CHIEF COMPLAINT: Nausea/vomiting

PRESENT ILLNESS: 60F with a history of diabetes mellitus (type I vs. type II),
HTN, HLD, PVD and multiple recent hospital admissions (first for
pneumonia, requiring ICU admission with intubation) and then
earlier this month for altered mental status felt secondary to
UTI. At that time, she was initially treated with IV antibiotics
(vanco/cefepime -> ceftriaxone) but then discharged on Bactrim
to complete a 14-day course. No organism was ever isolated from
the urine. At home, she reports continued dysuria (burning) that
never resolved. For the last several days, she's been having
worsening nausea and vomiting (mulitple 6-7 episodes today prior
to presentation) as well as diarrhea/loose stool (no blood). She
has not had a bowel movement since arrival in the ED.

MEDICAL HISTORY: 1. DM2: insulin-dependent may be Type 1
-followed by [**Hospital **] Clinic
-c/b recurrent ulcers, urosepsis
-Charcot deformity
2. s/p amputation of L 2nd & 3rd toe
3. chronic ulcer of R pretibia
4. hx of MRSA foot [**3-/2125**]
5. HTN
6. PVD
7. hypercholesterolemia
8. Anemia, ? ACD, baseline low 30s
9. Hematemesis in [**2125**] thought to be [**1-15**] small [**Doctor First Name 329**] [**Doctor Last Name **],
EGD ulcer in GE junction

MEDICATION ON ADMISSION: - insulin levemir 70 units qHS
- insulin lispro sliding scale-
rough idea of: Bglc 150- 2-3U; Bglc 200- 15U; Bglc 250- 30U;
Bglc 300- 40U
- lisinopril 20 mg PO once a day
- nortriptyline 75 mg PO HS
- pantoprazole 40 mg PO Q24H
- rosuvastatin 20 mg PO DAILY
- aspirin 325 mg PO DAILY
- hydrochlorothiazide 25 mg PO DAILY
- docusate sodium 100 mg PO BID as needed for constipation
- senna 8.6 mg PO BID as needed for constipation
- sulfamethoxazole-trimethoprim 800-160 mg PO BID last dose
[**2133-3-5**]

ALLERGIES: Gatifloxacin / Penicillins / Ciprofloxacin / Bactrim

PHYSICAL EXAM: ADMISSION EXAM:
General: Alert, oriented, no acute distress. Speaking in full
sentences.
HEENT: Sclera anicteric, MMM, oropharynx clear. Left pupil is
1-2 mm bigger than the right, slightly irregular, and poorly
reactive compared with the right. Patient reports prior surgery
on this eye and thinks this may be her baseline.
Neck: Supple, JVP not elevated (though difficult to assess given
body habitus), no LAD
Lungs: Clear to auscultation bilaterally (distant given body
habitus), no wheezes, rales, rhonchi
CV: Regular rate and rhythm, distant S1 + S2 but no audible
murmurs, rubs, gallops
Abdomen: Soft/obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: Foley in place
Ext: Chronic venous stasis changes bilaterally on lower
extremities. Multiple skin lesions/ulcerations more on the right
leg which appear chronic but per patient are healing slowly.

FAMILY HISTORY: Mother had DM2, died of diabetes related coma
Father has DM2, still alive
Several family members on paternal side with DM2
No FH of CAD, MI, or cancer.

SOCIAL HISTORY: The patient lives with her husband and has a 10 year old child.
She works at the Causeway VA as a secretary. She smokes 10 cigs
per day x 40 years. No ETOH and drugs.
Acute kidney failure, unspecified,Ulcer of calf,Paroxysmal ventricular tachycardia,Nausea with vomiting,Hyperpotassemia,Arthropathy associated with neurological disorders,Other and unspecified hyperlipidemia,Morbid obesity,Sulfonamides causing adverse effects in therapeutic use,Peripheral vascular disease, unspecified,Other nonspecific findings on examination of urine,Other second degree atrioventricular block,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Personal history of Methicillin resistant Staphylococcus aureus,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
Acute kidney failure NOS,Ulcer of calf,Parox ventric tachycard,Nausea with vomiting,Hyperpotassemia,Arthropathy w nerve dis,Hyperlipidemia NEC/NOS,Morbid obesity,Adv eff sulfonamides,Periph vascular dis NOS,Abn urine findings NEC,Av block-2nd degree NEC,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Long-term use of insulin,Hx Methicln resist Staph,DMII neuro uncntrld
Admission Date:  [**2133-3-6**]              Discharge Date:   [**2133-3-11**]

Date of Birth:  [**2072-6-13**]             Sex:   F

Service: MEDICINE

Allergies:
Gatifloxacin / Penicillins / Ciprofloxacin / Bactrim

Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
Nausea/vomiting

Major Surgical or Invasive Procedure:
PICC placement

History of Present Illness:
60F with a history of diabetes mellitus (type I vs. type II),
HTN, HLD, PVD and multiple recent hospital admissions (first for
pneumonia, requiring ICU admission with intubation) and then
earlier this month for altered mental status felt secondary to
UTI. At that time, she was initially treated with IV antibiotics
(vanco/cefepime -> ceftriaxone) but then discharged on Bactrim
to complete a 14-day course. No organism was ever isolated from
the urine. At home, she reports continued dysuria (burning) that
never resolved. For the last several days, she's been having
worsening nausea and vomiting (mulitple 6-7 episodes today prior
to presentation) as well as diarrhea/loose stool (no blood). She
has not had a bowel movement since arrival in the ED.

In the ED inital vitals were T 97.8, HR 70, BP 140/91, RR 16, O2
sat 97% RA. Initial labs returned notable for hyperkalemia in
non-hemolyzed specimen to 7.2. Subsequently, the patient was
noted to develop arrhythmia on telemetry with
bigeminy/Wenckebach and short runs of VT (~10 beats). During
runs of VT, she had palpable pulse in 40s despite rate in
110s-150s on monitor, and was symptomatic (lightheaded) with
these episodes. She was given albuterol nebs, 40 mg IV
furosemide, calcium gluconate, insulin/D50 and kayexelate. Prior
to transfer, a U/A was checked and returned dirty, so she
received a dose of ceftriaxone and also got 2g of IV magnesium.
Vitals on transfer were HR 102, BP 124/84, O2 sat 100% on RA, T
98.6.

On arrival to the ICU, she is vomiting x multiple times,
non-bloody, non-bilious. She reports having some SOB in the ED
with the arrhythmias, but no chest pain or palpitations.
Breathing is now comfortable. She denies abdominal pain but
still having nausea (especially with movement).


Past Medical History:
1. DM2: insulin-dependent may be Type 1
-followed by [**Hospital **] Clinic
-c/b recurrent ulcers, urosepsis
-Charcot deformity
2. s/p amputation of L 2nd & 3rd toe
3. chronic ulcer of R pretibia
4. hx of MRSA foot [**3-/2125**]
5. HTN
6. PVD
7. hypercholesterolemia
8. Anemia, ? ACD, baseline low 30s
9. Hematemesis in [**2125**] thought to be [**1-15**] small [**Doctor First Name 329**] [**Doctor Last Name **],
EGD ulcer in GE junction


Social History:
The patient lives with her husband and has a 10 year old child.
She works at the Causeway VA as a secretary. She smokes 10 cigs
per day x 40 years. No ETOH and drugs.


Family History:
Mother had DM2, died of diabetes related coma
Father has DM2, still alive
Several family members on paternal side with DM2
No FH of CAD, MI, or cancer.

Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, no acute distress. Speaking in full
sentences.
HEENT: Sclera anicteric, MMM, oropharynx clear. Left pupil is
1-2 mm bigger than the right, slightly irregular, and poorly
reactive compared with the right. Patient reports prior surgery
on this eye and thinks this may be her baseline.
Neck: Supple, JVP not elevated (though difficult to assess given
body habitus), no LAD
Lungs: Clear to auscultation bilaterally (distant given body
habitus), no wheezes, rales, rhonchi
CV: Regular rate and rhythm, distant S1 + S2 but no audible
murmurs, rubs, gallops
Abdomen: Soft/obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: Foley in place
Ext: Chronic venous stasis changes bilaterally on lower
extremities. Multiple skin lesions/ulcerations more on the right
leg which appear chronic but per patient are healing slowly.

DISCHARGE EXAM:
VS; TC 98.4 BP 137-159/74-75 HR 78-82 RR 18-20 96% RA
GENERAL - well-appearing F in NAD, comfortable, appropriate
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - ctab, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, ecchymosis at heparin shot sites
EXTREMITIES - hyperpigementation from mid-shin down bilaterally
with erythema and several draining wounds bilaterally, feet
wrapped, with weeping, raw erythema (per patient, this is
chronic), no edema
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-18**] throughout, sensation grossly intact throughout


Pertinent Results:
ADMISSION LABS:
[**2133-3-6**] 06:20PM BLOOD WBC-10.5 RBC-5.11 Hgb-15.1 Hct-48.9*
MCV-96 MCH-29.6 MCHC-30.9* RDW-13.8 Plt Ct-248
[**2133-3-6**] 06:20PM BLOOD Neuts-79.7* Lymphs-15.0* Monos-2.8
Eos-1.8 Baso-0.8
[**2133-3-6**] 09:50PM BLOOD Glucose-484* UreaN-28* Creat-2.1* Na-138
K-5.6* Cl-100 HCO3-25 AnGap-19
[**2133-3-6**] 06:20PM BLOOD Glucose-359* UreaN-28* Creat-2.0*
[**2133-3-6**] 09:50PM BLOOD CK(CPK)-84
[**2133-3-6**] 06:20PM BLOOD cTropnT-0.01
[**2133-3-7**] 02:10PM BLOOD CK-MB-4 cTropnT-0.01
[**2133-3-6**] 06:20PM BLOOD Calcium-9.5 Phos-3.9 Mg-1.8
[**2133-3-7**] 03:06AM BLOOD Osmolal-312*
[**2133-3-7**] 03:20AM BLOOD Type-ART pO2-70* pCO2-41 pH-7.41
calTCO2-27 Base XS-0
[**2133-3-7**] 03:20AM BLOOD Lactate-2.3* Na-136 K-4.4 Cl-99
[**2133-3-7**] 03:20AM BLOOD freeCa-1.13

DISCHARGE LABS:
[**2133-3-11**] 05:58AM BLOOD WBC-6.1 RBC-4.37 Hgb-12.9 Hct-42.1 MCV-96
MCH-29.6 MCHC-30.7* RDW-13.6 Plt Ct-189
[**2133-3-11**] 05:58AM BLOOD Glucose-144* UreaN-22* Creat-1.5* Na-139
K-4.2 Cl-102 HCO3-27 AnGap-14
[**2133-3-11**] 05:58AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.9

MICROBIOLOGIC DATA:
[**2133-3-6**] Urine culture - yeast

IMAGING STUDIES:
[**2133-3-7**] CHEST (PORTABLE AP) - Heart size and mediastinum are
unremarkable. There is no evidence of interstitial pulmonary
edema. There is no appreciable pleural effusion. Minimal
bibasal, left more than right, atelectasis is present.

STRESS [**2133-3-10**]:
INTERPRETATION: 60 yo woman with HTN, HL, DM and morbid obesity;
h/o
stage III CHD and PVD was referred to evaluate an episode of
nonsustained VT. The patient was administered 0.142 mg/kg/min of

Persantine over 4 minutes. No chest, back, neck or arm
discomforts were
reported by the patient during the procedure. No significant ST
segment
changes were noted. The rhythm was sinus with one instance of a
sinus
pause vs SA Exit block noted post-infusion; there was no blocked
sinus
or atrial premature beat noted on the ECG. The heart rate and
blood
pressure response to exercise was appropriate. Post-infusion,
the
patient was administered 125 mg Aminophylline IV.
IMPRESSION: No anginal symptoms or ischemic ST segment changes.
Appropriate hemodynamic response to the Persantine infusion.
Nuclear
report sent separately.

MIBI [**2133-3-11**]:

The image quality is poor due to extensive soft tissue and
breast attenuation.
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal probably uniform
tracer uptake
throughout the left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 58% with an
EDV of 78 ml.
IMPRESSION:
1. Probably normal myocardial perfusion in the setting of
extensive
attenuation.
2. Normal left ventricular cavity size and systolic function.
In the setting of diabetes, normal myocardial perfusion does not
necessarily imply a low risk of adverse cardiac events.


Brief Hospital Course:
60 y/o F with diabetes (multiple complications), HTN, HLD, PVD
and two recent hospitalizations who presented with N/V/D and
found to have hyperkalemia and arrhythmia in the ED.

# HYPERKALEMIA - Patient was noted to have hyperkalemia to 7.2
on admission. The etiology of her symptoms is not entirely
clear, but it was possibly multifactorial with contributions
from ACE inhibitor use, hyperglycemia and low insulin state,
worsening renal failure in the setting of dehydration, and
recent Bactrim use. However, the relationship with bactrim seems
to be most striking as her elctrolyte imbalances were corrected
after she stopped taking the bactrim. She received multiple
treatments in the ED including calcium gluconate, furosemide,
albuterol, insulin with D50 and kayexelate. Her potassium
improved with these interventions. She was monitored via
telemetry and her EKGs remained stable. Her ACEI was held in
this setting. CK values stable without evidence of
rhabdomyolysis.

# ARRHYTHMIA - Patient was noted to have bigeminy and Wenckebach
pattern on telemetry in the ED, with multiple self-limited runs
of ? VT with rate in 100s-150s associated with palpable pulse
drop to 40s and lightheadedness (patient reports symptoms were
not severe, no LOC). This was attributed to electrolyte
imbalance. She was maintained on telemetry and her EKGs remained
reassuring. However, she continued to have brief runs of VT
(upto 11 beats) even after stabilization. She was started on
metoprolol XL 25. A percantine MIBI was performed which showed
NO ISCHEMIA and normal myocardium.

# ACUTE ON CHRONIC RENAL FAILURE - Baseline of 1.1-1.3, peaked
at 2.1. Likely partially prerenal in the setting of dehydration
from nausea and emesis.  FeNA >2%, concerning intrinsic causes
such as ATN, Bactrim-induced crystal nephropathy was felt to be
msot likely. Now trending still 1.6-1.7.  Patient initially
received IVF boluses.  Lisinopril and HCTZ were held but HTZ was
restarted.

# POSITIVE U/A - Patient hax > 182 WBCs in urine despite
recently completing a course of Bactrim for UTI (ended day prior
to admission). No organisms were isolated from her last culture
at prior admission. Patient continues to report dysuria
(burning) never fully resolved since last admission. A urine
culture was obtained and she was treated with IV Ceftriaxone x3
days till urine culture showed yeast and no bacteria. Vaginal
estrogen for UTI prevention was started.

# VOMITING/DIARRHEA - Unclear etiology, though given presence of
diarrhea viral gastroenteritis seems likely. Diarrhea could also
be due to recent antibiotics, with N/V due to other cause such
as UTI or medications (Bactrim). Cardiac etiology is unlikely,
and troponin negative.  Tolerated regular diet on discharge.

# HYPERGLYCEMIA/DIABETES MELLITUS - Possibly type I as the
patient is insulin dependent and has multiple complications. She
was hyperglycemic on arrival to 359 on labs, which may be
related to underlying illness (e.g. gastroenteritis vs. UTI).
After receiving D50 in the ED, glucose was elevated to
"critically high" on arrival to the ICU. This may represent HONK
given calculated serum osm of 313. She received 10 units of
regular insulin with improvement on arrival to the MICU.
Subsequent glucose values improved.  On the floor, patient with
difficult to control blood glucose, in the 300-400s, partially
because she did not know her insulin sliding scale, which was
uptitrated rapidly.

# SKIN CHANGES - Chronic ulcerations are improving per patient.
A wound consult was obtained for guidance with dressing changes.

# HYPERTENSION - Lisinopril and HCTZ were held in the setting of
[**Last Name (un) **] (see above).  SBP 130-150s off antihypertensives.  Received
PO hydralazine 10mg x1 for SBP>160. Howeevr, HTZ was restarted
and she was initiated on amlodipine 5mg and metoprolol XL 25.

# HYPERCHOLESTEROLEMIA - Her statin medication was continued.

# TRANSITION OF CARE ISSUES:
Lisinopril is being held and can be restarted if Cr stable on
visit to Dr [**Last Name (STitle) 1147**]. Vaginal estrogen for UTI prevention was
started. Metoprolol XL and amlodipine were also started. Pt has
followup with [**Last Name (un) **] and PCP.

Medications on Admission:
- insulin levemir 70 units qHS
- insulin lispro sliding scale-
rough idea of: Bglc 150- 2-3U; Bglc 200- 15U; Bglc 250- 30U;
Bglc 300- 40U
- lisinopril 20 mg PO once a day
- nortriptyline 75 mg PO HS
- pantoprazole 40 mg PO Q24H
- rosuvastatin 20 mg PO DAILY
- aspirin 325 mg PO DAILY
- hydrochlorothiazide 25 mg PO DAILY
- docusate sodium 100 mg PO BID as needed for constipation
- senna 8.6 mg PO BID as needed for constipation
- sulfamethoxazole-trimethoprim 800-160 mg PO BID last dose
[**2133-3-5**]

Discharge Medications:
1. nortriptyline 75 mg Capsule Sig: One (1) Capsule PO at
bedtime.
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
8. conjugated estrogens 0.625 mg/gram Cream Sig: One (1) gram
Vaginal DAILY (Daily).
Disp:*3 tubes* Refills:*0*
9. Humalog  Subcutaneous
10. Levemir 100 unit/mL Solution Sig: Seventy (70) units
Subcutaneous at bedtime.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.


Discharge Disposition:
Home With Service

Facility:
All Care VNA of Greater [**Location (un) **]

Discharge Diagnosis:
PRIMARY:
Nausea/vomiting/diarrhea
Hyperkalemia
Pyuria

SECONDARY:
Hypertension
Diabetes Mellitus


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Ms. [**Known lastname 35127**],

It was a pleasure participating in your care at [**Hospital1 18**].  You were
admitted because you had nausea, vomiting and diarrhea.  We
thought this was likely due to Bactrim.  As a result of the
vomiting and diarrhea, your kidney function decreased.  We
stopped your lisinopril while your kidneys are recovering.  You
also had high potassium which we treated with medications.

There was a question of recurrent UTI and we treated you with
antibiotics.  We stopped your antibiotics because your urine
culture did not grow bacteria. You are being started on a
vaginal cream that should help prevent UTIs in the future.

There were also some irregular heart rhythms noted while you
were admitted. We performed a stress test which ruled out any
underlying heart damage that may have been contributing to the
abnormal heart rhythm. The results of the test were normal.

We made the following changes to your medications:
- STOPPED Lisinopril: please restart after having your kidney
function assessed by Dr [**Last Name (STitle) 1147**].
- STARTED Vaginal Estrogen Cream: this cream, applied once
daily, will help prevent Urinary Tract Infections in the future.

- STARTED Metoprolol XL 25mg to alleviate irregularities in
heart beat
- STARTED Amlodipine 5mg (Norvasc) for blood pressure control

**Please bring your insulin sliding scale chart with you to your
[**Last Name (un) **] appointment**

Followup Instructions:
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**], NP
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Appt:  Tuesday, [**3-17**] at 1:30pm

Department: ADULT MEDICINE
When: THURSDAY [**2133-3-26**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site
{'Acute kidney failure, unspecified,Ulcer of calf,Paroxysmal ventricular tachycardia,Nausea with vomiting,Hyperpotassemia,Arthropathy associated with neurological disorders,Other and unspecified hyperlipidemia,Morbid obesity,Sulfonamides causing adverse effects in therapeutic use,Peripheral vascular disease, unspecified,Other nonspecific findings on examination of urine,Other second degree atrioventricular block,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Personal history of Methicillin resistant Staphylococcus aureus,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled'}


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: Nausea/vomiting

PRESENT ILLNESS: 60F with a history of diabetes mellitus (type I vs. type II),
HTN, HLD, PVD and multiple recent hospital admissions (first for
pneumonia, requiring ICU admission with intubation) and then
earlier this month for altered mental status felt secondary to
UTI. At that time, she was initially treated with IV antibiotics
(vanco/cefepime -> ceftriaxone) but then discharged on Bactrim
to complete a 14-day course. No organism was ever isolated from
the urine. At home, she reports continued dysuria (burning) that
never resolved. For the last several days, she's been having
worsening nausea and vomiting (mulitple 6-7 episodes today prior
to presentation) as well as diarrhea/loose stool (no blood). She
has not had a bowel movement since arrival in the ED.

MEDICAL HISTORY: 1. DM2: insulin-dependent may be Type 1
-followed by [**Hospital **] Clinic
-c/b recurrent ulcers, urosepsis
-Charcot deformity
2. s/p amputation of L 2nd & 3rd toe
3. chronic ulcer of R pretibia
4. hx of MRSA foot [**3-/2125**]
5. HTN
6. PVD
7. hypercholesterolemia
8. Anemia, ? ACD, baseline low 30s
9. Hematemesis in [**2125**] thought to be [**1-15**] small [**Doctor First Name 329**] [**Doctor Last Name **],
EGD ulcer in GE junction

MEDICATION ON ADMISSION: - insulin levemir 70 units qHS
- insulin lispro sliding scale-
rough idea of: Bglc 150- 2-3U; Bglc 200- 15U; Bglc 250- 30U;
Bglc 300- 40U
- lisinopril 20 mg PO once a day
- nortriptyline 75 mg PO HS
- pantoprazole 40 mg PO Q24H
- rosuvastatin 20 mg PO DAILY
- aspirin 325 mg PO DAILY
- hydrochlorothiazide 25 mg PO DAILY
- docusate sodium 100 mg PO BID as needed for constipation
- senna 8.6 mg PO BID as needed for constipation
- sulfamethoxazole-trimethoprim 800-160 mg PO BID last dose
[**2133-3-5**]

ALLERGIES: Gatifloxacin / Penicillins / Ciprofloxacin / Bactrim

PHYSICAL EXAM: ADMISSION EXAM:
General: Alert, oriented, no acute distress. Speaking in full
sentences.
HEENT: Sclera anicteric, MMM, oropharynx clear. Left pupil is
1-2 mm bigger than the right, slightly irregular, and poorly
reactive compared with the right. Patient reports prior surgery
on this eye and thinks this may be her baseline.
Neck: Supple, JVP not elevated (though difficult to assess given
body habitus), no LAD
Lungs: Clear to auscultation bilaterally (distant given body
habitus), no wheezes, rales, rhonchi
CV: Regular rate and rhythm, distant S1 + S2 but no audible
murmurs, rubs, gallops
Abdomen: Soft/obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: Foley in place
Ext: Chronic venous stasis changes bilaterally on lower
extremities. Multiple skin lesions/ulcerations more on the right
leg which appear chronic but per patient are healing slowly.

FAMILY HISTORY: Mother had DM2, died of diabetes related coma
Father has DM2, still alive
Several family members on paternal side with DM2
No FH of CAD, MI, or cancer.

SOCIAL HISTORY: The patient lives with her husband and has a 10 year old child.
She works at the Causeway VA as a secretary. She smokes 10 cigs
per day x 40 years. No ETOH and drugs. 

### Response:
{'Acute kidney failure, unspecified,Ulcer of calf,Paroxysmal ventricular tachycardia,Nausea with vomiting,Hyperpotassemia,Arthropathy associated with neurological disorders,Other and unspecified hyperlipidemia,Morbid obesity,Sulfonamides causing adverse effects in therapeutic use,Peripheral vascular disease, unspecified,Other nonspecific findings on examination of urine,Other second degree atrioventricular block,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Personal history of Methicillin resistant Staphylococcus aureus,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled'}
