CHIEF COMPLAINT: Hyperosmotic nonketotic hyperglycemia.

PRESENT ILLNESS: This is a 75 year old man from
[**Hospital3 **] Center with severe Alzheimer's and
unable to provide any medical history and with a prolonged
prior tobacco history with chronic obstructive pulmonary
disease.  The patient had been on steroid taper for chronic
wheezes when he began to experience two to three days of
lethargy.  No specific records are fortunately available from
[**Hospital3 **], however, by report from the Emergency
Department, when [**Hospital3 **] tested the patient's
fingerstick glucose, the value was 1077.

MEDICAL HISTORY: 1.  Chronic obstructive pulmonary disease.
2.  Asthma and a Prednisone taper.
3.  Results of details of which are unfortunately unavailable
due to lack of confirmatory records.
4.  History of aspiration pneumonia.
5.  History of Alzheimer's disease including delusions and
hallucinations.
6.  Pituitary adenoma.
7.  History of B12 deficiency.
8.  Gait disorder.
9.  Prior history of ETOH abuse.

MEDICATION ON ADMISSION: 1.  Albuterol and Atrovent nebulizers.
2.  Bromocriptine 2.5 mg p.o. daily.
3.  B12 injections.
4.  Colace.
5.  Folate.
6.  Lasix 40 mg daily.
7.  Gabapentin 200 mg twice a day.
8.  Potassium Chloride.
9.  Thiamine.

ALLERGIES: According to the family the patient is "sensitive
to neuroleptics".

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient has a former tobacco and ETOH
history and is a resident of [**Hospital3 **].
Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Hyperosmolality and/or hypernatremia,Chronic obstructive asthma, unspecified,Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance
Food/vomit pneumonitis,CHF NOS,Hyperosmolality,Chronic obst asthma NOS,DMII hprsm nt st uncntrl,Alzheimer's disease,Dementia w/o behav dist
Admission Date:  [**2155-10-24**]       Discharge Date:  [**2155-10-30**]

Date of Birth:   [**2079-11-10**]       Sex:  M

Service:  ACOVE

CHIEF COMPLAINT:  Hyperosmotic nonketotic hyperglycemia.

HISTORY OF PRESENT ILLNESS:  This is a 75 year old man from
[**Hospital3 **] Center with severe Alzheimer's and
unable to provide any medical history and with a prolonged
prior tobacco history with chronic obstructive pulmonary
disease.  The patient had been on steroid taper for chronic
wheezes when he began to experience two to three days of
lethargy.  No specific records are fortunately available from
[**Hospital3 **], however, by report from the Emergency
Department, when [**Hospital3 **] tested the patient's
fingerstick glucose, the value was 1077.

The patient was brought into the Emergency Department where
his fingerstick was retested and was read as "critically
high".  The Emergency Department to explain the patient's
lethargy decided to rule out an intracranial bleed, and
noncontrast head CT was ordered.  The report is as follows:
No evidence of intra-axial or extra-axial hemorrhage. There
was a 1.8 by 1.7 centimeter suprasellar mass. There has been
no shift of the midline structures.  There was prominence of
the ventricles and sulci consistent with brain atrophy, but
no territorial infarcts were present.  No skull fractures
noted and overall impression was of no evidence of
intracranial bleed.

The patient had also been given eight units of regular
insulin subcutaneous as well as started on an insulin drip at
a rate of 8 units per hour.  As per report of the family, the
patient had no prior history of diabetes mellitus.  He had 48
hours of lethargy with decreased p.o. intake but no specific
complaints.  The patient's family also denies any other
symptoms such as cough, abdominal pain, diarrhea, however,
the patient's baseline mental status because of his dementia
was such that he was completely unable to answer questions.

As part of the patient's treatment in the Emergency
Department, he was also given intravenous fluids initially
with normal saline and then changed to one half normal
saline.  He was also given Solu-Medrol, Levofloxacin and
Flagyl.

Initial laboratories were notable for the following:  ALT was
36, AST 15, LDH 265, CK 200, but the alkaline phosphatase was
elevated at 163 and the amylase was elevated at 325.  Further
the lipase was elevated at 75.  Abdominal ultrasound was
ordered which was notable for the following:  No evidence of
cholelithiasis was seen.  Evaluation for pancreatitis was not
possible due to overlying bowel gas.  Initial Chem7 had a
sodium of 146, potassium 4.4, chloride 99, bicarbonate 28,
blood urea nitrogen 38, creatinine 2.1, and glucose 1134.
Cardiac enzymes were also serially followed with troponin
less than 0.3 for three separate time points and CK MB
peaking at a value of only 5.0, ruling the patient out for a
myocardial infarction.

Because of the patient's hyperosmotic state and the
hyperglycemia, the patient was directly admitted to the
Medical Intensive Care Unit for management of hyperosmolar
nonketotic hyperglycemia.  Urinalysis was notable for trace
blood, negative nitrites, negative leukocyte esterase and
negative ketones but with glucose greater than 1000.

Vital signs upon presentation to the Emergency Department
were as follows:  Blood pressure 126/115, heart rate 103,
respiratory rate 30, oxygen saturation 97% on 100%
nonrebreather mask.

PAST MEDICAL HISTORY:
1.  Chronic obstructive pulmonary disease.
2.  Asthma and a Prednisone taper.
3.  Results of details of which are unfortunately unavailable
due to lack of confirmatory records.
4.  History of aspiration pneumonia.
5.  History of Alzheimer's disease including delusions and
hallucinations.
6.  Pituitary adenoma.
7.  History of B12 deficiency.
8.  Gait disorder.
9.  Prior history of ETOH abuse.

ALLERGIES:  According to the family the patient is "sensitive
to neuroleptics".

MEDICATIONS ON ADMISSION:
1.  Albuterol and Atrovent nebulizers.
2.  Bromocriptine 2.5 mg p.o. daily.
3.  B12 injections.
4.  Colace.
5.  Folate.
6.  Lasix 40 mg daily.
7.  Gabapentin 200 mg twice a day.
8.  Potassium Chloride.
9.  Thiamine.

SOCIAL HISTORY:  The patient has a former tobacco and ETOH
history and is a resident of [**Hospital3 **].

LABORATORY DATA:  Electrocardiogram was notable for normal
sinus rhythm at 106 beats per minute, normal axis and
intervals.  T wave changes were noted in leads I, aVL, V5 and
V6, and ST changes were noted in V2 to V3.

Chest film was notable for lingular opacities in the right
lower lobe.  Interpretation of pneumonia versus atelectasis.

HOSPITAL COURSE:  In the Intensive Care Unit, the patient was
continued on intravenous fluids, initially normal saline two
to three liters and converted to one half normal saline.
Insulin drip was continued at 8 units per hour.  A subclavian
line was placed after obtaining the family's consent.

On day two of the patient's hospitalization, the patient was
noted to have rancorous breath sounds and decreased oxygen
saturation from 97 to 93% in room air which improved to 97%
on two liters nasal cannula.  The patient had low grade
temperature to 99.4 degrees.  The heart rate was 100, and
blood pressure was 151/77.  The patient denied any complaints
of shortness of breath or chest pain.  On examination, the
lungs were notable for positive rhonchi, but no wheezes and
no lower extremity edema.  Chest film revealed no changes
from prior.  The patient was given 20 mg of intravenous Lasix
and responded with 400 cc of urine output within one hour.
This episode was believed to be possibly due to an acute
congestive heart failure in the setting of aggressive
intravenous fluid resuscitation.  The patient was noted to be
plus six liters in since admission.

During the course of the patient's stay in the Intensive Care
Unit, the sodium which had initially been as high as 169
began to level down within normal range.  The patient was
also further weaned off the insulin drip and placed on
insulin sliding scale.  Nebulizers and suctioning were
continued to make sure that the patient's oxygen saturation
did not decline secondary to secretions.  The patient was
ruled out for myocardial infarction by cardiac enzymes
serially as well as electrocardiogram.

The patient's mental status improved so much that his
alertness improved although his orientation did not.  This
was believed to be the patient's baseline mental status.
Furthermore, lower extremity noninvasive Doppler was
performed of the legs just to rule out possible deep vein
thrombosis and in the ultrasound report, it was noted that
veins distal to the popliteal vein on the left were not
visible and the right common femoral vein was not visualized.
However, images of the left common femoral and the bilateral
superficial femoral and popliteal veins were obtained which
revealed normal color flow compressibility.  No thrombus
seen.

Sputum culture performed revealed positive gram positive
cocci and so Vancomycin was added to the patient's regimen.
The patient's status was clarified at that point with the
family and the patient was noted to be "Do Not Resuscitate".

An echocardiogram was also performed to evaluate for
congestive heart failure.  Report was notable for normal left
atrial size, normal left ventricular wall thickness, left
ventricular ejection fraction was found to be normal at
greater than 55%.  Right ventricle was notable for abnormal
systolic septal motion consistent with right ventricular
pressure overload.  No aortic regurgitation was seen and no
mitral valve prolapse was seen.  The tricuspid valve was not
well visualized.  No pericardial effusion was noted.

The patient's hyperglycemia was controlled and the
hyperosmotic state was also controlled and the oxygen
saturation was stable at 100% on four liters nasal cannula.
The patient was transferred to the floor to the Acove
Service.  Upon transfer, the patient was on the following
medications:  Levofloxacin, Flagyl, Vancomycin, Haldol
p.r.n., Tylenol, regular insulin siding scale with six doses
of NPH, subcutaneous Heparin, Protonix 40 mg intravenously,
Bromocriptine, Neurontin, Colace and Senna.

Upon transfer to the floor, the patient's vital signs were as
follows:  Temperature 98, blood pressure 160/80 with
respiratory rate 20 and heart rate 88.  The patient was 98%
on four liters per minute nasal cannula.  Fingerstick glucose
was in the range of 140 to 198.  On physical examination, the
patient was a pleasantly demented elderly man in no apparent
distress.  His speech was fluent but he had confused content.
The lungs were notable for bibasilar rhonchi.  Cardiovascular
was notable for normal S1 and S2 with no murmurs, rubs or
gallops.  The abdomen was soft, nontender, with normal bowel
sounds.  The extremities were notable for no lower extremity
edema.

Laboratories were notable for a sodium of 140, potassium 3.6,
chloride 108, bicarbonate 22, blood urea nitrogen 10,
creatinine 0.9, glucose 151.  White blood cell count was 7.8,
hematocrit 31.6, and platelet count was 200 with MCV of 85.

By report from the Intensive Care Unit team, the patient was
given a bedside swallow evaluation.  In the report, the
evaluation was notable for the following:  The oral motor
assessment was limited by the patient's dementia and
inability to follow commands.  The patient was started on
p.o. but confused.  Intermittent cough was noted to thick
liquids but not noted to pureed.  The impression was that
according to the report the patient demonstrated overt signs
and symptoms of aspiration with consistencies of thickened
liquids and unclear with pureed solid.  The patient's lack of
cognition also placed him at further aspiration risk which
was discussed at length with the daughter.

A video study was also performed and was notable for the
following:  There is premature spillage to the pyriform
sinuses noted with all consistencies and delayed initiation
of the pharyngeal vaso-swallow.  There was no aspiration or
penetration visualized.  No structural abnormalities were
noted.  Barium swallow study performed was notable for the
following:  The patient presented with mild to moderate oral
and mild pharyngeal dysphagia characterized by reduced bolus
control and premature spillage of liquids to pyriform sinuses
with a mild delay initiation to pharyngeal swallow.
Recommendations were to change to diet of pureed solids and
thin thick liquids and put pills in apple sauce and puree.
The patient was also recommended to stay upright for meals
and for thirty minutes afterwards.

With the patient's glucose normalized and with his swallow
ability evaluated, the patient was deemed stable for transfer
to rehabilitation.  The patient was transferred to [**Hospital3 21684**].  The patient was
transferred on [**2155-10-30**].

DISCHARGE DIAGNOSES:
1.  Hyperosmolar nonketotic hyperglycemia.
2.  Aspiration pneumonia.
3.  Chronic obstructive pulmonary disease.
4.  Asthma.
5.  Alzheimer's disease.
6.  Prior history of ETOH.
7.  History of pituitary adenoma.
8.  B12 deficiency.
9.  Gait disorder.

MEDICATIONS ON DISCHARGE:
1.  Acetaminophen 650 mg p.o. q4-6hours p.r.n.
2.  Bromocriptine 2.5 mg p.o. once daily.
3.  Senna two tablets p.o. once daily.
4.  Colace 100 mg p.o. twice a day.
5.  Lasix 20 mg p.o. once daily.
6.  Potassium Chloride 10 mg p.o. once daily.
7.  Gabapentin 200 mg p.o. twice a day.
8.  Thiamine 100 mg p.o. once daily.
9.  Clindamycin 450 mg p.o. four times a day times three
days.
10. Folate 1 mg p.o. once daily.
11. Vitamin B12.
12. Albuterol and Atrovent nebulizers, two puffs p.o. q6hours
p.r.n.
13. Regular insulin sliding scale.

Recommend diet pureed solids and thin thick liquids with p.o.
medication pills put in puree.  Also recommend that the
patient have potassium checked on the morning of [**2155-10-31**], as
well as phosphate and have four times a day fingerstick for
checking blood glucose.




                            [**First Name8 (NamePattern2) 1569**] [**Last Name (NamePattern1) 8560**], M.D.  [**MD Number(1) 8561**]

Dictated By:[**Last Name (NamePattern1) 8442**]
MEDQUIST36

D:  [**2155-12-29**]  15:51
T:  [**2155-12-29**]  19:47
JOB#:  [**Job Number 33094**]
{"Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Hyperosmolality and/or hypernatremia,Chronic obstructive asthma, unspecified,Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance"}


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: Hyperosmotic nonketotic hyperglycemia.

PRESENT ILLNESS: This is a 75 year old man from
[**Hospital3 **] Center with severe Alzheimer's and
unable to provide any medical history and with a prolonged
prior tobacco history with chronic obstructive pulmonary
disease.  The patient had been on steroid taper for chronic
wheezes when he began to experience two to three days of
lethargy.  No specific records are fortunately available from
[**Hospital3 **], however, by report from the Emergency
Department, when [**Hospital3 **] tested the patient's
fingerstick glucose, the value was 1077.

MEDICAL HISTORY: 1.  Chronic obstructive pulmonary disease.
2.  Asthma and a Prednisone taper.
3.  Results of details of which are unfortunately unavailable
due to lack of confirmatory records.
4.  History of aspiration pneumonia.
5.  History of Alzheimer's disease including delusions and
hallucinations.
6.  Pituitary adenoma.
7.  History of B12 deficiency.
8.  Gait disorder.
9.  Prior history of ETOH abuse.

MEDICATION ON ADMISSION: 1.  Albuterol and Atrovent nebulizers.
2.  Bromocriptine 2.5 mg p.o. daily.
3.  B12 injections.
4.  Colace.
5.  Folate.
6.  Lasix 40 mg daily.
7.  Gabapentin 200 mg twice a day.
8.  Potassium Chloride.
9.  Thiamine.

ALLERGIES: According to the family the patient is "sensitive
to neuroleptics".

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient has a former tobacco and ETOH
history and is a resident of [**Hospital3 **]. 

### Response:
{"Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Hyperosmolality and/or hypernatremia,Chronic obstructive asthma, unspecified,Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance"}
