CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: 83M with hx of COPD, afib who was sent to the ER from [**Doctor Last Name **] House
after he was found to be tachypneic to the 40s. Per nurse [**First Name (Titles) 767**] [**Name (NI) 63570**] House, pt normally keeps to himself and is generally
healthy except for his breathing. She states that his physician
has been trying to get him to wear O2 but he has refused. Pt
states that over the past two weeks, he has been having loose
stools and crampy, squeezing abdominal pain. He has been eating
normal meals but his pain worsens after eating. He describes
some nausea but has not had any emesis. Pt states his breathing
has felt fine until the last day when it started to feel
labored, associated with productive cough.
.
In the [**Name (NI) **], pt found to be hypotensive to 50s/30s with HR in the
40s, RR in the 40s, 100% on NRB. Of note, he had taken his 200mg
of toprol XL in the am. He was given Glucagon 1mg IV x 1 with no
improvement in HR. He was then started on Dopamine which
improved both HR and BP. This was titrated up to 25mcg to
maintain MAPs in the 60s. He was then given ceftriaxone and
vancomycin to cover for PNA. He was given solumedrol, albuterol
and atrovent nebs to cover for COPD flare. And he was given 10mg
of Lasix for possible CHF but also had received 2L of NS
earlier. He was then admitted to the ICU.

MEDICAL HISTORY: * HTN
* COPD, unknown FEV1
* CHF, EF unknown
* Afib
* Spinal stenosis
* anemia
* hx of pneumonia
* hx of PVD

MEDICATION ON ADMISSION: * ASA 81mg qd
* HCTZ 25mg qd
* Toprol XL 200mg qd
* Prilosec 20mg qd
* MVI
* Verapamil 180mg qd
* Colace 100mg [**Hospital1 **]
* Cilostazol 50mg [**Hospital1 **]
* Tylenol 650mg tid
* Motrin 600mg tid
* Lipitor 10mg qd
* Neurontin 100mg qhs
* MOM
* albuterol
* atrovent

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam: temp 98.4, BP 110/40, HR 67, R 15, O2 94-98% on 4L
Gen: NAD, pleasant, AO x 3
HEENT: MM dry, EOMI, left pupil 4mm and reactive, right pupil
2mmand reactive
neck: JVD to 8cm
CV: regular
Chest: crackles at bilateral bases but otherwise clear
Abd: hypoactive bowel sounds, nontender, soft, nondistended, no
rebound
ext: feet cool; 2+ pitting edema, nonpapable and nondopplerable
pulses; dopplerable popliteal pulses, 1+ radial pulse; fingers
blue
neuro: CN 2-12 intact, 5/5 strength bilaterally

FAMILY HISTORY: NC

SOCIAL HISTORY: 2-3ppd x 48yrs, lives in [**Doctor Last Name **] house; not married, no children;
nephews are very involved
Unspecified septicemia,Septic shock,Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Atrial fibrillation,Acute kidney failure with lesion of tubular necrosis,Volume depletion, unspecified,Mitral valve disorders,Congestive heart failure, unspecified,Severe sepsis,Unspecified essential hypertension
Septicemia NOS,Septic shock,Pneumonia, organism NOS,Obs chr bronc w(ac) exac,Atrial fibrillation,Ac kidny fail, tubr necr,Volume depletion NOS,Mitral valve disorder,CHF NOS,Severe sepsis,Hypertension NOS
Admission Date:  [**2199-8-18**]              Discharge Date:   [**2199-8-21**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Hypotension

Major Surgical or Invasive Procedure:
none


History of Present Illness:
83M with hx of COPD, afib who was sent to the ER from [**Doctor Last Name **] House
after he was found to be tachypneic to the 40s. Per nurse [**First Name (Titles) 767**] [**Name (NI) 63570**] House, pt normally keeps to himself and is generally
healthy except for his breathing. She states that his physician
has been trying to get him to wear O2 but he has refused. Pt
states that over the past two weeks, he has been having loose
stools and crampy, squeezing abdominal pain. He has been eating
normal meals but his pain worsens after eating. He describes
some nausea but has not had any emesis. Pt states his breathing
has felt fine until the last day when it started to feel
labored, associated with productive cough.
.
In the [**Name (NI) **], pt found to be hypotensive to 50s/30s with HR in the
40s, RR in the 40s, 100% on NRB. Of note, he had taken his 200mg
of toprol XL in the am. He was given Glucagon 1mg IV x 1 with no
improvement in HR. He was then started on Dopamine which
improved both HR and BP. This was titrated up to 25mcg to
maintain MAPs in the 60s. He was then given ceftriaxone and
vancomycin to cover for PNA. He was given solumedrol, albuterol
and atrovent nebs to cover for COPD flare. And he was given 10mg
of Lasix for possible CHF but also had received 2L of NS
earlier. He was then admitted to the ICU.


Past Medical History:
* HTN
* COPD, unknown FEV1
* CHF, EF unknown
* Afib
* Spinal stenosis
* anemia
* hx of pneumonia
* hx of PVD


Social History:
2-3ppd x 48yrs, lives in [**Doctor Last Name **] house; not married, no children;
nephews are very involved

Family History:
NC

Physical Exam:
Exam: temp 98.4, BP 110/40, HR 67, R 15, O2 94-98% on 4L
Gen: NAD, pleasant, AO x 3
HEENT: MM dry, EOMI, left pupil 4mm and reactive, right pupil
2mmand reactive
neck: JVD to 8cm
CV: regular
Chest: crackles at bilateral bases but otherwise clear
Abd: hypoactive bowel sounds, nontender, soft, nondistended, no
rebound
ext: feet cool; 2+ pitting edema, nonpapable and nondopplerable
pulses; dopplerable popliteal pulses, 1+ radial pulse; fingers
blue
neuro: CN 2-12 intact, 5/5 strength bilaterally


Pertinent Results:
** ADMIT LABS **
WBC-13.6*
HCT-31.2*
NEUTS-85.7* LYMPHS-9.8* MONOS-3.9 EOS-0.4 BASOS-0.1
PLT COUNT-294
INR(PT)-1.2*
.
proBNP-[**Numeric Identifier **]*
.
GLUCOSE-135*
UREA N-43*
CREAT-1.9*
SODIUM-136
POTASSIUM-5.0
CHLORIDE-98
TOTAL CO2-24
.
ALT(SGPT)-2191*
AST(SGOT)-2076*
LD(LDH)-2325*
ALK PHOS-101
AMYLASE-505*
TOT BILI-0.8
LIPASE-19
.
LACTATE-4.4* --> 4.8 --> 3.3
.
ABG: TYPE-ART PO2-221* PCO2-53* PH-7.21* on 100% NRB
.
CXR: Heart size is at upper limits of normal. The aorta is
calcified and tortuous. Pulmonary vasculature is unremarkable.
There is a left lower lobe opacity and small left pleural
effusion. Left lower lobe opacity could represent atelectasis;
however, pneumonia cannot be excluded.
.
ECHO: The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild to moderate ([**2-4**]+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
RUQ U/S:
1. Patent hepatic vasculature.
2. Unremarkable liver echotexture.
3. Trace ascites.
4. Simple-appearing cyst of the mid left kidney.
.


Brief Hospital Course:
83M with hx of COPD, afib now in ICU for hypotension found to
have abdominal pain and elevated LFTs
.
# Shock: Volume depletion vs sepsis vs adrenal insufficiency or
combination. Volume depletion likely due to 2 weeks of loose
stools and decreased po intake. Sepsis also likely given lactate
of 4.8, possible pneumonia and possible intra-abd source.
Adrenal insufficiency was impossible to test given that pt
received solumedrol in ED. Cardiogenic shock not likely given
lack of EKG changes and negatige enzymes and TTE showed
preserved systolic function.  Patient was given fluids and
started on dopamine to maintain MAPs>60.  Steroids were changed
to decadron to perform [**Last Name (un) 104**] stim test but initial level was 40
so stim was not performed.  Steroids were d/c'd.  Pt was weaned
off dopamine on hospital day #2 and BPs remained stable. BB was
resumed for rate control and verapamil was restarted.  SBPs
remained 120s-140s.
.
# Sepsis: Possible sources include lung, urine, abdomen. CXR
with possible infiltrate so started levaquin/flagyl. UA was
clean and urine culture was negative. blood cultures remain
negative. Pt remained afebrile with elevated WBC count,
attributed to possible PNA and steroids.  His WBC should be
followed in rehab to make sure it is trending down.
.
# Transaminitis: ALT and AST equally elevated to the [**2193**] on
admission. Ddx of this includes right heart failure (which may
explain elevated BNP), shock liver, viral hepatitis (which could
explain pt's abd pain, nausea, diarrhea), med related (he is on
650mg standing tylenol TID), budd chiari. No hx of etoh abuse.
RUQ US was normal without evidence of clot and tylenol level was
neg.  PAtient's HepAV Ab was positive, [**Last Name (un) **] IgM is pending.  We
will continue to hold his statin and she should not be on
standing tylenol.  His LFTs should also be trended to make sure
they are trending down.
.
# Abd Pain/diarrhea: Stool was sent for E. coli 0157 given h/o
diarrhea and ARF.  C diff also sent.  Patient's diarrhea
resolved as did his abdominal pain.  As above, his abd U/S was
negative.  It may be secondary to hepatitis A but IgM was
pending on time of discharge.
.
# Tachypnea/COPD: Likely that pt has an underlying pneumonia
causing an exacerbation of his underlying COPD.  He was given
standing nebs along with oxygen.  His breathing improved
dramatically over the first few hours of his hospital stay.  He
should continue on albuterol and atrovent inhalers.  He also
should continue to wear oxygen at rest and with ambulation.  He
was started on advair.  He may benefit from an outpatient
pulmonary appointment along with PFTs.  He may also need
additional medications including tiotropium.
.
# CHF: By report only.  Echo was normal with preserved funciton.
 BNP elevated to 18,000 on admission but appeared dry on exam so
he improved with fluids. He was continued on his beta blocker
after BP normalized.
.
# Afib: Patient was in NSR on admission and converted to a-fib
while in MICU with HR 100's-120's. He is not anticoagulated
likely due to fall risk.  He is rate controlled with beta
blocker and verapamil.
.
# ARF: Baseline is unknown.  Urine lytes showed FeNa of 0.9%
indicating pre-rernal etiology verses acute tubular necrosis
from hypotension.  Creatinine peaked at 2.8 from 1.9 on
admission and is now trending down.  This should be followed and
medications adjusted for creatinine clearance.
.
# Glucse Intolerance: Pt was covered with insulin sliding scale
but required none.
.
# Code: Pt is DNR/DNI, confirmed with PCP
.
# Comm: nephew [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 63571**]; PCP [**Known firstname **] [**Last Name (NamePattern1) 1266**]


Medications on Admission:
* ASA 81mg qd
* HCTZ 25mg qd
* Toprol XL 200mg qd
* Prilosec 20mg qd
* MVI
* Verapamil 180mg qd
* Colace 100mg [**Hospital1 **]
* Cilostazol 50mg [**Hospital1 **]
* Tylenol 650mg tid
* Motrin 600mg tid
* Lipitor 10mg qd
* Neurontin 100mg qhs
* MOM
* albuterol
* atrovent


Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Multi-Vitamin     Tablet Sig: One (1) Tablet PO once a day.
5. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
8. Atrovent 18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 3 days.
10. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 3 days.
11. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1643**] Center

Discharge Diagnosis:
Primary Diagnosis:
1. Sepsis
2. Community Acquired Pneumonia
3. Transaminitis [**3-7**] hepatitis A verses shock liver
4. Diarrhea, ? hepatitis A
5. Acute Renal Failure [**3-7**] acute tubular necrosis
.
Secondary Diagnosis:
1. COPD
2. Atrial Fibrillation


Discharge Condition:
good, afebrile and oxygenating well on 3L


Discharge Instructions:
Take all medications as prescibed and go to all follow-up
appointments.  Your oxygen level is low so you should wear
oxygen at home.  You will need to take the levaquin and flagyl
(antibiotics for your pneumonia) for 3 more days.  Your liver
function was slightly lower than normal so you should avoid
taking tylenol while it recovers.

Please avoid both tylenol and motrin given your liver and kidney
disease.

Return to the ER or call your PCP if you experience any
dizziness, shortness of breath, abdominal pain, diarrhea, nausea
or vomiting.

Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 1266**] on [**2199-8-29**] at 3:30pm.
 If you want to cancel this, please call [**Telephone/Fax (1) 608**].

You will need to have your creatinine and liver function tests
checked on Friday and Monday to make sure they are improving.
{'Unspecified septicemia,Septic shock,Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Atrial fibrillation,Acute kidney failure with lesion of tubular necrosis,Volume depletion, unspecified,Mitral valve disorders,Congestive heart failure, unspecified,Severe sepsis,Unspecified essential hypertension'}


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: 83M with hx of COPD, afib who was sent to the ER from [**Doctor Last Name **] House
after he was found to be tachypneic to the 40s. Per nurse [**First Name (Titles) 767**] [**Name (NI) 63570**] House, pt normally keeps to himself and is generally
healthy except for his breathing. She states that his physician
has been trying to get him to wear O2 but he has refused. Pt
states that over the past two weeks, he has been having loose
stools and crampy, squeezing abdominal pain. He has been eating
normal meals but his pain worsens after eating. He describes
some nausea but has not had any emesis. Pt states his breathing
has felt fine until the last day when it started to feel
labored, associated with productive cough.
.
In the [**Name (NI) **], pt found to be hypotensive to 50s/30s with HR in the
40s, RR in the 40s, 100% on NRB. Of note, he had taken his 200mg
of toprol XL in the am. He was given Glucagon 1mg IV x 1 with no
improvement in HR. He was then started on Dopamine which
improved both HR and BP. This was titrated up to 25mcg to
maintain MAPs in the 60s. He was then given ceftriaxone and
vancomycin to cover for PNA. He was given solumedrol, albuterol
and atrovent nebs to cover for COPD flare. And he was given 10mg
of Lasix for possible CHF but also had received 2L of NS
earlier. He was then admitted to the ICU.

MEDICAL HISTORY: * HTN
* COPD, unknown FEV1
* CHF, EF unknown
* Afib
* Spinal stenosis
* anemia
* hx of pneumonia
* hx of PVD

MEDICATION ON ADMISSION: * ASA 81mg qd
* HCTZ 25mg qd
* Toprol XL 200mg qd
* Prilosec 20mg qd
* MVI
* Verapamil 180mg qd
* Colace 100mg [**Hospital1 **]
* Cilostazol 50mg [**Hospital1 **]
* Tylenol 650mg tid
* Motrin 600mg tid
* Lipitor 10mg qd
* Neurontin 100mg qhs
* MOM
* albuterol
* atrovent

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam: temp 98.4, BP 110/40, HR 67, R 15, O2 94-98% on 4L
Gen: NAD, pleasant, AO x 3
HEENT: MM dry, EOMI, left pupil 4mm and reactive, right pupil
2mmand reactive
neck: JVD to 8cm
CV: regular
Chest: crackles at bilateral bases but otherwise clear
Abd: hypoactive bowel sounds, nontender, soft, nondistended, no
rebound
ext: feet cool; 2+ pitting edema, nonpapable and nondopplerable
pulses; dopplerable popliteal pulses, 1+ radial pulse; fingers
blue
neuro: CN 2-12 intact, 5/5 strength bilaterally

FAMILY HISTORY: NC

SOCIAL HISTORY: 2-3ppd x 48yrs, lives in [**Doctor Last Name **] house; not married, no children;
nephews are very involved 

### Response:
{'Unspecified septicemia,Septic shock,Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Atrial fibrillation,Acute kidney failure with lesion of tubular necrosis,Volume depletion, unspecified,Mitral valve disorders,Congestive heart failure, unspecified,Severe sepsis,Unspecified essential hypertension'}
