CHIEF COMPLAINT: DKA, AMS, Chest Pain

PRESENT ILLNESS: 41 year old man w/ poorly controlled DMI (neuropathy,
retinopathy, nephropathy),  CKD VI s/p fistula placement for
diabetic nephropathy, hyperparathyroidism, HTN, CAD (s/p MI) and
polysubstance abuse (heroin, marijuana, cocaine) who presents in
DKA.  The patient states that he last heroin 2 days ago.  Since
that time, he has not used his lantus.  He notes that this
morning, his brother found him passed out on the floor and
brought him to an OSH.  At the OSH, the patient's glucose was
1300, with a serum pH of 7.22 and anion gap of 24.  He was also
noted to have substernal chest pain.  Trop I at the OSH 0.04
(normal range).  The patient was altered and agitated.  He was
given 5mg haldol and 2mg ativan.  The patient was transferred to
[**Hospital1 18**] for further management.

MEDICAL HISTORY: -- Diabetes Mellitus:  diagnosed at age 2, poorly controlled;
Last A1C = 9.4 ([**2115-1-4**]); complicated by neuropathy, nephropathy,
and blindness
-- Polysubstance Abuse, previous use of heroine, cocaine
-- Hypertension
-- History of coronary artery disease. He reports three MIs in
the past: the first at age 20yo associated with steroids and BDP
abuse, the second at age 28 associated with anxiety, and a third
at age 34 associated with cocaine use.
-- Hx osteomylitis (Coagulase negative staph and pseudomonas)
-- arthroplasty R hallux [**2114-7-12**]
-- Venous Stasis Dermatitis
-- Legally Blind - s/p Vitreoectomies [**2101**]
-- Chronic Renal Insufficiency, stage 4
-- proteinuria
-- Bipolar Disorder
-- Anxiety Disorder, NOS
-- Hypercholesterolemia
-- Hyperparathyroidism, secondary (Renal disease)

MEDICATION ON ADMISSION: Confirmed with patient/family
- Humalog SS with meals, 3U for 150-200 and 3U for every incr.
of 50 thereafter.
- Lantus 30 units SC daily
- Clonazepam 1 mg TID
- Simvastatin 20 mg PO qHS
- Carvedilol 25 mg PO Bid
- Amlodipine 5mg daily
- Furosemide 80mg daily
- Suboxone 8mg/2mg 1 [**Hospital1 **]
- Calcitriol 0.5 mcg - 2 capsules daily
- Omeprazole 20 mg daily
- Abilify 20 mg daily
- Lamictal 25mg AM 50mg PM
- Vitamin D 400 mg daily
- Fe 325mg [**Hospital1 **]
- ASA 81mg

ALLERGIES: Penicillins / Tegaderm

PHYSICAL EXAM: On Admission:
Vitals: 98.6 176/89  92 100%RA
General: Alert, oriented to place, person, no acute distress;
occasionally jerks head as if uncomfortable
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic flow
murmur best heard in right and left 2nd intercostal space; no
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: No history of kidney disease, DM or gout. No history of CAD in
parents. Brother with substance abuse; Maternal Grandmother with

SOCIAL HISTORY: The patient lives with his mother and brother. His mother is his
Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Other encephalopathy,Acute kidney failure, unspecified,Chronic kidney disease, Stage IV (severe),Secondary hyperparathyroidism (of renal origin),Other acute and subacute forms of ischemic heart disease, other,Drug withdrawal,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through stage IV, or unspecified,Polyneuropathy in diabetes,Background diabetic retinopathy,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Volume depletion, unspecified,Cannabis abuse, unspecified,Pure hypercholesterolemia,Legal blindness, as defined in U.S.A.,Anemia, unspecified,Long-term (current) use of insulin,Personal history of noncompliance with medical treatment, presenting hazards to health,Bipolar disorder, unspecified,Opioid type dependence, unspecified,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere
DMI ketoacd uncontrold,Encephalopathy NEC,Acute kidney failure NOS,Chr kidney dis stage IV,Sec hyperparathyrd-renal,Ac ischemic hrt dis NEC,Drug withdrawal,Ben hy kid w cr kid I-IV,Neuropathy in diabetes,Diabetic retinopathy NOS,Crnry athrscl natve vssl,Old myocardial infarct,Volume depletion NOS,Cannabis abuse-unspec,Pure hypercholesterolem,Legal blindness-usa def,Anemia NOS,Long-term use of insulin,Hx of past noncompliance,Bipolar disorder NOS,Opioid dependence-unspec,Nephritis NOS in oth dis
Admission Date:  [**2117-3-27**]              Discharge Date:   [**2117-3-31**]

Date of Birth:  [**2076-1-12**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Tegaderm

Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
DKA, AMS, Chest Pain


Major Surgical or Invasive Procedure:
none

History of Present Illness:
41 year old man w/ poorly controlled DMI (neuropathy,
retinopathy, nephropathy),  CKD VI s/p fistula placement for
diabetic nephropathy, hyperparathyroidism, HTN, CAD (s/p MI) and
polysubstance abuse (heroin, marijuana, cocaine) who presents in
DKA.  The patient states that he last heroin 2 days ago.  Since
that time, he has not used his lantus.  He notes that this
morning, his brother found him passed out on the floor and
brought him to an OSH.  At the OSH, the patient's glucose was
1300, with a serum pH of 7.22 and anion gap of 24.  He was also
noted to have substernal chest pain.  Trop I at the OSH 0.04
(normal range).  The patient was altered and agitated.  He was
given 5mg haldol and 2mg ativan.  The patient was transferred to
[**Hospital1 18**] for further management.

In the ED, initial VS were:  99.6 108 175/86 16 100% 3L NC.
Fingerstick revealed glucose of 1200; anion gap .  Labs with
troponin T of 0.1, anion gap of 17.  UA was without evidence of
UTI.  CXR with cardiomegaly, but without evidence of pneumonia.
The patient was continued on a regular insulin drip at 10
units/hr.  He was evaluated by transplant surgery, given new
fistula placement - who recommended no change in management from
perspective of fistula.

On arrival to the MICU, patient's VS 98.6 176/89  92 100%RA.
The patient complains of "not feeling well" but is without
localizing symptoms.  He does endorse an episode of coffee
ground emesis and diarrhea.  He complains of epigastric
abdominal pain.  Otherwise, no fevers, chills, neck stiffness,
cough, shortness of breath, dysuria, frequency, urgency, rash.


Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies palpitations. Denies constipation. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.


Past Medical History:
-- Diabetes Mellitus:  diagnosed at age 2, poorly controlled;
Last A1C = 9.4 ([**2115-1-4**]); complicated by neuropathy, nephropathy,
and blindness
-- Polysubstance Abuse, previous use of heroine, cocaine
-- Hypertension
-- History of coronary artery disease. He reports three MIs in
the past: the first at age 20yo associated with steroids and BDP
abuse, the second at age 28 associated with anxiety, and a third
at age 34 associated with cocaine use.
-- Hx osteomylitis (Coagulase negative staph and pseudomonas)
-- arthroplasty R hallux [**2114-7-12**]
-- Venous Stasis Dermatitis
-- Legally Blind - s/p Vitreoectomies [**2101**]
-- Chronic Renal Insufficiency, stage 4
-- proteinuria
-- Bipolar Disorder
-- Anxiety Disorder, NOS
-- Hypercholesterolemia
-- Hyperparathyroidism, secondary (Renal disease)


Social History:
The patient lives with his mother and brother. His mother is his

healthcare proxy and administers all of his medications. The pt
admits to using heroin in the past few days. He also smokes
marijauna frequently.  No recent cocaine use.  He denies
alcohol. Smoked 1 ppd x 4 months, but quit smoking. Pt was on
methadone in the past, now on suboxone for the past 2 months.


Family History:
No history of kidney disease, DM or gout. No history of CAD in
parents. Brother with substance abuse; Maternal Grandmother with

hypertension, Lung ca, cardiovascular dz


Physical Exam:
On Admission:
Vitals: 98.6 176/89  92 100%RA
General: Alert, oriented to place, person, no acute distress;
occasionally jerks head as if uncomfortable
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic flow
murmur best heard in right and left 2nd intercostal space; no
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

GU: no foley
Ext: Cool, well perfused, 2+ pulses, 1+ edema to ankle; no
clubbing, cyanosis
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
sensation diminished to ankle and hands bilaterally; gait
deferred


Pertinent Results:
[**2117-3-27**] 10:30PM   GLUCOSE-731* UREA N-72* CREAT-4.7*
SODIUM-127* POTASSIUM-3.8 CHLORIDE-92* TOTAL CO2-18* ANION
GAP-21*
[**2117-3-27**] 10:30PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2117-3-27**] 10:30PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
.
CXR [**2117-3-27**]: IMPRESSION: Apparent enlargement of the cardiac
silhouette is most likely related to technique. No acute
cardiopulmonary process.
.
Head CT [**2117-3-27**]: IMPRESSION: Extremely limited study with marked
motion artifact. Within this limitation, no definite acute
intracranial pathology. If there is strong clinical concern for
pathology, then repeat imaging can be obtained when the patient
is able to lie still.


Brief Hospital Course:
41 year old male with DMI, CKD s/p fistula, polysubstance abuse,
and [**Hospital **] transfered from [**Location (un) **] with DKA, altered mental status,
and substernal chest pain.
.
#. Diabetic ketoacidosis / Diabetes mellitus type 1,
uncontrolled, with complications:  Patient with history of
poorly controlled type 1 diabetes admitted with glucose 1200.
At OSH ph 7.22, K 5.2, Anion gap 24.  Started on an insulin drip
at 10 units per hour (0.1 units/kg) at [**Hospital3 **].  On
transfer here, glucose 731, K+ 5.8, pH 3.6, anion gap 17.
Etiology of DKA most likely related to not taking lantus at
home. Patient reports that he relapsed in his heroin addiction
recently. He had not been taking his lantus for 2 days prior to
admission. On the day of admission, the patient??????s brother found
him passed out on the ground (from heroin/tylenol X 3). He
assumed that the patient must be hypoglycemic so he gave him
glucagon and soda. This probably explains why patient presented
with glucose of 1200 but only a moderate anion gap. In terms of
other possible precipitating factors, there was no evidence of
infection on exam.  No evidence of UTI on urinalysis.  CXR
without evidence of pneumonia. He may have had some transient
cardiac ischemia as discussed below, but that was probably
secondary to the acute illness rather than being causative of
it.
.
He improved and was transferred to the floor.  [**Last Name (un) **]
Diabetology was consulted.  He was continued on his home dose of
Lantus 30 units qhs.  [**Last Name (un) **] adjusted his Humalog sliding scale
as indicated in the "Medications" section below. He will
follow-up in the [**Hospital **] [**Hospital 982**] clinic.
.
#. Polysubstance abuse:  Patient with positive opiates and THC
at outside hospital.  He states that he last used heroin 2 days
prior to admission.  He also states that he has been on suboxone
for the past 2 months.  When he presented he had jerky body
movements and diarrhea which may have been from opiate
withdrawal.  After transfer to the general medical [**Hospital1 **] he felt
generall well, and he had no signs of opiate withdrawal.  He was
not given Suboxone.  He can resume Suboxone as an outpatient as
previously prescribed.  He was seen by Social Work.
.
# Hypertension, benign:  Patient with hypertensive urgency to
SBP 200 on admission, asymptomatic.  Patient is on amlodipine,
lasix, carvedilol at home.  Per past clinic and ED notes,
patient appears to be chronically hypertensive. Patient reports
that his BP is rarely less than 150 systolic even when he is
taking all of his meds. His amlodpine was increased to 10 mg
daily, and clonidine was added for better BP control.
.
#. Encephalopathy:  Patient transferred from OSH with altered
mental status.  Given haldol and ativan in the OSH ED for
agitation.  AMS likely was secondary to delirium from
hyperglycemia/diabetic ketoacidosis.  No localizing symptoms of
infection.  Head CT negative for ICH. The patient??????s mental
status returned to baseline after resolution of DKA.
.
#. Chest Pain:  Resolved.  Trop was 0.10 at admission in the
setting of 3 previous MIs and acute on chronic kidney injury.
Repeat was 0.09, then 0.05. CK-MB normal x3 and EKG without
evidence of acute ischemia.  Patient likely had demand ischemia
in the setting of DKA or hypertensive urgency or this is just
his baseline due to renal failure.
.
# Acute on chronic kidney disease:  Patient with diabetic kidney
disease; CKD IV s/p fistula placement in the left arm.  He
continues to make urine.  Most recent baseline appears to be
around 3.5-4.0 although all of those numbers are from when
patient is hospitalized.  Patient likely had prerenal azotemia
overlying his CKD, due to volume depletion from DKA.  Creatinine
normalized to baseline with volume repletion. He has a follow-up
appointment scheduled in the Transplant Surgery clinic for
evaluation of his L arm AV fistula.  NP from the [**Hospital 1326**]
clinic briefly evaluated the (nonpainful) swelling around his
fistula site, and saw no need for intervention
.
# Abdominal pain/Diarrhea:  Patient presented with abdominal
pain, diarrhea, and one episode of emesis. These were likely
from diabetic ketoacidosis as they improved with resolution of
anion gap. Symptoms may also be exacerbated by opioid
withdrawal. Patient did endorse coffee ground emesis and bloody
stools, but has grossly brown stool with only trace guaiac
positivity.  C. diff was negative.  After transfer to the
medical floor, he had no further abdominal pain.
.
# Bipolar disorder: continued lamotrigine and abilify
.
# Normocytic Anemia: Unclear etiology. Hct was stable during
this hospitalization (32 on last check). Patient did not have
melena, hematochezia or emesis during the admission. Patient
reported a prior history of coffee ground emesis and bloody
stools, but on admission has grossly brown stool with only trace
guaiac positivity.  Anemia may be related to chronic kidney
disease.  Additional work-up can be considered as outpatient.
.
TRANSITIONAL ISSUES:
====================
- Further anemia workup per PCP (had guaiac-positive stools, but
is on iron). Hct 32 on last check.
- Follow-up of chronic kidney disease; Cr 3.6 on last check
- Substance abuse treatment
- Follow-up with [**Last Name (un) **]
- HIV antibody test pending at the time of discharge
- Titration of antihypertensives.  Might consider adding
ACE-inhibitor and titrating off clonidine.

Medications on Admission:
Confirmed with patient/family
- Humalog SS with meals, 3U for 150-200 and 3U for every incr.
of 50 thereafter.
- Lantus 30 units SC daily
- Clonazepam 1 mg TID
- Simvastatin 20 mg PO qHS
- Carvedilol 25 mg PO Bid
- Amlodipine 5mg daily
- Furosemide 80mg daily
- Suboxone 8mg/2mg 1 [**Hospital1 **]
- Calcitriol 0.5 mcg - 2 capsules daily
- Omeprazole 20 mg daily
- Abilify 20 mg daily
- Lamictal 25mg AM 50mg PM
- Vitamin D 400 mg daily
- Fe 325mg [**Hospital1 **]
- ASA 81mg


Discharge Medications:
1. lamotrigine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
2. lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
3. furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
8. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
11. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. aripiprazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
14. insulin glargine 100 unit/mL Solution Sig: Thirty (30) UNITS
Subcutaneous at bedtime.
15. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day: Please follow Humalog sliding
scale - you have been given a copy.
.
HUMALOG SLIDING SCALE
Before Breakfast, Before Lunch, Before Dinner
Glucose<80: 0 units Humalog
81-100: 2 units
101-150: 3 units
151-200: 5 units
201-250: 6 units
251-300: 7 units
301-350: 9 units
351-400: 10 units
>401: 10 units
.
Before Bedtime (along with Lantus 30 units)
Glucose<80: 0 units Humalog
81-100: 0 units
101-150: 0 units
151-200: 0 units
201-250: 2 units
251-300: 3 units
301-350: 4 units
351-400: 5 units
>401: 6 units

Discharge Disposition:
Home

Discharge Diagnosis:
-Diabetic ketoacidosis
-Diabetes mellitus type 1, uncontrolled, with complications
-Chronic kidney disease, stage 4
-CAD s/p MI
-Polysubstance abuse
-Hypertension, benign


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted for diabetic ketoacidosis.  You should
continue to take insulin every day, as instructed, to avoid this
serious condition.  It is also important that you eat on a
regular basis, and that you avoid foods that can cause your
blood sugar levels to rise excessively, as described to you by
the Nutrition specialists.
.
Please follow-up in the [**Hospital **] [**Hospital 982**] clinic.  Please call
[**Telephone/Fax (1) 2378**] to set up an appointment to see your diabetologist.
.
You have an appointment scheduled for Friday [**2117-4-2**] to see a new
primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], at [**Hospital1 18**] in [**Location (un) 86**].  See
below for the appointment information.

Followup Instructions:
Please call [**Telephone/Fax (1) 2378**] to set up an appointment to see your
diabetologist at [**Last Name (un) **].

Department: [**Hospital3 249**]
When: FRIDAY [**2117-4-2**] at 3:45 PM
With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
Dr [**First Name (STitle) **] is your new physician at [**Name9 (PRE) 191**]. She works closely with Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] both will be involved in your care.  Please
call your insurance  and name Dr. [**Last Name (STitle) **] as your PCP. [**Name10 (NameIs) **]
MUST BE DONE BEFORE YOUR APPOINTMENT.

Department: RADIOLOGY
When: THURSDAY [**2117-4-15**] at 2:00 PM
With: VASCULAR STUDY [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: TRANSPLANT CENTER
When: THURSDAY [**2117-4-15**] at 2:45 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
{'Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Other encephalopathy,Acute kidney failure, unspecified,Chronic kidney disease, Stage IV (severe),Secondary hyperparathyroidism (of renal origin),Other acute and subacute forms of ischemic heart disease, other,Drug withdrawal,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through stage IV, or unspecified,Polyneuropathy in diabetes,Background diabetic retinopathy,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Volume depletion, unspecified,Cannabis abuse, unspecified,Pure hypercholesterolemia,Legal blindness, as defined in U.S.A.,Anemia, unspecified,Long-term (current) use of insulin,Personal history of noncompliance with medical treatment, presenting hazards to health,Bipolar disorder, unspecified,Opioid type dependence, 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: DKA, AMS, Chest Pain

PRESENT ILLNESS: 41 year old man w/ poorly controlled DMI (neuropathy,
retinopathy, nephropathy),  CKD VI s/p fistula placement for
diabetic nephropathy, hyperparathyroidism, HTN, CAD (s/p MI) and
polysubstance abuse (heroin, marijuana, cocaine) who presents in
DKA.  The patient states that he last heroin 2 days ago.  Since
that time, he has not used his lantus.  He notes that this
morning, his brother found him passed out on the floor and
brought him to an OSH.  At the OSH, the patient's glucose was
1300, with a serum pH of 7.22 and anion gap of 24.  He was also
noted to have substernal chest pain.  Trop I at the OSH 0.04
(normal range).  The patient was altered and agitated.  He was
given 5mg haldol and 2mg ativan.  The patient was transferred to
[**Hospital1 18**] for further management.

MEDICAL HISTORY: -- Diabetes Mellitus:  diagnosed at age 2, poorly controlled;
Last A1C = 9.4 ([**2115-1-4**]); complicated by neuropathy, nephropathy,
and blindness
-- Polysubstance Abuse, previous use of heroine, cocaine
-- Hypertension
-- History of coronary artery disease. He reports three MIs in
the past: the first at age 20yo associated with steroids and BDP
abuse, the second at age 28 associated with anxiety, and a third
at age 34 associated with cocaine use.
-- Hx osteomylitis (Coagulase negative staph and pseudomonas)
-- arthroplasty R hallux [**2114-7-12**]
-- Venous Stasis Dermatitis
-- Legally Blind - s/p Vitreoectomies [**2101**]
-- Chronic Renal Insufficiency, stage 4
-- proteinuria
-- Bipolar Disorder
-- Anxiety Disorder, NOS
-- Hypercholesterolemia
-- Hyperparathyroidism, secondary (Renal disease)

MEDICATION ON ADMISSION: Confirmed with patient/family
- Humalog SS with meals, 3U for 150-200 and 3U for every incr.
of 50 thereafter.
- Lantus 30 units SC daily
- Clonazepam 1 mg TID
- Simvastatin 20 mg PO qHS
- Carvedilol 25 mg PO Bid
- Amlodipine 5mg daily
- Furosemide 80mg daily
- Suboxone 8mg/2mg 1 [**Hospital1 **]
- Calcitriol 0.5 mcg - 2 capsules daily
- Omeprazole 20 mg daily
- Abilify 20 mg daily
- Lamictal 25mg AM 50mg PM
- Vitamin D 400 mg daily
- Fe 325mg [**Hospital1 **]
- ASA 81mg

ALLERGIES: Penicillins / Tegaderm

PHYSICAL EXAM: On Admission:
Vitals: 98.6 176/89  92 100%RA
General: Alert, oriented to place, person, no acute distress;
occasionally jerks head as if uncomfortable
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic flow
murmur best heard in right and left 2nd intercostal space; no
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: No history of kidney disease, DM or gout. No history of CAD in
parents. Brother with substance abuse; Maternal Grandmother with

SOCIAL HISTORY: The patient lives with his mother and brother. His mother is his 

### Response:
{'Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Other encephalopathy,Acute kidney failure, unspecified,Chronic kidney disease, Stage IV (severe),Secondary hyperparathyroidism (of renal origin),Other acute and subacute forms of ischemic heart disease, other,Drug withdrawal,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through stage IV, or unspecified,Polyneuropathy in diabetes,Background diabetic retinopathy,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Volume depletion, unspecified,Cannabis abuse, unspecified,Pure hypercholesterolemia,Legal blindness, as defined in U.S.A.,Anemia, unspecified,Long-term (current) use of insulin,Personal history of noncompliance with medical treatment, presenting hazards to health,Bipolar disorder, unspecified,Opioid type dependence, unspecified,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere'}
