CHIEF COMPLAINT: Dyspnea, Acute Renal Failure

PRESENT ILLNESS: Mr. [**Known lastname **] is a 69 yo M with h/o CKD stage IV, HTN, DM2,
Hyperlipidemia presented to [**Location (un) **] ED with weakness, nausea for
several days. Also noted poor appetite, shortness of breath
worsened by exertion, chest pain and cough prodcutive of clear
sputum. Also with two loose stools and abdominal pain. reported
fever to 103.

MEDICAL HISTORY: - HTN
- DM2
- CKD Stage IV (Baseline Cr 4.55)
- Atrophic left kidney

MEDICATION ON ADMISSION: Atenolol 50mg PO daily
Lasix 40mg PO daily
Sodium Bicarbonate 2 tabs PO bid
minitran patch

ALLERGIES: Penicillins / IV Dye, Iodine Containing

PHYSICAL EXAM: Admission
Tmax: 36.8 ??????C (98.2 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 62 (59 - 65) bpm
BP: 114/57(72) {112/57(72) - 114/59(73)} mmHg
RR: 25 (22 - 25) insp/min
SpO2: 95%
Heart rhythm: SB (Sinus Bradycardia)
Height: 72 Inch
General Appearance: Well nourished, intubated, sedated
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG
tube
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Bronchial: RML)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives with partner in [**Name (NI) 22022**] MA, current smoker. Denies EtOH,
illicit drugs.
Unspecified septicemia,Septic shock,Acute respiratory failure,Pneumonia due to Legionnaires' disease,Cardiac arrest,End stage renal disease,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Critical illness myopathy,Acidosis,Polycystic kidney, unspecified type,Severe sepsis,Renal dialysis status,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Thrombocytopenia, unspecified,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,Other and unspecified hyperlipidemia,Anemia, unspecified,Renal sclerosis, unspecified,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere
Septicemia NOS,Septic shock,Acute respiratry failure,Legionnaires' disease,Cardiac arrest,End stage renal disease,Acute kidney failure NOS,Hyp kid NOS w cr kid V,Urin tract infection NOS,Critical illness myopthy,Acidosis,Polycystic kidney NOS,Severe sepsis,Renal dialysis status,Enterococcus group d,Thrombocytopenia NOS,DMII ophth nt st uncntrl,Diabetic retinopathy NOS,Hyperlipidemia NEC/NOS,Anemia NOS,Renal sclerosis NOS,Nephritis NOS in oth dis
Admission Date:  [**2180-3-29**]              Discharge Date:   [**2180-4-13**]

Date of Birth:  [**2110-7-20**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / IV Dye, Iodine Containing

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Dyspnea, Acute Renal Failure

Major Surgical or Invasive Procedure:
Temporary Dialysis Catheter Placement
Tunneled Dialysis Catheter Placement
Central Venous Line Placement


History of Present Illness:
Mr. [**Known lastname **] is a 69 yo M with h/o CKD stage IV, HTN, DM2,
Hyperlipidemia presented to [**Location (un) **] ED with weakness, nausea for
several days. Also noted poor appetite, shortness of breath
worsened by exertion, chest pain and cough prodcutive of clear
sputum. Also with two loose stools and abdominal pain. reported
fever to 103.

At [**Location (un) **] VS T 98.4, pulse 77, RR 18, BP 167/77, O2 sat 93%/RA.
CXR demonstrated RLL/RML infiltrate. Given vanc 1g, ceftriaxone
1g and levofloxacin 500mg IV for PNA. ABG 7.24/31/63/88,
admitted to ICU and intubated. Put on vent at AC Vt 600, RR 20,
FiO2 50, PEEP 5, on propofol for sedation. Lytes demonstrated Cr
8.8, BUN 133, K 5.7. ECG demonstrated no peaked T waves. Given
calcium gluconate, kayexalate. Given 200mg IV lasix and put out
200cc urine. OG output "coffee grounds materials" and he was
started on pantoprazole 40mg IV q12. Transferred to [**Hospital1 18**] for
consideration of urgent hemodialysis.

Past Medical History:
- HTN
- DM2
- CKD Stage IV (Baseline Cr 4.55)
- Atrophic left kidney


Social History:
Lives with partner in [**Name (NI) 22022**] MA, current smoker. Denies EtOH,
illicit drugs.

Family History:
Noncontributory

Physical Exam:
Admission
Tmax: 36.8 ??????C (98.2 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 62 (59 - 65) bpm
BP: 114/57(72) {112/57(72) - 114/59(73)} mmHg
RR: 25 (22 - 25) insp/min
SpO2: 95%
Heart rhythm: SB (Sinus Bradycardia)
Height: 72 Inch
General Appearance: Well nourished, intubated, sedated
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG
tube
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Bronchial: RML)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace

On discharge:
Tmax: 97.6
Tcurrent: 97.6
HR: 82 (68-82) bpm
BP: 144/83 {136/80 - 152/86} mmHg
RR: 18 (18 - 20) insp/min
SpO2: 96% RA
Heart rhythm: Irregular
Height: 72 Inch
General Appearance: Obese, edematous, but aware and appropriate
Eyes / Conjunctiva: PERRL
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), GII holosystolic
murmur RUSB
Pulmonary: no increased work of breathing, wheezes at upper lung
[**Last Name (un) 8434**], good movement of ir throughout.
Abdominal: Protuberant, soft, Non-tender, Bowel sounds present
Extremities: Diffuse edema but decreased from yesterday,
strength 4/5 throughout.


Pertinent Results:
Admission Labs:
[**2180-3-29**] 12:00AM BLOOD WBC-31.6* RBC-3.35* Hgb-10.6* Hct-31.1*
MCV-93 MCH-31.5 MCHC-34.0 RDW-14.4 Plt Ct-267
[**2180-3-29**] 12:00AM BLOOD PT-15.3* PTT-31.9 INR(PT)-1.3*
[**2180-3-29**] 12:00AM BLOOD Glucose-176* UreaN-137* Creat-9.7*
Na-130* K-5.6* Cl-97 HCO3-13* AnGap-26*
[**2180-3-29**] 12:00AM BLOOD ALT-34 AST-57* AlkPhos-85 TotBili-0.7
[**2180-3-29**] 12:00AM BLOOD Albumin-2.4* Calcium-8.9 Phos-11.7*
Mg-2.3
[**2180-3-29**] 01:00AM BLOOD Type-ART Temp-36.8 Rates-14/13 Tidal
V-500 PEEP-5 FiO2-50 pO2-87 pCO2-34* pH-7.21* calTCO2-14* Base
XS--13 Intubat-INTUBATED

Legionella Antigen positive - [**2180-3-30**]

Imaging:

CXR on admission:
An endotracheal tube lies with its tip approximately 4 cm from
the carina. An NG tube lies with its tip below the diaphragm
although the tip is not
visualized on this study. There is increased opacity at the
right base with homogenous opacification consistent with a
pleural effusion. This makes assessment of the right lung base
difficult. There are air bronchograms evident in the right lower
lung; however, this may be related to either compressive
atelectasis or pneumonia

CT Abdomen:
1. Endotracheal tube is seen 5 cm above the carina. The right
internal
jugular line is seen with the distal tip in the proximal
superior vena cava.  The nasogastric tube is seen coiled with
the tip within the antrum of the stomach.
2. Complete opacification of the right lower lung lobe with a
moderate-sized pleural effusion. There is a smaller
consolidation and tiny pleural effusion at the base of the left
lung.
3. No intra-abdominal or intrapelvic source of infection. There
is
perinephric stranding seen around the right kidney as well as
free fluid
within the pelvis from likely from aggressive hydration or poor
nutritinoal status.
4. Several hypodensities seen bilaterally and a soft tissue
density lesion
seen in the inferior pole of the right kidney. This right kidney
lesion can be further evaluated with ultrasound after the
patient's acute clinical condition resolves.

CT Chest:
1. Endotracheal tube is seen 5 cm above the carina. The right
internal
jugular line is seen with the distal tip in the proximal
superior vena cava.  The nasogastric tube is seen coiled with
the tip within the antrum of the stomach.
2. Complete opacification of the right lower lung lobe with a
moderate-sized pleural effusion. There is a smaller
consolidation and tiny pleural effusion at the base of the left
lung.
3. No intra-abdominal or intrapelvic source of infection. There
is
perinephric stranding seen around the right kidney as well as
free fluid
within the pelvis from likely from aggressive hydration or poor
nutritinoal status.
4. Several hypodensities seen bilaterally and a soft tissue
density lesion
seen in the inferior pole of the right kidney. This right kidney
lesion can be further evaluated with ultrasound after the
patient's acute clinical condition resolves.

Pertinent labs on discharge:
Hemoglobin 7.5 Hct 22.6. Final urine culture on [**2180-4-11**] was
negative for growth.

Brief Hospital Course:
Mr. [**Known lastname **] is a 69 y/o M with Stage IV CKD (Cr 4.5), HTN, DM2, p/w
weakness & SOB x 3 days, found to have RML/RLL PNA and acute on
chronic renal failure, transferred for consideration of urgent
hemodialysis.

#. Hypoxemia/Pneumonia: Patient arrrived intubated and sedated
on mechanical ventilation.  He was treated initially for
community acquired pneumonia with azithromycin and ceftriaxone,
but switched to vancomycin and cefepime as he did not intially
improve.  Urine legionella antigen was positive and antibiotics
were narrowed to levofloxacin. His WBC count continued to rise,
infectious disease was consulted and coverage was broadened to
tigecycline on [**2180-3-31**].  He was extubated initially on [**2180-4-3**],
but became acute hypoxic due to mucous plugging and suffered PEA
arrest.  He was emergently reintubated, and put back on the
ventilator.  On [**2180-4-7**], he passed a spontaneous breathing trial
and was extubated without complication.  His white count trended
down to 12 on transfer to the floor.  He was continued on
levofloxacin with a planned total course of 21 days (Day #15 at
discharge).

# Cardiac Arrest: On [**2180-4-3**] patient was extubated, became
acutely hypoxic and suffered PEA arrest.  Chest compressions
were started promptly, he received epinephrine, atropine and
received one electrical defibrillation for ventricular
fibrillation.  He received adenosine for SVT, then switchedinto
atrial fibrillation with RVR.  Restoration of sponteous
circulation was achieved in 8 minutes.
He was give amiodarone 150mg IV, followed by an infusion at
1mg/hr for six hours, then 0.5 mg/hr for 18 hours.  His rate was
stable in the 80s.

#. Sepsis: On hospital day 2, patient became progressively
tachycardic and hypotensive responsive to fluid boluses and
briefly required norepinephrine.

#. Acute on Chronic Renal Failure: On arrival patient had
increased BUN and creatinine (4.5 -> 8.8) from baseline, mild
hyperkalemia (5.7) and metabolic acidosis.  He was initially
treated with kayexalate, and IV bicarbonate.  A temporary
dialysis catheter was placed and CVVH was initiated.  His
electrolyte abnormalities gradually improved.  A left internal
jugular tunneled catheter was placed, and he was started on
intermittent hemodialysis.  He was started on Aluminum
Hydroxide, this was changed to calcium acetate on discharge.
Mr. [**Known lastname **] will likely require longterm hemodilaysis from this
point on. He was noted to be severely anemic (Hct 22-25) and
possibility of transfusion was discussed, but patient refused.

# Atrial Fibrillation.  On hospital day two, patient was noted
to be in atrial fibrillation.  Anticoagulation was initially
held.  After completing his course of amiodarone post arrest, he
was started on diltiazem 30mg PO qid with fair to good rate
control (80s to 100s).  He was started on a heaprin drip and
warfarin.  As his platelets trended down from 267 to 110, there
was concern for HIT. Heparin dependent antibodies were sent and
he was initially switched to argatroban; antibodies returned
negative.  Once his INR was > 2.0, argatroban was stopped. INR
was initially therapeutic on 4 mg warfarin, but then became
supratherapeutic. Dose was decreased to 2.5 mg on [**2180-4-11**] and
should be held on [**2180-4-13**]. He will require INR checks on [**2180-4-14**]
and [**2180-4-17**] with further adjustments as needed. He should follow
up with his PCP at discharge to discuss cardiology referral for
evaluation/management of his atrial fibrillation. His blood
pressures have been very stable on his current dose of
diltiazem, which may be titrated up if his heart rate persists
above 90s. If he maintains good rate control, a long-acting form
of diltiazem may be appropriate at discharge from rehab to aid
with compliance.

# Abdominal Pain:  Patient had tenderness to palpation of the
abdomen on exam.  Given rising white count and question of
perinephric fluid collection on the outside CT, an abdominal
ultrasound was performed that were unremarkable.  He was treated
empirically for possible abodminal infection with tigecycline
from [**2180-3-31**] to [**2180-4-6**] and his pain resolved.

#. DM2: Fingerstick blood glucose was checked daily. Mr. [**Known lastname **]
did not require insulin therapy upon discharge.

# Elevated Alkaline Phosphatase:  Alk phos increased after
admission to 500s.  This was thought to be secondary to
levofloxacin therapy.

TRANSITIONAL CARE ISSUES:
- Patient will need nephrology follow up after discharge from
rehab, either with his prior nephrologist or a new provider.
[**Name Initial (NameIs) **] [**Name11 (NameIs) **] will need to arrange for regular INR checks while on
warfarin after discharge. He should see his PCP to discuss
cardiology referral for his atrial fibrillation.
- Patient will need INR monitored tomorrow and Monday and
warfarin dose adjusted accordingly.
- Patient will need to be monitored for heart rate control
(diltiazem may be increased as needed).
- Patient will complete his course of levofloxacin after 3
additional doses Q48H (next dose [**2180-4-14**]).
- CBC/hematocrit should be checked on Monday (patient may
require transfusion for Hct < 21).

Medications on Admission:
Atenolol 50mg PO daily
Lasix 40mg PO daily
Sodium Bicarbonate 2 tabs PO bid
minitran patch


Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for pain, fever.
Disp:*90 Tablet(s)* Refills:*0*
4. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: PLEASE HOLD TODAY [**2180-4-13**] for INR of 4.6.
Disp:*30 Tablet(s)* Refills:*2*
5. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours).
Disp:*3 Tablet(s)* Refills:*0*
6. PhosLo 667 mg Capsule Sig: As directed Capsule PO twice a
day: Take 1 tab after breakfast, 1 tab after lunch, 2 tab after
dinner.
Disp:*120 Capsule(s)* Refills:*2*


Discharge Disposition:
Extended Care

Facility:
St. [**Hospital 11042**] Hospital rehab

Discharge Diagnosis:
Primary:
Legionella pneumonia
Acute renal failure necessitating dialysis
Pulseless electrical activity cardiac arrest
Atrial fibrillation/flutter (new)
Anemia

Secondary:
Type II diabetes
Hypertension


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Mr. [**Known lastname **] you presented to the [**Hospital1 18**] on [**2180-3-29**] in severe
respiratory distress due to pneumonia illness.  This illness
required an admission to the medical intensive care unit and for
you to be intubated and placed on a respirator. During this time
you were diagnosed with pneumonia due to legionella infection
and were begun on Levofloxacin IV antibiotics. However, during
this time you stopped making urine and required dialysis. Your
ICU course was complicated by an arrhythmia called atrial
flutter/fibrillation. You were started on warfarin
anticoagulation therapy to minimize your risk of stroke. This
will require following INR on a regular basis.  You also had an
episode where your heart stopped (lost pulse) and you required
rescusitation, which was successful.

You improved on antibiotics and were transfered to the medical
floor where your respiratory status improved and you defervesed.
You were continued on dialysis 3x per week.  You also
demonstrated significant weakness likely due to the long
admission in the intensive care unit. However your strength
improved somewhat during your stay.

Your renal failure requires hemodialysis at this time. You will
need to copntinue hemodialysis as an outpatient with a renal
physician following your care.

We have made the following changes to your medication regimen:
- STOP TAKING atenolol while using the diltiazem.
- STOP TAKING minitran patch while using the diltiazem.
- STOP TAKING furosemide until/unless instructed to resume by
your doctors.
- STOP TAKING sodium bicarbonate until/unless instructed to
resume by your doctors.
- BEGIN TAKING diltiazem 30 mg PO every 6 hours for heart rate
control (your doctor may wish to change you to a once-daily
formula once you are stable on this regimen)
- BEGIN TAKING warfarin 2.5 mg PO daily (your doctor will need
to monitor your INR and may need to adjust your dose)
- BEGIN TAKING Phos-Lo to control your phosphate levels (total 4
tablets daily or as directed by your nephrologist)
- BEGIN TAKING aspirin 81 mg PO daily
- TAKE AS NEEDED acetaminophen for fever or pain
- COMPLETE COURSE of levofloxacin (antibiotic) for your
pneumonia (3 more doses over 6 days)

Please continue to take your medications as prescribed.

Followup Instructions:
Please have make an appointment with your primary care physician
on discharge from rehab. You should review your medications with
your doctor and discuss referral to a cardiologist for your
atrial fibrillation. You will also need to have your INR
monitored regularly while on anticoagulation therapy with
warfarin.

You will need to follow up with a nephrologist at discharge from
rehab (either your prior nephrologist or a new provider) to
monitor your kidney function and need for dialysis.



Completed by:[**2180-4-13**]
{"Unspecified septicemia,Septic shock,Acute respiratory failure,Pneumonia due to Legionnaires' disease,Cardiac arrest,End stage renal disease,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Critical illness myopathy,Acidosis,Polycystic kidney, unspecified type,Severe sepsis,Renal dialysis status,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Thrombocytopenia, unspecified,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,Other and unspecified hyperlipidemia,Anemia, unspecified,Renal sclerosis, unspecified,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere"}


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: Dyspnea, Acute Renal Failure

PRESENT ILLNESS: Mr. [**Known lastname **] is a 69 yo M with h/o CKD stage IV, HTN, DM2,
Hyperlipidemia presented to [**Location (un) **] ED with weakness, nausea for
several days. Also noted poor appetite, shortness of breath
worsened by exertion, chest pain and cough prodcutive of clear
sputum. Also with two loose stools and abdominal pain. reported
fever to 103.

MEDICAL HISTORY: - HTN
- DM2
- CKD Stage IV (Baseline Cr 4.55)
- Atrophic left kidney

MEDICATION ON ADMISSION: Atenolol 50mg PO daily
Lasix 40mg PO daily
Sodium Bicarbonate 2 tabs PO bid
minitran patch

ALLERGIES: Penicillins / IV Dye, Iodine Containing

PHYSICAL EXAM: Admission
Tmax: 36.8 ??????C (98.2 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 62 (59 - 65) bpm
BP: 114/57(72) {112/57(72) - 114/59(73)} mmHg
RR: 25 (22 - 25) insp/min
SpO2: 95%
Heart rhythm: SB (Sinus Bradycardia)
Height: 72 Inch
General Appearance: Well nourished, intubated, sedated
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG
tube
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Bronchial: RML)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives with partner in [**Name (NI) 22022**] MA, current smoker. Denies EtOH,
illicit drugs. 

### Response:
{"Unspecified septicemia,Septic shock,Acute respiratory failure,Pneumonia due to Legionnaires' disease,Cardiac arrest,End stage renal disease,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Critical illness myopathy,Acidosis,Polycystic kidney, unspecified type,Severe sepsis,Renal dialysis status,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Thrombocytopenia, unspecified,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,Other and unspecified hyperlipidemia,Anemia, unspecified,Renal sclerosis, unspecified,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere"}
