CHIEF COMPLAINT: CC: elevated blood sugar

PRESENT ILLNESS: 56 yo M with history of renal cell cancer s/p nephrectomy and
renal transplant in [**2101**], hypertension who presents with 2 days
of general malaise, weakness, nausea, polyuria, polydipsia, and
chills. Pt notes 1 week h/o nonproductive cough. Denies fever,
CP, or SOB. Pt was seen in renal clinic today where he was noted
to have a glucose of >500. On arrival to [**Name (NI) **], pt found to have
glucose >900, T 99.1, BP 236/108. In ED given 10 units of SC
insulin x2 and then started on insulin gtt. Pt had a h/o DM
while on Prograf in [**2101**]. Not currently treated for DM.  Pt was
transferred to the MICU and was placed on an insulin drip with
better sugar control was transferred to the floor.

MEDICAL HISTORY: Renal cell ca s/p L nephrectomy [**2093**]
s/p cadaveric renal transplant [**8-7**]
diabetes mellitus type 2
asthma- not treated, hospitalized as child
s/p left AV graft
h/o ciguatera poisening from barracuda ingestion
nasal polyps
hypertension
DM type 2
Barrett's esophagus
mild pulmonary hypertension
trivial MR

MEDICATION ON ADMISSION: - Diovan 320 mg a day
- metoprolol 100 twice a day
- lisinopril 40 a day
- Norvasc 5 daily
- Lasix 40 mg a day
- clonidine 0.3 twice a day
- Rapamune 4 mg a day
- Bactrim single strength MWF
- CellCept [**Pager number **] twice a day
- baby aspirin
- prednisone 5 mg daily

ALLERGIES: Vancomycin

PHYSICAL EXAM: VS: Tm 98.4  Tc98.1  86 68-96 BP 170/39  150-204/39-82  RR 19
SaO2 96, 95-97 RA I/O 5300/750
Gen: well appearing male in NAD
HEENT: dry MM, PERRL, EOMI, No JVD
CV: rrr, SEM II/VI greatest RUSB
Chest: CTA b/l
Abd: soft, NT/ND, +BS
Ext: no edema, strong DP/PT pulses
Neuro: A&Ox3

FAMILY HISTORY: mother with renal disease

SOCIAL HISTORY: married, works in nutrition at [**Hospital1 18**]
remote tob hs, no EtOH, no IVDA
Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled,Complications of transplanted kidney,Primary pulmonary hypertension,Hypopotassemia,Unspecified essential hypertension,Unspecified sleep apnea,Anemia, unspecified,Personal history of malignant neoplasm of kidney,Barrett's esophagus
DMII hprosmlr uncontrold,Compl kidney transplant,Prim pulm hypertension,Hypopotassemia,Hypertension NOS,Sleep apnea NOS,Anemia NOS,Hx of kidney malignancy,Barrett's esophagus
Admission Date:  [**2104-1-25**]              Discharge Date:   [**2104-2-1**]

Date of Birth:  [**2045-12-2**]             Sex:   M

Service: MEDICINE

Allergies:
Vancomycin

Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
CC: elevated blood sugar

Major Surgical or Invasive Procedure:
PICC
Renal Artery Stent

History of Present Illness:
56 yo M with history of renal cell cancer s/p nephrectomy and
renal transplant in [**2101**], hypertension who presents with 2 days
of general malaise, weakness, nausea, polyuria, polydipsia, and
chills. Pt notes 1 week h/o nonproductive cough. Denies fever,
CP, or SOB. Pt was seen in renal clinic today where he was noted
to have a glucose of >500. On arrival to [**Name (NI) **], pt found to have
glucose >900, T 99.1, BP 236/108. In ED given 10 units of SC
insulin x2 and then started on insulin gtt. Pt had a h/o DM
while on Prograf in [**2101**]. Not currently treated for DM.  Pt was
transferred to the MICU and was placed on an insulin drip with
better sugar control was transferred to the floor.


Past Medical History:
Renal cell ca s/p L nephrectomy [**2093**]
s/p cadaveric renal transplant [**8-7**]
diabetes mellitus type 2
asthma- not treated, hospitalized as child
s/p left AV graft
h/o ciguatera poisening from barracuda ingestion
nasal polyps
hypertension
DM type 2
Barrett's esophagus
mild pulmonary hypertension
trivial MR

Social History:
married, works in nutrition at [**Hospital1 18**]
remote tob hs, no EtOH, no IVDA

Family History:
mother with renal disease

Physical Exam:
VS: Tm 98.4  Tc98.1  86 68-96 BP 170/39  150-204/39-82  RR 19
SaO2 96, 95-97 RA I/O 5300/750
Gen: well appearing male in NAD
HEENT: dry MM, PERRL, EOMI, No JVD
CV: rrr, SEM II/VI greatest RUSB
Chest: CTA b/l
Abd: soft, NT/ND, +BS
Ext: no edema, strong DP/PT pulses
Neuro: A&Ox3

Pertinent Results:
[**2104-1-25**] 09:15PM   GLUCOSE-732* UREA N-18 CREAT-1.8* SODIUM-134
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-19* ANION GAP-21*
[**2104-1-25**] 06:49PM   GLUCOSE-931* K+-6.1*
[**2104-1-25**] 06:30PM   GLUCOSE-837* UREA N-20 CREAT-1.8* SODIUM-127*
POTASSIUM-4.6 CHLORIDE-89* TOTAL CO2-23 ANION GAP-20
[**2104-1-25**] 06:30PM   CK(CPK)-294*
[**2104-1-25**] 06:30PM   CK-MB-4 cTropnT-0.03*
[**2104-1-25**] 06:30PM   CALCIUM-10.7* PHOSPHATE-2.3* MAGNESIUM-2.3
[**2104-1-25**] 06:30PM   WBC-4.5 RBC-5.35 HGB-13.8* HCT-43.2 MCV-81*
MCH-25.8* MCHC-31.9 RDW-13.7
[**2104-1-25**] 06:30PM   NEUTS-67.6 LYMPHS-26.6 MONOS-4.7 EOS-1.2
BASOS-0.1
[**2104-1-25**] 06:30PM   HYPOCHROM-3+ MICROCYT-1+
[**2104-1-25**] 06:30PM   PLT SMR-NORMAL PLT COUNT-168 LPLT-2+
[**2104-1-25**] 06:30PM   PT-12.4 PTT-25.0 INR(PT)-1.0
[**2104-1-25**] 01:14AM   GLUCOSE-692*
[**2104-1-25**] 01:14AM   UREA N-19 CREAT-1.8* SODIUM-134 POTASSIUM-3.7
CHLORIDE-94* TOTAL CO2-30 ANION GAP-14
[**2104-1-25**] 01:14AM   ALT(SGPT)-30 AST(SGOT)-19 TOT BILI-0.5
[**2104-1-25**] 01:14AM   ALBUMIN-3.7 CALCIUM-10.4* PHOSPHATE-2.1*
[**2104-1-25**] 01:14AM   rapamycin-14.6*
[**2104-1-25**] 01:14AM URINE  HOURS-RANDOM CREAT-41 TOT PROT-207
PROT/CREA-5.0*
[**2104-1-25**] 01:14AM   WBC-4.2 RBC-5.52 HGB-14.0 HCT-44.1 MCV-80*
MCH-25.3* MCHC-31.7 RDW-13.3
[**2104-1-25**] 01:14AM   PLT SMR-NORMAL PLT COUNT-167
[**2104-1-25**] 01:14AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.036*
[**2104-1-25**] 01:14AM URINE  BLOOD-TR NITRITE-NEG PROTEIN->300
GLUCOSE->1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
[**2104-1-25**] 01:14AM URINE  RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
<BR>
CXR in ED: No active lung disease.
<BR>
ECHO: The left atrium is moderately dilated. There is probably
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size is
normal. Right ventricular systolic function is normal. The
aortic valve leaflets are mildly thickened. The study is
inadequate to exclude significant aortic valve stenosis. The
mitral valve leaflets are mildly thickened. There is no
pericardial effusion.
<BR>
CXR [**1-26**] (after unsuccessful SC/IJ line attempts): Cardiac
silhouette and mediastinum is within normal limits.  No
pneumothoraces are identified on either side.  No parenchymal
opacities are seen. There is no evidence for gross pulmonary
edema.
<BR>
RUE US: No evidence of right upper extremity DVT.
<BR>
Renal Artery Cath:
1. Significant renal artery stenosis of the transplanted kidney.

2. Normal central blood pressure.
3. Successful stenting of transplant renal artery.
4. Successful Perclose Proglide closure of right femoral artery.

5. Successful Angioseal closure of left femoral artery.
<BR>
Renal US:  Normal appearance of transplant kidney. No evidence
of
hydronephrosis.
<BR>
V/Q Scan: Low likelihood for pulmonary embolism.
<BR>
Abdominal/Pelvic CT:
1. No evidence of intra-abdominal hematoma.
2. Status post left nephrectomy, with a residual soft tissue
nodule of unclear etiology.  If there is a neoplasm and any
concern for recurrence, comparison to prior studies could be
helpful if available.
3. Renal transplant in the right lower quadrant, with delayed
excretion of contrast from prior catheterization procedure.
4. Bibasilar atelectasis.


Brief Hospital Course:
Mr. [**Known lastname **] was initially treated for severe hyperglycemia in
the ICU, and once stable, transferred to the [**Location (un) **] Chief
Medicine Service for further evaluation of his symptoms and
underlying medical problems. During his admission, he was noted
to have severe HTN, and received surgical intervention for his
renal artery stenosis. He was also noted to be hypoxic on finger
pulse oximetry to 85% RA, leading to a workup for causes of this
hypoxia which was most likely [**2-7**] venous/arterial mixing of
blood in his extremities due to b/l shunts and grafts. SaO2 as
measured on his ear was much improved. His creatinine levels
rose slightly after the procedure, with concern for renal
toxicity from surgical contrast. CT scan was remarkable for a
small soft tissue mass in the area of his L nephrectomy, with
concern for malignancy. Renal team recommended f/u with repeat
CT scan in three months.
<BR>
1) Hyperosmolar Nonketotic Hyperglycemia: Upon initial
presentation to the [**Name (NI) **], pt. had glucose of 837. He had been
symptomatic for hyperglycemia for past several weeks
(polydipsia, polyuria, malaise). Pt was not on medications for
DM2 prior to admission. In [**2100**], he was noted to be
hyperglycemic, but this was thought to be [**2-7**] his Prograf and
this medication was changed. Random glucose in [**Month (only) 1096**] had been
measured at 214. His hyperglycemia was likely exacerbated by his
steroid medications. Other possibilities included viral syndrome
or bacterial bronchitis, although blood and urine Cxs were
negative. There was also a possibility that the renal artery
stenosis, combined with mild dehydration, could have lead to a
pre-renal azotemia that compounded the underlying hyperglycemia.
<BR>
The pt. was aggressively hydrated in the ICU and started on an
insulin drip until glucose levels returned to baseline. He was
then transferred to the floor with a RISS and followed by the
[**Last Name (un) **] endocrine service for modifications to his sliding scale.
Prior to d/c, pt. was educated about the use of insulin and
symptoms of hyper/hypoglycemia.
<BR>
2) HTN: Pt. stated that his BP has not been well controlled for
a long time, and that the loss of his R kidney had originally
been due to HTN. He was on an extensive list of medications for
bp at home, including amlodipine, clonidine, lisinopril,
valsartan, furosomide, and metoprolol. These medications were
optimized when possible, and hydralazine and nitro prn were also
added to his regimen. Metoprolol was switched to labetalol in
consult with the renal service out of concern for a paradoxical
interaction between his beta-blocker and the alpha-agonist. It
was thought that the beta-2 agonism and alpha-1 antagonism
effects of labetalol would avoid the risk of unopposed alpha-2
vasoconstriction. When his pressures remained elevated to the
190s on this aggressive regimen, interventional cardiology was
consulted to evaluate his known renal artery stenosis.
<BR>
A renal artery stent was placed on [**1-30**], at which time it was
determined that the stenosis had occluded 90% of the renal
artery, with a 30mmHg pressure gradient across the stenosis. His
bps were much improved the next day, and he was able to come off
of the nitro. Gradually, he was also taken off of his [**Last Name (un) **],
ACE-I, and hydralazine as SBPs remained 120s-140s out of concern
for preserved renal function.
<BR>
3) Hypoxia/SOB: The pt. complained of chest tightness upon
admission, and was ruled out for MI with three sets of cardiac
enzymes, EKGs, and telemetry. He had an ECHO which did not show
any acute processes. His symptoms resolved without intervention.
Once out of the ICU, the pt. was noted to have mild SOB on
occasion in the AM, stating he found it easier to breathe when
sitting upright. His O2 sats as measured on his fingers were
typically lowest overnight and in the AM, down to 85% on room
air, and ranging from 89-97% on 4LPM via nasal cannula. His O2
sat did not drop appreciably upon ambulation. Ddx for his SOB
was considered to be infectious/PNA/PCP [**Last Name (NamePattern4) **]. fluid overload vs.
cardiac vs. PE vs. OSA/obestity-hypoventilaion syndrome. He
stated that IV fluids made his SOB worse, but CXR showed no
acute process and physical exam showed clear lung sounds
throughout. The pt. was monitored with telemetry and EKGs to
monitor cardiac activity. The pt. was evaluated for PE w/ a V/Q
scan (CTA contraindicated given decreased renal function).
Blood/urine cultures were obtained and negative at 48 hours,
without evidence for an infectious process. An ABG showed
hypercapnea, hyperoxemia, and a normal pH and A-a gradient. The
level of hyperoxemia did not correlate with the SaO2 as measured
on the pulse oximeter on his fingers bilaterally. An oximeter
was applied to his ear, which indicated an SaO2 in the
middle-to-high 90s on RA, which better fit his clinical picture.
<BR>
A sleep study from the medical record had remarked about his
nocturnal hypoxia and symptoms concerning for OSA. Pt. was not
using CPAP/BiPAP at home as had been recommended. He was started
on BiPAP prior to discharge, with improvement in his oxygenation
and symptoms.
<BR>
4) Anemia: The pt. had a fall in hematocrit from 35.9 -> 29.6 on
the day following his cath. This was concerning for a femoral or
RP bleed, which was ruled out with a non-contrast CT. Crit
remained constant after the initial drop, and the retic count
was appropriately elevated.
<BR>
5) OSA: Pt previously had a sleep study at [**Hospital1 **] showing very bad
OSA. He has pHTN, daytime sleepiness, and apnea/[**Last Name (un) 6055**] [**Doctor Last Name 6056**]
breathing while sleeping. He was started on BiPAP while in
hospital and scheduled for follow-up in the sleep clinic.
<BR>
6) S/P Renal Transplant: Pt was continued on his home doses of
CellCept, Rapamune, and prednisone while in hospital. His
rapamycin trough was found to be within the therapeutic range.
His creatinine rose gradually on the days following his stent
placement, which was concerning for contrast toxicity. The rise
was gradual, however, and pt. was not thought to be in renal
failure or have the need for HD. He will need creatinine levels
monitored as an outpt.
<BR>
7) Soft Tissue Mass: A 14mm x 8mm soft tissue mass in the area
of the pt's L nephrectomy was seen on CT. This could be old
scarring, but given pt.'s Hx of RCC, could be malignancy. No CT
scan was available for comparison, so pt. was recommended to
repeat the CT in three months.
<BR>
8) FEN: Pt. was monitored with daily lytes, and repleted as
necessary. He was kept on a Cardiac/Diabetic diet. RISS was
initiated as described above.
<BR>
9) Access: Given difficultly of placing peripheral lines and
need for hydration/medications/procedure, pt. had a PICC placed.
It was removed prior to discharge.
<BR>
10) Code: Pt was FULL CODE on this admission.

Medications on Admission:
- Diovan 320 mg a day
- metoprolol 100 twice a day
- lisinopril 40 a day
- Norvasc 5 daily
- Lasix 40 mg a day
- clonidine 0.3 twice a day
- Rapamune 4 mg a day
- Bactrim single strength MWF
- CellCept [**Pager number **] twice a day
- baby aspirin
- prednisone 5 mg daily

Discharge Medications:
1. Sirolimus 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Disp:*120 Tablet(s)* Refills:*2*
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
Disp:*12 Tablet(s)* Refills:*2*
3. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
Subcutaneous twice a day: Take 24 U in the morning.
Take 22 U in the evening.
Disp:*1 qs* Refills:*0*
11. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: Use  per sliding scale.
Disp:*1 qs* Refills:*0*
12. Insulin Needles (Disposable) 29 X [**1-7**]   Needle Sig: Four (4)
 Miscell.  four times a day.
Disp:*1 qs* Refills:*2*
13. Lab Work  Sig: One (1)   once a day: On [**2104-2-4**] please go to
the lab and have your CBC, Chem-10, drawn and faxed to Dr.
[**Last Name (STitle) **], and Dr. [**Last Name (STitle) 5717**]
[**Name (STitle) 21867**]10 = sodium, potassium, chloride, bicarbonate, bun,
creatine, magnesium, calcium, phosphate.
Disp:*1 time* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary: Hyperosmolar Nonketotic Hyperglycemia, Diabetes
Mellitus  Type 2, Renal Artery Stenois, Hypertension, Sleep
Apnea
<BR>
Secondary: s/p renal transplant


Discharge Condition:
stable

stable


Discharge Instructions:
-please continue with medications as prescribed
-please attend all of your appointments
-if symptoms of nausea, vomiting, headaches, shortness of
breath, chest pain/palpitations, leg swelling, or any other
concerning symptoms occur, please come back to the ED
immediately
-if you start to feel symptoms of increased thirst, increased
urination, dizziness, weakness, or fatigue, check your blood
sugar levels. If you are having trouble controlling your blood
sugar, please call the [**Hospital **] clinic or your primary doctor.

You will need to schedule the following appointment with your
primary doctor: CT scan of your abdomen and pelvis in 3 months.
Provider:


Followup Instructions:
You have the following appointments scheduled:

[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2104-2-20**] 10:00

[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2104-2-5**] 8:30
AM

[**Last Name (un) **] Diabetes with Dr. [**Last Name (STitle) 978**] on [**2104-2-5**] at 4:00pm

[**Last Name (LF) **],[**Name8 (MD) **] MD, SLEEP CLINIC Phone:[**Telephone/Fax (1) 6856**]
Date/Time:[**2104-2-5**] 3:00 PM

You will need to schedule the following appointment with your
primary doctor: CT scan of your abdomen and pelvis in 3 months.
Provider:
{"Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled,Complications of transplanted kidney,Primary pulmonary hypertension,Hypopotassemia,Unspecified essential hypertension,Unspecified sleep apnea,Anemia, unspecified,Personal history of malignant neoplasm of kidney,Barrett's esophagus"}


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: CC: elevated blood sugar

PRESENT ILLNESS: 56 yo M with history of renal cell cancer s/p nephrectomy and
renal transplant in [**2101**], hypertension who presents with 2 days
of general malaise, weakness, nausea, polyuria, polydipsia, and
chills. Pt notes 1 week h/o nonproductive cough. Denies fever,
CP, or SOB. Pt was seen in renal clinic today where he was noted
to have a glucose of >500. On arrival to [**Name (NI) **], pt found to have
glucose >900, T 99.1, BP 236/108. In ED given 10 units of SC
insulin x2 and then started on insulin gtt. Pt had a h/o DM
while on Prograf in [**2101**]. Not currently treated for DM.  Pt was
transferred to the MICU and was placed on an insulin drip with
better sugar control was transferred to the floor.

MEDICAL HISTORY: Renal cell ca s/p L nephrectomy [**2093**]
s/p cadaveric renal transplant [**8-7**]
diabetes mellitus type 2
asthma- not treated, hospitalized as child
s/p left AV graft
h/o ciguatera poisening from barracuda ingestion
nasal polyps
hypertension
DM type 2
Barrett's esophagus
mild pulmonary hypertension
trivial MR

MEDICATION ON ADMISSION: - Diovan 320 mg a day
- metoprolol 100 twice a day
- lisinopril 40 a day
- Norvasc 5 daily
- Lasix 40 mg a day
- clonidine 0.3 twice a day
- Rapamune 4 mg a day
- Bactrim single strength MWF
- CellCept [**Pager number **] twice a day
- baby aspirin
- prednisone 5 mg daily

ALLERGIES: Vancomycin

PHYSICAL EXAM: VS: Tm 98.4  Tc98.1  86 68-96 BP 170/39  150-204/39-82  RR 19
SaO2 96, 95-97 RA I/O 5300/750
Gen: well appearing male in NAD
HEENT: dry MM, PERRL, EOMI, No JVD
CV: rrr, SEM II/VI greatest RUSB
Chest: CTA b/l
Abd: soft, NT/ND, +BS
Ext: no edema, strong DP/PT pulses
Neuro: A&Ox3

FAMILY HISTORY: mother with renal disease

SOCIAL HISTORY: married, works in nutrition at [**Hospital1 18**]
remote tob hs, no EtOH, no IVDA 

### Response:
{"Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled,Complications of transplanted kidney,Primary pulmonary hypertension,Hypopotassemia,Unspecified essential hypertension,Unspecified sleep apnea,Anemia, unspecified,Personal history of malignant neoplasm of kidney,Barrett's esophagus"}
