CHIEF COMPLAINT: Diabetic ketoacidosis, non ST segment myocardial infarction

PRESENT ILLNESS: Ms. [**Known lastname 57980**] is a 74 year old female with a past medical history
of Diabetes Melitis type 2, now insulin dependent, hyperlipid,
[**Last Name (un) 32665**]-[**Doctor Last Name 122**] disease, and  dementia who presented to an out
side hospital with uncontrolled finger stick glucoses (500s
despite sliding scale insulin at home), lethargy, mental status
changes, and nausea and emesis (1 day prior). She was found to
be in diabetic ketoacidosis, with a urinalysis positive for
infection, ECG with diffuse t wave inversions, CK 700, MB 129,
and TropI 33. She was given aspirin, subcutaneous lovenox,
integrilin, levofloxacin, subcutaneous insulin and transfered to
[**Hospital1 18**] for further management & consideration of cardiac
catheterization.

MEDICAL HISTORY: DM2 on insulin
Hypercholesterolemia
Dementia/[**Doctor Last Name 122**] disease (an inherited spinocerebellar ataxia:
progressive neurological disorder of ataxia, peripheral
neuropathy)
(No known HTN)

MEDICATION ON ADMISSION: Synthyroid 88 mcg once a day
Lipitor 10 mg once a day
70/30 insulin 24 units qam, 24 units qpm

ALLERGIES: Penicillins

PHYSICAL EXAM: T: 98.5 HR: 89 BP: 129/50 RR: 21 O2sat 100% 1L NC
Gen: cachectic female.
HEENT: MM dry. no sceral icterus. EOMI.
Neck: supple, no lymphadenopathy. No JVD.
Chest: pectus carinarum
CV: RRR, II/VI systolic murmur heard best at LLSB.
Lungs: Course breath sounds bilaterally.
Abd: thin, S/NT/ND. +BS. No HSM
Ext: no c/c/e. Pulses 2+ femoral, 1+ bilaterally DP/PT.
Neuro: Oriented to person. Non-focal. strength 5/5 throughout.
MAEW - alternating contracting muscles in legs and pulling them
up to chest.

FAMILY HISTORY: [**Last Name (un) 32665**]-[**Doctor Last Name 11042**] disease.

SOCIAL HISTORY: Prior to admission the patient was living at home with her
daughter. The patient was bedridden and very dependent on family
members to care for her. She has a significant smoking history
of 50 pack years, though she quit smoking 10 years ago. Denies
EtOH or other drugs.
Subendocardial infarction, initial episode of care,Acute respiratory failure,Acidosis,Congestive heart failure, unspecified,Cardiogenic shock,Iatrogenic pneumothorax,Methicillin susceptible pneumonia due to Staphylococcus aureus,Urinary tract infection, site not specified,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled
Subendo infarct, initial,Acute respiratry failure,Acidosis,CHF NOS,Cardiogenic shock,Iatrogenic pneumothorax,Meth sus pneum d/t Staph,Urin tract infection NOS,DMII ketoacd uncontrold
Admission Date:  [**2137-9-8**]              Discharge Date:   [**2137-10-2**]

Date of Birth:  [**2063-1-4**]             Sex:   F

Service: MED

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Diabetic ketoacidosis, non ST segment myocardial infarction

Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
tracheostomy
PEG tube placement
transfusions


History of Present Illness:
Ms. [**Known lastname 57980**] is a 74 year old female with a past medical history
of Diabetes Melitis type 2, now insulin dependent, hyperlipid,
[**Last Name (un) 32665**]-[**Doctor Last Name 122**] disease, and  dementia who presented to an out
side hospital with uncontrolled finger stick glucoses (500s
despite sliding scale insulin at home), lethargy, mental status
changes, and nausea and emesis (1 day prior). She was found to
be in diabetic ketoacidosis, with a urinalysis positive for
infection, ECG with diffuse t wave inversions, CK 700, MB 129,
and TropI 33. She was given aspirin, subcutaneous lovenox,
integrilin, levofloxacin, subcutaneous insulin and transfered to
[**Hospital1 18**] for further management & consideration of cardiac
catheterization.

Past Medical History:
DM2 on insulin
Hypercholesterolemia
Dementia/[**Doctor Last Name 122**] disease (an inherited spinocerebellar ataxia:
progressive neurological disorder of ataxia, peripheral
neuropathy)
(No known HTN)


Social History:
Prior to admission the patient was living at home with her
daughter. The patient was bedridden and very dependent on family
members to care for her. She has a significant smoking history
of 50 pack years, though she quit smoking 10 years ago. Denies
EtOH or other drugs.

Family History:
[**Last Name (un) 32665**]-[**Doctor Last Name 11042**] disease.

Physical Exam:
T: 98.5 HR: 89 BP: 129/50 RR: 21 O2sat 100% 1L NC
Gen: cachectic female.
HEENT: MM dry. no sceral icterus. EOMI.
Neck: supple, no lymphadenopathy. No JVD.
Chest: pectus carinarum
CV: RRR, II/VI systolic murmur heard best at LLSB.
Lungs: Course breath sounds bilaterally.
Abd: thin, S/NT/ND. +BS. No HSM
Ext: no c/c/e. Pulses 2+ femoral, 1+ bilaterally DP/PT.
Neuro: Oriented to person. Non-focal. strength 5/5 throughout.
MAEW - alternating contracting muscles in legs and pulling them
up to chest.


Pertinent Results:
Head CT ([**2137-9-12**]):
Limited study secondary to motion artifact with severely limited
examination/ of the infratentorial structures and the middle
cranial fossa. Within the limits of this study, there was no
evidence of major vascular territorial infarction or acute
intracranial hemorrhage.
*
EEG ([**2137-9-13**]):
Markedly abnormal EEG due to the low voltage slow
background with occasional surpressive bursts and with runs of
uniformly
distributed alpha frequencies throughout. Overall, the tracing
indicates a widespread and moderately severe encephalopathy.
This can
come from anoxia or severe metabolic derangements, but the
widespread
alpha frequency suggests medication effect. There were no
epileptiform
features.

[**2137-9-8**] 11:56PM   CK(CPK)-1453*
[**2137-9-8**] 11:56PM   CK-MB-129* MB INDX-8.9* cTropnT-3.77*
[**2137-9-8**] 11:56PM   WBC-20.3* RBC-3.82* HGB-11.5* HCT-34.4*
MCV-90 MCH-30.2 MCHC-33.5 RDW-14.0
[**2137-9-8**] 11:56PM URINE  BLOOD-LGE NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2137-9-8**] 11:56PM URINE  RBC-62* WBC-20* BACTERIA-OCC YEAST-NONE
EPI-2
[**2137-9-26**] 9:04 am SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2137-9-28**]**

   GRAM STAIN (Final [**2137-9-26**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.

   RESPIRATORY CULTURE (Final [**2137-9-28**]):
      OROPHARYNGEAL FLORA ABSENT.
      STAPH AUREUS COAG +.    HEAVY GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------  0.25 S
OXACILLIN-------------   0.5 S
PENICILLIN------------ =>0.5 R


Brief Hospital Course:
Overall it was hypothesized that the patient developed an
infection (i.e., urinary tract infection) leading to DKA & had a
non ST elevation myocardial infarction in this setting of acute
infection & metabolic abnormalities.
1. Cardiovascular:
A. CAD: NSTEMI - ECG changes and + cardiac enzymes; CK peaked at
1450 and then trended down. CK did rise again later after pt was
intubated, but MB and troponin continued to trend down. Because
the patient was not felt to be a good candidate for
catheterization, she was managed medically. She was started on
ASA, Plavix, and her statin was increased to 20 per day. She was
initially started on Metoprolol to control heart rate and blood
pressure, and when her blood pressure allowed she was given
captopril. She was given Lovenox for 48 hours but no integrillin
since she was not going to catheterization. The aspirin and
plavix were held during periods when concerns for intracranial
bleeding were present, but then restarted when this was felt to
be less likely.

Later, Ms. [**Known lastname 57980**] pulled out her NG tube repeatedly and it was
not possible to maintain her on plavix since it cannot be
administered otherwise. Her aspirin was continued rectally and
other medications were administered intravenously until her PEG
tube was placed. Of note, she had sufficient bleeding around her
tracheostomy site that her surgeon had to return to stitch it
down. It was thought that hemostasis was difficult to achieve
since she was on aspirin and plavix. Once her PEG was placed, it
was decided not to continue her plavix in the interest of
preserving hemodynamic stability.

B. Pump: EF 30-35%; Pt initially received aggressive intravenous
fluids for diabetic ketoacidosis, and then was diuresed since
oxygen saturations dropped and the patient was having more
labored breathing. The patient's blood pressures were initially
high and would go even higher with agitation. She was maintained
on a labetolol gtt for a short time to control these BP's. Her
labored breathing eventually led to intubation, followed by
extubation during a period where her hemodynamics had
stablilized, and then re-intubation since pt's breathing was
extremely labored on the shovel mask. For the second intubation
the patient was given propofol for sedation and her BP dropped
acutely. She required 3 pressors (Dopamine, Neo, Levophed) with
MAPs in 70s, SBP in 110s. Bedside Echo showed no changes after
these events. Her hemodynamics were gradually stablized and BP
eventually became high again. Throughout her hospitalization the
pt had extremely labile BP's that seemed to be affected by her
position and level of agitation. These changes were of unclear
etiology and thought to be possibly related to her underlying
[**Doctor Last Name 11042**] disease vs. pain. Her blood pressure medications were
titrated aggressively since she developed flash pulmonary edema
nearly each time she became hypertensive, tachycardic, and
tachypneic. Upon discharge, she was stable and normotensive.

C. Rhythm: Pt was in NSR for most of her hospitalizaton. During
the time she was maintained on Dopamine, however, EKG's showed a
junctional rhythm which resolved when the Dopa was weaned. She
remained in sinus throughout the remainder of her intensive care
unit stay.

2. Pulmonary: As discussed above, the pt was intubated on [**9-12**]
for primary respiratory acidosis with hypercarbic failure.
Extubated to face mask later on the same day but persistently
tachypneic to 30s. Tried BIPAP to no avail. Off BIPAP  patient
continued to breathe at 30 and breathing looked extremely
labored. It was felt that it would be unlikely that the patient
would be able to leave the hospital without some kind of
respiratory support and so it was collectively decided with the
family that a temporary tracheostomy might help her improve yet
be more comfortable than the breathing tube. On [**9-13**] she was
electively intubated (as bridge to PEG and TRACH) with
subsequent hypotension requiring 3 pressors as described above.
She was stabilized from this and eventually had a tracheostomy
placed with a minor bleeding complication due to administration
of aspirin and plavix. Ms. [**Known lastname 57980**] also suffered a small
pneumothorax as a consequence of an attempted right subclavian
line. This was followed with serial chest x rays and did not
require a chest tube to be placed. It resolved within 2 days.
She then developed a methicillin sensitive staph aureus
ventilator associated pneumonia. She was started on levofloxacin
for a total course of 8 days.

3. Endocrine: The patient was admitted in diabetic ketoacidosis
with blood glucose 559, ketones & an anion gap of 20 at an
outside hospital and only covered with sliding scale insulin
there. Her anion gap was 15 on arrival. The precipitant was
likely infection (urinary tract) and the patient was managed on
insulin drip until [**9-9**], after which she was covered with NPH
[**Hospital1 **] and HSS. She initially had presented with hypernatremia (Na
was 150) which was corrected wwith [**1-11**] normal saline and
normalized. Throughout her stay, her blood sugars were very
labile and difficult to control although she was on an insulin
drip. She was stabilized on glargine 35 units QPM and covered
with a regular insulin sliding scale.

4. ID: The patient presented with elevated white blood cell
count and neutrophilia. Her urinalysis was positive at the
outside (although with some epithelial cells so it may have been
contaminated). She was started on Levofloxacin for the urinary
tract infection and was treated for 7 days. Her chest x ray was
initially clear, but then developed a questionable left upper
lobe infiltrate. Any possible pneumonia would likely have been
covered by the Levaquin, however, then the patient's blood
pressures dropped following intubation and there was a concern
that she may have been septic. Thus, she was started on
Ceftazidime, vancomycin, and flagyl to cover wider for the
possible pneumonia as well as any line infection with
methicillin resistant staph aureus. However, no cultures ever
grew out any organism. The patient spiked a few fevers while on
these antibiotics, however, then the fevers resolved on their
own and all antibiotics were discontinued since no organisms
were ever identified. Later in her course, Ms. [**Known lastname 57980**] developed
increasing secretions and clinical decompensation. Although she
never became febrile and her chest x ray was unchanged, she was
started on vancomycin. Her sputum was sent for culture and it
was determined that she had heavy growth of methicillin
sensitive staph aureus. She was de-escalated to levoquin and
will finish her 8 day course at the outside rehabilitation
facility. Following the second day of treatment the patient's
mental status and tone improved.

5. Neuro: History of [**Last Name (un) 32665**] [**Doctor Last Name 11042**] disease; per family,
initially lethargic at outside hospital (Head CT neg there),
near baseline on admission to [**Hospital1 18**]. After extubation, however,
pt was more lethargic. She followed some commands but was too
drowsy to swallow. Her mental status declined until eventually,
she did not even respond to noxious stimuli applied to her
nailbeds or sternum.

Her head CT was repeated with no changes seen (no intracranial
hemorrhage). She was evaluated by neurology who felt that she
may have been having a seizure since she had symptoms concerning
for myoclonus and posturing. The EEG was abnormal in that it
showed encephalopathy but did not show seizure activity.
However, the patient was started on phenytoin since she had been
given Ativan before the EEG was taken and it thus seizure was
able to be completely ruled out. After several days without
evidence of seizure activity, the team decided to stop the
phenytoin as it was thought that the medication might contribute
to the patient's decreased mental status. She slowly became more
alert during her course, but would wax and wane continually.
Eventually she would respond to commands and was occasionally
alert and oriented to person and place. It was thought that the
etiology to her obtundation was toxic metabolic.

6. Lines: The patient was initially managed with peripheral
IV's, however, as her condition worsened central access was
attempted at the right internal jugular and right subclavian
without success. See above pulmonary section for complications.
She was thus managed with a right femoral line for several days
which was changed to a left femoral line until a PICC was
placed.
*
6. FEN: Speech/swallow had evaluated the patient before her
intubation and had recommended prethickened liquids. However,
after her intubation for the second time it was felt that the
patient was not able to handle her secretions well and would
likely need a PEG placed for nutrition as well as for safety
reasons. Her tracheostomy placement was complicated with some
difficulty attaining hemostasis. Her PEG tube was placed without
complications and she was fed through it during the remainder of
her hospitalization. Upon speech and swallow evaluation of her
after placement of the tracheostomy, it was decided that she was
not ready for any oral feeds since she appeared to be aspirating
her secretions. It was thought that once she was weaned from the
ventilator, she could be evaluated again. She should not be
given anything by mouth because she is a serious aspiration
risk.

7. Communication: Full code. The family was heavily involved in
making decisions about the patient's care and all along
expressed wishes for aggressive care.


Medications on Admission:
Synthyroid 88 mcg once a day
Lipitor 10 mg once a day
70/30 insulin 24 units qam, 24 units qpm


Discharge Medications:
1. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).

3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day) as needed.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
6. Acetaminophen 160 mg/5 mL Elixir Sig: One (1)  PO Q4-6H
(every 4 to 6 hours) as needed.
7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO BID (2 times a day).
12. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
13. Captopril 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
14. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
15. Insulin Glargine 100 unit/mL Solution Sig: 35 units QPM
Subcutaneous once a day.
16. sliding scale insulin
please see attached sliding scale for regular insulin
17. Outpatient Lab Work
Please check electrolytes within 3 days
18. Outpatient Speech/Swallowing Therapy
Can be evaluated for swallowing when ventilator is weaned and is
tolerating passey muir valve


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
non ST segment MI
[**Last Name (un) 32665**]-[**Doctor Last Name 11042**] Disease
Respiratory failure, requiring intubation
cardiogenic shock
Anemia
Congestive heart failure with EF of 35%
Diabetes type 2, now insulin dependent
ventilator associated pneumonia

Discharge Condition:
fair

Discharge Instructions:
Vent settings: PS 10, PEEP 5, FiO2 of 40%.
Titrate blood pressure meds closely. The patient has a tendency
to flash pulmonary edema if she becomes hypertensive. Keep her
ins and outs even and check her potassium in the next day since
her captopril was recently increased.
Titrate glargine and sliding scale insulin carefully. The
patient is a brittle diabetic with a tendency to both hypo and
hyperglycemia. Check blood sugars frequently. Do not allow her
to eat since she has failed her speech swallow evaluation. She
was fitted for a Passey Muir valve and can use it once her
respiratory status becomes stable.


Followup Instructions:
Please see Dr. [**Last Name (STitle) **] on Monday [**10-7**] at 9:45 PM
([**Telephone/Fax (1) 33330**]) on [**Street Address(2) 14531**] in [**Hospital1 1474**], [**Location (un) 10043**].

If there are problems with the tracheostomy or the PEG tube,
call Dr. [**Last Name (STitle) **]. He is located at [**Hospital Unit Name 57981**], [**Location (un) 86**], [**Numeric Identifier 718**], Phone: [**Telephone/Fax (1) 2981**] Fax: [**Telephone/Fax (1) 57982**]
{'Subendocardial infarction, initial episode of care,Acute respiratory failure,Acidosis,Congestive heart failure, unspecified,Cardiogenic shock,Iatrogenic pneumothorax,Methicillin susceptible pneumonia due to Staphylococcus aureus,Urinary tract infection, site not specified,Diabetes with ketoacidosis, 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: Diabetic ketoacidosis, non ST segment myocardial infarction

PRESENT ILLNESS: Ms. [**Known lastname 57980**] is a 74 year old female with a past medical history
of Diabetes Melitis type 2, now insulin dependent, hyperlipid,
[**Last Name (un) 32665**]-[**Doctor Last Name 122**] disease, and  dementia who presented to an out
side hospital with uncontrolled finger stick glucoses (500s
despite sliding scale insulin at home), lethargy, mental status
changes, and nausea and emesis (1 day prior). She was found to
be in diabetic ketoacidosis, with a urinalysis positive for
infection, ECG with diffuse t wave inversions, CK 700, MB 129,
and TropI 33. She was given aspirin, subcutaneous lovenox,
integrilin, levofloxacin, subcutaneous insulin and transfered to
[**Hospital1 18**] for further management & consideration of cardiac
catheterization.

MEDICAL HISTORY: DM2 on insulin
Hypercholesterolemia
Dementia/[**Doctor Last Name 122**] disease (an inherited spinocerebellar ataxia:
progressive neurological disorder of ataxia, peripheral
neuropathy)
(No known HTN)

MEDICATION ON ADMISSION: Synthyroid 88 mcg once a day
Lipitor 10 mg once a day
70/30 insulin 24 units qam, 24 units qpm

ALLERGIES: Penicillins

PHYSICAL EXAM: T: 98.5 HR: 89 BP: 129/50 RR: 21 O2sat 100% 1L NC
Gen: cachectic female.
HEENT: MM dry. no sceral icterus. EOMI.
Neck: supple, no lymphadenopathy. No JVD.
Chest: pectus carinarum
CV: RRR, II/VI systolic murmur heard best at LLSB.
Lungs: Course breath sounds bilaterally.
Abd: thin, S/NT/ND. +BS. No HSM
Ext: no c/c/e. Pulses 2+ femoral, 1+ bilaterally DP/PT.
Neuro: Oriented to person. Non-focal. strength 5/5 throughout.
MAEW - alternating contracting muscles in legs and pulling them
up to chest.

FAMILY HISTORY: [**Last Name (un) 32665**]-[**Doctor Last Name 11042**] disease.

SOCIAL HISTORY: Prior to admission the patient was living at home with her
daughter. The patient was bedridden and very dependent on family
members to care for her. She has a significant smoking history
of 50 pack years, though she quit smoking 10 years ago. Denies
EtOH or other drugs. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute respiratory failure,Acidosis,Congestive heart failure, unspecified,Cardiogenic shock,Iatrogenic pneumothorax,Methicillin susceptible pneumonia due to Staphylococcus aureus,Urinary tract infection, site not specified,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled'}
