CHIEF COMPLAINT: s/p fall

PRESENT ILLNESS: 46 yo M s/p renal transplant 17 yrs ago and ESRD on HD secondary
to focal glomerulosclerosis status post deceased donor kidney
transplantation on [**2163-5-13**] withgraft loss in [**2179-12-10**],
with multiple placements of HD catheters and recent
transposition of right upper arm arteriovenous fistula on
[**2180-11-8**]. He was found on the bathroom floor w/ blood on face
and in the mouth by family. Per EMS the patinet was
hypertensive, tachycardiac and intially unresponsive but MS
improved on way to [**Hospital3 3583**]. On arrival to OSH, his MS
declined and he had a witnessed seized. He was then intubated
with vecuronium and loaded with fosphenytoin at that time. BO
was recorded as high as 220/110. Electrolytes were WNL and TnI
was positive.
.
Per report, episdoe of arrythmnia (?afib) in field, terminated
w/ diltiazem. Rec'd dilantin. Head CT no bleed at OSH. Neck CT:
cervical fx, transferred to [**Hospital1 18**].
.
Of note urine tox was positive for cocaine and opiates.

MEDICAL HISTORY: -Cadaveric Renal Transplant 16 yrs ago on immunosuppressants
-HTN poorly controlled
-Anemia on Procrit
-Chronic Allograft Nephropathy baseline Cr 4.2 ([**2179-1-10**])
-Admitted last [**Month (only) 1096**] to MICU with acute on chronic renal
failure, coagulase negative staphylococcal bacteremia, community

MEDICATION ON ADMISSION: - metoprolol 50mg TID
- sulfamethoxazole TMP 1 tab MWF
- prednisone 10mg QOD
- lisinopril 20mg QD
- levothyroxine 75mcg QD
- diltiazem 90mg QID
- omeprazole 20mg [**Hospital1 **]
- mirtazapine 7.5mg QPM
- Renagel 800mg TID W/MEALS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals - T:97.9 BP:131/91 HR:99 RR:16
VENT SETTINGS: AC 600x14 80% PEEP5
GENERAL: intubated and sedated
SKIN: palpable thrill in RUE, warm and well perfused, no
excoriations or lesions, no rashes
HEENT: AT, dried blood in right nare, small contusion on L
maxilla, anicteric sclera, pink conjunctiva, no JVD
CARDIAC: RRR, blowing holosystolic 2/6 SEM @ apex, S1/S2, no mrg

FAMILY HISTORY: unknown

SOCIAL HISTORY: lives with 2 children and mother
Closed fracture of fourth cervical vertebra,End stage renal disease,Complications of transplanted kidney,Chronic glomerulonephritis with unspecified pathological lesion in kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Cocaine dependence, continuous,Encephalopathy, unspecified,Pneumonia due to escherichia coli [E. coli],Septicemia due to escherichia coli [E. coli],Sepsis,Intervertebral disc disorder with myelopathy, cervical region,Chronic osteomyelitis, other specified sites,Disruption of internal operation (surgical) wound,Pulmonary collapse,Blood in stool,Other convulsions,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in unspecified place,Unspecified fall,Atrial fibrillation,Other and unspecified complications of medical care, not elsewhere classified,Unspecified acquired hypothyroidism,Kyphosis (acquired) (postural),Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Personal history of noncompliance with medical treatment, presenting hazards to health
Fx c4 vertebra-closed,End stage renal disease,Compl kidney transplant,Chronic nephritis NOS,Hyp kid NOS w cr kid V,Cocaine depend-contin,Encephalopathy NOS,Pneumonia e coli,E coli septicemia,Sepsis,Cerv disc dis w myelopat,Chr osteomyelit NEC,Disrup internal op wound,Pulmonary collapse,Blood in stool,Convulsions NEC,Abn react-org transplant,Accident in place NOS,Fall NOS,Atrial fibrillation,Complic med care NEC/NOS,Hypothyroidism NOS,Kyphosis NOS,Gstr/ddnts NOS w/o hmrhg,Hx of past noncompliance
Admission Date:  [**2180-11-9**]              Discharge Date:   [**2180-12-5**]

Date of Birth:  [**2133-12-20**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
s/p fall

Major Surgical or Invasive Procedure:
C4-6 corpectomy
Washout of cervical spine surgical site


History of Present Illness:
46 yo M s/p renal transplant 17 yrs ago and ESRD on HD secondary
to focal glomerulosclerosis status post deceased donor kidney
transplantation on [**2163-5-13**] withgraft loss in [**2179-12-10**],
with multiple placements of HD catheters and recent
transposition of right upper arm arteriovenous fistula on
[**2180-11-8**]. He was found on the bathroom floor w/ blood on face
and in the mouth by family. Per EMS the patinet was
hypertensive, tachycardiac and intially unresponsive but MS
improved on way to [**Hospital3 3583**]. On arrival to OSH, his MS
declined and he had a witnessed seized. He was then intubated
with vecuronium and loaded with fosphenytoin at that time. BO
was recorded as high as 220/110. Electrolytes were WNL and TnI
was positive.
.
Per report, episdoe of arrythmnia (?afib) in field, terminated
w/ diltiazem. Rec'd dilantin. Head CT no bleed at OSH. Neck CT:
cervical fx, transferred to [**Hospital1 18**].
.
Of note urine tox was positive for cocaine and opiates.


Past Medical History:
-Cadaveric Renal Transplant 16 yrs ago on immunosuppressants
-HTN poorly controlled
-Anemia on Procrit
-Chronic Allograft Nephropathy baseline Cr 4.2 ([**2179-1-10**])
-Admitted last [**Month (only) 1096**] to MICU with acute on chronic renal
failure, coagulase negative staphylococcal bacteremia, community

acquired pneumonia, duodenal ulcers status post thermal
therapy/injection and pericardial effusion
No history of seizures.


Social History:
lives with 2 children and mother


Family History:
unknown

Physical Exam:
Vitals - T:97.9 BP:131/91 HR:99 RR:16
VENT SETTINGS: AC 600x14 80% PEEP5
GENERAL: intubated and sedated
SKIN: palpable thrill in RUE, warm and well perfused, no
excoriations or lesions, no rashes
HEENT: AT, dried blood in right nare, small contusion on L
maxilla, anicteric sclera, pink conjunctiva, no JVD
CARDIAC: RRR, blowing holosystolic 2/6 SEM @ apex, S1/S2, no mrg

LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact


Pertinent Results:
Admission Labs:
Ca: 7.0 Mg: 2.9 P: 9.9 D
LDH: 332
[**Doctor First Name **]: 84
Lip: 36
.
WBC 11.2
Hct: 40
Plt: 205
N:80.7 L:11.4 M:5.7 E:2.0 Bas:0.2
.
PT: 14.2  PTT: 28.6  INR: 1.3
ABG: 7.38/54/204/33 Lactate 1.2
.
U/A: opiates and cocaine positive initially.
.
136  91  47
--------------< 117
5.9  26  10.2
CRP: 48.3
ESR: 80
.
Trends:
Hct: 42 - 40 - 34 - 33 - 29 - 30 ([**11-21**])
CK: [**Telephone/Fax (1) 106885**] - 2960 - 2967 - 1717 - 5493 - 5378 - 1591
Trop: 0.15 - 0.18 - 0.16
.
Imaging:
[**11-9**] KUB: NG tube in the stomach. No metal is seen in the
abdomen and pelvis
.
[**11-9**] CT Head/Neck:
1. Compression fractures of C4 and C5 with fracture lines
extending through the right transverse foramen of C5. Vascular
injury cannot be excluded at this level.
2. Grade I retrolisthesis of C4 on C5 with likely ligamentous
disruption is identified.
3. Fracture of the posterior-superior facet of C6.
.
[**11-9**]: CT Head: No intracranial hemorrhage or edema. No fracture
.
[**11-10**]: MRI/MRA head/neck:
BRAIN:
IMPRESSION: No evidence of acute infarct. Small vessel disease
and chronic right-sided lacunar infarct. Soft tissue changes
right-sided maxillary, frontal, and ethmoid sinuses.
NECK
IMPRESSION: The right vertebral artery is small in size which
could be congenital variation as the vertebral artery is not
occluded or affected at the site of abnormality seen at C4-5
level. However, the MRA is limited by motion and for better
evaluation repeat MRA or CT angiography are recommended.
MRA OF THE HEAD:
IMPRESSION: Except for nonvisualization of distal right
vertebral artery, no other abnormalities are seen.
.
[**11-10**]: ECHO:
IMPRESSION: suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Dilated ascending aorta. No
structural cardiac cause of syncope identified.  Compared with
the prior study (images reviewed) of [**2179-12-23**], the seveirty
mitral regurgitation is reduced and a resting LVOT gradient is
no longer identified.
.
[**11-11**] MRI thoracic and lumbar spine:
FINDINGS: There is no evidence to support the presence of either
discitis or osteomyelitis within either the thoracic or lumbar
spine.
The visualized spinal cord, conus medullaris, and cauda equina
appear within normal limits. Within the limitations of coverage
of this study, there are no overt paraspinal abnormalities
discerned, either.
CONCLUSION: No evidence for discitis or osteomyelitis, or other
causes for spinal cord compression are seen.
.
[**11-11**]: EEG: This is an abnormal portable EEG due to bursts of
generalized mixed frequency slowing in the setting of a slow,
disorganized, poorly reactive background with the tracing also
notable
for triphasic waves. This constellation of findings is
consistent with
a moderate encephalopathy suggesting dysfunction of bilateral
subcortical or deep midline structures. Medications, metabolic
disturbance, infections, and anoxia are among the common causes
of
encephalopathy. There were no clearly focal or lateralized
features
although encephalopathic patterns can sometimes obscure focal
findings.
There were no clearly epileptiform features and no
electrographic
seizures were noted.
.
[**11-12**]: Prevertebral pathology:
A.  Prevertebral tissue:
Fibrovascular and adipose tissue with reactive vascular and
fibroblastic proliferation and mild chronic inflammation.
B.  C4 vertebral body:
1.  Fragments of reactive bone.
2.  Maturing trilineage hematopoiesis.
3.  No malignancy identified.
.
[**11-14**]: CT Sinus:
There is complete opacification of the right frontal sinus,
ethmoid air cells, and near complete opacification of the
sphenoid sinus and the right maxillary sinus. Moderate mucosal
thickening and retention cysts versus polyps of the left
maxillary sinus are seen. The OMUs are obstructed bilaterally.
High- density material is seen within the sphenoid sinus, which
may represent inspissated secretions versus fungal colonization
and less likely hemorrhage.
.
[**11-14**] CT Chest w contrast:
1. No central or segmental pulmonary emboli, however,
subsegmental emboli in the lower lobes cannot be excluded due to
atelectasis in the lower lobes.
2. Atelectasis and consolidation at the lung bases as described
above. Subcentimeter ground-glass opacity in the right middle
lobe is likely infectious or inflammatory.
3. Extensive atherosclerosis is present in the coronary arteries
4. Findings concerning for pulmonary artery hypertension.
.
[**11-14**] ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). There
is a mild resting left ventricular outflow tract obstruction
(measurement of gradient was technically suboptimal; ?peak of 11
mmHg). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened.
There is a no significant aortic stenosis (slightly increased
velocities due to left ventricular outflow gradient). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is mild functional mitral stenosis (mean
gradient 4 mmHg) due to mitral annular calcification. Trivial
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
[**11-19**]: LENI: no DVT
.
MR CERVICAL SPINE W/O CONTRAST  [**2180-11-29**]
IMPRESSION:

Anterior and posterior cervical fusion as described above. There
is fluid within the bone graft and surrounding the bone graft in
the corpectomy defect extending from C3 to C5 without adjacent
bone marrow edema which likely represents postoperative change.

There is a large superficial fluid collection dorsal to the
cervical spine which likely represents a postoperative seroma,
although an infected fluid collection cannot be excluded.


Brief Hospital Course:
Mr. [**Known lastname 1445**] is a 46 y.o. M s/p fall with resultant C4-6
nonsurgical fracture s/p corpectomy now being treated for
cervical osteomyelitis and pneumonia, s/p recent fever and
leukocytosis with fluid collection around cervical surgical site
that had 2+ PML, s/p [**Known lastname **] spine washout of cervical lesion.
.
#S/P fall: Unclear etiology but felt that it may be that the
patient had a seizure vs. syncope in the setting of arrythmia.
Patient was also noticed to have high BPs and suggests
hypertensive encephalopathy, which could be related to cocaine
use (pt  had one positive tox screen).   A definitive cause was
not determined; however these were all treated as below.
.
#Seizure: On arrival to OSH, the patients mental status declined
and he had a witnessed seizure.  He was initially loaded with
Dilantin.  The possible precipitants included cocaine use and/or
hypertension. Head imaging was negative. An LP did not show
evidence of infection. Neurology followed for the seizure and
dilantin levels and the dilantin was adjusted to goal level of
[**10-28**].  The patient was continued on maintenance doses of
dilantin throughout his hospital stay.  No further seizures
occured.  He was discharged with dilantin for an additional 4
weeks and instructions to follow up with neurology as an
outpatient.
.
#Osteomyelitis and C4-6 Fracture: Patient sustained C4-6 acute
fracture, although CT scan suggested ? infection vs fluid
collection. [**Month/Year (2) 1957**] was consulted who recommended MRI head/neck
which showed chronic-appearing endplate changes at C4-5 level
which could be trauma related vs ligament injury vs chronic
disckitis or spondylarthritis without spinal cord compression.
MR T/L/S was also performed which showed no evidence for
discitis or osteomyelitis, or other causes for spinal cord
compression are seen. [**Month/Year (2) 1957**] spine was following, and on [**2180-11-12**],
pt underwent C4-C5 corpectomy and reconstruction. In the OR,
C4-C6 appearance was suspicious for infection/osteomyelitis, and
prevertebral tissue biopsy, bone biopsy, prevertebral fluid
culture were obtained.  THe patient was intially started on
Ceftriaxone and vancomuycin started on the night of [**11-12**]. As
there was a concern for ?TB per surgery, so consulted ID for abx
and planted ppd on [**11-13**] which was negative. Pt remained in
collar and continued prednisone for cervical swelling.  On [**11-13**],
pt had a temp to 102 and later on [**11-14**] became hypotensive
requiring a pressor. ABX was broadened to Zosyn and vanc, and
also stress dose steroid was started given his chronic steroid
use for renal transplant. Later on [**11-14**], tissue culture grew GP
bacteria. On [**11-16**] patient went back to OR for posterior fusion.
Patient was followed by ID and [**Month/Day (4) 1957**] thorughout his stay.  ID
felt the patient needed 8-12 weeks of Vancomycin to cover the
osteomyelitis and he will follow up with ID as an outpatient.
[**Month/Day (4) 1957**] felt the surgery was successful and patient will follow up
as an outpatient.  However, post-operatively, his incision site
began to drain some yellowish fluid and he had a low grade
fever. Blood cultures were obtained and pending at this time.
Wound culture showed 2+ PML with no organisms.  Orthopedic spine
felt that the area needed to be washed out.  The patient was
taken to the OR on Friday, [**12-1**] for cervical spine
washout.  Samples of the bone, soft tissue, and superficial and
deep fluid were obtained that showed [**1-11**]+ PML without organisms.
Cultures negative.  He remained afebrile.  Pt has follow up with
orthopedic spine ~2 weeks after discharge.
.
#Ventilator Associated Pneumonia-Patient had an episode of
hypontension thought to be due to sepsis from E.Coli VAP and was
started on pressors as well as Vanc and Zosyn; later changed to
Cipro for pna coverage. The hypotension resolved and he was
quickly weaned off pressors. He also was found to have
pansinusitis on CT. Patient was continued on Cipro for the
pneumonia to complete a 10 day course.
.
#AFib: PT had AF with RVR right before going to OR for spine
reconstruction as well as when febrile and hypotensive. Although
he responded with IV beta blocker and diltiazem. On [**11-14**], he had
a hypotensive episode and amiodarone was started in the setting
of septic shock picture.  A CTA chest done on [**11-14**] to rule out
PE in the setting of AF with RVR post-operatively which was
negative.  Amioradone was loaded and then changed to PO.  This
was discontinued on [**11-22**] and Lopressor was titrated up. The
patient was subsequently in sinus rhythem and did not require
further amiodarone.
.
# Melena: On [**11-21**] pt had episode of melena. He had received
stress dose steroids and motrin intermittently for fevers and
has a history of PUD. GI was consulted and the patient had an
EGD which showed antral erosions but no active bleeding. THe
patient was placed on a PPI which was continued throughout his
stay and upon d/c.  No further intervention was needed.
.
#Renal: Patient is s/p failed transplant with recent revision of
AV fisula. Transplant team followed the patient while in the
hospital.  HIs was Cr 10.2 on admission.  He was continued on
dialysis during his stay.  He was continued on Bactrim
prophylactically and once the stress dose steroids were
discontinued as above, he was placed on his home dose of
Prednisone for the rest of his stay.  He was also started on
Lanthanum.  He continued dialysis while in the hospital and will
return to his home schedule on discharge. He will need to remain
on vancomycin per HD schedule until [**2181-1-22**].
.
#Respiratory: Patient was intially intubated on admission for
airway protection.  He was extubated on [**11-20**] and did well on
room air.  He was weaned off of nasal canula adn his respiratory
status remained stable
.
#HTN: Patient was hypertensive when he was transferred from the
ICU to the floor.  His medications were changed from Captopril
to Lisinopril.  He is Metoprolol wasincreased to 125 mg TID.
.
#Hypothyroid: Patient was continued on home Synthroid.
.
#Delirium-Patient was agitated while on the floor, most notably
he tended to sundown in the evening.  In addition, he was not
oriented  This was initially treated with Haldol.  Psychiatry
was consulted and felt the delirium was normal given the
patients long ICU stay.  Patient was continued on Haldol and his
MS improved over time.

Medications on Admission:
- metoprolol 50mg TID
- sulfamethoxazole TMP 1 tab MWF
- prednisone 10mg QOD
- lisinopril 20mg QD
- levothyroxine 75mcg QD
- diltiazem 90mg QID
- omeprazole 20mg [**Hospital1 **]
- mirtazapine 7.5mg QPM
- Renagel 800mg TID W/MEALS


Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMWF ().
2. Levothyroxine 25 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
6. Outpatient Lab Work
please draw weekly CBC, chem 7, LFTs, and vanc trough while on
IV therapy. Please fax results to [**Telephone/Fax (1) 457**]
7. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
8. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
9. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID
(3 times a day) as needed.
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed.
11. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO three
times a day.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO qAM for 4 weeks: last day of therapy [**12-31**].
14. Phenytoin Sodium Extended 100 mg Capsule Sig: Four (4)
Capsule PO qPM for 4 weeks: last day of therapy [**12-31**].
15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
16. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
17. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) injection
Injection Q4H (every 4 hours) as needed.
18. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
20. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous qHD: per HD protocol
last dose [**2181-1-22**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
C4-6 Fracture
Vertebral Osteomyelitis
Ventilator Associated Pneumonia
Seizure Disorder NOS


Discharge Condition:
Stable


Discharge Instructions:
You were admitted to the hospital after a fall.  It is unclear
what caused the fall but it is thought that it might be due to a
seizure or an arrhythmia in your heart. You sustained a fracture
to your cervical spine which was operated on by orthopedic
surgery.  You were also found to have an infection of the bone
at this site. You will need to continue IV antibiotics to
complete a [**8-20**] week course. Your surgical site started to drain
some fluid, and you were taken back to surgery by the orthopedic
surgeons where the fluid was drained out successfully.

You were also treated for a pneumonia.  You complete the
antibiotics while you were in the hospital.

You were evaluated by neurology and you were started on a
medicine called Dilantin.  You will need to continue this
medication for 1 month and follow up with them as an outpatient.

You will need to follow up with neurology, infectious disease
and your PCP as below.

If you have any fever,chills, pain in your neck, neck stiffness,
headache, nausea, vomiting, abdominal pain, or any other
concerning symptoms, please call your PCP or return to the ED.

Followup Instructions:
Please call to make an appointment with neurology: ([**Telephone/Fax (1) 8951**]

Please follow up with infectious disease:Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**],
MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2180-12-25**] 11:00

Please follow up with [**Month/Day/Year **] spine: Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] on
[**2180-12-13**]. Please arrive at 11:40 for your 12PM appointment
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2180-12-13**] 11:40
Provider: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2180-12-13**] 12:00
{'Closed fracture of fourth cervical vertebra,End stage renal disease,Complications of transplanted kidney,Chronic glomerulonephritis with unspecified pathological lesion in kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Cocaine dependence, continuous,Encephalopathy, unspecified,Pneumonia due to escherichia coli [E. coli],Septicemia due to escherichia coli [E. coli],Sepsis,Intervertebral disc disorder with myelopathy, cervical region,Chronic osteomyelitis, other specified sites,Disruption of internal operation (surgical) wound,Pulmonary collapse,Blood in stool,Other convulsions,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in unspecified place,Unspecified fall,Atrial fibrillation,Other and unspecified complications of medical care, not elsewhere classified,Unspecified acquired hypothyroidism,Kyphosis (acquired) (postural),Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,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: s/p fall

PRESENT ILLNESS: 46 yo M s/p renal transplant 17 yrs ago and ESRD on HD secondary
to focal glomerulosclerosis status post deceased donor kidney
transplantation on [**2163-5-13**] withgraft loss in [**2179-12-10**],
with multiple placements of HD catheters and recent
transposition of right upper arm arteriovenous fistula on
[**2180-11-8**]. He was found on the bathroom floor w/ blood on face
and in the mouth by family. Per EMS the patinet was
hypertensive, tachycardiac and intially unresponsive but MS
improved on way to [**Hospital3 3583**]. On arrival to OSH, his MS
declined and he had a witnessed seized. He was then intubated
with vecuronium and loaded with fosphenytoin at that time. BO
was recorded as high as 220/110. Electrolytes were WNL and TnI
was positive.
.
Per report, episdoe of arrythmnia (?afib) in field, terminated
w/ diltiazem. Rec'd dilantin. Head CT no bleed at OSH. Neck CT:
cervical fx, transferred to [**Hospital1 18**].
.
Of note urine tox was positive for cocaine and opiates.

MEDICAL HISTORY: -Cadaveric Renal Transplant 16 yrs ago on immunosuppressants
-HTN poorly controlled
-Anemia on Procrit
-Chronic Allograft Nephropathy baseline Cr 4.2 ([**2179-1-10**])
-Admitted last [**Month (only) 1096**] to MICU with acute on chronic renal
failure, coagulase negative staphylococcal bacteremia, community

MEDICATION ON ADMISSION: - metoprolol 50mg TID
- sulfamethoxazole TMP 1 tab MWF
- prednisone 10mg QOD
- lisinopril 20mg QD
- levothyroxine 75mcg QD
- diltiazem 90mg QID
- omeprazole 20mg [**Hospital1 **]
- mirtazapine 7.5mg QPM
- Renagel 800mg TID W/MEALS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals - T:97.9 BP:131/91 HR:99 RR:16
VENT SETTINGS: AC 600x14 80% PEEP5
GENERAL: intubated and sedated
SKIN: palpable thrill in RUE, warm and well perfused, no
excoriations or lesions, no rashes
HEENT: AT, dried blood in right nare, small contusion on L
maxilla, anicteric sclera, pink conjunctiva, no JVD
CARDIAC: RRR, blowing holosystolic 2/6 SEM @ apex, S1/S2, no mrg

FAMILY HISTORY: unknown

SOCIAL HISTORY: lives with 2 children and mother 

### Response:
{'Closed fracture of fourth cervical vertebra,End stage renal disease,Complications of transplanted kidney,Chronic glomerulonephritis with unspecified pathological lesion in kidney,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Cocaine dependence, continuous,Encephalopathy, unspecified,Pneumonia due to escherichia coli [E. coli],Septicemia due to escherichia coli [E. coli],Sepsis,Intervertebral disc disorder with myelopathy, cervical region,Chronic osteomyelitis, other specified sites,Disruption of internal operation (surgical) wound,Pulmonary collapse,Blood in stool,Other convulsions,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in unspecified place,Unspecified fall,Atrial fibrillation,Other and unspecified complications of medical care, not elsewhere classified,Unspecified acquired hypothyroidism,Kyphosis (acquired) (postural),Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Personal history of noncompliance with medical treatment, presenting hazards to health'}
