CHIEF COMPLAINT: hyperglycemia

PRESENT ILLNESS: Patient is a 54 year old male with PMH of type II diabetes on
insulin(previous presentation for hyperglycemic, hyperosmolar
state), hypertension, chronic kidney disease, and diastolic
congestive heart failure presenting with hyperglycemia in the
setting of not taking his insulin for 4 days.  Patient states
that he normally take 16 units insulin in the evening, but
forgot the last few days. He glucometer broke and he got a new
one that he did not know how to use. He says that over the last
few days he has felt weak with poor po intake. Also on day prior
to admission experienced abdominal pain and then n/v on morning
of presentation. Patient denies fevers, cough, chest pain.  He
does report some nausea. He denies dysuria but does report
urinary frequency and thirst. EMS initial blood sugar report was
>600.
.
In the ED, initial vital signs were 98.0 83 165/76 16 100%.
Glucose was noted to be >1000.  Patient was noted to be drowsy,
but arousable to voice.  His lungs were clear to auscultation
bilaterally.   His abdomen was tender diffusely.  Potassium was
4.4 with a creatinine of 5.9.  Anion gap was noted to be 20.
Chest X-ray was performed and showed no acute process.
Urinalysis showed no evidence of infection, and no ketones.  VBG
was performed and showed 7.35/48/58/28 with a lactate of 1.7.
Insulin 10 units IV were given and patient was started on an
insulin gtt at 7 units per hour.  He received 2 liters NS in the
ED.  Renal was consulted and requested urine electrolytes.
.
On arrival to the MICU, patient feels improved from presentation
but still weak.

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 several years.  He has a history of retinopathy
and
is status post laser surgery, and has some mild neuropathy.
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**].
8)  History of right Charcot joint surgery with hardware in
place
9) Glaucoma

MEDICATION ON ADMISSION: AMLODIPINE -  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
Lisinopril 20 mg daily
Niacin PO daily
Fish oil PO daily

ALLERGIES: Penicillins / simvastatin

PHYSICAL EXAM: Physical Exam on Admission:
Vitals: T: 99.1 BP: 177/84 P: 95 R: 22 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, 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
.

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: From [**Country 2045**], lives with wife and 2 sons in [**Location (un) 686**]. Works for
meals on wheels. Denies tobacco, etoh, illicits.
Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, Stage V,Chronic diastolic heart failure,Acute kidney failure, unspecified,Long-term (current) use of insulin,Polyneuropathy in diabetes,Background diabetic retinopathy,Pure hypercholesterolemia,Personal history of noncompliance with medical treatment, presenting hazards to health,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Nonspecific reaction to tuberculin skin test without active tuberculosis,Unspecified glaucoma
DMII ketoacd uncontrold,Hyp kid NOS w cr kid V,Chron kidney dis stage V,Chr diastolic hrt fail,Acute kidney failure NOS,Long-term use of insulin,Neuropathy in diabetes,Diabetic retinopathy NOS,Pure hypercholesterolem,Hx of past noncompliance,Hx TIA/stroke w/o resid,Nonsp rea skn test wo tb,Glaucoma NOS
Admission Date:  [**2182-7-3**]              Discharge Date:   [**2182-7-8**]

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

Service: MEDICINE

Allergies:
Penicillins / simvastatin

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
hyperglycemia

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Patient is a 54 year old male with PMH of type II diabetes on
insulin(previous presentation for hyperglycemic, hyperosmolar
state), hypertension, chronic kidney disease, and diastolic
congestive heart failure presenting with hyperglycemia in the
setting of not taking his insulin for 4 days.  Patient states
that he normally take 16 units insulin in the evening, but
forgot the last few days. He glucometer broke and he got a new
one that he did not know how to use. He says that over the last
few days he has felt weak with poor po intake. Also on day prior
to admission experienced abdominal pain and then n/v on morning
of presentation. Patient denies fevers, cough, chest pain.  He
does report some nausea. He denies dysuria but does report
urinary frequency and thirst. EMS initial blood sugar report was
>600.
.
In the ED, initial vital signs were 98.0 83 165/76 16 100%.
Glucose was noted to be >1000.  Patient was noted to be drowsy,
but arousable to voice.  His lungs were clear to auscultation
bilaterally.   His abdomen was tender diffusely.  Potassium was
4.4 with a creatinine of 5.9.  Anion gap was noted to be 20.
Chest X-ray was performed and showed no acute process.
Urinalysis showed no evidence of infection, and no ketones.  VBG
was performed and showed 7.35/48/58/28 with a lactate of 1.7.
Insulin 10 units IV were given and patient was started on an
insulin gtt at 7 units per hour.  He received 2 liters NS in the
ED.  Renal was consulted and requested urine electrolytes.
.
On arrival to the MICU, patient feels improved from presentation
but still weak.


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 several years.  He has a history of retinopathy
and
is status post laser surgery, and has some mild neuropathy.
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**].
8)  History of right Charcot joint surgery with hardware in
place
9) Glaucoma


Social History:
From [**Country 2045**], lives with wife and 2 sons in [**Location (un) 686**]. Works for
meals on wheels. Denies tobacco, etoh, illicits.


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:
Vitals: T: 99.1 BP: 177/84 P: 95 R: 22 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, 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
.


Pertinent Results:
Admission Labs:
[**2182-7-3**] 06:00PM BLOOD WBC-14.7* RBC-3.77* Hgb-10.5* Hct-33.8*#
MCV-90# MCH-27.8 MCHC-31.0# RDW-14.5 Plt Ct-455*
[**2182-7-3**] 06:00PM BLOOD Neuts-92.2* Lymphs-5.0* Monos-2.1 Eos-0.3
Baso-0.4
[**2182-7-3**] 06:00PM BLOOD Glucose-1092* UreaN-68* Creat-5.9*#
Na-121* K-4.4 Cl-81* HCO3-20* AnGap-24*
[**2182-7-3**] 09:23PM BLOOD CK(CPK)-176
[**2182-7-3**] 09:23PM BLOOD CK-MB-2 cTropnT-0.04*
[**2182-7-3**] 09:23PM BLOOD Calcium-8.8 Phos-3.3 Mg-2.7*
[**2182-7-3**] 06:35PM BLOOD Osmolal-349*
[**2182-7-3**] 06:41PM BLOOD Type-[**Last Name (un) **] pO2-58* pCO2-48* pH-7.35
calTCO2-28 Base XS-0 Comment-GREEN
[**2182-7-3**] 06:41PM BLOOD Lactate-1.4
.
urine
[**2182-7-3**] 07:40PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.014
[**2182-7-3**] 07:40PM URINE Blood-SM  Nitrite-NEG Protein-100
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2182-7-3**] 07:40PM URINE RBC-<1 WBC-8* Bacteri-NONE Yeast-NONE
Epi-<1
[**2182-7-3**] 08:23PM URINE Hours-RANDOM UreaN-214 Creat-32 Na-30
K-16 Cl-24
[**2182-7-3**] 08:23PM URINE Osmolal-411
.
micro:
blood culture pending
urine culture pending
.
IMAGING:
Radiology Report CHEST (PA & LAT) Study Date of [**2182-7-3**] 7:20 PM

IMPRESSION:  No acute intrathoracic process
.
EKG:  Sinus rhythm. LVH. TWI in I, II, avL, V4-V6 (new in II,
V4-V6)


Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is a 54yo male with
PMH of T2DM, CHF, and CKD5 who presents with hyperglycemic,
hyperosmolar state. He was admitted to the ICU on an insulin gtt
and had correction of blood sugar with resolution of elevated
anion gap overnight. He was transferred to the general medical
floor.
.
# Non-ketotic hyperglycemic hyperosmolar state: Patient reports
not having taken his insulin in the past 4 days. He experienced
general malaise, abdominal pain, n/v and presented with blood
sugar in the low 1000's. On admission, he was placed on an
insulin drip and had blood sugars reduced to 100's overnight
following admission. He receieved IVF resuscitation and D5 as
FSBS fell. Lantus was overlapped with the drip and the drip was
discontinued. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 387**] consult was obtained and recommended that
his out pt insulin regimen be uptitrated to Glargine 30U at
night and an insulin sliding scale with humalog. His dinner time
sliding scale was made more aggressive due to his persistent
elevated glucose levels after dinner.
.
# Altered mental status: Patient's mental status on admission
was reported to be drousy but arousable, however upon reaching
the floor mental status was much improved. This is likely
explained by the non-ketotic hyperglycemic, hyperosmolar state,
but also would consider toxic metabolic encephalopathy from
infection given leukocytosis. His hyperglycemia was corrected
and mental status remained normal.

# Troponin elevation: Patient presented with ECG with TWI and
troponin to 0.04 in the setting of CKD-5. Previous labs have
shown troponin in the range of 0.03. Three sets of troponins
were obtained and each was 0.04. The pt was asymptomatic and
this was determined to not be ACS.
.
# Leukocytosis: Unclear etiology. Stress response vs. underlying
infection. CXR clear and rest of infectious workup including UA,
Blood and urine cultures were negative. The pt was afebrile
during this hospitalization. His WBC trended down without
treatment.
.
#T2DM: Patient has been non-adherent to insulin for four days
prior to admission. He has had [**Last Name (un) **] consult on previous
similar presentation. Will treat the hyperglycemia as above with
additional education and aid of the [**Hospital **] clinic.
.
#Acute on CKD5: CKD [**3-14**] DM and HTN. Patient has a bump in his
creatinine to 5.9 from last known baseline of around 5.0.
Pre-renal etiology is most likely considering his kidney
function improved with IVF administration. He was followed by
renal during this hospitalization who did not recommend any
changes to his current regimen. He had no acute indication for
dialysis.
.
#Hypertension:
- continued amlodipine
- continued metoprolol 200mg daily
- continued Lisinopril 20mg daily
.
#Chronic Diastolic CHF: The pt was not volume overloaded on exam
even after volume resuscitation due to hyperglycemia. We
continued his ACEi and Beta Blocker but initially held
diurectics as pt was severely dehydrated due to hyperglycemia on
admission. His diurectics were added back to his regimen at time
of discharge.
.
#TRANSITIONAL:
 1. F/U appointments were made with his primary care and
nephrology

Medications on Admission:
AMLODIPINE -  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
Lisinopril 20 mg daily
Niacin PO daily
Fish oil PO daily


Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
4. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. niacin 1,000 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day.
7. Fish Oil 1,000 mg Capsule Sig: Two (2) Capsule PO once a day.

8. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
9. Humalog 100 unit/mL Solution Subcutaneous


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Hyperosmolar non ketotic hyperglycemia

Secondary:
Chronic kidney disease
Diabetes
Hypertension
Hyperlipidemia
Glaucoma


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


Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with high
blood sugar levels after not taking your insulin for several
days. It is very important that you continue to take all of your
medications everyday to keep your blood sugar under better
control.  You were seen by the [**Last Name (un) **] consultants, who approved
the recommended insulin changes.

The following changes have been made to your medications:
CHANGE Insulin dosing; you should take 30 units of glargine
every evening, and please see attached new insulin sliding scale
DISCONTINUE your FUROSEMIDE and CHLORTHALIDONE; please discuss
when to restart this medications with your regular doctors at
your follow up appointments (see below for details).

Please see below for follow up appointments that have been made
on your behalf.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Name: [**Name8 (MD) **],SHANTHY
Location: [**Hospital1 641**]
Department: Internal Medicine
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Appointment: Tuesday [**2182-7-9**] 1:00pm

Name: NP [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 26581**]
Location: [**Hospital1 641**]
Department: Nephrology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2263**]
Appointment: Tuesday [**2182-7-9**] 2:30pm
{'Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, Stage V,Chronic diastolic heart failure,Acute kidney failure, unspecified,Long-term (current) use of insulin,Polyneuropathy in diabetes,Background diabetic retinopathy,Pure hypercholesterolemia,Personal history of noncompliance with medical treatment, presenting hazards to health,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Nonspecific reaction to tuberculin skin test without active tuberculosis,Unspecified glaucoma'}


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: Patient is a 54 year old male with PMH of type II diabetes on
insulin(previous presentation for hyperglycemic, hyperosmolar
state), hypertension, chronic kidney disease, and diastolic
congestive heart failure presenting with hyperglycemia in the
setting of not taking his insulin for 4 days.  Patient states
that he normally take 16 units insulin in the evening, but
forgot the last few days. He glucometer broke and he got a new
one that he did not know how to use. He says that over the last
few days he has felt weak with poor po intake. Also on day prior
to admission experienced abdominal pain and then n/v on morning
of presentation. Patient denies fevers, cough, chest pain.  He
does report some nausea. He denies dysuria but does report
urinary frequency and thirst. EMS initial blood sugar report was
>600.
.
In the ED, initial vital signs were 98.0 83 165/76 16 100%.
Glucose was noted to be >1000.  Patient was noted to be drowsy,
but arousable to voice.  His lungs were clear to auscultation
bilaterally.   His abdomen was tender diffusely.  Potassium was
4.4 with a creatinine of 5.9.  Anion gap was noted to be 20.
Chest X-ray was performed and showed no acute process.
Urinalysis showed no evidence of infection, and no ketones.  VBG
was performed and showed 7.35/48/58/28 with a lactate of 1.7.
Insulin 10 units IV were given and patient was started on an
insulin gtt at 7 units per hour.  He received 2 liters NS in the
ED.  Renal was consulted and requested urine electrolytes.
.
On arrival to the MICU, patient feels improved from presentation
but still weak.

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 several years.  He has a history of retinopathy
and
is status post laser surgery, and has some mild neuropathy.
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**].
8)  History of right Charcot joint surgery with hardware in
place
9) Glaucoma

MEDICATION ON ADMISSION: AMLODIPINE -  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
Lisinopril 20 mg daily
Niacin PO daily
Fish oil PO daily

ALLERGIES: Penicillins / simvastatin

PHYSICAL EXAM: Physical Exam on Admission:
Vitals: T: 99.1 BP: 177/84 P: 95 R: 22 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, 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
.

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: From [**Country 2045**], lives with wife and 2 sons in [**Location (un) 686**]. Works for
meals on wheels. Denies tobacco, etoh, illicits. 

### Response:
{'Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, Stage V,Chronic diastolic heart failure,Acute kidney failure, unspecified,Long-term (current) use of insulin,Polyneuropathy in diabetes,Background diabetic retinopathy,Pure hypercholesterolemia,Personal history of noncompliance with medical treatment, presenting hazards to health,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Nonspecific reaction to tuberculin skin test without active tuberculosis,Unspecified glaucoma'}
