CHIEF COMPLAINT: bilateral flank pain

PRESENT ILLNESS: Ms. [**Known lastname 17301**] is a 64 yo female h/o urinary retension, stroke,
cardiac arrest, hypertension who presents from her [**Hospital 4382**] facility with bilateral flank pain. This pain began on
[**7-25**] and has progressively worsened. She also noted subjective
fevers and chills and mild nausea though no vomiting. Patient's
aid called 911 given concern.
.
In the ED, vitals were: 101.4 128/80 87 24-28 97% RA. CT
ABD/PELV showed Left UPJ and UVJ stones, with associated left
mild hydroureter and mild pelvocaliectasis with surrounding
stranding. Seen by urology who recommended percutaneous
nephrostomy tube by IR. She received 1 L NS and Cipro IV x 1 an
flagyl. Highest fever was 101.4.
.
On the floor, patient describes mainly L sided flank pain.
Otherwise feeling thirsty.

MEDICAL HISTORY: MEDICAL HISTORY:
1. hypertension
2. gait disorder s/p CVA
3. urinary incontinence x12 months
4. hydronephrosis
5. chronic kidney disease: crt low to mid 2's
6. post-menopausal vaginal bleeding with thickened endometrial
stripe
7. remote deep venous thrombosis
8. hypothyroidism s/p partial thyroidectomy
9. cardiac arrest 1/05 per report
10. depression
11. pvd ?: seen by Dr. [**Last Name (STitle) **] of vascular surgery [**8-27**] but no
note from that visit, arterial studies normal [**4-/2146**]
12. Basal cell carcinoma of the left upper lip, s/p Mohs'
surgery
in [**1-/2149**]

MEDICATION ON ADMISSION: Lasix 160 mg TID
Labetolol 300mg TID
Nortriptyline 25mg QAM, 50mg QPM
Sertraline 100mg daily
ASA 81 mg daily (not compliant)
Ergocalciferol 50,000 IU qmonthly

ALLERGIES: Benadryl / Penicillins / Morphine

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, + LLQ tenderness and mild RLQ tenderness,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, 2+ LE edema, no clubbing or
cyanosis
Neuro: AOx3, CN II-XII grossly intact, 5/5 strength bilateral
UEs, [**3-24**] in RLE, 4+/5 LLE

FAMILY HISTORY: She was adopted; her mother died when she was very young, and
her father abused alcohol.

SOCIAL HISTORY: The patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Scientist. She lives alone in a
facility for handicapped senior citizens; her boyfriend lives
two blocks away. She denies tobacco, alcohol, or illicit drug
use or abuse.
Calculus of ureter,Acute kidney failure, unspecified,Acute pyelonephritis without lesion of renal medullary necrosis,Pulmonary collapse,Hydronephrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diarrhea,Depressive disorder, not elsewhere classified,Postsurgical hypothyroidism,Urinary incontinence, unspecified
Calculus of ureter,Acute kidney failure NOS,Ac pyelonephritis NOS,Pulmonary collapse,Hydronephrosis,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Diarrhea,Depressive disorder NEC,Postsurgical hypothyroid,Urinary incontinence NOS
Admission Date:  [**2150-7-27**]              Discharge Date:   [**2150-8-1**]

Date of Birth:  [**2085-9-6**]             Sex:   F

Service: MEDICINE

Allergies:
Benadryl / Penicillins / Morphine

Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
bilateral flank pain

Major Surgical or Invasive Procedure:
Left percutaneous nephrostomy placement ([**2150-7-27**])

History of Present Illness:
Ms. [**Known lastname 17301**] is a 64 yo female h/o urinary retension, stroke,
cardiac arrest, hypertension who presents from her [**Hospital 4382**] facility with bilateral flank pain. This pain began on
[**7-25**] and has progressively worsened. She also noted subjective
fevers and chills and mild nausea though no vomiting. Patient's
aid called 911 given concern.
.
In the ED, vitals were: 101.4 128/80 87 24-28 97% RA. CT
ABD/PELV showed Left UPJ and UVJ stones, with associated left
mild hydroureter and mild pelvocaliectasis with surrounding
stranding. Seen by urology who recommended percutaneous
nephrostomy tube by IR. She received 1 L NS and Cipro IV x 1 an
flagyl. Highest fever was 101.4.
.
On the floor, patient describes mainly L sided flank pain.
Otherwise feeling thirsty.


Past Medical History:
MEDICAL HISTORY:
1. hypertension
2. gait disorder s/p CVA
3. urinary incontinence x12 months
4. hydronephrosis
5. chronic kidney disease: crt low to mid 2's
6. post-menopausal vaginal bleeding with thickened endometrial
stripe
7. remote deep venous thrombosis
8. hypothyroidism s/p partial thyroidectomy
9. cardiac arrest 1/05 per report
10. depression
11. pvd ?: seen by Dr. [**Last Name (STitle) **] of vascular surgery [**8-27**] but no
note from that visit, arterial studies normal [**4-/2146**]
12. Basal cell carcinoma of the left upper lip, s/p Mohs'
surgery
in [**1-/2149**]


Social History:
The patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Scientist. She lives alone in a
facility for handicapped senior citizens; her boyfriend lives
two blocks away. She denies tobacco, alcohol, or illicit drug
use or abuse.


Family History:
She was adopted; her mother died when she was very young, and
her father abused alcohol.

Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, + LLQ tenderness and mild RLQ tenderness,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, 2+ LE edema, no clubbing or
cyanosis
Neuro: AOx3, CN II-XII grossly intact, 5/5 strength bilateral
UEs, [**3-24**] in RLE, 4+/5 LLE

CHANGES ON DISCHARGE

1) Left Nephrostomy in place
2) Less tender abdomen

Pertinent Results:
Labs on admission:

[**2150-7-27**] 02:45PM   GLUCOSE-83 UREA N-66* CREAT-4.0* SODIUM-133
POTASSIUM-3.3 CHLORIDE-94* TOTAL CO2-25 ANION GAP-17
[**2150-7-27**] 11:20AM   WBC-32.7*# RBC-4.73 HGB-13.2 HCT-40.3 MCV-85
MCH-28.0 MCHC-32.9 RDW-13.4
[**2150-7-27**] 11:20AM   NEUTS-96.1* LYMPHS-2.3* MONOS-0.8* EOS-0.4
BASOS-0.3
[**2150-7-27**] 11:20AM   PLT COUNT-207
[**2150-7-27**] 11:20AM   PT-14.9* PTT-29.6 INR(PT)-1.3*
[**2150-7-27**] 11:20AM   ALT(SGPT)-23 AST(SGOT)-43* CK(CPK)-205* ALK
PHOS-77 TOT BILI-0.5
[**2150-7-27**] 11:50AM URINE  RBC-[**4-29**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2150-7-27**] 11:50AM URINE  BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD

LABS ON DISCHARGE:
[**2150-7-29**] 08:20AM BLOOD WBC-15.4* RBC-4.00* Hgb-11.2* Hct-34.3*
MCV-86 MCH-28.1 MCHC-32.7 RDW-14.1 Plt Ct-182
[**2150-7-28**] 05:08AM BLOOD PT-13.3 PTT-26.8 INR(PT)-1.1
[**2150-7-29**] 08:20AM BLOOD Glucose-94 UreaN-68* Creat-3.8* Na-138
K-3.3 Cl-103 HCO3-25 AnGap-13

Micro:
[**2150-7-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2150-7-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2150-7-27**] 10:44 pm FLUID,OTHER      NEPHROSTOMY FLUID.

   GRAM STAIN (Final [**2150-7-28**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Preliminary):
      Due to mixed bacterial types (>=3) an abbreviated workup
is
      performed; P.aeruginosa, S.aureus and beta strep. are
reported if
      present. Susceptibility will be performed on P.aeruginosa
and
      S.aureus if sparse growth or greater..
      GRAM NEGATIVE ROD(S).    SPARSE GROWTH.
         OF TWO COLONIAL MORPHOLOGIES.
      PROBABLE ENTEROCOCCUS.    SPARSE GROWTH.

   ANAEROBIC CULTURE (Preliminary):

[**2150-7-27**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2150-7-27**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2150-7-27**] 12:00 pm BLOOD CULTURE

   Blood Culture, Routine (Preliminary):
      ESCHERICHIA COLI.    FINAL SENSITIVITIES.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

[**2150-7-27**] URINE URINE CULTURE-PENDING EMERGENCY [**Hospital1 **]

Imaging:
CT abd/pelvis ([**2150-7-27**]):
IMPRESSION
1. Left UPJ and UVJ stones, with associated left mild
hydroureter and mild
pelvocaliectasis.
2. Left perinephric and periureteric inflammatory stranding.
3. Cholelithiasis without evidence of cholecystitis.

CXR ([**2150-7-28**]):
Left lower lobe opacity. Considerations include atelectasis,
infection, or combination of the two.

Percutaneous Nephrostomy ([**2150-7-27**]):
Successful replacement of left percutaneous nephrostomy with
8-French Flexima nephrostomy tube under fluoroscopic guidance.
Mild left hydronephrosis and hydroureter noted. There is a
partially obstructing left UVJ stone and nonobstructing left UPJ
stone.


Brief Hospital Course:
IN SUMMARY
This is a 64 yo female with a history of urinary retention and
indwelling foley who presents with bilateral flank pain and
found to have L obstructing ureteral stones, leukocytosis to 32,
fever and acute on chronic renal failure. She has responded to
Meropenem and nephrostomy placement. That nephrostomy was not
putting out, so she had a nephrostogram that showed no problems
with the system but confirmed a large obstructing stone

BY PROBLEM
# Pyelonephritis/Peri-Urosepsis: The reason for her
presentation. Related to obstructing ureteral stones. Given the
stones seen on CT, her high WBC (33) and ARF (4.0 from 2.2) in
the setting of her multiple medical problems, she received ICU
care. She [**Last Name (un) **] required pressors. She was started on cipro and
flagyl and given PCN allergy was transitioned to Meropenem.
Cultures of urine and blood were positive for enterococcus and
ecoli. These were sensitive to ciprofloxacin. The patient was
kept on meropenem because of penicillin allergy and transitioned
to cipro. Surveilance cultures were negative. Pt defervesced
rapidly and WBC fell slowly.
.
# L ureteral stones: Seen by urology who rec urgent
decompression of L collecting system with PCN by IR. PCN blocked
up on [**2150-7-28**], IR assessed with nephrostogram that confirmed the
stone. She require more definitive management after this
emergent intervention. She will f/u on [**8-10**]. She was
discharged with a PCN that drained clear, bloody fluid.
.
# Acute on Chronic Renal Failure: Baseline 2-2.6. Acutely
related to ureteral stone obstruction in setting of poor renal
reserve vs pre-renal or even ATN in setting of evolving
infection and continued diuresis. She fell from 4.0 to 2.8 by
the time of discharge.
.
# HTN: Pressures currently in the 110's systolic, baseline
around 150's in setting of peri-sepsis. Continue Labetalol and
Furosemide on d/c or outpatient; was held inpatient
.
# LLL Opacity: CXR read as infection vs atelectasis. Very
possible this represents atelectasis given pt describes
splinting past few days. Could also be a sympathetic effusion.
No cough, hypoxia. Most likely atelecasis
.
# Depression: Mood stable. Cont outpt regimen of sertraline and
nortriptyline.
.
ISSUES TO BE RESOLVED OUTPATIENT
1) Pyelonephritis - cipro 500 mg until [**8-11**]
2) Kidney Stones - Urology appointment on [**8-10**]
3) Hypertension - Labetalol and furosemide were held inpatient.
[**Month (only) 116**] consider restarting if clinically indicated.


Medications on Admission:
Lasix 160 mg TID
Labetolol 300mg TID
Nortriptyline 25mg QAM, 50mg QPM
Sertraline 100mg daily
ASA 81 mg daily (not compliant)
Ergocalciferol 50,000 IU qmonthly


Discharge Medications:
1. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
2. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO QAM (once
a day (in the morning)).
3. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
standard injection Injection TID (3 times a day): As long as
immobile .
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Transport
Patient will need transportation to medical appointments on
[**2150-8-6**] and - especially - [**2150-8-10**]
8. Outpatient Physical Therapy
If indicated after rehab discharge, patient will need physical
therapy outpatient
9. Outpatient Lab Work
Please check chemistry (sodium, potassium, BUN, creatinine) on
Monday, [**8-3**].

If less than 2.0, can switch to 750 mg Ciprofloxacin daily until
[**2150-8-11**]
10. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day for 10
days: Last Day is [**2150-8-11**].
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for rash.
12. Labetalol 300 mg Tablet Sig: One (1) Tablet PO three times a
day: THIS MEDICATION WAS HELD FOR SEPSIS AND THEN PERSISTENT
NORMOTENSION. Can restart if clinically indicated.
13. Lasix 80 mg Tablet Sig: Two (2) Tablet PO three times a day:
WAS HELD THIS ADMISSION FOR SEPSIS AND THEN ACUTE RENAL FAILURE.



Discharge Disposition:
Extended Care

Facility:
[**Hospital1 4860**] - [**Location (un) 4310**]

Discharge Diagnosis:
PRIMARY
Pyelonephritis
Ureteral Stone
SECONDARY
Diarrhea
s/p Stroke


Discharge Condition:
afebrile, stable, left nephrostomy draining some bloody urine


Discharge Instructions:
You were admitted with flank pain. This was caused by a serious
kidney infection related to a stone blocking the flow of urine.
You received antibiotics and a procedure to relieve the
blockage. You did well. You will have to follow up with a
urologist to address the stone.
.
NEW MEDICATION
CIPROFLOXACIN - this is the antibiotic, take it as directed
SARNA LOTION - this will help with your rash and itch
.
Return to the hospital if you experience high fevers, severe
pain or any symptoms that concern you.
.
Follow ups:
1: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2150-8-10**]
10:15
2: After being discharged, follow up with [**Company 191**] POST [**Hospital 894**]
CLINIC Phone:[**Telephone/Fax (1) 250**]

Followup Instructions:
Upon discharge, please follow up with [**Company 191**] POST [**Hospital 894**] CLINIC
Phone:[**Telephone/Fax (1) 250**]
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2150-8-10**] 10:15



Completed by:[**2150-8-1**]
{'Calculus of ureter,Acute kidney failure, unspecified,Acute pyelonephritis without lesion of renal medullary necrosis,Pulmonary collapse,Hydronephrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diarrhea,Depressive disorder, not elsewhere classified,Postsurgical hypothyroidism,Urinary incontinence, 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: bilateral flank pain

PRESENT ILLNESS: Ms. [**Known lastname 17301**] is a 64 yo female h/o urinary retension, stroke,
cardiac arrest, hypertension who presents from her [**Hospital 4382**] facility with bilateral flank pain. This pain began on
[**7-25**] and has progressively worsened. She also noted subjective
fevers and chills and mild nausea though no vomiting. Patient's
aid called 911 given concern.
.
In the ED, vitals were: 101.4 128/80 87 24-28 97% RA. CT
ABD/PELV showed Left UPJ and UVJ stones, with associated left
mild hydroureter and mild pelvocaliectasis with surrounding
stranding. Seen by urology who recommended percutaneous
nephrostomy tube by IR. She received 1 L NS and Cipro IV x 1 an
flagyl. Highest fever was 101.4.
.
On the floor, patient describes mainly L sided flank pain.
Otherwise feeling thirsty.

MEDICAL HISTORY: MEDICAL HISTORY:
1. hypertension
2. gait disorder s/p CVA
3. urinary incontinence x12 months
4. hydronephrosis
5. chronic kidney disease: crt low to mid 2's
6. post-menopausal vaginal bleeding with thickened endometrial
stripe
7. remote deep venous thrombosis
8. hypothyroidism s/p partial thyroidectomy
9. cardiac arrest 1/05 per report
10. depression
11. pvd ?: seen by Dr. [**Last Name (STitle) **] of vascular surgery [**8-27**] but no
note from that visit, arterial studies normal [**4-/2146**]
12. Basal cell carcinoma of the left upper lip, s/p Mohs'
surgery
in [**1-/2149**]

MEDICATION ON ADMISSION: Lasix 160 mg TID
Labetolol 300mg TID
Nortriptyline 25mg QAM, 50mg QPM
Sertraline 100mg daily
ASA 81 mg daily (not compliant)
Ergocalciferol 50,000 IU qmonthly

ALLERGIES: Benadryl / Penicillins / Morphine

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, + LLQ tenderness and mild RLQ tenderness,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, 2+ LE edema, no clubbing or
cyanosis
Neuro: AOx3, CN II-XII grossly intact, 5/5 strength bilateral
UEs, [**3-24**] in RLE, 4+/5 LLE

FAMILY HISTORY: She was adopted; her mother died when she was very young, and
her father abused alcohol.

SOCIAL HISTORY: The patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Scientist. She lives alone in a
facility for handicapped senior citizens; her boyfriend lives
two blocks away. She denies tobacco, alcohol, or illicit drug
use or abuse. 

### Response:
{'Calculus of ureter,Acute kidney failure, unspecified,Acute pyelonephritis without lesion of renal medullary necrosis,Pulmonary collapse,Hydronephrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diarrhea,Depressive disorder, not elsewhere classified,Postsurgical hypothyroidism,Urinary incontinence, unspecified'}
