CHIEF COMPLAINT: AMS, hyperglycemia, hypertension

PRESENT ILLNESS: History of Present Illness: 24-year-old gentleman with poorly
controlled Type I diabetes with ESRD recently started HD,
hypertension, retinopathy, with three separate admissions this
past week who was referred to the ED from dialysis for elevated
blood sugar and vomiting. Per patient's family, patient took am
dose of insulin today. He had awoken feeling unwell and had been
vomiting prior to going to dialysis. He reportedly was not
febrile. He reportedly did not take his am BP meds.
.
In the ED, initial vs were: T98 HR:88 BP:193/113 RR:16
O2Sat:100RA. Serum glucose on arrival was 818 with AG of 21. He
received 10 units of regular insulin. He received less than 1
liter NS. For BP got total of 30 mg IV labetolol. Pt acting
confused and agitated requiring total 10mg IM Haldol, Ativan
2mg. Given his extreme agitation he was intubated and
transferred to MICU for further management.
.
On the floor,patient intubated and sedated. He appeared
comfortable on the ventilator.
.
Review of systems: (unable to obtain)

MEDICAL HISTORY: - Diabetes mellitus, type I. Diagnosed in [**2162**]. Poorly
controlled with past DKA. Complicated with retinopathy,
nephropathy
- Hypertension, poorly controlled
- Chronic kidney disease
- Chronic constipation
- Chronic Anemia (baseline hematocrit 30-35)

MEDICATION ON ADMISSION: Glargine 10 units qHS
Humalog SS
Humalog 2 units after each meal
Metoprolol succinate 200mg daily
Metoclopramide 5mg PO Q6
Omeprazole 20 mg Capsule PO DAILY
Ondansetron HCl 4 mg Tablet Q8PRN
Docusate Sodium 100 mg Capsule [**Hospital1 **]:PRN
B Complex-Vitamin C-Folic Acid 1 mg daily
Amlodipine 10 mg Tablet daily
Lisinopril 10 mg Tablet DAILY
Sevelamer HCl 800 mg Tablet TID with meals
Aspirin 81 mg Tablet daily

ALLERGIES: Codeine

PHYSICAL EXAM: Vitals: T:99 BP:184/106 P:104 R:14
CMV Tv 500 RR 16 PEEP 5 FiO2 100%
General: sedated, intubated
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, 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: Father, grandmother with diabetes mellitus. No relatives
currently on dialysis.

SOCIAL HISTORY: Lives with aunt in [**Location (un) 686**]. Smokes 2 packs per week since age
16. Denies recent alcohol use. Denies illicit drug use, now or
in the past.
Diabetes with renal manifestations, type I [juvenile type], uncontrolled,Other encephalopathy,Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,Acidosis,Other pulmonary insufficiency, not elsewhere classified,End stage renal disease,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Anemia in chronic kidney disease,Legal blindness, as defined in U.S.A.,Hematuria, unspecified,Awaiting organ transplant status,Other musculoskeletal symptoms referable to limbs,Fever, unspecified
DMI renal uncntrld,Encephalopathy NEC,Mal hyp kid w cr kid V,Acidosis,Other pulmonary insuff,End stage renal disease,Diabetic retinopathy NOS,Nephritis NOS in oth dis,Anemia in chr kidney dis,Legal blindness-usa def,Hematuria NOS,Await organ transplnt st,Muscskel sympt limb NEC,Fever NOS
Admission Date:  [**2185-10-7**]              Discharge Date:   [**2185-10-17**]

Date of Birth:  [**2160-11-6**]             Sex:   M

Service: MEDICINE

Allergies:
Codeine

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
AMS, hyperglycemia, hypertension

Major Surgical or Invasive Procedure:
intubation, central line placement

History of Present Illness:
History of Present Illness: 24-year-old gentleman with poorly
controlled Type I diabetes with ESRD recently started HD,
hypertension, retinopathy, with three separate admissions this
past week who was referred to the ED from dialysis for elevated
blood sugar and vomiting. Per patient's family, patient took am
dose of insulin today. He had awoken feeling unwell and had been
vomiting prior to going to dialysis. He reportedly was not
febrile. He reportedly did not take his am BP meds.
.
In the ED, initial vs were: T98 HR:88 BP:193/113 RR:16
O2Sat:100RA. Serum glucose on arrival was 818 with AG of 21. He
received 10 units of regular insulin. He received less than 1
liter NS. For BP got total of 30 mg IV labetolol. Pt acting
confused and agitated requiring total 10mg IM Haldol, Ativan
2mg. Given his extreme agitation he was intubated and
transferred to MICU for further management.
.
On the floor,patient intubated and sedated. He appeared
comfortable on the ventilator.
.
Review of systems: (unable to obtain)


Past Medical History:
- Diabetes mellitus, type I. Diagnosed in [**2162**]. Poorly
controlled with past DKA. Complicated with retinopathy,
nephropathy
- Hypertension, poorly controlled
- Chronic kidney disease
- Chronic constipation
- Chronic Anemia (baseline hematocrit 30-35)


Social History:
Lives with aunt in [**Location (un) 686**]. Smokes 2 packs per week since age
16. Denies recent alcohol use. Denies illicit drug use, now or
in the past.


Family History:
Father, grandmother with diabetes mellitus. No relatives
currently on dialysis.

Physical Exam:
Vitals: T:99 BP:184/106 P:104 R:14
CMV Tv 500 RR 16 PEEP 5 FiO2 100%
General: sedated, intubated
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, 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


Pertinent Results:
Labs on admission:

[**2185-10-6**] 05:35AM   WBC-8.2 RBC-2.98* HGB-8.5* HCT-26.6* MCV-89
MCH-28.6 MCHC-32.0 RDW-15.3
[**2185-10-6**] 05:35AM   GLUCOSE-151* UREA N-27* CREAT-6.4* SODIUM-138
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-31 ANION GAP-12
[**2185-10-7**] 04:30PM   PLT COUNT-329
[**2185-10-7**] 04:30PM   NEUTS-77.6* LYMPHS-17.3* MONOS-3.1 EOS-1.5
BASOS-0.4
[**2185-10-7**] 09:17PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2185-10-7**] 11:11PM URINE  RBC-0-2 WBC-[**7-13**]* BACTERIA-OCC
YEAST-NONE EPI-<1
[**2185-10-7**] 11:11PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG

Micro:
[**2185-10-9**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2185-10-9**] URINE URINE CULTURE-PENDING INPATIENT
[**2185-10-8**] CSF;SPINAL FLUID GRAM STAIN-negative; FLUID
CULTURE-PRELIMINARY INPATIENT
[**2185-10-8**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2185-10-7**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT

Imaging:
CT head ([**10-7**])
IMPRESSION: No acute intracranial process. Sinus disease.

CXR ([**10-10**])
FINDINGS: There is a right IJ line with tip at the cavoatrial
junction.
There is volume loss in the left lower lobe. The heart is
moderately
enlarged, similar to prior. There is no focal infiltrate.

MRI Head Stroke Protocol ([**10-14**]):
1. No acute intracranial abnormality; specifically, there is no
evidence of either acute or previous ischemic event.
2. Unremarkable cranial MRA, with no flow-limiting stenosis. \

EEG ([**10-11**]):
IMPRESSION: This is a mild to moderately abnormal routine EEG in
the
waking and drowsy states secondary to diffuse attenuation of
signal over
the left hemisphere and overall mildly slow and disorganized
background.
There were no epileptiform features noted.


Brief Hospital Course:
This is a 24 yo male with type I DM, ESLD on HD, resistant HTN
who presents with hyperglycemia and emesis and found to have
significantly elevated blood pressures.

# Fever/Mental Status Changes/? delirium: When patient arrived
to the hospital, he was agitated and required intubation for
airway protection. He does have a history of oppositional
defiant disorder. Was agitated and confused on admission. Pt was
laughing and crying inappropriately. Head CT read neg for any
acute IC process.  Infectious w/u was negative though pt was
febrile on admission, and LP and blood cx were negative.  Pt was
covered for bacterial and HSV meningitis until cx results
returned. [**Month (only) 116**] also have had some component of uremic
encephalopathy, and pt underwent dialysis in-house.  All
electrolyte abnormalities have been aggressively corrected.
Glucose management as [**First Name8 (NamePattern2) **] [**Last Name (un) **] (see below). Neuro was
consulted and recommended MRI to r/o PRES and/or stroke,
particularly given RUE weakness, and MRI stroke protocol was
negative. Pt was started on ASA 81mg and Simvastatin 20mg for
preventative measures. Psych consulted in light of ODD; he was
deemed not to have capacity due to lack of insight and lack of
cooperation, and pt was restrained from leaving AMA by security
on two occasions.  However, on the mental status improved during
hospitalization back to baseline, per family, and pt was
re-evaluated by psychiatry and was deemed to have capacity,
after which he signed out AMA (with close f/u arranged prior to
sign out).
.
# Hyperglycemia: On initial presentation, pt in HHS given no
ketonemia, though AG present, liekly [**3-7**] insulin non-compliance.
AG resolved after only 10 units of IM regular insulin, but blood
glucose remained difficult to control give pt's irregularly
timed eating habits, during which he does not receive insulin
(as insulin is regularly scheduled with mealtimes, during which
times pt does not eat).  [**Last Name (un) **] followed pt and sliding scale
and lantus was adjusted, but sugars remained in 200's prior to
discharge.  Infectious workup was all negative.  f/u with [**Last Name (un) **]
was scheduled prior to pt's signing out AMA.
.
# Anion Gap Acidosis: Resolved after only 10 units of IM
insulin. Tox screen positive only for opiates. Lactate 1. Most
likely [**3-7**] renal failure.

# Hypertension: BP >200's/100's on admission. Has run similarly
high on previous admissions. Was on labetalol drip and home
doses of metoprolol, lisinopril, and amlodipine.
Anti-hypertensive regimen was changed to labetolol [**Hospital1 **],
lisinopril, nifedipine and clonodine patch. Clonodine patch and
labetolol are new on this admission and the lisinopril was
doubled on this admission. Pt's home amlodipine was switched to
nifedipine per renal, and dosed at night as pt typically had
high BP's during the night.
.
# ESRD on HD: Received HD in-house, but all HD sessions were
terminated prematurely due to pt's inability to tolerate due to
symptoms.  Renal followed, started pt on sevelamer.
.
#Anemia: s/p 1 unit PRBC. Likely [**3-7**] chronic renal failure
(baseline about 25). Patient received epo after dialysis
sessions.


Medications on Admission:
Glargine 10 units qHS
Humalog SS
Humalog 2 units after each meal
Metoprolol succinate 200mg daily
Metoclopramide 5mg PO Q6
Omeprazole 20 mg Capsule PO DAILY
Ondansetron HCl 4 mg Tablet Q8PRN
Docusate Sodium 100 mg Capsule [**Hospital1 **]:PRN
B Complex-Vitamin C-Folic Acid 1 mg daily
Amlodipine 10 mg Tablet daily
Lisinopril 10 mg Tablet DAILY
Sevelamer HCl 800 mg Tablet TID with meals
Aspirin 81 mg Tablet daily


Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three
times a day.
4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
Disp:*5 Patch Weekly(s)* Refills:*2*
6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO at bedtime.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
7. Labetalol 300 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
PRN as needed for constipation.
10. Ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO q8h PRN
as needed for nausea.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
13. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous as directed: Please follow the instruction for
insulin doses from your sliding scale.


Discharge Disposition:
Home

Discharge Diagnosis:
Type I Diabetes Mellitus
Hypertension
End Stage Renal Disease


Discharge Condition:
Inadequate blood pressure and blood glucose control.  Not
medically stable, advised patient not to leave the hospital but
patient wished to leave against medical advice.


Discharge Instructions:
You were admitted for confusion, high blood pressures, and high
blood sugars.  You were intubated due to your confusion.  An
extensive workup failed to find a cause of your confusion, but
your mental status improved.  Your blood pressure medications
were changed in order to better control your blood pressure.
Your insulin regimen was also adjusted to better manage your
blood sugars.  Eating regular meals at intervals at least 4
hours apart and taking your insulin prior to eating will help
regulate your blood sugar.
.
The following changes were made to your medications:
- Metoprolol was stopped
- Amlodipine was stopped
- Lisinopril was increased to 40mg daily
- Labetalol 300mg twice daily was added
- Nifedipine 90mg daily AT NIGHT was added
- Clonidine patch 0.2mg/24hr 1 patch every Wednesday was added
- Atorvastatin 20mg daily was added
- Your insulin scales were adjusted (please see attached sheet)
.
Please come to the emergency department or call your primary
care physician if you have confusion, severe headaches, change
in vision, chest pain, fevers, chills, or any other concerning
symptoms.

Followup Instructions:
You have scheduled the following appointments:
.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] at [**Last Name (un) **] Diabetes Center ([**Telephone/Fax (1) 2378**])
Tuesday [**2185-10-25**] @ 3:00pm
.
Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2185-10-27**] 3:20
.
Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2185-11-21**] 1:40
.
Dr. [**Last Name (STitle) 14166**] (Phone [**Telephone/Fax (1) 14167**]) on [**10-30**] at 8:30 PM.
You are also scheduled to see Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on Thursday [**10-20**] at 1:30 PM.
{'Diabetes with renal manifestations, type I [juvenile type], uncontrolled,Other encephalopathy,Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,Acidosis,Other pulmonary insufficiency, not elsewhere classified,End stage renal disease,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Anemia in chronic kidney disease,Legal blindness, as defined in U.S.A.,Hematuria, unspecified,Awaiting organ transplant status,Other musculoskeletal symptoms referable to limbs,Fever, unspecified'}


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: AMS, hyperglycemia, hypertension

PRESENT ILLNESS: History of Present Illness: 24-year-old gentleman with poorly
controlled Type I diabetes with ESRD recently started HD,
hypertension, retinopathy, with three separate admissions this
past week who was referred to the ED from dialysis for elevated
blood sugar and vomiting. Per patient's family, patient took am
dose of insulin today. He had awoken feeling unwell and had been
vomiting prior to going to dialysis. He reportedly was not
febrile. He reportedly did not take his am BP meds.
.
In the ED, initial vs were: T98 HR:88 BP:193/113 RR:16
O2Sat:100RA. Serum glucose on arrival was 818 with AG of 21. He
received 10 units of regular insulin. He received less than 1
liter NS. For BP got total of 30 mg IV labetolol. Pt acting
confused and agitated requiring total 10mg IM Haldol, Ativan
2mg. Given his extreme agitation he was intubated and
transferred to MICU for further management.
.
On the floor,patient intubated and sedated. He appeared
comfortable on the ventilator.
.
Review of systems: (unable to obtain)

MEDICAL HISTORY: - Diabetes mellitus, type I. Diagnosed in [**2162**]. Poorly
controlled with past DKA. Complicated with retinopathy,
nephropathy
- Hypertension, poorly controlled
- Chronic kidney disease
- Chronic constipation
- Chronic Anemia (baseline hematocrit 30-35)

MEDICATION ON ADMISSION: Glargine 10 units qHS
Humalog SS
Humalog 2 units after each meal
Metoprolol succinate 200mg daily
Metoclopramide 5mg PO Q6
Omeprazole 20 mg Capsule PO DAILY
Ondansetron HCl 4 mg Tablet Q8PRN
Docusate Sodium 100 mg Capsule [**Hospital1 **]:PRN
B Complex-Vitamin C-Folic Acid 1 mg daily
Amlodipine 10 mg Tablet daily
Lisinopril 10 mg Tablet DAILY
Sevelamer HCl 800 mg Tablet TID with meals
Aspirin 81 mg Tablet daily

ALLERGIES: Codeine

PHYSICAL EXAM: Vitals: T:99 BP:184/106 P:104 R:14
CMV Tv 500 RR 16 PEEP 5 FiO2 100%
General: sedated, intubated
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, 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: Father, grandmother with diabetes mellitus. No relatives
currently on dialysis.

SOCIAL HISTORY: Lives with aunt in [**Location (un) 686**]. Smokes 2 packs per week since age
16. Denies recent alcohol use. Denies illicit drug use, now or
in the past. 

### Response:
{'Diabetes with renal manifestations, type I [juvenile type], uncontrolled,Other encephalopathy,Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,Acidosis,Other pulmonary insufficiency, not elsewhere classified,End stage renal disease,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Anemia in chronic kidney disease,Legal blindness, as defined in U.S.A.,Hematuria, unspecified,Awaiting organ transplant status,Other musculoskeletal symptoms referable to limbs,Fever, unspecified'}
