CHIEF COMPLAINT: hypotension at HD

PRESENT ILLNESS: 55F with ESRD on HD, PVD s/p R AKA, HTN, DM, presents with
hypotension at HD. Pt was feeling in her usual state of health
until she went to HD this morning. At HD, her BP was found to be
56/12. EMS was called and BP per the EMTs was 58/41. She was
brought to the [**Hospital1 18**] ED.
.
On arrival to the ED, vitals were T 97.6, BP 62/34, HR 72, RR
17, SaO2 98% 2L. SBP initially maintained in the 60s but
improved to 110s with manipulation on exam and attempts at IV
access. She was initially very lethargic, and then became
agitated, yelling out in pain. At best, she was answering yes/no
questions. CXR negative. CT abd/pelvis showed mild increase in R
pleural effusion but no acute intraabdominal process. Received
vanco, zosyn, and 200cc IVF. Admitted to the MICU for close
monitoring.

MEDICAL HISTORY: - Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]

MEDICATION ON ADMISSION: [**Month (only) **] 325mg PO daily
Plavix 75mg PO daily
Simvastatin 80mg PO daily
Rifampin 300mg PO q12
Doxy 100mg PO q12
Regular insulin sliding scale
Protonix 40mg PO daily
Reglan 5mg PO QIDACHS
Lanthanum 500mg PO PO TID w/meals
Cinacalcet 60mg PO daily
Nephrocaps 1mg PO daily
Sevelamer 2400mg PO TID with meals
Percocet 5-325mg 1-2 tabs q4-6h prn
Gabapentin 300mg PO qHD
[**Month (only) 95641**]
Mirtazapine 15mg PO qHS
Tramadol 50mg PO BID
Colace prn
Senna prn

ALLERGIES: Lisinopril

PHYSICAL EXAM: T 98.1, BP 120/doppler, HR 75, RR 75, SaO2 95% 2L
General: obese female, alert and interactive.
Neck: obese, unable to determine JVP
Heart: RRR, distant HS [**12-31**] body habitus
Chest: L subclavian tunneled HD line without surrounding
erythema, CTAB anteriorly but difficult to auscultate
Abdomen: +BS, obese, soft, non-tender with stethescope exam.
Extrem: L upper arm incision with sutures in place, no erythema,
s/p L BKA (stump is mildly edematous but no erythema or
drainage), dopplerable R DP pulse, 1+ RLE edema, +anasarca
Back: sacral decub ulcers by report
Neuro: A+Ox2 (name and place), she believes this is [**2191**] and is
unable to repeat date when told. CN2-12 grossly intact.

FAMILY HISTORY: Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

SOCIAL HISTORY: Admitted from rehab. Has two sisters, one daughter.  [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago.
Hypotension, unspecified,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic osteomyelitis, other specified sites,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Above knee amputation status,Personal history of malignant neoplasm of kidney
Hypotension NOS,End stage renal disease,Hyp kid NOS w cr kid V,Chr osteomyelit NEC,DMII wo cmp nt st uncntr,Chr airway obstruct NEC,Obstructive sleep apnea,Status amput above knee,Hx of kidney malignancy
Admission Date:  [**2193-3-23**]              Discharge Date:   [**2193-3-27**]

Date of Birth:  [**2138-3-6**]             Sex:   F

Service: MEDICINE

Allergies:
Lisinopril

Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
hypotension at HD

Major Surgical or Invasive Procedure:
Dialysis on [**3-25**]

History of Present Illness:
55F with ESRD on HD, PVD s/p R AKA, HTN, DM, presents with
hypotension at HD. Pt was feeling in her usual state of health
until she went to HD this morning. At HD, her BP was found to be
56/12. EMS was called and BP per the EMTs was 58/41. She was
brought to the [**Hospital1 18**] ED.
.
On arrival to the ED, vitals were T 97.6, BP 62/34, HR 72, RR
17, SaO2 98% 2L. SBP initially maintained in the 60s but
improved to 110s with manipulation on exam and attempts at IV
access. She was initially very lethargic, and then became
agitated, yelling out in pain. At best, she was answering yes/no
questions. CXR negative. CT abd/pelvis showed mild increase in R
pleural effusion but no acute intraabdominal process. Received
vanco, zosyn, and 200cc IVF. Admitted to the MICU for close
monitoring.


Past Medical History:
- Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]

- Likely left AKA stump osteomyelitis requiring admission in
[**3-/2192**], on IV antibiotics, VAC dressing in place
- ESRD on HD. Last HD yesterday. Usually MWF schedule.
- HTN
- Diabetes Mellitus
- Renal Cell Carcinoma s/p right nephrectomy
- Obesity
- Depression
- s/p CCY
- Gastric Ulcer
- Obstructive Sleep Apnea. The patient reports that she used to
use a CPAP however her machine broke and she no longer uses it.

- Gastroparesis
- COPD on 3-4L NC baseline
- h/o ischemic colitis
- left adrenal adenoma


Social History:
Admitted from rehab. Has two sisters, one daughter.  [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago.


Family History:
Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

Physical Exam:
T 98.1, BP 120/doppler, HR 75, RR 75, SaO2 95% 2L
General: obese female, alert and interactive.
Neck: obese, unable to determine JVP
Heart: RRR, distant HS [**12-31**] body habitus
Chest: L subclavian tunneled HD line without surrounding
erythema, CTAB anteriorly but difficult to auscultate
Abdomen: +BS, obese, soft, non-tender with stethescope exam.
Extrem: L upper arm incision with sutures in place, no erythema,
s/p L BKA (stump is mildly edematous but no erythema or
drainage), dopplerable R DP pulse, 1+ RLE edema, +anasarca
Back: sacral decub ulcers by report
Neuro: A+Ox2 (name and place), she believes this is [**2191**] and is
unable to repeat date when told. CN2-12 grossly intact.


Pertinent Results:
Admission labs:

[**2193-3-23**] 12:45PM   NEUTS-66.9 LYMPHS-27.4 MONOS-5.0 EOS-0.3
BASOS-0.4
[**2193-3-23**] 12:45PM   WBC-8.0 RBC-3.13* HGB-10.0* HCT-32.7*
MCV-104* MCH-32.0 MCHC-30.7* RDW-19.7*
[**2193-3-23**] 12:45PM   GLUCOSE-128* UREA N-25* CREAT-4.5* SODIUM-141
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-21* ANION GAP-21*

Cardiac enzymes:

[**2193-3-23**] 12:45PM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2193-3-23**] 08:10PM BLOOD CK-MB-NotDone cTropnT-0.16*\

CXR:

1. Cardiomegaly, pulmonary vascular engorgement, interstitial
edema, and bilateral pleural effusions are consistent with
volume overload.
2. Right lung base infiltrate. Please ensure follow-up to
clearance.
3. No focal consolidation to suggest pneumonia.

CT abdomen:

CT ABDOMEN WITH CONTRAST AND RECONSTRUCTIONS: There has been
interval
increase in size to a small-to-moderate right simple pleural
effusion.
Bibasilar atelectasis is again demonstrated. Calcification of
the mitral
annulus and aortic valve is only partially visualized is of
unknown
hemodynamic significance. No pericardial effusion is
demonstrated. Right
atrial enlargement is again suspected.

No change is identified to the appearance of the liver.
Gallbladder is not
detected consistent with prior resection. The spleen is stable
on appearance with enhancing 1-cm rounded lesion in the inferior
pole consistent with a hemangioma or hamartoma. No change in an
8 x 10 mm left adrenal adenoma since [**2192-2-16**]. A small amount
of perihepatic fluid is again demonstrated, becoming confluent
with the right abdominal subcutaneous anasarca. Asymmetric
diffuse anasarca has been stable since at least 2/[**2191**]. No
evidence of bowel obstruction is demonstrated. Severe calcified
atherosclerotic plaque within the abdominal aorta, celiac axis,
SMA and [**Female First Name (un) 899**] as well as iliac vessels again appreciated with
gross luminal patency.

CT PELVIS WITH CONTRAST AND RECONSTRUCTIONS: Extensive vascular
calcifications in the pelvis. Rectum, sigmoid colon and
unopacified loops of small bowel appear stable. No diffuse free
pelvic fluid identified.

OSSEOUS STRUCTURES: Extensive scoliosis and multilevel
degenerative changes.

IMPRESSION:

Little change since prior study aside from increase in size to
moderate right pleural effusion. No evidence of new inflammatory
change or acute bowel pathology within the abdomen.


Brief Hospital Course:
55F with ESRD on HD, PVD s/p R AKA complicated by chronic
osteomyelitis, HTN, DM, was admitted to the ICU on [**3-23**] after
being found to be hypotensive and with altered mental status at
HD.
.
.
# Hypotension: BP normalized after only 250cc of fluid in the
ED. BP was only attainable using Doppler on right upper
extremity, with manual cuff, which brings into question accuracy
of previous BP recordings.  She was admitted to the ICU where
her blood pressure was 120s-140s systolic using the above
technique. She was afebrile, no leukocytosis, no acute process
on CXR or CT abd/pelvis.  However, she was covered empirically
with Vanco/Zosyn initially given her chronic osteo and history
of bacteremia.  This was later narrowed to vancomycin, as below.
 In the future, BP measurement should be done in right arm, with
manual cuff and doppler.
.
# Positive blood cultures:  Blood cultures showed 1/4 bottles
with gram positive cocci.  Zosyn was discontinued.  Vancomycin
was continued, and her line was changed over a wire. When her
blood cultures speciated as coagulase negative staph, this was
thought to most likely be a contaminant; however, given her
history of bacteremia the renal team elected to continue
vancomycin, to be dosed by level at HD for a total 3 week course
(16 more days).
.
# Altered mental status: Patient's mental status improved with
holding benzodiazepenes and narcotics. Per discussion with rehab
facility, patient has been receiving increased doses of
narcotics recently. As she was not having any pain, she was
discharged off all narcotics.  Benzodiazepenes and narcotics
should be avoided if possible in this patient.
.
# CAD: Troponins flat x 2, there was no chest pain, no EKG
changes. [**Month/Year (2) **], Plavix, and statin were continued. Of note, she is
not on a beta blocker or ACE inhibitor because of hypotension.

.
# ESRD on HD: There was no indication for urgent HD. Recently
had AV graft to upper left arm (lower left arm graft failed)
which was complicated by hematoma and perioperative NSTEMI. This
admission, the graft appeared intact, but she had a tunnelled
line that was used instead.  She had missed her recent Saturday
dialysis session [**3-23**]. She received HD on [**3-25**], but this was
limited by hypotension, so she underwent another session on [**3-26**]
and then ultrafiltration on [**3-27**].  Sevelamer, lanthanum, and
cinacalcet were continued.  She should now resume her outpatient
Tues/Thurs/Sat hemodialysis, next due [**3-28**].
.
# Chronic osteomyelitis: Followed in [**Hospital **] clinic. Currently taking
Doxycycline 100mg PO BID and rifampin 300mg PO bid for chronic
suppression of MRSA vertebral osteomyelitis (hardware in place)
for indefinite period of time. Doxycycline and rifampin were
continued, and she was discharged with ID follow-up on [**3-29**] as
previously scheduled.
.
# DMII:  Insulin sliding scale was continued.  FSBG were mid
100s.
.
# COPD:  The patient had O2 Saturation ~95% on 2L O2.  She
should continue supplemental oxygen as needed.
.
# OSA: CPAP was continued.
.
The patient clearly stated that she wanted to be full code
status.


Medications on Admission:
[**Month (only) **] 325mg PO daily
Plavix 75mg PO daily
Simvastatin 80mg PO daily
Rifampin 300mg PO q12
Doxy 100mg PO q12
Regular insulin sliding scale
Protonix 40mg PO daily
Reglan 5mg PO QIDACHS
Lanthanum 500mg PO PO TID w/meals
Cinacalcet 60mg PO daily
Nephrocaps 1mg PO daily
Sevelamer 2400mg PO TID with meals
Percocet 5-325mg 1-2 tabs q4-6h prn
Gabapentin 300mg PO qHD
[**Month (only) 95641**]
Mirtazapine 15mg PO qHS
Tramadol 50mg PO BID
Colace prn
Senna prn


Discharge Disposition:
Extended Care

Facility:
Roscommon

Discharge Diagnosis:
primary:  hypotension, altered mental status
secondary:  coronary artery disease, peripheral vascular
disease, diabetes, hypertension


Discharge Condition:
stable


Discharge Instructions:
You came to the hospital because of low blood pressure and
confusion.  You were given fluids, and your pain medications
were stopped.  Your blood pressure and confusion improved.

The following medications were changed:
Percocet was stopped
Gabapentin was stopped
Mirtazapine was stopped
Tramadol was stopped
Reglan was stopped

Please call your doctor or return to the emergency room for
chest pain or shortness of breath, fevers and chills, or other
symptoms that are concerning to you.


Followup Instructions:
You will need to continue dialysis every Tuesday, Thursday, and
Saturday.

Please follow up with the nurse practitioner who works with Dr.
[**Last Name (STitle) 2450**]:
Provider: [**Name10 (NameIs) 10160**] [**Name11 (NameIs) 10161**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2193-4-15**] 11:00

Also follow up as previously scheduled with infectious disease
and cardiology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2193-3-29**]
11:00
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2193-7-15**] 10:20



Completed by:[**2193-3-27**]
{'Hypotension, unspecified,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic osteomyelitis, other specified sites,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Above knee amputation status,Personal history of malignant neoplasm of kidney'}


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 at HD

PRESENT ILLNESS: 55F with ESRD on HD, PVD s/p R AKA, HTN, DM, presents with
hypotension at HD. Pt was feeling in her usual state of health
until she went to HD this morning. At HD, her BP was found to be
56/12. EMS was called and BP per the EMTs was 58/41. She was
brought to the [**Hospital1 18**] ED.
.
On arrival to the ED, vitals were T 97.6, BP 62/34, HR 72, RR
17, SaO2 98% 2L. SBP initially maintained in the 60s but
improved to 110s with manipulation on exam and attempts at IV
access. She was initially very lethargic, and then became
agitated, yelling out in pain. At best, she was answering yes/no
questions. CXR negative. CT abd/pelvis showed mild increase in R
pleural effusion but no acute intraabdominal process. Received
vanco, zosyn, and 200cc IVF. Admitted to the MICU for close
monitoring.

MEDICAL HISTORY: - Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]

MEDICATION ON ADMISSION: [**Month (only) **] 325mg PO daily
Plavix 75mg PO daily
Simvastatin 80mg PO daily
Rifampin 300mg PO q12
Doxy 100mg PO q12
Regular insulin sliding scale
Protonix 40mg PO daily
Reglan 5mg PO QIDACHS
Lanthanum 500mg PO PO TID w/meals
Cinacalcet 60mg PO daily
Nephrocaps 1mg PO daily
Sevelamer 2400mg PO TID with meals
Percocet 5-325mg 1-2 tabs q4-6h prn
Gabapentin 300mg PO qHD
[**Month (only) 95641**]
Mirtazapine 15mg PO qHS
Tramadol 50mg PO BID
Colace prn
Senna prn

ALLERGIES: Lisinopril

PHYSICAL EXAM: T 98.1, BP 120/doppler, HR 75, RR 75, SaO2 95% 2L
General: obese female, alert and interactive.
Neck: obese, unable to determine JVP
Heart: RRR, distant HS [**12-31**] body habitus
Chest: L subclavian tunneled HD line without surrounding
erythema, CTAB anteriorly but difficult to auscultate
Abdomen: +BS, obese, soft, non-tender with stethescope exam.
Extrem: L upper arm incision with sutures in place, no erythema,
s/p L BKA (stump is mildly edematous but no erythema or
drainage), dopplerable R DP pulse, 1+ RLE edema, +anasarca
Back: sacral decub ulcers by report
Neuro: A+Ox2 (name and place), she believes this is [**2191**] and is
unable to repeat date when told. CN2-12 grossly intact.

FAMILY HISTORY: Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

SOCIAL HISTORY: Admitted from rehab. Has two sisters, one daughter.  [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago. 

### Response:
{'Hypotension, unspecified,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic osteomyelitis, other specified sites,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Above knee amputation status,Personal history of malignant neoplasm of kidney'}
