CHIEF COMPLAINT: Fevers

PRESENT ILLNESS: HPI: Mr. [**Known lastname 30197**] is a 57 year-old man with hx of ESRD on
hemodialysis since [**Month (only) 205**] who presented with 1 day history of
fever to 101 at home and 1 week history of cough. The patient
reports he developed a cough approximately one week ago that has
been productive of copius white sputum. He describes daily
episodes of coughing upon waking and "throwing up white stuff."
There is no evidence of food or bile in the secretions and he
believes they are coming from his lungs rather than his stomach.
He also notes that these coughing fits make him feel nauseus. 2
days prior to admission he was given Reglan for nausea and
"throwing up." He subsequently developed diarrhea, and has had
approximately 5 mushy brown, non-bloody stools daily. He has not
experienced any sore throat, chills, abdominal pain, dysuria. He
notes lightheadedness on changing positions but has been
experiencing this since begininning dialysis in [**Month (only) 205**]. He also
experiences achiness following dialysis. He denies any fever
prior to the day before admission.
.
ROS: Has DOE at baseline, cannot walk up a flight of stairs.
Denies chest pain, abdominal pain, sweats.
.
In the ED, the patient's temperature was 100.6. He underwent CXR
(clear) and CT with contrast. Blood cultures were sent and he
received Levofloxacin 500mg, Flagyl 1000mg, Vancomycin 1g

MEDICAL HISTORY: 1. ESRD on hemodialysis, awaiting placement on transplant list
2. Renal cell carcinoma of left kidney (s/p partial nephrectomy
[**5-17**]) T1, N0, M0. Surveillance MR [**First Name8 (NamePattern2) **] [**2165-5-15**] was negative
for recurrence.
3. Hypertension
4. Diabetes type 2, recently diagnoses, HbA1C 9
5. Hepatitis C infection
6. Bilateral hearing loss
7. Gout
8. Anemia
9. [**Doctor Last Name 15532**]??????s Esophagus
10.Prostate nodule, PSA 2.8 fall [**2164**]

MEDICATION ON ADMISSION: Aspirin 81 mg daily
Nephrocaps 1 cap daily
Allopurinol 100 mg QOD
Valsartan 320mg daily
Amlodipine 5mg daily
Diltiazem SR 360mg daily
Glipizide 5mg daily
Lantus 10units QAM
Prilosec 40mg [**Hospital1 **]

ALLERGIES: Iron Dextran Complex

PHYSICAL EXAM: Physical Exam:
VS: T100.6  BP 107/76  HR 101  RR 22  O2sat 94%RA
GEN: Subdued-appearing middle-aged man in NAD
HEENT: Icteric sclera, OP clear, MMM
NECK: supple, no LAD, no JVD
CARD: Tachycardic, regular rhythm, normal S1, S2. 3/6 systolic
murmur at L upper sternal border
LUNG: Crackles on R from base to middle lung field. Crackle on L
at base only. Moving air well.
ABD: Protuberant, soft, ND, slightly tender in site of recent bx
in RUQ, no ascites. Liver edge nonpalpable. No splenomegaly
EXT: WWP, dry, scaly skin on lower legs and feet bilaterally. DP
2+ bilaterally

FAMILY HISTORY: Sister- DM
[**Name (NI) **] reported CAD.
Positive for alcoholism.
Mother died of "liver problems"; father died of stroke at 51. He

SOCIAL HISTORY: Lives with sister, previously worked in a hotel, quit after [**Month (only) **]
Acute idiopathic pericarditis,Other complications due to renal dialysis device, implant, and graft,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic hepatitis C without mention of hepatic coma,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Barrett's esophagus,Anemia in chronic kidney disease,Gout, unspecified,Personal history of malignant neoplasm of kidney
Ac idiopath pericarditis,Comp-ren dialys dev/grft,End stage renal disease,Hyp kid NOS w cr kid V,Chrnc hpt C wo hpat coma,Abn react-anastom/graft,DMII wo cmp nt st uncntr,Barrett's esophagus,Anemia in chr kidney dis,Gout NOS,Hx of kidney malignancy
Admission Date:  [**2166-1-24**]              Discharge Date:   [**2166-2-1**]

Date of Birth:  [**2108-4-9**]             Sex:   M

Service: MEDICINE

Allergies:
Iron Dextran Complex

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Fevers

Major Surgical or Invasive Procedure:
-L IJ central line
-AV fistulagram with recannalization attempt by Interventional
Radiology
-CT with contrast
-Echocardiogram
-Pericardiocentesis
-Thrombectomy of AV graft thrombus


History of Present Illness:
HPI: Mr. [**Known lastname 30197**] is a 57 year-old man with hx of ESRD on
hemodialysis since [**Month (only) 205**] who presented with 1 day history of
fever to 101 at home and 1 week history of cough. The patient
reports he developed a cough approximately one week ago that has
been productive of copius white sputum. He describes daily
episodes of coughing upon waking and "throwing up white stuff."
There is no evidence of food or bile in the secretions and he
believes they are coming from his lungs rather than his stomach.
He also notes that these coughing fits make him feel nauseus. 2
days prior to admission he was given Reglan for nausea and
"throwing up." He subsequently developed diarrhea, and has had
approximately 5 mushy brown, non-bloody stools daily. He has not
experienced any sore throat, chills, abdominal pain, dysuria. He
notes lightheadedness on changing positions but has been
experiencing this since begininning dialysis in [**Month (only) 205**]. He also
experiences achiness following dialysis. He denies any fever
prior to the day before admission.
.
ROS: Has DOE at baseline, cannot walk up a flight of stairs.
Denies chest pain, abdominal pain, sweats.
.
In the ED, the patient's temperature was 100.6. He underwent CXR
(clear) and CT with contrast. Blood cultures were sent and he
received Levofloxacin 500mg, Flagyl 1000mg, Vancomycin 1g



Past Medical History:
1. ESRD on hemodialysis, awaiting placement on transplant list
2. Renal cell carcinoma of left kidney (s/p partial nephrectomy
[**5-17**]) T1, N0, M0. Surveillance MR [**First Name8 (NamePattern2) **] [**2165-5-15**] was negative
for recurrence.
3. Hypertension
4. Diabetes type 2, recently diagnoses, HbA1C 9
5. Hepatitis C infection
6. Bilateral hearing loss
7. Gout
8. Anemia
9. [**Doctor Last Name 15532**]??????s Esophagus
10.Prostate nodule, PSA 2.8 fall [**2164**]

Social History:
Lives with sister, previously worked in a hotel, quit after [**Month (only) **]

admission to hospital.
Previous 80 pack year smoking history, quit in [**2165-5-15**].
Previous ETOH history of 1 pint per week, quit in [**2165-5-15**]
Previous crack cocaine use (1-2 times per month), quite in [**Month (only) **]
[**2164**]
Previous heroin use, quite 5-6 years ago


Family History:
Sister- DM
[**Name (NI) **] reported CAD.
Positive for alcoholism.
Mother died of "liver problems"; father died of stroke at 51. He

is unsure of any other medical problems in his family.

Physical Exam:
Physical Exam:
VS: T100.6  BP 107/76  HR 101  RR 22  O2sat 94%RA
GEN: Subdued-appearing middle-aged man in NAD
HEENT: Icteric sclera, OP clear, MMM
NECK: supple, no LAD, no JVD
CARD: Tachycardic, regular rhythm, normal S1, S2. 3/6 systolic
murmur at L upper sternal border
LUNG: Crackles on R from base to middle lung field. Crackle on L
at base only. Moving air well.
ABD: Protuberant, soft, ND, slightly tender in site of recent bx
in RUQ, no ascites. Liver edge nonpalpable. No splenomegaly
EXT: WWP, dry, scaly skin on lower legs and feet bilaterally. DP
2+ bilaterally



Pertinent Results:
CXR [**2166-1-24**]:
The left-sided IJ central venous line has migrated slightly more
proximally and the distal tip is in the distal left
brachiocephalic vein.  The cardiac size is prominent but
unchanged.  There is some tortuosity to the thoracic aorta.
Some streaky density seen at the left base, best seen on the
lateral radiograph.  This is likely secondary to atelectasis,
however, early infiltrate cannot be completely excluded.
Attention to this region is recommended on followup studies.
.
.
CT ABDOMEN/PELVIS W/ CONTRAST [**2166-1-24**]:
CT ABDOMEN: There is bilateral pleural thickening and bibasilar
atelectasis, which is unchanged from prior exam. There has been
interval development of a large pericardial effusion. The
effusion measures higher than fluid density at 30 Hounsfield
units and was not present previously. The liver, gallbladder,
pancreas, spleen, adrenal glands, and kidneys are stable in
appearance. The patient is status post partial left nephrectomy.
Multiple low attenuation renal foci are noted and may represent
cysts but are too small to be fully characterized. The stomach
and bowel loops are within normal limits. There is no free air
or free fluid. Of note, are prominent left diaphragmatic,
paraesophageal, and para vena caval lymph nodes. They are
increased in size compared to prior examination.
CT PELVIS: The bladder, prostate, seminal vesicles, and rectum
are unremarkable. There is focal segment of narrowing in the
sigmoid colon, which may relate to transient peristalsis.
Contrast is seen passing beyond this point. There is no free
fluid and no pelvic or inguinal lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. Interval development of a large pericardial effusion with
high attenuation fluid.
2. Interval increase in size of left diaphragmatic,
paraesophageal, and para vena caval lymph nodes. These could be
inflammatory, however, given the patient's history of renal cell
carcinoma, neoplastic involvement cannot be excluded.
3. Low attenuation renal foci, which may represent cysts but are
too small to be fully characterized.
4. Pleural thickening and atelectasis at both lung bases.
.
.
CXR PA & LATERAL [**2166-1-26**]:
Cardiomegaly is unchanged. A left internal jugular central
venous catheter is in unchanged position, with the tip in the
superior portion of the SVC. No pneumothorax is identified.
There is no consolidation or evidence of congestive failure. No
pleural effusion. IMPRESSION: Cardiomegaly. No evidence of
pneumonia.
.
.
EKG [**2166-1-26**]:
Sinus tachycardia
Modest ST-T wave changes with Probable QT interval prolonged
although is
difficult to measure - are nonspecific but clinical correlation
is suggested. Since previous tracing of [**2166-1-24**], probable no
significant change
.
.
Echocardiogram [**2166-1-27**]:
Conclusions:
1.The left atrium is mildly dilated. The left atrium is
elongated. The
inferior vena cava is dilated (>2.5 cm).
2.Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen.
5.The mitral valve leaflets are structurally normal. No mitral
regurgitation seen.
6.There is a moderate to large sized pericardial effusion. The
effusion
appears circumferential. There is very mild diastolic
invagination of the
right ventricular outflow tract and there is respiratory
variation of mitral valve inflow consistent with early
tamponade.
.
.
Cardiac Cath/Pericardiocentesis [**2166-1-28**]:
1.  Right heart catheterization revealed severe elevation of
right and
left sided filling pressures along with equalization of RA, RV
end
diastolic, PA diastolic and PCWP at about 20mmHG.  The cardiac
index was
preserved at 3.7.  There was marked respiratory variation (peak
to peak
of 30mmHG) in the femoral artery pressure tracing.
2.  Pericardiocentesis was uncomplicated and revealed an opening

pressure of 20mmHG and was essentially identical to RA pressure.
 600 cc
of bloody fluid were drained with improvement in RA pressure to
10mmHG.
The cardiac index remained unchanged at 3.6.
3.  Echo done post procedure revealed only minimal effusion
posteriorly
(pt had 2.5cm circumfrential effusion yesterday).
FINAL DIAGNOSIS:
1. Pericardial effusion with tamponade physiology
2. Successful pericardiocentesis.
.
.
ECHO [**2166-1-29**]:
Conclusions:
There is a trivial/small pericardial effusion. There are no
echocardiographic
signs of tamponade.
.
.
LABS:
[**2166-1-24**] 01:50PM:
WBC-15.1* RBC-3.41* HGB-9.6* HCT-30.4* PLT COUNT-692
MCV-89 MCH-28.1 MCHC-31.5 RDW-16.0*
NEUTS-69.3 LYMPHS-23.3 MONOS-5.7 EOS-1.0 BASOS-0.8
PT-13.4* PTT-24.9 INR(PT)-1.2*
GLUCOSE-79 UREA N-29* CREAT-7.9*# SODIUM-138 POTASSIUM-3.7
CHLORIDE-93* TOTAL CO2-27 ANION GAP-22* LACTATE-1.6
[**2166-1-24**] 06:10PM:
URINE  SP [**Last Name (un) 155**]-1.022 BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG RBC-0 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2

Brief Hospital Course:
#. Issues to be followed-up as outpatient:
1) Needs echo to assess for reaccumulation of pericardial
effusion in 4 weeks followed by appointement with Dr. [**First Name4 (NamePattern1) 919**]
[**Last Name (NamePattern1) 911**]. The patient has been instructed to call to schedule echo
and appointment.
2) Assymetric LAD of the left paraesophageal, diaphragmatic and
vena caval lymph nodes seen on CT chest [**1-24**]. Needs repeat CT in
[**3-20**] weeks.
3) Had one dark, guaiac-positive stool on [**1-31**]. Should have
outpatient colonoscopy.
4) RCC, PSA
.
#.Pericardial effusion: First noted on CT chest on [**1-24**]. Viral
etiology was felt to be most likely. Despite his ESRD it was
thought that this was unlikely to be a uremic effusion because
he has been well-dialyzed. On [**1-26**], the patient's SBP was in the
90's. It was unclear if this drop in BP Was secondary to the
effusion or to intravascular depletion from dialysis the day
before. He was given 3 boluses of IVF and BP improved. Pulsus
paradoxus was monitored and remained stable at 10-12mmHg.
Cardiology was consulted and the patient underwent TTE on [**1-27**]
which showed 1.5-2cm pericardial effusion. On [**1-28**] he underwent
pericardiocentesis: 600cc of fluid was removed and a pericardial
drain was placed which drained 80cc of serosanginous fluid over
24 hours. The patient tolerated the procedure well and went to
the CCU for post-procedure monitoring. Pericardial fluid was
found to be an exudate. [**2159**] WBCs were seen. Diff was: N 27%, L
41%, Mono 4%, Eos 4%, Macros 24%. Gram stain and Acid Fast smear
were negative.  Fluid culture showed no growth, anaerobic
culture preliminarily no growth. Fungal cultures preliminarily
negative, Acid Fast culture pending. Cytology was negative for
malignant cells. PPD was negative. He tolerated the procedure
well and a pericardial drain was placed. On [**1-29**], drain output
was minimal and removal of the drain was attempted. Removal was
not successful and the patient underwent angiography for removal
of the drain, which was found to be incorporated into a
loculated portion of the pericardial sac. Given these findings,
this is most likely viral etiology, however, malignancy must
still be considered. On echocardiogram 24 hours post-procedure,
no re-accumulation of fluid was seen. The patient remained
hemodynamically stable until discharged. He is to schedule a
follow-up echocardiogram with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] ([**Telephone/Fax (1) 128**]) in
about 4 weeks ([**3-1**]).
.
#.Fever:
The patient presented with fever to 101 at home, in the setting
of 1 week of productive cough. His WBC was also elevated to 15.1
on admission, and he received Vancomycin, Levo and Flagyl in the
ED. Blood cultures, urine cultures and stool cultures were sent
and found to be negative. There was no evidence of pneumonia on
chest films. Given that Mr. [**Known lastname 30197**] is a hemodailysis patient,
the team's greatest concern was for infected venous access
causing bacteremia, and blood cultures were repeated x3. As
there was no evident source of infection, no further antibiotics
were given. Tylenol was held so fever curve could be monitored,
and he continued to have low grade fever until his effusion was
drained on [**1-28**]. Following drainage of the effusion the patient
continued to become febrile during/after hemodialysis
treatments, but was otherwise afebrile. Given his history of
renal cell carcinoma, this was also considered as a possible
source of fevers. RCC is being followed as an outpatient. By the
day of discharge, Mr. [**Known lastname 30197**] was afebrile and his WBC had
decreased to 9.9.
.
#.ESRD:
The patient has received hemodialysis since [**2165-6-14**], on Tues,
Thurs, Sat schedule. Dialysis was continued on this schedule
while the patient was hospitalized. On Saturday [**1-25**], 2.2kg
fluid was removed resulting in SBP in 90's. He also reported
lightheadedness with changes in position. Subsequently, he
received IV fluid boluses and his blood pressure improved. On
[**1-27**] the patient underwent fistulagram that had been scheduled
as an outpatient to work-up difficulty with fistula access. The
graft was found to be stenosed, and revision by angiography was
performed. On post-procedure imaging the graft was found to be
thrombosed, and re-cannulation was again attempted that
afternoon. Ultrasound the following morning ([**1-28**]) revealed
complete occlusion of the fistula throughout its graft portion
from the arterial anastomosis to the venous anastomosis.
Transplant surgery performed thrombectomy on [**1-29**], and
post-procedure exam revealed 2+ graft pulse and restoration of a
graft thrill. The patient missed his Tuesday hemodialysis
secondary to graft thrombosis and was subsequently dialyzed
Wednesday-Thursday-Friday-Saturday. He continued to have good
pulse and graft thrill at discharge. In addition to continuing
dialysis, the patient was continued on calcium carbonate 500mg
TID. Electolytes were monitored. The transplant service was
aware of the patient, and the renal service followed him while
inpatient.
.
#. Hypoxia: On [**1-26**] the patient became hypoxic to 88% on RA. He
was placed on 2L NC with sats 94-97%. He denied SOB or chest
pain at the time. Concern was for pneumonia of CHF, given his
reports of dyspnea on exertion at baseline. CXR was checked with
no evidence of pneumonia, pulmonary edema, or pleural effusion.
His oxygen sats were monitored and the patient was instructed to
use an incentive spirometer. Sats improved over the next two
days and supplemental oxygen was discontinued.
.
#.Anemia:
The patient has had anemia requiring transfusions in the past,
likely related to ESRD. On admission HCT was 30.4, then declined
over several days to 25.3. He was transfused 1 unit prior to
pericardiocentesis, and his HCT increased appropriately with the
transfusion. On [**1-31**] he had one dark, soft formed stool that was
guaiac positive. HCT was monitored. It remained stable and was
30.4 on the day of discharge.
Given recent negative colonoscopy ([**2-16**]) patient will simply
require regular follow-up in 5 years.
.
#.Nausea and Diarrhea:
At baseline, the patient has frequent nausea associated with
acid reflux, for which he takes prilosec 40mg [**Hospital1 **]. He also gives
a history of food "getting stuck" and being regurgitated,
suggesting gastroparesis. On admission, the patient reported
post-tussive nausea for 1 week. He has also described daily
episodes of "throwing up" upon waking up in the morning, but
these episodes were always associated with coughing, and the
description given of the secretions was suggestive of sputum
rather than emesis. On the day following admission the patient
had one episode of vomiting after eating breakfast. He noted
that he had not been eating for the week prior to adimission. He
continued to experience intermittent nausea until [**1-26**], when his
appetite improved. The patient had been started on Reglan 2 days
prior to admission for presumed nausea and vomiting and
subsequently developed soft stools, approximately 5 per day.
Stool cultures were sent, and c. difficile toxin was negative.
He continued to have guaiac-negative soft stools while
hospitalized. One guaiac-positive dark, soft formed stool was
recorded on [**1-31**]. HCT remained stable and the patient had a
normal brown colored BM prior to discharge. He was not
orthostatic on discharge.
.
#.Depression:
Patient has had ongoing discussion with his outpatient treaters
about starting an antidepressant medication. During his
hospitalization he informed the team that he now feels that he
needs to start a medication to help with depression. He was
started on Zoloft 25mg daily and advised of possible side
effects of nausea, vomiting and diarrhea. He was also advised
that the medication would most likely not have any effect on his
mood for several weeks.
.
#. Hypertension: Remained stable. Home medications (Valsartan
360mg, diltiazem 320mg, amlodipine 5mg) were continued until
[**1-26**], when the patient found to have low BP. Valsartan was then
decreased to 80mg daily and amlodipine was held. All BP meds
were held on [**1-27**] due to concern for early tamponade. Home
regimen was resumed after drainage of pericardial effusion; the
patient's BP remained stable.
.
#. Diabetes: The patient was placed on QID finger sticks and
insulin sliding scale while hospitalized. He was continued on
glipizide 5mg daily and Lantus 10 units daily except when NPO
for procedures. The majority of his finger sticks were at goal.

.
#.Gout: Remained stable, without symptoms. Allopurinol 100mg QOD
was continued.
.
#.[**Doctor Last Name 15532**]??????s Esophagus: Continued PPI 40mg [**Hospital1 **]
.
#.Hepatitis C: Viral load was sent (currently pending).
.
#.Prophylaxis: While on bed rest, the patient was maintained on
SC heparin. This was discontinued when he began to feel better
and get out of bed frequently.
.
#.Fluids, electrolytes, nutrition: The patient was maintained on
a renal/cardiac diet. Electrolytes were checked daily and the
patient received hemodialysis on his outpatient schedule plus
two additional sessions.


Medications on Admission:
Aspirin 81 mg daily
Nephrocaps 1 cap daily
Allopurinol 100 mg QOD
Valsartan 320mg daily
Amlodipine 5mg daily
Diltiazem SR 360mg daily
Glipizide 5mg daily
Lantus 10units QAM
Prilosec 40mg [**Hospital1 **]

Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Prilosec 40mg one tablet twice daily
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Diltiazem HCl 360 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Sertraline 50 mg Tablet Sig: half Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Insulin Glargine 100 unit/mL Solution Sig: One (1) 10 units
Subcutaneous once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Fever
New pericardial effusion
End-stage renal disease on hemodialysis
Occlusion of hemodialysis fistula graft
Anemia
Diabetes


Discharge Condition:
Good


Discharge Instructions:
1. Please call your doctor or return to the Emergency Department
if you develop fever >101, chills, vomiting, abdominal pain,
chest pain, fainting, shortness of breath at rest or lying down,
lightheadedness, or for any other concerning symptoms.
2. Please keep all of your appointments as scheduled (see
below).
3. Please keep your dialysis schedule of Tues/Thurs/Sat.
4. Restart all of your home medications, including your diabetes
medicines. We have added an antidepressant to your medications
(Sertraline 25mg); take half a tablet once a day


Followup Instructions:
1. DR. [**First Name8 (NamePattern2) **] [**2-12**] at 4PM Phone:[**Telephone/Fax (1) 250**]

2. DR. [**First Name (STitle) **] [**Name8 (MD) **], MD--[**3-5**] at 8:40AM Phone:[**Telephone/Fax (1) 673**]

3. Please call ([**Telephone/Fax (1) 19380**] to schedule an appointment with
Dr. [**Last Name (STitle) 911**] to have an echocardiogram in 4 weeks.
{"Acute idiopathic pericarditis,Other complications due to renal dialysis device, implant, and graft,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic hepatitis C without mention of hepatic coma,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Barrett's esophagus,Anemia in chronic kidney disease,Gout, unspecified,Personal history of malignant neoplasm of kidney"}


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: Fevers

PRESENT ILLNESS: HPI: Mr. [**Known lastname 30197**] is a 57 year-old man with hx of ESRD on
hemodialysis since [**Month (only) 205**] who presented with 1 day history of
fever to 101 at home and 1 week history of cough. The patient
reports he developed a cough approximately one week ago that has
been productive of copius white sputum. He describes daily
episodes of coughing upon waking and "throwing up white stuff."
There is no evidence of food or bile in the secretions and he
believes they are coming from his lungs rather than his stomach.
He also notes that these coughing fits make him feel nauseus. 2
days prior to admission he was given Reglan for nausea and
"throwing up." He subsequently developed diarrhea, and has had
approximately 5 mushy brown, non-bloody stools daily. He has not
experienced any sore throat, chills, abdominal pain, dysuria. He
notes lightheadedness on changing positions but has been
experiencing this since begininning dialysis in [**Month (only) 205**]. He also
experiences achiness following dialysis. He denies any fever
prior to the day before admission.
.
ROS: Has DOE at baseline, cannot walk up a flight of stairs.
Denies chest pain, abdominal pain, sweats.
.
In the ED, the patient's temperature was 100.6. He underwent CXR
(clear) and CT with contrast. Blood cultures were sent and he
received Levofloxacin 500mg, Flagyl 1000mg, Vancomycin 1g

MEDICAL HISTORY: 1. ESRD on hemodialysis, awaiting placement on transplant list
2. Renal cell carcinoma of left kidney (s/p partial nephrectomy
[**5-17**]) T1, N0, M0. Surveillance MR [**First Name8 (NamePattern2) **] [**2165-5-15**] was negative
for recurrence.
3. Hypertension
4. Diabetes type 2, recently diagnoses, HbA1C 9
5. Hepatitis C infection
6. Bilateral hearing loss
7. Gout
8. Anemia
9. [**Doctor Last Name 15532**]??????s Esophagus
10.Prostate nodule, PSA 2.8 fall [**2164**]

MEDICATION ON ADMISSION: Aspirin 81 mg daily
Nephrocaps 1 cap daily
Allopurinol 100 mg QOD
Valsartan 320mg daily
Amlodipine 5mg daily
Diltiazem SR 360mg daily
Glipizide 5mg daily
Lantus 10units QAM
Prilosec 40mg [**Hospital1 **]

ALLERGIES: Iron Dextran Complex

PHYSICAL EXAM: Physical Exam:
VS: T100.6  BP 107/76  HR 101  RR 22  O2sat 94%RA
GEN: Subdued-appearing middle-aged man in NAD
HEENT: Icteric sclera, OP clear, MMM
NECK: supple, no LAD, no JVD
CARD: Tachycardic, regular rhythm, normal S1, S2. 3/6 systolic
murmur at L upper sternal border
LUNG: Crackles on R from base to middle lung field. Crackle on L
at base only. Moving air well.
ABD: Protuberant, soft, ND, slightly tender in site of recent bx
in RUQ, no ascites. Liver edge nonpalpable. No splenomegaly
EXT: WWP, dry, scaly skin on lower legs and feet bilaterally. DP
2+ bilaterally

FAMILY HISTORY: Sister- DM
[**Name (NI) **] reported CAD.
Positive for alcoholism.
Mother died of "liver problems"; father died of stroke at 51. He

SOCIAL HISTORY: Lives with sister, previously worked in a hotel, quit after [**Month (only) **] 

### Response:
{"Acute idiopathic pericarditis,Other complications due to renal dialysis device, implant, and graft,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic hepatitis C without mention of hepatic coma,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Barrett's esophagus,Anemia in chronic kidney disease,Gout, unspecified,Personal history of malignant neoplasm of kidney"}
