CHIEF COMPLAINT: Altered mental status

PRESENT ILLNESS: All H/P taken from OSH records in conjunction to talking to NH
and OSH staff.  Code status at OSH full code.

MEDICAL HISTORY: DM type I c/b neuropathy, retinopathy, ESRD
ESRD s/p cadaveric renal transplant [**3-16**] c/b LLE arterial
thrombus s/p angioplasty and stent, on coumadin
HTN
Depression
Hypothyroidism
Peripheral vascular disease
GERD
Esophagitis
s/p R CEA
s/p L heel debridement and calcanectomy [**7-16**]
s/p removal of peritoneal dialysis cath & removal R IJ PermCath
[**3-16**] - Renal tx
[**4-16**] - Angioplasty of Left SFA, popliteal, tibioperoneal and
peroneal arteries and anterior tibial, Stenting of the
below-the-knee popliteal and tibioperoneal trunk

MEDICATION ON ADMISSION: Procrit SQ twice a week, Bactrim 400-80', Cellcept [**Pager number **]", Prograf
3", Indur 30', Lantus 20U qAM, Levothyroxine 150', Metoprolol
50", Norvasc 10', Omeprazole 20', oxybutynin 3.9 mg', Paxil 20',
Lexapro 10', reglan 10 QID, NaHCO3 650', metamucil, loperamide
2.5'''

ALLERGIES: Penicillins

PHYSICAL EXAM: (In ED):  33.8, 65, 95/39, 15, 100 NC
On pressors: Dopamine at 20, Levaphed 0.5, right IJ in
Confused, obeys commands, MAE X 4
RRR
Crackles right base
Soft/ND/NT, surgical scar well healed, kidney palpated, no
surrounding erythema/crepitus, has right femoral dialysis cath
in
no c/c/e

FAMILY HISTORY: heart disease, diabetes

SOCIAL HISTORY: Previously lived her husband but has been living in rehab since
transplant in [**3-16**]. Quit smoking over 10 years ago, 45 pack year
history. Rarely drinks and denies illicit drug use.
Unspecified septicemia,Acute kidney failure, unspecified,Complications of transplanted kidney,Septic shock,Pyelonephritis, unspecified,Atherosclerosis of native arteries of the extremities with gangrene,Acidosis,Ventilator associated pneumonia,End stage renal disease,Intestinal infection due to Clostridium difficile,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Esophageal reflux,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Severe sepsis,Pressure ulcer, heel,Anemia, unspecified,Other acquired deformities of ankle and foot
Septicemia NOS,Acute kidney failure NOS,Compl kidney transplant,Septic shock,Pyelonephritis NOS,Ath ext ntv art gngrene,Acidosis,Ventltr assoc pneumonia,End stage renal disease,Int inf clstrdium dfcile,Hyp kid NOS w cr kid V,Hypothyroidism NOS,Depressive disorder NEC,Abn react-org transplant,Esophageal reflux,DMI neuro nt st uncntrld,Neuropathy in diabetes,Diabetic retinopathy NOS,Nephritis NOS in oth dis,Severe sepsis,Pressure ulcer, heel,Anemia NOS,Acq ankle-foot def NEC
Admission Date:  [**2177-8-11**]              Discharge Date:   [**2177-9-13**]

Date of Birth:  [**2110-7-24**]             Sex:   F

Service: SURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:
[**2177-9-10**] Percutaneous gastrostomy tube
[**2177-8-12**] Transplant nephrectomy

History of Present Illness:
All H/P taken from OSH records in conjunction to talking to NH
and OSH staff.  Code status at OSH full code.

Briefly 67F ESRD s/p deceased donor tx in [**2176**] by Dr. [**First Name (STitle) **].
Was followed in our system until late [**2176**] when she transfered
care to a rehab facility ([**Hospital1 1562**] Care Rehab).  Over the past
week, the staff has been noticing waxing and [**Doctor Last Name 688**] mental
status from baseline (somewhat demented at baseline).  She was
ultimately transferred to [**Hospital 1562**] hospital where she was
hypotensive in the 80's, bradycardic to the 40's, and
hypothermic (89 degrees per rectal probe).  Atropine was given
as her HR dropped to the 20 which she responded to.  Pressors
were started (Dopamine and Levaphed) for her hypotension.  Vanco
and Levaquin X 1 were given.  A foley was placed with immediate
return of cloudy purulent fluid. A CT scan without contrast was
done showing air in her transplanted kidney.  No abscess was
seen. In preparation for ICU transfer at [**Hospital1 1562**], a right
quinton femoral line was placed in anticipation for HD.  A RIJ
was also placed.
The patient was then transferred to [**Hospital1 18**].  In the ED she was
hypothermic, hypotensive despite being on pressors.  She
recieved Flagyl. She was quickly transferred to the SICU and
intubated.
In terms of her transplant, the patient recieves her care at
[**Hospital1 1562**].  Her nephrologist is Dr. [**Last Name (STitle) 68844**] at Mashby Dialysis
(sp?).  Per reports she has not been on dialysis since her
transplant.

Past Medical History:
DM type I c/b neuropathy, retinopathy, ESRD
ESRD s/p cadaveric renal transplant [**3-16**] c/b LLE arterial
thrombus s/p angioplasty and stent, on coumadin
HTN
Depression
Hypothyroidism
Peripheral vascular disease
GERD
Esophagitis
s/p R CEA
s/p L heel debridement and calcanectomy [**7-16**]
s/p removal of peritoneal dialysis cath & removal R IJ PermCath
[**3-16**] - Renal tx
[**4-16**] - Angioplasty of Left SFA, popliteal, tibioperoneal and
peroneal arteries and anterior tibial, Stenting of the
below-the-knee popliteal and tibioperoneal trunk

Social History:
Previously lived her husband but has been living in rehab since
transplant in [**3-16**]. Quit smoking over 10 years ago, 45 pack year
history. Rarely drinks and denies illicit drug use.


Family History:
heart disease, diabetes

Physical Exam:
(In ED):  33.8, 65, 95/39, 15, 100 NC
On pressors: Dopamine at 20, Levaphed 0.5, right IJ in
Confused, obeys commands, MAE X 4
RRR
Crackles right base
Soft/ND/NT, surgical scar well healed, kidney palpated, no
surrounding erythema/crepitus, has right femoral dialysis cath
in
no c/c/e


Pertinent Results:
Labs on admission:
WBC: 8.2 (94 PMNs with 1 band)   Hct: 31.7   Plt: 175
PT: 13.4   PTT: 60.3   INR: 1.1
Chem 10: 140/3.5/122/5/61/5.0/166/ no Ca/1.8/5.8
Alt: 17    AST: 10   AP: 153   TB: 0.1  Lipase: 38
CK: 32,  Trpn: 0.05                  Lactate: 1.9

UA: grossly positive, many bacteria, mod leuko, > 50 WBC

CT Abd/Pelvis OSH - 12mm collection of air in the transplant
right pelvic kidney pelvis, may be [**2-10**] foley instrumentation;
however, given clinical history of puss draining from bladder
cannot exclude abscess. only one region of air in the pelvis of
the right TP kidney. no air or fluid around the kidney.
bilateral pleural effusions. otherwise, no acute path in
ab/pelvis.
CXR - No PTX, RIJ in appropriate position, atelectasis RLL with
some opacification, ? aspiration PNA
[**8-11**]: CT: 12mm collection of air in the transplant right pelvic
kidney pelvis, cannot exclude abscess. only one region of air in
the pelvis of the right TP kidney. no air or fluid around the
kidney. bilateral pleural effusions. otherwise, no acute path in
ab/pelvis.
[**8-11**]: U/S: PFI: There is indistinct corticomedullary
differentiation with elevated resistive indices in upper,
middle, and lower pole measuring up to 0.8. There is lack of
diastolic flow in the main renal artery. Overall, features are
concerning for worsening of the parenchymal process noted on the
prior examination. There are no perinephric collections. There
is no hydronephrosis. The bladder was collapsed
[**8-15**] CT Torso: jej and large bowel thickening, b/l extensive PNAs
and effusions



Brief Hospital Course:
The patient was admitted to the SICU already on pressor support
from OSH.  She was intubated on arrival given her instability.
She received aggressive fluid resuscitation overnight on [**8-11**].
Infectious disease was consulted and remained involved on her
antibiotic regimen.  Over the ensuing 18 hours from admission
she remained acidemic requiring vasopressors.  It was determined
that conservative
management with fluids and antibiotics were not controlling her
infection and the decision was made to proceed with transplant
nephrectomy as a definitive procedure for infection source
control. She underwent the transplant nephrectomy on [**2177-8-12**]
without any acute events.  Broad spectrum antibiotics were
continued. CVVH was initiated on [**8-12**].  She was unable to wean
from the vasopressor support initially, however after 24hrs she
gradually began to improve with a lessening pressor requirement.
 Her UCx grew MDR E. Coli. Vascular surgery was consulted for
her left lower extremity chronic ischemia.  Multipodus boots
were recommended but no acute intervention was required.  An
outpatient angiogram will be performed to further assess. A
postpyloric dobhoff tube was placed for TF.  She was extubated
on [**8-20**] and remained stable as oxygen therapy was weaned.  A
tunnelled line for HD was placed by IR on [**8-21**].  She
transitioned from CVVH to HD on [**2177-8-21**].  Initial attempts at HD
resulted in hypotension so midodrine was started.  She then
underwent successful HD with gradual fluid removal over the next
week and ensuing hospital stay.  Her mental status gradually
improved.  Speech and swallow was consulted and initally
recommended NPO however as her mental status improved she was
advanced to nectar liquids and purees, then to ground solids.

She was transferred to the floor on [**8-28**] where she gradually
improved. Tube feedings continued via the postpyloric feeding
tube. Speech and swallow evaluations gradually liberalized her
diet. She was initially at risk for aspiration, but improved to
advance to regular food and thin liquids. A PEG tube was placed
on [**2177-9-10**]. She tolerated this well and was kept npo x 24 hours.
Diet and tube feeds via the PEG were resumed. She tolerated this
well and the postop pyloric feeding tube was removed.

Blood sugars were difficult to control given multiple changes in
diet. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtain and insulin was adjusted with
increase of the Glargine and a Humalog sliding scale ordered.

PT worked with her extensively. She had developed plantar
flexion. Multipodis splints were utilized. By [**9-12**], she was able
to ambulate in the room with max assist. Please refer to
physical therapy notes.

A family meeting was done with the health care proxy noted as
her husband [**Name (NI) 37938**] with her sister [**Name (NI) 4115**] as back up proxy. The
patient declared that she wanted to have DNR status and a
comfort care form was sign.

Medications on Admission:
Procrit SQ twice a week, Bactrim 400-80', Cellcept [**Pager number **]", Prograf
3", Indur 30', Lantus 20U qAM, Levothyroxine 150', Metoprolol
50", Norvasc 10', Omeprazole 20', oxybutynin 3.9 mg', Paxil 20',
Lexapro 10', reglan 10 QID, NaHCO3 650', metamucil, loperamide
2.5'''


Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Pager number **]: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Pager number **]:
2-4 Puffs Inhalation Q2H (every 2 hours) as needed for wheezy.
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2) Tablet, Chewable
PO DAILY (Daily).
5. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
6. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. Paroxetine HCl 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
9. Vancomycin 125 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H (every
6 hours) for 3 days: stop after [**9-15**].
10. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (4) **]: One (1) ml
Injection [**Hospital1 **] (2 times a day).
11. Levothyroxine 100 mcg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
12. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: Five (5)
ML PO Q4H (every 4 hours) as needed for pain.
14. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Twenty (20) units
Subcutaneous once a day.
15. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: follow sliding
scale   Subcutaneous four times a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2857**] - [**Hospital1 1562**]

Discharge Diagnosis:
sepsis secondary to UTI
kidney transplant nephrectomy


Discharge Condition:
stable


Discharge Instructions:
Please call Dr.[**Name (NI) 8584**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, increased abdominal pain, incision
redness/bleeding/drainage, malfunction of the tunnelled dialysis
line
continue Hemodialysis via the tunnelled line


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2177-9-24**] 12:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2177-9-24**] 1:30
{'Unspecified septicemia,Acute kidney failure, unspecified,Complications of transplanted kidney,Septic shock,Pyelonephritis, unspecified,Atherosclerosis of native arteries of the extremities with gangrene,Acidosis,Ventilator associated pneumonia,End stage renal disease,Intestinal infection due to Clostridium difficile,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Esophageal reflux,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Severe sepsis,Pressure ulcer, heel,Anemia, unspecified,Other acquired deformities of ankle and foot'}


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: Altered mental status

PRESENT ILLNESS: All H/P taken from OSH records in conjunction to talking to NH
and OSH staff.  Code status at OSH full code.

MEDICAL HISTORY: DM type I c/b neuropathy, retinopathy, ESRD
ESRD s/p cadaveric renal transplant [**3-16**] c/b LLE arterial
thrombus s/p angioplasty and stent, on coumadin
HTN
Depression
Hypothyroidism
Peripheral vascular disease
GERD
Esophagitis
s/p R CEA
s/p L heel debridement and calcanectomy [**7-16**]
s/p removal of peritoneal dialysis cath & removal R IJ PermCath
[**3-16**] - Renal tx
[**4-16**] - Angioplasty of Left SFA, popliteal, tibioperoneal and
peroneal arteries and anterior tibial, Stenting of the
below-the-knee popliteal and tibioperoneal trunk

MEDICATION ON ADMISSION: Procrit SQ twice a week, Bactrim 400-80', Cellcept [**Pager number **]", Prograf
3", Indur 30', Lantus 20U qAM, Levothyroxine 150', Metoprolol
50", Norvasc 10', Omeprazole 20', oxybutynin 3.9 mg', Paxil 20',
Lexapro 10', reglan 10 QID, NaHCO3 650', metamucil, loperamide
2.5'''

ALLERGIES: Penicillins

PHYSICAL EXAM: (In ED):  33.8, 65, 95/39, 15, 100 NC
On pressors: Dopamine at 20, Levaphed 0.5, right IJ in
Confused, obeys commands, MAE X 4
RRR
Crackles right base
Soft/ND/NT, surgical scar well healed, kidney palpated, no
surrounding erythema/crepitus, has right femoral dialysis cath
in
no c/c/e

FAMILY HISTORY: heart disease, diabetes

SOCIAL HISTORY: Previously lived her husband but has been living in rehab since
transplant in [**3-16**]. Quit smoking over 10 years ago, 45 pack year
history. Rarely drinks and denies illicit drug use. 

### Response:
{'Unspecified septicemia,Acute kidney failure, unspecified,Complications of transplanted kidney,Septic shock,Pyelonephritis, unspecified,Atherosclerosis of native arteries of the extremities with gangrene,Acidosis,Ventilator associated pneumonia,End stage renal disease,Intestinal infection due to Clostridium difficile,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Esophageal reflux,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Severe sepsis,Pressure ulcer, heel,Anemia, unspecified,Other acquired deformities of ankle and foot'}
