CHIEF COMPLAINT: AMS

PRESENT ILLNESS: 60F insulin-dependent Diabetes mellitus complicated by
ophthalmopathy, polyneuropathy, and nephropathy, hypertension
hyperlipidemia, peripheral arterial disease p/w AMS.
.
Family called EMS because she was not acting like herself;
returned from work, slurring speech and ramming wheelchair into
wall. they deny overdose, no obvious symptoms, save for open
sores on feet. No sick contacts. Presented via EMS
yelling/mumbling, tachy to 103, dry skin, flushed. unable to
follow commands. Thrashing about in bed. Per family report was
dry heaving today and not acting like herself, otherwise no
changes in medical history or meds they believe.
.
ED Course :
- Initial Vitals/Trigger: 99 79 179/67 20 99%
- Has Rx for Nortriptyline, Urine tox + for TCA
- physostigmine 2 mg dose for concern of TCA overdose. Equivocal
whether any effect on mental status.
- 5 mg Haldol, 6 mg Ativan to control behaviour
Serial EKG:
- EKG: SR@83 QRS 98 QTc 452 no terminal R
- EKG: SR@83 QRS 100 QTc 444, ? terminal R aVR now
- EKG: SR@73 QRS 96 no terminal R
- cxr (My read) - ? atelectasis on left, vascular prominence
bilaterally
- head ct  - Normal
- Torso CT - incidental findings and atelectasis
- foley placed
- fluids (unknown amount)
- IO in left tibia
- suc, etomidate via tibia
- 7.5 ET tube
- UA pending
- propofol swicthed to fentanyl and versed
- IJ central line
- LP - attempted x3
- carboxy Hgb  - 1
- abg  - pH 7.28 pCO2 50 pO2 231 HCO3 24 BaseXS -3
- Abx vanc 1g, cefepime 2g - patient pcn allergic
Admission Vitals:  188/72, p88 bp 188/72, rr 24, sat 100 with
fiO2 50, Vt450

MEDICAL HISTORY: 1. DM2: insulin-dependent may be Type 1
-followed by [**Hospital **] Clinic
-c/b recurrent ulcers, urosepsis
-Charcot deformity
2. s/p amputation of L 2nd & 3rd toe
3. chronic ulcer of R pretibia
4. hx of MRSA foot [**3-/2125**]
5. HTN
6. PVD
7. hypercholesterolemia
8. Anemia, ? ACD, baseline low 30s
9. Hematemesis in [**2125**] thought to be [**1-15**] small [**Doctor First Name 329**] [**Doctor Last Name **],
EGD ulcer in GE junction

MEDICATION ON ADMISSION: HYDROCHLOROTHIAZIDE -  25 mg Tablet - 1 Tablet(s) by mouth once
a day
INSULIN DETEMIR [LEVEMIR] -  70 Units at bedtime
INSULIN LISPRO [HUMALOG] -
LISINOPRIL -  20 mg Tablet - 1Tablet(s) by mouth once a day
NORTRIPTYLINE -  75 mg Capsule qd
PANTOPRAZOLE -  40 mg Tablet qd
ROSUVASTATIN [CRESTOR] - 20 mg Tablet qd

ALLERGIES: Gatifloxacin / Penicillins / Ciprofloxacin

PHYSICAL EXAM: Admission Exam:
188/72, p88 bp 188/72, rr 24, sat 100 with fiO2 50, Vt450
General: Intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, ETT in place.
Neck: Obese,JVP inestimatable, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused; diffuse ulcerations on lower
extremities

FAMILY HISTORY: Mother had DM2, died of diabetes related coma
Father has DM2, still alive
Several family members on paternal side with DM2
No FH of CAD, MI, or cancer.

SOCIAL HISTORY: The patient lives with her husband and has a 10 year old child.
She works at the Causeway VA as a secretary. She smokes 10 cigs
per day x 40 years. No ETOH and drugs.
Toxic encephalopathy,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Acidosis,Body Mass Index 50.0-59.9, adult,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Arthropathy associated with neurological disorders,Unspecified essential hypertension,Ventral, unspecified, hernia without mention of obstruction or gangrene,Morbid obesity,Other and unspecified hyperlipidemia,Tobacco use disorder,Esophageal reflux,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Long-term (current) use of insulin,Physical restraints status
Toxic encephalopathy,Pneumonia, organism NOS,Ac kidny fail, tubr necr,Acidosis,BMI 50.0-59.9, adult,DMII neuro nt st uncntrl,Neuropathy in diabetes,Arthropathy w nerve dis,Hypertension NOS,Ventral hernia NOS,Morbid obesity,Hyperlipidemia NEC/NOS,Tobacco use disorder,Esophageal reflux,Nephritis NOS in oth dis,Long-term use of insulin,Physical restrain status
Admission Date:  [**2133-2-10**]              Discharge Date:   [**2133-2-17**]

Date of Birth:  [**2072-6-13**]             Sex:   F

Service: MEDICINE

Allergies:
Gatifloxacin / Penicillins / Ciprofloxacin

Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
AMS

Major Surgical or Invasive Procedure:
Mechanical Ventilation

History of Present Illness:
60F insulin-dependent Diabetes mellitus complicated by
ophthalmopathy, polyneuropathy, and nephropathy, hypertension
hyperlipidemia, peripheral arterial disease p/w AMS.
.
Family called EMS because she was not acting like herself;
returned from work, slurring speech and ramming wheelchair into
wall. they deny overdose, no obvious symptoms, save for open
sores on feet. No sick contacts. Presented via EMS
yelling/mumbling, tachy to 103, dry skin, flushed. unable to
follow commands. Thrashing about in bed. Per family report was
dry heaving today and not acting like herself, otherwise no
changes in medical history or meds they believe.
.
ED Course :
- Initial Vitals/Trigger: 99 79 179/67 20 99%
- Has Rx for Nortriptyline, Urine tox + for TCA
- physostigmine 2 mg dose for concern of TCA overdose. Equivocal
whether any effect on mental status.
- 5 mg Haldol, 6 mg Ativan to control behaviour
Serial EKG:
- EKG: SR@83 QRS 98 QTc 452 no terminal R
- EKG: SR@83 QRS 100 QTc 444, ? terminal R aVR now
- EKG: SR@73 QRS 96 no terminal R
- cxr (My read) - ? atelectasis on left, vascular prominence
bilaterally
- head ct  - Normal
- Torso CT - incidental findings and atelectasis
- foley placed
- fluids (unknown amount)
- IO in left tibia
- suc, etomidate via tibia
- 7.5 ET tube
- UA pending
- propofol swicthed to fentanyl and versed
- IJ central line
- LP - attempted x3
- carboxy Hgb  - 1
- abg  - pH 7.28 pCO2 50 pO2 231 HCO3 24 BaseXS -3
- Abx vanc 1g, cefepime 2g - patient pcn allergic
Admission Vitals:  188/72, p88 bp 188/72, rr 24, sat 100 with
fiO2 50, Vt450


Past Medical History:
1. DM2: insulin-dependent may be Type 1
-followed by [**Hospital **] Clinic
-c/b recurrent ulcers, urosepsis
-Charcot deformity
2. s/p amputation of L 2nd & 3rd toe
3. chronic ulcer of R pretibia
4. hx of MRSA foot [**3-/2125**]
5. HTN
6. PVD
7. hypercholesterolemia
8. Anemia, ? ACD, baseline low 30s
9. Hematemesis in [**2125**] thought to be [**1-15**] small [**Doctor First Name 329**] [**Doctor Last Name **],
EGD ulcer in GE junction


Social History:
The patient lives with her husband and has a 10 year old child.
She works at the Causeway VA as a secretary. She smokes 10 cigs
per day x 40 years. No ETOH and drugs.


Family History:
Mother had DM2, died of diabetes related coma
Father has DM2, still alive
Several family members on paternal side with DM2
No FH of CAD, MI, or cancer.

Physical Exam:
Admission Exam:
188/72, p88 bp 188/72, rr 24, sat 100 with fiO2 50, Vt450
General: Intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, ETT in place.
Neck: Obese,JVP inestimatable, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused; diffuse ulcerations on lower
extremities

Discharge Exam:
97.7 156/82 72 18 98%RA
GENERAL - Alert, interactive, well-appearing, NAD
HEENT - PERRL, EOMI, MMM
HEART - distant heart sounds, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, fair air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, morbidly obese, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, charcot deformities of feet, several ulcers,
discolorations in digits of feet
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact

Pertinent Results:
Admission Labs:
[**2133-2-9**] 09:15PM BLOOD WBC-9.0 RBC-4.47 Hgb-13.9 Hct-40.8 MCV-91
MCH-31.2 MCHC-34.2 RDW-13.0 Plt Ct-208
[**2133-2-10**] 04:30AM BLOOD PT-11.3 PTT-25.4 INR(PT)-1.0
[**2133-2-9**] 09:15PM BLOOD Glucose-349* UreaN-24* Creat-1.3* Na-134
K-5.5* Cl-97 HCO3-22 AnGap-21*
[**2133-2-9**] 09:15PM BLOOD ALT-16 AST-34 AlkPhos-119* TotBili-0.6
[**2133-2-11**] 04:25PM BLOOD CK-MB-4 cTropnT-0.04*
[**2133-2-12**] 03:15AM BLOOD CK-MB-4 cTropnT-0.03*
[**2133-2-12**] 03:47PM BLOOD CK-MB-3 cTropnT-0.03*
[**2133-2-9**] 09:15PM BLOOD Albumin-4.2 Calcium-9.8 Phos-3.2 Mg-1.6
[**2133-2-10**] 04:30AM BLOOD Free T4-1.3
[**2133-2-10**] 04:30AM BLOOD TSH-2.3
[**2133-2-10**] 04:30AM BLOOD VitB12-323
[**2133-2-9**] 09:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
[**2133-2-10**] 12:07AM BLOOD Type-ART Rates-20/ Tidal V-450 PEEP-5
FiO2-100 pO2-231* pCO2-50* pH-7.28* calTCO2-24 Base XS--3
AADO2-436 REQ O2-75 -ASSIST/CON Intubat-INTUBATED
[**2133-2-9**] 09:25PM BLOOD Lactate-2.1*
[**2133-2-11**] 08:00PM BLOOD freeCa-1.12

Pertinent Interval Labs:
[**2133-2-13**] 04:11AM BLOOD WBC-8.1 RBC-3.70* Hgb-11.3* Hct-34.6*
MCV-94 MCH-30.5 MCHC-32.6 RDW-13.3 Plt Ct-163
[**2133-2-17**] 07:50AM BLOOD WBC-6.7 RBC-3.86* Hgb-11.8* Hct-34.8*
MCV-90 MCH-30.6 MCHC-33.9 RDW-13.8 Plt Ct-191
[**2133-2-10**] 04:56PM BLOOD Glucose-124* UreaN-31* Creat-2.0* Na-139
K-3.6 Cl-104 HCO3-25 AnGap-14
[**2133-2-13**] 04:11AM BLOOD Glucose-286* UreaN-53* Creat-2.4* Na-141
K-4.7 Cl-105 HCO3-24 AnGap-17
[**2133-2-15**] 09:00AM BLOOD Glucose-234* UreaN-42* Creat-1.5* Na-139
K-4.3 Cl-103 HCO3-24 AnGap-16
[**2133-2-17**] 07:50AM BLOOD Glucose-105* UreaN-34* Creat-1.3* Na-144
K-4.2 Cl-108 HCO3-26 AnGap-14
[**2133-2-11**] 04:25PM BLOOD CK-MB-4 cTropnT-0.04*
[**2133-2-12**] 03:15AM BLOOD CK-MB-4 cTropnT-0.03*
[**2133-2-12**] 03:47PM BLOOD CK-MB-3 cTropnT-0.03*
METHYLMALONIC ACID            767  H              87-318 nmol/L
Beta-Hydroxybutyrate        H         0.4         mmol/L
<0.4

Urine:
[**2133-2-10**] 03:12AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2133-2-10**] 03:12AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2133-2-10**] 03:12AM URINE RBC-12* WBC-95* Bacteri-FEW Yeast-OCC
Epi-2
[**2133-2-14**] 11:41PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2133-2-14**] 11:41PM URINE Blood-SM  Nitrite-NEG Protein-100
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2133-2-14**] 11:41PM URINE RBC-3* WBC-5 Bacteri-FEW Yeast-NONE Epi-2

CSF:
Herpes Simplex Virus PCR
   Specimen Source                   CSF
   Result                            Negative               Not
Applicable

[**2133-2-10**] 04:43PM CEREBROSPINAL FLUID (CSF) WBC-9 RBC-0 Polys-63
Lymphs-21 Monos-14 Macroph-2
[**2133-2-10**] 04:43PM CEREBROSPINAL FLUID (CSF) TotProt-88*
Glucose-128

Micro:
Blood cultures ([**2-9**], [**2-10**]): no growth
Urine ([**2-10**], [**2-14**]): no growth
RPR: non-reactive
CSF:
   GRAM STAIN (Final [**2133-2-10**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
      This is a concentrated smear made by cytospin method,
please refer to
      hematology for a quantitative white blood cell count..

   FLUID CULTURE (Final [**2133-2-16**]):    NO GROWTH.

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   VIRAL CULTURE (Preliminary):    NO VIRUS ISOLATED.
Sputum:
   GRAM STAIN (Final [**2133-2-11**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2133-2-13**]):
      RARE GROWTH Commensal Respiratory Flora.

   GRAM STAIN (Final [**2133-2-12**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2133-2-14**]):    NO GROWTH.

CT Head ([**2133-2-9**]):
There is no hemorrhage, mass, mass effect, or acute
large territorial infarction. The ventricles and sulci are
normal in size and configuration. There is no shift of the
usually midline structures.
Suprasellar and basal cisterns are widely patent. Areas of
periventricular
and deep white matter hyperattenuation are suggestive of chronic
small vessel ischemic changes. A punctate hypodensity within the
posterior limb of the right internal capsule suggests prior
lacunar infarct. There is no scalp hematoma or acute skull
fracture. There is mild mucosal thickening within the right
sphenoid and left maxillary sinuses. The remainder of the
visualized paranasal sinuses and mastoid air cells are well
aerated.
.
CT C/A/P ([**2133-2-9**]):
1. Bibasilar atelectasis. No confluent consolidation to suggest
pneumonia. No pleural effusion.
2. Malpositioned endotracheal tube terminating in the right main
stem
bronchus. Findings were reported to Dr. [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 5850**] at 11:48
p.m. on
[**2133-2-10**] who stated that she was aware, given recent chest
x-ray.
3. Extreme laxity of the anterior abdominal wall.
4. Normal appendix.
5. Multiple thyroid nodules. Dedicated thyroid ultrasound is
recommended for further characterization, if it has not been
completed previously.
6. Bilateral indeterminate adrenal nodules. Further
characterization with
adrenal protocol (contrast washout) CT can be completed if
clinically
indicated.
7. Fibroid uterus
.
EEG ([**2-10**]):
ABNORMALITY #1: The background is slow and disorganized with 5-6
Hz
theta activity posteriorly.
ABNORMALITY #2: There are frequent bursts of 2 Hz generalized
delta
slowing.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No sleep morphology was recorded.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Abnormal EEG due to the slow and disorganized
background
rhythm and bursts of generalized slowing indicative of a
widespread
encephalopathy affecting cortical and subcortical structures.
Possible
causes include infectious, metabolic or toxic etiologies. There
were no
areas of prominent focal slowing although widespread
encephalopathies
can obscure focal findings. There were no epileptiform features.
.
MRI Brain ([**2133-2-11**]):
1. Old lacunar infarcts and small vessel ischemic disease
without without
evidence of acute ischemic infarct, intracranial hemorrhage, or
mass.
2. Bilateral opacification of the mastoid air cells as well as
sphenoid sinus disease.
.
MRI C/T/L Spine ([**2133-2-11**]):
1. No evidence of epidural abscess intracanal mass on this
non-enhanced scan.
2. Multilevel, relatively mild degenerative changes of the
spinal axis as
detailed above, most notably with bilateral pars defects and
anterolisthesis of L5 on S1.

CXR ([**2133-2-12**]):
Tip of the endotracheal tube is just below the upper margin of
the clavicles, no less than 3 cm from the carina. Moderate
bilateral pleural effusions, left greater than right and
moderately severe pulmonary edema have all worsened.
Cardiomegaly is severe, probably not appreciably changed. No
pneumothorax. Right jugular line passes at least as far as the
low SVC and possibly into the upper right atrium. No mediastinal
widening or other evidence of complications.

EKG ([**2-13**]): Sinus rhythm. Premature atrial complexes. Delayed R
wave progression is likely a normal variant. Left atrial
abnormality. Low voltage in the precordial leads. Compared to
the previous tracing of [**2133-2-10**] no significant difference.


Brief Hospital Course:
===============
BRIEF PATIENT SUMMARY
===============
60 F with IDDM here with AMS requiring admission to the MICU for
mechanical ventilation for airway protection.  The patient was
weaned off the ventilator and transferred to the medical [**Hospital1 **]
2-3 days prior to discharge.

===============
ACTIVE ISSUES
===============
# AMS: Likely due to toxic/metabolic encephalopathy in the
setting of CAP.  Was originally thought that UTI may have
contributed, but no growth in urine. Positive serum TCA tox
screen was initially concerning for TCA toxicity, but her
toxidrome was not consistent with this given the absence of QRS
widening and prominent anticholinergic findings. However, +
serum TCA screen is usually representative of a toxic dose, and
as such, a component of TCA toxicity cannot be ruled out. EEG
was performed and showed only generalized slowing consistent
with encephalopathy but no epileptiform activity. There was some
concern for meningitis, and the pt was started on
Vanc/Ceftrixone/Acyclovir while in the ICU. LP was performed and
showed: WBC 7 RBC 1 PMN 52% Lymp 23% Mono 24% Macro 1%. HSV PCR
was negative. Given her mild pleocytosis and hyperactive
patellar reflexes bilaterally, neurology was concerned for an
epidural abscess or other spinal infectious process. For this,
MRI brain and spine was performed, which showed no cause for her
symptoms (see report). TSH, FT4, B12 and RPR were all normal.
ABG showed: 7.28/50/231 on 100% FiO2, intubated. Hypercarbia was
felt to not be contributing to her AMS given improvement with
intubation and slow recovery of her mental status. She was
extubated on [**2133-2-14**] without event. At the time call out from the
MICU, MMA and Beta-Hydroxybutyrate were pending. MMA returned
elevated, but unlikely to be related to B12 metabolism as B12
well w/in normal limits.  Beta-hydroxybutyrate borderline. For
her UTI/CAP, she was treated with Ceftriaxone and Levothyroxine
initially, and transitioned to cefpodoxime on floor.  The
patient was sent home with a total 7 d course of abx for CAP,
through [**2133-2-18**]. She was at baseline mental status and eager to
return home.
.
# Troponinemia: Pt with very mild tropinemia in MICU, likely
related to demand in the setting of CKD. There was no e/o ACS
throughout her course and upon being extubated denied
CP/SOB/N/V, lightheadedness or palpitations.
.
# [**Last Name (un) **]: Likely CIN c/b ATN in the setting of a large contrast
load for CT C/A/P with contrast. She has baseline CKD, which is
likely related to her DM and HTN. Renal was consulted and
recommended holding ACEI and continuing supportive care. Her
urine ouput initially decreased, likely related to ATN, and the
pt subsequently autodiuresed with improvement in her Cr. Cr
peaked at 2.4 in MICU, and recovered to 1.3 x2 measurements on
day of discharge (near b/l).  The patient was initiated back on
HCTZ and lisinopril on day of discharge and was sent with
prescription for Outpatient Lab Work Check chem 7 (esp Cr
considering restarting HCTZ and lisinopril) on [**2133-2-19**], to be
faxed to Dr. [**Last Name (STitle) 1147**] at [**Telephone/Fax (1) 8474**].

# Charcot Foot Deformities: pt w/ charcot foot deformities and
chronic skin changes.  podiatry evaluated pt both in MICU and on
the [**Hospital1 **] a day prior to discharge, and they thought extremely
low likelihood there is an active infection.  Pt w/ significant
neuropathic pain, and pt restarted on nortryptilene at home
dose, and advised pt not to take more than directed on
prescription. Pt had podiatry f/u arranged.

======================
Chronic Issues:
======================
# HTN: HTN controlled w/ labetalol in MICU and floor until HCTZ
and lisinopril started on day of discharge (secondary to [**Last Name (un) **])
.
# DM: pt was maintained on lantus and a humalog insulin sliding
scale
.
# HLD: pt was continued on statin

======================
Transitional Issues:
======================
1. Radiology Incidental Findings:
-Multiple thyroid nodules. Dedicated thyroid ultrasound is
recommended for further characterization, if it has not been
completed previously.
-Bilateral indeterminate adrenal nodules. Further
characterization with
adrenal protocol (contrast washout) CT can be completed if
clinically
indicated.
2. F/U w/ PCP
3. F/U w/ podiatry

Medications on Admission:
HYDROCHLOROTHIAZIDE -  25 mg Tablet - 1 Tablet(s) by mouth once
a day
INSULIN DETEMIR [LEVEMIR] -  70 Units at bedtime
INSULIN LISPRO [HUMALOG] -
LISINOPRIL -  20 mg Tablet - 1Tablet(s) by mouth once a day
NORTRIPTYLINE -  75 mg Capsule qd
PANTOPRAZOLE -  40 mg Tablet qd
ROSUVASTATIN [CRESTOR] - 20 mg Tablet qd


Discharge Medications:
1. insulin detemir 100 unit/mL Solution Sig: Seventy (70) units
Subcutaneous at bedtime: take insulin regimen as you had prior
to hospitalization.
2. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous before each meal: dose per sliding scale.
3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: take thirty
minutes prior to meal.
6. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*0*
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*qs * Refills:*0*
9. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
10. Outpatient Lab Work
Check chem 7 (esp Cr considering restarting HCTZ and lisinopril)
on [**2133-2-19**] and fax to Dr. [**Last Name (STitle) 1147**] at [**Telephone/Fax (1) 8474**]
11. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 days: take through [**2133-2-18**].
Disp:*4 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
primary diagnoses:
acute delirium secondary to toxic/metabolic encephalopathy
pneumonia

secondary diagnoses:
insulin dependent DMII w/ renal complications
Acute-on-chronic kidney disease
HTN
HLD
Charcot foot abnormalities


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:
Dear Ms. [**Known lastname 35127**],

It was a pleasure taking care of you.

You were admitted to the [**Hospital1 69**]
for altered mental status.  It was thought that this was
secondary to you having a potential infection in your lungs or
urine.  You have been treated with antibiotics for this.  You
also had some renal (kidney) dysfunction while you were in the
hospital, which has recovered.

You have an appointment coming up with Dr. [**Last Name (STitle) **], who may decide
to replace the felted foam offloaded dressings at that time.

You should continue to take all of your medications as you
previously had prior to your hospitalization, EXCEPT:
- START cefpodoxime 200mg twice per day through [**2133-2-18**]
- CONTINUE insulin as you previously had been taking, call your
doctor if you have persistent readings > 250, one [**Location (un) 1131**] > 400
or low readings < 80.
- START aspirin 81 mg once per day
- START miconazole nitrate  2 % Powder  to affected areas

Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE/CARDIOLOGY
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**0-0-**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) 1147**]
within 1 week. You will be called at home with the appointment.
If you have not heard from the office within 2 days or have any
questions, please call the number above.**

Department: PODIATRY
When: TUESDAY [**2133-2-24**] at 4:20 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage
{'Toxic encephalopathy,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Acidosis,Body Mass Index 50.0-59.9, adult,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Arthropathy associated with neurological disorders,Unspecified essential hypertension,Ventral, unspecified, hernia without mention of obstruction or gangrene,Morbid obesity,Other and unspecified hyperlipidemia,Tobacco use disorder,Esophageal reflux,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Long-term (current) use of insulin,Physical restraints 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: AMS

PRESENT ILLNESS: 60F insulin-dependent Diabetes mellitus complicated by
ophthalmopathy, polyneuropathy, and nephropathy, hypertension
hyperlipidemia, peripheral arterial disease p/w AMS.
.
Family called EMS because she was not acting like herself;
returned from work, slurring speech and ramming wheelchair into
wall. they deny overdose, no obvious symptoms, save for open
sores on feet. No sick contacts. Presented via EMS
yelling/mumbling, tachy to 103, dry skin, flushed. unable to
follow commands. Thrashing about in bed. Per family report was
dry heaving today and not acting like herself, otherwise no
changes in medical history or meds they believe.
.
ED Course :
- Initial Vitals/Trigger: 99 79 179/67 20 99%
- Has Rx for Nortriptyline, Urine tox + for TCA
- physostigmine 2 mg dose for concern of TCA overdose. Equivocal
whether any effect on mental status.
- 5 mg Haldol, 6 mg Ativan to control behaviour
Serial EKG:
- EKG: SR@83 QRS 98 QTc 452 no terminal R
- EKG: SR@83 QRS 100 QTc 444, ? terminal R aVR now
- EKG: SR@73 QRS 96 no terminal R
- cxr (My read) - ? atelectasis on left, vascular prominence
bilaterally
- head ct  - Normal
- Torso CT - incidental findings and atelectasis
- foley placed
- fluids (unknown amount)
- IO in left tibia
- suc, etomidate via tibia
- 7.5 ET tube
- UA pending
- propofol swicthed to fentanyl and versed
- IJ central line
- LP - attempted x3
- carboxy Hgb  - 1
- abg  - pH 7.28 pCO2 50 pO2 231 HCO3 24 BaseXS -3
- Abx vanc 1g, cefepime 2g - patient pcn allergic
Admission Vitals:  188/72, p88 bp 188/72, rr 24, sat 100 with
fiO2 50, Vt450

MEDICAL HISTORY: 1. DM2: insulin-dependent may be Type 1
-followed by [**Hospital **] Clinic
-c/b recurrent ulcers, urosepsis
-Charcot deformity
2. s/p amputation of L 2nd & 3rd toe
3. chronic ulcer of R pretibia
4. hx of MRSA foot [**3-/2125**]
5. HTN
6. PVD
7. hypercholesterolemia
8. Anemia, ? ACD, baseline low 30s
9. Hematemesis in [**2125**] thought to be [**1-15**] small [**Doctor First Name 329**] [**Doctor Last Name **],
EGD ulcer in GE junction

MEDICATION ON ADMISSION: HYDROCHLOROTHIAZIDE -  25 mg Tablet - 1 Tablet(s) by mouth once
a day
INSULIN DETEMIR [LEVEMIR] -  70 Units at bedtime
INSULIN LISPRO [HUMALOG] -
LISINOPRIL -  20 mg Tablet - 1Tablet(s) by mouth once a day
NORTRIPTYLINE -  75 mg Capsule qd
PANTOPRAZOLE -  40 mg Tablet qd
ROSUVASTATIN [CRESTOR] - 20 mg Tablet qd

ALLERGIES: Gatifloxacin / Penicillins / Ciprofloxacin

PHYSICAL EXAM: Admission Exam:
188/72, p88 bp 188/72, rr 24, sat 100 with fiO2 50, Vt450
General: Intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, ETT in place.
Neck: Obese,JVP inestimatable, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused; diffuse ulcerations on lower
extremities

FAMILY HISTORY: Mother had DM2, died of diabetes related coma
Father has DM2, still alive
Several family members on paternal side with DM2
No FH of CAD, MI, or cancer.

SOCIAL HISTORY: The patient lives with her husband and has a 10 year old child.
She works at the Causeway VA as a secretary. She smokes 10 cigs
per day x 40 years. No ETOH and drugs. 

### Response:
{'Toxic encephalopathy,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Acidosis,Body Mass Index 50.0-59.9, adult,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Arthropathy associated with neurological disorders,Unspecified essential hypertension,Ventral, unspecified, hernia without mention of obstruction or gangrene,Morbid obesity,Other and unspecified hyperlipidemia,Tobacco use disorder,Esophageal reflux,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Long-term (current) use of insulin,Physical restraints status'}
