CHIEF COMPLAINT: hypotension

PRESENT ILLNESS: Patient is a 64 year old man with a history of CAD, COPD, CHF,
diabetes, and hypertension who presented to the ED from
[**Hospital1 **] with ectopy during a sleep apnea test.  On the night
prior to admission the patient had a sleep study done at
[**Hospital1 **] which showed frequent SVT.  He also complained of
itching during the study.  He was transfered to the ED there
where an ECG showed NSR at a rate of 61 with Q in III, aVF but
no other abnormalities.  BP was 124/79. Patient had a bladder
scan that showed 550 cc of urine but he refused a urinary
catheter. Patient requested transfer to [**Hospital1 18**].
.
At the [**Hospital1 18**] ED BP was 106/50, HR 65, RR 16, O2 94% RA, T 97.3.
He was given his am meds which included isosorbide mononitrate
60 mg, finasteride 5 mg, lisinopril 5 mg, metoprolol XL 25 mg,
and aspirin 325 mg. At 3 pm his BP was noted to be 73/58. He
denied dizziness, shortness of breath, chest pain. He received
500 ml of NS with no change in BP.  At 4:30 BP was 101/49, but
at 7:30 BP was 90/69 and patient was somnolent. He received
another 700 cc of NS and BP was 80/58.
.
ROS: positive for vision changes, headaches.  negative for
fevers, chills, sweats, nausea, vomiting, shortness of breath,
chest pain, dysuria, abdominal pain, diarrhea, black or bloody
stools.

MEDICAL HISTORY: 1) CHF, EF 45% from most recent echo [**6-5**], mixed LV systolic and
diastolic dysfunction, cardiomyopathy
2) CAD, NSTEMI in [**3-6**] during admission for urosepsis with
hypotension and coma.
3) Type II DM c/b neuropathy, nephropathy, per pt no retinopathy

MEDICATION ON ADMISSION: escitalopram 5 mg qam, 10 mg qhs
calcium carbonate 500 mg qam
lasix 60 mg daily
aspirin EC 325 mg daily
colace 100 [**Hospital1 **]
tamsulosin SR 0.8 mg daily
isosorbide mononitrate SR 60 mg daily
finasteride 5 mg daily
calcitriol 0.25 micrograms daily
lisinopril 5 mg daily
toprol 25 mg daily
protonix 40 mg [**Hospital1 **]
oxycodone prn
lantus 11 units qhs
regular insulin sliding scale
oxycontin 15 mg [**Hospital1 **] prn

ALLERGIES: Vicodin / Ms Contin

PHYSICAL EXAM: VS: T 96.8 HR 63 BP 103/50 RR 15 O2 sat 87-96% 2L
Gen: Well appearing, comfortable, lying in bed in NAD. Slightly
somnolent but arousable and oriented x 3.
HEENT: PERRL, EOMI, sclera anicteric, MMM.
Neck: No LAD, or thyromegly. JVP at 10 cm.
CV: RRR with no m/r/g
Lungs: Decreased BS bilaterally with expiratory wheezes.
Abd: soft, NT, ND active BS, no hepatosplenomegly.
ext: cool with 1+ DP pulses. No clubbing, cyanosis or edema

FAMILY HISTORY: CVA - brother
Breast [**Name (NI) 3730**] - mother
emphysema - father

SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] does not smoke. Only minimal
ethanol. Otherwise, he is extremely sedentary.
Hypotension, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Dehydration,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Postinflammatory pulmonary fibrosis,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Anemia of other chronic disease,Obstructive sleep apnea (adult)(pediatric),Pain in joint, pelvic region and thigh,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Esophageal reflux,Unspecified glaucoma,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Old myocardial infarction,Depressive disorder, not elsewhere classified,Long-term (current) use of insulin,Hip joint replacement,Unspecified drug or medicinal substance causing adverse effects in therapeutic use
Hypotension NOS,Acute kidney failure NOS,Hyp kid NOS w cr kid V,Dehydration,CHF NOS,Chr airway obstruct NEC,Postinflam pulm fibrosis,BPH w urinary obs/LUTS,Anemia-other chronic dis,Obstructive sleep apnea,Joint pain-pelvis,DMII neuro nt st uncntrl,Neuropathy in diabetes,Esophageal reflux,Glaucoma NOS,Osteoarthros NOS-unspec,Old myocardial infarct,Depressive disorder NEC,Long-term use of insulin,Joint replaced hip,Adv eff medicinal NOS
Admission Date:  [**2142-5-28**]              Discharge Date:   [**2142-6-4**]

Date of Birth:  [**2078-1-6**]             Sex:   M

Service: MEDICINE

Allergies:
Vicodin / Ms Contin

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypotension

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Patient is a 64 year old man with a history of CAD, COPD, CHF,
diabetes, and hypertension who presented to the ED from
[**Hospital1 **] with ectopy during a sleep apnea test.  On the night
prior to admission the patient had a sleep study done at
[**Hospital1 **] which showed frequent SVT.  He also complained of
itching during the study.  He was transfered to the ED there
where an ECG showed NSR at a rate of 61 with Q in III, aVF but
no other abnormalities.  BP was 124/79. Patient had a bladder
scan that showed 550 cc of urine but he refused a urinary
catheter. Patient requested transfer to [**Hospital1 18**].
.
At the [**Hospital1 18**] ED BP was 106/50, HR 65, RR 16, O2 94% RA, T 97.3.
He was given his am meds which included isosorbide mononitrate
60 mg, finasteride 5 mg, lisinopril 5 mg, metoprolol XL 25 mg,
and aspirin 325 mg. At 3 pm his BP was noted to be 73/58. He
denied dizziness, shortness of breath, chest pain. He received
500 ml of NS with no change in BP.  At 4:30 BP was 101/49, but
at 7:30 BP was 90/69 and patient was somnolent. He received
another 700 cc of NS and BP was 80/58.
.
ROS: positive for vision changes, headaches.  negative for
fevers, chills, sweats, nausea, vomiting, shortness of breath,
chest pain, dysuria, abdominal pain, diarrhea, black or bloody
stools.


Past Medical History:
1) CHF, EF 45% from most recent echo [**6-5**], mixed LV systolic and
diastolic dysfunction, cardiomyopathy
2) CAD, NSTEMI in [**3-6**] during admission for urosepsis with
hypotension and coma.
3) Type II DM c/b neuropathy, nephropathy, per pt no retinopathy

4) HTN
5) CRI, baseline creatinine of 1.7
6) Anemia of chronic disease.
7) Sleep apnea on BiPAP, currently [**10-10**]
8) Chronic restrictive ventilatory disease secondary to a bile
duct leak with pulmonary fibrosis requiring decortication
9) Neuropathy - hands and feet
10) Lower extremity claudication
11) BPH.
12) Glaucoma; on carbonic anhydrase inhibitor
13) Bilateral cataracts s/p surgical removal
14) Depression
15) Osteoarthritis
16) Erectile dyscunction s/p Penile implant [**11-6**]
..
Past surgical history:
1) [**2138**] Roux-en-y reconstruction after laparoscopic
cholecystectomy c/b damage to CBD
2) [**2139**] Decortication for fibrothorax complicated by
respiratory failure requiring tracheostomy.
3) Appendectomy.
4) Left knee/hip replacement


Social History:
The patient lives with his wife. [**Name (NI) **] does not smoke. Only minimal
ethanol. Otherwise, he is extremely sedentary.


Family History:
CVA - brother
Breast [**Name (NI) 3730**] - mother
emphysema - father

Physical Exam:
VS: T 96.8 HR 63 BP 103/50 RR 15 O2 sat 87-96% 2L
Gen: Well appearing, comfortable, lying in bed in NAD. Slightly
somnolent but arousable and oriented x 3.
HEENT: PERRL, EOMI, sclera anicteric, MMM.
Neck: No LAD, or thyromegly. JVP at 10 cm.
CV: RRR with no m/r/g
Lungs: Decreased BS bilaterally with expiratory wheezes.
Abd: soft, NT, ND active BS, no hepatosplenomegly.
ext: cool with 1+ DP pulses. No clubbing, cyanosis or edema

Pertinent Results:
[**2142-5-28**] 08:00AM   PLT COUNT-133*
[**2142-5-28**] 08:00AM   NEUTS-70.4* LYMPHS-20.0 MONOS-4.1 EOS-4.6*
BASOS-0.8
[**2142-5-28**] 08:00AM   CALCIUM-8.4 PHOSPHATE-6.4*# MAGNESIUM-2.6
[**2142-5-28**] 08:00AM   WBC-6.7 RBC-3.89* HGB-12.2* HCT-34.8* MCV-90
MCH-31.4 MCHC-35.1* RDW-13.9
[**2142-5-28**] 08:00AM   cTropnT-0.10*
[**2142-5-28**] 08:00AM   CK(CPK)-257*
[**2142-5-28**] 08:00AM   GLUCOSE-185* UREA N-63* CREAT-3.0* SODIUM-138
POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-27 ANION GAP-17
[**2142-5-28**] 04:20PM   CK-MB-4
[**2142-5-28**] 04:20PM   cTropnT-0.11*
[**2142-5-28**] 04:20PM   CK(CPK)-275*
[**2142-5-28**] 10:45PM   PLT COUNT-148*
[**2142-5-28**] 10:45PM   WBC-12.2*# RBC-3.76* HGB-11.9* HCT-34.0*
MCV-91 MCH-31.6 MCHC-34.8 RDW-14.1
[**2142-5-28**] 10:45PM   CALCIUM-7.7* PHOSPHATE-8.8*# MAGNESIUM-2.6
.
Blood cultures remained negative
.
CXR [**5-29**]: Unchanged appearance of the chest without evidence of
acute
cardiopulmonary disease.
.
ECG: NSR at 60 bpm with normal intervals. Normal axis. Q in III
and aVF. Biphasic TW in III. No change from prior.
.
[**5-29**] Renal US:
1.  No hydronephrosis.
2.  Renal size asymmetry is stable, but raises the possibility
of underlying renal artery stenosis and clinical correlation is
suggested.
2.  Splenomegaly.


Brief Hospital Course:
64 year old man with CHF, CRF (baseline Cr 1.7), CAD and COPD
who presents from ED after developing asymptomatic hypotension
and acute on chronic renal failure after taking his blood
pressure medications.
.
Chronic pain: Mr. [**Known lastname **] suffers from chronic pain in his left
hip s/p hip replacement ([**2135**]) and pain in his left shoulder
secondary to bursitis.  He had previously been treated at the
[**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Center ([**2137**]) for left hip pain.   After four doses
of MS Contin, he developed lethargy and hypotension and was
referred to the [**Hospital1 **] Emergency Department.  MS contin was believed
to cause the itching present on presentation in addition to
possibly contributing to his hypotension. It was also felt that
his blood pressure medications had been given all together and
this compounded his drop in blood pressure.  Due to the
potential for MS Contin misuse in addition to the above
concerns, he was changed to percocet for pain control.  The pain
service was consulted who recommended Topiramate which was
started on [**6-1**].  He will follow up with the [**Hospital1 **] pain center as
an outpatient and will continue with Mind Body Program.
.
ARF on CKD: On admission, the patient's creatinine had peaked at
4.0 before normalizing.  He was noted to be in non-oliguric
acute renal failure.  The patient was given IVF with resolution
of ARF; his creatinine returned to baseline 1.4.  As his
creatinine responded to fluids, the renal team felt that the
etiology of his renal failure was pre-renal.  Renal US showed
asymmetric sized kidneys.  He will follow up with Dr. [**Last Name (STitle) 4090**] as
outpt.  Pt voided well after foley d/c.
.
Hypotension:  Mr. [**Known lastname **] presented with persistent hypotension
despite boluses of NS in the ED.  After work-up in MICU, the
differential was narrowed to include hypotension from
dehydration vs. med related hypotension.  He was able to regain
a normal blood pressure holding his BP meds for short period of
time.  Fluids were also administered.  A renal US was done on
admission to evaluate cause of ARF which showed that the patient
had asymmetric sized kidneys and raised the possibility of renal
artery stenosis in the setting of starting an ACE-I.  The ACE-I
had been stopped on admission due to hypotension, but the renal
team felt that the patient could be restarted on a low dose [**Last Name (un) **].
 Once his blood pressure stabilized, losartan and metoprol were
restarted.  He was kept even fluid-wise.
.
OSA: Mr. [**Known lastname **] had a sleep study done which reaffirmed complex
sleep-disordered breathing with partially successful titration
study.  They recommended home therapy at BiPAP 16/13 with 100 mL
of dead space and 4 liters of O2.
.
DM: While in the hospital he was kept on a RISS and was followed
by [**Last Name (un) **].
.
HTN:  Once his blood pressure stabilized he was put back on
Losartan and Metoprolol. Lisinopril and Imdur were held.
.
BPH:  He was continued on Flomax and Proscar.
.
Anemia: The patient's hematocrit ranged between 32-34 which
appears to be his baseline.  Fe studies in [**11-6**] were consistent
with ACD.  We recommend that the patient undergo outpatient
evaluation by hematology for chronically low hematocrit.
.
CAD:  He did have one episode of epigastric abdominal discomfort
while in hospital for which he had serial EKGs and serial
enzymes, which did not show any evidence of an ongoing acute
coronary syndrome.  He was continued on ASA but Imdur was held
given recent hypotension.
.
Diastolic dysfunction: Mr. [**Known lastname **] had a recent Echo on [**11-6**]
which showed an EF of 65%.  His Is/Os and weights were closely
monitored and he remained asymptomatic from this perspective.
.
Depression: He was maintained on Lexapro for depression.
.
FEN: Maintained on a cardiac and diabetic diet and electrolytes
were repleted prn.
.
Code: Full code


Medications on Admission:
escitalopram 5 mg qam, 10 mg qhs
calcium carbonate 500 mg qam
lasix 60 mg daily
aspirin EC 325 mg daily
colace 100 [**Hospital1 **]
tamsulosin SR 0.8 mg daily
isosorbide mononitrate SR 60 mg daily
finasteride 5 mg daily
calcitriol 0.25 micrograms daily
lisinopril 5 mg daily
toprol 25 mg daily
protonix 40 mg [**Hospital1 **]
oxycodone prn
lantus 11 units qhs
regular insulin sliding scale
oxycontin 15 mg [**Hospital1 **] prn


Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. Escitalopram 10 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QAM (once a day (in the morning)).
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Disp:*1 bottle* Refills:*1*
9. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
11. Topiramate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
15. Insulin Glargine 100 unit/mL Solution Sig: Seven (7) Units
Subcutaneous at bedtime.
Disp:*30 Units* Refills:*2*
16. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: ASDIR
per sliding scale  Subcutaneous four times a day: per sliding
scale.
Disp:*qs * Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Hypotension
Acute renal failure
Urinary retention
Chronic hip and shoulder pain
--------------
CHF
CAD
Type II DM
HTN
Anemia of chronic disease.
Sleep apnea on BiPAP, currently [**10-10**]


Discharge Condition:
Stable.


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction
Please take all medications as prescribed. Please do not
continue to take Lisinopril. We started you on Losartan 50mg
instead.
You are now taking Isosorbide Mononitrate 30mg, NOT 60mg.
You have been started on Topiramate 25mg to take at bedtime, for
pain.
If you start to feel lightheaded or dizzy, please [**Name6 (MD) 138**] your MD.


Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] 1-2 weeks after discharge.
Please follow up with [**Hospital1 **] pain center.
Please continue to attend the Mind Body program.
Please follow up with Dr. [**First Name (STitle) 4102**] [**Name (STitle) 4090**] [**Telephone/Fax (1) 12142**] after
discharge.
{'Hypotension, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Dehydration,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Postinflammatory pulmonary fibrosis,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Anemia of other chronic disease,Obstructive sleep apnea (adult)(pediatric),Pain in joint, pelvic region and thigh,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Esophageal reflux,Unspecified glaucoma,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Old myocardial infarction,Depressive disorder, not elsewhere classified,Long-term (current) use of insulin,Hip joint replacement,Unspecified drug or medicinal substance causing adverse effects in therapeutic use'}


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: Patient is a 64 year old man with a history of CAD, COPD, CHF,
diabetes, and hypertension who presented to the ED from
[**Hospital1 **] with ectopy during a sleep apnea test.  On the night
prior to admission the patient had a sleep study done at
[**Hospital1 **] which showed frequent SVT.  He also complained of
itching during the study.  He was transfered to the ED there
where an ECG showed NSR at a rate of 61 with Q in III, aVF but
no other abnormalities.  BP was 124/79. Patient had a bladder
scan that showed 550 cc of urine but he refused a urinary
catheter. Patient requested transfer to [**Hospital1 18**].
.
At the [**Hospital1 18**] ED BP was 106/50, HR 65, RR 16, O2 94% RA, T 97.3.
He was given his am meds which included isosorbide mononitrate
60 mg, finasteride 5 mg, lisinopril 5 mg, metoprolol XL 25 mg,
and aspirin 325 mg. At 3 pm his BP was noted to be 73/58. He
denied dizziness, shortness of breath, chest pain. He received
500 ml of NS with no change in BP.  At 4:30 BP was 101/49, but
at 7:30 BP was 90/69 and patient was somnolent. He received
another 700 cc of NS and BP was 80/58.
.
ROS: positive for vision changes, headaches.  negative for
fevers, chills, sweats, nausea, vomiting, shortness of breath,
chest pain, dysuria, abdominal pain, diarrhea, black or bloody
stools.

MEDICAL HISTORY: 1) CHF, EF 45% from most recent echo [**6-5**], mixed LV systolic and
diastolic dysfunction, cardiomyopathy
2) CAD, NSTEMI in [**3-6**] during admission for urosepsis with
hypotension and coma.
3) Type II DM c/b neuropathy, nephropathy, per pt no retinopathy

MEDICATION ON ADMISSION: escitalopram 5 mg qam, 10 mg qhs
calcium carbonate 500 mg qam
lasix 60 mg daily
aspirin EC 325 mg daily
colace 100 [**Hospital1 **]
tamsulosin SR 0.8 mg daily
isosorbide mononitrate SR 60 mg daily
finasteride 5 mg daily
calcitriol 0.25 micrograms daily
lisinopril 5 mg daily
toprol 25 mg daily
protonix 40 mg [**Hospital1 **]
oxycodone prn
lantus 11 units qhs
regular insulin sliding scale
oxycontin 15 mg [**Hospital1 **] prn

ALLERGIES: Vicodin / Ms Contin

PHYSICAL EXAM: VS: T 96.8 HR 63 BP 103/50 RR 15 O2 sat 87-96% 2L
Gen: Well appearing, comfortable, lying in bed in NAD. Slightly
somnolent but arousable and oriented x 3.
HEENT: PERRL, EOMI, sclera anicteric, MMM.
Neck: No LAD, or thyromegly. JVP at 10 cm.
CV: RRR with no m/r/g
Lungs: Decreased BS bilaterally with expiratory wheezes.
Abd: soft, NT, ND active BS, no hepatosplenomegly.
ext: cool with 1+ DP pulses. No clubbing, cyanosis or edema

FAMILY HISTORY: CVA - brother
Breast [**Name (NI) 3730**] - mother
emphysema - father

SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] does not smoke. Only minimal
ethanol. Otherwise, he is extremely sedentary. 

### Response:
{'Hypotension, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Dehydration,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Postinflammatory pulmonary fibrosis,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Anemia of other chronic disease,Obstructive sleep apnea (adult)(pediatric),Pain in joint, pelvic region and thigh,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Esophageal reflux,Unspecified glaucoma,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Old myocardial infarction,Depressive disorder, not elsewhere classified,Long-term (current) use of insulin,Hip joint replacement,Unspecified drug or medicinal substance causing adverse effects in therapeutic use'}
