CHIEF COMPLAINT: Flank pain and epistaxis with dropping Hct, SOB, worsening
edema.

PRESENT ILLNESS: 83yo F with history of hypertension, chronic renal
insufficiency, and right renal cystic mass, initially treated at
[**Hospital 1474**] Hospital (admitted [**9-1**], dicharged [**9-3**] and readmitted
on [**2181-9-4**]) for congestive heart failure, renal failure, and
left upper lobe pneumonia with the chief complaint of shortness
of breath, increasing pedal edema, and increasing fatigue. She
was treated for congestive heart and worsening renal failure
(baseline creatinine 2.0 in [**2179**]). At rehab, her hct dropped
37-->27 over 4-5 days. On [**2181-9-23**], she was noted to have had
dark stool and significant epistaxis. On [**2181-9-24**], she was found
to have a Hct of 16 which continued to drop despite multiple
blood transfusions. She also began to complain of right flank
pain. A CT of the abdomen and pelvis showed a right-sided
retroperitoneal hematoma displacing the right renal artery
anteriorly. At [**Hospital1 1474**], the patient received 10 units of packed
RBCs, 2 units of FFP, and 2 doses ddAVP. She was started on
dopamine IV drip .625 for renal insufficiency and was continued
on lasix IV 80 tid and zaroxylyn. At the outside hospital, she
was also being treated for a enterococcal pan-senstivie urinary
tract infection. She was transferred to [**Hospital1 18**] on [**2181-9-29**] for the
management of acute renal failure and retroperitoneal bleed. She
was transferred from the MICU to the floor service on [**2181-9-30**].

MEDICAL HISTORY: HTN, hypothyroid, gout, CRI (baseline Cr 2.0), diastolic
dysfunction (EF 55% 7/04), 4 cm right renal mass (cystic RCC vs
multiloculated cyst, seen on CT on [**11-11**], followed),
hysterectomy, arthritis

MEDICATION ON ADMISSION: Levobunolol HCl 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QOD (every
other day). Tablet
ASA

ALLERGIES: Shellfish

PHYSICAL EXAM: Vitals: T:96.9, BP: 156/64, HR: 96, RR:16, O2:98% 2L
Gen: elderly woman, appears younger than stated age, in NAD.
HEENT: EOMI, PERL, mild proptosis, OP clear, mmm, neck supple,
not LAD, elevated JVD.
CV: RRR, II/VI SEM at LLSB, no rubs
Resp: decreased BS, + rales 2/3 up, scattered exp wheezing
Abd: edema to mid abd, NDNT, +BS, soft
Ext: [**3-13**]+ pitting edema to abd, good distal pulses.
Skin: warm, no rash
Neuro: grossly intact, A&O x3.
GUIAC Neg

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: The patient is a non-smoker, does not drink alcohol. She had 2
prior pregnancies.
Acute kidney failure with other specified pathological lesion in kidney,Hemorrhage, unspecified,Other and unspecified coagulation defects,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Pulmonary collapse,Diastolic heart failure, unspecified
Acute kidney failure NEC,Hemorrhage NOS,Coagulat defect NEC/NOS,Hyp kid NOS w cr kid V,Urin tract infection NOS,Pulmonary collapse,Diastolc hrt failure NOS
Admission Date:  [**2181-9-29**]              Discharge Date:   [**2181-10-12**]


Service: MED

Allergies:
Shellfish

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Flank pain and epistaxis with dropping Hct, SOB, worsening
edema.

Major Surgical or Invasive Procedure:
Hemodialysis started [**2181-10-4**] with tunneled catheter placement in
right subclavian on [**2181-10-3**].


History of Present Illness:
83yo F with history of hypertension, chronic renal
insufficiency, and right renal cystic mass, initially treated at
[**Hospital 1474**] Hospital (admitted [**9-1**], dicharged [**9-3**] and readmitted
on [**2181-9-4**]) for congestive heart failure, renal failure, and
left upper lobe pneumonia with the chief complaint of shortness
of breath, increasing pedal edema, and increasing fatigue. She
was treated for congestive heart and worsening renal failure
(baseline creatinine 2.0 in [**2179**]). At rehab, her hct dropped
37-->27 over 4-5 days. On [**2181-9-23**], she was noted to have had
dark stool and significant epistaxis. On [**2181-9-24**], she was found
to have a Hct of 16 which continued to drop despite multiple
blood transfusions. She also began to complain of right flank
pain. A CT of the abdomen and pelvis showed a right-sided
retroperitoneal hematoma displacing the right renal artery
anteriorly. At [**Hospital1 1474**], the patient received 10 units of packed
RBCs, 2 units of FFP, and 2 doses ddAVP. She was started on
dopamine IV drip .625 for renal insufficiency and was continued
on lasix IV 80 tid and zaroxylyn. At the outside hospital, she
was also being treated for a enterococcal pan-senstivie urinary
tract infection. She was transferred to [**Hospital1 18**] on [**2181-9-29**] for the
management of acute renal failure and retroperitoneal bleed. She
was transferred from the MICU to the floor service on [**2181-9-30**].


Past Medical History:
HTN, hypothyroid, gout, CRI (baseline Cr 2.0), diastolic
dysfunction (EF 55% 7/04), 4 cm right renal mass (cystic RCC vs
multiloculated cyst, seen on CT on [**11-11**], followed),
hysterectomy, arthritis

Social History:
The patient is a non-smoker, does not drink alcohol. She had 2
prior pregnancies.

Family History:
Non-contributory

Physical Exam:
Vitals: T:96.9, BP: 156/64, HR: 96, RR:16, O2:98% 2L
Gen: elderly woman, appears younger than stated age, in NAD.
HEENT: EOMI, PERL, mild proptosis, OP clear, mmm, neck supple,
not LAD, elevated JVD.
CV: RRR, II/VI SEM at LLSB, no rubs
Resp: decreased BS, + rales 2/3 up, scattered exp wheezing
Abd: edema to mid abd, NDNT, +BS, soft
Ext: [**3-13**]+ pitting edema to abd, good distal pulses.
Skin: warm, no rash
Neuro: grossly intact, A&O x3.
GUIAC Neg


Pertinent Results:
[**2181-9-29**] 09:58PM   GLUCOSE-102 UREA N-144* CREAT-4.2* SODIUM-141
POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-24 ANION GAP-20
[**2181-9-29**] 09:58PM   ALT(SGPT)-25 AST(SGOT)-26 LD(LDH)-375* ALK
PHOS-159* AMYLASE-540* TOT BILI-1.6*
[**2181-9-29**] 09:58PM   LIPASE-18
[**2181-9-29**] 09:58PM   ALBUMIN-3.1* CALCIUM-9.3 PHOSPHATE-6.8*
MAGNESIUM-2.3 URIC ACID-10.2*
[**2181-9-29**] 09:58PM   TSH-18*
[**2181-9-29**] 09:58PM   WBC-11.7* RBC-3.24* HGB-10.0* HCT-29.8*
MCV-92 MCH-30.9 MCHC-33.6 RDW-15.1
[**2181-9-29**] 09:58PM   NEUTS-93* BANDS-0 LYMPHS-4* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2181-9-29**] 09:58PM   HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
STIPPLED-OCCASIONAL
[**2181-9-29**] 09:58PM   PLT COUNT-117*
[**2181-9-29**] 09:58PM   PT-14.0* PTT-39.8* INR(PT)-1.2
[**2181-9-29**] 09:58PM URINE  COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2181-9-29**] 09:58PM URINE  BLOOD-LG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2181-9-29**] 09:58PM URINE  RBC->50 WBC->50 BACTERIA-MOD YEAST-MANY
EPI-[**4-13**]

ECG: Normal sinus rhythm
Possible anterior infarct - age undetermined
Leftward axis - ? inferior myocardial infarction
No previous tracing

ECHO: ([**10-2**]): Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or
color Doppler. There is severe symmetric left ventricular
hypertrophy. The
left ventricular cavity is small. Overall left ventricular
systolic function
is normal (LVEF 60%). No masses or thrombi are seen in the left
ventricle.
There is no ventricular septal defect. Right ventricular chamber
size and free
wall motion are normal. The aortic arch is mildly dilated. There
are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly
thickened but not stenotic. Mild (1+) aortic regurgitation is
seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic
hypertension. There is no pericardial effusion.

Impression: small left ventricular cavity with severe concentric
left
ventricular hypertrophy and normal ejection fraction

CXR: ([**9-29**]) Rotated positioning. There are
moderate-to-moderately large bilateral layering pleural
effusions with underlying collapse and/or consolidation. A right
IJ central line is present, tip over distal SVC. No pneumothorax
is identified. There is no upper zone redistribution to suggest
CHF.

Abd CT: ([**10-3**]) 1. Large retroperitoneal hematomas as described.
2. Gallstones.
3. Multiple buttock calcifications secondary to prior
injections.
4. Anasarca/pleural effusions/ascites consistent with third
spacing.


Brief Hospital Course:
The patient is a 83 year old female with retroperitoneal bleed
likely secondary to right-sided renal mass, acute on chronic
renal failure with anasarca, now HD dependent.

HOSPITAL COURSE BY PROBLEM:

1. RETROPERITONEAL BLEED, likely [**3-12**] renal mass given proximity
to R hematoma.
- No further enlargement of retroperitoneal bleed during
admission. Hct remained stable, no furhter transfusions
required.
- Coagulopathy reversed with FFP and Vit K suggestiong
nutritional etiology.
- Mixing studies performed at [**Hospital1 2025**] showed reversal of
coagulopathy with the addition of factors, [**Last Name (un) 7162**] suggesting a
nutritional etiology.

2. VOLUME OVERLOAD - CVP 15, tense edema to abd, pleural
effusions on CXR
- Overload most likely [**3-12**] RF and not cardiogenic (no ischemia
on EKG, EF 55%-although does have known diastolic dysfunction)
- Pt was taken off od dopamine on arrival from OSH and d/c'd all
diuretics.
- Pt started on dialysis for fluid removal and ultrafiltration
on [**2181-10-4**]. Dialysis was successful and able to removel large
amounts of fluid without change in BP. Beta blockers held. Much
of the edema has resolved but not completely by the tiem of
discharege and pt will most likely need lifelong HD.

3. ACUTE ON CHRONIC RENAL FAILURE
- CT, MRI and U/S performed with ruled out obstruction and IVC
thrombus. Renal mass could not be fully appreciated on imaging
and would require bx for diagnosis. Pt does not want surgery and
therefore refused bx.
- Sent [**Doctor First Name **], ANCA, C3, C4 studied whcih were negative.
- Urine studies initially showed achanthocytes, but nephritis
later ruled out by follow-up analysis. 24 hr protien was 2.5,
not nephrotic syndrome.
- Final diagnosis is that pt had substantial chronic renal
failure woth creat of 2.0 and had a second insult that placed
her in acute renal failure.
- Pt followed by Reanl team throughout admission.

4. RENAL MASS - Appears cystic on imaging. Has not increased in
size since dx [**11-11**]. Supportive care only.

5. ENTEROCOCCUS UTI - Put on renally dosed amox 500 q24. D/c'd
after 2 weeks course. No further + cx's for enterococcus. Pt did
ahve yeast in urine and was treated for 3 days with Fluconazole.


6. RECENT PNA? - CXR with large bilateral pleural effusions.
Difficult to assess for PNA. Most likely not a pna. Probable
combination of colapsed lung within the pleural effusion and
atelectasis. Pt did not spike fever and did not have a cough.
O2sats improved with diuresis.

7: CV: Pt's Bp meds held initially while trying to take off
large amounts of fluid. Pt then became hypertensive and was
placed back on home medications.

8. Urinary retention: Foley removed and pt had difficulty
urinating. No evidence of saddle numbness, no fecal
incontinence. No other neurologic deficits. Urology consulted,
but in light of the fact that the pt does not want any surgery,
they recommended returning as an outpt for further treatment.

9. Psych: Throughout admission pt was very [**Last Name (un) 1425**] with good
mood and appropriate affect. However, on day of discharge after
pt realized that she would be unable to return home safely, her
mood became depressed and she was withdrawn. Thsi is most likely
transient and should improve as the pt makes progress at rehab,
however, if it does not it should be addressed in the future
possibly with a psych consult vs. anti-depresseants. Pt does not
have a history of depression.

10. PROPH - Ranitidine, pneumoboots. No Heparin [**3-12**] recent
coagulopathy.

11. ACCESS - R subclavian tunelled catherter. Foley

12. CODE: FULL

Medications on Admission:
Levobunolol HCl 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QOD (every
other day). Tablet
ASA


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO QD (once a day).
4. Levobunolol HCl 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
5. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
6. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. Calcium Acetate 667 mg Tablet Sig: 1.5 Tablets PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QOD (every
other day). Tablet(s)


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Right renal cystic mass with large right retroperitoneal bleed,
acute on chronic renal failure with unclear etiology, anasarca


Discharge Condition:
Stable.

Discharge Instructions:
Please return to the ER or call your primary care physician if
you experience worsening shortness of breath, chest pain,
abdominal pain, increased swelling or start having nosebleeds or
blood in your stool.

Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6984**], in
1 week. Please follow up with a Urologist in your area if
urinaru retention does not resolve.
{'Acute kidney failure with other specified pathological lesion in kidney,Hemorrhage, unspecified,Other and unspecified coagulation defects,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Pulmonary collapse,Diastolic heart failure, 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: Flank pain and epistaxis with dropping Hct, SOB, worsening
edema.

PRESENT ILLNESS: 83yo F with history of hypertension, chronic renal
insufficiency, and right renal cystic mass, initially treated at
[**Hospital 1474**] Hospital (admitted [**9-1**], dicharged [**9-3**] and readmitted
on [**2181-9-4**]) for congestive heart failure, renal failure, and
left upper lobe pneumonia with the chief complaint of shortness
of breath, increasing pedal edema, and increasing fatigue. She
was treated for congestive heart and worsening renal failure
(baseline creatinine 2.0 in [**2179**]). At rehab, her hct dropped
37-->27 over 4-5 days. On [**2181-9-23**], she was noted to have had
dark stool and significant epistaxis. On [**2181-9-24**], she was found
to have a Hct of 16 which continued to drop despite multiple
blood transfusions. She also began to complain of right flank
pain. A CT of the abdomen and pelvis showed a right-sided
retroperitoneal hematoma displacing the right renal artery
anteriorly. At [**Hospital1 1474**], the patient received 10 units of packed
RBCs, 2 units of FFP, and 2 doses ddAVP. She was started on
dopamine IV drip .625 for renal insufficiency and was continued
on lasix IV 80 tid and zaroxylyn. At the outside hospital, she
was also being treated for a enterococcal pan-senstivie urinary
tract infection. She was transferred to [**Hospital1 18**] on [**2181-9-29**] for the
management of acute renal failure and retroperitoneal bleed. She
was transferred from the MICU to the floor service on [**2181-9-30**].

MEDICAL HISTORY: HTN, hypothyroid, gout, CRI (baseline Cr 2.0), diastolic
dysfunction (EF 55% 7/04), 4 cm right renal mass (cystic RCC vs
multiloculated cyst, seen on CT on [**11-11**], followed),
hysterectomy, arthritis

MEDICATION ON ADMISSION: Levobunolol HCl 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QOD (every
other day). Tablet
ASA

ALLERGIES: Shellfish

PHYSICAL EXAM: Vitals: T:96.9, BP: 156/64, HR: 96, RR:16, O2:98% 2L
Gen: elderly woman, appears younger than stated age, in NAD.
HEENT: EOMI, PERL, mild proptosis, OP clear, mmm, neck supple,
not LAD, elevated JVD.
CV: RRR, II/VI SEM at LLSB, no rubs
Resp: decreased BS, + rales 2/3 up, scattered exp wheezing
Abd: edema to mid abd, NDNT, +BS, soft
Ext: [**3-13**]+ pitting edema to abd, good distal pulses.
Skin: warm, no rash
Neuro: grossly intact, A&O x3.
GUIAC Neg

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: The patient is a non-smoker, does not drink alcohol. She had 2
prior pregnancies. 

### Response:
{'Acute kidney failure with other specified pathological lesion in kidney,Hemorrhage, unspecified,Other and unspecified coagulation defects,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Pulmonary collapse,Diastolic heart failure, unspecified'}
