CHIEF COMPLAINT: Hematuria, dyspnea.

PRESENT ILLNESS: The patient is a 58-year-old
male with a history of renal cell carcinoma status post
cadaveric renal transplant in [**2101-8-5**] with native
nephrectomy in [**2093**], hypertension with recent admission for
hypoglycemia and severe hypertension. The patient was found
to have REF status post renal stent to the transplant renal
artery on [**2104-1-30**]. There was 90% stenosis noted. At
that time, he was also hypoxic, and work-up was negative.

MEDICAL HISTORY: DM Type 2, hypertension, end-stage
renal disease, left nephrectomy for renal cell carcinoma in
[**2093**], renal artery stenosis in the transplant kidney status
post PTCA in [**2104-1-6**], obstructive sleep apnea, Barrett's
esophagus, hypertension.

MEDICATION ON ADMISSION: CellCept [**Pager number **] mg p.o. b.i.d.,
Rapamune 4 mg p.o. daily, prednisone 5 mg p.o. daily, Bactrim
single strength 1 tablet p.o. q.Monday, Wednesday and Friday,
NPH Insulin 10 units q.a.m., clonidine 0.3 mg p.o. b.i.d.,
Lasix 40 mg p.o. daily, labetalol 400 mg p.o. t.i.d., aspirin
325 mg p.o. daily.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: Mother with renal disease.

SOCIAL HISTORY: The patient is married. He works in the
nutrition department at [**Hospital6 256**].
He denies alcohol, drugs and smoking.
Hemoglobinuria due to hemolysis from external causes,Acute posthemorrhagic anemia,Unspecified essential hypertension,Unspecified sleep apnea,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of kidney,Kidney replaced by transplant,Hypercalcemia
Hemolytic hemoglobinuria,Ac posthemorrhag anemia,Hypertension NOS,Sleep apnea NOS,DMII wo cmp nt st uncntr,Hx of kidney malignancy,Kidney transplant status,Hypercalcemia
Admission Date: [**2104-2-3**]        Discharge Date: [**2104-2-8**]

Date of Birth:  [**2045-12-2**]        Sex:  M

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


CHIEF COMPLAINT:  Hematuria, dyspnea.

HISTORY OF PRESENT ILLNESS:  The patient is a 58-year-old
male with a history of renal cell carcinoma status post
cadaveric renal transplant in [**2101-8-5**] with native
nephrectomy in [**2093**], hypertension with recent admission for
hypoglycemia and severe hypertension. The patient was found
to have REF status post renal stent to the transplant renal
artery on [**2104-1-30**]. There was 90% stenosis noted. At
that time, he was also hypoxic, and work-up was negative.

An angiogram was done. He was found to have a 14 mm x 8 mm
soft tissue mass in the area of the left nephrectomy site. He
complained of dyspnea on exertion and some chest pain, as
well as some weakness in his legs when walking. He complained
of hematuria since his previous admission with bilateral
groin pain. He also complained of positive chest pain and
light-headedness but denied dyspnea, nausea, vomiting and
diarrhea.

PAST MEDICAL HISTORY:  DM Type 2, hypertension, end-stage
renal disease, left nephrectomy for renal cell carcinoma in
[**2093**], renal artery stenosis in the transplant kidney status
post PTCA in [**2104-1-6**], obstructive sleep apnea, Barrett's
esophagus, hypertension.

PAST SURGICAL HISTORY:  Left nephrectomy in [**2093**], AV graft on
the left upper extremity, right lower extremity AV fistula,
nasal polyps, asthma.

MEDICATIONS ON ADMISSION:  CellCept [**Pager number **] mg p.o. b.i.d.,
Rapamune 4 mg p.o. daily, prednisone 5 mg p.o. daily, Bactrim
single strength 1 tablet p.o. q.Monday, Wednesday and Friday,
NPH Insulin 10 units q.a.m., clonidine 0.3 mg p.o. b.i.d.,
Lasix 40 mg p.o. daily, labetalol 400 mg p.o. t.i.d., aspirin
325 mg p.o. daily.

SOCIAL HISTORY:  The patient is married. He works in the
nutrition department at [**Hospital6 256**].
He denies alcohol, drugs and smoking.

FAMILY HISTORY:  Mother with renal disease.

PHYSICAL EXAMINATION:  Vital signs: Temperature 98.2, heart
rate 82, blood pressure 132/50, respiratory rate 18, 94% on
room air. General: He was alert and oriented in mild
distress. Lungs: Rhonchi diffusely throughout.
Cardiovascular: Regular rate and rhythm. There was a 3 out of
6 systolic ejection murmur. Abdomen: Soft, tender inferior to
the allograft, negative bruit.

LABORATORY DATA:  Hematocrit on admission was 20, previous
hematocrit had been 28 on [**1-27**]; sodium 135, potassium
4.3, chloride 100, CO2 28, BUN 22, creatinine 2.0.

On admission CT without contrast was done to evaluate the
falling hematocrit and right groin pain with elevated
creatinine, as well as hematuria. Findings demonstrated no
retroperitoneal hematoma, there was interval washout of
increased attenuation seen within the transplanted kidney
cortex consistent with washout of contrast. Stool was noted
throughout the colon consistent with constipation.

Chest x-ray demonstrated no evidence of pneumonia.

A renal transplant ultrasound demonstrated normal transplant
flow with normal arterial wave forms in the upper mid and
lower poles. Resistive indices were 0.8, 0.71 and 0.9
respectively. Venous flow and wave forms were normal as well.

Urine cytology was sent off. This demonstrated no malignant
cells, acellular debris, histiocytes, red blood cells and
bacteria. Urinalysis demonstrated RBCs [**6-14**], white blood
cells 0-2, rare growth of bacteria, no yeast, 0-2 epithelial
cells, negative nitrite, protein 100. Urine culture on
[**2104-2-3**], was negative. Repeat urine culture on
[**2104-2-4**], was contaminated. A repeat urine culture on
[**2-7**] demonstrated 10-100,000 colonies of gram-positive
bacteria, alpha-hemolytic colonies consistent with alpha
streptococcus or lactobacillus. Second isolate demonstrated
less than 10,000 organisms.

HOSPITAL COURSE:  Nephrology was consulted and followed
closely throughout this hospital course making
recommendations that were in agreement with the transplant
plan. Prednisone 5 mg was continued, as well as CellCept [**Pager number **]
mg p.o. b.i.d. and Rapamune 4 mg p.o. daily. Recommendations
included holding aspirin and Plavix; this was done.

A vascular consult was obtained for hematuria and hematocrit
of 20. An MRI was recommended to evaluate for retroperitoneal
bleed.  An MRI with and without contrast was obtained. This
demonstrated normal renal transplant located in the right
lower quadrant, patent transplant renal artery and vein, no
hydronephrosis or peritransplant collection. No cause for
hematuria was demonstrated. It was recommended to continue
the aspirin and Plavix.

He received 2 units of packed red blood cells for a
hematocrit of 20. There was concern for hemolysis with
hemoglobinuria. An LDH, haptoglobin, reticulocyte count,
parvovirus, IgG, IgAM, PCR and smear for cytoryctes were
obtained. Reticulocyte count was 3.6, fibrinogen 626, PT
11.5, PTT 20, INR 1, platelet count 317, LDH was 2640, total
bilirubin 2.2, direct bilirubin 0.4, TIBC 186, vitamin B21
1788, folate 11.8, haptoglobin was greater than [**2098**], TRF was
143.

On hospital day 4, the patient's oxygen saturation decreased
to 77%. He was placed on 4 L of oxygen. O2 saturation
improved to 100%. Lungs were clear. No edema was noted. The
patient was given an additional 2 units of packed red blood
cells.

Urine was rust color. Urology was consulted and recommended
Foley placement for hematuria with hand irrigation p.r.n. No
clots were noted. The patient was transferred to the SICU for
hemolysis work-up. No active source of bleeding was
identified. Hematuria was not enough to explain the drop in
hematocrit. Hematology/oncology was consulted to evaluate
anemia.

The concern was for hemolysis secondary to renal artery
stent. On admission to the SICU, it was noted that the
patient's blood sugar was greater than 500. He also
complained of some nausea and frequent urination. He was
placed on an insulin drip. Of note, the patient had received
a total of 6 units of packed red blood cells for anemia. His
hemodynamics were stable, and his lungs were clear
bilaterally.

Of note, the patient had a sleep study done last summer with
saturations to the mid 70s. He had not followed up; BIPAP was
recommended.

Repeat hematocrit was 25.3, white count 19.1.

Hematology/oncology consult was obtained. Given the elevated
LDH, total bilirubin and decreased haptoglobin, it was felt
that the patient had acute intravascular hemolysis likely
secondary to recent renal artery stent placement. There was
no evidence of immune mediated process given negative DAT,
negative indirect Coombs or infection. There was no
indication of underlying hemoglobinopathy. There was no
evidence of TTT or TIC given coags and normal platelets.

Recommendations included evaluating for possible removal of
stent and options for revision of the renal artery. Folic
acid was suggested with continuation of packed red blood
cells to improve hematocrit.

During this time in the SICU, the patient was afebrile, heart
rate in the 70s, blood pressure 143/61 to 150/76, respiratory
rate 13. It was difficult to obtain an O2 saturation from any
body location. Lisinopril 5 mg p.o. daily was started for
blood pressure control. Hematocrit was stable between 25 and
24. Hemolysis stabilized.

The Foley was removed. The patient was transferred back to
the medical surgical unit. White count had decreased to 14.5.
He was afebrile. He was retransfused with 2 more units of
packed red blood cells on [**2104-2-5**]. As noted, AV
fistula was positive for bruit and thrill. His lungs were
diminished bilaterally. There were no signs of respiratory
distress. His abdomen was soft and distended. He was
tolerating a regular diet.

On [**2104-2-6**], he reported shortness of breath without
chest pain. His O2 saturation was 98% on room air. An EKG
revealed ST changes in the lateral leads. The patient
appeared comfortable, breathing on nasal cannula O2 2 L with
a saturation of 98%. He was given morphine sulfate 1 mg IV,
aspirin 325 mg daily.

Chest x-ray was done which showed no evidence of congestive
heart failure. The patient was in sinus rhythm and was sinus
tachycardia with a heart rate of 75-110 without ectopy.
Cardiac enzymes were sent off. CPK was 1207; repeat CPK was
1202, CKMB 2, troponin 0.04, calcium 10.7, magnesium 2.1,
potassium 3.6, hematocrit 33.

EKG was unchanged from the previous EKG.

He was started on Epogen, Monday, Wednesday and Friday, with
continuation of folate. He was continued on aspirin and
Plavix to prevent stent occlusion. Of note, the hemolysis
appeared to be improving. Repeat UA demonstrated greater than
50 RBCs, 6-10 WBCs, [**3-9**] epithelial cells with positive
nitrite and greater than 300 of protein. He was started on
Levaquin for UTI. Urine culture was positive for gram-
positive bacteria, 100,000 alpha-hemolytic colonies
consistent with alpha strep or lactobacillus. White count was
11.6, and creatinine was 2.1.

Urology recommended doing a cystoscopy as an outpatient to
rule out bladder mass.

Hematology/oncology continued to follow throughout this
hospital course. The peripheral smear was reviewed;
spherocytes with nucleated RBCs with marked anisocytosis.
There were not as many cytoryctes as would have been expected
for microangiopathic hemolysis. A G6PD level was requested
with flow cytometry for PNH CD55 and CD59. G6PD was 6.7 with
[**Doctor Last Name 17012**] bodies being negative.

The patient was discharged home on [**2104-2-8**], in
stable condition without active hemolysis. His urine was
clearing. He was scheduled to followup in the outpatient
urology department for cystoscopy. He was alert and oriented.
He denied any pain. He had trace edema in his legs. His
breath sounds were clear. His abdomen was slightly distended
but soft and nontender. He was tolerating a regular diet and
voiding dark yellow urine independently. He is ambulatory.

DISCHARGE MEDICATIONS:  Folic acid 1 mg p.o. daily, CellCept
[**Pager number **] mg p.o. b.i.d., levofloxacin 250 mg p.o. daily x 6 days,
Lasix 40 mg p.o. daily, Epogen 10,000 units every Monday,
Wednesday and Friday, lisinopril 5 mg p.o. daily, aspirin 325
mg p.o. daily, lansoprazole 30 mg p.o. daily, pregnancy 5 mg
p.o. daily, clonidine 0.1 mg p.o. b.i.d., amlodipine 10 mg
p.o. daily, Bactrim single strength 1 tablet every Monday,
Wednesday and Friday, Rapamune 4 mg p.o. daily, NPH insulin
20 units q.a.m. and 18 units q.p.m. with insulin Humalog
sliding scale q.i.d. p.r.n.

FOLLOW UP:  He was scheduled to followup with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on [**2104-2-20**], at 10 a.m., as well as with
hematology and with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] for cystoscopy.

DISCHARGE DIAGNOSES:
1.  Spherocytic anemia.
2.  Hypertension.
3.  Diabetes mellitus, Type 2.
4.  Sleep apnea.
5.  Status post renal transplant with renal artery stent.
    Discharge Rapamune level was 5.6.



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

Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D:  [**2104-4-1**] 11:38:38
T:  [**2104-4-1**] 14:14:38
Job#:  [**Job Number 21868**]
{'Hemoglobinuria due to hemolysis from external causes,Acute posthemorrhagic anemia,Unspecified essential hypertension,Unspecified sleep apnea,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of kidney,Kidney replaced by transplant,Hypercalcemia'}


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: Hematuria, dyspnea.

PRESENT ILLNESS: The patient is a 58-year-old
male with a history of renal cell carcinoma status post
cadaveric renal transplant in [**2101-8-5**] with native
nephrectomy in [**2093**], hypertension with recent admission for
hypoglycemia and severe hypertension. The patient was found
to have REF status post renal stent to the transplant renal
artery on [**2104-1-30**]. There was 90% stenosis noted. At
that time, he was also hypoxic, and work-up was negative.

MEDICAL HISTORY: DM Type 2, hypertension, end-stage
renal disease, left nephrectomy for renal cell carcinoma in
[**2093**], renal artery stenosis in the transplant kidney status
post PTCA in [**2104-1-6**], obstructive sleep apnea, Barrett's
esophagus, hypertension.

MEDICATION ON ADMISSION: CellCept [**Pager number **] mg p.o. b.i.d.,
Rapamune 4 mg p.o. daily, prednisone 5 mg p.o. daily, Bactrim
single strength 1 tablet p.o. q.Monday, Wednesday and Friday,
NPH Insulin 10 units q.a.m., clonidine 0.3 mg p.o. b.i.d.,
Lasix 40 mg p.o. daily, labetalol 400 mg p.o. t.i.d., aspirin
325 mg p.o. daily.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: Mother with renal disease.

SOCIAL HISTORY: The patient is married. He works in the
nutrition department at [**Hospital6 256**].
He denies alcohol, drugs and smoking. 

### Response:
{'Hemoglobinuria due to hemolysis from external causes,Acute posthemorrhagic anemia,Unspecified essential hypertension,Unspecified sleep apnea,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of kidney,Kidney replaced by transplant,Hypercalcemia'}
