CHIEF COMPLAINT: Hyperglycemia

PRESENT ILLNESS: The patinet is a 52 year old male with a history of T1DM
diagnosed at age 38 w/ 2 insulin pumps placed for the first time
in the last month who presented to an OSH with altered mental
status.  The patient is currently intubated and unresponsive, so
most information is gained from the medical record.  The patinet
had been feeling unwell over the last few days, with decreased
energy, nausea/vomiting.  The patient was found by his daughters
boyfriend on the day of presentation in respiratory distress and
altered mental status, and was brought to an OSH ED for further
manegment.
.
On arrival to the OSH,  HR 88, BP 124/76, dyspneic with kussmal
breathing.  Lab work up revealed a K of 8.8, sodium of 127,
creatinine of 4.76, and glucose of 1157.  He had an anion gap of
27.  An ABP was checked, with a pH of 6.98 / 17 / 253 / 4.6.
The patinet develped HRs in the 40s, BPs in the 50s.  He was
given 3 amps of NaHCO3, insulin gtt at 9 which was uptitrated to
15, and calcium gluconate. His UA was + for moderate ketones.  A
R SC line was placed without complications. The patinet was
intubated for airway protection and respiratory distress.  He
was given 5L of NS.  The patient was transfered to [**Hospital1 18**] for
further care.
.
On arrival to our ED, initial VS: 94.4 85 161/68 100% on the
Vent.  His insulin [**Last Name (un) **] was reduced to 8 units/hr.  He was given
an addition L of NS.  The patient was given vanc/zosyn, but no
blood cultures were sent.  He blood sugars persisted in the
800s.  He was admitted to the MICU for further manemement.

MEDICAL HISTORY: DM1 (hbgA1C 9.6 on [**11-17**])
HTN
CRI ([**11-17**] Cr of 2.3)
dCHF
HL

MEDICATION ON ADMISSION: Ramipril 10mg take 1 capsule (10MG) by ORAL route every day
Zestril 10mg 1 time per day
Simvastatin 40mg 1 time per day
Viagra 100mg as directed, before sexual intercourse
Furosemide 80mg take 1 tablet (80MG) by ORAL route 2 times every
day
Aspirin 81mg take 1 tablet (81MG) by ORAL route every day
Avapro 300mg Take 2 tabs/d

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 36.9 ??????C (98.4 ??????F)
HR: 63 (62 - 69) bpm
BP: 141/62(81) {121/52(69) - 147/68(87)} mmHg
RR: 12 (8 - 17) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 111.5 kg (admission): 107.5 kg
Height: 72 Inch

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient is a former smoker, quit many years ago.  Works as a
diesal mechanic.  Has 2 children.
Anoxic brain damage,Acute respiratory failure,Acute kidney failure, unspecified,Acute pancreatitis,Meningitis, unspecified,Unspecified causes of encephalitis, myelitis, and encephalomyelitis,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Diastolic heart failure, unspecified,Hyperosmolality and/or hypernatremia,Dependence on respirator, status,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Anemia, unspecified,Other convulsions
Anoxic brain damage,Acute respiratry failure,Acute kidney failure NOS,Acute pancreatitis,Meningitis NOS,Encephalitis NOS,DMI ketoacd uncontrold,Diastolc hrt failure NOS,Hyperosmolality,Respirator depend status,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,Anemia NOS,Convulsions NEC
Admission Date:  [**2190-12-20**]              Discharge Date:   [**2191-1-5**]

Date of Birth:  [**2138-6-3**]             Sex:   M

Service: EMERGENCY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Hyperglycemia

Major Surgical or Invasive Procedure:
G-tube placement [**1-3**]
CVL
Intubation
PICC line

History of Present Illness:
The patinet is a 52 year old male with a history of T1DM
diagnosed at age 38 w/ 2 insulin pumps placed for the first time
in the last month who presented to an OSH with altered mental
status.  The patient is currently intubated and unresponsive, so
most information is gained from the medical record.  The patinet
had been feeling unwell over the last few days, with decreased
energy, nausea/vomiting.  The patient was found by his daughters
boyfriend on the day of presentation in respiratory distress and
altered mental status, and was brought to an OSH ED for further
manegment.
.
On arrival to the OSH,  HR 88, BP 124/76, dyspneic with kussmal
breathing.  Lab work up revealed a K of 8.8, sodium of 127,
creatinine of 4.76, and glucose of 1157.  He had an anion gap of
27.  An ABP was checked, with a pH of 6.98 / 17 / 253 / 4.6.
The patinet develped HRs in the 40s, BPs in the 50s.  He was
given 3 amps of NaHCO3, insulin gtt at 9 which was uptitrated to
15, and calcium gluconate. His UA was + for moderate ketones.  A
R SC line was placed without complications. The patinet was
intubated for airway protection and respiratory distress.  He
was given 5L of NS.  The patient was transfered to [**Hospital1 18**] for
further care.
.
On arrival to our ED, initial VS: 94.4 85 161/68 100% on the
Vent.  His insulin [**Last Name (un) **] was reduced to 8 units/hr.  He was given
an addition L of NS.  The patient was given vanc/zosyn, but no
blood cultures were sent.  He blood sugars persisted in the
800s.  He was admitted to the MICU for further manemement.

Past Medical History:
DM1 (hbgA1C 9.6 on [**11-17**])
HTN
CRI ([**11-17**] Cr of 2.3)
dCHF
HL

Social History:
Patient is a former smoker, quit many years ago.  Works as a
diesal mechanic.  Has 2 children.


Family History:
NC

Physical Exam:
Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 36.9 ??????C (98.4 ??????F)
HR: 63 (62 - 69) bpm
BP: 141/62(81) {121/52(69) - 147/68(87)} mmHg
RR: 12 (8 - 17) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 111.5 kg (admission): 107.5 kg
Height: 72 Inch

Ventilator mode: MMV/PSV/AutoFlow
Vt (Set): 500 (500 - 500) mL
Vt (Spontaneous): 477 (237 - 560) mL
PS : 10 cmH2O
RR (Set): 8
RR (Spontaneous): 12
 PEEP: 5 cmH2O
FiO2: 40%
RSBI: 38
PIP: 15 cmH2O
SpO2: 100%

GEN: trach in place, winces to pain in LE only
CV: RR, no MRG
PULM: Coarse breath sounds
ABD: Benign abdomen, g-tube in place, lap incisions well
healing, no bleeding, erythema or oozing. no guarding or rebound
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Skin:  Not assessed
Neurologic: Responds to pain (winces), pupils ~1mm with some
response to light, eyes moving in same direction as head
movement. No spontaneous movement of extremities



Pertinent Results:
Admission:

[**2190-12-20**] 12:19AM BLOOD WBC-18.1* RBC-3.15* Hgb-9.7* Hct-32.3*
MCV-103* MCH-30.7 MCHC-29.9* RDW-14.0 Plt Ct-249
[**2190-12-20**] 09:27PM BLOOD Neuts-91.3* Lymphs-5.6* Monos-2.8 Eos-0.2
Baso-0.2
[**2190-12-20**] 12:19AM BLOOD Plt Ct-249
[**2190-12-20**] 12:19AM BLOOD Fibrino-544*
[**2190-12-24**] 04:06AM BLOOD Ret Aut-0.6*
[**2190-12-20**] 01:52AM BLOOD Glucose-834* UreaN-66* Creat-4.0* Na-137
K-5.4* Cl-106 HCO3-13* AnGap-23*
[**2190-12-20**] 12:19AM BLOOD ALT-26 AST-33 LD(LDH)-319* AlkPhos-96
TotBili-0.1
[**2190-12-20**] 12:19AM BLOOD Lipase-869*
[**2190-12-20**] 03:17AM BLOOD Calcium-7.6* Phos-5.8* Mg-2.5
[**2190-12-20**] 09:27PM BLOOD calTIBC-174* Ferritn-372 TRF-134*
[**2190-12-20**] 04:44AM BLOOD Triglyc-191*
[**2190-12-20**] 01:52AM BLOOD Osmolal-362*
[**2190-12-20**] 12:19AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2190-12-20**] 12:20AM BLOOD Type-ART pO2-377* pCO2-34* pH-7.15*
calTCO2-13* Base XS--16
[**2190-12-20**] 12:13AM BLOOD Glucose-GREATER TH Lactate-2.6* K-5.7*

Discharge:

[**2191-1-5**] 03:16AM BLOOD WBC-9.6 RBC-2.54* Hgb-7.5* Hct-22.7*
MCV-89 MCH-29.6 MCHC-33.2 RDW-14.7 Plt Ct-245
[**2191-1-5**] 03:16AM BLOOD Plt Ct-245
[**2191-1-3**] 04:44AM BLOOD PT-12.5 PTT-28.0 INR(PT)-1.1
[**2191-1-5**] 03:16AM BLOOD Glucose-126* UreaN-97* Creat-3.9* Na-148*
K-3.7 Cl-104 HCO3-34* AnGap-14
[**2190-12-29**] 02:48AM BLOOD ALT-21 AST-26 LD(LDH)-257* AlkPhos-82
TotBili-0.1
[**2191-1-5**] 03:16AM BLOOD Calcium-8.2* Phos-4.5 Mg-3.4*
[**2191-1-3**] 05:19PM BLOOD Type-[**Last Name (un) **] Temp-36.4 Rates-/12 PEEP-5
pO2-36* pCO2-54* pH-7.50* calTCO2-44* Base XS-15
Intubat-INTUBATED
[**2190-12-20**] 04:35PM BLOOD Lactate-1.4

CXR: [**1-4**]
AP SUPINE CHEST RADIOGRAPH: Tracheostomy tube with its tip 4.9
cm above the
carina and a right PICC with its tip in the upper SVC are
unchanged. The
nasogastric tube has been removed. The lungs are clear without
effusion,
consolidation or pneumothorax. Heart size is normal.

IMPRESSION: No acute cardiopulmonary process.

TTE: [**12-28**]
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60-70%). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
No masses or vegetations are seen on the aortic valve. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.

IMPRESSION: no obvious vegetations seen

MRI Head: [**12-25**]
IMPRESSION:
1. Multifocal subacute infarction, configuration and
distribution favor
hypoxic ischemic insult such as sustained during acute
hypotension, cardiac
arrest. Given gyriform configuration, the embolic etiology is
felt less
likely, however, remains a differential consideration.
2. No evidence of mass effect, edema, herniation or hemorrhage.
3. Pansinusitis.

CT-head [**12-22**]
IMPRESSION:
1. Bitemporal regions of low attenuation, not significantly
changed since
[**2190-12-20**]. CT appearance is non-specific and further evaluation
with MR
(preferably with contrast), if feasible, is recommended to
exclude acute
infectious/inflammatory process such as cerebritis/encephalitis,
or ischemic
causes vs. chronic encphalomalacia, perhaps related to old
contusions.

2. Persistent opacification of paranasal sinuses.

CT-abd/pelvis: [**12-20**]
IMPRESSION:

1. Indistinct and hazy borders of the pancreas most compatible
with acute
pancreatitis. Pancreatic necrosis and other complication cannot
be evaluated
on the current study due to lack of IV contrast.

2. Extensive subcutaneous edema consistent with anasarca.

3. Colonic diverticulosis. Apparent descending colon wall
thickening may be
secondary under-distention, third-spacing, and/or colitis.

4. Bilateral small pleural effusions with adjacent associated
atelectasis;
superinfection can not be excluded.


Brief Hospital Course:
The patient is a 52 year old male with a history of DM1 with a
recent insulin pump placement, CRI (Cr 2.3) who presented in
respiratory distress and altered mental status, found to have
profound hyperglycemia and metabolic acidosis.

# DKA:  Patient presented with profound DKA with acidemia to 6.9
for an unknown period of time.  The precipitant was unclear but
he did have pancreatitis, with an elevated lipase.  His DKA
resolved with aggressive IVFs and an insulin drip.

# Anoxic brain injury:  He was intubated for lethargy in the
setting of DKA and was comatose off sedation early on during his
hospital course.  An LP was performed that did show pleocytosis
and he was empirically treated with vanc/zosyn.  An MRI was also
performed and had findings consistent with anoxic brain injury.
Nuero was consulted and felt that the anoxic injury was likely
related to prolonged acidemia in the setting of DKA.  A review
of the OSH records also demonstrated intervals lasting minutes
in which the patient had systolic BPs in the 70s, though he was
never asystolic.  His family initially planned to withdraw care
given the patient's preferences prior to illness and his poor
prognosis but on [**2190-12-30**], he withdrew to painful stimuli on his
legs and ears.  Given this finding, they decided to proceed with
tracheostomy ([**2191-1-1**]) and PEG, though they understood that
despite these findings, his prognosis was still very poor.

# Respiratory failure:  The patient was intubated in the setting
of lethargy.  He received tracheostomy on [**2191-1-1**] and PEG as
described above.  He had periods of apnea and therefore required
MMV; he did not tolerate trach collar for long periods of time.

# Pancreatitis:  He had an elevated lipase thought to be
secondary to DKA.  A non-contrast abdominal CT scan demonstrated
findings consistent with acute pancreatitis but necrosis could
not be visualized because of the lack of contrast, which was not
used because of [**Last Name (un) **].  Surgery was consulted and felt that there
were no acute surgical interventions indicated.

# Fevers:  He continued to spike fevers throughout his hospital
stay.  Cultures were consistently negative and he received broad
spectrum antibiotics for meningitis.  We felt his fevers were
most likely central/neurologic in origin.  Patient finished a 14
day course of Vancomycin and Cefepime on [**1-4**].

# Acute on Chronic Kidney Injury:  He had [**Last Name (un) **] in the setting of
hypovolemia and DKA and this improved with IVFs.  Renal was
consulted and recommended continued diuresis given his >15L
positive fluid balance.  A lasix drip was initiated and he
diuresed well and was transitioned to lasix [**Hospital1 **] boluses. He
subsequently had worsening [**Last Name (un) **] and renal re-evaluated; felt to
have prerenal etiology given diuresis on top of ATN; he was
given 1/2NS for 1 day with no improvement.  The patient should
have his renal function assessed daily and may eventually
require renal replacement therapy based on overall improvement,
prognosis and plan of care. Defer to rehab team.

# Hypernatremia: Patient noted to have hypernatremia with
average sodium concentration near 148 at time of discharge.
Patient required frequent free water flushes and will require
ongoing monitoring given patients inability to express thirst on
control fluid intake. Please obtain daily sodiums and replete
free water based on daily deficit.

# Anemia:  He has anemia of chronic inflammation and was
transfused 1u PRBC on [**2190-12-31**].  There was no evidence of active
bleeding.  He will need to have his hematocrit checked weekly.

# CONTACT:  Next of [**Doctor First Name **]: [**First Name4 (NamePattern1) 401**] [**Last Name (NamePattern1) 25766**] ([**Telephone/Fax (1) 62573**] C;
[**Telephone/Fax (1) 62574**] H)- brother
[**Name (NI) **] [**Name (NI) 62575**] [**Name (NI) 4580**] [**Telephone/Fax (1) 62576**]  Son [**Name (NI) **] [**Telephone/Fax (1) 62577**]
[**Name2 (NI) **]ter [**Name (NI) 47532**] [**Telephone/Fax (1) 62578**]


Medications on Admission:
Ramipril 10mg take 1 capsule (10MG) by ORAL route every day
Zestril 10mg 1 time per day
Simvastatin 40mg 1 time per day
Viagra 100mg as directed, before sexual intercourse
Furosemide 80mg take 1 tablet (80MG) by ORAL route 2 times every
day
Aspirin 81mg take 1 tablet (81MG) by ORAL route every day
Avapro 300mg Take 2 tabs/d


Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for fever.
3. Labetalol 200 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
4. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U
Injection TID (3 times a day).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for bm.
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
10. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
12. Lantus 100 unit/mL Solution Sig: Twenty Four (24) U
Subcutaneous qam.
13. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: per
sliding scale  Subcutaneous every six (6) hours: 120-159:14U
160-199:16U
200-239:18U
240-279:20U
280-319:22U
320-359:24U
360-399:26U
>400: [**Name8 (MD) 138**] MD.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Diabetic Ketoacidosis
Diffuse brain injury
Meningitis/Encephalitis
Acute on Chronic Renal Failure
Hypernatermia
Anemia


Discharge Condition:
Poor mental status- does not withdraw to pain; no purposeful
movements

Discharge Instructions:
.
It was a pleasure taking care of you in the hospital.  You were
admitted to the hospital because of elevated sugars and severe
acidosis.  You required intubation and had a prolonged admission
in the ICU.  You had fevers and were treated for an infection
with antibiotics for 14 days.  You were evaluated by neurology
and it is unclear the level of neurologic improvement you will
have.

Please see discharge summary for full hospital course.

Followup Instructions:
.
You will need renal follow-up regarding your Acute on Chronic
Renal Failure.
{'Anoxic brain damage,Acute respiratory failure,Acute kidney failure, unspecified,Acute pancreatitis,Meningitis, unspecified,Unspecified causes of encephalitis, myelitis, and encephalomyelitis,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Diastolic heart failure, unspecified,Hyperosmolality and/or hypernatremia,Dependence on respirator, status,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Anemia, unspecified,Other convulsions'}


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: Hyperglycemia

PRESENT ILLNESS: The patinet is a 52 year old male with a history of T1DM
diagnosed at age 38 w/ 2 insulin pumps placed for the first time
in the last month who presented to an OSH with altered mental
status.  The patient is currently intubated and unresponsive, so
most information is gained from the medical record.  The patinet
had been feeling unwell over the last few days, with decreased
energy, nausea/vomiting.  The patient was found by his daughters
boyfriend on the day of presentation in respiratory distress and
altered mental status, and was brought to an OSH ED for further
manegment.
.
On arrival to the OSH,  HR 88, BP 124/76, dyspneic with kussmal
breathing.  Lab work up revealed a K of 8.8, sodium of 127,
creatinine of 4.76, and glucose of 1157.  He had an anion gap of
27.  An ABP was checked, with a pH of 6.98 / 17 / 253 / 4.6.
The patinet develped HRs in the 40s, BPs in the 50s.  He was
given 3 amps of NaHCO3, insulin gtt at 9 which was uptitrated to
15, and calcium gluconate. His UA was + for moderate ketones.  A
R SC line was placed without complications. The patinet was
intubated for airway protection and respiratory distress.  He
was given 5L of NS.  The patient was transfered to [**Hospital1 18**] for
further care.
.
On arrival to our ED, initial VS: 94.4 85 161/68 100% on the
Vent.  His insulin [**Last Name (un) **] was reduced to 8 units/hr.  He was given
an addition L of NS.  The patient was given vanc/zosyn, but no
blood cultures were sent.  He blood sugars persisted in the
800s.  He was admitted to the MICU for further manemement.

MEDICAL HISTORY: DM1 (hbgA1C 9.6 on [**11-17**])
HTN
CRI ([**11-17**] Cr of 2.3)
dCHF
HL

MEDICATION ON ADMISSION: Ramipril 10mg take 1 capsule (10MG) by ORAL route every day
Zestril 10mg 1 time per day
Simvastatin 40mg 1 time per day
Viagra 100mg as directed, before sexual intercourse
Furosemide 80mg take 1 tablet (80MG) by ORAL route 2 times every
day
Aspirin 81mg take 1 tablet (81MG) by ORAL route every day
Avapro 300mg Take 2 tabs/d

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 36.9 ??????C (98.4 ??????F)
HR: 63 (62 - 69) bpm
BP: 141/62(81) {121/52(69) - 147/68(87)} mmHg
RR: 12 (8 - 17) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 111.5 kg (admission): 107.5 kg
Height: 72 Inch

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient is a former smoker, quit many years ago.  Works as a
diesal mechanic.  Has 2 children. 

### Response:
{'Anoxic brain damage,Acute respiratory failure,Acute kidney failure, unspecified,Acute pancreatitis,Meningitis, unspecified,Unspecified causes of encephalitis, myelitis, and encephalomyelitis,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Diastolic heart failure, unspecified,Hyperosmolality and/or hypernatremia,Dependence on respirator, status,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Anemia, unspecified,Other convulsions'}
