CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: 70-year old gentleman with a history of diabetes, chronic kidney
disease (baseline Cr 1.4) and diastolic CHF (EF LVEF>55)
originally presenting from rehab facility on [**11-7**] for one day
of hypotension 3 days after slipping and falling. Per report had
been getting twice his usual dose of valsartan for unclear
reasons. No chest pain, not SOB, but sweaty and mildly
nauseated.

MEDICAL HISTORY: Type 2 diabetes mellitus - diagnosed in [**2121**]
CKD Stage III
Anemia of CKD
Hypertension
Pontine CVA w/ residual left leg weakness
Chronic bronchitis
OSA
COPD
Obesity
Hyperlipidemia
Gout
BPH
H/o BCC
S/p R shoulder replacement

MEDICATION ON ADMISSION: MEDICATIONS AT HOME (per [**Hospital1 599**]):
- Allopurinol 300mg daily
- Carvedilol 25mg [**Hospital1 **]
- Clopidogrel 75mg daily
- Digoxin 125 mcg QOD, alternating with 250mcg
- Diltiazem SR 360mg daily
- Duloxetine DR 20mg [**Hospital1 **]
- Advair 100-50 1 puff [**Hospital1 **]
- Furosemide 80mg [**Hospital1 **]
- Insulin humalog SS
- Humulin 22 units daily
((- Insulin Regular Hum U-500 120units QAM, 110 units Qnoon,
110units QPM.))
- Duoneb Q6hrs PRN
- Multivitamin 1 tablet daily
- Niacin 500mg SR
- Ranitidine 300mg daily
- Rosuvastatin 40mg daily
- Valsartan 80mg [**Hospital1 **]??
- Warfarin 3.5mg daily
- Acetaminophen 650mg Q6hrs PRN
- Milk of Mag 30mg daily PRN
- Fexofenadine 60mg [**Hospital1 **]

ALLERGIES: Codeine / Morphine

PHYSICAL EXAM: VS: T 97.9 BP 102/64 HR 91 RR 22 O2sat 96 on room air BS 179
GEN: obese, comfortable, NAD
HEENT: MMM
Neck: JVP flat
Cardiac: irregular irregular no R/G/M
Chest: mild bibasilar crackles, otherwise CTAB
Abdomen: soft, NT, ND, NABS
Extremities: 1+ bilateral nonpitting edema
Neuro: AXx3, CNII-XII grossly intact, EOMI
Skin: diaphoretic

FAMILY HISTORY: Largely Noncontributory. The patient's mother had a type of
sarcoma but he is uncertain of additional details.

SOCIAL HISTORY: He is a retired teacher. He does not smoke or drink alcohol
currently but used both remotely in [**2083**]. He admits to
occasional marijuana. Prior to his worsening weakness and last
hospitalization on [**2131-10-10**] he lived alone and did his own
shopping/cooking and was independent with ADLs/IADLs. He was
admitted now after having 2-3 weeks of rehab and he had been
home for only 1 day. He has no children and has never been
married but has siblings with whom he keeps in touch with
regularly.
Other iatrogenic hypotension,Acute kidney failure, unspecified,Unspecified disease of pericardium,Chronic diastolic heart failure,Pulmonary collapse,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Atrial fibrillation,Chronic kidney disease, Stage III (moderate),Anemia in chronic kidney disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Obstructive chronic bronchitis without exacerbation,Other late effects of cerebrovascular disease,Other disorders of muscle, ligament, and fascia,Obesity, unspecified,Leukocytosis, unspecified,Gout, unspecified,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified
Iatrogenc hypotnsion NEC,Acute kidney failure NOS,Pericardial disease NOS,Chr diastolic hrt fail,Pulmonary collapse,Adv eff cardiovasc NEC,Atrial fibrillation,Chr kidney dis stage III,Anemia in chr kidney dis,Hy kid NOS w cr kid I-IV,Obst chr bronc w/o exac,Late effect CV dis NEC,Muscle/ligament dis NEC,Obesity NOS,Leukocytosis NOS,Gout NOS,Long-term use anticoagul,Abnrml coagultion prfile,Adv eff anticoagulants,Chr pulmon heart dis NEC,DMII wo cmp uncntrld,Obstructive sleep apnea,Depressive disorder NEC
Admission Date:  [**2132-11-7**]              Discharge Date:   [**2132-11-12**]

Date of Birth:  [**2061-12-9**]             Sex:   M

Service: MEDICINE

Allergies:
Codeine / Morphine

Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Hypotension

Major Surgical or Invasive Procedure:
None

History of Present Illness:
70-year old gentleman with a history of diabetes, chronic kidney
disease (baseline Cr 1.4) and diastolic CHF (EF LVEF>55)
originally presenting from rehab facility on [**11-7**] for one day
of hypotension 3 days after slipping and falling. Per report had
been getting twice his usual dose of valsartan for unclear
reasons. No chest pain, not SOB, but sweaty and mildly
nauseated.

Review of systems on admission was notable for malaise since his
admission for chest pain at the start of [**Month (only) 359**]. He feels
generally weak and apathetic, which is unusual for him. He has
also had a non-productive cough for several weeks, for which he
was started on azithromycin five days ago. He has recently been
constipated. He denies recent fevers, chills, difficulty
urinating or headaches.

In the emergency department his VS were T 98, BP 94/48 improving
to 134/99, HR 60, RR 18 and 100% on RA. He was found to have a
new leukocytosis and crackles on lung exam and was given vanc,
zosyn and flagyl for a hospital-acquired pneumonia. A right IJ
was placed and he was given 3.5L of normal saline with
improvement of BPs. He had elevated LFTs and an abdominal and
pelvic CT scan was done, revealing a moderate pericardial
effusion. He was admitted to the ICU for suspected sepsis.

Past Medical History:
Type 2 diabetes mellitus - diagnosed in [**2121**]
CKD Stage III
Anemia of CKD
Hypertension
Pontine CVA w/ residual left leg weakness
Chronic bronchitis
OSA
COPD
Obesity
Hyperlipidemia
Gout
BPH
H/o BCC
S/p R shoulder replacement

Social History:
He is a retired teacher. He does not smoke or drink alcohol
currently but used both remotely in [**2083**]. He admits to
occasional marijuana. Prior to his worsening weakness and last
hospitalization on [**2131-10-10**] he lived alone and did his own
shopping/cooking and was independent with ADLs/IADLs. He was
admitted now after having 2-3 weeks of rehab and he had been
home for only 1 day. He has no children and has never been
married but has siblings with whom he keeps in touch with
regularly.

Family History:
Largely Noncontributory. The patient's mother had a type of
sarcoma but he is uncertain of additional details.

Physical Exam:
VS: T 97.9 BP 102/64 HR 91 RR 22 O2sat 96 on room air BS 179
GEN: obese, comfortable, NAD
HEENT: MMM
Neck: JVP flat
Cardiac: irregular irregular no R/G/M
Chest: mild bibasilar crackles, otherwise CTAB
Abdomen: soft, NT, ND, NABS
Extremities: 1+ bilateral nonpitting edema
Neuro: AXx3, CNII-XII grossly intact, EOMI
Skin: diaphoretic

Pertinent Results:
Labs on Admission:
[**2132-11-7**] 05:45PM BLOOD WBC-17.2* RBC-4.58* Hgb-13.7* Hct-40.8
MCV-89 MCH-30.0 MCHC-33.7 RDW-15.3 Plt Ct-301
[**2132-11-7**] 05:45PM BLOOD Neuts-88.4* Lymphs-6.0* Monos-4.6 Eos-0.7
Baso-0.4
[**2132-11-7**] 05:45PM BLOOD Glucose-175* UreaN-37* Creat-2.6*# Na-134
K-3.8 Cl-90* HCO3-31 AnGap-17
[**2132-11-7**] 05:45PM BLOOD ALT-85* AST-64* CK(CPK)-53 AlkPhos-352*
TotBili-0.9
[**2132-11-7**] 05:45PM BLOOD Calcium-8.9 Phos-3.6 Mg-2.3
[**2132-11-7**] 06:14PM BLOOD Glucose-174* Lactate-1.8 Na-134* K-3.1*
Cl-87* calHCO3-33*
[**2132-11-7**] 06:14PM BLOOD freeCa-1.02*

Labs on Discharge:
[**2132-11-12**] 04:50AM BLOOD WBC-13.9* RBC-4.02* Hgb-12.0* Hct-35.8*
MCV-89 MCH-29.7 MCHC-33.4 RDW-15.6* Plt Ct-417
[**2132-11-8**] 03:32AM BLOOD Neuts-85.7* Lymphs-7.9* Monos-5.3 Eos-0.8
Baso-0.3
[**2132-11-12**] 04:50AM BLOOD Glucose-73 UreaN-34* Creat-1.6* Na-141
K-3.7 Cl-99 HCO3-30 AnGap-16
[**2132-11-9**] 01:38AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.7*

Imaging:
LIVER OR GALLBLADDER US [**2132-11-7**]:
1. Gallbladder sludge without secondary findings to suggest
acute
cholecystitis.
2. Diffusely echogenic liver consistent with fatty infiltration.
Other forms of liver disease and more advanced liver diseases
including significant hepatic fibrosis/cirrhosis cannot be
excluded in this examination. Hypoechoic focus adjacent to the
gallbladder fossa most likely represents focal sparing.

CT PELVIS W/O CONTRAST Study Date of [**2132-11-7**]:
1. Moderate sized pericardial effusion, which is larger compared
to [**2132-10-22**].
2. Small bilateral pleural effusions, with opacification of the
right lower [**Last Name (LF) 3630**], [**First Name3 (LF) **] reflect atelectasis or consolidation.
3. Diverticulosis, without evidence of diverticulitis.
4. Single locule of air within the anterior subcutaneous fat in
the lower
abdomen. This may relate to subcutaneous injection. Clinical
correlation
suggested.

CHEST (PORTABLE AP) Study Date of [**2132-11-9**]:
Comparison is made with prior study [**11-8**]. Enlarged
cardiomediastinal
silhouette is stable. Patient has known pericardial effusion and
mild
cardiomegaly. Minimal bibasilar atelectases larger on the right
side are
unchanged. There is no pneumothorax or enlarging pleural
effusions. Right IJ catheter remains in place.
IMPRESSION: Stable appearance of the chest.

Brief Hospital Course:
Hypotension likely related to the recent increase in his
valsartan. There was some concern that he might have an
increasing pericardial effusion based on his chest CT. An
echocardiogram showed no evidence of tamponade. Observed in MICU
for 24 hours and pressures rising and stable. Transferred to
floor for further monitoring.

1. Hypotension: Resolved with IVF. Given response to fluids most
likely due to doubling of dose of [**Last Name (un) **] and possibly some volume
depletion and not sepsis. Only SIRS criteria was leukocytosis.
Initial concern for tamponade but no evidence of evolving
effusion on echo.  Valsartan dose decreased to 40mg Daily from
80mg [**Hospital1 **].  Lasix dose decreased from 80mg Daily from [**Hospital1 **].

2. Acute on chronic renal failure: The patient's Cr is now
resolving to 1.7 from a peak of 2.6 vs a baseline of ~ 1.4. Most
likely cause is pre-renal exacerbated by high levels of [**Last Name (un) **] and
hypotension.

3. Leukocytosis: Improving. 17.2 on admission --> 13.9 day
discharge. UA negative. No clinical symptoms of pneumonia and
CXR suggests atelactasis. Afebrile throughout admission.
Cultures negative on discharge.

4. Pericardial Effusion: New pericardial effusion on CT scan not
present three weeks ago but without significant effusion on
echo. No clinical symptoms of tamponade.

5. Atrial fibrillation: Currently in NSR. Patient had newly
diagnosed Afib on his last admission ~ 4 weeks prior to the
current admission. Continue diltiazem and digoxin.

6. INR elevated 3.8 on day of discharge, recommended to hold
coumadin on day of discharged and start decreased coumadin dose
2 mg on [**2132-11-13**].

7. Type 2 diabetes mellitus: Patient has difficult to control
diabetes and is followed at the [**Last Name (un) **]. His most recent A1c was
8.3%. Was on Insulin 100 units TID

8. Diastolic CHF: No sign of acute CHF episode. Continued
outpatient medications.
Decreased Lasix to 80mg Daily from [**Hospital1 **]. Can increase if patient
becomes fluid overloaded. Recommend daily weights and strict
I/O, if becomes positive increase Lasix.  Patient will follow up
with cardiology Dr. [**Last Name (STitle) **] in [**1-11**] weeks.

9. Elevated transaminases: Stable from prior admission when
changes consistent with fatty liver were seen on ultrasound.

10. Depression: Patient reports poor mood and satisfaction. TSH
was normal. He was continued on his Effexor and Celexa.

11. Hyperlidemia: Continued rosuvastatin and niacin.

12. GOUT: Continued Allopurinol

13. COPD: continue Advair, albuterol and ipratropium.

14. History of CVA: Continue plavix.

15. OSA: Pt refuses to use CPAP

Medications on Admission:
MEDICATIONS AT HOME (per [**Hospital1 599**]):
- Allopurinol 300mg daily
- Carvedilol 25mg [**Hospital1 **]
- Clopidogrel 75mg daily
- Digoxin 125 mcg QOD, alternating with 250mcg
- Diltiazem SR 360mg daily
- Duloxetine DR 20mg [**Hospital1 **]
- Advair 100-50 1 puff [**Hospital1 **]
- Furosemide 80mg [**Hospital1 **]
- Insulin humalog SS
- Humulin 22 units daily
((- Insulin Regular Hum U-500 120units QAM, 110 units Qnoon,
110units QPM.))
- Duoneb Q6hrs PRN
- Multivitamin 1 tablet daily
- Niacin 500mg SR
- Ranitidine 300mg daily
- Rosuvastatin 40mg daily
- Valsartan 80mg [**Hospital1 **]??
- Warfarin 3.5mg daily
- Acetaminophen 650mg Q6hrs PRN
- Milk of Mag 30mg daily PRN
- Fexofenadine 60mg [**Hospital1 **]


Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QHS (once a day (at bedtime)).
6. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Insulin Regular Hum U-500 Conc 500 unit/mL Solution Sig: One
Hundred (100) units Injection TID w/ meals ().
12. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: max 4 grams a day.
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
15. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): Hold for SBp < 100.
16. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
17. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
18. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP < 90.
20. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold for SBP < 90.
21. Diltzac ER 360 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day: Hold for SBP < 90, HR
< 60.
22. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Start [**2132-11-13**]. Due to elevated INR 3.8 holding dose [**2132-11-12**].

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]

Discharge Diagnosis:
1. Hypotension
2. Diastolic Heart Failure
3. Prerenal acute renal failure on CKD
4. Pericardial effusion without tamponade
5. Type 2 diabetes mellitus
6. Atrial fibrillation
7. Gout

Discharge Condition:
Good

Discharge Instructions:
You were admitted for low blood pressure which was felt to be
secondary to blood pressure medication because of this we have
decreased your Valsartan.

We have made changes to your medication - please follow the list
given to rehab.

Follow-up with your primary care doctor and cardiologist.

Call your doctor if you experience dizziness, chest pain,
shortness of breath or any other concerning symptoms.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Adhere to 2 gm sodium diet.

You are being discharged to [**Hospital 100**] Rehab.

Followup Instructions:
Appointments scheduled:
Provider: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 10476**], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2132-12-23**] 11:30

Schedule an appointment with your cardiologist Dr. [**Last Name (STitle) **] in [**1-11**]
weeks.

Schedule an appointment with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e from rehab. Dr. [**First Name (STitle) **] [**Location (un) **] COMMUNITY HEALTH
CENTER [**0-0-**]


Completed by:[**2132-11-12**]
{'Other iatrogenic hypotension,Acute kidney failure, unspecified,Unspecified disease of pericardium,Chronic diastolic heart failure,Pulmonary collapse,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Atrial fibrillation,Chronic kidney disease, Stage III (moderate),Anemia in chronic kidney disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Obstructive chronic bronchitis without exacerbation,Other late effects of cerebrovascular disease,Other disorders of muscle, ligament, and fascia,Obesity, unspecified,Leukocytosis, unspecified,Gout, unspecified,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Obstructive sleep apnea (adult)(pediatric),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: Hypotension

PRESENT ILLNESS: 70-year old gentleman with a history of diabetes, chronic kidney
disease (baseline Cr 1.4) and diastolic CHF (EF LVEF>55)
originally presenting from rehab facility on [**11-7**] for one day
of hypotension 3 days after slipping and falling. Per report had
been getting twice his usual dose of valsartan for unclear
reasons. No chest pain, not SOB, but sweaty and mildly
nauseated.

MEDICAL HISTORY: Type 2 diabetes mellitus - diagnosed in [**2121**]
CKD Stage III
Anemia of CKD
Hypertension
Pontine CVA w/ residual left leg weakness
Chronic bronchitis
OSA
COPD
Obesity
Hyperlipidemia
Gout
BPH
H/o BCC
S/p R shoulder replacement

MEDICATION ON ADMISSION: MEDICATIONS AT HOME (per [**Hospital1 599**]):
- Allopurinol 300mg daily
- Carvedilol 25mg [**Hospital1 **]
- Clopidogrel 75mg daily
- Digoxin 125 mcg QOD, alternating with 250mcg
- Diltiazem SR 360mg daily
- Duloxetine DR 20mg [**Hospital1 **]
- Advair 100-50 1 puff [**Hospital1 **]
- Furosemide 80mg [**Hospital1 **]
- Insulin humalog SS
- Humulin 22 units daily
((- Insulin Regular Hum U-500 120units QAM, 110 units Qnoon,
110units QPM.))
- Duoneb Q6hrs PRN
- Multivitamin 1 tablet daily
- Niacin 500mg SR
- Ranitidine 300mg daily
- Rosuvastatin 40mg daily
- Valsartan 80mg [**Hospital1 **]??
- Warfarin 3.5mg daily
- Acetaminophen 650mg Q6hrs PRN
- Milk of Mag 30mg daily PRN
- Fexofenadine 60mg [**Hospital1 **]

ALLERGIES: Codeine / Morphine

PHYSICAL EXAM: VS: T 97.9 BP 102/64 HR 91 RR 22 O2sat 96 on room air BS 179
GEN: obese, comfortable, NAD
HEENT: MMM
Neck: JVP flat
Cardiac: irregular irregular no R/G/M
Chest: mild bibasilar crackles, otherwise CTAB
Abdomen: soft, NT, ND, NABS
Extremities: 1+ bilateral nonpitting edema
Neuro: AXx3, CNII-XII grossly intact, EOMI
Skin: diaphoretic

FAMILY HISTORY: Largely Noncontributory. The patient's mother had a type of
sarcoma but he is uncertain of additional details.

SOCIAL HISTORY: He is a retired teacher. He does not smoke or drink alcohol
currently but used both remotely in [**2083**]. He admits to
occasional marijuana. Prior to his worsening weakness and last
hospitalization on [**2131-10-10**] he lived alone and did his own
shopping/cooking and was independent with ADLs/IADLs. He was
admitted now after having 2-3 weeks of rehab and he had been
home for only 1 day. He has no children and has never been
married but has siblings with whom he keeps in touch with
regularly. 

### Response:
{'Other iatrogenic hypotension,Acute kidney failure, unspecified,Unspecified disease of pericardium,Chronic diastolic heart failure,Pulmonary collapse,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Atrial fibrillation,Chronic kidney disease, Stage III (moderate),Anemia in chronic kidney disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Obstructive chronic bronchitis without exacerbation,Other late effects of cerebrovascular disease,Other disorders of muscle, ligament, and fascia,Obesity, unspecified,Leukocytosis, unspecified,Gout, unspecified,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified'}
