CHIEF COMPLAINT: nausea, vomiting

PRESENT ILLNESS: 44 yo  seen by her PCP on the [**2133-12-31**] for viral gastroenteritis
with N,V, diarrhea and food intolerance, who presented on the
[**2134-1-2**] with peristent nausea, resolved abd.pain and was found
to be in DKA with glucose of 1200, AG of 21 and a bicarbonate of
less than 3. A CT scan of the abdomen was done and was positive
for portal venous gas within the liver and pneumatosis within
loops of ileum in the right hemipelvis.  Findings were worrisome
for ischemic bowel. Pt was admitted to the surgery team and was
started on Piperacillin-Tazobactam Na 4.5 gm IV and Vancomycin
HCl 1000 mg IV Q 12H. A repeat CT scan one day later was not
able to confirm the finding but showed interval development of
extensive thickening of the bowel wall of the ileum. She was
thought to have ischemic bowel from profound hypovolemia due to
DKA.
Pt was started on Insulin gtt for management of her DKA. Later
on admission day pt was noted to be in respiratory distress and
was intubated. A CT of the head was done and was negative. The
anion gap improved and the pt became more clear and stable. She
was extubated on the [**7-4**]. Anion gap now resolved.
The pt was also noted to have a drop in her hematocrit of 10
points on the [**7-3**]. She was found to be guaiac
positive but never had any gross GI bleed. The hematorcit was
attributed to slow grade GI bleed as well as hemodilution. No
hemolysis labs were send. The pt was transfused 2 u PRBC over
the subsequent day and increased with her Hct appropriately.
On the [**7-4**] the pt was also noted to have decreased
platelet counts, coming down from 395 on admission to 132. HIT
abx were sent and came back positive on the [**2134-1-6**]. All heparin
products were stopped and Argatroban was started. It was
recommended by hematology to start the pt on Coumadin with a
five day overlap to Argatroban for 5 days.
.
Pt currently states she is feeling fine. She denies HA, N, V,
abd. pain, CP, SOB, joint pain. She had two episodes of watery
diarrhea today, with blood (but currently with menstruation).
She denies any melena.

MEDICAL HISTORY: ? Diabetes -diet controlled per patient for one year since
diagonsis
Asthma.
2 Abortions
Uterine Fibroids

MEDICATION ON ADMISSION: none
.
on transfer:
Acetaminophen
Albuterol
Argatroban
Fluconazole
Insulin
Ipratropium Bromide MDI
Levofloxacin
Metronidazole
Pantoprazole

ALLERGIES: Heparin Agents

PHYSICAL EXAM: 98.4 100/70 106 16 100RA
Gen: lying in bed, in NAD
HEENT: EOMI, PERRL, moist mucous membranes
NECK: JVD 8 cm, no LAD, no thyroideomegaly
Chest: CTA b/l, mild crackles at bases, negative egophony
CV: RRR, S1/S2 intact, [**2-1**] SM over RUSB radiating into the
axillae
Abd: obese, soft, NT, ND +BS
Ext: no c/c, 2+ DP, 2+ pitting edema of the b/l LE and 1+ of UE,
negative [**Last Name (un) 4709**] sign
Neuro: CN 2-12 intact. AAO x3. strength 5/5 grossly throughout,
reflexes 2+ b/l.

FAMILY HISTORY: FH: Diabetes type II in several family members, no heart
disease, no malignancy

SOCIAL HISTORY: SH: divorced, originally from [**State 9512**], lives alone, has family
in [**Location (un) 86**], denies alcohol, tobacco or drug abuse currently or in
the past
.
Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Acute vascular insufficiency of intestine,Hypopotassemia,Hemorrhage of gastrointestinal tract, unspecified,Anticoagulants causing adverse effects in therapeutic use,Anemia, unspecified
DMI ketoacd uncontrold,Ac vasc insuff intestine,Hypopotassemia,Gastrointest hemorr NOS,Adv eff anticoagulants,Anemia NOS
Admission Date:  [**2134-1-2**]              Discharge Date:   [**2134-1-13**]

Date of Birth:  [**2089-6-20**]             Sex:   F

Service: MEDICINE

Allergies:
Heparin Agents

Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
nausea, vomiting

Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
44 yo  seen by her PCP on the [**2133-12-31**] for viral gastroenteritis
with N,V, diarrhea and food intolerance, who presented on the
[**2134-1-2**] with peristent nausea, resolved abd.pain and was found
to be in DKA with glucose of 1200, AG of 21 and a bicarbonate of
less than 3. A CT scan of the abdomen was done and was positive
for portal venous gas within the liver and pneumatosis within
loops of ileum in the right hemipelvis.  Findings were worrisome
for ischemic bowel. Pt was admitted to the surgery team and was
started on Piperacillin-Tazobactam Na 4.5 gm IV and Vancomycin
HCl 1000 mg IV Q 12H. A repeat CT scan one day later was not
able to confirm the finding but showed interval development of
extensive thickening of the bowel wall of the ileum. She was
thought to have ischemic bowel from profound hypovolemia due to
DKA.
Pt was started on Insulin gtt for management of her DKA. Later
on admission day pt was noted to be in respiratory distress and
was intubated. A CT of the head was done and was negative. The
anion gap improved and the pt became more clear and stable. She
was extubated on the [**7-4**]. Anion gap now resolved.
The pt was also noted to have a drop in her hematocrit of 10
points on the [**7-3**]. She was found to be guaiac
positive but never had any gross GI bleed. The hematorcit was
attributed to slow grade GI bleed as well as hemodilution. No
hemolysis labs were send. The pt was transfused 2 u PRBC over
the subsequent day and increased with her Hct appropriately.
On the [**7-4**] the pt was also noted to have decreased
platelet counts, coming down from 395 on admission to 132. HIT
abx were sent and came back positive on the [**2134-1-6**]. All heparin
products were stopped and Argatroban was started. It was
recommended by hematology to start the pt on Coumadin with a
five day overlap to Argatroban for 5 days.
.
Pt currently states she is feeling fine. She denies HA, N, V,
abd. pain, CP, SOB, joint pain. She had two episodes of watery
diarrhea today, with blood (but currently with menstruation).
She denies any melena.


Past Medical History:
? Diabetes -diet controlled per patient for one year since
diagonsis
Asthma.
2 Abortions
Uterine Fibroids


Social History:
SH: divorced, originally from [**State 9512**], lives alone, has family
in [**Location (un) 86**], denies alcohol, tobacco or drug abuse currently or in
the past
.


Family History:
FH: Diabetes type II in several family members, no heart
disease, no malignancy

Physical Exam:
98.4 100/70 106 16 100RA
Gen: lying in bed, in NAD
HEENT: EOMI, PERRL, moist mucous membranes
NECK: JVD 8 cm, no LAD, no thyroideomegaly
Chest: CTA b/l, mild crackles at bases, negative egophony
CV: RRR, S1/S2 intact, [**2-1**] SM over RUSB radiating into the
axillae
Abd: obese, soft, NT, ND +BS
Ext: no c/c, 2+ DP, 2+ pitting edema of the b/l LE and 1+ of UE,
negative [**Last Name (un) 4709**] sign
Neuro: CN 2-12 intact. AAO x3. strength 5/5 grossly throughout,
reflexes 2+ b/l.

Pertinent Results:
[**2134-1-2**] 01:45PM   PT-15.4* PTT-33.1 INR(PT)-1.6
[**2134-1-2**] 01:45PM   PLT SMR-NORMAL PLT COUNT-395
[**2134-1-2**] 01:45PM   HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
[**2134-1-2**] 01:45PM   NEUTS-88.5* BANDS-0 LYMPHS-6.5* MONOS-4.6
EOS-0.2 BASOS-0.2
[**2134-1-2**] 01:45PM   WBC-21.2* RBC-4.24 HGB-13.4 HCT-43.7 MCV-103*
MCH-31.6 MCHC-30.6* RDW-16.9*
[**2134-1-2**] 01:45PM   WBC-21.2* RBC-4.24 HGB-13.4 HCT-43.7 MCV-103*
MCH-31.6 MCHC-30.6* RDW-16.9*
[**2134-1-2**] 01:45PM   CK-MB-4 cTropnT-<0.01
[**2134-1-2**] 01:45PM   CK-MB-4 cTropnT-<0.01
[**2134-1-2**] 04:48PM   LACTATE-2.2*

Brief Hospital Course:
As above before admission to medicine.
44 yo with possible type one diabetes, presenting in DKA with
pneumatosis coli/ileal thickening in the setting of severe
dehydration, anemia, and HIT-II with positive abx on argatroban.
.
# HIT: antibody positive, makes HIT II more likely although
platelets never lower than 90 000. Serotonin release assay
pending on discharge. Pt with increased risk of thrombosis due
to hypercoagulable status. All heparin products were stopped.
Argatroban was started with a goal of PTT 60-80. Coumadin was
started at 2mg QHS once PTT therapeutic for 24 hourse. Platelets
started to rise again to normal limits. No evidence of
thrombosis was found. As pt was low probability for thrombosis
she was switched to Fondaparinux and was sent home on
Fondaparinux, transitioning to Coumadin. Follow up was arranged
with Dr. [**Last Name (STitle) 101845**] for [**2134-1-15**]. [**Hospital 197**] clinic was informed
about the pt.
.
# Anemia: unclear etiology. Initial drop attributed to
hemodilution in the setting of preexisting  anemia and low grade
GI bleed as guaiac postive. No surgical intervention done.
Hemolysis labs negative. 2U PRBC transfused. Also low Vit B12 -
possible related to bowel disease as resorption in the Ileum vs
pernicious anemia. Anti-intrinsic factor antibodies should be
check as an outpatient, also TTG to rule out celiac sprue should
be considered. On Vitamin B12 2000mcg QD for life. GI follow up
should be considered.
.
# Diabetes:  Presented in DKA and body habitus more suspicious
for type I. Gap resolved. GAD/ Islet cell Abx were pending on
discharge. Sliding scale was adjusted according to [**Last Name (un) **]
recommendations with Glargine and ISSC. It is unusual in that
the patient had some mildly elevated sugars over the past year
or two and did not present with frank DKA until now.
.
# Ileal thickening: most likely ischemic bowel in the setting of
DKA and profound hypovolemia. Predominance in the Ileum would be
suspicious for Crohns disease or Yersinia. Stool cultures
negative for Cdiff and Yersinia. Initially with leukocytosis and
improvement with fluids and antibiotics therefore more likely
hypovolemia and/or infectious cause. Leukocytosis also seen in
DKA and severe stress reaction. Chronic low grade Crohns disease
affecting the ileum could be considered also given Vit B12
deficiency. Pain and diarrhea now resolved. Antibiotics (Flagyl,
Levofloxacin and Fluconazole) were discontinued on day of
transfer to medicine team. GI follow up should be considered.
.
# Peripheral edema: resolving

Medications on Admission:
none
.
on transfer:
Acetaminophen
Albuterol
Argatroban
Fluconazole
Insulin
Ipratropium Bromide MDI
Levofloxacin
Metronidazole
Pantoprazole


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed: Do not exceed 4g per day.
Disp:*20 Tablet(s)* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*qs * Refills:*0*
3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*qs * Refills:*2*
4. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection as directed: Please follow sliding scale.
Disp:*2 * Refills:*2*
6. One touch Ultra teststrips  Sig: One (1)   four times a day.
Disp:*200 * Refills:*5*
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*20 Tablet(s)* Refills:*0*
8. Fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1)  Subcutaneous
DAILY (Daily): until INR is therapeutic.
Disp:*7 * Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Primary -
DKA
ischemic ileitis
HIT II
Anemia
Diabetes mellitus


Discharge Condition:
Good, anemia stable, abdominal pain resolved, diabetes
controlled with ISSC and INR 1.2 on Coumadin and Fondaparinux

Discharge Instructions:
Please come back to the hospital or see your primary care doctor
if you experience any abdominal pain, fevers, shortness of
breath, lower extremity swelling, pain or any other concern.
.
Please continue with all medications as prescribed.


Followup Instructions:
You will an appointment with [**Last Name (un) **] today at 4pm with Ms [**Name13 (STitle) 11712**]
for Diabetes teaching. They will arrange follow up with [**Last Name (un) **]
for you.
.
You will have VNA services to monitor your coagulation on
Coumadin.
Results will be faxed to your primary care doctor Dr. [**Last Name (STitle) 4390**].
She will adjust the Coumadin dose for you. She should also get
the following test on you: Test for consideration
post-discharge: anti-Tissue Transglutaminase Antibody, IgA.
You have an appointment with Dr. [**Last Name (STitle) 4390**] on the [**7-15**], at 2.35 pm.
.
You also have the following appointments scheduled for you:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 101846**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 95321**]
Date/Time:[**2134-3-8**] 9:30
{'Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Acute vascular insufficiency of intestine,Hypopotassemia,Hemorrhage of gastrointestinal tract, unspecified,Anticoagulants causing adverse effects in therapeutic use,Anemia, unspecified'}


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: nausea, vomiting

PRESENT ILLNESS: 44 yo  seen by her PCP on the [**2133-12-31**] for viral gastroenteritis
with N,V, diarrhea and food intolerance, who presented on the
[**2134-1-2**] with peristent nausea, resolved abd.pain and was found
to be in DKA with glucose of 1200, AG of 21 and a bicarbonate of
less than 3. A CT scan of the abdomen was done and was positive
for portal venous gas within the liver and pneumatosis within
loops of ileum in the right hemipelvis.  Findings were worrisome
for ischemic bowel. Pt was admitted to the surgery team and was
started on Piperacillin-Tazobactam Na 4.5 gm IV and Vancomycin
HCl 1000 mg IV Q 12H. A repeat CT scan one day later was not
able to confirm the finding but showed interval development of
extensive thickening of the bowel wall of the ileum. She was
thought to have ischemic bowel from profound hypovolemia due to
DKA.
Pt was started on Insulin gtt for management of her DKA. Later
on admission day pt was noted to be in respiratory distress and
was intubated. A CT of the head was done and was negative. The
anion gap improved and the pt became more clear and stable. She
was extubated on the [**7-4**]. Anion gap now resolved.
The pt was also noted to have a drop in her hematocrit of 10
points on the [**7-3**]. She was found to be guaiac
positive but never had any gross GI bleed. The hematorcit was
attributed to slow grade GI bleed as well as hemodilution. No
hemolysis labs were send. The pt was transfused 2 u PRBC over
the subsequent day and increased with her Hct appropriately.
On the [**7-4**] the pt was also noted to have decreased
platelet counts, coming down from 395 on admission to 132. HIT
abx were sent and came back positive on the [**2134-1-6**]. All heparin
products were stopped and Argatroban was started. It was
recommended by hematology to start the pt on Coumadin with a
five day overlap to Argatroban for 5 days.
.
Pt currently states she is feeling fine. She denies HA, N, V,
abd. pain, CP, SOB, joint pain. She had two episodes of watery
diarrhea today, with blood (but currently with menstruation).
She denies any melena.

MEDICAL HISTORY: ? Diabetes -diet controlled per patient for one year since
diagonsis
Asthma.
2 Abortions
Uterine Fibroids

MEDICATION ON ADMISSION: none
.
on transfer:
Acetaminophen
Albuterol
Argatroban
Fluconazole
Insulin
Ipratropium Bromide MDI
Levofloxacin
Metronidazole
Pantoprazole

ALLERGIES: Heparin Agents

PHYSICAL EXAM: 98.4 100/70 106 16 100RA
Gen: lying in bed, in NAD
HEENT: EOMI, PERRL, moist mucous membranes
NECK: JVD 8 cm, no LAD, no thyroideomegaly
Chest: CTA b/l, mild crackles at bases, negative egophony
CV: RRR, S1/S2 intact, [**2-1**] SM over RUSB radiating into the
axillae
Abd: obese, soft, NT, ND +BS
Ext: no c/c, 2+ DP, 2+ pitting edema of the b/l LE and 1+ of UE,
negative [**Last Name (un) 4709**] sign
Neuro: CN 2-12 intact. AAO x3. strength 5/5 grossly throughout,
reflexes 2+ b/l.

FAMILY HISTORY: FH: Diabetes type II in several family members, no heart
disease, no malignancy

SOCIAL HISTORY: SH: divorced, originally from [**State 9512**], lives alone, has family
in [**Location (un) 86**], denies alcohol, tobacco or drug abuse currently or in
the past
. 

### Response:
{'Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Acute vascular insufficiency of intestine,Hypopotassemia,Hemorrhage of gastrointestinal tract, unspecified,Anticoagulants causing adverse effects in therapeutic use,Anemia, unspecified'}
