CHIEF COMPLAINT: Fatigue

PRESENT ILLNESS: Mrs. [**Known lastname 6314**] is a 70 yo female with MMP, including CHF with EF
30-35%,including PEG tube for achalasia & esophagitis,
osteoporosis c/b compression fractures, and pituitary adenoma
s/p radiation (last treatment [**2161-5-26**]) who presented from rehab
w/ lethargy and fatigue. Patient is a poor historian and is only
oriented to person and place. Complains only of back pain which
she reports having for months. Denies CP, SOB, cough, abd pain,
N/V, diarrhea, BRBPR, dizziness. Per written records & pt's
brother report, patient had MI on [**5-27**] with a CK-MB of 7.[**Street Address(2) 27038**] elevations in V1-V3 per record but no labs or EKGs sent from
rehab. Per rehab records, patient was on fluid restriction x24
hours on [**6-4**], then given lasix 100mg IV BID which was decreased
to daily and was continued on fluid restriction of 1 liter.
.
In the ED, T 97.8, HR 94, BP 94/64 RR 24 96 % RA. She received 1
liter NS and levofloxacin 500 mg IV x1.
.
On the wards, pt found to have UTI (though UA notable only for
[**3-16**] RBC & postive nitrites, only 0-2WBC). Urine cx growing
Klebsiella & other unidentified gram (-) rod. She was tx'd w/
levo. Her SBP trended down from 90s-110s to 80s. Was initially
responsive to IVF then non-responsive to it. She received >3.3:
(was 2.5L (+)) over 24hr. She had low grade fevers ~99.8 and was
reportedly more tired appearing, "less perky." Abx broadened to
ceftaz & vanc. Again, pt w/o complaints. Reports feeling like
usual self.

MEDICAL HISTORY: 1. Coronary artery disease with history of V. fib arrest, S/P
LAD stent and repeat cath in [**10/2159**] The LAD had patent stnets
with
50-60% proximal moderate instent restenosis. and Left
ventriculography demonstrated extensive anteroapical and
inferoapical akinesis and aneurysm with a contrast calculated
ejection fraction of 26%. There was no mitral regurgitation.
2. CHF - EF 30-35% in [**2159**].
3. Osteoporosis - early menopause, no history of hip fractures
but verterbral compression fractures noted earlier this month.
4. Depression
5. History of colonic AVM and anemia of chronic blood loss
6. S/P Appendectomy
7. Hypertension
8. H/o achalasia, peptic stricture at EG junction
9. h/o TAH and bilateral oopherectomy in her 30s
10. Admission [**3-18**] for melena found to have Dilation at the
lower third of the esophagus Grade 4 esophagitis in the lower
third of the esophagus
11. s/p G tube placement
12. Per written records patient had MI on [**5-27**] with a CK-MB of
7.[**Street Address(2) 27039**] elevations in V1-V3 per record but no labs or EKGs
sent

MEDICATION ON ADMISSION: Remeron 7.5 mg Po QHS
Zofran 4 mg IV Q6H
Nitro paste 1inch Q6H, hold for SBP<90
Senna 2 tabs per Gtube [**Hospital1 **]
Colace 100 mg GT TID
Fentanyl patch 100 mg TP Q72 hours
Simvastatin 40 mg po QD
Ferrous sulfate 325 mg po QD
Reglans 10 mg via GT QD
Fragmin 5000 units sc Q12H
Plavix 75 mg PO QD
Lopressor 12.5 mg via GT TOD
Cymbalta 30 mg via GT QD
Aldactone 50 mg via GT [**Hospital1 **] (increased from 25 mg on [**6-5**])
Lidoderm patch to upper middle back Q12H on and off
Potassium 20 [**Female First Name (un) **] via GT [**Hospital1 **]
Zaroxalyn 2.5 mg via G tube Qdaily
Perative 50 cc hr 7pm-7am and oerative 40 cc/hr 7am-7pm

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: 99.8 BP: 90/50 P: 88 RR: 18 O2 sats: 100 % on 2L
Gen: cachetic appearing elderly female in NAD
HEENT: MM mildly dry, OP clear
Neck: no Cervical LAD, no JVD
CV: RR, no m/g/r
Resp: decreased BS w/ bibasilar crackles R>L
Abd: G tube in place, site c/d/i; hypoactive BS, soft, NT/ND
Back: lidoderm patch in place, mild tendernness to palpation of
mid back, kyphotic
GU: foley in place
Ext: no edema, no calf tenderness, 2+ rad pulses b/l; PICC in L
arm
Neuro: Oriented to person and hospital but not date. Mild L
facial droop. CN II-XII grossly intact, strength in b/l UE and
LE [**4-16**] and symmetric, sensation to light touch intact

FAMILY HISTORY: FHx - multiple members in the family with who has had early TAH
and bilateral oopherectomy

SOCIAL HISTORY: Soc: Patient lives with her brother and sister-in-law.  She has
60 pack-year tobacco history but quit 20 yrs ago; denies EtoH
and drug use
Hypoxemia,Facial weakness,Gastrostomy status,Severe sepsis,Other septicemia due to gram-negative organisms,Subendocardial infarction, initial episode of care,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Hyposmolality and/or hyponatremia,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Septic shock,Other primary cardiomyopathies,Hemorrhage of gastrointestinal tract, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Benign neoplasm of pituitary gland and craniopharyngeal duct,Achalasia and cardiospasm,Osteoporosis, unspecified,Leukocytosis, unspecified,Kyphosis (acquired) (postural),Iron deficiency anemia, unspecified,Percutaneous transluminal coronary angioplasty status
Hypoxemia,Facial weakness,Gastrostomy status,Severe sepsis,Gram-neg septicemia NEC,Subendo infarct, initial,Urin tract infection NOS,CHF NOS,Hyposmolality,Klebsiella pneumoniae,Septic shock,Prim cardiomyopathy NEC,Gastrointest hemorr NOS,Crnry athrscl natve vssl,Hypertension NOS,Benign neo pituitary,Achalasia & cardiospasm,Osteoporosis NOS,Leukocytosis NOS,Kyphosis NOS,Iron defic anemia NOS,Status-post ptca
Admission Date:  [**2161-6-8**]              Discharge Date:   [**2161-6-25**]

Date of Birth:  [**2091-5-12**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
Fatigue

Major Surgical or Invasive Procedure:
1. PICC line placement


History of Present Illness:
Mrs. [**Known lastname 6314**] is a 70 yo female with MMP, including CHF with EF
30-35%,including PEG tube for achalasia & esophagitis,
osteoporosis c/b compression fractures, and pituitary adenoma
s/p radiation (last treatment [**2161-5-26**]) who presented from rehab
w/ lethargy and fatigue. Patient is a poor historian and is only
oriented to person and place. Complains only of back pain which
she reports having for months. Denies CP, SOB, cough, abd pain,
N/V, diarrhea, BRBPR, dizziness. Per written records & pt's
brother report, patient had MI on [**5-27**] with a CK-MB of 7.[**Street Address(2) 27038**] elevations in V1-V3 per record but no labs or EKGs sent from
rehab. Per rehab records, patient was on fluid restriction x24
hours on [**6-4**], then given lasix 100mg IV BID which was decreased
to daily and was continued on fluid restriction of 1 liter.
.
In the ED, T 97.8, HR 94, BP 94/64 RR 24 96 % RA. She received 1
liter NS and levofloxacin 500 mg IV x1.
.
On the wards, pt found to have UTI (though UA notable only for
[**3-16**] RBC & postive nitrites, only 0-2WBC). Urine cx growing
Klebsiella & other unidentified gram (-) rod. She was tx'd w/
levo. Her SBP trended down from 90s-110s to 80s. Was initially
responsive to IVF then non-responsive to it. She received >3.3:
(was 2.5L (+)) over 24hr. She had low grade fevers ~99.8 and was
reportedly more tired appearing, "less perky." Abx broadened to
ceftaz & vanc. Again, pt w/o complaints. Reports feeling like
usual self.


Past Medical History:
1. Coronary artery disease with history of V. fib arrest, S/P
LAD stent and repeat cath in [**10/2159**] The LAD had patent stnets
with
50-60% proximal moderate instent restenosis. and Left
ventriculography demonstrated extensive anteroapical and
inferoapical akinesis and aneurysm with a contrast calculated
ejection fraction of 26%. There was no mitral regurgitation.
2. CHF - EF 30-35% in [**2159**].
3. Osteoporosis - early menopause, no history of hip fractures
but verterbral compression fractures noted earlier this month.
4. Depression
5. History of colonic AVM and anemia of chronic blood loss
6. S/P Appendectomy
7. Hypertension
8. H/o achalasia, peptic stricture at EG junction
9. h/o TAH and bilateral oopherectomy in her 30s
10. Admission [**3-18**] for melena found to have Dilation at the
lower third of the esophagus Grade 4 esophagitis in the lower
third of the esophagus
11. s/p G tube placement
12. Per written records patient had MI on [**5-27**] with a CK-MB of
7.[**Street Address(2) 27039**] elevations in V1-V3 per record but no labs or EKGs
sent


Social History:
Soc: Patient lives with her brother and sister-in-law.  She has
60 pack-year tobacco history but quit 20 yrs ago; denies EtoH
and drug use


Family History:
FHx - multiple members in the family with who has had early TAH
and bilateral oopherectomy

Physical Exam:
T: 99.8 BP: 90/50 P: 88 RR: 18 O2 sats: 100 % on 2L
Gen: cachetic appearing elderly female in NAD
HEENT: MM mildly dry, OP clear
Neck: no Cervical LAD, no JVD
CV: RR, no m/g/r
Resp: decreased BS w/ bibasilar crackles R>L
Abd: G tube in place, site c/d/i; hypoactive BS, soft, NT/ND
Back: lidoderm patch in place, mild tendernness to palpation of
mid back, kyphotic
GU: foley in place
Ext: no edema, no calf tenderness, 2+ rad pulses b/l; PICC in L
arm
Neuro: Oriented to person and hospital but not date. Mild L
facial droop. CN II-XII grossly intact, strength in b/l UE and
LE [**4-16**] and symmetric, sensation to light touch intact


Pertinent Results:
[**2161-6-17**] 05:50AM BLOOD WBC-12.9* RBC-3.41* Hgb-9.2* Hct-27.2*
MCV-80* MCH-26.8* MCHC-33.6 RDW-21.2* Plt Ct-321
[**2161-6-12**] 05:07AM BLOOD Neuts-93.2* Bands-0 Lymphs-3.9* Monos-2.7
Eos-0.1 Baso-0.1
[**2161-6-12**] 05:07AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-1+ Stipple-2+
[**2161-6-17**] 05:50AM BLOOD Plt Ct-321
[**2161-6-17**] 05:50AM BLOOD Glucose-93 UreaN-15 Creat-0.4 Na-135
K-4.4 Cl-105 HCO3-22 AnGap-12
[**2161-6-16**] 04:17PM BLOOD CK(CPK)-59
[**2161-6-16**] 04:17PM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2161-6-16**] 02:52AM BLOOD Calcium-8.1* Phos-1.4* Mg-2.0
[**2161-6-17**] 05:50AM BLOOD Vanco-10.0
[**2161-6-14**] 01:05AM BLOOD Lactate-1.0

Brief Hospital Course:
70 yo female with CAD, CHF, achalasia w/ PEG tube, pituitary
adenoma s/p recent XRT, s/p klebsiella and steotrophomonas UTI
and GPC bacteremia, flash pulmonary edema, probable ACS event,
and L facial droop c/w ischemic stroke.
.
On the wards, pt found to have UTI (though UA notable only for
[**3-16**] RBC & postive nitrites, only 0-2WBC). Urine cx grew
pansensitive Klebsiella & Stenotrophomonas sensitive to Bactrim.
She was tx'd w/ levo. Her SBP trended down from 90s-110s to 80s
which was initially responsive to IVF and then unresponsive. She
received >3.3L IVF in 24 hours (was 2.5L (+)). She had low grade
fevers ~99.8 and was reportedly more tired appearing, "less
perky" but was without complaints. Abx broadened to ceftaz &
vanc. Given concern for potential early urosepsis patient was
transferred to the MICU for further management on [**2161-6-12**].
In the MICU, blood cultures from [**6-12**] grew out pansensitive
enterococcus as did her PICC tip. Source of her bacteremia
unclear.   She was continued on vanco, ceftaz, and flagyl (?
aspiration on CTA chest) as well as Bactrim for
stenotrophomonas. She had intermittent hypoxia thought to be due
to CHF and pulm edema which was responsive to prn lasix. Also
received short course of CPAP. Also intermittent hypotension
responsive to IVF and holding of BP meds. Ddx sepsis vs.
cardiogenic shock. On [**6-14**], patient had an episode of increased
RR, increased O2 requirement, hypertensive requiring NTG gtt,
lasix, lopressor, and morphine. EKG showed new TWI in inferior
and precordial leads. CEs showed elevation w/ TnT peak of 0.15
(on [**6-15**], and [**6-16**]) as well as CK peak of 204 ([**6-14**]) and MB of
17 ([**6-14**]). Treated with asa/plavix, heparin given h/o GI bleeding
and Hct drop. Received 1 unit PRBCs on [**6-15**] for Hct 21 w/ guiaic
positive stools. At approximately the same time, patient
developed a new L facial droop. Cardiology was consulted for
NSTEMI and recommended medical management.  Repeat TTE showd
worsening LVEF .  Neuro was consulted for L facial droop.  CT
head was negative for bleed. Carotid u/s negative for stenosis.
MRI has not yet been obtained.  Neuro attributed to toxic
metabolic derangements vs. watershed infarct but no further
intervention entertained. Most recently, has had intermittent
sinus tachycardia. Today [**6-17**], received 20 mg IV lasix w/ brisk
diuresis leading to tachycardia to 120s (baseline has been
90s-100s) which resolved back to baseline w/ 250 cc NS. Also
attempted to increase beta blocker but systolic BPs dropped to
90s which returned to the 100s with IVF.  Back pain has also
[**Last Name 19301**] problem throughout admission on multiple pain medications
and lidocaine patch.
Currently, patient w/o complaint. Denies back pain, chest pain,
SOB, abdominal pain, N/V, diarrhea.  Breathing comfortably.
.
# Hypotension: baseline SBPs have been in 80s-100s. Pt's MS
reportedly at baseline right now. DDx includes sepsis,
cardiogenic hypotension. More likely cardiogenic given severely
depressed EF.  Patient currently afebrile with fluctuating but
currently improving Completed 7 day course of ceftaz/bactrim for
UTI. Hct stable following PRBC transfusion so less likely
bleeding. Also unlikely adrenal insufficiency given random [**Last Name (un) 104**]
of 21 ([**6-9**]).  She was continued on antibiotics for her
enterococcus bacteremia.  She was started on low dose captopril,
3.125 mg QID which was decreased to TID due to more frequent low
BPs in the 80s.  However, she tolerated the TID dosing with BPs
continuing in the 90s-100s without change in mentation.
.
# NSTEMI: cardiology consulted and recommended medical
management. She was continued on asa, plavix, beta blocker,
statin.  She had no further evidence of ischemia following event
and remained stable throughout remainder of course.
.
# CHF: EF <20% on TTE [**6-15**] with HK and akinetic walls. Anterior
LV aneurysm as well.  Tenuous volume status intermittently
requiring lasix and IVF to manage hypotension in the ICU. Upon
arrival to the floor, patient's volume status remained stable
and only intermittently required small NS boluses for poor po
intake and low SBPs into 80s (although always asymptomatic).
Digoxin was started following drop in EF post NSTEMI.  Low dose
ace inhibitor started as described above.  She was otherwise
continued on her low dose beta blocker.  She remained
tachycardic in the low 100s.  However, this was presumed
necessary to augment her cardiac output given her poor stroke
volume so there was no increase in her beta blocker dose made.
She should follow up with her outpatient cardiologist as
scheduled and may benefit from evaluation by EP for potential
AICD placement.  It was noted that she could benefit from
anticoagulation given her LC aneurysm but given her history of
GI bleed and guiaic positive stools in house, this intervention
was not pursued. She was continued on a full dose aspirin.
.
# Left facial droop: New as of [**6-14**] AM. Concerning given
hypotension on previous day. CT head and carotids negative.  Per
Neuro, likely toxic metabolic vs. watershed infarct. MRI showed
R frontal lobe punctate lesions the chronicity of which could
not be determined. It was thought that these could potentially
be acute, but as above, GI bleeding precluded anticoagulation
and she was already on antiplatelet therapy.  She was therefore
continued on her aspirin and plavix without further
intervention.  Her facial droop slowly improved over the course
of admission and her Neuro exam otherwise remained unchanged.
.
# UTI: discharged on ciprofloxacin for 2 days to complete a 7
day course.
.
# Anemia- Chronic Fe deficicient anemia, likely from chronic
GIB. HCT slowly trended downward over admission. Received 1 unit
PRBCs. No active bleeding currently on asa, plavix but did
continue to be intermittently guiaic positive.  She was
transfused 1 additional unit of PRBCs on the floor and
following, Hct remained stable. She was continued on PPI and
iron supplements throughout.
.
# Back pain: Chronic [**2-13**] to vertebral compression fractures.
She was continued on standing tylenol and lidocaine patch with
oxycodone prn with reasonable control of her pain. Her fentanyl
patch was dc'ed during admission due to her hypotension.
.
# Lethargy and fatigue: Likely multifactorial with combination
of pain medication, metabolic derangements including
hyponatremia and infection with UTI/bactermia.  Back to baseline
after the above interventions.
.
# depression: No active issues. She was continued on her
mirtazipine and Cymbalta.
.
# Pituitary Adenoma- completed radiation on [**5-26**]. No focal
deficits. [**Month (only) 116**] be contributing to hyponatremia w/ potential
adrenal abnormalies although random cortisol normal.  Neuro exam
was unchanged except for facial droop as above and there were no
other significant changes noted on MRI.  She should follow up
with Dr. [**Last Name (STitle) 724**] as an outpatient.
.
# PPx- SC heparin, PPI, fall precautions, bowel regimen
.
# FEN: cont tubefeeds. Diet advanced without evidence of
aspiration despite achalasia.
.
# Code- DNR/DNI
.
# Contact: Brother [**Name (NI) **] [**Name (NI) 27040**] (h) [**Telephone/Fax (1) **] (c)
[**Telephone/Fax (1) 27041**]

Medications on Admission:
Remeron 7.5 mg Po QHS
Zofran 4 mg IV Q6H
Nitro paste 1inch Q6H, hold for SBP<90
Senna 2 tabs per Gtube [**Hospital1 **]
Colace 100 mg GT TID
Fentanyl patch 100 mg TP Q72 hours
Simvastatin 40 mg po QD
Ferrous sulfate 325 mg po QD
Reglans 10 mg via GT QD
Fragmin 5000 units sc Q12H
Plavix 75 mg PO QD
Lopressor 12.5 mg via GT TOD
Cymbalta 30 mg via GT QD
Aldactone 50 mg via GT [**Hospital1 **] (increased from 25 mg on [**6-5**])
Lidoderm patch to upper middle back Q12H on and off
Potassium 20 [**Female First Name (un) **] via GT [**Hospital1 **]
Zaroxalyn 2.5 mg via G tube Qdaily
Perative 50 cc hr 7pm-7am and oerative 40 cc/hr 7am-7pm


Discharge Medications:
1. Mirtazapine 15 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime).

2. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. Ferrous Sulfate 300 mg/5 mL Liquid [**Hospital1 **]: Three Hundred (300)
mg PO DAILY (Daily).
4. Metoclopramide 5 mg/5 mL Solution [**Hospital1 **]: Ten (10) mg PO TID (3
times a day).
5. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO QD ().
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical Q12H (every 12 hours):
to be worn for 12 hours every 24 hours.
8. Therapeutic Multivitamin     Liquid [**Hospital1 **]: Five (5) ML PO DAILY
(Daily).
9. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
10. Zinc Sulfate 220 (50) mg Capsule [**Hospital1 **]: One (1) Capsule PO
DAILY (Daily) for 14 days.
11. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed.
12. Acetaminophen 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H
(every 6 hours).
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
14. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).

15. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000)
units Injection TID (3 times a day).
16. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash at PEG site.
17. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO Q 12H
(Every 12 Hours).
18. Digoxin 125 mcg Tablet [**Hospital1 **]: 0.0625 mg PO DAILY (Daily).
19. Ondansetron 4 mg IV Q8H:PRN
20. 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.
21. Colace 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day.
22. Senna 8.6 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day.
23. Captopril 12.5 mg Tablet [**Hospital1 **]: 0.25 Tablet PO TID (3 times a
day).
24. Ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.


Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **]

Discharge Diagnosis:
Primary:
1. Urinary tract infection
2. bacteremia
3. NSTEMI
4. Congestive Heart Failure
5. anemia

Secondary:
1. coronary artery disease
2. pituitary adenoma
3. achalasia
4. hypertension
5. compression fractures


Discharge Condition:
Vitals stable. Afebrile.


Discharge Instructions:
You were admitted to the hospital for fatigue. You were found to
have a urinary tract infection as well as a blood stream
infection that were treated with antibiotics.  You also had a
small heart attack during your admission which was treated with
medications.

Please continue to take all medications as prescribed.  Note
that your Nitropaste, aldactone, and potassium have been
stopped.  Your fentanyl patch has been replaced with Tylenol and
oxycodone as needed to help prevent low blood pressures.  You
have also been started on lansoprazole, aspirin, digoxin, and
captopril.

Please follow up as listed below.

Please call your doctor or return to the hospital if you
experience chest pain, shortness of breath, fevers, chills,
abdominal pain, or any other concerns.

Followup Instructions:
Please call your Primary Care Provider to schedule [**Name Initial (PRE) **] follow up
appointment after discharge from rehab. Phone: [**Telephone/Fax (1) 1247**]

Please keep all other follow up appointments:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2161-6-29**]
1:55
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2161-6-29**]
3:00
{"Hypoxemia,Facial weakness,Gastrostomy status,Severe sepsis,Other septicemia due to gram-negative organisms,Subendocardial infarction, initial episode of care,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Hyposmolality and/or hyponatremia,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Septic shock,Other primary cardiomyopathies,Hemorrhage of gastrointestinal tract, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Benign neoplasm of pituitary gland and craniopharyngeal duct,Achalasia and cardiospasm,Osteoporosis, unspecified,Leukocytosis, unspecified,Kyphosis (acquired) (postural),Iron deficiency anemia, unspecified,Percutaneous transluminal coronary angioplasty status"}


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: Fatigue

PRESENT ILLNESS: Mrs. [**Known lastname 6314**] is a 70 yo female with MMP, including CHF with EF
30-35%,including PEG tube for achalasia & esophagitis,
osteoporosis c/b compression fractures, and pituitary adenoma
s/p radiation (last treatment [**2161-5-26**]) who presented from rehab
w/ lethargy and fatigue. Patient is a poor historian and is only
oriented to person and place. Complains only of back pain which
she reports having for months. Denies CP, SOB, cough, abd pain,
N/V, diarrhea, BRBPR, dizziness. Per written records & pt's
brother report, patient had MI on [**5-27**] with a CK-MB of 7.[**Street Address(2) 27038**] elevations in V1-V3 per record but no labs or EKGs sent from
rehab. Per rehab records, patient was on fluid restriction x24
hours on [**6-4**], then given lasix 100mg IV BID which was decreased
to daily and was continued on fluid restriction of 1 liter.
.
In the ED, T 97.8, HR 94, BP 94/64 RR 24 96 % RA. She received 1
liter NS and levofloxacin 500 mg IV x1.
.
On the wards, pt found to have UTI (though UA notable only for
[**3-16**] RBC & postive nitrites, only 0-2WBC). Urine cx growing
Klebsiella & other unidentified gram (-) rod. She was tx'd w/
levo. Her SBP trended down from 90s-110s to 80s. Was initially
responsive to IVF then non-responsive to it. She received >3.3:
(was 2.5L (+)) over 24hr. She had low grade fevers ~99.8 and was
reportedly more tired appearing, "less perky." Abx broadened to
ceftaz & vanc. Again, pt w/o complaints. Reports feeling like
usual self.

MEDICAL HISTORY: 1. Coronary artery disease with history of V. fib arrest, S/P
LAD stent and repeat cath in [**10/2159**] The LAD had patent stnets
with
50-60% proximal moderate instent restenosis. and Left
ventriculography demonstrated extensive anteroapical and
inferoapical akinesis and aneurysm with a contrast calculated
ejection fraction of 26%. There was no mitral regurgitation.
2. CHF - EF 30-35% in [**2159**].
3. Osteoporosis - early menopause, no history of hip fractures
but verterbral compression fractures noted earlier this month.
4. Depression
5. History of colonic AVM and anemia of chronic blood loss
6. S/P Appendectomy
7. Hypertension
8. H/o achalasia, peptic stricture at EG junction
9. h/o TAH and bilateral oopherectomy in her 30s
10. Admission [**3-18**] for melena found to have Dilation at the
lower third of the esophagus Grade 4 esophagitis in the lower
third of the esophagus
11. s/p G tube placement
12. Per written records patient had MI on [**5-27**] with a CK-MB of
7.[**Street Address(2) 27039**] elevations in V1-V3 per record but no labs or EKGs
sent

MEDICATION ON ADMISSION: Remeron 7.5 mg Po QHS
Zofran 4 mg IV Q6H
Nitro paste 1inch Q6H, hold for SBP<90
Senna 2 tabs per Gtube [**Hospital1 **]
Colace 100 mg GT TID
Fentanyl patch 100 mg TP Q72 hours
Simvastatin 40 mg po QD
Ferrous sulfate 325 mg po QD
Reglans 10 mg via GT QD
Fragmin 5000 units sc Q12H
Plavix 75 mg PO QD
Lopressor 12.5 mg via GT TOD
Cymbalta 30 mg via GT QD
Aldactone 50 mg via GT [**Hospital1 **] (increased from 25 mg on [**6-5**])
Lidoderm patch to upper middle back Q12H on and off
Potassium 20 [**Female First Name (un) **] via GT [**Hospital1 **]
Zaroxalyn 2.5 mg via G tube Qdaily
Perative 50 cc hr 7pm-7am and oerative 40 cc/hr 7am-7pm

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: 99.8 BP: 90/50 P: 88 RR: 18 O2 sats: 100 % on 2L
Gen: cachetic appearing elderly female in NAD
HEENT: MM mildly dry, OP clear
Neck: no Cervical LAD, no JVD
CV: RR, no m/g/r
Resp: decreased BS w/ bibasilar crackles R>L
Abd: G tube in place, site c/d/i; hypoactive BS, soft, NT/ND
Back: lidoderm patch in place, mild tendernness to palpation of
mid back, kyphotic
GU: foley in place
Ext: no edema, no calf tenderness, 2+ rad pulses b/l; PICC in L
arm
Neuro: Oriented to person and hospital but not date. Mild L
facial droop. CN II-XII grossly intact, strength in b/l UE and
LE [**4-16**] and symmetric, sensation to light touch intact

FAMILY HISTORY: FHx - multiple members in the family with who has had early TAH
and bilateral oopherectomy

SOCIAL HISTORY: Soc: Patient lives with her brother and sister-in-law.  She has
60 pack-year tobacco history but quit 20 yrs ago; denies EtoH
and drug use 

### Response:
{"Hypoxemia,Facial weakness,Gastrostomy status,Severe sepsis,Other septicemia due to gram-negative organisms,Subendocardial infarction, initial episode of care,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Hyposmolality and/or hyponatremia,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Septic shock,Other primary cardiomyopathies,Hemorrhage of gastrointestinal tract, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Benign neoplasm of pituitary gland and craniopharyngeal duct,Achalasia and cardiospasm,Osteoporosis, unspecified,Leukocytosis, unspecified,Kyphosis (acquired) (postural),Iron deficiency anemia, unspecified,Percutaneous transluminal coronary angioplasty status"}
