CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 72-year-old female
with a history of type 2 diabetes mellitus and hypertension
who presented with confusion, lightheadedness, and malaise.

MEDICAL HISTORY: 1.  Type 2 diabetes mellitus times 12 years.
2.  Hypertension.
3.  Lower gastrointestinal bleed secondary to diverticulosis;
failed embolization requiring subtotal colectomy with
ileostomy in [**2111-12-12**].
4.  Uterine fibroids.
5.  Colonic polyps.

MEDICATION ON ADMISSION: 1.  Glipizide 10 mg once per day.
2.  Glucophage 500 mg twice per day.
3.  Lisinopril 5 mg once per day.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Acute kidney failure, unspecified,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Personal history of malignant neoplasm of breast,Ileostomy status
Acute kidney failure NOS,Duodenal ulcer NOS,DMII wo cmp nt st uncntr,Anemia NOS,Hx of breast malignancy,Ileostomy status
Admission Date:  [**2112-6-1**]     Discharge Date:  [**2112-6-8**]

Date of Birth:   [**2039-7-15**]     Sex:  F

Service:

HISTORY OF PRESENT ILLNESS:  This is a 72-year-old female
with a history of type 2 diabetes mellitus and hypertension
who presented with confusion, lightheadedness, and malaise.

The patient reported some visual hallucinations for
approximately 10 months which were not mentioned during her
earlier hospitalization in [**2111-12-12**].  She reports
feeling thirsty but not urinating frequently.  She admits to
a 50-pound weight loss, increased fatigue, weak legs with
minimal ambulation during the past two months.

By report, the patient was a somewhat poor historian on
initial evaluation.  Initially, the patient was thought to
have significant mental status changes, lethargy, and
borderline unresponsiveness.

In the Emergency Department, she was noted to be in acute
renal failure with a creatinine increased to 5.8 from a
baseline of 0.7.  Her arterial blood gas was notable for a
bicarbonate of 8.  The patient was initially transferred to
the Intensive Care Unit for immediate care and management.

In the Intensive Care Unit, the patient was treated with
Kayexalate with resolution of her hyperkalemia.  The Renal
team was consulted for acute renal failure and acidosis.
Initially, there was some question if the patient had a renal
tubular acidosis, specifically type 1, given her
metabolic derangements.  However, the patient responded
immediately to intravenous fluids with her creatinine
decreasing from 5.8 to 2 quickly, making prerenal acute renal
failure the most likely diagnosis.

Further history revealed the patient had some question of
increased ostomy output, although there was no reported
decrease in oral intake.  Gastroenterology was consulted,
.................... nongap acidosis possibly related to
increased ostomy output.  In addition, the patient had been
on an ACE inhibitor prior to admission.

PAST MEDICAL HISTORY:
1.  Type 2 diabetes mellitus times 12 years.
2.  Hypertension.
3.  Lower gastrointestinal bleed secondary to diverticulosis;
failed embolization requiring subtotal colectomy with
ileostomy in [**2111-12-12**].
4.  Uterine fibroids.
5.  Colonic polyps.

MEDICATIONS ON ADMISSION:
1.  Glipizide 10 mg once per day.
2.  Glucophage 500 mg twice per day.
3.  Lisinopril 5 mg once per day.

PHYSICAL EXAMINATION ON PRESENTATION:  Vital signs on initial
presentation revealed a temperature of 98.1, her blood
pressure was 125/52, her heart rate was 78, her respiratory
rate was 11, and 97% on room air.  An elderly female,
lethargic.  Head, eyes, ears, nose, and throat examination
revealed atraumatic.  The pupils were equal, round, and
reactive to light.  The mucous membranes were moist.  The
neck was supple.  No lymphadenopathy.  No thyromegaly.  No
jugular venous distention.  Cardiovascular examination
revealed a regular rate and rhythm.  Normal first heart
sounds and second heart sounds.   A [**2-16**] diastolic murmur.
Her lungs were clear to auscultation bilaterally.  No
crackles, wheezes, or rhonchi.  Her abdomen was soft,
nontender, and nondistended.  Active bowel sounds.  The
ostomy was clean and intact.  There was no costovertebral
angle tenderness bilaterally.  Her extremities were without
edema.  Her skin showed several seborrheic keratoses over the
back, face, and chest.  Her neurological examination was
alert and oriented times three without asterixis.

PERTINENT LABORATORY VALUES ON PRESENTATION:  Notable for a
creatinine of 5.8, her potassium was 7.5, and her lactate was
0.8.  Urinalysis showed a specific gravity of 1.000,
leukocyte esterase was negative, nitrites were negative,
protein was negative, and glucose was negative.  The
patient's serum osmolalities were 322.  Her urine creatinine
was 0, sodium was less 10, urine osmolalities were 3.  Her
fractional excretion of sodium was initially greater than 1.

RADIOLOGY/IMAGING FINDINGS:  The patient had an
electrocardiogram with a normal sinus rhythm in the 60s,
normal axis, first-degree AV block, flat T waves in aVL,
biphasic in V5 and V6.  No ST segment changes.  Read as
unchanged from prior.

Her renal ultrasound showed no hydronephrosis, stones, or
masses.

BRIEF SUMMARY OF HOSPITAL COURSE:  This is a 72-year-old
female with a past medical history of hypertension and type 2
diabetes times 12 years who presented with confusion and was
noted to have acute renal failure.

1.  ACUTE RENAL FAILURE ISSUES:  The patient was initially
evaluated in the Intensive Care Unit.  There was some concern
the patient had type 1 renal tubular acidosis; however, the
patient responded quickly to intravenous hydration, and it
was felt that this picture was most likely consistent with
prerenal acute renal failure.

The patient's creatinine returned to the 1.3 to 1.4 range
from a peak of 5.8 quite quickly over several days with
intravenous fluids.  The patient was deemed stable enough to
be transferred to the general medical floor on [**2112-6-3**].  At the time of transfer, her creatinine had improved
to 2.

The patient had several kidney studies including the renal
ultrasound which was negative for obstruction.  She had a
serum protein electrophoresis and urine protein
electrophoresis sent which were normal; to rule out multiple
myeloma.  In addition, she had urine eosinophils sent to
evaluate for allergic interstitial nephritis which were
negative.  The patient had a urinalysis sent and a urine
culture which was no growth to date.

It was felt that the prerenal state was likely induced
secondary to increased ostomy output.  The ostomy output was
followed closely and was noted to be in the normal range;
approximately 1 liter to 1.5 liters per day.  It was felt
that the patient was likely just not keeping up with the by
mouth fluid requirements given her ostomy output.  The
patient was encouraged to continue to take adequate by mouth
hydration.

The Gastroenterology Service had been consulted to further
evaluate the ostomy.  This will be discussed further down.

2.  EXCESSIVE OSTOMY OUTPUT ISSUES:  There was a concern
raised that the patient was actually having excessive ostomy
output which was causing her prerenal state.  However,
further observation revealed that the patient was simply not
keeping up with her output.

Gastroenterology did evaluate the patient with an ileoscopy
and did not note any abnormalities.  In addition, the patient
had an endoscopy performed which noted several duodenal
ulcerations.  The patient was begun on a higher dose of
Protonix 40 twice per day for eight weeks.  She will continue
this medication for eight weeks and then decrease to 40 mg by
mouth every day.

3.  TYPE 2 DIABETES MELLITUS ISSUES:  The patient's by mouth
hypoglycemics were discontinued on admission given her acute
renal failure.  As her renal failure improved, the patient
was restarted on glipizide at initially 5 mg and then
titrated up to 10 mg by mouth once per day.   At the time of
discharge, the patient was not taking her metformin.  Her
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10208**], was contact[**Name (NI) **] and was
aware that the patient will need to have her fingerstick
glucoses followed and will likely need to restart her
Glucophage as an outpatient.

4.  HYPERTENSION ISSUES:  The patient had been on an ACE
inhibitor which may have contributed to the prerenal picture.
The ACE inhibitor was held during this admission.  She was
started on a beta blocker; 50 mg by mouth twice per day was
the dose she was discharged on.  This was also communicated
to her primary care physician (Dr. [**Last Name (STitle) 10208**].

5.  ANEMIA ISSUES:  The patient had iron studies sent which
were borderline for anemia of chronic disease.  The patient
was continued on by mouth liquid iron.  She did have one
guaiac-positive stool during this hospital stay.  It was felt
that this was likely secondary to her duodenal ulcerations.
The Gastroenterology Service stated that the patient should
not need a small-bowel follow-through to further evaluate her
anemia.

6.  MENTAL STATUS CHANGES:  The patient's mental status
significantly improved with improvement of her renal failure.
On discharge, the patient was alert and oriented.  She felt
nearly back to herself; not quite 100% but was ambulating
without difficulty and eating a good by mouth diet.

CONDITION AT DISCHARGE:  Stable, eating a full diet, and
ambulating without difficulty.

DISCHARGE STATUS:  To home with [**Hospital6 407**]
services.  [**Hospital6 407**] for home safety
evaluation, blood pressure checks, fingerstick checks, and
blood draw to check her creatinine.

DISCHARGE DIAGNOSES:
1.  Acute renal failure; prerenal.
2.  Status post ileostomy.
3.  Type 2 diabetes mellitus.
4.  Hypertension.
5.  Duodenal ulcerations.

MEDICATIONS ON DISCHARGE:
1.  Tylenol 325 mg one to two tablets by mouth q.4-6h.
2.  Iron sulfate 300-mg liquid 5 mL by mouth twice per day.
3.  Pantoprazole 40 mg one tablet by mouth twice per day
times eight weeks then decrease to 40 mg by mouth once per
day ongoing.
4.  Glipizide 10 mg by mouth once per day.
5.  Metoprolol 50 mg by mouth twice per day.

DISCHARGE INSTRUCTIONS/FOLLOWUP:
1.  The patient was to follow up with her primary care
physician (Dr. [**Last Name (STitle) 10208**].
2.  She was aware that she needs to call Dr. [**Last Name (STitle) 10208**] for an
appointment in the next week.
3.  In addition, she will have followup by the [**Hospital6 1587**] for home blood pressure checks, as well as
fingerstick checks to follow her glucose level, and a
laboratory draw two days after discharge to follow up on her
creatinine.
4.  The [**Hospital6 407**] were advised that they
should call these results to Dr. [**Last Name (STitle) 10208**] (her primary care
physician) [**University/College 45471**] Health Center.  Dr.
[**Last Name (STitle) 10208**] can be contact[**Name (NI) **] at [**Telephone/Fax (1) 35879**].






                          [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D.  [**MD Number(1) 3475**]

Dictated By:[**Name8 (MD) 3482**]

MEDQUIST36

D:  [**2112-6-8**]  15:23
T:  [**2112-6-8**]  18:01
JOB#:  [**Job Number 45472**]
{'Acute kidney failure, unspecified,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Personal history of malignant neoplasm of breast,Ileostomy status'}


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: 

PRESENT ILLNESS: This is a 72-year-old female
with a history of type 2 diabetes mellitus and hypertension
who presented with confusion, lightheadedness, and malaise.

MEDICAL HISTORY: 1.  Type 2 diabetes mellitus times 12 years.
2.  Hypertension.
3.  Lower gastrointestinal bleed secondary to diverticulosis;
failed embolization requiring subtotal colectomy with
ileostomy in [**2111-12-12**].
4.  Uterine fibroids.
5.  Colonic polyps.

MEDICATION ON ADMISSION: 1.  Glipizide 10 mg once per day.
2.  Glucophage 500 mg twice per day.
3.  Lisinopril 5 mg once per day.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Acute kidney failure, unspecified,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Personal history of malignant neoplasm of breast,Ileostomy status'}
