CHIEF COMPLAINT: leg swelling, sob

PRESENT ILLNESS: HMED ATTENDING ADMISSION NOTE
.
ADMIT DATE: [**2161-12-23**]
ADMIT TIME: 0200
.
PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 16518**] [**Last Name (NamePattern1) 174**]
.
72 yo F with CKD stage 5 peri-RRT, COPD, DM II with
complications and hypertension who presents to the ED
complaining of lower extremity edema nad shortness of breath.
.
Patient is a poor historian.  Reports increased fatigue and
lethargy x several days.  Also with new dyspnea on exertion,
lower extremity edema and orthopnea. Mild dry cough.  No chest
pain or fevers.  Reports increased salt intake.
.
Patient was initially seen at [**Hospital3 **], bp was 206/102 -
given 1 inch of ntp, 20 iv labetalol and 40 lasix with
improvement in symptoms.  Bilateral LENI's were negative.
Patient transferred to [**Hospital1 18**] for further evaluation.
.
ED: 97.0  76P  197/106  20  98%4LNC; wheeze on exam thought to
be consistent with copd exacerbation - given albuterol neb,
ipratropium neb, methylprednisolone 125 iv and azithromycin
500mg.
.
ROS as per HPI, 10 pt ROS otherwise negative

MEDICAL HISTORY: 1) Type II DM: neuropathy, nephropathy
2) Atypical CP X 16 years: Evaluated in [**State 760**] in [**2136**] with
a stress test and cardiac catheterization, which the patient
reports were normal
3) Hypertension
4) Emphysema
5) s/p discectomy
6) s/p bunionectomy and hammer toe repair
7) s/p hysterectomy and removal of one ovary/fallopian tube
8) CKD (Cr. 2.9 in [**Month (only) 404**] per [**Hospital3 **] ED)
9) Myasthenia [**Last Name (un) **] - diagnosed 1 year ago, on pyridostigimine
- sees Neurologist Dr. [**Last Name (STitle) 37159**]
10) Diverticulosis

MEDICATION ON ADMISSION: Meds per OMR - patient does not recall her medications
albuterol prn
bumetanide 2mg qam, 1mg qpm
calcitriol 0.25mcg qMWF
Aranesp
Diltiazem 360mg daily
Folic acid 1mg daily
Hydralazine 50mg [**Hospital1 **]
Lantus 14 units qam
Isosorbide mononitrate 120mg daily
Labetalol 400mg [**Hospital1 **]
Reglan 10mg q8h prn
Modafinil 200mg [**Hospital1 **]
Oxybutynin 5mg daily
Protonix 40mg daily
Pyridostigmine 30mg [**Hospital1 **]
Renvela 800mg TID
Simvastatin 40mg daily
Terazosin 10mg daily
Venlafaxine 37.5mg [**Hospital1 **]
ASA 325mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: admission exam
VS: 97.4  157/88  18  93P  98%4L NC -> 87% on RA
Appearance: drowsy but arousable, aaox3
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmd, neck supple, difficult to assess
JVD
Cv: +s1, s2  -m/r/g, 2+ peripheral edema, 1+ dp/pt bilaterally,
left UE AVF with palpable thrill
Pulm: diminished at bases, scattered wheeze
Abd: soft, obese, nt, nd, +bs
Msk: 5/5 strength throughout
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]
.
discharge exam
VS - 98.3 154/62 (145/66-196/97) 56 (56-72) 18 97% RA
GENERAL - African American female comfortable in NAD
LUNGS - decreased breath sounds at bases bilaterally.
Respirations unlabored, no accessory muscle use
HEART - RRR, nl S1-S2, 2/6 systolic murmur
ABDOMEN - NABS, soft. NT/ND. abdominal hernia noted. no rebound
or guarding
EXTREMITIES - WWP, 1+ pitting edema bilaterally, 2+ DP pulses
SKIN - no rashes or lesions; right chest with tunneled line in
place -no surrounding erythma
NEURO - awake and interactive, A&Ox3.

FAMILY HISTORY: Mother's sisters with Myeloma and leukemia

SOCIAL HISTORY: Retired [**Location (un) 86**] Police Dept Detective.  Lives with husband and
two grandchildren.  Smokes 1 ppd x 50 years.  No etoh or
illicits.
Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Subendocardial infarction, initial episode of care,Toxic encephalopathy,Acute on chronic diastolic heart failure,Pulmonary congestion and hypostasis,Unspecified pleural effusion,Mixed acid-base balance disorder,Other alteration of consciousness,Chronic airway obstruction, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Polyneuropathy in diabetes,Myasthenia gravis without (acute) exacerbation,Diarrhea,Hypocalcemia,Anemia in chronic kidney disease,Other and unspecified hyperlipidemia,Esophageal reflux,Diverticulosis of colon (without mention of hemorrhage),Depressive disorder, not elsewhere classified,Long-term (current) use of insulin,Personal history of noncompliance with medical treatment, presenting hazards to health
Hyp kid NOS w cr kid V,End stage renal disease,Subendo infarct, initial,Toxic encephalopathy,Ac on chr diast hrt fail,Pulm congest/hypostasis,Pleural effusion NOS,Mixed acid-base bal dis,Other alter consciousnes,Chr airway obstruct NEC,DMII renl nt st uncntrld,Nephritis NOS in oth dis,Neuropathy in diabetes,Mysthna grvs w/o ac exac,Diarrhea,Hypocalcemia,Anemia in chr kidney dis,Hyperlipidemia NEC/NOS,Esophageal reflux,Dvrtclo colon w/o hmrhg,Depressive disorder NEC,Long-term use of insulin,Hx of past noncompliance
Admission Date:  [**2161-12-22**]              Discharge Date:   [**2161-12-30**]

Date of Birth:  [**2089-10-3**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 983**]
Chief Complaint:
leg swelling, sob

Major Surgical or Invasive Procedure:
temporary dialysis catheter placement
tunneled dialysis catheter placement


History of Present Illness:
HMED ATTENDING ADMISSION NOTE
.
ADMIT DATE: [**2161-12-23**]
ADMIT TIME: 0200
.
PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 16518**] [**Last Name (NamePattern1) 174**]
.
72 yo F with CKD stage 5 peri-RRT, COPD, DM II with
complications and hypertension who presents to the ED
complaining of lower extremity edema nad shortness of breath.
.
Patient is a poor historian.  Reports increased fatigue and
lethargy x several days.  Also with new dyspnea on exertion,
lower extremity edema and orthopnea. Mild dry cough.  No chest
pain or fevers.  Reports increased salt intake.
.
Patient was initially seen at [**Hospital3 **], bp was 206/102 -
given 1 inch of ntp, 20 iv labetalol and 40 lasix with
improvement in symptoms.  Bilateral LENI's were negative.
Patient transferred to [**Hospital1 18**] for further evaluation.
.
ED: 97.0  76P  197/106  20  98%4LNC; wheeze on exam thought to
be consistent with copd exacerbation - given albuterol neb,
ipratropium neb, methylprednisolone 125 iv and azithromycin
500mg.
.
ROS as per HPI, 10 pt ROS otherwise negative

Past Medical History:
1) Type II DM: neuropathy, nephropathy
2) Atypical CP X 16 years: Evaluated in [**State 760**] in [**2136**] with
a stress test and cardiac catheterization, which the patient
reports were normal
3) Hypertension
4) Emphysema
5) s/p discectomy
6) s/p bunionectomy and hammer toe repair
7) s/p hysterectomy and removal of one ovary/fallopian tube
8) CKD (Cr. 2.9 in [**Month (only) 404**] per [**Hospital3 **] ED)
9) Myasthenia [**Last Name (un) **] - diagnosed 1 year ago, on pyridostigimine
- sees Neurologist Dr. [**Last Name (STitle) 37159**]
10) Diverticulosis

Social History:
Retired [**Location (un) 86**] Police Dept Detective.  Lives with husband and
two grandchildren.  Smokes 1 ppd x 50 years.  No etoh or
illicits.

Family History:
Mother's sisters with Myeloma and leukemia

Physical Exam:
admission exam
VS: 97.4  157/88  18  93P  98%4L NC -> 87% on RA
Appearance: drowsy but arousable, aaox3
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmd, neck supple, difficult to assess
JVD
Cv: +s1, s2  -m/r/g, 2+ peripheral edema, 1+ dp/pt bilaterally,
left UE AVF with palpable thrill
Pulm: diminished at bases, scattered wheeze
Abd: soft, obese, nt, nd, +bs
Msk: 5/5 strength throughout
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]
.
discharge exam
VS - 98.3 154/62 (145/66-196/97) 56 (56-72) 18 97% RA
GENERAL - African American female comfortable in NAD
LUNGS - decreased breath sounds at bases bilaterally.
Respirations unlabored, no accessory muscle use
HEART - RRR, nl S1-S2, 2/6 systolic murmur
ABDOMEN - NABS, soft. NT/ND. abdominal hernia noted. no rebound
or guarding
EXTREMITIES - WWP, 1+ pitting edema bilaterally, 2+ DP pulses
SKIN - no rashes or lesions; right chest with tunneled line in
place -no surrounding erythma
NEURO - awake and interactive, A&Ox3.

Pertinent Results:
admission labs:
[**2161-12-22**] 10:29PM   LACTATE-0.7
[**2161-12-22**] 10:20PM   GLUCOSE-168* UREA N-48* CREAT-5.6* SODIUM-145
POTASSIUM-3.8 CHLORIDE-117* TOTAL CO2-14* ANION GAP-18
[**2161-12-22**] 10:20PM   estGFR-Using this
[**2161-12-22**] 10:20PM   cTropnT-0.18*
[**2161-12-22**] 10:20PM   proBNP-GREATER TH
[**2161-12-22**] 10:20PM   WBC-4.7 RBC-2.65*# HGB-7.1*# HCT-24.4*#
MCV-92 MCH-26.9* MCHC-29.2* RDW-17.4*
[**2161-12-22**] 10:20PM   NEUTS-75.3* LYMPHS-16.2* MONOS-5.0 EOS-3.0
BASOS-0.4
[**2161-12-22**] 10:20PM   PLT COUNT-355
[**2161-12-22**] 10:20PM   PT-11.8 PTT-28.1 INR(PT)-1.1
.
discharge labs:
[**2161-12-30**] 08:20AM BLOOD WBC-5.0 RBC-3.10* Hgb-8.6* Hct-27.9*
MCV-90 MCH-27.8 MCHC-30.8* RDW-17.0* Plt Ct-322
[**2161-12-30**] 08:20AM BLOOD Glucose-109* UreaN-18 Creat-3.5* Na-140
K-3.2* Cl-104 HCO3-29 AnGap-10
[**2161-12-30**] 08:20AM BLOOD Calcium-7.7* Phos-3.1 Mg-1.8
.
micro:
blood cultures x 2 - no growth
Cdif - negative
.
[**2161-12-22**] EKG: NSR 81, TWI V4-V6, i, ii - unchanged from prior ecg
.
[**2161-12-22**] pa/lat cxr:
Increased cardiomegaly with mild engorgement of pulmonary
vessels
and basilar atelectasis and trace pleural effusion. Findings may
represent
early failure.

TTE (Complete) Done [**2161-12-23**] at 4:18:14 PM      FINAL
The left atrium is mildly dilated. The estimated right atrial
pressure is 5-10 mmHg. There is moderate symmetric left
ventricular hypertrophy. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is mildly dilated with
mild global free wall hypokinesis. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. The
mitral valve appears structurally normal with trivial mitral
regurgitation. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is a trivial/physiologic pericardial effusion.
IMPRESSION: Trivial pericardial effusion. Moderate symmetric
left ventricular hypertrophy with preserved regional and global
systolic function. Mild right ventricular dilatation and global
hypokinesis. Large pleural effusion.
Compared with the prior study dated [**2161-4-22**] (images reviewed),
pulmonary pressures are higher. Right ventricular systolic
dysfunction is new. A large pleural effusion is now noted.
.
CXR [**12-25**]
Severe cardiomegaly is stable. Worsening left lower lobe
consolidation is
worrisome for progression of pneumonia. Left mid lung plate-like
atelectasis
is unchanged. There is no pneumothorax. If any, there is a small
left
pleural effusion. There is no evidence of pulmonary edema.
.
IR procedure [**12-28**]
IMPRESSION: Successful conversion of temporary to tunneled
hemodialysis
catheter through the right internal jugular vein approach. The
tip is located
in the right atrium and the catheter is ready for use.


Brief Hospital Course:
72 yo F with CKD stage 5 peri-RRT, COPD, DM II with
complications and hypertension who was admitted with
hypertensive emergency, volume overload, hypoxemia, demand
ischemia and worsening uremia.
.
# demand ischemia/NSTEMI: Patient intially presented with
hypertensive urgency and was found to have an elevated troponin
with flat MB likely elevated in the setting of CKD and possible
demand ischemia. However despite improvement of blood pressures,
she subsequently experienced chest pain that was not responsive
to antacids but improved with nitroglycerin. Patient found to
have elevated troponin and CK-MB without ECG changes. Given
concern for ACS, she was evaluated by cardiology and it was felt
that elevated biomarkers were most likely [**12-17**] to poor BP control
and volume overload. Patient was treated for 48 hours with a
heparin gtt. Troponins continue to be elevated but CKMB
downtrended and patient remained chest pain free. She was
medically managed with ASA, statin, bblocker, imdur and improved
blood pressure control. She was discharged with plans to
establish care with a cardiologist.
.
# CKD stage V: Patient presented with symptoms of volume
overload and lethargy likely [**12-17**] to worsening renal function.
Patient had L. fistula placed but not yet mature. Renal team was
consulted in the ICU and agreed dialysis likely necessary, but
did not see urgent need for dialysis as medication
non-compliance large component to volume overload, pleural
effusions, and hypertensive urgency.  However, patient continued
to be somnolent and the decision was made to place a tunneled
line and start dialysis. Patient underwent 3 sessions of
dialysis and somnolence and volume status improved. She was
continued on bumex 2 mg daily given that she still makes some
urine. She was also continued on calcium carbonate, sevelemer
and nephrocaps. She was set up at an outpatient dialysis center
and has plans for MWF dialysis.
.
#Hypertensive emergency: Patient has history of medication
noncompliance prior to presentation. Patient presented with with
+troponin and pulmonary edema, bp 200/106 upon arrival to [**Hospital1 **] with likely flash pulmonary edema that responded to
lasix/nitro/labetalol; all in the setting of near-end stage
renal disease and dietary indiscretions. Antihypertensive
regimen was adjusted and volume was removed during dialysis.
Blood pressures improved to the 140s-160s. At time of discharge
her antihypertensive regimen included labetalol 600 mg TID,
amlodipin 10 mg daily, lisinopril 2.5 mg daily, Imdur 60 mg
daily.
.
# toxic metabolic encephalopathy [**12-17**] uremia - Patient was noted
to be very lethargic and somnolent on presentation. She was
initially transferred from [**Hospital3 4107**] and admitted to the
hospitalist service. However, given increasing somnolence she
was transferred to the [**Hospital Unit Name 153**]. Myasthenia [**Last Name (un) 2902**] crisis was
considered, and patient was evaluated by neurology. Neurology
felt that myasthenia crisis was unlikely the cause of her
symptoms. ABG did not show evidence of hypercarbia. She was then
transferred to the medicine service. She underwent 3 sessions of
dialysis and mental status improved making uremia most likely
cause of somnolence. Undiagnosed OSA may also be contributing to
daytime lethargy, and patient was noted to have witnessed
hypoxia overnight. Patient was discharged with plans to continue
dialysis and to undergo an outpatient sleep study evaluation.
.
#Hypoxemia: When patient was transferred from [**Hospital1 **] to [**Hospital1 18**],
there was initial concern that patient was having a COPD
exacerbation. In the ED, she was treated with steroids and
antibiotics. However this was discontinued when patient reached
the floor. While in the ICU, patient briefly was on 3-4L oxygen
due to pulmonary edema/ volume overload/ pleural effusions.
There was low suspicion for COPD exacerbation as patient not
bronchospastic on exam. During ICU stay, patient was weaned onto
room air.  She was given bumex, up to 4mg during the course of
the day to increase urine producrtion with little effect.
Patient eventually underwent dialysis and some volume was
removed on session 2 and 3. Patient continued to remain stable
on room air through the remainder of her admission.
.
# diarrhea - chronic x1 year. Unclear etiology. Diarrhea
unlikely infectious given duration of symptoms, and absence of
leukocytosis and fevers. Cdif negative. Patient was treated with
immodium prn with symptomatic relief.
.
# myasthenia [**Last Name (un) 2902**]  - continued pyridostigmine
.
# Diabetes  - continued lantus at reduced dose due to renal
function and insulin sliding scale.
.
# anemia - likely [**12-17**] to worsening renal function and missed
aranesp dose. There may also be component that is dilutional [**12-17**]
to volume overload. Guiac negative in the ED. Pt now s/p 1 unit
pRBC in [**Hospital Unit Name 153**]. HCT continued to remain stable through duration of
hospital course.
.
# COPD  - contined albuterol and ipratropium nebs
.
# depression - venlafaxine was held given renal function
.
# HLD  - continue simvastatin, but had to reduce dose with the
addition of amlodipine.
.
# GERD  - continued PPI
.
transitional issues:
- no labs pending at time of discharge
- patient will need outpatient sleep study evaluation
- patient will need further outpatient workup of chronic
diarrhea
- patient's dose of simvastatin was reduced given the addition
of amlodipine. Lipids should be followed and an alternative
statin should be considered.
- patient's venlafaxine was discontinued given renal function.
This should be addressed at follow up
- patient was full code on this admission
- HCP: [**Name (NI) **] [**Name (NI) 37160**] (husband) [**Telephone/Fax (1) 37161**]


Medications on Admission:
Meds per OMR - patient does not recall her medications
albuterol prn
bumetanide 2mg qam, 1mg qpm
calcitriol 0.25mcg qMWF
Aranesp
Diltiazem 360mg daily
Folic acid 1mg daily
Hydralazine 50mg [**Hospital1 **]
Lantus 14 units qam
Isosorbide mononitrate 120mg daily
Labetalol 400mg [**Hospital1 **]
Reglan 10mg q8h prn
Modafinil 200mg [**Hospital1 **]
Oxybutynin 5mg daily
Protonix 40mg daily
Pyridostigmine 30mg [**Hospital1 **]
Renvela 800mg TID
Simvastatin 40mg daily
Terazosin 10mg daily
Venlafaxine 37.5mg [**Hospital1 **]
ASA 325mg daily


Discharge Medications:
1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. pyridostigmine bromide 60 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
5. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
7. modafinil 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
9. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
11. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest
discomfort: take 1st tablet at onset of chest pain. If pain
persists longer than 5 minutes take a 2nd pill. If pain persists
longer than 10 minute take a 3rd pill and call 911.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
15. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
16. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*30 Capsule(s)* Refills:*0*
18. labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
Disp:*270 Tablet(s)* Refills:*2*
19. amlodipine 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
20. bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
21. insulin glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous once a day for 1 months.
Disp:*QS units* Refills:*2*
22. insulin aspart 100 unit/mL Solution Sig: as directed units
Subcutaneous four times a day: please take as directed by
sliding scale before meals and before bed.
23. wheel chair
standard wheelchair for community distances


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
Stage V chronic kidney disease, diastolic heart failure


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Ms. [**Known lastname 37160**],

It was a pleasure caring for you while you were admitted to
[**Hospital1 18**]. You were admitted because you were lethargic, short of
breath and had lower extremity swelling. You also had very high
blood pressures. You were evaluated by the kidney doctors and
eventually it was decided that you would benefit from starting
dialysis. You tolerated three dialysis sessions well during your
hospitalization. Your blood pressure medications were altered
and your blood pressures improved prior to discharge.
.
During your hospitalization, you experienced some chest pain and
your heart enzymes were elevated in your blood concerning for
heart damage. You were evaluated by the cardiologists and it was
determined that you would benefit from medical management rather
than intervention at this time. You were scheduled to establish
care with a cardiologist after discharge for regular follow up.
.
You were noted to be very tired during the day. It is important
that you schedule a sleep study to investigate if you have a
oondition called sleep apnea that may be causing you to feel
this way.
.
The following changes have been made to your medication regimen
Please START taking
- lisinopril 2.5 mg daily
- amlodipine 10 mg at bed time
.
Please STOP taking
- clonidine
- terazosin
- metoclopramide
- oxybutynin
- diltiazem
- venlafaxine
.
Please CHANGE
- simvastatin to 20 mg daily
- labetalol to 600 mg three times daily
- bumex to 2 mg daily
- imdur to 60 mg daily
- lantus to 6 units in the morning

Followup Instructions:
Location: [**Last Name (un) **] [**Hospital1 **] KIDNEY CENTER
Address: [**Hospital 37162**] MEDICAL OFFICE BLD M107, [**Location (un) **],
[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 26526**]
**YOUR DIALYSIS SCHEDULE IS MONDAY,WEDNESDAY, FRIDAY AT
11:30AM**

Specialty: PULMONARY AND CRITICAL CARE & SLEEP MEDICINE
Location: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Hospital **] MEDICAL CENTER
Address: [**Location (un) **] [**Location (un) **], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 612**]
**Please contact the Pulmonary Department to schedule a sleep
study within 1 week of your discharge from the hospital.**

Name: BROWN,[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 37163**]: INTERNAL MEDICINE
Address: [**Street Address(2) 4472**] [**Apartment Address(1) 37164**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 37165**]
Appointment: TUESDAY [**1-5**] AT 1:45PM

Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2162-1-12**] at 2:30 PM
With: [**Name6 (MD) 11170**] [**Last Name (NamePattern4) 11171**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage

Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: CARDIOLOGY
Address: [**Doctor Last Name 37166**], [**Location (un) **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 5315**]
Appointment: TUESDAY [**2-2**] AT 11:20AM



Completed by:[**2162-1-3**]
{'Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Subendocardial infarction, initial episode of care,Toxic encephalopathy,Acute on chronic diastolic heart failure,Pulmonary congestion and hypostasis,Unspecified pleural effusion,Mixed acid-base balance disorder,Other alteration of consciousness,Chronic airway obstruction, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Polyneuropathy in diabetes,Myasthenia gravis without (acute) exacerbation,Diarrhea,Hypocalcemia,Anemia in chronic kidney disease,Other and unspecified hyperlipidemia,Esophageal reflux,Diverticulosis of colon (without mention of hemorrhage),Depressive disorder, not elsewhere classified,Long-term (current) use of insulin,Personal history of noncompliance with medical treatment, presenting hazards to health'}


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: leg swelling, sob

PRESENT ILLNESS: HMED ATTENDING ADMISSION NOTE
.
ADMIT DATE: [**2161-12-23**]
ADMIT TIME: 0200
.
PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 16518**] [**Last Name (NamePattern1) 174**]
.
72 yo F with CKD stage 5 peri-RRT, COPD, DM II with
complications and hypertension who presents to the ED
complaining of lower extremity edema nad shortness of breath.
.
Patient is a poor historian.  Reports increased fatigue and
lethargy x several days.  Also with new dyspnea on exertion,
lower extremity edema and orthopnea. Mild dry cough.  No chest
pain or fevers.  Reports increased salt intake.
.
Patient was initially seen at [**Hospital3 **], bp was 206/102 -
given 1 inch of ntp, 20 iv labetalol and 40 lasix with
improvement in symptoms.  Bilateral LENI's were negative.
Patient transferred to [**Hospital1 18**] for further evaluation.
.
ED: 97.0  76P  197/106  20  98%4LNC; wheeze on exam thought to
be consistent with copd exacerbation - given albuterol neb,
ipratropium neb, methylprednisolone 125 iv and azithromycin
500mg.
.
ROS as per HPI, 10 pt ROS otherwise negative

MEDICAL HISTORY: 1) Type II DM: neuropathy, nephropathy
2) Atypical CP X 16 years: Evaluated in [**State 760**] in [**2136**] with
a stress test and cardiac catheterization, which the patient
reports were normal
3) Hypertension
4) Emphysema
5) s/p discectomy
6) s/p bunionectomy and hammer toe repair
7) s/p hysterectomy and removal of one ovary/fallopian tube
8) CKD (Cr. 2.9 in [**Month (only) 404**] per [**Hospital3 **] ED)
9) Myasthenia [**Last Name (un) **] - diagnosed 1 year ago, on pyridostigimine
- sees Neurologist Dr. [**Last Name (STitle) 37159**]
10) Diverticulosis

MEDICATION ON ADMISSION: Meds per OMR - patient does not recall her medications
albuterol prn
bumetanide 2mg qam, 1mg qpm
calcitriol 0.25mcg qMWF
Aranesp
Diltiazem 360mg daily
Folic acid 1mg daily
Hydralazine 50mg [**Hospital1 **]
Lantus 14 units qam
Isosorbide mononitrate 120mg daily
Labetalol 400mg [**Hospital1 **]
Reglan 10mg q8h prn
Modafinil 200mg [**Hospital1 **]
Oxybutynin 5mg daily
Protonix 40mg daily
Pyridostigmine 30mg [**Hospital1 **]
Renvela 800mg TID
Simvastatin 40mg daily
Terazosin 10mg daily
Venlafaxine 37.5mg [**Hospital1 **]
ASA 325mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: admission exam
VS: 97.4  157/88  18  93P  98%4L NC -> 87% on RA
Appearance: drowsy but arousable, aaox3
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmd, neck supple, difficult to assess
JVD
Cv: +s1, s2  -m/r/g, 2+ peripheral edema, 1+ dp/pt bilaterally,
left UE AVF with palpable thrill
Pulm: diminished at bases, scattered wheeze
Abd: soft, obese, nt, nd, +bs
Msk: 5/5 strength throughout
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]
.
discharge exam
VS - 98.3 154/62 (145/66-196/97) 56 (56-72) 18 97% RA
GENERAL - African American female comfortable in NAD
LUNGS - decreased breath sounds at bases bilaterally.
Respirations unlabored, no accessory muscle use
HEART - RRR, nl S1-S2, 2/6 systolic murmur
ABDOMEN - NABS, soft. NT/ND. abdominal hernia noted. no rebound
or guarding
EXTREMITIES - WWP, 1+ pitting edema bilaterally, 2+ DP pulses
SKIN - no rashes or lesions; right chest with tunneled line in
place -no surrounding erythma
NEURO - awake and interactive, A&Ox3.

FAMILY HISTORY: Mother's sisters with Myeloma and leukemia

SOCIAL HISTORY: Retired [**Location (un) 86**] Police Dept Detective.  Lives with husband and
two grandchildren.  Smokes 1 ppd x 50 years.  No etoh or
illicits. 

### Response:
{'Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Subendocardial infarction, initial episode of care,Toxic encephalopathy,Acute on chronic diastolic heart failure,Pulmonary congestion and hypostasis,Unspecified pleural effusion,Mixed acid-base balance disorder,Other alteration of consciousness,Chronic airway obstruction, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Polyneuropathy in diabetes,Myasthenia gravis without (acute) exacerbation,Diarrhea,Hypocalcemia,Anemia in chronic kidney disease,Other and unspecified hyperlipidemia,Esophageal reflux,Diverticulosis of colon (without mention of hemorrhage),Depressive disorder, not elsewhere classified,Long-term (current) use of insulin,Personal history of noncompliance with medical treatment, presenting hazards to health'}
