CHIEF COMPLAINT: Nausea and Vomiting

PRESENT ILLNESS: 3 yo F w/ PMH of IgA nephropathy s/p failed cadaveric transplant
on HD via Left AV fistula, Afib/flutter (on coumadin), Diastolic
heart failure and hx of malignant hypertension p/w nausea and
vomiting x 3 days. Pt reports she was in her USOH when on [**10-3**]
she developed nausea vomiting, diarrhea 6-7x/day, and headache.
She reports she would start vomiting everytime she would try to
drink anything, and then would have diarrhea with incontinece.
She missed her dialysis yesterday and on day of admission felt
wek and dizzy and called EMS to bring her to the ED. On arrival
to the ED her initial vitals were 100.3, 125/61, 16, 97% RA. CXR
showed mild pulmonary edema and gave 1L bolus. And labs were
signficant for K=5.3, Lactate- 4.2, anion gap of 29, WBC 15.1
with 91.6%PMN and INR=3.3. Renal felt she needed urgent dialysis
to assist with hyperkalemia. She had a pneumonia with
respiratory failure and hyperkalemia in [**2-/2198**] where she was
intubated and treated with Vanc/Cefepime for 7 day course
without growth in cultures.
.
In dialysis, she did not have any ultrafiltrate as she was felt
to be below her dry weight. She was AAOx3 and conversant. She
was given tylenol and carvedilol and transferred to the floor.
.
On arrival to the floor her initial VS were 100.1, 176/80, 80,
30, 93%2L. She was difficult to arose, was oriented to person
and not answering questions, and no further history was able to
be obtained. Patient triggered 1 hour after arriving on the
floor, had an ABG which was signficant for 7.57/34/71/32,
showing a metabolic alkalosis, metabolic gap acidosis. Patient
was complaining of feeling hot and her temp was 102.4, she was
given 1g acetaminophen. After 1 hour her O2 sats improved to 98%
on 2L, and she was more coherent. And was able togive the
following additional history: Patient reports not taking her
coumdain x multiple days because unable to keep anything down.
She denies sick contacts aside from being in dialysis 3x/week.
She denies cough or rhinorrhea. she complains of headache that
is frontal with some right facial pain. No changes in vision, no
neck stiffness, no tick exposures and does not spend much time
outdoors.

MEDICAL HISTORY: 1. Atrial fibrillation/flutter: first diagnosed in [**Month (only) **]
[**2195**].
2. End-stage renal disease on hemodialysis secondary to IgA
nephropathy s/p cadaveric kidney transplant in [**2173**] which has
eventually failed, and started on hemodialysis in [**2193**].
3. History of upper GI bleeding on [**2195-2-20**] with evidence
of
esophagitis, gastric ulcer, and bleeding duodenal vessel s/p
clipping, cauterization and PPI.
4. Diastolic heart failure supported by an echocardiography from

MEDICATION ON ADMISSION: Medications per OMR, unable to verify with patient at this time.
AMIODARONE - 200 mg Tablet - 1 Tablet(s) by mouth daily
AMLODIPINE - (Dose adjustment - no new Rx) (Not Taking as
Prescribed: pt states not taking) - 5 mg Tablet - 2 Tablet(s) by
mouth once a day
CALCIUM ACETATE - (Prescribed by Other Provider) - 667 mg
Capsule - 3 Capsule(s) by mouth three times a day with meals and
1 tab with snack
CARVEDILOL - 6.25 mg Tablet - 1 Tablet(s) by mouth twice daily
CINACALCET [SENSIPAR] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 30 mg Tablet - 1 Tablet(s) by mouth
twice daily
CITALOPRAM - 40 mg Tablet - 1.5 Tablet(s) by mouth qam
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth once a day
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth once a day Name Brand Only, No Substitutions - No
Substitution
SEVELAMER CARBONATE [RENVELA] - (Prescribed by Other Provider) -
800 mg Tablet - 3 Tablet(s) by mouth three times a day with
meals
and 1 tab with snack
SODIUM POLYSTYRENE SULFONATE - (Dose adjustment - no new Rx) -
Powder - 15grams Powder(s) by mouth every Saturday and Sunday
WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 1
Tablet(s) by mouth once a day take up to 4 tablets a day on
m-w-f adn 2 tabs on tu-[**Last Name (un) **]-sat sun per inr results
Medications - OTC
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1
cap Capsule(s) by mouth once daily

ALLERGIES: Dilantin Kapseal

PHYSICAL EXAM: Physical Exam on Admission:
Vitals: 100.1, 176/80, 80, 30, 93%2L
General: Somulent, arousable when spoken to and then becomes
unresponsive. Responsive to pain with moaning and withdrawal. At
times speaking incoherent sentences.
HEENT: Sclera anicteric, mild conjunctival pallor.
MMM, oropharynx clear
Neck: able to move chin to chest on patient, JVP elevated to
>10, no LAD appreciated
Lungs: Difficult to assess based on patient unable to cooperate
with exam, but moving air bilaterally, no obvious crackles
rhonchi or wheezes appreciated.
CV: Regular rate and rhythm, normal S1 + S2. 2/6 Systolic mumur
heard best at the LUSB
Abdomen: soft, +[**Doctor Last Name 515**] sign (patient opened eyes and yelled on
palpation), and tender in epigastric area. Nondistended, +BS, no
rebound or guarding.
Ext: warm, well-perfused. no cyanosis, clubbing, or edema.
Neuro: Unable to fully assess due to mental status, but moving
all four extremities
.
Physical Exam on Discharge:
VS: T 98.2 135/72 84 18 92%RA
GENERAL: NAD. Oriented x3. Alert and talkative
HEENT: NCAT. Sclera anicteric.
NECK: Supple JVP flat
CARDIAC: Irregularly irregular with tachycardia.  harsh
diastolic murmur best heard at LUSB but radiating throughout
precordium. No S3/S4
LUNGS: CTAB, decreased breath sounds in b/l bases. No E->A
changes
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. Left arm with fistula
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas, nails
without splinter hemorrhages
NEURO: A+Ox3, CN II-XII intact, strength 5/5 in all extremities,
speech normal
LN: No palpable LN in ant/post neck, submandibula,
supraclavicula, axilla, femoral, or popliteal fossa bilaterally
Biopsy site in Right supraclavicular region without any
erythema, drainage or tenderness.

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Her father
died at the age of 80. Her mother died at the age of 64 from
lung CA. She has a sister with breast CA. MI in uncle in his
60s.

SOCIAL HISTORY: Single, lives by herself in [**Location (un) 686**], and has no children. She
quit smoking 25 years ago (10-pack-years). She rarely drinks
alcohol, and denies illicit drug use. She used to work part-time
in a coffee shop, but currently does not work.
Acute and subacute bacterial endocarditis,Acute respiratory failure,Pneumonia, organism unspecified,End stage renal disease,Cerebral embolism with cerebral infarction,Septic pulmonary embolism,Bacteremia,Complications of transplanted kidney,Chronic diastolic heart failure,Acidosis,Atrioventricular block, complete,Septic arterial embolism,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease,Secondary malignant neoplasm of bone and bone marrow,Atrial flutter,Arteriovenous fistula, acquired,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other malignant neoplasm without specification of site,Anemia in chronic kidney disease,Dysthymic disorder,Enlargement of lymph nodes,Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney,Personal history of tobacco use,Renal dialysis status,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Ac/subac bact endocard,Acute respiratry failure,Pneumonia, organism NOS,End stage renal disease,Crbl emblsm w infrct,Septic pulmonary embolsm,Bacteremia,Compl kidney transplant,Chr diastolic hrt fail,Acidosis,Atriovent block complete,Septic arterial embolism,Ben hyp kid w cr kid V,Secondary malig neo bone,Atrial flutter,Acq arterioven fistula,Mth sus Stph aur els/NOS,DMII renl nt st uncntrld,Malignant neoplasm NOS,Anemia in chr kidney dis,Dysthymic disorder,Enlargement lymph nodes,Nephritis NOS,History of tobacco use,Renal dialysis status,Abn react-org transplant
Admission Date:  [**2198-10-6**]              Discharge Date:   [**2198-10-19**]

Date of Birth:  [**2134-9-9**]             Sex:   F

Service: MEDICINE

Allergies:
Dilantin Kapseal

Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
Nausea and Vomiting

Major Surgical or Invasive Procedure:
Fine needle aspiration of lymph node


History of Present Illness:
3 yo F w/ PMH of IgA nephropathy s/p failed cadaveric transplant
on HD via Left AV fistula, Afib/flutter (on coumadin), Diastolic
heart failure and hx of malignant hypertension p/w nausea and
vomiting x 3 days. Pt reports she was in her USOH when on [**10-3**]
she developed nausea vomiting, diarrhea 6-7x/day, and headache.
She reports she would start vomiting everytime she would try to
drink anything, and then would have diarrhea with incontinece.
She missed her dialysis yesterday and on day of admission felt
wek and dizzy and called EMS to bring her to the ED. On arrival
to the ED her initial vitals were 100.3, 125/61, 16, 97% RA. CXR
showed mild pulmonary edema and gave 1L bolus. And labs were
signficant for K=5.3, Lactate- 4.2, anion gap of 29, WBC 15.1
with 91.6%PMN and INR=3.3. Renal felt she needed urgent dialysis
to assist with hyperkalemia. She had a pneumonia with
respiratory failure and hyperkalemia in [**2-/2198**] where she was
intubated and treated with Vanc/Cefepime for 7 day course
without growth in cultures.
.
In dialysis, she did not have any ultrafiltrate as she was felt
to be below her dry weight. She was AAOx3 and conversant. She
was given tylenol and carvedilol and transferred to the floor.
.
On arrival to the floor her initial VS were 100.1, 176/80, 80,
30, 93%2L. She was difficult to arose, was oriented to person
and not answering questions, and no further history was able to
be obtained. Patient triggered 1 hour after arriving on the
floor, had an ABG which was signficant for 7.57/34/71/32,
showing a metabolic alkalosis, metabolic gap acidosis. Patient
was complaining of feeling hot and her temp was 102.4, she was
given 1g acetaminophen. After 1 hour her O2 sats improved to 98%
on 2L, and she was more coherent. And was able togive the
following additional history: Patient reports not taking her
coumdain x multiple days because unable to keep anything down.
She denies sick contacts aside from being in dialysis 3x/week.
She denies cough or rhinorrhea. she complains of headache that
is frontal with some right facial pain. No changes in vision, no
neck stiffness, no tick exposures and does not spend much time
outdoors.

Past Medical History:
1. Atrial fibrillation/flutter: first diagnosed in [**Month (only) **]
[**2195**].
2. End-stage renal disease on hemodialysis secondary to IgA
nephropathy s/p cadaveric kidney transplant in [**2173**] which has
eventually failed, and started on hemodialysis in [**2193**].
3. History of upper GI bleeding on [**2195-2-20**] with evidence
of
esophagitis, gastric ulcer, and bleeding duodenal vessel s/p
clipping, cauterization and PPI.
4. Diastolic heart failure supported by an echocardiography from

[**2195-12-21**]. Clinically asx.
5. History of malignant hypertension, which was complicated by
seizure on [**2193-5-20**]. Not on antiepileptic meds. Denies h/o CVA.

6. Depression.
7. Rheumatic fever in childhood

Social History:
Single, lives by herself in [**Location (un) 686**], and has no children. She
quit smoking 25 years ago (10-pack-years). She rarely drinks
alcohol, and denies illicit drug use. She used to work part-time
in a coffee shop, but currently does not work.


Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Her father
died at the age of 80. Her mother died at the age of 64 from
lung CA. She has a sister with breast CA. MI in uncle in his
60s.

Physical Exam:
Physical Exam on Admission:
Vitals: 100.1, 176/80, 80, 30, 93%2L
General: Somulent, arousable when spoken to and then becomes
unresponsive. Responsive to pain with moaning and withdrawal. At
times speaking incoherent sentences.
HEENT: Sclera anicteric, mild conjunctival pallor.
MMM, oropharynx clear
Neck: able to move chin to chest on patient, JVP elevated to
>10, no LAD appreciated
Lungs: Difficult to assess based on patient unable to cooperate
with exam, but moving air bilaterally, no obvious crackles
rhonchi or wheezes appreciated.
CV: Regular rate and rhythm, normal S1 + S2. 2/6 Systolic mumur
heard best at the LUSB
Abdomen: soft, +[**Doctor Last Name 515**] sign (patient opened eyes and yelled on
palpation), and tender in epigastric area. Nondistended, +BS, no
rebound or guarding.
Ext: warm, well-perfused. no cyanosis, clubbing, or edema.
Neuro: Unable to fully assess due to mental status, but moving
all four extremities
.
Physical Exam on Discharge:
VS: T 98.2 135/72 84 18 92%RA
GENERAL: NAD. Oriented x3. Alert and talkative
HEENT: NCAT. Sclera anicteric.
NECK: Supple JVP flat
CARDIAC: Irregularly irregular with tachycardia.  harsh
diastolic murmur best heard at LUSB but radiating throughout
precordium. No S3/S4
LUNGS: CTAB, decreased breath sounds in b/l bases. No E->A
changes
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. Left arm with fistula
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas, nails
without splinter hemorrhages
NEURO: A+Ox3, CN II-XII intact, strength 5/5 in all extremities,
speech normal
LN: No palpable LN in ant/post neck, submandibula,
supraclavicula, axilla, femoral, or popliteal fossa bilaterally
Biopsy site in Right supraclavicular region without any
erythema, drainage or tenderness.

Pertinent Results:
ADMISSION LABS:
[**2198-10-6**] 10:45AM BLOOD WBC-15.1*# RBC-3.60* Hgb-11.5* Hct-34.1*
MCV-95 MCH-31.9 MCHC-33.7 RDW-14.6 Plt Ct-163
[**2198-10-6**] 10:45AM BLOOD Neuts-91.6* Lymphs-6.0* Monos-2.2 Eos-0.1
Baso-0.1
[**2198-10-6**] 10:45AM BLOOD PT-33.6* PTT-32.9 INR(PT)-3.3*
[**2198-10-6**] 10:45AM BLOOD Glucose-152* UreaN-73* Creat-12.6*#
Na-134 K-5.4* Cl-87* HCO3-23 AnGap-29*
[**2198-10-6**] 10:45AM BLOOD ALT-22 AST-20 AlkPhos-71 TotBili-0.3
DirBili-0.2 IndBili-0.1
[**2198-10-6**] 10:45AM BLOOD Lipase-14
[**2198-10-6**] 10:45AM BLOOD Calcium-10.6* Phos-7.3*# Mg-2.2
.

LABS ON DISCHARGE:
[**2198-10-19**] 06:33AM BLOOD WBC-11.7* RBC-2.74* Hgb-8.3* Hct-26.0*
MCV-95 MCH-30.4 MCHC-32.0 RDW-15.5 Plt Ct-306
[**2198-10-16**] 06:45AM BLOOD Neuts-83.1* Lymphs-11.1* Monos-3.4
Eos-2.0 Baso-0.4
[**2198-10-19**] 06:33AM BLOOD Plt Ct-306
[**2198-10-19**] 06:33AM BLOOD PT-15.0* INR(PT)-1.3*
[**2198-10-19**] 06:33AM BLOOD Glucose-77 UreaN-35* Creat-6.6*# Na-131*
K-4.4 Cl-91* HCO3-25 AnGap-19
[**2198-10-19**] 06:33AM BLOOD ALT-1 AST-19 AlkPhos-77 TotBili-0.5
[**2198-10-19**] 06:33AM BLOOD Calcium-8.8 Phos-5.0*# Mg-2.0
.
EKG [**2198-10-6**]:
Regular bradycardic rhythm with possible P waves in the late QRS
complex or early ST segment. Intraventricular conduction delay.
Consider junctional or idioventricular rhythm. Leftward axis.
Intraventricular conduction delay of left bundle-branch block
type. Q-T interval prolongation. ST-T wave
abnormalities. Since the previous tracing atrial tachycardia or
atrial
fibrillation no longer present. The QRS width is now wider but
of similar
morphology. Clinical correlation is suggested.
.
Imaging:
CT chest without contrast [**10-14**]
IMPRESSION:
1. In view of clinical history and pattern of lung nodules
though septic
emboli is likely possibility, presence of L2 vertebral body
lytic lesion focal and focal lucency in D11 vertebra along with
enlarged mediastnal and
supraclavicular lymph nodes is concerning for metastatic disease
from
primary/lymphoma.
2. Bilateral moderate complex pleural effusions.
3. Bilateral atrophic kidneys with parenchymal calcification
suggestive of
chronic renal disease.
4. Dense mitral annulus calcification and minimal pericardial
effusion.
.
CTA head and neck with and without contrast [**10-14**]:
IMPRESSION:
1. Overall unremarkable cranial CTA with no finding to
specifically suggest mycotic aneurysm formation, though this
imaging modality may be insensitive for this diagnosis.
2. Congenitally hypoplastic left vertebral artery with effective

PICA-termination and secondary atherosclerosis with reduced
flow, likely
accounting for the findings on the prompting recent cranial MRA.

3. No evidence of flow-limiting stenosis or dissection involving
the cervical vessels.
4. Markedly abnormal appearance to the limited included lung
apices,
including several peripheral irregular solid nodular opacities;
in the setting of known MSSA endocarditis, these are highly
suspicious for septic pulmonary emboli.
5. Large bilateral pleural effusions with patchy ground-glass
opacities and interlobular septal thickening, suggestive of
pulmonary edema.
6. Extensive superior mediastinal adenopathy, incompletely
imaged. This
finding is quite striking, and appears unlikely to be accounted
for by either #4 or #5, above, and should be correlated with
clinical data, i.e. is there a history of malignancy,
particularly in the thorax?
.
COMMENT: A preliminary interpretation of "Patent but attenuated
(likely
secondary to atherosclerosis) left vertebral artery is a
non-dominant vessel.
.
No aneurysm. Multiple bilateral pulmonary nodules with
mediastinal
lymphadenopathy, bilateral effusions are concerning for a
malignancy," with a recommendation for dedicated chest CT, was
posted to CCC by Dr. [**Last Name (STitle) **] (2:20 p.m., [**2198-10-14**]).
.
As recommended, the findings in the thorax would be
better-characterized by CECT of the thorax, to follow.
.
MRI/MRA head without contrast [**10-13**]
IMPRESSION:
1. Numerous small supratentorial and infratentorial infarcts in
multiple
vascular territories, suggesting embolic etiology. A punctate
left medial
temporal lobe infarct is new, but others were present on
[**2198-10-10**]. Evaluation is otherwise limited in the absence of
intravenous gadolinium.
2. No flow in the intracranial left vertebral artery and left
posterior
inferior cerebellar artery, which represents a change since
[**2193-6-4**]. If
clinically indicated, this may be better assessed by CTA.
3. MRA has poor sensitivity for mycotic aneurysms, which tend to
affect small distal arteries. No evidence of an aneurysm is seen
in the proximal
intracranial arteries.
.
TTE [**10-12**]
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No spontaneous echo
contrast or thrombus is seen in the body of the right atrium or
the right atrial appendage. The right atrial appendage ejection
velocity is depressed (<0.2m/s). No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). There are simple non mobile
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve.
Trace aortic regurgitation is seen. The mitral valve leaflets
are moderately thickened. There is no mitral valve prolapse.
There is a moderate-sized (1.3 x 0.8 cm) vegetation on the
posterior mitral leaflet. Anterior mitral leaflet has some focal
thickening, though no definite vegetation is seen there. There
is no paravalvular abscess see. Mild (1+) mitral regurgitation
is seen. No masses or vegetations are seen on the pulmonic
valve, but cannot be fully excluded due to suboptimal image
quality. There is no pericardial effusion.
.
IMPRESSION: Moderate-sized mitral valve vegetation. Mild mitral
regurgitation. No paravalvular abscess seen.
.
MRI head with and without contrast [**10-10**]:
IMPRESSION: Scattered foci of slow diffusion seen in bilateral
cerebellar and cerebral hemispheres in multiple vascular
distributions with no obvious enhancement. Imaging findings are
suggestive of thromboembolic shower from a proximal source.
Given the lack of enhancement in the lesions, septic emboli are
less likely.
.
MRI cervical spine without contrast [**10-10**]:
IMPRESSION:
Markedly motion-limited examination:
1. Performed in cooperation with the Hemodialysis service, who
will be
dialyzing the patient immediately following the examination. The
patient
provided informed consent for the contrast-enhanced examination.

2. Though the patient consented to, and dialysis arrangements
were made, to follow the contrast-enhanced portion of the
examination, only enhanced imaging of the brain was possible.
3. The non-enhanced images demonstrate no finding suspicious for
discitis,
vertebral osteomyelitis or associated abscess, particularly in
the cervical spine.
4. Severe multilevel, multifactorial degenerative disease of the
cervical
spine with canal stenosis and cord remodeling, but no definite
intrinsic
signal abnormality.
5. Multilevel, multifactorial degenerative disease of the lumbar
spine with canal and foraminal stenosis, most marked at the L3-4
and L4-5 levels.
6. Bilateral pleural effusions with associated atelectasis.
.
CXR [**2198-10-6**] IMPRESSION: Mild interstitial edema likely due to
fluid overload.
.
CT head [**2198-10-6**] MPRESSION: No acute intracranial process.
.
CXR [**2198-10-6**] FINDINGS: Worsening volume status of the patient,
with increasing interstitial edema and development of small
bilateral pleural effusions. Otherwise no relevant changes since
recent radiograph.
.
MICROBIOLOGY:
[**2198-10-6**] 2:57 pm BLOOD CULTURE      Source: Line-dialysis.

                            **FINAL REPORT [**2198-10-9**]**

   Blood Culture, Routine (Final [**2198-10-9**]):
      STAPH AUREUS COAG +.
         Consultations with ID are recommended for all blood
cultures
         positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.

         FINAL SENSITIVITIES.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------       R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   0.5 S
OXACILLIN-------------   0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S

   Aerobic Bottle Gram Stain (Final [**2198-10-7**]):
      Reported to and read back by DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5386**] @ 5:49A
[**2198-10-7**].
      GRAM POSITIVE COCCI.
      IN PAIRS ANS CLUSTERS.

   Anaerobic Bottle Gram Stain (Final [**2198-10-7**]):
      GRAM POSITIVE COCCI.
      IN PAIRS AND CLUSTERS.
.
[**2198-10-10**] 6:45 am BLOOD CULTURE
      RECEIVED SPECIMENS RECEIVED IN LAB @ 12:10PM.

                            **FINAL REPORT [**2198-10-16**]**

   Blood Culture, Routine (Final [**2198-10-16**]):
      STAPH AUREUS COAG +.
         Consultations with ID are recommended for all blood
cultures
         positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.

         FINAL SENSITIVITIES.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------       R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   0.5 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S

   Anaerobic Bottle Gram Stain (Final [**2198-10-11**]):
      GRAM POSITIVE COCCI IN CLUSTERS.
      Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31704**] @ 3PM [**2198-10-11**].
.
Time Taken Not Noted     Log-In Date/Time: [**2198-10-18**] 6:55 pm
      FLUID,OTHER      CERVICAL LYMPH NODE.

   GRAM STAIN (Final [**2198-10-18**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Preliminary):    NO GROWTH.

   ANAEROBIC CULTURE (Preliminary):


Brief Hospital Course:
64 y/o F with h/o ESRD on HD, malignant hypertension, atrial
fibrillation/atrial flutter presenting with MSSA bacteremia c/b
endocarditis and septic emboli to the brain and lung with
incidental finding on CT scan of lumbar lytic lesion concerning
for malignancy.

# MSSA endocarditis: Patient was febrile on admission with an
altered mental status with MSSA bacteremia. On TTE she was found
to have a vegetation of her Mitral valve leaflet.  She was
complaining of headaches with a nonfocal neuro exam and pain of
her neck. On MRI of her brain she was shown to have scattered
embolic infarcts that were consistent with septic emboli. She
had a TEE which showed the same lesion of her valve and no
abscess and no thrombus in her left atrium or left atrial
appendage. We was switched from vancomycin to cefazolin to be
dosed with HD as per protocol. She completed 3 days of
gentamycin, and will continue:
- Cefazolin 2gm IV with Mon/Wed HD and 3gm IV with Friday HD
start date: [**2198-10-11**]
stop date: [**2198-11-22**]
.
Laboratory [**Month/Day/Year 7941**] required
frequency: [**Month/Day/Year 20515**]
- CBC with diff
- BMP
- LFTs
.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions regarding
outpatientantibiotics should be directed to the infectious
is closed.
.
# Lytic lumbar lesion: On CT chest, a lytic lumbar lesion was
noted.  This, taken in context with mediastinal and
supraclavicular lymphadenopathy in addition to bilateral complex
pleural effusions was concerning for an underlying malignancy.
Specifically, lymphoma, multiple myeloma, or a solid lung,
breast tumor were considered.  Oncology was consulted for
assistance in labs/studies that were necessary while patient was
in the hospital.  Labs were significant for a normal IgG, IgM
and elevated IgA (known IgA nephropathy).  In addition, beta2
microglobulin and kappa/lambda light chains were elevated.
This, however, may be secondary to systemic infection, and also
could be explained by amyloidosis.  Given patient's ESRD,
amyloid is likely, as she has also had echo evidence of a
restrictive cardiomyopathy concerning for amyloid.  Multiple
myeloma is less likely at this time as SPEP was negative (unable
to obtain UPEP as patient is anuric).  On HD 12 patient had an
ultrasound guided biopsy of a right enlarged supraclavicular
lymph node.  The results were pending on the day of discharge,
and patient will be contact by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from oncology
regarding the results and any further workup. Finally, oncology
recommends outpatient age appropriate cancer screening including
mammogram and colonoscopy.
.
# Arrhythmia- patient has a history of Afib and was on coumadin.
 Her INR levels were rising and this was felt to be due to
interaction with her antibiotic regimen as she had no other
signs of liver failure, or DIC.  She had an episode of
asymptomatic bradycardia down into the 30s with a junctional
rhythm which was nonresponsive to atropine. She was transferred
to the CCU during this time for concern of the MV vegetation
affecting her conduction system.  After her TEE (which was
negative for perivalvular abscess and other complications) and
her rhythm, which converted back to afib in the low 100s, she
was transferred back to the medical floor.  Patient was
restarted on amiodarone and carvedilol on HD11 as patient was
tachycardic, however, on HD12 patient had another episode of
bradycardia to 38.  She spontaneously converted to sinus rhythm,
but amiodarone and carvedilol were discontinued and not
restarted prior to discharge. She is to remain off these agents,
and will follow-up with cardiology. With regard to her
anticoagulation, she met with neurology, and given her septic
emboli, it is recommended that she stay of anticoagulation for
at least 1 month. Anticoagulation can be re-addressed by PCP and
neurology. She was started on aspirin 81 mg daily per neurology.
.
.
# ESRD- patient is s/p failed transplant and is on HD MWF. She
continued her HD during her stay with extra sessions in the
setting of getting gadolinium for her head MRI. She will need to
continue cefazolin with HD, as prescribed.
.
#Transitional issues:
- Patient has LN biopsy results pending re: malignancy work-up.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from oncology will be following up on these labs
and will inform PCP if further testing is necessary.  Dr. [**First Name (STitle) **]
will also contact patient with results
- Patient is going to Epic of [**Location (un) 55**] Rehab. Contact
#[**Telephone/Fax (1) 9714**]
- Carvedilol and amiodarone were discontinued as patient had two
episodes of bradycardia. Patient should discuss restarting these
medications with PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] needs age appropriate cancer screening including
mammogram and colonoscopy
- continued treatment of MSSA bacteremia/endocarditis with
cefazolin at HD. All laboratory results should be faxed to
Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions
regarding outpatientantibiotics should be directed to the
when clinic is closed.

Medications on Admission:
Medications per OMR, unable to verify with patient at this time.
AMIODARONE - 200 mg Tablet - 1 Tablet(s) by mouth daily
AMLODIPINE - (Dose adjustment - no new Rx) (Not Taking as
Prescribed: pt states not taking) - 5 mg Tablet - 2 Tablet(s) by
mouth once a day
CALCIUM ACETATE - (Prescribed by Other Provider) - 667 mg
Capsule - 3 Capsule(s) by mouth three times a day with meals and
1 tab with snack
CARVEDILOL - 6.25 mg Tablet - 1 Tablet(s) by mouth twice daily
CINACALCET [SENSIPAR] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 30 mg Tablet - 1 Tablet(s) by mouth
twice daily
CITALOPRAM - 40 mg Tablet - 1.5 Tablet(s) by mouth qam
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth once a day
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth once a day Name Brand Only, No Substitutions - No
Substitution
SEVELAMER CARBONATE [RENVELA] - (Prescribed by Other Provider) -
800 mg Tablet - 3 Tablet(s) by mouth three times a day with
meals
and 1 tab with snack
SODIUM POLYSTYRENE SULFONATE - (Dose adjustment - no new Rx) -
Powder - 15grams Powder(s) by mouth every Saturday and Sunday
WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 1
Tablet(s) by mouth once a day take up to 4 tablets a day on
m-w-f adn 2 tabs on tu-[**Last Name (un) **]-sat sun per inr results
Medications - OTC
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1
cap Capsule(s) by mouth once daily

Discharge Medications:
1. CefazoLIN 2 g IV QMON
please give after dialysis
2. CefazoLIN 2 g IV QWED
please give after dialysis
3. CefazoLIN 3 gm IV QFRI Start: [**2198-10-12**]
please give after dialysis
4. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. citalopram 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
10. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
14. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS): and 1 tablet with snack.



Discharge Disposition:
Extended Care

Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]

Discharge Diagnosis:
PRIMARY:
1. High grade methicillin sensitive staph aureus bacteremia
2. Methicillin sensitive staph aureus endocarditis
3. Septic emboli to brain and lungs
4. Lytic lumbar lesion noted on CT scan
.
Secondary:
1. Atrial fibrillation/flutter
2. End stage renal disease on hemodialysis
3. Diastolic congestive heart failure
4. Hypertension


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Ms. [**Known lastname 101213**],
.
It was a pleasure taking care of you here at [**Hospital1 771**].
.
You were admitted to the hospital for nausea and vomiting, and
were noted to have missed one of your dialysis sessions. You
underwent dialysis without complication, but developed high
fevers. You were found to have bacteria in the blood
(bacteremia) and were placed on intravenous antibiotics.  We
found that this bacteria had made a cluster on your heart valve
(endocarditis), and small pieces had broken off and travelled
through the blood up to your brain and to your lungs giving you
tiny areas of very tiny strokes.  You did not have any findings
on exam of a stroke. You met with the neurology [**Hospital1 21334**], and
will remain off blood thinners for at least 1 month.  You were
on IV antibiotics which you will continue to receive at
dialysis.
.
You also had a very slow heart rate at one point during your
hospitalization you were monitored in the cardiac intensive care
unit. You had one other episode of this abnormal rhythm while
inpatient and so the decision was made to discontinue the
medications that can slow your heart rate (carvedilol and
amiodarone).  You should discuss these medication changes with
your primary care doctor as an outpatient.
.
Lastly, you had some findings on a CT scan of your chest which
were concerning for cancer.  You were evaluated by the
oncologists who sent several tests to evaluate for cancer which
did not give a definitive diagnosis.  You had a biopsy of one of
the enlarged lymph nodes.  The results of this are also pending.
 The oncologist who saw you in the hospital, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
will be in touch with you and your primary care doctor regarding
the results of these tests and further work-up that is
necessary.
.
As you had an extended stay in the hospital, physical therapy
felt that you would be safest going to a rehab facility to get
stronger prior to going home.
.
MEDICATION CHANGES:
- STOP coumadin. You will need to discuss with your PCP and
neurology when it is safe to resume.
- STOP amiodarone
- STOP carvedilol
- STOP calcium acetate
- CONTINUE cefazolin with dialysis
- START baby aspirin daily
.
Please seek medical attention for any worsening symptoms. Please
keep your follow-up appointments noted below. Weigh yourself
every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.

Followup Instructions:
Department: INFECTIOUS DISEASE
When: FRIDAY [**2198-10-26**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
Please make sure you keep your appointment in [**Hospital 4898**] clinic with
the Infectious Diseases [**Hospital **]. [**First Name (Titles) **] [**Last Name (Titles) 21334**] are [**Name5 (PTitle) 7941**]
your progress on your antibiotics as well as watching you for
any significant side effects.
.
Department: NEUROLOGY
When: TUESDAY [**2198-11-6**] at 7:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2198-11-23**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13125**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2198-11-21**] at 11:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2198-12-26**] at 2:15 PM
With: [**First Name8 (NamePattern2) 48**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


Completed by:[**2198-10-19**]
{'Acute and subacute bacterial endocarditis,Acute respiratory failure,Pneumonia, organism unspecified,End stage renal disease,Cerebral embolism with cerebral infarction,Septic pulmonary embolism,Bacteremia,Complications of transplanted kidney,Chronic diastolic heart failure,Acidosis,Atrioventricular block, complete,Septic arterial embolism,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease,Secondary malignant neoplasm of bone and bone marrow,Atrial flutter,Arteriovenous fistula, acquired,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other malignant neoplasm without specification of site,Anemia in chronic kidney disease,Dysthymic disorder,Enlargement of lymph nodes,Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney,Personal history of tobacco use,Renal dialysis status,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: Nausea and Vomiting

PRESENT ILLNESS: 3 yo F w/ PMH of IgA nephropathy s/p failed cadaveric transplant
on HD via Left AV fistula, Afib/flutter (on coumadin), Diastolic
heart failure and hx of malignant hypertension p/w nausea and
vomiting x 3 days. Pt reports she was in her USOH when on [**10-3**]
she developed nausea vomiting, diarrhea 6-7x/day, and headache.
She reports she would start vomiting everytime she would try to
drink anything, and then would have diarrhea with incontinece.
She missed her dialysis yesterday and on day of admission felt
wek and dizzy and called EMS to bring her to the ED. On arrival
to the ED her initial vitals were 100.3, 125/61, 16, 97% RA. CXR
showed mild pulmonary edema and gave 1L bolus. And labs were
signficant for K=5.3, Lactate- 4.2, anion gap of 29, WBC 15.1
with 91.6%PMN and INR=3.3. Renal felt she needed urgent dialysis
to assist with hyperkalemia. She had a pneumonia with
respiratory failure and hyperkalemia in [**2-/2198**] where she was
intubated and treated with Vanc/Cefepime for 7 day course
without growth in cultures.
.
In dialysis, she did not have any ultrafiltrate as she was felt
to be below her dry weight. She was AAOx3 and conversant. She
was given tylenol and carvedilol and transferred to the floor.
.
On arrival to the floor her initial VS were 100.1, 176/80, 80,
30, 93%2L. She was difficult to arose, was oriented to person
and not answering questions, and no further history was able to
be obtained. Patient triggered 1 hour after arriving on the
floor, had an ABG which was signficant for 7.57/34/71/32,
showing a metabolic alkalosis, metabolic gap acidosis. Patient
was complaining of feeling hot and her temp was 102.4, she was
given 1g acetaminophen. After 1 hour her O2 sats improved to 98%
on 2L, and she was more coherent. And was able togive the
following additional history: Patient reports not taking her
coumdain x multiple days because unable to keep anything down.
She denies sick contacts aside from being in dialysis 3x/week.
She denies cough or rhinorrhea. she complains of headache that
is frontal with some right facial pain. No changes in vision, no
neck stiffness, no tick exposures and does not spend much time
outdoors.

MEDICAL HISTORY: 1. Atrial fibrillation/flutter: first diagnosed in [**Month (only) **]
[**2195**].
2. End-stage renal disease on hemodialysis secondary to IgA
nephropathy s/p cadaveric kidney transplant in [**2173**] which has
eventually failed, and started on hemodialysis in [**2193**].
3. History of upper GI bleeding on [**2195-2-20**] with evidence
of
esophagitis, gastric ulcer, and bleeding duodenal vessel s/p
clipping, cauterization and PPI.
4. Diastolic heart failure supported by an echocardiography from

MEDICATION ON ADMISSION: Medications per OMR, unable to verify with patient at this time.
AMIODARONE - 200 mg Tablet - 1 Tablet(s) by mouth daily
AMLODIPINE - (Dose adjustment - no new Rx) (Not Taking as
Prescribed: pt states not taking) - 5 mg Tablet - 2 Tablet(s) by
mouth once a day
CALCIUM ACETATE - (Prescribed by Other Provider) - 667 mg
Capsule - 3 Capsule(s) by mouth three times a day with meals and
1 tab with snack
CARVEDILOL - 6.25 mg Tablet - 1 Tablet(s) by mouth twice daily
CINACALCET [SENSIPAR] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 30 mg Tablet - 1 Tablet(s) by mouth
twice daily
CITALOPRAM - 40 mg Tablet - 1.5 Tablet(s) by mouth qam
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth once a day
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth once a day Name Brand Only, No Substitutions - No
Substitution
SEVELAMER CARBONATE [RENVELA] - (Prescribed by Other Provider) -
800 mg Tablet - 3 Tablet(s) by mouth three times a day with
meals
and 1 tab with snack
SODIUM POLYSTYRENE SULFONATE - (Dose adjustment - no new Rx) -
Powder - 15grams Powder(s) by mouth every Saturday and Sunday
WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 1
Tablet(s) by mouth once a day take up to 4 tablets a day on
m-w-f adn 2 tabs on tu-[**Last Name (un) **]-sat sun per inr results
Medications - OTC
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1
cap Capsule(s) by mouth once daily

ALLERGIES: Dilantin Kapseal

PHYSICAL EXAM: Physical Exam on Admission:
Vitals: 100.1, 176/80, 80, 30, 93%2L
General: Somulent, arousable when spoken to and then becomes
unresponsive. Responsive to pain with moaning and withdrawal. At
times speaking incoherent sentences.
HEENT: Sclera anicteric, mild conjunctival pallor.
MMM, oropharynx clear
Neck: able to move chin to chest on patient, JVP elevated to
>10, no LAD appreciated
Lungs: Difficult to assess based on patient unable to cooperate
with exam, but moving air bilaterally, no obvious crackles
rhonchi or wheezes appreciated.
CV: Regular rate and rhythm, normal S1 + S2. 2/6 Systolic mumur
heard best at the LUSB
Abdomen: soft, +[**Doctor Last Name 515**] sign (patient opened eyes and yelled on
palpation), and tender in epigastric area. Nondistended, +BS, no
rebound or guarding.
Ext: warm, well-perfused. no cyanosis, clubbing, or edema.
Neuro: Unable to fully assess due to mental status, but moving
all four extremities
.
Physical Exam on Discharge:
VS: T 98.2 135/72 84 18 92%RA
GENERAL: NAD. Oriented x3. Alert and talkative
HEENT: NCAT. Sclera anicteric.
NECK: Supple JVP flat
CARDIAC: Irregularly irregular with tachycardia.  harsh
diastolic murmur best heard at LUSB but radiating throughout
precordium. No S3/S4
LUNGS: CTAB, decreased breath sounds in b/l bases. No E->A
changes
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. Left arm with fistula
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas, nails
without splinter hemorrhages
NEURO: A+Ox3, CN II-XII intact, strength 5/5 in all extremities,
speech normal
LN: No palpable LN in ant/post neck, submandibula,
supraclavicula, axilla, femoral, or popliteal fossa bilaterally
Biopsy site in Right supraclavicular region without any
erythema, drainage or tenderness.

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Her father
died at the age of 80. Her mother died at the age of 64 from
lung CA. She has a sister with breast CA. MI in uncle in his
60s.

SOCIAL HISTORY: Single, lives by herself in [**Location (un) 686**], and has no children. She
quit smoking 25 years ago (10-pack-years). She rarely drinks
alcohol, and denies illicit drug use. She used to work part-time
in a coffee shop, but currently does not work. 

### Response:
{'Acute and subacute bacterial endocarditis,Acute respiratory failure,Pneumonia, organism unspecified,End stage renal disease,Cerebral embolism with cerebral infarction,Septic pulmonary embolism,Bacteremia,Complications of transplanted kidney,Chronic diastolic heart failure,Acidosis,Atrioventricular block, complete,Septic arterial embolism,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease,Secondary malignant neoplasm of bone and bone marrow,Atrial flutter,Arteriovenous fistula, acquired,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other malignant neoplasm without specification of site,Anemia in chronic kidney disease,Dysthymic disorder,Enlargement of lymph nodes,Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney,Personal history of tobacco use,Renal dialysis status,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
