CHIEF COMPLAINT: Fatigue, shortness of breath, edema

PRESENT ILLNESS: This patient is a 65 year old male with history of type 1
diabetes melltius for 35 years (A1c 6.7), kidney transplant in
[**2165**], who was transferred from [**Hospital3 24012**] ED where he
presented with fatigue x5 days, worsening edema and mild dyspnea
on exertion. He was was in the ER to have acute on chronic renal
failure with a creatinine of 5.6, hyponatremia to 113 and
question of PNA on chest Xray.

MEDICAL HISTORY: - Diabetes type 1 x34 years  Last Hb A1c 6.7 [**8-4**]
- s/p living related kidney transplant [**1-/2166**]
- gastroparesis
- neuropathy
- retinopathy with microaneurysms, s/p surgery [**2155**]
- GERD
- Hypercholesterolemia
- Gastroparesis
- Osteopenia

MEDICATION ON ADMISSION: Fosamax 70mg qweek
 Azathioprine 50mg once a day
 Calcium 600mg daily
 Cyclosporine 50mg twice a day
 Fludrocortisone Acetate 0.1mg once a day
 Glyburide 5mg once a day
 Lipitor 10mg
 Lantus 5-6 units before breakfast. Novolog [**11-27**] units before
each meal
 Midodrine 5mg three times a day
 Protonix 40mg daily
 Prednisone 1mg 3 3 tablets once a day
 lasix 20mg twice daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:

FAMILY HISTORY: His mother's sister has type two diabetes, and a paternal aunt
also has type two diabetes mellitus. There is no family history
of heart disease.

SOCIAL HISTORY: Patient denies smoking, drinking, or ilicit drug use. He is a
retired teacher. lives in [**Location 24013**] with his wife. [**Name (NI) **] has 2
grown children, one in [**State **] one in [**Location (un) **].
Complications of transplanted kidney,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Hydronephrosis,Pneumonia, organism unspecified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Esophageal reflux,Gastroparesis,Pure hypercholesterolemia,Disorder of bone and cartilage, unspecified,Anemia in chronic kidney disease
Compl kidney transplant,Acute kidney failure NOS,Hyposmolality,Hydronephrosis,Pneumonia, organism NOS,Abn react-org transplant,DMI neuro nt st uncntrld,Neuropathy in diabetes,Nephritis NOS in oth dis,Diabetic retinopathy NOS,Esophageal reflux,Gastroparesis,Pure hypercholesterolem,Bone & cartilage dis NOS,Anemia in chr kidney dis
Admission Date:  [**2177-8-21**]              Discharge Date:   [**2177-8-22**]

Date of Birth:  [**2112-7-30**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Fatigue, shortness of breath, edema

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
This patient is a 65 year old male with history of type 1
diabetes melltius for 35 years (A1c 6.7), kidney transplant in
[**2165**], who was transferred from [**Hospital3 24012**] ED where he
presented with fatigue x5 days, worsening edema and mild dyspnea
on exertion. He was was in the ER to have acute on chronic renal
failure with a creatinine of 5.6, hyponatremia to 113 and
question of PNA on chest Xray.

Patient reports feeling extremely week for the past 5 days. He
complaints of extreme fatigue preventing him from getting up on
his own. he denies fevers, chills. he complains of some
difficulty breathing and orthopnea for the past week. He has
been nauseated with dry heave for the past 5 days. He has also
noticed increased scrotal edema x1 month and periorbital edema
occassionally for the past month. He has had worsening LE edema
since [**Month (only) **] and was started on lasix in the beginning of
[**Month (only) 462**]. He reports no change in his urination, denies
frequency or burning. No changed in the color. His stool has
changed, as he goes about 3 times a day now, and previously he
was constipated. He also reports decreased PO intake

His issues started around last [**Month (only) 547**] when he had an epsidode of
vomitting in the setting of 4 days of constipation. This
resolved, but he remained weak since then. He went to [**State **]
for a week at the end of [**Month (only) 116**] and that is when he first noticed
swelling in his feet. He recalls that the swelling has been
getting worse slowly since then. He finally called his
nephrologist Dr. [**First Name (STitle) **] in the middle of [**Month (only) **] who scheduled an
ECHO and requested him to have his labs drawn. He also adjusted
the dosages of his Tacro.

The patient went to [**Hospital3 24012**] [**7-22**] or low blood sugar and
again [**2177-7-28**] because he was feeling very weak. At that time he
was found to have low sodium and chloride and low blood count
and was given 2 units of blood and 2 bags of NS (according to
wife). He felt much better after this admission, was able to
take long walks with his wife, and his appetite returned. This
last until 5 days ago when he started with the above symptoms.

In the ED his blood pressure ranged from 151-208/77-106, T 97,
HR 65-79, RR 16 sat 100% RA. He was fiven LEvaquin 750mg IV,
Lasix 80mg IV, labetolol 10mg IV, Compazine 10mg IV. He put out
1300 cc lasix after a foley was placed.


Past Medical History:
- Diabetes type 1 x34 years  Last Hb A1c 6.7 [**8-4**]
- s/p living related kidney transplant [**1-/2166**]
- gastroparesis
- neuropathy
- retinopathy with microaneurysms, s/p surgery [**2155**]
- GERD
- Hypercholesterolemia
- Gastroparesis
- Osteopenia


Social History:
Patient denies smoking, drinking, or ilicit drug use. He is a
retired teacher. lives in [**Location 24013**] with his wife. [**Name (NI) **] has 2
grown children, one in [**State **] one in [**Location (un) **].


Family History:
His mother's sister has type two diabetes, and a paternal aunt
also has type two diabetes mellitus. There is no family history
of heart disease.


Physical Exam:
On admission:

Vitals: T: 97.5 BP: 142/79 P: 80 RR: 16 O2Sat 92% RA
Gen: no acute distress
HEENT: Clear OP, MMM, periorbital edema
NECK: Supple, No LAD, JVD about 7 cm
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS.  No HSM
EXT: 3+ pitting edema. Upper extremity edema. Anasarcic
Scrotum: edematous
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**11-27**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant


Pertinent Results:
[**2177-8-21**] 11:13PM   GLUCOSE-313* UREA N-50* CREAT-5.6*
SODIUM-112* POTASSIUM-3.9 CHLORIDE-82* TOTAL CO2-16* ANION
GAP-18
[**2177-8-21**] 06:30PM URINE  HOURS-RANDOM UREA N-169 CREAT-33
SODIUM-30
[**2177-8-21**] 06:30PM URINE  OSMOLAL-196
[**2177-8-21**] 06:30PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2177-8-21**] 06:30PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-500
GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2177-8-21**] 06:30PM URINE  RBC-0-2 WBC-[**1-29**] BACTERIA-FEW YEAST-NONE
EPI-[**1-29**]
[**2177-8-21**] 06:30PM URINE  AMORPH-FEW
[**2177-8-21**] 04:54PM   CYCLSPRN-43* tacroFK-LESS THAN
[**2177-8-21**] 03:50PM   GLUCOSE-273* UREA N-45* CREAT-5.6*#
SODIUM-113* POTASSIUM-3.8 CHLORIDE-79* TOTAL CO2-18* ANION
GAP-20
[**2177-8-21**] 03:50PM   estGFR-Using this
[**2177-8-21**] 03:50PM   proBNP-[**Numeric Identifier 24014**]*
[**2177-8-21**] 03:50PM   CALCIUM-8.2* PHOSPHATE-4.9* MAGNESIUM-2.3
[**2177-8-21**] 03:50PM   WBC-8.6 RBC-3.27* HGB-10.3* HCT-28.7* MCV-88#
MCH-31.5 MCHC-35.8* RDW-14.6
[**2177-8-21**] 03:50PM   PLT COUNT-351#
[**2177-8-21**] 03:50PM   PT-12.8 PTT-30.2 INR(PT)-1.1

Chest x-ray [**2177-8-21**]:
CONCLUSION:

Pulmonary edema, likely cardiogenic. Bibasal effusions.
Increased density at right lung base, confluent edema versus
pneumonia. Followup post diuresis is recomended.

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


Renal Ultrasound [**2177-8-21**]:
IMPRESSION:
1. Interval development of mild-to-moderate hydronephrosis
within the
transplanted kidney.
2. Slight broadening of the waveform of the mid pole renal
artery,
hoever resistive indices within normal range

Transthoracic Echo [**2177-8-22**]:
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). 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. There is no left
ventricular outflow obstruction at rest or with Valsalva. There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. There are focal calcifications in the aortic arch. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.

Compared with the findings of the prior report (images
unavailable for review) of [**2170-10-1**], concentric left
ventricular hypertrophy and moderate diastolic dysfunction now
evident.

IMPRESSION: moderate diastolic dysfunction of the left ventricle
with normal ejection fraction


Brief Hospital Course:
Patient is a 65 year old male with type one diabetes mellitus,
renal transplant in [**2165**], gastroparesis, who presented with
fatigue, hyponatremia, worsening edema, dyspnea on exertion, and
worsening renal insufficiency who was transferred from an
outside hospital for further management.

Patient was admitted to the medical intensive care unit. The
nephrology team was consulted and discussed dialysis with the
patient. He refused dialysis, and was able to state the risks
associated with doing so. He understood what dialysis entailed,
and was also not interested in temporary dialysis. It was
recommended that he be treated with trial hypertonic saline to
see if there was improvement in his hyponatremia and energy
level. He refused to stay as an inpatient and declined a PICC
line for administration of hypertonic saline. He was evaluated
by the psychiatry team to help assess whether there was a
component of depression, and to ensure that his mental status
was not clouded by his low sodium. The psychiatry team felt that
the patient was competent and had the capacity to make medical
decisions and fully understood the implications of refusing
dialysis and other treatments. His primary nephrologist
confirmed that this was in accordance with prior discussions
regarding the goals of his care.

The patient stated that his goals were to return home and spend
time with his wife. Social work, palliative care, and case
management were then involved to assist with arranging home
Hospice services to meet the patient's wishes. A Hospice bed was
available for the next day and would be arranged for him in his
home. Per his and his wife's wishes, he was discharged home. A
regimen of salt tabs and lasix was initiated for his
hyponatremia after discussion with the renal team.

His code status is DNR/DNI, and paperwork was completed for his
ambulance ride home for this order.

Medications on Admission:
 Fosamax 70mg qweek
 Azathioprine 50mg once a day
 Calcium 600mg daily
 Cyclosporine 50mg twice a day
 Fludrocortisone Acetate 0.1mg once a day
 Glyburide 5mg once a day
 Lipitor 10mg
 Lantus 5-6 units before breakfast. Novolog [**11-27**] units before
each meal
 Midodrine 5mg three times a day
 Protonix 40mg daily
 Prednisone 1mg 3 3 tablets once a day
 lasix 20mg twice daily


Discharge Medications:
1. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
3. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
5. Lasix 80 mg Tablet Sig: One (1) Tablet PO three times a day.
Disp:*90 Tablet(s)* Refills:*2*
6. Insulin Glargine 100 unit/mL Solution Sig: 5-6 units
Subcutaneous QAM: Resume your home dosing.
7. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours: As
needed for seizure, discomfort.
Disp:*30 Tablet(s)* Refills:*0*
8. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO q1
hour PRN: PRN shortness of breath, discomfort.
9. Insulin Aspart 100 unit/mL Solution Sig: [**11-27**] units
Subcutaneous before meals: Please resume your home dosing.


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **] Nursing Services

Discharge Diagnosis:
Primary diagnoses:
- Acute on chronic renal failure
- Hyponatremia

Secondary diagnoses:
- Diabetes Mellitus
- Renal transplant
- Gastroparesis
- Neuropathy
- Retinopathy
- GERD


Discharge Condition:
Fair, alert, oriented.


Discharge Instructions:
You were admitted from an outside hospital for management of
your renal failure, low sodium, mild shortness of breath,
fatigue, and swelling of your extremities. It was recommended
that you undergo dialysis or have other treatments for your low
sodium, however you declined these treatments. The psychiatry
team helped evaluate you, and they were in agreement that you
understood the risks and benefits of this decision. The
palliative care team and case management helped to arrange for a
discharge home with Hospice services.
.
Please call your primary care physician if you have any pain,
worsening shortness of breath, or other concerns that need
attention.
.
You should take 80 mg of lasix three times a day in addition to
[**11-27**] salt tabs 3 times a day. Please continue all of your other
medications as directed or appropriate. A foley catheter has
been placed for comfort and should be left in unless otherwise
directed.

Followup Instructions:
You decided that you wanted to go home with Hospice. Please
contact your primary care physician or other providers for any
needs you may have outside of Hospice services.
{'Complications of transplanted kidney,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Hydronephrosis,Pneumonia, organism unspecified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Esophageal reflux,Gastroparesis,Pure hypercholesterolemia,Disorder of bone and cartilage, unspecified,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: Fatigue, shortness of breath, edema

PRESENT ILLNESS: This patient is a 65 year old male with history of type 1
diabetes melltius for 35 years (A1c 6.7), kidney transplant in
[**2165**], who was transferred from [**Hospital3 24012**] ED where he
presented with fatigue x5 days, worsening edema and mild dyspnea
on exertion. He was was in the ER to have acute on chronic renal
failure with a creatinine of 5.6, hyponatremia to 113 and
question of PNA on chest Xray.

MEDICAL HISTORY: - Diabetes type 1 x34 years  Last Hb A1c 6.7 [**8-4**]
- s/p living related kidney transplant [**1-/2166**]
- gastroparesis
- neuropathy
- retinopathy with microaneurysms, s/p surgery [**2155**]
- GERD
- Hypercholesterolemia
- Gastroparesis
- Osteopenia

MEDICATION ON ADMISSION: Fosamax 70mg qweek
 Azathioprine 50mg once a day
 Calcium 600mg daily
 Cyclosporine 50mg twice a day
 Fludrocortisone Acetate 0.1mg once a day
 Glyburide 5mg once a day
 Lipitor 10mg
 Lantus 5-6 units before breakfast. Novolog [**11-27**] units before
each meal
 Midodrine 5mg three times a day
 Protonix 40mg daily
 Prednisone 1mg 3 3 tablets once a day
 lasix 20mg twice daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:

FAMILY HISTORY: His mother's sister has type two diabetes, and a paternal aunt
also has type two diabetes mellitus. There is no family history
of heart disease.

SOCIAL HISTORY: Patient denies smoking, drinking, or ilicit drug use. He is a
retired teacher. lives in [**Location 24013**] with his wife. [**Name (NI) **] has 2
grown children, one in [**State **] one in [**Location (un) **]. 

### Response:
{'Complications of transplanted kidney,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Hydronephrosis,Pneumonia, organism unspecified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Esophageal reflux,Gastroparesis,Pure hypercholesterolemia,Disorder of bone and cartilage, unspecified,Anemia in chronic kidney disease'}
