CHIEF COMPLAINT: hyperglycemia

PRESENT ILLNESS: [**Known firstname **] [**Known lastname **] 64 yo male hx of PVD, DM s/p renal transplant
[**2130**]. and ulcers.  Patient states that he has been nauseated
with vomiting and diarrhea for the past 2 weeks.   He reports
having decreased food intake and that he has not been able to
take or keep his medications down consistently.  He states that
in the past when he has been hyperglycemic, he has not had
nausea and vomiting like this.  He also reports SOB and DOE for
the past 4-5 days. He denies orthopnea and PND.  He reports some
edema in his legs bilat which is a chronic problem.  [**Name (NI) **] came to
the ER today because his wife finally made him after his
temperature spiked to 102.  Patient also has chronic ulcers. His
wife helps care for them and has not noticed any increasing
erythema 2 days ago when last she changed the dressing.
However, in ED, found to have swollen RLE with right ulcers some
and surrounding erythema concerning for celluliti.  In ED found
to be hyperglycemic with BS of 420 and AG 24.  They treated him
with SQ insulin rather than an insulin drip because they were
concerned about hypoglycemia.  ED with q 1-2 hr fingersticks
brought AG down to 16 currently.

MEDICAL HISTORY: 1. Coronary artery disease s/p CABG X 4 in [**2128**]. Echo [**9-2**] nml
LV function
2. Type 1 Diabetes with complications including retinopathy,
neuropathy, end-stage renal disease, and Charcot foot
3. End-stage renal disease status post cadaveric renal
transplant [**10-1**]
4. Right lower extremity DVT since [**7-4**] requiring life-long
anticoagulation on coumadin and IVC filter placement
5. Hypertension
6. GERD
7. Osteopenia of hip [**10-31**]
8. Neuropathy Rfoot > Lfoot
9. Bilateral cataract surgery
[**37**]. Right foot surgery and Charcot foot [**12/2125**]
11. Diverticulosis
12. Status post flexible bronchoscopy with biopsy of RUL,
lingula [**4-3**]
13. Cryptococcus pneumonia, treated with Fluconazole
14. ORIF left ulna [**4-3**]
15. IVC filter placement [**4-3**]
16. [**2135-6-9**]: Abdominal aortogram with RLE extremity
runoff, angioplasty of popliteal stenosis.

MEDICATION ON ADMISSION: Medications confirmed with pt's wife who has a handwritten list

ALLERGIES: Tegaderm / Prinivil / Reglan

PHYSICAL EXAM: Tmax: 38.4 ??????C (101.2 ??????F)
Tcurrent: 38.4 ??????C (101.2 ??????F)
HR: 82 (82 - 93) bpm
BP: 127/52(69) {123/51(68) - 127/52(69)} mmHg
RR: 20 (20 - 22) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Height: 65 Inch

FAMILY HISTORY: DM type II in father and paternal grandfater. Mother had "heart
disease."

SOCIAL HISTORY: He retired from his job as an electrician in the Marine Corps,
which required travel to HI, CA, NC, [**Country 5976**]. He lives at home with
his supportive wife. They have 3 children (M36, F34, M26).
Bacteremia,Acute kidney failure, unspecified,Cellulitis and abscess of foot, except toes,Ulcer of heel and midfoot,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Intestinal infection due to Clostridium difficile,Kidney replaced by transplant,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Coronary atherosclerosis of native coronary artery,Esophageal reflux,Unspecified essential hypertension,Polyneuropathy in diabetes,Infection with microorganisms resistant to penicillins,Aortocoronary bypass status
Bacteremia,Acute kidney failure NOS,Cellulitis of foot,Ulcer of heel & midfoot,Ac DVT/emb prox low ext,Int inf clstrdium dfcile,Kidney transplant status,DMI ketoacd uncontrold,Mth sus Stph aur els/NOS,Crnry athrscl natve vssl,Esophageal reflux,Hypertension NOS,Neuropathy in diabetes,Inf mcrg rstn pncllins,Aortocoronary bypass
Admission Date:  [**2136-5-28**]              Discharge Date:   [**2136-6-7**]

Date of Birth:  [**2071-10-10**]             Sex:   M

Service: MEDICINE

Allergies:
Tegaderm / Prinivil / Reglan

Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
hyperglycemia

Major Surgical or Invasive Procedure:
debridement of right foot ulcer
PICC line placement


History of Present Illness:
[**Known firstname **] [**Known lastname **] 64 yo male hx of PVD, DM s/p renal transplant
[**2130**]. and ulcers.  Patient states that he has been nauseated
with vomiting and diarrhea for the past 2 weeks.   He reports
having decreased food intake and that he has not been able to
take or keep his medications down consistently.  He states that
in the past when he has been hyperglycemic, he has not had
nausea and vomiting like this.  He also reports SOB and DOE for
the past 4-5 days. He denies orthopnea and PND.  He reports some
edema in his legs bilat which is a chronic problem.  [**Name (NI) **] came to
the ER today because his wife finally made him after his
temperature spiked to 102.  Patient also has chronic ulcers. His
wife helps care for them and has not noticed any increasing
erythema 2 days ago when last she changed the dressing.
However, in ED, found to have swollen RLE with right ulcers some
and surrounding erythema concerning for celluliti.  In ED found
to be hyperglycemic with BS of 420 and AG 24.  They treated him
with SQ insulin rather than an insulin drip because they were
concerned about hypoglycemia.  ED with q 1-2 hr fingersticks
brought AG down to 16 currently.

ED concerned about possible cellulitis started on Vanco and
unsyn for cellulitis.  xray of leg did not show osteomyelitis.
CXR clear.  [**Name (NI) **] was consulted and they took a foot cx.
Podiatry also saw patient.  Patient was going go to floor when
INR came back at 20.0. Patient then given FFP x1 unit and Vit K.



Past Medical History:
1. Coronary artery disease s/p CABG X 4 in [**2128**]. Echo [**9-2**] nml
LV function
2. Type 1 Diabetes with complications including retinopathy,
neuropathy, end-stage renal disease, and Charcot foot
3. End-stage renal disease status post cadaveric renal
transplant [**10-1**]
4. Right lower extremity DVT since [**7-4**] requiring life-long
anticoagulation on coumadin and IVC filter placement
5. Hypertension
6. GERD
7. Osteopenia of hip [**10-31**]
8. Neuropathy Rfoot > Lfoot
9. Bilateral cataract surgery
[**37**]. Right foot surgery and Charcot foot [**12/2125**]
11. Diverticulosis
12. Status post flexible bronchoscopy with biopsy of RUL,
lingula [**4-3**]
13. Cryptococcus pneumonia, treated with Fluconazole
14. ORIF left ulna [**4-3**]
15. IVC filter placement [**4-3**]
16. [**2135-6-9**]: Abdominal aortogram with RLE extremity
runoff, angioplasty of popliteal stenosis.


Social History:
He retired from his job as an electrician in the Marine Corps,
which required travel to HI, CA, NC, [**Country 5976**]. He lives at home with
his supportive wife. They have 3 children (M36, F34, M26).

Alcohol: History of up to [**7-8**] drinks daily, 5x/wk for many
years, only 1-2 beers/ week recently.
Tobacco: 30 pack years, quit [**2121**] after MI.

Family History:
DM type II in father and paternal grandfater. Mother had "heart
disease."

Physical Exam:
Tmax: 38.4 ??????C (101.2 ??????F)
Tcurrent: 38.4 ??????C (101.2 ??????F)
HR: 82 (82 - 93) bpm
BP: 127/52(69) {123/51(68) - 127/52(69)} mmHg
RR: 20 (20 - 22) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Height: 65 Inch

General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral [**Year (4 digits) **]: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed), capillary refill WNL
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, Obese
Extremities: Right: 1+, Left: Trace, No(t) Cyanosis, No(t)
Clubbing
Skin:  Not assessed, Rash: area of erythema on right lower leg
surrounding wound.  purpura present on back of hands.
Neurologic: Attentive, Responds to: Not assessed, Oriented (to):
person, place & time, Movement: Purposeful, Tone: Not assessed


Pertinent Results:
Admit labs:
134  90  34
---------------< 420
3.8  20  2.1 D
LDH: 296
.
WBC: 12.3
HCT: 37.8
PLT: 243
N:88.9 L:7.5 M:3.5 E:0.1 Bas:0.1
.
HCT: 37 -> 32 -> 29
AG: closed prior to d/c out of ICU
.
CXR: neg
Ankle: Cortical irregularity and soft tissue swelling at the
base of the
fifth metatarsal are unchanged. Stable neuropathic changes in
the mid foot. No new areas identified to indicate osteomyelitis.

.
EKG: NSR, Q III, no acute ST-T changes
.


Brief Hospital Course:
Mr. [**Known lastname **] is a 64 yo male with a history of T1DM s/p cadoveric
renal transplant, chronic RLE ulcers, and IVC filter on
coumadin, who was admitted with DKA in the setting of one week
of N/V, diarrhea and fevers.

#. DKA: Thought [**12-31**] infection (MRSA bacteremia and C diff
colitis found in workup)  He received aggressive IVF and IV
insulin bolus but no gtt.  His gap closed overnight in the ICU.
EKG without signs of active ischemia.  He was restarted on his
home insulin regimen once gap closed, with no further incidents.

#. R FOOT ULCER/CELLULITIS: was previously treated with
linezolid and followed by podiatry as out-patient; seen by
[**Month/Day (2) 1106**] and podiatry on admission.  He was started on vanco and
unasyn on admission, and this was narrowed to just vanco after
his culture data returned.  Initial wound swab grew MRSA and was
the likely source of MRSA bacteremia. He underwent debridement
in OR by podiatry on [**2136-5-31**], cultures sent from OR and also grew
MRSA. ID consulted and suggested 6 weeks vancomycin: his wound
probes to bone so there was certainly concern for osteomyelitis.
Pathology eventually confirmed acute osteomyelitis. He will
follow up with Dr. [**Last Name (STitle) 31564**] of podiatry.

#  MRSA BACTEREMIA:  [**12-31**] sets on admission.  Source likely foot
ulcer.  TTE negative.  Surveillance blood cultures neg to date.
Treating with 6 weeks vancomycin as above.

#. NAUSEA/VOMITING, DIARRHEA, C DIFF COLITIS:  sx improved with
appropriate tx with flagyl. Will be treated with 2 weeks Flagyl
and if diarrhea recurs while on vancomycin, will consider
retreating with Flagyl.

#. SOB: sx resolved without further intervention.  No signs ACS
or pneumonia.  Low suspicion PE.  No hypoxia

#. Right knee pain: There was initially significant concern for
possible septic knee in the setting of MRSA bacteremia; however
on further evaluation by rheum, they reported that he had no
effusion, no fluid for arthrocentesis.  Their differential
included CPPD/crystalline disease, other musculoskeletal such as
meniscal tear, avascular necrosis (chronic steroids), occult
fracture. MRI showed no evidence of meniscal or ligamentous
injury, non-specific circumferential subcutaneous edema, and
only trace joint fluid. His pain improved with conservative
management.

#. Coagulopathy: INR 20 on presentation likely [**12-31**] diarrhea and
poor PO intake over last week; received 1 unit FFP in the ED as
well as vitamin K.  INR improved to 6.  We held coumadin but
also gave no further vitamin K in the ICU. His INR was allowed
to drift down and was 3.7 on discharge. He will follow up with
[**Hospital3 **] who will determine when he will restart
coumadin.

#. ARF: Cr 2.1 on admission; with IVF in ED.  Likely prerenal as
it improved with appropriate hydration.  Continued
prednisone/prograf for renal allograft. On resumption of his
outpatient diuretics, his creatinine started rising again.
Diuretics were held as urine lytes suggested this was again
prerenal. Given his worsening lower extremity edema and after
his creatinine had stabilized around 1.7-1.8, Lasix was
restarted at 40mg qd and florinef was stopped.

#. Hx heavy EtOH use: ciwa scale and mvi/folate/thiamine; no
signs withdrawal so CIWA discontinued.

# T1 DM, uncontrolled with complications:  as above, DKA
resolved with appropriate insulin IV in ICU and tx of multiple
infections.

# CAD s/p CABG: continued ASA, Plavix

# Anemia: he was guaiac negative and iron studies were
consistent with ACD. Procrit was started in-house, to be
continued as an outpatient.

Medications on Admission:
Medications confirmed with pt's wife who has a handwritten list

OXYCODONE -  (Prescribed by Other Provider) - 5 mg Capsule -
as
needed for pain  ---> wife says most recently he has been using
percocet
ACETIC ACID (BULK) -  (Prescribed by Other Provider) - 3 %
Liquid
- to wash foot wound daily apply dressing after wash
AMLODIPINE [NORVASC] - 5 mg Tablet - 1 Tablet(s) by mouth once a
day
ASCENSIA ELITE TEST STRIPS -   - USE AS DIRECTED
ATORVASTATIN [LIPITOR] -  (Prescribed by Other Provider) - 80 mg
Tablet - 1 Tablet(s) by mouth hs
BECAPLERMIN [REGRANEX] -  (Prescribed by Other Provider) - 0.01
%
Gel -   as needed
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once
a
day
COUMADIN - 1MG Tablet - one to three Tablet(s) by mouth once a
day
FLUCONAZOLE - 200 mg Tablet - 1 Tablet(s) by mouth once a day
FLUDROCORTISONE [FLORINEF] - 0.1 mg Tablet - 1 Tablet(s) by
mouth
once a day - No Substitution
FUROSEMIDE -  (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth twice a day
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth every other day
GLUCAGON EMERGENCY KIT - 1MG Kit - USE AS DIRECTED
IMDUR - 60MG Tablet Sustained Release 24 hr - ONE TABLET EVERY
DAY
INSULIN GLARGINE [LANTUS] -  (Prescribed by Other Provider) -
100
unit/mL Solution - 36 units every noon
METOPROLOL TARTRATE - 50MG Tablet - ONE TABLET TWICE A DAY
NITROQUICK - 0.4MG Tablet, Sublingual - USE 0.4 MG UNDER THE
TONGUE AS NEEDED FOR CHEST PAIN
NOVOLOG - 100 U/ML Solution - SLIDING SCALE - [**First Name8 (NamePattern2) **] [**Last Name (un) **]
OS-CAL 500+D - 500-200 Tablet - ONE TABLET THREE TIMES A DAY

PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth once a day
PAPAIN-UREA [ETHEZYME] -  (Prescribed by Other Provider) - 1.1
million unit/gram Ointment -   as needed
PAPAIN-UREA-CHLOROPHYLLIN [PANAFIL] -  (Prescribed by Other
Provider) - 521,700 unit/gram-10 %-0.5 % Ointment -   as needed
POTASSIUM CHLORIDE -  (Prescribed by Other Provider) - 10 mEq
Tab
Sust.Rel. Particle/Crystal - 1 Tab(s) by mouth once a day
PREDNISONE - 5MG Tablet - ONE Tablet(s) by mouth q day
RISEDRONATE [ACTONEL] - 35 mg Tablet - 1 Tablet(s) by mouth once
a week take on empty stomach with lots of water, stay upright
for
30 min afterwards
SILVER SULFADIAZINE -  (Prescribed by Other Provider) - 1 %
Cream
-   as needed
TACROLIMUS [PROGRAF] - 1 mg Capsule - 1 Capsule(s) by mouth
twice
a day
TRAVOPROST (BENZALKONIUM) [TRAVATAN] -  (Prescribed by Other
Provider) - 0.004 % Drops - 1 drop in the left eye once a day
TRIMETHOPRIM-SULFAMETHOXAZOLE [BACTRIM] -  (Prescribed by Other
Provider) - 400 mg-80 mg Tablet - one Tablet(s) by mouth mon,
wed,fri

Medications - OTC
ALCOHOL SWABS -  Pads, Medicated - USE AS DIRECTED
ASCORBIC ACID [VITAMIN C] -  (Prescribed by Other Provider) -
500
mg Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN [ASPIRIN EC] -  (OTC) - 81 mg Tablet, Delayed Release
(E.C.) - 1 Tablet(s) by mouth once a day
CALCIUM CARBONATE [TUMS] -  (Prescribed by Other Provider) - 500
mg Tablet, Chewable - Tablet(s) by mouth  as needed
COLACE - 100MG Capsule - ONE TABLET TWICE A DAY
HYDROCOLLOID DRESSING [AQUACEL HYDROFIBER DRESSING] -
(Prescribed by Other Provider) - Dosage uncertain
HYDROCOLLOID DRESSING [AQUACEL HYDROFIBER DRESSING] -
(Prescribed by Other Provider) - 4" X 4" Bandage -   as needed
LANCETS -  Misc - AS DIRECTED 5 TIMES PER DAY
MULTIVITAMIN -  (OTC) -   Tablet - 1 Tablet(s) by mouth once a
day
NON-ADHERENT BANDAGE [ADAPTIC] -  (Prescribed by Other Provider)
- Dosage uncertain
POVIDONE-IODINE [BETADINE] -  (Prescribed by Other Provider) -
10
% Solution -   as needed


Discharge Medications:
1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) g
Intravenous Q48H (every 48 hours) for 5 weeks.
Disp:*18 g* Refills:*0*
2. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*100 ML(s)* Refills:*1*
3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) mL
Injection once a week.
Disp:*4 mL* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q 8H (Every 8 Hours).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Multivitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

13. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic once a
day: in left eye.
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

19. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
21. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 weeks.
Disp:*21 Tablet(s)* Refills:*0*
22. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
23. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
24. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
25. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
26. Insulin Glargine 100 unit/mL Solution Sig: Thirty Six (36)
Units Subcutaneous once a day.
27. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Methicillin Resistant Staph Aureus bacteremia
Right foot ulcer infection
Diabetic ketoacidosis, resolved
Acute renal failure
Clostridium difficile colitis

Secondary:
Type 1 diabetes mellitus with complications
hx of renal transplant
Coronary artery disease, s/p coronary artery bypass graft
peripheral [**Hospital1 1106**] disease
bilateral deep vein thrombosis


Discharge Condition:
stable, afebrile, ambulating with cane


Discharge Instructions:
You were admitted with cellulitis and found to have MRSA
bacteremia, likely from a foot ulcer. The ulcer was debrided by
podiatry and also grew MRSA. You will need IV antibiotics
(vancomycin) for 6 weeks from the date of [**2136-5-31**]. Visting nurses
will draw blood once a week and fax results to the [**Hospital **] clinic.
You should take Flagyl for one more week.

You should continue to hold coumadin. VNA will draw blood for
INR and fax the results to the [**Hospital3 **]. They will
tell you when to resume coumadin.

Resume your Lasix at 40mg daily. Depending on your creatinine
level, this may be adjusted by Dr. [**First Name (STitle) 805**] or Dr. [**Last Name (STitle) **].

If you have recurrent fevers, chills, worsening pain, or any
other concerning symptoms, call your doctor immediately.

If you have recurrent diarrhea, call the [**Hospital **] clinic, as you may
need to restart Flagyl.

Followup Instructions:
Podiatry: follow up with Dr. [**Last Name (STitle) **] in his [**Location (un) 701**] office
on [**6-15**] at 3:10.

PCP: [**Name10 (NameIs) **] up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3403**]
[**Last Name (NamePattern1) **], on [**6-13**] at 11:10am. You may call his office at
[**Telephone/Fax (1) 250**] with any questions.

[**Telephone/Fax (1) **]: Follow up with Dr. [**Last Name (STitle) **] on [**7-24**] at 1pm.

Renal: Follow up with Dr. [**First Name (STitle) 805**] on [**7-9**] at 11am.

ID: Follow up with Dr. [**Last Name (STitle) 12838**] on [**2136-6-21**] at 1:30pm.
Phone:[**Telephone/Fax (1) 457**]
{'Bacteremia,Acute kidney failure, unspecified,Cellulitis and abscess of foot, except toes,Ulcer of heel and midfoot,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Intestinal infection due to Clostridium difficile,Kidney replaced by transplant,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Coronary atherosclerosis of native coronary artery,Esophageal reflux,Unspecified essential hypertension,Polyneuropathy in diabetes,Infection with microorganisms resistant to penicillins,Aortocoronary bypass status'}


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: [**Known firstname **] [**Known lastname **] 64 yo male hx of PVD, DM s/p renal transplant
[**2130**]. and ulcers.  Patient states that he has been nauseated
with vomiting and diarrhea for the past 2 weeks.   He reports
having decreased food intake and that he has not been able to
take or keep his medications down consistently.  He states that
in the past when he has been hyperglycemic, he has not had
nausea and vomiting like this.  He also reports SOB and DOE for
the past 4-5 days. He denies orthopnea and PND.  He reports some
edema in his legs bilat which is a chronic problem.  [**Name (NI) **] came to
the ER today because his wife finally made him after his
temperature spiked to 102.  Patient also has chronic ulcers. His
wife helps care for them and has not noticed any increasing
erythema 2 days ago when last she changed the dressing.
However, in ED, found to have swollen RLE with right ulcers some
and surrounding erythema concerning for celluliti.  In ED found
to be hyperglycemic with BS of 420 and AG 24.  They treated him
with SQ insulin rather than an insulin drip because they were
concerned about hypoglycemia.  ED with q 1-2 hr fingersticks
brought AG down to 16 currently.

MEDICAL HISTORY: 1. Coronary artery disease s/p CABG X 4 in [**2128**]. Echo [**9-2**] nml
LV function
2. Type 1 Diabetes with complications including retinopathy,
neuropathy, end-stage renal disease, and Charcot foot
3. End-stage renal disease status post cadaveric renal
transplant [**10-1**]
4. Right lower extremity DVT since [**7-4**] requiring life-long
anticoagulation on coumadin and IVC filter placement
5. Hypertension
6. GERD
7. Osteopenia of hip [**10-31**]
8. Neuropathy Rfoot > Lfoot
9. Bilateral cataract surgery
[**37**]. Right foot surgery and Charcot foot [**12/2125**]
11. Diverticulosis
12. Status post flexible bronchoscopy with biopsy of RUL,
lingula [**4-3**]
13. Cryptococcus pneumonia, treated with Fluconazole
14. ORIF left ulna [**4-3**]
15. IVC filter placement [**4-3**]
16. [**2135-6-9**]: Abdominal aortogram with RLE extremity
runoff, angioplasty of popliteal stenosis.

MEDICATION ON ADMISSION: Medications confirmed with pt's wife who has a handwritten list

ALLERGIES: Tegaderm / Prinivil / Reglan

PHYSICAL EXAM: Tmax: 38.4 ??????C (101.2 ??????F)
Tcurrent: 38.4 ??????C (101.2 ??????F)
HR: 82 (82 - 93) bpm
BP: 127/52(69) {123/51(68) - 127/52(69)} mmHg
RR: 20 (20 - 22) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Height: 65 Inch

FAMILY HISTORY: DM type II in father and paternal grandfater. Mother had "heart
disease."

SOCIAL HISTORY: He retired from his job as an electrician in the Marine Corps,
which required travel to HI, CA, NC, [**Country 5976**]. He lives at home with
his supportive wife. They have 3 children (M36, F34, M26). 

### Response:
{'Bacteremia,Acute kidney failure, unspecified,Cellulitis and abscess of foot, except toes,Ulcer of heel and midfoot,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Intestinal infection due to Clostridium difficile,Kidney replaced by transplant,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Coronary atherosclerosis of native coronary artery,Esophageal reflux,Unspecified essential hypertension,Polyneuropathy in diabetes,Infection with microorganisms resistant to penicillins,Aortocoronary bypass status'}
