CHIEF COMPLAINT: hypotension

PRESENT ILLNESS: 87F history of C. difficile colitis since [**2179-8-9**] currently in
rehabilitation facility receiving p.o. vancomycin and Flagyl who
presents with hypotension. Per patient, she had increased bowel
movements this past weekend (had actually been improving in
frequency last week) and was found to have systolics in the 80s
at the rehabilitation facility. Denies fevers. She states her
abdominal pain as being constant and has not changed and her
during the last few days. Patient has been compliant on her
vancomycin/Flagyl regimen. She states she hasn't been staying
hydrated.
.
Also of note, per daughter, at rehab she had an asthma
exacerbation last week and received 5 days of solumedrol taper,
which stopped 2-3 days ago. She states the physcians that
started the steroids verified with ID that this would not
exacerbate C diff.
.
In the ED, initial VS were: T 97.5 HR 96 BP 70/50 Pox 97% ra.
She has a chronic indwelling foley and had a UA that showed
large leuk, many WBC, many bacteria and was given ceftriaxone.
KUB was done, which did not show toxic megacolon or dilated
loops of bowel. Labs were significant for lactate 3.4, Na 127,
BUN 59, Cr 1.9 , WBC 12.6 with 13% bands, INR 6.5. Got 4L IVF in
ER-->systolics high 90's-100's, though of note BP's usually
130's 140's. Close to time of transfer, systolic BP's dropped to
80's. She was asymptomatic, but the ER wanted to place a CVL and
start pressor. Pt refused femoral CVL and remarked she wants to
be DNR/DNI. She also reports she has met with palliative care in
the previous weeks. She did agree to levophed being run through
her existing PICC line. On transfer, VS: HR 111, RR 19-20, Pox
98% RA, BP 92-102/30's-40's. Access is 18g EJ and a R PICC.
Unclear why she has a R PICC line.
.
On arrival to the MICU, pt states "this is too much." She
reports abdominal pain and diarrhea. She is conversive and
confirms she is DNR/DNI.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, abdominal pain. Denies rashes or skin
changes.

MEDICAL HISTORY: afib on coumadin, per daughter had been on amiodarone
HTN
[**Name (NI) 2091**] baseline Cr 1.3-1.5
hypothyroidism
Cdiff colitis
Diabetes
Asthma

MEDICATION ON ADMISSION: amiodarone (per rehab notes, loaded over weekend, now continuing
on amiodarone but not noted in med list)
cholestyramine 4g daily
Cyanocobalamin 500mcg once a day
Insulin humalog sliding scale (on glipizide and januvia at home)

ALLERGIES: albuterol / Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: On admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP low, no LAD
CV: irreg irreg
Lungs: occ wheeze
Abdomen: soft, + BS, mild TTP, distended
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

FAMILY HISTORY: sister with diabetes, sister with throat cancer (smoker)

SOCIAL HISTORY: - Tobacco:  Distant
- Alcohol:  Occasional
- Illicits:  Denies
Came from [**Hospital 100**] Rehab MACU, previously independent prior to
hospitalization
Intestinal infection due to Clostridium difficile,Severe sepsis,Septic shock,Streptococcal septicemia,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Other and unspecified coagulation defects,Other and unspecified infection due to central venous catheter,Asthma, unspecified type, unspecified,Do not resuscitate status,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Unspecified acquired hypothyroidism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Infection with microorganisms without mention of resistance to multiple drugs,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution
Int inf clstrdium dfcile,Severe sepsis,Septic shock,Streptococcal septicemia,Hyposmolality,Urin tract infection NOS,Acute kidney failure NOS,Coagulat defect NEC/NOS,Oth/uns inf-cen ven cath,Asthma NOS,Do not resusctate status,Atrial fibrillation,Long-term use anticoagul,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Hypothyroidism NOS,DMII wo cmp nt st uncntr,Inf mcr rst ot drg nt ml,Abn react-procedure NEC,Accid in resident instit
Admission Date:  [**2179-10-27**]              Discharge Date:   [**2179-11-4**]


Service: MEDICINE

Allergies:
albuterol / Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
hypotension

Major Surgical or Invasive Procedure:
central line placement

History of Present Illness:
87F history of C. difficile colitis since [**2179-8-9**] currently in
rehabilitation facility receiving p.o. vancomycin and Flagyl who
presents with hypotension. Per patient, she had increased bowel
movements this past weekend (had actually been improving in
frequency last week) and was found to have systolics in the 80s
at the rehabilitation facility. Denies fevers. She states her
abdominal pain as being constant and has not changed and her
during the last few days. Patient has been compliant on her
vancomycin/Flagyl regimen. She states she hasn't been staying
hydrated.
.
Also of note, per daughter, at rehab she had an asthma
exacerbation last week and received 5 days of solumedrol taper,
which stopped 2-3 days ago. She states the physcians that
started the steroids verified with ID that this would not
exacerbate C diff.
.
In the ED, initial VS were: T 97.5 HR 96 BP 70/50 Pox 97% ra.
She has a chronic indwelling foley and had a UA that showed
large leuk, many WBC, many bacteria and was given ceftriaxone.
KUB was done, which did not show toxic megacolon or dilated
loops of bowel. Labs were significant for lactate 3.4, Na 127,
BUN 59, Cr 1.9 , WBC 12.6 with 13% bands, INR 6.5. Got 4L IVF in
ER-->systolics high 90's-100's, though of note BP's usually
130's 140's. Close to time of transfer, systolic BP's dropped to
80's. She was asymptomatic, but the ER wanted to place a CVL and
start pressor. Pt refused femoral CVL and remarked she wants to
be DNR/DNI. She also reports she has met with palliative care in
the previous weeks. She did agree to levophed being run through
her existing PICC line. On transfer, VS: HR 111, RR 19-20, Pox
98% RA, BP 92-102/30's-40's. Access is 18g EJ and a R PICC.
Unclear why she has a R PICC line.
.
On arrival to the MICU, pt states "this is too much." She
reports abdominal pain and diarrhea. She is conversive and
confirms she is DNR/DNI.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, abdominal pain. Denies rashes or skin
changes.


Past Medical History:
afib on coumadin, per daughter had been on amiodarone
HTN
[**Name (NI) 2091**] baseline Cr 1.3-1.5
hypothyroidism
Cdiff colitis
Diabetes
Asthma


Social History:
- Tobacco:  Distant
- Alcohol:  Occasional
- Illicits:  Denies
Came from [**Hospital 100**] Rehab MACU, previously independent prior to
hospitalization


Family History:
sister with diabetes, sister with throat cancer (smoker)


Physical Exam:
On admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP low, no LAD
CV: irreg irreg
Lungs: occ wheeze
Abdomen: soft, + BS, mild TTP, distended
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

Pertinent Results:
Labs on admission:

[**2179-10-27**] 07:39PM   GLUCOSE-163* UREA N-56* CREAT-1.8*
SODIUM-130* POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-20* ANION GAP-18
[**2179-10-27**] 08:08PM   LACTATE-2.8*
[**2179-10-27**] 07:39PM   CALCIUM-6.9* PHOSPHATE-4.5 MAGNESIUM-2.3
[**2179-10-27**] 12:45PM   PT-59.7* PTT-59.2* INR(PT)-6.5*

Micro:
[**2179-11-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2179-11-3**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2179-11-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2179-11-1**] SWAB R/O VANCOMYCIN RESISTANT
ENTEROCOCCUS-FINAL INPATIENT
[**2179-11-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2179-10-31**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2179-10-31**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2179-10-30**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2179-10-30**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2179-10-29**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2179-10-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2179-10-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2179-10-28**] CATHETER TIP-IV WOUND CULTURE-FINAL
INPATIENT
[**2179-10-28**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2179-10-27**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2179-10-27**] BLOOD CULTURE Blood Culture, Routine-FINAL
{KLEBSIELLA PNEUMONIAE, ENTEROCOCCUS FAECIUM}; Anaerobic Bottle
Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]

[**2179-10-27**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ENTEROCOCCUS FAECIUM}; Aerobic Bottle Gram Stain-FINAL
                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             KLEBSIELLA PNEUMONIAE
                             |          ENTEROCOCCUS FAECIUM
                             |          |
AMPICILLIN------------             =>32 R
AMPICILLIN/SULBACTAM--    16 I
CEFAZOLIN-------------  =>64 R
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------  =>64 R
CEFTRIAXONE-----------    16 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
LINEZOLID-------------                2 S
MEROPENEM-------------<=0.25 S
PENICILLIN G----------             =>64 R
PIPERACILLIN/TAZO-----       S
TOBRAMYCIN------------  =>16 R
TRIMETHOPRIM/SULFA----   <=1 S
VANCOMYCIN------------             =>32 R

Reports:
ct a/p
IMPRESSION:

1. Findings consistent with colitis.

2. Cholelithiasis.

3. Substantial pleural effusions.

4. Small quantity of ascites.

5. Macrolobulation of the hepatic contour in some areas of
uncertain significance although underlying liver disease could
be considered as a possibility clinically.

cxr [**11-3**]
Extensive bilateral pleural effusions with subsequent areas of
basal atelectasis


Brief Hospital Course:
Ms [**Known lastname **] is an 87yo F with w/ h/o afib on coumadin, recent
extended course at rehab for severe C dificil who presented with
septic shock. Originally, this was thought to be secondary to
recurrence of severe C dificile, but she subsequently was found
to have polymicrobial bacteremia, likely secondary to gut
translocation/microperforation. Her bloodstream organisms (as
above) were quite resistant, and she was treated with meropenem
and daptomycin, as well as IV flagyl/PO vancomycin for C
difficile.
Upon initial presentation, she required aggressive volume
resuscitation and two pressors. While she was able to wean off
of pressors, she ultimately was >20L positive for the
hospitalization. On [**2179-11-3**] she was started on lasix gtt and
diuril [**Hospital1 **] for diuresis, but with only minimal accomplishment.
The next step to improve her volume status would likely have
been CVVH, which were not in line with the patient's goals of
care.

Ms. [**Known lastname **] [**Last Name (Titles) 91371**] that if she could not achieve a functional
status where she was home and independent, as she was prior to
hospitalization, she would not want to continue maximal medical
care. It was [**Last Name (Titles) 91371**] to her that this goal of independence
seemed fairly unlikely. She and her family requested palliative
care consult with plans to discuss her discharge and goal to not
be rehospitalized. During that meeting, decision was made to
move towards comfort measures only and all antibiotics and
supportive care were discontinued (she continued only on lasix
gtt for comfort). She passed away on [**2179-11-4**] with her family at
the bedside.

Medications on Admission:
amiodarone (per rehab notes, loaded over weekend, now continuing
on amiodarone but not noted in med list)
cholestyramine 4g daily
Cyanocobalamin 500mcg once a day
Insulin humalog sliding scale (on glipizide and januvia at home)

Ipratropium [**Last Name (un) **] [**Hospital1 **] standing
Lactobacillus, 2 tabs [**Hospital1 **]
Levalbuterol 0.63mg Q12 hrs standing
Coumadin being held in setting of INR 3.6 on [**10-26**]
Flagyl
Lopressor 12.5mg TID
Mirtazapine 7.5mg QHS
Omerazole 20mg daily
Vancomycin 250mg QID
Tylenol 650mg Q4hrs PRN
Zofran 4mg Q8H PRN
Miconazole
Dyazide being held at rehab


Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
Clostridium difficile colitis
VRE bacteremia
Septic Shock

Discharge Condition:
Expired

Discharge Instructions:
Expired

Followup Instructions:
Expired
{'Intestinal infection due to Clostridium difficile,Severe sepsis,Septic shock,Streptococcal septicemia,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Other and unspecified coagulation defects,Other and unspecified infection due to central venous catheter,Asthma, unspecified type, unspecified,Do not resuscitate status,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Unspecified acquired hypothyroidism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Infection with microorganisms without mention of resistance to multiple drugs,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution'}


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: 87F history of C. difficile colitis since [**2179-8-9**] currently in
rehabilitation facility receiving p.o. vancomycin and Flagyl who
presents with hypotension. Per patient, she had increased bowel
movements this past weekend (had actually been improving in
frequency last week) and was found to have systolics in the 80s
at the rehabilitation facility. Denies fevers. She states her
abdominal pain as being constant and has not changed and her
during the last few days. Patient has been compliant on her
vancomycin/Flagyl regimen. She states she hasn't been staying
hydrated.
.
Also of note, per daughter, at rehab she had an asthma
exacerbation last week and received 5 days of solumedrol taper,
which stopped 2-3 days ago. She states the physcians that
started the steroids verified with ID that this would not
exacerbate C diff.
.
In the ED, initial VS were: T 97.5 HR 96 BP 70/50 Pox 97% ra.
She has a chronic indwelling foley and had a UA that showed
large leuk, many WBC, many bacteria and was given ceftriaxone.
KUB was done, which did not show toxic megacolon or dilated
loops of bowel. Labs were significant for lactate 3.4, Na 127,
BUN 59, Cr 1.9 , WBC 12.6 with 13% bands, INR 6.5. Got 4L IVF in
ER-->systolics high 90's-100's, though of note BP's usually
130's 140's. Close to time of transfer, systolic BP's dropped to
80's. She was asymptomatic, but the ER wanted to place a CVL and
start pressor. Pt refused femoral CVL and remarked she wants to
be DNR/DNI. She also reports she has met with palliative care in
the previous weeks. She did agree to levophed being run through
her existing PICC line. On transfer, VS: HR 111, RR 19-20, Pox
98% RA, BP 92-102/30's-40's. Access is 18g EJ and a R PICC.
Unclear why she has a R PICC line.
.
On arrival to the MICU, pt states "this is too much." She
reports abdominal pain and diarrhea. She is conversive and
confirms she is DNR/DNI.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, abdominal pain. Denies rashes or skin
changes.

MEDICAL HISTORY: afib on coumadin, per daughter had been on amiodarone
HTN
[**Name (NI) 2091**] baseline Cr 1.3-1.5
hypothyroidism
Cdiff colitis
Diabetes
Asthma

MEDICATION ON ADMISSION: amiodarone (per rehab notes, loaded over weekend, now continuing
on amiodarone but not noted in med list)
cholestyramine 4g daily
Cyanocobalamin 500mcg once a day
Insulin humalog sliding scale (on glipizide and januvia at home)

ALLERGIES: albuterol / Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: On admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP low, no LAD
CV: irreg irreg
Lungs: occ wheeze
Abdomen: soft, + BS, mild TTP, distended
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

FAMILY HISTORY: sister with diabetes, sister with throat cancer (smoker)

SOCIAL HISTORY: - Tobacco:  Distant
- Alcohol:  Occasional
- Illicits:  Denies
Came from [**Hospital 100**] Rehab MACU, previously independent prior to
hospitalization 

### Response:
{'Intestinal infection due to Clostridium difficile,Severe sepsis,Septic shock,Streptococcal septicemia,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Other and unspecified coagulation defects,Other and unspecified infection due to central venous catheter,Asthma, unspecified type, unspecified,Do not resuscitate status,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Unspecified acquired hypothyroidism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Infection with microorganisms without mention of resistance to multiple drugs,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution'}
