CHIEF COMPLAINT: generalized weakness, anorexia

PRESENT ILLNESS: [**Age over 90 **] y/o [**Age over 90 **] y/o F w/ AFib on coumadin, tachy-brady syndrome s/p
PPM, CKD, and diastolic CHF a/w malaise, weakness, and decreased
PO intake for two days and an episode of urinary incontinence
the night prior to admission. Per the patient's family, she felt
well until 2 days ago when she noted multiple episodes of
diarrhea in the setting of an increase in her laxative regimen
intended to treat constipation and associated abdominal
discomfort. She has not had any recent antibiotic use or health
care exposures. She denies fevers, chills, dysuria, hematuria,
flank pain, or changes in mental status. Family does state that
renal function has steadily declined over the past 6 months for
which she has been followed closely by a nephrologist.
.
In the ED VS 96.2, 60, 110/64 19 99% 2L. EKG unchanged from
prior. Had transient fluid-responsive systolic hypotension to
SBP 85. Received levofloxacin 750 mg x1. She was transferred to
the MICU for close observation given hypotension in the setting
of delicate volume status.

MEDICAL HISTORY: AFib
Tachy-brady s/p PPM [**3-9**]
CKD stage IV b/l ~Cr 2.2
SCC leg and neck s/p radiation [**1-9**]
4+ TR
2+ MR
[**First Name (Titles) **] [**Last Name (Titles) **] HTN
Hypothyroidism
HTN
IBS
Anemia b/l Hct ~34%
Diverticulosis

MEDICATION ON ADMISSION: ATORVASTATIN 10 mg PO daily
EPOETIN ALFA 40,000 units SC Q2wks
FUROSEMIDE 20 mg PO QOD
HYDROCORTISONE-PRAMOXINE CREAM (1 %-1%) TP to hemorrhoids TID
LEVOTHYROXINE 50 mcg PO daily
LOSARTAN 25 mg PO daily
METOPROLOL SUCCINATE - 50 mg PO QAM, 25 mg PO QPM
PANTOPRAZOLE - 40 mg PO Daily
POLYETHYLENE GLYCOL 1 tablespoon powder PO Daily
WARFARIN 2.5 mg Tablet PO Daily
Restasis *NF* 0.05 % OU [**Hospital1 **] to each eye
Citalopram Hydrobromide 10 mg PO QHS
CALCIUM CARBONATE 600 mg (1,500 mg) Tablet - 2 Tabs PO BID
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 400 unit Tablet 1 tab
PO daily

ALLERGIES: Penicillins / Sulfonamides / Tetracyclines

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
VS: 96.2 108/60 72 18 96% RA
Gen: NAD, Alert, Oriented to Location, Person, but not to date
HEENT: PERRLA, EOMI, Dry MM
Neck: Supple, No LAD, No appreciable JVD
CV: reg rate (paced) nl S1S2 no m/r/g
[**Location (un) **]: Decreased BS on R
Abd: Soft, mildly-distended, NT BS+
Extrem: warm, dry 2+ pitting edema to knees bilaterally

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Retired. No current alcohol or tobacco use. Dtrs very active in
Acute kidney failure, unspecified,Acute on chronic diastolic heart failure,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage IV (severe),Thrombocytopenia, unspecified,Anemia, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ
Acute kidney failure NOS,Ac on chr diast hrt fail,Urin tract infection NOS,Hy kid NOS w cr kid I-IV,Chr kidney dis stage IV,Thrombocytopenia NOS,Anemia NOS,Atrial fibrillation,Long-term use anticoagul,Status cardiac pacemaker
Admission Date:  [**2184-9-12**]              Discharge Date:   [**2184-9-21**]


Service: MEDICINE

Allergies:
Penicillins / Sulfonamides / Tetracyclines

Attending:[**First Name3 (LF) 710**]
Chief Complaint:
generalized weakness, anorexia

Major Surgical or Invasive Procedure:
Left internal jugular tunneled hemodialysis catheter [**2184-9-16**]


History of Present Illness:
[**Age over 90 **] y/o [**Age over 90 **] y/o F w/ AFib on coumadin, tachy-brady syndrome s/p
PPM, CKD, and diastolic CHF a/w malaise, weakness, and decreased
PO intake for two days and an episode of urinary incontinence
the night prior to admission. Per the patient's family, she felt
well until 2 days ago when she noted multiple episodes of
diarrhea in the setting of an increase in her laxative regimen
intended to treat constipation and associated abdominal
discomfort. She has not had any recent antibiotic use or health
care exposures. She denies fevers, chills, dysuria, hematuria,
flank pain, or changes in mental status. Family does state that
renal function has steadily declined over the past 6 months for
which she has been followed closely by a nephrologist.
.
In the ED VS 96.2, 60, 110/64 19 99% 2L. EKG unchanged from
prior. Had transient fluid-responsive systolic hypotension to
SBP 85. Received levofloxacin 750 mg x1. She was transferred to
the MICU for close observation given hypotension in the setting
of delicate volume status.

Past Medical History:
AFib
Tachy-brady s/p PPM [**3-9**]
CKD stage IV b/l ~Cr 2.2
SCC leg and neck s/p radiation [**1-9**]
4+ TR
2+ MR
[**First Name (Titles) **] [**Last Name (Titles) **] HTN
Hypothyroidism
HTN
IBS
Anemia b/l Hct ~34%
Diverticulosis

Social History:
Retired. No current alcohol or tobacco use. Dtrs very active in

her care. Lives in house in [**Location (un) 10059**] with live-in aide.


Family History:
Noncontributory

Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 96.2 108/60 72 18 96% RA
Gen: NAD, Alert, Oriented to Location, Person, but not to date
HEENT: PERRLA, EOMI, Dry MM
Neck: Supple, No LAD, No appreciable JVD
CV: reg rate (paced) nl S1S2 no m/r/g
[**Location (un) **]: Decreased BS on R
Abd: Soft, mildly-distended, NT BS+
Extrem: warm, dry 2+ pitting edema to knees bilaterally

Pertinent Results:
[**2184-9-19**] HEPARIN DEPENDENT ANTIBODIES

     TEST                           RESULT
     ----                           ------
HEPARIN DEPENDENT ANTIBODIES      NEGATIVE

COMMENT:       NEGATIVE FOR HEPARIN PF4 ANTIBODY BY [**Doctor First Name **]
.
[**2184-9-12**] 11:30AM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2184-9-12**] 11:30AM URINE  RBC-[**5-11**]* WBC-[**5-11**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
.
[**2184-9-12**] 9:24 pm URINE     Site: CLEAN CATCH      Source:
Catheter.

                            **FINAL REPORT [**2184-9-17**]**

   URINE CULTURE (Final [**2184-9-17**]):
      IDENTIFICATION AND SENSITIVITIES REQUESTED BY DR.[**Last Name (STitle) 99804**].

      STAPH AUREUS COAG +.    ~1000/ML.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.


                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
NITROFURANTOIN--------  <=16 S
OXACILLIN-------------   =>4 R
PENICILLIN G---------- =>0.5 R
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S
.
[**2184-9-12**] CHEST RADIOGRAPH, PA AND LATERAL
Dual-lead right pectoral pacemaker with
right atrial and right ventricular leads is unchanged from prior
studies.
Cardiomegaly is again noted, although the right heart border is
now obscured by right basilar opacity which also obscures the
right hemidiaphragm, consistent with moderate-sized pleural
effusion and related atelectasis, although underlying pneumonic
consolidation cannot be excluded. There is also a small left
pleural effusion with milder left retrocardiac atelectasis. The
remainder of the lungs are grossly clear, without evidence of
overt pulmonary edema or lung consolidation . There is no
evidence of pneumothorax. Calcifications are again noted along
the aorta. Old right lateral rib fracture is unchanged.

IMPRESSIONS: Increased right basilar opacity, with increased and
now
moderate-sized right pleural effusion, and related atelectasis,
although
underlying pneumonic consolidation cannot be excluded. Small
left pleural
effusion with left basilar atelectasis.
.
[**2184-9-14**] TTE
The left atrium is mildly dilated. The right atrium is markedly
dilated. The estimated right atrial pressure is 10-20mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF 55-60%). The right
ventricular cavity is moderately dilated with mild global free
wall hypokinesis. There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. The tricuspid valve leaflets fail to fully
coapt. Severe [4+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. Significant
pulmonic regurgitation is seen. The main pulmonary artery is
dilated. There is a trivial/physiologic pericardial effusion.

IMPRESSION: Dilated right ventricle with mild global systolic
dysfunction and evidence of volume overload. Normal global and
regional left ventricular systolic function. Mild aortic
regurgitation. Mild mitral regurgitation. Severe functional
tricuspid regurgitation.

Compared with the prior study (images reviewed) of [**2184-7-2**],
findings are similar. Left ventricular systolic function may
have been slightly underestimated on the prior study.
.
[**2184-9-16**] VASCULAR U/S-GUIDED CATHETER PLACEMENT
FINDINGS:
1. Patent left internal jugular vein, accessed under son[**Name (NI) 493**]
guidance.
2. Placement of tunneled 15.5 French x 27 cm cuff-to-tip
angiodynamics
hemodialysis catheter via the left internal jugular vein.
3. Post-procedure chest radiograph showed the catheter tip in
the right
atrium with no kinks along the course of the catheter and no
pneumothorax.

Incidental note is made of atrioventricular pacing wires in
expected position placed through the right subclavian vein.

IMPRESSION: Successful placement of left internal jugular
tunneled
hemodialysis catheter. The catheter is ready for immediate use.


Brief Hospital Course:
#CKD stage IV - The patient presented with symptoms consistent
with uremia. Volume overload was refractory to diuretic therapy
due to worsening renal function. Left IJ tunneled HD catheter
was placed on [**9-16**] with subsequent initiation of hemodialysis
that day, followed by [**9-17**], [**9-18**], [**9-20**], and [**9-21**]. Nephrocaps
were added. Lasix and [**Last Name (un) **] were discontinued. Phosphate binder
therapy was not added as the calcium-phosphate product was
approximately 18. PPD was read as 0 mm induration on [**9-19**]. The
patient will continue to receive HD as an outpatient.
.
#Acute on chronic diastolic CHF - Admission CXR showed a
moderately-sized right pleural effusion with associated
atelectasis and a small left pleural effusion with left basilar
atelectasis. TTE [**9-14**] showed a dilated RV with mild global
systolic dysfunction and evidence of volume overload, normal
global and regional LV systolic function (LVEF 55-60%), and
severe functional TR and mild AR/MR. Respiratory status remained
stable with adequate room air oxygenation. Volume status was
managed with HD, as above.
.
#Thrombocytopenia - The patient did not have clinical signs or
symptoms of bleeding or thrombosis. Attributed to an effect of
cephalosporin therapy but other possible offending medications
including heparin, protonix, and atorvastatin were discontinued.
Indwelling catheter was flushed with citrate solution rather
than heparin during HD sessions. PF4 antibody was negative. The
patient will have a repeat CBC two days after discharge to
continue to monitor platelet count.
.
#Anemia of chronic kidney disease - Hematocrit remained stable,
obviating the need for transfusion. She may continue to receieve
erythropoeitin therapy as an adjunct to hemodialysis.
.
#UTI - Admission urinalysis showed [**5-11**] WBC, moderate bacteria,
and trace leukocyte esterase. She was treated with 3 days of
ceftriaxone until urine culture revealed ~1000 colonies MRSA,
likely a skin contaminant. She was placed on contact precautions
accordingly.
.
#Atrial fibrillation - Anticoagulation was reversed with vitamin
K and FFP prior to HD catheter placement. Coumadin was resumed
after the procedure with a goal INR 2.0-3.0. The patient will be
discharged with VNA services to monitor INR and adjust coumadin
dosing accordingly.
.
#Hypertension - Blood pressure was low-normal during the
hospitalization and metoprolol was decreased to 25 mg qHS due to
concerns for hypotension, particularly in the setting of
hemodialysis.
.
#Hypothyroidism - Continued levothyroxine.
.
#Nutrition - Heart-healthy diet. Calcium and vitamin D were
continued.

Medications on Admission:
ATORVASTATIN 10 mg PO daily
EPOETIN ALFA 40,000 units SC Q2wks
FUROSEMIDE 20 mg PO QOD
HYDROCORTISONE-PRAMOXINE CREAM (1 %-1%) TP to hemorrhoids TID
LEVOTHYROXINE 50 mcg PO daily
LOSARTAN 25 mg PO daily
METOPROLOL SUCCINATE - 50 mg PO QAM, 25 mg PO QPM
PANTOPRAZOLE - 40 mg PO Daily
POLYETHYLENE GLYCOL 1 tablespoon powder PO Daily
WARFARIN 2.5 mg Tablet PO Daily
Restasis *NF* 0.05 % OU [**Hospital1 **] to each eye
Citalopram Hydrobromide 10 mg PO QHS
CALCIUM CARBONATE 600 mg (1,500 mg) Tablet - 2 Tabs PO BID
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 400 unit Tablet 1 tab
PO daily


Discharge Medications:
1. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] to each eye ().
2. Citalopram 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Lactaid 3,000 unit Tablet Sig: One (1) Tablet PO QAC ().
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Polyethylene Glycol 3350 100 % Powder Sig: One (1) tablespoon
powder PO once daily as directed.
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Adjust dose as directed to maintain INR 2.0-3.0.
8. Nystatin 100,000 unit/g Cream Sig: One (1) application
Topical twice a day as needed for itching.
9. Outpatient Lab Work
Please check complete blood count on Thursday, [**9-23**] and
fax the results to the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 716**].
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day: hold for sbp<100.
11. Home Equipment
Please provide a hospital bed for home.
12. Citracal + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO
twice a day.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
14. Medication
You may continue taking your hydrocortisone-lidocaine compound
topically as needed for discomfort due to hemorrhoids.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Primary
1) Chronic kidney disease stage V on hemodialysis
2) Acute on chronic diastolic heart failure
3) Thrombocytopenia
4) Urinary tract infection

Secondary
1) Atrial fibrillation
2) Anemia of chronic kidney disease
3) Hypothyroidism


Discharge Condition:
clinically improved with stable vital signs.


Discharge Instructions:
You were admitted to the hospital with generalized weakness and
poor appetite most attributable to worsening kidney function, or
uremia. A catheter was placed and hemodialysis was initiated on
[**2184-9-16**].

Your next hemodialysis session is at [**Location (un) **] [**Location (un) **] on
Thursday, [**9-23**] at 3:00 PM. You will continue to have
dialysis on Tuesdays, Thursdays, and Saturdays.

You were also found to have a low platelet count likely due to
an effect of medication. Antibiotics, protonix, and lipitor, all
of which can cause this problem, were discontinued. Please have
a complete blood count checked on Thursday, [**9-23**] and
ensure that the results are faxed to the office of Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 716**].

The follow medications were changed:
1) Vitamins called nephrocaps were started.
2) Lasix and losartan were discontinued as you will continue to
receive hemodialysis.
3) Metoprolol was decreased to 12.5 mg twice daily due to low
blood pressure.
4) Calcium and vitamin D were changed to a combination pill
called Citracal+D, 2 tablets twice daily.
5) Citalopram (celexa) was increased to 10 mg (1 full tablet)
daily.

Please weigh yourself daily and call your physician if your
weight increases by more than 3 pounds.
Please adhere to diet containing than 2 grams of sodium daily.

Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Wednesday [**9-29**] at 4:00 PM. If you need to reschedule this appointment,
please call [**Telephone/Fax (1) 719**].

Please call your physician or return to the Emergency Department
immediately if you experience fever, chills, sweats, dizziness,
lightheadedness, passing out, falling, chest pain, palpitations,
shortness of breath, cough, abdominal pain, vomiting, diarrhea,
bloody or dark stools, discomfort with urination, or leg
swelling or pain.

Followup Instructions:
Your next hemodialysis session is at [**Location (un) **] [**Location (un) **] on
Thursday, [**9-23**] at 3:00 PM. You will continue to have
dialysis on Tuesdays, Thursdays, and Saturdays.

Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Wednesday [**9-29**] at 4:00 PM. If you need to reschedule this appointment,
please call [**Telephone/Fax (1) 719**].

Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2184-10-22**]
10:00

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2184-10-22**] 10:40



Completed by:[**2184-9-21**]
{'Acute kidney failure, unspecified,Acute on chronic diastolic heart failure,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage IV (severe),Thrombocytopenia, unspecified,Anemia, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ'}


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: generalized weakness, anorexia

PRESENT ILLNESS: [**Age over 90 **] y/o [**Age over 90 **] y/o F w/ AFib on coumadin, tachy-brady syndrome s/p
PPM, CKD, and diastolic CHF a/w malaise, weakness, and decreased
PO intake for two days and an episode of urinary incontinence
the night prior to admission. Per the patient's family, she felt
well until 2 days ago when she noted multiple episodes of
diarrhea in the setting of an increase in her laxative regimen
intended to treat constipation and associated abdominal
discomfort. She has not had any recent antibiotic use or health
care exposures. She denies fevers, chills, dysuria, hematuria,
flank pain, or changes in mental status. Family does state that
renal function has steadily declined over the past 6 months for
which she has been followed closely by a nephrologist.
.
In the ED VS 96.2, 60, 110/64 19 99% 2L. EKG unchanged from
prior. Had transient fluid-responsive systolic hypotension to
SBP 85. Received levofloxacin 750 mg x1. She was transferred to
the MICU for close observation given hypotension in the setting
of delicate volume status.

MEDICAL HISTORY: AFib
Tachy-brady s/p PPM [**3-9**]
CKD stage IV b/l ~Cr 2.2
SCC leg and neck s/p radiation [**1-9**]
4+ TR
2+ MR
[**First Name (Titles) **] [**Last Name (Titles) **] HTN
Hypothyroidism
HTN
IBS
Anemia b/l Hct ~34%
Diverticulosis

MEDICATION ON ADMISSION: ATORVASTATIN 10 mg PO daily
EPOETIN ALFA 40,000 units SC Q2wks
FUROSEMIDE 20 mg PO QOD
HYDROCORTISONE-PRAMOXINE CREAM (1 %-1%) TP to hemorrhoids TID
LEVOTHYROXINE 50 mcg PO daily
LOSARTAN 25 mg PO daily
METOPROLOL SUCCINATE - 50 mg PO QAM, 25 mg PO QPM
PANTOPRAZOLE - 40 mg PO Daily
POLYETHYLENE GLYCOL 1 tablespoon powder PO Daily
WARFARIN 2.5 mg Tablet PO Daily
Restasis *NF* 0.05 % OU [**Hospital1 **] to each eye
Citalopram Hydrobromide 10 mg PO QHS
CALCIUM CARBONATE 600 mg (1,500 mg) Tablet - 2 Tabs PO BID
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 400 unit Tablet 1 tab
PO daily

ALLERGIES: Penicillins / Sulfonamides / Tetracyclines

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
VS: 96.2 108/60 72 18 96% RA
Gen: NAD, Alert, Oriented to Location, Person, but not to date
HEENT: PERRLA, EOMI, Dry MM
Neck: Supple, No LAD, No appreciable JVD
CV: reg rate (paced) nl S1S2 no m/r/g
[**Location (un) **]: Decreased BS on R
Abd: Soft, mildly-distended, NT BS+
Extrem: warm, dry 2+ pitting edema to knees bilaterally

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Retired. No current alcohol or tobacco use. Dtrs very active in 

### Response:
{'Acute kidney failure, unspecified,Acute on chronic diastolic heart failure,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage IV (severe),Thrombocytopenia, unspecified,Anemia, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ'}
