CHIEF COMPLAINT: Weakness

PRESENT ILLNESS: The patient is a 84F hx of multiple medical problems: ESRD on HD
(MWF), DM2, PVD (s/p multiple stents), Afib (on coumadin), AS
s/pmAVR, recurrent GIB [**2-9**] diverticulosis s/p colectomy with
ostomy who presents with weakness. She has been feeling weak for
the past 3 days, however has no localizing symptoms over that
time. 5 days ago, she had an episode where she was trying to
reach something no her bedside table but was unable to; she
ended up sliding off the bed on her knees - no head strike/LOC.
Denies fevers, chills, sweats, sore throat, chest pain,
shortness of breath, cough, N/V/D at home.
.
In the ED, initial VS: 96.4 80 103/54 16 96%. Patient was
initially refusing labs and interventions, however spiked a
fever to 101.6 in the ED. She received vancomycin, ceftriaxone,
azithromycin to cover pneumonia as well as possible line
infection as well as 2L NS. CXR was done which showed low lung
volumes and unable to rule out RLL infiltrate. Head CT showed no
acute intracranial process. Her BP did drop to 89 at one point,
but improved with IVF. On transfer vitals were: 97.6 - 83 - 21
102/60 100% 2 liters.
.
Currently, she feels well. She thinks the IVF made her feel much
better than she was previously.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.

MEDICAL HISTORY: 1. history of repeated GI bleeds: past work up revealing various

MEDICATION ON ADMISSION: 1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Protamine

PHYSICAL EXAM: Admission:
VS - Temp 98.1F, 101/56BP, 80HR , 18R , O2-sat 100% 2L
GENERAL - well-appearing female in NAD, comfortable, appropriate

FAMILY HISTORY: She is an only child. Grandfather died of cancer but son is not
sure of what type. Three sons with htn. Pt. denies any other
history of CA, DM, or HTN in her parents.

SOCIAL HISTORY: Denies tobacco, drug or illicit drug use. Lives at home with
husband and 53 year old son who prepares her medications. Other
sons lives in [**Name (NI) 47**] and [**Name (NI) 4565**], daughter lives in
[**Name (NI) 669**]. Pt is a retired work supervisor at Veteran's Hospital
in JP. Retired about 10 years ago.
Other staphylococcal septicemia,End stage renal disease,Septic shock,Acute on chronic diastolic heart failure,Acute and subacute bacterial endocarditis,Encephalopathy, unspecified,Acidosis,Delirium due to conditions classified elsewhere,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Infection and inflammatory reaction due to other vascular device, implant, and graft,Other candidiasis of other specified sites,Severe sepsis,Heart valve replaced by other means,Other secondary thrombocytopenia,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other chronic pulmonary heart diseases,Atrial fibrillation,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Anemia in chronic kidney disease,Hypoxemia,Peripheral vascular disease, unspecified,Diverticulosis of colon (without mention of hemorrhage),Knee joint replacement,Long-term (current) use of insulin,Acquired absence of intestine (large) (small),Renal dialysis status,Personal history of colonic polyps,Do not resuscitate status,Colostomy status,Other dependence on machines, supplemental oxygen,Other specified antibiotics causing adverse effects in therapeutic use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Staphylcocc septicem NEC,End stage renal disease,Septic shock,Ac on chr diast hrt fail,Ac/subac bact endocard,Encephalopathy NOS,Acidosis,Delirium d/t other cond,Hyp kid NOS w cr kid V,React-oth vasc dev/graft,Candidiasis site NEC,Severe sepsis,Heart valve replac NEC,Sec thrombocytpenia NEC,DMII renl nt st uncntrld,Chr pulmon heart dis NEC,Atrial fibrillation,Hyperlipidemia NEC/NOS,Hypothyroidism NOS,Anemia in chr kidney dis,Hypoxemia,Periph vascular dis NOS,Dvrtclo colon w/o hmrhg,Joint replaced knee,Long-term use of insulin,Acquire absnce intestine,Renal dialysis status,Prsnl hst colonic polyps,Do not resusctate status,Colostomy status,Depend-supplement oxygen,Adv eff antibiotics NEC,Abn react-procedure NEC
Admission Date:  [**2169-1-9**]              Discharge Date:   [**2169-1-28**]

Date of Birth:  [**2084-10-17**]             Sex:   F

Service: EMERGENCY

Allergies:
Protamine

Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Weakness

Major Surgical or Invasive Procedure:
Left IJ Central line Placement X 2
Left dialysis catheter interchange
arterial line placement
Left femoral CVC placement
Left temporary HD line placement
Left tunneled HD line placement

History of Present Illness:
The patient is a 84F hx of multiple medical problems: ESRD on HD
(MWF), DM2, PVD (s/p multiple stents), Afib (on coumadin), AS
s/pmAVR, recurrent GIB [**2-9**] diverticulosis s/p colectomy with
ostomy who presents with weakness. She has been feeling weak for
the past 3 days, however has no localizing symptoms over that
time. 5 days ago, she had an episode where she was trying to
reach something no her bedside table but was unable to; she
ended up sliding off the bed on her knees - no head strike/LOC.
Denies fevers, chills, sweats, sore throat, chest pain,
shortness of breath, cough, N/V/D at home.
.
In the ED, initial VS: 96.4 80 103/54 16 96%. Patient was
initially refusing labs and interventions, however spiked a
fever to 101.6 in the ED. She received vancomycin, ceftriaxone,
azithromycin to cover pneumonia as well as possible line
infection as well as 2L NS. CXR was done which showed low lung
volumes and unable to rule out RLL infiltrate. Head CT showed no
acute intracranial process. Her BP did drop to 89 at one point,
but improved with IVF. On transfer vitals were: 97.6 - 83 - 21
102/60 100% 2 liters.
.
Currently, she feels well. She thinks the IVF made her feel much
better than she was previously.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.


Past Medical History:
1. history of repeated GI bleeds: past work up revealing various

potential sources along her GI tract including small bowl AVM's,

colonic polyps, ascending and transverse colon diverticulosis.
Had L hemicolectomy with transverse colostomy and [**Doctor Last Name 3379**]
pouch in [**10/2162**] with pathology examination revealing
diverticulosis as the source of bleed.
2. Diastolic CHF (EF 65-75%) on 2L O2 at home
3. Severe AS s/p mechanical [**Year (4 digits) 1291**] [**12-15**], [**Hospital3 9642**]
4. HLD
5. ESRD on HD (MWF)
6. Hypothyroidism
7. Atrial fibrillation on amiodarone and coumadin
8. PVD
9. Diabetes Mellitus
10. HTN
11. [**2168-1-27**]: Stenting of left superficial femoral
artery/above-knee popliteal artery transition
12. [**2168-1-28**]: Left Calf Ulcer Debridement
13. [**2168-2-26**]: Left lower extremity wound debridement
14. [**2168-3-8**]: Split thickness skin graft from right thigh to left

lower calf
15. [**2168-4-19**]: left lower extremity angioplasty
16. [**2168-4-27**]: Debridement of eschar and bone from the posterior
aspect of the left heel
17. Bilateral TKR
18. Open cholecystectomy
[**76**]. ORIF right periprosthetic femur fracture with RLE plate [**2164**]

20. Left upper arm radiocephalic AV fistula [**2164**] , Left upper
arm arteriovenous graft angioplasty , L upper arm AV graft [**2165**].
 Angioplasty/fistulogram [**2166**] x 5 and [**2167**] x3


Social History:
Denies tobacco, drug or illicit drug use. Lives at home with
husband and 53 year old son who prepares her medications. Other
sons lives in [**Name (NI) 47**] and [**Name (NI) 4565**], daughter lives in
[**Name (NI) 669**]. Pt is a retired work supervisor at Veteran's Hospital
in JP. Retired about 10 years ago.

Family History:
She is an only child. Grandfather died of cancer but son is not
sure of what type. Three sons with htn. Pt. denies any other
history of CA, DM, or HTN in her parents.


Physical Exam:
Admission:
VS - Temp 98.1F, 101/56BP, 80HR , 18R , O2-sat 100% 2L
GENERAL - well-appearing female in NAD, comfortable, appropriate

HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly,
LUNGS - CTA bilat with decreased BS RLL
HEART - RRR, systolic murmur heard at apex
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, colostomy bag in place
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-13**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, bilateral resting hand tremor

.
Discharge
She is unresponsive to mechanical stimuli, does not have any
respirations visually or to auscultation, no heart sounds,
pupils
are fixed and dilated, nonreactive to light. Her son was
[**Name (NI) 653**] and notified and he is coming to the hospital


Pertinent Results:
Admission labs:
[**2169-1-9**] 08:07PM   WBC-10.5# RBC-3.39*# HGB-10.5*# HCT-31.6*#
MCV-93 MCH-31.0 MCHC-33.3 RDW-14.9
[**2169-1-9**] 08:07PM   NEUTS-84.3* LYMPHS-7.8* MONOS-7.3 EOS-0.4
BASOS-0.3
[**2169-1-9**] 08:07PM   PLT COUNT-211
[**2169-1-9**] 08:07PM   PT-30.5* PTT-36.6* INR(PT)-3.0*
[**2169-1-9**] 08:10PM   GLUCOSE-216* LACTATE-2.1* K+-4.5
[**2169-1-9**] 08:07PM   GLUCOSE-234* UREA N-24* CREAT-4.9*#
SODIUM-139 POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-28 ANION GAP-16
[**2169-1-9**] 08:07PM   ALT(SGPT)-10 AST(SGOT)-24 LD(LDH)-373*
CK(CPK)-81 ALK PHOS-137* TOT BILI-0.3
[**2169-1-9**] 08:07PM   LIPASE-49
[**2169-1-9**] 08:07PM   cTropnT-0.18*
[**2169-1-9**] 08:07PM   CK-MB-1
[**2169-1-9**] 08:07PM   CALCIUM-7.6* PHOSPHATE-1.5* MAGNESIUM-1.7

ECG [**2169-1-9**]: Sinus rhythm with non-diagnostic repolarization
abnormalities. Compared to the previous tracing of [**2168-9-30**] there
is no significant change.

CT HEAD [**2169-1-9**]: IMPRESSION: No acute intracranial process.

CXR [**2169-1-9**]: IMPRESSION: Small right pleural effusion and mild
pulmonary vascular congestion. Right basilar opacity is most
likely atelectasis, but infection cannot be entirely excluded.

ECG [**2169-1-10**]: The rhythm appears to be junctional with probable
A-V dissociation. The Q-T interval is prolonged. This has
replaced sinus rhythm seen on the previous tracing. The
previously noted non-specific ST segment abnormalities remain.
Clinical correlation is suggested

.
Discharge Labs

[**2169-1-27**] 02:05AM BLOOD WBC-5.3 RBC-2.67* Hgb-8.4* Hct-26.0*
MCV-97 MCH-31.6 MCHC-32.4 RDW-19.4* Plt Ct-75*
[**2169-1-26**] 04:07AM BLOOD WBC-4.8 RBC-2.79* Hgb-8.6* Hct-27.1*
MCV-97 MCH-30.9 MCHC-31.9 RDW-19.5* Plt Ct-92*
[**2169-1-25**] 04:25AM BLOOD WBC-5.6 RBC-3.01* Hgb-9.3* Hct-29.1*
MCV-97 MCH-30.7 MCHC-31.7 RDW-19.4* Plt Ct-127*
[**2169-1-24**] 03:53AM BLOOD WBC-4.5 RBC-3.06* Hgb-9.6* Hct-29.5*
MCV-97 MCH-31.3 MCHC-32.4 RDW-17.9* Plt Ct-145*
[**2169-1-23**] 04:34PM BLOOD Hct-29.3*
[**2169-1-22**] 05:11AM BLOOD WBC-6.3 RBC-3.13* Hgb-9.4* Hct-30.4*
MCV-97 MCH-30.2 MCHC-31.0 RDW-17.3* Plt Ct-231
[**2169-1-20**] 03:30AM BLOOD WBC-6.9 RBC-3.09* Hgb-9.2* Hct-29.3*
MCV-95 MCH-29.8 MCHC-31.4 RDW-16.7* Plt Ct-299
[**2169-1-27**] 02:05AM BLOOD Plt Ct-75*
[**2169-1-26**] 04:07AM BLOOD Plt Ct-92*
[**2169-1-26**] 04:07AM BLOOD PT-22.0* PTT-72.2* INR(PT)-2.1*
[**2169-1-25**] 10:37AM BLOOD PT-21.0* PTT-110.0* INR(PT)-2.0*
[**2169-1-27**] 06:20PM BLOOD Glucose-167* UreaN-33* Creat-3.7*# Na-138
K-4.0 Cl-100 HCO3-18* AnGap-24*
[**2169-1-27**] 02:05AM BLOOD Glucose-264* UreaN-82* Creat-7.3*# Na-135
K-4.7 Cl-96 HCO3-20* AnGap-24*
[**2169-1-26**] 04:07AM BLOOD Glucose-157* UreaN-52* Creat-5.6* Na-134
K-4.2 Cl-97 HCO3-19* AnGap-22*
[**2169-1-25**] 05:10PM BLOOD Glucose-161* UreaN-47* Creat-5.2* Na-138
K-4.1 Cl-100 HCO3-20* AnGap-22*
[**2169-1-25**] 04:25AM BLOOD Glucose-180* UreaN-40* Creat-4.5*# Na-137
K-4.4 Cl-99 HCO3-16* AnGap-26*
[**2169-1-24**] 03:53AM BLOOD Glucose-155* UreaN-51* Creat-6.3* Na-135
K-4.1 Cl-96 HCO3-22 AnGap-21*
[**2169-1-23**] 04:34PM BLOOD Glucose-176* UreaN-47* Creat-5.5* Na-132*
K-3.7 Cl-95* HCO3-24 AnGap-17
[**2169-1-23**] 03:29AM BLOOD Glucose-152* UreaN-37* Creat-4.7*# Na-136
K-4.2 Cl-97 HCO3-22 AnGap-21*
[**2169-1-25**] 04:25AM BLOOD ALT-67* AST-97* LD(LDH)-410* AlkPhos-124*
TotBili-1.2
[**2169-1-20**] 03:30AM BLOOD CK-MB-2 cTropnT-0.13*
[**2169-1-9**] 08:07PM BLOOD cTropnT-0.18*
[**2169-1-9**] 08:07PM BLOOD CK-MB-1
[**2169-1-27**] 06:20PM BLOOD Calcium-7.9* Phos-4.9*# Mg-2.2
[**2169-1-27**] 02:05AM BLOOD Calcium-7.7* Phos-7.3*# Mg-2.6
[**2169-1-26**] 04:07AM BLOOD Calcium-7.1* Phos-5.5* Mg-2.2
[**2169-1-25**] 05:10PM BLOOD Calcium-7.6* Phos-5.1* Mg-2.2
[**2169-1-25**] 04:25AM BLOOD Albumin-3.1* Calcium-7.5* Phos-5.6*
Mg-2.2
[**2169-1-24**] 03:53AM BLOOD Calcium-6.6* Phos-5.7* Mg-2.2
[**2169-1-19**] 02:48PM BLOOD Cortsol-35.1*
[**2169-1-19**] 01:11PM BLOOD Cortsol-23.0*
[**2169-1-27**] 07:52AM BLOOD Vanco-16.7
[**2169-1-23**] 03:29AM BLOOD Vanco-3.1*
[**2169-1-21**] 08:46AM BLOOD Vanco-19.7
[**2169-1-20**] 09:00AM BLOOD Vanco-24.2*
[**2169-1-27**] 06:38PM BLOOD Type-CENTRAL VE Temp-36.7 Rates-/17
pO2-28* pCO2-40 pH-7.35 calTCO2-23 Base XS--4 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2169-1-27**] 02:00PM BLOOD Type-CENTRAL VE
[**2169-1-26**] 12:05PM BLOOD Type-CENTRAL VE Temp-35.6 Rates-/20
pO2-32* pCO2-40 pH-7.32* calTCO2-22 Base XS--6 Intubat-NOT
INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2169-1-26**] 06:24AM BLOOD Type-[**Last Name (un) **] pH-7.30* Comment-GREEN TOP
[**2169-1-27**] 06:38PM BLOOD Lactate-5.3*
[**2169-1-27**] 02:00PM BLOOD Lactate-3.7*
[**2169-1-27**] 02:20AM BLOOD Lactate-3.8*
[**2169-1-26**] 10:53AM BLOOD Lactate-4.6*
[**2169-1-26**] 06:29AM BLOOD Lactate-3.9*
[**2169-1-26**] 04:24AM BLOOD Lactate-3.4*
[**2169-1-26**] 01:44AM BLOOD Lactate-3.2*
[**2169-1-25**] 10:35PM BLOOD Lactate-3.6*
[**2169-1-26**] 06:29AM BLOOD freeCa-0.90*
[**2169-1-16**] 10:48AM BLOOD freeCa-1.27
[**2169-1-15**] 10:08PM BLOOD freeCa-1.15
[**2169-1-15**] 04:24PM BLOOD freeCa-1.22
[**2169-1-15**] 10:35AM BLOOD freeCa-1.11*

CTA chest [**2169-1-26**]
1. Biatrial cardiomegaly and possible pulmonary arterial
hypertension. No
pulmonary emboli or acute aortic abnormality.
2. Small non-hemorrhagic right pleural effusion. Bilateral lower
lobe
atelectasis, worse on the right, makes it difficult to exclude
small foci of
pneumonia, but there is no good evidence for pulmonary
infection.
3. Moderately extensive mediastinal adenopathy, probably not
related to heart
failure.
4. Left PIC line ends in the mid SVC, subclavian line ends at
the superior
cavoatrial junction.

Surface Echo [**2169-1-25**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
a mild resting left ventricular outflow tract obstruction. Right
ventricular chamber size is normal. with borderline normal free
wall function. A bileaflet aortic valve prosthesis is present.
The transaortic gradient is normal for this prosthesis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Small linear structures under the mitral valve
which appear to be consistent with torn mitral chordae are
present. Moderate to severe (3+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] Moderate to severe [3+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. There is no pericardial effusion.

IMPRESSION: Mild symmetric left ventricular hypertrophy with
hyperdynamic function and resting outflow tract gradient. Severe
pulmonary hypertension. Normal right ventricular cavity size
with borderline normal function. Moderate to severe mitral
regurgitation. Moderate to severe tricuspid regurgitation.
Well-seated aortic valve prosthesis with mild regurgitation.


Brief Hospital Course:
MICU Green Course:

The patient was initiated on broad spectrum antibiotics on the
medicine floor and transferred to the medical intensive care
unit for the management of septic shock and cardiogenic shock as
follows.

84F hx of multiple medical problems: ESRD on HD (MWF), DM2, PVD
(s/p multiple stents), Afib (on coumadin), AS s/pmAVR, recurrent
GIB [**2-9**] diverticulosis s/p colectomy with ostomy who presented
with hypotension. The patient was intially treated with broad
spectrum antibiotics for presumed sepsis. She was found to have
a staph. coag negative oxacillin resistent bactremia which was
thought to be due to mitral valve endocarditis. For this, she
had been on a regimen of Linezolid, Rifampin and Vancomcin per
ID consult.

Days later, she also grew [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] from one culture
taken from the right radial aterial line; this culture was not
reproduced and the right radial arterial line tip culture was
negative. She competed a course of micafingin for this. Her left
tunneled hd line, right radial arterial line, and left femoral
CVC were removed; a two day line holiday was completed.

She was intermittently on Levophed with SBP from 70-120 in a
span of two weeks; she spent a majority of the time requring
levophed even after ititiation of midodrine and pseudophed
orally. She recieved dialysis until she was below her dry weight
and then recieved dialysis per renal and her fluid status.

Her platelets were trending down in the last days of life and it
was thought to be due to linezolid bone marrow suppression or,
less likely, HIT.  Her DIC labs were negative. A heme onc
consult was obtained which recommended to follow platelets Q
daily. After the patient's lactate was found to be 5 with a new
anion gap acidosis, a repeat echocardiogram revealed worsening
TR and pulm regurgitation, with severe mitral regurgitation. CTA
was negative for pulmonary embolism. The patient was on a
heparin drip for stroke prophylaxis due to her mechanical aortic
valve. Her elevated lactate and new echo findings were
consistent with decompensating shock likely of a combined
sepsis/cardiogenic. A cardiology consultation was obtained,
which indicated continuing cardiogenic shock with a complonent
of sepsis as well. A family meeting took place with her son the
health care proxy and it decided not to pursue any escalation of
care. The patient's vasopressor was weaned off but she became
hypotensive again and she expired on the morning of [**2-/2169**] at
8:15 AM. The family was notified and came to see her at the
bedside.


Medications on Admission:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. insulin lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous ASDIR (AS DIRECTED): Continue to use your home
Insulin Sliding Scale as prescribed.
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)

Capsule, Delayed Release(E.C.) PO once a day.
7. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID

W/MEALS (3 TIMES A DAY WITH MEALS).
8. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO once a day.
9. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: Coumadin dosing should be titrated by your [**Hospital 197**] Clinic
for an INR goal 2.5-3.5.

Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
expired

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired


Completed by:[**2169-1-29**]
{'Other staphylococcal septicemia,End stage renal disease,Septic shock,Acute on chronic diastolic heart failure,Acute and subacute bacterial endocarditis,Encephalopathy, unspecified,Acidosis,Delirium due to conditions classified elsewhere,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Infection and inflammatory reaction due to other vascular device, implant, and graft,Other candidiasis of other specified sites,Severe sepsis,Heart valve replaced by other means,Other secondary thrombocytopenia,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other chronic pulmonary heart diseases,Atrial fibrillation,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Anemia in chronic kidney disease,Hypoxemia,Peripheral vascular disease, unspecified,Diverticulosis of colon (without mention of hemorrhage),Knee joint replacement,Long-term (current) use of insulin,Acquired absence of intestine (large) (small),Renal dialysis status,Personal history of colonic polyps,Do not resuscitate status,Colostomy status,Other dependence on machines, supplemental oxygen,Other specified antibiotics causing adverse effects in therapeutic use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: Weakness

PRESENT ILLNESS: The patient is a 84F hx of multiple medical problems: ESRD on HD
(MWF), DM2, PVD (s/p multiple stents), Afib (on coumadin), AS
s/pmAVR, recurrent GIB [**2-9**] diverticulosis s/p colectomy with
ostomy who presents with weakness. She has been feeling weak for
the past 3 days, however has no localizing symptoms over that
time. 5 days ago, she had an episode where she was trying to
reach something no her bedside table but was unable to; she
ended up sliding off the bed on her knees - no head strike/LOC.
Denies fevers, chills, sweats, sore throat, chest pain,
shortness of breath, cough, N/V/D at home.
.
In the ED, initial VS: 96.4 80 103/54 16 96%. Patient was
initially refusing labs and interventions, however spiked a
fever to 101.6 in the ED. She received vancomycin, ceftriaxone,
azithromycin to cover pneumonia as well as possible line
infection as well as 2L NS. CXR was done which showed low lung
volumes and unable to rule out RLL infiltrate. Head CT showed no
acute intracranial process. Her BP did drop to 89 at one point,
but improved with IVF. On transfer vitals were: 97.6 - 83 - 21
102/60 100% 2 liters.
.
Currently, she feels well. She thinks the IVF made her feel much
better than she was previously.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.

MEDICAL HISTORY: 1. history of repeated GI bleeds: past work up revealing various

MEDICATION ON ADMISSION: 1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Protamine

PHYSICAL EXAM: Admission:
VS - Temp 98.1F, 101/56BP, 80HR , 18R , O2-sat 100% 2L
GENERAL - well-appearing female in NAD, comfortable, appropriate

FAMILY HISTORY: She is an only child. Grandfather died of cancer but son is not
sure of what type. Three sons with htn. Pt. denies any other
history of CA, DM, or HTN in her parents.

SOCIAL HISTORY: Denies tobacco, drug or illicit drug use. Lives at home with
husband and 53 year old son who prepares her medications. Other
sons lives in [**Name (NI) 47**] and [**Name (NI) 4565**], daughter lives in
[**Name (NI) 669**]. Pt is a retired work supervisor at Veteran's Hospital
in JP. Retired about 10 years ago. 

### Response:
{'Other staphylococcal septicemia,End stage renal disease,Septic shock,Acute on chronic diastolic heart failure,Acute and subacute bacterial endocarditis,Encephalopathy, unspecified,Acidosis,Delirium due to conditions classified elsewhere,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Infection and inflammatory reaction due to other vascular device, implant, and graft,Other candidiasis of other specified sites,Severe sepsis,Heart valve replaced by other means,Other secondary thrombocytopenia,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other chronic pulmonary heart diseases,Atrial fibrillation,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Anemia in chronic kidney disease,Hypoxemia,Peripheral vascular disease, unspecified,Diverticulosis of colon (without mention of hemorrhage),Knee joint replacement,Long-term (current) use of insulin,Acquired absence of intestine (large) (small),Renal dialysis status,Personal history of colonic polyps,Do not resuscitate status,Colostomy status,Other dependence on machines, supplemental oxygen,Other specified antibiotics causing adverse effects in therapeutic use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
