CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: 55 F with complicated medical history who has been transferred
from Rehab/[**Hospital3 417**] for dyspnea, acute on chronic renal
failure, volume overload, and fungemia. In [**Month (only) 116**] of this year,
presented to [**Hospital1 18**] ED with abdominal pain. Has significant PMHx
for T1DM, HTN, PVD and was found in the ED to have extensive
calcification of her mesenteric arteries. She was taken to the
OR and found to have infarction of her colon with intact small
bowel. She under went a colectomy with iliostomy at that time.
Post op had respiratory failure requiring prolonged intubation
and eventual tracheostomy. The etiology of her respiratory
failure was unclear at her discharge. She was discharged to [**Location (un) 4368**] [**Hospital 21079**] rehab on [**2158-6-1**] after ~30 day hospitalization on
TPN via CVL with tube feeds started. The plan was to advance
tube feeds and wean TPN.
  On [**2158-6-17**], she was still on TPN at rehab and spiked a
temperature up to 103 and blood cultures were positive for yeast
([**Female First Name (un) **] albicans by telephone report but not documented in
transfer records). She was transferred to [**Hospital3 417**] in
[**Hospital1 1474**] for further management. There she was initially given
voriconazole and her central line replaced. Culture from the
line again reportedly grew [**Female First Name (un) **]. She was then switched to
fluconazole and finally to caspofungin today. She was also
treated with ticarcillin/clavulanate for unclear reasons. During
her hospitalization, she also had a "troponin leak" without EKG
changes thought to be demand ischemia by their cardiology
consultants. An echo done on [**2158-6-18**] showed global hypokinesis
with EF 25-30%, dilated LA, LVH, moderated MR, moderate TR,
although image quality was poor. Her hospitalization was also
complicated by hyponatremia of unclear [**Name2 (NI) 10810**].
  Her hospitalization was also complicated by acute on chronic
renal failure (s/p transplant in [**2143**]). She did have episode of
ATN in setting of her mesenteric ischemia with peak Cr of 4.3
with return to her baseline of 1.4-1.8 at time of discharge.
Upon admission to [**Hospital3 417**] her Cr was 3.7 and remained
elevated. It is unclear what work up was done for this. On the
day of admission, she also developed respiratory distress with
increasing volume retention. Attempts at diuresis with Lasix 400
mg IV were unsuccesful. She was transferred to [**Hospital1 18**] for
management of her fungemia, renal failure and repiratory
distress. Immediately prior to discharge or in the ambulance she
was started on a nitro dip for again unclear reasons.

MEDICAL HISTORY: PMH:
-Mesenteric ischmia requiring coloectomy [**2158-4-24**]
-Respiratory failure requiring trach [**4-/2158**]
-CRI s/p transplant in [**2143**] (followed by Dr[**Doctor Last Name **] at [**Last Name (un) **],
transplant followed  by Dr. [**Last Name (STitle) 15473**]
-b/l Breast Cancer s/p lumpectomy/XRT and Chemo 199 (followed by
Dr. [**Last Name (STitle) 3274**]
-PVD s/p L BKA (followed by Dr.[**Last Name (STitle) 21080**]) - [**6-/2147**], fem-[**Doctor Last Name **] '[**48**]
with [**Doctor Last Name **]-DP bypass,
-MI X2 s/p CABG times 2
-hypercholesterolemia
-DM1 with retinopathy/neuropathy/nephropathy
-left eye prosthesis
-bilateral breast cancer
-chronic anemia
-gout

MEDICATION ON ADMISSION: -hydrocortisone 100 mg iv q8h
-SSI
-azathioprine 50 mg qd
-tylenol prn
-allopurinol 100mg qd
-clopidogrel 75 mg qd
-metoclopramide 20 mg qid
-nystatin swish and spit qid
-epo 10K qwk
-Femara 2.5 mg qd
-tacrolimus 1mg [**Hospital1 **]
-clonidine 0.2 mg tid
-Colshicine 0.6 mg qd
-colace
-emeprazole 40 qd
-Caspofungin 70 mg iv times 1 given [**6-22**]
-lasix 40 mg iv bid
-ASA 81 mg qd
-paroxetine 20mg qd
-metoprolol 50 mg tid
-lorazepam 0.5 prn
-Calcium [**Last Name (un) **] 500 mg tid
-calcium acetate 667 tid
-isosorbide dinitrate 50mg  tid
-albuterol prn
-ipratropium prn
-Ticarcillin/clavulanate 3.1g q8h
-Nitro drip

ALLERGIES: Dilaudid / Codeine / Ativan

PHYSICAL EXAM: Vitals: T:96.0 P:98-107 R:22-24 BP:163-176/76-95 SaO2:98% on 4L

FAMILY HISTORY: NC

SOCIAL HISTORY: lives with husband (a math professor [**First Name (Titles) **] [**Last Name (Titles) **]).
Acute and chronic respiratory failure,Complications of transplanted kidney,Acute kidney failure with lesion of tubular necrosis,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Urinary tract infection, site not specified,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Atrial fibrillation,Pneumonia due to Klebsiella pneumoniae,Disseminated candidiasis,Hallucinations,Toxic encephalopathy,Hypercalcemia,Malignant neoplasm of breast (female), unspecified,Anemia in chronic kidney disease,Attention to ileostomy,Other specified antibiotics causing adverse effects in therapeutic use,Attention to tracheostomy
Acute & chronc resp fail,Compl kidney transplant,Ac kidny fail, tubr necr,DMI renl nt st uncntrld,Urin tract infection NOS,End stage renal disease,Hyp kid NOS w cr kid V,CHF NOS,Atrial fibrillation,K. pneumoniae pneumonia,Disseminated candidiasis,Hallucinations,Toxic encephalopathy,Hypercalcemia,Malign neopl breast NOS,Anemia in chr kidney dis,Atten to ileostomy,Adv eff antibiotics NEC,Atten to tracheostomy
Admission Date:  [**2158-6-22**]              Discharge Date:   [**2158-9-16**]

Date of Birth:  [**2103-6-1**]             Sex:   F

Service: MEDICINE

Allergies:
Dilaudid / Codeine / Ativan

Attending:[**First Name3 (LF) 5301**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
None


History of Present Illness:
55 F with complicated medical history who has been transferred
from Rehab/[**Hospital3 417**] for dyspnea, acute on chronic renal
failure, volume overload, and fungemia. In [**Month (only) 116**] of this year,
presented to [**Hospital1 18**] ED with abdominal pain. Has significant PMHx
for T1DM, HTN, PVD and was found in the ED to have extensive
calcification of her mesenteric arteries. She was taken to the
OR and found to have infarction of her colon with intact small
bowel. She under went a colectomy with iliostomy at that time.
Post op had respiratory failure requiring prolonged intubation
and eventual tracheostomy. The etiology of her respiratory
failure was unclear at her discharge. She was discharged to [**Location (un) 4368**] [**Hospital 21079**] rehab on [**2158-6-1**] after ~30 day hospitalization on
TPN via CVL with tube feeds started. The plan was to advance
tube feeds and wean TPN.
  On [**2158-6-17**], she was still on TPN at rehab and spiked a
temperature up to 103 and blood cultures were positive for yeast
([**Female First Name (un) **] albicans by telephone report but not documented in
transfer records). She was transferred to [**Hospital3 417**] in
[**Hospital1 1474**] for further management. There she was initially given
voriconazole and her central line replaced. Culture from the
line again reportedly grew [**Female First Name (un) **]. She was then switched to
fluconazole and finally to caspofungin today. She was also
treated with ticarcillin/clavulanate for unclear reasons. During
her hospitalization, she also had a "troponin leak" without EKG
changes thought to be demand ischemia by their cardiology
consultants. An echo done on [**2158-6-18**] showed global hypokinesis
with EF 25-30%, dilated LA, LVH, moderated MR, moderate TR,
although image quality was poor. Her hospitalization was also
complicated by hyponatremia of unclear [**Name2 (NI) 10810**].
  Her hospitalization was also complicated by acute on chronic
renal failure (s/p transplant in [**2143**]). She did have episode of
ATN in setting of her mesenteric ischemia with peak Cr of 4.3
with return to her baseline of 1.4-1.8 at time of discharge.
Upon admission to [**Hospital3 417**] her Cr was 3.7 and remained
elevated. It is unclear what work up was done for this. On the
day of admission, she also developed respiratory distress with
increasing volume retention. Attempts at diuresis with Lasix 400
mg IV were unsuccesful. She was transferred to [**Hospital1 18**] for
management of her fungemia, renal failure and repiratory
distress. Immediately prior to discharge or in the ambulance she
was started on a nitro dip for again unclear reasons.


Past Medical History:
PMH:
-Mesenteric ischmia requiring coloectomy [**2158-4-24**]
-Respiratory failure requiring trach [**4-/2158**]
-CRI s/p transplant in [**2143**] (followed by Dr[**Doctor Last Name **] at [**Last Name (un) **],
transplant followed  by Dr. [**Last Name (STitle) 15473**]
-b/l Breast Cancer s/p lumpectomy/XRT and Chemo 199 (followed by
Dr. [**Last Name (STitle) 3274**]
-PVD s/p L BKA (followed by Dr.[**Last Name (STitle) 21080**]) - [**6-/2147**], fem-[**Doctor Last Name **] '[**48**]
with [**Doctor Last Name **]-DP bypass,
-MI X2 s/p CABG times 2
-hypercholesterolemia
-DM1 with retinopathy/neuropathy/nephropathy
-left eye prosthesis
-bilateral breast cancer
-chronic anemia
-gout


Social History:
lives with husband (a math professor [**First Name (Titles) **] [**Last Name (Titles) **]).

Family History:
NC

Physical Exam:
Vitals: T:96.0 P:98-107 R:22-24 BP:163-176/76-95 SaO2:98% on 4L

CVP 21
General: Awake, alert, .
HEENT: NC/AT, Pupil reactive on right, EOMI without nystagmus,
no scleral icterus noted, MMM, no lesions noted in OP
Neck: supple, no carotid bruits appreciated. unable to assess
JVP
Pulmonary: crackles bilaterally
Cardiac: distant RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, obese, NT/ND, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: 2+ edema in upper and lower ext, 2+ radial, DP and
PT pulses on right.
Skin: diffuse brusing on abdomen. No other rash noted.
Neurologic:
-mental status: Alert, oriented x 3.
-cranial nerves: II-XII


Pertinent Results:
POTASSIUM-3.9 CHLORIDE-90* TOTAL CO2-16* ANION GAP-23*
[**2158-6-22**] 08:23PM   WBC-18.9*# RBC-3.13* HGB-9.9* HCT-29.5*
MCV-94 MCH-31.7 MCHC-33.6 RDW-18.9*
NEUTS-95* BANDS-1 LYMPHS-1* MONOS-2 EOS-0 BASOS-0 ATYPS-0
METAS-1* MYELOS-0
[**2158-6-22**] 08:53PM   PT-12.8 PTT-25.9 INR(PT)-1.1
[**2158-6-22**] 08:51PM   TYPE-ART TEMP-36.7 O2 FLOW-3 PO2-40* PCO2-29*
PH-7.36 TOTAL CO2-17* BASE XS--7 INTUBATED-NOT INTUBA
COMMENTS-NASAL [**Last Name (un) 154**]
[**2158-6-22**] 08:51PM   LACTATE-2.4*
[**2158-6-22**] 08:23PM   GLUCOSE-293* UREA N-131* CREAT-3.1*#
SODIUM-125*
[**2158-6-22**] 08:23PM   CK(CPK)-17*
[**2158-6-22**] 08:23PM   CK-MB-4 cTropnT-0.26*
[**2158-6-22**] 08:23PM   CALCIUM-8.3* PHOSPHATE-4.7*# MAGNESIUM-2.5


Brief Hospital Course:
55 YOF with volume overload, dyspnea, renal failure, elevated
WBC, fungemia, chest pain, and hyponatremia; details below.
.
## Fungemia: Patient was diagnosed with fungemia by blood
culture at [**Hospital1 **] and [**Hospital3 417**], likely due to
TPN. Other sources include possible seeding of chronic thrombus
in UE. TTE on [**2158-6-23**] demonstrated no evidence of vegetations.
Ophthalmology eval demonstrated no opthalmic candidemia. Patient
was initially started on PO fluconazole from 6.30.06-7.13.06.
Patient did however continue to spike fevers while on antibiotic
therapy, concerning for a new or resistant infection in the
context of patient's immunosuppresion. Another possible source
was pulmonary since patient's CT chest from [**2158-7-6**] demonstrated
interval development of bilateral pulmonary nodules. Unclear
etiology for bilateral pulmonary nodules. Nodules may have
represented septic emboli from endocarditis, although no
vegetations were demonstrated by echo on [**2158-6-23**] or [**2158-7-11**].
Patient was converted to IV caspofungin on [**2158-7-6**] until
[**2158-7-12**]. During this time, patient remained afebrile and was
converted back to PO fluconazole prior to discharge.
Blood cultures from [**7-23**] had come back positive for yeast and
per ID was switched to caspofungin.  The evening before transfer
to the floor, the patient's HD cath was removed as a possible
site for infection.  She was given a loading dose of 70mg IV and
then given a daily dose of 50mg IV.  She remained afebrile.
Further workup was done to search for the source of the
fungemia.  A renal ultrasound was done which was normal.
Ophthalmology was consulted to evaluate eye grounds and they did
not feel the eye was a source of infection.  A TTE was done
which showed a small (0.7 x0.7 cm) mass attached to the highly
calcified mitral annulus which may be a vegetation or a mobile
piece of calcification coming off the larger mitral annular
calcification.  A follow up TEE was recommended, however the
patient began to have increased emesis and it was unable to be
performed.  ID further recommended the PICC line to be replaced
which was to be done with HD catheter placement.  Cultures from
[**Date range (1) 21081**] remained negative and a urine culture from this time was
negative as well.
.
## Klebsiella PNA: retrocardiac, pt received 10d of cefepime.
course completed.
.
## Renal Failure: Patient was admitted to MICU initally  and
received hemodialysis which greatly improved mental status.
Renal u/s [**2158-6-23**] showed stable borderline hydronephrosis in the
transplant kidney with elevated resistive indices and CT
ab/pelvis [**2158-6-23**] showed air within the transplant kidney
collecting systems, new from comparison, likely iatrogenic from
foley placement. Then upon admission to the floor, patient had
intractable fluid overload with associated edema and shortness
of breath. Patient underwent hemodialysis three times which
greatly improved fluid overload and shortness of breath. The
patient's creatinine fell to a low of 1.9 while on the floor.
However, the creatinine soon began to rise again to a high of
3.3 on the floor.  The patient's acute on chronic renal failure
was believed to be ATN vs. prerenal.  The renal service was
closely following the patient and recommended placement of an HD
catheter in preparation for hemodialysis based on her worsening
renal function and fluid status.  She was given boluses and
started on NS at 50cc/hr per renal.  She was started on Bicitra
30 mL TID for acidosis.  Allopurinol was decreased to q48h from
q24 based on the renal function.  The tacrolimus dose was halved
and then held.
.
## s/p renal transplant: Pt is normally on prednisone,
tacrolimus, and azathioprine for immunosuppression. Patient was
continued on steroids but tacrolimus and azathioprine were
temporarily discontinued during this admission secondary to
fungemia. Patient was eventually restarted on tacrolimus once
she demonstrated improved control of her infection. Tacrolimus
and prednisone was continued while the patient was on the floor.
 The FK506 was elevated and the tacrolimus dose was halved.
When the level did not decrease, tacrolimus was held.
Tacrolimus levels were followed with a goal trough [**2-26**].
Azathioprine was held.
.
## Respiratory failure and shortness of breath: Patient
initially had respiratory failure in the MICU, likely secondary
to a combination of acid-base abnormalities, stiffness from
fluid overload, and infectious process. Patient was started on
cefepime and vancomycin initially for concern of gram negatives
and MRSA, which was noted on OSH blood culture. Cefepime was
discontinued since there was no obvious target and vancomycin
was maintained for MRSA. Vancomycin was then discontinued given
negative blood cultures and concern for vancomycin-induced
thrombocytopenia. After transfer from the MICU, patient
developed increasing shortness of breath with concern for fluid
overload and infectious process. Patient's shortness of breath
improved significantly with three rounds of hemodialysis.
However, a CT scan of chest demonstrated interval development of
pleural effusions and bilateral pulmonary nodules, concerning
for an infectious process. Thoracentesis demonstrated a
transudate effusion. Patient received antibiotic treatment with
PO fluconazole and IV caspofungin. The patient was transferred
on a trach collar, 40%, satting 100%, with upper airway
secretions.  She was suctioned frequently and O2 sats remained
within normal limits.  She was given nebulizers as indicated.
Her fluid status was closely monitored as she was getting an
increasing fluid load for hypercalcemia treatment.  The patient
was triggered on 8/? for altered mental status and question of
respiratory distress. A CXR was done which showed worsening
pulmonary edema however the patient had good oxygen saturation
The patient's mental status did not impro
.
## Hypercalcemia: Ms. [**Known lastname **] had a persistently elevated Ca with
unknown cause.  A bone scan was negative for metastatic osseous
disease.  TSH and PTH were within normal limits.  She was
treated with calcitonin and pamidronate, given lasix and fluids
with some response. Per renal, further calcitonin was held as
the patient did not respond adequately to it and they did not
recommend pamidronate as it can contribute to renal failure.
PTHrp was sent and was normal. Hypercalcemia thought to be
secondary to imobilization.
.
## Hyponatremia: Pt was initially hyponatremic to 125 on
admission, likely in setting of volume overload from CHF/renal
failure. Patient's sodium resolved with hemodialysis and was
stable during admission.  The patient's sodium remained stable
while on the floor.
.
## Type 1 Diabetes melitus: Patient has type 1 diabetes with
major complications as listed above. She initially was started
on an insulin drip and her insulin regimen was adjusted with
help from [**Last Name (un) **].
.
## Anemia: Patient had anemia of chronic disease, most likely
secondary to chronic renal insufficiency. HCT was trending down
and guiac was positive, and patient received 1unit pRBC. She was
stable post transfusion on [**6-26**]. No other transfusions were
given, and th pt may require outpt colonoscopy.
..
## Thrombocytopenia: Patient developed thrombocytopenia during
admission. Thrombocytopenia was thought to have developed
secondary to vancomycin and platelets increased after
discontinuing vancomycin.
.
## UTI: During admission, patient's urine culture began growing
vancomycin-resistant enterococcus. Patient was treated with
linezolid. She again grew out many bacteria on a urine culture
and was treated with ciprofloxacin and fluconazole (last day of
cipro [**2158-9-23**], last day of fluconazole [**2158-9-18**])
.
## CAD: Patient is s/p MI x 2. Patient had no symptoms during
admission. Patient was maintained on home meds of ASA, BB, and
isosorbide dinitrate.
.
## HTN: Patient's blood pressures have been occasionally
elevated and hydralazine was increased to 15mg PO qid to assess
for improved BP control. Patient was otherwise maintained on
home doses of Clonidine, Metoprolol, and Isosorbide without
other problems.
.
## Depression/anxiety
Patient was maintained on paxil. Ativan and ambien were
discontinued secondary to increased somnolence with these meds.

.
.
.
MICU Transfer [**2158-8-21**] - [**2158-9-3**]
Pt was admitted for hypotension.  There was no clear source,
with possiblities being septic (LLL opacity and 4+ MRSA in
sputum, though no fever or WBC), adrenal insufficiency (started
empirically on stress dose steroids), or cardiogenic.  As she
was not felt to clearly be septic and didn't seem to briskly
respond to stress dose steroids, she had an echo performed,
showing an EF of 25%, down from an echo one month prior showing
35-45%.  Cardiology was consulted who felt that this was not
acute ischemia, and that the decrement in function was likely
overstated; it was felt that her prior study had been of
sub-optimal quality and that probably had not been a significant
interval change in LV-EF, and that this low EF was probably a
mix of a baseline ischemic cardiomyopathy with a superimposed
toxic/infectious cardiomyopathy.  There was also concern,
despite the physiologic controversy of this theory, that she was
grossly volume overloaded and thus had tipped over to the
disadvantageous arm of Starling's curve.  In the setting of this
gross volume overload with associated large bilateral pleural
effusions (that had been tapped one month prior and found to be
transudative, thought to be due to heart failure), she developed
worsening respiratory distress and was placed back on the
ventilator on minimal settings (p/s [**9-28**], fio2 40%) with
immediate relief of her dyspnea.  Over the next few days, she
continued with treatment of her VAP and was diuresed during
CVVH.  She tolerated this well and was able to be weaned off
pressure support and onto a trach mask without difficulty.  By
the time she was called out of the unit she had been tolerating
trach collar alone for several days.
.
She was treated for ten days with vancomycin and ceftazidime for
a hospital acquired pneumonia.  Her stress dose steroids were
tapered after three days of full dose, over the course of the
following week.  She was started on CVVHD to relieve her gross
volume overload.  With the combined effect of these
interventions, her bp slowly climbed over the week, and she
eventually became hypertensive with bp's in the 140-160's.  She
was then switched from CVVHD back to intermitten HD.
.
During the course, she had one episode of afib with RVR.  At the
time, her hr was in the 140's to 160's and a bp was not able to
be obtained, though she did not lose conciousness.  She was
bolused 500cc of NS and a phenylephrine drip was started.  She
received 20mg of diltiazem IV with heart rate decreasing to the
90's to low 100's and bp up to the 120's.  She receieved a 24`
IV amiodarone load with reversion to sinus rhythm and was then
switched over to oral amiodarone.
.
FLOOR COURSE:
.
## Hallucinations/delusions: Pt having active hallucinations.
Being treated for urine bacterial and fungal infections. No
other abnormalities other than encephalopthy per EEG to explain
new hallucinations. Unlikely to be from new-onset psyichiatric
disease. MRI was unrevealing, Ca under control, head CT negative
x2. Continue ciprofloxacin until [**9-23**]. Continue fluconazole
until [**9-18**].
.
## Atrial fibrillation: Pt went into atrial fibrillation in the
unit. Now in sinus rhythm after being treated with amiodarone.
Rate-controlled. INR goal is 2.0-3.0. Pt's warfarin dosing has
not been finalized, so should be adjusted daily. She was
continued on metoprolol 50 [**Hospital1 **] for rate control and amiodarone
200 for rhythm control.
.
## Coronary artery disease: No evidence of active ischemia.
Continued metoprolol 50 PO bid, aspirin 81 PO qd
.
## HTN: Pt is relatively normotensive. Continued metoprolol,
hydralazine, isosorbide.
.
## Ischemic cardiomyopathy: Total body volume overloaded given
sacral edema and bilateral pleural effusions. Not symptomatic.
.
## End stage renal disease s/p transplant: Needed HD and CVVH in
unit. Now being evaluated daily for HD requirement.
.
## Diabetes mellitus, Type 1: Mildly hyperglycemic throughout
the day. Followed by [**Last Name (un) **] service to adjust insulin daily.
.
## Respiratory failure: Pt c/o mild shortness of breath, but
ascribes this to the valve on the trach collar. Has required
intermittent nebs for wheeziness.
.
## Hypercalcemia: Unlikely to be related to breast cancer as she
has had a negative bone scan during this hospitalization. [**Month (only) 116**] be
hypercalcemia from immobility. Received pamidronate 30 mg IV x2
with some normalization of calcium.
.
## Breast cancer: Pt was started back on letrozole, but then
discontinued again when she started having hallucinations.

Medications on Admission:
-hydrocortisone 100 mg iv q8h
-SSI
-azathioprine 50 mg qd
-tylenol prn
-allopurinol 100mg qd
-clopidogrel 75 mg qd
-metoclopramide 20 mg qid
-nystatin swish and spit qid
-epo 10K qwk
-Femara 2.5 mg qd
-tacrolimus 1mg [**Hospital1 **]
-clonidine 0.2 mg tid
-Colshicine 0.6 mg qd
-colace
-emeprazole 40 qd
-Caspofungin 70 mg iv times 1 given [**6-22**]
-lasix 40 mg iv bid
-ASA 81 mg qd
-paroxetine 20mg qd
-metoprolol 50 mg tid
-lorazepam 0.5 prn
-Calcium [**Last Name (un) **] 500 mg tid
-calcium acetate 667 tid
-isosorbide dinitrate 50mg  tid
-albuterol prn
-ipratropium prn
-Ticarcillin/clavulanate 3.1g q8h
-Nitro drip

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]

Discharge Diagnosis:
PRIMARY
- s/p renal transplant in [**2143**]
- Candidemia
- Urinary tract infection
- Fluid Overload
- Acute on Chronic Renal Failure
- Thrombocytopenia
- Anemia
- Type 1 Diabetes Mellitus
- Hypertension
SECONDARY
- Depression


Discharge Condition:
Fair - Patient is taking oral intake and breathing well on room
air. Patient still requires PT to help her mobilize.


Discharge Instructions:
Please take all medications as prescribed. If you have symptoms
of fevers, chills, night sweats, chest pain, worsening shortness
of breath, or worsening swelling in lower extremities, please
seek immediate medical attention.

Followup Instructions:
-- Please see your kidney transplant [**Last Name (LF) 5059**], [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**],
MD on Date/Time:[**2158-7-25**] 10:45. His phone number is
[**Telephone/Fax (1) 673**].
-- Please see your infectious disease physician, [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6400**],
MD on Date/Time:[**2158-8-17**] 11:00. Her phone number is
[**Telephone/Fax (1) 457**].
-- Please see your cardiologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. at
Date/Time:[**2158-8-29**] 11:20. His phone number is [**Telephone/Fax (1) 5003**]
{'Acute and chronic respiratory failure,Complications of transplanted kidney,Acute kidney failure with lesion of tubular necrosis,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Urinary tract infection, site not specified,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Atrial fibrillation,Pneumonia due to Klebsiella pneumoniae,Disseminated candidiasis,Hallucinations,Toxic encephalopathy,Hypercalcemia,Malignant neoplasm of breast (female), unspecified,Anemia in chronic kidney disease,Attention to ileostomy,Other specified antibiotics causing adverse effects in therapeutic use,Attention to tracheostomy'}


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: dyspnea

PRESENT ILLNESS: 55 F with complicated medical history who has been transferred
from Rehab/[**Hospital3 417**] for dyspnea, acute on chronic renal
failure, volume overload, and fungemia. In [**Month (only) 116**] of this year,
presented to [**Hospital1 18**] ED with abdominal pain. Has significant PMHx
for T1DM, HTN, PVD and was found in the ED to have extensive
calcification of her mesenteric arteries. She was taken to the
OR and found to have infarction of her colon with intact small
bowel. She under went a colectomy with iliostomy at that time.
Post op had respiratory failure requiring prolonged intubation
and eventual tracheostomy. The etiology of her respiratory
failure was unclear at her discharge. She was discharged to [**Location (un) 4368**] [**Hospital 21079**] rehab on [**2158-6-1**] after ~30 day hospitalization on
TPN via CVL with tube feeds started. The plan was to advance
tube feeds and wean TPN.
  On [**2158-6-17**], she was still on TPN at rehab and spiked a
temperature up to 103 and blood cultures were positive for yeast
([**Female First Name (un) **] albicans by telephone report but not documented in
transfer records). She was transferred to [**Hospital3 417**] in
[**Hospital1 1474**] for further management. There she was initially given
voriconazole and her central line replaced. Culture from the
line again reportedly grew [**Female First Name (un) **]. She was then switched to
fluconazole and finally to caspofungin today. She was also
treated with ticarcillin/clavulanate for unclear reasons. During
her hospitalization, she also had a "troponin leak" without EKG
changes thought to be demand ischemia by their cardiology
consultants. An echo done on [**2158-6-18**] showed global hypokinesis
with EF 25-30%, dilated LA, LVH, moderated MR, moderate TR,
although image quality was poor. Her hospitalization was also
complicated by hyponatremia of unclear [**Name2 (NI) 10810**].
  Her hospitalization was also complicated by acute on chronic
renal failure (s/p transplant in [**2143**]). She did have episode of
ATN in setting of her mesenteric ischemia with peak Cr of 4.3
with return to her baseline of 1.4-1.8 at time of discharge.
Upon admission to [**Hospital3 417**] her Cr was 3.7 and remained
elevated. It is unclear what work up was done for this. On the
day of admission, she also developed respiratory distress with
increasing volume retention. Attempts at diuresis with Lasix 400
mg IV were unsuccesful. She was transferred to [**Hospital1 18**] for
management of her fungemia, renal failure and repiratory
distress. Immediately prior to discharge or in the ambulance she
was started on a nitro dip for again unclear reasons.

MEDICAL HISTORY: PMH:
-Mesenteric ischmia requiring coloectomy [**2158-4-24**]
-Respiratory failure requiring trach [**4-/2158**]
-CRI s/p transplant in [**2143**] (followed by Dr[**Doctor Last Name **] at [**Last Name (un) **],
transplant followed  by Dr. [**Last Name (STitle) 15473**]
-b/l Breast Cancer s/p lumpectomy/XRT and Chemo 199 (followed by
Dr. [**Last Name (STitle) 3274**]
-PVD s/p L BKA (followed by Dr.[**Last Name (STitle) 21080**]) - [**6-/2147**], fem-[**Doctor Last Name **] '[**48**]
with [**Doctor Last Name **]-DP bypass,
-MI X2 s/p CABG times 2
-hypercholesterolemia
-DM1 with retinopathy/neuropathy/nephropathy
-left eye prosthesis
-bilateral breast cancer
-chronic anemia
-gout

MEDICATION ON ADMISSION: -hydrocortisone 100 mg iv q8h
-SSI
-azathioprine 50 mg qd
-tylenol prn
-allopurinol 100mg qd
-clopidogrel 75 mg qd
-metoclopramide 20 mg qid
-nystatin swish and spit qid
-epo 10K qwk
-Femara 2.5 mg qd
-tacrolimus 1mg [**Hospital1 **]
-clonidine 0.2 mg tid
-Colshicine 0.6 mg qd
-colace
-emeprazole 40 qd
-Caspofungin 70 mg iv times 1 given [**6-22**]
-lasix 40 mg iv bid
-ASA 81 mg qd
-paroxetine 20mg qd
-metoprolol 50 mg tid
-lorazepam 0.5 prn
-Calcium [**Last Name (un) **] 500 mg tid
-calcium acetate 667 tid
-isosorbide dinitrate 50mg  tid
-albuterol prn
-ipratropium prn
-Ticarcillin/clavulanate 3.1g q8h
-Nitro drip

ALLERGIES: Dilaudid / Codeine / Ativan

PHYSICAL EXAM: Vitals: T:96.0 P:98-107 R:22-24 BP:163-176/76-95 SaO2:98% on 4L

FAMILY HISTORY: NC

SOCIAL HISTORY: lives with husband (a math professor [**First Name (Titles) **] [**Last Name (Titles) **]). 

### Response:
{'Acute and chronic respiratory failure,Complications of transplanted kidney,Acute kidney failure with lesion of tubular necrosis,Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled,Urinary tract infection, site not specified,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Atrial fibrillation,Pneumonia due to Klebsiella pneumoniae,Disseminated candidiasis,Hallucinations,Toxic encephalopathy,Hypercalcemia,Malignant neoplasm of breast (female), unspecified,Anemia in chronic kidney disease,Attention to ileostomy,Other specified antibiotics causing adverse effects in therapeutic use,Attention to tracheostomy'}
