CHIEF COMPLAINT: hypotension

PRESENT ILLNESS: Mr. [**Known lastname 45124**] is a 66 yo male with h/p inflammatory spinal disease,
CHF with EF 30%, recurrent UTIs,who presented on [**2-17**] from neuro
clinic for hypotension. He was being seen in clinic for f/u
after recent admission for flaccid paraplegia of unclear
etiology. In clinic, he was hypotensive to 80/50, (baseline BP
is 90-100 with EF of 30%), tachycardic at 110, with a temp of 99
and a productive cough. In the ED, he was noted to be mildly
confused, with some bilateral asterixis.He had a positive UA and
a lactated of 1.7. He was given levaquin and vancomycin. His CXR
was clear and EKG was unremarkable. On the floor he triggered 3
times for hypotension. He as given several boluses for a total
of 3 liters and blood pressure continued to be in the 70s
systolics. His UOP was 800 cc overnight and mental status was
stable. Overnight, he received 3L IVF and SBP remained 80s-100s.
As he was HD stable w/o evidence for sepsis, he was transferred
to medicine the next morning. He was treated with continued IV
ABx (vanc/zosyn). As his paraperesis again became the largest
issue in his care, he was transferred to neurology on [**2-23**]. MRI
demonstrated pan spinal cord inflammation and he was felt to
possibly have a myelitis of inflammatory etiology vs AVM; CT
myelogram, CTA for AVM, and spinal cord biopsy were beign
considered. At midnight, his BP dropped from his recently bl of
90s-100s to 70/58; at 4AM it was 74/52, at 8AM 78/52 and 93/67 @
1600. His creatinine rose from .5 on [**2-24**] to 1.3 to 2 today.
Nephrology was consulted. They evaluated his urine and felt AIN
most likely. At this time, the patient reports that he is
thirsty and has some R shoulder discomfort, but denies chest
pain/tightness, SOB, n/v, diarrhea, BRBPR, melena. On arrival to
floor, I gave the patient a 500cc bolus which rose his pressure
to 100/60. Within 20 minutes, this was down to 80/p so LEJ was
placed, IVF run in, and he was taken to the SICU under the MICU
[**Location (un) 2452**] service. In the MICU, he had a marginal response to a
cosyntropin stim test, so he was started on fludrocortisone for
his hypotension. His antibiotics were stopped, as he had
completed 10 days of antibiotics directed at hospital acquired
PNA.

MEDICAL HISTORY: Inflammatory disease of the spinal cord
Right frontal lobe lesion
Abnormal visual evoked potentials
Status post brain biopsy of right frontal lobe lesion
Pulmonary embolus
Status post IVC filter placement
Asthma
Coronary artery disease
Status post liver surgery for liver laceration following stab
wound
Chronic back pain
Vitiligo

MEDICATION ON ADMISSION: 1. Montelukast 10 mg QD
2. Atorvastatin 20 mg QD
3. Senna 8.6 mg [**Hospital1 **]
4. Trazodone 50 mg QHS
5. Pantoprazole 40 mg Tablet [**Hospital1 **]
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch QD
7. Simethicone 80 mg TID
8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk [**Hospital1 **]
9. Acetaminophen 325 mg Q4-6H
10. Tizanidine 2 mg TID
11. Albuterol 90 mcg/Actuation 1-2 PUFFS
12. Gabapentin 300 mg TID
13. Insulin Regular Human 100 unit/mL Solution
14. Heparin (Porcine) 5,000 unit/mL SC TID
15. Lactulose 10 g/15 mL TID
16. Docusate Sodium 100 mg QD
17. Bisacodyl 10 mg Suppository [**Hospital1 **]
18. Metoprolol Tartrate 12.5MG QD
19. Miconazole Nitrate 2 % Powder
20. Warfarin 3 mg QHS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 98.4/98.2 97/70 96 18 100%OFM
General: elderly man, NAD, A+Ox3, cooperative, pleasant
Neck: supple, no LAD, no JVD
Head: OP clear
Chest: coarse breath sounds diffusely but no w/r/r
Cardiovascular: rrr, no m/g/r
Abdomen: soft, nt, nd, +BS, gtube clean
Extremities: LLE 1+pitting edema, RLE trace edema, both feet in
multipodous boot

FAMILY HISTORY: No stroke, aneurysm, no seizure, no AAA.

SOCIAL HISTORY: Patient lives alone and is divorced. Has 3 healthy children.
Retired due to back pain, used to work as [**Doctor Last Name 9808**] driver.
Unspecified causes of encephalitis, myelitis, and encephalomyelitis,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Acidosis,Pressure ulcer, lower back,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Hypoxemia,Infection and inflammatory reaction due to indwelling urinary catheter,Cellulitis and abscess of trunk,Other pulmonary embolism and infarction,Paralysis, unspecified,Asthma, unspecified type, unspecified,Constipation, unspecified,Personal history of venous thrombosis and embolism,Hypotension, unspecified,Gastrostomy status,Depressive disorder, not elsewhere classified
Encephalitis NOS,Urin tract infection NOS,CHF NOS,Acidosis,Pressure ulcer, low back,Pneumonia, organism NOS,Ac kidny fail, tubr necr,Hypoxemia,React-indwell urin cath,Cellulitis of trunk,Pulm embol/infarct NEC,Paralysis NOS,Asthma NOS,Constipation NOS,Hx-ven thrombosis/embols,Hypotension NOS,Gastrostomy status,Depressive disorder NEC
Admission Date:  [**2105-2-17**]              Discharge Date:   [**2105-3-5**]

Date of Birth:  [**2038-4-1**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hypotension

Major Surgical or Invasive Procedure:
Wound vac placement


History of Present Illness:
Mr. [**Known lastname 45124**] is a 66 yo male with h/p inflammatory spinal disease,
CHF with EF 30%, recurrent UTIs,who presented on [**2-17**] from neuro
clinic for hypotension. He was being seen in clinic for f/u
after recent admission for flaccid paraplegia of unclear
etiology. In clinic, he was hypotensive to 80/50, (baseline BP
is 90-100 with EF of 30%), tachycardic at 110, with a temp of 99
and a productive cough. In the ED, he was noted to be mildly
confused, with some bilateral asterixis.He had a positive UA and
a lactated of 1.7. He was given levaquin and vancomycin. His CXR
was clear and EKG was unremarkable. On the floor he triggered 3
times for hypotension. He as given several boluses for a total
of 3 liters and blood pressure continued to be in the 70s
systolics. His UOP was 800 cc overnight and mental status was
stable. Overnight, he received 3L IVF and SBP remained 80s-100s.
As he was HD stable w/o evidence for sepsis, he was transferred
to medicine the next morning. He was treated with continued IV
ABx (vanc/zosyn). As his paraperesis again became the largest
issue in his care, he was transferred to neurology on [**2-23**]. MRI
demonstrated pan spinal cord inflammation and he was felt to
possibly have a myelitis of inflammatory etiology vs AVM; CT
myelogram, CTA for AVM, and spinal cord biopsy were beign
considered. At midnight, his BP dropped from his recently bl of
90s-100s to 70/58; at 4AM it was 74/52, at 8AM 78/52 and 93/67 @
1600. His creatinine rose from .5 on [**2-24**] to 1.3 to 2 today.
Nephrology was consulted. They evaluated his urine and felt AIN
most likely. At this time, the patient reports that he is
thirsty and has some R shoulder discomfort, but denies chest
pain/tightness, SOB, n/v, diarrhea, BRBPR, melena. On arrival to
floor, I gave the patient a 500cc bolus which rose his pressure
to 100/60. Within 20 minutes, this was down to 80/p so LEJ was
placed, IVF run in, and he was taken to the SICU under the MICU
[**Location (un) 2452**] service. In the MICU, he had a marginal response to a
cosyntropin stim test, so he was started on fludrocortisone for
his hypotension. His antibiotics were stopped, as he had
completed 10 days of antibiotics directed at hospital acquired
PNA.

Past Medical History:
Inflammatory disease of the spinal cord
Right frontal lobe lesion
Abnormal visual evoked potentials
Status post brain biopsy of right frontal lobe lesion
Pulmonary embolus
Status post IVC filter placement
Asthma
Coronary artery disease
Status post liver surgery for liver laceration following stab
wound
Chronic back pain
Vitiligo


Social History:
Patient lives alone and is divorced. Has 3 healthy children.
Retired due to back pain, used to work as [**Doctor Last Name 9808**] driver.


Family History:
No stroke, aneurysm, no seizure, no AAA.

Physical Exam:
98.4/98.2 97/70 96 18 100%OFM
General: elderly man, NAD, A+Ox3, cooperative, pleasant
Neck: supple, no LAD, no JVD
Head: OP clear
Chest: coarse breath sounds diffusely but no w/r/r
Cardiovascular: rrr, no m/g/r
Abdomen: soft, nt, nd, +BS, gtube clean
Extremities: LLE 1+pitting edema, RLE trace edema, both feet in
multipodous boot


Pertinent Results:
[**2105-2-17**] 01:40PM BLOOD WBC-7.6 RBC-4.27* Hgb-13.4* Hct-39.0*
MCV-91 MCH-31.5 MCHC-34.4 RDW-15.4 Plt Ct-422#
[**2105-3-4**] 07:00AM BLOOD WBC-6.3 RBC-3.09* Hgb-9.5* Hct-28.2*
MCV-91 MCH-30.8 MCHC-33.7 RDW-15.4 Plt Ct-258
[**2105-2-17**] 01:40PM BLOOD Neuts-67.9 Lymphs-22.2 Monos-7.6 Eos-1.9
Baso-0.3
[**2105-2-27**] 04:00AM BLOOD Neuts-71.2* Lymphs-18.4 Monos-8.5 Eos-1.4
Baso-0.5
[**2105-2-17**] 01:40PM BLOOD PT-27.8* PTT-31.5 INR(PT)-2.9*
[**2105-2-20**] 03:00PM BLOOD PT-47.5* PTT-36.9* INR(PT)-5.5*
[**2105-3-4**] 07:00AM BLOOD PT-26.2* PTT-63.3* INR(PT)-2.7*
[**2105-2-18**] 01:23PM BLOOD Fibrino-576*#
[**2105-2-18**] 08:52PM BLOOD ESR-70*
[**2105-2-17**] 01:40PM BLOOD Glucose-103 UreaN-13 Creat-0.5 Na-139
K-4.2 Cl-104 HCO3-25 AnGap-14
[**2105-2-26**] 05:24AM BLOOD Glucose-95 UreaN-16 Creat-2.0* Na-138
K-3.6 Cl-105 HCO3-28 AnGap-9
[**2105-3-4**] 07:00AM BLOOD Glucose-119* UreaN-13 Creat-1.6* Na-141
K-3.9 Cl-107 HCO3-27 AnGap-11
[**2105-2-18**] 08:52PM BLOOD ALT-22 AST-13 CK(CPK)-42 AlkPhos-90
TotBili-0.3
[**2105-2-24**] 05:05AM BLOOD ALT-12 AST-10 AlkPhos-88 Amylase-77
TotBili-0.4
[**2105-2-23**] 05:25AM BLOOD Lipase-15
[**2105-2-17**] 01:40PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2105-2-26**] 05:24AM BLOOD CK-MB-2 cTropnT-0.10*
[**2105-2-26**] 05:32PM BLOOD CK-MB-6 cTropnT-0.22*
[**2105-2-27**] 04:00AM BLOOD CK-MB-4 cTropnT-0.07*
[**2105-2-18**] 05:51AM BLOOD Calcium-8.2* Phos-4.0 Mg-1.8
[**2105-2-26**] 05:24AM BLOOD Calcium-8.2* Phos-4.7* Mg-2.1
[**2105-3-4**] 07:00AM BLOOD Calcium-8.1* Phos-4.4 Mg-1.7
[**2105-2-18**] 01:32PM BLOOD Hapto-155
[**2105-2-18**] 05:51AM BLOOD TSH-1.4
[**2105-2-18**] 05:51AM BLOOD Cortsol-9.3
[**2105-2-18**] 05:31PM BLOOD Cortsol-16.7
[**2105-2-18**] 05:58PM BLOOD Cortsol-25.6*
[**2105-2-26**] 05:32PM BLOOD Cortsol-16.2
[**2105-2-26**] 10:40PM BLOOD Cortsol-23.9*
[**2105-2-26**] 11:08PM BLOOD Cortsol-20.0
[**2105-2-27**] 04:24AM BLOOD Vanco-31.7*
[**2105-2-28**] 04:13AM BLOOD Vanco-22.3*
[**2105-2-17**] 01:42PM BLOOD Lactate-1.7
[**2105-2-26**] 08:16PM BLOOD Lactate-1.7
.
[**2105-2-18**] 10:41 am SWAB      Source: Sacral ulcer.
SENSITIVITIES: MIC expressed in MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
VANCOMYCIN------------   <=1 S

   ANAEROBIC CULTURE (Final [**2105-2-22**]):    NO ANAEROBES ISOLATED.

.
CHEST (PA & LAT)  [**2105-2-17**] 2:15 PM
No acute cardiopulmonary disease. Mild hyperinflation suggestive
of COPD.
.
ECG Study Date of [**2105-2-17**]  1:30:52 PM
Resting sinus tachycardia. Prior inferior wall myocardial
infarction. Ppossible prior anterior wall myocardial infarction.
Non-specific ST-T wave changes. Compared to the previous tracing
of [**2104-11-26**], allowing for lead placement variation, no
diagnostic change.
.
MR L SPINE WITH CONTRAST  [**2105-2-20**] 3:15 AM
MR [**Name13 (STitle) **] SCAN WITH CONTRAST; MR T SPINE SCAN WITH CONTRAST
1. Since [**2104-11-4**], marked worsening of the expansion and edema of
the thoracic cord now extending from the T2 level down to the
conus with some subtle patchy areas of enhancement at the T9/10
level and at the conus. These findings may represent a primary
tumor of the cord such as an ependymoma, though the relative
lack of enhancement would be atypical, or astrocytoma. Other
possibilities would include a demyelinating/inflammatory process
such as MS or an infectious process such as tropical spastic
paraparesis (HAM/TSP). 2. Multilevel degenerative changes as
described above but without high-grade canal stenosis.
.
CHEST (PORTABLE AP)  [**2105-3-2**] 11:42 AM
No acute cardiopulmonary process. No evidence of pneumonia.
.
RENAL U.S.  [**2105-2-27**] 2:15 PM
Increased echogenicity of both kidneys, possibly due to acute
renal parenchymal disease. Unchanged left renal cyst.
.
CT CHEST W/O CONTRAST  [**2105-3-2**] 4:39 PM
1. Septal thickening at the lung bases and small right pleural
effusion, consistent with hydrostatic pulmonary edema. Dependent
ground glass opacity in right lower lobe is likely due to a
combination of dependent atelectasis and minimal edema. No areas
of consolidation to suggest acute infectious pneumonia. 2. Right
middle lobe nodule is unchanged since [**2104-10-10**] and most
likely benign. However, if there is a concern for metastatic
disease or risk factor for primary lung cancer, then a followup
CT in [**2105-10-10**] may be helpful to ensure stability.
.
ECHO Study Date of [**2105-2-27**]
1.The left atrium is mildly dilated. 2. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is moderate to severe regional left ventricular
systolic dysfunction with XXX. No masses or thrombi are seen in
the left ventricle. 3. Right ventricular chamber size is normal.
4.The aortic root is moderately dilated athe sinus level. The
aortic arch is mildly dilated. 5.The aortic valve leaflets (3)
are mildly thickened. No aortic regurgitation seen. 6.The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. 7.There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2104-11-4**], no significant change. The previous assessment of
LV function was probably an overestimate.

Brief Hospital Course:
66 year old male with hx of inflammatory spinal disease, EF 30%,
recurrent UTIs, presents from neuro clinic for hypotension,
low-grade fever, cough, UTI.
.
# Hypotension/fevers:
Unclear etiology. He was transferred to the MICU twice for
recurrent hypotension, each time responding to IVF boluses.
Differential included hypovolemia (possibly [**3-13**] Hct drop).
Sepsis also possible given pseudomonas UTI during previous
admission, although no leukocytosis, normal differential,
afebrile since admission; alternative source included decub
sacral ulcer which grew MRSA. Cardiogenic shock less likely
given exam findings, no ECG changes, and troponins elevated only
in setting of acute renal failure. Concern for adrenal
insufficiency given history of corticosteroid exposure,
hypotension, low AM cortisol level, and elevated eosinophil
count. Briefly placed on fludricortisone during second MICU
course. Lactate of 1.7 made sepsis less likely and he had been
afebrile since completing 10 day course of vanc/zosyn for ?
HAP/UTI. Midodrine was considered by neurology but never
administered as BP responded to IVF during each hypotensive
episode. Currently hemodynamically stable, continuing to mentate
with good urine output. Outpatient beta blocker and ACEi were
held secondary to hypotension and renal failure and should be
restarted outpatient once BP appears to be stable and renal
function back to baseline normal.
.
# Acute renal failure:
Pt had gradual increase in creatnine from baseline Cr 0.5-0.7 to
peak of 2.0 from [**2-24**] to [**2-26**]. It has been trending down since
then and now remaining stable at 1.6. Urine negative for
eosinophils. Urine lytes consistent with intrinsic failure. UA
showed many wbc with clumps of wbc. In addition he had
peripheral eosinophilia for the past 2 days, likely interstitial
nephritis. Renal ultrasound revealed increased echogenicity of
both kidneys, possibly due to acute renal parenchymal disease
from AIN and WBC's in urine sediment. [**Month (only) 116**] also has a component
of prerenal due to decrease renal perfusion from hypotension and
volume contraction from decreased PO intake and many BM/day.
However, etiology may also be ATN [**3-13**] contrast nephropathy. Now
in polyuric phase with downward trending creatinine, will
continue to follow. Avoid nephrotoxins, renally dose
medications.
.
# CHF:
EF 30%, euvolemic. Unclear why patient not on afterload
reduction. Monitored I/O's for goal of even post fluid
resuscitation. Will continue to hold lopresser.
.
# Cough:
Pt with increased cough over past week, productive with clear
and occasional yellow sputum. Repeat CXR [**2-18**] negative for
infiltrates. Oxygen saturations stable on RA. Symptomatic
treatment with nebs/expectorant/cough suppresant.
.
# Hypoxia:
Baseline asthma, which has been stable throughout this hospital
course. Serial CXR's have been very clear with no evidence of
infiltrate or edema. Lung exam, however, noted to be markedly
worsened on [**3-2**] but again no evidence of infiltrate on CXR. CT
chest scan revealed Septal thickening at the lung bases and
small right pleural effusion, consistent with hydrostatic
pulmonary edema. Dependent ground glass opacity in right lower
lobe is likely due to a combination of dependent atelectasis and
minimal edema. Continue albuterol, advair, nebs, montelukast.
Continue incentive spirometry. Monitor respiratory status
closely.
.
# Hx of UTI:
Patient had a urinary tract infection on [**11-21**] associated with
foley and completed a 7 day course of Ciprofloxacin.
Pansensitive Pseudomonas aeruginosa grew from urine culture. Pt
was unable to perform self-cath due to lack of sensation below
T8. He has remained with indwelling foley. This has contributed
to recurrent UTIs. U/A positive on admission, started on
antibiotics. Switched from cipro to vanco/zosyn post trigger for
low BP, concern for urosepsis.
.
# Constipation:
On aggressive bowel regimen, along with daily lactulose and prn
golytely.
.
# Hx of DVT/PE:
PE and DVT (L superficial femoral) diagnosed in [**10-15**]. Patient
anticoagulated on coumadin, plus IVC filter. Found to have a
large DVT and asymptomatic pulmonary embolus. This was likely
due to immobility and stasis. IVC filter placed under IR on
[**11-24**] for unclear reasons. This was during the same
hospitalization and not clearly secondary to failure through
anticoagulation. INR therapeutic on coumadin increased, likely
from receiving ciprofloxacin on admission. Coumadin was held,
vitamin K was administered, and coumadin was later restarted
with heparin bridge until INR was therapeutic again.
.
# Inflammatory/demyelinating disease:
Pt presented in [**10-15**] with lower extremity weakness which
progressed to paralysis below T8 level during hospital stay. MRI
concerning for demyelinating disease. No improvement with
prolonged steroid course during previous admission. Repeat MRI
during current hospital course revealed expanding inflammatory
cord disease of unknown etiology (? demyelination vs. tumor vs.
AVM). RPR negative, lyme negative, ESR 70/CRP 66.8, [**Doctor First Name **]
negative. ACE wnl and neuromyelitis IgG negative. Ro and La
negative. Further work-up such as biopsy, spinal CTA deferred at
this time due to above acute issues. Appears to be MS variant
based on visual evoked potentials during prior admission,
however, no general consensus on disease process. On tizanidine
4 TID and Neurontin 600 QID. Neurology will followup with
further workup outpatient.
.
# Stage IV sacral decubitus ulcer:
Pt has large decub ulcer measuring 8x10cm in middle of sacrum
extending to bone in some areas. This is concerning for
infection including osteomyeltitis given his presentation with
low BP and fevers. Wound swab culture grew MRSA. Plastics placed
wound vacm, to be changed every 3 days. Recommend WTD dressings
[**Hospital1 **], kinair bed, frequent rotations. On MVI, Zinc, Vit C & tube
feeds for wound healing.
.
# FEN: cardiac diet
Poor PO intake, only taking sips. Continue supplementing diet
with tube feeds via PEG. On aspiration precautions.
.
# Prophylaxis: bowel regimen, ppi
.
# Code: FULL
Revisited during ICU course, Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] with the Palliative
Care service following as needed, patient states "I want to keep
on living."
.
# Communication: PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10145**], [**Telephone/Fax (1) 10573**]
.
# Dispo:
Followup with PCP for further medical management, [**Hospital1 18**] Plastic
Surgery, and [**Hospital1 18**] Neurology. DC to rehab.

Medications on Admission:
1. Montelukast 10 mg QD
2. Atorvastatin 20 mg QD
3. Senna 8.6 mg [**Hospital1 **]
4. Trazodone 50 mg QHS
5. Pantoprazole 40 mg Tablet [**Hospital1 **]
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch QD
7. Simethicone 80 mg TID
8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk [**Hospital1 **]
9. Acetaminophen 325 mg Q4-6H
10. Tizanidine 2 mg TID
11. Albuterol 90 mcg/Actuation 1-2 PUFFS
12. Gabapentin 300 mg TID
13. Insulin Regular Human 100 unit/mL Solution
14. Heparin (Porcine) 5,000 unit/mL SC TID
15. Lactulose 10 g/15 mL TID
16. Docusate Sodium 100 mg QD
17. Bisacodyl 10 mg Suppository [**Hospital1 **]
18. Metoprolol Tartrate 12.5MG QD
19. Miconazole Nitrate 2 % Powder
20. Warfarin 3 mg QHS

Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.

12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q4H (every 4 hours) as needed for cough.
14. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4-6H (every 4 to 6
hours) as needed.
15. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

17. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
18. Hexavitamin     Tablet Sig: Five (5) ML PO DAILY (Daily).
19. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
20. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
21. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
22. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
23. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
24. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
Q2H (every 2 hours) as needed for cough.
25. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
PRIMARY DIAGNOSES:
Paraparesis (unclear etiology)
Autonomic hypotension
Stage IV sacral decubitus ulcer
.
SECONDARY DIAGNOSES:
Right frontal lobe lesion s/p brain biopsy
Abnormal visual evoked potentials
h/p pulmonary embolus s/p IVC filter
Asthma
CAD s/p CABG ([**2100**]; LIMA->LAD, SVG->D1)
CHF (EF 25-30%)
s/p liver surgery for liver laceration following stab wound
Chronic back pain
Vitiligo
Indwelling foley catheter with recurrent UTIs
Decubitus ulcer
Altered mental status
(per OSH note: baseline "alert with periods of confusion")

Discharge Condition:
Stable.


Discharge Instructions:
You were admitted for low blood pressure and suspected
infection. Your low BP responded to fluids after being
transferred to the ICU multiple times, but no definitive soruce
of infection was found. It was thought that your neurological
disorder that resulted in leg paralysis during previous
admission may be contributing to your low blood pressure.
.
Please take all medications as prescribed. Call your PCP or
return to the ED if you experience fevers, chills, shortness of
breath, chest pain, lightheadedness, dizziness, low blood
pressure, nausea, vomiting.

Followup Instructions:
Please have INR level checked regularly to ensure its within
therapeutic range.
.
PLASTIC SURGERY CLINIC
Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2105-3-27**] 1:30
.
Please followup with your PCP [**Last Name (NamePattern4) **] 1 week for further medical
management, call number below to make an appointment:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD @[**Hospital1 18**] Neurology
Phone:[**Telephone/Fax (1) 5434**] Date/Time:[**2105-4-10**] 11:30


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
{'Unspecified causes of encephalitis, myelitis, and encephalomyelitis,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Acidosis,Pressure ulcer, lower back,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Hypoxemia,Infection and inflammatory reaction due to indwelling urinary catheter,Cellulitis and abscess of trunk,Other pulmonary embolism and infarction,Paralysis, unspecified,Asthma, unspecified type, unspecified,Constipation, unspecified,Personal history of venous thrombosis and embolism,Hypotension, unspecified,Gastrostomy status,Depressive disorder, not elsewhere classified'}


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: Mr. [**Known lastname 45124**] is a 66 yo male with h/p inflammatory spinal disease,
CHF with EF 30%, recurrent UTIs,who presented on [**2-17**] from neuro
clinic for hypotension. He was being seen in clinic for f/u
after recent admission for flaccid paraplegia of unclear
etiology. In clinic, he was hypotensive to 80/50, (baseline BP
is 90-100 with EF of 30%), tachycardic at 110, with a temp of 99
and a productive cough. In the ED, he was noted to be mildly
confused, with some bilateral asterixis.He had a positive UA and
a lactated of 1.7. He was given levaquin and vancomycin. His CXR
was clear and EKG was unremarkable. On the floor he triggered 3
times for hypotension. He as given several boluses for a total
of 3 liters and blood pressure continued to be in the 70s
systolics. His UOP was 800 cc overnight and mental status was
stable. Overnight, he received 3L IVF and SBP remained 80s-100s.
As he was HD stable w/o evidence for sepsis, he was transferred
to medicine the next morning. He was treated with continued IV
ABx (vanc/zosyn). As his paraperesis again became the largest
issue in his care, he was transferred to neurology on [**2-23**]. MRI
demonstrated pan spinal cord inflammation and he was felt to
possibly have a myelitis of inflammatory etiology vs AVM; CT
myelogram, CTA for AVM, and spinal cord biopsy were beign
considered. At midnight, his BP dropped from his recently bl of
90s-100s to 70/58; at 4AM it was 74/52, at 8AM 78/52 and 93/67 @
1600. His creatinine rose from .5 on [**2-24**] to 1.3 to 2 today.
Nephrology was consulted. They evaluated his urine and felt AIN
most likely. At this time, the patient reports that he is
thirsty and has some R shoulder discomfort, but denies chest
pain/tightness, SOB, n/v, diarrhea, BRBPR, melena. On arrival to
floor, I gave the patient a 500cc bolus which rose his pressure
to 100/60. Within 20 minutes, this was down to 80/p so LEJ was
placed, IVF run in, and he was taken to the SICU under the MICU
[**Location (un) 2452**] service. In the MICU, he had a marginal response to a
cosyntropin stim test, so he was started on fludrocortisone for
his hypotension. His antibiotics were stopped, as he had
completed 10 days of antibiotics directed at hospital acquired
PNA.

MEDICAL HISTORY: Inflammatory disease of the spinal cord
Right frontal lobe lesion
Abnormal visual evoked potentials
Status post brain biopsy of right frontal lobe lesion
Pulmonary embolus
Status post IVC filter placement
Asthma
Coronary artery disease
Status post liver surgery for liver laceration following stab
wound
Chronic back pain
Vitiligo

MEDICATION ON ADMISSION: 1. Montelukast 10 mg QD
2. Atorvastatin 20 mg QD
3. Senna 8.6 mg [**Hospital1 **]
4. Trazodone 50 mg QHS
5. Pantoprazole 40 mg Tablet [**Hospital1 **]
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch QD
7. Simethicone 80 mg TID
8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk [**Hospital1 **]
9. Acetaminophen 325 mg Q4-6H
10. Tizanidine 2 mg TID
11. Albuterol 90 mcg/Actuation 1-2 PUFFS
12. Gabapentin 300 mg TID
13. Insulin Regular Human 100 unit/mL Solution
14. Heparin (Porcine) 5,000 unit/mL SC TID
15. Lactulose 10 g/15 mL TID
16. Docusate Sodium 100 mg QD
17. Bisacodyl 10 mg Suppository [**Hospital1 **]
18. Metoprolol Tartrate 12.5MG QD
19. Miconazole Nitrate 2 % Powder
20. Warfarin 3 mg QHS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 98.4/98.2 97/70 96 18 100%OFM
General: elderly man, NAD, A+Ox3, cooperative, pleasant
Neck: supple, no LAD, no JVD
Head: OP clear
Chest: coarse breath sounds diffusely but no w/r/r
Cardiovascular: rrr, no m/g/r
Abdomen: soft, nt, nd, +BS, gtube clean
Extremities: LLE 1+pitting edema, RLE trace edema, both feet in
multipodous boot

FAMILY HISTORY: No stroke, aneurysm, no seizure, no AAA.

SOCIAL HISTORY: Patient lives alone and is divorced. Has 3 healthy children.
Retired due to back pain, used to work as [**Doctor Last Name 9808**] driver. 

### Response:
{'Unspecified causes of encephalitis, myelitis, and encephalomyelitis,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Acidosis,Pressure ulcer, lower back,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Hypoxemia,Infection and inflammatory reaction due to indwelling urinary catheter,Cellulitis and abscess of trunk,Other pulmonary embolism and infarction,Paralysis, unspecified,Asthma, unspecified type, unspecified,Constipation, unspecified,Personal history of venous thrombosis and embolism,Hypotension, unspecified,Gastrostomy status,Depressive disorder, not elsewhere classified'}
