CHIEF COMPLAINT: hyperglycemia and altered mental status

PRESENT ILLNESS: 63 yo M with h/o DM type 1, PVD, and HTN who presents with
hyperglycemia and altered mental status. The patient states that
he was in his USOH until Monday, when he awoke with abdominal
pain and nausea. He could not eat anything so he didn't take his
insulin. He did not vomit or experience fevers/chills, nor any
dysuria, new cough, or URI sxs. He did manage to go to his
numerous medical appointments that day, when he was seen by PCP,
[**Name10 (NameIs) **], and dentist.
.
Per wife, the dentist foud a large mouth abscess for which he
was prescribed clindamycin 150mg qid x 7 days. Otherwise visits
were without incident. Sugars have been running very
erratically, with FSG on [**1-19**]- [**1-20**] ranging from 70's to 500+.
Today, after returning from work, she found him slumped over at
his computer and confused. Checked BS and was so high meter
didn't read number. Called Dr. [**Last Name (STitle) 1007**], rechecked BS, was still
higher than readable, so called EMS. Was disoriented, calling
son by name and stating he needed 750 units of insulin.
.
In the ED, vitals were stable. Initial labs were notable for
glucose 769, HCO3 9, AG 32, WBC 21.3, lactate 3.9, UA positive
for ketones. CXR without acute process, EKG with new [**Street Address(2) 4793**] dep
V5-6, 0.[**Street Address(2) 1755**] dep II, III, aVF. ABG 7.08/25/104/8. He was
started on an insulin gtt at 8 units/hr, given 4 L IVFs, asa 325
po X 1, levaquin 500 mg IV X 1, and flagyl 500 mg IV X 1.
.
ROS positive for headache and blurry vision recently. Also
endorses poor appetite and po intake due to nausea, abdominal
pain, and vomiting today. Denies unusual polyuria or polydipsia.
Denies CP or SOB.

MEDICAL HISTORY: DM type 1 dx'ed [**2151**], c/b ulnar and median neuropathies, PVD,
retinopathy, and gastroparesis
Diabetic foot ulcers with multiple prior infections including
MRSA isolates, s/p L 4th toe osteomyelitis with gas gangrene in
[**3-30**] requiring amputation
OSA
PVD s/p L femoral bypass
GERD
HTN
Hypercholestolemia
Depression
Erectile dysfunction
h/o broken neck at age 13 with C1-C2 repair.

MEDICATION ON ADMISSION: (per OMR list [**1-19**], pt unable to confirm any)
Diovan 80 mg daily
Amlodipine 10 mg daily
Simvastatin 80 mg daily
Pantoprazole 40 mg daily
Lyrica 75 mg [**Hospital1 **]
Ibuprofen 400 mg q4-6h prn
Tylenol prn
Provigil 100 mg daily
Qualaquin 324 mg [**Hospital1 **] prn
Effexor XR 300 mg dialy
Trazodone 100 mg qhs prn
Varenicline 1 mg [**Hospital1 **]
Wellbutrin 300 mg daily
lisinopril 40 mg daily
Lantus 46 units qhs --> pt states he takes 75/25 42 units [**Hospital1 **],
which is not in keeping with most recent [**Last Name (un) **] note
HISS --> pt states does not do this anymore

ALLERGIES: Penicillins / Cephalosporins / Aztreonam / Latex

PHYSICAL EXAM: T  BP 126/46 HR 95 RR 19 O2 sat 98% 5L NC
Gen - elderly male, pleasant, NAD, tired, smells strongly of
acetone
HEENT - NC/AT, PERRLA, MM dry. Upper dentures. O/P clear, no
ulcers or abscess noted. No tenderness to palpations
CV - RRR, no m/r/g
Lungs - CTAB
Abd - S/NT/ND, + BS
Ext - R foot with small <1cm ulcer on sole, bandaged. Does not
appear infected. L foot with amputated 5th toe
Neuro - A+O x 3
Skin - no rashes or ulcers noted aside from above

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: (+) tobacco use x40 years, currently smokes 3 cigs/day, patient
denies past etoh abuse, although OMR notes indicate past chronic
alcohol use. Denies illicit drug use. Married.
Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Acute kidney failure, unspecified,Ulcer of heel and midfoot,Hyposmolality and/or hyponatremia,Subendocardial infarction, initial episode of care,Periapical abscess without sinus,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Polyneuropathy in diabetes,Gastroparesis,Background diabetic retinopathy,Obstructive sleep apnea (adult)(pediatric),Esophageal reflux,Pure hypercholesterolemia,Anemia, unspecified,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere
DMI ketoacd uncontrold,Acute kidney failure NOS,Ulcer of heel & midfoot,Hyposmolality,Subendo infarct, initial,Periapical abscess,Hypertension NOS,Periph vascular dis NOS,Neuropathy in diabetes,Gastroparesis,Diabetic retinopathy NOS,Obstructive sleep apnea,Esophageal reflux,Pure hypercholesterolem,Anemia NOS,Nephritis NOS in oth dis
Admission Date:  [**2189-1-21**]              Discharge Date:   [**2189-1-25**]

Date of Birth:  [**2125-1-31**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Cephalosporins / Aztreonam / Latex

Attending:[**Doctor Last Name 10493**]
Chief Complaint:
hyperglycemia and altered mental status

Major Surgical or Invasive Procedure:
none

History of Present Illness:
 63 yo M with h/o DM type 1, PVD, and HTN who presents with
hyperglycemia and altered mental status. The patient states that
he was in his USOH until Monday, when he awoke with abdominal
pain and nausea. He could not eat anything so he didn't take his
insulin. He did not vomit or experience fevers/chills, nor any
dysuria, new cough, or URI sxs. He did manage to go to his
numerous medical appointments that day, when he was seen by PCP,
[**Name10 (NameIs) **], and dentist.
.
Per wife, the dentist foud a large mouth abscess for which he
was prescribed clindamycin 150mg qid x 7 days. Otherwise visits
were without incident. Sugars have been running very
erratically, with FSG on [**1-19**]- [**1-20**] ranging from 70's to 500+.
Today, after returning from work, she found him slumped over at
his computer and confused. Checked BS and was so high meter
didn't read number. Called Dr. [**Last Name (STitle) 1007**], rechecked BS, was still
higher than readable, so called EMS. Was disoriented, calling
son by name and stating he needed 750 units of insulin.
.
In the ED, vitals were stable. Initial labs were notable for
glucose 769, HCO3 9, AG 32, WBC 21.3, lactate 3.9, UA positive
for ketones. CXR without acute process, EKG with new [**Street Address(2) 4793**] dep
V5-6, 0.[**Street Address(2) 1755**] dep II, III, aVF. ABG 7.08/25/104/8. He was
started on an insulin gtt at 8 units/hr, given 4 L IVFs, asa 325
po X 1, levaquin 500 mg IV X 1, and flagyl 500 mg IV X 1.
.
ROS positive for headache and blurry vision recently. Also
endorses poor appetite and po intake due to nausea, abdominal
pain, and vomiting today. Denies unusual polyuria or polydipsia.
Denies CP or SOB.

Past Medical History:
DM type 1 dx'ed [**2151**], c/b ulnar and median neuropathies, PVD,
retinopathy, and gastroparesis
Diabetic foot ulcers with multiple prior infections including
MRSA isolates, s/p L 4th toe osteomyelitis with gas gangrene in
[**3-30**] requiring amputation
OSA
PVD s/p L femoral bypass
GERD
HTN
Hypercholestolemia
Depression
Erectile dysfunction
h/o broken neck at age 13 with C1-C2 repair.


Social History:
(+) tobacco use x40 years, currently smokes 3 cigs/day, patient
denies past etoh abuse, although OMR notes indicate past chronic
alcohol use. Denies illicit drug use. Married.


Family History:
Non-contributory

Physical Exam:
T  BP 126/46 HR 95 RR 19 O2 sat 98% 5L NC
Gen - elderly male, pleasant, NAD, tired, smells strongly of
acetone
HEENT - NC/AT, PERRLA, MM dry. Upper dentures. O/P clear, no
ulcers or abscess noted. No tenderness to palpations
CV - RRR, no m/r/g
Lungs - CTAB
Abd - S/NT/ND, + BS
Ext - R foot with small <1cm ulcer on sole, bandaged. Does not
appear infected. L foot with amputated 5th toe
Neuro - A+O x 3
Skin - no rashes or ulcers noted aside from above


Pertinent Results:
[**2189-1-21**] ADMISSION
.
WBC-21.3*# RBC-3.60* Hgb-12.3* Hct-39.0* MCV-109* MCH-34.3*
MCHC-31.6 RDW-12.0 Plt Ct-369 Neuts-95.2* Bands-0 Lymphs-2.4*
Monos-2.1 Eos-0.1 Baso-0.2
.
PT-12.7 PTT-22.7 INR(PT)-1.1
.
Glucose-769* UreaN-43* Creat-1.6* Na-132* K-6.6* Cl-91* HCO3-9*
AnGap-39*
.
Glucose-682* UreaN-43* Creat-1.6* Na-138 K-5.4* Cl-98 HCO3-8*
AnGap-37*
.
[**2189-1-21**] 07:25PM BLOOD CK(CPK)-67
[**2189-1-21**] 07:25PM BLOOD CK-MB-NotDone
[**2189-1-21**] 07:25PM BLOOD cTropnT-<0.01
.
SERUM TOX:
ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
.
ABG
Type-ART O2 Flow-4 pO2-104 pCO2-25* pH-7.08* calTCO2-8* Base
XS--21
.
URINE:
Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-150
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
LABS DURING ICU STAY:
SERIAL CHEMISTRIES:
[**2189-1-22**]
Glucose-131* UreaN-30* Creat-1.1 Na-140 K-4.3 Cl-110* HCO3-21*
AnGap-13
[**2189-1-23**]
Glucose-56* UreaN-11 Creat-0.6 Na-131* K-4.2 Cl-103 HCO3-22
AnGap-10
[**2189-1-24**]
Glucose-237* UreaN-9 Creat-0.7 Na-131* K-3.9 Cl-95* HCO3-28
AnGap-12
.
CARDIAC ENZYMES:
[**2189-1-22**] 01:00AM CK(CPK)-82   CK-MB-7
cTropnT-0.02*
[**2189-1-22**] 12:26PM CK(CPK)-597* CK-MB-15* MB Indx-2.5
cTropnT-0.08*
[**2189-1-22**] 09:04PM CK(CPK)-603* CK-MB-14* MB Indx-2.3
cTropnT-0.05*
[**2189-1-23**] 04:32AM CK(CPK)-670* CK-MB-14* MB Indx-2.1
cTropnT-0.03*\
.
RADIOLOGY:
[**1-21**] CXR
IMPRESSION: No acute process.
.
CT HEAD W/O CONTRAST  [**2189-1-22**] 2:17 PM
Reason: eval for bleed

There is no evidence of hemorrhage, edema, masses, mass effect,
or infarction. The ventricles and sulci are normal in caliber
and configuration. No fractures are identified. There is
suggestion of a prior ethmoidectomy. There is a scalp hematoma
in the midline at the vertex.

IMPRESSION: Scalp hematoma. No acute bleed.
.
MICROBIOLOGY:
[**1-21**] BCx: NGTD

Brief Hospital Course:
63 yo M with h/o DM type 1 c/b gastroparesis and foot ulcers,
PVD, and HTN who presents with DKA.
.
1) DKA - On presentation, AG 30, HCO3 9, glucose 769. DDx
includes poor insulin adherence, infection, or ischemia. UA was
negative, CXR without acute process. Pt did c/o nausea and
vomiting for 2 days but it is unclear whether this was acute
precipitant of DKA or rather symptom. Appears that insulin
regimen was very erraticly taken at home, which is probably the
precipitant. Continued insulin gtt while checking q1h FS.
Received aggressive IVF hydration with 1/2 NS @ 300cc/hr. Lytes
were checked q4h with serial narrowing of AG noted. When AG
closed, glucose was 120's. Switched to D5 1/2NS @ 300cc hr,
d/c'ed NPO status, and initiated sQ long lasting insulin. D/C'ed
insulin gtt 30 minutes later, but pt had dropped glucose to
50's, was given juice with good response. Also ate breakfast
without problem. Threshold to add K to fluids was 4.0. [**Last Name (un) **]
was consulted to clarify insulin regimen and do teaching with
pt. Was continued on fixed 75/25 and HISS, with qid FSG, upon
transfer from ICU.  He was discharged the following day on
insulin regimen of 75-25 44 units before breakfast and 20 units
before dinner as well as a humalog sliding scale.  Follow up was
arranged with [**Last Name (un) **] prior to discharge.
.
2) Demand Ischemia - Occuring in setting of profound DKA
dehydration in a pt without known h/o CAD but with CAD
equivalent in DM. Cardiac enzymes trended upwards at admission
with TropT that peaked at 0.08.  EKG has some T wave flattening,
and at that point the pt was guaiac'ed (negative) and begun on a
heparin gtt as well as given ASA and metoprolol. With a peak of
the CE's and resolution of all sxs and EKG changes, heparin was
dc'ed the next day. Pt only c/o nausea, no significant CP. Was
monitored on tele with no events. An outpt stress is recommended
for further w/u. Metoprolol held on discharge due to concern for
labile diabetes and masking signs of hypoglycemia. He will
follow up with his primary care doctor, Dr. [**Last Name (STitle) 1007**] to decide if
adding metoprolol is appropriate.
.
3) Leukocytosis - presented with WBC 21.3 with left shift. UA
was negative, CXR was without acute processes. Per wife, seen at
[**Hospital1 **] dental earlier this week for ? tooth abscess;
however no abscess or pain noted on exam. Also pt afebrile.
Leukocytosis is also a classic feature of DKA so this is the
most likely etiology. WBC ct trended down during stay. Blood
cultures were negative. Was continued on clindamycin 7 day
regimen as precribed at outpt dental appointment ([**1-24**] = day
[**5-30**]).
.
4) Dental Abscess: continued outpt clindamycin 150mg qid as
above
.
5) Hyponatremia - presented with psuedohyponatremia [**1-24**] elevated
glucose. Normalized with glucose correction. However, with
subsequent aggressive hydration (almost 10 liters), pt developed
basilar crackles and sodium again dropped. Likely hypervolemic
hyponatremia, so was given a small amount of lasix and allowed
to autodiures as renal function normalized.  Sodium normalized
prior to discharge at 137.
.
6) Acute renal failure - In setting of DKA, was intravascularly
dry, BUN/Cr ratio > 20. Aggressive IVF hydration led to quick
reurn of renal function back to baseline.
.
7) Nausea/vomiting - Also likely [**1-24**] DKA. Checked LFTs and
amylase/lipase which were negaive. Pt also has a known history
of gastroparesis so preprandial reglan was added with good
effect.
.
8) DM type 1 - DKA management as above. Continued lyrica for
neuropathic pain. [**Last Name (un) **] was consulted as above. Reglan as
above.
.
9) Foot ulcers/PVD - Small noninfected ulcer on base of R foot.
Followed by podiatry and [**Hospital **] clinic. Called podiatry for
reassessment,no acute management required. Continued wound care.

.
10) HTN - Continued diovan, amlodipine, lisinopril.
.
11) Anemia ?????? HCT 28 on [**1-24**], down from 39 on presentation, most
likely hemoconcentrated on admission [**1-24**] DKA.  His historical
baseline is 27-30. He was guaiac negative on [**1-21**], with no e/o
head bleed on CT.  HCT on discharge 31.8
.
12) Hypercholesterolemia - Continued statin.
.
13) Depression - Continued wellbutrin, effexor.
.
14) Code - full
.
15) Communication - with pt and wife [**Name (NI) **] [**Name (NI) 5395**] [**Telephone/Fax (1) 109265**]

Medications on Admission:
(per OMR list [**1-19**], pt unable to confirm any)
Diovan 80 mg daily
Amlodipine 10 mg daily
Simvastatin 80 mg daily
Pantoprazole 40 mg daily
Lyrica 75 mg [**Hospital1 **]
Ibuprofen 400 mg q4-6h prn
Tylenol prn
Provigil 100 mg daily
Qualaquin 324 mg [**Hospital1 **] prn
Effexor XR 300 mg dialy
Trazodone 100 mg qhs prn
Varenicline 1 mg [**Hospital1 **]
Wellbutrin 300 mg daily
lisinopril 40 mg daily
Lantus 46 units qhs --> pt states he takes 75/25 42 units [**Hospital1 **],
which is not in keeping with most recent [**Last Name (un) **] note
HISS --> pt states does not do this anymore

Discharge Medications:
1. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO bid ().
2. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO QAM.
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
9. QUALAQUIN 324 mg Capsule Sig: One (1) Capsule PO once a day
as needed for cramps.
10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every [**3-29**]
hours as needed for pain.
11. Bupropion 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO three times a day.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
13. Clindamycin HCl 150 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 5 days: as directed by your dentist.
14. Insulin Lispro Protam & Lispro 100 unit/mL (75-25)
Suspension Sig: as directed units Subcutaneous twice a day:
Inject 44 units before breakfast and 20 units before dinner.
Disp:*1 bottle* Refills:*2*
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

16. Insulin Lispro 100 unit/mL Solution Sig: as directed
according to sliding scale  Subcutaneous four times a day:
inject according to sliding scale before breakfast, lunch and
dinner and before bed.
17. Effexor XR 150 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO twice a day.
18. Indomethacin 50 mg Capsule Sig: One (1) Capsule PO twice a
day.
19. Domperidone (Bulk)  Miscellaneous


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Diabetic Ketoacidosis
.
Secondary:
DM type 1 dx'ed [**2151**], c/b ulnar and median neuropathies, PVD,
retinopathy, and gastroparesis
Diabetic foot ulcers with multiple prior infections including
MRSA isolates, s/p L 4th toe osteomyelitis with gas gangrene in
[**3-30**] requiring amputation
OSA
PVD s/p L femoral bypass
GERD
HTN
Hypercholestolemia
Depression
Erectile dysfunction


Discharge Condition:
stable, improved, acidosis resolved


Discharge Instructions:
You were admitted to the hospital with uncontrolled diabetes
leading to a condition called diabetic ketoacidosis, which can
be life threatening. For this reason it is extremely important
that you take your regularly scheduled insulin at home,
regardless of whether or not you are eating. Your
endocrinologists at the [**Last Name (un) **] will help you with a plan for
adjusting your home insulin depending on what you eat.

Your insulin regimen was adjusted by the [**Last Name (un) **] physicians.  You
are now taking 75/25 44units in the [**Last Name (un) 44550**] and 20 units before
dinner.  You should also check your blood sugars four times
daily and follow the humalog sliding scale as directed.
.
Please take all of your medicines as prescribed. Please keep all
of your outpatient appointments. If you develop high blood
sugars, very frequent urination and thirst, confusion or
sleepiness, or any other symptoms whic disturb you, please call
your doctor right away, or go to the ER.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 17785**],MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2189-2-4**] 2:05

Please call and schedule an appointment to follow up with Dr.
[**Last Name (STitle) 1007**] in [**12-24**] weeks.

Please call the [**Last Name (un) **] and schedule an appointment to follow up
within 2-4 weeks.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
{'Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Acute kidney failure, unspecified,Ulcer of heel and midfoot,Hyposmolality and/or hyponatremia,Subendocardial infarction, initial episode of care,Periapical abscess without sinus,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Polyneuropathy in diabetes,Gastroparesis,Background diabetic retinopathy,Obstructive sleep apnea (adult)(pediatric),Esophageal reflux,Pure hypercholesterolemia,Anemia, unspecified,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere'}


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: hyperglycemia and altered mental status

PRESENT ILLNESS: 63 yo M with h/o DM type 1, PVD, and HTN who presents with
hyperglycemia and altered mental status. The patient states that
he was in his USOH until Monday, when he awoke with abdominal
pain and nausea. He could not eat anything so he didn't take his
insulin. He did not vomit or experience fevers/chills, nor any
dysuria, new cough, or URI sxs. He did manage to go to his
numerous medical appointments that day, when he was seen by PCP,
[**Name10 (NameIs) **], and dentist.
.
Per wife, the dentist foud a large mouth abscess for which he
was prescribed clindamycin 150mg qid x 7 days. Otherwise visits
were without incident. Sugars have been running very
erratically, with FSG on [**1-19**]- [**1-20**] ranging from 70's to 500+.
Today, after returning from work, she found him slumped over at
his computer and confused. Checked BS and was so high meter
didn't read number. Called Dr. [**Last Name (STitle) 1007**], rechecked BS, was still
higher than readable, so called EMS. Was disoriented, calling
son by name and stating he needed 750 units of insulin.
.
In the ED, vitals were stable. Initial labs were notable for
glucose 769, HCO3 9, AG 32, WBC 21.3, lactate 3.9, UA positive
for ketones. CXR without acute process, EKG with new [**Street Address(2) 4793**] dep
V5-6, 0.[**Street Address(2) 1755**] dep II, III, aVF. ABG 7.08/25/104/8. He was
started on an insulin gtt at 8 units/hr, given 4 L IVFs, asa 325
po X 1, levaquin 500 mg IV X 1, and flagyl 500 mg IV X 1.
.
ROS positive for headache and blurry vision recently. Also
endorses poor appetite and po intake due to nausea, abdominal
pain, and vomiting today. Denies unusual polyuria or polydipsia.
Denies CP or SOB.

MEDICAL HISTORY: DM type 1 dx'ed [**2151**], c/b ulnar and median neuropathies, PVD,
retinopathy, and gastroparesis
Diabetic foot ulcers with multiple prior infections including
MRSA isolates, s/p L 4th toe osteomyelitis with gas gangrene in
[**3-30**] requiring amputation
OSA
PVD s/p L femoral bypass
GERD
HTN
Hypercholestolemia
Depression
Erectile dysfunction
h/o broken neck at age 13 with C1-C2 repair.

MEDICATION ON ADMISSION: (per OMR list [**1-19**], pt unable to confirm any)
Diovan 80 mg daily
Amlodipine 10 mg daily
Simvastatin 80 mg daily
Pantoprazole 40 mg daily
Lyrica 75 mg [**Hospital1 **]
Ibuprofen 400 mg q4-6h prn
Tylenol prn
Provigil 100 mg daily
Qualaquin 324 mg [**Hospital1 **] prn
Effexor XR 300 mg dialy
Trazodone 100 mg qhs prn
Varenicline 1 mg [**Hospital1 **]
Wellbutrin 300 mg daily
lisinopril 40 mg daily
Lantus 46 units qhs --> pt states he takes 75/25 42 units [**Hospital1 **],
which is not in keeping with most recent [**Last Name (un) **] note
HISS --> pt states does not do this anymore

ALLERGIES: Penicillins / Cephalosporins / Aztreonam / Latex

PHYSICAL EXAM: T  BP 126/46 HR 95 RR 19 O2 sat 98% 5L NC
Gen - elderly male, pleasant, NAD, tired, smells strongly of
acetone
HEENT - NC/AT, PERRLA, MM dry. Upper dentures. O/P clear, no
ulcers or abscess noted. No tenderness to palpations
CV - RRR, no m/r/g
Lungs - CTAB
Abd - S/NT/ND, + BS
Ext - R foot with small <1cm ulcer on sole, bandaged. Does not
appear infected. L foot with amputated 5th toe
Neuro - A+O x 3
Skin - no rashes or ulcers noted aside from above

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: (+) tobacco use x40 years, currently smokes 3 cigs/day, patient
denies past etoh abuse, although OMR notes indicate past chronic
alcohol use. Denies illicit drug use. Married. 

### Response:
{'Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Acute kidney failure, unspecified,Ulcer of heel and midfoot,Hyposmolality and/or hyponatremia,Subendocardial infarction, initial episode of care,Periapical abscess without sinus,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Polyneuropathy in diabetes,Gastroparesis,Background diabetic retinopathy,Obstructive sleep apnea (adult)(pediatric),Esophageal reflux,Pure hypercholesterolemia,Anemia, unspecified,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere'}
