CHIEF COMPLAINT: Hypertensie Urgency

PRESENT ILLNESS: 58 y/o female with h/o ESRD on HD, s/p renal tx in [**2173**] with
acute on chronic rejection in [**2193-1-20**], initially presenting
with a 4-5 days episode of severe frontal headaches, N/V/D and
decreased appetite. Pt reports symptoms started on [**5-18**] after
she had received dialysis that day. She missed her HD 2 days
prior to admission due to severe HA and malaise. Pt denies
having had changes in vision, numbness or weaknesses, syncopes,
SOB, CP, anuria or edema during that time.
During her next HD session on [**5-23**] it was noted that pt had SBP
>200-250 patient was also c/o headache and sent to ED for HTN
management. Pt was admitted to the ED for severe hypertensive
crisis, given captopril, labetolol 20mg, 40mgx2, 80mg then
started on nitro and labetolol gtt. She also received dilaudid
for her HA and she was transferred to the MICU for hypertensive
urgency and fevers (102).
.
MICU	
She had two seizures on [**5-24**] in the early morning hours, most
likely due to hypertensive leucoencephalopathy. The first
tonic-clonic convulsion (at 4AM, lasting for about 3min) was
witnessed, a respiratory code was called but the intubation
failed (esophagus). At 6AM the pt awoke, was disoriented,
agitated and started screaming. Shortly after she suffered from
a second seizure which stopped after Lorazepam 2mg iv, pt was
then successfully intubated and entered brief post-ictal coma
(with intact brain stem reflexes).
Pt was transferred to the floor 48 hours later for
optimalization of her BP.

MEDICAL HISTORY: #S/p renal transplant in [**2173**], acute on chronic rejection in
[**1-25**], now ESRD on HD.
.
#IgA nephropathy in [**2169**], 7-8months HD prior to transplant
.
#HTN
.
#Depression
.
#s/p rheumatic fever in childhood

MEDICATION ON ADMISSION: Meds at home:
Labetalol 600 mg daily
ASA
Lipitor
Prednisone 5mg
Folic Acid
.
Upon Transfer:
Labetalol HCl 300mg po 	tid
Lisinopril 10mg PO daily
Aspirin 81mg po	daily
Prednisone 5mg po daily
traZODONE HCl 25mg po hs:prn
Phenytoin 100mg iv q8h
Oxymetazoline HCl 1 spry nu [**Hospital1 **]:prn
Amoxicillin 500mg po q24h
Acetaminophen 325/650mg po q4-6h:prn
Senna 1 tab po bid:prn
Magnesium Sulfate 2gm/100ml NS iv ONCE
ISS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 99.6   BP 174/75 (146/66-190/96)   HF  91 bpm (83-105  RR 18
(18-24)	
O2-Sat 100%(97%)on 2l
I/Os: 1012/275, after midnight 1132/0
General	 Alert, orientated, cooperative; pleasant;
Skin     Warm, good color, normal turgor; no signs of ulcers,
petechiae,
         erythema or jaundice; Pt has bruises on her back (left
lower chest)
         and arms; Mild bilat. LE edemas;
HEENT	 No visual impairment, no conjunctival injections,
anicteric sclerae;
         Moist gums and tongue;
Lymph	 No signs of lymphadenopathy;
Neck	 Good carotid pulses, no bruits;
Respir   No use of accessory muscles, no retractions,
symmetrical thorax
         expansion, both lungs are equally ventilated, no
wheezes, crackles
         over both lower lobes l>r, decreased BS over LLL;
Cardio	 Rhythmic, HR  91bpm, S1+ S2, systolic
crescendo-decrescendo [**2-25**]
         murmur, no gallops or rubs;
Abdomen	 No skin liver signs, normal bowel sounds over all four
quadrants, no
         pain on light or deep palpation, no guarding, no
masses; no
         hepatospleno-megaly, no flank pain;
Pulses	 Good palpable carotic, radialis, ulnaris, dorsalis pedis
and tibialis
         pos. pulses;
MuscSkel No swelling of joints, no redness, no warmth; normal
range of motion;
Neuro	 Coherent, alert and orientated; normal CN II to XII,
normal strength
         [**5-24**],normal sensory on both arms and legs;

FAMILY HISTORY: Father died age 80.
Mother with lung Ca, died @64.
Many aunts/uncles with Ca.
Sister with breast Ca, survived.
No family hx renal problems.

SOCIAL HISTORY: Lives alone with cats. No family in the area. Denies
tob/EtOH/IVDU/substances. Works part-time as asst. coffee shop
manager. Unable to obtain health insurance for past year, which
has limited her access to f/u medical care for her transplant.
Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Other non-autoimmune hemolytic anemias,Other convulsions,Other pulmonary insufficiency, not elsewhere classified,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Hypotension of hemodialysis,Depressive disorder, not elsewhere classified,Unspecified causes of encephalitis, myelitis, and encephalomyelitis,Long-term (current) use of steroids,Epistaxis,Third or oculomotor nerve palsy, partial,Personal history of other diseases of circulatory system
Mal hyp kid w cr kid V,End stage renal disease,Oth nonauto hem anemia,Convulsions NEC,Other pulmonary insuff,Pneumonia, organism NOS,Urin tract infection NOS,Hemododialysis hypotensn,Depressive disorder NEC,Encephalitis NOS,Long-term use steroids,Epistaxis,Partial third nerv palsy,Hx-circulatory dis NEC
Admission Date:  [**2193-5-23**]              Discharge Date:   [**2193-6-7**]

Date of Birth:  [**2134-9-9**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 22401**]
Chief Complaint:
Hypertensie Urgency

Major Surgical or Invasive Procedure:
Intubation due to acute respiratory distress
.
Hemodialysis


History of Present Illness:
58 y/o female with h/o ESRD on HD, s/p renal tx in [**2173**] with
acute on chronic rejection in [**2193-1-20**], initially presenting
with a 4-5 days episode of severe frontal headaches, N/V/D and
decreased appetite. Pt reports symptoms started on [**5-18**] after
she had received dialysis that day. She missed her HD 2 days
prior to admission due to severe HA and malaise. Pt denies
having had changes in vision, numbness or weaknesses, syncopes,
SOB, CP, anuria or edema during that time.
During her next HD session on [**5-23**] it was noted that pt had SBP
>200-250 patient was also c/o headache and sent to ED for HTN
management. Pt was admitted to the ED for severe hypertensive
crisis, given captopril, labetolol 20mg, 40mgx2, 80mg then
started on nitro and labetolol gtt. She also received dilaudid
for her HA and she was transferred to the MICU for hypertensive
urgency and fevers (102).
.
MICU	
She had two seizures on [**5-24**] in the early morning hours, most
likely due to hypertensive leucoencephalopathy. The first
tonic-clonic convulsion (at 4AM, lasting for about 3min) was
witnessed, a respiratory code was called but the intubation
failed (esophagus). At 6AM the pt awoke, was disoriented,
agitated and started screaming. Shortly after she suffered from
a second seizure which stopped after Lorazepam 2mg iv, pt was
then successfully intubated and entered brief post-ictal coma
(with intact brain stem reflexes).
Pt was transferred to the floor 48 hours later for
optimalization of her BP.

Past Medical History:
#S/p renal transplant in [**2173**], acute on chronic rejection in
[**1-25**], now ESRD on HD.
.
#IgA nephropathy in [**2169**], 7-8months HD prior to transplant
.
#HTN
.
#Depression
.
#s/p rheumatic fever in childhood

Social History:
Lives alone with cats. No family in the area. Denies
tob/EtOH/IVDU/substances. Works part-time as asst. coffee shop
manager. Unable to obtain health insurance for past year, which
has limited her access to f/u medical care for her transplant.


Family History:
Father died age 80.
Mother with lung Ca, died @64.
Many aunts/uncles with Ca.
Sister with breast Ca, survived.
No family hx renal problems.

Physical Exam:
T 99.6   BP 174/75 (146/66-190/96)   HF  91 bpm (83-105  RR 18
(18-24)	
O2-Sat 100%(97%)on 2l
I/Os: 1012/275, after midnight 1132/0
General	 Alert, orientated, cooperative; pleasant;
Skin     Warm, good color, normal turgor; no signs of ulcers,
petechiae,
         erythema or jaundice; Pt has bruises on her back (left
lower chest)
         and arms; Mild bilat. LE edemas;
HEENT	 No visual impairment, no conjunctival injections,
anicteric sclerae;
         Moist gums and tongue;
Lymph	 No signs of lymphadenopathy;
Neck	 Good carotid pulses, no bruits;
Respir   No use of accessory muscles, no retractions,
symmetrical thorax
         expansion, both lungs are equally ventilated, no
wheezes, crackles
         over both lower lobes l>r, decreased BS over LLL;
Cardio	 Rhythmic, HR  91bpm, S1+ S2, systolic
crescendo-decrescendo [**2-25**]
         murmur, no gallops or rubs;
Abdomen	 No skin liver signs, normal bowel sounds over all four
quadrants, no
         pain on light or deep palpation, no guarding, no
masses; no
         hepatospleno-megaly, no flank pain;
Pulses	 Good palpable carotic, radialis, ulnaris, dorsalis pedis
and tibialis
         pos. pulses;
MuscSkel No swelling of joints, no redness, no warmth; normal
range of motion;
Neuro	 Coherent, alert and orientated; normal CN II to XII,
normal strength
         [**5-24**],normal sensory on both arms and legs;


Pertinent Results:
[**2193-5-23**] 07:00PM   GLUCOSE-86 UREA N-18 CREAT-5.4*# SODIUM-142
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-30 ANION GAP-17
[**2193-5-23**] 07:00PM   ALT(SGPT)-11 AST(SGOT)-14 CK(CPK)-67 ALK
PHOS-58 AMYLASE-61 TOT BILI-1.0
[**2193-5-23**] 07:00PM   LIPASE-27
[**2193-5-23**] 07:00PM   cTropnT-0.04*
[**2193-5-23**] 07:00PM   CK-MB-NotDone
[**2193-5-23**] 07:00PM   ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-4.3#
MAGNESIUM-1.6
[**2193-5-23**] 07:00PM   WBC-3.4* RBC-3.17* HGB-9.9* HCT-29.8* MCV-94
MCH-31.4 MCHC-33.3 RDW-19.1*
[**2193-5-23**] 07:00PM   NEUTS-69.5 LYMPHS-23.5 MONOS-5.3 EOS-1.4
BASOS-0.3
[**2193-5-23**] 07:00PM   NEUTS-69.5 LYMPHS-23.5 MONOS-5.3 EOS-1.4
BASOS-0.3
[**2193-5-23**] 07:00PM   ANISOCYT-2+ MACROCYT-1+ MICROCYT-1+
[**2193-5-23**] 07:00PM   PLT SMR-VERY LOW PLT COUNT-44*#
[**2193-5-23**] 07:00PM   PT-12.4 PTT-23.4 INR(PT)-1.1
.
Upon d/c:
Hematology
  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2193-6-7**] 04:50AM    5.6 3.76* 11.4* 33.9* 90 30.3 33.5 18.4*
148*
  DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2193-5-29**] 05:17AM    55.4   33.1 6.5 4.1* 1.0
  RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr Ovalocy Bite Fragmen
[**2193-5-29**] 05:17AM      1+ 1+   1+
  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT) [**Name (NI) 11951**]
[**2193-6-7**] 04:50AM          148*
MISCELLANEOUS HEMATOLOGY ESR
[**2193-6-4**] 07:00PM    7

Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2193-6-7**] 04:50AM    80 22* 4.0*# 140 3.5 101 27 16
  ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
[**2193-6-6**] 05:00AM        281*
  OTHER ENZYMES & BILIRUBINS Lipase
[**2193-5-29**] 05:17AM    33
  CPK ISOENZYMES CK-MB cTropnT
[**2193-5-23**] 07:00PM      0.04*
[**2193-5-23**] 07:00PM    NotDone
  CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron

[**2193-6-7**] 04:50AM          8.6 4.3 1.7
  HEMATOLOGIC Folate Hapto
[**2193-6-6**] 05:00AM      <20*
OTHER CHEMISTRY Ammonia
[**2193-5-29**] 05:17AM    19
PITUITARY TSH
[**2193-6-1**] 06:20AM    2.0
OTHER ENDOCRINE Cortsol
[**2193-6-2**] 06:00AM    18.7
  ANTIBIOTICS Vanco
[**2193-5-29**] 05:17AM    14.3*
  NEUROPSYCHIATRIC Phenyto Valproa Phenyfr %Phenyf
[**2193-6-4**] 04:50AM      68
  LAB USE ONLY GreenHd Prblm RedHold
[**2193-6-5**] 07:15AM      AMARIE & J
.
ADAMTS 13: negative
Metanephrines Serum - wnl
HIT - negative
.
CT Head [**5-24**]:
IMPRESSION: Unchanged appearance of CT compared with the prior
examination obtained earlier on the same day. No hemorrhage is
seen. Hypodensities are again noted in the white matter
bilaterally. If hypertensive encephalopathy is clinically
suspected, MRI would be helpful for further assessment.
.
EEG [**5-25**]:
IMPRESSION: This is an abnormal portable EEG due to the presence
of
intermittent right central parietal and left temporal and
central sharp
transients. This finding appears to be independent and more
frequent
over the right side. Additionally, there are prolonged bursts of

generalized slowing, bifrontally predominant and slow and
disorganized
background rhythm. This abnormality suggests cortical
dysfunction over
the right central parietal region and possible left central and
temporal
region. The bursts of the generalized slowing and the background

slowing suggests a deep, midline subcortical dysfunction and are

consistent with an encephalopathy. There was no seizure activity

recorded.
.
Echo [**5-28**]:
Conclusions:
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal.
The aortic valve leaflets are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is a small pericardial
effusion.
.
MRI abdomen:
FINDINGS: Both native kidneys are markedly atrophic. Single
renal arteries are identified bilaterally, without evidence for
stenosis.

The transplant renal artery rises from the right external iliac
artery. There is no evidence for stenosis within the renal
transplant artery. This artery trifurcates approximately 1.4 cm
from its origin. The aorta is normal in caliber without evidence
for atherosclerosis. The common iliac, external iliac and
visualized portions of the common femoral arteries are widely
patent.

The transplanted kidney is identified in the right hemipelvis,
measuring 10.7 cm in length. There is severe cortical thinning.
The urothelium of the renal pelvis is abnormally thickened and
edematous and demonstrates enhancement on post-gadolinium
imaging. This finding is nonspecific, however, can be seen in
both rejection and infection. There is no significant
hydronephrosis of the transplanted kidney and no focal renal
lesions are identified.

The partially visualized liver is unremarkable. There is no
intra- or extrahepatic biliary dilatation. The pancreas and
adrenal glands are unremarkable. The spleen is abnormally low in
signal on T1-weighted imaging, consistent with iron deposition.
The visualized bowel is normal and there is no significant
lymphadenopathy.

IMPRESSION:
1. No evidence for renal artery stenosis in either the native
kidneys or transplant kidney.

2. Severe cortical thinning of the transplant kidney. Abnormally
thickened and edematous renal transplant urothelium. This is a
nonspecific finding that can be seen in rejection and infection.

Findings were discussed with Dr. [**Last Name (STitle) 6812**] at the time of the
examination.
.
MRI of the head:
IMPRESSION:
1. No interval change in multiple nonspecific foci of increased
FLAIR signal intensity throughout both cerebral hemispheres,
non-specific.
2. Apparent FLAIR-hyperintensity in the sulcal subarachnoid
spaces. This finding may represent a technical artifact, or less
likely blood products, cells or protein within the subarachnoid
space.
3. Normal MRA of the circle of [**Location (un) 431**].
.
Carotid US:
FINDINGS: Duplex evaluation was performed of both carotid
arteries. Minimal plaques identified.

On the right, peak systolic velocities are 106, 60, 87 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.6.
This is consistent with less than 40% stenosis.

On the left, peak systolic velocities are 75, 72, 78 in the ICA,
CCA, and ECA respectively. The ICA to CCA ratio is 1. This is
consistent with less than 40% stenosis.

There is antegrade flow in both vertebral arteries.

IMPRESSION: Minimal plaque with bilateral less than 40% carotid
stenosis.

Brief Hospital Course:
58 y.o. F admitted for malignant hypertension after missing HD
session and nonadherent with her medications.  Patient with
subsequent seizures due to severe hypertension and slowly
resolving confusion due to reversible hypertensive
leukoencephalopathy.  Patient was also found to be in
microangiopathic thrombotic anemia with platelet consumption.
Her symptoms, confusion and cbc returned to her normal baseline
upon control of her blood pressure.
.
# Confusion
The pt presented with waxing and [**Doctor Last Name 688**] episodes of confusion
when she was transferred from the MICU to the floor. She was
disoriented to location, time and suffered from post-ictal
amnesia. The possible DDx included post-ictal vs. IC bleeding
(CT scan was negative) vs. secondary to leukoencephalopathy vs.
sepsis vs. delirium vs. medication. Since the pt mental status
improved steadily parallel to BP control, it was thought to be
reversible changes secondary to hypertensive
leukoencephalopathy. The pt has been stable over the past days
and is discharged with a fully recovered mental status.
.
# Fevers
Pt spiked temperature when still on the MICU and started on 7
day course of Ceftriaxone. Since the pt had signs of LLL
atelectasis on CXR a possible PNA could not be fully excluded.
The pt also just had been intubated and had central lines in
place. The obtained sputum showed Strep. pneumoniae and she was
treated empirically for that with ceftriaxone. Drug fever was
also in the differential since the pt showed no other signs of
infections (chills, elevated WBC, SOB) but remained with
intermittent fevers.  She was newly started on phenytoin. After
she was changed to Valproic acid, pt remained afebrile over the
[**4-24**] prior to discharge and without any signs of active
infection.
.
#. Seizures:
Pt presented at MICU with new onset seizures, 2 generalized
clonic episodes (each about 3min), which required intubation. Pt
was monitored throughout post-ictal state and transferred to the
floor after she was stable. She has been seizure-free since
then.
Initial seizures likely [**2-21**] HTN emergency - hypertensive
leukoencephalopathy. Patient did not have evidence of trauma,
systemic infection, no electrolyte abnormalities especially with
ESRD, no evidence of acute bleed with underlying
thrombocytopenia.
- Head CT negative x 2 on [**5-24**] negative for hemorrhage or mass,
MRI was not thought to be necessary at this point, neuro recs.
- EEG impression: Suggests cortical dysfunction over the right
central parietal region and possible left central and temporal
region. The bursts of the generalized slowing and the background
slowing suggests a deep, midline subcortical dysfunction and are
consistent with an encephalopathy. There was no seizure activity
recorded.
Pt was initially started on phenytoin for seizure prophylaxis to
which she responded well. However, pt developed a fever which
was thought to be drug induced (eosinophilia accompanied febrile
episode). Therefore phenytoin was d/c and pt was started on
valproic acid instead. Her valproic acid have been monitored
closely to titrate dosage, currently she is on Valproic acid
500mg po bid standing, last valproic level on [**6-3**] was 75.
Pt will f/u with neurology as an outpatient to adjust further
treatment.
.
#. Hypertension:
Pt was admitted for hypertensive urgency with end organ damage -
hypertensive leukoencephalopathy and microangiopathic hemolytic
anemia. Obtained secondary hypertension work-up was negative
(incl. MRI Abdomen, TSH, Cortisol - serum epinephrine and
metanephrine were within normal limits).
She has a history of not taking her medications, missing HD may
also have complicated situation along with worsening renal
failure/hypoperfusion/high RAAS. History from previous admission
of bp elevated >200s but responded to Lasix and labetalol. Pt in
ED initially was started on nitro gtt and nipride gtt in ED.
Drips were stopped after seizures and improved BP control. There
were no ECG changes or evidence of cardiac ischemia.
BP was hard to control at first but stabilized over the past 72h
under enforced treatment with Labetalol, Lisinopril, Clonidine,
Nifedipine and intermittent Hydralazine (which was d/c on [**6-2**],
due to orthostatic symptoms). Repeated adjustments in BP-regimen
were made to optimize current treatment and prevent hypotensive
episodes.
Pt is discharged on Lisinopril 40mg po to qhs, Clonidine TTS 3
patch qthurs, Labetalol 800mg po bid and Nifedipine 120mg po
qhs.
The set goal for her SBP is 120-170, since the pt probably has a
history of long-standing maltreated HTN and is used to high
pressures. She complains about light-headedness and dizziness
once pressures get too low. However, given her recent
hypertensive episode it is essential for her to be well
controlled. Also considering a component of non-compliance it is
important that the pt will f/u with PCP and for monitoring of
compliance.
.
#. ESRD
Pt is s/p renal transplant in [**2173**] and tx rejection in [**Month (only) 404**]
[**2193**], now back on HD, 3 times a week. Pt received HD throughout
her hospital course and will be followed by renal as an
outpatient, receiving HD at the [**Hospital1 18**].
She will be continued on her prednisone taper for immuno
suppression with her graft.  There was no evidence of
compromising renal artery stenosis on the MRI.
HD per their schedule, next HD sessioned for [**6-8**].
.
#. CN III palsy
Pt had two episodes of right sides ptosis/lat.
deviation/diplopia and mydriasis (reactive to light),
accompanied by right hemicranial HA during HD on [**6-4**] -
resolving within 10 minutes.
Initial DDx included Arteritis temporalis (ESR 7) vs. TIA vs.
right posterior artery aneurysm. The obtained work-up included
MRI/MRA (questionable subarachnoidal bleeding), carotid duplex
(minimal bilat. stenosis <40%) and LP (no xanthocromia,clear and
colorless).
Since the clinical findings (ptosis, lat. deviation, mydriasis
or diplopia)totally resolved and the work/up was negative, the
intermittent CNIII palsy is thought to be secondary to transient
ischemia due to hypotension.
Pt will f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**], neurologist as an
outpatient.
.
#. Severe Headache
Pt presented with severe fronto-facial HA, accompanied by N/V on
[**6-6**] (day after LP). She reported that the HA was similar to the
one on her initial presentation.
The HA was thought to be triggered by pt not following
instruction after LP, such as bed-rest and high pressure
overnight (up to 220s SBP. HA resolved throughout the day,
initially treated with Oxycodone-Acetaminophen and Fioricet for
HA, as well as Dolasetron for nausea. Neuro saw pt and did not
find signs for focal lesion or papilledema, which could be
indicative for post-LP complications.
Pt is asymptomatic on day of discharge, denying HA, N/V,
dizziness or blurry vision this am.
.
#. Anemia - Normocytic.
Pt initially presented with Hct of 29.8, normocytotic. The
anemia is thought to be secondary to ESRD (not treated with EPO
previously) vs. occult bleeding vs. hemolysis. Retic count in
[**Month (only) 404**] was 1.4%, indicating an impaired production. The
hemolysis studies obtained revealed an elevated LDH and a
decreased haptoglobin, which are found in hemolysis.
The anemia is thought to be secondary to ESRD and initial
microangiopathic hemolytic anemia induced by hypertensive
urgency.
Hct slightly decreased over the days prior to discharge, 32.3 on
[**6-2**] to 25.6 on [**6-6**]. Hemolysis labs obtained revealed elevated
LDH (not compared to previous days), Haptoglobin <20 (measured
twice), normal direct and total Bili. No signs of active
bleeding, pt is asymptomatic (denies SOB, not tachycardic, no
dizziness) nor signs of severe hemolysis (jaundice,
splenomegaly).
Anemia and decrease in Hct is thought to be due to ESRD, ACD and
hospital course (HD, frequent blood draws). However, labs
indicate an additional hemolytic component.
Pt was given 2 Units of Blood on [**6-6**] at HD, in addition to
usual Epoetin administration during HD sessions.
She responded adequately to transfusion, Hct rose from 25.6 to
28.1 to 33.9 in am of [**6-7**].
.
#.  Thrombocytopenia
Pt initially presented with ptl of 44. The thrombocytopenia were
thought to be either microangiopathic hemolytic anemia secondary
to her hypertensive urgency vs. TTP. Indicative for an
underlying TTP are the following findings are thrombocytopenia,
hemolysis, schistocytes, elevated LDH, decreased haptoglobin,
elevated creatinine, mental status changes and fever.
However the obtained ADAMTS13 to test for TTP was negative.
Given that the pt Hct stabilized once her BP was controlled
better made a MHA secondary to hypertensive crisis most likely.
Interestingly, the pt had a similar thrombocytopenic episode in
[**2193-1-20**] when she was hospitalized for her renal tx
rejection.
The ptl count has been steadily increasing since [**5-24**], being 148
on day of discharge.
.
# Full code

Medications on Admission:
Meds at home:
Labetalol 600 mg daily
ASA
Lipitor
Prednisone 5mg
Folic Acid
.
Upon Transfer:
Labetalol HCl 300mg po 	tid
Lisinopril 10mg PO daily
Aspirin 81mg po	daily
Prednisone 5mg po daily
traZODONE HCl 25mg po hs:prn
Phenytoin 100mg iv q8h
Oxymetazoline HCl 1 spry nu [**Hospital1 **]:prn
Amoxicillin 500mg po q24h
Acetaminophen 325/650mg po q4-6h:prn
Senna 1 tab po bid:prn
Magnesium Sulfate 2gm/100ml NS iv ONCE
ISS


Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day).
Disp:*240 Tablet(s)* Refills:*2*
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
Disp:*4 Patch Weekly(s)* Refills:*2*
8. Valproic Acid 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
Disp:*120 Capsule(s)* Refills:*2*
9. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO ONCE MR1 (Once and
may repeat 1 time) as needed for insomnia for 1 doses.
Disp:*15 Tablet(s)* Refills:*0*
11. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Hypertensive urgency with secondary leukencephalopathy and
microangiopathic hemolytic anemia
.
ESRD, s/p renal transplantation in [**2173**], tx rejection in [**1-25**]
now back on dialysis


Discharge Condition:
Stable


Discharge Instructions:
Please go to [**Hospital 101208**] Clinic tomorrow to have your blood pressure
checked by a nurse.
.
Please see your primary care physician or present to the ED for
any of the following symptoms: headaches, blurry vision, changes
in vision, nausea, vomiting, chest pain, shortness of breath,
swelling of your legs, weaknesses of limbs or any other symptoms
that worry you.

Followup Instructions:
Please have your blood pressure checked at the Women's Clinic at
Carny tomorrow;
.
Your next scheduled appointment for dialysis at the [**Hospital1 18**] is on
thursday, the [**6-6**].
.
Please see Dr. [**Last Name (STitle) **], [**Doctor Last Name **], Neurology on thursday, [**6-6**] at
1pm on neurology unit CC8 (SB) for seizure follow-up.
[**Telephone/Fax (1) 44**].
.
You have an appointment with your primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 101209**], [**Known firstname **] [**Last Name (NamePattern1) 5969**] scheduled for Monday, [**6-10**] at 2.30pm,
Women's Clinic at [**Hospital 101208**] hospital. [**Telephone/Fax (1) 101210**].
.
You also have a set appointment with your therapist [**First Name8 (NamePattern2) 101211**] [**Doctor Last Name **]
for Monday [**6-10**] at 6pm, Women's Clinic at [**Hospital 101208**] hospital.
[**Telephone/Fax (1) 101210**].



Completed by:[**2193-7-2**]
{'Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Other non-autoimmune hemolytic anemias,Other convulsions,Other pulmonary insufficiency, not elsewhere classified,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Hypotension of hemodialysis,Depressive disorder, not elsewhere classified,Unspecified causes of encephalitis, myelitis, and encephalomyelitis,Long-term (current) use of steroids,Epistaxis,Third or oculomotor nerve palsy, partial,Personal history of other diseases of circulatory system'}


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: Hypertensie Urgency

PRESENT ILLNESS: 58 y/o female with h/o ESRD on HD, s/p renal tx in [**2173**] with
acute on chronic rejection in [**2193-1-20**], initially presenting
with a 4-5 days episode of severe frontal headaches, N/V/D and
decreased appetite. Pt reports symptoms started on [**5-18**] after
she had received dialysis that day. She missed her HD 2 days
prior to admission due to severe HA and malaise. Pt denies
having had changes in vision, numbness or weaknesses, syncopes,
SOB, CP, anuria or edema during that time.
During her next HD session on [**5-23**] it was noted that pt had SBP
>200-250 patient was also c/o headache and sent to ED for HTN
management. Pt was admitted to the ED for severe hypertensive
crisis, given captopril, labetolol 20mg, 40mgx2, 80mg then
started on nitro and labetolol gtt. She also received dilaudid
for her HA and she was transferred to the MICU for hypertensive
urgency and fevers (102).
.
MICU	
She had two seizures on [**5-24**] in the early morning hours, most
likely due to hypertensive leucoencephalopathy. The first
tonic-clonic convulsion (at 4AM, lasting for about 3min) was
witnessed, a respiratory code was called but the intubation
failed (esophagus). At 6AM the pt awoke, was disoriented,
agitated and started screaming. Shortly after she suffered from
a second seizure which stopped after Lorazepam 2mg iv, pt was
then successfully intubated and entered brief post-ictal coma
(with intact brain stem reflexes).
Pt was transferred to the floor 48 hours later for
optimalization of her BP.

MEDICAL HISTORY: #S/p renal transplant in [**2173**], acute on chronic rejection in
[**1-25**], now ESRD on HD.
.
#IgA nephropathy in [**2169**], 7-8months HD prior to transplant
.
#HTN
.
#Depression
.
#s/p rheumatic fever in childhood

MEDICATION ON ADMISSION: Meds at home:
Labetalol 600 mg daily
ASA
Lipitor
Prednisone 5mg
Folic Acid
.
Upon Transfer:
Labetalol HCl 300mg po 	tid
Lisinopril 10mg PO daily
Aspirin 81mg po	daily
Prednisone 5mg po daily
traZODONE HCl 25mg po hs:prn
Phenytoin 100mg iv q8h
Oxymetazoline HCl 1 spry nu [**Hospital1 **]:prn
Amoxicillin 500mg po q24h
Acetaminophen 325/650mg po q4-6h:prn
Senna 1 tab po bid:prn
Magnesium Sulfate 2gm/100ml NS iv ONCE
ISS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 99.6   BP 174/75 (146/66-190/96)   HF  91 bpm (83-105  RR 18
(18-24)	
O2-Sat 100%(97%)on 2l
I/Os: 1012/275, after midnight 1132/0
General	 Alert, orientated, cooperative; pleasant;
Skin     Warm, good color, normal turgor; no signs of ulcers,
petechiae,
         erythema or jaundice; Pt has bruises on her back (left
lower chest)
         and arms; Mild bilat. LE edemas;
HEENT	 No visual impairment, no conjunctival injections,
anicteric sclerae;
         Moist gums and tongue;
Lymph	 No signs of lymphadenopathy;
Neck	 Good carotid pulses, no bruits;
Respir   No use of accessory muscles, no retractions,
symmetrical thorax
         expansion, both lungs are equally ventilated, no
wheezes, crackles
         over both lower lobes l>r, decreased BS over LLL;
Cardio	 Rhythmic, HR  91bpm, S1+ S2, systolic
crescendo-decrescendo [**2-25**]
         murmur, no gallops or rubs;
Abdomen	 No skin liver signs, normal bowel sounds over all four
quadrants, no
         pain on light or deep palpation, no guarding, no
masses; no
         hepatospleno-megaly, no flank pain;
Pulses	 Good palpable carotic, radialis, ulnaris, dorsalis pedis
and tibialis
         pos. pulses;
MuscSkel No swelling of joints, no redness, no warmth; normal
range of motion;
Neuro	 Coherent, alert and orientated; normal CN II to XII,
normal strength
         [**5-24**],normal sensory on both arms and legs;

FAMILY HISTORY: Father died age 80.
Mother with lung Ca, died @64.
Many aunts/uncles with Ca.
Sister with breast Ca, survived.
No family hx renal problems.

SOCIAL HISTORY: Lives alone with cats. No family in the area. Denies
tob/EtOH/IVDU/substances. Works part-time as asst. coffee shop
manager. Unable to obtain health insurance for past year, which
has limited her access to f/u medical care for her transplant. 

### Response:
{'Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Other non-autoimmune hemolytic anemias,Other convulsions,Other pulmonary insufficiency, not elsewhere classified,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Hypotension of hemodialysis,Depressive disorder, not elsewhere classified,Unspecified causes of encephalitis, myelitis, and encephalomyelitis,Long-term (current) use of steroids,Epistaxis,Third or oculomotor nerve palsy, partial,Personal history of other diseases of circulatory system'}
