CHIEF COMPLAINT: Feeling unwell after Ambien

PRESENT ILLNESS: 77F d/c'd from rehab 1 wk ago after colectomy for colon cancer
(at [**Hospital1 882**]) in [**2179-3-7**]. Her husband gave her an ambien, and
then about 5-10 minutes later she rolled over on her side and
told him to call 911.  According to EMS report, on arrival, the
patient was alert and oriented x3.  She was warm and dry on
exam.  She said that ambien made her feel "crazy" with nausea
and vomiting.  Having general malaise.
.
In the ED, initial vitals were 97.8 58 97/52 20 100% ra, The
patient had episodes of hypotension w/ SBPs in 70s-80s. She has
been persistently tachycardic in 100s-110s with no attempt to
see if rate control would help her pressures.  Labs and imaging
significant for trop 0.29-->0.27 (MB and CK pending), BUN/Cr
41/2.0 (no baseline), H/H 9.6/32.8 MCV 80(no baseline), lactate
2.7, EKG according to ED showed atrial fibrillation at 109, QTc
457, PVCs.  CT head negative for acute intracranial process, CXR
with low lung volumes and increased vascular markings.  Patient
was given hydrocortisone for possibl adrenal insufficiency given
chronic steroid use, zofran for nausea and started on heparin
drip and plavix (aspirin allergy) for presumed ACS.  The patient
received 1L NS of fluids and HR decreased to 90s and BP rose to
the 100% systolic .  Cardiology was consulted and plan to admit
to CCU for further management.  Vitals on transfer were HR: 86
BP: 103/82, RR: 16 O2 sat: 100% 2L NC.
.
On arrival to the floor, patients vitals were afebrile, bp
108/82, hr 100, sat 98% on RA

MEDICAL HISTORY: DM, HTN, HLD, colon cancer, Restritive cardiomyopathy,
hypothyroidism, mild adrenal insufficiency, benign pituitary
adenoma, recent weight loss, depression

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. PredniSONE 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lovastatin *NF* 20 mg Oral Daily
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Furosemide 40 mg PO DAILY
8. Megestrol Acetate 800 mg PO DAILY
9. Sertraline 50 mg PO DAILY
10. Zolpidem Tartrate 5 mg PO HS

ALLERGIES: Penicillins / IV Dye, Iodine Containing Contrast Media /
Sulfa(Sulfonamide Antibiotics) / aspirin / Actonel / Fosamax /
Vioxx / lisinopril / Mobic / Lyrica / hydrochlorothiazide /
Procardia / clonidine / Hydrocodone / Oxycodone

PHYSICAL EXAM: Admission Physical Exam:
afebrile, bp 108/82, hr 100, sat 98% on 2L NC
GENERAL: disheveled appearing women in NAD. Oriented x 2.
HEENT: NCAT. PERRL, EOM grossly in tact. Conjunctiva were pink,
no pallor or cyanosis of the oral mucosa.
NECK: Supple, EJ distented.  Prominent carotid pulse at the
mandible.
CARDIAC: irregularly, irregular; no m/r/g
LUNGS: shallow respirations, with diminished breath sounds at
the bases.  No wheezes, rales, or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.  Midline incision
from prior colonic resection with stoma in place
EXTREMITIES: pulses 1+ at DP and radial b/l.  2+ pitting edema
in the LE with sacral edema
SKIN: wwp

FAMILY HISTORY: non-contributory.

SOCIAL HISTORY: Pt lives at home with husband.
-Tobacco history:  none
-ETOH:  None
-Illicit drugs:  none
Other amyloidosis,Acute on chronic diastolic heart failure,Glucocorticoid deficiency,Acute kidney failure, unspecified,Cellulitis and abscess of trunk,Other primary cardiomyopathies,Paroxysmal ventricular tachycardia,Acute cystitis,Malignant neoplasm of colon, unspecified site,Chronic kidney disease, Stage IV (severe),Infection of colostomy or enterostomy,Acquired absence of intestine (large) (small),Long-term (current) use of steroids,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Erysipelas,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Pressure ulcer, buttock,Altered mental status,Iron deficiency anemia, unspecified,Hyperpotassemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other sedatives and hypnotics causing adverse effects in therapeutic use,Osteoporosis, unspecified
Amyloidosis NEC,Ac on chr diast hrt fail,Glucocorticoid deficient,Acute kidney failure NOS,Cellulitis of trunk,Prim cardiomyopathy NEC,Parox ventric tachycard,Acute cystitis,Malignant neo colon NOS,Chr kidney dis stage IV,Colosty/enterost infectn,Acquire absnce intestine,Long-term use steroids,DMII wo cmp nt st uncntr,Hyperlipidemia NEC/NOS,Hypothyroidism NOS,Depressive disorder NEC,Erysipelas,Proteus infection NOS,Thrombocytopenia NOS,Pressure ulcer, buttock,Altered mental status,Iron defic anemia NOS,Hyperpotassemia,Hy kid NOS w cr kid I-IV,Adv eff sedat/hypnot NEC,Osteoporosis NOS
Admission Date:  [**2179-6-2**]              Discharge Date:   [**2179-6-12**]

Date of Birth:  [**2102-1-23**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media /
Sulfa(Sulfonamide Antibiotics) / aspirin / Actonel / Fosamax /
Vioxx / lisinopril / Mobic / Lyrica / hydrochlorothiazide /
Procardia / clonidine / Hydrocodone / Oxycodone

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Feeling unwell after Ambien

Major Surgical or Invasive Procedure:
None


History of Present Illness:
77F d/c'd from rehab 1 wk ago after colectomy for colon cancer
(at [**Hospital1 882**]) in [**2179-3-7**]. Her husband gave her an ambien, and
then about 5-10 minutes later she rolled over on her side and
told him to call 911.  According to EMS report, on arrival, the
patient was alert and oriented x3.  She was warm and dry on
exam.  She said that ambien made her feel "crazy" with nausea
and vomiting.  Having general malaise.
.
In the ED, initial vitals were 97.8 58 97/52 20 100% ra, The
patient had episodes of hypotension w/ SBPs in 70s-80s. She has
been persistently tachycardic in 100s-110s with no attempt to
see if rate control would help her pressures.  Labs and imaging
significant for trop 0.29-->0.27 (MB and CK pending), BUN/Cr
41/2.0 (no baseline), H/H 9.6/32.8 MCV 80(no baseline), lactate
2.7, EKG according to ED showed atrial fibrillation at 109, QTc
457, PVCs.  CT head negative for acute intracranial process, CXR
with low lung volumes and increased vascular markings.  Patient
was given hydrocortisone for possibl adrenal insufficiency given
chronic steroid use, zofran for nausea and started on heparin
drip and plavix (aspirin allergy) for presumed ACS.  The patient
received 1L NS of fluids and HR decreased to 90s and BP rose to
the 100% systolic .  Cardiology was consulted and plan to admit
to CCU for further management.  Vitals on transfer were HR: 86
BP: 103/82, RR: 16 O2 sat: 100% 2L NC.
.
On arrival to the floor, patients vitals were afebrile, bp
108/82, hr 100, sat 98% on RA

Past Medical History:
DM, HTN, HLD, colon cancer, Restritive cardiomyopathy,
hypothyroidism, mild adrenal insufficiency, benign pituitary
adenoma, recent weight loss, depression

Social History:
Pt lives at home with husband.
-Tobacco history:  none
-ETOH:  None
-Illicit drugs:  none

Family History:
non-contributory.

Physical Exam:
Admission Physical Exam:
afebrile, bp 108/82, hr 100, sat 98% on 2L NC
GENERAL: disheveled appearing women in NAD. Oriented x 2.
HEENT: NCAT. PERRL, EOM grossly in tact. Conjunctiva were pink,
no pallor or cyanosis of the oral mucosa.
NECK: Supple, EJ distented.  Prominent carotid pulse at the
mandible.
CARDIAC: irregularly, irregular; no m/r/g
LUNGS: shallow respirations, with diminished breath sounds at
the bases.  No wheezes, rales, or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.  Midline incision
from prior colonic resection with stoma in place
EXTREMITIES: pulses 1+ at DP and radial b/l.  2+ pitting edema
in the LE with sacral edema
SKIN: wwp

Discharge Physical Exam:
PHYSICAL EXAM:
Vitals - Tm/Tc: 98.4/97.7 HR: 69-90 BP: 86-122/43-64 RR:16 02
sat:99RA
In/Out: 760/650 ++ inc
Weight: 66.7 (66.7)kg

HEENT: NSAT, EOMI.
Card: Irregular rhythm, regular rate. No murmurs, rubs, or
gallops.
Resp: Shallow inspiratory effort, [**Month (only) **] BS at bases, faint
crackles on left base. Patient with little purposeful
inspiratory effort
Abdomen: Positive bowel sounds, stoma with formed output.
Nontender nondistended. NO erythema on left flank area.
Extremities: 2+ peripheral edema

Pertinent Results:
On Admission
[**2179-6-2**] 10:00PM URINE  HOURS-RANDOM UREA N-244 CREAT-217
SODIUM-17 POTASSIUM-97 CHLORIDE-12
[**2179-6-2**] 02:35AM   GLUCOSE-125* UREA N-41* CREAT-2.0* SODIUM-139
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-20* ANION GAP-20
[**2179-6-2**] 02:35AM   WBC-6.2 RBC-4.07* HGB-9.6* HCT-32.8* MCV-80*
MCH-23.5* MCHC-29.3* RDW-20.8*

On Discharge

[**2179-6-10**] 06:19AM BLOOD WBC-6.1 RBC-3.60* Hgb-8.3* Hct-28.6*
MCV-79* MCH-23.1* MCHC-29.0* RDW-20.6* Plt Ct-137*
[**2179-6-10**] 06:19AM BLOOD Glucose-105* UreaN-28* Creat-1.0 Na-142
K-3.9 Cl-107 HCO3-30 AnGap-9
[**2179-6-6**] 04:29AM BLOOD ALT-119* AST-82* AlkPhos-83 TotBili-1.3
[**2179-6-10**] 06:19AM BLOOD Phos-2.4* Mg-2.1

Notable Labs
[**2179-6-9**] 06:22AM BLOOD SEROTONIN RELEASE ASSAY-PND
[**2179-6-7**] 12:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES-
[**2179-6-7**] 06:30AM BLOOD FREE KAPPA AND LAMBDA, WITH K/L
RATIO-Test
[**2179-6-3**] 05:38AM BLOOD PEP-NO SPECIFIC ABNORMALITIES
SEEN;REPORTED BY SHU-LING FAN PHD;FINAL INTERPRETATION BY [**First Name11 (Name Pattern1) **]
[**Last Name (NamePattern4) 19695**] MD

-echo - moderate symmetric LVH with moderately depressed
systolic function. Restrictive left ventricular filling. The
appearance of the left ventricular myocardium suggests
infiltrative disease. Dilated and hypokinetic right ventricle.
Moderate mitral regurgitation. Moderate to severe tricuspid
regurgitation. While estimated pulmonary systolic pressures are
normal, they are likely UNDERestimated (or the right ventricular
function is so poor that it cannot elevate its pressure).

-renal/abdominal ultrasound - Echogenic liver compatible with
fatty infiltration. More serious forms of steatohepatitis,
fibrosis, and/or cirrhosis cannot be excluded on this study.
Normal kidneys without any explanation for acute renal
insufficiency. Moderate right pleural effusion. Numerous
anechoic ovoid lesions in the right lateral abdominal
subcutaneous fat. These lesions are incompletely characterized
by ultrasound. The location of these lesions should be
correlated with history of prior subcutaneous injections that
could represent incompletely absorbed injected medications.
Abdominal wall metastases cannot be excluded on this study. A CT
scan is recommended for further evaluation. Ideally, this would
be with intravenous contrast; however, a non-contrast CT may
still useful in the setting of acute renal failure.

[**6-8**]- Pyrophosphate Study-
1. Relatively low-level pyrophosphate uptake in the heart. Often

amyloid will show intense myocardial uptake; however
pyrophosphate should not accumulate in the normal heart.  2.
Multiple foci of uptake in the bones. Etiology of bony findings
could be further evaluated with a dedicated CT.  3. Moderate
bilateral pleural effusions.


Brief Hospital Course:
77 yo female with history of stage IIIA colon cancer s/p
resection who is admitted for restrictive cardiomyopathy
suggestive of cardiac amyloid. Hospital course complicated with
pre-renal acute renal failure.

ACUTE ISSUES:

# Restrictive Cardiomyopathy/?Cardiac Amyloid - displayed
predominantly right-sided symptoms in the setting of bilateral
ventricular failure.  Echocardiogram showed moderate symmetric
LVH with moderately depressed systolic function, restrictive
left ventricular filling, and a dilated and hypokinetic right
ventricle, and the appearance of the left ventricular myocardium
suggested infiltrative disease (likely amyloid). Pyrophosphate
scan showed update throughout mycardium, suggestive of
transthyretin cardiac amyloidosis. She was treated with a lasix
gtt, metoprolol, and fluid/sodium restriction. ACE-I/[**Last Name (un) **] was not
given in the setting of mildly low blood pressures (80-100s).
Her fluid status was optimized and she waill have outpatient FU
with Dr. [**Last Name (STitle) **] at [**Hospital6 1708**] to monitor heart
failure /cardiac amyloid along with TTR gene.

Of note, the patient as initially discharged to a rehab facility
on [**2179-6-12**].  However, she felt that the rehab facility was
unsatisfactory and she refused to stay.  That being said, the
patient returned to the hospital on the same day, and was placed
in observation status.  Case management and social work were
both working with the patient and coordinating her ultimate
disposition.  The patient refused to go to certain rehabs that
had open beds, prolonging her hospitalization.  The patient was
ultimately discharged to rehab.

# Acute Kidney Injury/Pre-Renal - creatinine on admission was
2.2 (from baseline of 1.3 earlier in the week, per conversation
with PCP).  This continued to rise during the first several days
of the hospital course, elevating as high as 3.1 with anuria,
but Cr began to decline and urine output began to improve with
aggressive diuresis (lasix gtt).  Likely was pre-renal in
etiology based on urine electrolytes and exam. Creatinine at
discharge improved to 1.0.

# Cellulitis/erysepilas on L flank - on [**6-3**] patient began to
complain of new pain on skin of left flank, which was found to
be erythematous and tender. ID was consulted.  Patient was
started on broad spectrum antibiotics with IV vancomycin and
ciprofloxacin (day 1=[**6-5**]). Symptoms improved and she was
transitioned to oral anitbiotics: PO doxycycline and Cipro, with
a total tx of 10 day course for each.

# Altered mental status - CT head was negative for acute
intracranial process in the emergency room. Her mental status
appeared to recover soon after admission, according to her
husband. She is lucent and A+OX3 throught entire admission.

# Elevated troponins - there did not appear to be any acute ST
or T-wave changes suggestive of ischemia, and her troponins
trended down quickly after admission.  She remained free of
chest pain and shortness of breath, and given her [**Last Name (un) **], this was
likely due to her renal dysfunction and not a cardiac cause, and
so her heparin gtt and plavix were discontinued soon after
admission.

#Ventricular Ectopy/Non sustained Ventricular tachycardia-
Patient has had multiple episodes of asymptomatic NSVT likely
secondary to her infiltrative and restrictive cardiomyopathy.
She was discharged on Metoprolol Succinate 200mg daily.

# Complicated Acute Cystitis - Urine grew proteus mirabilis
sensitive to ciprofloxacin. He will complete 10 days of cipro as
outpatient (started [**6-4**].)

# Thrombocytopenia - Patient's platelets initially dropped
(200->85) while on Heparin SQ (prophylaxis). HIT antibodies were
positive, but further review in the lab demonstrated low optical
density and unlikely to have true HIT. Heparin could continue to
be used for the patient as prophylaxis and was used in her port
a cath. Her Serotonin Release Assay will be communicated when
available.

CHRONIC ISSUES:

# Anemia - per PCP baseline hematocrit is in 30??????s. HCT 28-33
range throughout admission. Pt was asymptomatic throughout.

# Pituitary adenoma s/p transphenoidal resection in [**2160**] -
continued on home levothyroxine and prednisone.

TRANSITIONAL ISSUES:

#Patient will have follow-up appointment with Dr [**Last Name (STitle) **] at [**Hospital1 756**]
in the following 2-4 weeks. There, she will have continued
workup for her restrictive cardiomyopathy and cardiac amyloid.
During hospitalization, housestaff reached out to [**Hospital 3278**] Medical
Center to perform [**Country **]-red stain on removed colon cancer from
patient's previous surgery. They brought us pathology slides
that we are able to stain ourselves. In addition, TTR gene
testing will be performed and run at [**Hospital 3278**] Medical Center or
sent away, depending on Dr.[**Name (NI) 50760**] discretion.

# Colon cancer s/p resection in [**2179-3-7**] - stage IIIA cancer
(pT2N1bM0 per [**Hospital1 3278**] pathology report). Port in place for
chemotherapy, though she has not received it until this point.
Stoma with poor output and no erythema.  Superficial masses
palpated in abdomen, possibly due to multiple heparin injections
but potentially due to abdominal metastases.

# Thrombocytopenia developed during the hospital course and was
initially concerning for HIT (Heparin Induced Thrombocytopenia)
so appropriate antibodies were sent. PF4 antibodies came back
positive so all heparin prophylaxis was stopped but hematology
thought that due to the low optical density it was a false
positive and that heparin could be used. Heparin was restarted
to keep her port-a-cath open and then also was given heparin
subcutaneously for prophylaxis. Her platelets have since
decreased slightly (115) with a pending serotonin release assay
that was drawn on [**6-9**]. We suggest she continue subcutaneous
heparin prophylaxis during rehab with a change depending on the
results of the release assay. We will follow up with the
appropriate rehab facility when result is back.

# Patient's UTI was positive for Proteus mirabilis which was
sensitive to ciprofloxacin which she was started on a 10-day
course on [**6-4**]. Her last day of treatment will be [**2179-6-13**].

# Patient had left flank erythema adjacent to her stoma site.
The stoma itself looked clean and without infection, but due to
its proximity, her presumed cellulitis was treated with coverage
for GPC's with Vancomycin and GNR's with Ciprofloxacin which had
just been started as stated above. Her tenderness on her flank
subsided and her GPC coverage was meant for 10-days. Day 1 of
Vancomycin was [**6-5**] and she has been switched to PO Doxycycline
with her last day being [**2179-6-14**].

# Patient had been on telemetry throughout her stay at [**Hospital1 18**].
During the nights, she would have episodes of Non sustained
Ventricular tachycardia that was asymptomatic. During her second
to last night, she had her longest episode which was 25 beats
and she was then increased on her Metoprolol Tartrate to 100mg
[**Hospital1 **]. The following night, her ectopy decreased, and as an
outpatient she was put on Metoprolol Succinate 200 daily.

#Depression: Patient's activity level is incongruent with her
strength level. She denies low mood, but certainly may be
depressed. This should be investigated and addressed more
extensively on an outpatient basis.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. PredniSONE 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lovastatin *NF* 20 mg Oral Daily
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Furosemide 40 mg PO DAILY
8. Megestrol Acetate 800 mg PO DAILY
9. Sertraline 50 mg PO DAILY
10. Zolpidem Tartrate 5 mg PO HS


Discharge Medications:
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Lovastatin *NF* 20 mg Oral Daily
4. Megestrol Acetate 800 mg PO DAILY
5. PredniSONE 5 mg PO DAILY
6. Sertraline 50 mg PO DAILY
7. Metoprolol Succinate XL 200 mg PO DAILY
8. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
9. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours
10. Heparin 5000 UNIT SC TID
11. Docusate Sodium 100 mg PO BID
12. Pantoprazole 40 mg PO Q24H


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Healthcare Center - [**Location (un) 86**]

Discharge Diagnosis:
Acute on chronic diastolic heart failure
restrictive cardiomyopathy
amyloidosis of the heart
Acute Kidney Injury
Complicated Acute Cystitis (Proteus mirabilis)
Cellulitis
Stage 2 decubitus ulcer on R buttocks


Discharge Condition:
Patient is mentating well and eating a PO diet. She complains of
no chest pain, SOB, palpitations, or abdominal pain. She just
reports being tired..
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair with 2 people


Discharge Instructions:
Dear Ms [**Known lastname **],

It was a pleasure providing care for you during this
hospitalization.
You came to the hospital for a fast heart rate and swelling in
your feet. You have a new heart condition, likely called
Amyloidosis of the heart. We gave you medications to help you
urinate out the extra fluid that was building up in your legs.
You will follow up with a heart specialist for your heart
condition. For now, it is very important to take daily heart
medications: lasix and metoprolol.

You were found to have some kidney problems. Your kidneys
improved as we gave you medication to help you urinate off the
extra fluid.

You had a cellulitis of the skin of your stomach (skin
infection) for which we gave you antibiotics. You have a couple
more days to complete this regimen.

You also had a urine infection for which we treated with
antibiotics.


Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] R.
Specialty: Primary Care
Location: GENERAL MEDICAL ASSOCIATES AT [**Hospital1 **]
Address: [**State 50761**], BOX 398, [**Location (un) **],[**Numeric Identifier 8235**]
Phone: [**Telephone/Fax (1) 39989**]

Name: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 50762**]
Specialty: Hematology/Oncology
When: Monday [**7-5**] at 1pm
Where: [**First Name8 (NamePattern2) **] [**Location (un) 86**], MA
Phone: [**Telephone/Fax (1) 50763**]

Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 50764**]
Specialty: [**Last Name (un) **]-Rectal Surgery
When: Tuesday [**6-29**] at 11am
Where: [**First Name8 (NamePattern2) **] [**Location (un) 86**], MA
Phone: [**Telephone/Fax (1) 50765**]

Dr.[**Name (NI) 50760**] office will be contacting you with a follow up
appointment for his office at The [**Hospital1 756**] for your heart
condition.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
{'Other amyloidosis,Acute on chronic diastolic heart failure,Glucocorticoid deficiency,Acute kidney failure, unspecified,Cellulitis and abscess of trunk,Other primary cardiomyopathies,Paroxysmal ventricular tachycardia,Acute cystitis,Malignant neoplasm of colon, unspecified site,Chronic kidney disease, Stage IV (severe),Infection of colostomy or enterostomy,Acquired absence of intestine (large) (small),Long-term (current) use of steroids,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Erysipelas,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Pressure ulcer, buttock,Altered mental status,Iron deficiency anemia, unspecified,Hyperpotassemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other sedatives and hypnotics causing adverse effects in therapeutic use,Osteoporosis, 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: Feeling unwell after Ambien

PRESENT ILLNESS: 77F d/c'd from rehab 1 wk ago after colectomy for colon cancer
(at [**Hospital1 882**]) in [**2179-3-7**]. Her husband gave her an ambien, and
then about 5-10 minutes later she rolled over on her side and
told him to call 911.  According to EMS report, on arrival, the
patient was alert and oriented x3.  She was warm and dry on
exam.  She said that ambien made her feel "crazy" with nausea
and vomiting.  Having general malaise.
.
In the ED, initial vitals were 97.8 58 97/52 20 100% ra, The
patient had episodes of hypotension w/ SBPs in 70s-80s. She has
been persistently tachycardic in 100s-110s with no attempt to
see if rate control would help her pressures.  Labs and imaging
significant for trop 0.29-->0.27 (MB and CK pending), BUN/Cr
41/2.0 (no baseline), H/H 9.6/32.8 MCV 80(no baseline), lactate
2.7, EKG according to ED showed atrial fibrillation at 109, QTc
457, PVCs.  CT head negative for acute intracranial process, CXR
with low lung volumes and increased vascular markings.  Patient
was given hydrocortisone for possibl adrenal insufficiency given
chronic steroid use, zofran for nausea and started on heparin
drip and plavix (aspirin allergy) for presumed ACS.  The patient
received 1L NS of fluids and HR decreased to 90s and BP rose to
the 100% systolic .  Cardiology was consulted and plan to admit
to CCU for further management.  Vitals on transfer were HR: 86
BP: 103/82, RR: 16 O2 sat: 100% 2L NC.
.
On arrival to the floor, patients vitals were afebrile, bp
108/82, hr 100, sat 98% on RA

MEDICAL HISTORY: DM, HTN, HLD, colon cancer, Restritive cardiomyopathy,
hypothyroidism, mild adrenal insufficiency, benign pituitary
adenoma, recent weight loss, depression

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. PredniSONE 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lovastatin *NF* 20 mg Oral Daily
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Furosemide 40 mg PO DAILY
8. Megestrol Acetate 800 mg PO DAILY
9. Sertraline 50 mg PO DAILY
10. Zolpidem Tartrate 5 mg PO HS

ALLERGIES: Penicillins / IV Dye, Iodine Containing Contrast Media /
Sulfa(Sulfonamide Antibiotics) / aspirin / Actonel / Fosamax /
Vioxx / lisinopril / Mobic / Lyrica / hydrochlorothiazide /
Procardia / clonidine / Hydrocodone / Oxycodone

PHYSICAL EXAM: Admission Physical Exam:
afebrile, bp 108/82, hr 100, sat 98% on 2L NC
GENERAL: disheveled appearing women in NAD. Oriented x 2.
HEENT: NCAT. PERRL, EOM grossly in tact. Conjunctiva were pink,
no pallor or cyanosis of the oral mucosa.
NECK: Supple, EJ distented.  Prominent carotid pulse at the
mandible.
CARDIAC: irregularly, irregular; no m/r/g
LUNGS: shallow respirations, with diminished breath sounds at
the bases.  No wheezes, rales, or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.  Midline incision
from prior colonic resection with stoma in place
EXTREMITIES: pulses 1+ at DP and radial b/l.  2+ pitting edema
in the LE with sacral edema
SKIN: wwp

FAMILY HISTORY: non-contributory.

SOCIAL HISTORY: Pt lives at home with husband.
-Tobacco history:  none
-ETOH:  None
-Illicit drugs:  none 

### Response:
{'Other amyloidosis,Acute on chronic diastolic heart failure,Glucocorticoid deficiency,Acute kidney failure, unspecified,Cellulitis and abscess of trunk,Other primary cardiomyopathies,Paroxysmal ventricular tachycardia,Acute cystitis,Malignant neoplasm of colon, unspecified site,Chronic kidney disease, Stage IV (severe),Infection of colostomy or enterostomy,Acquired absence of intestine (large) (small),Long-term (current) use of steroids,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Erysipelas,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Pressure ulcer, buttock,Altered mental status,Iron deficiency anemia, unspecified,Hyperpotassemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other sedatives and hypnotics causing adverse effects in therapeutic use,Osteoporosis, unspecified'}
