05:04AM BLOOD Glucose-111* UreaN-36* Creat-1.0 Na-141
K-3.5 Cl-114* HCO3-18* AnGap-13
[**2156-3-29**] 06:54AM BLOOD Glucose-120* UreaN-31* Creat-1.1 Na-139
K-3.5 Cl-112* HCO3-16* AnGap-15
[**2156-3-23**] 07:45PM BLOOD CK(CPK)-597*
[**2156-3-24**] 04:54AM BLOOD ALT-194* AST-345* LD(LDH)-459*
CK(CPK)-529* AlkPhos-128 Amylase-224* TotBili-0.4
[**2156-3-25**] 04:29AM BLOOD ALT-150* AST-167* LD(LDH)-388*
AlkPhos-111 TotBili-0.4
[**2156-3-28**] 05:04AM BLOOD CK(CPK)-32*
[**2156-3-24**] 02:39PM BLOOD Lipase-15
[**2156-3-23**] 02:00PM BLOOD cTropnT-0.05*
[**2156-3-23**] 07:45PM BLOOD CK-MB-58* MB Indx-9.7*
[**2156-3-23**] 07:45PM BLOOD cTropnT-2.85*
[**2156-3-24**] 04:54AM BLOOD CK-MB-50* MB Indx-9.5* cTropnT-4.12*
[**2156-3-28**] 05:04AM BLOOD CK-MB-NotDone cTropnT-2.48*
[**2156-3-23**] 02:00PM BLOOD Calcium-9.1 Phos-4.1 Mg-2.0
[**2156-3-29**] 06:54AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1
[**2156-3-23**] 07:56PM BLOOD Lactate-2.6*
[**2156-3-24**] 05:16AM BLOOD Lactate-3.6*
[**2156-3-24**] 03:11PM BLOOD Lactate-1.5

Brief Hospital Course:
Patient is a 83 y/o M w PAF, CAD s/p CABG/PCI and chronic C.
diff infection who p/w hypotension, a. fib with RVR, and found
to have GNR bacteremia.

# Urosepsis- Patient was admitted to the ICU with hypotension.
He was volume resuscitated with adequately controlled blood
pressures not requiring additional fluids.  He was initially
treated with IV flagyl, IV zosyn and PO vancomycin given concern
for C.diff (patient has chronic C.diff).  Blood cultures grew
back GNR and urine cultures grew E.coli.  Patient diagnosed with
urosepsis.  He was switched to cefepime and flagyl.  Once
stabilized in the unit, he was transferred to the floor.  Blood
cultures remained negative since [**3-24**] and WBC trended down.
Patient remained afebrile with no systemic complaints.  He was
continued on PO vanc (125mg PO BID) for his chronic C.diff.  Of
note, C.diff was negative x 2 while here.  Cultures grew
pansensitive E.coli so he was switched from cefepime to PO cipro
(and continued on PO vancomycin).  He is to continue antibiotics
for 14 days (course started on [**2156-3-28**]).

# Atrial Fibrillation: Patient has paroxysmal atrial
fibrillation.  He required cardioversion in ED.  He went to slow
VT and then to A.fibrillation.  He was admitted to the CCU for
further stabilization.  While there, he was started on IV
amiodarone and then transitioned to PO on [**3-25**] (400mg TID x 1
week and then 200mg daily x 3 weeks).  He remained in sinus
rhythm while on the floor. It was thought that the RVR was due
to sepsis.  He is not anticoagulated with coumadin due to fall
risk and history of hemoperitoneum.  Home beta-blocker was held
given slow HR (60-65 on day of discharge).  Patient continued on
home dose of aspirin.

#. Coronary Artery Disease : CAD s/p CABG in [**2135**] with LIMA to
LAD which is totally occluded after D1, SVG-D1 (stent in graft),
SVG-OM (chronically occluded), with most recent PCI in [**5-26**]
with stenting Lcx, s/p hip replacement. EKG not consistent with
ACS, chest pain and elevated troponin presumed due to demand
ischemia (CK peaked [**3-24**]).

# Anemia: Chronic normocytic anemia (MCV 92).near or above
baseline, has a history of chronic anemia of unknown origin
requiring multiple transfusions, no active issues.  He did not
require any transfusions while here.

#ARF:  Patient admitted with Cr. of 1.5 (baseline 1.2).  Cr
trended down to 1.1 after getting IV fluids and remained stable.


#Metabolic Acidosis- Improved; occured in setting of elevated
lactate from sepsis/bacteremia; Patient received IV fluids (NS)
while here.

# Diarrhea: Patient has a history of C. diff infection x 5
years. Pt did present with worsening diarrhea prior to
admission; initially received treatment dose of flagyl/vanc and,
after urine culture returned, he resumed suppressive doses of
vancomycin which he will continue indefinitely.

Medications on Admission:
aspirin 81 mg daily
nigtroglycerin SR 2.5 mg
metoprolol 25mg q24
sertraline 100mg [**Hospital1 **]
vanco 125 [**Hospital1 **]
folic acid 400mg
avicor 20mg [**Hospital1 **]
multivitamin

Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days.
2. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
indigestion.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Sertraline 100 mg Tablet Sig: One (1) Tablet PO twice a day.

8. Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day as needed for chest
pain.
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day): through [**2156-3-31**].
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day
for 1 months: Please start on [**2156-4-1**] and take until [**2156-5-2**].
11. Heparin (Porcine) 5,000 unit/mL Cartridge Sig: One (1)
injection Injection three times a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 4103**] on the [**Doctor Last Name **]

Discharge Diagnosis:
Primary
Paroxysmal Atrial fibrillation
Urosepsis

Secondary
Clostridium difficile infection


Discharge Condition:
stable, good, baseline ambulatory status, baseline mental status



Discharge Instructions:
You were admitted to the hospital because you were having
weakness, diarrhea and chest pain. You were found to have atrial
fibrillation and an infection in your blood.  You were treated
with antibiotics, and your heart rhythm was cardioverted.  You
were started on a new medication for your heart rhythm,
amiodarone.  You infection improved, and upon discharge, you
were afebrile and hemodynamically stable.

The following changes were made to your medications:
1.  Please START taking ciprofloxacin 500mg by mouth every 12
hours for 14 days (day 1- [**2156-3-28**])
2.  Please continue taking your vancomycin by mouth twice a day
for your chronic C.diff infection
3.  Please STOP taking your metoprolol until you follow-up with
Dr. [**Last Name (STitle) **]
4.  Please continue taking amiodarone 400mg by mouth three times
per day until [**2156-3-31**].  On [**2156-4-1**], please take 200mg by mouth
daily for one month (until [**2156-5-2**])

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] on [**2156-4-26**] at 1PM.  You can
contact him at [**0-0-**].



Completed by:[**2156-3-29**]
{'Bacteremia,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Acidosis,Coronary atherosclerosis of autologous vein bypass graft,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Atrial fibrillation,Other chronic pulmonary heart diseases,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Anemia, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Personal history of malignant neoplasm of prostate,Hip joint replacement'}


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: Weakness, hypotension

PRESENT ILLNESS: Mr. [**Known lastname 1726**] is an 83M with hx parosysmal Afib not on coumadin,
CAD s/p CABG in [**2135**] with LIMA to LAD which is totally occluded
after D1, SVG-D1 (stent in graft), SVG-OM (chronically
occluded), with most recent PCI in [**5-26**] with stenting Lcx, s/p
hip replacement, with hx chronic c.diff infection x 5 years. Pt
was in USOH until the night prior to admission when he noted
that he was unable to get up out of bed secondary to weakness,
which he noted was worse in his legs than in his arms. He
struggled to get OOB for a while, eventually becoming SOB, with
subsequent mid sternal sharp non radiating chest pain
experienced, similar to his anginal episodes. The pain was not
associated with diaphoresis or nausea, p.o intake, there was no
positional or pleuritic component. He took SLNTG x1 and the CP
resolved. He continued to experience this weakness on the day of
admission, called life line, with EMS sent to his home. On
arrival he was noted to have ? NSVT on monitor. Of note, he has
experienced several days of diarrhea with 10 or more loose
stools a day. Increased from baseline.
.
In the ER, initial VS were T97.1, HR 150, BP 73/54 -> 86/59, RR
36, O2 100% NRB. EKG showed wide complex tachycardia afib with
aberancy. Having CP. Labs notable for WBC 26, Cr 1.9 from
baseline 1.3. Underwent cardioversion for A. Fib with
hypotension and subsequently converted to sinus rhythm with
resolution of his chest pain. CXR negative for PNA. Overall
impression was for sepsis [**2-24**] C. diff and patient given
metronidazole for his diarrhea and 2L of IVF. Prior to transfer
had been making urine >800cc.
.
Vitals prior to transfer HR72 113/70 17 100%2L.
.
ROS is notable for chronic fatigue. He denies recent URIs,
cough, hemoptysis, fever, chills, rigors, diaphoresis, abdominal
pain, sick contacts, travel, prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, black stools or red
stools. He denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
On arrival to the CCU he was seen to be in slow A.fib on EKG,
and hypotensive to the high 80s. IVF boluses were initiated with
subsequent improvement in pressure.  He was found to have GNR on
blood culture and was started on IV vanc/flagyll. He was started
on amniodorone drip .

MEDICAL HISTORY: -CAD with stable angina, s/p CABG '[**35**], multiple stents (last
cath report [**5-26**]: Two vessel CAD. Patent LIMA-LAD. Patent
SVG-D1. SVG-OM is known to be chronically occluded. The LCx had

MEDICATION ON ADMISSION: aspirin 81 mg daily
nigtroglycerin SR 2.5 mg
metoprolol 25mg q24
sertraline 100mg [**Hospital1 **]
vanco 125 [**Hospital1 **]
folic acid 400mg
avicor 20mg [**Hospital1 **]
multivitamin

ALLERGIES: Ticlid / Lipitor

PHYSICAL EXAM: VS - T: HR: 80 BP: 93/55 (64) RR: 13 SPO2: 99%
Gen: Notable pallor. Poor cap refill. Poor skin turgor.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 7 cm.
CV:mostly regular rymth. PMI located in 5th intercostal space,
midclavicular line. RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits. Cool lower extremities. [**5-26**]
muscle strength BUE, BLE.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
DP/PT: dopperable bilaterally.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Denies tobacco and ETOH use. 

### Response:
{'Bacteremia,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Acidosis,Coronary atherosclerosis of autologous vein bypass graft,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Atrial fibrillation,Other chronic pulmonary heart diseases,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Anemia, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Personal history of malignant neoplasm of prostate,Hip joint replacement'}
