CHIEF COMPLAINT: Hypoxia s/p elective ERCP

PRESENT ILLNESS: This is a 75 yo F with a past medical history significant for
COPD, CHF, CAD s/p CABG, CVA, who became increasingly hypoxic
and tachypneic following an elective ERCP today. The patient was
recently admitted to an OSH with cholangitis, treated and sent
to [**Hospital1 599**] [**Hospital1 1501**] in [**Location (un) 1439**] with this ERCP scheduled electively.
.
On the last admission in [**4-24**], the patient reportedly had
cholangitis induced sepsis. She underwent an ERCP at that time
and had a stent placed in the CBD. She was treated with
antibiotics and volume resuscitation and discharged to [**Hospital1 1501**] with
a scheduled follow up ERCP when the patient had stabilized.
.
From the ERCP periprocedure notes, the patient arrived today
satting 88% on 4L by NC. She was intubated for the procedure and
received a total of 400cc LR during the procedure and 500cc of
fluid in the PACU. She then gradually became more tachypneic to
20-25 and desatted to 88% on 4L, which increased to the low 90's
on 6L. She was given a nebulizer and a MICU eval was requested.

MEDICAL HISTORY: COPD
CAD s/p CABG, s/p MI
CHF (reported EF=50%)
HTN
s/p CVA, on coumadin - residual L hemiparesis
recent history of cholangitis s/p ERCP in [**4-24**] with gallstones
identified; reportedly was septic at this time.
Hyperlipidemia
Hx of psychosis
GERD, PUD
Hypothyroidism
5cm AAA
s/p R hip replacement
Paget's ds
depression, anxiety
Constipation
Diverticulosis
dementia

MEDICATION ON ADMISSION: Tylenol prn
Bisacodyl
MOM
nitroglycerin prn
compazine
colace
K-dur
Isosorbide dinitrate
Advair
Albuterol
Spiriva
reglan
ativan prn
vicodin prn
Amlodipine
zyprexa
MVI
prednisone 2.5mg qdaily
coumadin 5mg qhs (on hold for procedure)
Ritalin 10mg [**Hospital1 **]
lasix 20mg [**Hospital1 **]
metoprolol 25mg [**Hospital1 **]
lexapro 20mg

ALLERGIES: Aspirin / Nsaids

PHYSICAL EXAM: vitals: T 96.2 HR 101 BP 157/67 R 18 Sat 88-96% on facemask with
nasal airway in place
General: elderly female, asleep, drowsy, NAD
HEENT: AT/NC, PERRL, OP clear. MMM
neck: JVP elevated to earlobes
chest: RRR
lungs: decreased lung volumes with dependent rales
abd: obese, soft NT/ND +BS
ext: no e/c/c
neuro: unable to do full neuro exam as patient is extremely
sleepy. DTR's in tact bilaterally.
skin: wwp.

FAMILY HISTORY: NC

SOCIAL HISTORY: 
Urinary complications, not elsewhere classified,Acute kidney failure, unspecified,Calculus of bile duct without mention of cholecystitis, without mention of obstruction,Chronic airway obstruction, not elsewhere classified,Mixed acid-base balance disorder,Congestive heart failure, unspecified,Chronic kidney disease, unspecified,Urinary tract infection, site not specified,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Long-term (current) use of anticoagulants,Late effects of cerebrovascular disease, aphasia,Unspecified acquired hypothyroidism,Other persistent mental disorders due to conditions classified elsewhere,Depressive disorder, not elsewhere classified,Hip joint replacement,Osteitis deformans without mention of bone tumor,Hypotension, unspecified,Abdominal aneurysm without mention of rupture,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified
Surg compl-urinary tract,Acute kidney failure NOS,Choledocholithiasis NOS,Chr airway obstruct NEC,Mixed acid-base bal dis,CHF NOS,Chronic kidney dis NOS,Urin tract infection NOS,Obstructive sleep apnea,Hyperlipidemia NEC/NOS,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Long-term use anticoagul,Late eff CV dis-aphasia,Hypothyroidism NOS,Mental disor NEC oth dis,Depressive disorder NEC,Joint replaced hip,Osteitis deformans NOS,Hypotension NOS,Abdom aortic aneurysm,Hy kid NOS w cr kid I-IV
Name:  [**Known lastname 12274**],[**Known firstname 12275**]                   Unit No:   [**Numeric Identifier 12276**]

Admission Date:  [**2186-6-23**]              Discharge Date:   [**2186-7-1**]

Date of Birth:  [**2110-10-11**]             Sex:   F

Service: MEDICINE

Allergies:
Aspirin / Nsaids

Attending:[**First Name3 (LF) 12277**]
Addendum:
Lasix was not included in the prior discharge summary
medications on discharge.  The revised list includes Lasix 20mg
po daily.

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
4. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed for wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Metoprolol Tartrate 25 mg Tablet Sig: one half Tablet PO
twice a day.
20. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
21. Furosemide 20mg tablet Sig:  one (1) tablet po daily

Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12278**] Care Center - [**Location (un) **]

                             [**First Name11 (Name Pattern1) 801**] [**Last Name (NamePattern4) 12279**] MD [**MD Number(2) 12280**]

Completed by:[**2186-7-1**]

Admission Date:  [**2186-6-23**]              Discharge Date:   [**2186-7-1**]

Date of Birth:  [**2110-10-11**]             Sex:   F

Service: MEDICINE

Allergies:
Aspirin / Nsaids

Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
Hypoxia s/p elective ERCP

Major Surgical or Invasive Procedure:
ERCP

History of Present Illness:
This is a 75 yo F with a past medical history significant for
COPD, CHF, CAD s/p CABG, CVA, who became increasingly hypoxic
and tachypneic following an elective ERCP today. The patient was
recently admitted to an OSH with cholangitis, treated and sent
to [**Hospital1 599**] [**Hospital1 1501**] in [**Location (un) 1439**] with this ERCP scheduled electively.
.
On the last admission in [**4-24**], the patient reportedly had
cholangitis induced sepsis. She underwent an ERCP at that time
and had a stent placed in the CBD. She was treated with
antibiotics and volume resuscitation and discharged to [**Hospital1 1501**] with
a scheduled follow up ERCP when the patient had stabilized.
.
From the ERCP periprocedure notes, the patient arrived today
satting 88% on 4L by NC. She was intubated for the procedure and
received a total of 400cc LR during the procedure and 500cc of
fluid in the PACU. She then gradually became more tachypneic to
20-25 and desatted to 88% on 4L, which increased to the low 90's
on 6L. She was given a nebulizer and a MICU eval was requested.

.
On initial evaluation, the patient was slightly tachypneic,
satting 89-91% on 6L by facemask. An ABG and CXR were requested
and given the patient's history of CHF and the fact that she
takes daily lasix and received almost 1L of fluid in several
hours, a dose of 40mg IV lasix was suggested as well.
.
A foley was placed and lasix administered, which the patient
responded to promptly, with improvement of her symptoms. CXR was
confirmatory for diffuse perihilar infiltrates characteristic of
pulmonary edema. Anesthesia placed an a-line and then obtained
an ABG which was 7.30/66/93 and after several hundred cc's of
diuresis, it improved to 7.34/63/98 (on 6L facemask). She was
then transferred to the [**Hospital Unit Name 153**] for further management.


Past Medical History:
COPD
CAD s/p CABG, s/p MI
CHF (reported EF=50%)
HTN
s/p CVA, on coumadin - residual L hemiparesis
recent history of cholangitis s/p ERCP in [**4-24**] with gallstones
identified; reportedly was septic at this time.
Hyperlipidemia
Hx of psychosis
GERD, PUD
Hypothyroidism
5cm AAA
s/p R hip replacement
Paget's ds
depression, anxiety
Constipation
Diverticulosis
dementia


Family History:
NC

Physical Exam:
vitals: T 96.2 HR 101 BP 157/67 R 18 Sat 88-96% on facemask with
nasal airway in place
General: elderly female, asleep, drowsy, NAD
HEENT: AT/NC, PERRL, OP clear. MMM
neck: JVP elevated to earlobes
chest: RRR
lungs: decreased lung volumes with dependent rales
abd: obese, soft NT/ND +BS
ext: no e/c/c
neuro: unable to do full neuro exam as patient is extremely
sleepy. DTR's in tact bilaterally.
skin: wwp.


Pertinent Results:
[**2186-6-23**] 09:30AM   WBC-5.3 RBC-3.67* HGB-11.3* HCT-32.6* MCV-89
MCH-30.7 MCHC-34.6 RDW-18.2*
[**2186-6-23**] 09:30AM   PLT COUNT-306
[**2186-6-23**] 09:30AM   PT-13.2* PTT-27.3 INR(PT)-1.2*
[**2186-6-23**] 06:38PM   GLUCOSE-126* UREA N-35* CREAT-1.5*
SODIUM-146* POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-34* ANION
GAP-13
[**2186-6-23**] 06:38PM   ALT(SGPT)-12 AST(SGOT)-20 LD(LDH)-342*
CK(CPK)-88 ALK PHOS-88 TOT BILI-0.4
[**2186-6-23**] 06:38PM   CK-MB-6 cTropnT-0.08*
[**2186-6-23**] 06:43PM   LACTATE-0.8
[**2186-6-23**] 11:15PM   CK-MB-6 cTropnT-0.08*
.
[**6-23**]: CXR: IMPRESSION: 1. Left lower lobe opacity, suspicious for
pneumonic consolidation. 2. Congestive heart failure.
.
ERCP report [**2186-6-23**]:
1. Stent in the major papilla which was removed.
2. Stones in the biliary tree
3. Cholagiogram showed the presence of 2 stones in the distal
CBD.
4. Balloon sweeps were done to remove the stones.
5. A sphincterotomy was performed in the 12 o'clock position
using a sphincterotome over an existing guidewire.
.


Brief Hospital Course:
75 yo F with acute hypoxia and tachypnea following elective
ERCP, due to volume overload, exacerbated by sleep apnea.
.
1. Respiratory Distress: Given her improved CXR and clinical
picture post-diuresis, it appeared that the primary cause of
respiratory distress was likely fluid overload, and most likely,
given that her sats were already decreased pre-procedure, that
she was already volume overloaded before even receiving the
additional liter of fluid pre-procedure. She was successfully
diuresed about 3L with noticeable improvement in pulmonary
status. Cardiac enzymes were negative x 3. Of note, the patient
has multiple apneic episodes with significant desaturations
while sleeping highly suggestive of OSA / central sleep apnea.
Blood gas analysis suggests improvement of respiratory acidosis
with bipap 10/5/5L, likely chronic compensatory metabolic
alkalosis. By the time she was transferred out to the floor, she
was on her baseline O2 requirement of 2L by NC, and tolerating
bipap at night well. On the floor the patient had one episode of
oxygen desaturation to the 70s which resolved with increasing
oxygen via nasal canula to 5L.  A cxr was obtained at that time
which showed prominent pulmonary edema.  The patient's diuretic
regimen was increased to 40mg po bid however her serum
creatinine continued to rise and her lasix was held.  Her oxygen
saturation however has remained stable at her baseline requiring
2Liters nasal canula to maintain oxygen saturation at 92-94%.
We have restarted her lasix at a lower dose of 20mg daily.  She
has continued on her prior COPD regimen of spiriva, low dose
prednisone and nebs prn.
2. s/p ERCP - patient is stable from an ERCP perspective with
successful removal of stone from CBD and subsequent
sphincterotomy. LFTs trended down and normalized by [**6-28**].  She
will only need outpatient GI follow up with Dr. [**Last Name (STitle) **] if she
develops new abdominal symptoms or has recurrent evidence of
obstruction.

3. Cardiac
Ischemia - known CAD s/p MI, CABG. No evidence of ischemia on
EKG, enzymes negative.  Her BP meds were initially held after
she was transferred to the ICU however the isosorbide was added
back upon transfer to the floor.   The patient remained chest
pain free during the entire hospitalization.  Given her history
of CAD, a lipid panel was obtained showing evidence of
hypercholesterolemia with a cholesterol total of 259, LDL 158,
and triglycerides 250.  She was started on lipitor 20mg po daily
and will need to have her LFTs monitored in the future.  We have
added back her lopressor at a lower dose of 12.5mg po twice
daily which can be titrated as needed.


5. ARF - unclear baseline creatinine, prior cr of 1.5 suggesting
likely CKD at baseline.  As discussed above, her creatinine rose
to a maximum of 2.6 and we felt this was likely attributed to
lower BP (systolics in the 110s) in combination with diuresis.
On the day of discharge her serum creatinine is 1.7.  There were
no electrolyte abnormalities during this hospitalization.  She
will need future monitoring of her renal function while at
rehab.  We suggest checking a complete metabolic panel on [**7-2**].

6. s/p CVA - coumadin held for ERCP
-Resuming coumadin at prior dose of 5mg po daily.  She will need
follow up with her PCP and neurologist regarding goals of care.
She is currently subtherapeutic and will need continued
coagulation panels.  She is not a candidate for lovenox given
her renal function and it was felt that the risks outweighed the
benefits for starting her on IV heparin at this time.  This was
discussed with the patient's daughter who serves as the
health-proxy.
.
7. Depression, anxiety, ?psychosis
- continue ritalin, lexapro
- continue to hold all sedating meds
.
7. FEN: Low sodium diet, heart healthy, puree diet. Continue to
monitor electrolytes.
.
8. PPx: heparin subcut, bowel reg, ppi was administered while
she was an inpatient.


Medications on Admission:
Tylenol prn
Bisacodyl
MOM
nitroglycerin prn
compazine
colace
K-dur
Isosorbide dinitrate
Advair
Albuterol
Spiriva
reglan
ativan prn
vicodin prn
Amlodipine
zyprexa
MVI
prednisone 2.5mg qdaily
coumadin 5mg qhs (on hold for procedure)
Ritalin 10mg [**Hospital1 **]
lasix 20mg [**Hospital1 **]
metoprolol 25mg [**Hospital1 **]
lexapro 20mg


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
4. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed for wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for wheezing.
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) 13089**] Care Center - [**Location (un) 1439**]

Discharge Diagnosis:
Respiratory failure
Acute renal failure
Altered mental status
Secondary diagnoisis:
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease
Dyslipidemia
Stroke


Discharge Condition:
stable


Discharge Instructions:
Patient should continue on 2L nasal canula titrated to keep
oxygen saturation between 90-92% given her CO2 retention.  She
will require daily monitoring of her serum creatinine while her
lasix dose is titrated back to her baseline.

Followup Instructions:
She should follow up with her PCP [**Name9 (PRE) **],[**Name9 (PRE) 74395**]
[**Telephone/Fax (1) 74396**], in [**12-20**] weeks.  She should also follow up with her
neurologist in 6 weeks time.
{'Urinary complications, not elsewhere classified,Acute kidney failure, unspecified,Calculus of bile duct without mention of cholecystitis, without mention of obstruction,Chronic airway obstruction, not elsewhere classified,Mixed acid-base balance disorder,Congestive heart failure, unspecified,Chronic kidney disease, unspecified,Urinary tract infection, site not specified,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Long-term (current) use of anticoagulants,Late effects of cerebrovascular disease, aphasia,Unspecified acquired hypothyroidism,Other persistent mental disorders due to conditions classified elsewhere,Depressive disorder, not elsewhere classified,Hip joint replacement,Osteitis deformans without mention of bone tumor,Hypotension, unspecified,Abdominal aneurysm without mention of rupture,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or 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: Hypoxia s/p elective ERCP

PRESENT ILLNESS: This is a 75 yo F with a past medical history significant for
COPD, CHF, CAD s/p CABG, CVA, who became increasingly hypoxic
and tachypneic following an elective ERCP today. The patient was
recently admitted to an OSH with cholangitis, treated and sent
to [**Hospital1 599**] [**Hospital1 1501**] in [**Location (un) 1439**] with this ERCP scheduled electively.
.
On the last admission in [**4-24**], the patient reportedly had
cholangitis induced sepsis. She underwent an ERCP at that time
and had a stent placed in the CBD. She was treated with
antibiotics and volume resuscitation and discharged to [**Hospital1 1501**] with
a scheduled follow up ERCP when the patient had stabilized.
.
From the ERCP periprocedure notes, the patient arrived today
satting 88% on 4L by NC. She was intubated for the procedure and
received a total of 400cc LR during the procedure and 500cc of
fluid in the PACU. She then gradually became more tachypneic to
20-25 and desatted to 88% on 4L, which increased to the low 90's
on 6L. She was given a nebulizer and a MICU eval was requested.

MEDICAL HISTORY: COPD
CAD s/p CABG, s/p MI
CHF (reported EF=50%)
HTN
s/p CVA, on coumadin - residual L hemiparesis
recent history of cholangitis s/p ERCP in [**4-24**] with gallstones
identified; reportedly was septic at this time.
Hyperlipidemia
Hx of psychosis
GERD, PUD
Hypothyroidism
5cm AAA
s/p R hip replacement
Paget's ds
depression, anxiety
Constipation
Diverticulosis
dementia

MEDICATION ON ADMISSION: Tylenol prn
Bisacodyl
MOM
nitroglycerin prn
compazine
colace
K-dur
Isosorbide dinitrate
Advair
Albuterol
Spiriva
reglan
ativan prn
vicodin prn
Amlodipine
zyprexa
MVI
prednisone 2.5mg qdaily
coumadin 5mg qhs (on hold for procedure)
Ritalin 10mg [**Hospital1 **]
lasix 20mg [**Hospital1 **]
metoprolol 25mg [**Hospital1 **]
lexapro 20mg

ALLERGIES: Aspirin / Nsaids

PHYSICAL EXAM: vitals: T 96.2 HR 101 BP 157/67 R 18 Sat 88-96% on facemask with
nasal airway in place
General: elderly female, asleep, drowsy, NAD
HEENT: AT/NC, PERRL, OP clear. MMM
neck: JVP elevated to earlobes
chest: RRR
lungs: decreased lung volumes with dependent rales
abd: obese, soft NT/ND +BS
ext: no e/c/c
neuro: unable to do full neuro exam as patient is extremely
sleepy. DTR's in tact bilaterally.
skin: wwp.

FAMILY HISTORY: NC

SOCIAL HISTORY:  

### Response:
{'Urinary complications, not elsewhere classified,Acute kidney failure, unspecified,Calculus of bile duct without mention of cholecystitis, without mention of obstruction,Chronic airway obstruction, not elsewhere classified,Mixed acid-base balance disorder,Congestive heart failure, unspecified,Chronic kidney disease, unspecified,Urinary tract infection, site not specified,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Long-term (current) use of anticoagulants,Late effects of cerebrovascular disease, aphasia,Unspecified acquired hypothyroidism,Other persistent mental disorders due to conditions classified elsewhere,Depressive disorder, not elsewhere classified,Hip joint replacement,Osteitis deformans without mention of bone tumor,Hypotension, unspecified,Abdominal aneurysm without mention of rupture,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}
