CHIEF COMPLAINT: Fatigue, weakness, dysuria/hematuria

PRESENT ILLNESS: 57F DM, CAD, HTN in her USOH until 6d PTA, when she notes onset
of increased fatigue, weakness, and dysuria.  ~4-5d ago, she
notes the onset of frank hematuria.   She admits to 1-2 episodes
of loose stools over the week, but none in past 3-4 days.

MEDICAL HISTORY: - DM2 - on oral meds only, not consistently taking
- HTN
- CAD - s/p PTCA [**2130**]
- Hyperlipidemia
- TAH [**2-5**] fibroids
- Hypothyroidism

MEDICATION ON ADMISSION: Glyburide 5 mg daily
HCTZ 25 mg daily
Levothyroxine 88 mcg daily
Lipitor 20 mg daily
Metformin 850 mg [**Hospital1 **]
Metoprolol tartrate 50 mg tid
Ramipril 10 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
Vitals:   96.1  95  118/54  27  95%RA.
General: Alert, oriented, lethargic, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD.  no neck tenderness,
full ROM of neck without pain.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, +2/6 SEM c/w flow
murmur.  no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Works as interior designer. Nonsmoker, 1-2 drinks per week
Acute kidney failure, unspecified,Other septicemia due to gram-negative organisms,Urinary tract infection, site not specified,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Sepsis,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Anemia, unspecified,Unspecified acquired hypothyroidism,Percutaneous transluminal coronary angioplasty status
Acute kidney failure NOS,Gram-neg septicemia NEC,Urin tract infection NOS,DMII ketoacd uncontrold,Sepsis,Hypertension NOS,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Anemia NOS,Hypothyroidism NOS,Status-post ptca
Admission Date:  [**2142-6-11**]              Discharge Date:   [**2142-6-15**]

Date of Birth:  [**2085-1-23**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name8 (NamePattern2) 812**]
Chief Complaint:
Fatigue, weakness, dysuria/hematuria

Major Surgical or Invasive Procedure:
None

History of Present Illness:
57F DM, CAD, HTN in her USOH until 6d PTA, when she notes onset
of increased fatigue, weakness, and dysuria.  ~4-5d ago, she
notes the onset of frank hematuria.   She admits to 1-2 episodes
of loose stools over the week, but none in past 3-4 days.

She was evaluated by her PCP today, and noted to be hypotensive
to the 90s/70s by report, and was referred to the ED.

In ED VS= 97.7  87/60  92  14 99%RA.  Initial FSBS critically
high.  Labs revealed NA 116, CRE 2.8, HCO3 18, FSBS 680, WBC
16.2.  UA positive for UTI.  She was given 8U regular insulin
and started on insulin gtt @ 1640, with BP u to 134/72 with 2L
IVF.   She received IV zosyn for UTI.

ROS negative for fevers, chills, nightsweats, cough, chest pain,
sob, abdominal pain, recent diarrhea, rash, joint pains, or
medications chagnes.


Past Medical History:
- DM2 - on oral meds only, not consistently taking
- HTN
- CAD - s/p PTCA [**2130**]
- Hyperlipidemia
- TAH [**2-5**] fibroids
- Hypothyroidism

Social History:
Works as interior designer. Nonsmoker, 1-2 drinks per week

Family History:
Noncontributory

Physical Exam:
On admission:
Vitals:   96.1  95  118/54  27  95%RA.
General: Alert, oriented, lethargic, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD.  no neck tenderness,
full ROM of neck without pain.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, +2/6 SEM c/w flow
murmur.  no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

On discharge:
T afeb BP 120s-170s/60s-90s HR 70s-90s RR 16 O2sat 99% on RA
FS: 140, 127, 124, 144
General: Alert, oriented, pleasant, WNWD F, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD.
Lungs: Clear to auscultation bilaterally
CV: RRR, no MRG
Abdomen: soft, NTND, +bowel sounds, no rebound tenderness or
guarding, no organomegaly
Back: no CVS tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
CXR: No acute cardiopulmonary process

Renal US: No evidence of hydronephrosis.

Labs on admission:
[**2142-6-11**] 03:40PM BLOOD WBC-16.2*# RBC-4.61 Hgb-11.7* Hct-35.6*
MCV-77* MCH-25.3* MCHC-32.7 RDW-14.2 Plt Ct-280
[**2142-6-11**] 03:40PM BLOOD Neuts-80* Bands-6* Lymphs-6* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2142-6-11**] 03:40PM BLOOD PT-12.1 PTT-22.4 INR(PT)-1.0
[**2142-6-11**] 03:40PM BLOOD Glucose-680* UreaN-67* Creat-2.8*#
Na-116* K-4.1 Cl-76* HCO3-18* AnGap-26*
[**2142-6-12**] 04:51AM BLOOD ALT-32 AST-82* AlkPhos-105 TotBili-0.4
[**2142-6-11**] 03:40PM BLOOD Calcium-8.1* Phos-3.1 Mg-2.4
[**2142-6-11**] 04:52PM BLOOD Type-ART pO2-187* pCO2-33* pH-7.37
calTCO2-20* Base XS--4 Intubat-NOT INTUBA
[**2142-6-11**] 04:18PM BLOOD Glucose->500 Lactate-2.6* Na-119* K-3.6
Cl-82* calHCO3-20*

Other labs:
[**2142-6-15**] 06:15AM BLOOD WBC-9.4 RBC-3.51* Hgb-9.0* Hct-26.7*
MCV-76* MCH-25.7* MCHC-33.8 RDW-14.8 Plt Ct-450*
[**2142-6-15**] 06:15AM BLOOD Glucose-94 UreaN-23* Creat-1.7* Na-138
K-4.0 Cl-103 HCO3-23 AnGap-16
[**2142-6-15**] 06:15AM BLOOD Calcium-7.6* Phos-5.1* Mg-1.7 Cholest-149
[**2142-6-15**] 06:15AM BLOOD Triglyc-204* HDL-16 CHOL/HD-9.3
LDLcalc-92
[**2142-6-15**] 06:15AM BLOOD Hapto-420*
[**2142-6-12**] 09:10PM BLOOD calTIBC-177 Ferritn-1213* TRF-136*
[**2142-6-12**] 04:51AM BLOOD %HbA1c-15.2*

Urine and blood cultures from [**6-11**] with pansensitive Klebsiella
Surveillance cultures negative

UA positive with large blood

Brief Hospital Course:
57F with h/o DM2, admitted with UTI complicated by GNR
bacteremia and DKA, short admission to MICU for insulin gtt and
IVF. AG now closed and pt transitioned to SC insulin regimen.

# DKA - Thought to be type 2 on oral hypoglycemics, but Hgb A1C
later found to be >15. Patient initially with glucose of >600
and anion gap of 22.  UTI and medication noncompliance were
thought to be the precipitating factor to her DKA.  Pt was
initially treated in the MICU, where she recieved 8 U reg
insulin IV and was started on insulin gtt.  The patient received
fluid bolus with NS to goal MAP and UOP, electrolytes were
aggressively repleted. Glucose rapidly improved and anion gap
closed by early AM after admission.  She was transitioned to
subcutaneous insulin and transferred to the medical floor.
[**Last Name (un) **] followed and adjusted pt's insulin regimen, requiring
initiation of home insulin. Pt showed poor insight into the
severity of her presentation although was agreeable with plan
and had support from her husband to take her medical management
seriously.

# Klebsiella Bacteremia and UTI: Pt initially treated with
Zosyn, alternated between Cipro, Zosyn and back to Cipro once
Klebsiella was shown to be pansensitive. Pt is to complete 14
day course of renally dosed Cipro on discharge (another 9 days).


# Hematuria - Presumably due to klebsiella UTI but persistence
and severity was impressive and concerning. Microscopic
evaluation of urine showed some hemolysis but generally normal
RBCs without evidence of glomerular disease. Pt was not placed
on anticoagulation and aspirin temporarily stopped. Foley was
removed and pt continued to have frank hematuria, without
obvious clots but thick wine colored urine. Urology was
consulted and recommended flushing bladder head to dislodge any
clots obstructing outflow. Pt did pass a clot with this maneuver
but urine color did not improve. Hct was downtrending but
thought to be overall stable and minimally due to hematuria (see
below).

# Acute renal failure - Pt without prior history of renal
dysfunction. Cr on presentation was 2.8, slowly trending down to
1.7 on discharge. Likely prerenal with ATN given plateau. Renal
US without hydronephrosis but large kidneys consistent with
diabetes. Meds were renally dosed and nephrotoxins maximally
avoided.

# Anemia: 36 on admission, dropping high 20s after 8L IVF in the
ICU. However has been has long term microcytosis even when Hct
stable, Iron panel c/w anemia of chronic disease. Estimated
blood loss due to hematuria was thought to be approximately
1unit of hematocrit per day. Pt remained in high 20s without
further drop or symptoms, and thus was thought to be stable for
discharge with close follow up.

# Diabetes: %HbA1c: 15.2, pt reported to be noncompliant with
medical regimen. Pt was started on diabetic diet, nutrition was
consulted, as was [**Last Name (un) **] who uptitrated new insulin regimen
until well controlled on Lantus 45qhs, Humalog 10U prandial and
sliding scale (oral regimen stopped). Pt was given insulin
teaching and demonstrated good ability to give herself insulin
via a preloaded pen. She will be followed by [**Last Name (un) **] as an outpt
for further monitoring and adjustment of her regimen.

# HTN - Pt was continued on her metoprolol while ACEi and HCTZ
held in the setting of renal failure. BP remained stable,
increasing as pt's infection and DKA resolved.

# CAD - Pt was continued on metoprolol, statin. ACE and Aspirin
held as above

# Hyperlipidemia - Last checked in [**2-11**], not optimized with
LDL >100. Given slight AST elevation to 80s, statin was
continued at outpt dose and uptitrating can be considered as an
outpt.

# Hypothyroid - Outpt dose of levothyroxine was continued given
recent WNL TSH.

Medications on Admission:
Glyburide 5 mg daily
HCTZ 25 mg daily
Levothyroxine 88 mcg daily
Lipitor 20 mg daily
Metformin 850 mg [**Hospital1 **]
Metoprolol tartrate 50 mg tid
Ramipril 10 mg [**Hospital1 **]

Discharge Medications:
1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
5. Insulin Aspart 100 unit/mL Insulin Pen Sig: Ten (10) units
Subcutaneous with meals.
Disp:*5 pens* Refills:*2*
6. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Forty Five
(45) units Subcutaneous at bedtime.
Disp:*5 pens* Refills:*2*
7. Insulin Pen [**Hospital1 **] 31 X [**1-7**]   [**Month/Day (4) **] Sig: as directed
Miscellaneous as directed.
Disp:*90 needles* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
Primary:
Urinary tract infection Klebsiella causing sepsis
Bacteremia
Diabetic Ketoacidosis
Hematuria
Diabetes Mellitus type 2 uncontrolled
acute renal failure

Secondary:
HTN
CAD
hyperlipidemia
hypothryoidism


Discharge Condition:
Stable, Hct 26.7, BP 138/70, HR 84


Discharge Instructions:
You were admitted with Diabetic Ketoacidosis, a very serious
complication of diabetes, that can occur when your blood sugars
are too high. This can be due to infection, medication
noncompliance or many other changes in your body. In your
situation it is likely a combination of urinary tract infection
and hematuria (blood in your urine), loose stools, and not
taking your diabetes medications.

You had a short stay in the ICU and required aggressive
treatment with continuous IV insulin, large amounts of IV
fluids, and electrolyte repletion, all due to diabetic
ketoacidosis. You were then transitioned to subcutanous insulin
which you will need to continue at home, as labwork shows that
your diabetes is very poorly controlled on the current regimen
and you are in danger of having further complications if not
better controlled.

The bacteria in your urine was also found to have spread to the
blood. You were treated with IV antibiotics and eventually
switched to oral ciprofloxacin. You will need to complete a 2
week course of this at home, which is another 9 days. When you
see Dr [**First Name (STitle) **] on [**6-19**], he may adjust the dosing of Cipro
based on your kidney function.

You also had large amounts of blood in your urine. This may have
been due to your urinary tract infection or may have been the
cause of your infection. Given the large amounts, your blood
counts were monitored closely. You will need to follow up with
urology as an outpatient to confirm complete resolution
(microscopic) of the blood in your urine. Meanwhile please stop
taking aspirin, as this increases bleeding. Please discuss when
to restart this with your primary care physician.

Your kidney function decreased in the setting of your infection,
bleeding and low blood pressures. This will likely continue
improving with time and will need to be followed up as an
outpatient. Please make sure to keep yourself well hydrated, and
avoid the following medications until your kidney function is
resolved or stable: NSAIDs (Ibuprofen, Advil, Motrin, Naproxen,
Aleve, etc), Aspirin and Ramipril.

We have made the following changes to your prior medications:
1) STOP Glyburide and Metformin
2) START Insulin (45 units of Lantus(Glargine) at night, and 10U
of Humalog(Aspart) with each meal)
3) STOP Hydrochlorothiazide and Ramipril
4) START Ciprofloxacin for another 9 days
5) STOP Aspirin until you are seen by urology

Please call Dr [**First Name (STitle) **] or return to the hospital if you develop
chest pain, shortness of breath, lightheadedness, dizziness,
fevers, chills, abdominal pain, back pain, nausea/vomiting,
weakness or any other concerning symptoms.

It was a pleasure taking care of you, we wish you the best!

Followup Instructions:
MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Primary Care
Date and time: [**6-19**] at 10:45am
Location: [**State 7478**], [**Location (un) 86**]
Phone number: [**Telephone/Fax (1) 7477**]
Please have your hematocrit and creatinine checked at this time.


MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**]
Specialty: Urology
Date and time: [**7-5**] at 3pm
Location: [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 164**]

MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN
Specialty: Diabetes Nurse
Date and time: [**6-28**] at 9am and [**7-9**] at 9am
Location: [**Last Name (un) **] Diabetes Center, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 2384**]


                             [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]

Completed by:[**2142-7-2**]
{'Acute kidney failure, unspecified,Other septicemia due to gram-negative organisms,Urinary tract infection, site not specified,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Sepsis,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Anemia, unspecified,Unspecified acquired hypothyroidism,Percutaneous transluminal coronary angioplasty status'}


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: Fatigue, weakness, dysuria/hematuria

PRESENT ILLNESS: 57F DM, CAD, HTN in her USOH until 6d PTA, when she notes onset
of increased fatigue, weakness, and dysuria.  ~4-5d ago, she
notes the onset of frank hematuria.   She admits to 1-2 episodes
of loose stools over the week, but none in past 3-4 days.

MEDICAL HISTORY: - DM2 - on oral meds only, not consistently taking
- HTN
- CAD - s/p PTCA [**2130**]
- Hyperlipidemia
- TAH [**2-5**] fibroids
- Hypothyroidism

MEDICATION ON ADMISSION: Glyburide 5 mg daily
HCTZ 25 mg daily
Levothyroxine 88 mcg daily
Lipitor 20 mg daily
Metformin 850 mg [**Hospital1 **]
Metoprolol tartrate 50 mg tid
Ramipril 10 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
Vitals:   96.1  95  118/54  27  95%RA.
General: Alert, oriented, lethargic, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD.  no neck tenderness,
full ROM of neck without pain.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, +2/6 SEM c/w flow
murmur.  no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Works as interior designer. Nonsmoker, 1-2 drinks per week 

### Response:
{'Acute kidney failure, unspecified,Other septicemia due to gram-negative organisms,Urinary tract infection, site not specified,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Sepsis,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Anemia, unspecified,Unspecified acquired hypothyroidism,Percutaneous transluminal coronary angioplasty status'}
