CHIEF COMPLAINT: right upper quadrant pain, nausea, vomiting, fever

PRESENT ILLNESS: 46 year old female status post living-related donor renal
transplant (6 yrs ago), IDDM since age 11 with triopathy,
hypertension, and recent total vaginal hysterectomy with left
oopherectomy, presented with acute onset right upper quadrant
pain, nausea/vomiting, and fevers for a few hours. She was
febrile to 101 on admission, hypertensive, wbc 19 (90% polys, 6%
bands), and creatinine elevated to 2.9 (baseline low 2's).
Urinalysis revealed >50 wbcs and positive nitrite and leukocyte
esterase. She was started on renal dose levaquin for
pyelonephritis x one dose (250 mg IV)in the ED.

MEDICAL HISTORY: GYN HISTORY:
LMP: [**2170-7-17**] CURRENT CONTRACEPTION: None
DATE OF LAST PAP SMEAR: [**2168-9-14**] PLACE: [**Hospital1 18**] RESULT: WNL

MEDICATION ON ADMISSION: 1. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).

ALLERGIES: Darvon

PHYSICAL EXAM: T 97.9 BP 136/66 HR 78 RR 20 O2 96% RA
Gen - Alert, awake, in NAD
HEENT - extraocular motions intact, anicteric, mucous membranes
moist
Neck - supple, no jugular venous distention
Chest - bibasilar minimally coarse BS
CV - Normal S1/S2, regular rate and rhythm, + murmur (not new),
no rubs or gallops, 2+ pulses throughout
Abd - soft, nondistended, normoactive bowel sounds, no masses,
nontender, no rebound or guarding
Extr - warm, no clubbing, cyanosis, or edema
Neuro - AOx3, CN2-12 intact, ambulating well, denies loss of
sensation, face symmetric, tongue non-deviated, no dysarthria

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: divorced with 2 children. 20 pack year smoking history. denied
alcohol or illicit drug use. social pertinents: no HIV risk
factors (recent blood transfusions), trip to [**Location (un) **] this
summer but no other travel, sick contact on day prior to
admission w/ friend who was recovering from pna hospitalization
Complications of transplanted kidney,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Congestive heart failure, unspecified,Acute pyelonephritis without lesion of renal medullary necrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Polyneuropathy in diabetes,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction
Compl kidney transplant,Acute kidney failure NOS,Pneumonia, organism NOS,DMI neuro nt st uncntrld,CHF NOS,Ac pyelonephritis NOS,Hyp kid NOS w cr kid V,Neuropathy in diabetes,Diabetic retinopathy NOS,Nephritis NOS in oth dis,Abn react-org transplant,Cholelithiasis NOS
Admission Date:  [**2171-10-15**]              Discharge Date:   [**2171-10-24**]

Date of Birth:  [**2125-1-14**]             Sex:   F

Service: MEDICINE

Allergies:
Darvon

Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
right upper quadrant pain, nausea, vomiting, fever

Major Surgical or Invasive Procedure:
none


History of Present Illness:
46 year old female status post living-related donor renal
transplant (6 yrs ago), IDDM since age 11 with triopathy,
hypertension, and recent total vaginal hysterectomy with left
oopherectomy, presented with acute onset right upper quadrant
pain, nausea/vomiting, and fevers for a few hours. She was
febrile to 101 on admission, hypertensive, wbc 19 (90% polys, 6%
bands), and creatinine elevated to 2.9 (baseline low 2's).
Urinalysis revealed >50 wbcs and positive nitrite and leukocyte
esterase. She was started on renal dose levaquin for
pyelonephritis x one dose (250 mg IV)in the ED.


Past Medical History:
GYN HISTORY:
LMP: [**2170-7-17**] CURRENT CONTRACEPTION: None
DATE OF LAST PAP SMEAR: [**2168-9-14**] PLACE: [**Hospital1 18**] RESULT: WNL

OB HISTORY:
G: 2 P: 2 LIVE CHILDREN: 2

PAST MEDICAL/SURGICAL HISTORY:
-Type I DM (age 11) - neuropathy, retinopathy, nephropathy
-S/P living, related donor renal transplant (sister) [**2164**], on
stable immunosuppression (rapamune, cellcept) since that time,
no recent changes, denies any known rejection, followed closely
by [**Last Name (un) **]/transplant/renal teams. ESRD [**1-14**] IDDM. baseline
creatinine in the mid 2's.
-Anemia, on procrit/fe, occasional prbc's
-Hypertension
-Hyperlipidemia
-2+ MR, EF >55%, mild LVH
-Peripheral vascular disease s/p femoral-popliteal bypass x 2
-Cerebrovascular Accidents x 2-aphasia, no residual deficits
-Total vaginal hysterectomy on [**2171-8-20**] [**1-14**] menorrhagia, left
oopherectomy for large ovarian cyst; right cyst noted on u/s but
nothing seen in OR so right ovary still in place. Uncomplicated
post op course
-Right breast cyst removal
-Laser eye surgery
-C-section X 2
-Left labial abscess s/p drainage [**4-13**]
-?Septic L ankle joint [**7-17**] s/p tap, irrigation, contaminated
cultures but 62K wbc, >90% polys, no crystals

Allergies: NKDA


Social History:
divorced with 2 children. 20 pack year smoking history. denied
alcohol or illicit drug use. social pertinents: no HIV risk
factors (recent blood transfusions), trip to [**Location (un) **] this
summer but no other travel, sick contact on day prior to
admission w/ friend who was recovering from pna hospitalization

Family History:
non-contributory

Physical Exam:
T 97.9 BP 136/66 HR 78 RR 20 O2 96% RA
Gen - Alert, awake, in NAD
HEENT - extraocular motions intact, anicteric, mucous membranes
moist
Neck - supple, no jugular venous distention
Chest - bibasilar minimally coarse BS
CV - Normal S1/S2, regular rate and rhythm, + murmur (not new),
no rubs or gallops, 2+ pulses throughout
Abd - soft, nondistended, normoactive bowel sounds, no masses,
nontender, no rebound or guarding
Extr - warm, no clubbing, cyanosis, or edema
Neuro - AOx3, CN2-12 intact, ambulating well, denies loss of
sensation, face symmetric, tongue non-deviated, no dysarthria


Pertinent Results:
[**2171-10-24**] 06:50AM BLOOD WBC-9.2 RBC-2.97* Hgb-7.6* Hct-24.3*
MCV-82 MCH-25.7* MCHC-31.4 RDW-16.5* Plt Ct-700*
[**2171-10-23**] 07:00AM BLOOD WBC-8.6 RBC-2.72* Hgb-7.1* Hct-22.5*
MCV-83 MCH-26.3* MCHC-31.6 RDW-17.0* Plt Ct-624*
[**2171-10-21**] 06:30AM BLOOD WBC-12.9* RBC-3.10* Hgb-8.0* Hct-26.0*
MCV-84 MCH-25.8* MCHC-30.8* RDW-16.1* Plt Ct-649*
[**2171-10-20**] 04:51AM BLOOD WBC-12.4* RBC-3.26* Hgb-8.3* Hct-26.9*
MCV-83 MCH-25.5* MCHC-31.0 RDW-16.0* Plt Ct-626*
[**2171-10-19**] 05:57AM BLOOD WBC-13.8* RBC-3.22* Hgb-8.3* Hct-27.0*
MCV-84 MCH-25.7* MCHC-30.7* RDW-15.9* Plt Ct-557*
[**2171-10-18**] 07:10AM BLOOD WBC-18.8* RBC-3.39* Hgb-8.8* Hct-27.8*
MCV-82 MCH-26.1* MCHC-31.8 RDW-16.6* Plt Ct-519*
[**2171-10-17**] 03:59PM BLOOD WBC-19.1* RBC-3.70* Hgb-9.7* Hct-30.0*
MCV-81* MCH-26.2* MCHC-32.4 RDW-16.2* Plt Ct-555*
[**2171-10-17**] 06:55AM BLOOD WBC-16.7* RBC-3.28* Hgb-8.7* Hct-26.5*
MCV-81* MCH-26.4* MCHC-32.6 RDW-16.1* Plt Ct-507*
[**2171-10-16**] 09:00AM BLOOD WBC-19.9* RBC-3.83* Hgb-10.1*# Hct-31.8*
MCV-83 MCH-26.5* MCHC-31.9 RDW-15.4 Plt Ct-539*
[**2171-10-15**] 01:35PM BLOOD WBC-17.7* RBC-3.25* Hgb-8.0* Hct-27.4*
MCV-84 MCH-24.6* MCHC-29.2* RDW-16.1* Plt Ct-648*
[**2171-10-14**] 09:10PM BLOOD WBC-18.5* RBC-3.52* Hgb-8.9* Hct-27.8*
MCV-79*# MCH-25.4* MCHC-32.1 RDW-15.8* Plt Ct-649*
[**2171-10-24**] 06:50AM BLOOD Neuts-78.7* Lymphs-13.6* Monos-5.0
Eos-2.1 Baso-0.6
[**2171-10-22**] 07:05AM BLOOD Neuts-81* Bands-0 Lymphs-11* Monos-7
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2171-10-16**] 09:00AM BLOOD Neuts-87* Bands-6* Lymphs-1* Monos-5
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2171-10-15**] 01:35PM BLOOD Neuts-81* Bands-6* Lymphs-6* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2171-10-14**] 09:10PM BLOOD Neuts-89* Bands-6* Lymphs-2* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2171-10-24**] 06:50AM BLOOD Glucose-86 UreaN-32* Creat-2.7* Na-138
K-3.8 Cl-106 HCO3-19*
[**2171-10-23**] 07:00AM BLOOD Glucose-170*UreaN-36*Creat-3.0* Na-142
K-4.0 Cl-109* HCO3-19*
[**2171-10-22**] 03:55PM BLOOD Glucose-93 UreaN-38* Creat-3.1* Na-141
K-3.3 Cl-107 HCO3-17*
[**2171-10-22**] 07:05AM BLOOD Glucose-161*UreaN-39*Creat-3.4* Na-140
K-4.0 Cl-106 HCO3-18*
[**2171-10-21**] 06:30AM BLOOD Glucose-183*UreaN-37* Creat-2.8* Na-140
K-3.9 Cl-108 HCO3-18*
[**2171-10-20**] 04:51AM BLOOD Glucose-109*UreaN-32*Creat-2.9* Na-142
K-3.6 Cl-110* HCO3-18*
[**2171-10-19**] 05:57AM BLOOD Glucose-71 UreaN-37* Creat-3.0* Na-140
K-3.4 Cl-107 HCO3-17*
[**2171-10-18**] 07:10AM BLOOD Glucose-227*UreaN-44*Creat-3.3* Na-135
K-3.9 Cl-102 HCO3-14*
[**2171-10-17**] 06:55AM BLOOD Glucose-82 UreaN-36* Creat-3.1* Na-132*
K-3.6 Cl-101 HCO3-18*
[**2171-10-16**] 09:00AM BLOOD Glucose-152*UreaN-35* Creat-2.8* Na-139
K-3.8 Cl-105 HCO3-20*
[**2171-10-15**] 01:35PM BLOOD Glucose-42* UreaN-36* Creat-2.9* Na-143
K-3.9 Cl-108 HCO3-22
[**2171-10-14**] 09:10PM BLOOD Glucose-103 UreaN-43* Creat-2.9* Na-141
K-4.1 Cl-103 HCO3-23 -
[**2171-10-19**] 05:57AM BLOOD ALT-9 AST-8 CK(CPK)-86 AlkPhos-80
TotBili-0.3
[**2171-10-18**] 07:10AM BLOOD LD(LDH)-174 CK(CPK)-93
[**2171-10-14**] 09:10PM BLOOD ALT-13 AST-13 AlkPhos-85 Amylase-31
TotBili-0.2 Lipase-13
[**2171-10-24**] 06:50AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.0
[**2171-10-15**] 01:35PM BLOOD Calcium-8.4 Phos-3.7 Mg-1.9
[**2171-10-16**] 09:00AM BLOOD calTIBC-267 VitB12-639 Folate->20.0
Ferritn-119 TRF-205
[**2171-10-18**] 07:10AM BLOOD Osmolal-293
[**2171-10-22**] 03:55PM BLOOD Vanco-14.4*
[**2171-10-18**] 03:45PM BLOOD Type-ART pO2-68* pCO2-28* pH-7.36
calHCO3-16* Base XS--7
[**2171-10-18**] 03:12PM BLOOD Type-ART pO2-43* pCO2-27* pH-7.38
calHCO3-17* Base XS--7
[**2171-10-18**] 03:36AM BLOOD Type-ART pO2-61* pCO2-32* pH-7.32*
calHCO3-17* Base XS--8
[**2171-10-18**] 03:12PM BLOOD Lactate-1.5
[**2171-10-17**] 07:41PM BLOOD Lactate-1.1
.
TOXOPLASMA IgG & IgM ANTIBODY (Final [**2171-10-18**]): NEGATIVE FOR
TOXOPLASMA ANTIBODY
CMV IgG & IgM  ANTIBODY (Final [**2171-10-18**]): NEGATIVE FOR CMV IgG
ANTIBODY BY EIA.
MONOSPOT (Final [**2171-10-18**]): NEGATIVE BY LATEX AGGLUTINATION.
CRYPTOCOCCAL ANTIGEN (Final [**2171-10-18**]): CRYPTOCOCCAL ANTIGEN NOT
DETECTED.
Rapid Respiratory Viral Antigen Test (Final [**2171-10-19**]): not
detected.
[**2171-10-20**] 4:52 am BLOOD CULTURES x2
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
[**2171-10-18**] 9:44 pm BLOOD CULTURES x2
AEROBIC BOTTLE (Final [**2171-10-24**]):    NO GROWTH.
ANAEROBIC BOTTLE (Final [**2171-10-24**]):    NO GROWTH.
BLOOD/FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.
[**2171-10-16**] 4:00 pm BLOOD CULTURES x3
AEROBIC BOTTLE (Final [**2171-10-22**]):    NO GROWTH.
ANAEROBIC BOTTLE (Final [**2171-10-22**]):    NO GROWTH.
[**2171-10-15**] 3:50 pm BLOOD CULTURE
AEROBIC BOTTLE (Final [**2171-10-21**]):    NO GROWTH.
ANAEROBIC BOTTLE (Final [**2171-10-21**]):    NO GROWTH.
.
[**2171-10-24**] 02:11AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.015
[**2171-10-23**] 07:58PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2171-10-22**] 05:11PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2171-10-20**] 10:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2171-10-19**] 10:00AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2171-10-17**] 11:37AM URINE Color-Yellow Appear-SlHazy Sp [**Last Name (un) **]-1.020
[**2171-10-15**] 06:19PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2171-10-14**] 09:59PM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.018
[**2171-10-24**] 02:11AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2171-10-23**] 07:58PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2171-10-22**] 05:11PM URINE Blood-LGE Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2171-10-20**] 10:00PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2171-10-17**] 11:37AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2171-10-15**] 06:19PM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2171-10-14**] 09:59PM URINE Blood-LG Nitrite-POS Protein-500
Glucose-100 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2171-10-24**] 02:11AM URINE RBC-31* WBC-68* Bacteri-OCC Yeast-NONE
Epi-<1
[**2171-10-23**] 07:58PM URINE RBC-25* WBC-101* Bacteri-NONE Yeast-NONE
Epi-<1
[**2171-10-22**] 05:11PM URINE RBC-27* WBC->1000* Bacteri-NONE
Yeast-NONE Epi-<1
[**2171-10-20**] 10:00PM URINE RBC-3* WBC-0 Bacteri-RARE Yeast-NONE
Epi-<1
[**2171-10-19**] 10:00AM URINE RBC-5* WBC-0 Bacteri-OCC Yeast-NONE
Epi-<1
[**2171-10-15**] 06:19PM URINE RBC-23* WBC-106* Bacteri-MANY Yeast-NONE
Epi-<1
[**2171-10-14**] 09:59PM URINE RBC-[**5-23**]* WBC->50 Bacteri-MANY Yeast-NONE
Epi-<1
[**2171-10-22**] 05:11PM URINE Eos-NEGATIVE
[**2171-10-22**] 05:11PM URINE Hours-RANDOM UreaN-612 Creat-124 Na-52
[**2171-10-19**] 10:00AM URINE Hours-RANDOM UreaN-492 Creat-56 Na-61
TotProt-119 Prot/Cr-2.1*
[**2171-10-17**] 11:37AM URINE Hours-RANDOM Creat-94 Na-34 Calcium-0.0
[**2171-10-22**] 05:11PM URINE Osmolal-474
URINE CULTURE (Final [**2171-10-24**]):    NO GROWTH.
URINE CULTURE (Final [**2171-10-22**]): YEAST.  10,000-100,000
ORGANISMS/ML.
Legionella Urinary Antigen (Final [**2171-10-21**]): NEGATIVE
URINE CULTURE (Final [**2171-10-21**]) NO GROWTH. FUNGAL CULTURE:NO
YEAST ISOLATED.
.
MRI PELVIS W/O & W/CONTRAST  [**2171-10-22**] 9:17 AM 1) Large simple
cyst within the mid pelvis. The ovaries are not well visualized.
The differential diagnosis includes recurrence of an ovarian
cyst vs. a urinoma or lymphocele in patient who is status post
renal transplant. 2) Hydroureteral nephrosis of the right native
kidney with obstruction of the right native ureter at the level
of the pelvic cyst mass.
.
CT ABDOMEN W/O CONTRAST  [**2171-10-16**] 5:12 PM 1. Bilateral atrophic
kidneys consistent with endstage renal disease. However, mild
enlargement of the right kidney with respect to the left,with
noted mild hydronephrosis and hydroureter up to the level of a
thin band of soft tissue adjacent to the sidewall of the noted
mid-pelvic
cyst seen on ultrasound examination. This could represent the
native ovary with a large ovarian cyst although a focal lesion
at this level is not excluded. Correlation with pelvic
ultrasound is recommended. The possibility of a urinoma can't be
excluded. Other possibilities include a lymphocele or a
peritoneal inclusion cyst.2. Multiple small gallstones in
otherwise normal gallbladder.
.
PELVIS, NON-OBSTETRIC PELVIS U.S., TRANSVAGINAL [**2171-10-14**] 10:09
AM Status post hysterectomy with a right hemorrhagic cyst
adjacent to a fluid collection. This may represent a peritoneal
inclusion cyst. Although it has been only a short interval from
the prior exam, this cystic structure may represent a new
physiologic cyst.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN)  [**2171-10-14**] 11:22 PM
Cholelithiasis without cholecystitis. Atrophic native right
kidney.
.
ECHO [**2171-10-21**]  The left atrium is mildly dilated. There is mild
symmetric left ventricular  hypertrophy. The left ventricular
cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear  structurally normal with good
leaflet excursion and no aortic regurgitation.  The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is moderate pulmonary artery systolic hypertension. There
is an anterior space which most likely represents a fat pad,
though a loculated anterior pericardial effusion cannot be
excluded.
.
-CHEST (PA & LAT)  [**2171-10-20**] 11:38 AM Allowing for differences in
technique, there is no significant change in extent or
appearance of the alveolar opacities at both bases, or the
bilateral pleural effusions.
-CHEST (PA & LAT)  [**2171-10-19**] 4:23 PM The heart is enlarged. There
is mild vascular congestion with mild interstitial edema. There
are more focal alveolar opacities at both bases consistent with
bibasilar pneumonias. There are small bilateral pleural
effusions. Compared to [**2171-10-18**], the left effusion appears
slightly increased in size. No other changes are noted.
-CHEST (PORTABLE AP)  [**2171-10-18**] 3:13 PM Progressive right middle
and right lower lobe pneumonia. New opacity in left lower lobe
which may represent additional site of pneumonia or aspiration
event. New bilateral septal lines, which may be due to
interstitial edema from fluid overload or may reflect an
interstitial component of the infection.
-CHEST (PA & LAT)  [**2171-10-17**] 9:25 AM Focal faint opacities in the
right costophrenic angle, most likely representing pleural
effusion and atelectasis noted on the recent abdominal CT scan.
However, early pneumonia is also a consideration. Please
correlate clinically, andwith follow-up x-rays.
.




Brief Hospital Course:
46 year old lady status post living, related donor renal
transplant, IDDM, hypertension, recent total vaginal
hysterectomy and left oopherectomy who presented with
pyelonephritis, an enlarging pelvic cyst, right
hydroureter/hydronephrosis of her native kidney, rising
creatinine, and subsequently developed right middle and lower
lobe pneumonia with worsening hypoxia during her hospital
course.
.
FEVER, LEUKOCYTOSIS, BANDEMIA: Initially, her symptoms improved
but the fevers, leukocytosis, bandemia, and creatinine elevation
persisted so she was changed to ceftriaxone x 2 days for
treatment of pyelonephritis. Her nausea, vomiting, and abdominal
pain resolved within one day of starting the broad spectrum
antibiotics and she tolerated a regular diabetic and cardiac
prudent diet throughout her hospital stay. Given results of
urinalysis and the clinical picture, UTI/pyelonephritis was the
likely cause of the patient's presenting abdominal pain,
nausea/vomiting, fever, and bandemia.  Right upper quadrant
ultrasound was negative for hepatobiliary abnormalities.  The
gyn service was consulted since the patient had transvaginal
hysterectomy 1.5 months prior to admission.  Their gynecologic
exam was negative and the surgical suture felt to be intact.
Abdominal CT with contrast and MRI showed right-sided
hydroureter of the native kidney and a large central pelvic cyst
(larger than on preoperative ultrasound). The right sided
transplanted kidney appeared normal.  Because of persistent
fever, she was started on IV vancomycin (one dose, [**10-16**]) and
oral flagyl (3 doses, [**Date range (1) 25351**]). On [**10-16**] overnight, the patient
had a bout of dry coughing accompanied by acute onset dyspnea
with desaturation to 88%, possibly the result of aspiration.
Chest x ray revealed developed right middle and lower lobe
infiltrates. She was then started on zosyn [**10-18**]. Microbiological
data was negative for multiple blood cultures, including fungal
cultures. Urine cultres were negative for growth except for
culture [**10-20**] which grew 10-[**Numeric Identifier 4856**] yeast. However, urine cultures
were obtained after starting antibiotic therapy. Vaginal swab
was negative for bacterial vaginosis.  Cryptococcus antigen, CMV
antibody, toxoplamosis, and monospot were all negative. In
[**2171-7-14**], CMV virus was not detected, and screens for active
EBV and toxoplasmosis were negative. Urine was negative for
legionella antigen. No flu virus has been isolated from
nasopharyngeal swab.
.
PYELONEPHRITIS was possibly secondary to obstruction created by
enlarging pelvic cyst and sharing of the ureter among the right
native and transplanted kidney. It is also possible that the
enlarging pelvic cyst has a communication with the ureter,
although this has not been demonstrated on CT or MRI. The
patient will need to follow up with transplant nephrology and
urology as an outpatient to further evaluate and treat the
hydroureter/hydronephrosis. Both services were consulted during
this admission. Serial urinalyses demonstrated reduction of
wbc's over time and the final urine culture obtained was
negative. She continued a course of oral levoquin and
fluconazole at discharge (suggsested by urology service to cover
for candiduria).
.
PELVIC CYST: The differential diagnosis on MRI included ovarian
cyst vs. a urinoma or lymphocele in patient who is status post
renal transplant. However, ovarian cyst is not likely given that
the right ovary was examined during hysterectomy without
appearance of a cyst. Additionally, the pelvic cyst had been
seen prior to hysterectomy by ultrasound, although it was much
smaller in size at the time.  It is now enlarged and more
central. Drainage of this cyst will likely need to be performed
as an outpatient to relieve the renal obstruction and to aid
further diagnosis.
.
PNEUMONIA: While it is not fully clear, it is likely that the
patient developed pneumonia secondary to aspiration with
coughing in the middle of the night [**10-16**]. There was no initial
chest x ray performed at admission.  After [**10-16**], she developed
worsening right middle and lower lobe infiltrates and hypoxia.
On [**10-18**], she was tranferred to the ICU for worsened hypoxia and
concern for atypical infection versus progression to ARDS. In
the ICU, the patient was treated with nonrebreather mask oxygen
supplementation, albuterol/atrovent nebulizer, IV lasix, and
changed to levoquin, zosyn, along with vancomycin that were
continued until time of discharge. Her respiratory status
improved rapidly, suggesting she may have had flash pulmonary
edema or rapid decompensation. Chest xray showed small,
bilateral effusions that were resolving. Given the patient is
immunsuppressed taking cellcept and rapamune, concern for
infection by MRSA, legionella, histoplasmosis, PCP, [**Name10 (NameIs) **] atypical
organisms was expressed by the infectious disease consultants.
Sputum culture was contaminated.  She continued a course of oral
levoquin and fluconazole at discharge.
.
INCREASED CREATININE: Creatinine increased over the past 2
months from 2.2 to a peak of 3.3, with an unclear role of the
enlarging pelvic fluid mass and pyelonephritis. Creatinine had
been trending downward since [**10-19**] with IV hydration and good
urine output; however, it bumped from 2.8 to 3.4 on [**10-22**] after 2
doses 20mg IV lasix on [**10-21**]. Repeat urinalysis included sterile
pyuria (>1000 WBC). Subsequently, the patient's renal function
improved with better oral intake and witholding of lasix (3.4
-->3.0 [**10-23**]). Prerenal cause for dysfunction was suspected with
pyuria secondary to candiduria (unlikely communication with
pelvic cyst). Acute on chronic renal failure was possibly
secondary to the obstruction; however, it is not clear if the
native kidney plays any role in the analysis of creatinine
clearance. Urine output was uncompromised during the hosptial
course and the transplanted kidney appeared in good condition on
imaging. There were no clear signs of transplant rejection
although it is likely a chronic, low level process that may have
been exacerbated by use of lasix.  Medications were renally
dosed.
.
CHRONIC ANEMIA: Baseline HCT usually ranges from 25-30 as a
result of chronic disease. HCT increased from 27 to 31 after 2
units PRBCs on [**10-15**].  Dosage of procrit was increased per renal
consult recommendation and iron supplementation was continued.
.
HYPERTENSION: She was continued on home regimen including
metoprolol and nifedipine. Her home dose of lasix was held.
.
HYPERCHOLESTEROLEMIA: Lipitor was continued.
.
DIABETES: She was coninued on her regular schedule of humulin 30
units daily with sliding scale administration of humalog
insulin.
.
PERIPHERAL VASCULAR DISEASE: ASA, lipitor, metoprolol, and
nifedipine were continued.




Medications on Admission:
1. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).

2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
4. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
5. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000 units Injection
QMOWEFR (Monday -Wednesday-Friday). Disp:*qs units* Refills:*2*
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QFRI (every Friday).
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous qam.
9. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: as per SS
below units Subcutaneous four times a day: 2 units BG 150-200 4
units BG 201-250 6 units BG 251-300 8 units BG 301-350 10 units
BG 351-400.
10. Tricor 54 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lipitor 10 mg Tablet Sig: One (1) Tablet PO at bedtime.


Discharge Medications:
1. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).

2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
4. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
5. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000  units
Injection QMOWEFR (Monday -Wednesday-Friday).
Disp:*qs units* Refills:*2*
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QFRI (every Friday).
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous qam.
9. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: as per SS
below units Subcutaneous four times a day: 2 units BG 150-200
4 units BG 201-250
6 units BG 251-300
8 units BG 301-350
10 units BG 351-400.
10. Tricor 54 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lipitor 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 7 days: to start on [**10-25**].
Disp:*3 Tablet(s)* Refills:*0*
13. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 12 days: to start [**10-25**].
Disp:*12 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
pyelonephritis
pneumonia, nosocomial
candiduria
pelvic cyst
acute on chronic renal failure
s/p renal transplant


Discharge Condition:
afebrile, tolerating oral diet

Discharge Instructions:
Continue with current antibiotics to complete a 14 day course of
Levofloxacin and 14 day course of fluconazole. Return to ED in
case of recurrent fevers, abdominal pain, or inability to
tolerate oral intake.  Hold iron supplementation while taking
levofloxacin.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2172-7-22**] 9:00

Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 25352**] Call to schedule
appointment

in [**2-15**] days for repeat blood work and urinalysis.



Schedule outpatient appointment with Dr. [**Last Name (STitle) **] in [**12-14**] weeks
post-discharge - ([**Telephone/Fax (1) 3618**].



Please call for a urology followup appointment with Dr. [**Last Name (STitle) **]
in one month, as there is concern for the hydroureter in your
native kidney given that your kidney is not working properly.
The phone number is ([**Telephone/Fax (1) 772**].



Call for an appointment with Dr.[**Doctor Last Name 4849**] (nephrology) at ([**Telephone/Fax (1) 18591**] for within 2-4 weeks.
{'Complications of transplanted kidney,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Congestive heart failure, unspecified,Acute pyelonephritis without lesion of renal medullary necrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Polyneuropathy in diabetes,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,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: right upper quadrant pain, nausea, vomiting, fever

PRESENT ILLNESS: 46 year old female status post living-related donor renal
transplant (6 yrs ago), IDDM since age 11 with triopathy,
hypertension, and recent total vaginal hysterectomy with left
oopherectomy, presented with acute onset right upper quadrant
pain, nausea/vomiting, and fevers for a few hours. She was
febrile to 101 on admission, hypertensive, wbc 19 (90% polys, 6%
bands), and creatinine elevated to 2.9 (baseline low 2's).
Urinalysis revealed >50 wbcs and positive nitrite and leukocyte
esterase. She was started on renal dose levaquin for
pyelonephritis x one dose (250 mg IV)in the ED.

MEDICAL HISTORY: GYN HISTORY:
LMP: [**2170-7-17**] CURRENT CONTRACEPTION: None
DATE OF LAST PAP SMEAR: [**2168-9-14**] PLACE: [**Hospital1 18**] RESULT: WNL

MEDICATION ON ADMISSION: 1. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).

ALLERGIES: Darvon

PHYSICAL EXAM: T 97.9 BP 136/66 HR 78 RR 20 O2 96% RA
Gen - Alert, awake, in NAD
HEENT - extraocular motions intact, anicteric, mucous membranes
moist
Neck - supple, no jugular venous distention
Chest - bibasilar minimally coarse BS
CV - Normal S1/S2, regular rate and rhythm, + murmur (not new),
no rubs or gallops, 2+ pulses throughout
Abd - soft, nondistended, normoactive bowel sounds, no masses,
nontender, no rebound or guarding
Extr - warm, no clubbing, cyanosis, or edema
Neuro - AOx3, CN2-12 intact, ambulating well, denies loss of
sensation, face symmetric, tongue non-deviated, no dysarthria

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: divorced with 2 children. 20 pack year smoking history. denied
alcohol or illicit drug use. social pertinents: no HIV risk
factors (recent blood transfusions), trip to [**Location (un) **] this
summer but no other travel, sick contact on day prior to
admission w/ friend who was recovering from pna hospitalization 

### Response:
{'Complications of transplanted kidney,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Congestive heart failure, unspecified,Acute pyelonephritis without lesion of renal medullary necrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Polyneuropathy in diabetes,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction'}
