CHIEF COMPLAINT: weakness and upper back pain

PRESENT ILLNESS: 55 YO F w IDDM1 s/p renal transplant with recurrent ESRD,
non-ischemic cardiomyopathy with EF 30% s/p [**Hospital1 **]-v ICD placement,
chronic Hepatitis C, OSA with recent admission for
unresponsiveness [**2-8**] hypoglycemia who presents now with
weakness.

MEDICAL HISTORY: - s/p placement of right upper extremity arteriovenous graft
[**2162-10-19**] with recent revision 11/[**2163**]. L fistula did not mature.

MEDICATION ON ADMISSION: - digoxin 125 mcg Tablet Sig: One (1) Tablet PO QTUESDAY
- prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
- hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H
- insulin glargine 100 unit/mL (3 mL) Insulin Pen 6u qam, 3u
qpm.
- insulin lispro 100 unit/mL Insulin Pen Subcutaneous four times
a day: Please resume insulin sliding scale.
- isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr PO
DAILY
- metoprolol succinate 100 mg Tablet Sustained Release 24 hr
daily
- pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
- ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY
- B complex-vitamin C-folic acid 1 mg Capsule PO DAILY
- nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
- sevelamer carbonate 800 mg Two (2) Tablet PO TID W/ MEALS
- torsemide 100 mg Tablet Sig: One (1) Tablet PO once a day.

ALLERGIES: Percocet

PHYSICAL EXAM: Vitals: 97.8 144/67 60 18 96%2L FS 361
General: Alert, oriented, no acute distress.
HEENT: Sclera anicteric, [**Name (NI) 5674**]
Neck: supple, JVP to mandible at 45 degrees
CV: RRR, systolic murmur loudest at LUSB.
Lungs: CTAB with decreased BS at right lung base to mid lung
field and bronchial breath sounds at RML and RLL.
Abdomen: soft, non-tender, non-distended.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+
pitting edema b/l

FAMILY HISTORY: Sister died of [**Name (NI) 11398**]. Many other family members on maternal side
with diabetes, including grandmother and aunt. [**Name (NI) **] with
breast cancer.

SOCIAL HISTORY: No tobacco, quit 14 years ago after having previously smoked
1ppd x27 years. Occasional alcohol and no drug use.  Lives with
a son and daughter-in-law. She is divorced, has 2 children and 9
grandchildren.
Unspecified septicemia,Septic shock,Acute on chronic systolic heart failure,End stage renal disease,Unspecified pleural effusion,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other primary cardiomyopathies,Iatrogenic pneumothorax,Acquired coagulation factor deficiency,Cholecystitis, unspecified,Severe sepsis,Hypothermia not associated with low environmental temperature,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Renal dialysis status,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Long-term (current) use of insulin,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Automatic implantable cardiac defibrillator in situ,Obstructive sleep apnea (adult)(pediatric),Chronic passive congestion of liver,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol,Arthrodesis status,Anemia in chronic kidney disease,Esophageal reflux,Personal history of tobacco use
Septicemia NOS,Septic shock,Ac on chr syst hrt fail,End stage renal disease,Pleural effusion NOS,Compl kidney transplant,Hyp kid NOS w cr kid V,Prim cardiomyopathy NEC,Iatrogenic pneumothorax,Acq coagul factor defic,Cholecystitis NOS,Severe sepsis,Hypothrm-wo low env tmp,Abn react-org transplant,Renal dialysis status,DMI wo cmp nt st uncntrl,Long-term use of insulin,Abn react-procedure NEC,Status autm crd dfbrltr,Obstructive sleep apnea,Chr passiv congest liver,Chrnc hpt C wo hpat coma,Cirrhosis of liver NOS,Arthrodesis status,Anemia in chr kidney dis,Esophageal reflux,History of tobacco use
Admission Date:  [**2164-4-12**]              Discharge Date:   [**2164-4-17**]

Date of Birth:  [**2108-12-6**]             Sex:   F

Service: MEDICINE

Allergies:
Percocet

Attending:[**First Name3 (LF) 896**]
Chief Complaint:
weakness and upper back pain


Major Surgical or Invasive Procedure:
None


History of Present Illness:
55 YO F w IDDM1 s/p renal transplant with recurrent ESRD,
non-ischemic cardiomyopathy with EF 30% s/p [**Hospital1 **]-v ICD placement,
chronic Hepatitis C, OSA with recent admission for
unresponsiveness [**2-8**] hypoglycemia who presents now with
weakness.

The patient reports feeling generalized weakness for the past
week and has not been performing her ADLs as usual. She reports
poor appetite and nausea, but has been having normal bowel
movements and denies abdominal pain. The night prior to
presentation, the patient vomited non-bloody bilious emesis x2.
Although she continued to have nausea earlier this morning, she
was able to hold down soup and a [**Location (un) 6002**] today. She denies
fevers/chills, weight loss, myalgias or arthralgias, chest pain,
or changes in her stable dyspnea with walking up 5 stairs.
Denies sick contacts. She reports having prior similar symptoms
during her prior episodes of pneumonia. Patient went to dialysis
today and came to ED after undergoing a full dialysis session.

Of note, the patient reports episodes of intermittent nausea and
dry heaves for the past several weeks, and has notified her
medical providers of this, who attributed her symptoms to her
labile [**Location (un) **] pressures and dialysis sessions. She reports
decreased activity and energy since re-starting hemodialysis
[**10/2162**], but reports the past week has been an acute worsening.


Upon arrival to the ED, 98.9 65 183/78 18 95% ra. Exam notable
for pain across top of back with tense muscles. No cough. Labs
notable for creatinine of 3.8 and troponin of 0.14, INR of 1.8
and anion gap of 16. Lactate was 2.8EKG reportedly at rate of
68, Vpaced, with unchanged morphology. CXR showed increase in
size of her chronic right sided effusion and so she was given
ceftriaxone and azithromycin. VS on transfer: 96.5 64 151/84 18
95% on 2L.

Upon arrival to the floor, the patient reports improvement of
her nausea and reports feeling better after receiving
antibiotics in the ED.

Past Medical History:
- s/p placement of right upper extremity arteriovenous graft
[**2162-10-19**] with recent revision 11/[**2163**]. L fistula did not mature.

-Type 1 DM, since age 20
-Dilated non-ischemic cardiomyopathy, EF 30% by echo [**11/2163**]
-Biventricular ICD placement, [**7-/2162**]
-Hypertension
-ESRD s/p transplant in [**2152**], undergoing evaluation for possible
second transplant; currently on HD
-Hepatic fibrosis, of unknown cause - worked up at [**Hospital1 3278**]
-Intracranial right ICA aneurysm, s/p clipping [**2159-5-16**]
-s/p C4-5 and C5-6 anterior decompression and fusion after MVA
[**2157**]
-s/p discectomy at C6-C7 and fusion in [**2157**], with
instrumentation removal and reinsertion on [**2159-9-28**]
-Ulnar nerve impingement bilaterally
-GERD
-Asthma as a child
-Sleep apnea, unable to tolerate CPAP
-s/p right carpal tunnel release
-s/p rotator cuff repair
-Resting tremor
-h/o CMV in [**2155**]

Social History:
No tobacco, quit 14 years ago after having previously smoked
1ppd x27 years. Occasional alcohol and no drug use.  Lives with
a son and daughter-in-law. She is divorced, has 2 children and 9
grandchildren.


Family History:
Sister died of [**Name (NI) 11398**]. Many other family members on maternal side
with diabetes, including grandmother and aunt. [**Name (NI) **] with
breast cancer.

Physical Exam:
Vitals: 97.8 144/67 60 18 96%2L FS 361
General: Alert, oriented, no acute distress.
HEENT: Sclera anicteric, [**Name (NI) 5674**]
Neck: supple, JVP to mandible at 45 degrees
CV: RRR, systolic murmur loudest at LUSB.
Lungs: CTAB with decreased BS at right lung base to mid lung
field and bronchial breath sounds at RML and RLL.
Abdomen: soft, non-tender, non-distended.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+
pitting edema b/l

Pertinent Results:
Admission labs:

[**2164-4-12**] 05:30PM   GLUCOSE-181* UREA N-26* CREAT-3.8*#
SODIUM-136 POTASSIUM-4.1 CHLORIDE-94* TOTAL CO2-25 ANION GAP-21*
[**2164-4-12**] 05:38PM   LACTATE-2.8*
[**2164-4-12**] 05:30PM   ALT(SGPT)-121* AST(SGOT)-162* LD(LDH)-408*
ALK PHOS-228* TOT BILI-2.0* DIR BILI-0.9* INDIR BIL-1.1
[**2164-4-12**] 05:30PM   LIPASE-15
[**2164-4-12**] 05:30PM   cTropnT-0.13*
[**2164-4-12**] 05:30PM   ALBUMIN-4.0 CALCIUM-9.7 PHOSPHATE-4.6*
MAGNESIUM-1.9
[**2164-4-12**] 05:30PM   WBC-4.7 RBC-4.27 HGB-13.8 HCT-42.5 MCV-100*
MCH-32.4* MCHC-32.5 RDW-18.4*
[**2164-4-12**] 05:30PM   NEUTS-82.8* LYMPHS-12.4* MONOS-3.8 EOS-0.4
BASOS-0.5
[**2164-4-12**] 05:30PM   PLT COUNT-206
[**2164-4-12**] 05:30PM   PT-19.5* PTT-29.9 INR(PT)-1.8*
[**2164-4-12**] 05:15PM   WBC-5.3 RBC-4.42# HGB-14.3 HCT-45.3# MCV-103*
MCH-32.4* MCHC-31.6 RDW-18.0*
[**2164-4-12**] 05:15PM   NEUTS-79.2* LYMPHS-14.2* MONOS-5.5 EOS-0.3
BASOS-0.7
[**2164-4-12**] 05:15PM   PLT COUNT-195

Hep C VL - not detected

Micro:
All BCx - no growth or NGTD
ascitic fluid cx - no growth

Imaging:
CXR [**4-12**]:
IMPRESSION:
Unchanged moderate right pleural effusion.

Abdominal US with dopplers [**4-13**]:
IMPRESSION:
1) Findings again suggestive of congestive hepatopathy (nutmeg
liver) with
cardiomegaly and marked dilatation of the IVC and hepatic veins
as well as
probable third spacing within the gallbladder wall. No vascular
thrombosis is present.
2) Unchanged cholelithiasis and probable cholesterol polyps
within the
gallbladder. Interval increase in the degree of biliary sludge
within the
gallbladder lumen.
3) Echogenic atrophic kidneys consistent with known underlying
renal disease.  Moderate to large right pleural effusion.

TTE [**4-16**]:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
Based on [**2160**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

Brief Hospital Course:
55 year-old female with history of Type I DM, sCHF (EF 30%) s/p
ICD, ESRD s/p failed transplant and OSA who presented with a
couple of weeks of worsening fatigue and nausea and
transaminitis on labs s/p episode of hypotension/hypothermia
without identified cause whose symptoms resolved.

Active issues:
#  Episode of hypotension and hypothermia: The morning after
admission, the patient developed an episode of hypotension with
SBPs in the 60's and hypothermia with a temperature of 91.  She
was given IVF, started on vanc and cefepime, and transferred to
the MICU.  EKG showed only slight T wave changes and cardiac
enzymes were negative.  BP normalized by time of transfer and no
further IVF given. Bear hugger was applied and her temperature
normalized. U/S of graft site showed no fluid collection.
Diagnostic and therapeutic thoracentesis performed with IP team
with 1200mL serosanguinous drainage. CXR after [**Female First Name (un) 576**] showed
small R apical PTX. Catheter left in place overnight for
continued drainage and pulled in AM. Patient otherwise stable
and transferred back to medical floor.   Her antibiotics were
slowly stopped without change in her clinical status.  Cultures
have been negative.  Abd US did show chronic gallbladder wall
thickening and cholelithiasis, however no dilatation of her
common bile duct.  Surgery was consulted due to concern that her
decompensation could have been from a biliary source, but the
surgery team did not feel a cholecystecomty was indicated as
there was no evidence of inflammation of the gallbladder on the
abdominal US.  Cultures were still pending at time of discharge.

#  Weakness/nausea/transaminitis:  Her initial symptoms were
nonspecific.  A biliary source was worked up as above.  Symptoms
improved over her hospital course and her transaminitis trended
downward.  Hep C VL was negative.

# Hypertension: In the setting of hypotension her
antihypertensive medications were all held.  As she improved,
her [**Female First Name (un) **] pressure mediations were slowly added back and she was
discharged on her home regimen of metoprolol, nifedipine,
isosorbide [**Name (NI) 101507**], and [**Name2 (NI) 101508**].

Inactive issues:
# ESRD: She was dialyzed per her home schedule (T/Th/Sat) and
continued on prednisone (for her failed transplant), sevelamer,
and nephrocaps.

# Non-ischemic Cardiomyopathy: She was continued on Digoxin and
Metoprolol per home regimen.

# DM: BS generally well controlled except for one elevated BS
last night.
- Continue SSI and Glargine per home regimen.

# Dyslipidemia: The patient was continued on pravastatin.

CODE: Full
Communication: Patient. Daughter [**Telephone/Fax (1) 101509**]. Son-in-law [**Name (NI) 101510**]
[**Telephone/Fax (1) 101511**].

Transitions of care:
- follow up pending [**Telephone/Fax (1) **] cultures

Medications on Admission:
- digoxin 125 mcg Tablet Sig: One (1) Tablet PO QTUESDAY
- prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
- hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H
- insulin glargine 100 unit/mL (3 mL) Insulin Pen 6u qam, 3u
qpm.
- insulin lispro 100 unit/mL Insulin Pen Subcutaneous four times
a day: Please resume insulin sliding scale.
- isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr PO
DAILY
- metoprolol succinate 100 mg Tablet Sustained Release 24 hr
daily
- pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
- ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY
- B complex-vitamin C-folic acid 1 mg Capsule PO DAILY
- nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
- sevelamer carbonate 800 mg Two (2) Tablet PO TID W/ MEALS
- torsemide 100 mg Tablet Sig: One (1) Tablet PO once a day.

Discharge Medications:
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO QTUES (every
Tuesday).
3. hydralazine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
4. insulin glargine 100 unit/mL Solution Sig: 6 units qam, 3
units qpm . Subcutaneous .
5. insulin lispro 100 unit/mL Solution Sig: sliding scale .
Subcutaneous four times a day.
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. ranitidine HCl 15 mg/mL Syrup Sig: Seventy Five (75) mg PO
DAILY (Daily).
10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
12. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Malaise
Hypotension and hypothermia of unknown cause

Secondary:
End-stage kidney disease on dialysis
Systolic heart failure
Type I Diabetes


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital due to fatigue and nausea.
The day after admission you had an episode where your [**Telephone/Fax (1) **]
pressure and temperature dropped.  You were given IV fluids,
antibiotics, and sent to the medical ICU for monitoring.  Your
[**Telephone/Fax (1) **] pressure and temperature improved and no infectious
sources of your episode were identified.  Your [**Telephone/Fax (1) **] pressure
medications were slowly added back and you were eventually taken
off the antibiotics.

Medication changes:
No changes were made to your medications.  Continue your
outpatient medications as prescribed.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2164-5-28**] at 2:30 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2164-4-19**]
{'Unspecified septicemia,Septic shock,Acute on chronic systolic heart failure,End stage renal disease,Unspecified pleural effusion,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other primary cardiomyopathies,Iatrogenic pneumothorax,Acquired coagulation factor deficiency,Cholecystitis, unspecified,Severe sepsis,Hypothermia not associated with low environmental temperature,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Renal dialysis status,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Long-term (current) use of insulin,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Automatic implantable cardiac defibrillator in situ,Obstructive sleep apnea (adult)(pediatric),Chronic passive congestion of liver,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol,Arthrodesis status,Anemia in chronic kidney disease,Esophageal reflux,Personal history of tobacco use'}


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: weakness and upper back pain

PRESENT ILLNESS: 55 YO F w IDDM1 s/p renal transplant with recurrent ESRD,
non-ischemic cardiomyopathy with EF 30% s/p [**Hospital1 **]-v ICD placement,
chronic Hepatitis C, OSA with recent admission for
unresponsiveness [**2-8**] hypoglycemia who presents now with
weakness.

MEDICAL HISTORY: - s/p placement of right upper extremity arteriovenous graft
[**2162-10-19**] with recent revision 11/[**2163**]. L fistula did not mature.

MEDICATION ON ADMISSION: - digoxin 125 mcg Tablet Sig: One (1) Tablet PO QTUESDAY
- prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
- hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H
- insulin glargine 100 unit/mL (3 mL) Insulin Pen 6u qam, 3u
qpm.
- insulin lispro 100 unit/mL Insulin Pen Subcutaneous four times
a day: Please resume insulin sliding scale.
- isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr PO
DAILY
- metoprolol succinate 100 mg Tablet Sustained Release 24 hr
daily
- pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
- ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY
- B complex-vitamin C-folic acid 1 mg Capsule PO DAILY
- nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
- sevelamer carbonate 800 mg Two (2) Tablet PO TID W/ MEALS
- torsemide 100 mg Tablet Sig: One (1) Tablet PO once a day.

ALLERGIES: Percocet

PHYSICAL EXAM: Vitals: 97.8 144/67 60 18 96%2L FS 361
General: Alert, oriented, no acute distress.
HEENT: Sclera anicteric, [**Name (NI) 5674**]
Neck: supple, JVP to mandible at 45 degrees
CV: RRR, systolic murmur loudest at LUSB.
Lungs: CTAB with decreased BS at right lung base to mid lung
field and bronchial breath sounds at RML and RLL.
Abdomen: soft, non-tender, non-distended.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+
pitting edema b/l

FAMILY HISTORY: Sister died of [**Name (NI) 11398**]. Many other family members on maternal side
with diabetes, including grandmother and aunt. [**Name (NI) **] with
breast cancer.

SOCIAL HISTORY: No tobacco, quit 14 years ago after having previously smoked
1ppd x27 years. Occasional alcohol and no drug use.  Lives with
a son and daughter-in-law. She is divorced, has 2 children and 9
grandchildren. 

### Response:
{'Unspecified septicemia,Septic shock,Acute on chronic systolic heart failure,End stage renal disease,Unspecified pleural effusion,Complications of transplanted kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other primary cardiomyopathies,Iatrogenic pneumothorax,Acquired coagulation factor deficiency,Cholecystitis, unspecified,Severe sepsis,Hypothermia not associated with low environmental temperature,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Renal dialysis status,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Long-term (current) use of insulin,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Automatic implantable cardiac defibrillator in situ,Obstructive sleep apnea (adult)(pediatric),Chronic passive congestion of liver,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol,Arthrodesis status,Anemia in chronic kidney disease,Esophageal reflux,Personal history of tobacco use'}
