CHIEF COMPLAINT: End Stage Renal disease, needs dialysis access

PRESENT ILLNESS: Ms. [**Known lastname 37559**] is a 55-year-old woman with end-stage renal disease
and multiple accesses on her left upper extremity.  Her right
upper extremity was
deemed unusable and so we decided to try again on the left side.

MEDICAL HISTORY: - Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]

MEDICATION ON ADMISSION: rifampin 300'', doxycycline 100'', metoprolol 12.5'',
simvastatin 10, nexium 20, reglan 5 qid, insulin lispro,
sevelamer 800''', lanthanum 500''', cinacalcet 60, nephrocaps,
fentanyl patch 12 mcg/hr q72hr, oxycodone prn, gabapentin 300
qHD, mirtazapine 15 qHS, tramadol 50'', [**Last Name (LF) 95641**], [**First Name3 (LF) **] 81, colace,
senna

ALLERGIES: Lisinopril

PHYSICAL EXAM: VS: 97.2, 115/56, 74, 18, 100%
Card: RRR, II/VI systolic ejection murmur
Lungs: Diminished bases
Abd: Soft, non-tender, +BS
Extr: [**Last Name (un) **] swollen and with faintly palpable graft pulse.
HD line in place Left Chest
Extrem warm

FAMILY HISTORY: Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

SOCIAL HISTORY: Admitted from rehab. Has two sisters, one daughter.  [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago.
Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Hematoma complicating a procedure,Subendocardial infarction, initial episode of care,Diastolic heart failure, unspecified,Other iatrogenic hypotension,Atherosclerosis of native arteries of the extremities, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Below knee amputation status
Hyp kid NOS w cr kid V,End stage renal disease,Hematoma complic proc,Subendo infarct, initial,Diastolc hrt failure NOS,Iatrogenc hypotnsion NEC,Athscl extrm ntv art NOS,DMII wo cmp nt st uncntr,Chr airway obstruct NEC,Obstructive sleep apnea,Status amput below knee
Admission Date:  [**2193-2-13**]              Discharge Date:   [**2193-2-20**]

Date of Birth:  [**2138-3-6**]             Sex:   F

Service: SURGERY

Allergies:
Lisinopril

Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
End Stage Renal disease, needs dialysis access

Major Surgical or Invasive Procedure:
[**2193-2-13**]: Placement of left upper extremity arteriovenous graft.
[**2193-2-13**]: Evacuation of left upper extremity hematoma, Control of
bleeding, Revision of AV graft.


History of Present Illness:
Ms. [**Known lastname 37559**] is a 55-year-old woman with end-stage renal disease
and multiple accesses on her left upper extremity.  Her right
upper extremity was
deemed unusable and so we decided to try again on the left side.


Past Medical History:
- Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]

- Likely left AKA stump osteomyelitis requiring admission in
[**3-/2192**], on IV antibiotics, VAC dressing in place
- ESRD on HD. Last HD yesterday. Usually MWF schedule.
- HTN
- Diabetes Mellitus
- Renal Cell Carcinoma s/p right nephrectomy
- Obesity
- Depression
- s/p CCY
- Gastric Ulcer
- Obstructive Sleep Apnea. The patient reports that she used to
use a CPAP however her machine broke and she no longer uses it.

- Gastroparesis
- COPD on 3-4L NC baseline
- h/o ischemic colitis
- left adrenal adenoma


Social History:
Admitted from rehab. Has two sisters, one daughter.  [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago.


Family History:
Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

Physical Exam:
VS: 97.2, 115/56, 74, 18, 100%
Card: RRR, II/VI systolic ejection murmur
Lungs: Diminished bases
Abd: Soft, non-tender, +BS
Extr: [**Last Name (un) **] swollen and with faintly palpable graft pulse.
HD line in place Left Chest
Extrem warm

Pertinent Results:
At Admission: [**2193-2-13**]
WBC-6.6# RBC-3.48* Hgb-11.1*# Hct-35.0* MCV-101* MCH-32.0
MCHC-31.8 RDW-16.3* Plt Ct-116*
PT-16.4* PTT-41.0* INR(PT)-1.5*
Glucose-179* UreaN-32* Creat-4.7*# Na-141 K-3.9 Cl-110* HCO3-21*
AnGap-14
 Calcium-7.9* Phos-6.2*# Mg-1.5*
NSTEMI:
[**2193-2-14**] 07:39AM CK(CPK)-57   CK-MB-NotDone cTropnT-0.20*
[**2193-2-14**] 06:02PM CK(CPK)-423* CK-MB-104* MB Indx-24.6*
cTropnT-1.44*
[**2193-2-14**] 10:04PM CK(CPK)-377* CK-MB-92* MB Indx-24.4*
cTropnT-1.51*
At Discharge [**2193-2-19**]
Glucose-102 UreaN-28* Creat-3.8*# Na-135 K-4.0 Cl-101 HCO3-21*
AnGap-17
Calcium-8.8 Phos-4.2 Mg-1.9
WBC-6.7 RBC-3.06* Hgb-9.6* Hct-29.3* MCV-96 MCH-31.5 MCHC-33.0
RDW-18.1* Plt Ct-109*

Brief Hospital Course:
On [**2193-2-13**] this 54 y/o female was admitted for placement of left
upper extremity arteriovenous graft. She is known to have have
multiple access issues/failures and an attempt was being made to
place an AVG in her left arm as the right arm has been deemed
unusable for dialysis access.
She was taken to the OR by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] who placed a left upper
arm graft initially without complication.
In the immediate post op period while in the PACU, the team was
called to assess the patients left arm  due to swelling and
obvious discomfort. The arm was rigid and there was significant
oozing. Dr [**Last Name (STitle) 816**] took the patient back to the OR that evening for
evacuation of left upper extremity hematoma, control of
bleeding, and revision of the AV graft. The graft was able to be
salvaged, however the patient was kept intubated. The hematocrit
had an 8% drop. She received one unit of RBCs with good
response.
She remained in the PACU overnight and experienced hypotension
for which she was started on pressors. EKG and serial cardiac
enzymes were obtained. She was transferred to the ICU. She was
extubated but was still requiring some pressor support. She
complained of back pain, but never chest arm or jaw pain.
Serial CPK and troponins were followed which showed evidence of
MI. In addition, the EKG as interpreted by Cardiology showed an
NSTEMI. An echo was obtained showed hyperdynamic ventricles with
no specific wall motion abnormalities. In addition cardiology
did not feel a cardiac cath was indicated as she was a poor
candidate due to her co-morbidities.  Medical management was
initiated and she was started on [**Last Name (STitle) **] and Plavix. In addition a
heparin drip was initiated x 48 hours.

Enzymes continued to be cycled which slowly trended back toward
normal.
The patient received CVVH while in the ICU and then was
transitioned back to intermittent hemodialysis once transferred
back to the surgical floor and more stable.  She did continue to
have some degree of low BPs intermittently while in
hemodialysis. Last treatment [**2-19**] for which 3 liters was
ultrafiltrated via a subclavian tunnelled HD line. She also had
a R groin temporary dialysis catheter that was removed just
prior to discharge to the Nursing Home on [**2-20**].

The patient was seen by PT and recommended PT when back at her
home facility (St. Josephs in [**Location (un) 686**] ([**Telephone/Fax (1) **]).

Vascular was consulted for concern about right leg lower
extremity edema, compartment syndrome vs fluid overload. It was
deemed low suspicion for compartment syndrome as the calf was
soft and pulses dopplerable.Blood pressures returned to more
normal readings (SBP in 110s) Heparin drip d/c'd after 48 hours.


She will discharge back to St Josephs where she has been a
resident.
Outpatient follow-up with cardiology is arranged and is included
in the discharge paperwork.

Doxycycline 100mg PO BID and rifampin 300mg PO bid are to be
continued  for chronic suppression of MRSA vertebral
osteomyelitis (hardware in place) for indefinite period of time.
She will need a follow up appointment with Spine Surgery.


Medications on Admission:
rifampin 300'', doxycycline 100'', metoprolol 12.5'',
simvastatin 10, nexium 20, reglan 5 qid, insulin lispro,
sevelamer 800''', lanthanum 500''', cinacalcet 60, nephrocaps,
fentanyl patch 12 mcg/hr q72hr, oxycodone prn, gabapentin 300
qHD, mirtazapine 15 qHS, tramadol 50'', [**Last Name (LF) 95641**], [**First Name3 (LF) **] 81, colace,
senna


Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale
 Subcutaneous ASDIR (AS DIRECTED).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
4. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): x
30 days then decrease to 81mg po qd.
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): for 9-12 months per Cardiology for NSTEMI.
10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours): indefinate course per Spine surgery due to hardware.

13. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours): indefinate course per Spine surgery for
hardware.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection twice a day.
15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
16. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Doctor Last Name 1495**] Josephs

Discharge Diagnosis:
NSTEMI (perioperative) with diastolic heart failure
s/p placement of graft with arterial anastomosis rupture
Hematoma evacuation


Discharge Condition:
Stable/Fair


Discharge Instructions:
Please call the access clinic at [**Telephone/Fax (1) 673**] for bleeding, cold
fingers/hand, hand numbness, loss of pulse to left hand, loss of
bruit and thrill in left arm access or other concerning issues
with the left arm.
Monitor for bleeding or increased pain in the left arm
Dressing change daily to left arm, DSD
Continue hemodialysis per routine schedule. Last dialysis at
[**Hospital1 18**] was [**2-19**].
Continue home medications with:
FOLLOWING CARDIOLOGY RECOMENDATIONS:
**the addition of aspirin 325 mg x 30 days then 81 mg daily
**Continue Plavix 75 mg daily for 9 - 12 Months
**Simvastatin 80 mg daily
Continue patietns food, fluid restrictions per renal guidelines
If patient develops back, chest or jaw pain; transfer to ER for
evaluation
No shower or tub bath with dialysis catheter in place

Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2193-2-25**] 9:00
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2193-3-11**]
3:00
 APPT at [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 516**] [**Hospital1 18**], [**Location (un) **]; Cardiac

  Services



Completed by:[**2193-2-20**]
{'Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Hematoma complicating a procedure,Subendocardial infarction, initial episode of care,Diastolic heart failure, unspecified,Other iatrogenic hypotension,Atherosclerosis of native arteries of the extremities, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Below knee amputation status'}


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: End Stage Renal disease, needs dialysis access

PRESENT ILLNESS: Ms. [**Known lastname 37559**] is a 55-year-old woman with end-stage renal disease
and multiple accesses on her left upper extremity.  Her right
upper extremity was
deemed unusable and so we decided to try again on the left side.

MEDICAL HISTORY: - Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]

MEDICATION ON ADMISSION: rifampin 300'', doxycycline 100'', metoprolol 12.5'',
simvastatin 10, nexium 20, reglan 5 qid, insulin lispro,
sevelamer 800''', lanthanum 500''', cinacalcet 60, nephrocaps,
fentanyl patch 12 mcg/hr q72hr, oxycodone prn, gabapentin 300
qHD, mirtazapine 15 qHS, tramadol 50'', [**Last Name (LF) 95641**], [**First Name3 (LF) **] 81, colace,
senna

ALLERGIES: Lisinopril

PHYSICAL EXAM: VS: 97.2, 115/56, 74, 18, 100%
Card: RRR, II/VI systolic ejection murmur
Lungs: Diminished bases
Abd: Soft, non-tender, +BS
Extr: [**Last Name (un) **] swollen and with faintly palpable graft pulse.
HD line in place Left Chest
Extrem warm

FAMILY HISTORY: Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

SOCIAL HISTORY: Admitted from rehab. Has two sisters, one daughter.  [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago. 

### Response:
{'Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Hematoma complicating a procedure,Subendocardial infarction, initial episode of care,Diastolic heart failure, unspecified,Other iatrogenic hypotension,Atherosclerosis of native arteries of the extremities, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Below knee amputation status'}
