CHIEF COMPLAINT: 77-yo-woman with DM2, CRI, HTN, CHF, CAD called out of MICU to
floor, awaiting permacath placement [**11-14**] for dialysis. Had been
admitted to MICU for mgmt of acidosis in the setting of ARF.

PRESENT ILLNESS: Presented to ED [**11-12**] w/ tremor for 3 days, decreased appetite,
also urinary frequency x 1 week. See original MICU admission H&P
for full history and review of systems. In the [**Name (NI) **], pt was found
to have ARF w/ creatinine 6.1, K 4.8, and bicarb 10. ABG was
7.1/36/99 on room air.  Pt was admitted to the MICU for
management of acidosis/uremia.

MEDICAL HISTORY: Primary:
Bronchitis
Anemia of Chronic Renal Disease
Possible Mastitis

MEDICATION ON ADMISSION: 

ALLERGIES: Morphine / Iodine; Iodine Containing / Lipitor / Phenothiazines

PHYSICAL EXAM: 131/43 61 15 100% on 2.5L
Gen: morbidly obese woman, NAD, A+Ox3 conversing fluently
HEENT: anicteric, EOMI, MMM, no JVD
CV: RRR, +S3, +Systolic murmur loudest at apex
Pulm: CTAB
Abd: obese, +BS, soft, NT, ND
Ext: warm, palpable DP pulses B, + non-pitting edema to mid-leg,
venous stasis skin changes; ecchymosis over forearms bilaterally
Neuro: A+O x 3. + Asterixis bilaterally
Guaiac negative

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: No ETOH, NO Tobacco, NO drugs.  [**Name (NI) 1094**] husband and children
present and supportive.
Acute kidney failure, unspecified,Acidosis,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Percutaneous transluminal coronary angioplasty status,Unspecified acquired hypothyroidism,Anemia in chronic kidney disease,Chronic kidney disease, unspecified,Coronary atherosclerosis of autologous vein bypass graft,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere
Acute kidney failure NOS,Acidosis,Urin tract infection NOS,Hyp kid NOS w cr kid V,CHF NOS,Status-post ptca,Hypothyroidism NOS,Anemia in chr kidney dis,Chronic kidney dis NOS,Crn ath atlg vn bps grft,DMII renl nt st uncntrld,Nephritis NOS in oth dis
Admission Date:  [**2176-11-12**]              Discharge Date:   [**2176-11-18**]

Date of Birth:  [**2099-7-15**]             Sex:   F

Service: MEDICINE

Allergies:
Morphine / Iodine; Iodine Containing / Lipitor / Phenothiazines

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
77-yo-woman with DM2, CRI, HTN, CHF, CAD called out of MICU to
floor, awaiting permacath placement [**11-14**] for dialysis. Had been
admitted to MICU for mgmt of acidosis in the setting of ARF.

Major Surgical or Invasive Procedure:
Placement of right inferior jugular tunneled catheter for
hemodialysis


History of Present Illness:
Presented to ED [**11-12**] w/ tremor for 3 days, decreased appetite,
also urinary frequency x 1 week. See original MICU admission H&P
for full history and review of systems. In the [**Name (NI) **], pt was found
to have ARF w/ creatinine 6.1, K 4.8, and bicarb 10. ABG was
7.1/36/99 on room air.  Pt was admitted to the MICU for
management of acidosis/uremia.

Past Medical History:
Primary:
Bronchitis
Anemia of Chronic Renal Disease
Possible Mastitis

Secondary:
CAD/CHF s/p CABGx3 -- multiple caths, 3 stents [**5-31**], [**9-30**],
[**11-30**]
HTN
IDDM
CRI (Cr 2.4-2.7)
Hypothyroid
OA
Wheelchair bound [**1-31**] left knee removal right THR, left TKR
Polycythemia d/t erythropoetin, d/c'd [**2175-7-30**]

Social History:
No ETOH, NO Tobacco, NO drugs.  [**Name (NI) 1094**] husband and children
present and supportive.


Family History:
non-contributory

Physical Exam:
131/43 61 15 100% on 2.5L
Gen: morbidly obese woman, NAD, A+Ox3 conversing fluently
HEENT: anicteric, EOMI, MMM, no JVD
CV: RRR, +S3, +Systolic murmur loudest at apex
Pulm: CTAB
Abd: obese, +BS, soft, NT, ND
Ext: warm, palpable DP pulses B, + non-pitting edema to mid-leg,
venous stasis skin changes; ecchymosis over forearms bilaterally
Neuro: A+O x 3. + Asterixis bilaterally
Guaiac negative


Pertinent Results:
[**2176-11-12**] 07:48PM   GLUCOSE-164* UREA N-110* CREAT-5.8*
SODIUM-143 POTASSIUM-4.6 CHLORIDE-113* TOTAL CO2-12* ANION
GAP-23*
[**2176-11-12**] 07:48PM   CK(CPK)-28
[**2176-11-12**] 07:48PM   cTropnT-0.05*
[**2176-11-12**] 04:15PM   ABG PO2-99 PCO2-36 PH-7.10* TOTAL CO2-12*
BASE XS--17
[**2176-11-12**] 04:15PM   LACTATE-0.7 NA+-142 K+-4.3 CL--115*
[**2176-11-12**] 04:15PM   HGB-11.6* calcHCT-35
[**2176-11-12**] 04:15PM   freeCa-1.23
[**2176-11-12**] 03:48PM   WBC-6.2 RBC-4.01*# HGB-12.8# HCT-42.8#
MCV-107*# MCH-31.9 MCHC-29.9*# RDW-16.6*
[**2176-11-12**] 03:48PM   NEUTS-75.3* BANDS-0 LYMPHS-16.8* MONOS-3.8
EOS-3.0 BASOS-1.2
[**2176-11-12**] 03:48PM   PLT COUNT-132*
[**2176-11-12**] 01:55PM URINE  COLOR-Straw APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
[**2176-11-12**] 01:55PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2176-11-12**] 01:55PM URINE  RBC-[**6-7**]* WBC->1000 BACTERIA-MANY
YEAST-NONE EPI-0
[**2176-11-12**] 01:25PM   GLUCOSE-111* UREA N-113* CREAT-6.1*#
SODIUM-142 POTASSIUM-4.5 CHLORIDE-112* TOTAL CO2-10* ANION
GAP-25*
[**2176-11-12**] 01:25PM   CK(CPK)-32
[**2176-11-12**] 01:25PM   CK-MB-NotDone cTropnT-0.06*
[**2176-11-12**] 01:25PM   ASA-NEG ETHANOL-NEG ACETMNPHN-6.6
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG

Brief Hospital Course:
77-yo-woman w/ DM2, CAD, HTN, CRI and ARF, CHF presenting w/
improving tremor, improving acidemia secondary to uremia, also
w/ UTI and anemia.
.
1. Non-oliguric ARF on CRF, Uremia/Acidemia: ARF with Cr
increase from 3 to 6.1 was likely secondary to prerenal azotemia
from hypovolemia, given decreased PO intake over past 2 weeks,
though FENa of 4% supports intrinsic renal etiology. UTI is
another possible exacerbating factor, though unlikely as no
signs of pyelonephritis. The pt had evidence of uremia with
decreasing appetite, asterixis, and acidosis, no hyperkalemia.
The patient was admitted to the MICU on presentation for
management of uremia and acidosis.  A bicarbonate gtt was
initiated [**11-12**], and discontinued [**11-13**], after repeat ABG was
7.24/47/133/21.  Asterixis/tremor subsequently diminished.  The
patient was transferred from the MICU to the Medicine floor
service on [**11-13**].

The patient was followed by the nephrology team during the
course of her admission. Renal U/S performed [**11-13**] showed no
obstruction or hydronephrosis.
Given the pt's diabetes and worsening renal status, the
nephrology team recommended initiation of hemodialysis. The pt
received a tunneled right IJ catheter placed by IR on [**11-14**], and
started hemodialysis [**11-15**]. She received daily hemodialysis on
[**11-15**].  During her admission, the patient had weight,
fluid status, and electrolytes monitored daily.  She also was
started on Lisinopril by the nephrology team.  She was also seen
by transplant surgery, to discuss eventual need for AV fistula
placement for hemodialysis.  The patient was subsequently set up
for outpatient dialysis, and had her first appointment [**11-20**] at
11:15AM.
.
2. UTI: The pt was found to have a UTI on UA on admission, but
no fever or other signs of systemic infection.  Her acute
urinary infection may have contributed to her ARF. UCx >100,000
enterococcus, initially treated empirically w/ levofloxacin; the
patient received a full 3 day course which finished [**11-14**];
however, urine culture/sensitivities subsequently came back as
Levo resistant, and the pt's foley was removed, and she was
started on Vancomycin [**11-16**].  The pt was renally dosed, based on
trough levels; [**11-17**] Vanc trough was 6.8, and the patient
received an additional dose that day. Trough on [**11-18**] was 17.7,
and no further doses of vancomycin were given.  The pt remained
afebrile, with no elevation in white count.
.
3. CAD: The patient had a h/o CABG, stents, severe 3VD, w/ some
partially reversible defects on last PMIBI.  No cardiac symptoms
or EKG changes on admission. On admssion, troponin was elevated
at 0.06, however CK/MB were normal, and tropinin levels remained
constant; therefore, elevated troponin therefore most likely due
to renal failure.  On [**11-15**] during her first hemodialysis
session, the pt developed 5/10 chest pain which lasted 5
minutes, and spontaneously resolved, no associated symptoms. EKG
showed new left bundle (previously had IVCD) and peaked T waves.
 The patient never had any further chest pain, shortness of
breath or palpitations.  She remained on her home regimen of
ASA, Plavix, Metoprolol, Nitropatch, and statin.

4 Hypercarbia: The patient's ABGs showed respiratory acidosis
along with metabolic acidosis. The patient is a very obese woman
who reportedly snores at night, thus calling into question
possibility of pickwickean syndrome vs. sleep apnea.  Pulm
consult was requested, who stated that the patient has a
physiologically abnormal response to hypercarbia, and
recommmended obtaining a sleep study as outpatient.  During the
course of her admission, the team also attempted to limit
administration of narcotics, in order to minimize respiratory
depression. ABG's were checked daily until [**11-15**]; post-dialysis
ABG was attempted by multiple providers but failed, and pt
refused further attempts.  Renal team subsequently followed
bicarbonate levels on chem-10 during daily dialysis.
.
5. DM2: Controlled w/ home regimen of NPH 25units qam, Humalog
SS
.
5. HTN: Metoprolol, clonidine, nitro patch, lisinopril 2.5 mg qd
was started [**11-16**].
.
6. Anemia: Secondary to chronic renal disease, Hct decreased
from 42 [**11-12**] to 32.8 [**11-13**]. Guaiac negative. Possibly was
hemoconcentrated on admission, then hydrated resulting in
dilution. Erythropoietin was given at at each dialysis session.
Iron was discontinued, and the pt was started on nephrocaps.
.
7. Hypothyroid: Controlled w/ home regimen of Levoxyl.
.
8. FEN: cardiac/[**Doctor First Name **] diet
.
9. Proph: heparin sc, PPI, bowel regimen
.
10. Access: Peripheral IV - PICC attempted by RN but failed.
.
12. CODE STATUS:  Pt was initially DNR/DNI, however, pt
subseuqently discussed code status with Dr. [**Last Name (STitle) **] on [**11-15**], when
she stated that she wished to be full code, and would accept
intubation, shock, pharmacotherapy - however, that she did not
wish to have prolonged measures.

The patient was discharged on [**11-18**], after receiving her 3rd
in-house course of hemodialysis; she was scheduled for her first
outpatient dialysis session for [**11-20**].

Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Calcium Acetate 667 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Chronic renal failure/Acute renal failure, DMTypeII, coronary
artery disease, hypertension, urinary tract infection


Discharge Condition:
Stable


Discharge Instructions:
Outpatient hemodialysis as instructed.  Call your primary care
provider with any shortness of breath, chest pain,
edema/swelling, fever/chills, confusion, tremor, any other
worrisome symptoms

Followup Instructions:
- You have an appointment for dialysis at [**Location (un) **] [**Location (un) **],
Wednesday [**11-20**] 11:15AM, then on Tues/Thurs/Saturday
- Please call Dr.[**Name (NI) 5452**] office for follow-up appointment in [**2-1**]
weeks
- Please call [**Telephone/Fax (1) 6856**] to schedule a sleep study to evaluate
for sleep apnea



Completed by:[**2176-11-18**]
{'Acute kidney failure, unspecified,Acidosis,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Percutaneous transluminal coronary angioplasty status,Unspecified acquired hypothyroidism,Anemia in chronic kidney disease,Chronic kidney disease, unspecified,Coronary atherosclerosis of autologous vein bypass graft,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere'}


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: 77-yo-woman with DM2, CRI, HTN, CHF, CAD called out of MICU to
floor, awaiting permacath placement [**11-14**] for dialysis. Had been
admitted to MICU for mgmt of acidosis in the setting of ARF.

PRESENT ILLNESS: Presented to ED [**11-12**] w/ tremor for 3 days, decreased appetite,
also urinary frequency x 1 week. See original MICU admission H&P
for full history and review of systems. In the [**Name (NI) **], pt was found
to have ARF w/ creatinine 6.1, K 4.8, and bicarb 10. ABG was
7.1/36/99 on room air.  Pt was admitted to the MICU for
management of acidosis/uremia.

MEDICAL HISTORY: Primary:
Bronchitis
Anemia of Chronic Renal Disease
Possible Mastitis

MEDICATION ON ADMISSION: 

ALLERGIES: Morphine / Iodine; Iodine Containing / Lipitor / Phenothiazines

PHYSICAL EXAM: 131/43 61 15 100% on 2.5L
Gen: morbidly obese woman, NAD, A+Ox3 conversing fluently
HEENT: anicteric, EOMI, MMM, no JVD
CV: RRR, +S3, +Systolic murmur loudest at apex
Pulm: CTAB
Abd: obese, +BS, soft, NT, ND
Ext: warm, palpable DP pulses B, + non-pitting edema to mid-leg,
venous stasis skin changes; ecchymosis over forearms bilaterally
Neuro: A+O x 3. + Asterixis bilaterally
Guaiac negative

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: No ETOH, NO Tobacco, NO drugs.  [**Name (NI) 1094**] husband and children
present and supportive. 

### Response:
{'Acute kidney failure, unspecified,Acidosis,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Percutaneous transluminal coronary angioplasty status,Unspecified acquired hypothyroidism,Anemia in chronic kidney disease,Chronic kidney disease, unspecified,Coronary atherosclerosis of autologous vein bypass graft,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere'}
