CHIEF COMPLAINT: Acute Renal Failure

PRESENT ILLNESS: On a prior admission, pt admitted w/ STEMI that was thought to
have occurred 3-4 days prior admission. Because of timing, pt
did not undergo stenting during cardiac cath, which showed.
Following cath, she developed cardiogenic shock, for which she
was temporarily treated with an intra-aortic balloon pump,
levophed and milrinone. She was eventually weaned off all these.
She was started on aspirin, atorvastatin and digoxin. (She had
been on OCPs on admission which were dc'd). TTE from [**2147-3-8**]
showed an EF of 25% with septal, anterior and apical akinesis. A
repeat TTE was performed on [**2147-3-16**] to assess for interval
improvement, but there was no change in cardiac function. Pt
also had low-grade fevers throughout her hospitalization. Prior
to last admission, she was treated with a full course of
ciprofloxacin for a UTI. All blood cultures were negative and UA
negative. She was put on a five day course of vancomycin
empirically for possible line infection (it was thought that she
may have had transient bacteremia from the catherization
instrumentation, even thought cultures were negative). She was
also given a five day course of azithromycin for a possible
community acquired PNA given a LUL infiltrate on CXR. Despite
the course of azithromycin, her fevers persisted and there was
worsening of the left retrocardiac opacity. She was started on a
seven day course of IV cefepime and vancomycin for hospital
acquired pneumonia. A PICC line was placed in the left arm on
[**2147-3-18**] for out-patient administration of IV antibiotics.
During her stay, there was also concern for antiphospholipid
antibody syndrome, given her MI at a young age, with few cardiac
risk factors and given elevated PTT. Testing for
antiphospholipid antibodies was deferred in the in-patient
setting because of possible false positive results with acute
illness and anticoagulation.
.
Since discharge, the patient has reportedly continued to have
low grade fevers at [**Hospital1 **]. She had a R PICC line placed on
[**2147-3-23**] (unclear indication for placement). [**Name8 (MD) **] Crt has slowly
trended up over the past 7 days. The pt reportedly maintained
normal PO intake. She had low urine output and reportedly 25cc
on bladder scan. Her Hct dropped from 31.3 (on [**3-22**]) to 25.3 (on
[**3-28**]). Her SBP at rehab ranged from high 80s-110s--she was in
the 90s on discharge from [**Hospital1 18**] according to notes available.
She then developed a rash--total body--on the day of
presentation.
.
In the [**Name (NI) **] pt. was febrile to 101.6, HR 100, BP 91/45, 19, 100 on
2L. A pelvic exam was negative for foreign bodies. Renal US
showed no hydro. She was given tylenol, vanc, ceftaz and
ceftrioxone and 300cc of NS.

MEDICAL HISTORY: Cardiac Risk Factors: -Diabetes, -Dyslipidemia, -Hypertension
.
Cardiac History: NONE
.
Other PMH:
Mental Retardation
Seizure disorder (?--listed in chart, but questionable per
caretakers, [**Name (NI) 74959**] added recently for mood)
Recurrent UTIs

MEDICATION ON ADMISSION: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Omega-3 Fatty Acids 240-360-5 mg-mg-unit Capsule Sig: One (1)

ALLERGIES: Cefepime

PHYSICAL EXAM: VS: 98.3 (Tmax 101.6), 104, 96/54, 24, 95% on room air
Gen: huddled under blankets, cradling stuffed animal rabbit,
responds to most questions w/ "no", follows some commands,
overall in NAD
HEENT: NCAT, PERRL, sclera anicteric, OP clear, no desquamtion
of MM
Neck: Supple, JVP flat
CV: Tachy, S1/S2, no m/r/g
Resp: CTA B
Abdomen: Soft, NTND, BS+
Ext: No c/c/e. DP pulses are 2+ bilaterally
Neuro: alert, answers some questions with no, moving all
extremities
Skin: diffuse pink/erythematous papular rash w/ some areas of
confluence, no desquamation or bullae

FAMILY HISTORY: Family history unknown.

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Pt resides in group
home.
Acute kidney failure with lesion of tubular necrosis,Acute on chronic diastolic heart failure,Intestinal infection due to Clostridium difficile,Hyperosmolality and/or hypernatremia,Acute myocardial infarction of unspecified site, subsequent episode of care,Hypotension, unspecified,Unspecified intellectual disabilities,Stricture and stenosis of esophagus,Dermatitis due to drugs and medicines taken internally,Anemia of other chronic disease,Coronary atherosclerosis of native coronary artery
Ac kidny fail, tubr necr,Ac on chr diast hrt fail,Int inf clstrdium dfcile,Hyperosmolality,AMI NOS, subsequent,Hypotension NOS,Intellect disability NOS,Esophageal stricture,Drug dermatitis NOS,Anemia-other chronic dis,Crnry athrscl natve vssl
Admission Date:  [**2147-3-28**]              Discharge Date:   [**2147-4-19**]

Date of Birth:  [**2112-10-29**]             Sex:   F

Service: MEDICINE

Allergies:
Cefepime

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Acute Renal Failure


Major Surgical or Invasive Procedure:
None


History of Present Illness:
 On a prior admission, pt admitted w/ STEMI that was thought to
have occurred 3-4 days prior admission. Because of timing, pt
did not undergo stenting during cardiac cath, which showed.
Following cath, she developed cardiogenic shock, for which she
was temporarily treated with an intra-aortic balloon pump,
levophed and milrinone. She was eventually weaned off all these.
She was started on aspirin, atorvastatin and digoxin. (She had
been on OCPs on admission which were dc'd). TTE from [**2147-3-8**]
showed an EF of 25% with septal, anterior and apical akinesis. A
repeat TTE was performed on [**2147-3-16**] to assess for interval
improvement, but there was no change in cardiac function. Pt
also had low-grade fevers throughout her hospitalization. Prior
to last admission, she was treated with a full course of
ciprofloxacin for a UTI. All blood cultures were negative and UA
negative. She was put on a five day course of vancomycin
empirically for possible line infection (it was thought that she
may have had transient bacteremia from the catherization
instrumentation, even thought cultures were negative). She was
also given a five day course of azithromycin for a possible
community acquired PNA given a LUL infiltrate on CXR. Despite
the course of azithromycin, her fevers persisted and there was
worsening of the left retrocardiac opacity. She was started on a
seven day course of IV cefepime and vancomycin for hospital
acquired pneumonia. A PICC line was placed in the left arm on
[**2147-3-18**] for out-patient administration of IV antibiotics.
During her stay, there was also concern for antiphospholipid
antibody syndrome, given her MI at a young age, with few cardiac
risk factors and given elevated PTT. Testing for
antiphospholipid antibodies was deferred in the in-patient
setting because of possible false positive results with acute
illness and anticoagulation.
.
Since discharge, the patient has reportedly continued to have
low grade fevers at [**Hospital1 **]. She had a R PICC line placed on
[**2147-3-23**] (unclear indication for placement). [**Name8 (MD) **] Crt has slowly
trended up over the past 7 days. The pt reportedly maintained
normal PO intake. She had low urine output and reportedly 25cc
on bladder scan. Her Hct dropped from 31.3 (on [**3-22**]) to 25.3 (on
[**3-28**]). Her SBP at rehab ranged from high 80s-110s--she was in
the 90s on discharge from [**Hospital1 18**] according to notes available.
She then developed a rash--total body--on the day of
presentation.
.
In the [**Name (NI) **] pt. was febrile to 101.6, HR 100, BP 91/45, 19, 100 on
2L. A pelvic exam was negative for foreign bodies. Renal US
showed no hydro. She was given tylenol, vanc, ceftaz and
ceftrioxone and 300cc of NS.

.
On admission patient denied pain or compliants, otherwise does
not answer questions of verbally interact.


Past Medical History:
Cardiac Risk Factors: -Diabetes, -Dyslipidemia, -Hypertension
.
Cardiac History: NONE
.
Other PMH:
Mental Retardation
Seizure disorder (?--listed in chart, but questionable per
caretakers, [**Name (NI) 74959**] added recently for mood)
Recurrent UTIs

Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Pt resides in group
home.


Family History:
Family history unknown.


Physical Exam:

VS: 98.3 (Tmax 101.6), 104, 96/54, 24, 95% on room air
Gen: huddled under blankets, cradling stuffed animal rabbit,
responds to most questions w/ "no", follows some commands,
overall in NAD
HEENT: NCAT, PERRL, sclera anicteric, OP clear, no desquamtion
of MM
Neck: Supple, JVP flat
CV: Tachy, S1/S2, no m/r/g
Resp: CTA B
Abdomen: Soft, NTND, BS+
Ext: No c/c/e. DP pulses are 2+ bilaterally
Neuro: alert, answers some questions with no, moving all
extremities
Skin: diffuse pink/erythematous papular rash w/ some areas of
confluence, no desquamation or bullae


Pertinent Results:
[**2147-3-28**] 05:10PM   WBC-12.1*# RBC-3.29* HGB-9.2* HCT-27.3*
MCV-83 MCH-28.0 MCHC-33.8 RDW-14.6
[**2147-3-28**] 05:10PM   NEUTS-74.9* LYMPHS-16.4* MONOS-3.3 EOS-5.1*
BASOS-0.2
[**2147-3-28**] 05:10PM   PLT COUNT-385
[**2147-3-28**] 05:10PM   PT-34.0* PTT-51.9* INR(PT)-3.6*
[**2147-3-28**] 05:10PM   DIGOXIN-0.5*
[**2147-3-28**] 05:10PM   CALCIUM-8.2* PHOSPHATE-6.2*# MAGNESIUM-2.4
[**2147-3-28**] 05:10PM   ALT(SGPT)-47* AST(SGOT)-43* CK(CPK)-104 ALK
PHOS-56 TOT BILI-0.2
[**2147-3-28**] 05:10PM   GLUCOSE-110* UREA N-65* CREAT-6.4*#
SODIUM-139 POTASSIUM-4.8 CHLORIDE-110* TOTAL CO2-13* ANION
GAP-21*
.
.
Studies:
.
Renal Ultrasound
FINDINGS:  The right kidney measures 10.2 cm.  The left kidney
measures 10.5 cm.  There is no evidence of hydronephrosis or
stones.  There are no perinephric fluid collections.
IMPRESSION:  No evidence of hydronephrosis or stones
.
Echo
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears moderately-to-severely
depressed (ejection fraction 30 percent) secondary to akinesis
of the septum and apex, and hypokinesis of the anterior free
wall. There is no ventricular septal defect. Right ventricular
chamber size is normal. with focal hypokinesis of the apical
free wall. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2147-3-16**], the heart rate is increased; otherwise the
findings are similar.
.
Chest Xray
FINDINGS:  In the interim, the pulmonary edema has reappeared.
The heart is persistently enlarged.  No pleural effusion.
IMPRESSION:
1.  Reappearance of pulmonary edema with no focal areas to
suggest pneumonia.
2.  Persistent cardiomegaly.


Brief Hospital Course:
On admission, renal consult was obtained and the patient became
hypotensive on the floor.  She was transfered to the ICU when
her BPs were not fluid responsive.  An aline was placed in the
ICU which registered BPs that were 15 points higher than those
noted on the cuff.  She was transiently put on dopamine but
quickly weaned.  She was noted to have positive Cdiff and
started on IV flagyl.  Per report of micu team, she is not
taking oral meds at this time because of a distrust of MDs.  BP
stabilized and pt was transferred to the floor.
.
On the floor the pt became dyspneic with O2 sat drops to the
high 70s/low 80s, which responede to 70% facemask with O2 sats
in the low 90s.  CXR showed pulm edema.  Pt was diuresed with
resolution of dyspnea.  Soon after diuresis pt became
hypotensive with SBP in the 80s but no symptoms.  Pt was fluid
bolused and then became more dyspneic with repeat CXR showing
worsenign pulm edema.  Because of this tenuous fluid balance
decision was made only to bolus IVF for SBP<80 or for symptoms.
With these new criterea pt stabilized and was able to come off
supplemental O2 with O2 sats 94-96% on RA.  BP also stabilized.
When SBP rose to 100-105 pt was restarted on Beta Blocker and
ACEI.
.
As pt's hemodynamic and resp status improved she continued to
refuse PO meds, and when she would eat she would gag and vomit.
Initially the etiology of this was unclear.  Pt was transintly
supported on TPN, S&S eval ws unable to find a cause for
dysphagia.  GI was consulted, and they preformed an EGD which
showed an non-obstructive Schotsky's ring, which was dilated.
Despite this intervention dysphagia continued.  Pt's caretaker,
[**Name (NI) **] [**Name (NI) 4223**], came in to visit and reported that pt is a very
picky eater, but when she finds something she likes she eats it
very quickly.  [**Doctor First Name **] brought in foods that she new the pt liked
(including Pizza, Ice cream, and Diet Coke).  When the food was
cut into very small peices the pt would eat it without
difficulty.  When drinking liquids the straw would need to be
pulled away after pt took a small sip, otherwise she would take
too much and begin to gag and vomit.  Once this was made clear
TPN was discontinued and pt was able to take adequat POs.  She
also was able to take PO meds as long as they are crushed and
mixed in very well with either Diet Coke or Ice cream.

 # Hypoxia/tachypnea: As above.  Likely [**3-11**] CHF exacerbation and
fluid shifts.  Stabilized by the time of discharge on Furosemide
40 mg PO DAILY.
.
# Hypotension: Likely cardiogenic in setting of over-diuresis as
descibed above.  Pt's SBP stablized between 80-105 with no
further complications for the last 6 days of her
hospitalization.
.
#. C. Diff collitis: Pt completed a 14 day course of Flagyl in
house.
.
# ARF:   Patient initially admitted for this reason.  Followed
in house by renal team.  Urine sedement consistent with ATN;
however the etiology was unclear, likely from hypotension or a
hypovolemia.  Her Cdiff was treated and her blood pressures
closely monitored.  Cr recovered completely by the time of
discharge (creat=0.9)
.
# Hypernatremia:  Initially developed from poor po intake.  Her
Na deficit was calculated and she was slowly repleted with D5W
and hypernatremia resolved.
.
# Rash: Patient seen by derm and this was thought to be 'drug
dermal hypersensivity,' likely [**3-11**] to abx use, unclear which one
but suspicious for cefepime.  The rash cleared completely by the
time of discharge.
.
# Coagulopathy: Pt was treated with coumadin due to low EF.  Pts
INR elevated on admission, likely from interaction of coumadin
and one of her antibiotics or other new meds.  Her EF was
rechecked, and was still 30%.  Initially coumadin could not be
restarted because she was not taking PO meds, but then decision
was made to hold it due to substantial risk of fall and possible
bleeding.  This issue should be readdressed as an outpatient
after rehab and when she has stabilized.
.
# Anemia: HCT has been trended down since [**3-7**] admission (HCT
was 35), stablized around ~25.  Labs consistent with anemia of
chronic inflammation.
.
# CAD: known 100% LAD occlusion that was not able to be
revascularized.  Pt was treated with ASA and statin throughout
her stay.  BB and ACEI were transiently held for hypotension,
but when BP stabilized they were restarted.
.
# CHF: EF of 30% in an LAD distribution (after STEMI w/ TO LAD).
Started on warfarin on D/C from [**Hospital1 18**] [**3-11**] to low EF. Coumadin
was held as descibed above.  Fluid overload treated as descibed
above.  Pt stabilized at time of discharge of Lasix 40 mg PO
daily.  She was treated with ASA, Statin, BB, and ACE I.
.
# Sz d/o: There was initial confusion about whether pt had
history of seizure disorder and because she came in on
[**Month/Day (2) 74959**].  When not taking POs she ws transiently switched over
to IV keppra.  However, after speaking to father it was clear
that [**Month/Day (2) 74959**] was given for mood and pt had no history of
seizure.  Therefore keppra was D/Ced and [**Month/Day (2) 74959**] was not
restarted.
.
#. Nutrition: As described above.

Medications on Admission:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Omega-3 Fatty Acids 240-360-5 mg-mg-unit Capsule Sig: One (1)

Capsule PO TID (3 times a day).
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. BuSpar 30 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime.

11. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. Lactulose 10 gram Packet Sig: [**2-8**] Packets PO twice a day as

needed for constipation.
13. Warfarin 4 mg Tablet PO HS (at
bedtime).
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
15. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous

Q 12H (Every 12 Hours) for 6 days.
16. Cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q12H

(every 12 hours) for 6 days.
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
.
Meds on Transfer
Insulin SC Sliding Scale
Lactulose 30 mL PO Q8H:PRN
Acetaminophen 650 mg PO Q6H:PRN
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
Aspirin 300 mg PR DAILY
Mirtazapine 15 mg PO HS
BusPIRone 30 mg PO BID
Ondansetron 4 mg IV Q8H:PRN nausea
Digoxin 0.125 mg PO EVERY OTHER DAY
Oxcarbazepine 300 mg PO BID
Heparin 5000 UNIT SC TID
.
Allergies: NKDA

Discharge Medications:
1. Buspirone 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
2. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP<100 or HR <60.
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP<95 or HR <60.
8. Multi-Vitamin W/Minerals     Capsule Sig: One (1) Capsule PO
once a day.
9. Lactulose 10 gram Packet Sig: One (1)  PO twice a day as
needed for constipation.
10. Acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO every
six (6) hours as needed for fever or pain.
11. Omega-3 Fatty Acids 240-360-5 mg-mg-unit Capsule Sig: One
(1) Capsule PO three times a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
CHF Exacerbation
C. Difficile Colitis
Acute Renal Failure: Resolved at time of Discharge


Discharge Condition:
VS: T: 97.6,BP: 96/58,HR: 104, RR: 20, O2: 96%RA.
Pt is at basline, talking to doll in nad, breathing comfortably.


Discharge Instructions:
you were admitted with decreased kidney function, low blood
pressure, and infection of the colon called C. Diffiile
collitis.  During the admission congestive heart failure caused
transient shortness of breath and low blood pressure which
stabilized by the time of discharge.  You complete treatment for
C. Diff collitis.  Your kidney function improved by the time of
discharge.

Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 74961**].  Appointment on [**2147-5-2**] at
2:45 PM
.
Cardiology: [**Doctor Last Name **],[**Location (un) 2898**]
[**Location (un) **] ([**Location (un) **], MA), [**Location (un) **]
CARDIOLOGY [**Location (un) 2898**] (NHB) [**Telephone/Fax (1) 5068**]
[**2147-4-27**] at 1:45 PM
{'Acute kidney failure with lesion of tubular necrosis,Acute on chronic diastolic heart failure,Intestinal infection due to Clostridium difficile,Hyperosmolality and/or hypernatremia,Acute myocardial infarction of unspecified site, subsequent episode of care,Hypotension, unspecified,Unspecified intellectual disabilities,Stricture and stenosis of esophagus,Dermatitis due to drugs and medicines taken internally,Anemia of other chronic disease,Coronary atherosclerosis of native coronary artery'}


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: Acute Renal Failure

PRESENT ILLNESS: On a prior admission, pt admitted w/ STEMI that was thought to
have occurred 3-4 days prior admission. Because of timing, pt
did not undergo stenting during cardiac cath, which showed.
Following cath, she developed cardiogenic shock, for which she
was temporarily treated with an intra-aortic balloon pump,
levophed and milrinone. She was eventually weaned off all these.
She was started on aspirin, atorvastatin and digoxin. (She had
been on OCPs on admission which were dc'd). TTE from [**2147-3-8**]
showed an EF of 25% with septal, anterior and apical akinesis. A
repeat TTE was performed on [**2147-3-16**] to assess for interval
improvement, but there was no change in cardiac function. Pt
also had low-grade fevers throughout her hospitalization. Prior
to last admission, she was treated with a full course of
ciprofloxacin for a UTI. All blood cultures were negative and UA
negative. She was put on a five day course of vancomycin
empirically for possible line infection (it was thought that she
may have had transient bacteremia from the catherization
instrumentation, even thought cultures were negative). She was
also given a five day course of azithromycin for a possible
community acquired PNA given a LUL infiltrate on CXR. Despite
the course of azithromycin, her fevers persisted and there was
worsening of the left retrocardiac opacity. She was started on a
seven day course of IV cefepime and vancomycin for hospital
acquired pneumonia. A PICC line was placed in the left arm on
[**2147-3-18**] for out-patient administration of IV antibiotics.
During her stay, there was also concern for antiphospholipid
antibody syndrome, given her MI at a young age, with few cardiac
risk factors and given elevated PTT. Testing for
antiphospholipid antibodies was deferred in the in-patient
setting because of possible false positive results with acute
illness and anticoagulation.
.
Since discharge, the patient has reportedly continued to have
low grade fevers at [**Hospital1 **]. She had a R PICC line placed on
[**2147-3-23**] (unclear indication for placement). [**Name8 (MD) **] Crt has slowly
trended up over the past 7 days. The pt reportedly maintained
normal PO intake. She had low urine output and reportedly 25cc
on bladder scan. Her Hct dropped from 31.3 (on [**3-22**]) to 25.3 (on
[**3-28**]). Her SBP at rehab ranged from high 80s-110s--she was in
the 90s on discharge from [**Hospital1 18**] according to notes available.
She then developed a rash--total body--on the day of
presentation.
.
In the [**Name (NI) **] pt. was febrile to 101.6, HR 100, BP 91/45, 19, 100 on
2L. A pelvic exam was negative for foreign bodies. Renal US
showed no hydro. She was given tylenol, vanc, ceftaz and
ceftrioxone and 300cc of NS.

MEDICAL HISTORY: Cardiac Risk Factors: -Diabetes, -Dyslipidemia, -Hypertension
.
Cardiac History: NONE
.
Other PMH:
Mental Retardation
Seizure disorder (?--listed in chart, but questionable per
caretakers, [**Name (NI) 74959**] added recently for mood)
Recurrent UTIs

MEDICATION ON ADMISSION: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Omega-3 Fatty Acids 240-360-5 mg-mg-unit Capsule Sig: One (1)

ALLERGIES: Cefepime

PHYSICAL EXAM: VS: 98.3 (Tmax 101.6), 104, 96/54, 24, 95% on room air
Gen: huddled under blankets, cradling stuffed animal rabbit,
responds to most questions w/ "no", follows some commands,
overall in NAD
HEENT: NCAT, PERRL, sclera anicteric, OP clear, no desquamtion
of MM
Neck: Supple, JVP flat
CV: Tachy, S1/S2, no m/r/g
Resp: CTA B
Abdomen: Soft, NTND, BS+
Ext: No c/c/e. DP pulses are 2+ bilaterally
Neuro: alert, answers some questions with no, moving all
extremities
Skin: diffuse pink/erythematous papular rash w/ some areas of
confluence, no desquamation or bullae

FAMILY HISTORY: Family history unknown.

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Pt resides in group
home. 

### Response:
{'Acute kidney failure with lesion of tubular necrosis,Acute on chronic diastolic heart failure,Intestinal infection due to Clostridium difficile,Hyperosmolality and/or hypernatremia,Acute myocardial infarction of unspecified site, subsequent episode of care,Hypotension, unspecified,Unspecified intellectual disabilities,Stricture and stenosis of esophagus,Dermatitis due to drugs and medicines taken internally,Anemia of other chronic disease,Coronary atherosclerosis of native coronary artery'}
