CHIEF COMPLAINT: diarrhea

PRESENT ILLNESS: History of Present Illness:
88F with CAD, 3VD, DM2, CRI, p/w  Clostridium difficile
diarrhea. Patient notes 2 week history of diarrhea assoicated
with cramps. No f/c/ns. No hematochezia or melena. Patient also
notes 2 to 3 days of weakness. There was no focal numbness or
weakness, described as more generalized weakness involving her
legs. She started on 14 day course of antibiotics during her
last admission for aspiration pneumonia, initially levofloxacin
and clindamycin then changed to azithromycin/clindamycin on
discharge. Last dose of antibiotics was scheduled for [**2144-4-25**].
The patient was also started on a 7 day course of levofloxacin
for a UTI initiated on [**2144-4-20**]. The patient had a stool sample
taken [**5-13**] that was positive for C.difficile and her pcp referred
her into the emergency department for persistent diarrhea. The
patient had taken one Immodium and one dose of metronidazole
last evening.

MEDICAL HISTORY: Past Medical History:
1. CAD, 3VD, s/p RCA stent [**2140**]
2. CHF EF 45% on ventriculography on ccath [**1-11**]
3. CRI (BL 1.2 to 1.6)
4. Chronic Pain
5. h/o Anxiety D/O
6. s/p L humerus fx
7. Anemia (BL 31-36)
8. DM2 (on insulin)
9. HTN
10. Hyperlipidemia
11. Hosp [**4-14**] for aspiration pneumonia

MEDICATION ON ADMISSION: Medications on Admission:
1. Lantus 14 units qam
2. Acetaminophen 650 mg PO Q6H  O
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Aspirin EC 325 mg PO
5. Metronidazole 500 mg PO TID started [**2144-5-14**].
6. Atenolol 12.5 mg PO DAILY
7. Metoclopramide 5 mg PO HS:PRN
8. Folic Acid 1 mg PO DAILY
9. Multivitamins 1 CAP PO DAILY
10. Furosemide 40 mg PO DAILY
11 Oxazepam 10 mg PO HS
12. Gabapentin 100 mg PO TID
13. Simvastatin 40 mg PO DAILY  Order date: [**5-15**] @ 1439

ALLERGIES: Inderal / Ambien / Sulfonamides

PHYSICAL EXAM: Physical Exam:
Tm 102.3 in ED, 991, 98/46, 72, 20, 98% on 2L NC
GEN: alert, cooperative, hard of hearing.
HEENT: PERRLA, EOMI, OP clear with moist MM
Neck: supple, FROM
CV: reg rate, S1, S2, no murmurs, gallops or rubs
PULM: few basilar rales bilaterally, moderate air movement
ABD: soft, mild non localized tenderness throughout, mild
distended, + bs. No guard or rebound.
EXT: 2+ DP pulses b/l, 2+ edema to the knees b/l.
Neuro: A&O to person, place and time. CNII-XII intact, strength
[**5-14**] in distal extremities. sensation grossly intact.

FAMILY HISTORY: Family History:
Non-contributory
No history of Alzheimer's

SOCIAL HISTORY: Social History:
Lives at home with help from 2 daughters and [**Name (NI) 269**]
No ETOH/TOB, ambulatory with cane and walker. Bed bound mostly.
Worked as a typist at the department of motor vehicles.
Unspecified septicemia,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Acute kidney failure with lesion of tubular necrosis,Other shock without mention of trauma,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia
Septicemia NOS,Int inf clstrdium dfcile,Urin tract infection NOS,CHF NOS,Ac kidny fail, tubr necr,Shock w/o trauma NEC,Hyp kid NOS w cr kid V,Severe sepsis,DMII wo cmp nt st uncntr,Long-term use of insulin,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS
Admission Date:  [**2144-5-15**]              Discharge Date:   [**2144-5-20**]


Service: MEDICINE

Allergies:
Inderal / Ambien / Sulfonamides

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
diarrhea

Major Surgical or Invasive Procedure:
Central Line placement

History of Present Illness:
History of Present Illness:
88F with CAD, 3VD, DM2, CRI, p/w  Clostridium difficile
diarrhea. Patient notes 2 week history of diarrhea assoicated
with cramps. No f/c/ns. No hematochezia or melena. Patient also
notes 2 to 3 days of weakness. There was no focal numbness or
weakness, described as more generalized weakness involving her
legs. She started on 14 day course of antibiotics during her
last admission for aspiration pneumonia, initially levofloxacin
and clindamycin then changed to azithromycin/clindamycin on
discharge. Last dose of antibiotics was scheduled for [**2144-4-25**].
The patient was also started on a 7 day course of levofloxacin
for a UTI initiated on [**2144-4-20**]. The patient had a stool sample
taken [**5-13**] that was positive for C.difficile and her pcp referred
her into the emergency department for persistent diarrhea. The
patient had taken one Immodium and one dose of metronidazole
last evening.

On ROS she denies orthopnea or PND. She has increased lower
extremity edema since her rehab. The Pts 2 daughters notes
increased salt and sugar in her diet at rehab as she was not on
restrictions.  She also noted no cough, shortness of breath. She
admits to increased irritation with urination but no dysuria or
hematuria.

   In the ED she was febrile with a temperature of 102.3F, HR
87, BP 94/47, RR 18, and O2 sat of 95% (supplemental oxygen not
recorded). BCX's were taken. A CXR demonstrated increased
interstitial opacities of the right lung with bilateral pleural
effusions felt consistent with asymmetric pulmonary edema. She
received 2 liters of normal saline.


Past Medical History:
Past Medical History:
1. CAD, 3VD, s/p RCA stent [**2140**]
2. CHF EF 45% on ventriculography on ccath [**1-11**]
3. CRI (BL 1.2 to 1.6)
4. Chronic Pain
5. h/o Anxiety D/O
6. s/p L humerus fx
7. Anemia (BL 31-36)
8. DM2 (on insulin)
9. HTN
10. Hyperlipidemia
11. Hosp [**4-14**] for aspiration pneumonia

Social History:
Social History:
Lives at home with help from 2 daughters and [**Name (NI) 269**]
No ETOH/TOB, ambulatory with cane and walker. Bed bound mostly.
Worked as a typist at the department of motor vehicles.


Family History:
Family History:
Non-contributory
No history of Alzheimer's

Physical Exam:
Physical Exam:
Tm 102.3 in ED, 991, 98/46, 72, 20, 98% on 2L NC
GEN: alert, cooperative, hard of hearing.
HEENT: PERRLA, EOMI, OP clear with moist MM
Neck: supple, FROM
CV: reg rate, S1, S2, no murmurs, gallops or rubs
PULM: few basilar rales bilaterally, moderate air movement
ABD: soft, mild non localized tenderness throughout, mild
distended, + bs. No guard or rebound.
EXT: 2+ DP pulses b/l, 2+ edema to the knees b/l.
Neuro: A&O to person, place and time. CNII-XII intact, strength
[**5-14**] in distal extremities. sensation grossly intact.


Pertinent Results:
[**2144-5-15**] 08:30AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2144-5-15**] 08:30AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2144-5-15**] 08:13AM   GLUCOSE-214* LACTATE-2.5* K+-4.3
[**2144-5-15**] 08:00AM   GLUCOSE-191* UREA N-30* CREAT-1.5*
SODIUM-130* POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-19* ANION GAP-17
[**2144-5-15**] 08:00AM   ALT(SGPT)-10 AST(SGOT)-10 ALK PHOS-115
AMYLASE-12 TOT BILI-0.4
[**2144-5-15**] 08:00AM   LIPASE-10
[**2144-5-15**] 08:00AM   ALBUMIN-3.0* CALCIUM-8.6 PHOSPHATE-3.0
MAGNESIUM-1.5*
[**2144-5-15**] 08:00AM   WBC-32.7*# RBC-3.16* HGB-9.7* HCT-28.4*
MCV-90 MCH-30.8 MCHC-34.3 RDW-13.7
[**2144-5-15**] 08:00AM   NEUTS-86* BANDS-7* LYMPHS-4* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2144-5-15**] 08:00AM   PLT COUNT-269
[**2144-5-15**] 08:00AM   PT-13.2 PTT-26.2 INR(PT)-1.2

Brief Hospital Course:
Impression:
88 year old female with C.difficile diarrhea secondary to
antibiotics use for pneumonia and dehydration.

1. Infectious Diarrhea. Positive culture for C.diff as
outpatient (s/p treatment with clindamycin for aspiration
pneumonia), now down to one stool since yesterday afternoon. WBC
32K with a bandemia. She did take one dose of immodium last
night (night prior to admission), no further doses of
medications that will decrease gut motility. Followup on KUB
that was taken in the ED to evaluate for megacolon; this showed
some thickening of the colon.  She was initially started on PO
flagyl, and her WBC count increased to 40,000 on this therapy.
She was switched to IV flagyl and PO vancomycin.  CT scan of the
abdomen was obtained which showed thickening throughout the
colon with some stranding, but no abscess, toxic megacolon, or
perforation.  Her WBC remained elevated, and she continued to
have copious amounts of liquidy stool.  She was transferred to
the ICU on [**5-18**] for closer monitoring given her lack of clinical
improvement.

In the ICU, fluid resuscitation was continued (4L); central line
was inserted with CVP's slightly elevated at 14.  Pressors were
then tried (initially levophed and then vasopressin) without
effect.  The family decided that she would be CMO, and pressors
were stopped. She expired soon thereafter.

2. Dehydration. Received 2 liters of normal saline in the
emergency department. Now on exam there may be a component of
left heart failure with bibasilar rales. Patient is TBW
overloaded with lower extremity edema (it is unusual for her to
have LE edema and none noted on her admission exam last month).
Fluids were initially given carefully (concern for 3rd spacing
with history of CHF), but she developed hypotension (systolics
to the 70-80's).  She was given multiple fluid boluses without
improvement in blood pressure (lasix held).  Due to inability to
maintain adequate blood pressure, she was transferred to the ICU
for further monitoring.  As above, fluids and pressors were used
without success (also received PRBC initially upon transfer).

3.  ARF: Creatinine at baseline was 1.3-1.6.  Her creatinine
continued to rise and was 3.4 at time of transfer to [**Hospital Unit Name 153**] (with
minimal urine output).  Cause of this was thought to be a
combination of prerenal azotemia (FeNa calculated as 0.3%) and
secondary to dye nephropathy (got CT scan on [**5-16**] with IV
contrast, did receive IVF prior to scan).  Creatinine continued
to rise, and she expired from presumed sepsis as above (blood
pressure without response to fluids and pressors).

4. CHF. LVEF from [**1-11**] is 45%, unclear if her systolic
dysfunction has progressed. CXR today with possible asymmetric
right sided pulmonary edema. Patient with excellent oxygen
saturation on 2L NC initially.  When bolused for low SBP's, she
continued to accumulate peripheral edema.  Repeat TTE showed
EF=60% with 1-2+ MR.  As above, CVP was somewhat elevated when
measured in the ICU (?diastolic dysfunction).

5. Palpitations. Patient has a history of palpitations and was
on a KOH monitor as an outpatient. She was initially monitored
on telemetry with no events.

6. Code status: on discussion with patient and her daughter, it
was decided that that she did not want untubation or
compressions but would get shocks if necessary.  This was
maintained upon transfer to the ICU.  When fluid resuscitation
and pressors were ineffective, she was made CMO and expired in
the ICU.


Medications on Admission:
Medications on Admission:
1. Lantus 14 units qam
2. Acetaminophen 650 mg PO Q6H  O
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Aspirin EC 325 mg PO
5. Metronidazole 500 mg PO TID started [**2144-5-14**].
6. Atenolol 12.5 mg PO DAILY
7. Metoclopramide 5 mg PO HS:PRN
8. Folic Acid 1 mg PO DAILY
9. Multivitamins 1 CAP PO DAILY
10. Furosemide 40 mg PO DAILY
11 Oxazepam 10 mg PO HS
12. Gabapentin 100 mg PO TID
13. Simvastatin 40 mg PO DAILY  Order date: [**5-15**] @ 1439

ALLERG: Inderal-shortness of breath, ambien-ms changes,
sulfonamides -- unknown


Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
Primary Diagnoses:
1.  C. difficile colitis/sepsis
2.  Renal failure
3.  Hypotension
Secondary Diagnoses:
1.  Type 2 diabetes
2.  Diastolic CHF

Discharge Condition:
expired

Discharge Instructions:
none

Followup Instructions:
none

                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Unspecified septicemia,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Acute kidney failure with lesion of tubular necrosis,Other shock without mention of trauma,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia'}


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: diarrhea

PRESENT ILLNESS: History of Present Illness:
88F with CAD, 3VD, DM2, CRI, p/w  Clostridium difficile
diarrhea. Patient notes 2 week history of diarrhea assoicated
with cramps. No f/c/ns. No hematochezia or melena. Patient also
notes 2 to 3 days of weakness. There was no focal numbness or
weakness, described as more generalized weakness involving her
legs. She started on 14 day course of antibiotics during her
last admission for aspiration pneumonia, initially levofloxacin
and clindamycin then changed to azithromycin/clindamycin on
discharge. Last dose of antibiotics was scheduled for [**2144-4-25**].
The patient was also started on a 7 day course of levofloxacin
for a UTI initiated on [**2144-4-20**]. The patient had a stool sample
taken [**5-13**] that was positive for C.difficile and her pcp referred
her into the emergency department for persistent diarrhea. The
patient had taken one Immodium and one dose of metronidazole
last evening.

MEDICAL HISTORY: Past Medical History:
1. CAD, 3VD, s/p RCA stent [**2140**]
2. CHF EF 45% on ventriculography on ccath [**1-11**]
3. CRI (BL 1.2 to 1.6)
4. Chronic Pain
5. h/o Anxiety D/O
6. s/p L humerus fx
7. Anemia (BL 31-36)
8. DM2 (on insulin)
9. HTN
10. Hyperlipidemia
11. Hosp [**4-14**] for aspiration pneumonia

MEDICATION ON ADMISSION: Medications on Admission:
1. Lantus 14 units qam
2. Acetaminophen 650 mg PO Q6H  O
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Aspirin EC 325 mg PO
5. Metronidazole 500 mg PO TID started [**2144-5-14**].
6. Atenolol 12.5 mg PO DAILY
7. Metoclopramide 5 mg PO HS:PRN
8. Folic Acid 1 mg PO DAILY
9. Multivitamins 1 CAP PO DAILY
10. Furosemide 40 mg PO DAILY
11 Oxazepam 10 mg PO HS
12. Gabapentin 100 mg PO TID
13. Simvastatin 40 mg PO DAILY  Order date: [**5-15**] @ 1439

ALLERGIES: Inderal / Ambien / Sulfonamides

PHYSICAL EXAM: Physical Exam:
Tm 102.3 in ED, 991, 98/46, 72, 20, 98% on 2L NC
GEN: alert, cooperative, hard of hearing.
HEENT: PERRLA, EOMI, OP clear with moist MM
Neck: supple, FROM
CV: reg rate, S1, S2, no murmurs, gallops or rubs
PULM: few basilar rales bilaterally, moderate air movement
ABD: soft, mild non localized tenderness throughout, mild
distended, + bs. No guard or rebound.
EXT: 2+ DP pulses b/l, 2+ edema to the knees b/l.
Neuro: A&O to person, place and time. CNII-XII intact, strength
[**5-14**] in distal extremities. sensation grossly intact.

FAMILY HISTORY: Family History:
Non-contributory
No history of Alzheimer's

SOCIAL HISTORY: Social History:
Lives at home with help from 2 daughters and [**Name (NI) 269**]
No ETOH/TOB, ambulatory with cane and walker. Bed bound mostly.
Worked as a typist at the department of motor vehicles. 

### Response:
{'Unspecified septicemia,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Acute kidney failure with lesion of tubular necrosis,Other shock without mention of trauma,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Severe sepsis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia'}
