CHIEF COMPLAINT: Endstage renal disease, here for living
unrelated kidney transplant.

PRESENT ILLNESS: The patient is a 54 year old
male with endstage renal disease secondary to type 1 diabetes
who presents for kidney transplant from wife. [**Name (NI) **] was started
on dialysis in [**2152-7-4**] after having 47 years of diabetes
which was complicated by both retinopathy, requiring
bilateral laser surgery as well as right vitrectomy. History
of neuropathy in both hands and legs. He has had a CVA with
some left sided weakness. History of coronary artery disease.
He has had an myocardial infarction on several occasions in
the past and 6 stents were placed in [**2152-7-4**]. He also had
significant peripheral vascular disease with bilateral lower
extremity bypass and toe amputations bilaterally.

MEDICAL HISTORY: Gastroesophageal reflux disease.

MEDICATION ON ADMISSION: 

ALLERGIES: Ativan and non-steroidal anti-inflammatory drugs.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Complications of transplanted kidney,Pressure ulcer, buttock,Peripheral vascular complications, not elsewhere classified,Other iatrogenic hypotension,Anemia, unspecified,Peripheral vascular disease, unspecified,Esophageal reflux,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Other toe(s) amputation status
DMI renl nt st uncntrld,Compl kidney transplant,Pressure ulcer, buttock,Surg comp-peri vasc syst,Iatrogenc hypotnsion NEC,Anemia NOS,Periph vascular dis NOS,Esophageal reflux,Crnry athrscl natve vssl,Old myocardial infarct,Status-post ptca,Status amput othr toe(s)
Admission Date: [**2153-9-5**]        Discharge Date: [**2153-9-18**]

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

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


CHIEF COMPLAINT:  Endstage renal disease, here for living
unrelated kidney transplant.

HISTORY OF PRESENT ILLNESS:  The patient is a 54 year old
male with endstage renal disease secondary to type 1 diabetes
who presents for kidney transplant from wife. [**Name (NI) **] was started
on dialysis in [**2152-7-4**] after having 47 years of diabetes
which was complicated by both retinopathy, requiring
bilateral laser surgery as well as right vitrectomy. History
of neuropathy in both hands and legs. He has had a CVA with
some left sided weakness. History of coronary artery disease.
He has had an myocardial infarction on several occasions in
the past and 6 stents were placed in [**2152-7-4**]. He also had
significant peripheral vascular disease with bilateral lower
extremity bypass and toe amputations bilaterally.

PAST MEDICAL HISTORY:  Gastroesophageal reflux disease.

PAST SURGICAL HISTORY:  Cholecystectomy.

ALLERGIES:  Ativan and non-steroidal anti-inflammatory drugs.

MEDICATIONS:  The patient was taking:
1. Isordil - 60 mg once daily.
2. Aspirin, that was stopped on the day of admission.
3. Plavix, discontinued on [**9-1**].
4. Toprol 100 mg once daily.
5. Nephrocaps one once daily.
6. Lipitor.
7. Aciphex.
8. Temazepam.
9. Insulin - 12 units NPH q.a.m. and 6 units q p.m. Regular
   Insulin 8 units q.a.m. and 4 units q p.m.


PHYSICAL EXAMINATION:  GENERAL: In no acute distress. Alert
and oriented. No thyromegaly. Dentures upper and lower. NECK
- free range of motion. HEART: Regular rate and rhythm. No
murmurs or bruits. LUNGS: Clear to auscultation. ABDOMEN:
Nontender. Nondistended. EXTREMITIES: No clubbing, cyanosis
or edema. Mildly atrophic. Height 68 inches. Weight 160
pounds. Blood pressure 137/51, heart rate 66, oxygen
saturations 99% in room air.

LABORATORY DATA ON ADMISSION:  White blood cell count 5.2,
hematocrit 36.2, platelet count 177, sodium 144, potassium
4.3, chloride 99, PO2 32, BUN 36, creatinine 2.8, glucose 89,
EKG was within normal limits. Chest x-ray showed no bone
destruction, bilateral effusions, right greater than the
left, and enlarged cardiac silhouette.  The patient was taken
to the OR on [**2153-9-5**], for living unrelated renal
transplant. Surgeons were Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 9768**], and Dr.
[**Last Name (STitle) 39567**].

The patient received general anesthesia. Estimated blood loss
was 400 cc. The patient did well intraoperatively. Please
seen operative note. The patient intraoperatively required
take down of the renal artery anastomosis secondary to poor
arterial inflow.  He required iliac arteriotomy and
embolectomy. Post procedure he was managed in the post
anesthesia care unit doing well. Urine output was marginal
over several hours. Vital signs were stable. Duplex of the
kidney revealed good arterial wave forms with resistive
indices of 0.57 to 0.61. There was no perinephric fluid
collection.

The patient was given intraoperative immunosuppression with
500 of Solu-Medrol, 1 gram of CellCept, ATG 100 mg Ancef,
Valcyte and heparin assay preoperatively. Postoperative urine
output was 10 to 20 cc an hour with half normal saline cc per
cc replacement with a background IV of D5.5 of normal saline
at 50 cc an hour. The patient was treated with morphine PCA
for pain and was managed on insulin subcutaneous injections
for glucose control.

Postoperative hematocrit was 32.3, white blood cell count
4.6, K of 4.3, and creatinine of 3.3.  The patient was
transferred when stable to the medical surgical unit. Urine
output remained on the low side. Nephrology was consulted and
followed closely throughout the hospital course. IV fluid was
decreased. Breath sounds were decreased half way up on
bilaterally. Oxygen saturations were 98% on 2 liters, blood
pressure 100/58. Low dose Lopressor was started on
postoperative day 1.

Chest x-ray was repeated after placement of an NG tube for
abdominal distention, nausea. Repeat duplex revealed poorly
visualized venous outflow. The patient returned to the
operating room for reexploration of the kidney under general
anesthesia by Dr. [**First Name (STitle) **] [**Name (STitle) **] with assistant Dr. [**Known firstname **]
[**Last Name (NamePattern1) 9768**], resident on [**2153-9-6**]. Please see operative note.
Minimal estimated blood loss. Urine output q 1 hour 10 to 40
cc an hour. The patient was given IV dopamine and maintained
on an IV of normal saline at 10 cc an hour.

Repeat chest x-ray to assess endotracheal tube was done. ET
tube was pulled back 5 cm. The patient was treated with
morphine for pain, restarted on heparin 5000 units t.i.d. The
kidney was noted to be pink with good arterial and venous
flow. The patient was started on clear liquids on
postoperative day 1. He did complain of some nausea. [**Last Name (un) **]
was consulted for management of hyperglycemia. Blood sugars
ran in the 300s. IV insulin drip was started and then later
discontinued with adjustment of subcutaneous insulin.

The patient underwent a TEE on [**2153-9-6**] with notation
of severely depressed right ventricular systolic function
with moderate dilatation. Systolic function was noted to be
severely depressed globally. The apex was noted to be
akinetic with moderate to severe .....  Comments were noted
that mitral valve flow was normal. The patient was
transferred to the surgical intensive care unit postoperative
reexploration of the kidney transplant.

Postoperative hematocrit was 27.7 with a white blood cell
count of 6.6, creatinine was noted to be 3.7 and BUN of 58,
potassium 4.1. The patient ws intubated and sedated. He was
on propofol for sedation and dopamine to increase cardiac
output with goal to keep greater than cardiac index of 2 with
blood pressure greater than 120. The patient was started on a
Lasix strip. The patient was extubated on postoperative day
2, 1.

The patient was transferred from the post anesthesia care
unit to the medical surgical unit on [**2153-9-7**], with
renal attending reviewed this case. The patient produced 1270
cc of urine over the prior 17 hours on Lasix drip. Prograf
was deferred. The patient continued on ATG. He received a
total of 4, 100 mg once daily doses on postoperative day 4
and postoperative day 5. He received half dose for white
blood cell count of 2.3 and 2.1 respectively. NG tube
continued to drain minimal greenish drainage. The abdomen was
soft and nontender, nondistended with no bowel sounds heard.
Lasix was weaned off on postoperative day 4. Urine output for
the previous 24 hours had been 1102 with a creatinine of 3.5.
Vital signs remained stable. Repeat chest x-ray revealed
worsening CHF with notation of right large pleural effusion
with moderate left effusion with left lower lobe
consolidation.

Prograf was started on postoperative day 4 at 2 mg b.i.d,
Solu-Medrol was tapered down to 25 mg PO twice a day and then
stopped on postoperative day 7. He continued in CellCept 1
gram b.i.d until postoperative day 8 when this was decreased
to 500 mg QID. Prograf level returned on postoperative day 7
with a left of 20. Prograf was adjusted to 3 mg b.i.d. IV
Lasix was continued orally at 80 mg b.i.d Foley was removed.
The patient was unable to urinate. Foley was replaced. The
patient was given a second attempt at Foley beig removed and
again unable to void. Foley was replaced and the patient was
started on Flomax 0.4 mg PO qhs.

Of note the patient underwent biopsy of the transplant kidney
on [**9-6**], postoperative 1, during reexploration of the
transplanted kidney. Biopsy results demonstrated no
rejection. One unit of packed red blood cells was
administered on [**9-11**] for a hematocrit of 27.6. Post
transfusion hematocrit was 32.7. Urine output was 1 liter.
Improved graft function was noted with a creatinine of 3.5
and BUN of 88. The patient was advanced to renal diet.
Physical therapy was consulted. It was felt that the patient
would require 2 to 3 treatments to improve endurance, balance
and gait and see if safe for stair climbing. Right lower
quadrant incision remained intact with clips with scant
serosanguineous drainage. [**Location (un) 1661**]-[**Location (un) 1662**] output initially was
300 cc. This diminished postoperatively. [**Location (un) 1661**]-[**Location (un) 1662**] was
discontinued on postoperative day 7 and 6. Epogen was started
at 10,000 units 3 times a week. The patient was not iron
deficient. Protonix was started b.i.d for persistent nausea.
PhosLo was stopped. The patient was started on Colace for
complaints of inability to move bowels. The patient was
passing flatus. CellCept was decreased to 500 QID for
complaints of frequent stools. Colace was held.

Creatinine was noted to increase on postoperative day [**12-13**].
Creatinine increased to 4.5 with a BUN of 111. Previous day
urine output had been 755 cc with a combined PO and IV intake
of 300 cc. The patient had complained of nausea. IV fluid was
given. Urine output increased slightly for the subsequent 24
hours at a liter. Repeat creatinine was 4.2. The patient
remained afebrile. Blood pressure 110 to 120/68 to 81. Oxygen
saturations on room air 96%. Urine output averaged
approximately 20 cc an hour despite an extra dose of Lasix.
The patient received inpatient nutritional assessment for
decreased intake. Napro was recommended. Calorie counts were
started. Hemodialysis was deferred.

Cardiology was consulted on [**9-14**]. Cardiology was asked
to see the patient for persistent congestive heart failure
that was noted on x-ray and weight remained increased at 98
kg. Recommendations were to decrease IV fluids, to continue
with IV Lasix 80 mg and to restart aspirin and Plavix if
surgically acceptable. In addition it was recommended to
restart low-dose Toprol 25 mg PO once daily for low EF.
Dialysis was considered. A decision was made to hold off on
dialysis and to monitor urine output and creatinine. Repeat
duplex revealed no hydro, no perinephric fluid collection.
Arterial wave forms were normal. The renal vein appeared to
have a biphasic flow pattern consistent with right heart
failure.

Given the stabilization of creatinine to 4.1, BUN of 106, and
urine output of 700 cc, it was decided to discharge the
patient to home on Prograf 2.5 mg twice a day for Prograf
level of 8.9. CellCept [**Pager number **] mg QID, to monitor the patient for
the next few days. The patient was to be seen 2 days post
discharge in the transplant office after a.m. labs were to be
drawn. He was cleared by physical therapy. He was tolerating
PO intake with a fair intake. Vital signs were stable.
Visiting nurse was set up for home PT. Given the patient
appeared somewhat depressed, it was felt that he would
benefit by being at home with a hope that nutritional intake
would improve in home environment.

VNA was consulted to continue wound care. It was noted that
the patient had a 2.5 x 1.5 cm right gluteal stage 2 pressure
ulcer as well as a 2 x 1.5 cm inferior pressure ulcer on the
right gluteal area. Recommendations by wound skin care nurse
were to cleanse with normal saline, apply DuoDerm gel to the
open areas, with no-sting barrier wipe to peri-wound skin and
then leave in foam adhesive 4 x 4 dressing to be changed
every 3 days. These recommendations were conveyed to the VNA
for outpatient management. The patient was discharged with a
rolling walker to home to have physical therapy at home per
recommendations.

DISCHARGE MEDICATIONS:
1. Nystatin 5 ml po QID.
2. Bactrim single strength 1 tab once daily.
3. PhosLo 2 tabs PO t.i.d.
4. Valcyte 450 mg PO every other day.
5. Percocet 1 to 2 tabs PO q 4 to 6 hours.
6. Flomax 0.4 mg PO qhs.
7. Protonix 40 mg once daily
8. Colace 100 mg PO b.i.d.
9. CellCept [**Pager number **] one tab PO QID.
10.      Lasix 40 mg PO once daily.
11.      Toprol 25 sustained release tab once daily
12.      Prograf 3 mg PO b.i.d.
13.      Atorvastatin 10 mg PO once daily.
14.      Insulin regular sliding scale QID. NPH insulin 8
   units q a.m,  NPH insulin subcutaneous q p.m.
15.      Nephro one cap PO t.i.d.

Follow up appointment was made with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], on
[**2153-9-20**].

DISCHARGE DIAGNOSIS:
1. Endstage renal disease status post living unrelated kidney
   transplant [**2153-9-5**].
2. Reexploration of transplanted kidney with biopsy on [**9-6**], [**2153**].
3  Coronary artery disease.
1. Congestive heart failure.
2. Hyperlipidemia.
3. Type 1 diabetes.
4. Peripheral vascular disease.
5. Gastroesophageal reflux disease.
6. Peptic ulcer disease.
7. Gluteal fold decubitus.
8. Failure to thrive.
9. Delayed graft kidney function.

The patient was ambulatory and stable upon discharge.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]

Dictated By:[**Doctor Last Name 31787**]
MEDQUIST36
D:  [**2153-9-20**] 21:29:31
T:  [**2153-9-21**] 00:33:46
Job#:  [**Job Number 39568**]
{'Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Complications of transplanted kidney,Pressure ulcer, buttock,Peripheral vascular complications, not elsewhere classified,Other iatrogenic hypotension,Anemia, unspecified,Peripheral vascular disease, unspecified,Esophageal reflux,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Other toe(s) amputation status'}


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: Endstage renal disease, here for living
unrelated kidney transplant.

PRESENT ILLNESS: The patient is a 54 year old
male with endstage renal disease secondary to type 1 diabetes
who presents for kidney transplant from wife. [**Name (NI) **] was started
on dialysis in [**2152-7-4**] after having 47 years of diabetes
which was complicated by both retinopathy, requiring
bilateral laser surgery as well as right vitrectomy. History
of neuropathy in both hands and legs. He has had a CVA with
some left sided weakness. History of coronary artery disease.
He has had an myocardial infarction on several occasions in
the past and 6 stents were placed in [**2152-7-4**]. He also had
significant peripheral vascular disease with bilateral lower
extremity bypass and toe amputations bilaterally.

MEDICAL HISTORY: Gastroesophageal reflux disease.

MEDICATION ON ADMISSION: 

ALLERGIES: Ativan and non-steroidal anti-inflammatory drugs.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Complications of transplanted kidney,Pressure ulcer, buttock,Peripheral vascular complications, not elsewhere classified,Other iatrogenic hypotension,Anemia, unspecified,Peripheral vascular disease, unspecified,Esophageal reflux,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Other toe(s) amputation status'}
