CHIEF COMPLAINT: Seizure/sepsis

PRESENT ILLNESS: Ms. [**Known lastname **] is an 84 yo female with PMH of DM, resident of a
nursing home, who presented to [**Hospital3 4107**] after being found
at her nursing home with periods of unresponsiveness of facial
twitching. Per her daughter, she was talking and in her normal
state of health at her evening meal on [**6-6**].  She had a repeat
of these periods at [**Hospital1 **].  Per report, there was no
generalized tonic-clonic component but possibly some tonic head
turning and upper extremity shaking.  There, she was also noted
to be hypotensive with systolic BP in the 80s and as low as 50/p
and hypothermic to 95.  She was intubated for airway protection
in the setting of possible status and also for hypotension.  She
had a negative head CT as well as a CT thorax which was
unremarkable.  She was given phosphenytoin, vancomycin 1g,
possibly levo, ativan, cerebryx and sent to [**Hospital1 18**] because there
was no neurologist there.
.
She has had a big decline over the past year cognitively.  She
suffered a fall last year and has since been in a nursing
facility.  She has had dementia diagnosed.  She also has had two
heel ulcers in the last year, the latest over the past four
months last requiring antibiotics 2 months ago.  She has also
lost 15lb in the last 2 months with decreased appetite.
.
Initial vitals in the ED:
T 95  HR 73  110/60  RR18  intubated, sedated with
fentanyl/versed, on dopamin (10-15mcg).  Her pupils were
reactive and her neck supple.  She was noted to have pyuria >
50, + nitrite, WBC 20 with 90% neutrophils, and a heel ulcer
that looked infected.  Cefepime was added to the vanc she
already had.  An IJ was attempted for access, but was not
successful, so a right femoral line was placed.  She was given
2L IVF rapidly, but her SBP remained in the 80s if the dopa was
taken off.  They did however get her dopa down to 5mcg with the
fluid and reduction of her sedation.  Neurology was consulted
who recommended keppra 1g IV.  Her lactate was 1.5, down to 0.7
on repeat.  ABG showed pH 7.40/34/312.
.
Upon arrival, she is on 7.5mcg of dopa.
.

MEDICAL HISTORY: DM
neuropathy
gout
PVD
cervical CA age 49 s/p hysterectomy
chronic heel ulcers

MEDICATION ON ADMISSION: per Nursing Home
Allopurinol 100 mg daily
Lidoderm patch daily R cervical spine
MVI with minerals
Prilosec 40 mg daily
KCl 20 mEq daily
Lopid 600mg [**Hospital1 **]
Namenda 10 mg [**Hospital1 **]
Ultram 25 mg [**Hospital1 **]
Zyprexa 2.5 mg po BID
ES Tylenol 1000mg Q8H
Aricept 10 mg QHS
Melatonin 1mg QHS
Glucerna health
Novolin N 12U SC QAM before breakfast
FS 6:30AM, 4:30pm ISS with regular insulin
70-130 0
180 2
240 4
300 6
350 8
400 10
>400 12
PRN Glucagon

ALLERGIES: Penicillins

PHYSICAL EXAM: vitals: 110/56  86  100%   50% FiO2.  AC 500/12
gen: intubated sedated.  Not responding to voice or painful
stimuli.
heent: ncat, mmm.  pupils pinpoint 2 to 1 mm reactive to light.
neck: JVD 10-12 CM
pulm: CTA anteriorly.  no w/r/r
cv: HRRR, 1/6 SEM throughout.  quiet S1/S2.
abd: NT/ND. hypoactive BS
neuro: intubated, sedated, not responding to voice or painful
stimuli.  Not following commands.
Extremities: dressing on right heal ulcer.  No C/C/E.  Non
dopplerable LE peripheral pulses, 2+ in UEs.

FAMILY HISTORY: no history of seizure disorder

SOCIAL HISTORY: [**11-3**] yr smoking history, quit in her late 30s.  No alcohol.
Retired bookkeeper.  Lives in a nursing home.  Husband died in
his late 60s.
Septicemia due to escherichia coli [E. coli],Septic shock,Acute respiratory failure,Urinary tract infection, site not specified,Severe sepsis,Pressure ulcer, heel,Epilepsy, unspecified, without mention of intractable epilepsy,Other persistent mental disorders due to conditions classified elsewhere,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Atherosclerosis of native arteries of the extremities, unspecified,Personal history of malignant neoplasm of cervix uteri,Long-term (current) use of insulin,Personal history of infections of the central nervous system
E coli septicemia,Septic shock,Acute respiratry failure,Urin tract infection NOS,Severe sepsis,Pressure ulcer, heel,Epilep NOS w/o intr epil,Mental disor NEC oth dis,DMII neuro nt st uncntrl,Neuropathy in diabetes,Athscl extrm ntv art NOS,Hx-cervical malignancy,Long-term use of insulin,Personl hx infection CNS
Admission Date:  [**2197-6-7**]              Discharge Date:   [**2197-6-12**]

Date of Birth:  [**2112-10-10**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Seizure/sepsis

Major Surgical or Invasive Procedure:
CVL, intubation

History of Present Illness:
Ms. [**Known lastname **] is an 84 yo female with PMH of DM, resident of a
nursing home, who presented to [**Hospital3 4107**] after being found
at her nursing home with periods of unresponsiveness of facial
twitching. Per her daughter, she was talking and in her normal
state of health at her evening meal on [**6-6**].  She had a repeat
of these periods at [**Hospital1 **].  Per report, there was no
generalized tonic-clonic component but possibly some tonic head
turning and upper extremity shaking.  There, she was also noted
to be hypotensive with systolic BP in the 80s and as low as 50/p
and hypothermic to 95.  She was intubated for airway protection
in the setting of possible status and also for hypotension.  She
had a negative head CT as well as a CT thorax which was
unremarkable.  She was given phosphenytoin, vancomycin 1g,
possibly levo, ativan, cerebryx and sent to [**Hospital1 18**] because there
was no neurologist there.
.
She has had a big decline over the past year cognitively.  She
suffered a fall last year and has since been in a nursing
facility.  She has had dementia diagnosed.  She also has had two
heel ulcers in the last year, the latest over the past four
months last requiring antibiotics 2 months ago.  She has also
lost 15lb in the last 2 months with decreased appetite.
.
Initial vitals in the ED:
T 95  HR 73  110/60  RR18  intubated, sedated with
fentanyl/versed, on dopamin (10-15mcg).  Her pupils were
reactive and her neck supple.  She was noted to have pyuria >
50, + nitrite, WBC 20 with 90% neutrophils, and a heel ulcer
that looked infected.  Cefepime was added to the vanc she
already had.  An IJ was attempted for access, but was not
successful, so a right femoral line was placed.  She was given
2L IVF rapidly, but her SBP remained in the 80s if the dopa was
taken off.  They did however get her dopa down to 5mcg with the
fluid and reduction of her sedation.  Neurology was consulted
who recommended keppra 1g IV.  Her lactate was 1.5, down to 0.7
on repeat.  ABG showed pH 7.40/34/312.
.
Upon arrival, she is on 7.5mcg of dopa.
.


Past Medical History:
DM
neuropathy
gout
PVD
cervical CA age 49 s/p hysterectomy
chronic heel ulcers

Social History:
[**11-3**] yr smoking history, quit in her late 30s.  No alcohol.
Retired bookkeeper.  Lives in a nursing home.  Husband died in
his late 60s.


Family History:
 no history of seizure disorder

Physical Exam:
vitals: 110/56  86  100%   50% FiO2.  AC 500/12
gen: intubated sedated.  Not responding to voice or painful
stimuli.
heent: ncat, mmm.  pupils pinpoint 2 to 1 mm reactive to light.
neck: JVD 10-12 CM
pulm: CTA anteriorly.  no w/r/r
cv: HRRR, 1/6 SEM throughout.  quiet S1/S2.
abd: NT/ND. hypoactive BS
neuro: intubated, sedated, not responding to voice or painful
stimuli.  Not following commands.
Extremities: dressing on right heal ulcer.  No C/C/E.  Non
dopplerable LE peripheral pulses, 2+ in UEs.

Pertinent Results:
[**2197-6-7**] 05:49PM CEREBROSPINAL FLUID (CSF)  PROTEIN-50*
GLUCOSE-96
[**2197-6-7**] 05:49PM CEREBROSPINAL FLUID (CSF)  WBC-2 RBC-27*
POLYS-3 LYMPHS-46 MONOS-50 ATYPS-1
[**2197-6-7**] 04:20PM   TYPE-ART PO2-236* PCO2-41 PH-7.38 TOTAL
CO2-25 BASE XS-0
[**2197-6-7**] 04:20PM   LACTATE-1.5
[**2197-6-7**] 04:10PM   WBC-14.2* RBC-3.47* HGB-9.1* HCT-28.7* MCV-83
MCH-26.3* MCHC-31.7 RDW-18.0*
[**2197-6-7**] 04:10PM   PLT COUNT-483*
[**2197-6-7**] 04:10PM   PT-12.6 PTT-24.1 INR(PT)-1.1
[**2197-6-7**] 04:10PM   FIBRINOGE-596*
[**2197-6-7**] 05:09AM   GLUCOSE-141* LACTATE-0.7
[**2197-6-7**] 05:06AM   GLUCOSE-177* UREA N-18 CREAT-0.9 SODIUM-141
POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-21* ANION GAP-16
[**2197-6-7**] 05:06AM   ALT(SGPT)-9 AST(SGOT)-20 ALK PHOS-207* TOT
BILI-0.5
[**2197-6-7**] 05:06AM   CALCIUM-7.5* PHOSPHATE-3.8 MAGNESIUM-1.9
[**2197-6-7**] 05:06AM   WBC-17.2* RBC-3.39* HGB-9.1* HCT-28.3* MCV-83
MCH-26.9* MCHC-32.3 RDW-17.6*
[**2197-6-7**] 05:06AM   NEUTS-89.8* LYMPHS-6.5* MONOS-3.5 EOS-0.1
BASOS-0.1
[**2197-6-7**] 05:06AM   PLT COUNT-349
[**2197-6-7**] 01:18AM   TYPE-ART RATES-[**12-26**] TIDAL VOL-500 PEEP-5
PO2-312* PCO2-34* PH-7.40 TOTAL CO2-22 BASE XS--2 -ASSIST/CON
INTUBATED-INTUBATED
[**2197-6-7**] 12:59AM   GLUCOSE-185* LACTATE-1.5 K+-4.0
[**2197-6-7**] 12:50AM   UREA N-22* CREAT-1.2*
[**2197-6-7**] 12:50AM   LIPASE-35
[**2197-6-7**] 12:50AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2197-6-7**] 12:50AM URINE  HOURS-RANDOM
[**2197-6-7**] 12:50AM URINE  bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2197-6-7**] 12:50AM   WBC-20.0* RBC-4.08* HGB-10.5* HCT-34.1*
MCV-84 MCH-25.7* MCHC-30.8* RDW-17.6*
[**2197-6-7**] 12:50AM   NEUTS-90.9* LYMPHS-5.0* MONOS-3.7 EOS-0.1
BASOS-0.3
[**2197-6-7**] 12:50AM   PLT COUNT-415
[**2197-6-7**] 12:50AM   PT-12.3 PTT-23.6 INR(PT)-1.0
[**2197-6-7**] 12:50AM   FIBRINOGE-666*
[**2197-6-7**] 12:50AM URINE  COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020
[**2197-6-7**] 12:50AM URINE  BLOOD-LG NITRITE-POS PROTEIN-300
GLUCOSE-100 KETONE-15 BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-LG
[**2197-6-7**] 12:50AM URINE  RBC-21-50* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**6-29**]
[**2197-6-7**] 12:50AM URINE  AMORPH-MOD

CT head from [**Hospital1 **]:
There is no evidence for midline shift.  There is no CT evidence
for an acute infarct or intracranial hemorrhage or for
hydrocephalus.  Moderate white matter disease and volume loss
are identified.  The sinuses, mastoids and orbits appear normal.
 There is no evidence for an acute fracture or malalignment.
Impression:
There are no acute concerning abnormalities.
.
CT chest/abd/pelvis from [**Hospital1 **]:
There is no evidence for aortic dissection or for a pericardial
effusion on these noncontrast images.  It is not possilbe to
assess for pulmonary embolus on these noncontrast images.  The
tip of the endotracheal tube is approximately 3.5cm above the
carina.  There is no signficant adenopathy.  There is probable
atelectasis/scar in the lungs.  There is a small right pleural
effusion.  Tehre is no pneumothorax.  Degenerative change i
identified in the spine.  There is no evidence for acute
fracture or malalignment.

There has been a cholecystecomy.  there is no evidence for
pancreatitis.  There is no evidence for renal calcifications or
for hydronephrosis.  The urteters appear normal in caliber where
visualized.  Hypodenisities in the kidney are too small to
definitiely characterize although statistically they most likely
represent benign cysts.  there is a large amount of stool in the
rectosigmoid colon suggesive of constipation.  there is no
significant bowel dilation.  Bowel evaluation is limited on
these noncontrast images.  No bowel mass is seen.  Degenerative
change is identified in the spoine.  There is no evidence for
acute fracture or malalignment.  there is no evidence for
abdominal or pelvic adneopathy by CT size criteria.
Impression:
There is a large amount of stool in the rectosigmoid colon
suggestive of constipation.  There is a small right pleural
effusion.  There is no pneurmothorax.
.
CXR [**2197-6-6**]:
endotracheal 2.7 cmabove
advanced OG tube
gastric distension
streaky opacity likely atelectasis
no consolidation.
.
EEG: IMPRESSION: Abnormal portable EEG due to the disorganized
and slow
background and bursts of generalized slowing, a few with
triphasic or
sharp appearances. These findings indicate a widespread
encephalopathy
affecting both cortical and subcortical structures. There were
no areas
of prominent focal slowing, but encephalopathies may obscure
focal
findings. Sharp features appear to be more likely part of the
encephalopathy. There were no simple spike or sharp and slow
wave
discharges. An abnormal cardiac rhythm was noted, but this would
be
assessed better through routine ECG tracings.
.
MRI HEAD:
IMPRESSION:

1. No evidence of acute infarct, mass or hemorrhage.

2. Diffuse enlargement of the ventricles, including the temporal
horns
indicating brain and medial temporal atrophy.


Brief Hospital Course:
# Sepsis: Originally she met SIRS criteria with WBC 17-20 and
temp 95F, and most likely sources urinary +/- skin (right heel).
 She also has septic shock with low UOP and seizures possibly
related to her sepsis.  Pulmonary source less likely with
negative CXR.  CNS source had to be considered since she had
seizures.  A femoral line was placed because of collaps of her
IJ during insertion, suggesting still significant volume
depletion.  Lactate wnl and Cr wnl.  Intubation did not appear
to be for respiratory failure, but for airway protection and
sepsis. She was weaned off pressors after agressive IVF
resuscitation. She was initially started on broad spectrum abx
to cover meningitis, urinary sources, and heel ulcers as these
were thought most likely causes of her septic shock. Eventually
urine culture grew out Ecoli sensitive to Ceftriaxone (resistant
to Cipro), LP was negatve, and blood cultures were no growth so
patient's antibiotics were weaned to just Ceftriaxone for a
planned 14-day course. Her femoral line was replaced with a
midline prior to discharge to the floor.  On transfer to the
floor, she was changed to oral antibiotics (Cefpodoxime) with
plan to take 8 days as outpatient to complete 14 day course.  On
discharge, she was afebrile and hemodynamically stable.
Midline IV was pulled prior to discharge.

# Seizures: No known seizure history.  Differential includes
primary CNS vs related to septic process.  She does have a
remote history of cervical CA at age 49.  CT head from OSH not
suggesting primary CNS source.  Seen by neuro in the ED and
started on keppra. MRI of the head was unrevealing with only
age-related changes. LP was performed and was negative. Abx were
tailored to treat UTI only from meningitis coverage (originally
with vancomycin and ceftriaxone at 2gm to ceftriazone only).
Neurology continued to follow. Keppra was discontineud and eeg
off keppra showed no seizure activity.  Neurology recommended
she follow-up with a neurolgist as an outpatient.  Should Mrs.
[**Known lastname **] decide to follow-up at [**Hospital1 18**], the number has been
provided.  Ultram was not continued on discharge due to
potential to lower seizure threshold.

# Right Heel Pressure Ulcer - Present on admission and
originally concerned for possible source of infection.  Wound
consult was obtained and pressure ulcer was cared for per wound
care recommendations.

# DM: Controlled with humalog insulin sliding scale.  Discharged
on sliding scale without restarting standing Novolin N.  Nursing
home facility can restart Novolin N pending evaluation of PO
intake and blood sugars.

# Dementia: Restarted dementia medications after CNS infeciton
ruled-out.


Medications on Admission:
per Nursing Home
Allopurinol 100 mg daily
Lidoderm patch daily R cervical spine
MVI with minerals
Prilosec 40 mg daily
KCl 20 mEq daily
Lopid 600mg [**Hospital1 **]
Namenda 10 mg [**Hospital1 **]
Ultram 25 mg [**Hospital1 **]
Zyprexa 2.5 mg po BID
ES Tylenol 1000mg Q8H
Aricept 10 mg QHS
Melatonin 1mg QHS
Glucerna health
Novolin N 12U SC QAM before breakfast
FS 6:30AM, 4:30pm ISS with regular insulin
70-130 0
180 2
240 4
300 6
350 8
400 10
>400 12
PRN Glucagon


Discharge Medications:
1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 8 days: LAST DAY [**2197-6-20**].
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): To
right cervical spine. Apply for 12 hours then remove for 12
hours prior to placing next patch.
4. Multivitamin,Tx-Minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Hold for sedation.
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Melatonin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
13. Humalog 100 unit/mL Solution Sig: 0-10  Subcutaneous three
times a day: Per sliding scale.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 13990**]

Discharge Diagnosis:
Primary Diagnosis:
- Sepsis
- Respiratory Failure
- Urinary Tract Infection
- Hypotension
- Seizure
- Right Heel Pressure Ulcer (present on admission)

Secondary Diagnosis:
- Diabetes


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted to the hospital with a very serious infection
that affected many organs.  You required antibiotics, medicaiton
to raise your blood pressure and a machine to temporarily breath
for you.  The source of the infection was felt to be from an
untreated urinary tract infection.  You also had a seizure at
the emergency room prior to transfer to [**Hospital1 **]
Hospital.  You were temporarily placed on medication to help
prevent seizures while the neurologists evaluated you and felt
you did not need to continue the medication, but should be
evaluated by neurologist after discharge.

CHANGES IN MEDICATIONS:
START - Cefpodoxime 200 mg by mouth twice a day for 8 days
STOP - Ultram
STOP - Novolin N (may restart once PO intake improved)
STOP - Potassium Chloride
HOLD - Glucerna (may restart once evaluated in nursing home)

Please take all other medication as previously prescribed.

Followup Instructions:
Please follow-up with a Nuerologist as an outpatient.  An
appointment should be arranged at your earliest convenience.  If
you choose to see a Neurologist at [**Hospital1 1170**], please call [**Telephone/Fax (1) **]
{'Septicemia due to escherichia coli [E. coli],Septic shock,Acute respiratory failure,Urinary tract infection, site not specified,Severe sepsis,Pressure ulcer, heel,Epilepsy, unspecified, without mention of intractable epilepsy,Other persistent mental disorders due to conditions classified elsewhere,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Atherosclerosis of native arteries of the extremities, unspecified,Personal history of malignant neoplasm of cervix uteri,Long-term (current) use of insulin,Personal history of infections of the central nervous system'}


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: Seizure/sepsis

PRESENT ILLNESS: Ms. [**Known lastname **] is an 84 yo female with PMH of DM, resident of a
nursing home, who presented to [**Hospital3 4107**] after being found
at her nursing home with periods of unresponsiveness of facial
twitching. Per her daughter, she was talking and in her normal
state of health at her evening meal on [**6-6**].  She had a repeat
of these periods at [**Hospital1 **].  Per report, there was no
generalized tonic-clonic component but possibly some tonic head
turning and upper extremity shaking.  There, she was also noted
to be hypotensive with systolic BP in the 80s and as low as 50/p
and hypothermic to 95.  She was intubated for airway protection
in the setting of possible status and also for hypotension.  She
had a negative head CT as well as a CT thorax which was
unremarkable.  She was given phosphenytoin, vancomycin 1g,
possibly levo, ativan, cerebryx and sent to [**Hospital1 18**] because there
was no neurologist there.
.
She has had a big decline over the past year cognitively.  She
suffered a fall last year and has since been in a nursing
facility.  She has had dementia diagnosed.  She also has had two
heel ulcers in the last year, the latest over the past four
months last requiring antibiotics 2 months ago.  She has also
lost 15lb in the last 2 months with decreased appetite.
.
Initial vitals in the ED:
T 95  HR 73  110/60  RR18  intubated, sedated with
fentanyl/versed, on dopamin (10-15mcg).  Her pupils were
reactive and her neck supple.  She was noted to have pyuria >
50, + nitrite, WBC 20 with 90% neutrophils, and a heel ulcer
that looked infected.  Cefepime was added to the vanc she
already had.  An IJ was attempted for access, but was not
successful, so a right femoral line was placed.  She was given
2L IVF rapidly, but her SBP remained in the 80s if the dopa was
taken off.  They did however get her dopa down to 5mcg with the
fluid and reduction of her sedation.  Neurology was consulted
who recommended keppra 1g IV.  Her lactate was 1.5, down to 0.7
on repeat.  ABG showed pH 7.40/34/312.
.
Upon arrival, she is on 7.5mcg of dopa.
.

MEDICAL HISTORY: DM
neuropathy
gout
PVD
cervical CA age 49 s/p hysterectomy
chronic heel ulcers

MEDICATION ON ADMISSION: per Nursing Home
Allopurinol 100 mg daily
Lidoderm patch daily R cervical spine
MVI with minerals
Prilosec 40 mg daily
KCl 20 mEq daily
Lopid 600mg [**Hospital1 **]
Namenda 10 mg [**Hospital1 **]
Ultram 25 mg [**Hospital1 **]
Zyprexa 2.5 mg po BID
ES Tylenol 1000mg Q8H
Aricept 10 mg QHS
Melatonin 1mg QHS
Glucerna health
Novolin N 12U SC QAM before breakfast
FS 6:30AM, 4:30pm ISS with regular insulin
70-130 0
180 2
240 4
300 6
350 8
400 10
>400 12
PRN Glucagon

ALLERGIES: Penicillins

PHYSICAL EXAM: vitals: 110/56  86  100%   50% FiO2.  AC 500/12
gen: intubated sedated.  Not responding to voice or painful
stimuli.
heent: ncat, mmm.  pupils pinpoint 2 to 1 mm reactive to light.
neck: JVD 10-12 CM
pulm: CTA anteriorly.  no w/r/r
cv: HRRR, 1/6 SEM throughout.  quiet S1/S2.
abd: NT/ND. hypoactive BS
neuro: intubated, sedated, not responding to voice or painful
stimuli.  Not following commands.
Extremities: dressing on right heal ulcer.  No C/C/E.  Non
dopplerable LE peripheral pulses, 2+ in UEs.

FAMILY HISTORY: no history of seizure disorder

SOCIAL HISTORY: [**11-3**] yr smoking history, quit in her late 30s.  No alcohol.
Retired bookkeeper.  Lives in a nursing home.  Husband died in
his late 60s. 

### Response:
{'Septicemia due to escherichia coli [E. coli],Septic shock,Acute respiratory failure,Urinary tract infection, site not specified,Severe sepsis,Pressure ulcer, heel,Epilepsy, unspecified, without mention of intractable epilepsy,Other persistent mental disorders due to conditions classified elsewhere,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Atherosclerosis of native arteries of the extremities, unspecified,Personal history of malignant neoplasm of cervix uteri,Long-term (current) use of insulin,Personal history of infections of the central nervous system'}
