CHIEF COMPLAINT: Hypoglycemia

PRESENT ILLNESS: Pt is a 69yo Female, with MMP including ESRD on HD, HIV (cd4 940
[**7-23**], on HAART), CAD s/p MI, CHF, COPD, amongst others who was
found obtunded by her family last pm. Pt was recently discharged
from [**Hospital1 **] on [**2115-9-6**] after being admitted with shortness of
breath in the setting of missed hemodialysis secondary to a
clotted AV graft. Her course was complicated by a PEA arrest
following intubation from which she recovered. SHe was
discharged to rehab ([**Hospital3 **]) and only returned to home
three days ago.
.
FS was 265 in the evening and pt took 2 units of regular
insulin. At 10 pm last night, pt was visited by daughter, found
in bed sweating with rapid shallow breathing, foaming in her
mouth, and eyes looking down. The episode happened after pt ate
a snack and went to bed. She was found to be non-responsive
however, no abnormal movement of extremities noted. Episode
lasted 20 minutes until EMS arrived. FS was found to be 28, pt
was given 1 amp of D50 and became more responsive with FS of
260.
.
In the ED VS were: T: 96.8; BP: 110/palp; P: 78; RR: 18; with O2
sat 98% on RA. At 12:30 am, FS was 134. Pt then ate a [**Location (un) 6002**]
and had juice and FS at 1:45 am was 49. Pt was given an amp of
D50, juice, and started on a D10 gtt. BS at 3 am on D10 was 150,
4 am 236, and 5 am 201. U/A was found to be positive for a UTI
and pt was given a dose of 500 mg PO levaquin.
.
On ROS, no SOB, CP or abd pain. NO fever. Reports an upset
stomach for last week of [**Hospital3 2558**] stay. She reports good
appetite and regular po diet. Denies any diarrhea or any other
GI or GU complaints. Of note, reglan 5 tid was the only new med
started at the rehab. Per family, pt with labile blood sugars at
rehab ranging from 30-300s. She has not changed her regimen.
Also, family notes that pt's insulin is pre-drawn for her.

MEDICAL HISTORY: Past Medical History:
1. CAD s/p NSTEMI [**5-19**], s/p PTCA/stent LCX [**2113**]. Latest
catheterization in [**10-21**] with 2-vessel disease. Persantine MIBI
[**4-22**] without symptoms or EKG changes. MIBI images significant
for severe fixed inferior defect, EF 58%.
2. DM type 2, on NPH.
3. HIV, last CD4 count 940 in [**7-/2115**]
4. ESRD on HD since '[**10**] (M, W, F)
5. CHF, with mixed systolic (EF 45-50%) and diastolic
dysfunction.
6. Severe mitral regurgitation [**2115-6-20**]
7. History of RUL segmental PE in [**11/2114**], on coumadin
([**2114-12-5**]) D/C'd in 06/[**2115**].
8. Recently diagnosed right popliteal DVT [**7-/2115**], restarted on
Coumadin
9. H/o multiple AVF clots, s/p thrombectomies, last in [**2115-1-8**]
9. H/o GIB in the setting of coagulopathy and NSAIDs
10. Eosinophilic pneumonia diagnosed [**4-22**], on chronic
prednisone therapy.
11. Anemia [**2-20**] CRF
12. Vulvar intraepithelial neoplasia diagnosed in [**2113-4-18**].
13. COPD with PFTs with FVC 0.69 (27%), FEV1 0.46 (24%),
FEV1/FVC 92%.
14. History of positive Galactomannan antigen
15. RUL nodules on CT, not FDG avid on PET on [**8-20**]. Etiology
unclear.
16. Vulvar squamous cell carcinoma in situ.

MEDICATION ON ADMISSION: Bactrim 80-400 mg q M/W/Fri
Prednisone 20 mg qd (to be tapered slowly)
B Complex-Vitamin C-Folic Acid 1 mg qd
Zidovudine 200 [**Hospital1 **]
Nevirapine 200 [**Hospital1 **]
Lamivudine 100 qd
Docusate Sodium 100 mg [**Hospital1 **]
Pantoprazole 40 q 24
Albuterol q4 prn
Albuterol-Ipratropium q6
Hydromorphone 4 mg Q3-4H prn
Calcium Carbonate 500 tid
Oxycodontin 10 mg q12 hr
Senna 8.6 [**Hospital1 **] prn
Epogen inj
COumadin 2.5 qhs
Paricalcitol 5 mcg/mL Solution Sig: As decided at dialysis
Intravenous 3X/WEEK (MO,WE,FR).
NPH 20 units qam, with regular sliding scale twice a day
ASA 325 qday
Metoprolol 25 [**Hospital1 **]
Lisinopril 2.5 qday
Isordil 10 [**Hospital1 **]

ALLERGIES: Motrin / Lipitor

PHYSICAL EXAM: VS: T: 99.7; HR: 102; BP: 154/87; RR: 16; O2: 97% 2L
Gen: AA female speaking in 4 word sentences, mild SOB, but in
NAD
Neck: difficult to assess for JVP 2/2 neck girth and IV on right
CV: RRR S1S2. Distant heart sounds.
Lungs: Decreased BS at bases with crackles 1/3 up on right.
Abd: obese, nt, nd. +BS
Ext: No edema. DP 2+.
Neuro: A&O x 3. Somewhat slow in answers, though appropriate. CN
II-XII tested and intact. MS 5- throughout.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Recently was at the [**Hospital **] rehab. Lives in [**Location 686**] with her
daughter. [**Name (NI) **] EtOH. Ex-smoker (60 pack-year smoking history)
Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Chronic combined systolic and diastolic heart failure,Mitral valve disorders,Chronic airway obstruction, not elsewhere classified,Acidosis,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Asymptomatic human immunodeficiency virus [HIV] infection status,Anemia in chronic kidney disease,Long-term (current) use of insulin
DMII oth nt st uncntrld,Chr syst/diastl hrt fail,Mitral valve disorder,Chr airway obstruct NEC,Acidosis,Urin tract infection NOS,Hyp kid NOS w cr kid V,Asymp hiv infectn status,Anemia in chr kidney dis,Long-term use of insulin
Admission Date:  [**2115-9-24**]              Discharge Date:   [**2115-9-27**]

Date of Birth:  [**2046-6-27**]             Sex:   F

Service: MEDICINE

Allergies:
Motrin / Lipitor

Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Hypoglycemia

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Pt is a 69yo Female, with MMP including ESRD on HD, HIV (cd4 940
[**7-23**], on HAART), CAD s/p MI, CHF, COPD, amongst others who was
found obtunded by her family last pm. Pt was recently discharged
from [**Hospital1 **] on [**2115-9-6**] after being admitted with shortness of
breath in the setting of missed hemodialysis secondary to a
clotted AV graft. Her course was complicated by a PEA arrest
following intubation from which she recovered. SHe was
discharged to rehab ([**Hospital3 **]) and only returned to home
three days ago.
.
FS was 265 in the evening and pt took 2 units of regular
insulin. At 10 pm last night, pt was visited by daughter, found
in bed sweating with rapid shallow breathing, foaming in her
mouth, and eyes looking down. The episode happened after pt ate
a snack and went to bed. She was found to be non-responsive
however, no abnormal movement of extremities noted. Episode
lasted 20 minutes until EMS arrived. FS was found to be 28, pt
was given 1 amp of D50 and became more responsive with FS of
260.
.
In the ED VS were: T: 96.8; BP: 110/palp; P: 78; RR: 18; with O2
sat 98% on RA. At 12:30 am, FS was 134. Pt then ate a [**Location (un) 6002**]
and had juice and FS at 1:45 am was 49. Pt was given an amp of
D50, juice, and started on a D10 gtt. BS at 3 am on D10 was 150,
4 am 236, and 5 am 201. U/A was found to be positive for a UTI
and pt was given a dose of 500 mg PO levaquin.
.
On ROS, no SOB, CP or abd pain. NO fever. Reports an upset
stomach for last week of [**Hospital3 2558**] stay. She reports good
appetite and regular po diet. Denies any diarrhea or any other
GI or GU complaints. Of note, reglan 5 tid was the only new med
started at the rehab. Per family, pt with labile blood sugars at
rehab ranging from 30-300s. She has not changed her regimen.
Also, family notes that pt's insulin is pre-drawn for her.


Past Medical History:
Past Medical History:
1. CAD s/p NSTEMI [**5-19**], s/p PTCA/stent LCX [**2113**]. Latest
catheterization in [**10-21**] with 2-vessel disease. Persantine MIBI
[**4-22**] without symptoms or EKG changes. MIBI images significant
for severe fixed inferior defect, EF 58%.
2. DM type 2, on NPH.
3. HIV, last CD4 count 940 in [**7-/2115**]
4. ESRD on HD since '[**10**] (M, W, F)
5. CHF, with mixed systolic (EF 45-50%) and diastolic
dysfunction.
6. Severe mitral regurgitation [**2115-6-20**]
7. History of RUL segmental PE in [**11/2114**], on coumadin
([**2114-12-5**]) D/C'd in 06/[**2115**].
8. Recently diagnosed right popliteal DVT [**7-/2115**], restarted on
Coumadin
9. H/o multiple AVF clots, s/p thrombectomies, last in [**2115-1-8**]
9. H/o GIB in the setting of coagulopathy and NSAIDs
10. Eosinophilic pneumonia diagnosed [**4-22**], on chronic
prednisone therapy.
11. Anemia [**2-20**] CRF
12. Vulvar intraepithelial neoplasia diagnosed in [**2113-4-18**].
13. COPD with PFTs with FVC 0.69 (27%), FEV1 0.46 (24%),
FEV1/FVC 92%.
14. History of positive Galactomannan antigen
15. RUL nodules on CT, not FDG avid on PET on [**8-20**]. Etiology
unclear.
16. Vulvar squamous cell carcinoma in situ.

Social History:
Recently was at the [**Hospital **] rehab. Lives in [**Location 686**] with her
daughter. [**Name (NI) **] EtOH. Ex-smoker (60 pack-year smoking history)


Family History:
Non-contributory

Physical Exam:
VS: T: 99.7; HR: 102; BP: 154/87; RR: 16; O2: 97% 2L
Gen: AA female speaking in 4 word sentences, mild SOB, but in
NAD
Neck: difficult to assess for JVP 2/2 neck girth and IV on right
CV: RRR S1S2. Distant heart sounds.
Lungs: Decreased BS at bases with crackles 1/3 up on right.
Abd: obese, nt, nd. +BS
Ext: No edema. DP 2+.
Neuro: A&O x 3. Somewhat slow in answers, though appropriate. CN
II-XII tested and intact. MS 5- throughout.


Pertinent Results:
EKG:
NSR, 80, nl Axis, no ischemic changes. Early transition. no
change from prior.
.
CXR [**2115-9-24**]- No acute cardiopulmonary process.


Brief Hospital Course:
Ms. [**Known lastname **] is an 69 year old female, multiple medical problems,
who was recently hospitalized at [**Hospital1 **] admitted with SOB in
setting of missed HD secondary to clotted AV graft, complicated
by PEA arrest and intubation now presents w/ obtundation, found
to be hypoglycemic in the field and now transferred to MICU for
persistent hypoglycemia in the ED requiring D10 gtt and q1 FS
checks.
.
1. Hypoglycemia: Differential diagnosis includes excessive
insulin (most likely), missed meal, worsening renal failure with
resultant decrease in insulin clearance, medication induced,
sepsis, or an endocrinopathy. It is possible that the patient
mistakedly took too much of her insulin and we are still seeing
the effects of the NPH. Patient also has ESRD on HD and thus
insulin could be hanging around longer. While this is plausible,
she has been getting her regular dialysis, last yesterday.
However, she is slightly fluid overloaded. TSH on [**2115-8-27**] was
normal. Adrenal insufficiency possible, as pt on steroids
chronically for h/o eosinophilic PNA, however, no hypotension or
other symptoms. Pt is on bactrim which can cause hypoglycemia,
but no recent medication changes. Sepsis is another possible
cause. Pt with evidence of UTI, elevated lactate but does not
meet SIRS criteria. Patient was initially maintained on a D10
gtt which was later d/ced. Finger stickers were monitored q
hourly ranging from 84-225. Once her glucose went beyond 200,
RISS was restarted with good control. Patient was also started
on NHP insulin of 10 units at a reduced dose from her home
regimen of 20 units. Lactate was also monitored and remained
elevated at 2.7. Her UTI on U/A was treated with Ciprofloxacin
PO. She was also restarted on a diabetic, heart healthy, renal
diet.
.
2. Leukocytosis: Patient has a persistent leukocytosis thought
to be secondary to chronic steroids. Patient was treated with
cipro for a UTI.
.
3. Elevated Troponin: Patient noted to have a history of
elevated Troponins, on this admission 0.23->0.18->0.20 which
flat CK. Likely secondary to history of CPR and renal disease.
There were no EKG changes from previous.
.
4. ESRD on HD: Patient normally receives dialysis M,W,F. Renal
following the patient while admitted. Patient was dialysed on
[**2115-9-25**]. Calcium carbonate and Paricalcitol for secondary
hyperparathyroidism were continued.
.
5. Metabolic gap acidosis: Likely secondary to ESRD and elevated
lactate. UTI treated with ciprofloxacin, patient received
dialysis on [**2115-7-27**].
.
6. CAD s/p MI: Continued ASA, ACE, BB. Held isordil until later
this pm so can watch BPs. R/O as above.
.
7. [**Name (NI) **] Continued pt's home regimen on HAART. Last CD4 count was
940.
.
8. H/o eosinophilic pneumonia- Continued prednisone and bactrim
prophylaxis while immunosuppressed (bactrim leading to
hypoglycemia low on DDx.)
.
9. DVT- h/o DVT diagnosed in [**7-23**]. Coumadin apparently d/ced in
[**Month (only) **]/05 and then re-started in [**7-23**] for popliteal DVT, was held
initially then restarted on [**2115-9-25**]. Followed INR 1.4->1.2.
Follow up after restarting coumadin.
.
10. COPD- continued atrovent q6 hours and albuterol nebs prn.
.
11. PPx- PPI per outpt regimen, bowel regimen, pain regimen
tapered since patient no longer having chest pain from previous
CPR.
.
12. F/E/N- [**Doctor First Name **], heart healthy, renal diet.
.
13. Access-PIVs
.
14. Contact-Daughter [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42692**] is HCP. [**Name (NI) **] [**Numeric Identifier 101298**];
[**Name2 (NI) **]: [**Telephone/Fax (1) 101299**].
.
15. Code- Full Code. Discussed with pt.

Medications on Admission:
Bactrim 80-400 mg q M/W/Fri
Prednisone 20 mg qd (to be tapered slowly)
B Complex-Vitamin C-Folic Acid 1 mg qd
Zidovudine 200 [**Hospital1 **]
Nevirapine 200 [**Hospital1 **]
Lamivudine 100 qd
Docusate Sodium 100 mg [**Hospital1 **]
Pantoprazole 40 q 24
Albuterol q4 prn
Albuterol-Ipratropium q6
Hydromorphone 4 mg Q3-4H prn
Calcium Carbonate 500 tid
Oxycodontin 10 mg q12 hr
Senna 8.6 [**Hospital1 **] prn
Epogen inj
COumadin 2.5 qhs
Paricalcitol 5 mcg/mL Solution Sig: As decided at dialysis
Intravenous 3X/WEEK (MO,WE,FR).
NPH 20 units qam, with regular sliding scale twice a day
ASA 325 qday
Metoprolol 25 [**Hospital1 **]
Lisinopril 2.5 qday
Isordil 10 [**Hospital1 **]


Discharge Disposition:
Home With Service

Facility:
Uphams Corner Home Care

Discharge Diagnosis:
Hypoglycemia
ESRD on dialysis
Diabetes Type 2
CAD
HIV
CHF
Severe Mitral regurgitation
H/O PE
H/O DVT
Eosinophilic pneumonia
Anemia
Vulvar intraepithelial neoplasia


Discharge Condition:
Good


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet

Take coumadin 5 mg on Sat and Sun
Have your INR check at dialysis on Monday. They will adjust your
coumadin based on INR.
Do not use NPH anymore, you should check your FS with each meal
and before bedtime and use a sliding scale as provided.


Followup Instructions:
Follow up Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Where: [**Hospital 4054**] PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2115-9-30**] 1:30
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR [**First Name (STitle) **] Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2115-9-30**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2115-12-3**] 9:30

Call Dr. [**Last Name (STitle) **] for an appointment in [**1-20**] weeks
{'Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Chronic combined systolic and diastolic heart failure,Mitral valve disorders,Chronic airway obstruction, not elsewhere classified,Acidosis,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Asymptomatic human immunodeficiency virus [HIV] infection status,Anemia in chronic kidney disease,Long-term (current) use of insulin'}


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: Hypoglycemia

PRESENT ILLNESS: Pt is a 69yo Female, with MMP including ESRD on HD, HIV (cd4 940
[**7-23**], on HAART), CAD s/p MI, CHF, COPD, amongst others who was
found obtunded by her family last pm. Pt was recently discharged
from [**Hospital1 **] on [**2115-9-6**] after being admitted with shortness of
breath in the setting of missed hemodialysis secondary to a
clotted AV graft. Her course was complicated by a PEA arrest
following intubation from which she recovered. SHe was
discharged to rehab ([**Hospital3 **]) and only returned to home
three days ago.
.
FS was 265 in the evening and pt took 2 units of regular
insulin. At 10 pm last night, pt was visited by daughter, found
in bed sweating with rapid shallow breathing, foaming in her
mouth, and eyes looking down. The episode happened after pt ate
a snack and went to bed. She was found to be non-responsive
however, no abnormal movement of extremities noted. Episode
lasted 20 minutes until EMS arrived. FS was found to be 28, pt
was given 1 amp of D50 and became more responsive with FS of
260.
.
In the ED VS were: T: 96.8; BP: 110/palp; P: 78; RR: 18; with O2
sat 98% on RA. At 12:30 am, FS was 134. Pt then ate a [**Location (un) 6002**]
and had juice and FS at 1:45 am was 49. Pt was given an amp of
D50, juice, and started on a D10 gtt. BS at 3 am on D10 was 150,
4 am 236, and 5 am 201. U/A was found to be positive for a UTI
and pt was given a dose of 500 mg PO levaquin.
.
On ROS, no SOB, CP or abd pain. NO fever. Reports an upset
stomach for last week of [**Hospital3 2558**] stay. She reports good
appetite and regular po diet. Denies any diarrhea or any other
GI or GU complaints. Of note, reglan 5 tid was the only new med
started at the rehab. Per family, pt with labile blood sugars at
rehab ranging from 30-300s. She has not changed her regimen.
Also, family notes that pt's insulin is pre-drawn for her.

MEDICAL HISTORY: Past Medical History:
1. CAD s/p NSTEMI [**5-19**], s/p PTCA/stent LCX [**2113**]. Latest
catheterization in [**10-21**] with 2-vessel disease. Persantine MIBI
[**4-22**] without symptoms or EKG changes. MIBI images significant
for severe fixed inferior defect, EF 58%.
2. DM type 2, on NPH.
3. HIV, last CD4 count 940 in [**7-/2115**]
4. ESRD on HD since '[**10**] (M, W, F)
5. CHF, with mixed systolic (EF 45-50%) and diastolic
dysfunction.
6. Severe mitral regurgitation [**2115-6-20**]
7. History of RUL segmental PE in [**11/2114**], on coumadin
([**2114-12-5**]) D/C'd in 06/[**2115**].
8. Recently diagnosed right popliteal DVT [**7-/2115**], restarted on
Coumadin
9. H/o multiple AVF clots, s/p thrombectomies, last in [**2115-1-8**]
9. H/o GIB in the setting of coagulopathy and NSAIDs
10. Eosinophilic pneumonia diagnosed [**4-22**], on chronic
prednisone therapy.
11. Anemia [**2-20**] CRF
12. Vulvar intraepithelial neoplasia diagnosed in [**2113-4-18**].
13. COPD with PFTs with FVC 0.69 (27%), FEV1 0.46 (24%),
FEV1/FVC 92%.
14. History of positive Galactomannan antigen
15. RUL nodules on CT, not FDG avid on PET on [**8-20**]. Etiology
unclear.
16. Vulvar squamous cell carcinoma in situ.

MEDICATION ON ADMISSION: Bactrim 80-400 mg q M/W/Fri
Prednisone 20 mg qd (to be tapered slowly)
B Complex-Vitamin C-Folic Acid 1 mg qd
Zidovudine 200 [**Hospital1 **]
Nevirapine 200 [**Hospital1 **]
Lamivudine 100 qd
Docusate Sodium 100 mg [**Hospital1 **]
Pantoprazole 40 q 24
Albuterol q4 prn
Albuterol-Ipratropium q6
Hydromorphone 4 mg Q3-4H prn
Calcium Carbonate 500 tid
Oxycodontin 10 mg q12 hr
Senna 8.6 [**Hospital1 **] prn
Epogen inj
COumadin 2.5 qhs
Paricalcitol 5 mcg/mL Solution Sig: As decided at dialysis
Intravenous 3X/WEEK (MO,WE,FR).
NPH 20 units qam, with regular sliding scale twice a day
ASA 325 qday
Metoprolol 25 [**Hospital1 **]
Lisinopril 2.5 qday
Isordil 10 [**Hospital1 **]

ALLERGIES: Motrin / Lipitor

PHYSICAL EXAM: VS: T: 99.7; HR: 102; BP: 154/87; RR: 16; O2: 97% 2L
Gen: AA female speaking in 4 word sentences, mild SOB, but in
NAD
Neck: difficult to assess for JVP 2/2 neck girth and IV on right
CV: RRR S1S2. Distant heart sounds.
Lungs: Decreased BS at bases with crackles 1/3 up on right.
Abd: obese, nt, nd. +BS
Ext: No edema. DP 2+.
Neuro: A&O x 3. Somewhat slow in answers, though appropriate. CN
II-XII tested and intact. MS 5- throughout.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Recently was at the [**Hospital **] rehab. Lives in [**Location 686**] with her
daughter. [**Name (NI) **] EtOH. Ex-smoker (60 pack-year smoking history) 

### Response:
{'Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Chronic combined systolic and diastolic heart failure,Mitral valve disorders,Chronic airway obstruction, not elsewhere classified,Acidosis,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Asymptomatic human immunodeficiency virus [HIV] infection status,Anemia in chronic kidney disease,Long-term (current) use of insulin'}
