CHIEF COMPLAINT: Hyperglycemia, confusion

PRESENT ILLNESS: History of Present Illness: Mr. [**Known lastname **] is a 53 M with a history
of type II diabetes on insulin, hypertension, chronic kidney
disease, diastolic CHF who presents with malaise and confusion
following a barbeque this afternoon. He reports feeling fine in
the morning and attending a barbeque where he ate a significant
amount of food and drank soda. Afterward, he became confused and
reports hearing background noise "like voices on a radio." He
reports that he took his QHS insulin last night, however he did
not bring his insulin pen with him today to the barbeque.

MEDICAL HISTORY: Past Medical History:
1) CKD Grade 5, currently being evaluated for transplant
2)  Diabetes.  He says he has had this for 23 years and has been
on insulin for seven years.  He has a history of retinopathy and
is status post laser surgery, and has some mild neuropathy.  He
says his sugars are relatively well controlled.
3)  Hypertension.  He has had this about five years.
4)  High cholesterol.
5)  History of small CVA in [**2174**].  He said it was characterized
by tongue heaviness and he has no residual.
6)  History of congestive heart failure requiring admission in
[**2181-1-10**].
7)  History of latent TB by PPD that was treated 15 yrs ago and
then again he was started on INH in [**2180-10-11**].  He says he
has planned to take for six or seven months total at this time.
8)  History of right Charcot joint surgery with hardware in
place
9) Glaucoma

MEDICATION ON ADMISSION: Confirmed with PCP
[**Name Initial (PRE) **] -  10mg qd
CALCITRIOL -  0.25 mcg qd
CALCIUM carbonate 200 mg PO BID
CHLORTHALIDONE -  25 mg Tablet qd
FUROSEMIDE -  80 mg [**Hospital1 **]
INSULIN ASPART [NOVOLOG FLEXPEN] -  100 unit/mL Insulin Pen -
per sl sc
INSULIN GLARGINE [LANTUS] -  16 units qhs
Toprol XL -  200 mg qd
Niacin PO daily
Fish oil PO daily
INH 300 mg PO daily
B6 50 mg PO daily

ALLERGIES: Penicillins / simvastatin

PHYSICAL EXAM: Physical Exam on Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry, 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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Family History:
His family history is significant for HTN secondary to DM; no
CAD.  Both parents passed away from what he feels were
complications from DM.  He has had a brother and sister both
pass
away in [**2174**] from DM related complciations.  He has 2 other
brothers and 2 other sisters who are alive.

SOCIAL HISTORY: Social History:
Married, lives in [**Location 686**] with his wife and 2 sons, ages
17 and 6 who are both up-to-date on vaccinations.  They have no
pets.  He presently works as a driver for a food-services
company.  In [**Country 2045**], he was the director of social services
programs for the Ministry of Health, and spent a significant
amount of time in the Health Department interfacing with
numerous
clients.
Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled,Acute kidney failure, unspecified,Chronic diastolic heart failure,Acidosis,Chronic kidney disease, Stage V,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Polyneuropathy in diabetes,Long-term (current) use of insulin,Hallucinations,Unspecified glaucoma,Anemia in chronic kidney disease,Background diabetic retinopathy,Personal history of noncompliance with medical treatment, presenting hazards to health
DMII hprsm nt st uncntrl,Acute kidney failure NOS,Chr diastolic hrt fail,Acidosis,Chron kidney dis stage V,Hyp kid NOS w cr kid V,Neuropathy in diabetes,Long-term use of insulin,Hallucinations,Glaucoma NOS,Anemia in chr kidney dis,Diabetic retinopathy NOS,Hx of past noncompliance
Admission Date:  [**2181-8-6**]              Discharge Date:   [**2181-8-7**]

Date of Birth:  [**2128-1-18**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / simvastatin

Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Hyperglycemia, confusion

Major Surgical or Invasive Procedure:
None


History of Present Illness:
History of Present Illness: Mr. [**Known lastname **] is a 53 M with a history
of type II diabetes on insulin, hypertension, chronic kidney
disease, diastolic CHF who presents with malaise and confusion
following a barbeque this afternoon. He reports feeling fine in
the morning and attending a barbeque where he ate a significant
amount of food and drank soda. Afterward, he became confused and
reports hearing background noise "like voices on a radio." He
reports that he took his QHS insulin last night, however he did
not bring his insulin pen with him today to the barbeque.

In the ED, initial vs were: T 98.8, HR 82, BP 179/83, RR 16,
100% on RA. His fingerstick on arrival was noted to be
critically high and initial labs were notable for glucose > 1200
with anion gap of 15. He received 8 units of regular insulin SQ
with improvement after two hours to glucose > 1000. He then
received another 8 units SQ regular insulin. He also received 2L
of IVF with NS. He was noted to have K elevated to 6.6 and did
have some peaking of T waves on EKG, though no QRS widening.
Given that he will receive additional insulin, no further
intervention was taken to control his K, which came down to 5.0
on repeat BMP. He was transferred to the ICU for further
management of hyperglycemia. Vitals on admission were T 97.2, BP
137/56, HR 80, RR 18, O2 sat 100% on RA.

On the floor, he arrived on an insulin drip, was awake, alert
and cooperative.  He denied symptoms, endorsing only hunger and
thirst.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.


Past Medical History:
Past Medical History:
1) CKD Grade 5, currently being evaluated for transplant
2)  Diabetes.  He says he has had this for 23 years and has been
on insulin for seven years.  He has a history of retinopathy and
is status post laser surgery, and has some mild neuropathy.  He
says his sugars are relatively well controlled.
3)  Hypertension.  He has had this about five years.
4)  High cholesterol.
5)  History of small CVA in [**2174**].  He said it was characterized
by tongue heaviness and he has no residual.
6)  History of congestive heart failure requiring admission in
[**2181-1-10**].
7)  History of latent TB by PPD that was treated 15 yrs ago and
then again he was started on INH in [**2180-10-11**].  He says he
has planned to take for six or seven months total at this time.
8)  History of right Charcot joint surgery with hardware in
place
9) Glaucoma

Social History:
Social History:
Married, lives in [**Location 686**] with his wife and 2 sons, ages
17 and 6 who are both up-to-date on vaccinations.  They have no
pets.  He presently works as a driver for a food-services
company.  In [**Country 2045**], he was the director of social services
programs for the Ministry of Health, and spent a significant
amount of time in the Health Department interfacing with
numerous
clients.

Family History:
Family History:
His family history is significant for HTN secondary to DM; no
CAD.  Both parents passed away from what he feels were
complications from DM.  He has had a brother and sister both
pass
away in [**2174**] from DM related complciations.  He has 2 other
brothers and 2 other sisters who are alive.

Physical Exam:
Physical Exam on Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry, 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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Exam on Discharge:


Pertinent Results:
[**2181-8-5**] 11:15PM   PLT COUNT-474*
[**2181-8-5**] 11:15PM   NEUTS-82.9* LYMPHS-10.6* MONOS-3.2 EOS-2.4
BASOS-1.0
[**2181-8-5**] 11:15PM   WBC-11.7* RBC-3.26* HGB-9.4* HCT-29.5*
MCV-91# MCH-28.9 MCHC-31.9 RDW-14.8
[**2181-8-5**] 11:15PM   CK-MB-3 cTropnT-0.06*
[**2181-8-5**] 11:15PM   CK(CPK)-129
[**2181-8-5**] 11:15PM   GLUCOSE-1267* UREA N-76* CREAT-5.3*
SODIUM-115* POTASSIUM-6.6* CHLORIDE-80* TOTAL CO2-20* ANION
GAP-22*
[**2181-8-5**] 11:20PM   GLUCOSE->500 K+-5.7*
[**2181-8-5**] 11:15PM   GLUCOSE-1267* UREA N-76* CREAT-5.3*
SODIUM-115* POTASSIUM-6.6* CHLORIDE-80* TOTAL CO2-20* ANION
GAP-22*
[**2181-8-5**] 11:20PM   GLUCOSE->500 K+-5.7*
[**2181-8-5**] 11:30PM URINE  RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2181-8-5**] 11:30PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2181-8-5**] 11:30PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2181-8-6**] 01:50AM   GLUCOSE-1004* UREA N-76* CREAT-5.0*
SODIUM-120* POTASSIUM-5.0 CHLORIDE-85* TOTAL CO2-21* ANION
GAP-19
[**2181-8-6**] 06:12AM   PLT COUNT-505*
[**2181-8-6**] 06:12AM   WBC-12.1* RBC-3.28* HGB-9.6* HCT-26.6*
MCV-81*# MCH-29.3 MCHC-36.1*# RDW-14.1
[**2181-8-6**] 09:57AM URINE  BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE->1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2181-8-7**] 04:00AM BLOOD Glucose-218* UreaN-64* Creat-4.5* Na-132*
K-3.9 Cl-101 HCO3-20* AnGap-15

[**2181-8-5**] CXR
UPRIGHT FRONTAL AND LATERAL CHEST RADIOGRAPHS: The heart size is
normal. The hilar and mediastinal contours are within normal
limits. The central pulmonary vessels are prominent, however,
there is no overt edema. Mild bronchial wall thickening appears
chronic. There is no pneumothorax, focal consolidation, or
pleural effusion. IMPRESSION: No acute intrathoracic process.

[**2181-8-5**] EKG
Normal sinus rhythm. Marked peaking of T waves in leads V2-V4.
No other diagnostic abnormality. Compared to the previous
tracing of [**2181-1-31**] peaked T waves are new. Consider electrolyte
abnormality (hyperkalemia).


Brief Hospital Course:
Hospital Summary:
Mr. [**Known lastname **] was admitted [**8-5**] with confusion, hyperglycemia after
a barbecue in which he took in a copious amount of food and
[**Company 19015**]. He was started on an insulin gtt, progressed to a
diabetic diet, SSI w/ Lantus qhs. Hospital course was
complicated by, altered mental status and hyperkalemia.

#Nonketotic Hyperosmolar Hypoglycemia.
Pt. presented with a glucose of 1200 and an anion gap of 16 w/o
ketonuria, and patient was started on an insulin gtt. Gap closed
to 12 within 4 hours on gtt. On the first day of admission, BS
dropped to 200's and the insulin gtt was discontinued. Mr.
[**Known lastname **] was seen by the [**Last Name (un) **] diabetes service and they
recommended the following changes to his sliding scale diabetic
regimen:

Range  Meal  QHS
0-70    juice
70-120   4   0
120-160  6   0
160-200  8   0
200-240  10  2
240-280  12  3
280-320  13  4
320-360  14  5
360-400  16  6

[**Last Name (un) **] also recommended 16 units lantus qhs. By [**8-7**], Mr.
[**Known lastname 88088**] glucose had improved to 100's and [**Last Name (un) **] fellow agreed
with discharge. Diabetes education is of major concern with Mr.
[**Known lastname **] and the nursing staff spent ~30-45 minutes educating Mr.
[**Known lastname **] and his wife.

#Altered Mental Status.
Upon presentation, Mr. [**Known lastname **] was confused and complaining of
auditory hallucinations and was found to have waxing and [**Doctor Last Name 688**]
of consciousness. Delirium and auditory hallucinations resolved
upon normalization of glucose.

#Mr. [**Known lastname **] initially experienced hyperkalemia to 6.6 on
admission with an EKG demonstrating peaked T waves. Following
insulin therapy, hyperkalemia resolved to 4.3 on the day of
discharge [**8-7**].

Medications on Admission:
Confirmed with PCP
[**Name Initial (PRE) **] -  10mg qd
CALCITRIOL -  0.25 mcg qd
CALCIUM carbonate 200 mg PO BID
CHLORTHALIDONE -  25 mg Tablet qd
FUROSEMIDE -  80 mg [**Hospital1 **]
INSULIN ASPART [NOVOLOG FLEXPEN] -  100 unit/mL Insulin Pen -
per sl sc
INSULIN GLARGINE [LANTUS] -  16 units qhs
Toprol XL -  200 mg qd
Niacin PO daily
Fish oil PO daily
INH 300 mg PO daily
B6 50 mg PO daily


Discharge Medications:
Confirmed with PCP
[**Name Initial (PRE) **] -  10mg qd
CALCITRIOL -  0.25 mcg qd
CALCIUM carbonate 200 mg PO BID
CHLORTHALIDONE -  25 mg Tablet qd
FUROSEMIDE -  80 mg [**Hospital1 **]
INSULIN ASPART [NOVOLOG FLEXPEN] -  100 unit/mL Insulin Pen -
per new sliding scale outlined in brief hospital course.
INSULIN GLARGINE [LANTUS] -  16 units qhs
Toprol XL -  200 mg qd
Niacin PO daily
Fish oil PO daily
INH 300 mg PO daily
B6 50 mg PO daily


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
Hyperosmolar Nonketotic Hyperglycemic Episode
Acute on Chronic Renal Failure (stage 5)

Secondary Diagnosis:
Hypertension
Diabetes Type II (Insulin Dependent)


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Thank you for allowing us to take part in your care. You were
admitted to the hospital with high blood sugar levels. These
levels were dangerously high. While you were in the hospital,
you were given insulin and intravenous fluids to help control
your blood sugars. It is very important to control your blood
sugars at home. You should check your blood sugars several times
per day.

We made adjustments to your insulin sliding scale. Please check
your blood sugar before meals and before bed and use the new
scale to determine how much Novolog insulin to use. You should
continue to take your glargine (Lantus) insulin 16 units before
bed. Please take your other medications as prescribed.

Please follow up with your primary care doctor as well as the
endocrinology specialist as detailed below.

Until you see your primary care doctor to review your case, you
should not drive as these high blood sugars and confusion pose a
serious risk to your health. Please keep a record of your blood
sugar readings and bring it to your next appointments with your
PCP and endocrinologist. You should also call your PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) 86505**] tomorrow to report your blood sugar readings to make
sure that your sugars stay well-controlled.

Followup Instructions:
We have scheduled the following appointments for you to follow
up on your diabetes:

Name: [**Last Name (STitle) **],SHANTHY
Location: [**Location (un) 2274**] [**Location (un) **], Primary Care
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Appt:  [**8-16**] at 11am

Name: [**Last Name (LF) 88089**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) 2274**]-[**Location (un) **], Endocrinology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 88090**]
Appt:  [**8-21**] at 10:30am

You have the following appointments scheduled at [**Hospital1 18**]:

Department: RADIOLOGY
When: THURSDAY [**2181-8-23**] at 1:30 PM
With: VASCULAR STUDY [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: TRANSPLANT CENTER
When: THURSDAY [**2181-8-23**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
{'Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled,Acute kidney failure, unspecified,Chronic diastolic heart failure,Acidosis,Chronic kidney disease, Stage V,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Polyneuropathy in diabetes,Long-term (current) use of insulin,Hallucinations,Unspecified glaucoma,Anemia in chronic kidney disease,Background diabetic retinopathy,Personal history of noncompliance with medical treatment, presenting hazards to health'}


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, confusion

PRESENT ILLNESS: History of Present Illness: Mr. [**Known lastname **] is a 53 M with a history
of type II diabetes on insulin, hypertension, chronic kidney
disease, diastolic CHF who presents with malaise and confusion
following a barbeque this afternoon. He reports feeling fine in
the morning and attending a barbeque where he ate a significant
amount of food and drank soda. Afterward, he became confused and
reports hearing background noise "like voices on a radio." He
reports that he took his QHS insulin last night, however he did
not bring his insulin pen with him today to the barbeque.

MEDICAL HISTORY: Past Medical History:
1) CKD Grade 5, currently being evaluated for transplant
2)  Diabetes.  He says he has had this for 23 years and has been
on insulin for seven years.  He has a history of retinopathy and
is status post laser surgery, and has some mild neuropathy.  He
says his sugars are relatively well controlled.
3)  Hypertension.  He has had this about five years.
4)  High cholesterol.
5)  History of small CVA in [**2174**].  He said it was characterized
by tongue heaviness and he has no residual.
6)  History of congestive heart failure requiring admission in
[**2181-1-10**].
7)  History of latent TB by PPD that was treated 15 yrs ago and
then again he was started on INH in [**2180-10-11**].  He says he
has planned to take for six or seven months total at this time.
8)  History of right Charcot joint surgery with hardware in
place
9) Glaucoma

MEDICATION ON ADMISSION: Confirmed with PCP
[**Name Initial (PRE) **] -  10mg qd
CALCITRIOL -  0.25 mcg qd
CALCIUM carbonate 200 mg PO BID
CHLORTHALIDONE -  25 mg Tablet qd
FUROSEMIDE -  80 mg [**Hospital1 **]
INSULIN ASPART [NOVOLOG FLEXPEN] -  100 unit/mL Insulin Pen -
per sl sc
INSULIN GLARGINE [LANTUS] -  16 units qhs
Toprol XL -  200 mg qd
Niacin PO daily
Fish oil PO daily
INH 300 mg PO daily
B6 50 mg PO daily

ALLERGIES: Penicillins / simvastatin

PHYSICAL EXAM: Physical Exam on Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry, 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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Family History:
His family history is significant for HTN secondary to DM; no
CAD.  Both parents passed away from what he feels were
complications from DM.  He has had a brother and sister both
pass
away in [**2174**] from DM related complciations.  He has 2 other
brothers and 2 other sisters who are alive.

SOCIAL HISTORY: Social History:
Married, lives in [**Location 686**] with his wife and 2 sons, ages
17 and 6 who are both up-to-date on vaccinations.  They have no
pets.  He presently works as a driver for a food-services
company.  In [**Country 2045**], he was the director of social services
programs for the Ministry of Health, and spent a significant
amount of time in the Health Department interfacing with
numerous
clients. 

### Response:
{'Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled,Acute kidney failure, unspecified,Chronic diastolic heart failure,Acidosis,Chronic kidney disease, Stage V,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Polyneuropathy in diabetes,Long-term (current) use of insulin,Hallucinations,Unspecified glaucoma,Anemia in chronic kidney disease,Background diabetic retinopathy,Personal history of noncompliance with medical treatment, presenting hazards to health'}
