CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: 78 yo F with h/o DM, HTN, and cholecystectomy presented to
[**Hospital3 3583**] on [**2121-3-10**] with hypotension (SBP 80's) initially
improved with IVF's, RUQ pain, anorexia, loose stools, and
jaundice x3 days.  CT abd at [**Hospital3 3583**] revealed a
gallstone occluding CBD.  They were unable to perform ERCP at
OSH given h/o gastric bypass.  She was started on Ancef.  She
was noted to have ARF thought to be secondary to prerenal
azotemia given decreased po intake.
.
She was to be transferred to [**Hospital1 18**] on [**2121-3-12**] for ERCP, however,
she became hypotensive to the 50's on the evening of [**2121-3-11**].
She was started on Neo 10 mg and Vasopressin 0.4 units through
PIV's and transferred to the ICU at [**Hospital3 3583**].  She spiked
a temp to 102.5.  She was given a dose of Zosyn.  Her finger
stick was found to 58; she was given 1 amp of D50.  A left
femoral central line was placed by the surgical service under
sterile conditions.  A right fem line was attempted.  She
received ~ 3 liters of Normal Saline.
.
She was transferred emergently by [**Location (un) **] to [**Hospital1 18**] for ERCP
and further management of presumed sepsis secondary to
cholangitis.  She was intubated for airway protection prior to
the flight.  CXR reported as ETT in good position, lung fields
clear.  ABG prior to intubation: 7.35/35/55.
.
Currently she is intubated and sedated.  Her son is present to
answer questions.  He reports a gradual decline in her function
and a 20 lb wt loss over the last month.  She has had increasing
confusion, intermittent RUQ pain and bowel/bladder incontinence.
 Of note, she presented to an OSH in [**2120-8-8**] with RUQ pain; at
that time she was noted to have elevated LFT's; U/S revealed
fattly liver.  Her LFT's subsequently resolved.

MEDICAL HISTORY: - NIDDM
- HTN
- hypercholestreolemia
- s/p cholecystectomy [**59**] yrs ago
- OA
- osteoporosis
- s/p gastric bypass for obesity ~30 yrs ago by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
- B12 deficiency anemia
- s/p total hysterectomy
- h/o abnormal LFT's with abd U/S sig for fatty liver in [**Month (only) **]
[**2119**]; LFT's subsequently improved

MEDICATION ON ADMISSION: Home Meds (confirmed with son):
- [**Name (NI) **] 20 daily
- Lisinopril 40 daily
- Glyburide 40 daily
- Fosamax 70 weekly
- HCTZ 25 daily
- B12 1000 mcg daily
- Ca supplements
- Centrum Silver
- Tylenol prn
- ASA prn
.
Transfer Meds:
- Ancef x3 doses (start date [**2121-3-10**])
- Zosyn x1 dose [**2121-3-11**]
- ativan prn for sedation
- Neosynephrine gtt
- Vasopressin gtt

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
Tm 102.5  Tc 97.8  BP 105/51  HR 58  RR 16   Sat 97%
I/O (from [**Hospital1 46**]) 3585/1490
Vent: AC Vt 650/RR set 10, breathing at 16/PEEP 5/50% FiO2
Neo and Vasopressin turned off upon arrival; started Levophed
0.075 mcg/min
Gen: intubated, sedated
HENNT:  icteric, pupils ~2 mm minimally reactive to light
CV:  RRR, nl S1S2,  No M/R/G
Lungs: CTAB
Abd:  soft, NT/ND, +BS, No HSM
Ext:  warm, no edema, strong DP/PT pulses bilaterally
Skin:  no rash, jaundiced, mulitple excoriations over upper and
lower extremeties

FAMILY HISTORY: Mother died at age 86 of colon cancer.  Father died in his 70's
secondary to complications from DM.  She has 2 healthy children.

SOCIAL HISTORY: Lives alone, however, son dispenses meds and does shopping, home
health aide to assist with bathing and laundry 2x/wk, and meals
on wheels daily.  Has life line.  Son, [**Name (NI) 3065**], involved in her
care (h[**Telephone/Fax (1) 67267**], c[**Telephone/Fax (1) 67268**], w[**Telephone/Fax (1) 67269**]).  Pt does not
leave her house often.  She has a h/o poor hygiene and leaving
food out around the house.  Denies Tob, EtOH, or Illicit drug
use.  Widowed since [**2103**]. Husband was a urologist.
Unspecified septicemia,Severe sepsis,Septic shock,Cholangitis,Acute kidney failure, unspecified,Acute respiratory failure,Portal vein thrombosis,Injury to bladder and urethra, without mention of open wound into cavity,Unspecified accident,Volume depletion, unspecified,Unspecified disease of pancreas,Neoplasm of unspecified nature of digestive system,Personal history of other diseases of circulatory system,Intestinal bypass or anastomosis status,Other vitamin B12 deficiency anemia,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Disorders of magnesium metabolism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Septicemia NOS,Severe sepsis,Septic shock,Cholangitis,Acute kidney failure NOS,Acute respiratry failure,Portal vein thrombosis,Bladder/urethra inj-clos,Accident NOS,Volume depletion NOS,Pancreatic disease NOS,Digestive neoplasm NOS,Hx-circulatory dis NEC,Intestinal bypass status,B12 defic anemia NEC,Enterococcus group d,Hypertension NOS,Mental disor NEC oth dis,Dis magnesium metabolism,DMII wo cmp nt st uncntr
Admission Date:  [**2121-3-12**]              Discharge Date:   [**2121-3-21**]

Date of Birth:  [**2042-3-13**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypotension

Major Surgical or Invasive Procedure:
ERCP, percutaneous drain placement by IR

History of Present Illness:
78 yo F with h/o DM, HTN, and cholecystectomy presented to
[**Hospital3 3583**] on [**2121-3-10**] with hypotension (SBP 80's) initially
improved with IVF's, RUQ pain, anorexia, loose stools, and
jaundice x3 days.  CT abd at [**Hospital3 3583**] revealed a
gallstone occluding CBD.  They were unable to perform ERCP at
OSH given h/o gastric bypass.  She was started on Ancef.  She
was noted to have ARF thought to be secondary to prerenal
azotemia given decreased po intake.
.
She was to be transferred to [**Hospital1 18**] on [**2121-3-12**] for ERCP, however,
she became hypotensive to the 50's on the evening of [**2121-3-11**].
She was started on Neo 10 mg and Vasopressin 0.4 units through
PIV's and transferred to the ICU at [**Hospital3 3583**].  She spiked
a temp to 102.5.  She was given a dose of Zosyn.  Her finger
stick was found to 58; she was given 1 amp of D50.  A left
femoral central line was placed by the surgical service under
sterile conditions.  A right fem line was attempted.  She
received ~ 3 liters of Normal Saline.
.
She was transferred emergently by [**Location (un) **] to [**Hospital1 18**] for ERCP
and further management of presumed sepsis secondary to
cholangitis.  She was intubated for airway protection prior to
the flight.  CXR reported as ETT in good position, lung fields
clear.  ABG prior to intubation: 7.35/35/55.
.
Currently she is intubated and sedated.  Her son is present to
answer questions.  He reports a gradual decline in her function
and a 20 lb wt loss over the last month.  She has had increasing
confusion, intermittent RUQ pain and bowel/bladder incontinence.
 Of note, she presented to an OSH in [**2120-8-8**] with RUQ pain; at
that time she was noted to have elevated LFT's; U/S revealed
fattly liver.  Her LFT's subsequently resolved.

Past Medical History:
- NIDDM
- HTN
- hypercholestreolemia
- s/p cholecystectomy [**59**] yrs ago
- OA
- osteoporosis
- s/p gastric bypass for obesity ~30 yrs ago by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
- B12 deficiency anemia
- s/p total hysterectomy
- h/o abnormal LFT's with abd U/S sig for fatty liver in [**Month (only) **]
[**2119**]; LFT's subsequently improved


Social History:
Lives alone, however, son dispenses meds and does shopping, home
health aide to assist with bathing and laundry 2x/wk, and meals
on wheels daily.  Has life line.  Son, [**Name (NI) 3065**], involved in her
care (h[**Telephone/Fax (1) 67267**], c[**Telephone/Fax (1) 67268**], w[**Telephone/Fax (1) 67269**]).  Pt does not
leave her house often.  She has a h/o poor hygiene and leaving
food out around the house.  Denies Tob, EtOH, or Illicit drug
use.  Widowed since [**2103**]. Husband was a urologist.

Family History:
Mother died at age 86 of colon cancer.  Father died in his 70's
secondary to complications from DM.  She has 2 healthy children.

Physical Exam:
On Admission:
Tm 102.5  Tc 97.8  BP 105/51  HR 58  RR 16   Sat 97%
I/O (from [**Hospital1 46**]) 3585/1490
Vent: AC Vt 650/RR set 10, breathing at 16/PEEP 5/50% FiO2
Neo and Vasopressin turned off upon arrival; started Levophed
0.075 mcg/min
Gen: intubated, sedated
HENNT:  icteric, pupils ~2 mm minimally reactive to light
CV:  RRR, nl S1S2,  No M/R/G
Lungs: CTAB
Abd:  soft, NT/ND, +BS, No HSM
Ext:  warm, no edema, strong DP/PT pulses bilaterally
Skin:  no rash, jaundiced, mulitple excoriations over upper and
lower extremeties


Pertinent Results:
[**2121-3-12**] 04:10AM BLOOD WBC-43.8* RBC-3.87* Hgb-11.3* Hct-33.9*
MCV-88 MCH-29.3 MCHC-33.5 RDW-14.5 Plt Ct-208
[**2121-3-21**] 06:10AM BLOOD WBC-14.3* RBC-3.75* Hgb-10.8* Hct-33.3*
MCV-89 MCH-28.6 MCHC-32.3 RDW-15.5 Plt Ct-293
[**2121-3-12**] 04:10AM BLOOD Neuts-97.2* Lymphs-1.4* Monos-1.3* Eos-0
Baso-0.1
[**2121-3-20**] 05:50AM BLOOD Neuts-78.9* Lymphs-11.4* Monos-3.5
Eos-6.0* Baso-0.2
[**2121-3-12**] 04:10AM BLOOD PT-16.1* PTT-32.2 INR(PT)-1.5*
[**2121-3-12**] 04:10AM BLOOD Plt Ct-208
[**2121-3-21**] 06:10AM BLOOD Plt Ct-293
[**2121-3-19**] 10:50AM BLOOD PT-11.7 PTT-24.7 INR(PT)-1.0
[**2121-3-12**] 04:10AM BLOOD Fibrino-626* D-Dimer-6412*
[**2121-3-12**] 05:20AM BLOOD FDP-10-40
[**2121-3-12**] 04:10AM BLOOD Glucose-246* UreaN-44* Creat-2.2* Na-130*
K-3.3 Cl-101 HCO3-17* AnGap-15
[**2121-3-21**] 09:30AM BLOOD Glucose-325* UreaN-18 Creat-0.8 Na-135
K-4.4 Cl-106 HCO3-18* AnGap-15
[**2121-3-12**] 01:31PM BLOOD CK(CPK)-396*
[**2121-3-13**] 04:00AM BLOOD ALT-47* AST-87* AlkPhos-417* Amylase-93
TotBili-2.8*
[**2121-3-14**] 05:20AM BLOOD ALT-35 AST-54* LD(LDH)-179 AlkPhos-399*
Amylase-110* TotBili-2.7*
[**2121-3-15**] 08:10AM BLOOD ALT-28 AST-34 LD(LDH)-188 AlkPhos-439*
Amylase-103* TotBili-3.4*
[**2121-3-16**] 07:45AM BLOOD ALT-26 AST-31 AlkPhos-477* Amylase-117*
TotBili-2.7*
[**2121-3-17**] 05:55AM BLOOD ALT-30 AST-32 AlkPhos-526* Amylase-134*
TotBili-2.4*
[**2121-3-18**] 05:40AM BLOOD ALT-50* AST-45* AlkPhos-586* Amylase-128*
TotBili-2.2*
[**2121-3-19**] 10:50AM BLOOD ALT-76* AST-60* AlkPhos-498* Amylase-82
TotBili-2.3*
[**2121-3-20**] 05:50AM BLOOD ALT-59* AST-37 AlkPhos-386* Amylase-77
TotBili-1.6*
[**2121-3-21**] 06:10AM BLOOD ALT-51* AST-34 AlkPhos-440* TotBili-1.5
[**2121-3-21**] 09:30AM BLOOD Amylase-75
[**2121-3-12**] 04:10AM BLOOD Lipase-490*
[**2121-3-21**] 09:30AM BLOOD Lipase-101*
[**2121-3-12**] 04:10AM BLOOD CK-MB-4 cTropnT-<0.01
[**2121-3-12**] 01:31PM BLOOD CK-MB-4 cTropnT-<0.01
[**2121-3-20**] 05:50AM BLOOD Lipase-72*
[**2121-3-19**] 10:50AM BLOOD Lipase-85*
[**2121-3-12**] 04:10AM BLOOD Albumin-2.6* Calcium-7.2* Phos-3.7 Mg-2.0
[**2121-3-21**] 09:30AM BLOOD Calcium-9.0 Phos-2.4* Mg-1.6
[**2121-3-12**] 04:10AM BLOOD Hapto-234*
[**2121-3-12**] 01:31PM BLOOD Hapto-246*
[**2121-3-12**] 01:31PM BLOOD Cortsol-88.5*
[**2121-3-12**] 02:06PM BLOOD Cortsol-99.8*
[**2121-3-12**] 02:48PM BLOOD Cortsol-112.8*
[**2121-3-12**] 06:29AM BLOOD Type-[**Last Name (un) **] Temp-36.6 Rates-[**3-17**] Tidal V-650
PEEP-5 FiO2-50 pO2-42* pCO2-36 pH-7.31* calHCO3-19* Base XS--7
-ASSIST/CON Intubat-INTUBATED
[**2121-3-13**] 12:37PM BLOOD Glucose-49* Lactate-0.9 Na-143 K-3.2*
Cl-113* calHCO3-20*
[**2121-3-13**] 12:37PM BLOOD freeCa-1.17
==================
STUDIES:
[**2121-3-12**] ERCP
ERCP: A single spot fluoroscopic image was obtained without a
radiologist present demonstrating surgical clips and suture
material in the left upper quadrant. A nasogastric tube is noted
within the stomach. There is contrast within the transverse
colon from prior study. By report, cannulation of the bile duct
was not possible
.
PTC [**2121-3-12**]
IMPRESSION: Percutaneous transhepatic cholangiography
demonstrates dilated intra- and extra-hepatic bile ducts with
findings of a large calculus in the distal common bile duct.
A 10-French internal-external biliary drainage catheter was
placed via the right-sided bile ducts and has been left to
straight bag drainage.
Further definitive management of the biliary obstruction will be
performed once the cholangitis has settled with biliary drainage
and antibiotic treatment.
.
CXR [**2121-3-12**]
FINDINGS: Compared with the study at 3:33 a.m. the same day, the
ETT has been withdrawn slightly and now projects approximately 2
cm above the carina.
The lungs appear somewhat clearer than previously, probably due
to the lack of respiratory motion artifact on the current study.
.
CXR [**2121-3-12**]
IMPRESSION:
1) Tip of an endotracheal tube located 1 cm above the level of
the carina. The tube should be retracted approximately 3 cm for
optimal positioning.
2) Tortuous appearance of the thoracic aorta which could be
better evaluated with a PA and lateral chest radiograph.
.
CXR [**2121-3-14**]
IMPRESSION: Slight worsening of left lower lobe consolidation.
No pneumothorax.
.
MRA [**2121-3-15**]
IMPRESSION: No evidence of high-grade stenosis or occlusion in
the arteries of anterior or posterior circulation
.
CT head [**2121-3-15**]
IMPRESSION: Chronic watershed infarction in the right frontal
lobe. No significant associated mass effect. No evidence of
acute intracranial hemorrhage.
.
BILIARY STONE REMOVAL [**2121-3-18**]
IMPRESSION:
1. Pullback cholangiogram demonstrated obstruction at the distal
common bile which could be a long area of fibrous stricture or
the possibility of a small tumor of the pancreatic head.
2. Balloon dilatation of the obstructed common bile duct with 8
mm cutting balloon and 10 mm regular balloons.
3. 10-French external-internal biliary drainage catheter was
placed with the pigtail locked in the small bowel loop. The
catheter was connected with an external drainage bag.
.
CT ABDOMEN [**2121-3-19**]
IMPRESSION:
1. No evidence of a pancreatic mass.
2. Status post percutaneous biliary drainage with a catheter
extending into the duodenum. No intrahepatic biliary ductal
dilatation.
3. Obliteration of the portal vein in segments II and an
adjacent portion of segment IV with increased arterial perfusion
of the affected segments.
4. Borderline enlarged periportal lymph nodes, which may be
reactive.
5. Left adrenal gland fullness.
6. Small bilateral pleural effusions with bibasilar atelectasis.
.
ULTRASOUND RUQ WITH DOPPLER [**2121-3-20**]
IMPRESSION: No demonstrable flow in left portal vein consistent
with thrombus.
.

Brief Hospital Course:
Ms [**Known lastname **] is a 78 yo F with DM, HTN, s/p cholecystectomy who
was transferred by [**Location (un) **] from [**Hospital3 3583**]
intubated/sedated for ERCP and further management of sepsis
secondary to cholangitis. She was treated with Levophed for
hypotension, and fluid resuscitated. She was also continued on
Zosyn, with the plan to complete a full course of antibiotics
for cholangitis. The following morning she had an attempted ERCP
which could not be completed secondary to her prior bariatric
surgery. Therefore she underwent a PTC, with successful
placement of an internal/external drain. A large stone was
thought to be seen in the CBD which was later determined to be a
stricture. The pt quickly stabilized, was weaned off pressors,
and extubated without complication over the next 2 days. After
extubated and removal of sedation she was quite confused, and
was noted to have some asymmetry at her mouth. It was unclear if
this was new. An MRI was ordered, and it showed chronic right
frontal watershed infarct and moderate changes of small vessel
disease and brain atrophy. There was no evidence of mass effect
or midline shift and no evidence of acute or chronic hemorrhage.
The pt's mental status gradually came back to baseline and her
facial asymmetry resolved. Prior to her discharge from the ICU,
peripheral lines were placed, and the central femoral line
placed under sterile conditions at the outside hospital was
removed. During her time in the ICU her cultures from [**Hospital1 3325**] also grew pan-sensitive E Coli. She was continued on
Zosyn and her bile cultures grew gram negative rods,
enterococcus and viridans streptococci. She was maintained on IV
Zosyn and was transitioned to oral Levofloxacin to complete a 10
day course (to end [**2121-3-31**]). The pt's blood cultures were
negative. The pt underwent an interventional radiology guided
dilatation of CBD stenosis also had a percutaneous drain placed
in the common bile duct (as mentioned above). The drain will
stay in place for 4-6 weeks at which point pt will be
reevaluated by a cholangoigram (scheduled already) to determine
timing for removal of drainage by interventional radiology. The
pt was noted to have portal vein thrombosis for which she will
need work-up by her primary care physician.
.
Sepsis:
The pt was noted to have leukocytosis and fever (on admission)
secondary to acute cholangitis. She was treated with IV Zosyn
and transitioned to PO Levofloxacin to complete a 10 day course
(to end [**2121-3-31**]). Her blood cultures (2 sets) were negative. The
pt remained afebrile and her percutaneous drain (mentioned
above) in the bile duct continued to drain about 1.5 liters
daily. The bile drain was plugged prior to the pt's discharge
and will need to stay plugged until the pt's appointment with
interventional radiology on [**2121-4-23**]; at that time pt will be
reevaluated to see if restenosis has occurred. In the event of
restenosis, the pt will need another stricture dilatation. The
interventional radiology team (Dr. [**First Name8 (NamePattern2) 6339**] [**Last Name (NamePattern1) 19420**] or Dr. [**First Name (STitle) **]
[**Name (STitle) **]) at [**Hospital3 **] should be notified if the pt has
recurrence of abdominal pain, worsening levels of liver enzymes
(especially total bilirubin), rising white cell count or fever.
The IR team can be reached at phone# [**Telephone/Fax (1) 53981**].
.
GI:
The pt was noted to have acute cholangitis in the setting of CBD
stenosis. The GI team was unable to perform a successful ERCP
due to a previous gastric bypass procedure. The pt underwent a
10-French internal-external biliary drainage catheter placement
for drainage for dilated bile ducts. She underwent a CT abdomen
that showed no pancreatic mass or tumor.
.
Left portal vein thrombus:
The pt underwent a CT abdomen which showed portal vein
obliteration in segment II and an adjacent portion of segment
IV, with associated increased arterial perfusion of these
segments. A duplex ultrasound confirmed left portal vein
thrombosis. These findings were discussed with the pt's PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], and it was decided that he will initiate an out-patient
workup for the thrombosis.
.
Neuro:
The pt was noted (in ICU) to have facial asymmetry. However, the
chronicity of this asymmetry was unknown. The pt's head MRI was
significant for no acute strokes, however it did indicate a
chronic right frontal watershed infarct, moderate changes of
small vessel disease and brain atrophy and no evidence of
high-grade stenosis or occlusion in the arteries of anterior or
posterior circulation.
.
CV:
The pt has a history of hypertension and hypercholesterolemia
but no known CAD. Her ECG on admission showed no acute evidence
of ischemia and her cardiac enzymes ruled out an acute MI. Pt
was maintained on Captopril during the hospitalization and was
transitioned back to her home regimen of Lisinopril on
discharge.
.
Anemia:
The pt was noted to have a hematocrit drop from 40 to 33 with
IVF hydration in the ICU. Her baseline hematocrit is unknown.
The pt was noted to have no evidence of bleeding and her
hematocrit remained stable in the low 30s. The pt will likely
benefit from an out-patient workup of her anemia and will likely
need to be scheduled for a colonoscopy by her PCP.
.
Renal:
(Baseline unknown). The pt was noted to have acute renal failure
on admission (Cr 2.2) which resolved with hydration and
treatment of acute cholangitis. The pt sustained minor Foley
trauma when she accidentally pulled out her Foley (with bulb
inflated) while trying to get back into bed from chair. The
Foley was replaced and continued to drain normally. The foley
should eventually removed prior to discharge from rehab.
.
Endocrine:
The pt has a history of diabetes for which she was maintained on
a regular insulin sliding scale.
.
FEN:
The pt was maintained on a low fat diet and her electrolytes
were repleted as needed.
.
Prophylaxis: The pt was maintained on prophylaxis with SC
heparin and proton pump inhibitor.
.
Code: Full
.
Communication: Son, [**Name (NI) 3065**] [**Name (NI) **], is power of attorney
(h[**Telephone/Fax (1) 67267**], c[**Telephone/Fax (1) 67268**], w[**Telephone/Fax (1) 67269**])


Medications on Admission:
Home Meds (confirmed with son):
- [**Name (NI) **] 20 daily
- Lisinopril 40 daily
- Glyburide 40 daily
- Fosamax 70 weekly
- HCTZ 25 daily
- B12 1000 mcg daily
- Ca supplements
- Centrum Silver
- Tylenol prn
- ASA prn
.
Transfer Meds:
- Ancef x3 doses (start date [**2121-3-10**])
- Zosyn x1 dose [**2121-3-11**]
- ativan prn for sedation
- Neosynephrine gtt
- Vasopressin gtt

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: NOT to exceed 3 grams daily.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing.
6. Glyburide 5 mg Tablet Sig: Eight (8) Tablet PO once a day:
home dose: 40mg daily of Glyburide.
7. Warfarin 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Outpatient [**Name (NI) **] Work
Pt to have INR checked every 2 days and Coumadin uptitrated
until therapeutic INR (2 to 3) reached.
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 doses: Start date: [**2121-3-21**]
End date: [**2121-3-31**].
10. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day:
hold for sbp<100.
11. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. CALCIUM 600 + D 600-125 mg-unit Tablet Sig: One (1) Tablet
PO TID with meals: Do NOT give at the same time as
Levofloxacin!.
13. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
14. [**Month/Day/Year **] 20 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 11057**] Nursing & Rehabilitation Center - [**Location (un) 3320**]

Discharge Diagnosis:
Primary:
Acute cholangitis with placement of (temporary) percutaneous
drain
Left portal vein thrombosis
.
Secondary:
- NIDDM
- HTN
- hypercholestreolemia
- s/p cholecystectomy [**59**] yrs ago
- OA
- osteoporosis
- s/p gastric bypass for obesity ~30 yrs ago by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
- B12 deficiency anemia
- s/p total hysterectomy
- h/o abnormal LFT's with abd U/S sig for fatty liver in [**Month (only) **]
[**2119**]; LFT's subsequently improved


Discharge Condition:
Stable


Discharge Instructions:
Please report to the nearest emergency department if you have
fever,  worsening abdominal pain, nausea, vomiting, diarrhea,
lightheadedness, loss of consciousness and increased itching.
.
There has been a change in your medications.
.
Your will need to follow-up with the appointments arranged for
your. Your tube draining the bile will need to stay in place for
4-6 weeks at which point you will need to be re-evaluated to see
if the tube can come out.
.
You were noted to have a clot in one of your liver veins. Your
PCP will do further workup of this clotting.
.
You were noted to have anemia for which you will need to ask
your PCP to schedule you for a colonoscopy as an out-patient.
.
You have been started on a 10 day course of Levofloxacin (to end
[**2121-3-31**]) for your bile infection.  If you have fever, chills or
abdominal pain you should call #[**Telephone/Fax (1) 53981**] and ask to speak
with any of the interventional radiologists.

Followup Instructions:
***REHAB WILL NEED TO ARRANGE FOR PATIENT TO BE TRANSPORTED TO
HER APPOINTMENT IN A BLS AMBULANCE ****
.
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Date/Time: [**2121-4-2**] at 3:00pm
Location: [**Street Address(2) 67270**], [**Location (un) 3320**], [**Numeric Identifier 40624**]. Phone:
[**Telephone/Fax (1) 13266**]  Fax: [**Telephone/Fax (1) 67271**].
.
You have been scheduled for a CHOLANGIOGRAM. Date/Time: [**2121-4-23**]
at 7:00am. Location: report to Daycare on [**Hospital Ward Name 121**] building [**Location (un) **]. Call the physician's assistant [**Telephone/Fax (1) 6747**] with any
questions.
Phone: [**Telephone/Fax (1) 9387**].


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

Completed by:[**2121-3-21**]
{'Unspecified septicemia,Severe sepsis,Septic shock,Cholangitis,Acute kidney failure, unspecified,Acute respiratory failure,Portal vein thrombosis,Injury to bladder and urethra, without mention of open wound into cavity,Unspecified accident,Volume depletion, unspecified,Unspecified disease of pancreas,Neoplasm of unspecified nature of digestive system,Personal history of other diseases of circulatory system,Intestinal bypass or anastomosis status,Other vitamin B12 deficiency anemia,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Disorders of magnesium metabolism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: 78 yo F with h/o DM, HTN, and cholecystectomy presented to
[**Hospital3 3583**] on [**2121-3-10**] with hypotension (SBP 80's) initially
improved with IVF's, RUQ pain, anorexia, loose stools, and
jaundice x3 days.  CT abd at [**Hospital3 3583**] revealed a
gallstone occluding CBD.  They were unable to perform ERCP at
OSH given h/o gastric bypass.  She was started on Ancef.  She
was noted to have ARF thought to be secondary to prerenal
azotemia given decreased po intake.
.
She was to be transferred to [**Hospital1 18**] on [**2121-3-12**] for ERCP, however,
she became hypotensive to the 50's on the evening of [**2121-3-11**].
She was started on Neo 10 mg and Vasopressin 0.4 units through
PIV's and transferred to the ICU at [**Hospital3 3583**].  She spiked
a temp to 102.5.  She was given a dose of Zosyn.  Her finger
stick was found to 58; she was given 1 amp of D50.  A left
femoral central line was placed by the surgical service under
sterile conditions.  A right fem line was attempted.  She
received ~ 3 liters of Normal Saline.
.
She was transferred emergently by [**Location (un) **] to [**Hospital1 18**] for ERCP
and further management of presumed sepsis secondary to
cholangitis.  She was intubated for airway protection prior to
the flight.  CXR reported as ETT in good position, lung fields
clear.  ABG prior to intubation: 7.35/35/55.
.
Currently she is intubated and sedated.  Her son is present to
answer questions.  He reports a gradual decline in her function
and a 20 lb wt loss over the last month.  She has had increasing
confusion, intermittent RUQ pain and bowel/bladder incontinence.
 Of note, she presented to an OSH in [**2120-8-8**] with RUQ pain; at
that time she was noted to have elevated LFT's; U/S revealed
fattly liver.  Her LFT's subsequently resolved.

MEDICAL HISTORY: - NIDDM
- HTN
- hypercholestreolemia
- s/p cholecystectomy [**59**] yrs ago
- OA
- osteoporosis
- s/p gastric bypass for obesity ~30 yrs ago by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
- B12 deficiency anemia
- s/p total hysterectomy
- h/o abnormal LFT's with abd U/S sig for fatty liver in [**Month (only) **]
[**2119**]; LFT's subsequently improved

MEDICATION ON ADMISSION: Home Meds (confirmed with son):
- [**Name (NI) **] 20 daily
- Lisinopril 40 daily
- Glyburide 40 daily
- Fosamax 70 weekly
- HCTZ 25 daily
- B12 1000 mcg daily
- Ca supplements
- Centrum Silver
- Tylenol prn
- ASA prn
.
Transfer Meds:
- Ancef x3 doses (start date [**2121-3-10**])
- Zosyn x1 dose [**2121-3-11**]
- ativan prn for sedation
- Neosynephrine gtt
- Vasopressin gtt

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
Tm 102.5  Tc 97.8  BP 105/51  HR 58  RR 16   Sat 97%
I/O (from [**Hospital1 46**]) 3585/1490
Vent: AC Vt 650/RR set 10, breathing at 16/PEEP 5/50% FiO2
Neo and Vasopressin turned off upon arrival; started Levophed
0.075 mcg/min
Gen: intubated, sedated
HENNT:  icteric, pupils ~2 mm minimally reactive to light
CV:  RRR, nl S1S2,  No M/R/G
Lungs: CTAB
Abd:  soft, NT/ND, +BS, No HSM
Ext:  warm, no edema, strong DP/PT pulses bilaterally
Skin:  no rash, jaundiced, mulitple excoriations over upper and
lower extremeties

FAMILY HISTORY: Mother died at age 86 of colon cancer.  Father died in his 70's
secondary to complications from DM.  She has 2 healthy children.

SOCIAL HISTORY: Lives alone, however, son dispenses meds and does shopping, home
health aide to assist with bathing and laundry 2x/wk, and meals
on wheels daily.  Has life line.  Son, [**Name (NI) 3065**], involved in her
care (h[**Telephone/Fax (1) 67267**], c[**Telephone/Fax (1) 67268**], w[**Telephone/Fax (1) 67269**]).  Pt does not
leave her house often.  She has a h/o poor hygiene and leaving
food out around the house.  Denies Tob, EtOH, or Illicit drug
use.  Widowed since [**2103**]. Husband was a urologist. 

### Response:
{'Unspecified septicemia,Severe sepsis,Septic shock,Cholangitis,Acute kidney failure, unspecified,Acute respiratory failure,Portal vein thrombosis,Injury to bladder and urethra, without mention of open wound into cavity,Unspecified accident,Volume depletion, unspecified,Unspecified disease of pancreas,Neoplasm of unspecified nature of digestive system,Personal history of other diseases of circulatory system,Intestinal bypass or anastomosis status,Other vitamin B12 deficiency anemia,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Disorders of magnesium metabolism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
