CHIEF COMPLAINT: DKA

PRESENT ILLNESS: 53F with DMI s/p renal transplant [**2152**] complicated by graft
failure and ESRD with plan to initiate HD, idiopathic dilated
CMP with EF 20% admitted with hyperglycemia. Admitted to [**Hospital1 18**]
[**Date range (1) 101502**] for hypoglycemia during which a right upper
extremity AV graft was placed. Lantus was decreased from 4U [**Hospital1 **]
to 3U [**Hospital1 **] during that admission. At a routine follow-up
appointment at [**Hospital **] Clinic this morning, was noted to be
markedly hyperglycemic (finger stick greater than assay) and was
referred to the lab for additional [**Hospital **] work. Subsequently went
to work, where coworkers noted her to appears tired and unwell.
She took lantus 3U this AM and took 9 units when she checked her
sugar at work and it was greater than assay. She felt fatigued
with a dry mouth and excessive thirst. Endorses recent urinary
frequency. Denies fever, chills, sweats, headache, blurry vision
dizziness, lightheadedness, cough, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, or dysuria. Called
by her nephrologist Dr. [**First Name (STitle) 805**] who referred her to the ED for
evaluation and treatment of hyperglycemia (671).
In the ED, initial VS 98.8 80 156/71 16 100%RA. CXR showed LLL
PNA. BS 706 Given ceftriaxone 1 g IV, levofloxacin 500 mg IV,
10U regular insulin IV, insulin gtt @ 7 mg/hr, 1/2NS with 1 amp
HCO3 @ 100 cc/hr. Vital signs prior to transfer 98.8 73 150/66
13 98%RA.
Upon arrival in the MICU complains of pain in her RUE fistula
but otherwise feels well.

MEDICAL HISTORY: -s/p placement of right upper extremity arteriovenous graft
[**2162-10-19**]
-Type 1 DM, since age 20
-Dilated cardiomyopathy, EF < 20% 4/08 by echo
-Hypertension
-CKD s/p transplant in [**2152**], undergoing evaluation for possible
second transplant
-Hepatitis C, chronic, untreated
-Intracranial right ICA aneurysm, s/p clipping [**2159-5-16**]
-s/p C4-5 and C5-6 anterior decompression and fusion after MVA
[**2157**]
-s/p dickectomy at C6-C7 and fusion in [**2157**], with
instrumentation
removal and reinsertion on [**2159-9-28**]
-Ulnar nerve impingement bilaterally
-S/p Rotator cuff repair
-s/p release of right carpal tunnel
-GERD
-Asthma as a child
-Sleep apnea, unable tolerate CPAP
-s/p right carpal tunnel release
-s/p rotator cuff repair
-Resting tremor
-h/o Pneumonia
-Anemia
-h/o CMV in [**2155**]

MEDICATION ON ADMISSION: 1.Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2.Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
3.Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Percocet

PHYSICAL EXAM: VITAL SIGNS:
T- 99.4, HR- 72, BP- 137/57, R- 18, SaO2- 97% on RA

FAMILY HISTORY: Sister died of [**Name (NI) 101497**], many other family members on maternal side
with diabetes.

SOCIAL HISTORY: Divorced, has 2 children and 9 grandchildren. No tobacco, quit
12 years ago after having previously smoked 1ppd x27 years. No
EtOH although previously drank socially.
Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,End stage renal disease,Pneumonia, organism unspecified,Complications of transplanted kidney,Chronic systolic heart failure,Other primary cardiomyopathies,Long-term (current) use of insulin,Renal dialysis status,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Anemia in chronic kidney disease,Chronic hepatitis C without mention of hepatic coma,Obstructive sleep apnea (adult)(pediatric),Lesion of ulnar nerve,Abnormal involuntary movements,Personal history of tobacco use
DMI ketoacd uncontrold,End stage renal disease,Pneumonia, organism NOS,Compl kidney transplant,Chr systolic hrt failure,Prim cardiomyopathy NEC,Long-term use of insulin,Renal dialysis status,Adv eff insulin/antidiab,Anemia in chr kidney dis,Chrnc hpt C wo hpat coma,Obstructive sleep apnea,Ulnar nerve lesion,Abn involun movement NEC,History of tobacco use
Admission Date:  [**2162-10-22**]              Discharge Date:   [**2162-10-27**]

Date of Birth:  [**2108-12-6**]             Sex:   F

Service: MEDICINE

Allergies:
Percocet

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
DKA

Major Surgical or Invasive Procedure:
Dialysis x 3

History of Present Illness:
53F with DMI s/p renal transplant [**2152**] complicated by graft
failure and ESRD with plan to initiate HD, idiopathic dilated
CMP with EF 20% admitted with hyperglycemia. Admitted to [**Hospital1 18**]
[**Date range (1) 101502**] for hypoglycemia during which a right upper
extremity AV graft was placed. Lantus was decreased from 4U [**Hospital1 **]
to 3U [**Hospital1 **] during that admission. At a routine follow-up
appointment at [**Hospital **] Clinic this morning, was noted to be
markedly hyperglycemic (finger stick greater than assay) and was
referred to the lab for additional [**Hospital **] work. Subsequently went
to work, where coworkers noted her to appears tired and unwell.
She took lantus 3U this AM and took 9 units when she checked her
sugar at work and it was greater than assay. She felt fatigued
with a dry mouth and excessive thirst. Endorses recent urinary
frequency. Denies fever, chills, sweats, headache, blurry vision
dizziness, lightheadedness, cough, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, or dysuria. Called
by her nephrologist Dr. [**First Name (STitle) 805**] who referred her to the ED for
evaluation and treatment of hyperglycemia (671).
In the ED, initial VS 98.8 80 156/71 16 100%RA. CXR showed LLL
PNA. BS 706 Given ceftriaxone 1 g IV, levofloxacin 500 mg IV,
10U regular insulin IV, insulin gtt @ 7 mg/hr, 1/2NS with 1 amp
HCO3 @ 100 cc/hr. Vital signs prior to transfer 98.8 73 150/66
13 98%RA.
Upon arrival in the MICU complains of pain in her RUE fistula
but otherwise feels well.


Past Medical History:
-s/p placement of right upper extremity arteriovenous graft
[**2162-10-19**]
-Type 1 DM, since age 20
-Dilated cardiomyopathy, EF < 20% 4/08 by echo
-Hypertension
-CKD s/p transplant in [**2152**], undergoing evaluation for possible
second transplant
-Hepatitis C, chronic, untreated
-Intracranial right ICA aneurysm, s/p clipping [**2159-5-16**]
-s/p C4-5 and C5-6 anterior decompression and fusion after MVA
[**2157**]
-s/p dickectomy at C6-C7 and fusion in [**2157**], with
instrumentation
removal and reinsertion on [**2159-9-28**]
-Ulnar nerve impingement bilaterally
-S/p Rotator cuff repair
-s/p release of right carpal tunnel
-GERD
-Asthma as a child
-Sleep apnea, unable tolerate CPAP
-s/p right carpal tunnel release
-s/p rotator cuff repair
-Resting tremor
-h/o Pneumonia
-Anemia
-h/o CMV in [**2155**]

Social History:
Divorced, has 2 children and 9 grandchildren. No tobacco, quit
12 years ago after having previously smoked 1ppd x27 years. No
EtOH although previously drank socially.


Family History:
Sister died of [**Name (NI) 101497**], many other family members on maternal side
with diabetes.

Physical Exam:
VITAL SIGNS:
T- 99.4, HR- 72, BP- 137/57, R- 18, SaO2- 97% on RA

PHYSICAL EXAM
GENERAL: Pleasant, well appearing female in NAD
HEENT: Normocephalic, atraumatic.  No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. [**Name (NI) 5674**]. OP clear.  Neck Supple, No
LAD, No thyromegaly.
CARDIAC: [**3-12**] holosystolic murmur heard best at base.  Regular
rate and rhythm.  Normal S1, S2. JVP= not elevated
LUNGS: Bilateral inspiratory crackles (L>R), good air movement
biaterally.  No signs of respiratory distress
ABDOMEN: NABS. Soft, NT, ND.  No HSM
EXTREMITIES: Trace edema b/l.  No calf pain, 2+ dorsalis pedis/
posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-8**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant


Pertinent Results:
Admission Labs:

[**2162-10-21**] 07:35AM   WBC-3.7* RBC-4.08* HGB-9.7* HCT-32.4* MCV-80*
MCH-23.9* MCHC-30.0* RDW-17.6*
[**2162-10-21**] 07:35AM   NEUTS-71.1* LYMPHS-15.4* MONOS-7.0 EOS-4.9*
BASOS-1.7
[**2162-10-21**] 07:35AM   TRIGLYCER-446* HDL CHOL-66 CHOL/HDL-5.9
[**2162-10-21**] 07:35AM   CALCIUM-8.1* PHOSPHATE-7.0* MAGNESIUM-2.5
CHOLEST-391*
[**2162-10-21**] 07:35AM   GLUCOSE-217* UREA N-73* CREAT-7.3* SODIUM-137
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-22 ANION GAP-15
.
CXR - [**10-22**] - Left lung base opacity concerning for infection.
[**2162-10-22**] 11:56PM [**Month/Day/Year 3143**] WBC-6.9 RBC-4.37 Hgb-10.5* Hct-33.7*
MCV-77*# MCH-23.9* MCHC-31.0 RDW-17.0* Plt Ct-360
[**2162-10-22**] 11:59PM [**Month/Day/Year 3143**] WBC-4.8 RBC-3.85* Hgb-9.4* Hct-29.9*
MCV-78* MCH-24.3* MCHC-31.4 RDW-17.1* Plt Ct-296
[**2162-10-24**] 04:31AM [**Month/Day/Year 3143**] WBC-5.2 RBC-4.09* Hgb-9.8* Hct-31.7*
MCV-78* MCH-24.1* MCHC-31.0 RDW-17.2* Plt Ct-321
[**2162-10-25**] 05:25AM [**Month/Day/Year 3143**] WBC-4.0 RBC-3.92* Hgb-9.4* Hct-30.5*
MCV-78* MCH-23.9* MCHC-30.8* RDW-17.2* Plt Ct-282
[**2162-10-26**] 05:26AM [**Month/Day/Year 3143**] WBC-5.3 RBC-3.76* Hgb-9.3* Hct-29.1*
MCV-78* MCH-24.7* MCHC-31.8 RDW-17.4* Plt Ct-289
[**2162-10-27**] 05:32AM [**Month/Day/Year 3143**] WBC-5.7 RBC-3.72* Hgb-9.2* Hct-28.2*
MCV-76* MCH-24.8* MCHC-32.7 RDW-17.9* Plt Ct-299
[**2162-10-27**] 05:32AM [**Month/Day/Year 3143**] Plt Ct-299
[**2162-10-22**] 11:56PM [**Month/Day/Year 3143**] Glucose-28* UreaN-98* Creat-7.8* Na-137
K-4.4 Cl-103 HCO3-18* AnGap-20
[**2162-10-22**] 11:59PM [**Month/Day/Year 3143**] Glucose-123* UreaN-94* Creat-7.8* Na-134
K-4.7 Cl-103 HCO3-20* AnGap-16
[**2162-10-23**] 04:01PM [**Month/Day/Year 3143**] Glucose-164* UreaN-93* Creat-7.5* Na-131*
K-4.5 Cl-99 HCO3-17* AnGap-20
[**2162-10-24**] 04:31AM [**Month/Day/Year 3143**] Glucose-85 UreaN-101* Creat-8.1* Na-134
K-4.5 Cl-102 HCO3-17* AnGap-20
[**2162-10-24**] 04:07PM [**Month/Day/Year 3143**] Glucose-149* UreaN-103* Creat-8.5*
Na-132* K-4.5 Cl-99 HCO3-18* AnGap-20
[**2162-10-25**] 05:25AM [**Month/Day/Year 3143**] Glucose-158* UreaN-104* Creat-8.2* Na-133
K-3.9 Cl-101 HCO3-18* AnGap-18
[**2162-10-26**] 05:26AM [**Month/Day/Year 3143**] Glucose-269* UreaN-77* Creat-6.5*# Na-135
K-4.4 Cl-98 HCO3-24 AnGap-17
[**2162-10-27**] 05:32AM [**Month/Day/Year 3143**] Glucose-130* UreaN-58* Creat-5.3*# Na-139
K-3.8 Cl-99 HCO3-30 AnGap-14
[**2162-10-25**] 05:25AM [**Month/Day/Year 3143**] Calcium-7.7* Phos-6.9* Mg-2.5
[**2162-10-26**] 05:26AM [**Month/Day/Year 3143**] Calcium-7.4* Phos-4.7*# Mg-2.1
[**2162-10-27**] 05:32AM [**Month/Day/Year 3143**] Calcium-7.9* Phos-4.7* Mg-1.9
[**2162-10-22**] 02:55PM [**Month/Day/Year 3143**] HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2162-10-22**] 11:56PM [**Month/Day/Year 3143**] Vanco-21.3*
[**2162-10-24**] 04:31AM [**Month/Day/Year 3143**] Vanco-14.8
[**2162-10-22**] 02:55PM [**Month/Day/Year 3143**] Digoxin-0.5*
[**2162-10-22**] 11:56PM [**Month/Day/Year 3143**] rapmycn-5.1
[**2162-10-23**] 12:16AM [**Month/Day/Year 3143**] Lactate-1.1

Chest X-Ray ([**10-24**])-
IMPRESSION: Left lower lobe pneumonia.


Brief Hospital Course:
#DKA- The patient was found to be in DKA and was admitted to the
ICU for treatment. Her BS was 706.  She was given insulin at
0.1U/kg SC q2h followed by insulin drip @ 5 U/hr (~0.1U/kg/hr) x
2 hrs after SC regimen started to ensure adequate plasma insulin
levels.  Her sugars quickly normalized and her anion gap also
corrected quickly also (to 15).  Her corrected Na was 136 (given
BS of 706).  Cautious fluid resuscitation (D5-1/2NS @ 100 cc/hr)
was initiated given systolic dysfunction.  Electrolytes were
closely monitored.  K+ stayed within normal limits and her
sodium normalized.  [**Last Name (un) **] was consulted.

Patient did well in the ICU.  Her insulin drip was discontinued
and she was switched to her home insulin regimen with good
control of her sugars.  She was transferred to the floor on
[**10-24**].  Upon transfer to the floor, she was comfortable and
hemodynamically stable.  [**Month/Year (2) **] sugar was 149.  She denied any
syptoms.  While on the floor, her sugars remained under control
with her home regimen.  [**Last Name (un) **] continued to follow her.  She did
have some elevated AM sugar levels on day 2 on the floor [**First Name8 (NamePattern2) **]
[**Last Name (un) **] recommended increasing her nighttime lantus dose to 5U
(from 4U).  She was told to continue this insulin regimen on
discharge.  Upon discharge, her sugar was 130.  She was
asymptomatic and doing well.

#Pneumonia - Patient found to have probably left lower lobe
pneumonia on chest x-ray.  She was hemodynamically stable and
afebrile with no elevated WBC.  She denied any shortness of
breath, chest pain, headache, dizziness or abdominal pain.  She
was started on vanc and cefepime (day 1- [**10-22**]) empirically
given systemic immunosuppresion, recent hospitalization, &
frequent healthcare contacts.  [**Name (NI) **] cultures were drawn with no
growth at time of discharge.  Urine cultures were negative and
MRSA screen was also negative.  She was switched to PO
levofloxacin (renally-dosed) upon transfer to floor.  Her iron
was held given that it can affect absorption of the
levofloxacin.  She completed the full course by the time she was
discharged and was not sent home on antibiotics.  Her iron was
resumed upon discharge.

#ESRD on HD-  She is s/p renal transplant in [**2152**]- now with
rejection.  Patient had RUE AV graft placed on [**10-19**].  She was
transferred to the floor with plans to possible dialyze.  She
was seen by nephrology team throughout her stay.  They decided
to initiate dialysis on [**10-25**].  She received HD each day
(including day of discharge) and tolerated it well.  PPD was
planted on [**10-23**] for outpatient dialysis purposes and was
negative.  She was continued on her immunosupressants.  In
addition, she was started on nephrocaps.  She has dialysis
scheduled for [**10-28**] at [**Location (un) **] where she will see her
nephrologist, Dr. [**First Name (STitle) 805**].

#Chronic systolic CHF [**2-8**] idiopathic dilated CMP-  Given DKA and
resulting need for gentle hydration, her home lasix was held.
Her beta-blocker, nitrates, aspirin and statin were continued.
IV hydration was discontinued in the ICU.  She did demonstrate
some signs of fluid overload on exam once transferred to floor
(inspiratory crackles, pedal edema).  She was re-started on her
home dose of lasix.  Her fluid status improved daily while on
HD.  Given that she was now on HD, she was now able to begin an
ace-inhibitor for her CHF.  It was discussed with her
nephrologist and cardiologist who both agreed.  Her nifedipine
was discontinued and she was started on lisinopril 5mg by mouth
daily, which she tolerated well.  Upon discharge, her lungs
sounded much clearer and her pedal edema had improved.  She
denied any shortness of breath, chest pain, headache or
dizziness.

#HTN-  Patient was continued on home beta-blocker, calcium
channel blocker, hydralazine and imdur on admission.  Lasix was
held given DKA.  Given that patient has chronic systolic HF, she
was started on an ace-inhibitor now that she can tolerate it
(given that she is on HD).  Her nifedipine was discontinued.
Her [**Month/Day (2) **] pressures were stable and patient remained
asymptomatic.

#FEN: HH/DM/renal diet

#PPX: heparin 5000U SC TID

#CONTACT: HCP are daughter and nephew. Daughter [**Name2 (NI) 61615**] [**Name2 (NI) **]
[**Telephone/Fax (1) 101503**]. Nephew [**Name (NI) **] [**Name (NI) 2427**], [**First Name3 (LF) **]. [**Telephone/Fax (1) 101504**]


Medications on Admission:
1.Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2.Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
3.Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4.Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5.Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6.Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
7.Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8.Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet

Sustained Release PO DAILY (Daily).
9.Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10.Sirolimus 1 mg Tablet Sig: Eight (8) Tablet PO DAILY
(Daily).
11.Zemplar 1 mcg Capsule Sig: One (1) Capsule PO Three times a
week.
12.Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
13.Digoxin 125 mcg Tablet Sig: One (1) Tablet PO 1X/WEEK (TU).
14.Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain for 7 days.
Disp:*20 Tablet(s)* Refills:*0*
15.Glucagon Emergency 1 mg Kit Sig: One (1) Kit Injection once
a day as needed for Low [**Telephone/Fax (1) **] sugar.
Disp:*1 Kit* Refills:*0*
16.Insulin Glargine 100 unit/mL Solution Sig: Three (3) Units
Subcutaneous twice a day.
17.Novolog 100 unit/mL Solution Sig: One (1) Unit Subcutaneous
four times a day: Please follow sliding scale:
101-140 2 Units; 141-180 3 Units; 181-220 4 Units; 221-260 5
Units; 261-300 6 Units; 301-340 7 Units WITH MEALS. If you are
having a small meal or not eating then use: 141-180 1 Unit;
181-220 2 Units; 221-260 3 Units; 261-300 4 Units; 301-340 5
Units.
18.Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Medications:
1. Epogen 10,000 unit/mL Solution Sig: 7000 (7000) units
Injection with HD.
2. Paricalcitol 5 mcg/mL Solution Sig: One (1) mcg Intravenous
3X/week  (): with HD.
3. Sirolimus 1 mg Tablet Sig: Eight (8) Tablet PO DAILY (Daily).

4. Pravachol 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QTUES (every
Tuesday).
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a
day.
12. Zantac 150 mg Tablet Sig: 0.5 Tablet PO once a day.
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
14. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
17. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain.
18. Insulin
Please continue your sliding scale as shown below- the only
change made while you admitted was to increase your nighttime
lantus dose to 5 units (from 4 units).

-Insulin Glargine 100 unit/mL Solution Sig: 4 units in AM, 5
units at bedtime (Subcutaneous).

-Novolog 100 unit/mL Solution Sig: One (1) Unit Subcutaneous
four times a day: Please follow sliding scale:
101-140 2 Units; 141-180 3 Units; 181-220 4 Units; 221-260 5
Units; 261-300 6 Units; 301-340 7 Units WITH MEALS. If you are
having a small meal or not eating then use: 141-180 1 Unit;
181-220 2 Units; 221-260 3 Units; 261-300 4 Units; 301-340 5
Units.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:  Diabetic ketoacidosis- resolved, end stage renal
disease on hemodialysis

Secondary:  Type I diabetes mellitus, chronic systolic heart
failure


Discharge Condition:
Good.  Vital signs stable.


Discharge Instructions:
You were admitted to the MICU for diabetic ketoacidosis.  While
in the ICU, you were placed on an insulin drip and your sugars
responded well.  You were stablized and transferred to the floor
for continued care.  While on the floor, you were started on
hemodialysis, which you tolerated well.  You received dialysis
three times with plans to continue it as an outpatient.  You
were seen by the renal dietician who educated you on nutrition.
You remained hemodynamically stable and comfortable.

The following medication changes were made:
1.  Please start taking lisinopril 5mg by mouth daily
2.  Please stop taking your nifedipine now
3.  Please continue taking your iron
4.  Please start taking nephrocaps- 1 tablet by mouth daily
5.  Please stop taking your sodium bicarbonate
6.  Please increase your nighttime lantus dose to 5 units
(previously was 4U).  Otherwise, please continue your sliding
scale as it was before you were admitted. (Novolog 100 unit/mL
Solution Sig: One (1) Unit Subcutaneous four times a day: Please
follow sliding scale:
101-140 2 Units; 141-180 3 Units; 181-220 4 Units; 221-260 5
Units; 261-300 6 Units; 301-340 7 Units WITH MEALS. If you are
having a small meal or not eating then use: 141-180 1 Unit;
181-220 2 Units; 221-260 3 Units; 261-300 4 Units; 301-340 5
Units)

If you experience any fevers, shortness of breath, chest pain,
sudden weight gain, abdominal pain or any other medically
concerning symptoms, please contact your primary care physician
or go to the emergency department immediately.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Adhere to 2 gm sodium diet

Followup Instructions:
1.  Please follow up with your PCP (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) on
Thursday, [**10-28**] at 1:45pm
Location: [**Location (un) 1264**]., [**Location (un) **],[**Numeric Identifier 1265**]
Phone number: [**Telephone/Fax (1) 1260**]

Special instructions if applicable: Dr.[**Name (NI) 101505**] office may
call you at home with a different appt date and time.  Please
call above number tomorrow to confirm appt if you do not hear
from Dr.[**Name (NI) 101505**] office.

2.  Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10088**] on Thursday,
[**11-4**] at 2:00pm at One [**Last Name (un) **] Place, [**Location (un) 86**] [**Numeric Identifier 718**]
Phone number: ([**Telephone/Fax (1) 4847**]

3.  Please follow-up with your nephrologist (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**])
at dialysis tomorrow ([**10-28**]) at 3:30pm.
Location:  [**Location (un) **].
Phone number: [**Telephone/Fax (1) 3637**]

4.  Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2162-11-23**] 1:00
    Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
Date/Time:[**2162-11-23**] 2:00
    Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2162-11-23**] 3:00



Completed by:[**2162-10-27**]
{'Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,End stage renal disease,Pneumonia, organism unspecified,Complications of transplanted kidney,Chronic systolic heart failure,Other primary cardiomyopathies,Long-term (current) use of insulin,Renal dialysis status,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Anemia in chronic kidney disease,Chronic hepatitis C without mention of hepatic coma,Obstructive sleep apnea (adult)(pediatric),Lesion of ulnar nerve,Abnormal involuntary movements,Personal history of tobacco use'}


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

PRESENT ILLNESS: 53F with DMI s/p renal transplant [**2152**] complicated by graft
failure and ESRD with plan to initiate HD, idiopathic dilated
CMP with EF 20% admitted with hyperglycemia. Admitted to [**Hospital1 18**]
[**Date range (1) 101502**] for hypoglycemia during which a right upper
extremity AV graft was placed. Lantus was decreased from 4U [**Hospital1 **]
to 3U [**Hospital1 **] during that admission. At a routine follow-up
appointment at [**Hospital **] Clinic this morning, was noted to be
markedly hyperglycemic (finger stick greater than assay) and was
referred to the lab for additional [**Hospital **] work. Subsequently went
to work, where coworkers noted her to appears tired and unwell.
She took lantus 3U this AM and took 9 units when she checked her
sugar at work and it was greater than assay. She felt fatigued
with a dry mouth and excessive thirst. Endorses recent urinary
frequency. Denies fever, chills, sweats, headache, blurry vision
dizziness, lightheadedness, cough, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, or dysuria. Called
by her nephrologist Dr. [**First Name (STitle) 805**] who referred her to the ED for
evaluation and treatment of hyperglycemia (671).
In the ED, initial VS 98.8 80 156/71 16 100%RA. CXR showed LLL
PNA. BS 706 Given ceftriaxone 1 g IV, levofloxacin 500 mg IV,
10U regular insulin IV, insulin gtt @ 7 mg/hr, 1/2NS with 1 amp
HCO3 @ 100 cc/hr. Vital signs prior to transfer 98.8 73 150/66
13 98%RA.
Upon arrival in the MICU complains of pain in her RUE fistula
but otherwise feels well.

MEDICAL HISTORY: -s/p placement of right upper extremity arteriovenous graft
[**2162-10-19**]
-Type 1 DM, since age 20
-Dilated cardiomyopathy, EF < 20% 4/08 by echo
-Hypertension
-CKD s/p transplant in [**2152**], undergoing evaluation for possible
second transplant
-Hepatitis C, chronic, untreated
-Intracranial right ICA aneurysm, s/p clipping [**2159-5-16**]
-s/p C4-5 and C5-6 anterior decompression and fusion after MVA
[**2157**]
-s/p dickectomy at C6-C7 and fusion in [**2157**], with
instrumentation
removal and reinsertion on [**2159-9-28**]
-Ulnar nerve impingement bilaterally
-S/p Rotator cuff repair
-s/p release of right carpal tunnel
-GERD
-Asthma as a child
-Sleep apnea, unable tolerate CPAP
-s/p right carpal tunnel release
-s/p rotator cuff repair
-Resting tremor
-h/o Pneumonia
-Anemia
-h/o CMV in [**2155**]

MEDICATION ON ADMISSION: 1.Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2.Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
3.Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Percocet

PHYSICAL EXAM: VITAL SIGNS:
T- 99.4, HR- 72, BP- 137/57, R- 18, SaO2- 97% on RA

FAMILY HISTORY: Sister died of [**Name (NI) 101497**], many other family members on maternal side
with diabetes.

SOCIAL HISTORY: Divorced, has 2 children and 9 grandchildren. No tobacco, quit
12 years ago after having previously smoked 1ppd x27 years. No
EtOH although previously drank socially. 

### Response:
{'Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,End stage renal disease,Pneumonia, organism unspecified,Complications of transplanted kidney,Chronic systolic heart failure,Other primary cardiomyopathies,Long-term (current) use of insulin,Renal dialysis status,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Anemia in chronic kidney disease,Chronic hepatitis C without mention of hepatic coma,Obstructive sleep apnea (adult)(pediatric),Lesion of ulnar nerve,Abnormal involuntary movements,Personal history of tobacco use'}
