CHIEF COMPLAINT: Question of seizures.

PRESENT ILLNESS: The patient is a 63-year-old
mostly Spanish-speaking male with a history of end-stage
renal disease on hemodialysis, diabetes, coronary artery
disease, multiple line infections, recent presumed osteo of
cervical spine, who presents from an outside hospital for a
question of seizure.

MEDICAL HISTORY: 1.  End-stage renal disease, on hemodialysis.
2.  Type 2 diabetes.
3.  COPD.
4.  CAD, status post cardiac catheterization in [**2145-7-15**] with PTCA and stent of the LCX.
5.  CHF.
6.  History of MRSA epidural abscess, status post L2-3 I&D in
[**2144-5-15**].
7.  History of line infections with MRSA, VRE, Klebsiella.
8.  History of thrombosis in the right IJ, right subclavian,
right brachiocephalic from [**2145-9-14**]. Left IJ and left
brachiocephalic clots.
9.  PUD.
10. Hypertension.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient denied any tobacco or alcohol
use.  He lives at home with his wife, but has recently been
in rehabilitation since his last hospitalization in [**2145-10-15**].
Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Other complications due to other vascular device, implant, and graft,Atrial flutter,Pneumonia, organism unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease
DMII oth nt st uncntrld,Chr airway obstruct NEC,CHF NOS,Comp-oth vasc dev/graft,Atrial flutter,Pneumonia, organism NOS,Hyp kid NOS w cr kid V
Admission Date:  [**2145-11-22**]       Discharge Date:  [**2145-11-28**]

Date of Birth:   [**2082-10-25**]       Sex:  M

Service:  MEDICINE

NOTE:  This is a discharge summary for events that took place
between [**2145-11-22**] and [**2145-11-28**].

CHIEF COMPLAINT:  Question of seizures.

HISTORY OF THE PRESENT ILLNESS:  The patient is a 63-year-old
mostly Spanish-speaking male with a history of end-stage
renal disease on hemodialysis, diabetes, coronary artery
disease, multiple line infections, recent presumed osteo of
cervical spine, who presents from an outside hospital for a
question of seizure.

The patient was feeling poorly on the morning of admission as
well as at hemodialysis, complaining of increasing shortness
of breath as well as shaking of the upper extremities which
was interpreted as a possible seizure activity.  The patient
was given Ativan and Dilantin loading, and was intubated for
airway protection.  Head CT was negative for a mass or bleed.
The patient's wife states that he was not himself in the
morning, being tachypneic and confused.  In addition, she
feels that his head and neck have significantly swollen up.

PAST MEDICAL HISTORY:
1.  End-stage renal disease, on hemodialysis.
2.  Type 2 diabetes.
3.  COPD.
4.  CAD, status post cardiac catheterization in [**2145-7-15**] with PTCA and stent of the LCX.
5.  CHF.
6.  History of MRSA epidural abscess, status post L2-3 I&D in
[**2144-5-15**].
7.  History of line infections with MRSA, VRE, Klebsiella.
8.  History of thrombosis in the right IJ, right subclavian,
right brachiocephalic from [**2145-9-14**]. Left IJ and left
brachiocephalic clots.
9.  PUD.
10. Hypertension.

MEDICATIONS ON TRANSFER:
1.  Coumadin.
2.  Percocet p.r.n.
3.  Nepro, one can q.h.s.
4.  Nitroglycerin 0.3 mg sublingually p.r.n.
5.  Colace 100 mg p.o. b.i.d.
6.  Senna.
7.  Tylenol p.r.n.
8.  Milk of magnesia p.r.n.
9.  Epogen subcutaneously.
10. Dulcolax.
11. Lopressor 100 mg p.o. t.i.d.
12. Norvasc 10 mg p.o. b.i.d.
13. Enalapril 20 mg p.o. q.d.
14. Plavix 75 mg p.o. q.d.
15. Enteric coated aspirin 325 mg p.o. q.d.
16. Protonix 40 mg p.o. q.d.
17. Lantus 15 units q.a.m.
18. Regular insulin sliding scale.
19. Tums t.i.d.
20. Oxacillin 1 gram IV q. four hours through [**2145-12-13**].
21. Ambien 5 mg p.o. q.d.

ALLERGIES:  The patient has no known drug allergies.

SOCIAL HISTORY:  The patient denied any tobacco or alcohol
use.  He lives at home with his wife, but has recently been
in rehabilitation since his last hospitalization in [**2145-10-15**].

FAMILY HISTORY:  Noncontributory.

PHYSICAL EXAMINATION ON ADMISSION:  Temperature 97.5, pulse
73, blood pressure 140/50, respiratory rate 12, 02 saturation
100% on room air.  In general, the patient was sedated,
intubated.  HEENT examination revealed that the pupils were
minimally reactive, anicteric, significant facial/periorbital
edema, ET tube in place.  The neck was supple.  The lungs
were clear to auscultation bilaterally.  The cardiovascular
examination revealed a regular rate and rhythm, normal S1,
S2, no murmurs, rubs, or gallops.  The abdomen was soft,
nontender, nondistended, normoactive bowel sounds.  The
extremities revealed no clubbing, cyanosis or edema.  Left AV
fistula with positive thrill.  Neurologically, the patient
was sedated, but withdraws with legs to noxious stimuli.
Deep tendon reflexes could not be elicited.  Positive
Babinski bilaterally, positive corneal reflex and gag reflex,
normal muscle tone.

LABORATORY DATA ON TRANSFER: White count 4.2, hematocrit
26.7, platelets 333,000.  Sodium 139, potassium 6.0, chloride
96, bicarbonate 27, BUN 83, creatinine 8.4, glucose 41.  PT
21, PTT 57, INR 2.8, ALT 6, AST 17, CK 57, troponin less than
0.3, alkaline phosphatase 108, total bilirubin 0.2.  ABGs
7.59/30/519, lactate 2.4.

The head CT was negative for bleed.

The EKG revealed a normal sinus rhythm at 72 beats per
minute, normal axis, normal intervals, new T wave inversions
in V4 through V6, no peak Ts, no ST elevations or
depressions, no Q waves.  No significant changes from
[**2145-11-14**].

HOSPITAL COURSE:  In short, this is a 63-year-old mostly
Spanish-speaking male with a history of end-stage renal
disease on hemodialysis who presents with a question of
seizures, intubated, now transferred to the floor with
probable SVC syndrome and access issues.

1.  NEUROLOGY:  It is unlikely that the patient ever had a
seizure.  During this episode, trembling, the patient was
noted to have a fingerstick of 36.  In addition, he was
continually talking through the rhythmic motions.  It is much
more likely that the patient was simply having symptomatic
hypoglycemia.  The patient was intubated after receiving
loading doses of Ativan and Dilantin.  His head CT was
negative, and his MRI was negative for bleed but showed only
old bilateral lacunar disease.  No lumbar puncture was
performed because of a low index of suspicion for infectious
sources of mental status changes.  The patient continued to
be delirious, especially at night.  However, as the Ativan
came out of his system, he became less delirious and more
oriented.  He was continued on olanzapine 5 mg p.o. q.d.

At this time, there still is an EEG pending from [**Hospital3 16786**] from which he was transferred.  However, given the
low likelihood for seizure activity, this may not need to be
further followed.

2.  HEMATOLOGY:  The patient has known right and left-sided
upper extremity clots, and as of [**2145-11-3**], had 40%
occlusion of the SVC.  The patient was admitted on Coumadin.
This was held and the patient was started on heparin.  Given
the new upper torso pitting edema and concern for SVC, it is
probable that some of these clots have migrated into the path
of the SVC.  The patient was also sent for hypercoagulability
workup.  Many of these results are still pending.  The
patient was noted to have a protein S deficiency, but this
may not be significant in the presence of active clotting.

On [**2145-11-25**], the patient received an ultrasound vein mapping.
This showed the presence of only left-sided internal jugular
clots.  However, the SVC could not be assessed.  The plan at
this point is to visualize the upper torso venous system
through angiography while performing a fistulogram.  This is
scheduled for [**2145-11-29**].  For now, the patient is maintained
on a heparin drip.

3.  ACCESS:  On admission, the patient had an old left EJ
versus subclavian that was inserted on this past admission
about two weeks ago.  This line is used for temporary
dialysis.  The patient also has a right midline catheter that
was used for infusion of IV Oxacillin.  However, this was
found to be nonfunctioning.  The patient received a left
femoral central line for both Oxacillin and heparin infusion.
The patient also has a left AV fistula with positive thrill,
however, poor blood flow was noted during hemodialysis on
[**2145-11-24**].  The patient is status post fistulogram
and angioplasty of that same AV fistula about a week and a
half ago.

As already noted, the patient is scheduled for an AV
fistulogram on [**2145-11-29**].  If this is found to be operational,
the left EJ versus the subclavian line should be taken out,
especially as the patient has been spiking fevers.  If AV
fistula is not viable, Transplant Surgery will need to
reassess the fistula, and a temporary Perma-Cath will need to
be placed.  From past admissions, the patient is a big access
problem, and placement of even a [**Name (NI) 34028**] will be very
difficult in this patient.  The right midline catheter was
removed on [**2145-11-27**].

4.  INFECTIOUS DISEASE:  The patient is currently being
treated for presumed osteomyelitis in the setting of MSSA
bacteremia that was noted on past admissions.  He is
receiving Oxacillin IV, 1 gram q. four hours.  This is to be
continued through [**2145-12-13**].

Of note, the patient started spiking again on this admission,
up to 102 degrees Fahrenheit.  All of the patient's blood
cultures have been negative.  The patient is essentially
anuric.  His chest x-ray initially indicated the presence of
opacity, but the final read was read as atelectasis.  The
patient was initially placed on levo and Flagyl for
aspiration pneumonia.  However, once the chest x-ray was
confirmed, this combination was stopped.  The most likely
source of the fever is the left-sided EJ versus subclavian
that was placed on the last admission.  However, because the
patient is such an access issue, there was a decision to
treat through this infection as long as the blood cultures
remained negative.

5.  CARDIOVASCULAR:  The patient has a history of atrial
fibrillation.  On [**2145-11-24**], the patient was noted to be in
atrial flutter, hemodynamically stable.  The patient received
IV Lopressor and IV Diltiazem and converted to normal sinus
rhythm.  The patient had an echocardiogram on [**2145-11-25**], which
showed an EF of 60-70%, bidirectional stent, ASD, normal free
wall motion, and mild pulmonary artery hypertension.  The
patient was continued on his Lopressor, Captopril, aspirin.

6.  RENAL:  The patient continues hemodialysis on Mondays,
Wednesdays, and Fridays.  Continue on PhosLo, Nephrocaps,
Epogen, sodium bicarbonate.

7.  HEMATOLOGY:  The patient has anemia secondary to renal
failure.  His baseline hematocrit runs around 28.  Hematocrit
has been stable.

8.  PROPHYLAXIS:  The patient is to continue Protonix.

9.  CODE STATUS:  The patient is a full code.



                           DR.[**First Name (STitle) **],[**First Name3 (LF) 2515**] 12-927


Dictated By:[**Name8 (MD) 3839**]
MEDQUIST36

D:  [**2145-11-28**]  14:34
T:  [**2145-11-28**]  11:18
JOB#:  [**Job Number 34029**]


Name:  [**Known lastname 5967**], [**Known firstname 5968**]                    Unit No:  [**Numeric Identifier 5969**]

Admission Date:  [**2145-11-22**]     Discharge Date:  [**2145-12-13**]

Date of Birth:   [**2082-10-25**]     Sex:  M

Service:

ADDENDUM:  On [**12-4**], the patient spiked a fever, and an
x-ray revealed a new right upper lobe consolidation
consistent with pneumonia.

He was started on levofloxacin and complained a 10-day course
of this medication with a good result.  All blood cultures
remained negative throughout the admission.

HEMATOLOGIC SYSTEM:  Prior to arteriovenous fistulogram, it
was not known whether his apparent superior vena cava
syndrome was secondary to stenosis or secondary to an
superior vena cava.  He had a thrombophilia workup guided by
Hematology consultation recommendations; which included a
decrease in functional S activity (after the administration
of Coumadin), negative anticardiolipin and factor V levels,
and a negative protein S antigen.

The patient's old left internal jugular thrombus was felt to
be secondary to a catheter rather than thrombophilia.  Per
Hematology recommendations, he was to complete three months
of therapy with Coumadin to maintain an INR between 2 and 3
for this thrombus.

Also during this portion of the admission, the patient had
anemia which was felt to be multifactorial in etiology.  His
iron studies revealed decreased iron, decreased total
iron-binding capacity, and increased ferritin; consistent
with anemia of chronic disease.  He also received iron for
iron deficiency anemia and Epogen at dialysis for anemia of
renal disease.  Additionally, he received several units of
blood at dialysis over the two week period to maintain his
optimal hematocrit of over 30.

ENDOCRINE SYSTEM:  The patient has known type 2 diabetes
mellitus.  He was managed NPH insulin at fixed doses and a
regular insulin sliding-scale.  At the time of discharge, he
was on a total of 15 units NPH doses in the morning and 4
units NPH dosed in the evening.

MUSCULOSKELETAL SYSTEM:  The patient received visits from
Physical Therapy with good progress in his conditioning.  He
was felt to be most likely safe for discharge to home once
his INR became therapeutic (and heparin drip could be
discontinued) and the course of intravenous oxacillin was
complete.

NOTE:  Please refer to Discharge Summary Addendum for
discharge diagnoses, discharge condition, discharge
medications, and discharge status.

SECOND ADDENDUM:  The patient was free of chest pain
throughout this portion of his admission until the evening of
[**12-9**].  He described substernal pressure lasting the
duration of the evening.  Not associated with nausea,
vomiting, shortness of breath, or diaphoresis and resolved
with one sublingual nitroglycerin.  His electrocardiogram was
remarkable for T wave inversions in leads V4 through V6.  The
patient ruled out for a myocardial infarction with three sets
of negative creatine kinases and troponin I.

RENAL SYSTEM:  The patient was continued on his dialysis
three to four times per week with good results.  As
aforementioned, at the time of this dictation the patient had
adequate flow through his arteriovenous fistula, and did not
have any indwelling dialysis catheters present.  The patient
was continued on Phos-Lo and Renagel for elevated phosphate
levels.

INFECTIOUS DISEASE:  The patient was continued on oxacillin
with plans to discontinue this medication upon completing a
6-week course for methicillin-susceptible Staphylococcus
aureus on [**2145-12-13**].




                          [**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D.  [**MD Number(1) 522**]

Dictated By:[**Last Name (NamePattern1) 5970**]

MEDQUIST36

D:  [**2145-12-10**]  20:46
T:  [**2145-12-16**]  14:04
JOB#:  [**Job Number 5971**]
{'Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Other complications due to other vascular device, implant, and graft,Atrial flutter,Pneumonia, organism unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease'}


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: Question of seizures.

PRESENT ILLNESS: The patient is a 63-year-old
mostly Spanish-speaking male with a history of end-stage
renal disease on hemodialysis, diabetes, coronary artery
disease, multiple line infections, recent presumed osteo of
cervical spine, who presents from an outside hospital for a
question of seizure.

MEDICAL HISTORY: 1.  End-stage renal disease, on hemodialysis.
2.  Type 2 diabetes.
3.  COPD.
4.  CAD, status post cardiac catheterization in [**2145-7-15**] with PTCA and stent of the LCX.
5.  CHF.
6.  History of MRSA epidural abscess, status post L2-3 I&D in
[**2144-5-15**].
7.  History of line infections with MRSA, VRE, Klebsiella.
8.  History of thrombosis in the right IJ, right subclavian,
right brachiocephalic from [**2145-9-14**]. Left IJ and left
brachiocephalic clots.
9.  PUD.
10. Hypertension.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient denied any tobacco or alcohol
use.  He lives at home with his wife, but has recently been
in rehabilitation since his last hospitalization in [**2145-10-15**]. 

### Response:
{'Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Other complications due to other vascular device, implant, and graft,Atrial flutter,Pneumonia, organism unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease'}
