CHIEF COMPLAINT: rising creatinine

PRESENT ILLNESS: HPI: 78 y/o female with HTN, DM2, CAD S/P CABG, Afib, ESRD S/P
Renal Transplant, and RAS S/P Angioplasty who is referred in for
workup of rising creatinine, latest value of 3.5 up from last in
our system of 2.5 in mid [**Month (only) **]). She reports no complaints other
than continued left arm and bilateral leg swelling which has
been getting worse over the last month. She also has had some
intching of her back, but denies thirst, nausea, vomiting,
change in frequency/color/odor of urine. She denies headache,
[**Month (only) **], chills, chest pain, dyspnea on exertion, orthopnea, PND,
abdominal pain, graft tenderness, diarrhea, polyuria. She has
not been using any NSAIDS. She did have her metolazone restarted
one week ago and took a dose on thursday and saturday because of
worsening leg edema. Her furosemide dose has been stable. Her
potassium was changed from daily to [**Hospital1 **] last week as well. She
was started back on allopurinol about a month ago. Otherwise on
changes in her health and she has actually been feeling well.

MEDICAL HISTORY: # DM Type II
--Renal allograft artery angioplasty [**2-27**] HTN
--Renal transplant ([**2099**]): No information about donor
# Atrial fibrillation, not currently anticoagulated s/p [**8-1**]
hemicolectomy
# Right hemicolectomy ([**7-/2111**])
# CAD s/p CABG ([**2098**]: LIMA to LAD, SVG to PDA, SVG to OM, SVG to

MEDICATION ON ADMISSION: nsulin 12 untis NPH and regular insulin sliding scale
Prednisone 5 mg QAM
Amiodarone 100 mg QOD
Calcitriol 0.25 mcg DAILY
Levothyroxine 100 mcg DAILY
Pantoprazole 40 gm DAILY
Labetolol 150 mg [**Hospital1 **]
Tacrolimus (Prograf) 2 mg [**Hospital1 **]
Furosemide 80 mg [**Hospital1 **]
Amlodipine 5 mg DAILY
Lipitor 10 mg DAILY
Allipurinol 100 mg QHS
Metolazone 2.5 mg QSAT and QTHURS
Ferrous Sulfate 325 mg DAILY
Sodium Bicarbonate 650 mg DAILY
Potassium 20 mEQ [**Hospital1 **]
Clonidine 0.1 mg [**Hospital1 **]
Vitamin D
Aranesp
.

ALLERGIES: Percocet / Codeine / Hydrochlorothiazide / Percodan / Cardizem

PHYSICAL EXAM: General: AAOx3 in NAD, Elderly female wearing wig.
VITALS: T 97.3 BP 129/66 (129-188) HR 62 (62-70) RR 20 100% RA
HEENT: PERRL. EOMI, no scleral icterus, MMM.
Neck: No LAD or masses, no JVD or carotid bruits
Chest: CTABL.
Cardiac: Regularly irregular; S3 or split S2
Abdomen: Soft, NT, ND, active bowel sounds, RLQ graft nontender
and firm without a bruit.
Extremities: LE pitting edema to the knee and over the sacrum.
Left arm with blaiteral nonpatent AV fistula. Swelling of the
left arm but not right. Weak left radial and distal LE pulses
bilaterally.
Neuro: AAOx3, CNII-XII intact

FAMILY HISTORY: Mother died of ? htn in her 80s

SOCIAL HISTORY: # Personal: Widowed, lives with son
# Smoking: Never
# Alcohol: Never
# Also has VNS come to help weekly
Acute kidney failure, unspecified,Kidney replaced by transplant,Unspecified pleural effusion,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,End stage renal disease,Long-term (current) use of insulin,Atrial fibrillation,Aortocoronary bypass status,Secondary hyperparathyroidism (of renal origin),Anemia in chronic kidney disease
Acute kidney failure NOS,Kidney transplant status,Pleural effusion NOS,Hyp kid NOS w cr kid V,DMII renl nt st uncntrld,End stage renal disease,Long-term use of insulin,Atrial fibrillation,Aortocoronary bypass,Sec hyperparathyrd-renal,Anemia in chr kidney dis
Admission Date:  [**2111-12-14**]              Discharge Date:   [**2111-12-16**]

Date of Birth:  [**2033-11-9**]             Sex:   F

Service: MEDICINE

Allergies:
Percocet / Codeine / Hydrochlorothiazide / Percodan / Cardizem

Attending:[**First Name3 (LF) 21112**]
Chief Complaint:
rising creatinine

Major Surgical or Invasive Procedure:
Renal Biopsy


History of Present Illness:
HPI: 78 y/o female with HTN, DM2, CAD S/P CABG, Afib, ESRD S/P
Renal Transplant, and RAS S/P Angioplasty who is referred in for
workup of rising creatinine, latest value of 3.5 up from last in
our system of 2.5 in mid [**Month (only) **]). She reports no complaints other
than continued left arm and bilateral leg swelling which has
been getting worse over the last month. She also has had some
intching of her back, but denies thirst, nausea, vomiting,
change in frequency/color/odor of urine. She denies headache,
[**Month (only) **], chills, chest pain, dyspnea on exertion, orthopnea, PND,
abdominal pain, graft tenderness, diarrhea, polyuria. She has
not been using any NSAIDS. She did have her metolazone restarted
one week ago and took a dose on thursday and saturday because of
worsening leg edema. Her furosemide dose has been stable. Her
potassium was changed from daily to [**Hospital1 **] last week as well. She
was started back on allopurinol about a month ago. Otherwise on
changes in her health and she has actually been feeling well.

Past Medical History:
# DM Type II
--Renal allograft artery angioplasty [**2-27**] HTN
--Renal transplant ([**2099**]): No information about donor
# Atrial fibrillation, not currently anticoagulated s/p [**8-1**]
hemicolectomy
# Right hemicolectomy ([**7-/2111**])
# CAD s/p CABG ([**2098**]: LIMA to LAD, SVG to PDA, SVG to OM, SVG to

diag)
# Cholecystectomy
# Zoster

Social History:
# Personal: Widowed, lives with son
# Smoking: Never
# Alcohol: Never
# Also has VNS come to help weekly


Family History:
Mother died of ? htn in her 80s


Physical Exam:
General: AAOx3 in NAD, Elderly female wearing wig.
VITALS: T 97.3 BP 129/66 (129-188) HR 62 (62-70) RR 20 100% RA
HEENT: PERRL. EOMI, no scleral icterus, MMM.
Neck: No LAD or masses, no JVD or carotid bruits
Chest: CTABL.
Cardiac: Regularly irregular; S3 or split S2
Abdomen: Soft, NT, ND, active bowel sounds, RLQ graft nontender
and firm without a bruit.
Extremities: LE pitting edema to the knee and over the sacrum.
Left arm with blaiteral nonpatent AV fistula. Swelling of the
left arm but not right. Weak left radial and distal LE pulses
bilaterally.
Neuro: AAOx3, CNII-XII intact


Pertinent Results:
[**2111-12-14**] 10:20PM   PT-12.7 PTT-29.6 INR(PT)-1.1
[**2111-12-14**] 10:20PM   PLT COUNT-239
[**2111-12-14**] 10:20PM   WBC-5.5 RBC-3.81* HGB-11.3* HCT-33.9* MCV-89
MCH-29.6 MCHC-33.2 RDW-18.9*
[**2111-12-14**] 10:20PM   FREE T4-1.2
[**2111-12-14**] 10:20PM   TSH-8.4*
[**2111-12-14**] 10:20PM   CALCIUM-6.4* PHOSPHATE-6.5*# MAGNESIUM-1.4*
[**2111-12-14**] 10:20PM   estGFR-Using this
[**2111-12-14**] 10:20PM   GLUCOSE-227* UREA N-72* CREAT-4.6*#
SODIUM-139 POTASSIUM-3.1* CHLORIDE-103 TOTAL CO2-20* ANION
GAP-19
[**2111-12-16**] 06:10AM BLOOD PTH-397*
[**2111-12-14**] 10:20PM BLOOD TSH-8.4*
[**2111-12-16**] 08:46AM BLOOD FK506-7.6
[**2111-12-15**] 05:50AM BLOOD FK506-6.0
[**2111-12-16**] 06:10AM BLOOD BK VIRUS BY PCR, BLOOD-PND
[**2111-12-15**] 08:00AM URINE Hours-RANDOM UreaN-239 Creat-26 Na-98
TotProt-575 Prot/Cr-22.1*
[**2111-12-15**] 08:00AM URINE Eos-NEGATIVE
[**2111-12-15**] 08:00AM URINE Blood-NEG Nitrite-NEG Protein-500
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
.
RENAL ULTRASOUND: IMPRESSION: Unchanged overall appearance of
renal transplant with marked upper pole cortical thinning and
underlying focal hydronephrosis. Doppler examination
demonstrates relatively normal venous flow and preserved
systolic and diastolic arterial flow, though the latter is low
in amplitude, as before. The renal artery shows slightly
broadened spectral waveforms, with normal parenchymal resistive
indices, ranging from 0.54 to 0.62 in the mid- and lower poles;
these results are not significantly changed compared to prior
exams. The preserved brisk arterial upstroke would militate
against significant re-stenosis of the stented renal artery.

However, though the Doppler evaluation of the upper pole
parenchyma is limited, the elevated RIs, which appear new, in
the setting of rising creatinine, raise the possibility of
chronic rejection. This may need to be addressed directly, by
renal biopsy.
The study and the report were reviewed by the staff radiologist.


Brief Hospital Course:
A/P: 77 y/o Female with HTN, DM2, CAD S/P CABG, Afib, ESRD S/P
Renal Transplant, and RAS S/P Angioplasty with rising creatinine
and elevated blood pressure, but asymptomatic.
.
1. Acute on Chronic Renal Failure: Likely etiology of rising
creatinine is worsening of her chronic kidney disease due to
hypertensive nephrosclerosis and diabetic nephropathy. Urine
studies were consistent with an intrinsic cause of renal failure
and patient had nephrotic range proteinuria. Renal transplant
ultrasound with Dopplers was negative for RAS and showed normal
venous flow. Serum protein and urine protein had been negative
in [**Month (only) **]. The patient's diuretics were held for concern of
renal hypoperfusion. Prograf levels were followed and were
within therapeutic range, making renal failure secondary to
prograf unlikely.
-
2. Hypertension: Blood pressure was elevated while in hospital
and patient's medications were changed to correct this. We
increased her labetalol to 200mg, amlodipine was increased to
10mg and clonidine was increased to 0.2mg tid.
-
3. Leg Edema: Has normal EF, so possibly diastolic failure vs.
worsening renal disease. Etiology is most likely anasarca
secondary to protein losing nephropathy. However, patient's
diuretics were held.

-
4. Right Basilar Decreased breath sounds: Likely pleural
effusion. Doubt PNA given lack of cough, sputum, fevers. CXR
unread but appears to have stable chronic R sided effusion. As
appears stable otherwise, patient was not treated at this time.

-
5. Irregular rate: Hx of Afib, not on coumadin. On ECG, NSR with
PAC's, LVH and RBBB.
- continue beta blocker as well rate controlled
- coumadin has been held because of diverticular bleed requiring
hemicolectomy
-
6. DM Type II:
- diabetic diet
- regular insulin sliding scale
-
7. CAD s/p CABG and stenting: No chest pain.
- cont beta blocker and statin
- not on aspirin or plavix, unclear when last stent was put in,
but possibly stopped because of bleed.
-
8. Diastolic Dysfunction: Pt was continued on antihypertensives
with good effect.
-
9. Secondary Hyperparathyroidism: Pt was continued on
calcitriol. PTH level was checked and remained elevated. Calcium
levels were within normal.

-
10. Hypothyroidism: Continued on home regimen of levothyroxine;
TSH elevated but free T4 normal
-
11. Anemia: Likely ACD from renal disease. HCT was stable with
no evidence of bleeding.
-
12. h/o Gout: Allopurinol was held in house
-


Medications on Admission:
nsulin 12 untis NPH and regular insulin sliding scale
Prednisone 5 mg QAM
Amiodarone 100 mg QOD
Calcitriol 0.25 mcg DAILY
Levothyroxine 100 mcg DAILY
Pantoprazole 40 gm DAILY
Labetolol 150 mg [**Hospital1 **]
Tacrolimus (Prograf) 2 mg [**Hospital1 **]
Furosemide 80 mg [**Hospital1 **]
Amlodipine 5 mg DAILY
Lipitor 10 mg DAILY
Allipurinol 100 mg QHS
Metolazone 2.5 mg QSAT and QTHURS
Ferrous Sulfate 325 mg DAILY
Sodium Bicarbonate 650 mg DAILY
Potassium 20 mEQ [**Hospital1 **]
Clonidine 0.1 mg [**Hospital1 **]
Vitamin D
Aranesp
.


Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

10. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Outpatient Lab Work
Please draw CBC, chem-10, FK 506 level. Please fax results to
transplant center at [**Telephone/Fax (1) 697**]
12. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) UNITS Subcutaneous q AM.
15. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Community VNA, Attelboro

Discharge Diagnosis:
Primary:
Acute on chronic renal insufficiency
Hypertension
Diabetes Type II
Atrial fibrillation

Secondary:
CAD s/p CABG
Diastolic Dysfunction
End Stage Renal Failure S/P Renal Transplant
Secondary Hyperparathyroidism
Hypothyroidism
Anemia


Discharge Condition:
Good


Discharge Instructions:
You were admitted to the hospital with worsening renal function.
 This is most likely due to chronic kidney disease. You
underwent a kidney biopsy while you were in the hospital. You
should follow up with Dr. [**Last Name (STitle) **] on [**12-22**].
.
You should also have your blood drawn on THIS FRIDAY. We have
given you a prescription for this. You can have them drawn at
the transplant center.
.
If you develop any worrisome symptoms such as abdominal pain,
pain at the site of biopsy, bleeding, blood in your urine, pain
with urination, [**Month/Year (2) **], chest pain , shortness of breath, please
contact your doctor or return to the emergency room.
.


Followup Instructions:
You have the following appointment scheduled for you:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2111-12-22**] 8:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2112-2-2**] 10:30
{'Acute kidney failure, unspecified,Kidney replaced by transplant,Unspecified pleural effusion,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,End stage renal disease,Long-term (current) use of insulin,Atrial fibrillation,Aortocoronary bypass status,Secondary hyperparathyroidism (of renal origin),Anemia in chronic kidney disease'}


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: rising creatinine

PRESENT ILLNESS: HPI: 78 y/o female with HTN, DM2, CAD S/P CABG, Afib, ESRD S/P
Renal Transplant, and RAS S/P Angioplasty who is referred in for
workup of rising creatinine, latest value of 3.5 up from last in
our system of 2.5 in mid [**Month (only) **]). She reports no complaints other
than continued left arm and bilateral leg swelling which has
been getting worse over the last month. She also has had some
intching of her back, but denies thirst, nausea, vomiting,
change in frequency/color/odor of urine. She denies headache,
[**Month (only) **], chills, chest pain, dyspnea on exertion, orthopnea, PND,
abdominal pain, graft tenderness, diarrhea, polyuria. She has
not been using any NSAIDS. She did have her metolazone restarted
one week ago and took a dose on thursday and saturday because of
worsening leg edema. Her furosemide dose has been stable. Her
potassium was changed from daily to [**Hospital1 **] last week as well. She
was started back on allopurinol about a month ago. Otherwise on
changes in her health and she has actually been feeling well.

MEDICAL HISTORY: # DM Type II
--Renal allograft artery angioplasty [**2-27**] HTN
--Renal transplant ([**2099**]): No information about donor
# Atrial fibrillation, not currently anticoagulated s/p [**8-1**]
hemicolectomy
# Right hemicolectomy ([**7-/2111**])
# CAD s/p CABG ([**2098**]: LIMA to LAD, SVG to PDA, SVG to OM, SVG to

MEDICATION ON ADMISSION: nsulin 12 untis NPH and regular insulin sliding scale
Prednisone 5 mg QAM
Amiodarone 100 mg QOD
Calcitriol 0.25 mcg DAILY
Levothyroxine 100 mcg DAILY
Pantoprazole 40 gm DAILY
Labetolol 150 mg [**Hospital1 **]
Tacrolimus (Prograf) 2 mg [**Hospital1 **]
Furosemide 80 mg [**Hospital1 **]
Amlodipine 5 mg DAILY
Lipitor 10 mg DAILY
Allipurinol 100 mg QHS
Metolazone 2.5 mg QSAT and QTHURS
Ferrous Sulfate 325 mg DAILY
Sodium Bicarbonate 650 mg DAILY
Potassium 20 mEQ [**Hospital1 **]
Clonidine 0.1 mg [**Hospital1 **]
Vitamin D
Aranesp
.

ALLERGIES: Percocet / Codeine / Hydrochlorothiazide / Percodan / Cardizem

PHYSICAL EXAM: General: AAOx3 in NAD, Elderly female wearing wig.
VITALS: T 97.3 BP 129/66 (129-188) HR 62 (62-70) RR 20 100% RA
HEENT: PERRL. EOMI, no scleral icterus, MMM.
Neck: No LAD or masses, no JVD or carotid bruits
Chest: CTABL.
Cardiac: Regularly irregular; S3 or split S2
Abdomen: Soft, NT, ND, active bowel sounds, RLQ graft nontender
and firm without a bruit.
Extremities: LE pitting edema to the knee and over the sacrum.
Left arm with blaiteral nonpatent AV fistula. Swelling of the
left arm but not right. Weak left radial and distal LE pulses
bilaterally.
Neuro: AAOx3, CNII-XII intact

FAMILY HISTORY: Mother died of ? htn in her 80s

SOCIAL HISTORY: # Personal: Widowed, lives with son
# Smoking: Never
# Alcohol: Never
# Also has VNS come to help weekly 

### Response:
{'Acute kidney failure, unspecified,Kidney replaced by transplant,Unspecified pleural effusion,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,End stage renal disease,Long-term (current) use of insulin,Atrial fibrillation,Aortocoronary bypass status,Secondary hyperparathyroidism (of renal origin),Anemia in chronic kidney disease'}
