CHIEF COMPLAINT: acute renal failure

PRESENT ILLNESS: 85 yo man with several recent hospitalizations for gallstone
pancreatitis who was admitted to an OSH [**8-14**] with blood-loss
anemia and renal failure. Recent PMHx begins in late [**6-24**] when
he was admitted here with gallstone pancreatitis. ERCP was
attempted but they could not cannulate the CBD; symptoms
improved with supportive care and the pt was d/c home after one
week. Sx recurred in mid-[**7-25**] when he was admitted to an OSH.
There he was felt to need a ccy and so was sent here, where an
ERCP was repeated and the CBD cannulated with sphincterotomy and
stone extraction; duodenal ulcers were also incidentally noted
during this study. A CT scan showed ? non-enhancing lesion at
the head of the pancreas (necrotizing pancreatitis vs.
pseudocyst). His hospital course was c/b MRSA bacteremia found
on routine blood cxs [**7-28**]. A subsequent TEE was equivocal (debris
with calcifications vs. vegetations), so the plan was made for
empiric treatment of endocarditis with vanco x6 weeks through a
LUE PICC. The pt was ultimately discharged from the [**Hospital1 18**] on
[**8-5**] to a NH. There he was getting vanco [**Hospital1 **] for 7-8 days, also
prn Lasix for LE edema. He was sent in to an OSH [**8-13**] with a Cr
of 4.4 (baseline 1.4), Hct 25 (baseline 30). His anemia was
thought to likely be multifactorial (PUD vs. LGIB vs. renal
failure). He was initially given two unit pRBCs with an
appropriate response. His FeNa there was c/w pre-renal azotemia
in the setting of total body volume overload. His meds renally
dosed and his diuretics were held due to presumed intravascular
volume depletion. Despite low-salt albumin and the pRBC
transfusions noted above, his creatinine had increased to 6.0 on
the day prior to transfer here. He has also been oliguric
(200-400 cc/day for 5-6 days prior to transfer), and he has
developed hyperkalemia and pulmonary edema.  Discussions were
held with the patient and his family regarding the initiation of
hemodialysis, and ultimately the decision was made to pursue a
trial of hemodialysis. He is therefore transferred here for
initiation of hemodialysis.

MEDICAL HISTORY: 1. recurrent gallstone pancreatitis s/p cannulation of the CBD
and sphincterotomy [**7-25**]
2. cholelithiasis
3. presumptive diagnosis of endocarditis and MRSA bacteremia
[**7-25**]
4. UTI
5. gout
6. HTN
7. PUD
8. COPD
9. dyslipidemia
10. DM-II
11. chronic renal failure
12. achalasia/GERD
13. hiatal hernia
14. brachial nerve injury c/b RUE weakness
15. bipedal neuropathy [**12-22**] remote injury
16. prostate cancer (untreated)
17. colonic polyps
18. carpal tunnel syndrome
19. glaucoma
20. OA
21. MRSA (blood and sputum)
22. VRE (urine)
23. chronic L pleural effusion

MEDICATION ON ADMISSION: 1. imipenem 250 mg iv every twelve hours
2. metronidazole 500 orally twice daily
3. vancomycin dosed at hemodialysis
4. ferrous sulfate 325 mg daily
5. Advair 50/500 one puff twice daily
6. ASA 81 mg daily
7. pilocarpine ophthalmic drops 0.5% one both eyes four times
daily
8. zinc sulfate 220 mg daily
9. pantoprazole 40 mg daily
10. metoprolol 25 mg twice daily
11. amlexanox 5% 1/4 inch to mouth ulcers three times daily
12. docusate 100 mg twice daily
13. heparin 5000 units twice daily
14. timoptic ophthalmic drops 0.25% one drop left eye twice
daily
15. ursodiol 300 mg orally twice daily
16. regular insulin sliding scale
17. sevelamer 2400 mg three times daily
18. morphine sulfate as needed

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp 97.2,  BP 133/64,  HR 75,  RR 22,  SpO2 97% 2L nasal
cannula
Gen: Pleasant, obese man appearing his stated age and in mild
respiratory distress but able to speak in full sentences.
HEENT: NCAT, no sinus tenderness, PERRL, dry oral mucosa, OP
clear.
Neck: Soft and supple.
CV: Irregular rate, normal S1 and S2, no m/r/g, no carotid
bruits.
Pulm: Diffuse rhonchi with decreased breath sounds, crackles,
and dullness to percussion over the lower third of the lung
fields bilaterally.
Abd: Soft, non-tender, distended, active bowel sounds, mild
diffuse guarding but no rebound.
Back: No CVA or paraspinal tenderness.
Ext: 4+ bilateral lower extremity pitting edema, 2+ DP pulses.
Nodes: No cervical or inguinal adenopathy.
Skin: Telangiectasias over the superior-anterior chest wall,
mild diffuse erythema, no other focal lesions.
Neuro: Waxing and [**Doctor Last Name 688**] mental status with intermittently
appropriate responses to questions, very hard of hearing.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: World War II veteran. Lives in [**Location 620**] with his wife. [**Name (NI) **] has a
remote history of heavy alcohol use and now has 1-2 drinks
during the weekend. He no longer smokes but also has a remote
history of tobacco use.  He is a retired salesman. His daughter
is [**Name (NI) 553**] [**Last Name (NamePattern1) 57771**], [**First Name3 (LF) **] [**Company 191**] Clinical triage nurse.
Acute kidney failure, unspecified,Pneumonia, organism unspecified,Bacteremia,Cyst and pseudocyst of pancreas,Congestive heart failure, unspecified,Paralytic ileus,Candidiasis of mouth,Atherosclerosis of native arteries of the extremities with gangrene,Hypotension of hemodialysis,Anemia of other chronic disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Acute kidney failure NOS,Pneumonia, organism NOS,Bacteremia,Pancreat cyst/pseudocyst,CHF NOS,Paralytic ileus,Thrush,Ath ext ntv art gngrene,Hemododialysis hypotensn,Anemia-other chronic dis,DMII wo cmp nt st uncntr
Admission Date:  [**2105-8-19**]              Discharge Date:   [**2105-9-3**]


Service: MED

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
acute renal failure

Major Surgical or Invasive Procedure:
Tunnelled line placement for hemo dialysis on [**2105-8-24**]


History of Present Illness:
85 yo man with several recent hospitalizations for gallstone
pancreatitis who was admitted to an OSH [**8-14**] with blood-loss
anemia and renal failure. Recent PMHx begins in late [**6-24**] when
he was admitted here with gallstone pancreatitis. ERCP was
attempted but they could not cannulate the CBD; symptoms
improved with supportive care and the pt was d/c home after one
week. Sx recurred in mid-[**7-25**] when he was admitted to an OSH.
There he was felt to need a ccy and so was sent here, where an
ERCP was repeated and the CBD cannulated with sphincterotomy and
stone extraction; duodenal ulcers were also incidentally noted
during this study. A CT scan showed ? non-enhancing lesion at
the head of the pancreas (necrotizing pancreatitis vs.
pseudocyst). His hospital course was c/b MRSA bacteremia found
on routine blood cxs [**7-28**]. A subsequent TEE was equivocal (debris
with calcifications vs. vegetations), so the plan was made for
empiric treatment of endocarditis with vanco x6 weeks through a
LUE PICC. The pt was ultimately discharged from the [**Hospital1 18**] on
[**8-5**] to a NH. There he was getting vanco [**Hospital1 **] for 7-8 days, also
prn Lasix for LE edema. He was sent in to an OSH [**8-13**] with a Cr
of 4.4 (baseline 1.4), Hct 25 (baseline 30). His anemia was
thought to likely be multifactorial (PUD vs. LGIB vs. renal
failure). He was initially given two unit pRBCs with an
appropriate response. His FeNa there was c/w pre-renal azotemia
in the setting of total body volume overload. His meds renally
dosed and his diuretics were held due to presumed intravascular
volume depletion. Despite low-salt albumin and the pRBC
transfusions noted above, his creatinine had increased to 6.0 on
the day prior to transfer here. He has also been oliguric
(200-400 cc/day for 5-6 days prior to transfer), and he has
developed hyperkalemia and pulmonary edema.  Discussions were
held with the patient and his family regarding the initiation of
hemodialysis, and ultimately the decision was made to pursue a
trial of hemodialysis. He is therefore transferred here for
initiation of hemodialysis.

Of note, the patient has reportedly also had progressive
abdominal distension  over the [**Last Name (un) 18712**] 1-2 weeks. A KUB done at the
OSH on the day prior to transfer was suggestive of a partial
SBO. At no point, however, has he had n/v or abd pain. He is
having bowel movement and passing flatus, and he is tolerating a
po diet. His lipase and amylase were also increasing, thus
raising the question of recurrent pancreatitis.  For these
reasons, he was made NPO on the night prior to transfer.

Past Medical History:
1. recurrent gallstone pancreatitis s/p cannulation of the CBD
and sphincterotomy [**7-25**]
2. cholelithiasis
3. presumptive diagnosis of endocarditis and MRSA bacteremia
[**7-25**]
4. UTI
5. gout
6. HTN
7. PUD
8. COPD
9. dyslipidemia
10. DM-II
11. chronic renal failure
12. achalasia/GERD
13. hiatal hernia
14. brachial nerve injury c/b RUE weakness
15. bipedal neuropathy [**12-22**] remote injury
16. prostate cancer (untreated)
17. colonic polyps
18. carpal tunnel syndrome
19. glaucoma
20. OA
21. MRSA (blood and sputum)
22. VRE (urine)
23. chronic L pleural effusion

Social History:
World War II veteran. Lives in [**Location 620**] with his wife. [**Name (NI) **] has a
remote history of heavy alcohol use and now has 1-2 drinks
during the weekend. He no longer smokes but also has a remote
history of tobacco use.  He is a retired salesman. His daughter
is [**Name (NI) 553**] [**Last Name (NamePattern1) 57771**], [**First Name3 (LF) **] [**Company 191**] Clinical triage nurse.

Family History:
Noncontributory.

Physical Exam:
Temp 97.2,  BP 133/64,  HR 75,  RR 22,  SpO2 97% 2L nasal
cannula
Gen: Pleasant, obese man appearing his stated age and in mild
respiratory distress but able to speak in full sentences.
HEENT: NCAT, no sinus tenderness, PERRL, dry oral mucosa, OP
clear.
Neck: Soft and supple.
CV: Irregular rate, normal S1 and S2, no m/r/g, no carotid
bruits.
Pulm: Diffuse rhonchi with decreased breath sounds, crackles,
and dullness to percussion over the lower third of the lung
fields bilaterally.
Abd: Soft, non-tender, distended, active bowel sounds, mild
diffuse guarding but no rebound.
Back: No CVA or paraspinal tenderness.
Ext: 4+ bilateral lower extremity pitting edema, 2+ DP pulses.
Nodes: No cervical or inguinal adenopathy.
Skin: Telangiectasias over the superior-anterior chest wall,
mild diffuse erythema, no other focal lesions.
Neuro: Waxing and [**Doctor Last Name 688**] mental status with intermittently
appropriate responses to questions, very hard of hearing.

Pertinent Results:
WBC-12.0 HCT-33.5 MCV-94 PLT COUNT-323

PT-13.9 PTT-26.8 INR(PT)-1.2

SODIUM-137 POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-18 UREA N-107
CREAT-6.0 GLUCOSE-191
CALCIUM-7.0 MAGNESIUM-2.2 PHOSPHATE-8.9 ALBUMIN-2.5
ALT-12 AST-8 ALK PHOS-64 TOT BILI-0.4 AMYLASE-197 LIPASE-116

CXR: Enlarged cardiac silhouette, prominent vasculature
consistent with pulmonary edema, bilateral pleural effusions (L
> R), no free air under the diaphragm

KUB: Non-specific bowel gas pattern, no evidence of obstruction

Brief Hospital Course:
85 yo man with several recent hospitalizations for gallstone
pancreatitis now transferred from OSH with acute renal failure.

1. Acute Renal Failure: Cr of 6.0 on admission markedly elevated
from prior baseline of 1.2. Differential initially included
intravascular volume depletion vs. ATN (contrast nephropathy?)
vs. medication toxicity. OSH FeNa of 0.8% was c/w pre-renal
etiology. Pt was total-body volume overload. This gradually
improved with hemo dilysis. As the admission progressed, renal
felt etiology more likely to be cholesterol emboli. Renal US was
done which ruled out obstructive etiology. Renal consult was
obtained on admission and hemo dialysis was initiated. Pt was
stabalized on a Mon-Wed-Fri regimen. Decision was made not to
persue a renal biopsy as pt and family did not want any invasive
procedures. Hemodialysis became increasingly challenging
secondary to hypotension. On [**2103-9-1**], family decided not to
continue with dialysis.

2. Pancreatitis/Pseudocyst: Enzymes mildly elevated on admission
([**Doctor First Name **] 197, lipase 116). Noncontrast CT of abdomen was obtained
which was concerning for a pancreatic pseudocyst. Surgery was
initially consulted but did not feel surgical intervention was
warrented. Pt was initially kept NPO with a NG tube and TPN for
nutrition. However, he self discontined the NG tube on
[**2105-7-23**]. On [**2105-7-26**], the pt developed increased abdominal
pain on exam. Abdominal film was unremarkable. After extensive
discussion with the pt and family, they decided not to persue
further imaging including CT scan or MRCP. They declined any
invasive intervention no matter the cause of abdominal pain. At
that time, the TPN was discontinued. Pt was allowed to eat as
desired with a pureed diet. However, he took little by mouth. Pt
was covered throughout the admission with meropenem and was
discontinued on the day of discharge.

5. Pneumonia: Unclear diagnosis at OSH, although there was a
question of bibasilar infiltrates on admission CXR. He was
treated with ceftriaxone and flagyl.  He is currently
comfortable on room air with prn nebulizer treatments for
audible wheezing.

5. Anemia: Lab panel at OSH c/w anemia of chronic disease. Hct
stable here.

7. MRSA Bacteremia: Patient was treated with vancomycin dosed by
level and was maintained on contact precautions. Vancomycin was
discontinued when pt was made CMO as levels were no longer
obtained.

8. VRE: Likely simply colonization of urinary tract.

9. Access: LUE PICC, dialysis catheter

10. F/E/N: POs as tolerated.

11. Communication: With wife and daughter.

12. Code: DNR/DNI. CMO status established on [**2105-9-1**] after
extensive discussions with wife and daughter.

13. Disposition: Hospice

Medications on Admission:
1. imipenem 250 mg iv every twelve hours
2. metronidazole 500 orally twice daily
3. vancomycin dosed at hemodialysis
4. ferrous sulfate 325 mg daily
5. Advair 50/500 one puff twice daily
6. ASA 81 mg daily
7. pilocarpine ophthalmic drops 0.5% one both eyes four times
daily
8. zinc sulfate 220 mg daily
9. pantoprazole 40 mg daily
10. metoprolol 25 mg twice daily
11. amlexanox 5% 1/4 inch to mouth ulcers three times daily
12. docusate 100 mg twice daily
13. heparin 5000 units twice daily
14. timoptic ophthalmic drops 0.25% one drop left eye twice
daily
15. ursodiol 300 mg orally twice daily
16. regular insulin sliding scale
17. sevelamer 2400 mg three times daily
18. morphine sulfate as needed

Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-21**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*10 nebs* Refills:*0*
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*100 cc* Refills:*0*
3. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q 72 HOURS ().
Disp:*10 Patch 72HR(s)* Refills:*0*
4. Morphine Sulfate 10 mg/5 mL Solution Sig: 5-10 cc PO Q2H
(every 2 hours) as needed.
Disp:*50 cc* Refills:*0*
5. Lorazepam Intensol 2 mg/mL Concentrate Sig: 0.2-0.4 cc PO q2
as needed for agitation, anxiety, tremor.
Disp:*20 cc* Refills:*0*
6. hycosamine  Sig: 0.2 ml  every six (6) hours as needed for
end stage congestion: Please dispense 1.25mg/ml suspension.
Disp:*2 cc* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 13054**] Hospice/[**Last Name (un) 2646**] Health Services

Discharge Diagnosis:
Primary diagnosis:
Renal failure on hemo dialysis

Secondary diagnosis:
Pancreatitis
Pseudocyst
MRSA bacteremia
Possible MRSA endocarditis
HTN
COPD
Pneumonia
GERD
Type 2 diabetes mellitus
Glaucoma


Discharge Condition:
Prognosis poor

Discharge Instructions:
None

Followup Instructions:
No follow up needed


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

Completed by:[**0-0-0**]
{'Acute kidney failure, unspecified,Pneumonia, organism unspecified,Bacteremia,Cyst and pseudocyst of pancreas,Congestive heart failure, unspecified,Paralytic ileus,Candidiasis of mouth,Atherosclerosis of native arteries of the extremities with gangrene,Hypotension of hemodialysis,Anemia of other chronic disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: acute renal failure

PRESENT ILLNESS: 85 yo man with several recent hospitalizations for gallstone
pancreatitis who was admitted to an OSH [**8-14**] with blood-loss
anemia and renal failure. Recent PMHx begins in late [**6-24**] when
he was admitted here with gallstone pancreatitis. ERCP was
attempted but they could not cannulate the CBD; symptoms
improved with supportive care and the pt was d/c home after one
week. Sx recurred in mid-[**7-25**] when he was admitted to an OSH.
There he was felt to need a ccy and so was sent here, where an
ERCP was repeated and the CBD cannulated with sphincterotomy and
stone extraction; duodenal ulcers were also incidentally noted
during this study. A CT scan showed ? non-enhancing lesion at
the head of the pancreas (necrotizing pancreatitis vs.
pseudocyst). His hospital course was c/b MRSA bacteremia found
on routine blood cxs [**7-28**]. A subsequent TEE was equivocal (debris
with calcifications vs. vegetations), so the plan was made for
empiric treatment of endocarditis with vanco x6 weeks through a
LUE PICC. The pt was ultimately discharged from the [**Hospital1 18**] on
[**8-5**] to a NH. There he was getting vanco [**Hospital1 **] for 7-8 days, also
prn Lasix for LE edema. He was sent in to an OSH [**8-13**] with a Cr
of 4.4 (baseline 1.4), Hct 25 (baseline 30). His anemia was
thought to likely be multifactorial (PUD vs. LGIB vs. renal
failure). He was initially given two unit pRBCs with an
appropriate response. His FeNa there was c/w pre-renal azotemia
in the setting of total body volume overload. His meds renally
dosed and his diuretics were held due to presumed intravascular
volume depletion. Despite low-salt albumin and the pRBC
transfusions noted above, his creatinine had increased to 6.0 on
the day prior to transfer here. He has also been oliguric
(200-400 cc/day for 5-6 days prior to transfer), and he has
developed hyperkalemia and pulmonary edema.  Discussions were
held with the patient and his family regarding the initiation of
hemodialysis, and ultimately the decision was made to pursue a
trial of hemodialysis. He is therefore transferred here for
initiation of hemodialysis.

MEDICAL HISTORY: 1. recurrent gallstone pancreatitis s/p cannulation of the CBD
and sphincterotomy [**7-25**]
2. cholelithiasis
3. presumptive diagnosis of endocarditis and MRSA bacteremia
[**7-25**]
4. UTI
5. gout
6. HTN
7. PUD
8. COPD
9. dyslipidemia
10. DM-II
11. chronic renal failure
12. achalasia/GERD
13. hiatal hernia
14. brachial nerve injury c/b RUE weakness
15. bipedal neuropathy [**12-22**] remote injury
16. prostate cancer (untreated)
17. colonic polyps
18. carpal tunnel syndrome
19. glaucoma
20. OA
21. MRSA (blood and sputum)
22. VRE (urine)
23. chronic L pleural effusion

MEDICATION ON ADMISSION: 1. imipenem 250 mg iv every twelve hours
2. metronidazole 500 orally twice daily
3. vancomycin dosed at hemodialysis
4. ferrous sulfate 325 mg daily
5. Advair 50/500 one puff twice daily
6. ASA 81 mg daily
7. pilocarpine ophthalmic drops 0.5% one both eyes four times
daily
8. zinc sulfate 220 mg daily
9. pantoprazole 40 mg daily
10. metoprolol 25 mg twice daily
11. amlexanox 5% 1/4 inch to mouth ulcers three times daily
12. docusate 100 mg twice daily
13. heparin 5000 units twice daily
14. timoptic ophthalmic drops 0.25% one drop left eye twice
daily
15. ursodiol 300 mg orally twice daily
16. regular insulin sliding scale
17. sevelamer 2400 mg three times daily
18. morphine sulfate as needed

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp 97.2,  BP 133/64,  HR 75,  RR 22,  SpO2 97% 2L nasal
cannula
Gen: Pleasant, obese man appearing his stated age and in mild
respiratory distress but able to speak in full sentences.
HEENT: NCAT, no sinus tenderness, PERRL, dry oral mucosa, OP
clear.
Neck: Soft and supple.
CV: Irregular rate, normal S1 and S2, no m/r/g, no carotid
bruits.
Pulm: Diffuse rhonchi with decreased breath sounds, crackles,
and dullness to percussion over the lower third of the lung
fields bilaterally.
Abd: Soft, non-tender, distended, active bowel sounds, mild
diffuse guarding but no rebound.
Back: No CVA or paraspinal tenderness.
Ext: 4+ bilateral lower extremity pitting edema, 2+ DP pulses.
Nodes: No cervical or inguinal adenopathy.
Skin: Telangiectasias over the superior-anterior chest wall,
mild diffuse erythema, no other focal lesions.
Neuro: Waxing and [**Doctor Last Name 688**] mental status with intermittently
appropriate responses to questions, very hard of hearing.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: World War II veteran. Lives in [**Location 620**] with his wife. [**Name (NI) **] has a
remote history of heavy alcohol use and now has 1-2 drinks
during the weekend. He no longer smokes but also has a remote
history of tobacco use.  He is a retired salesman. His daughter
is [**Name (NI) 553**] [**Last Name (NamePattern1) 57771**], [**First Name3 (LF) **] [**Company 191**] Clinical triage nurse. 

### Response:
{'Acute kidney failure, unspecified,Pneumonia, organism unspecified,Bacteremia,Cyst and pseudocyst of pancreas,Congestive heart failure, unspecified,Paralytic ileus,Candidiasis of mouth,Atherosclerosis of native arteries of the extremities with gangrene,Hypotension of hemodialysis,Anemia of other chronic disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
