CHIEF COMPLAINT: hypoglycemia

PRESENT ILLNESS: 79M with CAD s/p recent admission persistent chest pain, ruling
in for NSTEMI, 3VD on cath and now s/p in CABG w/[**First Name3 (LF) 1291**] on [**2180-10-5**],
DMII found unresponsive at NH with a finger stick of 37 and
given glucagon x2.  he was taken to [**Hospital 4068**] Hospital and
intubated for airway protection.  He had a CXR with possible RLL
pna and a Head CT that was negative.  he was given Levo/Flagyl
and transferred to [**Hospital1 18**]. In our ED his vitals were:

MEDICAL HISTORY: CAD s/p 3v CABG [**2180-10-5**] (LIMA to LAD, SVG to OM, SVG to RCA)
St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] 8/28/8
dCHF (EF 55-60% [**2179-4-23**] TTE)
AS ([**Location (un) 109**] 1.0 cm2 [**2179-4-23**] TTE)
DMII
HTN
hyperlipidemia
prostate CA s/p prostatectomy

MEDICATION ON ADMISSION: Aspirin 81 mg Tablet
Acetaminophen 325 mg
Docusate Sodium 100 mg [**Hospital1 **]
Albuterol Sulfate prn
Ipratropium Bromide 0.02 % prn
Folic Acid 1 mg qd
Thiamine HCl 100 mg qd
Atorvastatin 80 mg qd
Atenolol 12.5 mg qd
Furosemide 20 mg [**Hospital1 **]
Insulin Glargine 25U daily
Insulin Lispro Sliding Scale
Fosamax 70 mg Tablet weekly
Metformin 500 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tmax: 35.9 ??????C (96.6 ??????F)

FAMILY HISTORY: Mother had CVA. Father had bladder CA. No known h/o premature
CAD.

SOCIAL HISTORY: Lives with wife in [**Name (NI) **], MA. Retired salesman. Former 3
pack/day smoker, quit >30 years ago. Currently smokes a pipe.
Drinks 2-4 ETOH 2-3x/week.
Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Acute on chronic combined systolic and diastolic heart failure,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Ventilator associated pneumonia,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Heart valve replaced by transplant,Subendocardial infarction, subsequent episode of care,Aortocoronary bypass status,Personal history of malignant neoplasm of prostate
Acute respiratry failure,Food/vomit pneumonitis,Ac/chr syst/dia hrt fail,Urin tract infection NOS,Acute kidney failure NOS,Ventltr assoc pneumonia,DMII oth nt st uncntrld,Hypertension NOS,Hyperlipidemia NEC/NOS,Heart valve transplant,Subendo infarct, subseq,Aortocoronary bypass,Hx-prostatic malignancy
Admission Date:  [**2180-12-4**]              Discharge Date:   [**2180-12-13**]

Date of Birth:  [**2101-6-9**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
hypoglycemia

Major Surgical or Invasive Procedure:
arterial line placement

History of Present Illness:
79M with CAD s/p recent admission persistent chest pain, ruling
in for NSTEMI, 3VD on cath and now s/p in CABG w/[**First Name3 (LF) 1291**] on [**2180-10-5**],
DMII found unresponsive at NH with a finger stick of 37 and
given glucagon x2.  he was taken to [**Hospital 4068**] Hospital and
intubated for airway protection.  He had a CXR with possible RLL
pna and a Head CT that was negative.  he was given Levo/Flagyl
and transferred to [**Hospital1 18**]. In our ED his vitals were:

986 60 117/40 16*550 PEEP 5 100Fi02

he was given 1 amp dextrose and started on a D5 1/2NS infusion.
He had a CXR repeated which confirmed a RLL process vs CHF and
CTX was added to his antibiotic regimen. He was also given Lasix
40 IV.

He was transferred to the ICU intubated.

As per nursing staff, confused this morning, no cough, no fevers
documented. Admitted to [**Hospital **] Nursing Home on [**2180-11-29**] with no
medication changes since admission.  Patient had enterococcus
UTI and was given Cipro [**2180-12-2**].  Patient reportedly was
eating well.  No documented decreased PO intake and last dose of
insulin was given lantus 20 U this morning. 9pm BS last night
was 186 and not given any sliding scale.


Past Medical History:
CAD s/p 3v CABG [**2180-10-5**] (LIMA to LAD, SVG to OM, SVG to RCA)
St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] 8/28/8
dCHF (EF 55-60% [**2179-4-23**] TTE)
AS ([**Location (un) 109**] 1.0 cm2 [**2179-4-23**] TTE)
DMII
HTN
hyperlipidemia
prostate CA s/p prostatectomy


Social History:
Lives with wife in [**Name (NI) **], MA. Retired salesman. Former 3
pack/day smoker, quit >30 years ago. Currently smokes a pipe.
Drinks 2-4 ETOH 2-3x/week.


Family History:
Mother had CVA. Father had bladder CA. No known h/o premature
CAD.

Physical Exam:
Tmax: 35.9 ??????C (96.6 ??????F)

Tcurrent: 35.9 ??????C (96.6 ??????F)

HR: 58 (58 - 58) bpm

BP: 124/106(109) {124/106(109) - 124/106(109)} mmHg

RR: 13 (13 - 13) insp/min

SpO2: 100%

Heart rhythm: SB (Sinus Bradycardia)

General Appearance: Overweight / Obese

Head, Ears, Nose, Throat: Normocephalic

Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),
III/VI holosystolic ejection murmurs at apex and base

Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)

Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : slight crackles @ r base, No(t) Diminished: ,
Rhonchorous: L base)

Abdominal: Soft, Bowel sounds present

Extremities: Right: 2+, Left: 2+

Skin:  Not assessed

Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed


Pertinent Results:
LAB RESULTS:
[**2180-12-13**] 07:55AM BLOOD WBC-10.3 RBC-3.92* Hgb-11.0* Hct-34.0*
MCV-87 MCH-28.1 MCHC-32.4 RDW-14.8 Plt Ct-308
[**2180-12-8**] 04:09AM BLOOD Neuts-71.4* Lymphs-16.3* Monos-6.9
Eos-5.3* Baso-0.2
[**2180-12-13**] 07:55AM BLOOD Plt Ct-308
[**2180-12-13**] 07:55AM BLOOD Glucose-110* UreaN-17 Creat-1.1 Na-142
K-3.7 Cl-108 HCO3-28 AnGap-10
[**2180-12-13**] 07:55AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.1
[**2180-12-5**] 04:28AM BLOOD calTIBC-218* VitB12-1147* Folate-GREATER
TH Ferritn-185 TRF-168*
[**2180-12-9**] 11:39AM BLOOD %HbA1c-5.8
[**2180-12-5**] 04:28AM BLOOD TSH-2.1
[**2180-12-6**] 03:41AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2180-12-6**] 03:41AM BLOOD HCV Ab-NEGATIVE

Echo [**12-6**]: The left atrium is moderately dilated. No atrial
septal defect is seen by 2D or color Doppler. The right atrial
pressure is indeterminate. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. No masses or thrombi are seen in the left ventricle.
Overall left ventricular systolic function is moderately
depressed (LVEF= 30-35 %) with global hypokinesis and akinesis
of the antero-septum, anterior wall and apex. There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with moderate global free wall hypokinesis. A
bileaflet aortic valve prosthesis is present. The prosthetic
aortic valve leaflets appear normal The transaortic gradient is
normal for this prosthesis. Mild (1+) aortic regurgitation is
seen. This may be paravalvular and/or eccentric. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2180-10-10**], the
technical quality of th study has improved. The LVEF is similar.
Aortic regurgitation is now detected (was probably present on
prior study but difficult to assess).
.
.
CTA CHEST [**2180-12-4**]:
A heterogeneous lobualated left thyroid lobe is enlarged to 3.7
x 2.6 cm.

The pulmonary arteries are patent to the subsegmental level. The
aorta and
great vessels show extensive atherosclerosis . Several
borderline enlarged
mediastinal nodes include a right paratracheal and an AP window
node.
Extensive coronary artery calcification as well as post CABG.
Cardiomegaly is moderate. There is no pericardial effusion.
Bilateral effusions are moderate with left relaxation
atelectasis and right atelectasis versus consolidation noted.

The imaged upper abdomen including the liver and spleen appear
unremarkable except to note a 3 mm gallstone without evidence of
cholecystitis.

BONE WINDOWS: No concerning lytic or sclerotic lesion is
identified.
Bilateral healed and healing rib fractures are noted.
A nasogastric tube courses through the esophagus to terminate in
the upper
stomach and may be advanced further.

IMPRESSION:
1. No pulmonary embolism.
2. Moderate bilateral effusions and atelectasis.
3. Large lobulated left thyroid. Recommend correlation with
ultrasound.
4. Right lower lobe atelectasis versus pneumonia.
.
.

Brief Hospital Course:
The patient was admitted to the medical intensive care unit from
the referring hospital. He continued to be mechanically
ventilated. His hypoglycemia resolved. He had 3 days of
spontaneous breathing trials in which he was unable to come of
the vent. His hypoxia was thought secondary to decompensated
CHF. He was therefore  diuresed with a lasix drip and with the
help of phenylephrine infusion and showed improvement in blood
pressure such that phenylephrine was able to be weaned off
easily. He continued to have thick secretions from his ETT tube
and was covered with vancomycin and zosyn for healthcare
associated pneumonia, but with suspicion for aspiration during
his initial event. He was extubated on hospital day five without
complication. The patient was transferred to the general
medicine floor on hospital day six.  His oxygenation continued
to improve.  He completed a seven day course of antibiotics for
his pneumonia.
.
# Hypoglycemia: The patient is a diabetic, type II.  The
patient's hypoglycemic episode occurred on regimen of Lantus 20
units qHS, metformin, and an insulin sliding scale.  This
regimen was likely too aggressive for this patient.  His wife
reported that the patient was not eating much at the nursing
home because he did not like the food.  This change in food
intake may have contributed to his episode of hypoglycemia.  The
patient's HbA1c is 5.8.  We recommend that the patient follow
the following an insulin sliding scale and that you consider
transitioning patient to an oral regimen.
.
# Coronary artery disease/heart failure: Patient is s/p recent
CABG/[**Month/Day/Year 1291**] [**9-15**] with bioprosthetic valve.  The patient does not
require anti-coagulation for his bioprosthetic valve.  We
recommend that the patient continue to take aspirin, pravastatin
and his lasix at 20 mg PO BID.  We switched the patient's
beta-blocker to metoprolol 12.5 mg PO BID.  We recommend that
the patient start an ACEI as the patient's blood pressure
allows.
.
# renal function: The patient had a worsening in his renal
function on hospital day seven, likely related to overdiuresis.
The patient's renal function improved with gentle IVF and
holding his lasix.

Medications on Admission:
Aspirin 81 mg Tablet
Acetaminophen 325 mg
Docusate Sodium 100 mg [**Hospital1 **]
Albuterol Sulfate prn
Ipratropium Bromide 0.02 % prn
Folic Acid 1 mg qd
Thiamine HCl 100 mg qd
Atorvastatin 80 mg qd
Atenolol 12.5 mg qd
Furosemide 20 mg [**Hospital1 **]
Insulin Glargine 25U daily
Insulin Lispro Sliding Scale
Fosamax 70 mg Tablet weekly
Metformin 500 mg [**Hospital1 **]

Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.

4. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
5. Multivitamin,Tx-Minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.

7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day). Tablet(s)
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Insulin Regular Human 100 unit/mL Solution Sig: 2-10 units
Injection ASDIR (AS DIRECTED): as per sliding scale.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]

Discharge Diagnosis:
Hypoglycemia, in type II Diabetic on insulin
Pneumonia

Secondary Diagnoses:
Cornoary Artery Disease
s/p Aortic Valve Replacement
Systolic Heart Failure (EF 30-35%)
Diabetes Mellitus, Type II, well controlled, HbA1C 5.8
hypertension
hyperlipidemia
history of prostate cancer s/p prostatectomy


Discharge Condition:
stable


Discharge Instructions:
You were admitted after you were found unresponsive with a very
low blood sugar.  We think that your insulin regimen was too
aggressive for your decreased level of food intake at the
nursing home.  We recommend that you check you blood sugars [**4-11**]
times a day and adhere to the attached insuling sliding scale.
During this admission you were also treated for a pneumonia.

We have made the following changes to your medication regimen.
We have discontinued your insulin glargine (lantus).
We have discontinued your atenolol and instead started
metoprolol 12.5 mg tablets, 1 tab by mouth twice daily.
We have discontinued your albuterol and ipratropium inhalers.
You do not have a history of lung disease.  You did not require
any inhalers this admission.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet

Please contact your doctor or go to the emergency room if you
have any of the following symptoms: feeling shaky, sweating,
dizziness, nausea, vomiting, confusion, worsening cough, fever
greater that 100.4, chills, shortness of breath or any other
concerning symtpoms.

Followup Instructions:
You have a follow up appointment scheduled with your PCP, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**1-10**], at 2pm.  Please call
[**Telephone/Fax (1) 67509**] if you have questions.

Please consider adding a ACE inhibitor for his heart failure if
his blood pressure will tolerate.  We have not started this
medication due to systolic blood pressures in the 100-110s.
We recommend that the patient get a thyroid ultrasound to follow
up on a lobulated left thyroid gland noted incidentally on CTA
CHEST on [**2180-12-4**].



Completed by:[**2180-12-13**]
{'Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Acute on chronic combined systolic and diastolic heart failure,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Ventilator associated pneumonia,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Heart valve replaced by transplant,Subendocardial infarction, subsequent episode of care,Aortocoronary bypass status,Personal history of malignant neoplasm of prostate'}


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: hypoglycemia

PRESENT ILLNESS: 79M with CAD s/p recent admission persistent chest pain, ruling
in for NSTEMI, 3VD on cath and now s/p in CABG w/[**First Name3 (LF) 1291**] on [**2180-10-5**],
DMII found unresponsive at NH with a finger stick of 37 and
given glucagon x2.  he was taken to [**Hospital 4068**] Hospital and
intubated for airway protection.  He had a CXR with possible RLL
pna and a Head CT that was negative.  he was given Levo/Flagyl
and transferred to [**Hospital1 18**]. In our ED his vitals were:

MEDICAL HISTORY: CAD s/p 3v CABG [**2180-10-5**] (LIMA to LAD, SVG to OM, SVG to RCA)
St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] 8/28/8
dCHF (EF 55-60% [**2179-4-23**] TTE)
AS ([**Location (un) 109**] 1.0 cm2 [**2179-4-23**] TTE)
DMII
HTN
hyperlipidemia
prostate CA s/p prostatectomy

MEDICATION ON ADMISSION: Aspirin 81 mg Tablet
Acetaminophen 325 mg
Docusate Sodium 100 mg [**Hospital1 **]
Albuterol Sulfate prn
Ipratropium Bromide 0.02 % prn
Folic Acid 1 mg qd
Thiamine HCl 100 mg qd
Atorvastatin 80 mg qd
Atenolol 12.5 mg qd
Furosemide 20 mg [**Hospital1 **]
Insulin Glargine 25U daily
Insulin Lispro Sliding Scale
Fosamax 70 mg Tablet weekly
Metformin 500 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tmax: 35.9 ??????C (96.6 ??????F)

FAMILY HISTORY: Mother had CVA. Father had bladder CA. No known h/o premature
CAD.

SOCIAL HISTORY: Lives with wife in [**Name (NI) **], MA. Retired salesman. Former 3
pack/day smoker, quit >30 years ago. Currently smokes a pipe.
Drinks 2-4 ETOH 2-3x/week. 

### Response:
{'Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Acute on chronic combined systolic and diastolic heart failure,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Ventilator associated pneumonia,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Heart valve replaced by transplant,Subendocardial infarction, subsequent episode of care,Aortocoronary bypass status,Personal history of malignant neoplasm of prostate'}
