CHIEF COMPLAINT: hypotension

PRESENT ILLNESS: Pt is a 59 yo female with a history of Addison disease, COPD, on
0.5 dexamethasone daily, presented to NWH with a couple days
fever, cough, n/v/d, lethargy. Per pt and family, she was
feeling on unwell on Friday and called daughter. [**Name (NI) **] vomited 2
times, no blood, food contents. Daughter [**Name (NI) 28167**] mother in bed
w/temp of 103.7, mildly confused, weak and took to hospital
([**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 3714**]). Found to be hypotensive and given 100mg
hydrocortisone and 3L IVF at OSH. SBP remained 65-80 and pt was
transferred to [**Hospital1 18**] for further management of hypotension;
concern for possible sepsis or adrenal crisis. Pt reports some
epigastric pain prior to vomitting, also some lingering cough
from a pneumonia she was recovering from during prior
hospitalizaition several weeks ago. Also noted some mild leg
swelling and ?SOB. B/c of N/V pt did not take any of her meds on
Friday.
.
At [**Hospital1 18**], initial VS were: 96.7 76 83/47 19 93% 4L NC, although
SBP dropped to 65 when sitting up. She has received 1L IVF here
(probably 5L total incl EMS and OSH). Exam with L basilar
crackles, patient mentating well, good UOP. Bedside U/S showed
30% IVC collapse with respiration, no pericardial effusion, no
abdominal fluid. Has RIJ and got vanc, pip-tazo. VS at time of
singout were: 80s 85/50 18-22 96,3L; was concern she'd need
pressors but BP improved. CXR per prelim showed atelectasis.
Access also includes 18g PIV.
.
Of note, per records, pt reported fatigue and occasional dizzy
spells at office visit on [**2173-4-9**] (told pt to reduce pain meds).
Pt called [**Hospital 3782**] clinic on [**2173-4-14**] and [**2173-4-16**] stating she
continued to feel lightheaded ans was concerned b/c her bp had
been low while in the hospital (80/50) although at that time she
reported feeling fine.  However, on [**2173-4-16**] she was dizzy.  Pt
pt reported taking 2 percocets Q 6-7 hrs, was eating and
drinking, "but not a lot". She was advised [**Doctor First Name **] increae POs and
decreasing percocet use w/further eval recommended. However at
that time she was unable to drive, plan was to visit UC
tomorrow.  On [**4-17**] at [**University/College **] urgent care pt was seen for
dizziness in addition to episodes of discomfort in her chest,
with some shortness of breath, lasting a few minutes, mild,
increasing in frequency.  Had one episode of pressure in the
chest which radiated to her left arm. Per records faithfully
compliant with dexamethasone 0.25 mg daily for Addisons.
.
ROS was otherwise negative. The pt denied recent unintended
weight loss, hematemesis, coffee-ground emesis, dysphagia,
odynophagia, chest pain, palpitations.

MEDICAL HISTORY: - Addison's disease (dx 8-9 years ago [**2-24**] fatigue) - on low dose
dexamethasone followed by [**Doctor Last Name **].
- Baseline hyponatremia [**2-24**] adrenal insufficiency
- chronic low back pain
- paraesophageal hernia and gastric volvulus requiring surgical
repair in [**2169-7-23**]
- post-thoracotomy syndrome - followed by pain clinic, on
chronic percocet
- Diverticulitis/Diverticulosis
- Internal hemorrhoids
- IBS
- GERD
- Hiatal hernia
- s/p cholesystectomy ([**2142**])
- Migraines
- EtOH abuse
- COPD
- depression/anxiety
- h/o Tb - treated x 18months
- gastric stricture s/p dilatation

MEDICATION ON ADMISSION: Per Atrius records:
Gabapentin 600 mg tid
Abilify 2 mg daily
Klonopin 0.5 mg [**Hospital1 **], 1 mg qhs
Duloxetine 60 mg daily
Nexium 40 mg daily
Lamictal 200 mg qhs
Lidocaine patch
Advair - dose unknown
Dexamethasone 0.5 mg daily (recently decreased from 0.5 mg twice
daily)
Trazadone 200 mg qhs prn
Calcium citrate-vit D3 2 tabs twice daily

ALLERGIES: Codeine

PHYSICAL EXAM: Admission Physical Exam
Vitals: T: 97.2 BP: 104/53 P: 70 R: 15 SaO2: 96% 3L
General: Awake, alert, NAD, pleasant, appropriate, cooperative.

FAMILY HISTORY: Non-contributory.  Son with alcohol abuse, daughter with
psychiatric issues.

SOCIAL HISTORY: Recently divorced and lives alone. 30 years x 1.5 ppd tobbacco,
last Etoh [**4-29**], previously drinking [**3-26**] liter liquor daily x [**2-25**]
years "quit regular etoh few years ago". Denies IVDU. One
daughter is her social support.
Glucocorticoid deficiency,Bacterial pneumonia, unspecified,Hyposmolality and/or hyponatremia,Hypotension, unspecified,Flatulence, eructation, and gas pain,Chronic airway obstruction, not elsewhere classified,Lumbago,Diverticulosis of colon (without mention of hemorrhage),Other chronic pain,Anemia, unspecified,Dysthymic disorder,Internal hemorrhoids without mention of complication,Irritable bowel syndrome,Esophageal reflux,Functional disturbances following cardiac surgery,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Personal history of tuberculosis,History of physical abuse,Personal history of alcoholism,Personal history of tobacco use,Acquired absence of both cervix and uterus
Glucocorticoid deficient,Bacterial pneumonia NOS,Hyposmolality,Hypotension NOS,Flatul/eructat/gas pain,Chr airway obstruct NEC,Lumbago,Dvrtclo colon w/o hmrhg,Chronic pain NEC,Anemia NOS,Dysthymic disorder,Int hemorrhoid w/o compl,Irritable bowel syndrome,Esophageal reflux,Hrt dis postcardiac surg,Migrne unsp wo ntrc mgrn,Prsnl hst tuberculosis,Hx of physical abuse,Hx of alcoholism,History of tobacco use,Acq absnce cervix/uterus
Admission Date:  [**2173-4-24**]              Discharge Date:   [**2173-4-30**]

Date of Birth:  [**2113-7-29**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine

Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
hypotension


Major Surgical or Invasive Procedure:
None


History of Present Illness:
Pt is a 59 yo female with a history of Addison disease, COPD, on
0.5 dexamethasone daily, presented to NWH with a couple days
fever, cough, n/v/d, lethargy. Per pt and family, she was
feeling on unwell on Friday and called daughter. [**Name (NI) **] vomited 2
times, no blood, food contents. Daughter [**Name (NI) 28167**] mother in bed
w/temp of 103.7, mildly confused, weak and took to hospital
([**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 3714**]). Found to be hypotensive and given 100mg
hydrocortisone and 3L IVF at OSH. SBP remained 65-80 and pt was
transferred to [**Hospital1 18**] for further management of hypotension;
concern for possible sepsis or adrenal crisis. Pt reports some
epigastric pain prior to vomitting, also some lingering cough
from a pneumonia she was recovering from during prior
hospitalizaition several weeks ago. Also noted some mild leg
swelling and ?SOB. B/c of N/V pt did not take any of her meds on
Friday.
.
At [**Hospital1 18**], initial VS were: 96.7 76 83/47 19 93% 4L NC, although
SBP dropped to 65 when sitting up. She has received 1L IVF here
(probably 5L total incl EMS and OSH). Exam with L basilar
crackles, patient mentating well, good UOP. Bedside U/S showed
30% IVC collapse with respiration, no pericardial effusion, no
abdominal fluid. Has RIJ and got vanc, pip-tazo. VS at time of
singout were: 80s 85/50 18-22 96,3L; was concern she'd need
pressors but BP improved. CXR per prelim showed atelectasis.
Access also includes 18g PIV.
.
Of note, per records, pt reported fatigue and occasional dizzy
spells at office visit on [**2173-4-9**] (told pt to reduce pain meds).
Pt called [**Hospital 3782**] clinic on [**2173-4-14**] and [**2173-4-16**] stating she
continued to feel lightheaded ans was concerned b/c her bp had
been low while in the hospital (80/50) although at that time she
reported feeling fine.  However, on [**2173-4-16**] she was dizzy.  Pt
pt reported taking 2 percocets Q 6-7 hrs, was eating and
drinking, "but not a lot". She was advised [**Doctor First Name **] increae POs and
decreasing percocet use w/further eval recommended. However at
that time she was unable to drive, plan was to visit UC
tomorrow.  On [**4-17**] at [**University/College **] urgent care pt was seen for
dizziness in addition to episodes of discomfort in her chest,
with some shortness of breath, lasting a few minutes, mild,
increasing in frequency.  Had one episode of pressure in the
chest which radiated to her left arm. Per records faithfully
compliant with dexamethasone 0.25 mg daily for Addisons.
.
ROS was otherwise negative. The pt denied recent unintended
weight loss, hematemesis, coffee-ground emesis, dysphagia,
odynophagia, chest pain, palpitations.


Past Medical History:
- Addison's disease (dx 8-9 years ago [**2-24**] fatigue) - on low dose
dexamethasone followed by [**Doctor Last Name **].
- Baseline hyponatremia [**2-24**] adrenal insufficiency
- chronic low back pain
- paraesophageal hernia and gastric volvulus requiring surgical
repair in [**2169-7-23**]
- post-thoracotomy syndrome - followed by pain clinic, on
chronic percocet
- Diverticulitis/Diverticulosis
- Internal hemorrhoids
- IBS
- GERD
- Hiatal hernia
- s/p cholesystectomy ([**2142**])
- Migraines
- EtOH abuse
- COPD
- depression/anxiety
- h/o Tb - treated x 18months
- gastric stricture s/p dilatation

Social History:
Recently divorced and lives alone. 30 years x 1.5 ppd tobbacco,
last Etoh [**4-29**], previously drinking [**3-26**] liter liquor daily x [**2-25**]
years "quit regular etoh few years ago". Denies IVDU. One
daughter is her social support.


Family History:
Non-contributory.  Son with alcohol abuse, daughter with
psychiatric issues.

Physical Exam:
Admission Physical Exam
Vitals: T: 97.2 BP: 104/53 P: 70 R: 15 SaO2: 96% 3L
General: Awake, alert, NAD, pleasant, appropriate, cooperative.

HEENT: NCAT, PERRL, EOMI, no scleral icterus, mild dry MM, no
lesions noted in OP
Neck: supple, no significant JVD or carotid bruits appreciated;
RIJ in place
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales;
has mild chronic cough
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3. Able to relate history but does
not remember some of events when had very high fever. Cranial
nerves II-XII intact. Normal bulk, strength and tone throughout.
No abnormal movements noted. No deficits to light touch
throughout.

Discharge exam:
Afebrile, VSS (SBP 140s)
General: AO x 3, NAD
HEENT: NC/AT, PERRL, EOMI, MMM, OP clear
Neck: supple, no LAD
Chest: CTA-B, no w/r/r
CV: RRR s1 s2 normal, no m/g/r
Abd: soft, slightly distended, NABS, no HSM, no fluid wave
Ext: no c/c/e, wwp
Neuro: AO x 3, CN II-XII, non-focal exam

Pertinent Results:
Admission labs ([**2173-4-24**]):
-WBC-7.7 RBC-3.73* Hgb-12.2 Hct-34.7* MCV-93 MCH-32.6* MCHC-35.0
RDW-13.2 Plt Ct-203 Neuts-88.4* Lymphs-9.4* Monos-1.7* Eos-0.2
Baso-0.4
-Glucose-130* UreaN-15 Creat-0.8 Na-131* K-4.1 Cl-102 HCO3-24
AnGap-9
-ALT-25 AST-32 LD(LDH)-179 AlkPhos-59 Amylase-44 TotBili-0.2
-Lipase-15
-ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
-Glucose-122* Lactate-0.9 K-4.0
.
Discharge labs ([**2173-4-30**]):

[**2173-4-30**] 05:15AM BLOOD WBC-9.2 RBC-3.10* Hgb-9.8* Hct-28.7*
MCV-93 MCH-31.6 MCHC-34.1 RDW-13.4 Plt Ct-254
[**2173-4-30**] 05:15AM BLOOD Glucose-110* UreaN-6 Creat-0.7 Na-137
K-4.1 Cl-103 HCO3-26 AnGap-12
[**2173-4-25**] 05:00AM BLOOD ALT-25 AST-32 LD(LDH)-179 AlkPhos-59
Amylase-44 TotBili-0.2
.
[**2173-4-24**] CXR:

Right IJ line ends at the cavoatrial junction. Thre is no
pneumothorax.
There are mild reticular bibasilar opacities and mild vascular
congestion.
Right basilar opacity has mildly improved. Mild hyperinflation
of the lungs.
Calcified granulomas at the right lung apex are stable.

IMPRESSION: Mild vascular congestion. Improving right bascilar
opacity.
.
[**2173-4-26**] CXR:
FINDINGS: A right pleural effusion is best seen on the lateral
projection and
is mild to moderate in size. A poorly defined opacity in the
right lower lobe
has progressed since [**2173-4-24**] and most likely represents an
evolving pneumonia,
linear densities in the medial right lower lobe likely represent
atelectasis.
Fluid seen in both major fissures is new since [**2173-3-23**].

IMPRESSION:
1. Bilateral pleural effusions, larger on the right, but small
in volume.
2. Evolving hazy opacity in the right lower lobe likely reflects
pneumonia.
.
[**2173-4-26**] RUQ u/s:

FINDINGS: Liver appears normal in echotexture without focal
abnormality or
intrahepatic biliary ductal dilatation. Moderate-sized layering
right pleural
effusion. Trace perihepatic ascites. No fluid is seen in both
lower
quadrants or within the pelvis. The gallbladder is surgically
absent. The
proximal common duct is mildly dilated measuring 7 mm and is
nonspecific in
the setting of cholecystectomy. The visualized pancreatic neck
and proximal
body are unremarkable. The remainder of the pancreas is obscured
by overlying
bowel gas. Main portal vein is patent with antegrade flow.
Intrahepatic
portion of the IVC has normal ultrasound appearance. The
proximal aorta is
normal in caliber and the distal aorta is obscured.

The right kidney measures 9.6 cm and the left kidney measures
10.9 cm.
Preserved corticomedullary differentiation and cortical
thickening
bilaterally. Adrenal glands are not well visualized on
ultrasound.

IMPRESSION:
1. Moderate layering right pleural effusion.
2. Trace perihepatic ascites without significant fluid in the
four quadrants
or pelvis.
3. Status post cholecystectomy. Proximal common duct measures 7
mm,
minimally dilated and nonspecific.
4. Adrenal glands not well visualized on ultrasound.
.
[**2173-4-28**] KUB:
FINDINGS:

Supine and upright views of the abdomen demonstrate multiple
dilated loops of
small bowel. There is no pneumatosis or free air. There is air
in the
rectosigmoid colon. Surgical clips project over pelvis. Small
bilateral
pleural effusions are noted. Right lower lobe hazy opacity
appears improved
from [**2173-4-26**] exam.

IMPRESSION:

Multiple dilated loops of bowel, compatible with obstruction .
No free air.
.
[**2173-4-29**] CT abd:
IMPRESSION:
1. No small bowel obstruction.
2. Mild intrahepatic biliary ductal dilatation with the common
duct maximally
measuring 1.5 cm, unchanged since [**2169-7-23**].
3. Small-moderate bilateral pleural effusions, right greater
than left.
4. Effusions in combination with mild periportal edema, small
amount of
simple ascites and subcutaneous edema suggest increased volume
status.


Brief Hospital Course:
This is a 59 yo woman with PMHx significant for Addison's
disease on chronic steroids, COPD, chronic pain who presented to
OSH with fever, cough, n/v/d, and lethargy. Found to be
hypotensive and transferred to [**Hospital1 18**] for further management of
hypotension; concern for possible sepsis or adrenal crisis.
.
# Hypotension: Likely secondary to adrenal insufficiency and
mild hypovolemia in the setting of not taking steroids and
inadequate PO intake from nausea and vomiting. Patient was
started on stress dose steroids (100 mg of Hydrocortisone) and
received IV fluid boluses with subsequent improvement in her
blood pressures. On admission she received broad antibiotics out
of concern for sepsis; however, these were discontinued
secondary to low clinical suspicion for bacterial illness and
rapid improvement with hydration. Blood and urine cultures were
negative. Endocrine was contact[**Name (NI) **] regarding steroid tapering and
recommended Hydrocortisone 50 mg [**Hospital1 **] through [**4-26**], then
decreasing to double her home dose for 3 days, then continuing
her on home dose. Her blood pressures remained stable prior to
transfer to the floor.  On the medical floor, her steroids were
tapered accordingly to Endocrine recommendations.  However, as
she developed a pneumonia (see below), she was discharged on 1
mg twice daily of Dexamethasone to be taken until her
antibiotics are completed (higher dose kept in setting of
current infection).  At that time, she is to decrease her dose
to 0.5 mg twice daily until follow-up with her primary
endocrinologist.
.
# Adrenal insufficiency: This episode of hypotension was likely
secondary to nausea/vomiting (secondary to viral illness) and
relative adrenal insufficiency due to inability to take po
steroids and concurrent stress.  She responded quickly to IV
fluids and stress-dose steroids.  Her steroids were slowly
weaned, however she was continued on a higher-dose (1 mg twice
daily of dexamethasone) due to her concurrent pneumonia.  She
was instructed to taper to 0.5 mg twice daily afte completion of
her antibiotics and to stay on this dose until follow-up with
her endocrinologist.  She recently had been hospitalized for
another episode of hypotension at [**Hospital3 **] prior to this
hospitalization; the etiology of this is not clear.  Her BPs
were stable during this hospitalization.
.
# Pneumonia, bacterial: Patient reported development of a cough
and slight shortness of breath during her hospitalization.
Initial CXR was negative for a PNA, however repeat CXR
demonstrated progression of a RLL infiltrate.  She was afebrile
and concern for resistant organisms was very low, so she was
started on Ciprofloxacin for a 7-day course.  She had small
bilateral pleural effusions on CXR; in discussion with
pulmonary, these were too small to be tapped.  She remained
afebrile, with improvement in her respiratory symptoms.  Her O2
sats were stable at 94-96%/RA.  She would benefit from a repeat
CXR next week to ensure no enlargement of the effusions.  These
effusions are likely secondary to her aggressive fluid
resuscitation on arrival.
.
# Abdominal distension without obstruction - The patient
complained of acute on chronic abd distension (for months, with
worsening over the past few days), without n/v.  She noted
excess flatus chronically and irregular bowel bovements.  Abd
u/s was negative for ascites (slight perihepatic fluid only,
likely secondary to her aggressive fluid resuscitation).  KUB
was read as obstruction, however upon review with the
radiologist, the KUB was only significant for dilated bowel.  A
subsequent CT abd revealed NO evidence of obstruction. She was
started on simethicone and miralax with improvement in her
symptoms.  She was tolerating a regular diet for several days
without any difficulty.
.
# Hyponatremia - stable during her hospitalization
.
# COPD: continued on outpatient regimen of combivent and advair.
.
# Depression/Anxiety: continued on outpatient regimen. She was
seen by SW during hospitalization as she does have many
stressors in her family life.  She would likely benefit from a
neuropsych evaluation, as there is concern that this may be
impacting her abilityto manage her medications and health on her
own.
.
# Chronic Pain: continued on outpatient regimen. Initially,
frequency of narcotics were reduced in setting of hypotension,
but were restarted at her home dose during her hospitalization.
She was recommended to taper these medications, as they can be
contributing to her constipation and hypotension, however she
notes that her pain is still at a constant and chronic level,
requiring her current dose of medications.
.
# GERD - continued on PPI


Medications on Admission:
Per Atrius records:
Gabapentin 600 mg tid
Abilify 2 mg daily
Klonopin 0.5 mg [**Hospital1 **], 1 mg qhs
Duloxetine 60 mg daily
Nexium 40 mg daily
Lamictal 200 mg qhs
Lidocaine patch
Advair - dose unknown
Dexamethasone 0.5 mg daily (recently decreased from 0.5 mg twice
daily)
Trazadone 200 mg qhs prn
Calcium citrate-vit D3 2 tabs twice daily

Discharge Medications:
1. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
2. aripiprazole 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety: one tablet in the morning, one tablet
at dinner, 2 tablets at night.
4. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: Two (2) Capsule, Delayed Release(E.C.) PO once a day.
6. lamotrigine 200 mg Tablet Sig: One (1) Tablet PO at bedtime.

7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 3 days: Please take this dose through
[**2173-5-3**].  Then start 0.5 mg twice daily on Tuesday, [**2173-5-4**]. .
Disp:*12 Tablet(s)* Refills:*0*
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days: Last dose on [**2173-5-3**]. .
Disp:*6 Tablet(s)* Refills:*0*
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO BID (2 times a day) as needed for constipation.
Disp:*qs grams* Refills:*0*
12. trazodone 100 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for insomnia.
13. simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed for gas, bloating.
Disp:*30 Tablet, Chewable(s)* Refills:*0*
14. calcium citrate-vitamin D3 315-200 mg-unit Tablet Sig: Two
(2) Tablet PO twice a day.


Discharge Disposition:
Home With Service

Facility:
All Care VNA of Greater [**Location (un) **]

Discharge Diagnosis:
Hypotension
Adrenal insuffieciency
Pneumonia, bacterial
Abdominal distension without obstruction
Hyponatremia
COPD
Chronic back pain, chronic post-thoracotomy pain
GERD
Depression, anxiety


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
O2 sats 95-96%/RA at rest, >92% while ambulating


Discharge Instructions:
You were admitted for low blood pressure, nausea, vomiting, and
fever.  You required several liters of fluid and high-dose
steroids to bring your blood pressure back to normal.  Your
steroid dose was slowly tapered to 1 mg twice of dexamethasone,
which you will continue through [**2173-5-3**].  On [**2173-5-4**], you should
decrease your dose to 0.5 mg twice daily and continue this dose
until your follow-up with Dr. [**Last Name (STitle) **].
Your initial work-up did not show evidence of an infection, but
a repeat chest x-ray on [**4-26**] showed concern for a developing
pneumonia, so you were started on Ciprofloxacin for a 7-day
course.  This antibiotic is generally well-tolerated, but can
rarely cause rupture of the Achilles' tendon in the ankle. If
you develop pain in the ankle, please STOP this antibiotic
immediately.  The last dose will be on Monday, [**2173-5-3**].  Your
xray also showed some fluid in the lung spaces, but this was too
small to be drained.  You should have a follow-up xray next week
to ensure this is not getting bigger.
You also had abdominal distension, so an ultrasound was done,
which ruled out signficant fluid in the belly.  An xray showed a
lot of air in the bowel, so a CT scan was done to evaluate for
obstruction.  This was negative for obstruction and only
confirmed gas in the colon.
.
MEDICATION CHANGES:
1. START Dexamethasone 1 mg twice daily through Monday, [**2173-5-3**].
Change back to 0.5 mg dexamethasone twice daily on Tuesday,
[**2173-5-4**].  Continue this dose until you see Dr. [**Last Name (STitle) **] on
[**5-12**].
2. START Ciprofloxacin 500 mg twice daily and continue through
Monday, [**2173-5-3**].
3. CONTINUE Miralax and simethicone as needed for constipation
and gas.

No other medication changes were made.

Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A
Location: [**Location (un) 2274**]-[**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 85132**]
Phone: [**Telephone/Fax (1) 17476**]
Appointment: Tuesday [**2173-5-4**] 10:40am

Department: SPINE CENTER
When: FRIDAY [**2173-5-7**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2173-5-12**] at 4:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]

Completed by:[**2173-5-3**]
{'Glucocorticoid deficiency,Bacterial pneumonia, unspecified,Hyposmolality and/or hyponatremia,Hypotension, unspecified,Flatulence, eructation, and gas pain,Chronic airway obstruction, not elsewhere classified,Lumbago,Diverticulosis of colon (without mention of hemorrhage),Other chronic pain,Anemia, unspecified,Dysthymic disorder,Internal hemorrhoids without mention of complication,Irritable bowel syndrome,Esophageal reflux,Functional disturbances following cardiac surgery,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Personal history of tuberculosis,History of physical abuse,Personal history of alcoholism,Personal history of tobacco use,Acquired absence of both cervix and uterus'}


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: Pt is a 59 yo female with a history of Addison disease, COPD, on
0.5 dexamethasone daily, presented to NWH with a couple days
fever, cough, n/v/d, lethargy. Per pt and family, she was
feeling on unwell on Friday and called daughter. [**Name (NI) **] vomited 2
times, no blood, food contents. Daughter [**Name (NI) 28167**] mother in bed
w/temp of 103.7, mildly confused, weak and took to hospital
([**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 3714**]). Found to be hypotensive and given 100mg
hydrocortisone and 3L IVF at OSH. SBP remained 65-80 and pt was
transferred to [**Hospital1 18**] for further management of hypotension;
concern for possible sepsis or adrenal crisis. Pt reports some
epigastric pain prior to vomitting, also some lingering cough
from a pneumonia she was recovering from during prior
hospitalizaition several weeks ago. Also noted some mild leg
swelling and ?SOB. B/c of N/V pt did not take any of her meds on
Friday.
.
At [**Hospital1 18**], initial VS were: 96.7 76 83/47 19 93% 4L NC, although
SBP dropped to 65 when sitting up. She has received 1L IVF here
(probably 5L total incl EMS and OSH). Exam with L basilar
crackles, patient mentating well, good UOP. Bedside U/S showed
30% IVC collapse with respiration, no pericardial effusion, no
abdominal fluid. Has RIJ and got vanc, pip-tazo. VS at time of
singout were: 80s 85/50 18-22 96,3L; was concern she'd need
pressors but BP improved. CXR per prelim showed atelectasis.
Access also includes 18g PIV.
.
Of note, per records, pt reported fatigue and occasional dizzy
spells at office visit on [**2173-4-9**] (told pt to reduce pain meds).
Pt called [**Hospital 3782**] clinic on [**2173-4-14**] and [**2173-4-16**] stating she
continued to feel lightheaded ans was concerned b/c her bp had
been low while in the hospital (80/50) although at that time she
reported feeling fine.  However, on [**2173-4-16**] she was dizzy.  Pt
pt reported taking 2 percocets Q 6-7 hrs, was eating and
drinking, "but not a lot". She was advised [**Doctor First Name **] increae POs and
decreasing percocet use w/further eval recommended. However at
that time she was unable to drive, plan was to visit UC
tomorrow.  On [**4-17**] at [**University/College **] urgent care pt was seen for
dizziness in addition to episodes of discomfort in her chest,
with some shortness of breath, lasting a few minutes, mild,
increasing in frequency.  Had one episode of pressure in the
chest which radiated to her left arm. Per records faithfully
compliant with dexamethasone 0.25 mg daily for Addisons.
.
ROS was otherwise negative. The pt denied recent unintended
weight loss, hematemesis, coffee-ground emesis, dysphagia,
odynophagia, chest pain, palpitations.

MEDICAL HISTORY: - Addison's disease (dx 8-9 years ago [**2-24**] fatigue) - on low dose
dexamethasone followed by [**Doctor Last Name **].
- Baseline hyponatremia [**2-24**] adrenal insufficiency
- chronic low back pain
- paraesophageal hernia and gastric volvulus requiring surgical
repair in [**2169-7-23**]
- post-thoracotomy syndrome - followed by pain clinic, on
chronic percocet
- Diverticulitis/Diverticulosis
- Internal hemorrhoids
- IBS
- GERD
- Hiatal hernia
- s/p cholesystectomy ([**2142**])
- Migraines
- EtOH abuse
- COPD
- depression/anxiety
- h/o Tb - treated x 18months
- gastric stricture s/p dilatation

MEDICATION ON ADMISSION: Per Atrius records:
Gabapentin 600 mg tid
Abilify 2 mg daily
Klonopin 0.5 mg [**Hospital1 **], 1 mg qhs
Duloxetine 60 mg daily
Nexium 40 mg daily
Lamictal 200 mg qhs
Lidocaine patch
Advair - dose unknown
Dexamethasone 0.5 mg daily (recently decreased from 0.5 mg twice
daily)
Trazadone 200 mg qhs prn
Calcium citrate-vit D3 2 tabs twice daily

ALLERGIES: Codeine

PHYSICAL EXAM: Admission Physical Exam
Vitals: T: 97.2 BP: 104/53 P: 70 R: 15 SaO2: 96% 3L
General: Awake, alert, NAD, pleasant, appropriate, cooperative.

FAMILY HISTORY: Non-contributory.  Son with alcohol abuse, daughter with
psychiatric issues.

SOCIAL HISTORY: Recently divorced and lives alone. 30 years x 1.5 ppd tobbacco,
last Etoh [**4-29**], previously drinking [**3-26**] liter liquor daily x [**2-25**]
years "quit regular etoh few years ago". Denies IVDU. One
daughter is her social support. 

### Response:
{'Glucocorticoid deficiency,Bacterial pneumonia, unspecified,Hyposmolality and/or hyponatremia,Hypotension, unspecified,Flatulence, eructation, and gas pain,Chronic airway obstruction, not elsewhere classified,Lumbago,Diverticulosis of colon (without mention of hemorrhage),Other chronic pain,Anemia, unspecified,Dysthymic disorder,Internal hemorrhoids without mention of complication,Irritable bowel syndrome,Esophageal reflux,Functional disturbances following cardiac surgery,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Personal history of tuberculosis,History of physical abuse,Personal history of alcoholism,Personal history of tobacco use,Acquired absence of both cervix and uterus'}
