CHIEF COMPLAINT: lethargy, altered MS, hyperglycemia

PRESENT ILLNESS: 58 yo M w/ brittle DMI c/b neuropathy, narcotics abuse, past
etoh abuse, CRI, HTN, bipolar, p/w lethargy, confusion at home
and became unresponsive in the ED. Admitted to the MICU for
respitory failure (now intubated), hypotension, hyperglycemia.
Per pts. partner he has been disoriented with intermittent
hallucinations, nonsensical speech, difficulty ambulating and
poor po intake for the past several days. He has also had uri
symptoms and a dry cough for 1 week. His partner was a sick
contact (URI w/ cough). He was brought in to [**Hospital1 18**] by his
partner.
.
In the ED: T 97.5 HR 73 BP 109/62 RR 16 SPO2 98% FS 443
Initial labs were significant for a K of 6.1 with peaked T waves
on ECG. He was given calcium, insulin, and IVF (total 6L of NS).
A CXR showed dilated loops of bowel on initial read, therefore,
an OGT placement was attempted. During this procedure the pt.
desaturated to 86% on RA, this in combination with the pts. poor
MS resulted in the patient being intubated (w/
etomidate/rocuronium) for airway protection and hypoxia. A CT
scan of the abdomen showed no acute pathology but did reveal
bibasilar lung consolidation (L>R). He was given levoflox 500 iv
x1 and zosyn 4.5gm iv x 1. A head CT was significant for a Left
parietal 1 cm lesion (per partner this is old). Also pts. UA was
+ bacteria and nitrates. Additionally, in the [**Name (NI) **], pts. BP
transiently dropped to 85/53 and he was started on a levophed
GTT.

MEDICAL HISTORY: IDDM
CRI
Chronic Fatigue
Gout
bipolar disorder
GERD
ETOH abuse (sober x 6 years)
narcotics abuse
multiple TIA's
HTN
known brain lesion (yearly MRI)

MEDICATION ON ADMISSION: Allopurinol 300mg 2 per day
Aolchicine 0.6mg PO daily
Atenolol 100mg PO daily
Lisinopril 20mg PO daily
Protonix 40mg PO daily
Oxycontin 40mg q8h
Oxycodone 30mg PRN
Soma/Carisiprodol 350mg tablets
Lipram 4500 cap rxmeal
Humalog 75/25 SS
Levemir Flex Pen ?units

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Temp:95.1 BP: 108/62 HR:67 RR:16 O2sat 100% on AC 550/18
peep 5 Fi02 100%
GEN: intubated, responsive to pain (off sedation)
HEENT: PERRL anicteric,intubated, poor dentition
NECK: No JVD, right IJ in place
RESP: clear anteriorly
CV: RR, distant heart sounds, no murmurs
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: 1+ ankle edema bilat. 2+DP on right and 1+ DP on left
SKIN: no rashes/no jaundice

FAMILY HISTORY: 15 brothers/sisters, 5 of whom died of brain tumors

SOCIAL HISTORY: 1 PPD x 40 years. No etoh in last six years. No recreational
drugs. Lives with GF, on disability.
Acute respiratory failure,Influenza with pneumonia,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Acidosis,Toxic encephalopathy,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Gout, unspecified,Diabetes with neurological manifestations, type I [juvenile type], uncontrolled,Polyneuropathy in diabetes
Acute respiratry failure,Influenza with pneumonia,Meth sus pneum d/t Staph,Acute kidney failure NOS,Int inf clstrdium dfcile,Acidosis,Toxic encephalopathy,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Gout NOS,DMI neuro uncntrld,Neuropathy in diabetes
Admission Date:  [**2116-4-5**]              Discharge Date:   [**2116-4-24**]

Date of Birth:  [**2058-1-1**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
lethargy, altered MS, hyperglycemia

Major Surgical or Invasive Procedure:
Percutaneous tracheostomy [**2116-4-13**]
Intubation/mechanical intubation
Central Line placement
Lumbar Puncture


History of Present Illness:
58 yo M w/ brittle DMI c/b neuropathy, narcotics abuse, past
etoh abuse, CRI, HTN, bipolar, p/w lethargy, confusion at home
and became unresponsive in the ED. Admitted to the MICU for
respitory failure (now intubated), hypotension, hyperglycemia.
Per pts. partner he has been disoriented with intermittent
hallucinations, nonsensical speech, difficulty ambulating and
poor po intake for the past several days. He has also had uri
symptoms and a dry cough for 1 week. His partner was a sick
contact (URI w/ cough). He was brought in to [**Hospital1 18**] by his
partner.
.
In the ED: T 97.5 HR 73 BP 109/62 RR 16 SPO2 98% FS 443
Initial labs were significant for a K of 6.1 with peaked T waves
on ECG. He was given calcium, insulin, and IVF (total 6L of NS).
A CXR showed dilated loops of bowel on initial read, therefore,
an OGT placement was attempted. During this procedure the pt.
desaturated to 86% on RA, this in combination with the pts. poor
MS resulted in the patient being intubated (w/
etomidate/rocuronium) for airway protection and hypoxia. A CT
scan of the abdomen showed no acute pathology but did reveal
bibasilar lung consolidation (L>R). He was given levoflox 500 iv
x1 and zosyn 4.5gm iv x 1. A head CT was significant for a Left
parietal 1 cm lesion (per partner this is old). Also pts. UA was
+ bacteria and nitrates. Additionally, in the [**Name (NI) **], pts. BP
transiently dropped to 85/53 and he was started on a levophed
GTT.


Past Medical History:
IDDM
CRI
Chronic Fatigue
Gout
bipolar disorder
GERD
ETOH abuse (sober x 6 years)
narcotics abuse
multiple TIA's
HTN
known brain lesion (yearly MRI)

Social History:
1 PPD x 40 years. No etoh in last six years. No recreational
drugs. Lives with GF, on disability.

Family History:
15 brothers/sisters, 5 of whom died of brain tumors

Physical Exam:
VS: Temp:95.1 BP: 108/62 HR:67 RR:16 O2sat 100% on AC 550/18
peep 5 Fi02 100%
GEN: intubated, responsive to pain (off sedation)
HEENT: PERRL anicteric,intubated, poor dentition
NECK: No JVD, right IJ in place
RESP: clear anteriorly
CV: RR, distant heart sounds, no murmurs
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: 1+ ankle edema bilat. 2+DP on right and 1+ DP on left
SKIN: no rashes/no jaundice


Pertinent Results:
HEMATOLOGY
[**2116-4-5**] 05:30PM BLOOD WBC-10.4 RBC-3.84* Hgb-11.4* Hct-33.4*
MCV-87 MCH-29.6 MCHC-34.0 RDW-17.0* Plt Ct-234
[**2116-4-6**] 12:56AM BLOOD WBC-7.6 RBC-3.27* Hgb-9.5* Hct-29.0*
MCV-89 MCH-29.1 MCHC-32.8 RDW-16.3* Plt Ct-191
[**2116-4-16**] 03:02AM BLOOD WBC-17.0* RBC-2.80* Hgb-8.1* Hct-24.2*
MCV-86 MCH-28.8 MCHC-33.4 RDW-18.3* Plt Ct-477*
[**2116-4-17**] 03:47AM BLOOD WBC-16.4* RBC-2.57* Hgb-7.5* Hct-22.5*
MCV-88 MCH-29.2 MCHC-33.4 RDW-18.3* Plt Ct-510*
[**2116-4-5**] 05:30PM BLOOD Neuts-67 Bands-7* Lymphs-17* Monos-8
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0

COAGULATION
[**2116-4-6**] 12:56AM BLOOD PT-12.6 PTT-38.5* INR(PT)-1.1

CHEMISTRY
[**2116-4-5**] 05:30PM BLOOD Glucose-491* UreaN-55* Creat-4.6* Na-132*
K-6.3* Cl-104 HCO3-12* AnGap-22*
[**2116-4-5**] 07:51PM BLOOD Glucose-377* UreaN-52* Creat-3.8* Na-137
K-4.6 Cl-113* HCO3-13* AnGap-16
[**2116-4-17**] 03:47AM BLOOD Glucose-207* UreaN-37* Creat-2.4* Na-152*
Cl-122* HCO3-20*

LFTS
[**2116-4-5**] 07:51PM BLOOD ALT-13 AST-14 LD(LDH)-131 AlkPhos-146*
TotBili-0.2
[**2116-4-8**] 05:34AM BLOOD ALT-18 AST-18 LD(LDH)-189 AlkPhos-128*
TotBili-0.5
[**2116-4-11**] 03:02AM BLOOD ALT-29 AST-23 LD(LDH)-205 AlkPhos-268*
TotBili-1.0

CA/MG/PHOS
[**2116-4-5**] 05:30PM BLOOD Calcium-9.1 Phos-6.4* Mg-1.7
[**2116-4-7**] 05:53AM BLOOD Albumin-2.6* Calcium-8.1* Phos-4.2 Mg-1.9
[**2116-4-8**] 05:34AM BLOOD Albumin-2.6* Calcium-7.8* Phos-4.6*
Mg-1.7

VITAMIN
[**2116-4-11**] 03:02AM BLOOD VitB12-[**2105**]*
[**2116-4-12**] 02:49AM BLOOD calTIBC-113* VitB12-GREATER TH
Folate-16.0 Ferritn-1062* TRF-87*
[**2116-4-13**] 03:23AM BLOOD VitB12-1742*

AMMONIA
[**2116-4-5**] 07:51PM BLOOD Ammonia-8*

THYROID
[**2116-4-12**] 02:49AM BLOOD TSH-1.4
[**2116-4-12**] 02:49AM BLOOD Free T4-0.65*

IMMUNE
[**2116-4-7**] 05:53AM BLOOD IgG-663*

TOXICOLOGY
[**2116-4-5**] 05:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Barbitr-NEG Tricycl-POS

BLOOD GAS
[**2116-4-5**] 09:06PM BLOOD Type-ART Rates-/14 PEEP-5 FiO2-100
pO2-295* pCO2-43 pH-7.13* calTCO2-15* Base XS--14 AADO2-395 REQ
O2-68 -ASSIST/CON Intubat-INTUBATED
[**2116-4-6**] 02:24AM BLOOD Type-ART pO2-183* pCO2-38 pH-7.18*
calTCO2-15* Base XS--13
[**2116-4-17**] 05:22AM BLOOD Comment-GREEN TOP
[**2116-4-5**] 05:35PM BLOOD Lactate-1.9 K-6.4*

CSF
ANALYSIS              WBC RBC Polys Lymphs Monos
[**2116-4-8**] 05:20PM    11 1*  02     87      13
TUBE#4
CHEMISTRY            TotProt Glucose LD(LDH)
[**2116-4-8**] 05:20PM    20     108     21
CULTURE NEGATIVE
HSV NEGATIVE
NEGATIVE FOR MALIGNANT CELLS


URINE: CULTURE GROUP B STREP
SPUTUM: COAG AUREUS MSSA
FLU: POSITIVE B
RPR: NR
STOOL: NEGATIVE FOR C. DIFF

HEAD CT2/24/08
1. No evidence of acute intracranial hemorrhage.

2. Left parietal ovoid lesion with questionable punctate central
calcification. Recommend MRI with gadolinium for better
evaluation. No appreciable surrounding edema. No mass effect.

CT ABD/PELVIS
1. No evidence of bowel obstruction.
2. Air and stool-filled colon.
3. Bibasilar consolidations, left significantly greater than
right, likely representing aspiration or other pneumonia.
4. Nonspecific periportal edema. Possible etiologies include
acute intravenous hydration, hypoalbuminemia, or hepatitis or
other liver disease, or HIV-related disease.

MRI/MRA OF HEAD
There is an area of susceptibility artifact in the left
periatrial region with a central portion of high signal on T2
images consistent with a cavernoma. There is no mass effect,
midline shift or hydrocephalus seen. No acute infarct is
identified. There is fluid seen in bilateral mastoid air cells.

IMPRESSION: No evidence of acute infarct. Cavernoma left
periatrial region of the parietal lobe.


Brief Hospital Course:
RESPIRATORY FAILURE / INFLUENZA B / MSSA PNEUMONIA
Mr. [**Known lastname 15655**] was brought to the ED for altered mental status, and
became unresponsive while in the emergency department, primarily
for airway protection. He exhibited sepsis physiology with
hypotension, and was treated started on levophed initially. CT
of the abdomen revealed consolidation at the lung bases. Trials
to wean the vent toward extubation were difficult with decreased
oxygenation. DFA revealed that the patient was INFLUENZA B
positive. Culture of sputum was positive for methicillin
sensitive staph aureus, and this was felt to be high likelihood
for staph superinfection. Because of his respiratory failure, he
was covered broadly with vancomycin and zosyn for a ten day
course. Because of his protracted vent course, he underwent
tracheostomy placement on [**2116-4-13**]. Post-tracheostomy, his
respiratory status improved and he had stable O2 saturation. On
[**2116-4-21**] his trach fell out and he was transferred to the MICU
for further management, but he continued to have stable
respiratory status post-trach and was transferred back to the
floor. By discharge, his O2 saturation was 100% on room air.
.
ALTERED MENTAL STATUS
The patient had a history of confusion and of dropping objects
per his family/partner just prior to admission. Tox screen on
admission was negative in urine, and positive for TCA in serum.
When sedation was weaned, he became hemodynamically agitated but
mainly unresponsive with disconjugate gaze. MRI/MRA showed no
acute infarct. EEG showed diffuse slowing consistent with
toxic/metabolic encephalopathy. Neurology was consulted and
followed the patient while in house through the work-up. The
patient had no gross thyroid function abnormality. An RPR was
negative. Ultimately, he was weaned off of his sedation of
versed and fentanyl in a very slow manner, and over 2-3 days
became arousable and eventually conversant. By discharge, he was
oriented to name, not place and date but was able to carry out
simple conversations. Mini mental status score was 17 at
discharge.
.
RECALCITRANT HYPERTENSION
As sedation was weaned for extubation, the patient's blood
pressure rose to 190-200 / 70s-80s consistently. He was treated
with a mixture of labetolol gtt, hydralazine IV/PO, and isordil.
He was started on captopril given stable though lower renal
function/eGFR and this was titrated upwards. He additionally was
continued on PO labetolol, hydralazine, and isosorbide
mononitrate. His captopril was switched to lisinopril, and
labetolol to metoprolol by discharge.
.
ASPIRATION
On suctioning of the trach, it was discovered that the patient
had been aspirating tube feeds and also crushed fragments of
pills.  A post-pyloric Dobhoff was placed with success, but was
eventually lost. RN trial of PO pills at the bedside was
successful.
.
ACUTE ON CHRONIC KIDNEY FAILURE/DISEASE
The patient's creatinine on admission was 4.6, eventually
declining over the course of hospital stay to 1.9. This was felt
to be consistent with an acute kidney injury picture.
.
DIARRHEA
The patient briefly exhibited large stool volumes, and c.diff
associated diarrhea/colitis was considered given hospital and
antibiotic exposure. A toxin was eventually positive. He was
started on treatment with a 14-day course of metronidazole to be
finished on [**2116-4-30**].
.
DIABETES: his FS was mostly high in the 200s-300s during most of
the hospital stay but decreased by discharge. He was discharged
with glargine 8 units at hs and a sliding scale. His insulin
regimen would likely need to be adjusted at rehab for better
glucose control.
.
NUTRITION
The patient was not immediately PEG'd given possibility of
awakening after sedation was weaned off. He was supported with
tube feeds for a short time then was able to tolerate liquid
diet. He was discharged with soft solids and thin liquids.
.
CODE STATUS/DISPOSITION
The patient was a full code.

Medications on Admission:
Allopurinol 300mg 2 per day
Aolchicine 0.6mg PO daily
Atenolol 100mg PO daily
Lisinopril 20mg PO daily
Protonix 40mg PO daily
Oxycontin 40mg q8h
Oxycodone 30mg PRN
Soma/Carisiprodol 350mg tablets
Lipram 4500 cap rxmeal
Humalog 75/25 SS
Levemir Flex Pen ?units


Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
unit Injection TID (3 times a day).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Lidocaine (PF) 1 % (10 mg/mL) Solution Sig: Three (3) ML
Injection Q2H (every 2 hours) as needed for Cough.
5. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
6. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days: Until [**2116-4-30**].
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever > 101.0.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
11. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: see
comment  Subcutaneous four times a day: Pre-meal FS 100-150: 2
unit; 151-200: 3 units; 201-250: 6 units; 251-300: 9 units;
301-350: 12 units. Bedtime FS 200-250: 3 units; 251-300: 6
units; 301-350: 9 units.
12. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
13. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO TID (3 times a
day).
15. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) unit
Subcutaneous at bedtime.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital

Discharge Diagnosis:
Primary diagnoses: influenza, MSSA infection, Clostrodium
difficile colitis

Secondary diagnoses: insulin-dependent diabetes mellitus,
chronic kidney disease, chronic fatigue, gout, bipolar disorder,
GERD, alcohol abuse, narcotics abuse, multiple TIA's,
hypertension, known brain lesion (yearly MRI)


Discharge Condition:
stable


Discharge Instructions:
You presented to [**Hospital1 18**] with unresponsiveness and respiratory
failure. You were found to have a lung infection. You were
intubated and later underwent a tracheostomy. The tracheostomy
tube later fell out but your respiratory status continued to
improve greatly. You also had an infection of your colon called
C. diff colitis and were started on metronidazole to be finished
on [**2116-4-30**].

Please take all your medications and go to your follow-up
appointment as instructed below.

If you develop recurrent respiratory difficulty, fevers, chills,
abdominal pain, diarrhea, or any other concerning symptom,
please call your physician or go to the nearest Emergency Room.

Followup Instructions:
* Dr. [**Last Name (STitle) 1057**], [**Telephone/Fax (1) 77309**]: 11:15 am, [**2116-5-18**].
{'Acute respiratory failure,Influenza with pneumonia,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Acidosis,Toxic encephalopathy,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Gout, unspecified,Diabetes with neurological manifestations, type I [juvenile type], uncontrolled,Polyneuropathy in diabetes'}


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: lethargy, altered MS, hyperglycemia

PRESENT ILLNESS: 58 yo M w/ brittle DMI c/b neuropathy, narcotics abuse, past
etoh abuse, CRI, HTN, bipolar, p/w lethargy, confusion at home
and became unresponsive in the ED. Admitted to the MICU for
respitory failure (now intubated), hypotension, hyperglycemia.
Per pts. partner he has been disoriented with intermittent
hallucinations, nonsensical speech, difficulty ambulating and
poor po intake for the past several days. He has also had uri
symptoms and a dry cough for 1 week. His partner was a sick
contact (URI w/ cough). He was brought in to [**Hospital1 18**] by his
partner.
.
In the ED: T 97.5 HR 73 BP 109/62 RR 16 SPO2 98% FS 443
Initial labs were significant for a K of 6.1 with peaked T waves
on ECG. He was given calcium, insulin, and IVF (total 6L of NS).
A CXR showed dilated loops of bowel on initial read, therefore,
an OGT placement was attempted. During this procedure the pt.
desaturated to 86% on RA, this in combination with the pts. poor
MS resulted in the patient being intubated (w/
etomidate/rocuronium) for airway protection and hypoxia. A CT
scan of the abdomen showed no acute pathology but did reveal
bibasilar lung consolidation (L>R). He was given levoflox 500 iv
x1 and zosyn 4.5gm iv x 1. A head CT was significant for a Left
parietal 1 cm lesion (per partner this is old). Also pts. UA was
+ bacteria and nitrates. Additionally, in the [**Name (NI) **], pts. BP
transiently dropped to 85/53 and he was started on a levophed
GTT.

MEDICAL HISTORY: IDDM
CRI
Chronic Fatigue
Gout
bipolar disorder
GERD
ETOH abuse (sober x 6 years)
narcotics abuse
multiple TIA's
HTN
known brain lesion (yearly MRI)

MEDICATION ON ADMISSION: Allopurinol 300mg 2 per day
Aolchicine 0.6mg PO daily
Atenolol 100mg PO daily
Lisinopril 20mg PO daily
Protonix 40mg PO daily
Oxycontin 40mg q8h
Oxycodone 30mg PRN
Soma/Carisiprodol 350mg tablets
Lipram 4500 cap rxmeal
Humalog 75/25 SS
Levemir Flex Pen ?units

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Temp:95.1 BP: 108/62 HR:67 RR:16 O2sat 100% on AC 550/18
peep 5 Fi02 100%
GEN: intubated, responsive to pain (off sedation)
HEENT: PERRL anicteric,intubated, poor dentition
NECK: No JVD, right IJ in place
RESP: clear anteriorly
CV: RR, distant heart sounds, no murmurs
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: 1+ ankle edema bilat. 2+DP on right and 1+ DP on left
SKIN: no rashes/no jaundice

FAMILY HISTORY: 15 brothers/sisters, 5 of whom died of brain tumors

SOCIAL HISTORY: 1 PPD x 40 years. No etoh in last six years. No recreational
drugs. Lives with GF, on disability. 

### Response:
{'Acute respiratory failure,Influenza with pneumonia,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Acidosis,Toxic encephalopathy,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Gout, unspecified,Diabetes with neurological manifestations, type I [juvenile type], uncontrolled,Polyneuropathy in diabetes'}
