CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: 61 yo male with a PMH for Acid reflux, TIIDM, HTN, s/p
nephrectomy following RCC diagnosis, ESRD with dialysis 3x/week,
and s/p cadaveric kidney transplant after lone kidney became
dialysis dependent and stopped functioning well, who comes in
complaining of CP. He was last well 3 days PTA when lifting
heavy trash right after lunch at work when he felt acute chest
pain that was burning in nature in his sternum that radiated to
his back. It was severe in nature and was relieved with rest
after 30 minutes. He did feel some SOB with this episode and
does not remember how long it lasted for.

MEDICAL HISTORY: DM2
ESRD s/p cadaveric renal transplant in [**8-8**]
renal transplant artery stenosis s/p dilatation/stent in [**8-8**]
hemolysis with unknown etiology ([**1-11**])
ciguatera intoxication ([**4-9**])
Barrett's esophagus ([**12-7**])
asthma
RCC s/p L nephrectomy ('[**93**])
obstructive sleep apnea
s/p AV graft on LUE and AV fistula RLE
hypercalcemia

MEDICATION ON ADMISSION: Minoxidil 10mg 1TAB 2xday
Prednisone 5mg 1TAB daily
Clonidine  0.1mg 1TAB 2x daily
Calcitriol 0.25mcg 1capdaily
Furosemide 3TAB 2xday
Mycophenolate 500mg 1TAB 2xday
Lisinopril 10mg 1TAB QHS
Labetalol 200mg 3TAB 2xday
ASA 81 mg
Humalin NPH 20 units AM and 15 in PM

ALLERGIES: Vancomycin

PHYSICAL EXAM: Vitals: T:96.1 BP:146/54 P:82 R:18 O2:98RA
General: Alert and oreinted obese African American male in no
acute distress
HEENT: Scar in right eye from childhood injury, sclera
anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, crescendo-decrescendo murmur heard best in the aortic
valve distribution
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, non pitting mild edema
bilaterally in feet, no C/E
Skin: W+M, no rash, petichiae, or echymosis
Neuro:CN II-XII grossly intact
motor: [**5-10**] throughout
Sensation: Intact to light touch throughout
DTR: 2+ biceps bilaterally
Coordination: Intact to rapid alternating movements and
finger-to-nose

FAMILY HISTORY: Mother and 3 uncles died of "kidney disease." Otherwise all 8 of
his siblings are healthy.

SOCIAL HISTORY: Married with 7 children. Originally born in [**Country **] and moved to
the U.S. in [**2078**]. Currently works as a cook at [**Hospital1 18**] and is
planning on retiring over the next couple of years. Last travel
was in [**Month (only) 1096**] to [**Country **]. Former smoker-quit 20 yrs ago.
Denies alcohol or IVDU.
Acute kidney failure, unspecified,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis,Chronic diastolic heart failure,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,End stage renal disease,Long-term (current) use of insulin
Acute kidney failure NOS,Compl kidney transplant,Hyp kid NOS w cr kid V,Acidosis,Chr diastolic hrt fail,DMII renl nt st uncntrld,Esophageal reflux,End stage renal disease,Long-term use of insulin
Admission Date:  [**2107-8-13**]              Discharge Date:   [**2107-8-26**]

Date of Birth:  [**2045-12-2**]             Sex:   M

Service: MEDICINE

Allergies:
Vancomycin

Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
intubation
renal artery angiography


History of Present Illness:
61 yo male with a PMH for Acid reflux, TIIDM, HTN, s/p
nephrectomy following RCC diagnosis, ESRD with dialysis 3x/week,
and s/p cadaveric kidney transplant after lone kidney became
dialysis dependent and stopped functioning well, who comes in
complaining of CP. He was last well 3 days PTA when lifting
heavy trash right after lunch at work when he felt acute chest
pain that was burning in nature in his sternum that radiated to
his back. It was severe in nature and was relieved with rest
after 30 minutes. He did feel some SOB with this episode and
does not remember how long it lasted for.

He had no pain the following day and then 1 day PTA the same
pain returned while watching TV and after eating spicy food.
This time the pain lasted for 30 minutes and was relieved by
burping and drinking gingerale and milk. The pain retuned this
morning without eating and  was again relieved by drinking milk.
The pain this morning was not as severe as times before.

Of note, he states that he does not experience any exercise
chest pain and is on his feet and walking all day without
problem. If he walks uphill he does get short of breath but
otherwise does not feel limited by his lung capacity.

.
In the ED, initial vs were: T 98 P 85 BP171/83 R 16 O2 97 sat.on
RA Patient had an EKG that showed no change from previous EKGs
and a normal chest x-ray.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea, dysphagia
or congestion. Denies cough, chest tightness, or palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Denied arthralgias or myalgias.


Past Medical History:
DM2
ESRD s/p cadaveric renal transplant in [**8-8**]
renal transplant artery stenosis s/p dilatation/stent in [**8-8**]
hemolysis with unknown etiology ([**1-11**])
ciguatera intoxication ([**4-9**])
Barrett's esophagus ([**12-7**])
asthma
RCC s/p L nephrectomy ('[**93**])
obstructive sleep apnea
s/p AV graft on LUE and AV fistula RLE
hypercalcemia


Social History:
Married with 7 children. Originally born in [**Country **] and moved to
the U.S. in [**2078**]. Currently works as a cook at [**Hospital1 18**] and is
planning on retiring over the next couple of years. Last travel
was in [**Month (only) 1096**] to [**Country **]. Former smoker-quit 20 yrs ago.
Denies alcohol or IVDU.

Family History:
Mother and 3 uncles died of "kidney disease." Otherwise all 8 of
his siblings are healthy.

Physical Exam:
Vitals: T:96.1 BP:146/54 P:82 R:18 O2:98RA
General: Alert and oreinted obese African American male in no
acute distress
HEENT: Scar in right eye from childhood injury, sclera
anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, crescendo-decrescendo murmur heard best in the aortic
valve distribution
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, non pitting mild edema
bilaterally in feet, no C/E
Skin: W+M, no rash, petichiae, or echymosis
Neuro:CN II-XII grossly intact
motor: [**5-10**] throughout
Sensation: Intact to light touch throughout
DTR: 2+ biceps bilaterally
Coordination: Intact to rapid alternating movements and
finger-to-nose

Pertinent Results:
[**2107-8-13**] 11:00AM BLOOD WBC-4.2 RBC-3.55* Hgb-9.6* Hct-32.4*
MCV-91 MCH-27.0 MCHC-29.6* RDW-12.7 Plt Ct-177
[**2107-8-14**] 06:05AM BLOOD WBC-4.9 RBC-3.22* Hgb-9.1* Hct-29.0*
MCV-90 MCH-28.3 MCHC-31.4 RDW-13.5 Plt Ct-170
[**2107-8-15**] 05:10AM BLOOD WBC-5.7 RBC-3.19* Hgb-8.8* Hct-29.1*
MCV-91 MCH-27.7 MCHC-30.4* RDW-12.9 Plt Ct-167
[**2107-8-24**] 03:35AM BLOOD WBC-10.2 RBC-3.03* Hgb-8.4* Hct-28.2*
MCV-93 MCH-27.6 MCHC-29.6* RDW-12.5 Plt Ct-179
[**2107-8-25**] 03:35AM BLOOD WBC-6.1 RBC-2.76* Hgb-7.4* Hct-25.6*
MCV-93 MCH-26.8* MCHC-29.0* RDW-13.3 Plt Ct-190
[**2107-8-26**] 05:00AM BLOOD WBC-5.0 RBC-2.87* Hgb-7.7* Hct-26.6*
MCV-93 MCH-26.8* MCHC-28.9* RDW-12.4 Plt Ct-190
[**2107-8-13**] 11:00AM BLOOD Neuts-71.8* Lymphs-20.4 Monos-6.4 Eos-1.2
Baso-0.2
[**2107-8-24**] 03:35AM BLOOD Neuts-82.5* Lymphs-11.8* Monos-3.9
Eos-1.6 Baso-0.2
[**2107-8-13**] 11:00AM BLOOD PT-13.1 PTT-28.5 INR(PT)-1.1
[**2107-8-26**] 05:00AM BLOOD PT-12.6 PTT-27.5 INR(PT)-1.1
[**2107-8-13**] 11:00AM BLOOD Glucose-221* UreaN-59* Creat-4.5*# Na-140
K-3.8 Cl-102 HCO3-27 AnGap-15
[**2107-8-13**] 08:50PM BLOOD Glucose-250* UreaN-60* Creat-4.6* Na-140
K-3.9 Cl-102 HCO3-28 AnGap-14
[**2107-8-14**] 06:05AM BLOOD Glucose-81 UreaN-60* Creat-4.7* Na-144
K-3.6 Cl-107 HCO3-27 AnGap-14
[**2107-8-18**] 06:15AM BLOOD Glucose-137* UreaN-70* Creat-5.5* Na-137
K-4.1 Cl-103 HCO3-25 AnGap-13
[**2107-8-19**] 05:15AM BLOOD Glucose-56* UreaN-72* Creat-5.5* Na-141
K-3.9 Cl-105 HCO3-27 AnGap-13
[**2107-8-22**] 06:20AM BLOOD Glucose-126* UreaN-51* Creat-3.6* Na-143
K-3.6 Cl-103 HCO3-29 AnGap-15
[**2107-8-23**] 10:21AM BLOOD Glucose-134* UreaN-42* Creat-3.3* Na-143
K-3.6 Cl-105 HCO3-29 AnGap-13
[**2107-8-23**] 05:24PM BLOOD Glucose-126* UreaN-43* Creat-3.4* Na-141
K-4.4 Cl-102 HCO3-31 AnGap-12
[**2107-8-24**] 03:35AM BLOOD Glucose-132* UreaN-46* Creat-3.8* Na-141
K-4.5 Cl-104 HCO3-33* AnGap-9
[**2107-8-25**] 03:35AM BLOOD Glucose-81 UreaN-51* Creat-4.3* Na-142
K-4.4 Cl-104 HCO3-31 AnGap-11
[**2107-8-26**] 05:00AM BLOOD Glucose-58* UreaN-57* Creat-4.1* Na-144
K-4.5 Cl-105 HCO3-30 AnGap-14
[**2107-8-16**] 05:15AM BLOOD ALT-12 AST-13 LD(LDH)-152 AlkPhos-92
TotBili-0.6
[**2107-8-24**] 03:35AM BLOOD LD(LDH)-178 TotBili-0.9
[**2107-8-26**] 05:00AM BLOOD ALT-9 AST-14 AlkPhos-82 TotBili-0.8
[**2107-8-13**] 11:00AM BLOOD cTropnT-0.05*
[**2107-8-13**] 08:50PM BLOOD CK-MB-6 cTropnT-0.03*
[**2107-8-14**] 06:05AM BLOOD CK-MB-6 cTropnT-0.05*
[**2107-8-19**] 06:45PM BLOOD CK-MB-8 cTropnT-0.06*
[**2107-8-15**] 05:10AM BLOOD Calcium-10.0 Phos-3.8# Mg-2.5
[**2107-8-16**] 05:15AM BLOOD Albumin-3.7 Calcium-9.9 Phos-4.5 Mg-2.6
[**2107-8-17**] 05:50AM BLOOD Calcium-9.9 Phos-4.9* Mg-2.6
[**2107-8-23**] 05:24PM BLOOD Calcium-10.5* Phos-3.4 Mg-2.2
[**2107-8-24**] 03:35AM BLOOD Calcium-10.3* Phos-4.6* Mg-2.1
[**2107-8-25**] 03:35AM BLOOD Calcium-10.7* Phos-4.8* Mg-2.4
[**2107-8-26**] 05:00AM BLOOD Calcium-10.7* Phos-3.4 Mg-2.8*
[**2107-8-25**] 12:58PM BLOOD calTIBC-192* Ferritn-572* TRF-148*
[**2107-8-25**] 12:58PM BLOOD PTH-355*
[**2107-8-16**] 11:32PM BLOOD Type-[**Last Name (un) **] pO2-148* pCO2-57* pH-7.30*
calTCO2-29 Base XS-0
[**2107-8-17**] 08:27PM BLOOD Type-[**Last Name (un) **] pO2-232* pCO2-53* pH-7.28*
calTCO2-26 Base XS--2
[**2107-8-23**] 12:20PM BLOOD Type-ART Temp-36.5 Rates-/26 PEEP-5
FiO2-50 pO2-81* pCO2-85* pH-7.22* calTCO2-37* Base XS-3
Intubat-INTUBATED Vent-SPONTANEOU
[**2107-8-23**] 12:56PM BLOOD Type-ART Temp-36.5 Rates-/28 PEEP-12
FiO2-100 pO2-130* pCO2-104* pH-7.14* calTCO2-38* Base XS-2
AADO2-499 REQ O2-82 Vent-SPONTANEOU
[**2107-8-23**] 01:32PM BLOOD Type-ART pO2-266* pCO2-68* pH-7.26*
calTCO2-32* Base XS-1
[**2107-8-23**] 03:12PM BLOOD Type-ART Temp-36.9 Rates-/12 PEEP-12
pO2-70* pCO2-70* pH-7.27* calTCO2-34* Base XS-2 Intubat-NOT
[**Month/Day/Year **]
[**2107-8-23**] 05:38PM BLOOD Type-ART Temp-37.7 Rates-/30 PEEP-12
pO2-70* pCO2-76* pH-7.25* calTCO2-35* Base XS-2 Intubat-NOT
[**Month/Day/Year **]
[**2107-8-23**] 08:34PM BLOOD Type-ART pO2-88 pCO2-68* pH-7.29*
calTCO2-34* Base XS-3
[**2107-8-24**] 03:18PM BLOOD Type-ART Temp-36.9 Rates-/18 Tidal V-50
pO2-78* pCO2-67* pH-7.29* calTCO2-34* Base XS-2 Intubat-NOT
[**Month/Day/Year **]
[**2107-8-24**] 10:08PM BLOOD Type-ART Temp-37.1 FiO2-40 pO2-73*
pCO2-73* pH-7.25* calTCO2-34* Base XS-1 Intubat-NOT [**Month/Day/Year **]
Comment-NEBULIZER
[**2107-8-25**] 03:59AM BLOOD Type-ART Temp-37.4 pO2-99 pCO2-66*
pH-7.27* calTCO2-32* Base XS-0 Intubat-NOT [**Month/Day/Year **]
[**2107-8-24**] 08:02AM BLOOD Type-ART Temp-36.0 PEEP-12 pO2-104
pCO2-67* pH-7.29* calTCO2-34* Base XS-2 Intubat-NOT [**Month/Day/Year **]
[**2107-8-24**] 06:17AM BLOOD Type-ART pO2-69* pCO2-82* pH-7.22*
calTCO2-35* Base XS-2
[**2107-8-24**] 03:50AM BLOOD Type-ART pO2-102 pCO2-75* pH-7.25*
calTCO2-34* Base XS-2
[**2107-8-16**] 11:32PM BLOOD Lactate-0.7
[**2107-8-17**] 08:27PM BLOOD Lactate-1.0
[**2107-8-23**] 05:38PM BLOOD Lactate-0.6
[**2107-8-24**] 08:02AM BLOOD Lactate-0.6
[**2107-8-23**] 01:32PM BLOOD freeCa-1.27
[**2107-8-24**] 08:02AM BLOOD freeCa-1.36*
[**2107-8-16**] 02:46PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2107-8-14**] 05:31PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2107-8-16**] 02:46PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2107-8-14**] 05:31PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2107-8-16**] 02:46PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
[**2107-8-14**] 05:31PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
[**2107-8-16**] 02:46PM URINE CastHy-8*
[**2107-8-14**] 05:31PM URINE CastHy-3*
[**2107-8-18**] 12:56PM URINE Hours-RANDOM UreaN-621 Creat-182 Na-LESS
THAN
[**2107-8-16**] 02:46PM URINE Hours-RANDOM Creat-184 Na-LESS THAN  K-34
Cl-LESS THAN
[**2107-8-16**] 02:46PM URINE Hours-RANDOM
[**2107-8-14**] 05:31PM URINE Hours-RANDOM Creat-177 Na-19 K-28 Cl-14
TotProt-64 Prot/Cr-0.4*
[**2107-8-14**] 05:31PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG

[**2107-8-14**] 5:31 pm URINE      Source: CVS.

                            **FINAL REPORT [**2107-8-16**]**

   URINE CULTURE (Final [**2107-8-16**]):
      ESCHERICHIA COLI.    10,000-100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

						
[**Known lastname **],[**Known firstname 21874**]	[**Medical Record Number 21875**]	M  61  [**2045-12-2**]
Radiology Report	CHEST (PA & LAT)	Study Date of [**2107-8-13**] 10:19
AM

[**Last Name (LF) **],[**First Name3 (LF) **]	EU	 	[**2107-8-13**] 10:19 AM
CHEST (PA & LAT)	 	Clip # [**Clip Number (Radiology) 21876**]
Reason: infiltrate?
[**Hospital 93**] MEDICAL CONDITION:
   61 year old man chest pain
REASON FOR THIS EXAMINATION:
   infiltrate?
Final Report
CLINICAL HISTORY: Chest pain. Renal transplant.

CHEST: Comparison is made with the prior chest x-ray of [**Month (only) 404**]
[**2106**].
Cardiac size is somewhat smaller. No failure is present. The
lung fields are
clear. The costophrenic angles are sharp.

IMPRESSION: Normal chest.

DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Approved: SAT [**2107-8-13**] 3:40 PM
 	Imaging Lab

						
[**Known lastname **],[**Known firstname 21874**]	[**Medical Record Number 21875**]	M  61  [**2045-12-2**]
Radiology Report	RENAL TRANSPLANT U.S.	Study Date of [**2107-8-14**]
3:48 PM

[**Last Name (LF) **],[**First Name3 (LF) **]	MED	CC7A	[**2107-8-14**] 3:48 PM
RENAL TRANSPLANT U.S.	 	Clip # [**Clip Number (Radiology) 21877**]
Reason: Please evaluate transplant kidney and evaluate flow in
renal
[**Hospital 93**] MEDICAL CONDITION:
   61 year old man with HTN, DM, ESRD s/p right cadaveric
transplant [**2101**] s/p
   renal artery re-stenosis [**2105**], now with worsening renal
function.
REASON FOR THIS EXAMINATION:
   Please evaluate transplant kidney and evaluate flow in renal
artery with
   doppler study.
Provisional Findings Impression: SBNa SUN [**2107-8-14**] 4:43 PM
slightly elevated RIs. No perinephric fluid collection or hydro
Final Report
RENAL TRANSPLANT

COMPARISON: [**2105-11-2**].

HISTORY: Worsening renal function. Evaluate with Doppler.

FINDINGS: The right lower quadrant renal transplant kidney
measures 13.7 cm.
There is no evidence of hydronephrosis or perinephric fluid
collections. There
is normal color flow within the transplanted kidney. The
resistive indices in
the upper, mid and lower pole of the transplant kidney measure
0.78-0.81,
0.81-0.87, and 0.77 respectively. These are slightly elevated
when compared
to most recent prior exam, which had resistive indices measuring
0.77, 0.70
and 0.70 in the upper, mid and lower pole respectively.

There is normal color flow and waveforms within the main renal
artery and
vein. The bladder is unremarkable.

IMPRESSION: Slightly increased resistive indices in the upper,
mid, and lower
pole as described above. No perinephric fluid collection or
hydronephrosis
identified.



The study and the report were reviewed by the staff radiologist.

DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: SUN [**2107-8-14**] 10:34 PM
 	Imaging Lab
						
[**Known lastname **],[**Known firstname 21874**]	[**Medical Record Number 21875**]	M  61  [**2045-12-2**]
Cardiology Report	STRESS	Study Date of [**2107-8-15**]

EXERCISE RESULTS

RESTING DATA
EKG:  SR, NSSTTW, ONE VPB, PROLONGED QT	
HEART RATE:  70	BLOOD PRESSURE:  162/68

PROTOCOL MODIFIED [**Doctor First Name 569**] - TREADMILL
STAGE	TIME	SPEED	ELEVATION	HEART	BLOOD	RPP
 	(MIN)	(MPH)	(%)	RATE	PRESSURE	
0	0-3	1.0	8	103	170/68	[**Numeric Identifier 21878**]
1	3-5.5	1.7	10	115	200/70	[**Numeric Identifier **]

TOTAL EXERCISE TIME:  5.5	% MAX HRT RATE ACHIEVED:  72

INTERPRETATION: This 61 yo IDDM man with ESRD s/p transplant '[**01**]
was
referred for evaluation of chest pain. The patient performed 5.5
minutes
of a modified [**Doctor First Name **] protocol(~4.2 METs) and stopped due to
progressive
shortness of breath. This represents a limited exercise
tolerance. The
patient presented with 1/5 dyspnea which he states he has all
the time.
This progressed rapidly to a [**5-10**] by peak exercise. In the
presence of
baseline non-specific ST-T wave changes, there was additional
0.5-1mm of
horizontal/slighlydownsloping ST segment depression
inferolaterally at
peak exercise. These changes became inverted/biphasic T waves in
recovery and returned to baseline by 10 min. Rhythm was sinus
with rare
isolated VPBs. Heart rate response to exercise was blunted(72%
of
predicted maximum) in the presence of beta-blockade therapy.
Baseline
systolic hypertension with an appropriate/slightly exaggerated
exaggerated response to exercise.

IMPRESSION: Limited exercise tolerance due to shortness of
breath.
Possible ischemic EKG changes(although are probably nonspecific)
in the
presence of baseline ST-T abnls. Nuclear report sent separately.
SIGNED: 	[**Last Name (LF) **],[**First Name3 (LF) 177**] W	[**Last Name (LF) **],[**First Name3 (LF) **] A


(04-[**Age over 90 **]M)

						
[**Known lastname **],[**Known firstname 21874**]	[**Medical Record Number 21875**]	M  61  [**2045-12-2**]
Radiology Report	CARDIAC PERFUSION	Study Date of [**2107-8-15**]

[**Last Name (LF) **],[**First Name3 (LF) **]	 	 	[**2107-8-15**]
CARDIAC PERFUSION	 	Clip # [**Clip Number (Radiology) 21879**]
Reason: ANGINAL CHEST PAIN EVAL FOR ISCHEMIC SIGNS
Final Report

RADIOPHARMACEUTICAL DATA:
2.8 mCi Tl-201 Thallous Chloride ([**2107-8-15**]);
18.4 mCi Tc-[**Age over 90 **]m Tetrofosmin Stress ([**2107-8-15**]);
HISTORY: 61year old male with HTN, DM, presenting with angina

SUMMARY OF DATA FROM THE EXERCISE LAB:

Exercise protocol: modified [**Doctor First Name **]
Resting heart rate: 70
Resting blood pressure: 162/68
Exercise Duration: 5.5 min
Peak heart rate: 115
Percent maximum predicted heart rate obtained: 72%
Peak blood pressure: 200/70
Symptoms during exercise: progressive dyspnea, no chest pain
Reason exercise terminated: progressive dyspnea
ECG findings: 0.5-1 mm horizontal/downsloping inferolaterally

METHOD:

Resting perfusion images were obtained with Thallium-201. Tracer
was injected
approximately 30 minutes prior to obtaining the resting images.

At peak exercise, approximately three times the resting dose of
Tc-[**Age over 90 **]m
tetrofosmin was administered IV. Stress images were obtained
approximately 15
minutes following tracer injection.

Imaging Protocol: Gated SPECT

INTERPRETATION:

The image quality is adequate.

Left ventricular cavity size is slightly increased.

Resting and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.

Gated images reveal normal wall motion.

The calculated left ventricular ejection fraction is 60%.

Compared with the study of [**2101-7-27**], the left ventricular size
is slightly
increased.
IMPRESSION: 1. Normal myocardial perfusion at the level of
exercise achieved.
2. Slightly dilated left ventricular cavity size, normal left
ventricular
systolic function, LVEF=60%.


[**Name6 (MD) 21880**] [**Name8 (MD) 21881**], M.D.

[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11925**], M.D.
Approved: TUE [**2107-8-16**] 3:22 PM
 	Imaging Lab
						
[**Known lastname **],[**Known firstname 21874**]	[**Medical Record Number 21875**]	M  61  [**2045-12-2**]
Radiology Report	CT ABDOMEN W/O CONTRAST	Study Date of [**2107-8-16**]
4:34 PM

[**Last Name (LF) 2106**],[**First Name3 (LF) 2105**]	MED	CC7A	[**2107-8-16**] 4:34 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST	 	Clip #
[**Clip Number (Radiology) 21882**]
Reason: Please evalute for posisble cause of ascites.
[**Hospital 93**] MEDICAL CONDITION:
   61 year old man with ESRD s/p right-sided transplant with
re-canalization of
   RAS. Now with worsening renal function and possible ascites.
REASON FOR THIS EXAMINATION:
   Please evalute for posisble cause of ascites.
CONTRAINDICATIONS FOR IV CONTRAST:
   Renal Failure
Provisional Findings Impression: SBNa TUE [**2107-8-16**] 6:13 PM
Mesenteric edema, nonspecific. Causes include third spacing and
vascular
compromise. Clinical correlation is recommended. No significant
amount of
ascites. Small amount of free fluid in the perihepatic and right
paracolic
gutter.
Final Report
CT ABDOMEN AND PELVIS WITHOUT CONTRAST.

COMPARISON: [**2104-2-3**].

HISTORY: 51-year-old male with end-stage renal disease status
post right side
transplant with worsening renal function and possible ascites.

TECHNIQUE: MDCT axially acquired images through the abdomen and
pelvis were
obtained. No IV contrast was administered. Coronal and sagittal
reformats
were performed.

FINDINGS: There are tiny bilateral pleural effusions. There is a
5-mm left
lung base nodule (2, 15) which is stable since [**2104**]. Within the
limitations
of a non-contrast exam, the liver, gallbladder, right adrenal
gland is
unremarkable. The patient is status post left nephrectomy and
left
adrenalectomy. The right kidney is atrophic. The pancreas is
unremarkable.
Just inferior to the pancreas within the root of the mesentery
extending from
the inferior portion of the duodenum is extensive fat stranding
and edema
within the mesentery. This is nonspecific (2, 48). Small bowel
loops are
normal in caliber and without focal wall thickening. There is no
evidence of
free air. Small amount of free fluid is identified within the
perihepatic
space (2, 18) and along the right paracolic gutter (2, 70).
Incidental note
is made of a distal esophageal duplication cyst (2, 21) which
measures
approximately 1.2 x 1.4 cm. Small bowel loops are normal in
caliber and
without focal wall thickening. There is no evidence of
pneumatosis or free
air.

CT OF THE PELVIS: Patient is status post transplanted kidney in
the right
lower quadrant. A stent is identified within the renal artery.
The appendix
is normal. The rectum, sigmoid colon, prostate is unremarkable.
Scattered
calcifications in the prostate gland are noted. A clip within
the bladder is
unchanged (2, 81). There is no pelvic or inguinal
lymphadenopathy.

BONE WINDOWS: There are no suspicious lytic or sclerotic lesions
identified.
Increased diffuse sclerosis of the osseous structures are likely
related to
renal osteodystrophy.

IMPRESSION:
1. Mesenteric edema extending from the root of the mesentry just
inferior to
the pancreas adjacent to the duodenum, nonspecific in etiology.
Differential
diagnosis includes edema secondary to third spacing or vascular
compromise
(SMA/SMV thrombosis?), or possibly bowel pathology although not
abnormalities
are noted in the bowel. It is unlikely that this represents
pancreatitis as
the edema and fat stranding are inferior to the pancreatic bed.

Findings were discussed with Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 21883**] by telephone at
5:30 p.m.




The study and the report were reviewed by the staff radiologist.

DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21884**]
Approved: WED [**2107-8-17**] 2:24 PM
 	Imaging Lab

						
[**Known lastname **],[**Known firstname 21874**]	[**Medical Record Number 21875**]	M  61  [**2045-12-2**]
Radiology Report	RENAL TRANSPLANT U.S. RIGHT	Study Date of
[**2107-8-17**] 3:48 PM

[**Last Name (LF) 2106**],[**First Name3 (LF) 2105**]	MED	CC7A	[**2107-8-17**] 3:48 PM
RENAL TRANSPLANT U.S. RIGHT	 	Clip # [**Clip Number (Radiology) 21885**]
Reason: Duplex US for possible renal artery stenosis--Please
[**Hospital **]
[**Hospital 93**] MEDICAL CONDITION:
   61 year old man with history of ESRD s/p rt. renal transplant
and subsequent
   rt. renal artery stent
REASON FOR THIS EXAMINATION:
   Duplex US for possible renal artery stenosis--Please document
flow velocities
   to assess degree of stenosis.
Final Report
TRANSPLANT RENAL ULTRASOUND

CLINICAL HISTORY: Possible renal artery stenosis. Evaluate flow
velocities
and degree of stenosis.

FINDINGS: Transplant Doppler ultrasound was performed. The
transplant kidney
measures 13.2 cm, and appears similar in size when compared to
the prior
examination, without evidence of hydronephrosis or perinephric
collection.
Vascular assessment, including both color and pulse wave Doppler
demonstrates
resistive indices between 0.79 and 0.82 within the parenchyma,
and 0.86 in the
main renal vein. There is no tardus-parvus morphology of the
waveforms or
delayed upstroke to suggest the presence of renal artery
stenosis of the
transplant kidney. The renal vein draining the transplant kidney
also appears
within normal limits.

DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2107-8-18**] 3:16 AM
 	Imaging Lab

						
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname **], [**Known firstname 21874**]       [**Hospital1 18**] [**Numeric Identifier 21886**]TTE (Complete)
Done [**2107-8-18**] at 11:28:24 AM      FINAL
Referring Physician	 	[**Name9 (PRE) **] Information
[**Name9 (PRE) 2106**], [**First Name3 (LF) 2105**]
[**Hospital1 18**] - Division of Nephrology
[**Location (un) 830**], [**Location 21887**] [**First Name8 (NamePattern2) **]
[**Location (un) 86**], [**Numeric Identifier 718**]	Status:	Inpatient	DOB:	[**2045-12-2**]
Age (years):	61 M	Hgt (in):	67
BP (mm Hg):	131/66	Wgt (lb):	237
HR (bpm):	71	BSA (m2):	2.18 m2
Indication:	Congestive heart failure.
ICD-9 Codes:	424.1, 424.0
Test Information
Date/Time:	[**2107-8-18**] at 11:28	 	Interpret MD:	[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type:	TTE (Complete)	Son[**Name (NI) 930**]:	[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], RDCS
Doppler:	Full Doppler and color Doppler	Test Location:	West Echo
Lab
Contrast:	None	Tech Quality:	Adequate
Tape #:	2009W052-0:20	Machine:	Vivid [**7-11**]
Echocardiographic Measurements
Results	Measurements	Normal Range
Left Atrium - Long Axis Dimension:	*6.0 cm	<= 4.0 cm
Left Atrium - Four Chamber Length:	*7.1 cm	<= 5.2 cm
Right Atrium - Four Chamber Length:	*5.5 cm	<= 5.0 cm
Left Ventricle - Septal Wall Thickness:
*1.6 cm	0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:
*1.5 cm	0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension:
5.6 cm	<= 5.6 cm
Left Ventricle - Systolic Dimension:
3.3 cm	
Left Ventricle - Fractional Shortening:
0.41	>= 0.29
Left Ventricle - Ejection Fraction:
>= 55%	>= 55%
Left Ventricle - Lateral Peak E':
*0.07 m/s	> 0.08 m/s
Left Ventricle - Septal Peak E':
*0.07 m/s	> 0.08 m/s
Left Ventricle - Ratio E/E':
*19	< 15
Aorta - Sinus Level:	3.2 cm	<= 3.6 cm
Aorta - Ascending:	3.2 cm	<= 3.4 cm
Aortic Valve - Peak Velocity:
*2.4 m/sec	<= 2.0 m/sec
Mitral Valve - E Wave:	1.3 m/sec	
Mitral Valve - A Wave:	1.1 m/sec	
Mitral Valve - E/A ratio:	1.18	
Mitral Valve - E Wave deceleration time:	244 ms	140-250 ms
[**First Name (Titles) **] [**Last Name (Titles) 21888**] (+ RA = PASP):
*35 mm Hg	<= 25 mm Hg
Findings
This study was compared to the prior study of [**2107-5-19**].
LEFT ATRIUM: Marked LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.

LEFT VENTRICLE: Moderate symmetric LVH. Top normal/borderline
dilated LV cavity size. Normal regional LV systolic function.
Overall normal LVEF (>55%). TDI E/e' >15, suggesting
PCWP>18mmHg. Transmitral Doppler and TVI c/w Grade II (moderate)
LV diastolic dysfunction. No resting LVOT [**Year (4 digits) **].

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
valvular AS. The increased transaortic velocity is related to
high cardiac output. No AR.

MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. [**Male First Name (un) **] of the mitral chordae (normal variant). No
resting LVOT [**Male First Name (un) **]. Calcified tips of papillary muscles.
Trivial MR. [Due to acoustic shadowing, the severity of MR may
be significantly UNDERestimated.]

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.

PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is markedly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is borderline dilated. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler
and tissue velocity imaging are consistent with Grade II
(moderate) LV diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened. There is no valvular aortic stenosis.
The increased transaortic velocity is likely related to high
cardiac output. No aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. Trivial mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.

IMPRESSION: Symmetric left ventricular hypertrophy with normal
global and regional biventricular systolic function. Moderate
diastolic LV dysfunction with elevated LVEDP. Mild pulmonary
hypertension.

Compared with the prior study (images reviewed) of [**2107-5-19**],
the findings are similar.
	Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2107-8-18**] 12:45

?????? [**2101**] CareGroup IS. All rights reserved.

						

OPERATIVE REPORT

[**Last Name (LF) 21889**],[**First Name3 (LF) **] E.
**NOT REVIEWED BY ATTENDING**

Name:  [**Known lastname **], [**Known firstname 21874**]            Unit No:  [**Numeric Identifier **]

Service:                          Date:  [**2107-8-23**]

Date of Birth:  [**2045-12-2**]        Sex:  M

Surgeon:  [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 21890**]

PREOPERATIVE DIAGNOSIS:  Acute renal failure, status post
renal transplant.

POSTOPERATIVE DIAGNOSIS:  Acute renal failure, status post
renal transplant.

OPERATION:
1. Ultrasound-guided puncture of the right common femoral
    artery.
2. Catheterization of the right external iliac artery and
    the transplanted renal artery.
3. Pelvic angiogram and arteriogram of the transplant renal
    artery.
4. Balloon angioplasty of transplant renal artery stent.

ASSISTANT:  [**Name6 (MD) 547**] [**Last Name (NamePattern4) 21891**], MD.

TOTAL FLUORO TIME:  21.10 minutes.

TOTAL CONTRAST USED:  10 ml of Visipaque.

INDICATIONS FOR PROCEDURE:  This is a 61-year-old male with a
history of end-stage renal disease, who is status post renal
transplant.  He has a history of acute renal failure and
renal artery stenosis of the transplanted renal artery.  She
had previously undergone stenting of the transplant renal
artery, followed by in-stent angioplasty.  He presents again
with acute renal failure and suspected renal artery stenosis.

PROCEDURE IN DETAIL:  After informed consent was obtained,
the patient was brought to the angiography suite and placed
in supine on the angiography table.  After induction of
anesthesia, both groins were shaved, prepped and draped in
the usual sterile fashion.  Using ultrasound the right common
femoral artery was identified.  It was patent.  Real-time
visualization needle puncture into the right common femoral
artery was achieved with the ultrasound.  Hard copies of the
images were stored in the patient's chart for documentation
purposes.  Using a micro sheath the right common femoral
artery was accessed.  This was followed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire in
the abdominal aorta and a #5 French right tip sheath.  A
pelvic angiogram and transplant renal arteriogram were
performed.  This showed a patent transplant renal artery.
Given that the patient has repeated history of transplant
renal artery stenosis, we elected to intervene.

Using a Glidewire and an Omni flush catheter, we selected the
renal artery.  The catheter was then exchanged for a slip
cath and a spider coil wire was then placed across the stent.
Using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 21892**] 6 x 20 mm balloon, we performed an in-stent
angioplasty.  No discrete stenoses was noted.  As there was
no lesion, we elected to terminate the procedure at this
point.  All catheters and wires were withdrawn and the right
common femoral arteriotomy was closed with a Perclose device.

Dr. [**Last Name (STitle) **] was present throughout the entire case.

ANGIOGRAPHIC FINDINGS:
1. The right common iliac artery was widely patent, without
    stenosis.
2. The transplant renal artery was widely patent, without
    stenosis.  The stent was crossed with a combination of
    Omniflush catheter and Glidewire.  A 6 x 20 mm [**Location (un) 21892**]
    balloon was used to angioplasty within the stent,
    however no stenosis was noted.

                        [**Name6 (MD) 547**] [**Last Name (NamePattern4) 21891**], MD

Dictated By:[**Last Name (NamePattern4) 21893**]
MEDQUIST36
D:  [**2107-8-23**] 10:10:24
T:  [**2107-8-23**] 22:30:59
Job#:  [**Job Number 21894**]


Brief Hospital Course:
Patient is a 61 yo male with PMH for GERD/Barretts, HTN, TIIDM,
ESRD, and s/p kidney transplant, who came to the ED complaining
of CP. In the ED he had EKG done and cardiac enzymes started.
His EKG showed no difference to prior EKGs and only Troponin T
was mildly elevated at 0.05. He was admitted to the floor for
observation and to rule out MI.

#Chest pain: Cardiac problems are less likely because his
cardiac enzymes were negative and his second EKG showed no
changes. He underwent stress testing, which was notable for
marked reduction in ability to exercise due to SOB but he had
normal cardiac perfusion and an echo demonstrating LVEF of 60%.
In summary his cardiac workup showed it to be non-contributory
to this process. and second EKG ruled out MI and NSTEMI. His CP
symptoms and history of GERD and Baretts makes relfux the likley
cause of his pain, which brought him to the ED.

#Renal disease:Patient was noted to have elevated creatinine
from baseline elevation (2.5-3.5). Also has history of ESRD in
his cadaveric transplant kidney. His FENA on admission was <1%
which is suggestive of prerenal azotemia. He did not report
being very dry and had this high creatinine in the setting of
high BPs so he was considered also for renal artery stenosis (he
is s/p stenting in transplant kidney renal artery). The team was
also worried about chronic kidney rejection and/or glomerular
nephropathy from diabetes and longstanding HTN. Labs showed
proetinuria of 30, but his baseline is up near 300. Renal
service followed his admission closely and was advising on BP
meds, fluids, and imaging of renal artery. On imaging he had a
renal artery US which showed increased resitance throughout the
transplant but no color flow changes in the renal artery. He
continued to produce adequate urine despite his Lasix being
held. Also, a vascular surgery consult was ordered to assess for
re-stenosis. He was taken to the OR for renal artery angiongram
and possible intervention on 3 different occasions. On the first
two no intervention could be taken as he was unable to lay flat
on the operating table. He was started on lasix and his
orthopnea improved. On [**8-23**] he was taken to the OR for the third
time and was intubated for the procedure. Angiogram revealed
patency of the renal artery, despite this the vessel was
angioplastied. He developed mild respiratory failure after
extubation, had to be put on NIPPV and was transfered to the
MICU. In the MICU he was continued on diuretics and was
successfully weaned off NIPPV. He was transfered to the floor on
[**8-25**] where he was continued on diuretics and his RF improved.

#Orthopnea/Hypercarbic Respiratory Failure/OSA: Patient reported
multiple epsiodes of SOB, once while lying flat. Patient reports
a history of SOB with exertion from childhood (he has asthma
history but no attacks as adult). Of note is he has significant
central obesity that seems to be contributing to this orthopnea.
He also commented on abdominal distension and so CT scan was
ordered to assess for ascites, which would also be a mechanism
for pressure on the diaphragm. It showed mesenteric edema but no
ascitic fluid. His lungs have remained clear on physical exam.
He had an ABG whihc showed chronic respiratory acidosis. He also
had liver panel done to assess for hepatitis reasons for
possible ascites, which showed adequate liver function. His
orthopnea was thought to be due to a combination of dCHF, ARF
and OSA. Once patient was diuresed his orthopnea improved. He
developed mild hypercarbic respiratory failure after extubation
during renal artery angiogram, had to be put on NIPPV and was
transfered to the MICU. In the MICU he was continued on
diuretics and was successfully weaned off non-invasive
ventilation. He was transfered to the floor on [**8-25**] where he was
continued on diuretics and had no more respiratory problems off
O2. The option of nightly use of NIPPV was discussed with the
patient for treatment of OSA but he refused.

#HTN: His HTN was very hard to control while in the hospital,
his medications had to be adjusted on several occasions because
of SBP up to 200s. While in the MICU he was treated with a
labetalol drip that effectively decreased his BP. On transfer he
was transitioned to PO labetalol. His HTN was under better
control on the new regimen.

#TIIDM: His blood sugars fluctuated each day throughout his
stay. He was started on his home dose of NPH but this did not
manage his sugars well and so we switched to 20units AM and 10
units PM and a sliding scale. It is unclear why his home doses
were not effectively managing his sugars. He reported that he
eats differently at home, which could be partially contributing.
He had no more issues with hyper or hypoglycemia after his NPH
adjustment.

#CHF: His last echo showed compensated diastolic heart failure
and the echo during this hospitalization showed LVEF of 60%
demonstrating adequate compensation. In light of these results
and phsyical exam his CHF was thought to not be contributing to
his chest pain. He did have a slight troponin leak on admission
but this was thought to be due to RF.

#Tertiary Hyperparathyroidism: Patient was found to have a
persistently high Ca and a high PTH at 355. This was thought to
be due to tertiary hyperparathyroidism caused by his CRF. He was
started on cinacalcet to treat this condition.


Medications on Admission:
Minoxidil 10mg 1TAB 2xday
Prednisone 5mg 1TAB daily
Clonidine  0.1mg 1TAB 2x daily
Calcitriol 0.25mcg 1capdaily
Furosemide 3TAB 2xday
Mycophenolate 500mg 1TAB 2xday
Lisinopril 10mg 1TAB QHS
Labetalol 200mg 3TAB 2xday
ASA 81 mg
Humalin NPH 20 units AM and 15 in PM


Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
Disp:*360 Tablet(s)* Refills:*2*
4. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Ten (10) units Subcutaneous qPM.
9. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Twenty (20) Units Subcutaneous qAM.


Discharge Disposition:
Home

Discharge Diagnosis:
 Primary:
- Acute renal failure
- ESRD s/p renal transplant
- HTN
- Diabetes, type 2, insulin dependent
- Renal Cell Carcinoma, s/p nephrectomy
- GERD / Barrett's Esophagus
Secondary:
- s/p AV fistulas
- s/p patella avulsion repair

Discharge Condition:
good


Discharge Instructions:
You were seen in th [**Hospital1 18**] Emergency department for chest pain.
You were admitted and had labwork done to make sure you did not
have a heart attack or some other cardiac reason for your chest
pain. During this workup you had a cardiac stress test that
showed normal heart function and ability. You also had labwork
and tests done to make sure that your chest pain was not caused
by your heart. Your chest pain was most likely caused by your
reflux disease. You did not have any further episodes of pain
during this hospitalization. While in the hospital your kidney
transplant was also being followed because of some elevations in
your labwork. The kidney doctors followed your health throughout
this stay to see if it was still functioning appropriately. You
underwent a test to check the blood supply to your kidney which
did not show a reason for your renal failure.  You were
intubated for this procedure and you required a 2 day ICU stay
after extubation.  Your renal failure was improving by the time
you were discharged.

Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5717**], next week, and your
nephrologist, Dr. [**Last Name (STitle) **], as below.

It is very important to your health to use your CPAP machine at
night.  Many of your lung problems are directly or indirectly
related to your obstructive sleep apnea, which is treated with
the CPAP.  Please use your CPAP machine.  Please discuss with
Dr. [**Last Name (STitle) 5717**] about possibly getting another sleep study to titrate
your CPAP.

Medication Changes:
- your labetalol was increased to 800mg three times a day
- your clonidine was increased to 0.2mg three times a day
- your lasix was decreased to 60mg twice daily
- your calcitriol was changed to cinacalcet 30mg daily
- your nighttime insuline (NPH) was decreased to 10U.  Please
discuss your insulin dosing with Dr. [**Last Name (STitle) 5717**].
- your minoxidil was stopped
- your lisinopril was stopped
- your aspirin was stopped.  Please discuss restarting with your
PCP and your nephrologist.
- Your NPH evening dose was decreased to 10U.  Please follow-up
with [**Last Name (un) **] about titrating this dose.

Please check your blood sugar at least daily.  Please call Dr.
[**Last Name (STitle) 5717**] or the [**Last Name (un) **] Center with any blood sugars greater than
300 or less than 75.  If your blood sugar is less than 75 or you
feel symptoms of low blood sugar such as shakiness,
lightheadedness, confusion, or nausea, please eat something and
call Dr. [**Last Name (STitle) 5717**], the [**Last Name (un) **] Center, or come to the emergency
department.  Please follow-up with the [**Last Name (un) **] Diabetes Center as
soon as possible as below.

If you experience chest pain, shortness of breath, fever >100.4,
weight gain, shakiness, lightheadedness, confusion, nausea,
blood sugar higher than 300 or lower than 75, or any other
symptom that may concern you please contact your primary care
physician or seek help at the nearest emergency room.

Followup Instructions:
Please follow up with your PCP and Dr. [**Last Name (STitle) **] at the following
appointment:

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2107-8-30**] 9:10

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2107-10-31**] 1:20

The [**Last Name (un) **] Diabetes Center will call you to make an appointment
with Dr. [**Last Name (STitle) 978**] as soon as possible to help with your insulin
dosing.

You should discuss the possibility of further testing
(endoscopy) for your reflux disease. You should also make an
appointment with [**Last Name (un) **] to have your diabetes medications
assessed.


                             [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
{'Acute kidney failure, unspecified,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis,Chronic diastolic heart failure,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,End stage renal disease,Long-term (current) use of insulin'}


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: chest pain

PRESENT ILLNESS: 61 yo male with a PMH for Acid reflux, TIIDM, HTN, s/p
nephrectomy following RCC diagnosis, ESRD with dialysis 3x/week,
and s/p cadaveric kidney transplant after lone kidney became
dialysis dependent and stopped functioning well, who comes in
complaining of CP. He was last well 3 days PTA when lifting
heavy trash right after lunch at work when he felt acute chest
pain that was burning in nature in his sternum that radiated to
his back. It was severe in nature and was relieved with rest
after 30 minutes. He did feel some SOB with this episode and
does not remember how long it lasted for.

MEDICAL HISTORY: DM2
ESRD s/p cadaveric renal transplant in [**8-8**]
renal transplant artery stenosis s/p dilatation/stent in [**8-8**]
hemolysis with unknown etiology ([**1-11**])
ciguatera intoxication ([**4-9**])
Barrett's esophagus ([**12-7**])
asthma
RCC s/p L nephrectomy ('[**93**])
obstructive sleep apnea
s/p AV graft on LUE and AV fistula RLE
hypercalcemia

MEDICATION ON ADMISSION: Minoxidil 10mg 1TAB 2xday
Prednisone 5mg 1TAB daily
Clonidine  0.1mg 1TAB 2x daily
Calcitriol 0.25mcg 1capdaily
Furosemide 3TAB 2xday
Mycophenolate 500mg 1TAB 2xday
Lisinopril 10mg 1TAB QHS
Labetalol 200mg 3TAB 2xday
ASA 81 mg
Humalin NPH 20 units AM and 15 in PM

ALLERGIES: Vancomycin

PHYSICAL EXAM: Vitals: T:96.1 BP:146/54 P:82 R:18 O2:98RA
General: Alert and oreinted obese African American male in no
acute distress
HEENT: Scar in right eye from childhood injury, sclera
anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, crescendo-decrescendo murmur heard best in the aortic
valve distribution
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, non pitting mild edema
bilaterally in feet, no C/E
Skin: W+M, no rash, petichiae, or echymosis
Neuro:CN II-XII grossly intact
motor: [**5-10**] throughout
Sensation: Intact to light touch throughout
DTR: 2+ biceps bilaterally
Coordination: Intact to rapid alternating movements and
finger-to-nose

FAMILY HISTORY: Mother and 3 uncles died of "kidney disease." Otherwise all 8 of
his siblings are healthy.

SOCIAL HISTORY: Married with 7 children. Originally born in [**Country **] and moved to
the U.S. in [**2078**]. Currently works as a cook at [**Hospital1 18**] and is
planning on retiring over the next couple of years. Last travel
was in [**Month (only) 1096**] to [**Country **]. Former smoker-quit 20 yrs ago.
Denies alcohol or IVDU. 

### Response:
{'Acute kidney failure, unspecified,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis,Chronic diastolic heart failure,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,End stage renal disease,Long-term (current) use of insulin'}
