CHIEF COMPLAINT: CC: Shortness of breath/Anasarca/acute renal failure
Reason for MICU transfer: Hypercarbia, Somnolence

PRESENT ILLNESS: Mr [**Known lastname 17028**] is a 38 year old man with poorly controlled type 1
diabetes (c/b nephropathy, neuropathy and retinopathy),
hypertension, hyperlipidemia, question of coronary artery
disease and prior polysubstance abuse, presenting from [**Hospital **]
clinic for dyspnea and weight gain, being transferred from the
floor for hypercapnea and somnolence.
.
Briefly, patient has been residing at [**Hospital1 **] for treatment of
osteomyelitis. He was seen at [**Hospital **] [**Hospital 2793**] clinic earlier on the
day of admission for worsening weight gain, renal failure and
shortness of breath. He was found to have increased creatinine
from baseline and was sent to ED for further evaluation.
.
In the ED, vital signs were initially:  98% RA, 63, 12, 141/88.
Patient was admitted to the medical service where he was noted
to be very somnolent and witnessed to have acute desaturation
event to 70's on supplemental oxygen. Episode is described by
team as "excessive sleepiness" at time of interview, where he
was falling asleep in mid sentence while aswering questions.
Patient had no complaints at the time of desaturation, no
convulsions or apneic episodes were witnessed.
.
Given concern for hypercapnea and somnolence, patient had
arterial blood gas which revealed pH 7.42 pCO2 58 pO2 177.
Overall assessment is that he needed BiPAP for apneic episodes
while remainder of workup was performed.
.
Review of [**Hospital1 **] progress notes reveals patient completed 8
weeks of Vancomycin and Ciprofloxacin on [**2114-12-17**] for R toe
osetomyelitis. He is now on suppression dose doxycycline. He
developed anasarca and was treated with escalating doses of
diuretics including 120mg PO Lasix + Metolazone resulting in
worsening renal function.

MEDICAL HISTORY: #. Healing osteomylitis (Coagulase negative staph and
pseudomonas)
- arthroplasty R hallux [**2114-7-12**]
- s/p 8 weeks IV vancomycin, followed ciprofloxacin
#. 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.
- Per OSH records, he had a cath at a different hospital that
demonstrated clean coronary arteries.
#. Venous Stasis Dermatitis
#. Legally Blind - s/p Vitreoectomies [**2101**]
#. Chronic Renal Insufficiency, stage 3
- proteinuria
- follows with Dr. [**Last Name (STitle) 4090**]
- baseline creatinine 2.3-2.8
#. Bipolar Disorder
- follows with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Last Name (un) **]
#. Anxiety Disorder, NOS
#. Hypercholesterolemia
#. Hyperparathyroidism, secondary (Renal disease)

MEDICATION ON ADMISSION: Lyrica 75 Mg PO TID
Clonidine 0.1 mg QID
methadone 150 mg PO Q daily
Amlodipine 10 mg PO Q daily
Lamictal 100 mg PO BID
Furosemide 80 mg Q day
Clonazepam 1 mg PO TID
Calcitrol 0.25 mg PO Q Day
Saline nasal spray
Simvastatin 40 mg PO Q day
Carvedilol 25 mg PO BID
Aspirin 81 mg PO Q day
Docusate 100 mg PO BID
Vit D 400 U PO BID
Abilify 20 mg PO Q day
Mag [**Doctor Last Name **] plus 15 ml PO Q4 PRN indegestion
Chloride hydrate 1000 mg PRN insomnia
saline nasal spray
Glargine 30 U Q HS
doxycycline 100 mg PO Q day
Ascorbic acid 5-00 mg PO TID

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: AF, 138/87, 61, 20, 97 RA
GEN: The patient is in no distress and appears comfortable
SKIN: No rashes or skin changes noted
HEENT: difficult to assess JVD, neck supple, No lymphadenopathy
in cervical, posterior, or supraclavicular chains noted.
CHEST: Lungs remarkably clear to auscultation.
CARDIAC: Regular rhythm; nl S1, loud P2.
ABDOMEN: No apparent scars. Distended, and soft without
tenderness
EXTREMITIES: marked 3+ edema to thighs, warm without cyanosis. R
index toe with skin breakdown, blister, negative bone probe.
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**4-3**], and BLE [**4-3**] both proximally and distally. No pronator
drift. Reflexes were symmetric. Downward going toes.

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

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 and cocaine in the past, but states he
currently does not use either. He does currently smoke marijauna
frequently. He denies alcohol. Smoked 1 ppd x 4 months, but quit
smoking. Pt is on methadone 150 mg a day which he gets from
Habbitt Opco.
Acute diastolic heart failure,Acute kidney failure, unspecified,Ulcer of heel and midfoot,Opioid type dependence, continuous,Chronic kidney disease, Stage IV (severe),Secondary hyperparathyroidism (of renal origin),Chronic osteomyelitis, ankle and foot,Diabetes with renal manifestations, type I [juvenile type], uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Background diabetic retinopathy,Obstructive sleep apnea (adult)(pediatric),Coronary atherosclerosis of native coronary artery,Venous (peripheral) insufficiency, unspecified,Other chronic pulmonary heart diseases,Bipolar I disorder, most recent episode (or current) unspecified,Legal blindness, as defined in U.S.A.,Iron deficiency anemia, unspecified,Hypoxemia,Tobacco use disorder,Other specified disorders of skin,Pure hypercholesterolemia,Anxiety state, unspecified,Anemia in chronic kidney disease,Old myocardial infarction,Long-term (current) use of insulin,Personal history of noncompliance with medical treatment, presenting hazards to health
Ac diastolic hrt failure,Acute kidney failure NOS,Ulcer of heel & midfoot,Opioid dependence-contin,Chr kidney dis stage IV,Sec hyperparathyrd-renal,Chr osteomyelit-ankle,DMI renal uncntrld,Hy kid NOS w cr kid I-IV,Diabetic retinopathy NOS,Obstructive sleep apnea,Crnry athrscl natve vssl,Venous insufficiency NOS,Chr pulmon heart dis NEC,Bipolor I current NOS,Legal blindness-usa def,Iron defic anemia NOS,Hypoxemia,Tobacco use disorder,Skin disorders NEC,Pure hypercholesterolem,Anxiety state NOS,Anemia in chr kidney dis,Old myocardial infarct,Long-term use of insulin,Hx of past noncompliance
Admission Date:  [**2115-1-4**]              Discharge Date:   [**2115-1-8**]

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

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
CC: Shortness of breath/Anasarca/acute renal failure
Reason for MICU transfer: Hypercarbia, Somnolence

Major Surgical or Invasive Procedure:
PICC line

History of Present Illness:
Mr [**Known lastname 17028**] is a 38 year old man with poorly controlled type 1
diabetes (c/b nephropathy, neuropathy and retinopathy),
hypertension, hyperlipidemia, question of coronary artery
disease and prior polysubstance abuse, presenting from [**Hospital **]
clinic for dyspnea and weight gain, being transferred from the
floor for hypercapnea and somnolence.
.
Briefly, patient has been residing at [**Hospital1 **] for treatment of
osteomyelitis. He was seen at [**Hospital **] [**Hospital 2793**] clinic earlier on the
day of admission for worsening weight gain, renal failure and
shortness of breath. He was found to have increased creatinine
from baseline and was sent to ED for further evaluation.
.
In the ED, vital signs were initially:  98% RA, 63, 12, 141/88.
Patient was admitted to the medical service where he was noted
to be very somnolent and witnessed to have acute desaturation
event to 70's on supplemental oxygen. Episode is described by
team as "excessive sleepiness" at time of interview, where he
was falling asleep in mid sentence while aswering questions.
Patient had no complaints at the time of desaturation, no
convulsions or apneic episodes were witnessed.
.
Given concern for hypercapnea and somnolence, patient had
arterial blood gas which revealed pH 7.42 pCO2 58 pO2 177.
Overall assessment is that he needed BiPAP for apneic episodes
while remainder of workup was performed.
.
Review of [**Hospital1 **] progress notes reveals patient completed 8
weeks of Vancomycin and Ciprofloxacin on [**2114-12-17**] for R toe
osetomyelitis. He is now on suppression dose doxycycline. He
developed anasarca and was treated with escalating doses of
diuretics including 120mg PO Lasix + Metolazone resulting in
worsening renal function.

Past Medical History:
#. Healing osteomylitis (Coagulase negative staph and
pseudomonas)
- arthroplasty R hallux [**2114-7-12**]
- s/p 8 weeks IV vancomycin, followed ciprofloxacin
#. 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.
- Per OSH records, he had a cath at a different hospital that
demonstrated clean coronary arteries.
#. Venous Stasis Dermatitis
#. Legally Blind - s/p Vitreoectomies [**2101**]
#. Chronic Renal Insufficiency, stage 3
- proteinuria
- follows with Dr. [**Last Name (STitle) 4090**]
- baseline creatinine 2.3-2.8
#. Bipolar Disorder
- follows with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Last Name (un) **]
#. 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 and cocaine in the past, but states he
currently does not use either. He does currently smoke marijauna
frequently. He denies alcohol. Smoked 1 ppd x 4 months, but quit
smoking. Pt is on methadone 150 mg a day which he gets from
Habbitt Opco.

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:
VS: AF, 138/87, 61, 20, 97 RA
GEN: The patient is in no distress and appears comfortable
SKIN: No rashes or skin changes noted
HEENT: difficult to assess JVD, neck supple, No lymphadenopathy
in cervical, posterior, or supraclavicular chains noted.
CHEST: Lungs remarkably clear to auscultation.
CARDIAC: Regular rhythm; nl S1, loud P2.
ABDOMEN: No apparent scars. Distended, and soft without
tenderness
EXTREMITIES: marked 3+ edema to thighs, warm without cyanosis. R
index toe with skin breakdown, blister, negative bone probe.
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**4-3**], and BLE [**4-3**] both proximally and distally. No pronator
drift. Reflexes were symmetric. Downward going toes.

Pertinent Results:
LABS ON ADMISSION:
[**2115-1-4**] 12:50PM BLOOD WBC-8.2 RBC-3.62* Hgb-9.8* Hct-29.6*
MCV-82 MCH-27.2 MCHC-33.2 RDW-15.0 Plt Ct-327
[**2115-1-4**] 12:50PM BLOOD Neuts-82.3* Lymphs-10.8* Monos-4.0
Eos-2.5 Baso-0.4
[**2115-1-4**] 12:50PM BLOOD PT-11.4 PTT-31.7 INR(PT)-0.9
[**2115-1-4**] 12:50PM BLOOD Glucose-73 UreaN-95* Creat-4.1*# Na-128*
K-4.1 Cl-85* HCO3-34* AnGap-13
[**2115-1-4**] 12:50PM BLOOD CK(CPK)-417*
[**2115-1-4**] 12:50PM BLOOD Calcium-9.0 Phos-5.2* Mg-3.6*
[**2115-1-5**] 07:13PM BLOOD TSH-4.0
[**2115-1-7**] 07:10AM BLOOD ANCA-NEGATIVE B
[**2115-1-7**] 07:10AM BLOOD RheuFac-7
[**2115-1-7**] 07:10AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2115-1-7**] 07:10AM BLOOD HIV Ab-NEGATIVE
[**2115-1-4**] 07:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2115-1-4**] 06:36PM BLOOD Type-ART pO2-177* pCO2-58* pH-7.42
calTCO2-39* Base XS-11
.
LABS ON DISCHARGE:
[**2115-1-8**] 06:10AM BLOOD WBC-6.3 RBC-3.70* Hgb-9.8* Hct-31.1*
MCV-84 MCH-26.5* MCHC-31.7 RDW-14.4 Plt Ct-274
[**2115-1-8**] 06:10AM BLOOD Plt Ct-274
[**2115-1-8**] 06:10AM BLOOD Glucose-437* UreaN-64* Creat-2.9* Na-130*
K-4.2 Cl-86* HCO3-34* AnGap-14
[**2115-1-6**] 06:25AM BLOOD CK(CPK)-113
[**2115-1-8**] 06:10AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.4
.
CXR: [**1-4**]
IMPRESSION: No acute cardiopulmonary abnormality.
.
ECHO [**2115-1-7**]:
The left and right atria are moderately dilated. The estimated
right atrial pressure is 0-5 mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild
pulmonary artery systolic hypertension. Biatrial enlargement.
.
Compared with the prior study (images reviewed) of [**2114-5-14**],
the findings are similar.
.
RENAL ULTRASOUND [**2115-1-5**]:
IMPRESSION: Unremarkable renal ultrasound.

Brief Hospital Course:
38 year old man with poorly controlled diabetes, hypertension,
chronic renal failure, presenting with worsening edema/anasarca,
shortness of breath, found to be in acute renal failure and
severe somnolence on arrival.
.
#  ALTERED MENTAL STATUS: Patient was admitted to the medical
service where he was noted to be very somnolent and witnessed to
have acute desaturation event to 70's on supplemental oxygen.
The episode was described by team as "excessive sleepiness" at
time of interview, where he was falling asleep in mid sentence
while aswering questions. Patient had no complaints at the time
of desaturation, no convulsions or apneic episodes were
witnessed. Given concern for hypercapnea and somnolence, patient
had arterial blood gas which revealed pH 7.42 pCO2 58 pO2 177.
Overall assessment involved BiPAP for apneic episodes while
remainder of workup was performed. His medications were adjusted
with a decrease in pregabalin from 75mg TID to 25mg TID and
decrease in methadone to 100mg.  His mental status improved back
to baseline by the AM. He was continued on CPAP at night daily.
.
# ANASARCA/VOLUME OVERLOAD: DDx included proteinuria vs. liver
disease vs. [**Last Name (un) **] on [**Last Name (un) 2091**] vs. cardiac disease, specifically from
pulmonary hypertension, as there was evidence from prior TTE
that patient had mild-moderate pulmonary artery hypertension.
Unlikely to be liver disease, given only minimal evidence of
synthetic dysfunction. In addition, degree of proteinuria was
only minimal to explain 20-40 lb weight gain. Patient was also
on a calcium channel blocker previously, which may have been a
slight contributor. However, suspect primary etiology to be
cardiac disease, or right heart failure, given elevated RV
pressures and elevated pulmonary artery pressures. Patient
underwent TTE at [**Hospital1 **] on [**2114-12-7**] showing estimated end
systolic RV pressure > 35mmHg.  DDx for right sided heart
failure included HIV, OSA, polysubstance abuse, and
rheumatologic causes. Workup included negative HIV testing,
negative ANCA, negative rheumatoid factor, and negative [**Doctor First Name **].
Patient did have evidence of prior polysubstance absuse,
including cocaine and methamphetamine, which can contribute to R
heart failure. He was also noted to have an episode of
somnolence with an acute desaturation event, which may be
related to apnea. He was set up with a sleep clinic appointment
for OSA evaluation as an outpatient. He was informed to
eliminate any drug use, which may be contributing. He was
decreased on his lyrica from 75 mg tid to 25 mg tid, since it
may have contributed to his presentation as well. After IV lasix
diuresis for three days, patient had returned to his dry weight
and had lost approximately 15 liters of fluid. His BUN/Cr also
returned to [**Location 213**]. Repeat TTE here showed slightly improved
PA/RV pressures. Patient was discharged on home regimen of 80 mg
PO lasix.
.
# ACUTE RENAL FAILURE ON STAGE IV [**Location 2091**]: Patient with chronic
diabetic nephropathy, however with acute decompensation. It is
possible that OSA is causing severe increase in pulmonary
pressures leading to decreased forward flow, however other
causes of renal failure were considered. DDx included
obstruction (however renal ultrasound was negative), intrinsic
renal failure (although AIN and/or ATN were unlikely given bland
urine sediment). Of note, after aggressive IV diuresis,
patient's BUN and Cr returned to [**Location 213**] (discharge values 64 and
2.9, respectively).
.
# DIABETES TYPE 1: known to be poorly controlled. Insulin dose
adjusted in setting of ARF and hypoglycemic episode on one
morning. Patient continued on SSI. Have arranged for close
follow-up with PCP to adjust BG regimen as needed.
.
# BIPOLAR DISORDER: Continued home regimen of Lamictal and
Abilify
.
# H/O POLYSUBSTANCE ABUSE: Continued methadone.
.
# HYPERTENSION: patient was continued on prior medications, as
[**First Name8 (NamePattern2) **] [**Hospital1 **] notes. His blood pressure was well controlled on
discharge.
.
# OSTEOMYELITIS: s/p 8 week treatment with vancomycin and
ciprofloxacin for osteomyelitis. Continued home regimen of
doxycycline for suppressive therapy. Patient was seen by
[**Hospital1 **], and they noted healing heel ulcers as well as healing
right 5th digit blister. They recommended wet to dry dressings
on discharge. Of note, patient has follow-up arranged with Dr.
[**Last Name (STitle) **].
.
# ANEMIA OF IRON DEFICIENCY AND [**Last Name (STitle) 2091**]: Hct remainded at baseline.
Patient continued his home iron regimen.
.
# CARDIAC: Pt reported MI, normal angiogram [**Location (un) 7349**], subsequent
ETT-MIBI OSH which showed a small anterior mixed defect.
.
# DISPO: discharge to home with PCP, [**Name10 (NameIs) **], sleep clinic
follow-up. He is to obtain chemistry 10 panel and fax results to
Dr. [**Last Name (STitle) 4090**].

Medications on Admission:
Lyrica 75 Mg PO TID
Clonidine 0.1 mg QID
methadone 150 mg PO Q daily
Amlodipine 10 mg PO Q daily
Lamictal 100 mg PO BID
Furosemide 80 mg Q day
Clonazepam 1 mg PO TID
Calcitrol 0.25 mg PO Q Day
Saline nasal spray
Simvastatin 40 mg PO Q day
Carvedilol 25 mg PO BID
Aspirin 81 mg PO Q day
Docusate 100 mg PO BID
Vit D 400 U PO BID
Abilify 20 mg PO Q day
Mag [**Doctor Last Name **] plus 15 ml PO Q4 PRN indegestion
Chloride hydrate 1000 mg PRN insomnia
saline nasal spray
Glargine 30 U Q HS
doxycycline 100 mg PO Q day
Ascorbic acid 5-00 mg PO TID


Discharge Medications:
1. Outpatient Lab Work
Please obtain chemistry 10 panel on [**2115-1-10**] and have results
faxed to [**Telephone/Fax (1) 12142**].  Dr. [**Last Name (STitle) 4090**] will review these results.
2. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*30 Capsule(s)* Refills:*2*
3. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Aripiprazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
14. Methadone 10 mg Tablet Sig: Fifteen (15) Tablet PO DAILY
(Daily): prescribed by alternate provider at methadone clinic.
15. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
16. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
Disp:*1 vial* Refills:*2*
17. Humalog 100 unit/mL Solution Sig: as per sliding scale sheet
units Subcutaneous before breakfast, lunch, and dinner as per
sliding scale.
Disp:*1 vial* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
- Acute right heart failure.
- Pulmonary artery hypertension.
- Anasarca.
.
Secondary:
- Diabetes mellitus type I.
- [**Last Name (STitle) 2091**] stage IV
- Neuropathy, retinopathy, and blindness
- Substance Abuse
- Bipolar disorder type I
- Hypertension
- Osteomyelitis right big toe.
- Anemia of iron deficiency and [**Name (NI) 2091**]
- Pt reported MI, normal angiogram [**Location (un) 7349**], subsequent ETT-MIBI OSH
which showed a small anterior mixed defect.


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


Discharge Instructions:
You were admitted to [**Hospital1 69**] for
worsening weight gain and shortness of breath. You were noted to
have some acute kidney injury and your total body volume
overload was felt to be from high blood pressure in your lungs
(pulmonary hypertension). This is likely from multiple causes
including obstructive sleep apnea, prior drug use, and
potentially high dose lyrica. You were given IV lasix and you
were discharged when your weight had returned to baseline. You
will likely require a sleep study on discharge. It will be
critical for you to continue CPAP to keep the fluid from
re-accumulating. The sleep study should be arranged by your
primary care doctor, and can be discussed at next visit. In
addition, you were seen by the [**Hospital1 **] team for your heel
ulcers and your right 5th digit ulceration. They recommended wet
to dry dressings on discharge, and have arranged for a follow-up
appointment, as noted below.
.
NEW MEDICATIONS/MEDICATION CHANGES:
- DECREASE lyrica to 25 mg three times a day
- continue CPAP at night
- wet to dry dressing changes to right 5th digit
.
Please seek medical attention for worsening volume overload,
progressive shortness of breath, fevers, worsening drainage from
your heel/toe ulcer, chest pain, abdominal pain or distension,
or any other concerns. Please discuss outpatient sleep study
with your primary care doctor.

Followup Instructions:
We have made an appointment with your primary care doctor, Dr.
[**Last Name (STitle) 17029**], on [**2115-1-15**] at 11:45 AM. Please call [**Telephone/Fax (1) 17030**] if
you need to re-schedule.
.
We have made an appointment for you at sleep clinic on [**2115-1-17**]
at 1 pm with Dr. [**First Name (STitle) **]. It will be at [**Hospital Ward Name 23**] [**Location (un) 436**]. Please
call [**Telephone/Fax (1) 612**] if you need to reschedule.
.
Provider [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2115-1-15**] 10:10 ([**Month/Day/Year **])
.
You will obtain a chemistry 10 laboratory blood draw and have
these results faxed to Dr. [**Last Name (STitle) 4090**] as noted below.



Completed by:[**2115-1-8**]
{'Acute diastolic heart failure,Acute kidney failure, unspecified,Ulcer of heel and midfoot,Opioid type dependence, continuous,Chronic kidney disease, Stage IV (severe),Secondary hyperparathyroidism (of renal origin),Chronic osteomyelitis, ankle and foot,Diabetes with renal manifestations, type I [juvenile type], uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Background diabetic retinopathy,Obstructive sleep apnea (adult)(pediatric),Coronary atherosclerosis of native coronary artery,Venous (peripheral) insufficiency, unspecified,Other chronic pulmonary heart diseases,Bipolar I disorder, most recent episode (or current) unspecified,Legal blindness, as defined in U.S.A.,Iron deficiency anemia, unspecified,Hypoxemia,Tobacco use disorder,Other specified disorders of skin,Pure hypercholesterolemia,Anxiety state, unspecified,Anemia in chronic kidney disease,Old myocardial infarction,Long-term (current) use of insulin,Personal history of noncompliance with medical treatment, presenting hazards to health'}


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: Shortness of breath/Anasarca/acute renal failure
Reason for MICU transfer: Hypercarbia, Somnolence

PRESENT ILLNESS: Mr [**Known lastname 17028**] is a 38 year old man with poorly controlled type 1
diabetes (c/b nephropathy, neuropathy and retinopathy),
hypertension, hyperlipidemia, question of coronary artery
disease and prior polysubstance abuse, presenting from [**Hospital **]
clinic for dyspnea and weight gain, being transferred from the
floor for hypercapnea and somnolence.
.
Briefly, patient has been residing at [**Hospital1 **] for treatment of
osteomyelitis. He was seen at [**Hospital **] [**Hospital 2793**] clinic earlier on the
day of admission for worsening weight gain, renal failure and
shortness of breath. He was found to have increased creatinine
from baseline and was sent to ED for further evaluation.
.
In the ED, vital signs were initially:  98% RA, 63, 12, 141/88.
Patient was admitted to the medical service where he was noted
to be very somnolent and witnessed to have acute desaturation
event to 70's on supplemental oxygen. Episode is described by
team as "excessive sleepiness" at time of interview, where he
was falling asleep in mid sentence while aswering questions.
Patient had no complaints at the time of desaturation, no
convulsions or apneic episodes were witnessed.
.
Given concern for hypercapnea and somnolence, patient had
arterial blood gas which revealed pH 7.42 pCO2 58 pO2 177.
Overall assessment is that he needed BiPAP for apneic episodes
while remainder of workup was performed.
.
Review of [**Hospital1 **] progress notes reveals patient completed 8
weeks of Vancomycin and Ciprofloxacin on [**2114-12-17**] for R toe
osetomyelitis. He is now on suppression dose doxycycline. He
developed anasarca and was treated with escalating doses of
diuretics including 120mg PO Lasix + Metolazone resulting in
worsening renal function.

MEDICAL HISTORY: #. Healing osteomylitis (Coagulase negative staph and
pseudomonas)
- arthroplasty R hallux [**2114-7-12**]
- s/p 8 weeks IV vancomycin, followed ciprofloxacin
#. 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.
- Per OSH records, he had a cath at a different hospital that
demonstrated clean coronary arteries.
#. Venous Stasis Dermatitis
#. Legally Blind - s/p Vitreoectomies [**2101**]
#. Chronic Renal Insufficiency, stage 3
- proteinuria
- follows with Dr. [**Last Name (STitle) 4090**]
- baseline creatinine 2.3-2.8
#. Bipolar Disorder
- follows with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Last Name (un) **]
#. Anxiety Disorder, NOS
#. Hypercholesterolemia
#. Hyperparathyroidism, secondary (Renal disease)

MEDICATION ON ADMISSION: Lyrica 75 Mg PO TID
Clonidine 0.1 mg QID
methadone 150 mg PO Q daily
Amlodipine 10 mg PO Q daily
Lamictal 100 mg PO BID
Furosemide 80 mg Q day
Clonazepam 1 mg PO TID
Calcitrol 0.25 mg PO Q Day
Saline nasal spray
Simvastatin 40 mg PO Q day
Carvedilol 25 mg PO BID
Aspirin 81 mg PO Q day
Docusate 100 mg PO BID
Vit D 400 U PO BID
Abilify 20 mg PO Q day
Mag [**Doctor Last Name **] plus 15 ml PO Q4 PRN indegestion
Chloride hydrate 1000 mg PRN insomnia
saline nasal spray
Glargine 30 U Q HS
doxycycline 100 mg PO Q day
Ascorbic acid 5-00 mg PO TID

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: AF, 138/87, 61, 20, 97 RA
GEN: The patient is in no distress and appears comfortable
SKIN: No rashes or skin changes noted
HEENT: difficult to assess JVD, neck supple, No lymphadenopathy
in cervical, posterior, or supraclavicular chains noted.
CHEST: Lungs remarkably clear to auscultation.
CARDIAC: Regular rhythm; nl S1, loud P2.
ABDOMEN: No apparent scars. Distended, and soft without
tenderness
EXTREMITIES: marked 3+ edema to thighs, warm without cyanosis. R
index toe with skin breakdown, blister, negative bone probe.
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**4-3**], and BLE [**4-3**] both proximally and distally. No pronator
drift. Reflexes were symmetric. Downward going toes.

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

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 and cocaine in the past, but states he
currently does not use either. He does currently smoke marijauna
frequently. He denies alcohol. Smoked 1 ppd x 4 months, but quit
smoking. Pt is on methadone 150 mg a day which he gets from
Habbitt Opco. 

### Response:
{'Acute diastolic heart failure,Acute kidney failure, unspecified,Ulcer of heel and midfoot,Opioid type dependence, continuous,Chronic kidney disease, Stage IV (severe),Secondary hyperparathyroidism (of renal origin),Chronic osteomyelitis, ankle and foot,Diabetes with renal manifestations, type I [juvenile type], uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Background diabetic retinopathy,Obstructive sleep apnea (adult)(pediatric),Coronary atherosclerosis of native coronary artery,Venous (peripheral) insufficiency, unspecified,Other chronic pulmonary heart diseases,Bipolar I disorder, most recent episode (or current) unspecified,Legal blindness, as defined in U.S.A.,Iron deficiency anemia, unspecified,Hypoxemia,Tobacco use disorder,Other specified disorders of skin,Pure hypercholesterolemia,Anxiety state, unspecified,Anemia in chronic kidney disease,Old myocardial infarction,Long-term (current) use of insulin,Personal history of noncompliance with medical treatment, presenting hazards to health'}
