CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 20-year-old
woman who felt well until the morning of admission when she
awoke with a "belly ache."

MEDICAL HISTORY: Type 1 diabetes diagnosed at the age
of nine.

MEDICATION ON ADMISSION: 1.  Insulin Glargine 30 units q.h.s.
2.  Humalog insulin sliding-scale.

ALLERGIES: CEFACLOR.

PHYSICAL EXAM: 

FAMILY HISTORY: The patient's mother has a history of
gallstones.

SOCIAL HISTORY: The patient denies tobacco, alcohol, or
recreational or intravenous drug abuse.  She is a senior at
[**University/College 4700**].  She denies current sexual activity.  She
has no history of unprotected sexual intercourse; although,
she admits to protected intercourse twice in the past.
Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Paralytic ileus,Nausea with vomiting,Other specified cardiac dysrhythmias,Other specified disease of white blood cells,Personal history of noncompliance with medical treatment, presenting hazards to health
DMI ketoacd uncontrold,Paralytic ileus,Nausea with vomiting,Cardiac dysrhythmias NEC,Wbc disease NEC,Hx of past noncompliance
Admission Date:  [**2106-10-6**]     Discharge Date:  [**2106-10-10**]

Date of Birth:   [**2085-11-3**]     Sex:  F

Service:  MICU

HISTORY OF PRESENT ILLNESS:  The patient is a 20-year-old
woman who felt well until the morning of admission when she
awoke with a "belly ache."

She states that the pain was primarily hypogastric and was
not radiating or associated with any precipitating factors.
She stated that she checked a fingerstick glucose on the
morning of admission, and it was 145; so "I didn't think
anything of" the pain.  The patient states that she did not
have anything to eat; however, she did not take her morning
Humalog sliding-scale insulin.

At about 11 o'clock on the morning of admission, the patient
states that she became nauseous and vomited "clear fluid."
This fluid was nonbilious, nonbloody, and did not have a
coffee-grounds appearance.  She states that she vomited a
total of four times on the day of admission; the last time
was at 2:30 in the afternoon.  At approximately 1 p.m., she
began having diarrhea that was neither bright red nor jet
black, but it was "dark."  She last had diarrhea at
approximately 3:15 on the afternoon of admission.

Her abdominal pain persisted, however, and at 4:30 p.m. she
called for an ambulance.

Of note, the patient states that she was admitted to
[**Hospital3 1810**] two weeks prior to this admission with
hypoglycemia.

On the day of this admission, the patient states that she
took her regular nighttime insulin dose, but then did not eat
"as soon as I should have, so I blacked out."  The patient's
fingerstick glucose was 45 at that time.

At [**Hospital3 1810**], she had ketonuria and was treated for
"dehydration" and released.  She denies subsequent ketonuria.
She states that she has otherwise felt well recently; and she
denies recent upper respiratory symptoms, cough, fevers,
chills, sweats, dysuria, frequency, hematuria, unusual
vaginal discharge, chest pain, shortness of breath, headache,
lightheadedness, dizziness, neck stiffness, photophobia,
rash, sick contacts, recent travel (although the patient did
return from [**Country 6171**] on [**8-14**]), raw fish or unusual foods,
fresh-water swimming, or other complaints.  Her last
menstrual period was two weeks prior to admission.  She
states that she is completely compliant with her medications.

During an interview in the Emergency Department, the patient
stated that she had more right upper quadrant than
hypogastric pain.  She also complained of thirst.

PAST MEDICAL HISTORY:  Type 1 diabetes diagnosed at the age
of nine.

PAST SURGICAL HISTORY:  Tonsillectomy.

MEDICATIONS ON ADMISSION:
1.  Insulin Glargine 30 units q.h.s.
2.  Humalog insulin sliding-scale.

ALLERGIES:  CEFACLOR.

SOCIAL HISTORY:  The patient denies tobacco, alcohol, or
recreational or intravenous drug abuse.  She is a senior at
[**University/College 4700**].  She denies current sexual activity.  She
has no history of unprotected sexual intercourse; although,
she admits to protected intercourse twice in the past.

FAMILY HISTORY:   The patient's mother has a history of
gallstones.

PHYSICAL EXAMINATION ON PRESENTATION:  On initial physical
examination the patient's temperature was 97.5 degrees
Fahrenheit, heart rate was 122, blood pressure was 155/77,
respiratory rate was 24, and oxygen saturation was 100% on
room air.  In general, she was awake, spoke in full
sentences, but was clearly short of breath, in mild distress
secondary to her shortness of breath and abdominal pain.  She
had no sinus tenderness.  Her pupils were equally round and
reactive to light and accommodation.  Extraocular movements
were intact.  The oropharynx was clear.  Mucous membranes
were dry; especially her tongue.  Her neck was soft and
supple.  There was no lymphadenopathy or thyromegaly.  Her
heart rate was tachycardic, it was of a regular rhythm.
There was normal first and second heart sounds, and there
were no murmurs, rubs, or gallops.  Her lungs were clear to
auscultation bilaterally.  Her abdomen was soft and diffusely
tender; especially in the right upper quadrant much greater
than the right lower quadrant which was also greater than the
left upper or lower quadrants.  She had a [**Doctor Last Name **] sign, and
she also had tenderness at McBurney point.  She had no
abdominal distention, and there were active bowel sounds.
She had no costovertebral angle or paraspinal tenderness.  No
had no calf tenderness, no peripheral edema, and she had good
peripheral pulses bilaterally.  She was alert and oriented
times three, and her neurologic examination was nonfocal.
Her skin was warm, and she had mild facial erythema.

PERTINENT LABORATORY DATA ON PRESENTATION:  On initial
laboratory evaluation the patient's white blood cell count
was 30.5, hematocrit was 44.7, and platelets were 374.  The
differential of the white count included 80 polys, 4 bands,
7 lymphocytes, 9 monocytes, no eosinophils, and no basophils.
Her PT was 15.1, PTT was 25.9, and INR was 1.6.  Her serum
chemistries revealed sodium was 144, potassium was 3.8,
chloride was 113, bicarbonate was less than 5, blood urea
nitrogen was 15, creatinine was 1, and blood glucose was 407.
Her calcium was 7.4, magnesium was 1.5, and phosphate
was 3.9.  Her liver function tests were unremarkable.  Her
urinalysis demonstrated 30 protein, 500 glucose, greater than
80 ketones, 5 red blood cells, 1 white blood cell, a few
bacteria, no yeast, 1 epithelial cell, and a pH of 5.  An
arterial blood gas done on room air in the Emergency
Department demonstrated a pH of 6.88, PCO2 of 10, PO2 of 144,
and a base deficit of 2.  The urine pregnancy test was
negative.

RADIOLOGY/IMAGING:  A right upper quadrant ultrasound done in
the Department of Radiology was, in summary, a normal study;
and there was no evidence of acute cholecystitis.

She also had an abdominal CT scan without contrast that was
also largely negative, with the exception of an incidental
left ovarian cyst.

Her chest x-ray demonstrated gaseous gastric distention
consistent with a paralytic ileus; there was no evidence of
free intraperitoneal air.

HOSPITAL COURSE BY SYSTEM:

1.  ENDOCRINE:  The patient presented to the [**Hospital1 346**] Emergency Department with a serum
glucose of 407, an anion gap of at least 26, dry mucous
membranes, severe acidemia, glucosuria, and ketonuria; all of
which were consistent with a presentation of diabetic
ketoacidosis.

Her severe acidemia likely caused her compensatory
respirations tachypnea that quickly began to improve as her
acidemia improved.  She was administered a bolus of 10 units
of regular insulin intravenously while in the Emergency
Department, and she was then started on an insulin drip at
10 units of regular insulin per hour.  She was  also
aggressively resuscitated with intravenous fluids; initially
with 6 liters of normal saline while in the Emergency
Department.  These fluids were continued when the patient
arrived in the Medical Intensive Care Unit.

While in the Medical Intensive Care Unit, the patient's
fingersticks were monitored every hour.  Once her
fingersticks began to trend downward and reached roughly a
level of 250, the patient was started on D-5 half normal
saline instead of regular normal saline as she had been
receiving previously.  The patient remained on an insulin
drip, and her insulin drip was titrated to a goal of
fingerstick [**Location (un) 1131**] of 140 to 180.  She was ultimately
tapered off of the insulin drip in the morning of
[**10-8**].  She was also restarted on her baseline insulin
regimen at this time.  She was administered 30 units of
insulin Glargine at 4 o'clock in the morning on [**10-8**].
Given that this medication was administered slightly later
than the patient normally takes her evening insulin, her
insulin regimen was adjusted as needed to maintain relative
euglycemia throughout the remainder of the hospitalization.
By the time of discharge, the patient was largely euglycemic
on her baseline insulin regimen of Humalog insulin
sliding-scale during the day and 30 units of insulin Glargine
at bedtime.

Of note, the patient's significant anion gap acidosis
gradually resolved throughout the course of her
hospitalization.  Although, it was less than 5 on admission,
it reached a plateau ranging between 24 and 27 by the time of
her discharge from the hospital.

2.  FLUIDS/ELECTROLYTES/NUTRITION:  Given the patient's
presentation with diabetic ketoacidosis, she subsequently
manifested many of the electrolyte abnormalities consistent
with this diagnosis.  Of note, she developed severe
hypokalemia, hypocalcemia, hypomagnesemia, and
hypophosphatemia.  All of these electrolytes were
aggressively repleted throughout the course of her
hospitalization.

Her electrolytes had all stabilized within a normal range at
the time of her discharge.

3.  CARDIOVASCULAR:   The patient's initial tachycardia and
relative hypotension improved following her extensive fluid
resuscitation.  Overall, she was roughly 10 liters to 11
liters positive throughout this hospitalization.

4.  GASTROINTESTINAL:  Although there was an initial concern
for an acute surgical abdomen, diabetic ketoacidosis can
often present with abdominal pain that mimics a surgical
abdomen.  Although the possibilities of acute cholecystitis
and acute appendicitis were ruled out with the appropriate
imaging studies.  The patient's abdominal pain spontaneously
resolved by hospital day two.  She had no subsequent nausea,
vomiting, or diarrhea.

5.  INFECTIOUS DISEASE:  While the patient had a significant
leukocytosis on presentation, this was also likely secondary
to her presentation with diabetic ketoacidosis.  Her
leukocytosis spontaneously resolved with resolution of her
diabetic ketoacidosis, and she had no longer had a
leukocytosis at the time of discharge.

6.  SUMMARY:  Overall, at the time of discharge, the patient
was tolerating a regular diabetic diet.  She was back on her
baseline insulin regimen, and all of her laboratory
abnormalities present on admission had resolved.  She was
therefore deemed stable for discharge to home with close
followup by her primary endocrinologist.

CONDITION AT DISCHARGE:  Condition on discharge was good.

DISCHARGE STATUS:  The patient was discharged to home.

DISCHARGE DIAGNOSES:
1.  Diabetic ketoacidosis.
2.  Type 1 diabetes mellitus.
3.  Hypokalemia.
4.  Hypophosphatemia.
5.  Hypocalcemia.
6.  Hypomagnesemia.

MEDICATIONS ON DISCHARGE:
1.  Insulin Glargine 30 units subcutaneous q.h.s.
2.  Humalog insulin sliding-scale.

DISCHARGE FOLLOWUP:   The patient was instructed to phone her
primary endocrinologist (Dr. [**Last Name (STitle) 36244**] at [**Hospital3 18242**] to arrange for a follow-up appointment with him
during the week following discharge.





                          [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 4561**]

Dictated By:[**Name8 (MD) 2507**]

MEDQUIST36

D:  [**2106-10-10**]  15:13
T:  [**2106-10-15**]  10:47
JOB#:  [**Job Number 45385**]
{'Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Paralytic ileus,Nausea with vomiting,Other specified cardiac dysrhythmias,Other specified disease of white blood cells,Personal history of noncompliance with medical treatment, presenting hazards to health'}


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: The patient is a 20-year-old
woman who felt well until the morning of admission when she
awoke with a "belly ache."

MEDICAL HISTORY: Type 1 diabetes diagnosed at the age
of nine.

MEDICATION ON ADMISSION: 1.  Insulin Glargine 30 units q.h.s.
2.  Humalog insulin sliding-scale.

ALLERGIES: CEFACLOR.

PHYSICAL EXAM: 

FAMILY HISTORY: The patient's mother has a history of
gallstones.

SOCIAL HISTORY: The patient denies tobacco, alcohol, or
recreational or intravenous drug abuse.  She is a senior at
[**University/College 4700**].  She denies current sexual activity.  She
has no history of unprotected sexual intercourse; although,
she admits to protected intercourse twice in the past. 

### Response:
{'Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Paralytic ileus,Nausea with vomiting,Other specified cardiac dysrhythmias,Other specified disease of white blood cells,Personal history of noncompliance with medical treatment, presenting hazards to health'}
