CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: The patient is a 78-year-old
gentleman with a recent prolonged hospital stay who failed
antibiotic therapy but developed C. difficile colitis, ultimately
three days, had lethargy, progressive hypotension.  They have
been holding all medications.  Today he was pancultured and
laboratories showed a white count of 27,000, creatinine
increased to 3.4, and a bicarbonate decreased to 15.  He was
given wide-open intravenous fluids, levofloxacin, Flagyl and
4 liters of normal saline, and was started on a Neo-Synephrine
drip and blood pressure improved.  His examination was
creatinine, and a decreased bicarbonate, and he was transferred
to the Intensive Care Unit for further management.

MEDICAL HISTORY: 1.  Right lower leg popliteal-to-dorsalis pedis bypass with
skin graft on [**2114-10-18**]
2.  Episode of C. difficile colitis in [**2114-10-1**]
3.  Diabetes
4.  Hypertension
5.  Cerebrovascular accident in [**2112**]

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is a retired postal worker, lives
with his wife.  Former tobacco, 30+ pack years. Occasional
alcohol.
Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Ulcer of heel and midfoot,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension
Int inf clstrdium dfcile,Acute kidney failure NOS,Ulcer of heel & midfoot,DMII wo cmp nt st uncntr,Hypertension NOS
Admission Date:  [**2114-11-4**]       Discharge Date:  [**2114-11-26**]


Service:  MICU
CHIEF COMPLAINT:  Hypotension

HISTORY OF PRESENT ILLNESS:   The patient is a 78-year-old
gentleman with a recent prolonged hospital stay who failed
antibiotic therapy but developed C. difficile colitis, ultimately
three days, had lethargy, progressive hypotension.  They have
been holding all medications.  Today he was pancultured and
laboratories showed a white count of 27,000, creatinine
increased to 3.4, and a bicarbonate decreased to 15.  He was
given wide-open intravenous fluids, levofloxacin, Flagyl and
4 liters of normal saline, and was started on a Neo-Synephrine
drip and blood pressure improved.  His examination was
creatinine, and a decreased bicarbonate, and he was transferred
to the Intensive Care Unit for further management.

PAST MEDICAL HISTORY:
1.  Right lower leg popliteal-to-dorsalis pedis bypass with
skin graft on [**2114-10-18**]
2.  Episode of C. difficile colitis in [**2114-10-1**]
3.  Diabetes
4.  Hypertension
5.  Cerebrovascular accident in [**2112**]

MEDICATIONS:   Glyburide 2.5 every morning, sliding scale
regular insulin, Neurontin 300 mg twice a day, Lopressor 25
mg twice a day, Lisinopril 40 mg once daily, Zoloft 50 mg
once daily, Zantac 150 twice a day, Oxycontin 10 mg twice a
day, heparin subcutaneously 5000 units twice a day, and the
patient received one dose of Unasyn, Flagyl and Levaquin.

ALLERGIES:   No known drug allergies.

SOCIAL HISTORY:   The patient is a retired postal worker, lives
with his wife.  Former tobacco, 30+ pack years. Occasional
alcohol.

PHYSICAL EXAMINATION:   Vitals on admission:  Temperature
100.6, pulse 110, blood pressure 70/30, respiratory rate 20,
oxygen saturation 95% on room air.  In general, pleasant,
elderly gentleman, in no acute distress.  Head, eyes, ears,
nose and throat:  Normocephalic, atraumatic, pupils equal,
round and reactive to light, mucous membranes dry.  Neck
supple.  Heart:  Tachycardic, normal S1 and S2.  Chest clear
to auscultation bilaterally.  Abdomen soft, distended,
nontender to deep palpation.  Guaiac negative.  Extremities:
Right leg well healing, an incision in the right lower
extremity.  Left heel ulcer with eschar.  Right Achilles,
right heel ulcer, also appears well healing.  Neurological
examination:  Alert and oriented x 3, cranial nerves II
through XII intact, moving all extremities, with good
strength.

LABORATORY DATA:   On admission, white count 35.0, hematocrit
40.1, platelets 416.  SMA-7:  Sodium 136, potassium 4.6,
chloride 115, bicarbonate 16, BUN 63, creatinine 3.0, glucose
218.  Calcium 6.6, magnesium 1.6, albumin 1.6.  INR 1.2.
Liver function tests normal.  Urinalysis negative.  Blood
culture, stool culture and urine culture pending.  Chest
x-ray revealed good lung volumes and elevated right
hemidiaphragm, no infiltrates.  KUB showed no distended loops
of bowel, no evidence of free air.  Electrocardiogram
revealed sinus tachycardia at a rate of 100, left axis
deviation, right bundle branch block, left ventricular
hypertrophy, T wave inversions in V1 through V3, no old
electrocardiogram for comparison.

HOSPITAL COURSE:
1.  Hypotension:  The patient was aggressively hydrated with
intravenous fluids.  He was started on a Neo-Synephrine drip for
the possibility of a septic picture.  However, the patient
responded well to volume resuscitation.  Neo-Synephrine was
weaned off rapidly.  The patient's hypotension most likely
secondary to hypovolemia secondary to diarrhea.  The patient
was transferred to the floor on the third day of hospitalization
on [**2114-11-6**].

2.  Infectious Disease:  Patient admitted with a presumed
infectious picture with a white count of 35.0.  Stool cultures
came back positive for C. difficile colitis.  The patient had a
CT of his abdomen which revealed a pancolitis with the large
bowel edema and inflammation, no evidence of intra-abdominal
abscesses.  The patient was started on oral Flagyl.  The patient
was transferred to the floor on oral Flagyl.  The patient's white
count initially started to decrease on his medicines.  Number of
bowel movements remained five to six per day.  White count went
from 35 to a low of around 18, although it was found out that the
patient was having difficulty taking some of his pills and had
missed several doses of his Flagyl, and his white count had
rebounded up to 25.  Abdominal pain persisted.  A repeat CT
of the abdomen revealed slight improvement of his pancolitis, and
again no evidence of any intra-abdominal fluid collections or
abscesses.  The patient was continued on his Flagyl for up to a
14 day course, with signs of improvement, bowel movements down to
about three to four a day, however, the patient still with watery
stools and a slightly elevated white count.  The patient was
switched, after a 14 day course of oral Flagyl, to oral
vancomycin 125 mg four times a day, for further empiric therapy
of C. diff colitis.  The patient continued to improve, down to
only one or two bowel movements.  C. difficile toxin was negative
on repeat analysis on [**11-21**],24, and 25. The patient is to
be discharged to rehabilitation on oral vancomycin to complete an
empiric 10 day course.

3.  Renal:  Patient admitted in acute renal failure. Baseline
creatinine around 1 to 1.3, presenting with a creatinine at 3.0.
The patient was aggressively volume hydrated and the patient's
creatinine slowly decreased back to normal from 3.0 to .7 to .8
on discharge.

4.  Vascular:  Patient status post right lower extremity
bypass for a right intratibial ulcer in [**Month (only) 359**].  Vascular
was following the ulcer throughout the hospital stay.  The
patient's ulcer was healed well, with twice a day wet-to-dry
dressing changes.  The patient is to continue with twice a
day dressing changes at [**Hospital 38**] Rehabilitation.

5.  Podiatry:  Podiatry was consulted for a right heel ulcer.
Podiatry deemed that the Achilles tendon needed debridement
during this hospitalization.  The patient was taken to the
operating room for debridement of the right Achilles tendon.
The patient was continued on twice a day dressing changes
using Duoderm hydrogel to Adaptic dressing followed by saline
soaked gauze.  Also added Regranex to encourage wound healing.
The patient will follow up with Podiatry, Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) **]
for probable skin grafting over the right Achilles tendon site
on [**2114-12-11**] at 9:10 am.

6.  Nutrition:  Patient initially admitted dehydrated and
malnourished.  Initially the patient was aggressively hydrated
with intravenous fluids and was encouraged to have a clear diet
with Boost supplements.  Nutrition was consulted. The patient was
continued on Boost plus supplements with meals, however,
nutritional intake was not adequate.  The patient was initially
started on peripheral parenteral nutrition, then switched to
total parenteral nutrition and made nothing by mouth. The patient
was given six days of total parenteral nutrition with increase in
energy level and increase in appetite as the frequency of bowel
movements decreased.  The patient started to take clears, and
then a BRAT diet.  The patient will be discharged on a low
residue BRAT diet.

7.  Endocrine:  Patient with diabetes, continued on Glyburide
2.5 mg in the morning and a sliding scale of regular insulin.
When total parenteral nutrition was added, insulin into his total
parenteral nutrition mix.  He is now on Glyburide and sliding
scale regular insulin.

DISCHARGE DIAGNOSIS:
1.  C. difficile colitis
2.  Acute renal failure
3.  Hypovolemic hypotension
4.  Status post debridement of right Achilles tendon

DISCHARGE MEDICATIONS:  Same as on arrival, with the
exception of increasing Zoloft from 50 mg to 100 mg by mouth
once daily, adding vancomycin 125 mg by mouth four times a
day for 10 days which was started on [**11-19**], adding
heparin 5000 units subcutaneously twice a day until the
patient is fully ambulatory, adding Duoderm hydrogel for
twice a day dressing changes to the right Achilles tendon,
adding Regranex applied to the right Achilles tendon at
night.

DISCHARGE CONDITION:  Stable.  Patient to be discharged to
[**Hospital 38**] Rehabilitation.  To follow up with primary care
physician, [**Last Name (NamePattern4) **]. [**Name (NI) **] [**Last Name (NamePattern1) **], in one to two weeks.  Also to
follow up with Dr. [**Last Name (STitle) **], podiatrist, [**Telephone/Fax (1) **], for further
skin grafting on [**2114-12-11**] at 9:10 am.




                            [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(2) 4814**]

Dictated By:[**Name8 (MD) 2439**]
MEDQUIST36

D:  [**2114-11-23**]  02:00
T:  [**2114-11-23**]  02:49
JOB#:  [**Job Number 35989**]
{'Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Ulcer of heel and midfoot,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,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: The patient is a 78-year-old
gentleman with a recent prolonged hospital stay who failed
antibiotic therapy but developed C. difficile colitis, ultimately
three days, had lethargy, progressive hypotension.  They have
been holding all medications.  Today he was pancultured and
laboratories showed a white count of 27,000, creatinine
increased to 3.4, and a bicarbonate decreased to 15.  He was
given wide-open intravenous fluids, levofloxacin, Flagyl and
4 liters of normal saline, and was started on a Neo-Synephrine
drip and blood pressure improved.  His examination was
creatinine, and a decreased bicarbonate, and he was transferred
to the Intensive Care Unit for further management.

MEDICAL HISTORY: 1.  Right lower leg popliteal-to-dorsalis pedis bypass with
skin graft on [**2114-10-18**]
2.  Episode of C. difficile colitis in [**2114-10-1**]
3.  Diabetes
4.  Hypertension
5.  Cerebrovascular accident in [**2112**]

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is a retired postal worker, lives
with his wife.  Former tobacco, 30+ pack years. Occasional
alcohol. 

### Response:
{'Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Ulcer of heel and midfoot,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}
