CHIEF COMPLAINT: Displaced tunnelled HD catheter

PRESENT ILLNESS: 71F ventilator-dependent h/o COPD, ESRD on HD, HTN, and CHF
(unknown EF) presented after her tunneled HD catheter was found
displaced [**3-9**] pt's scratching the site.  HD catheter was noted
to be displaced at HD, and pt was sent to ED for evaluation.
.
ED course:
# Meds: Ceftriaxone x1 dose, azithromycin x1 dose, IVF 500cc.
# Studies:
--CXR: Mild volume overload, displaced HD catheter.
# Clinical course: IR-guided catheter replacement; admitted to
MICU for further management.

MEDICAL HISTORY: --CV
# PVD, s/p R CEA, s/p B iliac stents, B toe gangrene
autoamputating
# HTN
# CHF no previous echo here, so unclear [**Name2 (NI) **]
# Paroxysmal AF
# Anemia
# s/p multiple embolic CVA
# h/o Cholesterol emboli syndrome
--GU
# ESRD on HD of unclear etiology. ? d/t chronic pyelo and
uncontrolled HTN.  Outpatient nephrologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]
--Pulmonary
# Respiratory failure s/p trach in [**2-11**], vent-dependent with
chronic PS at rehab, currently undergoing trach collar trials.
# COPD
# Recurrent aspiration PNA
--GI
# h/o GI bleeding
# Adenocarcinoma of the colon s/p resection in [**2186**]
# s/p PEG
--Endocrine
# Hypothyroidism
--Neuro
# Dementia
--ID
# h/o MRSA colonization
# h/o VRE infection
# h/o C.diff colitis

MEDICATION ON ADMISSION: Digoxin 0.125mg PO daily
Aspirin 81mg daily
Levothyroxine 125 mcg PO daily
Vancomycin PO 125mg QID
Diphenhydramine 25mg PO Q8H:PRN
Omeprazole
Lactobacillus
Respiratory regimen: Tiotropium, ipratropium, albuterol
Pain regimen: Lidocaine 5% patch daily, oxycodone 2.5mg PO
Q6H:PRN, hydromorphone 0.75mg PO Q2H:PRN, acetaminophen PRN

ALLERGIES: Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines

PHYSICAL EXAM: VS: T afebrile, BP 98/38, HR 64, RR 10, O2Sat 100% on current
vent settings
Vent Settings: SIMV+PS, PS 10, PEEP 5, TV 450, FiO2 50%
Gen: NAD
Heart: RRR, S1/S2, no m/r/g.
Lungs: Rales throughout anterior lung fields.
Abd: Soft, NTND, BS+.
Ext: WWP

FAMILY HISTORY: # Siblings: MI in 60s. Schizophrenia.

SOCIAL HISTORY: # Personal: Lives at [**Hospital 100**] Rehab.  Divorced.  Three adult
children.
# Tobacco: Former smoker.  3 packs per day x 13 years.
# Alcohol: Occasional past use.
Mechanical complication of other vascular device, implant, and graft,Pneumonia, organism unspecified,Intestinal infection due to Clostridium difficile,End stage renal disease,Chronic respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atherosclerosis of native arteries of the extremities with gangrene,Dependence on respirator, status,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Unspecified acquired hypothyroidism,Tracheostomy status,Gastrostomy status,Personal history of malignant neoplasm of large intestine
Malfunc vasc device/graf,Pneumonia, organism NOS,Int inf clstrdium dfcile,End stage renal disease,Chronic respiratory fail,Hyp kid NOS w cr kid V,Ath ext ntv art gngrene,Respirator depend status,Abn react-surg proc NEC,Chr airway obstruct NEC,Atrial fibrillation,Hypothyroidism NOS,Tracheostomy status,Gastrostomy status,Hx of colonic malignancy
Admission Date:  [**2187-12-28**]              Discharge Date:   [**2187-12-30**]

Date of Birth:  [**2116-10-30**]             Sex:   F

Service: MEDICINE

Allergies:
Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines

Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Displaced tunnelled HD catheter

Major Surgical or Invasive Procedure:
Replacement of tunnelled HD catheter

History of Present Illness:
71F ventilator-dependent h/o COPD, ESRD on HD, HTN, and CHF
(unknown EF) presented after her tunneled HD catheter was found
displaced [**3-9**] pt's scratching the site.  HD catheter was noted
to be displaced at HD, and pt was sent to ED for evaluation.
.
ED course:
# Meds: Ceftriaxone x1 dose, azithromycin x1 dose, IVF 500cc.
# Studies:
--CXR: Mild volume overload, displaced HD catheter.
# Clinical course: IR-guided catheter replacement; admitted to
MICU for further management.

Past Medical History:
--CV
# PVD, s/p R CEA, s/p B iliac stents, B toe gangrene
autoamputating
# HTN
# CHF no previous echo here, so unclear [**Name2 (NI) **]
# Paroxysmal AF
# Anemia
# s/p multiple embolic CVA
# h/o Cholesterol emboli syndrome
--GU
# ESRD on HD of unclear etiology. ? d/t chronic pyelo and
uncontrolled HTN.  Outpatient nephrologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]
--Pulmonary
# Respiratory failure s/p trach in [**2-11**], vent-dependent with
chronic PS at rehab, currently undergoing trach collar trials.
# COPD
# Recurrent aspiration PNA
--GI
# h/o GI bleeding
# Adenocarcinoma of the colon s/p resection in [**2186**]
# s/p PEG
--Endocrine
# Hypothyroidism
--Neuro
# Dementia
--ID
# h/o MRSA colonization
# h/o VRE infection
# h/o C.diff colitis

Social History:
# Personal: Lives at [**Hospital 100**] Rehab.  Divorced.  Three adult
children.
# Tobacco: Former smoker.  3 packs per day x 13 years.
# Alcohol: Occasional past use.

Family History:
# Siblings: MI in 60s. Schizophrenia.

Physical Exam:
VS: T afebrile, BP 98/38, HR 64, RR 10, O2Sat 100% on current
vent settings
Vent Settings: SIMV+PS, PS 10, PEEP 5, TV 450, FiO2 50%
Gen: NAD
Heart: RRR, S1/S2, no m/r/g.
Lungs: Rales throughout anterior lung fields.
Abd: Soft, NTND, BS+.
Ext: WWP

Pertinent Results:
Admission labs:
[**2187-12-28**] 11:40AM   WBC-9.7 RBC-3.12* HGB-10.6* HCT-31.3*
MCV-100* MCH-33.8* MCHC-33.8 RDW-18.2*
[**2187-12-28**] 11:40AM   NEUTS-67 BANDS-0 LYMPHS-20 MONOS-4 EOS-6*
BASOS-1 ATYPS-2* METAS-0 MYELOS-0
[**2187-12-28**] 11:40AM   GLUCOSE-92 UREA N-88* CREAT-5.0*# SODIUM-136
POTASSIUM-4.9 CHLORIDE-93* TOTAL CO2-28 ANION GAP-20
[**2187-12-28**] 12:39PM   LACTATE-1.6
[**2187-12-28**] 11:40AM   PLT COUNT-371
[**2187-12-28**] 11:40AM   PT-13.3 PTT-31.7 INR(PT)-1.1
.
# CHEST (PORTABLE AP)  [**2187-12-28**] 11:33 AM
Evidence of fluid overload with malpositioned right-sided
hemodialysis catheter.

Brief Hospital Course:
71F vent-dependent, h/o ESRD on HD, h/o refractory C. diff
infection, admitted for HD catheter replacement.
.
# ESRD on HD of unclear etiology:  Upon admission, pt's tunneled
catheter was removed and then replaced with a 15.5 French
double-lumen hemodialysis catheter with 23 cm tip-to-cuff length
via the left internal jugular vein with the tip in the right
atrium.  Pt underwent hemodialysis on [**12-29**] with approximately
1.6L removed, and tolerated hemodialysis without a BP drop.
Calcium acetate was started TID with meals.
.
# Query line infection: Line site was found to be erythematous
and tender to palpation, mildly indurated, but without
purulence.  Blood cultures drawn [**12-28**] with no growth at time of
discharge.  Pt was started on vancomycin 1 gm IV per HD protocol
to cover skin flora in institutionalized pt, and discharge with
plan to continue vancomycin for a total 7 day course, ending
[**1-3**].
.
# Possible PNA: Pt had copious green secretions upon admission;
CXR revealed retrocardiac opacity and pneumonia could not be
excluded. Pt was broadly covered for nosocomial and nursing
home-acquired PNA with vancomycin as above, as well as
piperacillin-tazobactam for a total of a 7 day course.  Pt was
therefore discharged with plan to continue
piperacillin-tazobactam until [**1-3**].
.
# Diarrhea possibly [**3-9**] C.Diff: Pt had h/o refractory C. diff,
and had >10 episodes of diarrhea on day of admission.  WBC was
within normal limits and no abdominal tenderness was evident on
clinical exam.  C. diff A and B toxins were pending at time of
discharge.  She was continued on vancomycin 125 mg PO Q6H and
metronidazole 500 mg PO TID, with plan to continue both for one
week after discontinuing vancomycin IV and
piperacillin-tazobactam IV (end [**2188-1-12**]).
.
# Chronic vent-dependent respiratory failure, s/p trach:  Pt
continued on pressure support per [**Hospital 100**] Rehab regimen.
.
# DNR

Medications on Admission:
Digoxin 0.125mg PO daily
Aspirin 81mg daily
Levothyroxine 125 mcg PO daily
Vancomycin PO 125mg QID
Diphenhydramine 25mg PO Q8H:PRN
Omeprazole
Lactobacillus
Respiratory regimen: Tiotropium, ipratropium, albuterol
Pain regimen: Lidocaine 5% patch daily, oxycodone 2.5mg PO
Q6H:PRN, hydromorphone 0.75mg PO Q2H:PRN, acetaminophen PRN

Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Hospital **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Levothyroxine 125 mcg Tablet [**Hospital **]: One (1) Tablet PO DAILY
(Daily).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on, then 12 hours off.
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Diphenhydramine HCl 25 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q8H
(every 8 hours) as needed.
7. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO Q6H (every 6 hours)
as needed.
8. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
injection Injection TID (3 times a day).
9. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation
Q2H (every 2 hours) as needed for wheezing.
10. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation Q6H (every 6 hours).
11. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3
times a day) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
12. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
13. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
14. Hydromorphone 2 mg Tablet [**Hospital1 **]: 0.5 Tablet PO Q2H (every 2
hours) as needed.
15. Calcium Acetate 667 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Vancomycin 1,000 mg Recon Soln [**Hospital1 **]: One (1) injection
Intravenous once a day for 7 days.
Disp:*7 g* Refills:*0*
17. Piperacillin-Tazobactam 2.25 gram Recon Soln [**Hospital1 **]: One (1)
injection Intravenous Q12H (every 12 hours) for 7 days: Please
dispense 31.5 g (2.25 g per injection, for 14 injections).
Disp:*QS g* Refills:*0*
18. Vancomycin 125 mg Capsule [**Hospital1 **]: One (1) Capsule PO once a day
for 14 days: Please use vancomycin 125mg PO liquid.
Disp:*14 Capsule(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Primary diagnosis:
# Tunnelled hemodialysis catheter removal and replacement
# Possible tunnelled catheter infection
# Possible C. Difficile colitis
# Hospital acquired PNA
.
Secondary diagnosis:
# End stage renal disease on hemodialysis

Discharge Condition:
Afebrile, stable BP and HR


Discharge Instructions:
You were admitted to the hospital to replace your dialysis
catheter.  You were treated for a possible HD catheter infection
with IV Vancomycin, which you should continue for 7 more days
(you started this antibiotic on [**12-28**]).  You also had increased
discolored mucus and potential pneumonia on chest X-ray for
which you should continue 7 days of another antibiotic called
Zosyn.
.
Also, you had more than 10 episodes of diarrhea while you were
in the hospital.  You should therefore take oral vancomycin and
oral metronidazole until [**1-12**].
.
You should continue with your usual regimen of hemodialysis at
your rehabilitation center.

Followup Instructions:
Please follow-up per your rehab physician's instructions.



Completed by:[**2188-6-1**]
{'Mechanical complication of other vascular device, implant, and graft,Pneumonia, organism unspecified,Intestinal infection due to Clostridium difficile,End stage renal disease,Chronic respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atherosclerosis of native arteries of the extremities with gangrene,Dependence on respirator, status,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Unspecified acquired hypothyroidism,Tracheostomy status,Gastrostomy status,Personal history of malignant neoplasm of large intestine'}


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: Displaced tunnelled HD catheter

PRESENT ILLNESS: 71F ventilator-dependent h/o COPD, ESRD on HD, HTN, and CHF
(unknown EF) presented after her tunneled HD catheter was found
displaced [**3-9**] pt's scratching the site.  HD catheter was noted
to be displaced at HD, and pt was sent to ED for evaluation.
.
ED course:
# Meds: Ceftriaxone x1 dose, azithromycin x1 dose, IVF 500cc.
# Studies:
--CXR: Mild volume overload, displaced HD catheter.
# Clinical course: IR-guided catheter replacement; admitted to
MICU for further management.

MEDICAL HISTORY: --CV
# PVD, s/p R CEA, s/p B iliac stents, B toe gangrene
autoamputating
# HTN
# CHF no previous echo here, so unclear [**Name2 (NI) **]
# Paroxysmal AF
# Anemia
# s/p multiple embolic CVA
# h/o Cholesterol emboli syndrome
--GU
# ESRD on HD of unclear etiology. ? d/t chronic pyelo and
uncontrolled HTN.  Outpatient nephrologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]
--Pulmonary
# Respiratory failure s/p trach in [**2-11**], vent-dependent with
chronic PS at rehab, currently undergoing trach collar trials.
# COPD
# Recurrent aspiration PNA
--GI
# h/o GI bleeding
# Adenocarcinoma of the colon s/p resection in [**2186**]
# s/p PEG
--Endocrine
# Hypothyroidism
--Neuro
# Dementia
--ID
# h/o MRSA colonization
# h/o VRE infection
# h/o C.diff colitis

MEDICATION ON ADMISSION: Digoxin 0.125mg PO daily
Aspirin 81mg daily
Levothyroxine 125 mcg PO daily
Vancomycin PO 125mg QID
Diphenhydramine 25mg PO Q8H:PRN
Omeprazole
Lactobacillus
Respiratory regimen: Tiotropium, ipratropium, albuterol
Pain regimen: Lidocaine 5% patch daily, oxycodone 2.5mg PO
Q6H:PRN, hydromorphone 0.75mg PO Q2H:PRN, acetaminophen PRN

ALLERGIES: Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines

PHYSICAL EXAM: VS: T afebrile, BP 98/38, HR 64, RR 10, O2Sat 100% on current
vent settings
Vent Settings: SIMV+PS, PS 10, PEEP 5, TV 450, FiO2 50%
Gen: NAD
Heart: RRR, S1/S2, no m/r/g.
Lungs: Rales throughout anterior lung fields.
Abd: Soft, NTND, BS+.
Ext: WWP

FAMILY HISTORY: # Siblings: MI in 60s. Schizophrenia.

SOCIAL HISTORY: # Personal: Lives at [**Hospital 100**] Rehab.  Divorced.  Three adult
children.
# Tobacco: Former smoker.  3 packs per day x 13 years.
# Alcohol: Occasional past use. 

### Response:
{'Mechanical complication of other vascular device, implant, and graft,Pneumonia, organism unspecified,Intestinal infection due to Clostridium difficile,End stage renal disease,Chronic respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atherosclerosis of native arteries of the extremities with gangrene,Dependence on respirator, status,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Unspecified acquired hypothyroidism,Tracheostomy status,Gastrostomy status,Personal history of malignant neoplasm of large intestine'}
