CHIEF COMPLAINT: ESRD

PRESENT ILLNESS: 58 y/o M with long standing ESRD on HD since [**2-/2150**], currently
receiving dialysis through LUE AV graft.  Renal disease thought
to be due to history of DM and HTN. Presents today for renal
transplant.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension

MEDICATION ON ADMISSION: Aspirin 325mg daily
Plavix 75mg daily
Novolog scale
Insulin NPH 20 bedtime
synthroid 300 mcg daily
toprol XL 12.5 [**Hospital1 **]
Nephrocaps 1 tab daily
Sevelamer 2400 before meals
Zocor 40mg at bedtime

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: 98.3, 92, 81/53, 20, 98%RA
Gen: NAD, AOx3
HEENT: anicteric, EOMI, few missing teath
CV: RRR, no m/r/g, median sternotomy scar
P: CTAB
GI: soft, NTND, ecchymosis from insulin injections, NABS
Ext: Graft in LUE with positive thrill, no c/c/e

FAMILY HISTORY: Father with kidney disease. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death. Uncle
with cancer, NOS.

SOCIAL HISTORY: Lives in [**Location **] with his wife and sister-in-law.  [**Name (NI) **] 3
children who live in the area.  Retired 3 years ago.  Since
[**4-/2157**] CABG, has been back to his baseline after (except
lifting), but he is not very active at baseline.
Tobacco history: 30 pack year history, quit at time of CABG in
[**2155**].
ETOH: never
Illicit drugs: denies
Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other acute and subacute forms of ischemic heart disease, other,Acute posthemorrhagic anemia,Complications of transplanted kidney,Oliguria and anuria,Hyperpotassemia,End stage renal disease,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Polyneuropathy in diabetes,Background diabetic retinopathy,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Renal osteodystrophy,Coronary atherosclerosis of unspecified type of vessel, native or graft,Bariatric surgery status,Renal dialysis status,Personal history of sudden cardiac arrest
DMII renl nt st uncntrld,Hyp kid NOS w cr kid V,Ac ischemic hrt dis NEC,Ac posthemorrhag anemia,Compl kidney transplant,Oliguria & anuria,Hyperpotassemia,End stage renal disease,Abn react-org transplant,Neuropathy in diabetes,Diabetic retinopathy NOS,Hypothyroidism NOS,Hyperlipidemia NEC/NOS,Renal osteodystrophy,Cor ath unsp vsl ntv/gft,Bariatric surgery status,Renal dialysis status,Hx sudden cardiac arrest
Admission Date:  [**2157-11-30**]              Discharge Date:   [**2157-12-9**]

Date of Birth:  [**2099-9-15**]             Sex:   M

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 14255**]
Chief Complaint:
ESRD

Major Surgical or Invasive Procedure:
[**2157-12-1**] deceased donor renal transplant


History of Present Illness:
58 y/o M with long standing ESRD on HD since [**2-/2150**], currently
receiving dialysis through LUE AV graft.  Renal disease thought
to be due to history of DM and HTN. Presents today for renal
transplant.


Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension

2. CARDIAC HISTORY:
- CABG:
-[**6-/2155**]  VFib arrest with CABG at [**Hospital1 112**] for 3vd, 5vessel-CABG with

 LIMA to LAD double touchdown with endarterectomy from D1 to
 apex; SVG1 to OM1 and jump to OM2; and SVG2 to PDA
-[**4-/2157**]  CABG Redo sternotomy and coronary artery bypass graft
x3, saphenous vein graft to obtuse marginal 1, 2 and 3.
- PERCUTANEOUS CORONARY INTERVENTIONS:
[**2-/2157**] PCI POBA to 70% L main occulsion, POBA 90% in LAD, DES
placed to L circ for 80% prox with 60% mid occlusion
Repeat cath [**5-2**] showed instent restenosis of L circ (extending
to L main)
- PACING/ICD:  None
3. OTHER PAST MEDICAL HISTORY:
- ESRD on hemodialysis (at Quality Care [**Location (un) **], Tu,[**Last Name (LF) 5929**],[**First Name3 (LF) **]
overnight dialysis)
- Diabetes mellitus with renal complications
- Neuropathy
- Retinopathy
-Obstructive Sleep Apnea (previously on CPAP, now resolved after
weight loss)
- Cataract
- Charcot foot due to diabetes mellitus
- Hypothyroidism
- Hyperlipidemia
- Obesity s/p Lap Band ([**2154**])
- Hyperparathyroidism [**3-17**] renal
- Renal osteodystrophy
- Pulmonary Nodule (Solitary)
- History of Colonic Adenoma
- Left arm fistula
- s/p Lap Band ([**2154**])


Social History:
Lives in [**Location **] with his wife and sister-in-law.  [**Name (NI) **] 3
children who live in the area.  Retired 3 years ago.  Since
[**4-/2157**] CABG, has been back to his baseline after (except
lifting), but he is not very active at baseline.
Tobacco history: 30 pack year history, quit at time of CABG in
[**2155**].
ETOH: never
Illicit drugs: denies


Family History:
Father with kidney disease. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death. Uncle
with cancer, NOS.


Physical Exam:
Vitals: 98.3, 92, 81/53, 20, 98%RA
Gen: NAD, AOx3
HEENT: anicteric, EOMI, few missing teath
CV: RRR, no m/r/g, median sternotomy scar
P: CTAB
GI: soft, NTND, ecchymosis from insulin injections, NABS
Ext: Graft in LUE with positive thrill, no c/c/e

Pertinent Results:
[**2157-11-30**] 10:17AM BLOOD WBC-8.0 RBC-4.24* Hgb-14.4 Hct-42.2
MCV-100* MCH-34.0* MCHC-34.2 RDW-15.0 Plt Ct-261

[**2157-12-9**] 05:38AM BLOOD WBC-3.7* RBC-3.17* Hgb-10.1* Hct-29.0*
MCV-92 MCH-31.9 MCHC-34.8 RDW-16.3* Plt Ct-159
[**2157-12-6**] 06:00AM BLOOD PT-11.5 PTT-29.0 INR(PT)-1.1
[**2157-11-30**] 10:17AM BLOOD UreaN-20 Creat-5.4* Na-134 K-4.9 Cl-93*
HCO3-32 AnGap-14
[**2157-12-9**] 05:38AM BLOOD Glucose-139* UreaN-26* Creat-4.6* Na-136
K-3.7 Cl-98 HCO3-31 AnGap-11
[**2157-12-9**] 05:38AM BLOOD Calcium-7.6* Phos-3.5 Mg-2.0
[**2157-12-9**] 05:38AM BLOOD tacroFK-14.6

Brief Hospital Course:
58 year old man with significant CAD s/p multiple CABG and
multiple PCI interventions due to multiple episodes of in stent
restenosis (most recent [**7-26**]), ESRD on HD for over 7 years was
admitted to the Tranplant Service for preop renal transplant
from high risk donor with h/o IV drugs and high risk sexual
behavior. Donor tested negative for HIV and hepatis panel. On
[**2157-12-1**], he underwent deceased donor renal transplant to the
right iliac fossa with [**Doctor Last Name 406**] drain placement and double-J
ureteral stent placed with uretero-vesicular anastomosis. Given
preop chronically low BP (sbp in 90s), Neo-Synephrine was
infused for most of the OR time and was continued in the PACU.
Surgeon was Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **]. Please refer to operative note
for details. Induction immunosuppression was given which
consisted of solumedrol, cellcept and prograf. Of note,he was
kept on ASA/Plavix for cardiac stents.

Postop, in PACU, urine was negligible and bloody. [**Doctor Last Name 406**] drain
output was bloody with high output (~600cc). Hct decreased to
27.5 from 42.2 (preop). A total of 4 units of PRBC, FFP and
platelets were transfused. There was concern for need to return
to OR. However, renal transplant duplex demonstrated no
hydronephrosis/hematoma, appropriate arterial and venous
vascular signals. Intraparenchymal arterial signals were noted
to have low velocity, however acceleration time was good and
diastolic flow was seen throughout. Flow was not demonstrated in
the subcortical region on color Doppler imaging. Hct remained
stable.

He was transferred to the SICU for management. Blood pressure
continued to be low  and Levo was added. He was tachycardic with
MAP of 65. SOB and volume overloaded.  Epinephrine was started,
substernal chest pain and numbness radiating down left arm. Pain
was similar to pas anginal pain. EKG showed new ST depressions
in the anterior leads concerning for posterior infarct.
Epinephrine was stopped and morphine given with resolution of
chest discomfort. Repeat EKG showed resolution of ST
depressions. No NTG was administered secondary to hypotension.
Cardiac enzymes were trended and ASA was given. Swan-Ganz
catheter was placed.

Cardiac enzymes were cycled with notation of increased troponins
in setting of renal failure. Cardiology was consulted noting
high risk for stent re stenosis. Cardiac echo showed EF of 65%.
ASA/plavix were restarted. Cardiology felt ST depression was
secondary to demand ischemia due to either surgery/fluid shifts,
tachycardia or epinephrine. Medical management was recommended
(ASA/Plavix/BB/Statin). Transplant  was concerned that symptoms
were possibly due reaction to Thymoglobulin. THymoglobulin was
run over a longer period of time after pre-meds (solumedrol,
tylenol and benadryl).

He became hyperkalemic and SOB. Decision was made to start CVVHD
for no urine output. A L IJ temporary HD line was placed and
CVVHD started

Hct dropped from 32 to 27 and he was transfused 2 units PRBCs.
Potassium and calcium continue to trend down. BP improved and
pressors were stopped. Hct remained stable.

On [**12-4**], neo was off and he tolerated volume off. The decision
was made to stop CVVHD and start HD on [**12-6**]. He transferred out
of the SICU.

Diet was advanced and tolerated. Immunsuppression consisted of 4
doses of ATG (150mg doses), steroid taper, Cellcept and prograf
with dose adjustment per trough levels. He did have high
glucoses from steroids and insulin was adjusted. Nephrology
followed closely and adjusted his medications such resumption of
metoprolol and adding tums/vit D for low calcium.

Urine output (bloody) remained low with approximately low 100s.
HD was tolerated via the LUE AVF on [**12-8**]. Left temporary HD
line was removed. JP drain outputs continued to remain high (up
to 400cc) serosanguinous fluid. RLQ incision had serosanguinous
drainage. Hct decreased to 24-25. 2 units of PRBC were given at
HD on [**12-8**] to keep hct high as he was on ASA/Plavix and
JP/incision had sanguinous drainage.

He was assisted OOB and ambulated with PT. PT cleared him for
home. Foley was removed on [**12-8**]. Urine output was less than 100
for 24 hours. He did well with transplant teaching and felt well
enough to go home on [**12-9**]. [**Location (un) 2203**] VNA was set up to
assist/assess him at home.

Plans were to continue HD via AVF at outpatient center. Labs
were to be drawn on [**12-10**] as Prograf dose increased to 17 on
[**12-7**]. 2 doses were held then dose was decreased to 8 for a day
as level was 14.8. On [**12-9**], level was 14.6. PM dose was held
and 5mg was ordered for [**12-10**].

He was discharged to home on [**12-9**]. R CVL was removed prior to
discharge.


Medications on Admission:
Aspirin 325mg daily
Plavix 75mg daily
Novolog scale
Insulin NPH 20 bedtime
synthroid 300 mcg daily
toprol XL 12.5 [**Hospital1 **]
Nephrocaps 1 tab daily
Sevelamer 2400 before meals
Zocor 40mg at bedtime


Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Calcium Carbonate 1000 mg PO TID:PRN indigestion
5. Calcium Carbonate [**2145**] mg PO HS
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. HYDROmorphone (Dilaudid) 0.5-1 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg 0.5-1 tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
9. NPH 10 Units Breakfast
NPH 30 Units Bedtime
Insulin SC Sliding Scale using novolog Insulin
10. Levothyroxine Sodium 300 mcg PO 5X/WEEK (MO,TU,WE,TH,FR)
11. Metoprolol Tartrate 12.5 mg PO BID
12. Mycophenolate Mofetil 1000 mg PO BID
13. Nephrocaps 1 CAP PO DAILY
14. Nystatin Oral Suspension 5 ml PO QID
15. Omeprazole 40 mg PO DAILY
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
17. Tucks Hemorrhoidal Oint 1% 1 Appl PR TID
18. ValGANCIclovir 450 mg PO 2X/WEEK (TU,FR)
19. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
RX *ergocalciferol (vitamin D2) [Vitamin D2] 50,000 unit [**Unit Number **]
capsule(s) by mouth once a week Disp #*12 Capsule Refills:*0
20. Tacrolimus 0 mg PO ONCE Duration: 1 Doses
do not take pm of [**12-9**]
21. Tacrolimus 5 mg PO ONCE Duration: 1 Doses
take am [**12-10**] after prograf level drawn at 9am at [**Hospital Ward Name 1826**] 7


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 **] VNA

Discharge Diagnosis:
ESRD
s/p deceased donor renal transplant
Delayed graft failure
anemia
CAD


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


Discharge Instructions:
[**Location (un) 2203**] VNA arranged. They will call you to schedule home visit.

Please call the [**Hospital 1326**] clinic [**Telephone/Fax (1) 673**] if you have any
of the following:
temperature of 101 or greater, chills, nausea, vomiting,
inability to eat/drink or take ANY of you medications, increased
abdominal pain, incision redness/increased drainage or bleeding,
increased "JP" drain output or fluid appears more bloody,
increased urine output or urine output stops, constipation or
diarrhea, malfunction of left arm AVF
-continue hemodialysis 3x per week
-Prograf level has been too high (goal level about 10); You will
need to have blood drawn Saturday [**12-10**] for lab monitoring at
[**Hospital Ward Name **], [**Hospital Ward Name 1826**] 7 th Floor  at 9am then twice weekly as
directed
-You may shower with soap & water, pat incision dry, cover drain
and incision with dry gauze
-Empty your drain and record all fluid out.
-no heavy lifting ( nothing heavier than 10 pounds)

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2157-12-15**] 2:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2157-12-15**] 3:00
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2157-12-19**] 1:00



Completed by:[**2157-12-9**]
{'Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other acute and subacute forms of ischemic heart disease, other,Acute posthemorrhagic anemia,Complications of transplanted kidney,Oliguria and anuria,Hyperpotassemia,End stage renal disease,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Polyneuropathy in diabetes,Background diabetic retinopathy,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Renal osteodystrophy,Coronary atherosclerosis of unspecified type of vessel, native or graft,Bariatric surgery status,Renal dialysis status,Personal history of sudden cardiac arrest'}


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: ESRD

PRESENT ILLNESS: 58 y/o M with long standing ESRD on HD since [**2-/2150**], currently
receiving dialysis through LUE AV graft.  Renal disease thought
to be due to history of DM and HTN. Presents today for renal
transplant.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension

MEDICATION ON ADMISSION: Aspirin 325mg daily
Plavix 75mg daily
Novolog scale
Insulin NPH 20 bedtime
synthroid 300 mcg daily
toprol XL 12.5 [**Hospital1 **]
Nephrocaps 1 tab daily
Sevelamer 2400 before meals
Zocor 40mg at bedtime

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: 98.3, 92, 81/53, 20, 98%RA
Gen: NAD, AOx3
HEENT: anicteric, EOMI, few missing teath
CV: RRR, no m/r/g, median sternotomy scar
P: CTAB
GI: soft, NTND, ecchymosis from insulin injections, NABS
Ext: Graft in LUE with positive thrill, no c/c/e

FAMILY HISTORY: Father with kidney disease. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death. Uncle
with cancer, NOS.

SOCIAL HISTORY: Lives in [**Location **] with his wife and sister-in-law.  [**Name (NI) **] 3
children who live in the area.  Retired 3 years ago.  Since
[**4-/2157**] CABG, has been back to his baseline after (except
lifting), but he is not very active at baseline.
Tobacco history: 30 pack year history, quit at time of CABG in
[**2155**].
ETOH: never
Illicit drugs: denies 

### Response:
{'Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other acute and subacute forms of ischemic heart disease, other,Acute posthemorrhagic anemia,Complications of transplanted kidney,Oliguria and anuria,Hyperpotassemia,End stage renal disease,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Polyneuropathy in diabetes,Background diabetic retinopathy,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Renal osteodystrophy,Coronary atherosclerosis of unspecified type of vessel, native or graft,Bariatric surgery status,Renal dialysis status,Personal history of sudden cardiac arrest'}
