CHIEF COMPLAINT: Diarrhea with fever

PRESENT ILLNESS: [**Age over 90 **] yo with HTN, CAD s/p CABG, severe TR, pHTN, PVD, s/p CVA in
[**2140**], prior MSSA UTI in [**5-/2157**], history of c. diff in [**6-/2157**],
presents with diarrhea. The patient reports over the last week
she has experienced diarrhea, up to 4-5 times daily. She reports
her diarrhea improved after coming home from rehab, but recurred
a week ago. She also reports abdominal pain, located on her
right upper quadrant and epigastrium. She discussed her symptoms
with her PCP two days ago, and he encouraged her to come in for
evaluation, but she declined and was started on empiric flagyl.
Stool c diff toxin sent from home, found to be positive. Her 24
hour caregiver at home noted her temp to be up to [**Age over 90 **] yesterday.

MEDICAL HISTORY: 1. Coronary artery disease, status post CABG in [**2140**].
2. Peripheral arterial disease with status post right carotid
endarterectomy in [**2140**].
3. CVA [**2140**], status post right CEA.
4. Hypertension.
5. Dyslipidemia.
6. Pulmonary hypertension.
7. Severe tricuspid regurgitation.
8. Presyncope.
9. Depression

MEDICATION ON ADMISSION: Bupropion HCl 75 mg PO BID
Cilostazol 50 mg PO twice a day.
Labetalol 100 mg PO BID
Lisinopril 10 mg PO DAILY
Nifedipine 30 mg PO DAILY
Pravastatin 80 mg PO q PM.
Acetaminophen 325 mg 1-2 Tablets PO Q6H as needed for pain.
Aspirin 81 mg PO DAILY
Vitamin D 1,000 unit PO once a day.
Senna 8.6 mg PO every other day.
Trazodone 50 mg 0.5 Tablet PO HS as needed for insomnia.
flagyl started [**8-23**]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Initial physical exam
Vitals: T: 97.3 BP: 139/66 P: 80 R: 18 O2: 100% on 4L
General: Alert, oriented, elderly female in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, 3/6 systolic murmur at RUSB with RV
heave, no rubs, gallops
Abdomen: soft, tender to palpation at RUQ, no guarding, no
rebound tenderness, mildly distended, bowel sounds present
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: [**2-28**] children with HTN

SOCIAL HISTORY: Lives alone, family nearby. Uses cane with ambulation. Widowed
in [**2114**]. Worked subsequently in a bank. Has 6 living children -
children check on her daily. Has home health aide 2x/week. +
remote minor tobacco, occasional glass of wine with dinner, no
IVDU.
Septicemia due to anaerobes,Septic shock,Encephalopathy, unspecified,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Paralytic ileus,Acidosis,Hemorrhage of gastrointestinal tract, unspecified,Severe sepsis,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Unspecified essential hypertension,Diseases of tricuspid valve,Other chronic pulmonary heart diseases,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Depressive disorder, not elsewhere classified
Anaerobic septicemia,Septic shock,Encephalopathy NOS,Int inf clstrdium dfcile,Acute kidney failure NOS,Paralytic ileus,Acidosis,Gastrointest hemorr NOS,Severe sepsis,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Hypertension NOS,Tricuspid valve disease,Chr pulmon heart dis NEC,Hx TIA/stroke w/o resid,Depressive disorder NEC
Admission Date:  [**2157-8-24**]              Discharge Date:   [**2157-8-30**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Doctor Last Name 10493**]
Chief Complaint:
Diarrhea with fever

Major Surgical or Invasive Procedure:
None

History of Present Illness:
[**Age over 90 **] yo with HTN, CAD s/p CABG, severe TR, pHTN, PVD, s/p CVA in
[**2140**], prior MSSA UTI in [**5-/2157**], history of c. diff in [**6-/2157**],
presents with diarrhea. The patient reports over the last week
she has experienced diarrhea, up to 4-5 times daily. She reports
her diarrhea improved after coming home from rehab, but recurred
a week ago. She also reports abdominal pain, located on her
right upper quadrant and epigastrium. She discussed her symptoms
with her PCP two days ago, and he encouraged her to come in for
evaluation, but she declined and was started on empiric flagyl.
Stool c diff toxin sent from home, found to be positive. Her 24
hour caregiver at home noted her temp to be up to [**Age over 90 **] yesterday.

.
In the ED, initial VS were 100 89 131/49 12 100%. Labs
significant for leukocytosis of 28.9, creatinine up to 1.3,
negative cardiac enzymes, negative lactate, normal LFTs,
negative UA. EKG revealed RBBB. She was given ciprofloxacin and
flagyl, prior to noticing positive C diff toxin. She was given
3Ls NS. CT Abd revealed bile duct dilation, enlarged gallbladder
without clear stones, without obstruction, worsening bowel wall
edema in sigmoid (present on last CT [**5-/2157**]) consistent with
either ischemic or infectious colitis. General surgery was
consulted and recommended no surgical intervention at this time,
stated that gallbladder distension could be related to c diff or
poor nutrition, will follow. VS on transfer 99.6 145/52 69 16
100% on RA.
.
On the floor, the patient has persisent abdominal pain at the
right upper quadrant. She reports small amounts of liquid stool
while in the ED. She denies nausea and vomiting at this time.

Past Medical History:
1. Coronary artery disease, status post CABG in [**2140**].
2. Peripheral arterial disease with status post right carotid
endarterectomy in [**2140**].
3. CVA [**2140**], status post right CEA.
4. Hypertension.
5. Dyslipidemia.
6. Pulmonary hypertension.
7. Severe tricuspid regurgitation.
8. Presyncope.
9. Depression

Social History:
Lives alone, family nearby. Uses cane with ambulation. Widowed
in [**2114**]. Worked subsequently in a bank. Has 6 living children -
children check on her daily. Has home health aide 2x/week. +
remote minor tobacco, occasional glass of wine with dinner, no
IVDU.


Family History:
[**2-28**] children with HTN

Physical Exam:
Initial physical exam
Vitals: T: 97.3 BP: 139/66 P: 80 R: 18 O2: 100% on 4L
General: Alert, oriented, elderly female in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, 3/6 systolic murmur at RUSB with RV
heave, no rubs, gallops
Abdomen: soft, tender to palpation at RUQ, no guarding, no
rebound tenderness, mildly distended, bowel sounds present
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

On discharge:
VS:97.7 162/82 (140-162/60-86) 74(74-109) 18 94% RA
GENERAL: elderly woman, confused
HEENT: PERRLA, mucous membs dry, no lymphadenopathy
CHEST: diffuse inspiratory crackles
CV: rapid rate, irregular, II/VI holosystolic murmur at the apex

ABD: + BS, non-tender, mildly distended
EXT: warm, well perfused, no clubbing cyanosis or edema.
Dorsalis pedis pulses 2+ BL
NEURO: Responsive but confused, oriented to person, place and
year. left facial assymetry unchanged from prior, remaining
cranial nerves intact BL, difficult to assess neurologically as
pt is not cooperative, moving all extremities

Pertinent Results:
CBC
[**2157-8-30**] 09:05AM BLOOD WBC-21.8* RBC-4.00* Hgb-12.1 Hct-36.4
MCV-91 MCH-30.3 MCHC-33.2 RDW-15.9* Plt Ct-411
[**2157-8-29**] 06:50AM BLOOD WBC-17.0* RBC-3.77* Hgb-11.3* Hct-34.6*
MCV-92 MCH-29.9 MCHC-32.6 RDW-15.9* Plt Ct-385
[**2157-8-28**] 06:50AM BLOOD WBC-20.2* RBC-3.37* Hgb-10.5* Hct-30.9*
MCV-92 MCH-31.1 MCHC-33.9 RDW-15.8* Plt Ct-353
[**2157-8-27**] 04:16AM BLOOD WBC-37.2* RBC-3.48*# Hgb-10.6*# Hct-32.8*
MCV-94 MCH-30.6 MCHC-32.4 RDW-15.9* Plt Ct-358
[**2157-8-26**] 04:03AM BLOOD WBC-38.4* RBC-2.59* Hgb-7.8* Hct-24.1*
MCV-93 MCH-30.3 MCHC-32.5 RDW-15.8* Plt Ct-294
[**2157-8-25**] 12:12PM BLOOD WBC-31.7* RBC-2.98* Hgb-8.9* Hct-27.4*
MCV-92 MCH-29.8 MCHC-32.4 RDW-15.8* Plt Ct-296
[**2157-8-25**] 10:15AM BLOOD WBC-36.4* RBC-2.95* Hgb-9.0* Hct-27.3*
MCV-92 MCH-30.4 MCHC-32.9 RDW-15.4 Plt Ct-285
[**2157-8-25**] 04:05AM BLOOD WBC-33.6* RBC-3.20* Hgb-9.8* Hct-28.8*
MCV-90 MCH-30.7 MCHC-34.0 RDW-15.6* Plt Ct-269
[**2157-8-24**] 09:20AM BLOOD WBC-28.3* RBC-3.70* Hgb-11.3* Hct-34.5*
MCV-93 MCH-30.7 MCHC-32.9 RDW-15.7* Plt Ct-296
[**2157-8-23**] 11:10PM BLOOD WBC-28.9*# RBC-3.49* Hgb-10.7* Hct-31.9*
MCV-91 MCH-30.6 MCHC-33.4 RDW-15.6* Plt Ct-290

Coags
[**2157-8-30**] 09:05AM BLOOD PT-12.8 PTT-23.0 INR(PT)-1.1
[**2157-8-29**] 06:50AM BLOOD PT-12.6 PTT-22.8 INR(PT)-1.1
[**2157-8-28**] 06:50AM BLOOD PT-12.9 PTT-23.3 INR(PT)-1.1
[**2157-8-26**] 04:03AM BLOOD PT-14.3* PTT-25.5 INR(PT)-1.2*
[**2157-8-25**] 12:12PM BLOOD PT-15.2* PTT-36.5* INR(PT)-1.3*
[**2157-8-23**] 11:10PM BLOOD PT-13.2 PTT-24.7 INR(PT)-1.1

Chemistry
[**2157-8-30**] 09:05AM BLOOD Glucose-147* UreaN-15 Creat-0.8 Na-144
K-4.0 Cl-111* HCO3-25 AnGap-12
[**2157-8-29**] 06:50AM BLOOD Glucose-133* UreaN-19 Creat-0.9 Na-143
K-3.7 Cl-114* HCO3-20* AnGap-13
[**2157-8-28**] 06:50AM BLOOD Glucose-76 UreaN-22* Creat-1.0 Na-144
K-3.7 Cl-115* HCO3-21* AnGap-12
[**2157-8-27**] 04:16AM BLOOD Glucose-81 UreaN-29* Creat-1.2* Na-140
K-4.1 Cl-112* HCO3-16* AnGap-16
[**2157-8-26**] 04:24PM BLOOD Glucose-99 UreaN-34* Creat-1.3* Na-137
K-3.4 Cl-110* HCO3-16* AnGap-14
[**2157-8-26**] 04:03AM BLOOD Glucose-63* UreaN-37* Creat-1.4* Na-138
K-3.3 Cl-110* HCO3-14* AnGap-17
[**2157-8-25**] 12:12PM BLOOD Glucose-63* UreaN-40* Creat-1.6* Na-136
K-3.4 Cl-106 HCO3-18* AnGap-15
[**2157-8-25**] 04:05AM BLOOD Glucose-120* UreaN-35* Creat-1.5* Na-134
K-3.7 Cl-103 HCO3-19* AnGap-16
[**2157-8-24**] 09:20AM BLOOD Glucose-96 UreaN-17 Creat-1.0 Na-139
K-3.7 Cl-104 HCO3-22 AnGap-17
[**2157-8-23**] 11:10PM BLOOD Glucose-110* UreaN-20 Creat-1.3* Na-135
K-3.3 Cl-99 HCO3-23 AnGap-16
[**2157-8-30**] 09:05AM BLOOD Calcium-7.8* Phos-2.8 Mg-2.0
[**2157-8-29**] 06:50AM BLOOD Calcium-8.2* Phos-2.0* Mg-2.0
[**2157-8-28**] 06:50AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.1
[**2157-8-27**] 04:16AM BLOOD Calcium-8.6 Phos-1.9* Mg-2.4
[**2157-8-26**] 04:24PM BLOOD Calcium-8.3* Phos-1.8* Mg-2.3
[**2157-8-26**] 04:03AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.7
[**2157-8-25**] 12:12PM BLOOD Calcium-8.0* Phos-3.2 Mg-1.7
[**2157-8-25**] 04:05AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.8
[**2157-8-24**] 09:20AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.8

LFT
[**2157-8-26**] 04:03AM BLOOD ALT-10 AST-15 AlkPhos-66 TotBili-0.3
[**2157-8-25**] 12:12PM BLOOD ALT-9 AST-17 AlkPhos-76 TotBili-0.4
[**2157-8-25**] 04:05AM BLOOD ALT-6 AST-15 LD(LDH)-184 AlkPhos-87
TotBili-0.5
[**2157-8-24**] 09:20AM BLOOD ALT-7 AST-13 AlkPhos-93 TotBili-0.6
[**2157-8-23**] 11:10PM BLOOD ALT-10 AST-13 AlkPhos-91 Amylase-25
TotBili-1.1

Lipase
[**2157-8-25**] 12:12PM BLOOD Lipase-11
[**2157-8-23**] 11:10PM BLOOD Lipase-8

LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2157-8-24**]
2:34 PM
IMPRESSION:
1. Massively dilated gallbladder with pericholecystic fluid
without
gallbladder wall edema. Acute cholecystitis cannot be excluded.
2. Diffuse biliary dilatation and pancreatic duct dilatation,
unchanged from CT [**2157-8-24**]. The specific etiology cannot be
identified and could be further evaluated with ERCP.

ABDOMEN (SUPINE & ERECT) Study Date of [**2157-8-24**] 12:40 AM
IMPRESSION: Multiple dilated loops of bowel, can be seen in
[**Last Name (un) **] syndrome.

PORTABLE ABDOMEN Study Date of [**2157-8-25**] 10:50 AM
IMPRESSION: Diffuse dilation of the proximal large bowel and
small bowel
loops, which do not appear significantly changed compared to
prior. These
findings are concerning for ileus or [**Last Name (un) **] syndrome. No
evidence of large amount of free air. The bowel gas pattern is
not suggestive of obstruction. No significant change from the
prior.

CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2157-8-24**]
12:08 AM
IMPRESSION:
1. Massive dilation of the gallbladder with intra- and
extra-hepatic biliary dilation.
2. Diffuse sigmoid and rectal wall thickening concerning for
infection.
Proximal loops of large bowel are dilated, which can be seen in
[**Last Name (un) **]
syndrome.
3. No evidence of pulmonary embolism or acute aortic process.
4. Bibasilar interstitial abnormality concerning for
interstitial lung
disease, similar in appearance to the prior examination.

CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2157-8-23**]):
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 259**] @ 11:28P [**2157-8-23**].
      CLOSTRIDIUM DIFFICILE.
         FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
           (Reference Range-Negative).
         A positive result in a recently treated patient is of
uncertain
         significance unless the patient is currently
symptomatic
         (relapse).


Brief Hospital Course:
[**Age over 90 **] yo female with CAD, CVA, PVD, severe TR, HTN, depression,
admitted for persistent C diff colitis and abdominal pain.
Hospital course complicated by MICU stay for tachycardia &
hypotension likely [**12-28**] sepsis.
.
#. C diff colitis/abdominal pain: patient was admitted for
persistent diarrhea secondary to C diff.  Had been treated at
home with flagyl, then vancomycin, but not improving.  On
admission, she was noted to have a large distended abdomen
especially in RUQ and was found to have a large dilated
gallbladder on CT.  GI and surgery were consulted, but they were
of the opinion that it was likely due to ileus from the C diff
infection.  There were also concerns for obstruction given her
dilated CBD, however no obstruction was visualized on
ultrasound, and there were no signs of acute cholecystitis
radiologically.  Patient was urgently transferred to the MICU on
this admission for hypotension and unresponsiveness, likely due
to sepsis from the severe C diff infection.  Her blood pressure
was fluid responsive, but still required pressors in the ICU to
maintain blood pressures.  She stablizied in the ICU and was
subsequently called out to the floor, remaining on PO
vancomycin.  She will be discharged to rehab where she will
continue to receive PO vancomycin 4x/day for another week, then
once every 3 days for 2 weeks.
.
#. Goals of care:  Patient is DNR/DNI.  Following call out from
the MICU, a family meeting was held in order to discuss
patient's goals of care.  [**Name (NI) **] HCP (daughter) and son were
present at this meeting.  The family would like for her to be
discharged to a rehabilitation facility where she can be
reconditioned, and then go home with bridge to home hospice.  We
discussed at length what her comfort measures would include.
The family would like for her diarrhea to be addressed as a
comfort measure.  Should the patient again have diarrhea
concerning for C diff while at home on hospice, the family will
call her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**], who will provide them with a
prescription for PO vancomycin, in this way they would like to
avoid admission to the hospital.
.
#. Gallbladder distension: likely related to her C diff
infection causing ileus.  Surgery and GI were consulted and no
acute interventions were warranted.
.
#. Upper GI bleed - patient noted to have coffee ground emesis
prior to transfer to the ICU.  She received one unit of pRBC,
and since then has had stable hematocrits and been normotensive.
Aspirin and cilostazol were discontinued at the time given the
acute bleed.  Patient will continue on [**Hospital1 **] pantoprazole.  As her
hematocrits have been stable, we will also restart aspirin given
her history of stroke.
.
#. CAD/PVD: patient is s/p CABG, however aspirin was held for GI
bleed.  Patient will continue on betablocker, ACE inhibitor, and
statin.
.
#. HTN: patient will continue on metoprolol and lisinopril.
Blood pressure has been well controlled on this regimen.
.
#. Depression/agitation - home bupropion and trazadone were held
given acute illness.  Her mood and affect have been fairly good.
 Had been agitated in the ICU, but has since felt well following
transfer to the medicine floors.  Bupriopion and trazadone may
be restarted as needed.
.
#. Hx of CVA - Patient had been on cilostazol at home, but was
held for acute upper GI bleed.  She will be continued on
aspirin.

Medications on Admission:
Bupropion HCl 75 mg PO BID
Cilostazol 50 mg PO twice a day.
Labetalol 100 mg PO BID
Lisinopril 10 mg PO DAILY
Nifedipine 30 mg PO DAILY
Pravastatin 80 mg PO q PM.
Acetaminophen 325 mg 1-2 Tablets PO Q6H as needed for pain.
Aspirin 81 mg PO DAILY
Vitamin D 1,000 unit PO once a day.
Senna 8.6 mg PO every other day.
Trazodone 50 mg 0.5 Tablet PO HS as needed for insomnia.
flagyl started [**8-23**]


Discharge Disposition:
Extended Care

Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]

Discharge Diagnosis:
Primary diagnosis
C. Difficil colitis
.
Secondary diagnoses:
1. Coronary artery disease, status post CABG in [**2140**].
2. Peripheral arterial disease with status post right carotid
endarterectomy in [**2140**].
3. CVA [**2140**], status post right CEA.
4. Hypertension.
5. Dyslipidemia.
6. Pulmonary hypertension.
7. Severe tricuspid regurgitation.
8. Presyncope.
9. Depression
10. Upper gastrointestinal bleed
11. Massively enlarged gallbladder


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Ms [**Known lastname 7749**],
 It was a pleasure taking care of you in your stay at [**Hospital1 18**]. As
you know, you were admitted for C. Diff colitis. You were
treated with antibiotics with improvment in your symptoms. Your
hospitalization was complicated by a bleed from your stomach,
you were transfused one unit of blood and stabalized in the
intensive care unit.
-
We made the following changes to your medications
- STOP Cilostasol
- Continue Vancomycin antiboitic daily for one week, then change
to every three days for two weeks (total of three weeks of
therapy with decreasing frequency in last two weeks)

Followup Instructions:
We recommend that your follow up with your primary care
provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**] 1-2 weeks after leaving rehabilitation to
discuss your goals of care.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
{'Septicemia due to anaerobes,Septic shock,Encephalopathy, unspecified,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Paralytic ileus,Acidosis,Hemorrhage of gastrointestinal tract, unspecified,Severe sepsis,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Unspecified essential hypertension,Diseases of tricuspid valve,Other chronic pulmonary heart diseases,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,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: Diarrhea with fever

PRESENT ILLNESS: [**Age over 90 **] yo with HTN, CAD s/p CABG, severe TR, pHTN, PVD, s/p CVA in
[**2140**], prior MSSA UTI in [**5-/2157**], history of c. diff in [**6-/2157**],
presents with diarrhea. The patient reports over the last week
she has experienced diarrhea, up to 4-5 times daily. She reports
her diarrhea improved after coming home from rehab, but recurred
a week ago. She also reports abdominal pain, located on her
right upper quadrant and epigastrium. She discussed her symptoms
with her PCP two days ago, and he encouraged her to come in for
evaluation, but she declined and was started on empiric flagyl.
Stool c diff toxin sent from home, found to be positive. Her 24
hour caregiver at home noted her temp to be up to [**Age over 90 **] yesterday.

MEDICAL HISTORY: 1. Coronary artery disease, status post CABG in [**2140**].
2. Peripheral arterial disease with status post right carotid
endarterectomy in [**2140**].
3. CVA [**2140**], status post right CEA.
4. Hypertension.
5. Dyslipidemia.
6. Pulmonary hypertension.
7. Severe tricuspid regurgitation.
8. Presyncope.
9. Depression

MEDICATION ON ADMISSION: Bupropion HCl 75 mg PO BID
Cilostazol 50 mg PO twice a day.
Labetalol 100 mg PO BID
Lisinopril 10 mg PO DAILY
Nifedipine 30 mg PO DAILY
Pravastatin 80 mg PO q PM.
Acetaminophen 325 mg 1-2 Tablets PO Q6H as needed for pain.
Aspirin 81 mg PO DAILY
Vitamin D 1,000 unit PO once a day.
Senna 8.6 mg PO every other day.
Trazodone 50 mg 0.5 Tablet PO HS as needed for insomnia.
flagyl started [**8-23**]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Initial physical exam
Vitals: T: 97.3 BP: 139/66 P: 80 R: 18 O2: 100% on 4L
General: Alert, oriented, elderly female in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, 3/6 systolic murmur at RUSB with RV
heave, no rubs, gallops
Abdomen: soft, tender to palpation at RUQ, no guarding, no
rebound tenderness, mildly distended, bowel sounds present
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: [**2-28**] children with HTN

SOCIAL HISTORY: Lives alone, family nearby. Uses cane with ambulation. Widowed
in [**2114**]. Worked subsequently in a bank. Has 6 living children -
children check on her daily. Has home health aide 2x/week. +
remote minor tobacco, occasional glass of wine with dinner, no
IVDU. 

### Response:
{'Septicemia due to anaerobes,Septic shock,Encephalopathy, unspecified,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Paralytic ileus,Acidosis,Hemorrhage of gastrointestinal tract, unspecified,Severe sepsis,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Unspecified essential hypertension,Diseases of tricuspid valve,Other chronic pulmonary heart diseases,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Depressive disorder, not elsewhere classified'}
