CHIEF COMPLAINT: acute renal failure

PRESENT ILLNESS: 81 yo Greek speaking only woman with CHF, EF 50% with cirrhosis,
portal HTN, CRI, BL 1.5 admitted to [**Hospital3 **]1 week ago
([**6-2**])with RUQ abdominal pain. RUQ US and HIDA scan per OSH
showed acute cholecystitis for which unasyn was started. Cr
gradually increased from 1.6 on admit despite hydration. Per
notes, renal was consulted and gave fluid challenge, urine lytes
with UNa of 6. Was thought to be in hepatorenal syndrome and
started on octreotide and midodrine with minimal response. per
notes, also started on IV steroids and dopamine at times for ?
hypotension, though none documented. Urine output 100 cc for
past 24 hours with gradual increase in LE edema
Was afebrile throughout with no localizing sx. other than
continued RUQ abdominal pain. On d/c, labs significant for Na
131, HCO3 16, BUN 62, Cr 4.0. CBC, INR 1.4. On day of transfer
had emesis X1 and O2 transiently decreased with new o2
requirement of 4L. ABG 7.20/33/127 on 4L. Family concerned with
care at [**Location (un) **] and requested transfer to [**Hospital1 18**].
.
In ambulance, apparently pt. with desats and increased lethargy.
In ED, afebrile satting well. CKs flat, head CT done, and
negative.

MEDICAL HISTORY: - CHF with EF 50%, severe tricuspid regurg, R pulmonary HTN on
ECHO in [**2120**].
- Atrial fibrillation, not on coumadin since subdural bleed s/p
fall 4 years ago
- Anemia
- h/o pancreatitis
- dyslipidemia
- Hypothyroidism
- Hepatic cirrhosis NOS with portal HTN
- pancytopenia
- Dementia

MEDICATION ON ADMISSION: lasix 80bid
levothyroxine 150 qdaily
prozac 10mg qdaily
detrol LA 4mg qdaily
lipitor 20 mg qdaily
protonix 40 qdaily
aldactone 37.5bid
dextromethorphan LA one po bid
FeS04 qdaily
ranitidine 150bid
resource instant powder: 1 scoop tid with food

ALLERGIES: Digoxin / Heparin Agents

PHYSICAL EXAM: Vitals - T afebrile, BP 109/55, HR 73, RR 26, O2 94%/3L
General - awake, alert, oriented to person and somewhat to place
("[**Location (un) 86**]")
HEENT - PERRL, EOMI, MMM
Neck - unable to assess JVP given RIJ which is C/D/I, no
tenderness or erythema. no carotid bruits
CVS - irregularly irregular, no MRGs
Lungs - decreased BS R base. + crackles bilaterally, no wheezes
Abd - soft, mildly distended. no dullness to percussion. TTP in
RUQ, + rebound. otherwise, no TTP.
Ext - no palmar erythema, 2+ pitting edema throughout, including
abdomen, back
Skin no stigmata of liver dz
Neuro: + asterixis. CN III-XII grossly intact

FAMILY HISTORY: 

SOCIAL HISTORY: 
Acute respiratory failure,Congestive heart failure, unspecified,Cirrhosis of liver without mention of alcohol,Acute kidney failure with lesion of tubular necrosis,Atrial fibrillation,Urinary tract infection, site not specified,Acquired coagulation factor deficiency,Toxic encephalopathy,Cardiogenic shock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Portal hypertension,Long-term (current) use of anticoagulants,Chronic passive congestion of liver,Anticoagulants causing adverse effects in therapeutic use,Unspecified acquired hypothyroidism,Other persistent mental disorders due to conditions classified elsewhere
Acute respiratry failure,CHF NOS,Cirrhosis of liver NOS,Ac kidny fail, tubr necr,Atrial fibrillation,Urin tract infection NOS,Acq coagul factor defic,Toxic encephalopathy,Cardiogenic shock,Hyp kid NOS w cr kid V,Portal hypertension,Long-term use anticoagul,Chr passiv congest liver,Adv eff anticoagulants,Hypothyroidism NOS,Mental disor NEC oth dis
Admission Date:  [**2122-6-9**]              Discharge Date:   [**2122-6-29**]

Date of Birth:  [**2040-7-16**]             Sex:   F

Service: MEDICINE

Allergies:
Digoxin / Heparin Agents

Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
acute renal failure

Major Surgical or Invasive Procedure:
femoral hemodialysis line placement
central venous catheterization

History of Present Illness:
81 yo Greek speaking only woman with CHF, EF 50% with cirrhosis,
portal HTN, CRI, BL 1.5 admitted to [**Hospital3 **]1 week ago
([**6-2**])with RUQ abdominal pain. RUQ US and HIDA scan per OSH
showed acute cholecystitis for which unasyn was started. Cr
gradually increased from 1.6 on admit despite hydration. Per
notes, renal was consulted and gave fluid challenge, urine lytes
with UNa of 6. Was thought to be in hepatorenal syndrome and
started on octreotide and midodrine with minimal response. per
notes, also started on IV steroids and dopamine at times for ?
hypotension, though none documented. Urine output 100 cc for
past 24 hours with gradual increase in LE edema
Was afebrile throughout with no localizing sx. other than
continued RUQ abdominal pain. On d/c, labs significant for Na
131, HCO3 16, BUN 62, Cr 4.0. CBC, INR 1.4. On day of transfer
had emesis X1 and O2 transiently decreased with new o2
requirement of 4L. ABG 7.20/33/127 on 4L. Family concerned with
care at [**Location (un) **] and requested transfer to [**Hospital1 18**].
.
In ambulance, apparently pt. with desats and increased lethargy.
In ED, afebrile satting well. CKs flat, head CT done, and
negative.

Past Medical History:
- CHF with EF 50%, severe tricuspid regurg, R pulmonary HTN on
ECHO in [**2120**].
- Atrial fibrillation, not on coumadin since subdural bleed s/p
fall 4 years ago
- Anemia
- h/o pancreatitis
- dyslipidemia
- Hypothyroidism
- Hepatic cirrhosis NOS with portal HTN
- pancytopenia
- Dementia

Physical Exam:
Vitals - T afebrile, BP 109/55, HR 73, RR 26, O2 94%/3L
General - awake, alert, oriented to person and somewhat to place
("[**Location (un) 86**]")
HEENT - PERRL, EOMI, MMM
Neck - unable to assess JVP given RIJ which is C/D/I, no
tenderness or erythema. no carotid bruits
CVS - irregularly irregular, no MRGs
Lungs - decreased BS R base. + crackles bilaterally, no wheezes
Abd - soft, mildly distended. no dullness to percussion. TTP in
RUQ, + rebound. otherwise, no TTP.
Ext - no palmar erythema, 2+ pitting edema throughout, including
abdomen, back
Skin no stigmata of liver dz
Neuro: + asterixis. CN III-XII grossly intact

Pertinent Results:
[**2122-6-9**] 10:39PM URINE  HOURS-RANDOM UREA N-145 CREAT-79
SODIUM-58
[**2122-6-9**] 10:39PM URINE  OSMOLAL-312
[**2122-6-9**] 06:57PM   GLUCOSE-150* UREA N-78* CREAT-4.9* SODIUM-135
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-15* ANION GAP-24*
[**2122-6-9**] 06:57PM   CALCIUM-8.6 PHOSPHATE-5.6* MAGNESIUM-2.6
[**2122-6-9**] 06:57PM   OSMOLAL-301
[**2122-6-9**] 05:15PM URINE  HOURS-RANDOM UREA N-104 CREAT-49
SODIUM-87
[**2122-6-9**] 05:15PM URINE  OSMOLAL-304
[**2122-6-9**] 05:15PM URINE  COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.025
[**2122-6-9**] 05:15PM URINE  BLOOD-LG NITRITE-NEG PROTEIN->300
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-MOD
[**2122-6-9**] 05:15PM URINE  RBC-[**10-27**]* WBC-21-50* BACTERIA-MANY
YEAST-MANY EPI-0
[**2122-6-9**] 05:15PM URINE  EOS-NEGATIVE
[**2122-6-9**] 08:50AM   GLUCOSE-106* UREA N-73* CREAT-4.7* SODIUM-135
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-15* ANION GAP-24*
[**2122-6-9**] 08:50AM   CK(CPK)-19*
[**2122-6-9**] 08:50AM   cTropnT-0.08*
[**2122-6-9**] 08:50AM   WBC-6.9 RBC-3.63* HGB-10.9* HCT-33.9* MCV-94
MCH-30.0 MCHC-32.1 RDW-19.2*
[**2122-6-9**] 08:50AM   NEUTS-90.5* LYMPHS-4.2* MONOS-5.0 EOS-0.2
BASOS-0.2
[**2122-6-9**] 08:50AM   PLT COUNT-104*
[**2122-6-9**] 06:55AM   AMMONIA-85*
[**2122-6-9**] 03:45AM   PT-15.9* PTT-33.2 INR(PT)-1.4*
[**2122-6-9**] 02:58AM   TYPE-[**Last Name (un) **] PO2-75* PCO2-34* PH-7.26* TOTAL
CO2-16* BASE XS--10
[**2122-6-9**] 02:58AM   GLUCOSE-110* LACTATE-2.0 NA+-133* K+-3.7
CL--104
[**2122-6-9**] 02:58AM   O2 SAT-92 CARBOXYHB-2 MET HGB-0
[**2122-6-9**] 02:58AM   freeCa-1.12
[**2122-6-9**] 02:50AM   GLUCOSE-118* UREA N-70* CREAT-4.5* SODIUM-135
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-12* ANION GAP-27*
[**2122-6-9**] 02:50AM   estGFR-Using this
[**2122-6-9**] 02:50AM   ALT(SGPT)-4 AST(SGOT)-16 LD(LDH)-228
CK(CPK)-22* ALK PHOS-66 AMYLASE-156* TOT BILI-0.8 DIR BILI-0.4*
INDIR BIL-0.4
[**2122-6-9**] 02:50AM   LIPASE-76*
[**2122-6-9**] 02:50AM   CK-MB-NotDone
[**2122-6-9**] 02:50AM   PHOSPHATE-5.4* MAGNESIUM-2.6
[**2122-6-9**] 02:50AM   WBC-7.6# RBC-3.46* HGB-10.6* HCT-31.7* MCV-92
MCH-30.6 MCHC-33.4 RDW-19.4*
[**2122-6-9**] 02:50AM   NEUTS-91.8* LYMPHS-2.9* MONOS-5.1 EOS-0.2
BASOS-0
[**2122-6-9**] 02:50AM   PLT COUNT-95*
[**2122-6-9**] 02:50AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2122-6-9**] 02:50AM URINE  BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2122-6-9**] 02:50AM URINE  RBC-[**5-17**]* WBC-[**2-9**] BACTERIA-MOD YEAST-MOD
EPI-[**2-9**]

[**6-9**] head ct with contrast:
IMPRESSION:

No acute intracranial pathology. Atrophy with dilatation of
lateral ventricles including temporal horns. [**Month (only) 116**] be seen with
communicating hydrocephalus in appropriate setting. If old exams
are available, comparison would be helpful.
[**6-10**] abd us:
IMPRESSION:
1. Nondistended gallbladder with multiple shadowing stones
within its lumen. A small amount of fluid adjacent to it. No
prior studies are available for comparison. Findings are
equivocal for acute cholecystitis, please correlate clinically.
2. Patent portal veins and hepatic veins with biphasic flow
suggestive of hepatic congestion and right heart failure.
3. Borderline splenomegaly.
4. Bilateral small pleural effusions.
5. Small amount of ascites.
[**2122-6-11**] CTA abd/pelvis
IMPRESSION:
1. Nondistended gallbladder with multiple shadowing stones
within its lumen. A small amount of fluid adjacent to it. No
prior studies are available for comparison. Findings are
equivocal for acute cholecystitis, please correlate clinically.
2. Patent portal veins and hepatic veins with biphasic flow
suggestive of hepatic congestion and right heart failure.
3. Borderline splenomegaly.
4. Bilateral small pleural effusions.
5. Small amount of ascites.


Brief Hospital Course:
81 yo with cirrhosis, renal failure, biventricular heart failure
presented with abdominal pain and renal failure, now intubated
on pressors, received trial of CRRT with no improvement with
worsenign volume overload, respiratory failure.
.
# Fever: Increased secretions but no clear infiltrate on CXR.
Also with positive U/A. Femoral HD line another potensial
source. Spiked to 100.9F 3d ago. Leukocytosis but lactate
normal. Pt initially received vanco/zosyn for broad coverage
(dose vanco by level, goal 15-20). vanco d/c'd as no e/o G+
infection. Pt then was found to have Burkholderia Cepacia in
sputum, ceftaz sensitive, but apparently this bug develops ESBL
rather fast, so will tx with bactim per ID recs. started today
(day 1=[**6-28**]) will continue for 14d course. During [**6-28**] and [**6-29**]
the patient began to have increasing pressor requirements due to
morbidity of her other conditions.  After multiple discussions
with the family, the patient was first made DNR and then changed
to CMO and expired shortly afterwards.   Blood cultures never
turned positive.
.
# Hypotension: Likely biventricular failure based on elevated
PCWP and dilated RV, worsened in the setting of acute infection
and possibly volume overload. Echo with normal EF, mild
hypertrophy suggesting some diastolic dysfunction; trial of Swan
with fluid challenges showed no change in CI/CO which was
2.8/41. Initiall on steroids but had appropriate [**Last Name (un) 104**] stim so
tapered off. Pressor requirement increased yesterday but now
decreasing.  Patient was maintained on levophed gtt for the last
7 days of the hospital course.  As her the heart failure became
more severe and while the patient was off cvvhd, the pressor
rquirements increased.  Renal recommended no CVVHD continuation
since there is no chance of recovery to HD.  Patien experied on
[**2122-6-29**] after being made CMO.
.
# Respiratory failure: Pt initally Hypercarbic with low tidal
volumes, resp rate; likely from fatigue in context of metabolic
acidosis and pulmonary effusions from renal failure although
could also be a central cause. Later in the hospital course, due
to the patient's heart failure, she developed pulmonary edema,
increasing distress, now on AC. currently overbreathing the vent
, likely due to central causes, putting self into respiratory
alkalosis. AC ventillation was maintained until the patietn was
made CMO and was terminally extubated.
.
# Heme: Thrombocytopenia - patient [**12-9**]'d her platelets while
receiving CVVHD with heparin.  Pt was HIT positive, confirmed by
SRA, in setting of heparin flushes for HD line. No evidence of
arterial thrombosis. Plt now slowly recovering. Also with
coagulopathy due to combination of underlying liver disease and
argatroban. DIC/hemolysis labs negative. plt count recovering.
Pt was transfused platelets with procedures.  Platelet counts
continued to recover, but the patient was made CMO due to no
chance of recovery from other insults.
.
# Neuro: Presented with AMS likely toxic-metabolic [**1-9**] hepatic
and renal status. CT head negative. Non-reactive pupils
(?surgical) concerning for intracran pathology in the setting of
high bleeding risk given thrombocytopenia and coagulopathy;
however, repeat head CT without evidence of bleed.   Lactulose
titrated to [**1-10**] BMs per day for hepatic encephalopathy.
Sedation was weaned, but the patient continued only to be
responsive to painful stimuli.  Since no chance of neurologic
recovery was possible, and in addtion to the morbidity of other
conditions (i.e. irreversible biventricular heart failure), the
patient was made CMO and expired shortly afterwards.
.
# Acute on chronic renal failure: Most likely ATN rather than
hepatorenal, possibly due to CHF vs. sepsis. Nearly anuric, no
real recovery of renal function as of yet. Renal and hepatology
believe more likely ATN; failed lasix + thiazide + albumin
challenge and, per OSH, also failed fluid challenge. Briefly on
octreotide, midodrine which were then d/c'd. Received
dopamine/hydorocort at OSH suggesting hypotension which would
support ATN. Urine eos negative. Temporary femoral dialysis line
d/c'd.  Pt. had trial of CVVHD with no improvement in pressor
requirements, so decision was made to not restart.  The patient
progressively became more fluid overloaded as cvvhd was pulle of
and decision was made not to restart due to futility of this
treatment.  Patient expired shortly after decision to make the
patient CMO was made.
.
# Cirrhosis: Childs B. Possible [**1-9**] right heart failure; less
likely NASH. No biopsies. Unclear how much it has been worked up
in the past. Hepatology consulted. U/S with little ascites.
Elevated LFTs from hepatic congestion.  Hep serologies neg for
B, C; HAV Ab positive.  Not a significant contributor to this
[**Hospital 228**] hospital course.
.
# RUQ pain: Most likely from capsule distension due to right
heart failure as improves with fluid off-loading. Treated with
unasyn at OSH for acute cholecystitis, then zosyn/levo for
?intra-abdominal process given rising lactate but unknown source
(d/c'd [**6-16**]). U/S here for cholecystitis nondiagnostic. Surgery
consulted, who did not believe this represents cholangitis or
cholecystitis. Also no e/o mesenteric ischemia on CT scan,
although non-contrast study. Minimal ascites makes SBP less
likely.
.
# Code: Patient remainded full code for the majority of her
stay.  Together with social work, ethics, multiple attnedings,
the patietn was made DNR.  Due to overall complexity of the
medical problmes, it was explained to the patient's family that
Mrs. [**Known lastname 39694**] was unlikely to ever recover and leave the ICU.  As
she developed increasing pressor requirements and was unable to
maintain her blood pressures, the decision was made to make her
CMO.  She expired shortly afterwards.  Daughter, [**Name (NI) 803**] same
as above
Daughter [**Name (NI) 3908**] ([**Telephone/Fax (1) 39695**]
transferring MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 732**]: [**Telephone/Fax (1) 39696**], ICU:
[**Telephone/Fax (1) 39697**]
Dr. [**Last Name (STitle) 39698**]: ([**Telephone/Fax (1) 39699**] or 3270


Medications on Admission:
lasix 80bid
levothyroxine 150 qdaily
prozac 10mg qdaily
detrol LA 4mg qdaily
lipitor 20 mg qdaily
protonix 40 qdaily
aldactone 37.5bid
dextromethorphan LA one po bid
FeS04 qdaily
ranitidine 150bid
resource instant powder: 1 scoop tid with food

Discharge Disposition:
Expired

Discharge Diagnosis:
Biventricular heart failure
Renal failure due to acute tubular necrosis
Hepatic cirrhosis due to right heart failure
Heparin-Induced Thrombocytopenia


Discharge Condition:
expired

Discharge Instructions:
n/a

Followup Instructions:
n/a


Completed by:[**2122-6-30**]
{'Acute respiratory failure,Congestive heart failure, unspecified,Cirrhosis of liver without mention of alcohol,Acute kidney failure with lesion of tubular necrosis,Atrial fibrillation,Urinary tract infection, site not specified,Acquired coagulation factor deficiency,Toxic encephalopathy,Cardiogenic shock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Portal hypertension,Long-term (current) use of anticoagulants,Chronic passive congestion of liver,Anticoagulants causing adverse effects in therapeutic use,Unspecified acquired hypothyroidism,Other persistent mental disorders due to conditions 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: acute renal failure

PRESENT ILLNESS: 81 yo Greek speaking only woman with CHF, EF 50% with cirrhosis,
portal HTN, CRI, BL 1.5 admitted to [**Hospital3 **]1 week ago
([**6-2**])with RUQ abdominal pain. RUQ US and HIDA scan per OSH
showed acute cholecystitis for which unasyn was started. Cr
gradually increased from 1.6 on admit despite hydration. Per
notes, renal was consulted and gave fluid challenge, urine lytes
with UNa of 6. Was thought to be in hepatorenal syndrome and
started on octreotide and midodrine with minimal response. per
notes, also started on IV steroids and dopamine at times for ?
hypotension, though none documented. Urine output 100 cc for
past 24 hours with gradual increase in LE edema
Was afebrile throughout with no localizing sx. other than
continued RUQ abdominal pain. On d/c, labs significant for Na
131, HCO3 16, BUN 62, Cr 4.0. CBC, INR 1.4. On day of transfer
had emesis X1 and O2 transiently decreased with new o2
requirement of 4L. ABG 7.20/33/127 on 4L. Family concerned with
care at [**Location (un) **] and requested transfer to [**Hospital1 18**].
.
In ambulance, apparently pt. with desats and increased lethargy.
In ED, afebrile satting well. CKs flat, head CT done, and
negative.

MEDICAL HISTORY: - CHF with EF 50%, severe tricuspid regurg, R pulmonary HTN on
ECHO in [**2120**].
- Atrial fibrillation, not on coumadin since subdural bleed s/p
fall 4 years ago
- Anemia
- h/o pancreatitis
- dyslipidemia
- Hypothyroidism
- Hepatic cirrhosis NOS with portal HTN
- pancytopenia
- Dementia

MEDICATION ON ADMISSION: lasix 80bid
levothyroxine 150 qdaily
prozac 10mg qdaily
detrol LA 4mg qdaily
lipitor 20 mg qdaily
protonix 40 qdaily
aldactone 37.5bid
dextromethorphan LA one po bid
FeS04 qdaily
ranitidine 150bid
resource instant powder: 1 scoop tid with food

ALLERGIES: Digoxin / Heparin Agents

PHYSICAL EXAM: Vitals - T afebrile, BP 109/55, HR 73, RR 26, O2 94%/3L
General - awake, alert, oriented to person and somewhat to place
("[**Location (un) 86**]")
HEENT - PERRL, EOMI, MMM
Neck - unable to assess JVP given RIJ which is C/D/I, no
tenderness or erythema. no carotid bruits
CVS - irregularly irregular, no MRGs
Lungs - decreased BS R base. + crackles bilaterally, no wheezes
Abd - soft, mildly distended. no dullness to percussion. TTP in
RUQ, + rebound. otherwise, no TTP.
Ext - no palmar erythema, 2+ pitting edema throughout, including
abdomen, back
Skin no stigmata of liver dz
Neuro: + asterixis. CN III-XII grossly intact

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Acute respiratory failure,Congestive heart failure, unspecified,Cirrhosis of liver without mention of alcohol,Acute kidney failure with lesion of tubular necrosis,Atrial fibrillation,Urinary tract infection, site not specified,Acquired coagulation factor deficiency,Toxic encephalopathy,Cardiogenic shock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Portal hypertension,Long-term (current) use of anticoagulants,Chronic passive congestion of liver,Anticoagulants causing adverse effects in therapeutic use,Unspecified acquired hypothyroidism,Other persistent mental disorders due to conditions classified elsewhere'}
