CHIEF COMPLAINT: Diarrhea, hypotension

PRESENT ILLNESS: 87 male with history of untreated colon cancer, PAF (not on
anticoagulation), recent hospitalization for hypoxia, weakness
and a UTI who presents with ongoing weakness and diarrhea. He
was noted to be weak at home, and a friend urged him to activate
his lifeline. He states that he has been having lots of
diarrhea, roughly every two hours, since his last discharge. He
has not been having any fevers, chills, abdominal pain, nausea,
vomiting, or bleeding.
.
His last hospitalization concluded that his weakness was due to
deconditioning, and his shortness of breath was due to fluid
overload. He was treated with flagyl for two days last
admission, and, and was discharged on Augmentin to complete a
course for a UTI. He had a positive c.dif toxin noted in the
computer last admission, but was not discharged on any
treatment.

MEDICAL HISTORY: Colonoscopy [**2184-3-25**]:
>Polyp in the transverse colon (polypectomy) - adenoma
>Polyps in the sigmoid colon (polypectomy)- Colonic mucosa with
focal hyperplastic features
>Polypoid, ulcerated mass in the hepatic flexure (biopsy) -
Superficial fragments of colonic mucosa with ulceration, marked
acute inflammation, and highly atypical glands, suspicious for
carcinoma.

MEDICATION ON ADMISSION: 1. Amiodarone 200 mg daily
2. Finasteride 5 mg daily
3. Furosemide 40 mg daily
4. Metoprolol Succinate 25 mg SR daily
5. Terazosin 5 mg daily
6. Aspirin 81 mg daily
7. Hexavitamin daily
8. Ferrous Sulfate 325 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vs- 99 88/41 70 20 90% 5L
Gen- Tired appearing elderly male, sleeping at 30 degrees HOB
elevation
Heent- MM dry, anicteric, poor dentition, no oral lesions
Neck- supple, JVP 8cm
Cor- regular, soft II/VI HSM along sternal border
Chest- Expiratory wheezes, bibasilar rales
Abd- soft, ttp RUQ and RLQ, no guarding or rebound tenderness.
Positive bowel sounds.
Ext- 3+ edema right leg, 2+ edema left leg. No clubbing or
cyanosis.
Neuro- AAO x 3. No focal findings.
Skin- Venous stasis changes L>R lower extremity.
Msk- moves all extremities. no obvious findings.

FAMILY HISTORY: brother had [**Name2 (NI) 500**] marrow stem cell transplant at age 82
Sister died from heart attack. Also had an unknown cancer.
Mother died from an unknown cancer.
Neice has unknown cancer.

SOCIAL HISTORY: living at lone at home with VNA, Former smoker with 35-pk-yrs,
quit 50-55 yrs ago. Social ETOH.
Intestinal infection due to Clostridium difficile,Other pulmonary embolism and infarction,Malignant neoplasm of colon, unspecified site,Abscess of anal and rectal regions,Acute on chronic diastolic heart failure,Dehydration,Sinoatrial node dysfunction,Anemia in neoplastic disease,Unspecified disorder of kidney and ureter,Other specified acquired hypothyroidism,Osteoporosis, unspecified,Osteitis deformans without mention of bone tumor,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Cardiac pacemaker in situ
Int inf clstrdium dfcile,Pulm embol/infarct NEC,Malignant neo colon NOS,Anal & rectal abscess,Ac on chr diast hrt fail,Dehydration,Sinoatrial node dysfunct,Anemia in neoplastic dis,Renal & ureteral dis NOS,Acquired hypothyroid NEC,Osteoporosis NOS,Osteitis deformans NOS,Osteoarthros NOS-unspec,Status cardiac pacemaker
Admission Date:  [**2188-7-2**]              Discharge Date:   [**2188-7-14**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Diarrhea, hypotension

Major Surgical or Invasive Procedure:
none

History of Present Illness:
87 male with history of untreated colon cancer, PAF (not on
anticoagulation), recent hospitalization for hypoxia, weakness
and a UTI who presents with ongoing weakness and diarrhea. He
was noted to be weak at home, and a friend urged him to activate
his lifeline. He states that he has been having lots of
diarrhea, roughly every two hours, since his last discharge. He
has not been having any fevers, chills, abdominal pain, nausea,
vomiting, or bleeding.
.
His last hospitalization concluded that his weakness was due to
deconditioning, and his shortness of breath was due to fluid
overload. He was treated with flagyl for two days last
admission, and, and was discharged on Augmentin to complete a
course for a UTI. He had a positive c.dif toxin noted in the
computer last admission, but was not discharged on any
treatment.


Past Medical History:
Colonoscopy [**2184-3-25**]:
>Polyp in the transverse colon (polypectomy) - adenoma
>Polyps in the sigmoid colon (polypectomy)- Colonic mucosa with
focal hyperplastic features
>Polypoid, ulcerated mass in the hepatic flexure (biopsy) -
Superficial fragments of colonic mucosa with ulceration, marked
acute inflammation, and highly atypical glands, suspicious for
carcinoma.


Past history:
# Colon mass during colonoscopy for guaiac positive stools in
[**2184**]. Pathology was worrisome for carcinoma. Although the
patient was offered resection by Dr. [**Last Name (STitle) **], he declined
# hematuria/BPH - traumatic foley insertion and manipulation
[**3-16**] lead to urosepsis and subsequent urinary retention
# sick sinus syndrome and bifascicular block s/p pacemaker [**2184**]

# PAF - on amiodarone, not on coumadin d/t concern for
malignancy
# H/O SVT
# Atrial flutter status post ablation [**2-/2186**] - not on
anticoagulation d/t concern for malignancy
# Anemia - on arenesp and iron
# Echo [**2186**]: mild-to-moderate mitral regurgitation, RA and LA
# BPH s/p TURMP [**2187**]
# b/l edema with skin changes
# hard of hearing
# hx of guiaic positive stools/GI bleeding
# osteoarthritis
# osteoporosis
# subclinical hypothyroid state as per record
# [**Year (4 digits) **] insufficiency
# right pleural effusion - Found on CT on [**2188-2-25**] for increasing
DOE. [**3-6**] and [**3-18**] thoracentesis c/w transudative. Workup during
last admission revealed RV diastolic dysfunction. Concern was
for PE as etiology, but unable to get CTA d/w ARF and V/Q not
helpful. Not anticoagulated due to h/o GIB, pleurodesis not an
option d/t transudative.
# Tibial talar dislocation with comminuted distal tib fib
fracture status post surgery [**2181**]
# hx syncope in [**2181**], unclear etiology


Social History:
living at lone at home with VNA, Former smoker with 35-pk-yrs,
quit 50-55 yrs ago. Social ETOH.


Family History:
brother had [**Name2 (NI) 500**] marrow stem cell transplant at age 82
Sister died from heart attack. Also had an unknown cancer.
Mother died from an unknown cancer.
Neice has unknown cancer.


Physical Exam:
Vs- 99 88/41 70 20 90% 5L
Gen- Tired appearing elderly male, sleeping at 30 degrees HOB
elevation
Heent- MM dry, anicteric, poor dentition, no oral lesions
Neck- supple, JVP 8cm
Cor- regular, soft II/VI HSM along sternal border
Chest- Expiratory wheezes, bibasilar rales
Abd- soft, ttp RUQ and RLQ, no guarding or rebound tenderness.
Positive bowel sounds.
Ext- 3+ edema right leg, 2+ edema left leg. No clubbing or
cyanosis.
Neuro- AAO x 3. No focal findings.
Skin- Venous stasis changes L>R lower extremity.
Msk- moves all extremities. no obvious findings.


Pertinent Results:
ADMISSION LABS

[**2188-7-2**] 02:52AM BLOOD WBC-25.0*# RBC-3.81* Hgb-10.4* Hct-32.8*
MCV-86 MCH-27.2 MCHC-31.7 RDW-16.3* Plt Ct-251
[**2188-7-2**] 02:52AM BLOOD Neuts-72* Bands-23* Lymphs-2* Monos-2
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2188-7-2**] 02:52AM BLOOD PT-14.9* PTT-33.2 INR(PT)-1.3*
[**2188-7-2**] 02:52AM BLOOD Glucose-106* UreaN-33* Creat-1.2 Na-143
K-3.5 Cl-109* HCO3-25 AnGap-13
[**2188-7-2**] 02:52AM BLOOD ALT-34 AST-37 LD(LDH)-268* AlkPhos-189*
TotBili-0.5
[**2188-7-2**] 02:52AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.0
[**2188-7-2**] 03:04AM BLOOD Lactate-1.3

MICRO

[**7-2**] blood cultres-NGTD
[**7-2**] urine cultres-NGTD
[**7-2**]-c.diff positive

IMAGING

[**7-2**]-liver u/s-Gallbladder distension likely related to
patient's having been NPO for 48 hours, without evidence of
acute cholecystitis. These findings were posted to the ED
dashboard at 10:30 a.m. on [**2188-7-2**]
.
[**7-2**]-CT abdomen-1. New pancolitis with rectal involvement, with
"accordion"-like accentuated haustration, a marked change since
[**2188-3-5**], is highly suggestive of C. difficile colitis; given
the history of previous episode, this likely represents the
chronic "recurrent" form.
2. Infectious pancolitis (due to Campylobacter, CMV, parasitic
or staphylococcal infection) is a less likely consideration.
3. No evidence of bowel obstruction.
4. Congestive heart failure, with multi-chamber cardiac
enlargement and bilateral pleural effusions, right greater than
left.
.

[**7-2**]-CXR-Portable upright chest radiograph is reviewed and
compared to [**2188-6-22**]. Mildly enlarged cardiac silhouette is
unchanged, with left pacemaker and two intracardiac leads. Right
pleural effusion is little changed, but there is still right
basilar consolidative opacity. Left basilar atelectasis is
unchanged. There is no left pleural effusion. There is no
pneumothorax.
IMPRESSION: Little change in CHF, with slightly decreased right
pleural fluid. Unchanged right basilar atelectasis

[**7-5**]-CXR-Moderate-sized bilateral pleural effusions

[**7-9**]-CT abdomen/CT chest-1. Multisegmental bilateral pulmonary
emboli.
2. Atelectasis and aspiration/pneumonia of the lung bases
bilaterally, with aspirated barium seen within the left lung
base.
3. Fluid overload, with anasarca and moderate bilateral pleural
effusions.
4. Colonic wall thickening, also involving the rectum. Although
some of the wall thickening may be attributable to volume
overload, these findings are again compatible with a pancolitis
such as pseudomembranous colitis, improved from [**2188-7-2**].
5. Area of stricturing and narrowing of the hepatic flexure,
compatible with known colonic malignancy.
6. Perirectal abscess, measuring approximately 2.7 cm.


Brief Hospital Course:
87 male with history of colon cancer (untreated), atrial
fibrillation, recent UTI, and positive C.dif toxin assay who
presents with diarrhea, hypotension, and dehydration.
.
# Hypotension: On admission he was hypotensive to SBP 80's and
thus admitted to the MICU, this was likely in the setting of
profound dehydration from GI losses and poor PO intake. He was
fluid responsive thus far (a total of 5L of isotonic fluids).
Alternate etiologies, such as distributive or cardiogenic shock
at this point were considered less likely.  He received a total
of 4-5L and his BP improved such that he was transferred to the
medical floor.  His BP remained normal afterwards. Metoprolol
and terazosin were held throughout admission which patient
tolerated well.
.
# Diarrhea/C.dificile colitis. He has had several positive C
Diff toxin assays, and had one course of treatment after an
[**Month (only) 547**] admission. It is not clear that he was treated during his
past admission.  He was C diff toxin positive again and he was
treated with IV flagyl and PO vancomycin as his diarrhea was
severe and there was concern about the vancomycin working in the
setting of a rapid transit time.  Initially he did not have
abdominal pain, but began having lower abdominal pain and some
rebound tenderness on exam.  A CT abdomen showed improvement in
the colitis and a new perirectal abscess but no other
abnormalities.  At the time of discharge he was tolerating a
regular diet without difficulty and had improvement in his
abdominal pain and diarrhea.  Antibiotics were started on [**7-2**]
with a plan to complete a 21 day course of flagyl and vanco as
an outpatient.
.
#Perirectal Abscess-Seen on CT, non-symptomatic but on exam he
had tender fluctuance in the posterior rectum. Gen [**Doctor First Name **] was
consulted and stated I&D at this time is not necessary as it
could not be performed bedside, because of the position of the
abscess they may have to use a percutaneous approach which would
raise concern about creating a colon-skin fistual tract.  They
recommended added cipro for gram negative coverage but given
concern over exacerbating his c.diff which was already slow to
improve, it was not added and conservatively management was
pursued. He will be seen for follow-up by surgery as an
outpatient.
.
# Edema / CHF: He has bilateral pleural effusions, which have
recently been tapped and found to be transudative. He is
currently intravascularly dry but total body overloaded. He has
a normal LVEF, but has had recent issues with fluid
overload-likely [**2-23**] MR, TR.  He was diuresed with IV lasix 4-5L,
now patient is lasix dose of 40mg daily.
.
# Hypoxia: Initially thought to be related to fluid overload /
cardiac cause.   However he was suspected to have PEs in the
setting of untreated malignancy (colon cancer-he refused
surgery), he was on 4L O2 NC.  Initially he was diuresed, and
his oxygenation slowly improved.  He had a CTA with bilateral
subsegmental PEs, nonobstructive and an IVC filter was placed on
[**7-10**] given inability to anticoagulate due to known colon
malignancy.  His oxygenation has improved to 94% on room air
prior to discharge.

# PE: Thought to be in setting of known malignancy. As above,
seen on recent CTA. Not anticoagulated due to colon malignancy,
permanent IVC filter placed.
.
# Sick Sinus: His pacer was interrogated by EP, and appears to
be working well.
He was continued on home amiodarone. As above, metoprolol was
held. He will follow-up with PCP and cardiology to discuss
restarting medication.
.
# [**Month/Year (2) 2793**] isufficiency: He appears to be at his baseline - but his
BUN was elevated on admission likely due to dehydration. [**Month/Year (2) 2793**]
function remained at baseline.
.
# Anemia: He had a recent transfusion - possibly due to
underlying malignancy.
Hct was monitored, there was no need for transfusion as he is
actually above recent baseline. Will continue iron supplements.

.

# Code status: Full, discussed with pateint.
# Communication: Daugher is HCP. [**Name (NI) 501**]



Medications on Admission:
1. Amiodarone 200 mg daily
2. Finasteride 5 mg daily
3. Furosemide 40 mg daily
4. Metoprolol Succinate 25 mg SR daily
5. Terazosin 5 mg daily
6. Aspirin 81 mg daily
7. Hexavitamin daily
8. Ferrous Sulfate 325 mg daily


Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
7. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 8 days.
8. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 8
days.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary:
clostridium difficle diarrhea
pulmonary emboli
perirectal abscess
colon cancer untreated
[**Hospital6 **] insufficiency
sick sinus syndrome

Secondary:
hematuria/BPH - traumatic foley insertion and manipulation
[**3-16**] lead to urosepsis and subsequent urinary retention
sick sinus syndrome and bifascicular block s/p pacemaker [**2184**]
PAF - on amiodarone, not on coumadin d/t concern for
malignancy
H/O SVT
Atrial flutter status post ablation [**2-/2186**] - not on
anticoagulation d/t concern for malignancy
Anemia - was on arenesp and iron
BPH s/p TURMP [**2187**]
b/l edema with skin changes
hard of hearing
hx of guiaic positive stools/GI bleeding
osteoarthritis
osteoporosis
subclinical hypothyroid state as per record
right pleural effusion - Found on CT on [**2188-2-25**] for increasing
DOE. [**3-6**] and [**3-18**] thoracentesis c/w transudative. Workup during

last admission revealed RV diastolic dysfunction. Concern was
for PE as etiology, but unable to get CTA d/w ARF and V/Q not
helpful. Not anticoagulated due to h/o GIB, pleurodesis not an
option d/t transudative.
Tibial talar dislocation with comminuted distal tib fib
fracture status post surgery [**2181**]
Paget's disease of pelvis


Discharge Condition:
stable, afebrile, good po intake, diarrhea improved.


Discharge Instructions:
You were admitted with low blood pressure and were found to have
C.difficle diarrhea.  You were in the medical ICU for 2 days,
your blood pressure improved after you received IV fluids and
antibiotics.  You were transferred to a medical floor where your
diarrhea improved, you were found to have a perirectal abscess
which was not treated with medication due to your c.difficile
infection. You should follow up with outpatient surgery for
further treatment.  Your oxygen level was low, you had a CT of
your chest that showed pulmonary emboli (blood clots in your
lungs) and an IVC filter was placed.
.
Please continue to take your medications as prescribed. You will
need to continue on the antibiotics flagyl and vancomycin as
prescribed for your c.difficile infection. Please note your
lasix dose has been increased to 40mg daily. Please note your
metoprolol and terazosin were stopped, please discuss restarting
these with your PCP.
.
You should follow up as outlined below.
.
You should seek medical attention if you have worsening
diarrhea, dizzyness, abdominal pain, chest pain ,shortness of
breath or any other concerning symptoms.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:2L

Followup Instructions:
please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 324**] [**Last Name (NamePattern1) 311**] [**Telephone/Fax (1) 1713**] and make an
appointment within the next two weeks

Provider: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD Phone:[**Telephone/Fax (1) 1579**]
Date/Time:[**2188-7-23**] 1:30
Provider: [**Name Initial (NameIs) 703**] (H3) GENERAL 2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2188-8-25**] 1:30
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2188-8-28**] 11:00
Provider: [**Last Name (NamePattern4) **].[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 8792**] on [**2188-8-14**] at
8:30am
Provider: [**Last Name (NamePattern4) **].[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2232**] Phone: ([**Telephone/Fax (1) 8793**] on [**2188-7-23**] at
11:20am


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
{'Intestinal infection due to Clostridium difficile,Other pulmonary embolism and infarction,Malignant neoplasm of colon, unspecified site,Abscess of anal and rectal regions,Acute on chronic diastolic heart failure,Dehydration,Sinoatrial node dysfunction,Anemia in neoplastic disease,Unspecified disorder of kidney and ureter,Other specified acquired hypothyroidism,Osteoporosis, unspecified,Osteitis deformans without mention of bone tumor,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Cardiac pacemaker in situ'}


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: Diarrhea, hypotension

PRESENT ILLNESS: 87 male with history of untreated colon cancer, PAF (not on
anticoagulation), recent hospitalization for hypoxia, weakness
and a UTI who presents with ongoing weakness and diarrhea. He
was noted to be weak at home, and a friend urged him to activate
his lifeline. He states that he has been having lots of
diarrhea, roughly every two hours, since his last discharge. He
has not been having any fevers, chills, abdominal pain, nausea,
vomiting, or bleeding.
.
His last hospitalization concluded that his weakness was due to
deconditioning, and his shortness of breath was due to fluid
overload. He was treated with flagyl for two days last
admission, and, and was discharged on Augmentin to complete a
course for a UTI. He had a positive c.dif toxin noted in the
computer last admission, but was not discharged on any
treatment.

MEDICAL HISTORY: Colonoscopy [**2184-3-25**]:
>Polyp in the transverse colon (polypectomy) - adenoma
>Polyps in the sigmoid colon (polypectomy)- Colonic mucosa with
focal hyperplastic features
>Polypoid, ulcerated mass in the hepatic flexure (biopsy) -
Superficial fragments of colonic mucosa with ulceration, marked
acute inflammation, and highly atypical glands, suspicious for
carcinoma.

MEDICATION ON ADMISSION: 1. Amiodarone 200 mg daily
2. Finasteride 5 mg daily
3. Furosemide 40 mg daily
4. Metoprolol Succinate 25 mg SR daily
5. Terazosin 5 mg daily
6. Aspirin 81 mg daily
7. Hexavitamin daily
8. Ferrous Sulfate 325 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vs- 99 88/41 70 20 90% 5L
Gen- Tired appearing elderly male, sleeping at 30 degrees HOB
elevation
Heent- MM dry, anicteric, poor dentition, no oral lesions
Neck- supple, JVP 8cm
Cor- regular, soft II/VI HSM along sternal border
Chest- Expiratory wheezes, bibasilar rales
Abd- soft, ttp RUQ and RLQ, no guarding or rebound tenderness.
Positive bowel sounds.
Ext- 3+ edema right leg, 2+ edema left leg. No clubbing or
cyanosis.
Neuro- AAO x 3. No focal findings.
Skin- Venous stasis changes L>R lower extremity.
Msk- moves all extremities. no obvious findings.

FAMILY HISTORY: brother had [**Name2 (NI) 500**] marrow stem cell transplant at age 82
Sister died from heart attack. Also had an unknown cancer.
Mother died from an unknown cancer.
Neice has unknown cancer.

SOCIAL HISTORY: living at lone at home with VNA, Former smoker with 35-pk-yrs,
quit 50-55 yrs ago. Social ETOH. 

### Response:
{'Intestinal infection due to Clostridium difficile,Other pulmonary embolism and infarction,Malignant neoplasm of colon, unspecified site,Abscess of anal and rectal regions,Acute on chronic diastolic heart failure,Dehydration,Sinoatrial node dysfunction,Anemia in neoplastic disease,Unspecified disorder of kidney and ureter,Other specified acquired hypothyroidism,Osteoporosis, unspecified,Osteitis deformans without mention of bone tumor,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Cardiac pacemaker in situ'}
