CHIEF COMPLAINT: DKA, UTI

PRESENT ILLNESS: 61F w/ PMH DM, CKD (Cr 1.5-1.8), HTN, with recent
hospitalization for DKA/UTI now presenting to ED from PCP with
persistent dysuria, nausea and chills.  She was discharged on
cefuroxime based on prior history of pan-sensitive
proteus/ecoli.  During that hospitalization, she was noted to
have elevated blood glucose, increased anion gap, and ketones in
urine reflective of DKA thought to be precipitated by the UTI.
She initially received IV insulin and was transitioned to a SC
regimen.

MEDICAL HISTORY: 1. DM2: insulin-dependent may be Type 1
-followed by [**Hospital **] Clinic
-c/b recurrent ulcers, urosepsis
-Charcot deformity
2. s/p amputation of L 2nd & 3rd toe
3. chronic ulcer of R pretibia
4. hx of MRSA foot [**3-/2125**]
5. HTN
6. PVD
7. hypercholesterolemia
8. Anemia, ? ACD, baseline low 30s
9. Hematemesis in [**2125**] thought to be [**1-15**] small [**Doctor First Name 329**] [**Doctor Last Name **],
EGD ulcer in GE junction

MEDICATION ON ADMISSION: 1. Hydrochlorothiazide 25 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Nortriptyline 150 mg PO HS
4. Pantoprazole 40 mg PO Q24H
5. Rosuvastatin Calcium 20 mg PO DAILY
6. Vitamin D 50,000 UNIT PO MONTHLY
7. cefUROXime 500 mg [**Hospital1 **]
8. Detemir 70 Units Bedtime

ALLERGIES: Gatifloxacin / Penicillins / Ciprofloxacin / Bactrim

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: T: 98.5, 188/95, 98, 14, 96% RA
General: obese female lying in bed, somnelent, but [**Last Name (un) **]/oriented
and answering questions
HEENT: dry MM, OP clear, EOM intact, rosy face
Neck: supple, JVP not elevated, no LAD
CV: distant heart sounds but regular, no murmurs
Lungs: distant breath sounds, but clear bilaterally
Abdomen: obese, NT/ND, BS+
GU: foley
Ext: warm, well perfused, 1+ pulses, chronic venous stasis
changes and bilateral erythema of the shins with open ulcers,
multiple toe-amputations
Neuro: moving all extremities, A/O x2 (didn't have date right),
but lethargic

FAMILY HISTORY: Mother had DM2, died of diabetes related coma
Father has DM2, still alive
Several family members on paternal side with DM2
No FH of CAD, MI, or cancer.

SOCIAL HISTORY: The patient lives with her husband and has a 10 year old child.
She works at the Causeway VA as a secretary. She smokes 10 cigs
per day x 40 years. No ETOH and drugs.
Urinary tract infection, site not specified,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Gastroparesis,Ulcer of other part of foot,Long-term (current) use of insulin,Candidiasis of vulva and vagina,Arthropathy associated with neurological disorders,Atherosclerosis of native arteries of the extremities with ulceration,Venous (peripheral) insufficiency, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Proliferative diabetic retinopathy,Other toe(s) amputation status,Personal history of Methicillin resistant Staphylococcus aureus
Urin tract infection NOS,DMII ketoacd uncontrold,Gastroparesis,Ulcer other part of foot,Long-term use of insulin,Candidal vulvovaginitis,Arthropathy w nerve dis,Ath ext ntv art ulcrtion,Venous insufficiency NOS,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,Prolif diab retinopathy,Status amput othr toe(s),Hx Methicln resist Staph
Admission Date:  [**2133-9-22**]              Discharge Date:   [**2133-9-26**]

Date of Birth:  [**2072-6-13**]             Sex:   F

Service: MEDICINE

Allergies:
Gatifloxacin / Penicillins / Ciprofloxacin / Bactrim

Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
DKA, UTI

Major Surgical or Invasive Procedure:
none

History of Present Illness:
61F w/ PMH DM, CKD (Cr 1.5-1.8), HTN, with recent
hospitalization for DKA/UTI now presenting to ED from PCP with
persistent dysuria, nausea and chills.  She was discharged on
cefuroxime based on prior history of pan-sensitive
proteus/ecoli.  During that hospitalization, she was noted to
have elevated blood glucose, increased anion gap, and ketones in
urine reflective of DKA thought to be precipitated by the UTI.
She initially received IV insulin and was transitioned to a SC
regimen.

She was discharged on [**9-18**] and notes that that the nausea and
chills returned the following day despite taking cefuroxime [**Hospital1 **]
as directed. She experiences dysuria and myalgias. No hematuria.
No back pain. No recorded fevers. Poor po intake x3 days.

In the ED, initial VS were 96 91 146/100 20 97% ra.  She
received 2L NS, 4mg IV zofran, and ciprofloxacin 400mg IV x1 for
UTI (59 wbc, lg leuks, 300 protein, 1000 glu on UA) .  She was
noted to have AG of 17 and glucose in the 300s, so was given 10U
regular insulin and started on insulin ggt at 2u/hr.  Lactate
was 2.8.  K+ was elevated to 6.3 but hemolyzed, and was 4.5 on
green top.  WBC was elevated to 12.6 from 7.7 on last d/c.

Pt admitted to MICU for insulin ggt requirement.  Access is 2
PIVs.  Of note, ED reports that she appears more
somnelent/lethargic on transfer.

Past Medical History:
1. DM2: insulin-dependent may be Type 1
-followed by [**Hospital **] Clinic
-c/b recurrent ulcers, urosepsis
-Charcot deformity
2. s/p amputation of L 2nd & 3rd toe
3. chronic ulcer of R pretibia
4. hx of MRSA foot [**3-/2125**]
5. HTN
6. PVD
7. hypercholesterolemia
8. Anemia, ? ACD, baseline low 30s
9. Hematemesis in [**2125**] thought to be [**1-15**] small [**Doctor First Name 329**] [**Doctor Last Name **],
EGD ulcer in GE junction


Social History:
The patient lives with her husband and has a 10 year old child.
She works at the Causeway VA as a secretary. She smokes 10 cigs
per day x 40 years. No ETOH and drugs.


Family History:
Mother had DM2, died of diabetes related coma
Father has DM2, still alive
Several family members on paternal side with DM2
No FH of CAD, MI, or cancer.

Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.5, 188/95, 98, 14, 96% RA
General: obese female lying in bed, somnelent, but [**Last Name (un) **]/oriented
and answering questions
HEENT: dry MM, OP clear, EOM intact, rosy face
Neck: supple, JVP not elevated, no LAD
CV: distant heart sounds but regular, no murmurs
Lungs: distant breath sounds, but clear bilaterally
Abdomen: obese, NT/ND, BS+
GU: foley
Ext: warm, well perfused, 1+ pulses, chronic venous stasis
changes and bilateral erythema of the shins with open ulcers,
multiple toe-amputations
Neuro: moving all extremities, A/O x2 (didn't have date right),
but lethargic

DISCHARGE PHYSICAL EXAM
VS: T97.6 BP 156/60 HR 75 RR 18 O2 sat 98% (RA)
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear, poor dentition
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft obese NT ND normoactive bowel sounds, no r/g
EXT warm, well perfused, 1+ distal pulses, chronic venous stasis
changes and bilateral erythema of lower extremities, multiple
toe-amputations
NEURO CNs2-12 intact, motor function grossly normal


Pertinent Results:
ADMISSION LABS
[**2133-9-22**] 07:00PM BLOOD WBC-12.6*# RBC-5.18 Hgb-16.1*# Hct-48.8*
MCV-94 MCH-31.0 MCHC-32.9 RDW-13.6 Plt Ct-289
[**2133-9-22**] 07:00PM BLOOD Neuts-89.7* Lymphs-6.5* Monos-2.8 Eos-0.3
Baso-0.6
[**2133-9-22**] 07:00PM BLOOD Glucose-354* UreaN-29* Creat-1.3* Na-133
K-5.9* Cl-97 HCO3-19* AnGap-23*
[**2133-9-22**] 07:00PM BLOOD ALT-18 AST-46* AlkPhos-113* TotBili-0.7
[**2133-9-22**] 07:00PM BLOOD Lipase-16
[**2133-9-22**] 07:00PM BLOOD Albumin-4.2 Calcium-9.8 Phos-5.0*# Mg-1.8
[**2133-9-22**] 08:05PM BLOOD Osmolal-313*
[**2133-9-23**] 01:37AM BLOOD Type-[**Last Name (un) **] pO2-93 pCO2-44 pH-7.36
calTCO2-26 Base XS-0 Comment-GREEN TOP
[**2133-9-22**] 07:11PM BLOOD Glucose-347* Na-133 K-9.9* Cl-101
calHCO3-22
[**2133-9-22**] 07:00PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2133-9-22**] 07:00PM URINE Blood-SM  Nitrite-NEG Protein-300
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
[**2133-9-22**] 07:00PM URINE RBC-5* WBC-59* Bacteri-FEW Yeast-RARE
Epi-1 TransE-<1
[**2133-9-23**] 06:32PM URINE CastHy-15*

Discharge:
[**2133-9-26**] 08:33AM BLOOD WBC-8.9 RBC-3.88* Hgb-12.0 Hct-36.3
MCV-94 MCH-31.1 MCHC-33.2 RDW-14.0 Plt Ct-259
[**2133-9-26**] 08:33AM BLOOD Glucose-141* UreaN-31* Creat-1.5* Na-143
K-4.1 Cl-106 HCO3-26 AnGap-15
[**2133-9-25**] 07:35AM BLOOD ALT-13 AST-17 AlkPhos-89 TotBili-0.3
[**2133-9-25**] 07:35AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.7
[**2133-9-24**] 08:00AM BLOOD CK-MB-5 cTropnT-0.01
[**2133-9-23**] 04:00PM BLOOD CK-MB-4 cTropnT-0.02*

MICRO:
URINE CULTURE [**9-22**]
   URINE CULTURE (Final [**2133-9-23**]):
      MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
      AND/OR GENITAL CONTAMINATION.

URINE CULTURE (Final [**2133-9-25**]):
      YEAST.    >100,000 ORGANISMS/ML..

IMAGING:
[**9-23**] FINDINGS:  In comparison with the study of [**9-16**], there is
again enlargement of the cardiac silhouette.  There is better
penetration of the image, so that there is no evidence of
pulmonary vascular congestion at this time.  The lateral view is
limited due to extensive scattered radiation related to the size
of the patient.  No acute focal pneumonia.


Brief Hospital Course:
Brief Course:
Ms. [**Known lastname 35127**] is a 61 year old female admitted with diabetic
ketoacidosis (DKA) likely exacerbated by gastroparesis and UTI.

Active Issues:
# DKA:  Patient presented with blood sugars in the 300s along
with anion gap metabolic acidosis and ketones in the urine.  She
was maintained on an insulin drip and transitioned to
subcutaneous insulin when her anion gap closed.  She tolerated
this well and was able to eat. Her precipitant was initially
thought to be due to cellulitis of the left lower leg. Her
outpatient provider reported that her leg looked much more
infected than previously in clinic 1 week prior.  We consulted
podiatry about her leg to try to debride the chronic ulcers and
get culture data, but they did not think that the ulcers
warranted debridement.  We felt the her leg exam was more
consistent with venous stasis changes than cellulitis. She
endorsed dysuria, however repeated urinalyses and urine cultures
showed contaminated from normal flora and yeast. We treated the
patient with 4 days of 1V ceftriaxone, based on prior culture
date.  Her CXR was negative and her EKG was at baseline.  She
did have a severe candidiasis of the intertriginous region of
her groin which may have contributed to her DKA. We treated her
with miconazole and a dose of fluconazole. [**Last Name (un) **] was consulted
to help transition to outpatient insulin regimen.

# Nausea and vomiting:  Has been chronic for several months and
has prompted several admissions to the hospital for symptomatic
management.  Likely also contributes to her DKA.  She was
started on metoclopromide empirically and phenergan prn.  She
has never had a work-up for gastroparesis but her symptoms would
fit with this and would help explain her difficult to control
blood sugars. She was discharged on metoclopramide and should
follow up with her PCP about continuing this medication. A
gastric emptying study can be considered as an outpatient.

# HTN:  Patient hypertensive to the 170s-180s even after
restarting her home losartan and hydrochlorothiazide.  Thus, she
was started on labetalol 200 mg [**Hospital1 **]. She will follow up with her
PCP about further HTN management.

# Lower extremity ulcers:  Chronic appearing, likely secondary
to peripheral vascular disease and diabetes.  Has element of
chronic venous stasis which can be confused with cellulitis but
she did not have evidence on exam of real cellulitis.

# Flattened affect:  Had a recent head CT which was negative,
her neurologic exam was non-focal.  She is slow to answer
questions and has a flattened affect which is likely her
baseline.  Her nortriptyline was held initially but restarted on
discharge.

# Yeast infection:  Likely in setting of poor glycemic control.
Was given miconazole powder and treated with 1 dose of
fluconazole.

# Chronic kidney disease:  Stable. On admission Cr 1.3, within
recent baseline. Medications were renally dosed.

Transitional Issues:
1. Codes Status: DNR/DNO
2. Communication: patient
3. Medication Changes:
-CHANGE your Humalog sliding scale according to the attached
sheet
-START Labetolol for your high blood pressure
-START Metoclopramide for your gastroparesis. But please follow
up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1147**] to see if you should continue this
medicine long term.
4. Pending studies: fungal urine culture
5. Follow up: PCP, [**Name10 (NameIs) **], Podiatry

Medications on Admission:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Nortriptyline 150 mg PO HS
4. Pantoprazole 40 mg PO Q24H
5. Rosuvastatin Calcium 20 mg PO DAILY
6. Vitamin D 50,000 UNIT PO MONTHLY
7. cefUROXime 500 mg [**Hospital1 **]
8. Detemir 70 Units Bedtime


Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Rosuvastatin Calcium 20 mg PO DAILY
4. Nortriptyline 150 mg PO HS
5. Pantoprazole 40 mg PO Q24H
6. Vitamin D 50,000 UNIT PO MONTHLY
7. Detemir 70 Units Bedtime
8. Labetalol 200 mg PO BID
hold for systolic blood pressure < 130
RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
9. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 tablet by mouth QIDACHS Disp #*30
Tablet Refills:*0


Discharge Disposition:
Home With Service

Facility:
All Care VNA of Greater [**Location (un) **]

Discharge Diagnosis:
Primary:
DKA
UTI


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


Discharge Instructions:
Dear Ms. [**Known lastname 35127**],

It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
because you weren't feeling well and your glucose level was
found to be very high, and you were in DKA. We were able to
control your blood sugar and we made some adjustments to your
insulin regimen. You also were found to have a UTI which may
have been the same infection as your last admission that never
fully resolved. You were treated with antibiotics through your
veins.

Please make the following changes to your medications:
-CHANGE your Humalog sliding scale according to the attached
sheet
-START Labetolol for your high blood pressure
-START Metoclopramide for your gastroparesis. But please follow
up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1147**] to see if you should continue this
medicine long term.

Please call [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3146**] [**Location (un) 4628**] Services at [**Telephone/Fax (1) 35130**] to
arrange a home health aid that can help with bathing and wound
care.

Followup Instructions:
Please follow up with the following appointment:

Department: PODIATRY
When: MONDAY [**2133-9-28**] at 8:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Name: [**Last Name (LF) **], [**First Name3 (LF) **]. MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Appointment Monday [**2133-9-28**] 10:00am

Department: ADULT MEDICINE
When: THURSDAY [**2133-10-1**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], MD [**Telephone/Fax (1) 6662**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site



Completed by:[**2133-9-27**]
{'Urinary tract infection, site not specified,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Gastroparesis,Ulcer of other part of foot,Long-term (current) use of insulin,Candidiasis of vulva and vagina,Arthropathy associated with neurological disorders,Atherosclerosis of native arteries of the extremities with ulceration,Venous (peripheral) insufficiency, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Proliferative diabetic retinopathy,Other toe(s) amputation status,Personal history of Methicillin resistant Staphylococcus aureus'}


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: DKA, UTI

PRESENT ILLNESS: 61F w/ PMH DM, CKD (Cr 1.5-1.8), HTN, with recent
hospitalization for DKA/UTI now presenting to ED from PCP with
persistent dysuria, nausea and chills.  She was discharged on
cefuroxime based on prior history of pan-sensitive
proteus/ecoli.  During that hospitalization, she was noted to
have elevated blood glucose, increased anion gap, and ketones in
urine reflective of DKA thought to be precipitated by the UTI.
She initially received IV insulin and was transitioned to a SC
regimen.

MEDICAL HISTORY: 1. DM2: insulin-dependent may be Type 1
-followed by [**Hospital **] Clinic
-c/b recurrent ulcers, urosepsis
-Charcot deformity
2. s/p amputation of L 2nd & 3rd toe
3. chronic ulcer of R pretibia
4. hx of MRSA foot [**3-/2125**]
5. HTN
6. PVD
7. hypercholesterolemia
8. Anemia, ? ACD, baseline low 30s
9. Hematemesis in [**2125**] thought to be [**1-15**] small [**Doctor First Name 329**] [**Doctor Last Name **],
EGD ulcer in GE junction

MEDICATION ON ADMISSION: 1. Hydrochlorothiazide 25 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Nortriptyline 150 mg PO HS
4. Pantoprazole 40 mg PO Q24H
5. Rosuvastatin Calcium 20 mg PO DAILY
6. Vitamin D 50,000 UNIT PO MONTHLY
7. cefUROXime 500 mg [**Hospital1 **]
8. Detemir 70 Units Bedtime

ALLERGIES: Gatifloxacin / Penicillins / Ciprofloxacin / Bactrim

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: T: 98.5, 188/95, 98, 14, 96% RA
General: obese female lying in bed, somnelent, but [**Last Name (un) **]/oriented
and answering questions
HEENT: dry MM, OP clear, EOM intact, rosy face
Neck: supple, JVP not elevated, no LAD
CV: distant heart sounds but regular, no murmurs
Lungs: distant breath sounds, but clear bilaterally
Abdomen: obese, NT/ND, BS+
GU: foley
Ext: warm, well perfused, 1+ pulses, chronic venous stasis
changes and bilateral erythema of the shins with open ulcers,
multiple toe-amputations
Neuro: moving all extremities, A/O x2 (didn't have date right),
but lethargic

FAMILY HISTORY: Mother had DM2, died of diabetes related coma
Father has DM2, still alive
Several family members on paternal side with DM2
No FH of CAD, MI, or cancer.

SOCIAL HISTORY: The patient lives with her husband and has a 10 year old child.
She works at the Causeway VA as a secretary. She smokes 10 cigs
per day x 40 years. No ETOH and drugs. 

### Response:
{'Urinary tract infection, site not specified,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Gastroparesis,Ulcer of other part of foot,Long-term (current) use of insulin,Candidiasis of vulva and vagina,Arthropathy associated with neurological disorders,Atherosclerosis of native arteries of the extremities with ulceration,Venous (peripheral) insufficiency, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Proliferative diabetic retinopathy,Other toe(s) amputation status,Personal history of Methicillin resistant Staphylococcus aureus'}
