CHIEF COMPLAINT: fatigue, imbalance

PRESENT ILLNESS: Ms. [**Known lastname 21051**] is a 59 year-old woman with a history of type 1
diabetes who has been fatigued and developed a sense of
imbalance in the past two weeks.
*
Ms. [**Known lastname 21051**] was in her usual state of health until two weeks ago
when she began to feel fatigued.  She would start yawning at 5pm
which is unusual for her and would go to sleep early.  One week
ago, she noticed difficulty in controlling her glucose levels
and she began to feel malaise and some nausea.  She was eating
less and administering more insulin but was still measuring high
glucose levels.  She attributed her fatigue, nausea, and malaise
to her diabetes.  She also noticed that she was waking up every
hour during the night to urinate.  Six days ago ([**7-17**]), she
visited her PCP who worked her up for a urinary tract infection.
*
Five days ago, she noticed that when she drove, the car was
veering off to left. She sidescraped two cars while coming out
of a parking lot and hit the rocks on the side of her driveway
resulting in two flat tires.  She has been feeling "off-balance"
- a friend noted that she was not walking straight - and nearly
fell out of a chair.
*
Four days ago, she called her PCP who recommended that she come
into the ED.  She planned to come in the next day, but when she
fell asleep at 4:30 in the afternoon, which is unusual for her,
her fourteen-year old daughter became concerned and asked a
friend to bring her into the [**Name (NI) **].
*
While in the ED, she was found to have a fever to 101.3F;
however she did not know she had one.  She does recall now that
she had chills at night in the week prior to coming to the ED
and wore a heavy jacket and robe to the ED in 90 degree heat on
her night of admission.  Since admission, Ms. [**Known lastname 21051**] has
developed fevers and night sweats.  She has felt fatigued and
spends most of the day sleeping.
*
On review of symptoms, she denies any chest pain, shortness of
breath, neck stiffness, abdominal pain, dysuria, hematuria,
diarrhea, blood in her stool, or any numbness, burning, or
tingling sensations in her arms or legs.  A travel history is
significant for a visit to [**Hospital1 6687**] a week and a half ago
(after her symptoms of fatigue began).  She lives in a wooded
area but does not go into the [**Doctor Last Name 6641**].  She reports decreased
appetite and 15 lb wt loss since
[**1-30**] when her husband died. She has had some chills recently,
but no fevers at home. She also reports that she was noted to
have a "rash" on her legs, but is unsure of how long she has had
this rash and did not notice it before.
.
In the ED, VS on arrival T 101.3, BP 148/61, HR 74, RR 12, SaO2
97%/RA. Blood cx x 2 and urine cx were drawn. Pt was given 2 gm
Rocephin x 1 and 1 gm Vanc x 1. She was also given 2 L NS and
D5NS. 4 units of regular insulin was also given for BS 275.

MEDICAL HISTORY: IDDM (since age 16); A1C usually in 8 range - on NPH and RISS
Hyperlipidemia
Seasonal allergies
Breast masses (diabetic mastopathy) [**2166**]; mammogram [**2175-7-3**]
Colonoscopy [**2170**] nl
Nl bone density [**4-29**]
Some depression, anxiety after death of husband
Mild mitral valve regurg (murmur per old notes)
Borderline glaucoma

MEDICATION ON ADMISSION: Lipitor 20 mg once a day
Celexa 20 mg once a day (since [**Month (only) 116**])
Insulin NPH 17 units qam, 6 units
Ativan 0.5 mg once a day PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 101.3 HR 74 BP 148/61 RR 12 97%RA
General: well appearing white female, NAD, though
appears fatigued
HEENT: NC/AT, PERRL, EOMI. No sinus tenderness. MM dry, OP
clear.
Neck: supple, no bruits or LAD
Heart: RRR s1 s2 normal, II/VI SEM loudest at apex
Lungs: CTA-B, no w/r/r
Abdomen: soft, NT/ND, NABD, no HSM
Extremities: no c/c/e, pulses 2+ b/l
Skin: palpable fine purpuric rash over lateral LE mid-shin b/l
Neuro: AO x 3, but sleepy. Good recall, intact language without
slurring. CN II-XII intact grossly, intact visual fields. Motor
strength 5/5 throughout with normal muscle tone and bulk.
Sensation to light touch and pin prick intact throughout. DTR's
2+ in UE and LE b/l (absent ankles), downgoing babinksi's.
Slight R>L ataxia with FTN, HTS normal. Gait not tested.

FAMILY HISTORY: No h/o cancer, strokes, seizures, CAD in family.

SOCIAL HISTORY: She lives with her fourteen year-old daughter. [**Name (NI) **] husband
passed away in [**Month (only) 116**] from metastatic melanoma.  She is active -
plays tennis daily.  She has a remote tobacco history and
usually drinks a drink or two of wine or vodka a night (CAGE
negative).  She has no elicit drug use.  She is independent with
all activities of daily living.
Babesiosis,Intracerebral hemorrhage,Hyposmolality and/or hyponatremia,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Pure hypercholesterolemia
Babesiosis,Intracerebral hemorrhage,Hyposmolality,DMI wo cmp nt st uncntrl,Pure hypercholesterolem
Admission Date:  [**2175-7-20**]              Discharge Date:   [**2175-7-26**]

Date of Birth:  [**2115-11-19**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
fatigue, imbalance

Major Surgical or Invasive Procedure:
Lumbar puncture


History of Present Illness:
Ms. [**Known lastname 21051**] is a 59 year-old woman with a history of type 1
diabetes who has been fatigued and developed a sense of
imbalance in the past two weeks.
*
Ms. [**Known lastname 21051**] was in her usual state of health until two weeks ago
when she began to feel fatigued.  She would start yawning at 5pm
which is unusual for her and would go to sleep early.  One week
ago, she noticed difficulty in controlling her glucose levels
and she began to feel malaise and some nausea.  She was eating
less and administering more insulin but was still measuring high
glucose levels.  She attributed her fatigue, nausea, and malaise
to her diabetes.  She also noticed that she was waking up every
hour during the night to urinate.  Six days ago ([**7-17**]), she
visited her PCP who worked her up for a urinary tract infection.
*
Five days ago, she noticed that when she drove, the car was
veering off to left. She sidescraped two cars while coming out
of a parking lot and hit the rocks on the side of her driveway
resulting in two flat tires.  She has been feeling "off-balance"
- a friend noted that she was not walking straight - and nearly
fell out of a chair.
*
Four days ago, she called her PCP who recommended that she come
into the ED.  She planned to come in the next day, but when she
fell asleep at 4:30 in the afternoon, which is unusual for her,
her fourteen-year old daughter became concerned and asked a
friend to bring her into the [**Name (NI) **].
*
While in the ED, she was found to have a fever to 101.3F;
however she did not know she had one.  She does recall now that
she had chills at night in the week prior to coming to the ED
and wore a heavy jacket and robe to the ED in 90 degree heat on
her night of admission.  Since admission, Ms. [**Known lastname 21051**] has
developed fevers and night sweats.  She has felt fatigued and
spends most of the day sleeping.
*
On review of symptoms, she denies any chest pain, shortness of
breath, neck stiffness, abdominal pain, dysuria, hematuria,
diarrhea, blood in her stool, or any numbness, burning, or
tingling sensations in her arms or legs.  A travel history is
significant for a visit to [**Hospital1 6687**] a week and a half ago
(after her symptoms of fatigue began).  She lives in a wooded
area but does not go into the [**Doctor Last Name 6641**].  She reports decreased
appetite and 15 lb wt loss since
[**1-30**] when her husband died. She has had some chills recently,
but no fevers at home. She also reports that she was noted to
have a "rash" on her legs, but is unsure of how long she has had
this rash and did not notice it before.
.
In the ED, VS on arrival T 101.3, BP 148/61, HR 74, RR 12, SaO2
97%/RA. Blood cx x 2 and urine cx were drawn. Pt was given 2 gm
Rocephin x 1 and 1 gm Vanc x 1. She was also given 2 L NS and
D5NS. 4 units of regular insulin was also given for BS 275.

Past Medical History:
IDDM (since age 16); A1C usually in 8 range - on NPH and RISS
Hyperlipidemia
Seasonal allergies
Breast masses (diabetic mastopathy) [**2166**]; mammogram [**2175-7-3**]
Colonoscopy [**2170**] nl
Nl bone density [**4-29**]
Some depression, anxiety after death of husband
Mild mitral valve regurg (murmur per old notes)
Borderline glaucoma


Social History:
She lives with her fourteen year-old daughter. [**Name (NI) **] husband
passed away in [**Month (only) 116**] from metastatic melanoma.  She is active -
plays tennis daily.  She has a remote tobacco history and
usually drinks a drink or two of wine or vodka a night (CAGE
negative).  She has no elicit drug use.  She is independent with
all activities of daily living.


Family History:
No h/o cancer, strokes, seizures, CAD in family.

Physical Exam:
T 101.3 HR 74 BP 148/61 RR 12 97%RA
General: well appearing white female, NAD, though
appears fatigued
HEENT: NC/AT, PERRL, EOMI. No sinus tenderness. MM dry, OP
clear.
Neck: supple, no bruits or LAD
Heart: RRR s1 s2 normal, II/VI SEM loudest at apex
Lungs: CTA-B, no w/r/r
Abdomen: soft, NT/ND, NABD, no HSM
Extremities: no c/c/e, pulses 2+ b/l
Skin: palpable fine purpuric rash over lateral LE mid-shin b/l
Neuro: AO x 3, but sleepy. Good recall, intact language without
slurring. CN II-XII intact grossly, intact visual fields. Motor
strength 5/5 throughout with normal muscle tone and bulk.
Sensation to light touch and pin prick intact throughout. DTR's
2+ in UE and LE b/l (absent ankles), downgoing babinksi's.
Slight R>L ataxia with FTN, HTS normal. Gait not tested.


Pertinent Results:
[**2175-7-26**] 06:25AM BLOOD WBC-3.5* RBC-3.06* Hgb-9.9* Hct-28.5*
MCV-93 MCH-32.3* MCHC-34.7 RDW-15.0 Plt Ct-198
[**2175-7-20**] 01:15AM BLOOD WBC-3.1* RBC-3.10* Hgb-10.1*# Hct-28.5*#
MCV-92# MCH-32.6* MCHC-35.5* RDW-14.4 Plt Ct-79*#
[**2175-7-25**] 06:15AM BLOOD Neuts-54 Bands-2 Lymphs-32 Monos-10 Eos-1
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2175-7-20**] 01:15AM BLOOD Neuts-59 Bands-2 Lymphs-24 Monos-12*
Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0
[**2175-7-26**] 06:25AM BLOOD Plt Ct-198
[**2175-7-26**] 06:25AM BLOOD PT-12.3 PTT-22.7 INR(PT)-1.1
[**2175-7-20**] 01:15AM BLOOD Plt Ct-79*#
[**2175-7-20**] 07:00AM BLOOD Fibrino-367 D-Dimer-1215*
[**2175-7-20**] 07:00AM BLOOD ESR-50*
[**2175-7-26**] 06:25AM BLOOD Glucose-226* UreaN-11 Creat-0.6 Na-136
K-4.9 Cl-101 HCO3-30 AnGap-10
[**2175-7-20**] 01:15AM BLOOD Glucose-163* UreaN-10 Creat-0.8 Na-125*
K-3.9 Cl-90* HCO3-27 AnGap-12
[**2175-7-26**] 06:25AM BLOOD ALT-40 AST-36 AlkPhos-91 Amylase-39
TotBili-0.6
[**2175-7-20**] 07:00AM BLOOD ALT-32 AST-38 LD(LDH)-361* AlkPhos-80
TotBili-1.6* DirBili-0.4* IndBili-1.2
[**2175-7-26**] 06:25AM BLOOD Albumin-3.0* Calcium-8.4 Phos-4.4 Mg-2.4
[**2175-7-20**] 07:00AM BLOOD Calcium-7.8* Phos-3.4 Mg-2.1 UricAcd-3.0
Iron-21*
[**2175-7-20**] 07:00AM BLOOD calTIBC-164* VitB12-1405* Folate-18.9
Hapto-<20* Ferritn-1536* TRF-126*
[**2175-7-20**] 07:00AM BLOOD Osmolal-269*
[**2175-7-20**] 07:00AM BLOOD TSH-1.7
[**2175-7-20**] 07:00AM BLOOD CRP-66.3*
[**2175-7-20**] 02:56PM BLOOD HIV Ab-NEGATIVE
[**2175-7-20**] 01:20AM BLOOD Lactate-0.6
[**2175-7-20**] 06:03PM BLOOD EHRLICHIA ANTIBODY PANEL (HME AND HGE)-
TEST
*
CXR - [**2175-7-20**]:
No acute cardiopulmonary process.
*
Head CT w/o contrast:
Small left basal ganglia intraparenchymal hemorrhage with small
amount of surrounding edema and no shift of normally midline
structures.  Calcification in the choroid plexus of the left
temporal [**Doctor Last Name 534**], a normal finding.
*
MR HEAD W & W/O CONTRAST  [**2175-7-20**] 7:26 AM
FINDINGS: There is no slow diffusion to indicate an acute
infarct.
.
There is an area of focal hemorrhage within the left putamen as
noted on the prior CT. This has high T1 and T2 signal indicating
late subacute stage blood products. A small hemosiderin rim is
present corresponding to the hyperdensity on the CT at the
periphery of the hemorrhage. There is only a tiny amount of
adjacent T2 signal abnormality, which could be due to vasogenic
edema. There are no enhancing abnormalities or areas of flow
void to indicate an AVM or neoplasm. There is no evidence of an
infection or abscess. These findings could be due to a
hypertensive hemorrhage. Please correlate with the patient's
history.
.
There is no midline shift, mass effect or hydrocephalus. The
normal vascular flow voids are present. Incidental note is made
of a subcutaneous 1.2 cm well defined lesion, which is low on T1
and T2 signal overlying the right parietal skull vertex, likely
due to an old sebaceous cyst. Please correlate with the physical
examination findings.
.
The paranasal sinuses are well pneumatized.
.
There are several T2 hyperintense foci within the centrum
semiovale and subcortical white matter of both cerebral
hemispheres consistent with chronic microvascular infarct.
.
IMPRESSION: No evidence of an acute infarct. There is a late
subacute hemorrhage within the left putamen and no acute blood
is identified. There is no evidence of AVM or neoplasm. No
significant mass effect.
.
MRA:
TECHNIQUE: 3D time-of-flight MRA of the circle of [**Location (un) 431**].

FINDINGS: The circle of [**Location (un) 431**] is normal with no evidence of an
aneurysm or significant intracranial atherosclerotic disease.
The anterior and posterior circulation appear normal.

IMPRESSION: Normal circle of [**Location (un) 431**] MRA.
.
Cytology SPINAL FLUID
Pending

Brief Hospital Course:
59 yo female with type I DM who presented with malaise and gait
instability, found to have babesiosis and sub acute basal
ganglia hemorrhagic stroke. Initially admitted to the medicine
ICU for close monitoring. Patient was hemodynamically stable but
had mild memory deficits and gait instability. Below is her
medical course by problems:
.
1. Babesiosis - Babesiosis was diagnosed by visualization of
intraerythrocytic parasites on peripheral blood smear.
Babesiosis is distinguishable from Plasmodium falciparum malaria
by the following features: (a) The absence of pigment granules
in infected erythrocytes, (b) the presence of exoerythrocytic
parasites, (c) pathognomonic tetrads of merozoites forming
"maltese crosses." Following diagnosis, Ms. [**Known lastname 21051**] was started
on accepted first-line combination therapy of quinine and
clindamycin; however, she reported a sensation of hearing loss,
a rare but terrible side-effect of quinine. The quinine and
clindamycin combination was discontinued out of concern for
hearing loss. She was started on [**7-22**] on an alternate
combination of azithromycin and atovaquone which has been
suggested to be an effective therapy in both animal and human
studies. (A comparison of the two regimens has shown them to be
of similar efficacy, but azithromycin/atovaquone is generally
better tolerated.) Finally, it is recommended that in areas
endemic for Lyme disease and ehrlichiosis, doxycycline may also
be given because of the high frequency of coinfection. The
diagnosis of babesiosis offers an explanation for her
presentation with pancytopenia, malaise, and hemolysis. LP not
suggestive of CNS infection. Patient will continue these
antibiotics at discharge:
-- Doxycycline (day 4 of 28 at discharge), per ID recommendation
to cover empirically for erlichosis
-- Atovaquone (day 4 of 7 at discharge)
-- Azithromycin (day 4 of 7 at discharge)
Her CSF lyme and HSV PCR results are pending and will be
followed up outpatient.
.
2. Left putamen hemorrhage:
Ms. [**Known lastname 21051**] [**Last Name (Titles) 21052**] status has improved and currently has
no neurologic deficits to correspond to area of injury seen on
imaging. It is possible that the etiology of her hemorrhage was
thrombocytopenia vs. Babesiosis-related vasculitis vs. CNS
involvement of Lyme disease. She was ruled out for an
atriovenous malformation or neoplasm by CT and there was no
evidence of acute hemorrhage. There is a question of whether she
could have neuroborelliosis, as Lyme disease and babesiosis can
be co-transmitted. Her serum Lyme titers are negative which can
remain negative in early disease, but a CSF concentration of
antibody to Borellia burdorferi is a more specific and sensitive
test for CSF Lyme than serum antibody titers. PCR can also be
used to identify the organism within the CSF.
.
ID was consulted and recommended an LP given her platelet count
of 76 to check for pleiocytosis. Pt's brain imaging findings did
not correlate with symptoms of ataxia, memory loss, and fatigue.
Incidence of CNS babesiosis infection has not been described in
humans. An LP would be able to better evaluate the etiology of
her [**Last Name (Titles) 21052**] symptoms. If CSF fluid analysis reveals
pleiocytosis, her treatment regimen would need to be changed
from doxycycline 100 mg [**Hospital1 **] to ceftriaxone 2g QD for 2-4 weeks,
which is the recommended treatment for CNS Lyme.
.
Neurology was called to ask about contraindications of doing an
LP with a platelet count of 76. They pointed out that her
platelet count is above the cut-off for contraindication for LP,
which is a platelet count of below 50.
.
Upon discharge, she did not have any residual [**Hospital1 21052**]
findings on exam, out of bed and ambulating without need for
assistance, mental status intact
.
3. Pancytopenia: Although the precise mechanism is unknown, it
is well documented that merazoite invasion of the RBC leads to
red cell lysis and hemolytic anemia. RBC, WBC, and platelet
counts (198 from 59 on admission) are trending up. It will
likely take some time for cell counts to return to normal.
.
4. Hyponatremia - Thought to be due to SIADH secondary to the
basal ganglia hemorrhage. She has been fluid restricted and her
sodium has come up to 137 on morning labs. Patient was switched
to regular PO intake and electrolytes were within normal.
.
5. Unsteadiness - Pt's gait has improved, without unsteadiness
or sizziness. PT worked with patient daily and was able to
assist her with walking. According to a neurology consult on
[**7-20**], her lack of balance and unsteadiness is not consistent
with the basal ganglia hemorrhage seen on CT. At discharge, she
was no longer unsteady, walking without difficulty.
.
6. Type I DM: Continue [**Hospital1 **] NPH plus SSI. QACHS fingersticks.
Patient has had intermittent episodes of hypoglycemia down to
50s, but has otherwise been hyperglycemic with sugars above
150s. Discussed patient's home insulin regimen to confirm
inpatient fixed dose. Her recent infection and stress
responsible for hyperglycemia. Levels should stabilize as
infection is treated and we will not modify therapy too much. We
will schedule her with [**Hospital **] clinic for outpatient followup.
Upon discussion with team, her evening NPH was increased from 6
to 8, patient had generally received 10U regular insulin per SSI
regimen daily. She will be discharged on sliding scale along
with fixed insulin dosage for better control of blood sugars.
.
7. Hyperlipidemia: continued Lipitor, LFTs within normal
.
8. FEN: diabetic/cardiac diet. Fluid restriction of 1.5 L in the
setting of resolving hyponatremia. Goal K>4, Mg>2.
.
9. Prophylaxis: Pneumoboots; hold heparin in setting of
thrombocytopenia.
.
10. Code status: full code.
.
11. Followup: Infectious disease clinic on [**8-14**] at 10:30
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] located on [**Last Name (NamePattern1) **]; [**Last Name (un) **]
Diabetes center appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21053**] on [**8-10**] at 2:30pm.

Medications on Admission:
Lipitor 20 mg once a day
Celexa 20 mg once a day (since [**Month (only) 116**])
Insulin NPH 17 units qam, 6 units
Ativan 0.5 mg once a day PRN

Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 24 days.
Disp:*48 Capsule(s)* Refills:*0*
3. Atovaquone 750 mg/5 mL Suspension Sig: One (1)  PO BID (2
times a day) for 3 days.
Disp:*1 * Refills:*0*
4. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Capsule(s)* Refills:*0*
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: One (1)  Subcutaneous twice a day: 17 units in AM, 8 in PM.
Disp:*1 * Refills:*2*
7. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
4 Subcutaneous before dinner: and as needed.
Disp:*1 * Refills:*2*

Discharge Disposition:
Home

Discharge Diagnosis:
Primary diagnosis: Babesiosis
.
Other diagnosis:
1. Type I Diabetes - Diagnosed at 16 years. Insulin-dependent.
No end organ disease. Followed by Dr. [**Last Name (STitle) **] at [**Last Name (un) **]. HBA1c
in [**7-2**]% range. Most recent HBA1c was 8.0 on [**2175-7-17**]. Mild
asymmetric background retinopathy.
2. Ovarian cyst and oopherectomy - 20 years old.
3. Mitral Regurgitation - Dianosed in [**2172-5-24**]. Flow murmur.
Echo-->mild MR, otherwise nl.
4. Hyperlipidemia - [**3-28**] homocysteine 13.6 (0-10.3).
5. Borderline hypertension
6. Depression/anxiety - since the death of her husband last [**Name2 (NI) 116**]


Discharge Condition:
Stable


Discharge Instructions:
Please take all medications. Do not perform strenuous
activities. Avoid driving alone.

Followup Instructions:
You have an appointment with Dr. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 9671**] at the
[**Hospital **] clinic on [**8-10**] at 2:30 pm.

Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2175-8-14**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2175-9-4**] 11:10
Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2175-9-7**] 10:15
{'Babesiosis,Intracerebral hemorrhage,Hyposmolality and/or hyponatremia,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Pure hypercholesterolemia'}


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: fatigue, imbalance

PRESENT ILLNESS: Ms. [**Known lastname 21051**] is a 59 year-old woman with a history of type 1
diabetes who has been fatigued and developed a sense of
imbalance in the past two weeks.
*
Ms. [**Known lastname 21051**] was in her usual state of health until two weeks ago
when she began to feel fatigued.  She would start yawning at 5pm
which is unusual for her and would go to sleep early.  One week
ago, she noticed difficulty in controlling her glucose levels
and she began to feel malaise and some nausea.  She was eating
less and administering more insulin but was still measuring high
glucose levels.  She attributed her fatigue, nausea, and malaise
to her diabetes.  She also noticed that she was waking up every
hour during the night to urinate.  Six days ago ([**7-17**]), she
visited her PCP who worked her up for a urinary tract infection.
*
Five days ago, she noticed that when she drove, the car was
veering off to left. She sidescraped two cars while coming out
of a parking lot and hit the rocks on the side of her driveway
resulting in two flat tires.  She has been feeling "off-balance"
- a friend noted that she was not walking straight - and nearly
fell out of a chair.
*
Four days ago, she called her PCP who recommended that she come
into the ED.  She planned to come in the next day, but when she
fell asleep at 4:30 in the afternoon, which is unusual for her,
her fourteen-year old daughter became concerned and asked a
friend to bring her into the [**Name (NI) **].
*
While in the ED, she was found to have a fever to 101.3F;
however she did not know she had one.  She does recall now that
she had chills at night in the week prior to coming to the ED
and wore a heavy jacket and robe to the ED in 90 degree heat on
her night of admission.  Since admission, Ms. [**Known lastname 21051**] has
developed fevers and night sweats.  She has felt fatigued and
spends most of the day sleeping.
*
On review of symptoms, she denies any chest pain, shortness of
breath, neck stiffness, abdominal pain, dysuria, hematuria,
diarrhea, blood in her stool, or any numbness, burning, or
tingling sensations in her arms or legs.  A travel history is
significant for a visit to [**Hospital1 6687**] a week and a half ago
(after her symptoms of fatigue began).  She lives in a wooded
area but does not go into the [**Doctor Last Name 6641**].  She reports decreased
appetite and 15 lb wt loss since
[**1-30**] when her husband died. She has had some chills recently,
but no fevers at home. She also reports that she was noted to
have a "rash" on her legs, but is unsure of how long she has had
this rash and did not notice it before.
.
In the ED, VS on arrival T 101.3, BP 148/61, HR 74, RR 12, SaO2
97%/RA. Blood cx x 2 and urine cx were drawn. Pt was given 2 gm
Rocephin x 1 and 1 gm Vanc x 1. She was also given 2 L NS and
D5NS. 4 units of regular insulin was also given for BS 275.

MEDICAL HISTORY: IDDM (since age 16); A1C usually in 8 range - on NPH and RISS
Hyperlipidemia
Seasonal allergies
Breast masses (diabetic mastopathy) [**2166**]; mammogram [**2175-7-3**]
Colonoscopy [**2170**] nl
Nl bone density [**4-29**]
Some depression, anxiety after death of husband
Mild mitral valve regurg (murmur per old notes)
Borderline glaucoma

MEDICATION ON ADMISSION: Lipitor 20 mg once a day
Celexa 20 mg once a day (since [**Month (only) 116**])
Insulin NPH 17 units qam, 6 units
Ativan 0.5 mg once a day PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 101.3 HR 74 BP 148/61 RR 12 97%RA
General: well appearing white female, NAD, though
appears fatigued
HEENT: NC/AT, PERRL, EOMI. No sinus tenderness. MM dry, OP
clear.
Neck: supple, no bruits or LAD
Heart: RRR s1 s2 normal, II/VI SEM loudest at apex
Lungs: CTA-B, no w/r/r
Abdomen: soft, NT/ND, NABD, no HSM
Extremities: no c/c/e, pulses 2+ b/l
Skin: palpable fine purpuric rash over lateral LE mid-shin b/l
Neuro: AO x 3, but sleepy. Good recall, intact language without
slurring. CN II-XII intact grossly, intact visual fields. Motor
strength 5/5 throughout with normal muscle tone and bulk.
Sensation to light touch and pin prick intact throughout. DTR's
2+ in UE and LE b/l (absent ankles), downgoing babinksi's.
Slight R>L ataxia with FTN, HTS normal. Gait not tested.

FAMILY HISTORY: No h/o cancer, strokes, seizures, CAD in family.

SOCIAL HISTORY: She lives with her fourteen year-old daughter. [**Name (NI) **] husband
passed away in [**Month (only) 116**] from metastatic melanoma.  She is active -
plays tennis daily.  She has a remote tobacco history and
usually drinks a drink or two of wine or vodka a night (CAGE
negative).  She has no elicit drug use.  She is independent with
all activities of daily living. 

### Response:
{'Babesiosis,Intracerebral hemorrhage,Hyposmolality and/or hyponatremia,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Pure hypercholesterolemia'}
