CHIEF COMPLAINT: change in mental status

PRESENT ILLNESS: 69 yo female w/ malignant HTN, DM, ESRD on HD, CAD, CHF (EF
55%), CVA, s/p R BKA 3 weeks ago, recent MSSA bacteremia s/p
line change,recent colitis, who was taken to [**Hospital 8**] Hospital
from [**Hospital **] rehab after 24hrs of hypotension to SBP 80's-90's
and new mental status changes s/p HD.  Pt was found unresponsive
this AM with SBP in 60's, FS of 163.  At [**Name (NI) 8**] Hospital, pt
was noted to have R fixed and dilated pupil.  Pt was also found
to be lethargic and aphasic.  At [**Name (NI) 8**] Hospital, pt had the
following vitals: T 97.9 BP 91/53 HR 97 RR 20 sat 100% 15L FM.
CXR showed RLL infiltrate, sugestive of aspiration PNA.  Pt was
transferred to [**Hospital1 18**] for further workup.  In the [**Name (NI) **], pt was
hypotensive to 80's-90's, was seen by neuro and found to have L
facial droop with L sided weakness.  Pt also had fever to 101
rectally.  Pt was given 2L NS, vanc/levo/flagyl, and 2mg IV
morphine.

MEDICAL HISTORY: DM >30 years with neuropathy, nephropathy, and retinopathy
ESRD on HD MWF
PVD s/p multiple bypasses and Right BKA [**2173-11-1**]
CAD s/p MI in [**2158**], CHF, EF on TTE [**2172**] was normal
stroke [**2158**], [**2170**] - both presented with right sided weakness,
found to have parapontine stroke in [**2170**] and was placed on
aggrenox, MRA [**2171**] shows left vertebral stenosis of the neck and

MEDICATION ON ADMISSION: (per [**Hospital1 **] records)
Insulin
cholestyramine/sucro 4 gram [**Hospital1 **] (?) PO
trypsin/balsam [**Location (un) 15555**] to excoriations q 12 hrs TP
bismuth prn
neurontin 300mg ([**Hospital1 **]?) PO
Zinc sulfate 220 mg PO daily
ascorbic acid 500mg daily
valsartan 40mg daily
metoprolol 100mg PO (frequency?)
amlopidine 10mg PO daily
topical lidocaine
epo 5000 units IV q WMF
diphenhydramine prn
heparin [**2168**] units IV q MWF
glycerin prn
mvi
latanoprost one drop to each eye (daily?)
SC heparin 5000 units q 8
tylenol 975 mg PO QID
isosorbide mononitrate 30mg PO daily
cyanocobalomin 25 mcg daily
atorvastatin 40mg daily
sertraline 50mg [**Hospital1 **]
lansoprazole 30mg daily
oxycodone 2.5mg q 6 hrs prn
vancomycin 250mg PO (frequency?)
nafcillin 2g q 4 hr IV, another order for q6
diphenoxylate PO QID
loperamide 2mg PO

ALLERGIES: A.C.E Inhibitors / Ativan / Ambien / Lisinopril

PHYSICAL EXAM: On admission:
Vitals: T 98.6 BP 121/61 HR 99 RR 20 O2 97% 3L
Gen:  Elderly woman, lying in bed, uncomfortable.  Lethargic,
but arousable and responsive to commands.
HEENT:  PERRL. EOMI intact, but sluggish. OP dry.
Neck: R tunneled cath on R side.  Unable to appreciate JVD.
Cardio: RRR, no m/r/g appreciated.
Resp: Course BS anteriorly.
Abd: soft, diffusely tender, +BS, no rebound/guarding, no
masses.
Ext: s/p R BKA, wound appears intact, but tender.  L extremity
cold, with gangrenous foot and necrotic toes.
Neuro:  Lethargic. Oriented to person and place only.  Able to
follow commands. Mild L sided weakness and L facial droop.

FAMILY HISTORY: HTN
CAD/MI

SOCIAL HISTORY: DNR/DNI, daughter is HCP [**Name (NI) **] [**Name (NI) 1661**] [**Telephone/Fax (1) 98751**].
Former [**Male First Name (un) **] at NE [**Location (un) **], has 4 PhD's. 5 kids. Widowed. No
tob/etoh/drugs. Has not lived at home since [**Month (only) 205**] (formerly
lived with her kids).
Pneumonitis due to inhalation of food or vomitus,Cerebral embolism with cerebral infarction,Atherosclerosis of native arteries of the extremities with gangrene,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Congestive heart failure, unspecified,Unspecified protein-calorie malnutrition,Pressure ulcer, lower back,Malignant neoplasm of kidney, except pelvis,Hypotension of hemodialysis,Candidiasis of other urogenital sites,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other amputation stump complication
Food/vomit pneumonitis,Crbl emblsm w infrct,Ath ext ntv art gngrene,Hyp kid NOS w cr kid V,End stage renal disease,CHF NOS,Protein-cal malnutr NOS,Pressure ulcer, low back,Malig neopl kidney,Hemododialysis hypotensn,Candidias urogenital NEC,DMII renl nt st uncntrld,Amputat stump compl NEC
Admission Date:  [**2173-11-23**]              Discharge Date:   [**2173-12-19**]

Date of Birth:  [**2103-11-27**]             Sex:   F

Service: MEDICINE

Allergies:
A.C.E Inhibitors / Ativan / Ambien / Lisinopril

Attending:[**First Name3 (LF) 465**]
Chief Complaint:
change in mental status

Major Surgical or Invasive Procedure:
L BKA


History of Present Illness:
69 yo female w/ malignant HTN, DM, ESRD on HD, CAD, CHF (EF
55%), CVA, s/p R BKA 3 weeks ago, recent MSSA bacteremia s/p
line change,recent colitis, who was taken to [**Hospital 8**] Hospital
from [**Hospital **] rehab after 24hrs of hypotension to SBP 80's-90's
and new mental status changes s/p HD.  Pt was found unresponsive
this AM with SBP in 60's, FS of 163.  At [**Name (NI) 8**] Hospital, pt
was noted to have R fixed and dilated pupil.  Pt was also found
to be lethargic and aphasic.  At [**Name (NI) 8**] Hospital, pt had the
following vitals: T 97.9 BP 91/53 HR 97 RR 20 sat 100% 15L FM.
CXR showed RLL infiltrate, sugestive of aspiration PNA.  Pt was
transferred to [**Hospital1 18**] for further workup.  In the [**Name (NI) **], pt was
hypotensive to 80's-90's, was seen by neuro and found to have L
facial droop with L sided weakness.  Pt also had fever to 101
rectally.  Pt was given 2L NS, vanc/levo/flagyl, and 2mg IV
morphine.

Past Medical History:
DM >30 years with neuropathy, nephropathy, and retinopathy
ESRD on HD MWF
PVD s/p multiple bypasses and Right BKA [**2173-11-1**]
CAD s/p MI in [**2158**], CHF, EF on TTE [**2172**] was normal
stroke [**2158**], [**2170**] - both presented with right sided weakness,
found to have parapontine stroke in [**2170**] and was placed on
aggrenox, MRA [**2171**] shows left vertebral stenosis of the neck and

intracranial atherosclerotic disease
DVT - (?treatment)
hyperhomocysteinemia
anemia
HTN
cervical spondylosis s/p C4-7 fusion [**2168**]
question of dementia ?
h/o multiple delirium admissions due to drugs (benzos, etc)
indwelling foley cath
MSSA bacteremia
? aspiration pneumonia
Colitis

Social History:
DNR/DNI, daughter is HCP [**Name (NI) **] [**Name (NI) 1661**] [**Telephone/Fax (1) 98751**].
Former [**Male First Name (un) **] at NE [**Location (un) **], has 4 PhD's. 5 kids. Widowed. No
tob/etoh/drugs. Has not lived at home since [**Month (only) 205**] (formerly
lived with her kids).

Family History:
HTN
CAD/MI

Physical Exam:
On admission:
Vitals: T 98.6 BP 121/61 HR 99 RR 20 O2 97% 3L
Gen:  Elderly woman, lying in bed, uncomfortable.  Lethargic,
but arousable and responsive to commands.
HEENT:  PERRL. EOMI intact, but sluggish. OP dry.
Neck: R tunneled cath on R side.  Unable to appreciate JVD.
Cardio: RRR, no m/r/g appreciated.
Resp: Course BS anteriorly.
Abd: soft, diffusely tender, +BS, no rebound/guarding, no
masses.
Ext: s/p R BKA, wound appears intact, but tender.  L extremity
cold, with gangrenous foot and necrotic toes.
Neuro:  Lethargic. Oriented to person and place only.  Able to
follow commands. Mild L sided weakness and L facial droop.

Pertinent Results:
REPORTS:

MR HEAD W/O CONTRAST  [**2173-11-23**] 7:49 PM
IMPRESSION:
1. MRI of the brain demonstrates two areas of diffusion signal
abnormality, which indicates recent infarction. There are new
areas of susceptibility artifacts since the old study, but
stable appearance of multiple chronic microvascular infarctions.

2. MRA of the circle of [**Location (un) 431**] is extremely limited due to
motion artifact. Flow is observed in the major branches of this
circulation, but vessels cannot be further assessed.

CTA ABD W&W/O C & RECONS  [**2173-11-23**] 3:05 PM
IMPRESSION:

1. Right lower lobe collapse/consolidation with small bilateral
pleural effusions.

2. Prominence of the intra and extrahepatic biliary duct system,
which is more than expected given the patient's age and history
of prior cholecystectomy. Clinical correlation with the
patient's LFTs is recommended.

3. Atrophic kidneys bilaterally with multiple complex cysts
demonstrated. One of these cysts within the mid pole of the
right kidney demonstrates enhancement after contrast
administration, which is concerning for a neoplastic process.
Further evaluation of these renal cysts can be performed with
MRI.

4. Patent mesenteric vessels without evidence of mesenteric
ischemia.

TTE:
Conclusions:
1. The left atrium is normal in size.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal
(LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation
seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation
seen.
6.Moderate [2+] tricuspid regurgitation is seen.
7.There is mild pulmonary artery systolic hypertension.
8.There is no pericardial effusion.

EKG:
Sinus rhythm
Consider left atrial abnormality
Prior anteroseptal myocardial infarction
Modest nonspecific low amplitude T waves
Since previous tracing of [**2173-11-23**], ventricular ectopy absent

CHEST (PA & LAT)  [**2173-11-28**] 11:00 AM
IMPRESSION: Probable atelectasis and/or scarring at both bases.
Slight blunting right costophrenic angle, which is equivocally
more prominent than on prior exams. Otherwise, no evidence of
acute pulmonary process.

CT ABDOMEN W/O CONTRAST  [**2173-12-1**] 3:45 PM
1. Hyperdense bilateral kidney cysts, stable from the previous
examination and worrisome for neoplastic process in partcular in
the right kidney. Further evaluation of these cysts with MRI is
recommended.

2. Interval improvement of the right lower lobe consolidation
with small bilateral pleural effusions. The remaining right
nodular consolidation is worrisome for metastasis given the
appearance of the kidneys and followup is recommended.

3. Prominence of the intra and extrahepatic biliary ductal
system, stable compared to the prior examination.

4. Subcutaneous nodule in the left lateral abdominal wall of
uncertain clinical significance.

5. No evidence of colitis.

CTA HEAD W&W/O C & RECONS  [**2173-11-26**] 1:49 PM
IMPRESSION:
1. Bilateral exuberant calcifications at the carotid
bifurcations with approximately 60% stenosis at the right
internal and 30-40% stenosis at the left internal origins.

2. Moderate-to-severe stenosis of the bilateral cavernous and
supraclinoid internal carotid arteries with exuberant
calcifications.

3. Exuberant calcifications involving distal vertebral arteries
with more than 50% stenosis involving both distal vertebral
arteries, Left > Right.

4. Diffuse atherosclerotic disease involving the basilar artery.

5. Somewhat poor opacification of the vascular structures could
be related to low contrast injection rate from inadequate IV
access.

6. Other changes as described above.

Abdominal MRI (prelim):
Likely bilateral renal cell carcinoma

PATH:
DIAGNOSIS:
Left below-the-knee amputation:
Gangrenous necrosis, distal foot.
Severe atherosclerosis.
Resection margins free of inflammation and necrosis.

LABS:

[**2173-12-5**] 06:05AM BLOOD WBC-14.1* RBC-2.75* Hgb-8.7* Hct-28.8*
MCV-105* MCH-31.7 MCHC-30.3* RDW-23.5* Plt Ct-505*
[**2173-12-1**] 03:56AM BLOOD WBC-18.8* RBC-2.75* Hgb-8.7* Hct-29.3*
MCV-106* MCH-31.5 MCHC-29.6* RDW-21.8* Plt Ct-561*
[**2173-11-29**] 06:20AM BLOOD WBC-18.1* RBC-3.10* Hgb-10.0* Hct-32.2*
MCV-104* MCH-32.3* MCHC-31.0 RDW-21.4* Plt Ct-498*
[**2173-11-27**] 06:27AM BLOOD WBC-15.1* RBC-3.08* Hgb-10.3* Hct-31.5*
MCV-103* MCH-33.4* MCHC-32.5 RDW-20.8* Plt Ct-405
[**2173-11-24**] 05:20AM BLOOD WBC-14.5* RBC-3.17* Hgb-10.3* Hct-34.3*
MCV-108* MCH-32.5* MCHC-30.0* RDW-20.8* Plt Ct-383
[**2173-11-23**] 09:50AM BLOOD WBC-12.4* RBC-3.08* Hgb-10.2* Hct-32.3*
MCV-105* MCH-33.0* MCHC-31.4 RDW-20.5* Plt Ct-411
[**2173-11-29**] 06:20AM BLOOD Neuts-84.6* Lymphs-10.6* Monos-2.8
Eos-1.5 Baso-0.4
[**2173-11-25**] 06:00AM BLOOD Neuts-82.2* Lymphs-11.5* Monos-3.8
Eos-2.4 Baso-0.2
[**2173-11-23**] 09:50AM BLOOD Neuts-83.0* Lymphs-12.7* Monos-3.8
Eos-0.4 Baso-0.2
[**2173-12-5**] 06:05AM BLOOD Plt Smr-VERY HIGH Plt Ct-505*
[**2173-12-4**] 05:56AM BLOOD PT-12.9 PTT-39.2* INR(PT)-1.1
[**2173-12-2**] 06:11AM BLOOD Plt Smr-HIGH Plt Ct-586*
[**2173-11-30**] 04:05AM BLOOD Plt Smr-HIGH Plt Ct-532*
[**2173-11-29**] 05:21PM BLOOD PT-13.9* PTT-40.8* INR(PT)-1.3
[**2173-11-29**] 06:20AM BLOOD PT-15.1* PTT-56.5* INR(PT)-1.5
[**2173-11-28**] 06:32AM BLOOD PT-15.1* PTT-51.2* INR(PT)-1.6
[**2173-11-27**] 06:27AM BLOOD PT-14.2* PTT-49.2* INR(PT)-1.4
[**2173-11-26**] 05:55AM BLOOD PT-14.6* PTT-72.1* INR(PT)-1.5
[**2173-11-25**] 06:00AM BLOOD PT-14.7* PTT-49.8* INR(PT)-1.5
[**2173-11-24**] 05:20AM BLOOD Plt Smr-NORMAL Plt Ct-383
[**2173-11-24**] 05:20AM BLOOD PT-39.1* PTT-96.0* INR(PT)-11.9
[**2173-11-23**] 11:45AM BLOOD PT-14.1* PTT-52.5* INR(PT)-1.3
[**2173-11-26**] 05:55AM BLOOD Ret Aut-1.8
[**2173-12-5**] 06:05AM BLOOD Glucose-188* UreaN-32* Creat-4.8*# Na-140
K-3.3 Cl-99 HCO3-27 AnGap-17
[**2173-12-2**] 06:11AM BLOOD Glucose-99 UreaN-22* Creat-4.2* Na-141
K-4.0 Cl-103 HCO3-25 AnGap-17
[**2173-11-29**] 05:21PM BLOOD Glucose-183* UreaN-13 Creat-3.2*# Na-138
K-3.9 Cl-98 HCO3-27 AnGap-17
[**2173-11-28**] 06:32AM BLOOD Glucose-74 UreaN-16 Creat-3.9* Na-138
K-3.7 Cl-98 HCO3-26 AnGap-18
[**2173-11-26**] 05:55AM BLOOD Glucose-107* UreaN-19 Creat-4.8* Na-135
K-3.5 Cl-100 HCO3-25 AnGap-14
[**2173-11-25**] 06:00AM BLOOD Glucose-88 UreaN-24* Creat-5.6* Na-136
K-4.3 Cl-99 HCO3-23 AnGap-18
[**2173-11-23**] 09:50AM BLOOD Glucose-131* UreaN-15 Creat-4.0*# Na-137
K-3.6 Cl-98 HCO3-26 AnGap-17
[**2173-11-29**] 05:21PM BLOOD CK(CPK)-111
[**2173-11-26**] 05:55AM BLOOD CK(CPK)-250*
[**2173-11-25**] 06:00AM BLOOD CK(CPK)-348*
[**2173-11-24**] 05:20AM BLOOD CK(CPK)-378*
[**2173-11-24**] 12:12AM BLOOD CK(CPK)-330*
[**2173-11-23**] 09:50AM BLOOD ALT-5 AST-15 CK(CPK)-159* AlkPhos-110
Amylase-34 TotBili-0.2
[**2173-11-29**] 05:21PM BLOOD CK-MB-5 cTropnT-0.17*
[**2173-11-26**] 05:55AM BLOOD CK-MB-4 cTropnT-0.16*
[**2173-11-25**] 06:00AM BLOOD CK-MB-6 cTropnT-0.17*
[**2173-11-24**] 05:20AM BLOOD CK-MB-6 cTropnT-0.18*
[**2173-11-24**] 12:12AM BLOOD CK-MB-7 cTropnT-0.17*
[**2173-11-23**] 09:50AM BLOOD CK-MB-6 cTropnT-0.12*
[**2173-12-5**] 06:05AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0
[**2173-12-1**] 03:56AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.5
[**2173-11-29**] 07:40AM BLOOD Albumin-1.9* Calcium-8.7 Phos-3.7 Mg-2.2
[**2173-11-27**] 08:50AM BLOOD Albumin-1.9* Calcium-8.2* Phos-2.7 Mg-1.6
[**2173-11-24**] 05:20AM BLOOD Calcium-8.0* Phos-5.8*# Mg-1.7
[**2173-11-26**] 05:55AM BLOOD calTIBC-46* Ferritn-GREATER TH TRF-35*
[**2173-11-23**] 09:50AM BLOOD Folate-7.0
[**2173-11-25**] 06:00AM BLOOD Triglyc-102 HDL-24 CHOL/HD-2.0 LDLcalc-4
[**2173-11-23**] 09:50AM BLOOD Homocys-3.0*
[**2173-11-24**] 12:45PM BLOOD TSH-2.3
[**2173-11-25**] 08:25AM BLOOD PTH-218*
[**2173-11-25**] 06:00AM BLOOD Cortsol-36.4*
[**2173-11-25**] 05:09AM BLOOD Cortsol-30.0*
[**2173-11-25**] 04:17AM BLOOD Cortsol-13.0
[**2173-12-5**] 06:05AM BLOOD Vanco-14.3*
[**2173-12-4**] 05:56AM BLOOD Vanco-15.5*
[**2173-12-3**] 05:37AM BLOOD Vanco-20.2*
[**2173-12-2**] 06:11AM BLOOD Vanco-8.4*
[**2173-12-1**] 03:56AM BLOOD Vanco-9.1*
[**2173-11-30**] 04:05AM BLOOD Vanco-8.8*
[**2173-11-25**] 06:00AM BLOOD Vanco-22.4*
[**2173-11-24**] 05:20AM BLOOD Vanco-12.7*
[**2173-11-24**] 12:12AM BLOOD Vanco-15.2*
[**2173-11-23**] 09:50AM BLOOD Valproa-<3*
[**2173-11-29**] 05:38PM BLOOD Type-ART pO2-84* pCO2-40 pH-7.44
calHCO3-28 Base XS-2
[**2173-11-29**] 01:02PM BLOOD Type-ART O2 Flow-5 pO2-161* pCO2-57*
pH-7.39 calHCO3-36* Base XS-8 Intubat-NOT INTUBA
[**2173-11-29**] 05:37PM BLOOD Lactate-3.0*
[**2173-11-23**] 10:03AM BLOOD Lactate-1.1

MICRO:
Blood cx: NGTD (x 14 cultures)
Stool cx: C.dif negative (x 3)

Brief Hospital Course:
A/P: Pt is 69 yo female with multiple medical problems,
including ESRD on HD, recent MSSA bacteremia, and CAD who
presented s/p multiple episodes of hypotension, fever, and acute
R frontal and R cerebellar infarcts. Pt was s/p L BKA last week.

.
#) Neuro: Pt with R frontal and R cerebellar infarcts. Pt with
hx of multiple strokes in the past. Pt had decreased
responsivenes for past 3 days.
- previously followed by stroke service. Stroke workup
completed.
- ASA was given
- strict BP control instituted (goal SBP 140-180's, MAP <110)
- TTE negative for source of embolus
- unclear reason for pt's decreased responsiveness over past
several days, possible infection vs. stroke, although likely
multifactorial
.
#) CV: Pt with hx of MI, hx of CHF (EF 55% by last TTE).
- ASA
- lipitor
- held all antihypertensives given hx of hypotension.
- vascular followed. Pt was s/p L BKA last week.
.
#) ID: Pt with hx of MSSA bacteremia, with episodes of
hypotension and fever. Pt afebrile over past several days.
- pt afebrile overnight. Blood cx's negative to date.
- pt was on vanc/levo/flagyl empirically, given hx of
hypotension and fever
- sacral decub possible source of pt's prior fevers
- WBC count had been trending down
- urine cx from [**12-7**] growing yeast, pt unable to take PO
treatment
.
#) Renal: Pt with ESRD on HD.
- prelim MRI read shows that BL renal masses are very suspicious
for renal cell carcinoma
- pt was dialyzed every MWF
- Abd CT findings:
1. Hyperdense bilateral kidney cysts, stable from the previous
examination and worrisome for neoplastic process. Further
evaluation of these cysts can be performed with MRI.
2. Interval improvement of the right lower lobe consolidation
with small bilateral pleural effusions. The remaining right
nodular consolidation is worrisome for metastasis given the
appearance of the kidneys and followup is recommended.
3. Prominence of the intra and extrahepatic biliary ductal
system, stable compared to the prior examination.
4. Subcutaneous nodule in the left lateral abdominal wall of
uncertain clinical significance.
5. No evidence of colitis.
.
#) GI: Pt had frequent episodes of liquid green stool.
- C. dif negative x 3, O&P negative x 1. Stool negative for
salmonella/shigella.
.
#) Endocrine: DM was stable.
- TSH normal
- cosyntropin stim test normal
- RISS was given
.
#) L leg pain/cramping: Pt s/p recent BKA on R, now s/p L BKA.
- PRN oxycodone was used for pain
- occasional dosees of toradol (between dialysis sessions) were
given as well
- Pt's pain was difficult to control without oversedation or
decreased BP.
.
#) Anemia:  iron studies consistent with ACD.
- pt was transfused occasionally at dialysis for goal hct>30
.
#) FEN: Pt passed swallow eval on admission, but has been unable
to take PO the past several days [**3-3**] somnolence. TPN also given
since poor PO intake. Family was not in favor of PEG/Dobhoff for
long-term feeding.
.
#) PPX: Hep SC, PPI.
.
#) Code: Pt was DNR/DNI.  Health care proxy then made pt [**Name (NI) 3225**].
Pt was given morphine titrated to comfort.  All additinoal meds
and blood draws were d/c'd. Dialysis was stopped.  The attending
and pt's PCP were aware of the change to [**Name (NI) 3225**].

Addendum:
Pt expired after several days of [**Name (NI) 3225**] care.

Medications on Admission:
(per [**Hospital1 **] records)
Insulin
cholestyramine/sucro 4 gram [**Hospital1 **] (?) PO
trypsin/balsam [**Location (un) 15555**] to excoriations q 12 hrs TP
bismuth prn
neurontin 300mg ([**Hospital1 **]?) PO
Zinc sulfate 220 mg PO daily
ascorbic acid 500mg daily
valsartan 40mg daily
metoprolol 100mg PO (frequency?)
amlopidine 10mg PO daily
topical lidocaine
epo 5000 units IV q WMF
diphenhydramine prn
heparin [**2168**] units IV q MWF
glycerin prn
mvi
latanoprost one drop to each eye (daily?)
SC heparin 5000 units q 8
tylenol 975 mg PO QID
isosorbide mononitrate 30mg PO daily
cyanocobalomin 25 mcg daily
atorvastatin 40mg daily
sertraline 50mg [**Hospital1 **]
lansoprazole 30mg daily
oxycodone 2.5mg q 6 hrs prn
vancomycin 250mg PO (frequency?)
nafcillin 2g q 4 hr IV, another order for q6
diphenoxylate PO QID
loperamide 2mg PO


Discharge Medications:
NA

Discharge Disposition:
Expired

Discharge Diagnosis:
ESRD
HTN
CAD
CHF
? renal cell CA
s/p multiple strokes


Discharge Condition:
Expired


Discharge Instructions:
NA

Followup Instructions:
NA


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

Completed by:[**2173-12-21**]
{'Pneumonitis due to inhalation of food or vomitus,Cerebral embolism with cerebral infarction,Atherosclerosis of native arteries of the extremities with gangrene,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Congestive heart failure, unspecified,Unspecified protein-calorie malnutrition,Pressure ulcer, lower back,Malignant neoplasm of kidney, except pelvis,Hypotension of hemodialysis,Candidiasis of other urogenital sites,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other amputation stump complication'}


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: change in mental status

PRESENT ILLNESS: 69 yo female w/ malignant HTN, DM, ESRD on HD, CAD, CHF (EF
55%), CVA, s/p R BKA 3 weeks ago, recent MSSA bacteremia s/p
line change,recent colitis, who was taken to [**Hospital 8**] Hospital
from [**Hospital **] rehab after 24hrs of hypotension to SBP 80's-90's
and new mental status changes s/p HD.  Pt was found unresponsive
this AM with SBP in 60's, FS of 163.  At [**Name (NI) 8**] Hospital, pt
was noted to have R fixed and dilated pupil.  Pt was also found
to be lethargic and aphasic.  At [**Name (NI) 8**] Hospital, pt had the
following vitals: T 97.9 BP 91/53 HR 97 RR 20 sat 100% 15L FM.
CXR showed RLL infiltrate, sugestive of aspiration PNA.  Pt was
transferred to [**Hospital1 18**] for further workup.  In the [**Name (NI) **], pt was
hypotensive to 80's-90's, was seen by neuro and found to have L
facial droop with L sided weakness.  Pt also had fever to 101
rectally.  Pt was given 2L NS, vanc/levo/flagyl, and 2mg IV
morphine.

MEDICAL HISTORY: DM >30 years with neuropathy, nephropathy, and retinopathy
ESRD on HD MWF
PVD s/p multiple bypasses and Right BKA [**2173-11-1**]
CAD s/p MI in [**2158**], CHF, EF on TTE [**2172**] was normal
stroke [**2158**], [**2170**] - both presented with right sided weakness,
found to have parapontine stroke in [**2170**] and was placed on
aggrenox, MRA [**2171**] shows left vertebral stenosis of the neck and

MEDICATION ON ADMISSION: (per [**Hospital1 **] records)
Insulin
cholestyramine/sucro 4 gram [**Hospital1 **] (?) PO
trypsin/balsam [**Location (un) 15555**] to excoriations q 12 hrs TP
bismuth prn
neurontin 300mg ([**Hospital1 **]?) PO
Zinc sulfate 220 mg PO daily
ascorbic acid 500mg daily
valsartan 40mg daily
metoprolol 100mg PO (frequency?)
amlopidine 10mg PO daily
topical lidocaine
epo 5000 units IV q WMF
diphenhydramine prn
heparin [**2168**] units IV q MWF
glycerin prn
mvi
latanoprost one drop to each eye (daily?)
SC heparin 5000 units q 8
tylenol 975 mg PO QID
isosorbide mononitrate 30mg PO daily
cyanocobalomin 25 mcg daily
atorvastatin 40mg daily
sertraline 50mg [**Hospital1 **]
lansoprazole 30mg daily
oxycodone 2.5mg q 6 hrs prn
vancomycin 250mg PO (frequency?)
nafcillin 2g q 4 hr IV, another order for q6
diphenoxylate PO QID
loperamide 2mg PO

ALLERGIES: A.C.E Inhibitors / Ativan / Ambien / Lisinopril

PHYSICAL EXAM: On admission:
Vitals: T 98.6 BP 121/61 HR 99 RR 20 O2 97% 3L
Gen:  Elderly woman, lying in bed, uncomfortable.  Lethargic,
but arousable and responsive to commands.
HEENT:  PERRL. EOMI intact, but sluggish. OP dry.
Neck: R tunneled cath on R side.  Unable to appreciate JVD.
Cardio: RRR, no m/r/g appreciated.
Resp: Course BS anteriorly.
Abd: soft, diffusely tender, +BS, no rebound/guarding, no
masses.
Ext: s/p R BKA, wound appears intact, but tender.  L extremity
cold, with gangrenous foot and necrotic toes.
Neuro:  Lethargic. Oriented to person and place only.  Able to
follow commands. Mild L sided weakness and L facial droop.

FAMILY HISTORY: HTN
CAD/MI

SOCIAL HISTORY: DNR/DNI, daughter is HCP [**Name (NI) **] [**Name (NI) 1661**] [**Telephone/Fax (1) 98751**].
Former [**Male First Name (un) **] at NE [**Location (un) **], has 4 PhD's. 5 kids. Widowed. No
tob/etoh/drugs. Has not lived at home since [**Month (only) 205**] (formerly
lived with her kids). 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Cerebral embolism with cerebral infarction,Atherosclerosis of native arteries of the extremities with gangrene,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Congestive heart failure, unspecified,Unspecified protein-calorie malnutrition,Pressure ulcer, lower back,Malignant neoplasm of kidney, except pelvis,Hypotension of hemodialysis,Candidiasis of other urogenital sites,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other amputation stump complication'}
