CHIEF COMPLAINT: Transfer [**Hospital1 100**] MACU for hemodialysis line replacement for
poorly functioning catheter

PRESENT ILLNESS: 71yo F with ESRD on HD, respiratory failure s/p trach on vent,
s/p PEG, COPD, recurrent aspiration PNA, and C.diff colitis is
transferred from [**Hospital 100**] Rehab MACU for poorly functioning HD
catheter and thus HD catheter change. She tolerated HD today
well at [**Hospital 100**] rehab and removed 1.7kg. She has multiple medical
problems as above, but all has been stable.
.
For respiratory failure, she is on pressure support and has had
30 minutes trial of trach mask this past weekend which was
stopped due to hypoxia. Rehab has been slowing weaning her from
the vent. Pt is on PS 4/5/50%.
.
For PVD, pt has necrotic, dry gangrene that is auto-amputating.
Getting pain meds/prn and lidoderm patch.
.
For AF, pt is on digoxin. Last level checked on [**12-12**] was 0.8. Pt
is not anticoagulated.

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

MEDICATION ON ADMISSION: 1. Hydromophone 0.75mg q2h/prn during HD sessions only
2. Vancomycin 125mg QID GT
3. Oxycodone 2.5mg q6h/prn GT
4. Benadryl 25mg [**Hospital1 **]/prn GT
5. Benadryl 25mg qhs GT
6. Tums 650mg po QID
7. colace 100mg [**Hospital1 **]/prn GT
8. Digoxin 0.125mg every other day GT, last dose given today
([**2187-12-17**]) at the rehab
9. Mucomyst 200mg TId inh
10 Tylenol Q6h/prn GT
11. Albuterol 2 puffs q6h/prn inh
12. Synthroid 125 mcg daily GT
13. Aspirin 81mg qday Gt
14. Combivent 6 puffs q6h inh
15. Lactinex 1 tab [**Hospital1 **] GT
16. Prilosec 20mg GT
17. Reglan 10mg TID GT
18. Lidoderm patch top daily
19. Lactobacillus 1 tab [**Hospital1 **]
20. Epogen at HD

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

PHYSICAL EXAM: VS: 98.7, 84, 110/50, 28, 95% on PS 5/5, 50%, Tv 525
GEN: Awake, opens eyes spontaneously. Does not follow commands.

FAMILY HISTORY: Per rehab d/c summary, her parents lived until old age. One
brother died of an MI in his 60s. Another brother with
schizophrenia. Son with hypothyroidism

SOCIAL HISTORY: Per rehab d/c summary, she has been bouncing around various long
term care facilities since her tracheostomy and vent dependency.
She is divorced. She is a former smoker 3 packs per day x 13
years. Occasionally used alcohol. Has 3 adult children. Her son
[**Name (NI) **] is her health care proxy and is very involved in her
care.
Mechanical complication of other vascular device, implant, and graft,End stage renal disease,Pressure ulcer, lower back,Atherosclerosis of native arteries of the extremities with gangrene,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hematoma complicating a procedure,Intestinal infection due to Clostridium difficile,Atrial fibrillation,Congestive heart failure, unspecified,Anemia in chronic kidney disease,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of large intestine,Chronic airway obstruction, not elsewhere classified,Tracheostomy status,Gastrostomy status
Malfunc vasc device/graf,End stage renal disease,Pressure ulcer, low back,Ath ext ntv art gngrene,Hyp kid NOS w cr kid V,Hematoma complic proc,Int inf clstrdium dfcile,Atrial fibrillation,CHF NOS,Anemia in chr kidney dis,Hypothyroidism NOS,Hx of colonic malignancy,Chr airway obstruct NEC,Tracheostomy status,Gastrostomy status
Admission Date:  [**2187-12-17**]              Discharge Date:   [**2187-12-19**]

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

Service: MEDICINE

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

Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Transfer [**Hospital1 100**] MACU for hemodialysis line replacement for
poorly functioning catheter

Major Surgical or Invasive Procedure:
s/p R subclavian tunnelled line removal
s/p a new tunnelled hemodialysis line placement


History of Present Illness:
71yo F with ESRD on HD, respiratory failure s/p trach on vent,
s/p PEG, COPD, recurrent aspiration PNA, and C.diff colitis is
transferred from [**Hospital 100**] Rehab MACU for poorly functioning HD
catheter and thus HD catheter change. She tolerated HD today
well at [**Hospital 100**] rehab and removed 1.7kg. She has multiple medical
problems as above, but all has been stable.
.
For respiratory failure, she is on pressure support and has had
30 minutes trial of trach mask this past weekend which was
stopped due to hypoxia. Rehab has been slowing weaning her from
the vent. Pt is on PS 4/5/50%.
.
For PVD, pt has necrotic, dry gangrene that is auto-amputating.
Getting pain meds/prn and lidoderm patch.
.
For AF, pt is on digoxin. Last level checked on [**12-12**] was 0.8. Pt
is not anticoagulated.


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


Social History:
Per rehab d/c summary, she has been bouncing around various long
term care facilities since her tracheostomy and vent dependency.
She is divorced. She is a former smoker 3 packs per day x 13
years. Occasionally used alcohol. Has 3 adult children. Her son
[**Name (NI) **] is her health care proxy and is very involved in her
care.

Family History:
Per rehab d/c summary, her parents lived until old age. One
brother died of an MI in his 60s. Another brother with
schizophrenia. Son with hypothyroidism

Physical Exam:
VS: 98.7, 84, 110/50, 28, 95% on PS 5/5, 50%, Tv 525
GEN: Awake, opens eyes spontaneously. Does not follow commands.

HEENT: PERRL, cloudy cornea, Mouth open with dry tongue. no
obvious OP lesions
NECK: trached with collar
CV: RRR, nl S1 and S2, no m/r/g
PULM: CTA bilaterally, no wheezes/rhonchi/crackles.
ABD: Soft, grimaces on palpation, mildly distended, active bowel
sounds. No hepatosplenomegaly
EXT: warm, no edema of LEs, no rashes, lidoderm patch on feet
bilaterally, dry gangrenous toes bilaterally and auto-amputated
toes on L. R great toe looks dry and auto-amputating. No signs
of infection in any toes, however.
NEURO: awake, alert and opens eyes spontaneously, but does not
follow any commands.


Pertinent Results:
Admission labs:
PT: 13.3  PTT: 35.7  INR: 1.2
140  100  29
---------------< 90
3.8  28  2.5
Ca: 9.2 Mg: 2.4 P: 3.4 D
WBC: 7.3
Hct 33.6
Plt 284
.
PT: 13.7  PTT: 137.3  INR: 1.2
.
Hct: 33 - 34 - 31 - 32 - 31
.
IR REPORT:
RADIOLOGISTS: The procedure was performed by Drs. [**Last Name (STitle) 9441**] and
[**Name5 (PTitle) 2492**], the attending radiologist who was present and
supervising throughout.
PROCEDURE AND FINDINGS: After informed consent was obtained, the
patient was placed supine on the angiography table and the right
neck and chest were prepped and draped in the standard sterile
fashion. After using approximately 10 cc of 1% lidocaine along
the subcutaneous tract of the previously placed hemodialysis
catheter, blunt dissection was performed until the cuff of the
catheter was completely exposed. Then two super stiff glide
wires were advanced through each one of the two lumens of the
previously placed catheter into the inferior vena cava and right
atrium under fluoroscopic guidance. The previously placed
catheter was then removed and a new double-lumen hemodialysis
catheter was advanced over both wires and the tip was positioned
into the right atrium under fluoroscopic guidance. The wires
were removed, the entry site on the skin was sutured with Vicryl
suture, and the catheter was secured to the skin with 2-0 silk
sutures. Catheter was then flushed, hep locked and a sterile
dressing was applied. The patient tolerated the procedure well
without immediate complications.
Moderate sedation was provided by administering divided doses of
75 mcg of fentanyl and 1 mg of versed throughout the total intra
service time of 55 minutes during which the patient's
hemodynamic parameters were continuously monitored.
IMPRESSION: Successful replacement of a double-lumen
hemodialysis catheter. Final fluoroscopic image of the chest
demonstrates the tip of the catheter to be located in the right
atrium approximately 2.0 cm below the tip of the previously
placed catheter. The line is ready for use.


Brief Hospital Course:
71yo F with multiple chronic medical problems but stable
admitted for a new HD catheter placement.  Brief hospital
course:
.
# ESRD: Pt was admitted in a very stable condition.  She
underwent HD with 1.7kg fluid removal at rehab prior to arrival
to MICU. Her 'lytes were all wnl.  She was continued on her
tums.  She was also given mucomyst per son's (HCP) request to
preserve any remaining renal function she has.  She was also
written for prn dilaudid for feet pain she has during HD after
fluid/electrolytes shift.  The malfuncting RSC tunnelled line
was removed and a new tunnelled line was placed by IR on
[**2187-12-18**].  She received 1h HD on [**12-18**] to confirm that it is
functioning.  She then received a more complete round of HD on
[**12-19**] prior to transfer back to MACU.
.
# Anemia: hct was 33.3 at admission which is stable. Epogen can
be continued during HD.   She had hematoma and bleeding at site
of HD line after the procedure.  Pressure was applied and it
stabilized.  Her HCT was followed serially and remained stable.
She was hemodynamically stable.
.
# Respiratory failure s/p trach: Pt is being followed closely by
Dr. [**Last Name (STitle) **]. Vent satting at [**Hospital **] rehab is PS 4/5/50%, rr25-30,
Vt350-402 satting 93-95%. Pt was placed on PS 5/5/50% and O2 sat
was in 93-95%.  Trach collar trial can be restarted at the
rehab.  Her COPD inhalers were continued.
- Continue pressure support
- trach collar trial as tolerated
- continue nebs for COPD
.
# C.diff colitis: continued PO vanc but [**Hospital1 18**] does not have
lactobacillus, so it was not given. Lactobacillus can be
continued at rehab.
.
# Hypothyroidism: Continued synthroid
.
# Atrial Fibrillation: Pt was in sinus rhythm.  We continued
digoxin every other day, recent digoxin level was 0.8 at the
rehab.  Pt was not started on anticoagulation as she was not on
it as outpatient.
.
# PVD: Followed by vascular surgery at rehab. dry gangrene of
toes and auto-amputating.  Continued wound care with betadine
and dry dressing and lidoderm patch on the feet and
oxycodone/prn for pain control.
.
# Decub ulcer: Followed by wound care team at rehab. Frequent
turns and [**Doctor First Name **] air bed.
.
# Pruritis: [**3-9**] previous fentanyl. Continued benadryl/prn
.
# FEN: Continued g-tube feeding with Nepro at 35cc/hr with [**Hospital1 **]
Prostat.
.
# PPX: Pt did receive a flu vaccine at rehab. PPI. No bowel
regimen given c.diff diarrhea.
.
# DNR per rehab d/c summary, confirmed with Dr. [**Last Name (STitle) 67217**]/HCP at
rehab
.
# Dispo: back to MACU

Medications on Admission:
1. Hydromophone 0.75mg q2h/prn during HD sessions only
2. Vancomycin 125mg QID GT
3. Oxycodone 2.5mg q6h/prn GT
4. Benadryl 25mg [**Hospital1 **]/prn GT
5. Benadryl 25mg qhs GT
6. Tums 650mg po QID
7. colace 100mg [**Hospital1 **]/prn GT
8. Digoxin 0.125mg every other day GT, last dose given today
([**2187-12-17**]) at the rehab
9. Mucomyst 200mg TId inh
10 Tylenol Q6h/prn GT
11. Albuterol 2 puffs q6h/prn inh
12. Synthroid 125 mcg daily GT
13. Aspirin 81mg qday Gt
14. Combivent 6 puffs q6h inh
15. Lactinex 1 tab [**Hospital1 **] GT
16. Prilosec 20mg GT
17. Reglan 10mg TID GT
18. Lidoderm patch top daily
19. Lactobacillus 1 tab [**Hospital1 **]
20. Epogen at HD


Discharge Medications:
1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
2. Oxycodone 5 mg/5 mL Solution Sig: 2.5 mg PO Q6H (every 6
hours) as needed for pain.
3. Digoxin 50 mcg/mL Solution Sig: 0.125 mcg PO EVERY OTHER DAY
(Every Other Day): last dose given on [**2187-12-17**].
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: Six Hundred
Fifty (650) mg PO QID (4 times a day).
5. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: Two (2)  PO
BID/PRN () as needed for pruritis.
6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q6H
(every 6 hours) as needed.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day. Capsule, Delayed
Release(E.C.)(s)
10. Combivent 18-103 mcg/Actuation Aerosol Sig: Six (6) puffs
Inhalation four times a day.
11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours as needed.
12. Hydromorphone 1 mg/mL Liquid Sig: 0.75  PO Q2H as needed for
pain: only during hemodialysis.
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY  (): to feet
bilaterally .
14. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1)
Miscellaneous TID (3 times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]

Discharge Diagnosis:
Primary diagnosis:
-End-stage renal disease
-Malfunctioning hemodialysis line s/p removal and a new
tunnelled hemodialysis placement
-Hematoma: HCT stable, hematoma resolved

Secondary diagnoses:
Respiratory failure s/p tracheotomy on ventilation
C. difficile colitis
Chronic obstructive pulmonary disease
Hypothyroidism
Paroxysmal atrial fibrillation
Peripheral vascular disease


Discharge Condition:
stable on ventilator


Discharge Instructions:
Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] if you develop
bleeding or redness around hemodialysis catheter, fever, chills,
nausea, vomiting, or any other concerning symptoms.
.
Take your medications as prescribed.  We did not make any
changes in your medications.  You may continue all your
medications you were taking at the [**Last Name (Titles) **].

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1366**] if needed.
{'Mechanical complication of other vascular device, implant, and graft,End stage renal disease,Pressure ulcer, lower back,Atherosclerosis of native arteries of the extremities with gangrene,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hematoma complicating a procedure,Intestinal infection due to Clostridium difficile,Atrial fibrillation,Congestive heart failure, unspecified,Anemia in chronic kidney disease,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of large intestine,Chronic airway obstruction, not elsewhere classified,Tracheostomy status,Gastrostomy status'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Transfer [**Hospital1 100**] MACU for hemodialysis line replacement for
poorly functioning catheter

PRESENT ILLNESS: 71yo F with ESRD on HD, respiratory failure s/p trach on vent,
s/p PEG, COPD, recurrent aspiration PNA, and C.diff colitis is
transferred from [**Hospital 100**] Rehab MACU for poorly functioning HD
catheter and thus HD catheter change. She tolerated HD today
well at [**Hospital 100**] rehab and removed 1.7kg. She has multiple medical
problems as above, but all has been stable.
.
For respiratory failure, she is on pressure support and has had
30 minutes trial of trach mask this past weekend which was
stopped due to hypoxia. Rehab has been slowing weaning her from
the vent. Pt is on PS 4/5/50%.
.
For PVD, pt has necrotic, dry gangrene that is auto-amputating.
Getting pain meds/prn and lidoderm patch.
.
For AF, pt is on digoxin. Last level checked on [**12-12**] was 0.8. Pt
is not anticoagulated.

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

MEDICATION ON ADMISSION: 1. Hydromophone 0.75mg q2h/prn during HD sessions only
2. Vancomycin 125mg QID GT
3. Oxycodone 2.5mg q6h/prn GT
4. Benadryl 25mg [**Hospital1 **]/prn GT
5. Benadryl 25mg qhs GT
6. Tums 650mg po QID
7. colace 100mg [**Hospital1 **]/prn GT
8. Digoxin 0.125mg every other day GT, last dose given today
([**2187-12-17**]) at the rehab
9. Mucomyst 200mg TId inh
10 Tylenol Q6h/prn GT
11. Albuterol 2 puffs q6h/prn inh
12. Synthroid 125 mcg daily GT
13. Aspirin 81mg qday Gt
14. Combivent 6 puffs q6h inh
15. Lactinex 1 tab [**Hospital1 **] GT
16. Prilosec 20mg GT
17. Reglan 10mg TID GT
18. Lidoderm patch top daily
19. Lactobacillus 1 tab [**Hospital1 **]
20. Epogen at HD

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

PHYSICAL EXAM: VS: 98.7, 84, 110/50, 28, 95% on PS 5/5, 50%, Tv 525
GEN: Awake, opens eyes spontaneously. Does not follow commands.

FAMILY HISTORY: Per rehab d/c summary, her parents lived until old age. One
brother died of an MI in his 60s. Another brother with
schizophrenia. Son with hypothyroidism

SOCIAL HISTORY: Per rehab d/c summary, she has been bouncing around various long
term care facilities since her tracheostomy and vent dependency.
She is divorced. She is a former smoker 3 packs per day x 13
years. Occasionally used alcohol. Has 3 adult children. Her son
[**Name (NI) **] is her health care proxy and is very involved in her
care. 

### Response:
{'Mechanical complication of other vascular device, implant, and graft,End stage renal disease,Pressure ulcer, lower back,Atherosclerosis of native arteries of the extremities with gangrene,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hematoma complicating a procedure,Intestinal infection due to Clostridium difficile,Atrial fibrillation,Congestive heart failure, unspecified,Anemia in chronic kidney disease,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of large intestine,Chronic airway obstruction, not elsewhere classified,Tracheostomy status,Gastrostomy status'}
