Medical Text: Admission Date:  [**2117-9-11**]              Discharge Date:   [**2117-9-17**]

Date of Birth:  [**2082-3-21**]             Sex:   F

Service: MEDICINE

Allergies:
Levaquin

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
nausea, vomiting


Major Surgical or Invasive Procedure:
none

History of Present Illness:
35F w/ poorly controlled Type 1 diabetes mellitus w/ neuropathy,
nephropathy, HTN, gastroparesis, CKD and retinopathy, recently
hospitalized for orthostatic hypotension [**2-3**] autonomic
neuropathy [**Date range (1) 25088**]; DKA hospitalizations in [**6-12**] and [**7-12**], now
returning w/ 5d history of worsening nausea, vomiting with
coffee-ground emesis, chills, and dyspnea on exertion.  Last
week she had a fall and hit her right face.  she also had 1 day
of diarrhea, which resolved early last week.  Found to be in DKA
with AG 30 and bicarb 11.
.
In the ED inital vitals were 09:00 0 98.2 113 181/99 22 100% RA.
K 4.7, HCO3 11, Anion Gap 30, Cr. 2.7 (baseline 1.6-2.0) She is
on her 3rd L NS. Insulin srip at 5 units/hr. On home at 22
levemir in am and 12 at with difficult to control sugars. BPs
have been high. Given 30 mtroprolol tartrate in ED.

She was started on an insulin drip at 5 units/hr and 3L NS
boluses. Also aspirin 325mg PO and Morphine 4mg IVx1 for pain.
CXr was clear.  EKG NAD.
.
Review of systems: otherwise negative.

Past Medical History:
Type 1 diabetes mellitis w/ neuropathy, nephropathy, and
retinopathy - 2 episodes of DKA in [**6-12**] and [**7-12**]
HTN - 5 years
gastroparesis - 1.5 years
CKD - stage III, baseline Cr 2.4-2.5, proteinuria
L1 vertebral fracture - [**2117-7-17**]
Systolic ejection murmur

Social History:
Patient lives at home in [**Location (un) **] with her 8 y/o daughter and
boyfriend. She has no history of EtOH, tobacco, or illicit drug
use. She is currently unemployed and seeking disability.


Family History:
Both parents have HTN and T2DM. Grandfather had an MI in his
40s.

Physical Exam:
GEN: Awake, alert, and oriented
HEENT: PERRLA. MMM. no JVD. neck supple. No cervical LAD
Cards: RRR, S1/S2 normal. II/VI systolic ejection murmur heard
best at the L upper sternal border.
Pulm: CTABL with no crackles or wheezes.
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. radials, DPs, PTs 2+.
Skin: no rashes or bruising. no skin tenting.
Neuro: CNs II-XII intact. Upper extremities: Power [**5-6**]
bilaterally. Le: left power: 4.5/5  right: power [**3-6**].  Bilateral
symmetric, reduced sensation distal LE to ankles.


Pertinent Results:
Admission Labs: [**2117-9-11**] 09:22AM
WBC-11.9* RBC-4.58 HGB-13.0 HCT-36.5 MCV-80* PLT COUNT-466*
LIPASE-22  ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-105 TOT BILI-0.5
GLUCOSE-260* UREA N-48* CREAT-2.7* SODIUM-137 POTASSIUM-4.9
CL-101 CO2-11*
LACTATE-1.9

Discharge Labs: [**2117-9-16**] 07:10AM
WBC-6.8 RBC-3.67* Hgb-10.4* Hct-30.2* MCV-82 Plt Ct-298
Glucose-118* UreaN-20 Creat-2.3* Na-137 K-3.7 Cl-104 HCO3-23
AnGap-14
Calcium-8.7 Phos-3.5 Mg-2.0

Radiology:
CXR: No evidence of pneumonia or other pathological
abnormalities. No
pleural effusions. No pulmonary edema. Normal size of the
cardiac
silhouette.

Microbiology: Urine culture negative, blood cultures no growth
to date, stool for C.difficile negative


Brief Hospital Course:
35 yo F with HTN & poorly controlled type I DM, c/b neuropathy,
gastroparesis, nephropathy ?????? CKD, retinopathy presents with DKA
and hypertension SBP to 200s.
.
# Diabetic ketoacidosis: Patient controls diabetes at home with
Humalog SS and long acting Levemir.  Sugars at home recently
have been in 250s. In the ED, glucose was 466. UA was +ve for
ketones ?????? corrected to 200s, but rose again to 300s. She was
treated with an insulin drip which was transitioned to subq when
she tolerated POs. Her electrolytes were repleted and she
received aggressive volume resuscitation. [**Last Name (un) **] saw her and
gave sliding scale recommendations which were implemented. No
source for DKA found, beleived to be [**2-3**] gastroparesis. Nausea
managed with ativan, compazine, and promethazine. She was
discharged on her home Insulin and sliding scale with
instructions to follow-up with [**Last Name (un) **].

# HTN: Hypertensive with SBP in 190s initially, attributed to
DKA, as she has experienced in the past. As she improved her
blood pressures normalized and she was re-started on her home
Lopressor and Midodrine regimen.

# Coffee grounds emesis: Emesis started off as clear, then with
prolonged wretching, she started having coffee-grounds vomiting.
This had also occurred on prior admissions for DKA with
associated vomiting. Her hematocrit remained stable and her
hematemesis self-resolved, and so work-up was deferred to the
outpatient setting.

# Acute on chronic kidney disease, Stage III: Patient's Cr on
admission was 2.7, trending down to 2.1-2.3 following fluids,
consistent with her known CKD secondary to diabetic nephropathy.


Medications on Admission:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Levemir 100 unit/mL Solution Sig: Twenty Two (22) units
Subcutaneous every AM.
3. Levemir 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
4. Humalog 100 unit/mL Solution Sig: sliding scale as directed
Subcutaneous four times a day: Please use sliding scale as
directed by MD [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) **].
5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily): take in the evening.
6. promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours) as needed for nausea.
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every

12 hours).
Disp:*60 Capsule(s)* Refills:*2*
8. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): Please take
only 1 capsule daily (30 mg) for first 2 weeks of treatment.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours as needed for pain.
10. midodrine 5 mg Tablet Sig: 1.5 Tablets PO every four (4)
hours: Can hold while sleeping.
Disp:*270 Tablet(s)* Refills:*2*


Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
Once Daily at 6 PM.
5. midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Levemir 100 unit/mL Solution Sig: As directed by [**Last Name (un) **] units
Subcutaneous As directed.


Discharge Disposition:
Home

Discharge Diagnosis:
Diabetic keotacidosis
Hematemesis (blood in your vomit)
Hypertension
Chronic renal insufficiency

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

Discharge Instructions:
You were admitted to the hospital with DKA, hypertension, and
blood in your vomit. You were initially treated in the ICU with
an insulin drip, and your blood sugars improved. Your blood
pressure medications were adjusted to better control your blood
pressure while you were in DKA, but you were re-started on your
home regimen at discharge. The blood in your vomit was likely
secondary to mechanical trauma from repeated wretching, but you
should follow-up with your primary care doctor to discuss
whether you should undergo further evaluation such as an upper
endoscopy. Given your complaints of chronic cough and heartburn,
you should also discuss beginning a trial of a proton pump
inhibitor such as Nexium or Prilosec to see if this helps your
symptoms.

Your insulin regimen was adjusted by the [**Last Name (un) **] team while you
were here. You should continue to follow-up with them with any
questions or concerns regarding your insulin management.

Followup Instructions:
Please call Dr.[**Last Name (STitle) 805**]' office to schedule a follow-up
appointment within 7-10 days of discharge. Her office number is
[**Telephone/Fax (1) 85219**].

You should also continue to follow-up with your [**Last Name (un) **] doctors
as needed.



ICD9 Codes: 5849