CHIEF COMPLAINT: hypotension

PRESENT ILLNESS: 56 yo W with ESRD on HD (MWF), HTN (last sBPs in 150s), HCV
cirrhosis, Hypothyroidism, Anxiety, chronic back pain on
methadone, presenting with systolic BPs in the 60s prior to and
during [**Hospital 58910**] transferred to [**Hospital Unit Name 153**] for evaluation and management of
hypotension.
.
She reports 1 month of increasing fatigue, weakness, and
occasional falls (knee buckling). Occasional cough with brown
sputum and chronic loose stools, but no fevers, chills, sweats,
dyspnea, nausea, vomiting, black or bloody stools. Regarding her
complaints, she reports that her BP medications have been
adjusted, but this has not helped. She has also experienced
intermittent L-sided sharp chest pains that worsen with arm
movement, and was prescribed nitroglycerin that she ended up
taking daily instead of on a PRN basis.
.
In the ED, initial vs were: T 97.4 P 69 BP 64/53 R 14 97% O2 sat
on RA. Per report, she was mentating appropriately. A triple
lumen femoral CVC was placed. She was bolused 500 cc, given
Vancomycin and Zosyn, and started on Levophed at 0.06. CXR was
unremarkable. CT C/A/P were obtained and prelim only significant
for a right adenexal cyst (present since [**Month (only) 404**]).
.
On the floor, the patient was appropriate and comfortable. She
was placed on a Nicom. CI and SVI improved with leg raise so Pt
was given 250 cc, then on repeat given additional 250 cc.
Levophed was weaned off.
.
Review of sytems: per HPI, otherwise negative

MEDICAL HISTORY: -HTN
-ESRD on hemodialysis
-HCV cirrhosis
-spinal stenosis with back pain
-seizure disorder
-depression
-hypothyroidism
-substance abuse
-Lumbar laminectomy
-status post failed renal transplant
-cholecystectomy
-thyroidectomy

MEDICATION ON ADMISSION: -Metoprolol succinate 25 daily
-Nitrostat PRN
-Simvastatin 20 daily
-ASA 81 daily
-Fluoxetine 40 daily
-Gabapentin 300 daily
-Lisinopril 2.5 daily
-Keppra 250 [**Hospital1 **]
-Folic acid 1 mg daily
-Sensipar 30 mg PRN
-Trazadone 50 qhs
-Omeprazole 20 daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: 97.6, 63, 133/86, 98% on RA
General: alert, oriented, no acute distress
HEENT: muddy sclera, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  soft, obese, +BS, TTP in RUQ with mild voluntary
guarding
GU: no foley
Ext: warm, well perfused, symmetric pulses, no clubbing,
cyanosis or edema, R hallux with nail bed removed, crusted
blood, no erythema or fluctuance, no purulence
Neuro: face symmetric, moves all extremities, sensation intact,
gait not observed

FAMILY HISTORY: Father: ESRD and hypertension
Mother: lung cancer

SOCIAL HISTORY: Retired special education teacher. Widowed, lives at home with
sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy.
# Tobacco: 3 packs per week since teenager
# Alcohol: Denies
# Drugs: Past IVDU, but not in several years
Hypotension of hemodialysis,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Complications of transplanted kidney,Opioid type dependence, continuous,Other antihypertensive agents causing adverse effects in therapeutic use,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified acquired hypothyroidism,Dysthymic disorder,Other chronic pain,Backache, unspecified,Chest pain, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Asthma, unspecified type, unspecified,Tobacco use disorder,Personal history of noncompliance with medical treatment, presenting hazards to health,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Thrombocytopenia, unspecified,Unspecified disorder of kidney and ureter,Other and unspecified ovarian cyst,Anemia in chronic kidney disease
Hemododialysis hypotensn,End stage renal disease,Hyp kid NOS w cr kid V,Compl kidney transplant,Opioid dependence-contin,Adv eff antihyperten agt,Abn react-org transplant,Hypothyroidism NOS,Dysthymic disorder,Chronic pain NEC,Backache NOS,Chest pain NOS,Epilep NOS w/o intr epil,Asthma NOS,Tobacco use disorder,Hx of past noncompliance,Abnrml coagultion prfile,Adv eff anticoagulants,Thrombocytopenia NOS,Renal & ureteral dis NOS,Ovarian cyst NEC/NOS,Anemia in chr kidney dis
Admission Date:  [**2129-4-20**]              Discharge Date:   [**2129-4-23**]

Date of Birth:  [**2072-5-1**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
hypotension

Major Surgical or Invasive Procedure:
none

History of Present Illness:
56 yo W with ESRD on HD (MWF), HTN (last sBPs in 150s), HCV
cirrhosis, Hypothyroidism, Anxiety, chronic back pain on
methadone, presenting with systolic BPs in the 60s prior to and
during [**Hospital 58910**] transferred to [**Hospital Unit Name 153**] for evaluation and management of
hypotension.
.
She reports 1 month of increasing fatigue, weakness, and
occasional falls (knee buckling). Occasional cough with brown
sputum and chronic loose stools, but no fevers, chills, sweats,
dyspnea, nausea, vomiting, black or bloody stools. Regarding her
complaints, she reports that her BP medications have been
adjusted, but this has not helped. She has also experienced
intermittent L-sided sharp chest pains that worsen with arm
movement, and was prescribed nitroglycerin that she ended up
taking daily instead of on a PRN basis.
.
In the ED, initial vs were: T 97.4 P 69 BP 64/53 R 14 97% O2 sat
on RA. Per report, she was mentating appropriately. A triple
lumen femoral CVC was placed. She was bolused 500 cc, given
Vancomycin and Zosyn, and started on Levophed at 0.06. CXR was
unremarkable. CT C/A/P were obtained and prelim only significant
for a right adenexal cyst (present since [**Month (only) 404**]).
.
On the floor, the patient was appropriate and comfortable. She
was placed on a Nicom. CI and SVI improved with leg raise so Pt
was given 250 cc, then on repeat given additional 250 cc.
Levophed was weaned off.
.
Review of sytems: per HPI, otherwise negative


Past Medical History:
-HTN
-ESRD on hemodialysis
-HCV cirrhosis
-spinal stenosis with back pain
-seizure disorder
-depression
-hypothyroidism
-substance abuse
-Lumbar laminectomy
-status post failed renal transplant
-cholecystectomy
-thyroidectomy


Social History:
Retired special education teacher. Widowed, lives at home with
sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy.
# Tobacco: 3 packs per week since teenager
# Alcohol: Denies
# Drugs: Past IVDU, but not in several years


Family History:
Father: ESRD and hypertension
Mother: lung cancer


Physical Exam:
VS: 97.6, 63, 133/86, 98% on RA
General: alert, oriented, no acute distress
HEENT: muddy sclera, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  soft, obese, +BS, TTP in RUQ with mild voluntary
guarding
GU: no foley
Ext: warm, well perfused, symmetric pulses, no clubbing,
cyanosis or edema, R hallux with nail bed removed, crusted
blood, no erythema or fluctuance, no purulence
Neuro: face symmetric, moves all extremities, sensation intact,
gait not observed


Brief Hospital Course:
56 yo W with Hx of ESRD on HD, HCV cirrhosis, HTN,
Hypothyroidism, and chronic pain on methadone presenting from HD
with hypotension to systolic BPs, initially admitted to ICU,
quickly transferred to medical floor.
.
# Hypotension: Appears to have been developing subacutely, over
the last month. Hypotension is likely secondary to a too
aggressive antihypertensive regimen, current medication misuse,
or possibly over-diuresis at HD (with need for reassessment of
dry weight). Supporting a possible over beta-blockade is a HR
that has consistently remained in the 60s despite BPs in the
60s. Additionally she was started on nitroglycerin and had been
taking it daily rather than on a PRN basis. She is responsible
for her medications, yet unable to correctly remember dosing
regimen. Other etiologies to consider given the chronicity
include endocrine causes such untreated hypothyroidism (pill
bottle not in bag) or adrenal insufficiency.  Received a total
of 1.5 L of volume resuscitation. Levophed weaned off. Outpt
Nephrologist reports dry weight as 74kg. She was started
initially on road spectrum antibiotics which were quickly
discontinued when all cultures were negative.
.
TSH, free T4, and AM Cortisol obtained and pt restarted home
levothyroxine dose for significant hypothyroidism. CT abd/pelvis
was unremarkable except for stable adnexal cyst. Blood pressures
remained stable while patient was off her anti-hypertensives.
After chart review she had been started on these during an
admission for chest pain at which time a cath revealed clean
coronary arteries. Therefore it is felt she does not need these
medications and they were stopped. She will continue on
simvastatin for her cholesterol management and ASA to reduce her
risk of stroke. She will follow up with her PCP or in
[**Name9 (PRE) 1944**] clinic for a BP check off of her medications and
will have VNA checking her BPs at home as well. Her PCP can
titrate medications as necessary
.
# Elevated bicarbonate: Likely [**2-16**] recent HD session, as well as
contraction from intravascular depletion. Supporting this is a
Hct above baseline likely reflecting hemoconcentration. Pt is on
advair without documented hx of COPD. CXR not reflective of this
and bicarb not chronically elevated.
.
# Hyperkalemia: Likely [**2-16**] ESRD. No evidence of peaked T waves
on EKG. She was given insulin, kayexelate overnight and repeated
insulin per renal recs prior to dialysis this AM. K was noted to
be wnl on follow up AM labs.
.
# Prolonged PT/PTT: INR mildly elevated likely [**2-16**] underlying
poor synthetic liver function from cirrhosis. Also may have a
nutritional component as well. Prolonged PTT likely [**2-16**] heparin
received at HD. No evidence to support bleeding.
PTT resolved off heparin.
.
# Thrombocytopenia: Chronic issue, likely [**2-16**] cirrhosis.
Platelets were stable and did not require transfusion.
.
# Anemia: [**2-16**] ESRD. BL Hct around 31. On EPO as outpt. Hct was
trended and stable; pt did not require transfusion of blood
components during her ICU stay.
.
# CAD: No evidence to suggest acute ischemia. EKG consistent
with prior. Trop at 0.05, likely [**2-16**] demand in setting of CKI.
CK and CKMB added on and non-concerning for ACS. Pt
asymptomatic. She was continued on asa 81mg, simvastatin 20mg.
BBlocker and ACEi held for observation of hemodynamic stability
given admission complaint.
.
# Hypothyroidism:  TSH grossly elevated with very low T4.
Levothyroxine was not in her pill bag, in discussion with her
pharmacy this prescription had not been filled in many months.
Pt was started on Levothyroxine 188mcg daily, will need repeat
TFT's in [**4-20**] weeks.  [**Month (only) 116**] be contributing to hypotension, fatigue
and depression.  Arranged for her pills to be delivered in a
bubble pack to help with med compliance in the future.
.
# Seizure Disorder: Continued on Keppra 250 mg [**Hospital1 **].
.
# Depression/Anxiety: SHe has severe depression, uncontrolled.
No SI/HI.  Restarted home clonazepam (held on admission given
hypotention), social work consulted, fluoxitine increased from
40 to 60 mg daily.  She is interested in outpt therapy, to
arranged by her PCP at follow up.
.
# Chronic Pain: On Gabapentin and methadone dose was confirmed
with [**Doctor Last Name 7594**] Op Co to be 44mg daily.
.
# Given prior hx of renal nodule seen on CT scan, pt was ordered
for MRI to be completed during her stay given concern for poor
outpt followup.  MRI renal wo contrast was performed; read was
pending at time of d/c and needs to be followed up by outpatient
providers (either Dr. [**First Name (STitle) 805**] or PCP)
.
# Right adnexal Cyst: Patient was told to follow up with pelvic
ultrasound for right adnexal cyst seen on CT scan. PCP [**Name Initial (PRE) **]/or
[**Hospital 1944**] clinic will help her coordinate this study.
.
Contact: sister [**Name2 (NI) **] at [**Telephone/Fax (1) 98152**]

# Transitions of care:
- Right adnexal cyst needs transvaginal ultrasound for further
evaluation. To be coordinated with PCP's help
- Blood cultures pending at time of discharge and need to be
followed up at [**Hospital 1944**] clinic
- Patient had MRI of abdomen to evaluate a renal cyst. Final
read pending at discharge and needs to be followed up through
outpatient providers either at [**Hospital 1944**] clinic or with Dr.
[**First Name (STitle) 805**]
- Patient seemed depressed and her fluoxetine was increased from
40mg to 60mg daily.  Denied SI. At her [**Hospital 1944**] clinic
please assess her mood and help arrange outpt therapy.
- Patient's BP meds were held given hypotension. Post-D/c clinic
will check her BP to ensure stable off meds still.
- Patient had a low blood count (and chronically low plts) which
should be repeated at her post-discharge follow up appt

Medications on Admission:
-Metoprolol succinate 25 daily
-Nitrostat PRN
-Simvastatin 20 daily
-ASA 81 daily
-Fluoxetine 40 daily
-Gabapentin 300 daily
-Lisinopril 2.5 daily
-Keppra 250 [**Hospital1 **]
-Folic acid 1 mg daily
-Sensipar 30 mg PRN
-Trazadone 50 qhs
-Omeprazole 20 daily


Discharge Medications:
1. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a
day: With the 100mcg tab.
Disp:*30 Tablet(s)* Refills:*2*
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
Disp:*30 Capsule(s)* Refills:*2*
6. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. methadone 10 mg/mL Concentrate Sig: Forty Four (44) mg PO
DAILY (Daily).
8. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
Disp:*90 Capsule(s)* Refills:*2*
9. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Sensipar 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
14. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Cargroup Home Care

Discharge Diagnosis:
Hypotension secondary to medications and dialysis
Hypothyroidism
Right adnexal cyst
Renal Cyst


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital with low blood pressure. This
was probably a combination of having dialysis and taking blood
pressure medications. We have stopped your blood pressure
medications as you don't need them. We looked for infections
(which can cause your blood pressure to be low) but could not
find any. Please take your medications exactly as prescribed.
 You also had a CT scan which showed a cyst on your right ovary.
You need an ultrasound of your ovary to evaluate this. You
should coordinate this study with your primary care provider.
 [**Name10 (NameIs) 2172**] CT scan also showed a cyst on your kidney. You had an MRI
to evaluate this. The read on the MRI is pending at this point
and you should follow up with your primary doctor to find out if
there is anything else that needs to be done about this.
.
Medication Changes:
START: Calcium acetate 667 TID with meals (to keep your calium
higher and your phosphorous lower)
START: Levothyroxine 200mcg daily
STOP: Lisinopril
STOP: Metoprolol
STOP: Nitroglycerin
CHANGE: Fluoxetine to 60mg daily

Followup Instructions:
You will be receiving a call with an appointment for next week
to come to the clinic and have your blood pressure checked and
go over your imaging tests. You will receive a call with this
appointment and if you do not you should call the clinic at
[**Telephone/Fax (1) 250**] to make an appointment.

Department: RADIOLOGY
When: MONDAY [**2129-4-25**] at 9:30 AM
With:  RADIOLOGY [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: HEMODIALYSIS
When: MONDAY [**2129-4-25**] at 7:30 AM



Completed by:[**2129-4-23**]
{'Hypotension of hemodialysis,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Complications of transplanted kidney,Opioid type dependence, continuous,Other antihypertensive agents causing adverse effects in therapeutic use,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified acquired hypothyroidism,Dysthymic disorder,Other chronic pain,Backache, unspecified,Chest pain, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Asthma, unspecified type, unspecified,Tobacco use disorder,Personal history of noncompliance with medical treatment, presenting hazards to health,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Thrombocytopenia, unspecified,Unspecified disorder of kidney and ureter,Other and unspecified ovarian cyst,Anemia in chronic kidney disease'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: hypotension

PRESENT ILLNESS: 56 yo W with ESRD on HD (MWF), HTN (last sBPs in 150s), HCV
cirrhosis, Hypothyroidism, Anxiety, chronic back pain on
methadone, presenting with systolic BPs in the 60s prior to and
during [**Hospital 58910**] transferred to [**Hospital Unit Name 153**] for evaluation and management of
hypotension.
.
She reports 1 month of increasing fatigue, weakness, and
occasional falls (knee buckling). Occasional cough with brown
sputum and chronic loose stools, but no fevers, chills, sweats,
dyspnea, nausea, vomiting, black or bloody stools. Regarding her
complaints, she reports that her BP medications have been
adjusted, but this has not helped. She has also experienced
intermittent L-sided sharp chest pains that worsen with arm
movement, and was prescribed nitroglycerin that she ended up
taking daily instead of on a PRN basis.
.
In the ED, initial vs were: T 97.4 P 69 BP 64/53 R 14 97% O2 sat
on RA. Per report, she was mentating appropriately. A triple
lumen femoral CVC was placed. She was bolused 500 cc, given
Vancomycin and Zosyn, and started on Levophed at 0.06. CXR was
unremarkable. CT C/A/P were obtained and prelim only significant
for a right adenexal cyst (present since [**Month (only) 404**]).
.
On the floor, the patient was appropriate and comfortable. She
was placed on a Nicom. CI and SVI improved with leg raise so Pt
was given 250 cc, then on repeat given additional 250 cc.
Levophed was weaned off.
.
Review of sytems: per HPI, otherwise negative

MEDICAL HISTORY: -HTN
-ESRD on hemodialysis
-HCV cirrhosis
-spinal stenosis with back pain
-seizure disorder
-depression
-hypothyroidism
-substance abuse
-Lumbar laminectomy
-status post failed renal transplant
-cholecystectomy
-thyroidectomy

MEDICATION ON ADMISSION: -Metoprolol succinate 25 daily
-Nitrostat PRN
-Simvastatin 20 daily
-ASA 81 daily
-Fluoxetine 40 daily
-Gabapentin 300 daily
-Lisinopril 2.5 daily
-Keppra 250 [**Hospital1 **]
-Folic acid 1 mg daily
-Sensipar 30 mg PRN
-Trazadone 50 qhs
-Omeprazole 20 daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: 97.6, 63, 133/86, 98% on RA
General: alert, oriented, no acute distress
HEENT: muddy sclera, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  soft, obese, +BS, TTP in RUQ with mild voluntary
guarding
GU: no foley
Ext: warm, well perfused, symmetric pulses, no clubbing,
cyanosis or edema, R hallux with nail bed removed, crusted
blood, no erythema or fluctuance, no purulence
Neuro: face symmetric, moves all extremities, sensation intact,
gait not observed

FAMILY HISTORY: Father: ESRD and hypertension
Mother: lung cancer

SOCIAL HISTORY: Retired special education teacher. Widowed, lives at home with
sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy.
# Tobacco: 3 packs per week since teenager
# Alcohol: Denies
# Drugs: Past IVDU, but not in several years 

### Response:
{'Hypotension of hemodialysis,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Complications of transplanted kidney,Opioid type dependence, continuous,Other antihypertensive agents causing adverse effects in therapeutic use,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified acquired hypothyroidism,Dysthymic disorder,Other chronic pain,Backache, unspecified,Chest pain, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Asthma, unspecified type, unspecified,Tobacco use disorder,Personal history of noncompliance with medical treatment, presenting hazards to health,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Thrombocytopenia, unspecified,Unspecified disorder of kidney and ureter,Other and unspecified ovarian cyst,Anemia in chronic kidney disease'}
