CHIEF COMPLAINT: 

PRESENT ILLNESS: Patient is a 58-year-old white
male with complicated past medical history including diabetes
mellitus type 1, complicated by retinopathy, nephropathy,
neuropathy, end-stage renal disease status post living
related kidney transplant in [**2130**] now with evidence of
chronic rejection, now on hemodialysis, status post
peritoneal dialysis catheter placement in [**2141-12-9**],
status post recent hospitalizations in [**2142-1-8**] for
choledocholithiasis, and cholecystitis status post ERCP and
cholecystectomy, presented on [**2142-3-1**] with complaints of
abdominal pain, nausea, vomiting, diarrhea, and elevated
systolic blood pressure.

MEDICAL HISTORY: 1. Diabetes mellitus type 1, diagnosed at age 28, complicated
by nephropathy, autonomic insufficiency causing orthostatic
hypotension and gastroparesis, sensomotor neuropathy and
retinopathy resulting in blindness.  Last hemoglobin A1C was
on [**2141-12-5**] 7.3.
2. End-stage renal disease on hemodialysis since [**2140-1-9**] via right tunneled Permacath.
3. Status post living related kidney transplant in [**2130**], with
[**Year (4 digits) **] in [**2140**] showing chronic inflammation consistent with
rejection.
4. Status post peritoneal dialysis catheter placement in
[**2141-12-26**].
5. Status post recent hospitalization on [**1-/2142**] for
choledocholithiasis complicated by cholecystitis status post
ERCP and sphincterotomy, status post cholecystectomy in
[**2142-2-7**] complicated by postoperative fevers, treated with
Vancomycin and Zosyn.  He was transferred to the Surgical ICU
after a period of unresponsiveness.  Workup failed to reveal
etiology of fevers.  He was discharged to rehabilitation
facility with one week of Augmentin therapy.
6. Recurrent presumed aspiration pneumonia with history of
hypoxic respiratory failure requiring intubation in [**2141-12-9**], bronchoalveolar lavage negative for organism.
Transbronchial [**Year (4 digits) **] in [**12/2141**] with patchy interstitial
fibrosis, status post VATS with right lower lobe wedge [**Year (4 digits) **]
with patchy acute and organizing pneumonia.
7. Multiple pulmonary nodules.
8. MGUS with SPEP significant for monoclonal IgG spikes,
status post bone marrow [**Year (4 digits) **] in [**2140-2-9**].  In [**2140-9-8**] with increased plasma cells.
9. Obstructive-sleep apnea.
10. Anemia of chronic disease secondary to renal disease.
11. History of left lower extremity DVT.
12. Coronary artery disease status post non-ST-elevation
myocardial infarction in [**2140-3-11**], status post PTCA
and stent to distal LAD [**7-10**].  Catheterization at that time
also with mild diffuse disease of the right coronary artery
and left circumflex artery.  Persantine MIBI in [**2142-1-11**]
showed fixed severe apical perfusion defects with moderate
size partially reversible defects in the inferior wall and
septum.  Unchanged from prior study of [**2141-2-8**].
13. CHF with echocardiogram in [**2141-8-8**] with an ejection
fraction of 40%.
14. History of right pontine lacunar infarction.
15. Gastroesophageal reflux disease with history of Barrett's
esophagitis.
16. Diverticulosis.
17. History of Clostridium difficile infection.
18. History of methicillin-resistant Staphylococcus aureus
bacteremia complicated by septic pulmonary emboli and
empyema.
19. History of hypoglycemic coma in [**2141-5-9**] and
[**2141-12-9**].
20. Hypertension.
21. History of nasopharyngeal swab positive for MRSA in
[**2141-12-9**].
22. Hypothyroidism.

MEDICATION ON ADMISSION: 

ALLERGIES: Patient reports allergies to Compazine and
dicloxacillin resulting in nausea and vomiting.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient lives with his wife and
daughter.  [**Name (NI) **] is a former military officer.  He reports a 20
pack year tobacco history, but quit approximately 20 years
ago.  He denies any alcohol or IV drug use.  He has a distant
history of [**Doctor Last Name 360**] [**Location (un) 2452**] exposure.
Complications of transplanted kidney,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Ulcer of other part of foot,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anemia in chronic kidney disease
Compl kidney transplant,DMI renl nt st uncntrld,Hyp kid NOS w cr kid V,CHF NOS,Ulcer other part of foot,Abn react-org transplant,Anemia in chr kidney dis
Admission Date:  [**2142-3-1**]     Discharge Date: [**2142-3-7**]

Date of Birth:   [**2083-10-25**]     Sex:  M

Service:  [**Hospital1 139**]

HISTORY OF PRESENT ILLNESS:  Patient is a 58-year-old white
male with complicated past medical history including diabetes
mellitus type 1, complicated by retinopathy, nephropathy,
neuropathy, end-stage renal disease status post living
related kidney transplant in [**2130**] now with evidence of
chronic rejection, now on hemodialysis, status post
peritoneal dialysis catheter placement in [**2141-12-9**],
status post recent hospitalizations in [**2142-1-8**] for
choledocholithiasis, and cholecystitis status post ERCP and
cholecystectomy, presented on [**2142-3-1**] with complaints of
abdominal pain, nausea, vomiting, diarrhea, and elevated
systolic blood pressure.

Patient reported that earlier on the day of admission, he had
undergone a session of hemodialysis.  While at hemodialysis,
his blood pressures elevated to a systolic blood pressure to
the 220s.  Per the patient, his baseline systolic blood
pressure is closer to 150.  After hemodialysis, later that
evening, he had the onset of nonbloody, nonbilious emesis,
and diffuse, generalized abdominal pain.  At that time, he
had also noted a fever of 102.9 associated with shaking
chills.

REVIEW OF SYSTEMS:  Upon admission was negative for chest
pain, shortness of breath, cough, sputum, sick contacts,
rash, medication changes, dysuria, or increased urinary
frequency.  Of note, the patient has a history of chronic
loose stools secondary to autonomic insufficiency caused by
his diabetes.  He also reports intermittent fevers of unclear
etiology dating back to his open cholecystectomy on [**2142-2-7**].

While in the Emergency Department, he was noted to have a
temperature of 102.0, blood pressure of 227/101, heart rate
of 95, respiratory rate of 22, oxygen saturation of 98% on
room air.  While in the Emergency Department, he received
total hydralazine of 10 mg IV x2, Phenergan 25 mg IV x2, and
levofloxacin 500 mg IV x1.  He also received Tylenol 650 mg
en route to the Emergency Department.

CT scan of the abdomen and pelvis was performed on [**2142-3-1**],
which noted two postoperative fluid collections with internal
air bubbles, one in the gallbladder fossa, and the other in
the subcutaneous tissue incision line.  Per the [**Location (un) 1131**],
could not exclude abscess formation.  There is stable
appearance of a transhepatic kidney with one large cyst.  Per
Transplant Surgery, the CT findings were consistent with
postoperative changes.  However, in light of these findings,
the patient was admitted to the Transplant Surgery service,
and was started on linezolid and levofloxacin for antibiotic
coverage.

During the admission, Surgical staff also noted trauma to the
right great toe.  He was seen by Podiatry.  Foot x-rays
demonstrated evidence of heavy calcification, but there was
no evidence of acute fracture in the region of the right
great toe.  There was noted an old healed fracture of the
fourth metatarsal bone.

While on the Surgical service, he continued to spike
temperatures to 101.3 and 101.5 while on linezolid and
levofloxacin.  He also had irregularities in his blood sugar,
for which he is followed by the [**Last Name (un) **] Diabetes consult
service for better blood sugar control.  In light of his
complicated medical history and hospital course, he was
transferred from the Transplant Surgical service to the
Medicine service on [**2142-3-5**].

PAST MEDICAL HISTORY:
1. Diabetes mellitus type 1, diagnosed at age 28, complicated
by nephropathy, autonomic insufficiency causing orthostatic
hypotension and gastroparesis, sensomotor neuropathy and
retinopathy resulting in blindness.  Last hemoglobin A1C was
on [**2141-12-5**] 7.3.
2. End-stage renal disease on hemodialysis since [**2140-1-9**] via right tunneled Permacath.
3. Status post living related kidney transplant in [**2130**], with
[**Year (4 digits) **] in [**2140**] showing chronic inflammation consistent with
rejection.
4. Status post peritoneal dialysis catheter placement in
[**2141-12-26**].
5. Status post recent hospitalization on [**1-/2142**] for
choledocholithiasis complicated by cholecystitis status post
ERCP and sphincterotomy, status post cholecystectomy in
[**2142-2-7**] complicated by postoperative fevers, treated with
Vancomycin and Zosyn.  He was transferred to the Surgical ICU
after a period of unresponsiveness.  Workup failed to reveal
etiology of fevers.  He was discharged to rehabilitation
facility with one week of Augmentin therapy.
6. Recurrent presumed aspiration pneumonia with history of
hypoxic respiratory failure requiring intubation in [**2141-12-9**], bronchoalveolar lavage negative for organism.
Transbronchial [**Year (4 digits) **] in [**12/2141**] with patchy interstitial
fibrosis, status post VATS with right lower lobe wedge [**Year (4 digits) **]
with patchy acute and organizing pneumonia.
7. Multiple pulmonary nodules.
8. MGUS with SPEP significant for monoclonal IgG spikes,
status post bone marrow [**Year (4 digits) **] in [**2140-2-9**].  In [**2140-9-8**] with increased plasma cells.
9. Obstructive-sleep apnea.
10. Anemia of chronic disease secondary to renal disease.
11. History of left lower extremity DVT.
12. Coronary artery disease status post non-ST-elevation
myocardial infarction in [**2140-3-11**], status post PTCA
and stent to distal LAD [**7-10**].  Catheterization at that time
also with mild diffuse disease of the right coronary artery
and left circumflex artery.  Persantine MIBI in [**2142-1-11**]
showed fixed severe apical perfusion defects with moderate
size partially reversible defects in the inferior wall and
septum.  Unchanged from prior study of [**2141-2-8**].
13. CHF with echocardiogram in [**2141-8-8**] with an ejection
fraction of 40%.
14. History of right pontine lacunar infarction.
15. Gastroesophageal reflux disease with history of Barrett's
esophagitis.
16. Diverticulosis.
17. History of Clostridium difficile infection.
18. History of methicillin-resistant Staphylococcus aureus
bacteremia complicated by septic pulmonary emboli and
empyema.
19. History of hypoglycemic coma in [**2141-5-9**] and
[**2141-12-9**].
20. Hypertension.
21. History of nasopharyngeal swab positive for MRSA in
[**2141-12-9**].
22. Hypothyroidism.

MEDICATIONS PRIOR TO ADMISSION:
1. Midodrine 5 mg p.o. t.i.d.
2. Prednisone 5 mg p.o. q.d.
3. Levoxyl 25 mcg p.o. q.d.
4. Nephrocaps.
5. Calcium carbonate 500 mg p.o. b.i.d.
6. Calcitriol 0.25 mcg p.o. q.d.
7. Protonix 40 mg p.o. q.d.
8. Nifedipine SR 60 mg p.o. q.d.
9. Calcium acetate 1334 mg p.o. t.i.d.
10. Isosorbide sustained release 90 mg p.o. q.d.
11. Colace 100 mg p.o. b.i.d.
12. Neurontin 300 mg p.o. b.i.d.
13. Pravastatin 40 mg p.o. q.d.
14. Atenolol 200 mg p.o. q.d.
15. Lantus 30 units subcutaneous q.h.s.
16. Epogen 20,000 units subcutaneous twice a week.
17. Insulin Lispro q.i.d. with meals.
18. Sublingual nitroglycerin 0.3 nanograms sublingual prn
chest pain.

ALLERGIES:  Patient reports allergies to Compazine and
dicloxacillin resulting in nausea and vomiting.

SOCIAL HISTORY:  The patient lives with his wife and
daughter.  [**Name (NI) **] is a former military officer.  He reports a 20
pack year tobacco history, but quit approximately 20 years
ago.  He denies any alcohol or IV drug use.  He has a distant
history of [**Doctor Last Name 360**] [**Location (un) 2452**] exposure.

FAMILY HISTORY:  Noncontributory.

PHYSICAL EXAM UPON ADMISSION:  T max 100.7, blood pressure
160/84, heart rate 82, respiratory rate 18-20, and oxygen
saturation 100% on room air.  Fingerstick blood glucose 189.
General appearance:  Well-developed and well-nourished white
male, comfortable in no acute distress.  HEENT:
Normocephalic, atraumatic.  Right eye with cataract and
ptosis.  Left pupil with post surgical changes.  Sclerae are
anicteric.  Mucous membranes moist.  Oropharynx clear.  Neck:
Supple, no masses, or lymphadenopathy.  No jugular venous
distention.  No carotid bruits.  Lungs:  Fair inspiratory
effort.  Clear to auscultation bilaterally, no rhonchi,
rales, wheezes.  Cardiac:  Regular rate and rhythm, normal
S1, S2 heart sounds auscultated.  Grade [**3-16**] holosystolic
murmur heard best at apex with radiation to axilla.  No rubs
or gallops.  Abdomen:  Soft, nontender, nondistended,
positive normoactive bowel sounds, peritoneal catheter in
place with no erythema, edema, or exudates.  Positive post
surgical/post cholecystectomy wound in the right upper
quadrant with overlying bandage clean, dry, and intact.
Extremities:  No clubbing or cyanosis, trace pretibial edema.
 Multiple healed lesions on shins and toes.  Left ankle
indicative of Charcot joint.  Extremities warm with good
capillary refill.  Two plus dorsalis pedis pulses.  Right
great toe bandage clean, dry, and intact.  Neurologic:  Alert
and oriented times three.  No evidence of asterixis.

PERTINENT LABORATORIES, X-RAYS, AND OTHER STUDIES:  Complete
blood count on transfer showed a WBC of 7.9, hematocrit 25.4,
platelets 215.  Serum chemistry demonstrated a sodium of 136,
potassium 3.7, chloride 98, bicarbonate 25, BUN 48,
creatinine 6.6, glucose 211.  Liver function tests showed ALT
11, AST 19, alkaline phosphatase 108, total bilirubin 0.4.
[**Month/Day (4) **] studies were pending at the time of this dictation.

Microbiological data demonstrated serial blood cultures from
[**2142-3-1**], [**2142-3-2**], [**2142-3-3**], and [**2142-3-5**] demonstrating no
growth to date.  Urine culture from [**2142-3-2**] was negative.  A
wound swab of his right hallux ulcer demonstrated no
polymorphonuclear cells, no microorganisms.  Culture had
evidence of rare coagulase positive Staphylococcus aureus.
Peritoneal dialysis fluid sample from [**2142-2-21**] demonstrated
one sample with 2+ polymorphonuclear, 2+ gram-positive cocci
in pairs, chains, clusters with culture demonstrating
coag-positive Staphylococcus aureus, oxacillin sensitive.
Second culture from [**2142-2-21**] demonstrated 3+
polymorphonuclear cells with sparse Enterococcus species
faecium, sensitive to Synercid, minocycline, and linezolid.
Followup peritoneal dialysis fluid culture on [**2142-3-3**]
demonstrated no polymorphonuclear cells, no microorganisms,
and fluid culture with no growth.

PA and lateral chest x-ray from [**2142-3-1**] demonstrated the
heart size and mediastinal contours were normal.  Central
venous line terminated within the mid right atrium.  The
pulmonary vascularity was normal with no evidence of failure.
There was scarring at the right lung base with old rib
fractures in the right that appeared unchanged compared with
prior radiographs.  There was atelectasis noted at the left
lung base.  There was no evidence of pneumothorax or pleural
effusion.  The osseous structures were unremarkable aside
from the old right healed rib fractures.  There was a
pulmonary parenchymal opacity at both lung bases that was
likely consistent with atelectasis.

CT scan of the abdomen and pelvis from [**2142-3-1**] noted two
postoperative fluid collections with internal air bubbles,
one in the gallbladder fossa, and the other in the
subcutaneous incision line.  [**Location (un) **] could not exclude
abscess formation.  There is stable appearance of a
transplanted kidney with one large cyst.

EKG demonstrated sinus rhythm at 90 beats per minute with
normal intervals.  The axis leftward deviated.  There was
evidence of left atrial enlargement and borderline left
ventricular hypertrophy with T-wave inversions in I, aVL, V5
through V6 with [**Street Address(2) 4793**] depressions in V6.  There was [**Street Address(2) 4793**]
elevations in leads V1 through V3, however, these were not
significantly changed from an [**2141-12-30**] study.

BRIEF SUMMARY OF HOSPITAL COURSE:
1. Fevers:  Patient had multiple sources for infection
including tunneled hemodialysis catheter, peritoneal
catheter, his wound infection status post cholecystectomy,
possibility of intraabdominal abscess status post
cholecystectomy, and the traumatic wound to his right great
toe.  However, it also felt that fever could be noninfectious
secondary to progression of his MGUS or due to another
malignancy or could be due to worsening rejection of his
transplanted kidney.

However, in light of the clinical history of abdominal pain,
nausea, and vomiting and associated fevers, it was felt
initially the most likely source appeared to be the
peritoneal dialysis catheter.  This was also reinforced by
the fact that his peritoneal dialysis catheter was not
functioning well and was not flushing easily.  Although prior
to this admission, the peritoneal dialysis catheter had not
been accessed for peritoneal exchange.  Decision was made to
attempt to use a catheter in order to attempt to obtain
further culture data as well as to assess its overall
function.

Another confusing factor was that the patient's temperature
spikes seemed to occur after his hemodialysis sessions.  This
led to the speculation that perhaps his hemodialysis catheter
was infected, and this could be the culprit of his recurrent
fevers.  However, culture data from both his peritoneal
dialysis catheter and his hemodialysis catheter had failed to
reveal any significant causative organism.

While he was on the Surgical service from [**2142-3-1**] to
[**2142-3-5**], the patient was receiving linezolid and Levaquin.
However, as it was not clear what organisms were being
covered with these antibiotics nor was it clear via our
culture data what his source of infection was, decision was
made to discontinue these antibiotics.  Infectious Disease
consultation was obtained on [**2142-3-6**].  The Infectious
Disease consultants agreed withholding antibiotics until
further culture data can be obtained.

As the patient was followed by the Renal team, there were
discussions in terms of whether discontinuation of his
peritoneal and hemodialysis catheters would be necessary in
order to remove the multiple lines that could be nidus sites
for infection.  At the time of this dictation, that
discussion was still ongoing.

Of note, in addition to the linezolid and Levaquin, the
patient did receive one dose of cefazolin through the
peritoneal dialysis catheter as ordered by the Renal team.
He also had a chest x-ray which ruled out any evidence of
infiltrative process or pneumonia.  At the time of dictation,
multiple culture data sets were will pending.  His culture
data will be followed while he is the patient in the MICU and
antibiotic coverage adjusted appropriately.

2. Diabetes mellitus type 1:  The patient was continued on
diabetic diet with Humalog insulin-sliding scale and glargine
insulin q.h.s.  He was followed closely by the [**Last Name (un) **]
Diabetes Center consultation service, and their
recommendations were taken in consideration and implemented.

3. End-stage renal disease on hemodialysis:  Patient was
continued on his outpatient prednisone dose for
immunosuppression status post his renal transplant.  He was
dialyzed via hemodialysis on a scheduled by the Renal team.
He was continued on Nephrocaps, calcium acetate, and a renal
diet.  His peritoneal dialysis catheter was accessed as per
Renal's recommendations with multiple culture samples sent
for evaluation of the peritoneal dialysis catheter as his
source of infection.

4. Coronary artery disease:  On initial presentation, there
was no clinical history suggest active coronary artery
disease.  Patient was initially continued on nifedipine,
Imdur, atenolol, Pravastatin, and aspirin.  His amlodipine
was discontinued in order to streamline his medication
regimen somewhat.

However, on the evening of [**2142-3-6**], the patient experienced
an episode of hypoxia in which he dropped his oxygen
saturation level to the mid 80s on room air.  He was
therefore transferred to the Medical Intensive Care Unit for
evaluation of his hypoxemia with a differential that was
related to volume overload versus transfusion reaction versus
possible coronary ischemic event.  At the time of this
dictation, the determination of that is still being
evaluated.

5. Neuropathy:  Patient was continued on Neurontin.  The
Podiatry service followed him for his right great toe injury
and felt that there was no evidence of any underlying
infection or fracture.  They made recommendations as to wound
changes which were appreciated.

6. Hypertension:  Patient is continued on atenolol, Imdur,
nifedipine.  These medications were to be titrated up for
better blood pressure control.  As he also has a history of
severe orthostasis, he was continued on midodrine in light of
history of autonomic insufficiency.  As stated above,
amlodipine was discontinued from his medication regimen
during this hospitalization.

7. Hypothyroidism:  Patient was continued on his outpatient
dose of Levoxyl.

8. Anemia:  Patient continues to receive Epogen twice weekly
at hemodialysis.  As there was a slow downward trend of his
hematocrit on [**2142-3-6**], he underwent transfusion of 1 unit of
packed red blood cells.  Chest x-ray prior to this did not
demonstrate any evidence of fluid overload.  However, during
the transfusion, the patient had an episode of hypoxemia as
well as elevated systolic hypertension.  Transfusion was
discontinued at that time.  He was transferred to the Medical
Intensive Care Unit for further evaluation and treatment.
The results of that portion of his hospital course will be
dictated as a separate addendum to this report.

9. Fluids, electrolytes, and nutrition:  Patient was
maintained on a diabetic and renal diet.  Electrolytes were
followed and repleted as needed.

10. Prophylaxis:  Patient was maintained on a bowel regimen,
Tylenol, subQ Heparin for DVT prophylaxis, and Ambien for
sleep.

11. Code status:  Patient is full code.

12. Disposition:  As outlined above, the patient had an
episode of hypoxemia and elevated systolic blood pressure on
[**2142-3-6**].  As they was concern for possible transfusion
related reaction versus fluid overload resulting in
congestive heart failure, the patient was transferred to the
Medical Intensive Care Unit.  The results of that portion of
his hospitalization will be dictated as a separate addendum
to this report.

In addition, a separate addendum will be dictated denoting
the remainder of his hospital course, post discharge
medications, and follow-up plans.



                          [**Name6 (MD) 251**] [**Last Name (NamePattern4) 11865**], M.D.  [**MD Number(1) 11866**]

Dictated By:[**Last Name (NamePattern1) 257**]

MEDQUIST36

D:  [**2142-3-7**]  16:43
T:  [**2142-3-8**]  06:53
JOB#:  [**Job Number 20636**]


Name:  [**Known lastname 3425**], [**Known firstname 499**]           Unit No:  [**Numeric Identifier 3426**]

Admission Date:  [**2142-3-1**]     Discharge Date: [**2142-3-11**]

Date of Birth:   [**2083-10-25**]     Sex:  M

Service:  [**Hospital1 248**]


ADDENDUM TO SUMMARY HOSPITAL COURSE:  On the evening of
[**2142-3-6**], the patient was receiving a blood transfusion.
During the transfusion, he had onset of severe dyspnea and
dropped his oxygen saturations to 80 percent on 2 litres of
nasal cannula.  At that time he also had an elevated blood
pressure, fever to 101.7 and rigors. Blood transfusion was
stopped and transfusion reaction investigation was
undertaken. Chest x-ray at that time was performed with
evidence of mild congestive heart failure and questionable
right lower lobe infiltrate. He was treated with nitropaste,
morphine, and Levaquin. Electrocardiogram was performed and
was unchanged.  He was transferred to the Medical Intensive
Care Unit for higher lever of care.

While in the Medical Intensive Care Unit, his hypoxia and
dyspnea improved with noninvasive ventilation, namely BiPAP
therapy.  He was also started on broad spectrum antibiotics
including Linezolid, meropenem, Kefzol, Phenergan. He will
continue to be pan cultured. From the evening of [**3-6**] to [**3-3**]
he was stable and was able to have his oxygen requirement
decreased and was afebrile, therefore antibiotics were
discontinued. After transfer back to the medical floor, he
had a transthoracic echo which was negative for any
vegetations or valvular abnormalities. His blood pressure
medication was also briefly changed in that he had been
converting to short acting [**Doctor Last Name 932**] in light of his hypotension
while he was in the Intensive Care Unit.  His insulin regimen
was adjusted several times for episodes of hyper and
hypoglycemia.

1.  Fevers:  The patient continued to have multiple sources
of infection including his tunnel dialysis catheter,
peritoneal catheter, possible intraabdominal abscess or wound
infection status post cholecystectomy. This also could be
secondary to rejection of his transplanted kidney. He was
followed by the Infectious Disease Service. He continued to
have cultures taken of his blood both peripherally and
through his hemodialysis catheter as well as peritoneal fluid
cultures. At the time of this dictation, culture data failed
to reveal any significant organismal growth. Therefore he was
maintained off antibiotics. Because of his fever, his white
blood counts were monitored. CMV viral load was also
evaluated and at the time of this dictation was pending. At
the time of this dictation on [**2142-3-11**], the patient had
been afebrile for about 2 days. He subjectively felt that his
fever was broken. We will continue to follow again his
temperature curve as well as culture data. We will hold off
on antibiotics.

2.  Diabetes mellitus. The patient was continued on diabetic
diet with Humalog sliding scale and Glargine at night.  He is
followed by the [**Last Name (un) 616**] Diabetic Consultation Service and
their recommendations were implemented regarding his insulin
regimen.

3.  End stage renal disease, on hemodialysis.  The patient
was continued on prednisone for immunosuppression status post
kidney transplant.  He was continued on hemodialysis as per
renal. He was also continued on peritoneal dialysis with
multiple different formulations and cycline regimens
investigated. His dialysis will continue to be managed by the
Renal Service.  He will continue on Nephrocaps and calcium
carbonate for phosphate binding.

4.  Coronary artery disease/ congestive heart failure. The
continues to have no clinic history to suggest active
coronary artery disease during this hospitalization. He was
continued on pravastatin and aspirin.  After transfer out
from the Intensive Care Unit he was restarted on his
outpatient dosages of atenolol and Imdur as he was more
comfortable on that regimen than on shorter acting agents.
In light of his history of congestive heart failure, his
peritoneal dialysis solution was adjusted in order to help
correct for volume overload.  He is continued on BiPAP at
night.

5.  Neuropathy.  He was restarted on Neurontin and tolerated
this well.

6.  Hypertension.  He was continued on his outpatient
atenolol and Imdur.

7.  Hypothyroidism.  He was continued on his outpatient dose
of Levoxyl.

8.  Anemia.  He is continued on Epogen twice weekly.

9.  Fluids, electrolytes, and nutrition. He tolerated
diabetic diet well. Electrolytes were followed serially and
repleted as needed.

Please note that a separate addendum will be done to this
report dictating the remainder of the [**Hospital 1325**] hospital
course as well a discharge medications and disposition plan.







                          [**Name6 (MD) 116**] [**Last Name (NamePattern4) 1531**], M.D.  [**MD Number(1) 1532**]

Dictated By:[**Last Name (NamePattern1) 3083**]

MEDQUIST36

D:  [**2142-3-11**]  14:28
T:  [**2142-3-12**]  02:58
JOB#:  [**Job Number 3432**]


Name:  [**Known lastname 3425**], [**Known firstname 499**]           Unit No:  [**Numeric Identifier 3426**]

Admission Date:  [**2142-3-1**]     Discharge Date: [**2142-3-11**]

Date of Birth:   [**2083-10-25**]     Sex:  M

Service:  [**Hospital1 248**]


ADDENDUM TO SUMMARY HOSPITAL COURSE:  On the evening of
[**2142-3-6**], the patient was receiving a blood transfusion.
During the transfusion, he had onset of severe dyspnea and
dropped his oxygen saturations to 80 percent on 2 litres of
nasal cannula.  At that time he also had an elevated blood
pressure, fever to 101.7 and rigors. Blood transfusion was
stopped and transfusion reaction investigation was
undertaken.

Chest x-ray at that time was performed with evidence of mild
congestive heart failure and questionable right lower lobe
infiltrate. He was treated with nitropaste, morphine, and
Levaquin. Electrocardiogram was performed and was unchanged.
He was transferred to the Medical Intensive Care Unit for
higher lever of care.

While in the Medical Intensive Care Unit, his hypoxia and
dyspnea improved with noninvasive ventilation, namely BiPAP
therapy.  He was also started on broad spectrum antibiotics
including Linezolid, meropenem, Kefzol, Phenergan. He will
continue to be pan cultured. From the evening of [**3-6**] to [**3-3**]
he was stable and was able to have his oxygen requirement
decreased and was afebrile, therefore antibiotics were
discontinued. After transfer back to the medical floor, he
had a transthoracic echo which was negative for any
vegetations or valvular abnormalities. His blood pressure
medication was also briefly changed in that he had been
converting to short acting [**Doctor Last Name 932**] in light of his hypotension
while he was in the Intensive Care Unit.  His insulin regimen
was adjusted several times for episodes of hyper and
hypoglycemia.

1.  Fevers:  The patient continued to have multiple sources
of infection including his tunnel dialysis catheter,
peritoneal catheter, possible intraabdominal abscess or wound
infection status post cholecystectomy. This also could be
secondary to rejection of his transplanted kidney. He was
followed by the Infectious Disease Service. He continued to
have cultures taken of his blood both peripherally and
through his hemodialysis catheter as well as peritoneal fluid
cultures. At the time of this dictation, culture data failed
to reveal any significant organismal growth. Therefore he was
maintained off antibiotics. Because of his fever, his white
blood counts were monitored. CMV viral load was also
evaluated and at the time of this dictation was pending. At
the time of this dictation on [**2142-3-11**], the patient had
been afebrile for about 2 days. He subjectively felt that his
fever was broken. We will continue to follow again his
temperature curve as well as culture data. We will hold off
on antibiotics.

2.  Diabetes mellitus. The patient was continued on diabetic
diet with Humalog sliding scale and Glargine at night.  He is
followed by the [**Last Name (un) 616**] Diabetic Consultation Service and
their recommendations were implemented regarding his insulin
regimen.

3.  End stage renal disease, on hemodialysis.  The patient
was continued on prednisone for immunosuppression status post
kidney transplant.  He was continued on hemodialysis as per
Renal. He was also continued on peritoneal dialysis with
multiple different formulations and cycline regimens
investigated. His dialysis will continue to be managed by the
Renal Service.  He will continue on Nephrocaps and calcium
carbonate for phosphate binding.

4.  Coronary artery disease/ congestive heart failure. The
continues to have no clinic history to suggest active
coronary artery disease during this hospitalization. He was
continued on pravastatin and aspirin.  After transfer out
from the Intensive Care Unit he was restarted on his
outpatient dosages of atenolol and Imdur as he was more
comfortable on that regimen than on shorter acting agents.
In light of his history of congestive heart failure, his
peritoneal dialysis solution was adjusted in order to help
correct for volume overload.  He is continued on BiPAP at
night.

5.  Neuropathy.  He was restarted on Neurontin and tolerated
this well.

6.  Hypertension.  He was continued on his outpatient
atenolol and Imdur.

7.  Hypothyroidism.  He was continued on his outpatient dose
of Levoxyl.

8.  Anemia.  He is continued on Epogen twice weekly.

9.  Fluids, electrolytes, and nutrition. He tolerated
diabetic diet well. Electrolytes were followed serially and
repleted as needed.

Please note that a separate addendum will be done to this
report dictating the remainder of the [**Hospital 1325**] hospital
course as well a discharge medications and disposition plan.





                          [**Name6 (MD) 116**] [**Last Name (NamePattern4) 1531**], M.D.  [**MD Number(1) 1532**]

Dictated By:[**Last Name (NamePattern1) 3083**]

MEDQUIST36

D:  [**2142-3-11**]  14:28
T:  [**2142-3-12**]  02:58
JOB#:  [**Job Number 3432**]


Name:  [**Known lastname 3425**], [**Known firstname 499**]             Unit No:  [**Numeric Identifier 3426**]

Admission Date: [**2142-3-12**]        Discharge Date: [**2142-3-15**]

Date of Birth:  [**2083-10-25**]        Sex:

Service:

During the last few days of hospitalization, [**Hospital 1325**]
hospital course was relatively uneventful.  Remainder of
hospital course will be dictated by systems.

Fevers:  The patient remained afebrile for the remainder of
hospitalization.  His white blood count was declining.
Microdata remained negative to date.  There still remains no
clear etiology of patient's fevers to date.  Is currently off
antibiotics.  Per previous ID consult thought was to obtain a
gadolinium scan as the patient spiked, however, this was not
necessary as patient did not develop any further fevers.  At
the time of discharge, the patient was afebrile and again
microdata was negative to date.

Diabetes:  The patient was continued on diabetic diet with
Humalog sliding scale and Glargine at night.  He is followed
by [**Last Name (un) 616**] and will be continued to follow with [**Last Name (un) 616**] as an
outpatient.

End-stage renal disease:  The patient is on hemodialysis.
Continued on low-dose prednisone for his renal transplant.
Patient received dialysis per renal schedule.  Daily
electrolytes were followed.  Patient was continued on
Nephrocaps and calcium carbonate for phosphate binding.

Cardiovascular:  The patient was continued on Imdur and
atenolol for blood pressure control.  He was continued on
pravastatin for lipid control.  Patient's blood pressure
remained stable during the remainder of hospitalization.

Anemia:  The patient was continued on Epogen on hemodialysis
twice weekly.

FEN:  The patient was given a diabetic diet, calcium
carbonate for phosphate binding, daily electrolytes were
followed.

Prophylaxis:  Was with Heparin and proton-pump inhibitor.

Code:  The patient remained full code during this
hospitalization.

DISCHARGE CONDITION:  Stable.

DISCHARGED TO:  Home with services.

DISCHARGE DIAGNOSES:  Fever of unknown origin.

Type 1 diabetes with neuropathy, nephropathy, and
retinopathy.

End-stage renal disease on dialysis.

Status post renal transplant.

Peritoneal dialysis catheter placement.

Cholecystectomy.

History of pneumonia.

History of multiple pulmonary nodules.

Obstructive-sleep apnea.

Anemia.

Coronary artery disease status post non-ST elevation
myocardial infarction status post left anterior descending
artery stent.

Congestive heart failure with ejection fraction of 40
percent.

Gastroesophageal reflux disease.

Diverticulosis.

History of methicillin-resistant Staphylococcus aureus
bacteremia.

Hypertension.

Hypothyroidism.

MEDICATIONS ON DISCHARGE:
1. Midodrine 5 mg p.o. t.i.d.
2. Prednisone 5 mg p.o. q.d.
3. Synthroid 25 mcg p.o. q.d.
4. B complex.
5. Vitamin C.
6. Folic acid 1 mg capsule one tablet p.o. q.d.
7. Calcium carbonate 500 mg p.o. b.i.d.
8. Calcitriol 2.5 mcg p.o. q.d.
9. Protonix 40 mg p.o. q.d.
10.      Nifedipine 60 mg p.o. q.d.
11.      Calcium acetate 667 mg two capsules p.o. t.i.d.
12.      Isosorbide mononitrate 90 mg p.o. q.d.
13.      Colace 100 mg p.o. b.i.d.
14.      Gabapentin 300 mg p.o. q.d.
15.      Pravastatin 40 mg p.o. q.d.
16.      Atenolol 200 mg p.o. q.d.
17.      Epogen 20,000 units biweekly.
18.      Aspirin 325 mg p.o. q.d.


FOLLOW UP:  Dr. [**First Name (STitle) **] of Nephrology within 7-10 days.

Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1614**] on [**2142-3-20**].

Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 980**] on [**2142-7-24**].



                       [**Name6 (MD) 116**] [**Last Name (NamePattern4) 1531**], M.D.  [**MD Number(1) 1532**]

Dictated By:[**Name8 (MD) 3433**]
MEDQUIST36
D:  [**2142-7-16**] 09:36:20
T:  [**2142-7-16**] 10:10:18
Job#:  [**Job Number 3434**]
{'Complications of transplanted kidney,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Ulcer of other part of foot,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,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: 

PRESENT ILLNESS: Patient is a 58-year-old white
male with complicated past medical history including diabetes
mellitus type 1, complicated by retinopathy, nephropathy,
neuropathy, end-stage renal disease status post living
related kidney transplant in [**2130**] now with evidence of
chronic rejection, now on hemodialysis, status post
peritoneal dialysis catheter placement in [**2141-12-9**],
status post recent hospitalizations in [**2142-1-8**] for
choledocholithiasis, and cholecystitis status post ERCP and
cholecystectomy, presented on [**2142-3-1**] with complaints of
abdominal pain, nausea, vomiting, diarrhea, and elevated
systolic blood pressure.

MEDICAL HISTORY: 1. Diabetes mellitus type 1, diagnosed at age 28, complicated
by nephropathy, autonomic insufficiency causing orthostatic
hypotension and gastroparesis, sensomotor neuropathy and
retinopathy resulting in blindness.  Last hemoglobin A1C was
on [**2141-12-5**] 7.3.
2. End-stage renal disease on hemodialysis since [**2140-1-9**] via right tunneled Permacath.
3. Status post living related kidney transplant in [**2130**], with
[**Year (4 digits) **] in [**2140**] showing chronic inflammation consistent with
rejection.
4. Status post peritoneal dialysis catheter placement in
[**2141-12-26**].
5. Status post recent hospitalization on [**1-/2142**] for
choledocholithiasis complicated by cholecystitis status post
ERCP and sphincterotomy, status post cholecystectomy in
[**2142-2-7**] complicated by postoperative fevers, treated with
Vancomycin and Zosyn.  He was transferred to the Surgical ICU
after a period of unresponsiveness.  Workup failed to reveal
etiology of fevers.  He was discharged to rehabilitation
facility with one week of Augmentin therapy.
6. Recurrent presumed aspiration pneumonia with history of
hypoxic respiratory failure requiring intubation in [**2141-12-9**], bronchoalveolar lavage negative for organism.
Transbronchial [**Year (4 digits) **] in [**12/2141**] with patchy interstitial
fibrosis, status post VATS with right lower lobe wedge [**Year (4 digits) **]
with patchy acute and organizing pneumonia.
7. Multiple pulmonary nodules.
8. MGUS with SPEP significant for monoclonal IgG spikes,
status post bone marrow [**Year (4 digits) **] in [**2140-2-9**].  In [**2140-9-8**] with increased plasma cells.
9. Obstructive-sleep apnea.
10. Anemia of chronic disease secondary to renal disease.
11. History of left lower extremity DVT.
12. Coronary artery disease status post non-ST-elevation
myocardial infarction in [**2140-3-11**], status post PTCA
and stent to distal LAD [**7-10**].  Catheterization at that time
also with mild diffuse disease of the right coronary artery
and left circumflex artery.  Persantine MIBI in [**2142-1-11**]
showed fixed severe apical perfusion defects with moderate
size partially reversible defects in the inferior wall and
septum.  Unchanged from prior study of [**2141-2-8**].
13. CHF with echocardiogram in [**2141-8-8**] with an ejection
fraction of 40%.
14. History of right pontine lacunar infarction.
15. Gastroesophageal reflux disease with history of Barrett's
esophagitis.
16. Diverticulosis.
17. History of Clostridium difficile infection.
18. History of methicillin-resistant Staphylococcus aureus
bacteremia complicated by septic pulmonary emboli and
empyema.
19. History of hypoglycemic coma in [**2141-5-9**] and
[**2141-12-9**].
20. Hypertension.
21. History of nasopharyngeal swab positive for MRSA in
[**2141-12-9**].
22. Hypothyroidism.

MEDICATION ON ADMISSION: 

ALLERGIES: Patient reports allergies to Compazine and
dicloxacillin resulting in nausea and vomiting.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient lives with his wife and
daughter.  [**Name (NI) **] is a former military officer.  He reports a 20
pack year tobacco history, but quit approximately 20 years
ago.  He denies any alcohol or IV drug use.  He has a distant
history of [**Doctor Last Name 360**] [**Location (un) 2452**] exposure. 

### Response:
{'Complications of transplanted kidney,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Ulcer of other part of foot,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anemia in chronic kidney disease'}
