CHIEF COMPLAINT: dizziness, recurrent diarrhea

PRESENT ILLNESS: 65 year old woman with signficant PMH of atrial fibrillation on
Coumadin, lung cancer s/p resection [**2109**], congestive heart
failure, diabetes, cirrhosis, gastritis, and hypertension with
recent admission for hypotension and dehydration at [**Hospital1 2025**] where
blood cx were negative, c.diff x3 negative, and she was found to
have a pansensitive e.coli UTI treated with ceftriaxone. More
recently she had an admission to [**Hospital1 18**] ([**2112-6-30**] - [**2112-7-6**]) for
dehydration, C.diff, possible diverticulitis, and sepsis with a
RML PNA. She was treated with vancomycin, cefepime, and flagyl
and transiently required pressor support. She presents today
with dizziness.

MEDICAL HISTORY: -s/p Left Lower Lobectomy ([**10/2110**]) for Large Cell Carcinoma of
Lung
- CHF (EF ~84 with mild MR, AS)
- A. Fib on coumadin
- DMII c/w peripheral neuropathy
- pansenitive e.coli uti
- c. diff
- COPD
- Chronic venous insuffiency LE cellulitis
- depression
- anemia baseline hct 28.7
- HLD
- Gastritis
- Nephrolithiasis
- Psoriasis
- History of choleycystectomy
- Obesity
- Osteoporosis
- Hypercholesterolemia

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO TID
3. Digoxin 0.125 mg PO DAILY
4. Duloxetine 20 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Enalapril Maleate 20 mg PO DAILY
hold for sbp < 100
7. Metoprolol Tartrate 25 mg PO BID
hold for sbp < 100 and hr < 60
8. Mirtazapine 30 mg PO HS
9. Pregabalin 150 mg PO BID
10. Simvastatin 40 mg PO DAILY
11. Vancomycin Oral Liquid 125 mg PO Q6H
12. NPH 52 Units Breakfast
NPH 56 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Vitamin D 800 UNIT PO DAILY
14. Warfarin 3 mg PO DAILY16

ALLERGIES: Amoxicillin / Glipizide / Ciprofloxacin / Bactrim / Soriatane /
Potassium Chloride / Bupropion / Calcium Channel Blocking
Agents-Benzothiazepines / atenolol

PHYSICAL EXAM: Admission:
Vitals: 98.2 135 93/53 17 96%RA
General: Alert, oriented, no acute distress
HEENT: Sclera are mildly icteric, DMM, oropharynx clear, EOMI,
PERRL
Neck: supple, JVP ~[**6-19**], no LAD
CV: Tachycardia with irregular rhythm, normal S1 + S2, [**2-16**]
systolic murmer, no rubs or gallops.
Lungs: Mild crackles at bases, wheezes, ronchi
Abdomen: obese, soft, non-distended, bowel sounds present, no
organomegaly, no suprapubic tenderness to palpation, no
rebound or guarding, psoriasis patches
GU: No foley
Ext: Warm, well perfused, 1+ pulses, 2+ edema mid-shin,
venous-stasis changes, no clubbing, cyanosis
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
.
Discharge Exam:
Vitals: T98.8 P 89 BP 124/46 O2 sat 93% RA
Gen: well appearing in  NAD
Neck: supple;  JVP ~8cm, no  LAD
HEENT: EOMI intact, MMM
Chest: irregular rate, 3/6 SEM murmmur
Lungs: mild crackles b/l at bases
Abodmen- soft NTND, normoactive BS,
Extremities- 1+ b/l LE edema, 2+ DP
Skin- chronic venous changes on b/l LE; no ulcerations notes,
multiple large erythematous plaques on back and chest

FAMILY HISTORY: +fh for diabetes, no FH for malignances

SOCIAL HISTORY: Lives with daughter. Retired file clerk in a law office. Current
smoker 1 ppd (60 pack year history). No alcohol
or illicits. Ambulates with a cane because walker doesn't fit
well
in hallways
Chronic diastolic heart failure,Acidosis,Atrial fibrillation,Other chronic pulmonary heart diseases,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Thrombocytopenia, unspecified,Other psoriasis,Venous (peripheral) insufficiency, unspecified,Cirrhosis of liver without mention of alcohol,Iron deficiency anemia, unspecified,Obesity, unspecified,Acquired absence of organ, lung,Osteoporosis, unspecified,Pure hypercholesterolemia,Tobacco use disorder,Depressive disorder, not elsewhere classified,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of bronchus and lung,Personal history, urinary (tract) infection,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Orthostatic hypotension,Cellulitis and abscess of leg, except foot
Chr diastolic hrt fail,Acidosis,Atrial fibrillation,Chr pulmon heart dis NEC,DMII neuro nt st uncntrl,Neuropathy in diabetes,Thrombocytopenia NOS,Other psoriasis,Venous insufficiency NOS,Cirrhosis of liver NOS,Iron defic anemia NOS,Obesity NOS,Acq absence of lung,Osteoporosis NOS,Pure hypercholesterolem,Tobacco use disorder,Depressive disorder NEC,Long-term use anticoagul,Hx-bronchogenic malignan,Personal history UTI,Int inf clstrdium dfcile,Acute kidney failure NOS,Orthostatic hypotension,Cellulitis of leg
Admission Date:  [**2112-7-7**]              Discharge Date:   [**2112-7-11**]

Date of Birth:  [**2046-9-9**]             Sex:   F

Service: MEDICINE

Allergies:
Amoxicillin / Glipizide / Ciprofloxacin / Bactrim / Soriatane /
Potassium Chloride / Bupropion / Calcium Channel Blocking
Agents-Benzothiazepines / atenolol

Attending:[**Doctor First Name 2080**]
Chief Complaint:
dizziness, recurrent diarrhea

Major Surgical or Invasive Procedure:
CV line placement

History of Present Illness:
65 year old woman with signficant PMH of atrial fibrillation on
Coumadin, lung cancer s/p resection [**2109**], congestive heart
failure, diabetes, cirrhosis, gastritis, and hypertension with
recent admission for hypotension and dehydration at [**Hospital1 2025**] where
blood cx were negative, c.diff x3 negative, and she was found to
have a pansensitive e.coli UTI treated with ceftriaxone. More
recently she had an admission to [**Hospital1 18**] ([**2112-6-30**] - [**2112-7-6**]) for
dehydration, C.diff, possible diverticulitis, and sepsis with a
RML PNA. She was treated with vancomycin, cefepime, and flagyl
and transiently required pressor support. She presents today
with dizziness.

Today at home she c/o "feeling faint" after raising from seated
position. She syncopized with LOC for "a few seconds" and fell
with a resulting left elbow abrasion. She denies headstrike or
other tramua, CP, abdominal pain, dysuria, fever, chills,
sweats, N/V, no associated tonic-clonic activity, incontinence
of bowel or bladder, she did not appear post-ictal. At the time
she was noted to be dry, pale and c/o headache since this AM and
Palpitations and SOB. She has had ~[**4-21**] watery BM the past few
days with 4 this AM. She is A+Ox3. Brought to the ED by EMS.

In ED, initial VS: 98.6, 86, 95/57, 16, 98%. In the ED she
recieved a total of 1000mL. Orthostatics were attempted but she
was unable to stand without tachycardia and hypotension that was
symptomatic. Pressures were in 90s while seated. She was
initially admited to to medicine, however considering she
becomes tachy to 140s-150s with pressures in the 90s systolic
she was admitted instead to the MICU.

On arrival to the MICU, she is AOx3 with PIV placed. She was
bolused with 1L NS due to hypotension and tachycardia.



Past Medical History:
-s/p Left Lower Lobectomy ([**10/2110**]) for Large Cell Carcinoma of
Lung
- CHF (EF ~84 with mild MR, AS)
- A. Fib on coumadin
- DMII c/w peripheral neuropathy
- pansenitive e.coli uti
- c. diff
- COPD
- Chronic venous insuffiency LE cellulitis
- depression
- anemia baseline hct 28.7
- HLD
- Gastritis
- Nephrolithiasis
- Psoriasis
- History of choleycystectomy
- Obesity
- Osteoporosis
- Hypercholesterolemia


Social History:
Lives with daughter. Retired file clerk in a law office. Current
smoker 1 ppd (60 pack year history). No alcohol
or illicits. Ambulates with a cane because walker doesn't fit
well
in hallways


Family History:
 +fh for diabetes, no FH for malignances


Physical Exam:
Admission:
Vitals: 98.2 135 93/53 17 96%RA
General: Alert, oriented, no acute distress
HEENT: Sclera are mildly icteric, DMM, oropharynx clear, EOMI,
PERRL
Neck: supple, JVP ~[**6-19**], no LAD
CV: Tachycardia with irregular rhythm, normal S1 + S2, [**2-16**]
systolic murmer, no rubs or gallops.
Lungs: Mild crackles at bases, wheezes, ronchi
Abdomen: obese, soft, non-distended, bowel sounds present, no
organomegaly, no suprapubic tenderness to palpation, no
rebound or guarding, psoriasis patches
GU: No foley
Ext: Warm, well perfused, 1+ pulses, 2+ edema mid-shin,
venous-stasis changes, no clubbing, cyanosis
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
.
Discharge Exam:
Vitals: T98.8 P 89 BP 124/46 O2 sat 93% RA
Gen: well appearing in  NAD
Neck: supple;  JVP ~8cm, no  LAD
HEENT: EOMI intact, MMM
Chest: irregular rate, 3/6 SEM murmmur
Lungs: mild crackles b/l at bases
Abodmen- soft NTND, normoactive BS,
Extremities- 1+ b/l LE edema, 2+ DP
Skin- chronic venous changes on b/l LE; no ulcerations notes,
multiple large erythematous plaques on back and chest


Pertinent Results:
Admission:
[**2112-7-7**] 12:00PM BLOOD WBC-14.8*# RBC-3.61* Hgb-9.4* Hct-30.7*
MCV-85 MCH-26.0* MCHC-30.6* RDW-19.7* Plt Ct-203#
[**2112-7-7**] 12:00PM BLOOD Neuts-73.6* Lymphs-18.2 Monos-5.7 Eos-2.2
Baso-0.3
[**2112-7-7**] 12:00PM BLOOD Glucose-128* UreaN-12 Creat-1.0 Na-143
K-3.6 Cl-107 HCO3-23 AnGap-17
[**2112-7-7**] 02:20PM BLOOD ALT-19 AST-21 AlkPhos-102 TotBili-0.5
[**2112-7-7**] 02:20PM BLOOD cTropnT-0.03* proBNP-943*
[**2112-7-7**] 06:44PM BLOOD Lactate-2.2*

Pertinent:
[**2112-7-8**] 05:06AM BLOOD Lactate-1.3
[**2112-7-8**] 11:39AM BLOOD calTIBC-238* Ferritn-29 TRF-183*
[**2112-7-7**] 09:52PM BLOOD CK-MB-2 cTropnT-0.02*

Discharge:
[**2112-7-11**] 06:50AM BLOOD WBC-7.3 RBC-3.00* Hgb-7.9* Hct-25.3*
MCV-84 MCH-26.4* MCHC-31.3 RDW-19.5* Plt Ct-105*
[**2112-7-11**] 06:50AM BLOOD PT-14.9* PTT-30.9 INR(PT)-1.4*
[**2112-7-11**] 06:50AM BLOOD Glucose-141* UreaN-12 Creat-0.7 Na-142
K-3.5 Cl-104 HCO3-32 AnGap-10
[**2112-7-7**] 02:20PM BLOOD ALT-19 AST-21 AlkPhos-102 TotBili-0.5
[**2112-7-11**] 06:50AM BLOOD Calcium-9.3 Phos-2.8 Mg-1.5*
Studies:

[**2112-7-8**] Echo:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.

[**2112-7-8**] ECHO
IMPRESSION:
1.  Right internal jugular venous access catheter terminates at
the cavoatrial junction, status post partial withdrawal.
2.  Progression of pulmonary edema.  Cannot exclude superimposed

consolidation.  Known right lower lobe spiculated lung lesion
not well
appreciated radiographically.

Brief Hospital Course:
65 year old woman with signficant PMH of atrial fibrillation on
Coumadin, lung cancer s/p resection [**2109**], congestive heart
failure, diabetes, cirrhosis, gastritis, and hypertension with
recent admission for PNA and C.diff presenting with syncope,
found to be hypotensive and tachycardic admitted to the MICU and
volume rescucitated.
.
Acute:
# Hypotension: DDx for this included hypovolemia, septic, and
cardiogenic sources. Given copious amounts of diarrhea and
recent broad coverage with antibiotics, hypovolemia was
considered more probable than sepsis. Cardiogenic was considered
in the setting of mild troponin elevation and palpitations and
SOB on ROS. On arrival to the MICU her Lactate was 2.2. She was
making adequate urine, although her Cr was 1.0 up from 0.6 at
last discharge. Mentating without difficulty. Blood cultures
were sent, her stool was guiac negative, and she remained
afrbrile. She responded well to 5L of NS and her pressures
improved to SBP of 130's the following morning ([**2112-7-8**]) with
resolution of Afib with RVR. Vancomycin and phenylepherine were
briefly utilized but were deemed unessesary given no source of
infection, clinical improvement, and stabilization of VS. She
was restarted on her home metoprolol once vitals stabilized.
This was uptitrated to 37.5 [**Hospital1 **] for better rate control.  Her
other BP medications including torsemide were held.  These were
restarted over the remainder of her hospitalization.  She is
currently hemodynamically stable and without diarrhea on
vancomycin 500mg PO Q6H.
.
# Syncope: Likely related to volume depleted state given
orthostasis. However did complain of palpitations so could
conceivably be due to underlying atrial fibrillation. TTE showed
mild LVH, LA enlargement, and mild valvular disease throughout.
No evidence of diastolic or systolic dysfunction, and mild
pulmonary artery hypertension was also noted.   She responded
well to fluid resuscitation as above. She was continually
monitored on Telemetry without return of RVR.  Her metoprolol
was uptitrated to improved rate control.
.
# C.Diff colitis: This is now her second episode since [**Month (only) 547**].
Should be classified as severe given age, white count, and ICU
admission.  The current episode has occurred for the past month
despited PO flagyl and Vanco 125 q6hrs.  This was the likely
precipitant of dehydration. Belly exam unremarkable.  Her PO
vanc was increased to 500 q6hrs.  By HOD2 her diarrhea had
resolved.  She was discharged with follow-up with ID for a PO
vanc taper given severe nature and recurrence, at least 2 weeks
of full dose therapy.
.
# Acute Renal Failure: Baseline Cr 0.6-0.7. Currently 0.8 Likely
related to dehydration. Her Cr improved to baseline with IVF.
.
# Cirrhosis, NOS: New diagnosis on recent abdominal CT with no
clear etiology.  Does not admit to alcohol abuse or IVDU. No
tattoes or transfusions. No family history of liver disease. Not
encephalopathic. No ascites on exam. Already has liver follow up
scheduled. Hep B negative. LFTs and INR were ordered as were
viral serologies. [**First Name8 (NamePattern2) 6**] [**Doctor First Name **], AMA, [**Last Name (un) 15412**], and ferritin were also
ordered.  Her anti-smooth muscle antibody was positive
concerning for possible autoimmune hepatitis, and her [**Doctor First Name **] were
mildly positive.  This should be discussed further with her
hepatologist.
.
# Atrial fibrillation: On arrival, not controlled. Likely
related to dehydration. Currently on digoxin and metoprolol at
home. Anticoagulated with warfarin. Her medications were held
and her rate slowed down with IVF. Once she was hemodynamically
stable, her metoprolol was restarted and uptitrated to _37.5mg
PO BID for improved rate control. The role of digoxin was
unclear in her therapy and was discontinued given room for
increased metoprolol.  Given her superimposed renal failure,
digoxin was held.  Her coumadin is being titrated up and she can
follow up at Rehab until she is therapeutic.
.
# CHF, chronic diastolic: Chronic Stable issue. Per report she
had a recent EF = 55% via TTE in [**Month (only) 547**] which was grossly
unchanged on repeat. Currently appears hypervolemic. CXR on
[**2112-7-8**] after five liters showed pulmonary edema. IVF were given
judiciciously following resuscitation.  Repeat echo showed
preserved EF.  Torsemide was held initially with hemodynamic
instability, but patient complained of some orthopnea during
admission and LE edema worsened.  Her home torsemide was
restarted as resulted.
.
#HLD: Chronic Stable. She was continued on her home simvastatin
40 mg PO DAILY.
.
Chronic:
#DM2, controlled: Chronic Stable. Her metformin was held and she
was started on a HISS and NPH.  Her NPH was increased to her
home dose after she was tolerating PO and became extremely
hyperglycemic. We will restart her metformin at time of
discharge
.
#Anemia: Chronic stable. Normocytic. Her H+H and platelets were
decreased on HD#1 but this is likely secondary to hemodilution.
She was started on PO ferrous sulfate.  Iron studies showed
mixed picture with some likely component of iron deficiency
anemia.
.
#Depression: Chronic Stable. Her home medicationd were
continued.

Transitional Issues:
# Transition to rehab
# Follow-up with ID for PO vanco taper
# Follow-up with GI for recurrent C Diff and Strep Bovis in
urine.
# Follow up hepatology as Anti-smooth muscle is positive
# Patient will need to be vaccinated for Hepatitis B given
Radiology finding of cirrhosis and not immunized
# trend H/H to make sure increasing on Iron deficiency.
Recommend outpatient screening colonoscopy

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO TID
3. Digoxin 0.125 mg PO DAILY
4. Duloxetine 20 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Enalapril Maleate 20 mg PO DAILY
hold for sbp < 100
7. Metoprolol Tartrate 25 mg PO BID
hold for sbp < 100 and hr < 60
8. Mirtazapine 30 mg PO HS
9. Pregabalin 150 mg PO BID
10. Simvastatin 40 mg PO DAILY
11. Vancomycin Oral Liquid 125 mg PO Q6H
12. NPH 52 Units Breakfast
NPH 56 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Vitamin D 800 UNIT PO DAILY
14. Warfarin 3 mg PO DAILY16


Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO TID
3. Duloxetine 20 mg PO DAILY
4. Enalapril Maleate 20 mg PO DAILY
hold for sbp < 100
5. NPH 65 Units Breakfast
NPH 65 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Metoprolol Tartrate 37.5 mg PO TID
hold for sbp < 100 and hr < 60
7. Mirtazapine 30 mg PO HS
8. Pregabalin 150 mg PO BID
9. Simvastatin 40 mg PO DAILY
10. Vancomycin Oral Liquid 500 mg PO Q6H
11. Vitamin D 800 UNIT PO DAILY
12. Warfarin 6.5 mg PO DAILY16
13. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
14. Ferrous Sulfate 325 mg PO DAILY
15. Torsemide 60 mg PO DAILY
16. MetFORMIN (Glucophage) 1000 mg PO BID


Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Location (un) 1821**]

Discharge Diagnosis:
Primary: C Difficile Infection
Secondary: Hypotension, Atrial Fibrillation, Acute Renal
Failure, Type II Diabetes


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Ms [**First Name8 (NamePattern2) **] [**Last Name (Titles) **],
It was a pleasure taking care of you during your recent stay at
[**Hospital1 18**].  You were admitted with a rapid heart rate and
dehydration because of your c difficile infection.  Your oral
antibiotic (vancomycin) was increased because you had apparently
failed therapy.  Your diarrhea resolved.  You will need a
prolonged taper of this medication because you have failed
therapy in the past.   Additionally your INR was low and so we
increased your metoprolol.  They will continue to adjust this at
Rehab.  We also continued to change your metoprolol for better
heart rate control.

Followup Instructions:
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2112-7-12**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: TUESDAY [**2112-7-12**] at 10:30 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: WEDNESDAY [**2112-7-13**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], PHARM D [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

[**2112-7-22**]  09:20a   [**Last Name (LF) **],[**First Name3 (LF) 640**] B (LIVER CENTER)
  LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **]
  LIVER CENTER (SB)

Department: INFECTIOUS DISEASE
When: FRIDAY [**2112-7-29**] at 10:00 AM
With: [**Name6 (MD) 27568**] [**Name8 (MD) 27569**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Name: [**Last Name (LF) **],[**First Name3 (LF) **] H.
Location: [**Hospital3 249**]
[**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 1, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2010**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
{'Chronic diastolic heart failure,Acidosis,Atrial fibrillation,Other chronic pulmonary heart diseases,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Thrombocytopenia, unspecified,Other psoriasis,Venous (peripheral) insufficiency, unspecified,Cirrhosis of liver without mention of alcohol,Iron deficiency anemia, unspecified,Obesity, unspecified,Acquired absence of organ, lung,Osteoporosis, unspecified,Pure hypercholesterolemia,Tobacco use disorder,Depressive disorder, not elsewhere classified,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of bronchus and lung,Personal history, urinary (tract) infection,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Orthostatic hypotension,Cellulitis and abscess of leg, except foot'}


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: dizziness, recurrent diarrhea

PRESENT ILLNESS: 65 year old woman with signficant PMH of atrial fibrillation on
Coumadin, lung cancer s/p resection [**2109**], congestive heart
failure, diabetes, cirrhosis, gastritis, and hypertension with
recent admission for hypotension and dehydration at [**Hospital1 2025**] where
blood cx were negative, c.diff x3 negative, and she was found to
have a pansensitive e.coli UTI treated with ceftriaxone. More
recently she had an admission to [**Hospital1 18**] ([**2112-6-30**] - [**2112-7-6**]) for
dehydration, C.diff, possible diverticulitis, and sepsis with a
RML PNA. She was treated with vancomycin, cefepime, and flagyl
and transiently required pressor support. She presents today
with dizziness.

MEDICAL HISTORY: -s/p Left Lower Lobectomy ([**10/2110**]) for Large Cell Carcinoma of
Lung
- CHF (EF ~84 with mild MR, AS)
- A. Fib on coumadin
- DMII c/w peripheral neuropathy
- pansenitive e.coli uti
- c. diff
- COPD
- Chronic venous insuffiency LE cellulitis
- depression
- anemia baseline hct 28.7
- HLD
- Gastritis
- Nephrolithiasis
- Psoriasis
- History of choleycystectomy
- Obesity
- Osteoporosis
- Hypercholesterolemia

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO TID
3. Digoxin 0.125 mg PO DAILY
4. Duloxetine 20 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Enalapril Maleate 20 mg PO DAILY
hold for sbp < 100
7. Metoprolol Tartrate 25 mg PO BID
hold for sbp < 100 and hr < 60
8. Mirtazapine 30 mg PO HS
9. Pregabalin 150 mg PO BID
10. Simvastatin 40 mg PO DAILY
11. Vancomycin Oral Liquid 125 mg PO Q6H
12. NPH 52 Units Breakfast
NPH 56 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Vitamin D 800 UNIT PO DAILY
14. Warfarin 3 mg PO DAILY16

ALLERGIES: Amoxicillin / Glipizide / Ciprofloxacin / Bactrim / Soriatane /
Potassium Chloride / Bupropion / Calcium Channel Blocking
Agents-Benzothiazepines / atenolol

PHYSICAL EXAM: Admission:
Vitals: 98.2 135 93/53 17 96%RA
General: Alert, oriented, no acute distress
HEENT: Sclera are mildly icteric, DMM, oropharynx clear, EOMI,
PERRL
Neck: supple, JVP ~[**6-19**], no LAD
CV: Tachycardia with irregular rhythm, normal S1 + S2, [**2-16**]
systolic murmer, no rubs or gallops.
Lungs: Mild crackles at bases, wheezes, ronchi
Abdomen: obese, soft, non-distended, bowel sounds present, no
organomegaly, no suprapubic tenderness to palpation, no
rebound or guarding, psoriasis patches
GU: No foley
Ext: Warm, well perfused, 1+ pulses, 2+ edema mid-shin,
venous-stasis changes, no clubbing, cyanosis
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
.
Discharge Exam:
Vitals: T98.8 P 89 BP 124/46 O2 sat 93% RA
Gen: well appearing in  NAD
Neck: supple;  JVP ~8cm, no  LAD
HEENT: EOMI intact, MMM
Chest: irregular rate, 3/6 SEM murmmur
Lungs: mild crackles b/l at bases
Abodmen- soft NTND, normoactive BS,
Extremities- 1+ b/l LE edema, 2+ DP
Skin- chronic venous changes on b/l LE; no ulcerations notes,
multiple large erythematous plaques on back and chest

FAMILY HISTORY: +fh for diabetes, no FH for malignances

SOCIAL HISTORY: Lives with daughter. Retired file clerk in a law office. Current
smoker 1 ppd (60 pack year history). No alcohol
or illicits. Ambulates with a cane because walker doesn't fit
well
in hallways 

### Response:
{'Chronic diastolic heart failure,Acidosis,Atrial fibrillation,Other chronic pulmonary heart diseases,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Thrombocytopenia, unspecified,Other psoriasis,Venous (peripheral) insufficiency, unspecified,Cirrhosis of liver without mention of alcohol,Iron deficiency anemia, unspecified,Obesity, unspecified,Acquired absence of organ, lung,Osteoporosis, unspecified,Pure hypercholesterolemia,Tobacco use disorder,Depressive disorder, not elsewhere classified,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of bronchus and lung,Personal history, urinary (tract) infection,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Orthostatic hypotension,Cellulitis and abscess of leg, except foot'}
