CHIEF COMPLAINT: malaise and abdominal pain

PRESENT ILLNESS: 79 yo F end stage renal dz, htn, hypothroid, hld who presents
with 5-6 days of N/V and diarrhea. Per daughter pt is not at
baseline and has been having hallucinations "someone trying to
shoot her." She also decribed increasing cough above her
baseline that is non-productive. She has also been feeling that
she is weak all over and more confused with some difficulty
walking. She also complains of whole body aches. She was unable
to go to dialysis today (usually TThSa) because she felt too
weak. Her daughter is a nurse and provides most of the history,
she lives with her son and is normally very indepdent. She
continues to make some urine. Subjective fevers at home. She has
been having increasing difficulty swallowing per family and
coughs frequently when taking PO. She denies any current CP, HA,
brbpr, or hemetemesis, difficulty swallowing/difficulty taking
PO.

MEDICAL HISTORY: - hypertension,
- end-stage renal disease on hemodialysis, (TThSa via left
brachiocephalic AVF made in [**10/2131**])
- congestive heart failure (systolic EF 50% in [**10/2134**]),
- hyperlipidemia,
- osteoarthritis,
- depression,
- anemia,secondary versus tertiary hyperparathyroidism,
- recently developing dementia.

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 650 mg PO Q6H:PRN pain
<4 g per day. Please tell HO if given for T>100.5
2. Simvastatin 20 mg PO DAILY
3. sevelamer CARBONATE 1600 mg PO TID W/MEALS
4. Omeprazole 40 mg PO DAILY
5. Sertraline 150 mg PO DAILY
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. Lidocaine-Prilocaine 1 Appl TP PRN with  HD access
9. Metoprolol Tartrate 75 mg PO BID
10. Valsartan 160 mg PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL
General: AOx3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no rubs
Lungs: bilateral crackles. Air movement bilaterally.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 4+/5 strength upper/lower extremities,
grossly normal sensation, gait deferred, finger-to-nose intact
with mild intention tremor

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives with son, but he works all day. Goes to [**Last Name (un) **] for HD.
uses a walker intermittently. She has a home health aide who
comes in for cleaning, etc. Lives in Mission [**Doctor Last Name **].
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
Acute on chronic systolic heart failure,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other amyloidosis,Nutritional and metabolic cardiomyopathy,Acidosis,Other ill-defined heart diseases,Cough,Dementia, unspecified, without behavioral disturbance,Unspecified acquired hypothyroidism,Renal dialysis status,Other and unspecified hyperlipidemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Depressive disorder, not elsewhere classified,Anemia, unspecified
Ac on chr syst hrt fail,End stage renal disease,Hyp kid NOS w cr kid V,Amyloidosis NEC,Metabolic cardiomyopathy,Acidosis,Ill-defined hrt dis NEC,Cough,Demen NOS w/o behv dstrb,Hypothyroidism NOS,Renal dialysis status,Hyperlipidemia NEC/NOS,Osteoarthros NOS-unspec,Depressive disorder NEC,Anemia NOS
Admission Date:  [**2136-10-3**]              Discharge Date:   [**2136-10-8**]

Date of Birth:  [**2057-2-25**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
malaise and abdominal pain

Major Surgical or Invasive Procedure:
None


History of Present Illness:
79 yo F end stage renal dz, htn, hypothroid, hld who presents
with 5-6 days of N/V and diarrhea. Per daughter pt is not at
baseline and has been having hallucinations "someone trying to
shoot her." She also decribed increasing cough above her
baseline that is non-productive. She has also been feeling that
she is weak all over and more confused with some difficulty
walking. She also complains of whole body aches. She was unable
to go to dialysis today (usually TThSa) because she felt too
weak. Her daughter is a nurse and provides most of the history,
she lives with her son and is normally very indepdent. She
continues to make some urine. Subjective fevers at home. She has
been having increasing difficulty swallowing per family and
coughs frequently when taking PO. She denies any current CP, HA,
brbpr, or hemetemesis, difficulty swallowing/difficulty taking
PO.

In the ED, initial VS were: 19:30 98 78 154/82 18 99% RA. The
patient remained afebrile with HR in the 60s-70s. Her Blood
pressure emained elevated around 150s/80s. She remained >97% O2
saturation. One 18g and one 22g were placed. She remained alert
and oriented x3. She has a fistula in her L arm.

Her initial exam was reportedly notable only for crackles in the
lungs, but a repeat exam revealed diffuse abdominal tenderness.
Thus, the patient underwent CT abdomen and pelvis, which did not
reveal acute pathology. She also was felt to have a swollen leg,
and so underwent CTA, which did not show PE. Her CXR did not
show a clear source of infection. Bedside echo was reportedly
without signs of cardiogenic shock.

The patient received Vancomycin, zosyn, flagyl, 500ml NS,
[**Doctor Last Name **]-dextro, thiamine.

Nephrology was consulted for HD, and were aware of dye load
given with CTA.

She was found to have an elevated lactate in the ED, which
increased to 5.6 but then began to trend down to 5.0 with IVF
(she got 1800cc total). She also had a gap of 18. The patient
was noted to also have a normal chemistry otherwise except for
her elevated creatinine. She had a slight leukocytosis with
normal differential. Her hematocrit and platelets were normal.
She did have a slight elevation in her ALT and AST, her INR was
elevated to 1.4. Her troponin was elevated to 0.04 with normal
CK/MB. UA was obtained.  A RIJ was placed and was oozing.

On arrival to the MICU, the patient says that she feels well,
she says that she feels much better than prior.

In speaking to her daughter, she brought her into the hospital
for concern for weakness, deconditioned. Unable to eat.
Forgetting her dialysis day. Hallucinating. The patient is in
the middle of moving from one apartment to another. The cough is
nagging and constant, the daughter says that this interferes
with her sleep. She endorsed coughing to the point of vomiting.

Past Medical History:
- hypertension,
- end-stage renal disease on hemodialysis, (TThSa via left
brachiocephalic AVF made in [**10/2131**])
- congestive heart failure (systolic EF 50% in [**10/2134**]),
- hyperlipidemia,
- osteoarthritis,
- depression,
- anemia,secondary versus tertiary hyperparathyroidism,
- recently developing dementia.

Social History:
Lives with son, but he works all day. Goes to [**Last Name (un) **] for HD.
uses a walker intermittently. She has a home health aide who
comes in for cleaning, etc. Lives in Mission [**Doctor Last Name **].
- Tobacco: denies
- Alcohol: denies
- Illicits: denies


Family History:
non-contributory

Physical Exam:
ADMISSION PHYSICAL
General: AOx3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no rubs
Lungs: bilateral crackles. Air movement bilaterally.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 4+/5 strength upper/lower extremities,
grossly normal sensation, gait deferred, finger-to-nose intact
with mild intention tremor

DISCHARGE PHYSICAL
Alert & oriented x3, pleasant, but forgetful.
Gait stable using walker.
Left brachiocephalic fistula intact, +bruit


Pertinent Results:
ADMISSION LABS
[**2136-10-2**] 09:35PM   WBC-11.9*# RBC-3.59* HGB-11.0* HCT-34.8*
MCV-97 MCH-30.7 MCHC-31.7 RDW-17.9*
[**2136-10-2**] 09:35PM   NEUTS-55.6 LYMPHS-34.8 MONOS-7.0 EOS-2.0
BASOS-0.7
[**2136-10-2**] 09:35PM   ALBUMIN-4.0 CALCIUM-9.3 PHOSPHATE-2.8
MAGNESIUM-2.0
[**2136-10-2**] 09:35PM   CK-MB-3 cTropnT-0.04*
[**2136-10-2**] 09:35PM   LIPASE-57
[**2136-10-2**] 09:35PM   ALT(SGPT)-43* AST(SGOT)-43* CK(CPK)-71 ALK
PHOS-101 TOT BILI-0.4
[**2136-10-2**] 09:35PM   GLUCOSE-146* UREA N-41* CREAT-6.2*#
SODIUM-139 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-22*
[**2136-10-2**] 09:40PM   LACTATE-3.8*
[**2136-10-2**] 09:50PM   PT-15.2* PTT-29.3 INR(PT)-1.4*

LACTATE:
[**2136-10-4**] 01:39      1.8
[**2136-10-3**] 16:16      3.0*
[**2136-10-3**] 13:10      8.2*1
[**2136-10-3**] 10:08      7.0*1
[**2136-10-3**] 09:43    88 7.0*1
[**2136-10-3**] 06:42      5.2*2
[**2136-10-3**] 03:55      5.0*3
[**2136-10-3**] 00:47      5.6*

CARDIAC ENZYMES
CK 71 MB 3 TropT 0.04
[**2136-10-3**] 15:48    3 0.04*1
[**2136-10-2**] 21:35    3 0.04*1

MICROBIOLOGY:
[**2136-10-2**] 11:27PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2136-10-2**] 11:27PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-NEG
[**2136-10-2**] 11:27PM URINE  RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-1
[**2136-10-2**] 11:27PM URINE  HYALINE-16*
[**2136-10-2**] 11:27PM URINE  MUCOUS-RARE
[**2136-10-6**] SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT
[**2136-10-5**] IMMUNOLOGY HCV VIRAL LOAD-PENDING INPATIENT
[**2136-10-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2136-10-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2136-10-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2136-10-3**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; LEGIONELLA CULTURE-PRELIMINARY; FUNGAL
CULTURE-PRELIMINARY INPATIENT
[**2136-10-3**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2136-10-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2136-10-2**] URINE URINE CULTURE-FINAL; Legionella
Urinary Antigen -FINAL EMERGENCY [**Hospital1 **]
[**2136-10-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]

URINE TOXICOLOGY:
[**2136-10-2**] 11:27PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2136-10-3**] 03:48PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2136-10-3**] 03:48PM   ACETONE-TRACE OSMOLAL-290

IMAGING/STUDIES:
ECG: NSR @ 67 bpm, leftward axis and LAFB, LAA, LVH, TWI
laterally, flattened Ts II, poor R-wave progression. Compared to
ECG from [**2134**], appears similar.

[**2136-10-2**] CHEST X-RAY:  Consistent with pulmonary vascular
congestion.
Frontal and lateral views of the chest were obtained.  The
cardiac
silhouette remains enlarged.  Prominence of the pulmonary
arteries is stable.  There is mild left base streaky
atelectasis/scarring.  There is minimal pulmonary vascular
congestion.  Mediastinal contours are stable.  No large pleural
effusion or pneumothorax.

[**2136-10-3**] CHEST X-RAY:
IMPRESSION:  Status post right IJ central line placement without
evidence of complication; worsening heart failure.

[**2136-10-3**] ECHO: Mildly dilated LA and moderately dilated RA.
Estimated RA pressure at least 15 mmHg. LV size borderline
dilated. LV systoli function severely depressed (LVEF 20%) with
akinesis of the apex and distal LV segments and moderate
hypokinesis remaining seg. Moderate LV thrombus seen. RV mildly
dilated with mild free wall hypokinesis. Mod-severe MR and
mod-severe TR. Severe PA systolic HTN (TR gradient 60). No
pericardial effusion.

[**2136-10-3**] CT chest/abdomen/pelvis w/ contrast:
1.  No PE or aortic dissection. 2.  Cardiomegaly and pulmonary
edema. 3.  Heterogeneous nodule of the left lobe of the thyroid
as described above.  4.  Atrophic kidneys with multiple
indeterminate lesions, some of which are cysts, but many of
which are incompletely characterized, so RCC cannot be excluded;
MR may be considered for further characterization. 5.
Descending and sigmoid colonic diverticulosis without
diverticulitis. 6.  Periportal edema and decompressed
gallbladder with wall edema, which is a nonspecific finding and
may reflect CHF, hyperproteinemia, or hepatic dysfunction. 7.
Small amount of free fluid in the pelvis, possibly reactive. 8.
Benign-appearing but indeterminate lytic lesion in the right
iliac bone without evidence of cortical disruption.

[**2136-10-3**] CT HEAD
IMPRESSION: Minimal cavernous carotid atheromatous disease,
otherwise normal

[**2136-10-5**] CARDIAC STRESS
IMPRESSION: No significant ST segment changes or anginal
symptoms.
Blunted hemodynamic response to regadenoson. Nuclear report sent

separately.

[**2136-10-5**] PHARMACOLOGIC STRESS
IMPRESSION:  1. No reversible or fixed myocardial perfusion
defects. 2. Severely
enlarged left ventricular cavity size. 3. Decreased left
ventricular function
with calculated EF of 24% and diffuse hypokinesia.

Brief Hospital Course:
79 yo woman with ESRD on dialysis, HTN, admitted for 6 weeks of
worsening cough, posttussive emesis, waxing and [**Doctor Last Name 688**] mental
status, found to have elevated lactate as high as 8 and new echo
with dramatically reduced EF, 3+ TR/MR, mild RV failure,
pulmonary hypertension, and LV thrombus.

# CHF:  Pt was found to have new biventricular heart failure (EF
20%) on echo with LV thrombus.  [**10/2134**] TTE which showed
systolic dysfunction with EF of 45-50%.  DDx includes recent
silent MI  (unlikely given lack of qwaves) or balanced ischemia
from 3 vessel disease since stress MIBI was negative (patient is
not a good candidate for CABG per discussion with family,
nephrologist), chronic deterioration of hypertensive
cardiomyopathy, or amyloid cardiomyopathy.  Trop 0.04 in ED
without EKG changes, and remained stable. P-MIBI [**2136-10-5**] showed
no reversible or fixed myocardial perfusion defects, diffuse
hypokinesia, EF 24%. Based on this interpretation, we cannot
rule out balanced ischemia, but since patient not candidate for
CABG, it was agreed upon that cardiac catheterization was not
necessary. Per Dr. [**First Name (STitle) 437**], congestive heart failure may be due to
amyloid cardiomyopathy.
- CT of head was negative for any intracranial process, so
patient was given heparin bolus and heparin gtt was started for
LV thrombus, until therapeutic on warfarin.
- Continued home valsartan, started metoprolol at decreased dose
(25mg TID) then uptitrated as tolerated back to home dose
- Cont simvastatin 20 mg PO/NG DAILY
- Cannot get spironolactone given ESRD
- Continue HD for fluid removal qSaTuThu
- Thiamine levels were not drawn prior to starting IV thiamine,
empirically treating with daily thiamine supplementation as wet
beri-beri is on the differential for cardiomyopathy with
elevated lactate.
- Consider outpatient workup of amyloid cardiomyopathy. If
cardiac amyloid were present, most likely this would be from
ESRD or senile, but have not yet ruled out light chain amyloid.
As outpatient, could get SPEP/UPEP, serum light chains, and
immunofixation, but deferred as inpaitnet.

# LV thrombus:  Apical hypokinesis and severely depressed LV
function likely cause.
- Heparin gtt bridge until therapeutic on warfarin

# Elevated lactate: Rose to lactate of 8 on day of admission and
then decreased to 1.8 with HD. Etiology of lactate elevation is
unclear.
- Normal serum osms.  VBG (pH. 7.45, CO2 40).
- There has been no known infectious process.  No leukocytosis,
CXR showed no consolidation, UA negative, blood cultures no
growth.  Got Vanc, cefepime, levofloxacin for one day but was
discontinued on HD2 because no evidence of infection.  Continued
azithromycin for 4 days for possible atypical pneumonia vs
pertussis given history of 6 weeks of severe cough with
post-tussive emesis
- HIV pending at time of discharge
- Hep serologies pending at time of discharge
- CT abd/pelvis negative for bowel ischemia, transplant surgery
saw and felt no surgical issues
- LV dysfunction without hypotension unlikely to cause this kind
of lactate elevation.
- Other etiologies include toxic ingestions:  Patient has
arthritis and dementia but does not endorse taking increased
amounts of over the counter pain medications such as tyelenol or
aspirin. LFTS only mildly elevated. Sertraline toxicity has been
seen in a case study in rats to cause mitochondrial dysfunction
and a lactic acidosis so this is a possibility.  Sertraline was
held per toxicology recommendations, but restarted with no new
elevation in lactate.  No blood in stool to suggest iron or
colchicine ingestion.  Negative serum tox screen.
- Thiamine deficiency can also cause a lactic acidosis. Thiamine
empirically repleted.

# Cough: Cough for a few months with some emesis after coughing
fits. Cough improved with diuresis, most likely etiology is
pulmonary edema.  Also possibly viral or pertussis given
increased incidence recently. Sent serum studies for pertussis
to state since swab will be negative 6 weeks out. Rec'd
azithromycin [**Date range (1) 6230**].  Infection control stated that patient
does not need to be on droplet precautions because onset was 6
weeks ago and cough is improved.

# AMS: Was brought in with confusion by her daughter that had
been worsening over the days before admission. Improved during
hospitalization but the patient per report has some baseline
dementia.

# ESRD on HD TThSa schedule: When she was admitted she had
missed a day of dialysis because of fatigue. On [**10-3**] she received
dialysis and then received a partial dialysis on [**10-4**] to get her
back on schedule.  Received dialysis [**2136-10-8**] prior to discharge.

# HTN: Kept on home valsartan. Lopressor restarted on [**10-4**] and
uptitrated back to her home dose on [**10-6**].

# HLD: Kept on home dose of simvastatin

# Osteoarthritis: Home tylenol was discontinued because of
concern for toxicity while in the hospital.

# Hypothyroidism: TSH 5.0 and free T4 0.99. Kept on home
levothyroxine.

# Depression: Held home sertraline in hospital for concern of
toxicity and contribution of lactic acidosis.  Restarted without
any increase in lactate.

# Anemia: HCT remained stable around 34.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 650 mg PO Q6H:PRN pain
<4 g per day. Please tell HO if given for T>100.5
2. Simvastatin 20 mg PO DAILY
3. sevelamer CARBONATE 1600 mg PO TID W/MEALS
4. Omeprazole 40 mg PO DAILY
5. Sertraline 150 mg PO DAILY
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. Lidocaine-Prilocaine 1 Appl TP PRN with  HD access
9. Metoprolol Tartrate 75 mg PO BID
10. Valsartan 160 mg PO DAILY


Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
<4 g per day. Please tell HO if given for T>100.5
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Metoprolol Tartrate 75 mg PO BID
4. Nephrocaps 1 CAP PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Sertraline 150 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Valsartan 160 mg PO DAILY
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*11
10. Lidocaine-Prilocaine 1 Appl TP PRN with  HD access
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
12. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*3
13. Warfarin 4 mg PO DAILY16
RX *warfarin 1 mg 4 tablet(s) by mouth DAILY Disp #*120 Tablet
Refills:*0
14. Outpatient Lab Work
428.0 Congestive heart failure
Please check INR on or before [**2136-10-11**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
PRIMARY:  Congestive heart failure, lactic acidosis, left
ventricular thrombus
SECONDARY:  Hypertension, end-stage renal disease,
hypothyroidism, anemia


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mrs. [**Known lastname 11622**],
It was a pleasure caring for you during your hospitalization for
congestive heart failure and blood clot in your heart.

Please keep the following appointments we have made for you.

MEDICATION CHANGES
- START warfarin, you should have your INR checked on or before
[**2136-10-11**]
- START thiamine 100mg daily

TRANSITION OF CARE
- Please contact Dr. [**Last Name (STitle) **] at [**Hospital3 **]
[**Telephone/Fax (1) 2010**], as soon as you know that you will be sent home
from rehab, so that your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], can
initiate your referral to the [**Hospital3 **]
[**Hospital3 271**].
- You may wish to consider outpatient workup of amyloid
cardiomyopathy as an outpatient.  You should discuss this with
Dr. [**Last Name (STitle) **] and your new cardiologist, Dr. [**First Name (STitle) 437**].

Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.

Please contact [**Hospital3 **] as above, so that Dr. [**Last Name (STitle) **]
can refer you to the [**Hospital3 **] [**Hospital 3052**].

Department: CARDIAC SERVICES
When: MONDAY [**2136-10-22**] at 10:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Department: ADVANCED VASC. CARE CNT
When: MONDAY [**2136-11-12**] at 10:00 AM
With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site

Department: [**Hospital3 249**]
When: MONDAY [**2136-11-19**] at 11:00 AM
With: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], NP [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Outpatient dialysis unit: [**Location (un) **] [**Location (un) **]
Outpatient nephrologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Schedule: Tuesday, Thursday, Saturday
*You will follow up for your hospitalization with your
nephrologist at your next dialysis day. Any questions or
concerns please call the office at [**Telephone/Fax (1) 5972**].



Completed by:[**2136-10-9**]
{'Acute on chronic systolic heart failure,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other amyloidosis,Nutritional and metabolic cardiomyopathy,Acidosis,Other ill-defined heart diseases,Cough,Dementia, unspecified, without behavioral disturbance,Unspecified acquired hypothyroidism,Renal dialysis status,Other and unspecified hyperlipidemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Depressive disorder, not elsewhere classified,Anemia, unspecified'}


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: malaise and abdominal pain

PRESENT ILLNESS: 79 yo F end stage renal dz, htn, hypothroid, hld who presents
with 5-6 days of N/V and diarrhea. Per daughter pt is not at
baseline and has been having hallucinations "someone trying to
shoot her." She also decribed increasing cough above her
baseline that is non-productive. She has also been feeling that
she is weak all over and more confused with some difficulty
walking. She also complains of whole body aches. She was unable
to go to dialysis today (usually TThSa) because she felt too
weak. Her daughter is a nurse and provides most of the history,
she lives with her son and is normally very indepdent. She
continues to make some urine. Subjective fevers at home. She has
been having increasing difficulty swallowing per family and
coughs frequently when taking PO. She denies any current CP, HA,
brbpr, or hemetemesis, difficulty swallowing/difficulty taking
PO.

MEDICAL HISTORY: - hypertension,
- end-stage renal disease on hemodialysis, (TThSa via left
brachiocephalic AVF made in [**10/2131**])
- congestive heart failure (systolic EF 50% in [**10/2134**]),
- hyperlipidemia,
- osteoarthritis,
- depression,
- anemia,secondary versus tertiary hyperparathyroidism,
- recently developing dementia.

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 650 mg PO Q6H:PRN pain
<4 g per day. Please tell HO if given for T>100.5
2. Simvastatin 20 mg PO DAILY
3. sevelamer CARBONATE 1600 mg PO TID W/MEALS
4. Omeprazole 40 mg PO DAILY
5. Sertraline 150 mg PO DAILY
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. Lidocaine-Prilocaine 1 Appl TP PRN with  HD access
9. Metoprolol Tartrate 75 mg PO BID
10. Valsartan 160 mg PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL
General: AOx3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no rubs
Lungs: bilateral crackles. Air movement bilaterally.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 4+/5 strength upper/lower extremities,
grossly normal sensation, gait deferred, finger-to-nose intact
with mild intention tremor

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives with son, but he works all day. Goes to [**Last Name (un) **] for HD.
uses a walker intermittently. She has a home health aide who
comes in for cleaning, etc. Lives in Mission [**Doctor Last Name **].
- Tobacco: denies
- Alcohol: denies
- Illicits: denies 

### Response:
{'Acute on chronic systolic heart failure,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other amyloidosis,Nutritional and metabolic cardiomyopathy,Acidosis,Other ill-defined heart diseases,Cough,Dementia, unspecified, without behavioral disturbance,Unspecified acquired hypothyroidism,Renal dialysis status,Other and unspecified hyperlipidemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Depressive disorder, not elsewhere classified,Anemia, unspecified'}
