CHIEF COMPLAINT: generalized weakness

PRESENT ILLNESS: 58F with history of nephrolithiasis and multiple episodes of
postobstructive renal failure, history of urosepsis; presenting
to ED with weakness, N/V/D x 3 days. Per patient, she has been
generally well except for 3 days ago, when had vomiting shortly
followed by diarrhea. States she has been okay in the last
couple days, but today had a visitor who told her she looked
unwell with weight loss, poor appetite, and abnormal looking
skin. She thus presented to the ED. Denies abdominal pain, back
pain, dysuria, cramping pain or feelings of passing kidney
stone. Does note ?hematuria. No fevers, chills, or shortness of
breath.
.
In the ED, initial vs were: T98.7, P116, BP 68/40, R18, O2 sat
99% on RA. UA with WBCs and RBCs. ARF with creatinine 4. Lactate
2.7, AG 21. WBCs 23K with immature forms. Patient was given 3L
IVFs, levofloxacin and metronidazole. BP improved to 90s
systolic. RR in 30s.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, headache, sinus tenderness, cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias. No back pain.

MEDICAL HISTORY: Multiple episodes of postobstructive renal failure related to
nephrolithiasis; creatinine as high as 7. Most recent creatinine
1.7 in 4/[**2118**].
- Nephrolithiasis [**1-1**] hyperPTH with residual calcium stones.
History of L laser lithotripsy, R perc nephrolithotripsy and L
ESWL, intermittent ureteral stents. No current stents in place.

MEDICATION ON ADMISSION: Vit D

ALLERGIES: Ciprofloxacin

PHYSICAL EXAM: General: Alert, oriented, no acute distress. Flat affect.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, diffuse
abdominal TTP max in LUQ> LLQ and epigastrium; no rebound
tenderness or guarding, no organomegaly
Back: +nephrostomy drain and pigtail catheter from L flank.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema or rash.

FAMILY HISTORY: No DM, coronary disease or cancers per the patient.

SOCIAL HISTORY: Lives with 23 year old daughter. Does not work. Nonsmoker, no
drug use, etoh few times per year only.
Unspecified septicemia,Renal and perinephric abscess,Septic shock,Acute kidney failure with lesion of tubular necrosis,Candidiasis of other urogenital sites,Hyperosmolality and/or hypernatremia,Hydronephrosis,Acute posthemorrhagic anemia,Severe sepsis,Leiomyoma of uterus, unspecified,Iron deficiency anemia, unspecified,Primary hyperparathyroidism,Calculus of kidney,Diarrhea,Depressive disorder, not elsewhere classified,Chronic kidney disease, Stage II (mild),Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Other specified cardiac dysrhythmias,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction
Septicemia NOS,Renal/perirenal abscess,Septic shock,Ac kidny fail, tubr necr,Candidias urogenital NEC,Hyperosmolality,Hydronephrosis,Ac posthemorrhag anemia,Severe sepsis,Uterine leiomyoma NOS,Iron defic anemia NOS,Primary hyperparathyroid,Calculus of kidney,Diarrhea,Depressive disorder NEC,Chro kidney dis stage II,Other streptococcus,Cardiac dysrhythmias NEC,Cholelithiasis NOS
Admission Date:  [**2120-8-17**]              Discharge Date:   [**2120-9-11**]

Date of Birth:  [**2062-7-28**]             Sex:   F

Service: MEDICINE

Allergies:
Ciprofloxacin

Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
generalized weakness

Major Surgical or Invasive Procedure:
Percutaneous nephrostomy tube placement
Aspiration and drainage of perinephric fluid collection


History of Present Illness:
58F with history of nephrolithiasis and multiple episodes of
postobstructive renal failure, history of urosepsis; presenting
to ED with weakness, N/V/D x 3 days. Per patient, she has been
generally well except for 3 days ago, when had vomiting shortly
followed by diarrhea. States she has been okay in the last
couple days, but today had a visitor who told her she looked
unwell with weight loss, poor appetite, and abnormal looking
skin. She thus presented to the ED. Denies abdominal pain, back
pain, dysuria, cramping pain or feelings of passing kidney
stone. Does note ?hematuria. No fevers, chills, or shortness of
breath.
.
In the ED, initial vs were: T98.7, P116, BP 68/40, R18, O2 sat
99% on RA. UA with WBCs and RBCs. ARF with creatinine 4. Lactate
2.7, AG 21. WBCs 23K with immature forms. Patient was given 3L
IVFs, levofloxacin and metronidazole. BP improved to 90s
systolic. RR in 30s.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, headache, sinus tenderness, cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias. No back pain.


Past Medical History:
 Multiple episodes of postobstructive renal failure related to
nephrolithiasis; creatinine as high as 7. Most recent creatinine
1.7 in 4/[**2118**].
- Nephrolithiasis [**1-1**] hyperPTH with residual calcium stones.
History of L laser lithotripsy, R perc nephrolithotripsy and L
ESWL, intermittent ureteral stents. No current stents in place.

- Primary hyperparathyroidism with resultant hypercalcemia;
surgically corrected.
- History of septic shock [**1-1**] urosepsis in [**1-/2118**] Medical Center


Social History:
Lives with 23 year old daughter. Does not work. Nonsmoker, no
drug use, etoh few times per year only.

Family History:
No DM, coronary disease or cancers per the patient.

Physical Exam:
General: Alert, oriented, no acute distress. Flat affect.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, diffuse
abdominal TTP max in LUQ> LLQ and epigastrium; no rebound
tenderness or guarding, no organomegaly
Back: +nephrostomy drain and pigtail catheter from L flank.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema or rash.


Pertinent Results:
Labs on admission:

[**2120-8-17**] 11:46PM   GLUCOSE-78 UREA N-101* CREAT-2.7* SODIUM-147*
POTASSIUM-3.5 CHLORIDE-114* TOTAL CO2-16* ANION GAP-21*
[**2120-8-17**] 11:46PM   CALCIUM-7.6* PHOSPHATE-3.8 MAGNESIUM-2.0
[**2120-8-17**] 11:46PM   WBC-22.3* RBC-3.78* HGB-9.8* HCT-28.9*
MCV-76* MCH-26.0* MCHC-34.1 RDW-16.0*
[**2120-8-17**] 11:46PM   NEUTS-77* BANDS-6* LYMPHS-9* MONOS-4 EOS-0
BASOS-0 ATYPS-2* METAS-2* MYELOS-0
[**2120-8-17**] 11:46PM   PLT COUNT-243
[**2120-8-17**] 04:05AM   ALT(SGPT)-39 AST(SGOT)-42* LD(LDH)-370* ALK
PHOS-132* AMYLASE-92 TOT BILI-5.6* DIR BILI-4.5* INDIR BIL-1.1
[**2120-8-17**] 12:29AM   LACTATE-2.7*
[**2120-8-16**] 07:00PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-9.0*
LEUK-MOD
[**2120-8-16**] 07:00PM URINE  RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0-2

Micro:
[**2120-8-30**] 3:40 pm ABSCESS      LEFT KIDNEY
   GRAM STAIN (Final [**2120-8-30**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS, CHAINS, AND
CLUSTERS.
      4+   (>10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE ROD(S).

[**2120-8-30**] SWAB (nephrostomy tube) GRAM STAIN-FINAL; WOUND
CULTURE-FINAL {VIRIDANS STREPTOCOCCI}; ANAEROBIC CULTURE-FINAL
[**2120-8-29**] URINE FUNGAL CULTURE-FINAL {[**Female First Name (un) **] ALBICANS}; ACID
FAST CULTURE-PRELIMINARY
[**2120-8-20**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2120-8-17**] URINE URINE-GRAM STAIN - UNSPUN-FINAL; URINE
CULTURE-FINAL {VIRIDANS STREPTOCOCCI} INPATIENT
[**2120-8-16**] BLOOD CULTURE Blood Culture, Routine-FINAL {ANAEROBIC
GRAM POSITIVE ROD(S)}; Anaerobic Bottle Gram Stain-FINAL
EMERGENCY [**Hospital1 **]
[**2120-8-16**] BLOOD CULTURE Blood Culture, Routine-FINAL {ANAEROBIC
GRAM POSITIVE ROD(S), ANAEROBIC GRAM POSITIVE ROD(S)}; Anaerobic
Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]

Labs on discharge:
[**2120-9-11**] 05:00AM BLOOD WBC-7.8 RBC-2.66* Hgb-6.4* Hct-21.4*
MCV-80* MCH-24.2* MCHC-30.1* RDW-21.4* Plt Ct-579*
[**2120-9-5**] 06:17AM BLOOD Neuts-63.6 Lymphs-28.3 Monos-5.7 Eos-1.7
Baso-0.7
[**2120-9-11**] 05:00AM BLOOD Plt Ct-579*
[**2120-9-3**] 06:14AM BLOOD Ret Man-2.8*
[**2120-9-11**] 05:00AM BLOOD Creat-1.1
[**2120-9-4**] 06:31AM BLOOD ALT-9 AST-16 AlkPhos-57 TotBili-0.5
[**2120-8-20**] 05:30AM BLOOD Lipase-39
[**2120-9-4**] 06:31AM BLOOD Albumin-2.2*

Pertinent Imaging:
[**2120-8-16**] CT ABDOMEN AND PELVIS
1. Obstructing stone at distal left ureter, measuring 7 mm and
increase of the left hydronephrosis, with significant amount of
perinephric stranding, and multiple calculi, which suggests
calyceal rupture though additional pyelonephritis not excluded.
Stable hydronephrosis on the right with a small amount of
perinephric stranding. Many renal stones seen in the left lower
calyx and the atrophic right kidney.
2. Peripancreatic stranding, with limited evaluation of pancreas
due to lack of IV contrast. In the appropriate clinical setting,
this finding could indicate acute pancreatitis.
3. Scattered diverticula in the descending colon with paracolic
fat stranding; however, stranding could be from the adjacent
left kidney.
4. Probably normal appendix.
.
[**2120-8-17**] Liver/Gallbladder U/S:
IMPRESSION:
Cholelithiasis without evidence of cholecystitis or
choledocholithiasis.
.
[**2120-8-16**] CXR:
IMPRESSION: Evidence of retrocardiac density - pneumonia versus
progressive atelectasis.
.
[**2120-8-23**] CT ABDOMEN AND PELVIS
IMPRESSIONS:
1. No change in size of low-density perinephric fluid collection
following left percutaneous nephrostomy. Again this likely
reflects a combination of hematoma mixed with urine.
2. Unchanged collection of contrast material posterior to the
left kidney
following procedure.
3. No intraperitoneal or retroperitoneal hematoma to explain
hematocrit drop.
4. 6-mm left ureteral calculus unchanged in location, with
decrease in
hydroureter.
5. Cholelithiasis without cholecystitis.
6. Bilateral renal calculi, unchanged.
.
[**2120-8-26**] UE DOPPLER
IMPRESSION: No left upper extremity DVT
.
[**2120-8-29**] CT ABDOMEN AND PELVIS
IMPRESSION:
1. Increase in size of low-density, perinephric fluid
collection, with
interval increase in number of air foci within the fluid
collection following left percutaneous nephrostomy, while this
may represent a urinoma, seroma or hematoma, superinfection
cannot be excluded.
2. Stable hydronephrosis of the left kidney with mild decrease
in size of
superior subcapsular fluid collection, concerning for calyceal
rupture, as described before.
3. Bilateral renal stones.
4. Atrophic right kidney.
5. Left 7 mm distal ureteral obstructing stone.
6. Stable bilateral small pleural effusion with bilateral
dependent
atelectasis; cannot rule out superinfection.
7. Cholelithiasis.
8. Fibroid uterus.
.
[**2120-9-5**] CT ABDOMEN AND PELVIS
IMPRESSION:
1. Interval improvement in multiloculated bilateral perinephric
collection, with near complete collapse of the left
posterolateral cavity containing a previously placed pigtail
catheter in situ.
2. Bilateral coarse renal calculi and ureteral calculi,
unchanged.
3. No other significant changes with persistent bilateral small
pleural
effusion and basilar atelectasis right hepatic lobe
hypoattenuating lesion, cholelithiasis and fibroid uterus.



Brief Hospital Course:
Ms [**Known lastname 28893**] is 58F with history of nephrolithiasis and
postobstructive renal failure, history of urosepsis, who
presented to the ER with N/V and weakness and found to have
UTI/pyelonephritis, ARF, and severe sepsis.  She was admitted to
the medicine service and a brief summary of her hospital course
organized by problem is described below.

## Sepsis/pyelonephritis/peri-nephric abscess: When patient was
admitted she had fever, leukocytosis, tachycardia with evidence
of end organ dysfunction. Her sepsis was likely due to a urinary
source given her history, UA with bacteria, and appearance of
left kidney.  She had previously had stents, but none currently.
 On HD2 she had a percutaneous nephrostomy placed to decompress
left ureter d/t obstruction with stone.  She was started on a
cipro/cefepime antibiotic regimen. Infectious disease was
consulted on HD 8 and followed her through the course of her
stay.  She improved clinically over the next 11 days.

Despite the nephrostomy placement and antibiotics, her
leukocytosis and intermittent fever resumed on HD11.  She had a
repeat CT scan on HD14 which revealed perinephric abscess. This
was accessed and drained by interventional radiology the
following day.  Antibiotics were changed to meropenem and
vancomycin. Patient defervesced and leukocytosis resolved.
Urology was made aware of her condition, but did not want to
intervene further until her abscess improved.

A repeat CT scan was done on HD21.  It revealed the abscess with
the pigtail catheter was resolving, but that 2 other abscesses
were present.  These were deemed too small to drain by IR and
will likely resolve with antibiotics.  Although the imaging
revealed a resolved abscess, her drain was still putting out
20-40ml of fluid/day.  The decision was made to keep it in.

At the time of discharge she had a normal WBC, was afebrile for
>10days.  Her vancomycin was stopped because she did not grow
out MRSA and her meropenem was changed to ertapenem for ease of
dosing.  According to ID, she will stay on this for 1-2 weeks
after the pigtail catheter drain is taken out.  Exact course
will be determined in her follow-up [**Known lastname 648**] with ID. She was
discharged with instructions for weekly labs (Weekly labs: LFT,
CBC w/ diff and BMP) to monitor for toxicity of the antibiotic.
She was set up with home nursing care to help with the pigtail
catheter drain to her perinephric abscess and the nephrostomy
tube at home.

She will return to discharge clinic this next week and her PCP
the week following.  When her drain stops putting out, she is to
have it clamped for a day.  After that day she will have a
repeat scan of her kidney to make sure the fluid did not
re-accumulate.  This will be coordinated by discharge clinic or
by her PCP.  [**Name10 (NameIs) **] note, she has an aversion to all of the CT scans
and IR Fellow [**First Name8 (NamePattern2) **] [**Doctor Last Name **] pgr[**Pager number 98787**] will protocol her scan to
just the kidney rather than a full abdomen and pelvis.  Please
page her to protocol this scan.

Patient will continue to follow-up with Infectious Diseases as
an outpatient as well.  An [**Pager number 648**] has been made for her.
They will dose and make further changes to her antibiotics.

## Anemia. Pt experienced a significant hct drop in setting of
her illness and IVF: 35->16.2 over course of 10 days  (HD1 to HD
11). Pt refused blood products d/t her religious beliefs
(orthodox Rastafari).  There was no evidence of active bleeding
with exception of small amount from nephrostomy drainage. CT
scan showed no retroperitoneal bleed on HD15. She had an INR of
1.8 on HD4 that was reversed with vitamin K.  Her anemia was
microcytic, but iron studies did not reveal iron deficiency.
Her cipro was stopped d/t concern for medication causing
hemolysis.  Hematology was consulted and did not feel this was
the case.  They started erythropoietin on HD21 ([**8-31**]).  Iron was
started as well.  Her Hct was followed daily and was stable and
slowly increasing on the last 9 hospital days (Hct 17--> 21).

She will follow-up with hematology in clinic and discuss Epo and
iron treatment as an outpatient.  She may be evaluated for G6PD
d/t the Cipro with hematology as well.

## Acute Renal Failure in the setting of CKD. Ms. [**Known lastname 28893**] has CKD
from previous episodes of postrenal failure. Her ARF was likely
due to both her stone obstructing her ureter and her sepsis
limiting flow to the kidney.  Her ARF resolved after the
nephrostomy tube was placed antibiotic therapy started.  Her Cr
went from 4.0 on HD1 to 1.1 at discharge.

## Elevated LFTs. Her bilirubin, transaminases, and LDH were
high at the time of admission. This was thought to be due to
ischemic insult from hypotensive episode. These lab
abnormalities resolved with treatment of urosepsis and IV
hydration. They were rechecked every 4 days and after being
within normal limits on HD11, HD15, and HD 20 they were no
longer checked.

## Nephrolithiasis. Patient has residual stone burden as was
seen previously. In the past she has not wanted to undergo
procedures to resolve this.  Urology put in her left
percutaneous nephrostomy tube, ordered a urine gram stain and
culture which grew out Strep Viridians.  Patient is to follow-up
with Dr. [**Last Name (STitle) 770**] as outpatient to discuss surgical management of
her stones after her infection resolves.  His number is:
[**Telephone/Fax (1) 5727**].  Patient was told that Dr. [**Last Name (STitle) **] could help her
initiate treatment with him again.

##Yeast in urine found on culture X2. She had fluconazole
treatment PO for this.

##Depression: Patient started to feel depressed about the
severity and course ofher treatment.  She did not want to see a
psychiatrist since she "knows the cause of her depression".
Social work was consulted to help her deal with some of her home
issues

## Diarrhea during hospital stay patient had diarrhea for 4
days.  Cdiff negative x 3. Stool sent for guaiac, cx, OP and
nothing was found. She had normal BM for 10days prior to
discharge

## Positive blood cultures.  The only positive blood cultures
revealed organisms suggestive of skin contamination
(propionibacterium and corynebacterium).  Repeat cultures with
no growth for the remainder of stay.

## Hypernatremia.  Patient was found to have hypernatremia (Na:
149) on HD [**1-3**]. With aggressive NS fluid resuscitation it
resolved for the remainder of her hospital course.

## FEN: At the time of discharge patient no longer required IV
fluids, was tolerating a normal diet, and oral medications

## Prophylaxis: Patient had heparin injection for the majority
of her stay.  When she was able ambulate without problem, she
requested pneumo boots/ambulation rather than heparin.  She had
no indication for GI ppx.

## Code: DNR/DNI

## Disposition: Patient discharged home with IV therapy, VNA for
drain care and weekly lab draws, appointments with hematology,
ID, discharge clinic, and her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].

Medications on Admission:
Vit D

Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) ml
Injection QMOWEFR (Monday -Wednesday-Friday) for 1 months.
Disp:*12 ml* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln Injection
DAILY (Daily).
Disp:*30 Recon Soln(s)* Refills:*2*
6. Outpatient Lab Work
Patient needs weekly BMP, CBC, and LFT's drawn while on
ertapenem.  These labs can be entered into the [**Hospital1 **] system to be
followed by all of her physcians


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Severe sepsis
Pyelonephritis
Nephrolithiasis
perinephric abscess


Discharge Condition:
Stable


Discharge Instructions:
You were admitted to the hospital because of a severe infection
that began in your kidney.  This infection likely started
because of a stone obstructing the urine flow from your kidney
to the bladder.  You required drainage of your kidney and a
nearby abscess and an extended course of antibiotics.
.
Please return to the hospital or call your doctor if you have
fever greater than 101, abdominal or back pain, bleeding or pain
with urination, difficulties with your nephrostomy tube, or any
new symptoms that you are concerned about.
.
Since you were admitted, the following changes were made to your
medication regimen:
* ertapenem: this is an antibiotic that will be administered IV
by your home care nurse.  This will be followed by the
infectious disease doctors. [**First Name (Titles) 2172**] [**Last Name (Titles) 648**] with them is listed
below
* Epoetin Alfa : this medicine is for your anemia, it will be
administerd by home health as well.  The hematologists will
follow your course on this medicine.  You have an [**Last Name (Titles) 648**]
with them in 2 days.  The information is below.
* Iron: these pills will help your anemia and this course will
be followed by the hematologists as well.  These medications can
cause constipation, so make sure to eat fiber and take medicines
like colace and senna to help with bowel movements.

Please continue to see the infectious disease doctors, here is
your next [**Last Name (Titles) 648**] information:
[**2120-9-25**]  09:30a   ID,[**First Name8 (NamePattern2) **] [**Doctor Last Name 1037**]
  LM [**Hospital Unit Name **], BASEMENT
  ID WEST (SB)

Please continue to see the hematologists for your anemia.  Your
next [**Hospital Unit Name 648**] information below:
[**2120-9-13**]  11:00a   [**Last Name (LF) **],[**First Name3 (LF) **] J.
  SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
  HEMATOLOGY/ONCOLOGY-SC

You have an [**Location (un) 648**] with discharge clinic at [**Hospital **] on the 20th to assess the drainage of your drain and
to help schedule a repeat CT scan when the drainage stops.
Please get your blood drawn before clinic so they can follow up
your labs. Your [**Hospital 648**] info is below:
[**2120-9-17**]  01:50p   [**Company 191**] POST [**Hospital 894**] CLINIC
  SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
  [**Hospital 191**] MEDICAL UNIT

Please see Dr. [**Last Name (STitle) **] for continuity of your care.  Your
[**Last Name (STitle) 648**] info is below:
[**2120-9-26**]  01:45p   [**Last Name (LF) **],[**First Name3 (LF) **] L.
  [**Hospital6 29**], [**Location (un) **]
  [**Hospital 191**] MEDICAL UNIT

After your infection resolves, Dr [**Last Name (STitle) 770**] (your urologist) will
have to be contact[**Name (NI) **]. At that point you can decide how to
approach the management of your stones and your nephrostomy
(tube draining urine from your kidney).  His number is
[**Telephone/Fax (1) 5727**].  Dr. [**Last Name (STitle) **] can help you reestablish care with him.


Followup Instructions:
Please continue to see the infectious disease doctors, here is
your next [**Last Name (STitle) 648**] information:
[**2120-9-25**]  09:30a   ID,[**First Name8 (NamePattern2) **] [**Doctor Last Name 1037**]
  LM [**Hospital Unit Name **], BASEMENT
  ID WEST (SB)

Please continue to see the hematologists for your anemia.  Your
next [**Hospital Unit Name 648**] information below:
[**2120-9-13**]  11:00a   [**Last Name (LF) **],[**First Name3 (LF) **] J.
  SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
  HEMATOLOGY/ONCOLOGY-SC

You have an [**Location (un) 648**] with discharge clinic at [**Hospital **] on the 20th to assess the drainage of your drain and
to help schedule a repeat CT scan when the drainage stops.
Please get your blood drawn before clinic so they can follow up
your labs. Your [**Hospital 648**] info is below:
[**2120-9-17**]  01:50p   [**Company 191**] POST [**Hospital 894**] CLINIC
  SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
  [**Hospital 191**] MEDICAL UNIT

Please see Dr. [**Last Name (STitle) **] for continuity of your care.  Your
[**Last Name (STitle) 648**] info is below:
[**2120-9-26**]  01:45p   [**Last Name (LF) **],[**First Name3 (LF) **] L.
  [**Hospital6 29**], [**Location (un) **]
  [**Hospital 191**] MEDICAL UNIT

After your infection resolves, Dr [**Last Name (STitle) 770**] (your urologist) will
have to be contact[**Name (NI) **]. At that point you can decide how to
approach the management of your stones and your nephrostomy
(tube draining urine from your kidney).  His number is
[**Telephone/Fax (1) 5727**].  Dr. [**Last Name (STitle) **] can help you reestablish care with him.
{'Unspecified septicemia,Renal and perinephric abscess,Septic shock,Acute kidney failure with lesion of tubular necrosis,Candidiasis of other urogenital sites,Hyperosmolality and/or hypernatremia,Hydronephrosis,Acute posthemorrhagic anemia,Severe sepsis,Leiomyoma of uterus, unspecified,Iron deficiency anemia, unspecified,Primary hyperparathyroidism,Calculus of kidney,Diarrhea,Depressive disorder, not elsewhere classified,Chronic kidney disease, Stage II (mild),Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Other specified cardiac dysrhythmias,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction'}


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: generalized weakness

PRESENT ILLNESS: 58F with history of nephrolithiasis and multiple episodes of
postobstructive renal failure, history of urosepsis; presenting
to ED with weakness, N/V/D x 3 days. Per patient, she has been
generally well except for 3 days ago, when had vomiting shortly
followed by diarrhea. States she has been okay in the last
couple days, but today had a visitor who told her she looked
unwell with weight loss, poor appetite, and abnormal looking
skin. She thus presented to the ED. Denies abdominal pain, back
pain, dysuria, cramping pain or feelings of passing kidney
stone. Does note ?hematuria. No fevers, chills, or shortness of
breath.
.
In the ED, initial vs were: T98.7, P116, BP 68/40, R18, O2 sat
99% on RA. UA with WBCs and RBCs. ARF with creatinine 4. Lactate
2.7, AG 21. WBCs 23K with immature forms. Patient was given 3L
IVFs, levofloxacin and metronidazole. BP improved to 90s
systolic. RR in 30s.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, headache, sinus tenderness, cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias. No back pain.

MEDICAL HISTORY: Multiple episodes of postobstructive renal failure related to
nephrolithiasis; creatinine as high as 7. Most recent creatinine
1.7 in 4/[**2118**].
- Nephrolithiasis [**1-1**] hyperPTH with residual calcium stones.
History of L laser lithotripsy, R perc nephrolithotripsy and L
ESWL, intermittent ureteral stents. No current stents in place.

MEDICATION ON ADMISSION: Vit D

ALLERGIES: Ciprofloxacin

PHYSICAL EXAM: General: Alert, oriented, no acute distress. Flat affect.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present, diffuse
abdominal TTP max in LUQ> LLQ and epigastrium; no rebound
tenderness or guarding, no organomegaly
Back: +nephrostomy drain and pigtail catheter from L flank.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema or rash.

FAMILY HISTORY: No DM, coronary disease or cancers per the patient.

SOCIAL HISTORY: Lives with 23 year old daughter. Does not work. Nonsmoker, no
drug use, etoh few times per year only. 

### Response:
{'Unspecified septicemia,Renal and perinephric abscess,Septic shock,Acute kidney failure with lesion of tubular necrosis,Candidiasis of other urogenital sites,Hyperosmolality and/or hypernatremia,Hydronephrosis,Acute posthemorrhagic anemia,Severe sepsis,Leiomyoma of uterus, unspecified,Iron deficiency anemia, unspecified,Primary hyperparathyroidism,Calculus of kidney,Diarrhea,Depressive disorder, not elsewhere classified,Chronic kidney disease, Stage II (mild),Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Other specified cardiac dysrhythmias,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction'}
