CHIEF COMPLAINT: Hyperglycemia

PRESENT ILLNESS: 73 yo M w/ DM2 (c/b left plantar ulcer), CAD s/p MI and CABG
[**2174**] (LIMA-LAD, rSVG-CX, SVG-PDA, SVGPL) who p/f [**Hospital1 1501**]([**Hospital1 **])
with nausea and SOB. Pt denies CP. Notes that emesis started 4
days ago (once daily), none today. Describes SOB as DOE that he
has at baseline and not a new symptom. No oxygen requirement at
[**Hospital1 1501**]. Limited in his ability to ambulate to due diabetic ulcer on
left foot, not limited by SOB. Of note patient has been poorly
compliant with meds x 4 month and almost fully refusing meds x 3
days, notes that 4 months ago [**Hospital1 1501**] staff changed his room around
not to his liking and 3 days ago again similar issue. Stopped
oral meds, continued insulin injections. Confirms DNR/DNI.
.
In the ED, initial vitals were 98.6 107 117/76 16 98% 4L. Labs
and imaging significant for BS>500, TnT 0.50, Cr 1.6, CK 69,  MB
5, WBC 13.7, 87.7%PMNs, CXR showed pulmonary edema could not r/o
PNA, ED interpretation of EKG: STE 1mm aVR/V1, STD 1-2mm I, II,
L, V3-6, septal Q's.  He was seen by cardiology in the ED and it
was explained to him that he may be having a STEMI, but patient
refused catheterization.
.
Patient given Glipizide 10mg, Metformin 500, Insulin 10 Units,
Azithro, not started Insulin gtt, not started on heparin gtt, no
ASA, no BB. BS from 565 to 480. DNR/DNI (confirmed with nursing
home). Has left plantar diabetic ulcer treated every Friday at
[**Doctor Last Name 1263**] with wet to dry dressing changes.
.
Vitals on transfer were 103 103/68 27 98%.
.
Vitals on arrival: NAD, 100, 132/77, 24, 89-92% on RA.
.
OVERNIGHT: Did not allow lab draw, checked FSBG  230, did not
want any interventions other than sq insulin, and some oral
meds. Refused Heparin gtt, refused plavix, refused cath. No CP,
no SOB.  Fell while going to the bathroom, did not want
assistance.

MEDICAL HISTORY: DM2 (Diabetic foot ulcer treated at [**Doctor Last Name 1263**] wound clinic every
Friday)
Dyslipidemia
Hypertension
CABG [**2174**] (LIMA-LAD, rSVG-CX, SVG-PDA, SVGPL)
Bell's Palsy
Diverticular disease w/hx GIB

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Metoprolol Tartrate 50 mg PO BID
hold for sbp < 100, hr < 55
2. Omeprazole 40 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. GlipiZIDE 10 mg PO BID
6. Lantus *NF* (insulin glargine) 40 U Subcutaneous HS
7. Aspirin 81 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL PRN chest pain

ALLERGIES: Penicillins

PHYSICAL EXAM: ADMISSION:
VS: 132/77, 100, 25, 89-93% on RA
GENERAL: looks stated age, poor hygeine, poor odor, Oriented x3,
Requires full control of situation and very clear about what he
does and does not want done.
HEENT: MMM, Sclera anicteric, EOMI, No pallor or cyanosis of the
oral mucosa. Poor dentition.
NECK: JVP seems to be to tragus?
CARDIAC: Tachycardic, +S1+S2, no M/R/G.
LUNGS: On RA. CrackleS 2/3 up b/l. Accessory muscle use. Can
speak in full sentences.
ABDOMEN: Distended but soft, non tender, no rebound.
EXTREMITIES: Pitting edema b/l Left > Right up to mid thigh,
patietn did not allow visualization of left plantar ulcer, right
toe nails yellow and dysmorphic.
- No Sensation up to knee on left lateral leg, right foot, left
foot
PULSES:  [**Name (NI) **] PT on left (did not allow DP), DP/PT on
right

FAMILY HISTORY: - Father MI in 60s, no heart history in mother
- Brother alive, no heart history

SOCIAL HISTORY: -Tobacco history: smoked for 1 year in past 50 years ago
-ETOH: none currently briefly in past
-Illicit drugs: none
- never married, no kids
- former CPA
- lives at [**Hospital1 1501**] [**Hospital1 **]
Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Acute on chronic systolic heart failure,Unspecified osteomyelitis, ankle and foot,Other acute and subacute forms of ischemic heart disease, other,Gangrene,Ulcer of heel and midfoot,Other bone involvement in diseases classified elsewhere,Long-term (current) use of insulin,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Other and unspecified hyperlipidemia,Physical restraints status,Personal history of noncompliance with medical treatment, presenting hazards to health,Cystitis, unspecified,Other and unspecified Escherichia coli [E. coli],Toxic encephalopathy,Narcissistic personality disorder,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Encounter for change or removal of surgical wound dressing
DMII oth uncntrld,Ac on chr syst hrt fail,Osteomyelitis NOS-ankle,Ac ischemic hrt dis NEC,Gangrene,Ulcer of heel & midfoot,Bone involv in oth dis,Long-term use of insulin,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Hyperlipidemia NEC/NOS,Physical restrain status,Hx of past noncompliance,Cystitis NOS,E.coli infection NEC/NOS,Toxic encephalopathy,Narcissistic personality,Acute kidney failure NOS,Chronic kidney dis NOS,Attn rem surg dressing
Admission Date:  [**2188-8-16**]              Discharge Date:   [**2188-8-29**]

Date of Birth:  [**2114-10-3**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Hyperglycemia

Major Surgical or Invasive Procedure:
Incisions and Drainages of left foot (bedside as well as in OR)
PICC line insertion


History of Present Illness:
73 yo M w/ DM2 (c/b left plantar ulcer), CAD s/p MI and CABG
[**2174**] (LIMA-LAD, rSVG-CX, SVG-PDA, SVGPL) who p/f [**Hospital1 1501**]([**Hospital1 **])
with nausea and SOB. Pt denies CP. Notes that emesis started 4
days ago (once daily), none today. Describes SOB as DOE that he
has at baseline and not a new symptom. No oxygen requirement at
[**Hospital1 1501**]. Limited in his ability to ambulate to due diabetic ulcer on
left foot, not limited by SOB. Of note patient has been poorly
compliant with meds x 4 month and almost fully refusing meds x 3
days, notes that 4 months ago [**Hospital1 1501**] staff changed his room around
not to his liking and 3 days ago again similar issue. Stopped
oral meds, continued insulin injections. Confirms DNR/DNI.
.
In the ED, initial vitals were 98.6 107 117/76 16 98% 4L. Labs
and imaging significant for BS>500, TnT 0.50, Cr 1.6, CK 69,  MB
5, WBC 13.7, 87.7%PMNs, CXR showed pulmonary edema could not r/o
PNA, ED interpretation of EKG: STE 1mm aVR/V1, STD 1-2mm I, II,
L, V3-6, septal Q's.  He was seen by cardiology in the ED and it
was explained to him that he may be having a STEMI, but patient
refused catheterization.
.
Patient given Glipizide 10mg, Metformin 500, Insulin 10 Units,
Azithro, not started Insulin gtt, not started on heparin gtt, no
ASA, no BB. BS from 565 to 480. DNR/DNI (confirmed with nursing
home). Has left plantar diabetic ulcer treated every Friday at
[**Doctor Last Name 1263**] with wet to dry dressing changes.
.
Vitals on transfer were 103 103/68 27 98%.
.
Vitals on arrival: NAD, 100, 132/77, 24, 89-92% on RA.
.
OVERNIGHT: Did not allow lab draw, checked FSBG  230, did not
want any interventions other than sq insulin, and some oral
meds. Refused Heparin gtt, refused plavix, refused cath. No CP,
no SOB.  Fell while going to the bathroom, did not want
assistance.


Past Medical History:
DM2 (Diabetic foot ulcer treated at [**Doctor Last Name 1263**] wound clinic every
Friday)
Dyslipidemia
Hypertension
CABG [**2174**] (LIMA-LAD, rSVG-CX, SVG-PDA, SVGPL)
Bell's Palsy
Diverticular disease w/hx GIB

Social History:
-Tobacco history: smoked for 1 year in past 50 years ago
-ETOH: none currently briefly in past
-Illicit drugs: none
- never married, no kids
- former CPA
- lives at [**Hospital1 1501**] [**Hospital1 **]

Family History:
- Father MI in 60s, no heart history in mother
- Brother alive, no heart history

Physical Exam:
ADMISSION:
VS: 132/77, 100, 25, 89-93% on RA
GENERAL: looks stated age, poor hygeine, poor odor, Oriented x3,
Requires full control of situation and very clear about what he
does and does not want done.
HEENT: MMM, Sclera anicteric, EOMI, No pallor or cyanosis of the
oral mucosa. Poor dentition.
NECK: JVP seems to be to tragus?
CARDIAC: Tachycardic, +S1+S2, no M/R/G.
LUNGS: On RA. CrackleS 2/3 up b/l. Accessory muscle use. Can
speak in full sentences.
ABDOMEN: Distended but soft, non tender, no rebound.
EXTREMITIES: Pitting edema b/l Left > Right up to mid thigh,
patietn did not allow visualization of left plantar ulcer, right
toe nails yellow and dysmorphic.
- No Sensation up to knee on left lateral leg, right foot, left
foot
PULSES:  [**Name (NI) **] PT on left (did not allow DP), DP/PT on
right

DISCHARGE:
VS: 98 94/57 p89 R16 99RA
I/O: 1640/725 yest + BMx3
GEN: Seated in chair. In no apparent distress.
LUNGS: CTA B/L but limited excursion.
CV: S1, S2 Regular rhythm. No murmurs/gallops/rubs.
BACK: No CVA tenderness. No presacral edema
EXTREMITIES: 2+ pitting edema b/l. dorasalis pedis 2+ on right.
Left foot wrapped in bandage clean/dry/intact. Ulcer covered in
black eschar to left great toe.


Pertinent Results:
ADMISSION:
[**2188-8-16**] 04:29PM BLOOD WBC-13.7*# RBC-3.78* Hgb-11.4*# Hct-33.8*
MCV-89 MCH-30.0 MCHC-33.6 RDW-16.3* Plt Ct-378#
[**2188-8-16**] 04:29PM BLOOD Neuts-87.7* Lymphs-8.4* Monos-3.3 Eos-0.5
Baso-0.1
[**2188-8-16**] 04:29PM BLOOD PT-13.0* PTT-23.4* INR(PT)-1.2*
[**2188-8-16**] 04:29PM BLOOD Glucose-452* UreaN-59* Creat-1.6* Na-134
K-4.4 Cl-98 HCO3-22 AnGap-18
[**2188-8-16**] 04:29PM BLOOD ALT-40 AST-30 CK(CPK)-69 AlkPhos-87
TotBili-0.4
[**2188-8-16**] 04:29PM BLOOD Albumin-4.3 Calcium-9.4 Phos-2.8 Mg-2.5
[**2188-8-16**] 04:29PM BLOOD CK-MB-5
[**2188-8-16**] 04:29PM BLOOD cTropnT-0.50*
[**2188-8-17**] 08:37PM BLOOD CK-MB-4 cTropnT-0.49*
[**2188-8-18**] 04:19AM BLOOD CK-MB-4 cTropnT-0.49*

INTERVAL:
[**2188-8-17**] 01:00AM BLOOD %HbA1c-10.9* eAG-266*
[**2188-8-20**] 07:35AM BLOOD CRP-179.6*
[**2188-8-23**] 06:15AM BLOOD CRP-123.1*
[**2188-8-25**] 06:05AM BLOOD cTropnT-0.36*
[**2188-8-27**] 07:45AM BLOOD Triglyc-80 HDL-34 CHOL/HD-2.8 LDLcalc-44
[**2188-8-27**] 07:45AM BLOOD Glucose-81 UreaN-32* Creat-1.6* Na-141
K-4.3 Cl-109* HCO3-23 AnGap-13

DISCHARGE:
[**2188-8-29**] 05:53AM BLOOD WBC-5.7 RBC-2.99* Hgb-8.7* Hct-26.7*
MCV-89 MCH-29.2 MCHC-32.7 RDW-15.8* Plt Ct-254
[**2188-8-29**] 05:53AM BLOOD PT-14.5* PTT-33.1 INR(PT)-1.4*
[**2188-8-29**] 05:53AM BLOOD Glucose-67* UreaN-29* Creat-1.9* Na-142
K-4.7 Cl-110* HCO3-22 AnGap-15
[**2188-8-29**] 05:53AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1

IMAGING:
PORTABLE CHEST:  [**2188-8-16**].
FINDINGS:  Single portable view of the chest is compared to
previous exam from [**2175-9-16**].  Indistinct pulmonary
vascular markings are seen
bilaterally.  Blunting of the costophrenic angle and
silhouetting the
hemidiaphragm suggestive of bilateral effusions.
Cardiomediastinal silhouette appears enlarged, likely slightly
accentuated by low inspiratory effort.
Median sternotomy wires are noted, now with a fracture of the
top two wires.  Osseous and soft tissue structures are
unremarkable.
IMPRESSION:  Findings suggestive of congestive failure with mild
pulmonary edema and bilateral effusions.  Component of
superimposed infection should be considered based on a clinical
basis.

ABDOMEN (SUPINE & ERECT) FINDINGS:  Supine and upright views of
the abdomen were obtained.  Bowel gas pattern is unremarkable
without dilated loops of small and large bowel.  Gas is present
within the rectum.  No fluid level or pneumoperitoneum is
present on the upright exam.  Several metallic clips overlie the
right femoral head, compatible with prior inguinal repair.
Sternotomy wires are intact.
IMPRESSION:  Normal bowel gas pattern without evidence of bowel
obstruction.

ECHO [**2188-8-18**]: Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is severely
depressed (LVEF= 25-30 %) with global hypokinesis and akinesis
of the infero-posterior segments. No masses or thrombi are seen
in the left ventricle. There is no ventricular septal defect.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2178-4-8**], the LVEF has decreased

FOOT AP,LAT & OBL LEFT
FINDINGS:  No previous images.  There have been resection of the
phalanges and a portion of the metatarsal of the fifth digit.
Either previous infectious changes or surgical change about the
metatarsophalangeal joints of the second, third, and fourth
digits in this patient with vascular calcification
consistent with diabetes.

In the absence of previous images, it is extremely difficult to
determine
whether there could be acute osteomyelitis.  MRI would be the
next imaging modality to attempt to make this clinical decision.



VENOUS DUP EXT UNI (MAP/DVT) Left Lower Extremity Venous Duplex
Findings: Duplex evaluation was performed on the left lower
extremity veins. There is normal compression and augmentation of
the common femoral, proximal femoral, mid femoral, distal
femoral, popliteal, posterior tibial and peroneal veins. There
is normal phasicity of the common femoral veins bilaterally.
Impression: No evidence of left lower extremity deep vein
thrombosis.

ART EXT (REST ONLY) Bilateral lower extremity ABIs, Doppler
waveforms and PVRs were performed at rest.

FINDINGS:
RIGHT:  The right ABIs are 1.17/1.12 at DP/PT.  Right-sided
Doppler waveforms are triphasic at all levels with normal PVRs.
LEFT:  The left ABIs are 1.12/1.17 at the DP/PT.  Left-sided
Doppler waveforms are all triphasic with normal PVRs.
IMPRESSION:  No evidence of any peripheral vascular disease at
rest.

PICC LINE PLACEMENT [**2188-8-27**]: IMPRESSION: Uncomplicated
ultrasound and fluoroscopically guided single-lumen PICC
placement via the right brachial venous approach. Final internal
length is 32 cm, with the tip positioned in SVC. The line is
ready to use.

PATHOLOGY/MICRO:
DIAGNOSIS:  Bone, left foot, debridement:
Bone with reactive changes and granulation tissue with focal
acute inflammation consistent with healing ulcer.  See note.
Note:  The findings may be compatible with treated/resolving
osteomyelitis.  Clinical correlation is recommended.
Gross:  The specimen is received fresh in a container labeled
with the patient's name, "[**Last Name (LF) 111697**], [**Known firstname **]", medical record
number and "left foot bone".  It consists of a 3 x 3 cm
aggregate of bone fragments; the largest fragment measures 2.2
cm in maximum dimension.  The specimen is represented in A
following decalcification.


Brief Hospital Course:
73M with PMH of CAD s/p MI and 4 vessel CABG [**2174**], DM2
complicated by multiple L foot ulcers, presented from [**Hospital1 1501**] for
nausea, FSBG > 500 and poor med compliance.  In ED found to have
Troponin T of 0.5, and non-specific ST depression on EKG. He was
also determined to have LLE osteomyelitis, decompensated
systolic CHF, osteomyelitis and a UTI. He is being treated with
broad spectrum antibiotics for his LLE osteomyelitis. His heart
failure has attempted to be optimized but has been limited by
fluctuating creatinine. Delivery of care has also been hindered
by psychiatric co-morbidities (e.g. narcissitic personality
disorder) with patient refusing care at some times.
.
# CAD with demand ischemia/Troponinemia : On evaluation in the
ED, he was found to have an elevated troponin (0.50) with ST
depressions in lateral leads on EKG, in the absence of chest
pain. This was concerning for evolving STEMI in the Emergency
department, so a cardiac catheterization was recommended, but
patient refused intervention, even if this were STEMI. In CCU pt
was started on IV Metop 10mg Q6H for HR 60s-70s, ASA 325mg and
Atorvastatin 80mg if patient agrees to take. Pt transferred to
medicine since he does not require CCU level of care and no
potential cardiac interventions will be done.  He was
transferred to the CCU for further management. Cardiology
consult stated that he likely had demand ischemia from heart
failure as discussed below and no apparent NSTEMI or STEMI.
There, he refused majority of medical care, including ASA and
Clopidogrel. His troponins have remained stable (~0.4) with
improvement of ST depressions on EKG. His troponinemia was most
likely demand ischemia/troponin spill in setting of CHF and
metabolic stress. Not likely ischemic event. He remained chest
pain free throughout his stay.

# Acute on Chronic sCHF exacerbation (Echo [**2177**] EF 50%): Patient
likely had decompensated systolic heart failure from infection
and poor medication compliance. Initially, patient had SaO2
89-92% on RA with B/L crackles 2/3 up. At baseline pt does have
DOE but unclear distance he can walk given left foot ulcer
limits mobility significantly. CXR showed significant pulmonary
edema. Patient had a TTE this admission that demonstrated an EF
of 25-30% (down from 50% approx 10 yrs ago). The patient was
given furosemide diuresis after which his saturations and
crackles improved.  He was saturating well and without shortness
of breath by the day of discharge. He is being discharged on a
limited anti-ischemic regimen given SBP in 90s/low 80s including
a statin. He should start lasix 20 mg PO qD. Future
considerations should be re-starting metoprolol, ACEi when renal
function stabilizes.
.
# Osteomyelitis: Patient was found to have a left foot ulcer
with dry and wet gangrene of left toe and lateral foot, which on
evaluation probed to bone and was purulent. He is being treated
with IV Vancomycin and Cefepime. Foot xray inconclusive.
Apparently, patient has been evaluated at [**Hospital 1263**] hospital for
this and recently (w/in a month) had an MRI there. Those records
were unable to be obtained, but there was high clinical
suspicion for osteomyelitis (secondary to elevated inflammatory
markers, L foot lateral plantar lower extremity probes to bone
and has purulence). Podiatry consulted and performed bedside
incisions and drainages followed by debridement under general
anesthesia on [**8-22**].

Patient will follow-up with podiatry as scheduled. He is being
discharged with a wet-to-dry and should have wound vac as
instructed re-started at rehab. He should keep wound vac on
until podiatry follow-up.
.
# Refusal of treatment in setting of Personality Disorder - Pt
is very difficult to manage and will intermittently refuse
various IV and PO medications daily, despite understanding the
risks and consquences. Additionally, the patient would not allow
any care whatsoever, including vital signs, repletion of vital
electrolytes, antibiotics for his foot medications, heparin SQ,
etc during evening and nighttime hours. Psychiatry was consulted
and determined that he had the mental capacity to make
decisions, even though he understood that he could die. Social
work was also consulted and determined from discussions with
patient's HCP that pt "will often respond well to encouragement
and reasoning behind a procedure/test but will 'dig his heels
in' should he be told he needs to have something done."
.
# Elevated FSBG: 565 in ED, AG = 14, FSBG fluctuates. Home dose
40U Lantus qHS. No signs and symptoms of DKA or non-ketotic
hyperosmolar come. HgA1C 10.6. [**Last Name (un) **] Diabetes was consulted and
assisted in the management of his blood glucose while an
inpatient with a standing lantus and a humalog insulin sliding
scale. His metformin and glipizide were discontinued and kept
off at discharge due to significant noncompliance with PO
medications.
.
# Acute vs chronic CKD? - Cr this admission fluctuated between
1.5 to 2, which is consistent with OSH records from earlier this
year, but values down to 1.2 seen in [**Month (only) 205**] records. Increase here
was likely secondary to diuresis vs poor renal perfusion in
setting of sCHF.  His Cr was 1.9 on day of discharge.
.
# Complicated cystitis secondary to E. Coli resistant to cipro:
He had evidence of infection on a urinalysis.  He denied
dysuria, but may have been confused so it was decided to treat
as a UTI. He was initially treated with Cipro, but his E. coli
was resistant so he was switched to Cefepime for 7 total doses.
Patient lost IV access so missed 2 doses in the middle of the
course. His course was also complicated by intermittent and
unpredicatble refusal of medications at times. He was
asymptomatic and urinating without issues by day of discharge.
.
# Acute encephalopathy,toxic-metabolic, resolved: The patient's
course was likely complicated by delirium, with report of
aggression towards medical staff requiring administration of
Haldol in the ED and CCU. On the medical floor, psychiatry was
consulted and by that time patient was alert and fully oriented
as well as capacitated.
.
# LLE swelling - Remained stable during the admission. Likely
due to CHF and/or PVD. Lower extremity noninvasive imaging
showed no DVT
.
# low normal BP/Hypotension (systolic in high 80s to low 90s) -
Likely due to hypovolemia s/p diuresis. Patient remained
asymptomatic at all times, mentating at his baseline. Offered
compression stockings to help increase venous return, as patient
spent all day in the chair and refused the bed unless it is
nighttime.
Metoprolol and lisinopril held due to hypotension. By day of
discharge His BP was stable with systolic 90s to low 100s with
HR 80s.
.
# TRANSITIONAL ISSUES:
1) Patient is DNR/DNI
2) Weekly Labs: Chem 7 including BUN, Cr, ESR, CRP, CBC with
differential
3) Continue diabetes therapy
4) Continue to advance heart failure therapy as above
5) Continue wound vac for LLE wound
6) Monitor diabetes regimen and PO intake

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Metoprolol Tartrate 50 mg PO BID
hold for sbp < 100, hr < 55
2. Omeprazole 40 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. GlipiZIDE 10 mg PO BID
6. Lantus *NF* (insulin glargine) 40 U Subcutaneous HS
7. Aspirin 81 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL PRN chest pain


Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Simvastatin 20 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL PRN chest pain
5. Ceftaroline 400 mg IV Q12H
d1 = [**2188-8-26**] for osteomyelitis. Course to be determined by
infectious disease.
6. Furosemide 20 mg PO DAILY
hold for SBP < 100
7. Heparin 5000 UNIT SC TID
8. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
d1 = [**2188-8-26**] for osteomyelitis.
10. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN groin rash
11. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
12. Outpatient Lab Work
Fax weekly safety labs to the below infectious disease provider:
[**Name10 (NameIs) 23870**], [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D.
Phone:([**Telephone/Fax (1) 4170**]
Fax:([**Telephone/Fax (1) 1353**]
ICD-9: 730 (osteomyelitis)
Start date: [**2188-9-1**]
Frequency: weekly
Labs: Chem 7 including BUN, Cr, ESR, CRP, CBC with differential


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] Northeast Hospitial

Discharge Diagnosis:
Primary: Osteomyelitis
Secondary: Acute on chronic systolic heart failure, complicated
cystitis, Diabetes Mellitus


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.


Discharge Instructions:
Dear Mr. [**Known lastname 111698**]:

It was a pleasure caring for you at [**Hospital1 827**].  You were admitted because you were found to
have several issues, including very high blood sugars, worsening
of your heart failure (characterized by fluid in your lungs and
your legs), a serious infection of your foot, and a urinary
tract infection.  We treated you with insulin to control your
sugar, antibiotics for your infections, and used a "water-pill"
to remove fluid from your body. The foot doctors (Podiatry)
opened up and drained/removed some of the infected material of
your foot.

You will need to follow-up with the podiatry and infectious
disease doctors for further [**Name5 (PTitle) **].

Followup Instructions:
Please follow-up with your primary care physician as below after
discharge from rehab:
[**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 8894**]

Department: INFECTIOUS DISEASE
When: TUESDAY [**2188-9-16**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: PODIATRY
When: FRIDAY [**2188-9-5**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], 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

Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2188-10-8**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23870**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2188-9-2**]
{'Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Acute on chronic systolic heart failure,Unspecified osteomyelitis, ankle and foot,Other acute and subacute forms of ischemic heart disease, other,Gangrene,Ulcer of heel and midfoot,Other bone involvement in diseases classified elsewhere,Long-term (current) use of insulin,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Other and unspecified hyperlipidemia,Physical restraints status,Personal history of noncompliance with medical treatment, presenting hazards to health,Cystitis, unspecified,Other and unspecified Escherichia coli [E. coli],Toxic encephalopathy,Narcissistic personality disorder,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Encounter for change or removal of surgical wound dressing'}


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: 73 yo M w/ DM2 (c/b left plantar ulcer), CAD s/p MI and CABG
[**2174**] (LIMA-LAD, rSVG-CX, SVG-PDA, SVGPL) who p/f [**Hospital1 1501**]([**Hospital1 **])
with nausea and SOB. Pt denies CP. Notes that emesis started 4
days ago (once daily), none today. Describes SOB as DOE that he
has at baseline and not a new symptom. No oxygen requirement at
[**Hospital1 1501**]. Limited in his ability to ambulate to due diabetic ulcer on
left foot, not limited by SOB. Of note patient has been poorly
compliant with meds x 4 month and almost fully refusing meds x 3
days, notes that 4 months ago [**Hospital1 1501**] staff changed his room around
not to his liking and 3 days ago again similar issue. Stopped
oral meds, continued insulin injections. Confirms DNR/DNI.
.
In the ED, initial vitals were 98.6 107 117/76 16 98% 4L. Labs
and imaging significant for BS>500, TnT 0.50, Cr 1.6, CK 69,  MB
5, WBC 13.7, 87.7%PMNs, CXR showed pulmonary edema could not r/o
PNA, ED interpretation of EKG: STE 1mm aVR/V1, STD 1-2mm I, II,
L, V3-6, septal Q's.  He was seen by cardiology in the ED and it
was explained to him that he may be having a STEMI, but patient
refused catheterization.
.
Patient given Glipizide 10mg, Metformin 500, Insulin 10 Units,
Azithro, not started Insulin gtt, not started on heparin gtt, no
ASA, no BB. BS from 565 to 480. DNR/DNI (confirmed with nursing
home). Has left plantar diabetic ulcer treated every Friday at
[**Doctor Last Name 1263**] with wet to dry dressing changes.
.
Vitals on transfer were 103 103/68 27 98%.
.
Vitals on arrival: NAD, 100, 132/77, 24, 89-92% on RA.
.
OVERNIGHT: Did not allow lab draw, checked FSBG  230, did not
want any interventions other than sq insulin, and some oral
meds. Refused Heparin gtt, refused plavix, refused cath. No CP,
no SOB.  Fell while going to the bathroom, did not want
assistance.

MEDICAL HISTORY: DM2 (Diabetic foot ulcer treated at [**Doctor Last Name 1263**] wound clinic every
Friday)
Dyslipidemia
Hypertension
CABG [**2174**] (LIMA-LAD, rSVG-CX, SVG-PDA, SVGPL)
Bell's Palsy
Diverticular disease w/hx GIB

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Metoprolol Tartrate 50 mg PO BID
hold for sbp < 100, hr < 55
2. Omeprazole 40 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. GlipiZIDE 10 mg PO BID
6. Lantus *NF* (insulin glargine) 40 U Subcutaneous HS
7. Aspirin 81 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL PRN chest pain

ALLERGIES: Penicillins

PHYSICAL EXAM: ADMISSION:
VS: 132/77, 100, 25, 89-93% on RA
GENERAL: looks stated age, poor hygeine, poor odor, Oriented x3,
Requires full control of situation and very clear about what he
does and does not want done.
HEENT: MMM, Sclera anicteric, EOMI, No pallor or cyanosis of the
oral mucosa. Poor dentition.
NECK: JVP seems to be to tragus?
CARDIAC: Tachycardic, +S1+S2, no M/R/G.
LUNGS: On RA. CrackleS 2/3 up b/l. Accessory muscle use. Can
speak in full sentences.
ABDOMEN: Distended but soft, non tender, no rebound.
EXTREMITIES: Pitting edema b/l Left > Right up to mid thigh,
patietn did not allow visualization of left plantar ulcer, right
toe nails yellow and dysmorphic.
- No Sensation up to knee on left lateral leg, right foot, left
foot
PULSES:  [**Name (NI) **] PT on left (did not allow DP), DP/PT on
right

FAMILY HISTORY: - Father MI in 60s, no heart history in mother
- Brother alive, no heart history

SOCIAL HISTORY: -Tobacco history: smoked for 1 year in past 50 years ago
-ETOH: none currently briefly in past
-Illicit drugs: none
- never married, no kids
- former CPA
- lives at [**Hospital1 1501**] [**Hospital1 **] 

### Response:
{'Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Acute on chronic systolic heart failure,Unspecified osteomyelitis, ankle and foot,Other acute and subacute forms of ischemic heart disease, other,Gangrene,Ulcer of heel and midfoot,Other bone involvement in diseases classified elsewhere,Long-term (current) use of insulin,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Other and unspecified hyperlipidemia,Physical restraints status,Personal history of noncompliance with medical treatment, presenting hazards to health,Cystitis, unspecified,Other and unspecified Escherichia coli [E. coli],Toxic encephalopathy,Narcissistic personality disorder,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Encounter for change or removal of surgical wound dressing'}
