CHIEF COMPLAINT: confusion

PRESENT ILLNESS: 40-year-old female DM2 transferred from [**Hospital 1562**] Hospital for
severe acidosis from ? DKA, altered mental status, and
respiratory failure. Patient presented to the outside hospital
with altered mental status and agitation. She was noted to be
hypotensive. Initial labs revealed elevated lipase. As the
patient became more agitated, she was intubated for airway
protection. She was given 6 L of NS with levophed at 3 mcg/min
started and increased to 25 mcg/min. Vent settings on transfer
were SIMV 12/500/1/5. She was given KCl 10 mEq x 2. She was
transferred to [**Hospital1 18**] for further management.

MEDICAL HISTORY: Insulin dependent diabetes mellitus

MEDICATION ON ADMISSION: Lantus 40 units SC daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
General Appearance: Intubated, sedated
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, atraumatic, IJ line in
place
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), no murmurs
Peripheral Vascular: pulses present throughout
Respiratory / Chest: clear bilaterally
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: no peripheral edema
Skin:  Warm
Neurologic: intubated, sedated

FAMILY HISTORY: Diabetes in multiple family members.
Denies family history of seizures and strokes.

SOCIAL HISTORY: Patient lives in [**Location **].  Her father is an internist and is
currently here visiting while she is in the hospital.
Tobacco: [**8-1**] pack year smoking history in the [**2134**]. Quit for 10
years, recent relapse, but now without smoking for 6 months.
EtOH: Socially; 2 drinks/month.
IVDU: Denies.
Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Other shock without mention of trauma,Acute pancreatitis,Thrombocytopenia, unspecified,Hyperosmolality and/or hypernatremia,Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Rhabdomyolysis,Candidiasis of other urogenital sites,Bloodstream infection due to central venous catheter,Bacteremia,Delirium due to conditions classified elsewhere,Long-term (current) use of insulin,Personal history of noncompliance with medical treatment, presenting hazards to health,Hypothermia not associated with low environmental temperature,Leukocytosis, unspecified,Unspecified essential hypertension,Mononeuritis multiplex,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Monoclonal paraproteinemia,Lesion of sciatic nerve,Other acquired deformities of ankle and foot,Other chronic nonalcoholic liver disease,Pure hyperglyceridemia,Thoracic or lumbosacral neuritis or radiculitis, unspecified
DMII ketoacd uncontrold,Shock w/o trauma NEC,Acute pancreatitis,Thrombocytopenia NOS,Hyperosmolality,SIRS-noninf w/o ac or ds,Rhabdomyolysis,Candidias urogenital NEC,Blood inf dt cen ven cth,Bacteremia,Delirium d/t other cond,Long-term use of insulin,Hx of past noncompliance,Hypothrm-wo low env tmp,Leukocytosis NOS,Hypertension NOS,Mononeuritis multiplex,MRSA elsewhere/NOS,Abn react-procedure NEC,Monoclon paraproteinemia,Sciatic nerve lesion,Acq ankle-foot def NEC,Chronic liver dis NEC,Pure hyperglyceridemia,Lumbosacral neuritis NOS
Admission Date:  [**2156-9-14**]              Discharge Date:   [**2156-10-4**]

Date of Birth:  [**2116-3-20**]             Sex:   F

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
confusion

Major Surgical or Invasive Procedure:
Dialysis on [**2156-9-14**] for acidosis and hypokalemia
Intubation
PICC line placement

History of Present Illness:
40-year-old female DM2 transferred from [**Hospital 1562**] Hospital for
severe acidosis from ? DKA, altered mental status, and
respiratory failure. Patient presented to the outside hospital
with altered mental status and agitation. She was noted to be
hypotensive. Initial labs revealed elevated lipase. As the
patient became more agitated, she was intubated for airway
protection. She was given 6 L of NS with levophed at 3 mcg/min
started and increased to 25 mcg/min. Vent settings on transfer
were SIMV 12/500/1/5. She was given KCl 10 mEq x 2. She was
transferred to [**Hospital1 18**] for further management.

Labs prior to transfer were lactate 0.8, alcohol < 10, lipase
1027, CK 86, cTropnT < 0.010, amylase 553, ALP 173, GGT 107, AST
50 ALT 58, Na 123, K 4, Cl 93, HCO3 3, BUN 42, Cr 1.05, Glc 685,
Mg 2.7, Ph 4.4, Gap 30. CBC WBC 35.9, Hgb 13.2, Plt 97, 8 %
bands.

In the ED, initial VS were: 82 95/51 22 100%

Patient received intubated from OSH. 7.5 ETT secured @ 22cm
@lips. Initial vent settings were FiO2: 100% PEEP: 5 RR: 14 Vt:
500

Initial ABG was pH 6.74 pCO2 33 pO2 385 HCO3 5. Based on ABG
results RR increased to 22 and FiO2 decreased to 40%.

A RIJ and left femoral a-line was placed in the ER.

Past Medical History:
Insulin dependent diabetes mellitus

Social History:
Patient lives in [**Location **].  Her father is an internist and is
currently here visiting while she is in the hospital.
Tobacco: [**8-1**] pack year smoking history in the [**2134**]. Quit for 10
years, recent relapse, but now without smoking for 6 months.
EtOH: Socially; 2 drinks/month.
IVDU: Denies.


Family History:
Diabetes in multiple family members.
Denies family history of seizures and strokes.

Physical Exam:
Admission Physical Exam:
General Appearance: Intubated, sedated
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, atraumatic, IJ line in
place
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), no murmurs
Peripheral Vascular: pulses present throughout
Respiratory / Chest: clear bilaterally
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: no peripheral edema
Skin:  Warm
Neurologic: intubated, sedated

Physical Exam on Discharge:

Vitals: afebrile, hemodynamically stable
General: Awake, cooperative, NAD.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: Alert, oriented x 3.  Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension.  Normal prosody.  There were no paraphasic
errors.   Speech was not dysarthric. Able to follow both midline
and appendicular commands. The pt. had good knowledge of current
events.  There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.  VFF to confrontation.
III, IV, VI: EOMI without nystagmus.  Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L  5    5   4+  5   3  3  5  5   5    5  2     5     3
R  5    5   5   5   5  5  5  5   5    4  2     5     3
-Sensory:decreased in  L 5 to midshin b/l, decreased at L ulnar
n distribution from 5th digit to wrist
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.


Pertinent Results:
ADMISSION LABS:
[**2156-9-14**] 12:52AM BLOOD WBC-37.36* RBC-4.25 Hgb-12.4 Hct-38.5
MCV-91 MCH-29.1 MCHC-32.1 RDW-14.0 Plt Ct-67*
[**2156-9-14**] 04:00AM BLOOD Neuts-59 Bands-8* Lymphs-16* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-11*
[**2156-9-14**] 12:52AM BLOOD PT-11.5 PTT-27.2 INR(PT)-1.1
[**2156-9-14**] 04:00AM BLOOD Glucose-568* UreaN-33* Creat-1.1 Na-134
K-2.1* Cl-109* HCO3-LESS THAN
[**2156-9-14**] 12:52AM BLOOD ALT-92* AST-129* AlkPhos-149* TotBili-0.4
[**2156-9-14**] 12:52AM BLOOD Lipase-612*
[**2156-9-14**] 04:00AM BLOOD cTropnT-<0.01
[**2156-9-14**] 12:52AM BLOOD Calcium-6.3* Phos-2.3* Mg-2.1
[**2156-9-19**] 09:00PM BLOOD calTIBC-221* Ferritn-293* TRF-170*
[**2156-9-14**] 04:00AM BLOOD %HbA1c-13.1* eAG-329*
[**2156-9-14**] 12:52AM BLOOD Triglyc-488*
[**2156-9-14**] 04:00AM BLOOD Acetone-SMALL Osmolal-336*
[**2156-9-14**] 04:00AM BLOOD TSH-1.2
[**2156-9-14**] 04:00AM BLOOD Cortsol-91.5*
[**2156-9-14**] 01:57PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2156-9-14**] 04:00AM BLOOD HCG-<5
[**2156-9-20**] 04:00PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2156-9-20**] 04:00PM BLOOD PEP-TRACE ABNO IgG-857 IgA-174 IgM-76
IFE-MONOCLONAL
[**2156-9-14**] 12:52AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2156-9-14**] 01:57PM BLOOD HCV Ab-NEGATIVE
[**2156-9-14**] 01:12AM BLOOD Type-ART Rates-14/ Tidal V-500 PEEP-5
FiO2-100 pO2-385* pCO2-33* pH-6.74* calTCO2-5* Base XS--33
AADO2-294 REQ O2-55 -ASSIST/CON Intubat-INTUBATED
[**2156-9-14**] 12:53AM BLOOD Glucose-500* Na-137 K-2.7* Cl-118*
calHCO3-3*
[**2156-9-14**] 12:52AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2156-9-14**] 12:52AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2156-9-14**] 12:52AM URINE RBC-<1 WBC-0 Bacteri-FEW Yeast-NONE Epi-1
[**2156-9-14**] 12:52AM URINE Mucous-RARE
[**2156-9-14**] 12:52AM URINE UCG-NEGATIVE
[**2156-9-14**] 12:52AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG

Relevant Labs:

[**2156-9-29**] 05:10AM BLOOD ESR-99*
[**2156-9-26**] 12:05PM BLOOD ESR-103*
[**2156-9-29**] 05:10AM BLOOD Ret Aut-8.5*
[**2156-9-20**] 07:24AM BLOOD Ret Aut-0.6*
[**2156-9-20**] 07:24AM BLOOD calTIBC-211* Hapto-286* Ferritn-256*
TRF-162*
[**2156-9-20**] 04:00PM BLOOD VitB12-1251*
[**2156-9-14**] 04:00AM BLOOD %HbA1c-13.1* eAG-329*
[**2156-9-15**] 07:55AM BLOOD Triglyc-276*
[**2156-9-14**] 04:00AM BLOOD TSH-1.2
[**2156-9-14**] 04:00AM BLOOD Cortsol-91.5*
[**2156-10-1**] 03:18AM BLOOD HIV Ab-PND
[**2156-9-14**] 01:57PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2156-9-24**] 05:21AM BLOOD ANCA-NEGATIVE B
[**2156-9-29**] 05:10AM BLOOD b2micro-1.5
[**2156-9-20**] 04:00PM BLOOD PEP-TRACE ABNO IgG-857 IgA-174 IgM-76
IFE-MONOCLONAL
[**2156-10-1**] 03:18AM BLOOD HIV Ab-PND
RPR [**2156-9-20**]: negative
Lyme [**2156-9-20**]: negative
[**2156-9-18**] 8:22 pm BLOOD CULTURE      Source: Venipuncture.

MICRO:
[**2-1**] blood cultures:

   Blood Culture, Routine (Preliminary):
      STAPH AUREUS COAG +.
         Consultations with ID are recommended for all blood
cultures
         positive for Staphylococcus aureus, yeast or other
fungi.
         FINAL SENSITIVITIES.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S

STUDIES:
ECHO ([**2156-9-14**])
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and hyperdynamic global biventricular systolic
function. No valvular pathology or pathologic flow identified.

CT Head Non-con ([**2156-9-14**]):
IMPRESSION:  No evidence of acute intracranial pathology.

CT Abd/Pelvis ([**2156-9-14**]):
1. Visualized lung bases show bilateral trace pleural effusions
with adjacent opacification which likely represents atelectasis;
however, a component of aspiration versus infectious process
such as pneumonia cannot be completely excluded.
2. Minimal edema within the fat in the groove between the
pancreas and
duodenum which may represent focal acute pancreatitis with
extension of edema to the pericholecystic region.
3. Multiple transient intussceptions are noted along the jejunum
(uncertain significance).
4. Significantly fatty liver.

ECHO ([**9-21**]):
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
No vegetation seen (cannot definitively exclude).
Compared with the prior study (images reviewed) of [**2156-9-14**],
findings are similar. The heart rate is now slower.

EMG [**2156-9-23**]
Abnormal study. There is electrophysiologic evidence for an
acute, severe, sensorimotor polyneuropathy affecting the
bilateral lower extremities. Although this neuropathy appears to
have axonal features, a demyelinating pathology cannot be
entirely excluded due to the absence of distal sensorimotor
responses. In addition, there is evidence for a severe, acute
ulnar neuropathy at the left elbow. A right lumbosacral
polyradiculopathy cannot be entirely excluded.

EMG [**2156-9-30**]
Taken together with the results of [**9-23**], the findings are
most consistent with severe, acute bilateral sciatic
neuropathies. Given the clinical history and evidence for left
ulnar neuropathy, a compressive etiology for these neuropathies
is most likely.

MRI L spine w/o contrast

FINDINGS:  Intervertebral disc heights and signals are
maintained.  There is no signal abnormality in the cord.
Vertebral body heights are maintained and show normal signal.
Imaged portions of the soft tissues are unremarkable. A small
disc buldge is present at L5-S1 with very minimal compression of
the thecal sac, but no contact with traversing nerve roots.
IMPRESSION:  Very minimal disc buldge of L5-S1. If there is
concern for
polyneuritis, post gadolineum imaging can be obtained.

Skeletal Survey

LATERAL SKULL:  No focal lytic or blastic lesions are seen.
BILATERAL HUMERI:  There is a portion of a central venous
catheter seen in the right arm.  There are no focal lytic or
blastic lesions or significant degenerative changes.
THORACIC SPINE:  No compression deformities are seen.  There is
minimal
spurring at the anterior aspect of several lower thoracic
vertebral bodies.  Visualized lung fields are clear.  There is a
central venous catheter with distal lead tip at the cavoatrial
junction.
LUMBAR SPINE:  There are five non-rib-bearing lumbar-type
vertebral bodies.  There is no compression deformity.  Minimal
spurring at the L4 and L5 vertebral bodies are seen anteriorly.
AP PELVIS AND BILATERAL FEMORA:  No focal lytic or blastic
lesions are seen.  The sacroiliac joints are grossly within
normal limits.  Bilateral hip joint spaces demonstrate mild
spurring in the superolateral aspect, consistent with early
degenerative changes.

IMPRESSION:
No focal lytic or blastic lesions in the skeleton to indicate
definite
myelomatous deposits.

Sural biopsy: final report pending at time of discharge. Prelim
read was normal.

Labs on Discharge: (most recent)

[**2156-10-1**] 03:18AM BLOOD WBC-3.7* RBC-3.08* Hgb-8.9* Hct-27.4*
MCV-89 MCH-29.0 MCHC-32.7 RDW-15.8* Plt Ct-327
[**2156-9-29**] 05:10AM BLOOD PT-11.5 PTT-25.9 INR(PT)-1.1
[**2156-10-1**] 03:18AM BLOOD Glucose-121* UreaN-14 Creat-0.5 Na-137
K-4.7 Cl-103 HCO3-27 AnGap-12
[**2156-9-29**] 05:10AM BLOOD ALT-45* AST-35 LD(LDH)-200 AlkPhos-81
TotBili-0.3
[**2156-9-29**] 05:10AM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.7 Mg-1.9

Brief Hospital Course:
40F unknown past medical history with Insulin dependant DM2
transferred to [**Hospital1 18**] for severe acidosis and hypokalemia in
setting of DKA.  Patient managed in the MICU for 6 days with
resolution of her acidosis noted. Patient was called out to the
floor on hospital day 6 after being stable on SubQ insulin.
Course complicated by new sensory-motor polyneuropathy of left
upper extremity and bilateral lower extremities.  Transfered to
neurology service after EMG concerning for axonal neuropathy on
hospital day 11, ultimately determined to be a compressive
neuropathy vs. multiple root radiculopathy.

# Severe acidosis likely DKA
Patient has severe acidosis on ABG with both primary metabolic
non-gap and gap acidoses with superimposed respiratory acidosis.
Etiology of primary metabolic non-gap acidosis may be from NS
volume resuscitation, diarrhea, or other etiologies. The likely
cause of the anion gap acidosis is DKA with no other apparent
MUDPILES etiologies based on urine/serum toxicology. Osmolar gap
initially 51, so methanol, polyethylene glycol or other
exogenous substance may explain extra osmoles that would not be
accounted for by DKA alone. Patient started on Insulin drip and
Bicarb which were rate limited so as not to drop K+ faster than
it could be repleted. Over the course of hospital day 1 patient
was noted to have progressive improvement of her acidosis. In
setting of severe acidosis and osmolar gap, patient received a
single episode of hemodialysis.  In the evening of hospital day
1 the patient's anion gap was noted to re-open to 24, patient
was given additional IV fluids and insulin drip was continued
with resolution of anion gap noted on repeat Chem7. Patient
tolerated a PO diet on hospital day 4 and was started on SubQ
insulin. Following initiation of SubQ insulin the insulin drip
was discontinued. The patient was observed in the MICU following
discontinuation of the insulin drip and her anion gap was noted
to remain closed. Once the patient was fully awake she endorsed
poor medication compliance with regards to her insulin. She
states that she was on vacation prior to onset of DKA and that
she did not utilize her insulin at all during a period of time
during her vacation making medication non-compliance the most
likely etiology of her DKA.  After transfer to the general
medicine, her blood sugars remained in the 120-250 range and she
was kept on Lantus 50 units in the am and humalog sliding scale.
 She was followed closely by the [**Last Name (un) **] service.  Insulin dose
on discharge was Lantus 40qam and 16qhs along with sliding
scale.  Instructed patient about importance of insulin
compliance and establishing care with a primary care doctor upon
return to [**State 4565**].

# Leukocytosis/hypothermia/MRSA bacteremia
Initial concern for hypothermic sepsis given marked
leukocytosis. Careful skin exam did not reveal any skin/soft
tissue infection. CXR showing ? atelectasis vs. developing LL
infiltrate after fluid resuscitation. CT Abdomen could suggest
colitis although indefinite. Host factors include DM2 - no
recent healthcare exposure- vancomycin/cefepime/flagyl given
empirically as patient critically ill pending culture results.
Patient's antibiotics discontinued on hospital day 3 as all
cultures acquired were negative. On hospital day 5, repeat CXR
concerning for new pneumonia and UA concerning for UTI. Repeat
cultures sent and patient re-started on vanc and cefepime.
Cultures sendt [**9-18**] noted to grow out gram positive cocci in
clusters, central line discontinued and patient continued on
vanc and cefepime.  She remained on Vancomycin after confirmed
MRSA bacteremia to complete a 2 week course ending [**2156-10-2**].  A
PICC was placed [**2155-9-22**] via IR guidance after an initial failed
attempt.  She also had a TTE which did not show evidence of
vegetation, thus low suspicion of endocarditis.  She completed a
course of Vancomycin per recommendations of the infectious
disease team on [**2156-10-3**].

# ? Pancreatitis
The patient had elevated pancreatic enzymes, which may reflect
either pancreatitis or increased pancreatic enzyme activities in
the setting of DKA. Her abdominal exam appears to be bengin. A
CT Abd/pelvis showed bowel wall thickening mainly involving the
proximal small bowel (duodenum and jejunum) which could
represent peristalsis, enteritis (such as infectious,
inflammatory or ischemic) with mild blurring of pancreatic
margins with minimal mesenteric stranding. It also shows
multiple transient intussusception of jejenum, little bit of
fluid in mesenetery and pancreas consistent with ? focal
pancreatitis. Patient was evaluated by surgery for questionable
CT abdomen findings, no surgical intervention indicated per
surgery. TG mildly elevated, but unclear if high enough to have
precipitated pancreatitis. Ca within normal limits; no evidence
of CBG/gallstone pancreatitis on CT Abd. As patient's mental
status improved appeared to be in pain with apparent tenderness
to palpation of epigastrum, in setting of elevated lipase we
have increased suspiscion of pancreatitis as cause of pain and
possibly as etiology of DKA. Treated with IV Dilaudid PRN pain.
Patient subsequently noted to have improvement of pain and
tenderness likely representing resolution of acute pancreatitis
episode.  There was no further abdominal pain/tenderness while
on the floor.

# Respiratory failure
Patient was intubated secondary to depressed mental status for
airway protection.  Patient passed spontaneous breathing test on
hospital day two and was extubated.  No further respiratory
distress.

# Shock
Patient likely had septic shock from underlying infection,
hypovolemic shock from osmotic diuresis in setting of DKA. Doubt
cardiogenic or distributive shock. Her opening CVP was 11 with
good urine output, normal lactate, and exam consistent with good
perfusion. ScVO2 is ~ 90 suggestive of likely tissue
mitochondrial dysfunction in setting of severe acidosis. She has
been responsive to IVF resuscitation. By hospital day 2 patient
was noted to have improvement in hemodynamics and was weaned off
of phenylephrine.

# Elevated LFTs
Patient had mild elevated LFTs at OSH and on admission at [**Hospital1 18**].
Uncertain etiology - abdominal CT not showed elevated Tbili or
other overt abnormalities. Could be from toxidrome vs. early
shock liver given hypotension or other causes. Patient's LFTs
were trended and returned to baseline.

# Thrombocytopenia
Admission platelets with thrombocytopenia. Etiology is likely
marrow suppresion from acute sepsis/illness. No evidence of
sequestration or destruction - firinogen and coagulation is
within normal limits speaking against DIC. Was noted to have
improvement of platelet count during ICU stay. Normal platelet
counts while on the floor.  She was seen by heme/onc who
recommended a skeletal survey which was normal.  Also
recommended HIV, which is pending at time of discharge.
Considered bone marrow biopsy, but deferred given abnormalities
likely in setting of acute illness.  Asked patient to seen a
hematologist/oncologist in 3 months and have them re-check SPEP,
free kappa/lambda chains. Also, re-consider a bone marrow biopsy
if values have not normalized.

#Anemia: She developed normocytic anemia during this
hospitalization (Hgb 12.5 -> 8.4).  This was likely secondary to
volume repletion.  B12, folate, and Iron studies within normal
limits.  No evidence of active bleeding.  Would continue to
follow H/H, although it has remained stable.

# Severe acute axonal sensory-motor polyneuropathy
Patient was in ICU for 6 days. Intubated and sedated. Then
extubated and off sedation and noted tingling in her hands and
feet.  She couldn't "wiggle her ankles".  Her exam was most
notable for an Left Ulnar neuropathy and difficulty with TA [**2-29**]
bilateralas well as weakness of the toe flexors.  Did not fit
distribution.  Differential was initially critical illness
neuropathy,  mononeurotis multiplex.  EMG looked like a severe
acute axonal sensorimotor polyneuropathy intially. Confirmed
that the left wrist was an ulnar neuropathy.  Had repeat EMG
which showed bilateral sciatic nerve neuropathies, probably
compression from position.  Also possible that she has a
multiple root lumbosacral radiculopathy. Currently, strength and
sensation improving as per discharge exam.  Does have painful
tingling in her lower extremities, likely nerve pain with
regeneration, which responds well to Gabapenin and tylenol with
codeine.  Since patient has bilateral foot drop, had orthotics
made for her.  She will follow up with neurology as an
outpatient once she returns to [**State 4565**].

TRANSITIONAL ISSUES:
- follow up with PCP regarding fatty liver on ultrasound, high
triglycerides, hepatitis serology
- 3 months from now (early [**Month (only) 1096**]) you should see a
hematologist/oncologist and ask them to check these labs: SPEP,
free kappa/lambda chains. Also, re-consider a bone marrow biopsy
if values have not normalized.
- HIV and final report of sural nerve biopsy pending at time of
discharge
- patient will follow up with a new PCP and neurologist upon
return to [**State 4565**].

Medications on Admission:
Lantus 40 units SC daily


Discharge Medications:
1. Gabapentin 200 mg PO TID
RX *gabapentin 100 mg 2 capsule(s) by mouth three times a day
Disp #*180 Capsule Refills:*2
2. Glargine 40 Units Breakfast
Glargine 16 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [Accu-Chek Active Test]    QAHS Disp
#*1 Not Specified Refills:*2
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL)  40
Units before BKFT; 16 Units before BED; Disp #*2 Not Specified
Refills:*2
RX *blood-glucose meter [Accu-Chek Active Care]   Before every
meal and at bedtime QAHS Disp #*1 Kit Refills:*1
RX *insulin lispro [Humalog KwikPen] 100 unit/mL Up to 25 Units
per sliding scale four times a day Disp #*2 Not Specified
Refills:*2
RX *lancets [Accu-Chek Multiclix Lancet]    QAHS Disp #*1 Not
Specified Refills:*1
3. Miconazole Powder 2% 1 Appl TP TID:PRN groin rah
RX *miconazole nitrate [Anti-Fungal] 2 % apply to affected area
three times a day Disp #*1 Tube Refills:*0
RX *miconazole nitrate [Anti-Fungal] 2 %  three times a day Disp
#*1 Tube Refills:*1
4. Acetaminophen w/Codeine [**1-26**] TAB PO Q4H:PRN pain
please hold for rr <12, sedation
RX *acetaminophen-codeine 300 mg-30 mg 1 tablet(s) by mouth
every four (4) hours Disp #*24 Tablet Refills:*0


Discharge Disposition:
Home

Discharge Diagnosis:
primary diagnosis:
diabetic ketoacidosis
bilateral sciatic neuropathies vs. multiple root lumbosacral
radiculopathy

secondary diagnosis:
diabetes mellitus type I
Critical illness polyneuropathy


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Ms. [**Known lastname 4566**],

It was a pleasure taking care of you.  You were admitted to the
[**Hospital1 69**] for a severe case of
diabetic ketoacidosis.  You were initially stabilized in the
intensive care unit (ICU).  We found that you had a blood stream
infection and treated you with intravenous antibiotics.

You had a weakness of your ankles and left arm that we
investigated. We biopsied several of your nerves and did EMGs.
We determined that the cause of your weakness was due to
compression of the scitic and ulnar nerves as you are at risk
for this with your diabetes.  During the hospital stay, your
strength and sensation gradually began to improve.  We think
this will continue to improve over the next year.  We started
you on Gabapentin (Neurontin) for the pain.  When you return to
[**State 4565**] it is important that you schedule an appointment with
a neurologist.

Also it is CRITICAL that you follow up with your primary care
doctor for STRICT management of your diabetes as we do not want
you to become ill from the high sugars as you did this time. You
MUST check your blood sugars regularly and [**Last Name (un) **] your insulin.

You had some abnormal blood counts so we asked the
hematology/oncology team to evaluate you.  They recommended an
x-ray of your body which was quite normal.    Most likely, these
abnormalities were in the setting of acute illness.  3 months
from now (early [**Month (only) 1096**]) you should see a
hematologist/oncologist and ask them to check these labs: SPEP,
free kappa/lambda chains.  Also, re-consider a bone marrow
biopsy if values have not normalized.

We have made the following changes to your medications:
START
Gabapentin 200mg three times per day for nerve pain
Tylenol with codeine up to every 4 hours as needed for pain
Miconazole powder as needed for rash
Insulin sliding scale

INCREASE
Lantus to 40 units in the morning and 16 units at bedtime

On discharge, please schedule appointments with a neurologist, a
primary care doctor as soon as possible.  Also, schedule an
appointment with a hematologist/oncologist in early [**Month (only) 1096**].

It was a pleasure taking care of you, we wish you all the best!

Followup Instructions:
On discharge, please schedule appointments with a neurologist
and primary care doctor as soon as possible.

Also, schedule an appointment with a hematologist/oncologist in
early [**Month (only) 1096**].  Please ask them to check the tests mentioned
above.


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]

Completed by:[**2156-10-4**]
{'Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Other shock without mention of trauma,Acute pancreatitis,Thrombocytopenia, unspecified,Hyperosmolality and/or hypernatremia,Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Rhabdomyolysis,Candidiasis of other urogenital sites,Bloodstream infection due to central venous catheter,Bacteremia,Delirium due to conditions classified elsewhere,Long-term (current) use of insulin,Personal history of noncompliance with medical treatment, presenting hazards to health,Hypothermia not associated with low environmental temperature,Leukocytosis, unspecified,Unspecified essential hypertension,Mononeuritis multiplex,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Monoclonal paraproteinemia,Lesion of sciatic nerve,Other acquired deformities of ankle and foot,Other chronic nonalcoholic liver disease,Pure hyperglyceridemia,Thoracic or lumbosacral neuritis or radiculitis, 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: confusion

PRESENT ILLNESS: 40-year-old female DM2 transferred from [**Hospital 1562**] Hospital for
severe acidosis from ? DKA, altered mental status, and
respiratory failure. Patient presented to the outside hospital
with altered mental status and agitation. She was noted to be
hypotensive. Initial labs revealed elevated lipase. As the
patient became more agitated, she was intubated for airway
protection. She was given 6 L of NS with levophed at 3 mcg/min
started and increased to 25 mcg/min. Vent settings on transfer
were SIMV 12/500/1/5. She was given KCl 10 mEq x 2. She was
transferred to [**Hospital1 18**] for further management.

MEDICAL HISTORY: Insulin dependent diabetes mellitus

MEDICATION ON ADMISSION: Lantus 40 units SC daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
General Appearance: Intubated, sedated
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, atraumatic, IJ line in
place
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), no murmurs
Peripheral Vascular: pulses present throughout
Respiratory / Chest: clear bilaterally
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: no peripheral edema
Skin:  Warm
Neurologic: intubated, sedated

FAMILY HISTORY: Diabetes in multiple family members.
Denies family history of seizures and strokes.

SOCIAL HISTORY: Patient lives in [**Location **].  Her father is an internist and is
currently here visiting while she is in the hospital.
Tobacco: [**8-1**] pack year smoking history in the [**2134**]. Quit for 10
years, recent relapse, but now without smoking for 6 months.
EtOH: Socially; 2 drinks/month.
IVDU: Denies. 

### Response:
{'Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Other shock without mention of trauma,Acute pancreatitis,Thrombocytopenia, unspecified,Hyperosmolality and/or hypernatremia,Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Rhabdomyolysis,Candidiasis of other urogenital sites,Bloodstream infection due to central venous catheter,Bacteremia,Delirium due to conditions classified elsewhere,Long-term (current) use of insulin,Personal history of noncompliance with medical treatment, presenting hazards to health,Hypothermia not associated with low environmental temperature,Leukocytosis, unspecified,Unspecified essential hypertension,Mononeuritis multiplex,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Monoclonal paraproteinemia,Lesion of sciatic nerve,Other acquired deformities of ankle and foot,Other chronic nonalcoholic liver disease,Pure hyperglyceridemia,Thoracic or lumbosacral neuritis or radiculitis, unspecified'}
