CHIEF COMPLAINT: Hypotension at HD, chronic diarrhea

PRESENT ILLNESS: 60 yo M w/ hx of CAD, PVD, ESRD on HD who presents with
hypotension at HD and chronic diarrhea of [**Last Name (un) 5487**] etiology.
Patient receives most of his care at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**] in
[**Hospital1 789**], RI and has multiple physicians. Patient has been
chronically ill, and has had multiple hospital stays at RW and
rehab centers in RI, most recently for pelvis and femur
fractures, complicated by severe PNA.
Patient reports history of chronic diarrhea for > 1 year and
enormous weight loss (60 lbs in 1 year). Started gradually, had
approximately [**2-6**] BMs daily (green, liquidy, non-bloody). No
associated abdominal pain. Has diarrhea with and without food,
but is exacerbated with meals. Has tried restricting lactose w/o
effect. Family reports no assessment for celiac sprue. Has been
followed by GI physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 84853**], and has reportedly
extensive work-up including endoscopies, and colonoscopies with
biopsies. Per family, no evidence of colonic masses or GI tract
cancers noted. Pt denies dysphagia, but has lost appetite
recently. Reports negative C. difficile and VRE testing in the
past few weeks. Has not tried pancreatic enzymes.
Today, patient was at HD when RN there noticed patient looked
ill, malnourished, and dehydrated. SBPs dropped to 70 systolic
during HD. Patient was sent to [**Hospital1 18**] for evaluation. Patient
admits to chronic cough with worsening sputum production. Denied
dysuria.
In ED VS were 97.8 68 78/41 28 100. Noted to have SBP to 78 in
ED with cool peripheries, received 300 cc NS with improved of
SBPs to 110. Received Vancomycin 1 gram IV x1 and Zosyn 4.75
grams IV x1, Magnesium 2 mg IV x1, and perocet 1 tab x1.

MEDICAL HISTORY: ESRD on HD since [**2152**] (unknown baseline Cr)
CAD s/p cardiac stenting x 2 ([**2145**], [**2146**]) due to MI
COPD (on 3 L home O2)
DM2 (no longer requiring insulin [**1-6**] weight loss, controlled on
oral [**Doctor Last Name 360**] only)
PVD s/p stention
?HL
Iron deficiency anemia
?Depression
.
PSH:
L femur/pelvic fx in [**7-13**] (from a fall) c/b severe pna)
L hip fx [**2153**]
s/p amputation of all 5 left toes
s/p back surgeries x 6 (due to injury)
s/p multiple L shoulder surgeries
s/p appendectomy

MEDICATION ON ADMISSION: Percocet 10/325 mg PO q8H:PRN pain
OxyContin 80 mg PO BID
Alprazolam 0.025 mg TID
Seroquel 300 mg PO QHS
Doxepin 200 mg PO QHS
Tircor 145 mg PO daily
Prantin 0.5 mg PO TIDAC if glucose > 150
Metoprolol 25 mg PO BID
Welchol 625 mg PO QID
Ferrous Sulfate 650 mg PO daily
MVI Norvasc 5 mg PO daily
Sertraline 100 mg PO daily
Plavix 75 mg PO daily
Protonix 40 mg PO daily
Lasix 40 mg PO [**Hospital1 **] daily
Advair INH 150/50 2 PUFFS daily
Albuterol INH as needed
ASA 81 mg PO daily
Renal caps 1 PO daily
Dephenoxyl atropine 2.5 mg TID

ALLERGIES: Morphine

PHYSICAL EXAM: Physical Exam on Admission:
VS: 97.3 99/62 66 20 100% 3 L NC
GA: cachectic M sitting in bed, AOx3, NAD
HEENT: PERRLA. MM dry. no LAD. elevated JVD. neck supple.
Cards: heart sounds distant. RRR S1/S2 heard. no
murmurs/gallops/rubs.
Pulm: diffuse crackles throughout all lung fields.
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. mild
tenderness over suprapubic region.
Extremities: no edema. poor DPs, PTs, limbs cold. +amputated
toes on left foot.
Skin: scattered echymoses and ?ruptured vesicles on extensor
surfaces of elbows and knees covered in crust.
Neuro/Psych: interacting appropriately.

FAMILY HISTORY: FH of DM and CVA in mother.  Denies FH of cancer, IBD, or celiac
sprue

SOCIAL HISTORY: Lives in RI with wife and daughter, both of whom are very
involved in his care.  Is retired, used to work as an attendant
in a mental health facility. 1200ppy smoking history, qhit 2
months ago. Denies etoh use or IVDU.
Hypovolemia,End stage renal disease,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Toxic encephalopathy,Pressure ulcer, stage III,Candidiasis of other urogenital sites,Chronic pancreatitis,Unspecified intestinal malabsorption,Acquired coagulation factor deficiency,Other and unspecified noninfectious gastroenteritis and colitis,Malnutrition of moderate degree,Other iatrogenic hypotension,Other antihypertensive agents causing adverse effects in therapeutic use,Diabetes with renal manifestations, type II or unspecified type, uncontrolled,Congestive heart failure, unspecified,Anemia in chronic kidney disease,Chronic airway obstruction, not elsewhere classified,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Peripheral vascular disease, unspecified,Other and unspecified hyperlipidemia,Gastroparesis,Unspecified vitamin D deficiency,Backache, unspecified,Dysthymic disorder
Hypovolemia,End stage renal disease,Food/vomit pneumonitis,Acute respiratry failure,Toxic encephalopathy,Pressure ulcer,stage III,Candidias urogenital NEC,Chronic pancreatitis,Intest malabsorption NOS,Acq coagul factor defic,Noninf gastroenterit NEC,Malnutrition mod degree,Iatrogenc hypotnsion NEC,Adv eff antihyperten agt,DMII renal uncntrld,CHF NOS,Anemia in chr kidney dis,Chr airway obstruct NEC,Status-post ptca,Old myocardial infarct,Periph vascular dis NOS,Hyperlipidemia NEC/NOS,Gastroparesis,Vitamin D deficiency NOS,Backache NOS,Dysthymic disorder
Admission Date:  [**2155-9-18**]              Discharge Date:   [**2155-10-3**]

Date of Birth:  [**2094-12-17**]             Sex:   M

Service: MEDICINE

Allergies:
Morphine

Attending:[**First Name3 (LF) 17865**]
Chief Complaint:
Hypotension at HD, chronic diarrhea

Major Surgical or Invasive Procedure:
PICC line placement
Hemodiaylsis
PEG tube placement


History of Present Illness:
60 yo M w/ hx of CAD, PVD, ESRD on HD who presents with
hypotension at HD and chronic diarrhea of [**Last Name (un) 5487**] etiology.
Patient receives most of his care at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**] in
[**Hospital1 789**], RI and has multiple physicians. Patient has been
chronically ill, and has had multiple hospital stays at RW and
rehab centers in RI, most recently for pelvis and femur
fractures, complicated by severe PNA.
Patient reports history of chronic diarrhea for > 1 year and
enormous weight loss (60 lbs in 1 year). Started gradually, had
approximately [**2-6**] BMs daily (green, liquidy, non-bloody). No
associated abdominal pain. Has diarrhea with and without food,
but is exacerbated with meals. Has tried restricting lactose w/o
effect. Family reports no assessment for celiac sprue. Has been
followed by GI physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 84853**], and has reportedly
extensive work-up including endoscopies, and colonoscopies with
biopsies. Per family, no evidence of colonic masses or GI tract
cancers noted. Pt denies dysphagia, but has lost appetite
recently. Reports negative C. difficile and VRE testing in the
past few weeks. Has not tried pancreatic enzymes.
Today, patient was at HD when RN there noticed patient looked
ill, malnourished, and dehydrated. SBPs dropped to 70 systolic
during HD. Patient was sent to [**Hospital1 18**] for evaluation. Patient
admits to chronic cough with worsening sputum production. Denied
dysuria.
In ED VS were 97.8 68 78/41 28 100. Noted to have SBP to 78 in
ED with cool peripheries, received 300 cc NS with improved of
SBPs to 110. Received Vancomycin 1 gram IV x1 and Zosyn 4.75
grams IV x1, Magnesium 2 mg IV x1, and perocet 1 tab x1.


Past Medical History:
ESRD on HD since [**2152**] (unknown baseline Cr)
CAD s/p cardiac stenting x 2 ([**2145**], [**2146**]) due to MI
COPD (on 3 L home O2)
DM2 (no longer requiring insulin [**1-6**] weight loss, controlled on
oral [**Doctor Last Name 360**] only)
PVD s/p stention
?HL
Iron deficiency anemia
?Depression
.
PSH:
L femur/pelvic fx in [**7-13**] (from a fall) c/b severe pna)
L hip fx [**2153**]
s/p amputation of all 5 left toes
s/p back surgeries x 6 (due to injury)
s/p multiple L shoulder surgeries
s/p appendectomy


Social History:
Lives in RI with wife and daughter, both of whom are very
involved in his care.  Is retired, used to work as an attendant
in a mental health facility. 1200ppy smoking history, qhit 2
months ago. Denies etoh use or IVDU.

Family History:
FH of DM and CVA in mother.  Denies FH of cancer, IBD, or celiac
sprue

Physical Exam:
Physical Exam on Admission:
VS: 97.3 99/62 66 20 100% 3 L NC
GA: cachectic M sitting in bed, AOx3, NAD
HEENT: PERRLA. MM dry. no LAD. elevated JVD. neck supple.
Cards: heart sounds distant. RRR S1/S2 heard. no
murmurs/gallops/rubs.
Pulm: diffuse crackles throughout all lung fields.
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. mild
tenderness over suprapubic region.
Extremities: no edema. poor DPs, PTs, limbs cold. +amputated
toes on left foot.
Skin: scattered echymoses and ?ruptured vesicles on extensor
surfaces of elbows and knees covered in crust.
Neuro/Psych: interacting appropriately.


Pertinent Results:
Admission Labs:
[**2155-9-17**] 09:15PM   GLUCOSE-83 UREA N-14 CREAT-2.0* SODIUM-139
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-31 ANION GAP-12
[**2155-9-17**] 09:15PM   ALT(SGPT)-22 AST(SGOT)-73* CK(CPK)-59 ALK
PHOS-97 TOT BILI-0.9
[**2155-9-17**] 09:15PM   LIPASE-16
[**2155-9-17**] 09:15PM   cTropnT-0.15*
[**2155-9-17**] 09:15PM   CK-MB-NotDone
[**2155-9-17**] 09:15PM   TOT PROT-5.2* ALBUMIN-2.5* GLOBULIN-2.7
CALCIUM-7.8* PHOSPHATE-2.8 MAGNESIUM-1.4*
[**2155-9-17**] 09:15PM   IgA-515*
[**2155-9-17**] 09:15PM   PT-20.7* PTT-34.9 INR(PT)-1.9*
[**2155-9-18**] 10:20AM   %HbA1c-5.1
[**2155-9-18**] 10:20AM   TRIGLYCER-110 HDL CHOL-7 CHOL/HDL-7.9
LDL(CALC)-26
[**2155-9-17**] 09:15PM   GLUCOSE-83 UREA N-14 CREAT-2.0* SODIUM-139
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-31 ANION GAP-12
.
CT ABD/PEL - [**9-18**]
1. Findings suggestive of pulmonary edema at the visualized lung
bases.
2. Right basilar bronchovascular opacity (15 mm) which could be
attributed to atelectasis or a lung nodule, although infection
cannot be excluded. Follow-up chest CT within three months is
recommended to evaluate further as a true lung nodule is not
excluded.
3. Pancreatic atrophy and calcifications consistent with chronic

pancreatitis.
4. Moderate gallbladder distention which can be seen in a
fasting state.
However, if there is clinical concern for a source of acute
infection, an
ultrasound could be considered as well as correlation with
pertinent
laboratory data.
5. Extensive vascular calcifications including stents along the
left common and external iliac arteries whose patency cannot be
assessed on this study.
6. Mild dilatation of the proximal small bowel, borderline in
caliber with
lack of distal passage of contrast. However, the appearance is
felt more
likely to reflect a mild ileus than obstruction, noting no sharp
transition. However, if there is continuing clinical concern for
obstruction, follow-up radiographs could be performed.
7. Considerable stool throughout the colon, which is mildly
distended, also suggestive of slow motility. The lower sigmoid
and rectal walls show mild thickening, which is seen in a more
patchy fashion elsewhere as well. This appearance could be seen
with anasarca in the setting of renal disease, although mild
colitis is difficult to exclude. The patient could be considered
at high risk for ischemic colitis given the history of diarrhea
and severe vascular disease, although usually associated CT
findings would be least prominent in the rectum.
8. Small amount of low-density ascites, which is nonspecific
with
splenomegaly.
.
CXR [**9-17**]
1. Findings are most consistent with moderate pulmonary edema,
with moderate cardiomegaly. However, underlying infection is not
excluded, and evaluation for such may be performed after
appropriate diuresis.
2. Dilated loops of bowel are incompletely assessed. Recommend
dedicated
abdominal radiographs for more complete assessment.
.
EKG [**9-17**]
Sinus rhythm. Diffuse T wave flattening makes the Q-T interval
difficult to interpret. No previous tracing available for
comparison.
.
CTA chest [**9-25**]:
FINDINGS:
There is no evidence of pulmonary embolism till the level of
subsegmental
pulmonary arteries bilaterally. The pulmonary arteries are
normal in diameter as well as the aorta. Extensive coronary
calcifications and coronary stents are noted with a coronary
stent being seen in LAD and right coronary artery at least.
Heart size is enlarged. There is no pericardial effusion. Small
left pleural effusion is noted with no evidence of right pleural
effusion.

The imaged portion of the upper abdomen demonstrates the NG tube
tip being in the stomach and otherwise is unremarkable within
the limitations of this study that was not designed for
evaluation of intra-abdominal pathology.

Extensive mediastinal lymphadenopathy involves the entire
mediastinum and
ranges up to 7.5 mm in the right upper paratracheal area, 12 mm
in right lower paratracheal area, 1 cm in the prevascular area,
8.5 mm in aortopulmonic window, 2 cm in subcarinal and
paraesophageal area with bilateral hilar lymph nodes ranging up
to 1.5 cm. This lymphadenopathy might be reactive to the
extensive parenchymal abnormality demonstrated throughout the
lungs and mostly consisting of two types of findings: Bilateral
peribronchovascular opacities
as well as confluent areas of ground-glass in the upper lungs,
3:14, with
focal areas of ground-glass mostly located in the posterior
segment of right upper lobe, 3:14, 15, 16, 18. The lower lobes
are also involved as well as posterior segment of right upper
lung, 3:24, 31, 37. The second
abnormality is bibasal opacities, right significantly more than
left. On the right, there are at least three consolidations in
the right lower lobe with the lowest one mostly posteriorly
located containing eccentric lucency, 3:68, approximately 12 mm
in diameter that might represent a consolidation with a cavity.
There are areas of air trapping, extensive and might be due to
bilateral external bronchial wall thickening and secretions that
are also seen in the main bronchi. Though secretions in
combination with patulous upper esophagus might be due to
aspiration, although infectious origin as part of the extensive
infectious process within the lungs cannot be excluded. The
findings are unlikely to represent pulmonary edema. Some of the
focal opacities might potentially represent hemorrhage in the
appropriate clinical setup.

There are no bone lesions worrisome for malignancy. Extensive
degenerative
changes are noted. No evidence of bone infection was
demonstrated.

[**9-24**] ECHO Conclusions:
The left atrium is elongated. There is symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.

[**10-1**] CXR:
The NG tube tip is in the stomach. Cardiomediastinal silhouette
is unchanged. There is no significant interval change in
bilateral predominantly upper lobe parenchymal opacities as well
as bibasal opacities involving the lung to a lesser extent
compared to upper portion. The right PICC line tip is in the
right atrium and should be pulled back for approximately 4.5 cm
to secure its position at low SVC. Small bilateral pleural
effusion cannot be excluded.
Overall the appearance of the lung has improved compared to
[**9-26**] and 24, [**2154**].


Brief Hospital Course:
60y/o man with multiple medical problems, numerous recent
hospitalizations, ESRD on HD, and chronic diarrhea and 60+ lb
weight loss of unclear etiology who presents with hypotension at
HD and diarrhea.
.
# Diarrhea/weight loss.  Unclear etiology.  Has had numerous
admissions for nausea/vomiting/diarrhea wouthout clear
diagnosis.  Numerous negative C diff tests at OSH, treated
empirically for C diff in past without improvement.  Colonoscopy
in [**6-12**] showed cryptitis, crypt abscesses.   Possible causes
include medication side effects, autoimmune, amyloidosis,
pancreatic insuffiency, protein losing enteropathy, malignancy,
infectious, bacterial overgrowth.  Given likely significant
malabsorption, vitamin deficiency, and weight loss, amyloidosis
and pancreatic insufficiency high on differential.  CT abd
showed signs of chronic pancreatitis and stool in colon
suggestive of slowed motility.  Amyloidosis could explain
patient's ESRD.  Thought to possibly also have a component of
gastroparesis as distended bowel loops and stool in bowels c/w
slowed motility on CT, and patient vomiting what looked like
"stool."  Medications possibly compounding problem.  Stopped
[**Name2 (NI) 84854**], as diarrhea common side effect, as well as cholesterol
agents.  Diarrhea was improved in-hospital, but also difficult
to tell given poor PO's (and patient soon made NPO due to
aspiration risk).  Infectious workup negative for C diff, E
coli, Salmonella, Shigella, Campylobacter, Yersenia, Vibrio,
O+P.  tTG-IGA negative for celiac.  Unable to obtain stool
collection for stool osmolality/lytes and fat content given
cessation of diarrhea in house.  SPEP and UPEP pending.
Intended to do colonoscopy and EGD but patient decompensated
from respiratory standpoint and forced to delay.

#. Nausea/vomiting/nutritional status. Likely related to
diarrhea.  Patient with very poor nutritional status, albumin of
approx 2, and periodic vomiting.  Massive weight loss and
cachexia, poor nutritional status.  Developed extremity edema
likely [**1-6**] low albumin, also with elevated PT/INR responsive to
Vitamin K suggestive of extreme malabsorption of fat absorbable
vitamins. Vitamin K level pending. Also with elevated PTH
(despite normal corrected calcium) suggesting Vit D deficiency.
Placed NG tube to improve nutritional status but was frequently
held due to poor tolerance.  [**Month (only) 116**] have component of
gastroparesis, given impaired intestinal mobility on CT and
reports of "vomiting stool".  Patient had a PEG tube placed on
[**10-2**] for ongoing tube feeds.
.
#. Hypotension.  Likely due to overmedication with
antihypertensives in the setting of volume depletion and HD.
History of HTN but has lost 60+lb and reports frequent symptoms
of orthostatis, as well as freuqent low BP's at HD.  Decreased
PO intake, with GI losses.  Thought to be unlikely sepsis given
normal WBC count on admission, lack of fever, and cool
extremities.  D/c'd norvasc and lasix, reduced lopressor from 25
to 12.5bid, held on HD days.  BP improved. Still with periodic
hypotension to 90's systolic at HD, 0-2L removed at HD.
.
#. SOB/COPD/pulmonary edema/aspiration/hospital-acquired
pneumonia. Patient on 3L 02 at baseline.  Significant congestion
on admission, thought to be c/w COPD as well as pulmonary edema
with resulting inability to maintain intravascular volume.  Then
developed increasing dyspnea during hospital stay, spiked fever,
leukocytosis.  Concern for pna, possible aspiration, either
before NPO or [**1-6**] secretions.  Given poor reserve and poor
nutritional status, decided to treat for hospital-acquired
pneumonia. Patient deteriorated from a respiratory standpoint
with increasing 02 requirement and RR in 40s, unable to clear
secretions [**1-6**] weakness.  Transferred to MICU on [**9-22**].
Initially covered pna broadly with vancomycin, cefepime, flagyl,
and azithromycin, then scaled back to vancomycin and cefepime.
Vanc/cefepime continued to complete 8 day course. Flagyl
continued for 14 days for aspiration pneumonia given cavitary
consolidation on chest CT.
.
#. UTI. Patient had dysuria, increased urinary frequency, and
suprapubic tenderness on admission.  Found to have UTI on
admission with 750 WBC.  Initially treated with cipro and was
covered with antibiotics for hospital acquired pneumonia.
.
#. Delirium.  Patient with waxing and [**Doctor Last Name 688**] mental status,
inattention, possible visual hallucinations.  Much of this is
after HD session where he can be minimally responsive.  Other
contributory factors including infection (UTI, pna),
medications, poor nutrition, and difficulty clearing secretions.
 His mental status improved with reduction of contributory
medications (d/c'd percocet and oxycontin, quetiapine, and
doxepin).
.
#. Elevated INR/PT.  Thought to be [**1-6**] vitamin K deficiency due
to poor absorption of fat soluble vitamins as well as poor PO's.
 INR and PT trended downwards with IV vitamin K.  Vitamin K
level normal.  Patient had a PEG tube placed on [**10-2**] for
ongoing tube feeds
.
# ESRD on HD MWF. Has  been on dialysis since [**2145**], reports
being told ESRD was [**1-6**] DM.  Pt continued with HD inhouse.  His
SPEP was negative for amyloidosis.
.
#. Sacral ulcer. Unstageable per wound care team.  Likely stage
II or III. Position changes q2hour, frequent dressing changes,
pain control with oxycodone.
.
#. Anemia.  Normocytic, stable. Known Fe deficiency anemia on
iron supplements.  [**Month (only) 116**] have ACD. Fe studies repeatedly ordered
?pending. Likely with low EPO, good candidate for Procrit. Could
also have combination of Fe deficiency anemia (microcytic) and
folate of B12 deficiency (macrocytic), giving a normocytic
picture, as patient known to have Fe deficiency in past, and
given diarrhea and poor nutritional state and possible
malabsorption, may have depletion in stores in either of these.
.
#. DM2. HgbA1c 5.1 on admission, suggesting hypoglycemic
episodes in recent past.  Likely [**1-6**] poor PO's and weight loss.
Stopped [**Month/Day (2) 84854**], which is also known to cause diarrhea, placed
on humalog sliding scale.  Sugars well controlled.
.
#. CAD/PVD.  Pt was continued on ASA and plavix.
.
#. ?HL.  On tricor and welchol at home but lipid levels returned
with HDL 7, LDL 26 Total chol 55.  His tricor and welchol were
also held due to due to risk of GI upset.
.
#. Psych.  Given delirium, pt was continued on sertraline 100
daily but quetiapine and doxepin were discontinued.
.
#. Coping.  Family frustrated with patient's course and
difficulties with care in RI, having difficulty coping with
severity of patient's illness, patient at times feeling like he
wants to go home and die.  Family meeting from [**10-1**] resulted in
wishes to continue HD, feed through PEG tube, and FULL CODE.
.
#. Chronic back pain:  Given his mental status, he was
discontinued from his oxycontin 40 q12h and was treated with
oxycodone prn, tylenol, and lidocaine patch.

Medications on Admission:
Percocet 10/325 mg PO q8H:PRN pain
OxyContin 80 mg PO BID
Alprazolam 0.025 mg TID
Seroquel 300 mg PO QHS
Doxepin 200 mg PO QHS
Tircor 145 mg PO daily
Prantin 0.5 mg PO TIDAC if glucose > 150
Metoprolol 25 mg PO BID
Welchol 625 mg PO QID
Ferrous Sulfate 650 mg PO daily
MVI Norvasc 5 mg PO daily
Sertraline 100 mg PO daily
Plavix 75 mg PO daily
Protonix 40 mg PO daily
Lasix 40 mg PO [**Hospital1 **] daily
Advair INH 150/50 2 PUFFS daily
Albuterol INH as needed
ASA 81 mg PO daily
Renal caps 1 PO daily
Dephenoxyl atropine 2.5 mg TID


Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO at bedtime:
FOR TOTAL DOSE OF 15 mg daily.
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO at bedtime: FOR
TOTAL DOSE OF 15 mg daily.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 10 days.
6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for cough, congestion.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for sob/wheezing.
9. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): TO the
back.
11. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1)
 PO BID (2 times a day).
12. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Three (3)
Tablet PO DAILY (Daily).
14. Ranitidine HCl 15 mg/mL Syrup Sig: One (1)  PO DAILY
(Daily).
15. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q6H (every
6 hours) as needed for pain: PLS hold for sedation.
16. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain, fever.
17. Insulin Lispro 100 unit/mL Solution Sig: 0-12 units
Subcutaneous ASDIR (AS DIRECTED): PLs see insulin sliding scale.

18. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
19. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: PICC,
heparin dependent: Flush with 10mL Normal Saline followed by
Heparin as above daily and PRN per lumen. .
20. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO twice a day: For
total of 37.5 mg [**Hospital1 **].  PLEASE HOLD ON HD DAYS.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 54351**] - [**Location (un) 5503**]

Discharge Diagnosis:
Primary:
[**Hospital **]
Hospital-acquired pneumonia
.
Secondary:
Aspiration
End stage renal disease
Coronary artery disease
Chronic obstructive pulmonary disease
Hypertension
Diabetes Mellitus
Depression
Anxiety


Discharge Condition:
HR 80-100s, SBP 120s-160s, 92-100% on 3L NC.  Pt does get
hypotensive during dialysis so please do not give him any
metoprolol on HD days.  Pt is also typically minimally
responsive after HD sessions--will not respond to verbal or
tactile stimuli--for the remainder of the day.

HR 80-100s, SBP 120s-160s, 92-100% on 3L NC.  Pt does get
hypotensive during dialysis so please do not give him any
metoprolol on HD days.  Pt is also typically minimally
responsive after HD sessions--will not respond to verbal or
tactile stimuli--for the remainder of the day.


Discharge Instructions:
You were admitted with diarrhea.  Unfortunately, due to your
pneumonia and resulting respiratory distress, you were unable to
have a colonoscopy.  All the blood work and stool studies have
NOT shown a cause for you diarrhea.  You will need to follow up
with outpatient Gastroenterology.
.
For your pneumonia, you received a course of antibiotics and
your respiratory status has improved.  You were noted to have a
cavitary lesion on the CT scan of your chest.  You will need to
complete a 14 day course of the antibiotic metronidazole and
have a follow up CT scan in 1 month.  Your primary care doctor
will help you arrange this study.
.
In addition, you were noted to have a nodule at the base of your
right lung and need a follow-up CT scan 3 months from your
[**Month (only) 1096**] scan.

Followup Instructions:
As we discussed you were seen to have a cavitary lesion in your
lung and need a follow CT scan in 1 month ([**2155-11-4**]) after
your course of antibiotics.  In addition, you were noted to have
a nodule at the base of your right lung and need a follow-up CT
scan 3 months from your [**Month (only) 1096**] scan.  Your primary care doctor
will help you arrange this study.  Please see your PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] within 2 weeks of discharge from rehab.

Please follow up with Gastroenterology regarding your diarrhea.
Please make an appointment with GI in 2 weeks with Attending Dr.
[**Last Name (STitle) 9916**] and Fellow Dr. [**First Name8 (NamePattern2) 1255**] [**Name (STitle) 1256**].  The clinic number is
([**Telephone/Fax (1) 2233**].
{'Hypovolemia,End stage renal disease,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Toxic encephalopathy,Pressure ulcer, stage III,Candidiasis of other urogenital sites,Chronic pancreatitis,Unspecified intestinal malabsorption,Acquired coagulation factor deficiency,Other and unspecified noninfectious gastroenteritis and colitis,Malnutrition of moderate degree,Other iatrogenic hypotension,Other antihypertensive agents causing adverse effects in therapeutic use,Diabetes with renal manifestations, type II or unspecified type, uncontrolled,Congestive heart failure, unspecified,Anemia in chronic kidney disease,Chronic airway obstruction, not elsewhere classified,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Peripheral vascular disease, unspecified,Other and unspecified hyperlipidemia,Gastroparesis,Unspecified vitamin D deficiency,Backache, unspecified,Dysthymic disorder'}


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, chronic diarrhea

PRESENT ILLNESS: 60 yo M w/ hx of CAD, PVD, ESRD on HD who presents with
hypotension at HD and chronic diarrhea of [**Last Name (un) 5487**] etiology.
Patient receives most of his care at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**] in
[**Hospital1 789**], RI and has multiple physicians. Patient has been
chronically ill, and has had multiple hospital stays at RW and
rehab centers in RI, most recently for pelvis and femur
fractures, complicated by severe PNA.
Patient reports history of chronic diarrhea for > 1 year and
enormous weight loss (60 lbs in 1 year). Started gradually, had
approximately [**2-6**] BMs daily (green, liquidy, non-bloody). No
associated abdominal pain. Has diarrhea with and without food,
but is exacerbated with meals. Has tried restricting lactose w/o
effect. Family reports no assessment for celiac sprue. Has been
followed by GI physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 84853**], and has reportedly
extensive work-up including endoscopies, and colonoscopies with
biopsies. Per family, no evidence of colonic masses or GI tract
cancers noted. Pt denies dysphagia, but has lost appetite
recently. Reports negative C. difficile and VRE testing in the
past few weeks. Has not tried pancreatic enzymes.
Today, patient was at HD when RN there noticed patient looked
ill, malnourished, and dehydrated. SBPs dropped to 70 systolic
during HD. Patient was sent to [**Hospital1 18**] for evaluation. Patient
admits to chronic cough with worsening sputum production. Denied
dysuria.
In ED VS were 97.8 68 78/41 28 100. Noted to have SBP to 78 in
ED with cool peripheries, received 300 cc NS with improved of
SBPs to 110. Received Vancomycin 1 gram IV x1 and Zosyn 4.75
grams IV x1, Magnesium 2 mg IV x1, and perocet 1 tab x1.

MEDICAL HISTORY: ESRD on HD since [**2152**] (unknown baseline Cr)
CAD s/p cardiac stenting x 2 ([**2145**], [**2146**]) due to MI
COPD (on 3 L home O2)
DM2 (no longer requiring insulin [**1-6**] weight loss, controlled on
oral [**Doctor Last Name 360**] only)
PVD s/p stention
?HL
Iron deficiency anemia
?Depression
.
PSH:
L femur/pelvic fx in [**7-13**] (from a fall) c/b severe pna)
L hip fx [**2153**]
s/p amputation of all 5 left toes
s/p back surgeries x 6 (due to injury)
s/p multiple L shoulder surgeries
s/p appendectomy

MEDICATION ON ADMISSION: Percocet 10/325 mg PO q8H:PRN pain
OxyContin 80 mg PO BID
Alprazolam 0.025 mg TID
Seroquel 300 mg PO QHS
Doxepin 200 mg PO QHS
Tircor 145 mg PO daily
Prantin 0.5 mg PO TIDAC if glucose > 150
Metoprolol 25 mg PO BID
Welchol 625 mg PO QID
Ferrous Sulfate 650 mg PO daily
MVI Norvasc 5 mg PO daily
Sertraline 100 mg PO daily
Plavix 75 mg PO daily
Protonix 40 mg PO daily
Lasix 40 mg PO [**Hospital1 **] daily
Advair INH 150/50 2 PUFFS daily
Albuterol INH as needed
ASA 81 mg PO daily
Renal caps 1 PO daily
Dephenoxyl atropine 2.5 mg TID

ALLERGIES: Morphine

PHYSICAL EXAM: Physical Exam on Admission:
VS: 97.3 99/62 66 20 100% 3 L NC
GA: cachectic M sitting in bed, AOx3, NAD
HEENT: PERRLA. MM dry. no LAD. elevated JVD. neck supple.
Cards: heart sounds distant. RRR S1/S2 heard. no
murmurs/gallops/rubs.
Pulm: diffuse crackles throughout all lung fields.
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. mild
tenderness over suprapubic region.
Extremities: no edema. poor DPs, PTs, limbs cold. +amputated
toes on left foot.
Skin: scattered echymoses and ?ruptured vesicles on extensor
surfaces of elbows and knees covered in crust.
Neuro/Psych: interacting appropriately.

FAMILY HISTORY: FH of DM and CVA in mother.  Denies FH of cancer, IBD, or celiac
sprue

SOCIAL HISTORY: Lives in RI with wife and daughter, both of whom are very
involved in his care.  Is retired, used to work as an attendant
in a mental health facility. 1200ppy smoking history, qhit 2
months ago. Denies etoh use or IVDU. 

### Response:
{'Hypovolemia,End stage renal disease,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Toxic encephalopathy,Pressure ulcer, stage III,Candidiasis of other urogenital sites,Chronic pancreatitis,Unspecified intestinal malabsorption,Acquired coagulation factor deficiency,Other and unspecified noninfectious gastroenteritis and colitis,Malnutrition of moderate degree,Other iatrogenic hypotension,Other antihypertensive agents causing adverse effects in therapeutic use,Diabetes with renal manifestations, type II or unspecified type, uncontrolled,Congestive heart failure, unspecified,Anemia in chronic kidney disease,Chronic airway obstruction, not elsewhere classified,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Peripheral vascular disease, unspecified,Other and unspecified hyperlipidemia,Gastroparesis,Unspecified vitamin D deficiency,Backache, unspecified,Dysthymic disorder'}
