CHIEF COMPLAINT: renal failure s/p CRT

PRESENT ILLNESS: 61M with history of ESRD s/p CRT [**2101**], hypertension, diabetes,
diastolic CHF, admitted on [**2107-11-12**] with acute on chronic
dyspnea, now s/p PEA arrest. He presented on [**11-12**] with 2 days of
worsening dyspnea, cough, and fever/chills.  Also with
orthopnea, PND, and worsening edema in all 4 extremities.
.
Labs showed ARF with creatinine of 5.8 (up from 2.9).  During
hospital course on the floor, renal function continued to worsen
and urine output was low even with furosemide (unclear etiology
of ARF).  Also noted to have intermittent somnolence but
arousable and fully oriented.  ABGs repeatedly with partially
compensated respiratory acidosis (has also had this in the
recent past), team unsure how reliable ABGs were given bilateral
UE fistulas.
.
Patient was in angio having hemodialysis line placed when his
arrest event occurred.  He was placed in a lateral decubitus
position due to difficulty lying flat due to shortness of
breath.  Towards the end of his line placement, he became more
agitated and was pushing his facemask away.  O2 sats were unable
to be obtained.  He was then placed in supine position for line
suturing.  He was then noted to be nonresponsive, code blue
call.  Then noted to be pulseless.  CPR initiated and initial
rhythm asystole/very slow PEA, subsequently faster PEA.  Total
pulseless time 13 minutes.  Received total 2 mg epinephrine, 2
amps bicarb, 1 mg atropine, insulin/D50, IVFs via new HD line.
Regained pulses with first SBP >180.  Intubated.
.
In the MICU, patient seemed to be waking up some but with also
evidence of extensor posturing in upper and lower extremities.
Neuro consulted.  Aline and CVL placed.
.
Review of systems: unable to obtain

MEDICAL HISTORY: - Renal cell carcinoma s/p resection [**2093**]
- Severe obstructive sleep apnea,(not wearing CPAP at home)
- ESRD s/p CRT [**2101**], complicated by transplant renal artery
stenosis necessitating stent placement in [**2103**]
- Resistant HTN
- Diastolic congestive heart failure, TTE [**2107-8-18**]: Moderate
diastolic LV dysfunction with elevated LVEDP. Mild pulmonary
hypertension
- Diabetes, type 2, on insulin
- GERD
- Barrett's Esophagus
- s/p patella avulsion repair
- history of hypercalcemia
- hyperparathyroidism

MEDICATION ON ADMISSION: -Amlodipine 10 mg [**Hospital1 **]
-Calcitriol 0.25mcg QD
-Cinacalcet 90 mg QD
-Clonidine 0.1 mg [**Hospital1 **]
-Lasix 120mg PO BID
-Labetalol 600mg [**Hospital1 **]
Lisinopril 10mg QHS
-Minoxidil 10mg [**Hospital1 **]
-Mycophenolate Mofetil 500mg [**Hospital1 **]
-Prednisone 5mg QD
Vardenafil 10mg PRN
-Aspirin 81mg QD
Insulin NPH & Regular Human Ten (10) units Subcutaneous qPM.
Insulin NPH & Regular Human Twenty (20) Units Subcutaneous qAM.

ALLERGIES: Vancomycin

PHYSICAL EXAM: Vitals: T: BP: P: R: 18 O2:
General: Intubated; initially not sedated.  Not opening eyes but
moving all extremities to pain and initally spontaneously.
?myoclonic and posturing as below.
HEENT: Sclera anicteric, pupils equal at 2 mm though minimal
reactive.  ETT in place.
Neck: HD line in place.  Obese neck, difficult to appreciate JVD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, loud systolic
murmur best at RUSB and LUSB.
Abdomen:  soft, distended, appears non-tender, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
[**2-8**]+ bilateral LE edema, also +bilateral UE edema, ?right
slightly greater than left
Neuro: Moving some spontaneously and responsive to pain in the
UEs, not much pain response in the LEs.  Seems to be
intermittently with extensor posturing (lasts 2-3 seconds at a
time), sometimes associated with ?myoclonic movements of ankles.
 + significant bilateral ankle clonus.

FAMILY HISTORY: Mother with kidney disease.

SOCIAL HISTORY: Married with seven children
Employment: Employed as a chef at [**Hospital1 18**]
Tobacco: No h/o
Alcohol: No h/o
Acute kidney failure, unspecified,Acute on chronic diastolic heart failure,Acute respiratory failure,Cardiac arrest,Pneumonitis due to inhalation of food or vomitus,Pneumonia due to other gram-negative bacteria,Complications of transplanted kidney,Anoxic brain damage,Other and unspecified infection due to central venous catheter,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Cardiac complications, not elsewhere classified,Urinary tract infection, site not specified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Pseudomonas infection in conditions classified elsewhere and of unspecified site,End stage renal disease,Long-term (current) use of insulin,Anemia of other chronic disease,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Other chronic pulmonary heart diseases,Acquired absence of kidney,Personal history of malignant neoplasm of kidney,Obstructive sleep apnea (adult)(pediatric),Disorders of phosphorus metabolism,Gout, unspecified,Other specified disorders of liver,Anticoagulants causing adverse effects in therapeutic use
Acute kidney failure NOS,Ac on chr diast hrt fail,Acute respiratry failure,Cardiac arrest,Food/vomit pneumonitis,Pneumo oth grm-neg bact,Compl kidney transplant,Anoxic brain damage,Oth/uns inf-cen ven cath,Hyp kid NOS w cr kid V,Surg compl-heart,Urin tract infection NOS,DMII renl nt st uncntrld,Pseudomonas infect NOS,End stage renal disease,Long-term use of insulin,Anemia-other chronic dis,Abn react-procedure NEC,Accid in resident instit,Chr pulmon heart dis NEC,Acquired absence kidney,Hx of kidney malignancy,Obstructive sleep apnea,Dis phosphorus metabol,Gout NOS,Liver disorders NEC,Adv eff anticoagulants
Admission Date:  [**2107-11-12**]              Discharge Date:   [**2107-12-21**]

Date of Birth:  [**2045-12-2**]             Sex:   M

Service: MEDICINE

Allergies:
Vancomycin

Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
renal failure s/p CRT

Major Surgical or Invasive Procedure:
HD line placement

History of Present Illness:
61M with history of ESRD s/p CRT [**2101**], hypertension, diabetes,
diastolic CHF, admitted on [**2107-11-12**] with acute on chronic
dyspnea, now s/p PEA arrest. He presented on [**11-12**] with 2 days of
worsening dyspnea, cough, and fever/chills.  Also with
orthopnea, PND, and worsening edema in all 4 extremities.
.
Labs showed ARF with creatinine of 5.8 (up from 2.9).  During
hospital course on the floor, renal function continued to worsen
and urine output was low even with furosemide (unclear etiology
of ARF).  Also noted to have intermittent somnolence but
arousable and fully oriented.  ABGs repeatedly with partially
compensated respiratory acidosis (has also had this in the
recent past), team unsure how reliable ABGs were given bilateral
UE fistulas.
.
Patient was in angio having hemodialysis line placed when his
arrest event occurred.  He was placed in a lateral decubitus
position due to difficulty lying flat due to shortness of
breath.  Towards the end of his line placement, he became more
agitated and was pushing his facemask away.  O2 sats were unable
to be obtained.  He was then placed in supine position for line
suturing.  He was then noted to be nonresponsive, code blue
call.  Then noted to be pulseless.  CPR initiated and initial
rhythm asystole/very slow PEA, subsequently faster PEA.  Total
pulseless time 13 minutes.  Received total 2 mg epinephrine, 2
amps bicarb, 1 mg atropine, insulin/D50, IVFs via new HD line.
Regained pulses with first SBP >180.  Intubated.
.
In the MICU, patient seemed to be waking up some but with also
evidence of extensor posturing in upper and lower extremities.
Neuro consulted.  Aline and CVL placed.
.
Review of systems: unable to obtain


Past Medical History:
- Renal cell carcinoma s/p resection [**2093**]
- Severe obstructive sleep apnea,(not wearing CPAP at home)
- ESRD s/p CRT [**2101**], complicated by transplant renal artery
stenosis necessitating stent placement in [**2103**]
- Resistant HTN
- Diastolic congestive heart failure, TTE [**2107-8-18**]: Moderate
diastolic LV dysfunction with elevated LVEDP. Mild pulmonary
hypertension
- Diabetes, type 2, on insulin
- GERD
- Barrett's Esophagus
- s/p patella avulsion repair
- history of hypercalcemia
- hyperparathyroidism

Social History:
Married with seven children
Employment: Employed as a chef at [**Hospital1 18**]
Tobacco: No h/o
Alcohol: No h/o

Family History:
Mother with kidney disease.

Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Intubated; initially not sedated.  Not opening eyes but
moving all extremities to pain and initally spontaneously.
?myoclonic and posturing as below.
HEENT: Sclera anicteric, pupils equal at 2 mm though minimal
reactive.  ETT in place.
Neck: HD line in place.  Obese neck, difficult to appreciate JVD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, loud systolic
murmur best at RUSB and LUSB.
Abdomen:  soft, distended, appears non-tender, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
[**2-8**]+ bilateral LE edema, also +bilateral UE edema, ?right
slightly greater than left
Neuro: Moving some spontaneously and responsive to pain in the
UEs, not much pain response in the LEs.  Seems to be
intermittently with extensor posturing (lasts 2-3 seconds at a
time), sometimes associated with ?myoclonic movements of ankles.
 + significant bilateral ankle clonus.


Pertinent Results:
[**2107-11-12**] 8:10p
.
Other Urine Chemistry:
UreaN:549
Creat:199
Na:<10
TotProt:53
Prot/Cr:0.3
Osmolal:347
.
Color
Yellow  Appear Clear  SpecGr 1.013  pH 5.0  Urobil Neg  Bili Neg

Leuk Tr  Bld Neg  Nitr Neg  Prot 75  Glu Neg  Ket Neg  RBC 0-2
WBC [**6-15**]  Bact None  Yeast None  Epi 0-2
Other Urine Counts
RenalEp: 0-2
CastHy: 0-2
.
[**2107-11-12**]  4:10p
138  103  72
------------- 178
5.0  27  5.8 &#8710;
.
Ca: 9.6 Mg: 2.6 P: 4.3 &#8710;
CK: 315  MB: 5  Trop-T: 0.08
.
Alb: 2.9
proBNP: 1817
.
.....8.4
5.5 ----- 212
.....26.8
N:68.5 L:21.8 M:6.9 E:2.4 Bas:0.5
.
CXR [**2107-11-14**]: In comparison with the study of [**11-12**], there are
lower lung volumes. Enlargement of the cardiac silhouette
persists with mild vascular congestion suggested.
.
EKG: NSR at 94, NANI, low limb lead voltage, poor RWP (old); no
significant change from prior.
.
TTE [**2107-11-14**]: The left atrium is moderately dilated. mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic arch is mildly dilated. There is
mild pulmonary artery systolic hypertension. There is a very
small circumferenital pericardial effusion.
.
Renal ultrasound [**11-13**]:  No new findings.
.
CT Chest [**11-15**]:  On CT, there is no evidence of air embolism.
Cardiomegaly, mild axillary and mediastinal lymphadenopathy.
Bilateral pleural effusions with areas of subsequent
atelectasis, patchy lower lobe predominant parenchymal opacity
is potentially suggestive of a combination of pneumonia and
atelectasis. No pathologic air collection in the mediastinum and
the lung interstitium.
.
CT Head [**11-15**]:  1. No acute intracranial hemorrhage or acute
vascular territorial infarction. There is no hydrocephalus.
2. Opacification of sphenoid sinus, maxillary, ethmoid air cells
and
nasopharynx, most likely related to recent intubation.
.
CT Head [**11-17**]:  1. No acute intracranial hemorrhage or obvious
major territorial acute infarct, mass effect, or hydrocephalus.
If there is continued concern, MR of the head with
diffusion-weighted imaging sequence is more sensitive in the
detection of acute stroke.
2. Diffuse opacification of the sphenoid sinus, nasopharynx, the
maxillary
and the ethmoid air cells partly related to mucosal thickening,
secretions
from intubation. However, patient also had a left antrochoanal
polyp in the past, which is incompletely assessed on the present
study.
3. Discontinuous foci in the left parietal bone may relate to
thinning of the bone, from arachnoid granulations or other
etiology, to correlate with any history of surgery. However,
this appearance is unchanged compared to the prior CT sinus
study done on [**2102-10-19**].
.
RUE US [**11-20**]:  Although subclavian vein not evaluated, remainder
of right upper extremity venous system appears normal with no
evidence of DVT, and DVT would be likely in the subclavian vein
given respiratory variation and normal appearance of remainder
of the study.
.
MR [**Name13 (STitle) 430**] [**11-21**]:  1. Severely limited examination demonstrates
changes of chronic microvascular white matter ischemic disease
with old left frontal encephalomalacia without evidence for
acute infarct.
2. Extensive paranasal sinus and mastoid air cell disease.
.
KUB [**11-25**]:  1. Severely limited examination demonstrates changes
of chronic microvascular white matter ischemic disease with old
left frontal encephalomalacia without evidence for acute
infarct.
2. Extensive paranasal sinus and mastoid air cell disease.
.
KUB [**11-26**]:   There is no evidence of free air. NG tube tip is in
the stomach. Right femoral catheter remains in place. There is
no evidence of bowel obstruction. There is nonspecific bowel gas
pattern.
.
Portable Abdomen XR [**11-29**]:  There is no evidence of ileus, small
or large bowel obstruction.
.
Abdominal US [**12-6**]:  Normal right upper quadrant ultrasound with
no findings to suggest the cause of the patient's pain.
.
CT Abd/Pelvis [**12-6**]:  1. Small thrombus within the IVC and at the
junction of the right common iliac vein and transplanted renal
vein.
2. Diffuse mesenteric stranding with no small or large bowel
pathology
identified.
.
CT Head [**12-11**]:  1. . No acute intracranial abnormality.
2. Partial opacification of mastoid air cells bilaterally,
maxillary, ethmoid and sphenoid sinuses, partly polypoidal.
.
CT Abd/Pelvis [**12-11**]:  1. Very large spontaneous hematoma
involving a majority of the left hepatic lobe. A small amount of
perihepatic hematoma and scattered areas of blood within the
mesentery and along the left pericolic gutters tracking into the
pelvis. No definite site of active extravasation identified.
2. Branches of left portal vein are attenuated and not well
visualized in
the midst of the hematoma but are patent.
3. No change in small 1.5 cm thrombus within the infrarenal IVC.
Second
separate smaller thrombus in the right common iliac vein near
the transplant renal vein anastomosis on the prior study not
definitely visualized and may have cleared with anticoagulation.

4. Atelectasis of both dependent lower lobes.
5. More confluent consolidative opacity of the superior right
lower lobe
could be explained with atelectasis but is concerning for
possible area of
aspiration or pneumonia.
.
CT Abdomen [**12-16**]:  Limited study but no gross evidence of
obstruction.
.
CXR [**12-19**]:  There is interval development of vascular
engorgement, perihilar opacities, and bibasilar opacities, left
more than right, findings which might be consistent with
interval progression of pulmonary edema. Evaluation after
diuresis is recommended to exclude the possibility of underlying
infectious process.


Brief Hospital Course:
61M with ESRD s/p CRT, HTN, DM, admitted with dyspnea and ARF.
During IR placement of an HD catheter he suffered a PEA arrest x
2. He was cooled using artic sun protocol. He slowly recovered,
but his hospitalization was complicated by prolonged intubation
leading to tacheostomy placement, Psuedomonas UTI, HAP,
Stenotrophomonas PNA, aspiration PNA, acute on chronic kidney
injury leading to loss of fuction of his transplanted kidney,
IVC thombosis, spontaneous intrahepatic hemorrage during
heparinization for his thrombus, gout flair, and altered mental
status which has slowly improved. After more than a month in the
hospital he has stabilized, is ambulating with assistance,
speaking through a Passe Muir valve, and tolerating tube feeds.
.
# Aspiration:  Patient had emesis [**2107-12-13**] and aspirated tube
feeds. Developed aspiration pneumonitis vs. aspiration PNA. CXR
showed no clear evidence of PNA but CT showed confluent
consolidative opacity of superior RLL. Pt was febrile following
aspiration event and ended up re-intubated. Now s/p 7-day course
of vanc/zosyn for aspiration that ended on [**2107-12-18**]. Respiratory
status has dramatically improved and he is now on trach mask
only. He had a video swallow evaluation on [**2107-12-20**] which showed
silent aspiration.  It was suggested that he have a diet of
nectar thick liquids and soft consistency solids.  meds must be
crushed in purees with Q6 hour oral care.  He should have follow
up with speech therapy at rehab with repeat video swallow if
diet is to be advanced.
.
# Stenotrophomonas PNA: Diagnosed from repeated sputum cultures.
On Bactrim x14 day course, day 1=[**12-16**] to d/c [**12-30**]. Note that
Bactrim must be give FOLLOWING HD as it is dialyzed off.
Intially diagnosed [**12-2**], but was inadquately treated as Bactrim
was given prior to HD rather than after.
.
# Pseudomonas UTI: Had a long course of Cefepime for UCx
positive for Pseudomonas x 2.
.
# Line infection: S/p Cefepime initially for UTI. Then Linezolid
was added for purulent appearing CVL. His lines were exchanged
and complicated by PEA arrest during procedure. His CVL grew out
Micrococcus. According to ID, the Cefepime should have covered
it. He received a 14d course of Cefepime and 9d course of
Linezolid. A PICC line and new HD line were placed and have had
no further complications.
.
# Labile blood pressures: Pt had been intermittently hypotensive
(infectious source vs hypovolemia vs adrenal insufficiency). His
infections were treated. He was given stress dose steroids. He
was on pressors for hypotension. Ultimately this resolved and he
became persistently hypertensive to the 190s to 220s. He was
started on a labetalol drip as well as PRN hydralazine. He has
been transitioned from Labetalol drip to PO Labetalol on [**12-9**],
then switched to Labetalol PRN. On [**12-14**], Labetalol was d/c??????ed.
Continue atenolol at 50mg daily. Continue lisinopril 10mg daily.

.
# Foot Pain:  Likely gout, particularly given resolving hematoma
and renal failure. Receiveing pulse steroids with Prednisone
40mg daily x5 days starting on [**2107-12-20**]. Will resume chronic
Prednisone 5mg PO daily for maintenance of transplanted kidney
thereafter. [**Month (only) 116**] need suppressive allopurinol in the future for
his gout.
.
# DVT: Patient found to have venous thrombi in several vessels
including his IVC.  He was on a heparin drip, being bridged with
coumadin.  However, all anticoagulation stopped when liver
hematoma developed (see helow). Hematology was consulted
regarding whether it is appropriate to resume anticoagulation
given the risk of bleed, and recommended SC Heparin tid until he
follows up with Hematology and possibly vascular surgery
regarding possible benefits vs. risks of an IVC filter
placement. The patient should not be anti-coagulated with agents
other than SC Heparin given his high risk of bleed.
.
# Abdominal Distension:  Patient??????s abdomen became distended and
tympanitic during this hospitalization. CT abdomen [**12-11**] showed
large liver hematoma with scattered areas of perihepatic
hematoma and scattered blood within the mesentery but without
definite sites of active extravasation.  Distension likely [**2-7**]
chemical peritonitis which is resolving following reversal of
anticoagulation vs. functional ileus/[**Last Name (un) **]??????s syndrome from
infection/sepsis, intra-abdominal bleed, narcotic use, or
respiratory failure.  This is consistent with the patient??????s
continued +bowel sounds and leukocytosis, but CT abdomen did not
show dilated R side of colon and loops of bowel were read as
WNL.  Currently improved abdominal pain and minimally improved
distension. Abd is much less tense than prior.  Continue Reglan
2.5mg TID standing for treatment of presumed diabetic
gastroparesis. Advancing diet as tolerated with tube feeds.
.
# Liver Hematoma:  As above, CT showed hematoma of liver while
on heparin drip for IVC thombus.  IR consulted re: possible
embolization, did not feel the bleed was acute (felt >48 hours
old) and wished to preserve hepatic artery and liver function if
possible, so recommended monitoring Hct.  General surgery
consulted re: possible relation to PEG placement, but did not
believe this was [**2-7**] procedure based on the location of the
hematoma.  Recommended montoring q6h Hct and coags, transfusing
as needed and keeping Hct >20.  Received total of 3 unit pRBC
after reversal of PTT with FFP. Awaiting hematology
recommendation for long term anticoagulation given presence of
IVC thombus but complication of hemorrhage. (Ultimately decided
to hold all anticoagulation given severity of liver bleed.)
.
# Respiratory failure. Originally intubated in setting of arrest
with hypoxia beforehand. Was very difficult to wean from vent
due to persistent hypoxia, recurrent PNA, and altered mental
status. Trach and PEG placed on [**12-2**]. Now stable on trach. Had
aspiration even as above leading to short tern re-intubation.
Now tolerating trach mask. Speaking with Passe Muir valve.
.
# Altered mental status s/p PEA arrest: S/p PEA arrest x 2.
Underwent Artic Sun cooling protocol. Suring weaning of sedation
was severely agitated. Ultimately was transitioned from fentanyl
to methadone and then weaned on seroquel. He had a significant
set back from his liver hematoma and aspiration PNA. Neuro was
consulted and noted a staring spell that was concerning for
seizures. He was monitored with continuous EEG, which showed
epileptiform spikes but not outright seizure activity. Neuro
recommended startingKeppra, with Keppra 500mg qday and an extra
250mg after HD. The patient has slowly improved and is not
conversant, [**Location (un) 1131**], walking with assistance, and no longer
agitated. He is alert and oriented.
.
# Acute on chronic renal failure. He is s/p CRT in [**2101**].
Etiology of ARF likely multifactorial due to hypotension from
PEA, sepsis, contrast loads, and nephrotoxic drugs. Her the
Renal Service, he will not recover renal function of his kidney.
He will require HD henceforth. Continue prednisone 5mg PO daily
for rejection as well as Renagel 800 tid, Sevelemer 800 tid.
.
# FEN:  Speech and Swallow Recs - video swallow: silent
aspiration seen on s/s for thin liquids. Recs: 1. Suggest a PO
diet of nectar thick liquids and soft consistency solids. 2. PMV
on for all POs. 3. Meds crushed with purees. 4. Monitor for
nutritional intake. 5. Q6 oral care. 6. Follow up speech therapy
in rehab s/p d/c

Medications on Admission:
-Amlodipine 10 mg [**Hospital1 **]
-Calcitriol 0.25mcg QD
-Cinacalcet 90 mg QD
-Clonidine 0.1 mg [**Hospital1 **]
-Lasix 120mg PO BID
-Labetalol 600mg [**Hospital1 **]
Lisinopril 10mg QHS
-Minoxidil 10mg [**Hospital1 **]
-Mycophenolate Mofetil 500mg [**Hospital1 **]
-Prednisone 5mg QD
Vardenafil 10mg PRN
-Aspirin 81mg QD
Insulin NPH & Regular Human Ten (10) units Subcutaneous qPM.
Insulin NPH & Regular Human Twenty (20) Units Subcutaneous qAM.



Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**]
units Injection PRN (as needed) as needed for line flush.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
4. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q6H
(every 6 hours) as needed for fever, pain.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
6. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-7**]
Drops Ophthalmic PRN (as needed) as needed for irritation.
8. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic QID (4 times a day).
9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
for renal transplant.
11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Four
(4) Tablet PO QHD (each hemodialysis): DC on [**12-29**].09. Give
AFTER HD.
12. Metoclopramide 10 mg Tablet Sig: 2.5 mg PO BID (2 times a
day).
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Increase as needed for persistent HTN.
14. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

15. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
dyspnea, wheeze.
17. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours) as needed for shortness of
breath, dyspnea.
18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 5 days: DC on [**2107-12-24**]. Please give IN ADDITION to standing
prednisone 5mg PO daily for rejection.
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
20. Keppra 250 mg Tablet Sig: One (1) Tablet PO after HD: in
addition to daily dose of Keppra 500mg PO BID.
21. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
22. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): For IVC thrombi until further
evaluated by vascular surgery as outpatient.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital

Discharge Diagnosis:
Primary:
- Renal failure
- Volume overload / acute on chronic CHF
- PEA arrest
- Altered mental status
- Bacterial pneumonia
- Ventilator associated pneumonia
- Aspiration pneumonia
- Urinary tract infection
- Hypertensive urgency
- Repiratory failure
.
Seconary:
- Renal cell carcinoma s/p resection [**2093**]
- Severe obstructive sleep apnea,(not wearing CPAP at home)
- ESRD s/p CRT [**2101**], complicated by transplant renal artery
stenosis necessitating stent placement in [**2103**]
- Resistant HTN
- Diastolic congestive heart failure, TTE [**2107-8-18**]: Moderate
diastolic LV dysfunction with elevated LVEDP. Mild pulmonary
hypertension
- Diabetes, type 2, on insulin
- GERD
- Barrett's Esophagus
- s/p patella avulsion repair
- history of hypercalcemia
- hyperparathyroidism

Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair


Discharge Instructions:
You were admitted initially for volume overload and shortness of
breath. You had a long and complicated hospitalization for
treatment of this and various complications. You suffered a
severe type of heart attack called a PEA arrest. You required
life support from this event and were dependent on a breathing
machine for several weeks. Due to this a tracheostomy (breathing
tube in your neck) and feeding tube were placed. You had several
infections including a urinary tract infection, blood infection,
and pneumonias. You developed a clot in your veins and was
placed on blood thinners. Unfortunately, you bled while on the
blood thinners and these were stopped. Your kidney function
worsened and your transplanted kidney stopped functioning. You
were restarted on dialysis.
.
Please continue to take your medications as ordered.
.
Please attend your follow up appointments.
.

Followup Instructions:
Appointment #1
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Neurology
Date/ Time: Wednesday, [**1-4**] at 1pm
Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] bldg, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 44**]

Appointment #2
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Transplant
Date/ Time: [**Last Name (LF) 766**], [**1-9**] at 3:20pm
Location: [**Hospital Ward Name 517**], [**Hospital Ward Name **] Bldg, [**Last Name (NamePattern1) 439**], [**Location (un) 436**]
Phone number: [**Telephone/Fax (1) 673**]

Appointment #3
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6944**]
Specialty: Hematology
Date/ Time: Wednesday, [**1-25**] at 1:40pm
Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] bldg, [**Location (un) 436**]
Phone number: [**Telephone/Fax (1) 6946**]

During your appointment with Dr. [**Last Name (STitle) 6944**] (Hematology), please
discuss whether you will need to be evaluated by vascular
surgery regarding possible placement of an Inferior Vena Cava
filter, and whether the benefits outweigh the risks, given your
blood clots.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]

Completed by:[**2107-12-21**]
{'Acute kidney failure, unspecified,Acute on chronic diastolic heart failure,Acute respiratory failure,Cardiac arrest,Pneumonitis due to inhalation of food or vomitus,Pneumonia due to other gram-negative bacteria,Complications of transplanted kidney,Anoxic brain damage,Other and unspecified infection due to central venous catheter,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Cardiac complications, not elsewhere classified,Urinary tract infection, site not specified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Pseudomonas infection in conditions classified elsewhere and of unspecified site,End stage renal disease,Long-term (current) use of insulin,Anemia of other chronic disease,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Other chronic pulmonary heart diseases,Acquired absence of kidney,Personal history of malignant neoplasm of kidney,Obstructive sleep apnea (adult)(pediatric),Disorders of phosphorus metabolism,Gout, unspecified,Other specified disorders of liver,Anticoagulants causing adverse effects in therapeutic use'}


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: renal failure s/p CRT

PRESENT ILLNESS: 61M with history of ESRD s/p CRT [**2101**], hypertension, diabetes,
diastolic CHF, admitted on [**2107-11-12**] with acute on chronic
dyspnea, now s/p PEA arrest. He presented on [**11-12**] with 2 days of
worsening dyspnea, cough, and fever/chills.  Also with
orthopnea, PND, and worsening edema in all 4 extremities.
.
Labs showed ARF with creatinine of 5.8 (up from 2.9).  During
hospital course on the floor, renal function continued to worsen
and urine output was low even with furosemide (unclear etiology
of ARF).  Also noted to have intermittent somnolence but
arousable and fully oriented.  ABGs repeatedly with partially
compensated respiratory acidosis (has also had this in the
recent past), team unsure how reliable ABGs were given bilateral
UE fistulas.
.
Patient was in angio having hemodialysis line placed when his
arrest event occurred.  He was placed in a lateral decubitus
position due to difficulty lying flat due to shortness of
breath.  Towards the end of his line placement, he became more
agitated and was pushing his facemask away.  O2 sats were unable
to be obtained.  He was then placed in supine position for line
suturing.  He was then noted to be nonresponsive, code blue
call.  Then noted to be pulseless.  CPR initiated and initial
rhythm asystole/very slow PEA, subsequently faster PEA.  Total
pulseless time 13 minutes.  Received total 2 mg epinephrine, 2
amps bicarb, 1 mg atropine, insulin/D50, IVFs via new HD line.
Regained pulses with first SBP >180.  Intubated.
.
In the MICU, patient seemed to be waking up some but with also
evidence of extensor posturing in upper and lower extremities.
Neuro consulted.  Aline and CVL placed.
.
Review of systems: unable to obtain

MEDICAL HISTORY: - Renal cell carcinoma s/p resection [**2093**]
- Severe obstructive sleep apnea,(not wearing CPAP at home)
- ESRD s/p CRT [**2101**], complicated by transplant renal artery
stenosis necessitating stent placement in [**2103**]
- Resistant HTN
- Diastolic congestive heart failure, TTE [**2107-8-18**]: Moderate
diastolic LV dysfunction with elevated LVEDP. Mild pulmonary
hypertension
- Diabetes, type 2, on insulin
- GERD
- Barrett's Esophagus
- s/p patella avulsion repair
- history of hypercalcemia
- hyperparathyroidism

MEDICATION ON ADMISSION: -Amlodipine 10 mg [**Hospital1 **]
-Calcitriol 0.25mcg QD
-Cinacalcet 90 mg QD
-Clonidine 0.1 mg [**Hospital1 **]
-Lasix 120mg PO BID
-Labetalol 600mg [**Hospital1 **]
Lisinopril 10mg QHS
-Minoxidil 10mg [**Hospital1 **]
-Mycophenolate Mofetil 500mg [**Hospital1 **]
-Prednisone 5mg QD
Vardenafil 10mg PRN
-Aspirin 81mg QD
Insulin NPH & Regular Human Ten (10) units Subcutaneous qPM.
Insulin NPH & Regular Human Twenty (20) Units Subcutaneous qAM.

ALLERGIES: Vancomycin

PHYSICAL EXAM: Vitals: T: BP: P: R: 18 O2:
General: Intubated; initially not sedated.  Not opening eyes but
moving all extremities to pain and initally spontaneously.
?myoclonic and posturing as below.
HEENT: Sclera anicteric, pupils equal at 2 mm though minimal
reactive.  ETT in place.
Neck: HD line in place.  Obese neck, difficult to appreciate JVD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, loud systolic
murmur best at RUSB and LUSB.
Abdomen:  soft, distended, appears non-tender, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
[**2-8**]+ bilateral LE edema, also +bilateral UE edema, ?right
slightly greater than left
Neuro: Moving some spontaneously and responsive to pain in the
UEs, not much pain response in the LEs.  Seems to be
intermittently with extensor posturing (lasts 2-3 seconds at a
time), sometimes associated with ?myoclonic movements of ankles.
 + significant bilateral ankle clonus.

FAMILY HISTORY: Mother with kidney disease.

SOCIAL HISTORY: Married with seven children
Employment: Employed as a chef at [**Hospital1 18**]
Tobacco: No h/o
Alcohol: No h/o 

### Response:
{'Acute kidney failure, unspecified,Acute on chronic diastolic heart failure,Acute respiratory failure,Cardiac arrest,Pneumonitis due to inhalation of food or vomitus,Pneumonia due to other gram-negative bacteria,Complications of transplanted kidney,Anoxic brain damage,Other and unspecified infection due to central venous catheter,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Cardiac complications, not elsewhere classified,Urinary tract infection, site not specified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Pseudomonas infection in conditions classified elsewhere and of unspecified site,End stage renal disease,Long-term (current) use of insulin,Anemia of other chronic disease,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Other chronic pulmonary heart diseases,Acquired absence of kidney,Personal history of malignant neoplasm of kidney,Obstructive sleep apnea (adult)(pediatric),Disorders of phosphorus metabolism,Gout, unspecified,Other specified disorders of liver,Anticoagulants causing adverse effects in therapeutic use'}
