CHIEF COMPLAINT: Increased shortness of breath, chest pain,
lethargy and difficulty ambulating.

PRESENT ILLNESS: The patient is a 37-year-old
female, status post cadaver kidney transplant, complicated by
humeral rejection, status post cadaver renal transplant on
[**2127-2-4**]. She has been receiving plasmapheresis up
until [**2127-2-11**]. Hematocrit had trended down since
surgery on [**2-4**]. Her hematocrit was 36. This decreased
to 27 on [**2-12**] and to 22 on [**2-13**]. Repeat hematocrit
was 18 on admission.

MEDICAL HISTORY: Significant for focal segmental
glomerulosclerosis, hypertension.

MEDICATION ON ADMISSION: 1.  Bactrim single strength once a day
2.  Nystatin 5 mL q.i.d.
3.  Coumadin 5 mg at bedtime
4.  CellCept [**Pager number **] mg p.o. b.i.d.
5.  Protonix 40 mg p.o. b.i.d.
6.  Valcyte 450 mg p.o. b.i.d.
7.  Colace 100 mg p.o. b.i.d.
8.  Prograf 9 mg p.o. b.i.d.
9.  Metoprolol 35 mg p.o. b.i.d.

ALLERGIES: Vancomycin, penicillin, iodine and Benadryl.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Abnormal coagulation profile,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Acute kidney failure, unspecified,Unspecified pleural effusion,Hemolytic-uremic syndrome
Abn react-org transplant,Accident in place NEC,Abnrml coagultion prfile,Compl kidney transplant,Hyp kid NOS w cr kid V,End stage renal disease,Acute kidney failure NOS,Pleural effusion NOS,Hemolytic uremic synd
Admission Date: [**2127-2-14**]        Discharge Date: [**2127-2-20**]

Date of Birth:  [**2089-4-11**]        Sex:  F

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


CHIEF COMPLAINT:  Increased shortness of breath, chest pain,
lethargy and difficulty ambulating.

The patient came in through the emergency department.

HISTORY OF PRESENT ILLNESS:  The patient is a 37-year-old
female, status post cadaver kidney transplant, complicated by
humeral rejection, status post cadaver renal transplant on
[**2127-2-4**]. She has been receiving plasmapheresis up
until [**2127-2-11**]. Hematocrit had trended down since
surgery on [**2-4**]. Her hematocrit was 36. This decreased
to 27 on [**2-12**] and to 22 on [**2-13**]. Repeat hematocrit
was 18 on admission.

PAST MEDICAL HISTORY:  Significant for focal segmental
glomerulosclerosis, hypertension.

ALLERGIES:  Vancomycin, penicillin, iodine and Benadryl.

MEDICATIONS ON ADMISSION:
1.  Bactrim single strength once a day
2.  Nystatin 5 mL q.i.d.
3.  Coumadin 5 mg at bedtime
4.  CellCept [**Pager number **] mg p.o. b.i.d.
5.  Protonix 40 mg p.o. b.i.d.
6.  Valcyte 450 mg p.o. b.i.d.
7.  Colace 100 mg p.o. b.i.d.
8.  Prograf 9 mg p.o. b.i.d.
9.  Metoprolol 35 mg p.o. b.i.d.

PHYSICAL EXAMINATION:  On admission, the patient's physical
exam, T-max 99.3, heart rate 103, BP 128/87, respiratory rate
18, and O2 saturation 98% on room air. The patient appeared
obese. Pupils equal, round and reactive to light and
accommodation. OP was clear. Neck supple. Lungs clear to
auscultation. Heart: Tachycardiac, regular rate and rhythm,
no murmurs, rubs or gallops. Abdomen: Tender only around the
transplant incision site, positive bowel sounds, guaiac
negative. No CVA tenderness.

LABORATORY DATA:  UA was done. This demonstrated 0 to 2 RBCs,
0 to 2 WBCs, rare bacteria, no yeast and 3 to 5 epithelial
cells, negative nitrite. Urine sodium was 117 and urine
creatinine 63. Renal ultrasound was done and this
demonstrated small organizing fluid collection anterior to
the transplanted kidney. Concern was for a small
postoperative seroma or localizing hematoma. Otherwise, the
Doppler evaluation was unremarkable. A chest x-ray done
demonstrated left central line tip in the distal SVC, no
pneumothorax and interval resolution of the right-sided
pleural effusion.

The patient was transferred to the SICU where she received 2
units of packed red blood cells for a hematocrit of 22.5 and
2 units of FFP for INR of 12.3. Creatinine on admission was
2.5. Prograf level was 14 and her Prograf was placed on hold.
INR decreased to 1.3. Hematocrit increased to 21. She
received another 2 units of packed red blood cells and a
total of 4 bags of FFP. Fibrinogen was 263. Creatinine was
2.4. AST was 104, ALT 161, alkaline phosphatase 128 and total
bilirubin 2.0. She was n.p.o. She continued to receive IV
fluid. Nephrology was consulted. There was concern for TTP-
HUS secondary to Prograf or humeral rejection. CT of the
abdomen was done. This demonstrated hemorrhage within the
lower [**2-10**] of the left rectus abdominis muscle. There was no
significant change in the appearance of the peritransplant
fluid collection, likely postoperative seroma or organizing
hematoma. There was a small amount of low attenuating free
fluid in the pelvis and bilateral atrophic native kidneys
were demonstrated containing several lesions, not completely
characterized on the current exam. Further evaluation was
recommended with either ultrasound or MRI to exclude solid
neoplasms.

The patient continued to receive plasmapheresis. Dr. [**First Name (STitle) **] from
pathology followed the patient. Two-volume exchange using FFP
was used as replacement fluid. This was continued daily. A
kidney biopsy was done on [**2127-2-15**]. This demonstrated
under light microscopy the specimen consisted of a renal
cortex containing approximately 6 glomeruli of which 1 was
globally sclerotic. The remainder all appeared bloodless,
with thrombosis and occasional intercapillary neutrophil
margination. There was minimal interstitial fibrosis and
tubular atrophy. The tubules appeared mildly dilated. Mild
interstitial edema was present. There was minimal chronic
inflammation accompanying the scarring. No significant
tubulitis was noted. Tubular capillaries were dilated with
prominent neutrophils. Acute antibiotic-mediated humeral
rejection, type 2, was noted. Please refer to original
pathology report. Thirty tubular capillaries were diffusely
positive for C4D. She received a total of 4 treatments of
plasmapheresis on 4 separate days. During this time, her
creatinine trended down to 2.0.

Valcyte was changed to 450 mg p.o. once a day as the
creatinine decreased to 1.9 on hospital day 3. She did
complain of some nausea and vomiting. She was better after
being treated with Anzemet Her diet was advanced slowly.
Hematocrit was stable in the range of 29 to 30. Platelet
count remained 58 to 59. INR was 1.1. Creatinine decreased to
1.9. She complained of a productive cough, slightly thick.
The patient was able to self-suction with a Yankauer suction.
The abdomen appeared soft with positive bowel sounds. She was
tolerating her diet fairly well. She was able to get out of
bed with assist. Nutrition services followed the patient and
recommended Boost Plus t.i.d.

She was given ATG 100 mg and Solu-Medrol for high class match
titers. She tolerated this without problems. On hospital day
4, it was noted the patient had right breast swelling with
tenderness. She complained of facial swelling as well. This
was demonstrated on physical exam. Her right breast was
significantly swollen as well as her right arm. She also had
a left chest tunnel-line catheter. Her right arm was
elevated. She was medicated for discomfort with fair relief.
Coumadin was restarted at 5 mg p.o. once a day. Of note, her
blood pressure had decreased to 114/71. Her Lopressor was
held. BP ranged between 116/79 to 142/88 with a heart rate of
74. She remained afebrile. Urine output gradually increased
to 1880 cc per day. Hematocrit trended down to 25. This
remained stable in the 25.2 to 26 range. Prograf was
decreased to 6 mg b.i.d. The Prograf level was 14.6 on
[**2127-2-19**].

Physical therapy was consulted. The patient was noted to be
deconditioned with decreased endurance. Outpatient physical
therapy was recommended. On hospital day 6, she was
discharged home in stable condition, alert and oriented,
comfortable, with clear lungs, voiding QS without difficulty.
Her abdominal incision was covered by a dry sterile dressing
for minimal serosanguineous drainage with clip still present.
She was out of bed ambulatory in the [**Doctor Last Name **] with supervision.
She was discharged home with visiting nurse with PT services
at home.

DISCHARGE MEDICATIONS:
1.  Bactrim single strength p.o. once a day 1 tablet once a
    day
2.  Nystatin 5 mL p.o. q.i.d.
3.  Colace 100 mg p.o. b.i.d.
4.  Protonix 40 mg p.o. once a day
5.  Metoprolol was changed to 37.5 mg p.o. t.i.d.
6.  Valcyte 450 mg p.o. q.i.d.
7.  CellCept [**Pager number **] mg p.o. q.i.d.
8.  Prednisone 20 mg p.o. once a day
9.  Coumadin 5 mg p.o. at bedtime
10. Prograf 6 mg p.o. b.i.d.
11. Dilaudid 2 mg p.o. p.r.n. q.4-6h. for discomfort

DISCHARGE DIAGNOSES:  Humeral rejection of the kidney
transplant, supratherapeutic INR, anemia, deep venous
thrombosis right arm, old incision wound, chronic, healing,
asthma and hypertension.

The patient was scheduled to follow up in the outpatient
clinic. She had a followup appointment with Dr. [**First Name (STitle) **]
[**Name (STitle) **] on [**2127-2-21**], as well as [**Year (4 digits) **] on
[**2127-2-21**].

DISCHARGE CONDITION:  Stable.


DISCHARGE INSTRUCTIONS:  Also included elevation of the right
arm as much as possible and to avoid Motrin-like medications
as well as aspirin.



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

Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D:  [**2127-3-26**] 14:36:19
T:  [**2127-3-26**] 16:08:29
Job#:  [**Job Number 107897**]
{'Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Abnormal coagulation profile,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Acute kidney failure, unspecified,Unspecified pleural effusion,Hemolytic-uremic syndrome'}


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: Increased shortness of breath, chest pain,
lethargy and difficulty ambulating.

PRESENT ILLNESS: The patient is a 37-year-old
female, status post cadaver kidney transplant, complicated by
humeral rejection, status post cadaver renal transplant on
[**2127-2-4**]. She has been receiving plasmapheresis up
until [**2127-2-11**]. Hematocrit had trended down since
surgery on [**2-4**]. Her hematocrit was 36. This decreased
to 27 on [**2-12**] and to 22 on [**2-13**]. Repeat hematocrit
was 18 on admission.

MEDICAL HISTORY: Significant for focal segmental
glomerulosclerosis, hypertension.

MEDICATION ON ADMISSION: 1.  Bactrim single strength once a day
2.  Nystatin 5 mL q.i.d.
3.  Coumadin 5 mg at bedtime
4.  CellCept [**Pager number **] mg p.o. b.i.d.
5.  Protonix 40 mg p.o. b.i.d.
6.  Valcyte 450 mg p.o. b.i.d.
7.  Colace 100 mg p.o. b.i.d.
8.  Prograf 9 mg p.o. b.i.d.
9.  Metoprolol 35 mg p.o. b.i.d.

ALLERGIES: Vancomycin, penicillin, iodine and Benadryl.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Abnormal coagulation profile,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Acute kidney failure, unspecified,Unspecified pleural effusion,Hemolytic-uremic syndrome'}
