CHIEF COMPLAINT: Hyperglycemia

PRESENT ILLNESS: Ms. [**Known lastname 4587**] is an 86 year old female with multiple medical
problems including bilateral unprovoked PE's on coumadin, CAD,
diabetes on home insulin complicated by LE ulcers who was
initially referreed into the ER by her VNA for hyperglycemia.
She has been being seen every other day by a VNA for wound care
of her lower extremity ulcers, which per her report have been
improving and this morning she was noted to have a blood sugar
of 411.  She says that she took her usual insulin regimen this
morning which is 6units of NPH and 20 units of regular.
Additionally, she completed an empiric 10 day course of
ciprofloxacin 4 days ago which was prescribed by her podiatrist
for her lower extremity ulcers, however the dysuria she had been
having improved but did not resolve.  She says that at baseline
she is incontinent, she continues to have dysuria but thinks
that her urine output has actually decreased recently.  She
thinks that her LE ulcers have been improving, she denies any
associated fever/chills, n/v/d, abdominal pain, leg pain, chest
pain or shortness of breath.

MEDICAL HISTORY: 1.  Bilateral pulmonary embolism of unknown etiology on
Coumadin.
2.  Recent history of osteomyelitis, now treatment completed.
3.  Diabetes mellitus type 2.
4.  Coronary artery disease.
5.  Hypertension.
6.  Hypercholesteremia.
7.  Hyperthyroidism.
8.  Depression.

MEDICATION ON ADMISSION: AMLODIPINE - 5 mg once a day
ATENOLOL - 50 mg once a day
CITALOPRAM - 20 mg at bedtime
CLOTRIMAZOLE-BETAMETHASONE - 1 %-0.05 % Cream - twice a day
COSOPT - Drops - ONE GTT EACH EYE AT BEDTIME
FUROSEMIDE - 20 mg once a day
LISINOPRIL - 40 mg twice a day
MIRTAZAPINE - 15 mg at bedtime
POTASSIUM CHLORIDE - 10 mEq once a day
SIMVASTATIN - 20 mg at bedtime
TERAZOSIN - 4 mg once a day
WARFARIN - 22 mg once a day
XALATAN - 0.005% Drops - ONE gTT EACH EYE AT BEDTIME
ASPIRIN - 325 mg once a day
FERROUS SULFATE - 325 mg (65 mg iron) once a day
INSULIN REGULAR - 20 u q am and 6 u before supper
MULTIVITAMIN-MINERALS-LUTEIN [SENIOR VITAMIN] - 1 Tablet once a
day
NPH INSULIN HUMAN RECOMB [HUMULIN N] -6 u q am and 6 q hs
OMEPRAZOLE - 20mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

FAMILY HISTORY: The patient's mother died in her early 80s with Alzheimer's
disease.  Her father had tuberculosis.  No other significant
family history.

SOCIAL HISTORY: The patient lives with her husband in [**Name (NI) 1468**]
and manages her activities of daily living as well as
instrumental activities of daily living without any problems.
She
has five sons, all of whom live close by.
Unspecified septicemia,Acute kidney failure with lesion of tubular necrosis,Urinary tract infection, site not specified,Ulcer of other part of lower limb,Unspecified essential hypertension,Pure hypercholesterolemia,Long-term (current) use of insulin,Personal history of pulmonary embolism,Coronary atherosclerosis of native coronary artery,Severe sepsis,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled
Septicemia NOS,Ac kidny fail, tubr necr,Urin tract infection NOS,Ulcer oth part low limb,Hypertension NOS,Pure hypercholesterolem,Long-term use of insulin,Hx pulmonary embolism,Crnry athrscl natve vssl,Severe sepsis,DMII oth nt st uncntrld
Admission Date:  [**2109-3-19**]              Discharge Date:   [**2109-3-21**]

Date of Birth:  [**2022-7-8**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
Hyperglycemia

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Ms. [**Known lastname 4587**] is an 86 year old female with multiple medical
problems including bilateral unprovoked PE's on coumadin, CAD,
diabetes on home insulin complicated by LE ulcers who was
initially referreed into the ER by her VNA for hyperglycemia.
She has been being seen every other day by a VNA for wound care
of her lower extremity ulcers, which per her report have been
improving and this morning she was noted to have a blood sugar
of 411.  She says that she took her usual insulin regimen this
morning which is 6units of NPH and 20 units of regular.
Additionally, she completed an empiric 10 day course of
ciprofloxacin 4 days ago which was prescribed by her podiatrist
for her lower extremity ulcers, however the dysuria she had been
having improved but did not resolve.  She says that at baseline
she is incontinent, she continues to have dysuria but thinks
that her urine output has actually decreased recently.  She
thinks that her LE ulcers have been improving, she denies any
associated fever/chills, n/v/d, abdominal pain, leg pain, chest
pain or shortness of breath.

In the ED, initial VS were: 99.4, 57, 110/44, 16, 100% on RA.
She was initially alert and interactive but about 30min later,
she was found to be much less interactive and her labs returned
with a blood sugar of 39, she was then given 1 amp of D50 with
improvement in her mental status and repeat FS was 238.  At the
time of her hypoglycemia she was also noted to feel cool to the
touch, at which time a rectal temperature was done that was 35
degress celsius.  Other than the hypoglycemia her labs were
notable for a Cr of 2.9 from a baseline of 1.1-1.6, her INR was
6.0, lactate of 1.4, white count was 7.9, no bands, but 1 meta
and 1 myelo, U/A with 135 WBC's, many bacteria, trace blood and
30 protein.  X-rays of her LLE did not show any evidnece of
osteomyelitis, and CXR did not show any evidence of pnuemonia.
Additionally, in the ER she had an episode of hypotension to
78/35, which improved to SBP's in the 110's after 2LNS.  She was
given ceftriaxone for the UTI and vancomycin for possible
cellulitis surrounding her LE ulcers.  VS on transfer: rectal
temp of 34.3C, 55, 111/63, 17, 95% on RA.
.
On arrival to the MICU, her initial VS were: 93.9, 69, 110/63,
16, 92% on RA.  She currently is denying any pain, her only
complaint is that she continues to feel cold.  She also says
that she has a chronic cough that is unchanged.

Past Medical History:
1.  Bilateral pulmonary embolism of unknown etiology on
Coumadin.
2.  Recent history of osteomyelitis, now treatment completed.
3.  Diabetes mellitus type 2.
4.  Coronary artery disease.
5.  Hypertension.
6.  Hypercholesteremia.
7.  Hyperthyroidism.
8.  Depression.


Social History:
The patient lives with her husband in [**Name (NI) 1468**]
and manages her activities of daily living as well as
instrumental activities of daily living without any problems.
She
has five sons, all of whom live close by.


Family History:
The patient's mother died in her early 80s with Alzheimer's
disease.  Her father had tuberculosis.  No other significant
family history.


Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact


Pertinent Results:
Labs:
[**2109-3-19**] 02:27PM BLOOD WBC-6.2 RBC-2.97* Hgb-8.5* Hct-27.5*
MCV-93 MCH-28.7 MCHC-31.1 RDW-13.8 Plt Ct-160
[**2109-3-19**] 02:27PM BLOOD Neuts-71.0* Lymphs-19.4 Monos-6.4 Eos-2.8
Baso-0.3
[**2109-3-19**] 04:00PM BLOOD PT-59.9* PTT-42.3* INR(PT)-6.0*
[**2109-3-19**] 02:27PM BLOOD Glucose-84 UreaN-83* Creat-2.9*# Na-142
K-4.9 Cl-106 HCO3-25 AnGap-16
[**2109-3-20**] 05:13AM BLOOD ALT-43* AST-69* AlkPhos-66 TotBili-0.4
[**2109-3-20**] 05:13AM BLOOD Albumin-2.8* Calcium-8.2* Phos-3.8 Mg-2.2
[**2109-3-19**] 04:00PM BLOOD TSH-0.11*
[**2109-3-20**] 05:13AM BLOOD Vanco-11.9
[**2109-3-19**] 04:06PM BLOOD Lactate-1.4

Studies:

Ankle film - IMPRESSION: No radiographic findings to suggest
acute osteomyelitis. Probable soft tissue defect overlying the
distal medial tibia. Extensive vascular calcifications.

CXR - IMPRESSION: 1. Flattening of the diaphragms suggests
chronic obstructive pulmonary disease. 2. Mild bibasilar
opacities may be due to atelectasis or mild aspiration.


Brief Hospital Course:
Ms. [**Known lastname 4587**] is an 86 year-old female with a complicated past
medical history who was admitted with hypotension.

Hospital Course
----------------
The patient presented to the ED due to fatigue and
hyperglycemia. In the ED, inital labs notable for Cr of 2.9 from
a baseline of 1.1-1.6, INR was 6.0, lactate of 1.4, white count
was 7.9, no bands, but 1 meta and 1 myelo, U/A with 135 WBC's,
many bacteria, trace blood and 30 protein. X-rays of her LLE did
not show any evidnece of osteomyelitis, and CXR did not show any
evidence of pnuemonia. Additionally, she had an episode of
hypotension to 78/35, which improved to SBP's in the 110's after
2LNS. She was given ceftriaxone for the UTI and vancomycin for
possible cellulitis surrounding her LE ulcers. Admitted to MICU.

.
In the MICU the patient was found to be HD stable and mentating
well. All anti-hypertensives were held. Blood sugars were
controlled on ISS alone. The patient had 1 episode of
hypotension overnight (75/40) which improved without
intervention. Otherwise maintained SBPs >90.
.
The patient was transferred to the medical floor on [**2109-3-20**].
She reported feeling greatly improved since admission and was
without new complaint. Her urine culutre returned with
contaminant only and, given lack of fevers or further
hypotension, all antibiotics were stopped. The patient was
maintained off lisinopril, atenolol, amlodipine, terazosin and
furosemide (all home medications) and was normotensive in-house.
The patient was discharged on [**2109-3-21**] with plans for close
outpatient follow-up.
.
#) Acute Renal Failure: On admission, the patient's creatinine
was 2.9. Her creatinine was previously 1.6 in [**Month (only) 404**] and ~1.1
prior. Her BUN was also elevated and labs showed a BUN:Cr of 28.
Appeared dry on initial exam. The patient's creatinine improved
over her hospital course with IVF alone. Her Cr was 1.5 on
discharge.
.
#) Prior pulmonary embolism on coumadin: INR on admission was
6.0. This was thought to be due to recent course of
ciprofloxacin (coumadin was not dose adjusted). The patient's
coumadin was initially held and her INR drifted down. Restarted
home dose of coumdadin on dsicharge.
.
#) CAD: Continued home simvastatin and ASA
.
#) Depression: Continued home citalopram and mirtazapine
.
#) Glaucoma: Continued her home cosopt and xalatan
.
#) Transitional Issues
All anti-hypertensives held on discharge. Can be restarted by
PCP/gerontology based on clinical assessment and pressures in
clinic.

Medications on Admission:
AMLODIPINE - 5 mg once a day
ATENOLOL - 50 mg once a day
CITALOPRAM - 20 mg at bedtime
CLOTRIMAZOLE-BETAMETHASONE - 1 %-0.05 % Cream - twice a day
COSOPT - Drops - ONE GTT EACH EYE AT BEDTIME
FUROSEMIDE - 20 mg once a day
LISINOPRIL - 40 mg twice a day
MIRTAZAPINE - 15 mg at bedtime
POTASSIUM CHLORIDE - 10 mEq once a day
SIMVASTATIN - 20 mg at bedtime
TERAZOSIN - 4 mg once a day
WARFARIN - 22 mg once a day
XALATAN - 0.005% Drops - ONE gTT EACH EYE AT BEDTIME
ASPIRIN - 325 mg once a day
FERROUS SULFATE - 325 mg (65 mg iron) once a day
INSULIN REGULAR - 20 u q am and 6 u before supper
MULTIVITAMIN-MINERALS-LUTEIN [SENIOR VITAMIN] - 1 Tablet once a
day
NPH INSULIN HUMAN RECOMB [HUMULIN N] -6 u q am and 6 q hs
OMEPRAZOLE - 20mg daily


Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. clotrimazole-betamethasone 1-0.05 % Cream Sig: One (1)
Topical twice a day.
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic HS  ().
5. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day.
7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
9. insulin regular human 100 unit/mL Solution Sig: Twenty (20)
Units Injection Before breakfast.
10. insulin regular human 100 unit/mL Solution Sig: Six (6)
Units Injection Before dinner.
11. Humulin N 100 unit/mL Suspension Sig: Six (6) Units
Subcutaneous Before breakfast and before dinner.
12. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. Senior Vitamin     Tablet Sig: One (1) Tablet PO once a day.

14. warfarin 10 mg Tablet Sig: Two (2) Tablet PO at bedtime.
15. warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 1468**] VNA

Discharge Diagnosis:
Primary: Hyperglycemia, Hypotension
Secondary: Diabetes Mellitus


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]!

You came to the hospital due to a high blood sugar. In the
hospital your blood pressure was low and you were admitted
initially to the intensive care unit. You were given intravenous
fluids and your blood pressure improved. You were transferred to
the general medicine [**Hospital1 **] where your blood sugar and blood
pressure were stable. You are now ready for discharge with close
outpatient follow-up.

You will wear a monitor of your heart rate for a few days after
discharge. You should discuss this with your primary care doctor
at your follow-up appointment.

See below for changes made to your home medication regimen:
1) Please STOP Atenolol
2) Please STOP Amlodipine
3) Please STOP Lisinopril
4) Please STOP Terazosin
5) Please STOP Furosemide
-->These medications can be re-started by your primary care
doctor at your follow-up appointment.
6) Please decrease your dose of aspirin to 81mg daily

See below for instructions regarding follow-up care:

Followup Instructions:
Department: GERONTOLOGY
When: FRIDAY [**2109-3-22**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2109-4-2**]
{'Unspecified septicemia,Acute kidney failure with lesion of tubular necrosis,Urinary tract infection, site not specified,Ulcer of other part of lower limb,Unspecified essential hypertension,Pure hypercholesterolemia,Long-term (current) use of insulin,Personal history of pulmonary embolism,Coronary atherosclerosis of native coronary artery,Severe sepsis,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled'}


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: Ms. [**Known lastname 4587**] is an 86 year old female with multiple medical
problems including bilateral unprovoked PE's on coumadin, CAD,
diabetes on home insulin complicated by LE ulcers who was
initially referreed into the ER by her VNA for hyperglycemia.
She has been being seen every other day by a VNA for wound care
of her lower extremity ulcers, which per her report have been
improving and this morning she was noted to have a blood sugar
of 411.  She says that she took her usual insulin regimen this
morning which is 6units of NPH and 20 units of regular.
Additionally, she completed an empiric 10 day course of
ciprofloxacin 4 days ago which was prescribed by her podiatrist
for her lower extremity ulcers, however the dysuria she had been
having improved but did not resolve.  She says that at baseline
she is incontinent, she continues to have dysuria but thinks
that her urine output has actually decreased recently.  She
thinks that her LE ulcers have been improving, she denies any
associated fever/chills, n/v/d, abdominal pain, leg pain, chest
pain or shortness of breath.

MEDICAL HISTORY: 1.  Bilateral pulmonary embolism of unknown etiology on
Coumadin.
2.  Recent history of osteomyelitis, now treatment completed.
3.  Diabetes mellitus type 2.
4.  Coronary artery disease.
5.  Hypertension.
6.  Hypercholesteremia.
7.  Hyperthyroidism.
8.  Depression.

MEDICATION ON ADMISSION: AMLODIPINE - 5 mg once a day
ATENOLOL - 50 mg once a day
CITALOPRAM - 20 mg at bedtime
CLOTRIMAZOLE-BETAMETHASONE - 1 %-0.05 % Cream - twice a day
COSOPT - Drops - ONE GTT EACH EYE AT BEDTIME
FUROSEMIDE - 20 mg once a day
LISINOPRIL - 40 mg twice a day
MIRTAZAPINE - 15 mg at bedtime
POTASSIUM CHLORIDE - 10 mEq once a day
SIMVASTATIN - 20 mg at bedtime
TERAZOSIN - 4 mg once a day
WARFARIN - 22 mg once a day
XALATAN - 0.005% Drops - ONE gTT EACH EYE AT BEDTIME
ASPIRIN - 325 mg once a day
FERROUS SULFATE - 325 mg (65 mg iron) once a day
INSULIN REGULAR - 20 u q am and 6 u before supper
MULTIVITAMIN-MINERALS-LUTEIN [SENIOR VITAMIN] - 1 Tablet once a
day
NPH INSULIN HUMAN RECOMB [HUMULIN N] -6 u q am and 6 q hs
OMEPRAZOLE - 20mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

FAMILY HISTORY: The patient's mother died in her early 80s with Alzheimer's
disease.  Her father had tuberculosis.  No other significant
family history.

SOCIAL HISTORY: The patient lives with her husband in [**Name (NI) 1468**]
and manages her activities of daily living as well as
instrumental activities of daily living without any problems.
She
has five sons, all of whom live close by. 

### Response:
{'Unspecified septicemia,Acute kidney failure with lesion of tubular necrosis,Urinary tract infection, site not specified,Ulcer of other part of lower limb,Unspecified essential hypertension,Pure hypercholesterolemia,Long-term (current) use of insulin,Personal history of pulmonary embolism,Coronary atherosclerosis of native coronary artery,Severe sepsis,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled'}
