CHIEF COMPLAINT: Volume overload.

PRESENT ILLNESS: The patient is a 54-year-old man
status post living-unrelated transplant [**2153-9-5**].
Transplant was difficult due to severe atherosclerotic
disease of aorta to iliac vessels. Postoperatively,
ultrasound demonstrated reasonable arterial flow, but the
renal vein was unable to be visualized. The patient was
brought back to the OR on [**2153-9-6**] for exploration of
kidney, which demonstrated no evidence of renal vein
thrombosis.

MEDICAL HISTORY: End-stage renal disease status post
living-unrelated transplant [**2153-9-5**] complicated by
poor arterial flow, status post exploration of kidney [**2153-9-6**], history of type 1 diabetes with complications,
complicated by retinopathy requiring bilateral laser surgery,
as well as right vitrectomy, history of neuropathy in both
hands and legs, history of CVA with some left-sided weakness,
history of CAD, history of MI on several occasions in the
past and 6 stents placed since [**2152-7-4**], history of PVD with
bilateral lower extremity bypass and toe amputation
bilaterally, status post myocardial infarctions, also has a
history of ejection fraction of 20%, GERD.

MEDICATION ON ADMISSION: 

ALLERGIES: Ativan and nonsteroidal anti-inflammatory drugs.

PHYSICAL EXAM: Temperature 96.8, heart rate 80, 114/68, 96
room air. No acute distress, awake, alert, oriented x3.
Cranial nerves grossly intact. CV regular rate and rhythm.
Lungs: Decreased breath sounds at bilateral base, right
greater than left. Abdomen: Well-healed incision, soft,
nontender, nondistended. Extremities: [**4-6**]+ pitting edema.

FAMILY HISTORY: 

SOCIAL HISTORY: 
Complications of transplanted kidney,Acute systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Bacteremia,Pressure ulcer, buttock,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Mitral valve disorders,Polyneuropathy in diabetes,Long-term (current) use of insulin,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Percutaneous transluminal coronary angioplasty status,Other toe(s) amputation status,Coronary atherosclerosis of native coronary artery,Diarrhea,Secondary hyperparathyroidism (of renal origin)
Compl kidney transplant,Ac systolic hrt failure,Ac kidny fail, tubr necr,Hyp kid NOS w cr kid V,Bacteremia,Pressure ulcer, buttock,DMI neuro nt st uncntrld,Mitral valve disorder,Neuropathy in diabetes,Long-term use of insulin,Pseudomonas infect NOS,Status-post ptca,Status amput othr toe(s),Crnry athrscl natve vssl,Diarrhea,Sec hyperparathyrd-renal
Admission Date: [**2153-10-7**]        Discharge Date: [**2153-10-23**]

Date of Birth:  [**2099-6-21**]        Sex:  M

Service:  [**Last Name (un) **]


CHIEF COMPLAINT:  Volume overload.

HISTORY OF PRESENT ILLNESS:  The patient is a 54-year-old man
status post living-unrelated transplant [**2153-9-5**].
Transplant was difficult due to severe atherosclerotic
disease of aorta to iliac vessels. Postoperatively,
ultrasound demonstrated reasonable arterial flow, but the
renal vein was unable to be visualized. The patient was
brought back to the OR on [**2153-9-6**] for exploration of
kidney, which demonstrated no evidence of renal vein
thrombosis.

On [**2153-10-7**], the patient presented with increased
weight gain, lower extremity edema, nausea, vomiting. Patient
after postop course was remarkable for DGF (ATN) and the
patient reports making approximately 1100 cc of urine per
day. Creatinine and BUN have been relatively elevated, BUN in
the 90s, creatinine 4.0 postoperatively. Patient also reports
dysuria. Patient complains of shortness of breath, dizziness,
lightheadedness. The patient has approximately 3 loose bowel
movements per day. Decreased appetite but stable. Three pound
weight gain over the last few days. Lasix was increased
recently to 80 once daily without improvement. No
hemodialysis postoperatively.

PAST MEDICAL HISTORY:  End-stage renal disease status post
living-unrelated transplant [**2153-9-5**] complicated by
poor arterial flow, status post exploration of kidney [**2153-9-6**], history of type 1 diabetes with complications,
complicated by retinopathy requiring bilateral laser surgery,
as well as right vitrectomy, history of neuropathy in both
hands and legs, history of CVA with some left-sided weakness,
history of CAD, history of MI on several occasions in the
past and 6 stents placed since [**2152-7-4**], history of PVD with
bilateral lower extremity bypass and toe amputation
bilaterally, status post myocardial infarctions, also has a
history of ejection fraction of 20%, GERD.

PAST SURGICAL HISTORY:  Cholecystectomy, status post living-
unrelated renal transplant [**2153-9-5**], with exploration
of kidney on [**2153-9-6**], status post bilateral lower
extremity bypass, status post toe amputation bilaterally,
status post placement of 6 cardiac stents in [**2152**].

MEDICATION ON ADMISSION:  Tacrolimus 2 and 2, MMF 500 q.i.d.,
Valcyte 450 every other day, Bactrim SS 1 tab once daily,
nystatin S and S 5 cc p.o. q.i.d., Protonix 40 mg once daily,
Colace 100 mg b.i.d., Toprol XL 25 mg once daily, Lasix 40 mg
once daily, PhosLo tabs, Plavix 75 once daily, rapamycin 2 mg
once daily.

ALLERGIES:  Ativan and nonsteroidal anti-inflammatory drugs.

PHYSICAL EXAM:  Temperature 96.8, heart rate 80, 114/68, 96
room air. No acute distress, awake, alert, oriented x3.
Cranial nerves grossly intact. CV regular rate and rhythm.
Lungs: Decreased breath sounds at bilateral base, right
greater than left. Abdomen: Well-healed incision, soft,
nontender, nondistended. Extremities: [**4-6**]+ pitting edema.

LABS ON ADMISSION:  The patient had a WBC of 1.9, hematocrit
of 33.2, PT of 13.9, PTT 27.8, platelets 240, sodium 129, K
4.2, chloride 91, bicarbonate 24, BUN and creatinine 81 and
4.1, glucose 230.

HOSPITAL COURSE:  So, the patient was admitted. Renal was
consulted. Patient was given IV Lasix. Plan was discussed
with Dr. [**Last Name (STitle) **]. Chest x-ray obtained on [**2153-10-7**]
demonstrating failure with bilateral effusions consistent
with fluid overload. On [**2153-10-8**], an ultrasound was
obtained of the kidney, duplex ultrasound, demonstrating
normal appearance of the renal transplant with normal
resistive indices ranging from 0.60 to 0.69, and also comment
about bilateral pleural effusions.

Patient went to ultrafiltration on [**2153-10-7**]. Patient
does have a left AV fistula which ultrafiltration was
performed through that. A 2-D echo was performed on [**2153-10-9**] demonstrating ejection fraction less than 20%,
compared with prior study that was reviewed on [**2152-6-27**].
Right ventricle is now dilated with freewall hypokinesis, and
the estimated pulmonary artery systolic pressure has
increased. Severity of mitral regurg and pulmonary artery
hypotension are also increased.

The patient continued with tacrolimus, rapamycin, MMF,
Valcyte. Cardiology was consulted. Cardiology met with
patient and felt that patient should be on aspirin, Plavix.
Suggested adjustment changes to medications. Agreed with 80
mg of IV Lasix for goal weight to be -1 to 2 liters. Wound
care nurse met with patient on [**2153-10-9**] because of
sacral pressure ulcers, in which the patient had a right
gluteal, left gluteal pressure ulcer, and made
recommendations in regards to dressing changes. A right foot
x-ray was obtained because of a right heel ulcer,
demonstrating that there was no radiologic evidence of
osteomyelitis.

On [**2153-10-11**], a right-sided ultrasound-guided
thoracentesis performed by Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **], in which
they removed 1300 cc of clear serosanguineous fluid. There
were no complications. During hospitalization, patient had
CMV viral load sent off which demonstrated that CMV-DNA was
not detected. On [**2153-10-11**], the patient had a cardiac
cath performed demonstrating baseline moderate-severe
elevation in right heart pressures with low cardiac index.
With dopamine infusion, no change in PCX and PA pressures, or
systolic blood pressure, with progressive increase in cardiac
index. A right HT left in place for continued hemodynamic
monitoring in the CCU with drug therapy.

So, the patient was on the cardiac service for monitoring,
and transplant saw the patient daily and also managed his
immune suppressant medications. Wound care frequently saw
patient for his decubitus pressure ulcers on his gluteus and
right heel. Infectious disease was consulted because of
fevers, and blood cultures were sent on [**2153-10-14**],
in which a blood culture, sputum culture and urine culture
were sent off, as well as a catheter-tip from PA line. All
were unremarkable except for blood culture on [**2153-10-14**] demonstrating Pseudomonas aeruginosa. The patient was
placed on Flagyl, Zosyn, vancomycin on [**2153-10-15**],
after he had a temperature and ID made recommendations. The
patient started having diarrhea, so C. diff was sent off
demonstrating no C. diff, no ova and parasites on [**2153-10-16**]. Repeat CMV viral load was obtained demonstrating
not detected.

Podiatry came to see patient on [**2153-10-16**] for his
right heel ulcer. Physical therapy/ occupational therapy saw
patient and were consulted. On [**2153-10-16**], patient
had ultrafiltration through his left upper extremity fistula.
He tolerated the procedure well. The patient was changed from
multiple antibiotics to meropenem, continued on Lasix.
Patient had repeat blood cultures on [**2153-10-17**] which
demonstrated no growth. On [**2153-10-19**], urine culture
obtained demonstrated no growth as well. Patient continued on
ultrafiltration on [**2153-10-17**]. Also, patient had
ultrafiltration on [**2153-10-19**], in which 1.5 L of
fluid removed. Patient's Lasix drip was discontinued on
[**2153-10-19**]. Patient was started on Epogen for anemia.

Patient was transferred from cardiac service to transplant
service on [**2153-10-21**], since patient was stable from
a cardiac standpoint, but cardiology was still continuing to
see patient. On [**2153-10-23**], the patient had a PICC
line placed for IV antibiotics, and also had his
ultrafiltration as well. Serial chest x-rays demonstrated
improved CHF. On [**2153-10-23**], placement of PICC line
demonstrates that there was more slightly prominent right
pleural effusion, satisfactory position to right-sided PICC
line, and this film was compared to a previous film. Question
whether or not it was due to position, but because patient
had very good saturations of 96-97% on room air, that
clinically patient had no new findings of shortness of
breath, chest pain which he did not require any oxygen, Dr.
[**Last Name (STitle) **] felt safely with confidence that the patient could go
home. Patient was transitioned from FK to rapamycin while
patient was an inpatient, and since the patient has been
here, he has been on a single dose of rapamycin 6 mg once
daily. Levels range from 7.3 to [**10-23**] which was 10.9.

So, even though patient was deconditioned and physical
therapy thought he should go to rehab, his wife who is an ICU
nurse felt strongly that she could take care of him with
services at home. So, the patient was discharged to home with
services on the following medications: tamsulosin 0.4 mg at
bedtime, calcium acetate 667--2 tabs t.i.d. with meals,
Bactrim SS 1 tab once daily, Protonix 40 mg q. 24, aspirin
325 mg once daily, Tylenol 325--1-2 tablets q. [**5-9**] h. p.r.n.,
Plavix 75 mg once daily, MMF 250 b.i.d., Ambien 1 mg at
bedtime, Valcyte 450 every other day, Epogen 4000 units q.
Monday, Wednesday and Friday, B-Complex, Vitamin C, folic
acid, isosorbide 1 tablet t.i.d., nystatin 10 mL p.o. q.i.d.,
tacrolimus 6 mg once daily, metolazone 10 mg once daily,
bumetanide 3 mg b.i.d., Aldactone 25 mg once daily, also
meropenem 500 mg q. 12 for 2 days, and ciprofloxacin 500 mg
once daily x4 days. Patient will also be on an insulin fixed
dose of 5 units of NPH for breakfast and 4 units for dinner,
and also sliding scale.

Patient has a [**Hospital 39569**] hospital bed at home. Patient has
PICC line care, IV pole pump, saline flushes, heparin
flushes. Physical activity can be weightbearing. The patient
is follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] next week.
Call [**Telephone/Fax (1) 673**] for an appointment. Patient should follow-
up with Dr. [**First Name (STitle) 1075**] which is his cardiologist in [**Location (un) 47**].
Patient should have wound care to his gluteal area and to his
right heel with DuoDerm gel and Aloe [**Doctor First Name **] ointment to his
heel with protective gauze. The patient should follow-up with
his podiatrist in [**Location (un) 47**] as soon as possible for an
appointment. Also, patient's wife should call Dr. [**Last Name (STitle) **]
this Friday for record of his weight since being home and
report that Dr. [**Last Name (STitle) **] by calling [**Telephone/Fax (1) 673**].

FINAL DIAGNOSES:  A 54-year-old status post living-unrelated
transplant with congestive heart failure/fluid overload.

MAJOR SURGICAL PROCEDURES:
1.  Cardiac catheterization to evaluate pulmonary pressures.
2.  Peripherally inserted central catheter line placement for
    bacteremia, specific organism Pseudomonas aeruginosa.



                        [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**]

Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D:  [**2153-10-24**] 11:36:49
T:  [**2153-10-24**] 12:58:48
Job#:  [**Job Number 39570**]
{'Complications of transplanted kidney,Acute systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Bacteremia,Pressure ulcer, buttock,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Mitral valve disorders,Polyneuropathy in diabetes,Long-term (current) use of insulin,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Percutaneous transluminal coronary angioplasty status,Other toe(s) amputation status,Coronary atherosclerosis of native coronary artery,Diarrhea,Secondary hyperparathyroidism (of renal origin)'}


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: Volume overload.

PRESENT ILLNESS: The patient is a 54-year-old man
status post living-unrelated transplant [**2153-9-5**].
Transplant was difficult due to severe atherosclerotic
disease of aorta to iliac vessels. Postoperatively,
ultrasound demonstrated reasonable arterial flow, but the
renal vein was unable to be visualized. The patient was
brought back to the OR on [**2153-9-6**] for exploration of
kidney, which demonstrated no evidence of renal vein
thrombosis.

MEDICAL HISTORY: End-stage renal disease status post
living-unrelated transplant [**2153-9-5**] complicated by
poor arterial flow, status post exploration of kidney [**2153-9-6**], history of type 1 diabetes with complications,
complicated by retinopathy requiring bilateral laser surgery,
as well as right vitrectomy, history of neuropathy in both
hands and legs, history of CVA with some left-sided weakness,
history of CAD, history of MI on several occasions in the
past and 6 stents placed since [**2152-7-4**], history of PVD with
bilateral lower extremity bypass and toe amputation
bilaterally, status post myocardial infarctions, also has a
history of ejection fraction of 20%, GERD.

MEDICATION ON ADMISSION: 

ALLERGIES: Ativan and nonsteroidal anti-inflammatory drugs.

PHYSICAL EXAM: Temperature 96.8, heart rate 80, 114/68, 96
room air. No acute distress, awake, alert, oriented x3.
Cranial nerves grossly intact. CV regular rate and rhythm.
Lungs: Decreased breath sounds at bilateral base, right
greater than left. Abdomen: Well-healed incision, soft,
nontender, nondistended. Extremities: [**4-6**]+ pitting edema.

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Complications of transplanted kidney,Acute systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Bacteremia,Pressure ulcer, buttock,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Mitral valve disorders,Polyneuropathy in diabetes,Long-term (current) use of insulin,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Percutaneous transluminal coronary angioplasty status,Other toe(s) amputation status,Coronary atherosclerosis of native coronary artery,Diarrhea,Secondary hyperparathyroidism (of renal origin)'}
