CHIEF COMPLAINT: Diabetic Ketoacidosis

PRESENT ILLNESS: Mr. [**Known lastname 7518**] is a 51 year old man with a lifelong history of
IDDM who presented with hyperglycemia and nausea after his puppy
bit through the tubing of his insulin pump and he is now
transferred to the [**Hospital Unit Name 153**] for insulin drip. The patient reports he
was playing with his puppy last night and when he awoke this
morning he did not feel himself. He felt progressively worse
with increasing nausea throughout the morning and vomited 4
times. He subsequently checked his blood glucose level and found
it was 400 mg/dL. He attempted to bolus himself using his
insulin pump with no effect. After a second bolus attempt he
realized the tubing from his pump was broken. He called 911. On
EMS arrival he reported only nausea and hyperglycemia and denied
any other complaints.
.
In the ED, initial vs were: T 96 P 97 BP 155/90 R 16 O2 sat 100.
Labs were initially hemolyzed and repeat set was notable for
potassium 5.5. EKG showed sinus tach without peaked T-waves.
Patient was given 2 L NS, zofran, 8 U regular insulin and 8 U/hr
insulin gtt.

MEDICAL HISTORY: IDDM (last HbA1C 6.1) occasional hypoglycemia to 20's w/o
symptoms
hyperlipidemia - controlled on medication
hypothyroid
depression

MEDICATION ON ADMISSION: Insulin pump
Levoxil 25 mg PO daily
Simvastatin 20 mg PO daily
Zoloft 25 mg PO daily
Folic acid 1 mg PO daily
Multivitamin 1 tab PO daily

ALLERGIES: Penicillins

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not appreciated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, systolic
crescendo-decrescendo flow murmur at L upper sternal border. No
rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Maternal grandmother and great ??????grandmother with Type I IDDM,
father with MI at 72, sister with lung CA at 39.

SOCIAL HISTORY: Lives on [**Hospital3 **] with wife and their six children. Also has
3 dogs (beagles). Works [**Street Address(1) 4736**] as VP in real estate
finance. Exercises regularly.
- Tobacco: None
- Alcohol: Occasional
- Illicits: None
Mechanical complication due to insulin pump,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Leukocytosis, unspecified,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Insulin pump status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation
Complcation-insulin pump,DMI ketoacd uncontrold,Hyposmolality,Acute kidney failure NOS,Leukocytosis NOS,Hyperlipidemia NEC/NOS,Hypothyroidism NOS,Depressive disorder NEC,Chronic kidney dis NOS,Long-term use of insulin,Insulin pump status,Abn react-artif implant
Admission Date:  [**2110-2-3**]              Discharge Date:   [**2110-2-4**]

Date of Birth:  [**2058-10-9**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Diabetic Ketoacidosis

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Mr. [**Known lastname 7518**] is a 51 year old man with a lifelong history of
IDDM who presented with hyperglycemia and nausea after his puppy
bit through the tubing of his insulin pump and he is now
transferred to the [**Hospital Unit Name 153**] for insulin drip. The patient reports he
was playing with his puppy last night and when he awoke this
morning he did not feel himself. He felt progressively worse
with increasing nausea throughout the morning and vomited 4
times. He subsequently checked his blood glucose level and found
it was 400 mg/dL. He attempted to bolus himself using his
insulin pump with no effect. After a second bolus attempt he
realized the tubing from his pump was broken. He called 911. On
EMS arrival he reported only nausea and hyperglycemia and denied
any other complaints.
.
In the ED, initial vs were: T 96 P 97 BP 155/90 R 16 O2 sat 100.
Labs were initially hemolyzed and repeat set was notable for
potassium 5.5. EKG showed sinus tach without peaked T-waves.
Patient was given 2 L NS, zofran, 8 U regular insulin and 8 U/hr
insulin gtt.

On the floor, the patient appeared generally well. He denied any
further nausea. A repeat FSG was 146.
.
Review of systems:
(+) Per HPI. Also endorses 1 week history of a cold now
resolving but with occasional non-productive cough.

(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies diarrhea, constipation or changes in bowel habits. Denies
dysuria or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.


Past Medical History:
IDDM (last HbA1C 6.1) occasional hypoglycemia to 20's w/o
symptoms
hyperlipidemia - controlled on medication
hypothyroid
depression


Social History:
Lives on [**Hospital3 **] with wife and their six children. Also has
3 dogs (beagles). Works [**Street Address(1) 4736**] as VP in real estate
finance. Exercises regularly.
- Tobacco: None
- Alcohol: Occasional
- Illicits: None


Family History:
 Maternal grandmother and great ??????grandmother with Type I IDDM,
father with MI at 72, sister with lung CA at 39.


Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not appreciated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, systolic
crescendo-decrescendo flow murmur at L upper sternal border. No
rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
Admission Labs:
[**2110-2-3**] 01:00PM BLOOD WBC-13.0* RBC-5.09 Hgb-15.6 Hct-47.3
MCV-93 MCH-30.8 MCHC-33.1 RDW-12.6 Plt Ct-242
[**2110-2-3**] 01:00PM BLOOD Neuts-88.0* Lymphs-8.6* Monos-2.6 Eos-0.5
Baso-0.2
[**2110-2-3**] 01:00PM BLOOD Glucose-552* UreaN-31* Creat-1.7* Na-129*
K-5.7* Cl-89* HCO3-18* AnGap-28*
[**2110-2-3**] 01:00PM BLOOD Calcium-9.9 Phos-2.9 Mg-1.8
[**2110-2-3**] 01:11PM BLOOD Glucose-499* Lactate-2.4* Na-132* K-6.7*
Cl-95* calHCO3-18*

Discharge Labs:
[**2110-2-4**] 04:06AM BLOOD WBC-10.3 RBC-4.43* Hgb-13.4* Hct-38.8*
MCV-88 MCH-30.3 MCHC-34.6 RDW-12.5 Plt Ct-226
[**2110-2-4**] 04:06AM BLOOD Neuts-63.6 Lymphs-27.0 Monos-6.5 Eos-2.6
Baso-0.3
[**2110-2-4**] 04:06AM BLOOD Glucose-140* UreaN-26* Creat-1.5* Na-140
K-4.4 Cl-110* HCO3-22 AnGap-12

Studies:
ECG Study Date of [**2110-2-3**]  1:45:16 PM
Sinus tachycardia. ST-T wave abnormalities. No previous tracing
available for
comparison.

ECG Study Date of [**2110-2-4**]  7:54:46 AM
Sinus rhythm. Since the previous tracing the rate is slower.
ST-T waves are
improved.

CHEST (PORTABLE AP)	Study Date of [**2110-2-4**] 5:50 AM
IMPRESSION: No acute cardiopulmonary abnormality. No pneumonia.

Brief Hospital Course:
Mr. [**Known lastname 7518**] is a 51 year old man with lifelong history of IDDM
who presented with hyperglycemia and nausea after his puppy bit
through the tubing of his insulin pump and he is now transferred
to the [**Hospital Unit Name 153**] for insulin drip.

#Diabetic Ketoacidosis: Due to sudden loss of insulin pump
function from his puppy chewing through the tubing. Patient has
had a cold in recent week but no other signs or symptoms of
infection. No recent medication changes or illicit drug use. Low
suspicion of any cardiac ischemia though he did have mild ST
depression in the lateral leads. Initial anion gap of 22 on
admission. He was placed on an insulin drip until his gap closed
supported with D5W infusion and was restarted on his insulin
pump requirements 2 hours prior to stopping his insulin drip.
His tubing was replaced and function was restored.

Per hospital policy, nutrition and [**Last Name (un) **] consults were ordered
per hospital protocol, however the patient declined both. He has
been diabetic for 41 years and by lab data, he is well
controlled. He felt as though he knows his diet very well, and
is able to control it on his own. He also felt that he knew the
reason for failure of his pump and felt the [**Last Name (un) **] consult was
unnecessary.

Cardiac issues: EKG showed ST changes on admission that
resolved. His enzymes were negative. However, given his risk
factors and having been diabetic for 41 years, as well as having
some renal insufficiency suggesting vascular disease, a stress
test may be indicated as an outpatient.
Follow-up:
- Out patient evaluation for possible stress test

# Renal insufficiency - Likely a component of pre-renal and
chronic kidney disease given his slight improvement with
hydration. Other possibilities include increased muscle mass and
diet supplementation in this gentleman who has a high muscle
mass. He had a creatinine of 1.7 on admission with mild
improvement to 1.5 after hydration. He will need follow-up as an
outpatient to clinically follow his kidney function.

# Hyponatremia - When corrected for hyperglycemia, expected
value ~140, suggesting minimal effect of diuresis, and primarily
driven by osmotic fluid shift. Normalized on discharge

# Hyperkalemia - Likely total body normal to low potassium with
extracellular shift related to low insulin, acidosis, and
osmotic shift on admission. His K was repleted below 4.5 and he
was monitored on telemetry.

# Hypothyroid, Hyperlipidemia, Depression - Chronic. Continue
home medications.

# Transition issues: He was discharged with instructions to
follow-up with his primary care physician [**Name Initial (PRE) 176**] 1-2 weeks for
further evaluation of his EKG changes and elevated creatinine.

Medications on Admission:
Insulin pump
Levoxil 25 mg PO daily
Simvastatin 20 mg PO daily
Zoloft 25 mg PO daily
Folic acid 1 mg PO daily
Multivitamin 1 tab PO daily

Discharge Medications:
1. insulin aspart 100 unit/mL Solution Sig: One (1)
Subcutaneous as directed: Please continue this medication as
previously prescribed. Any questions please contact Dr. [**Last Name (STitle) 40075**]
immediately.
2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Zoloft 25 mg Tablet Sig: One (1) Tablet PO once a day.
5. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).



Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
Diabetic ketoacidosis

Secondary Diagnosis:
Acute on chronic renal insufficiency
Hypothyroidism
Depression
Hyperlipidemia


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


Discharge Instructions:
You were admitted for diabetic ketoacidosis. This is likely
because your pump malfunctioned. You were treated in the ICU
with insulin and intravenous fluids and improved. Your blood
sugars were under good control back on your insulin pump and you
were discharged home.

Please note that your kidney function is slightly elevated. You
should discuss this with your primary care physician as this may
be a complication of your diabetes and may require treatment. If
not followed carefully it can lead to kidney failure.

Please follow up with your primary care physician ([**First Name4 (NamePattern1) 333**]
[**Last Name (NamePattern1) 40075**] [**Telephone/Fax (1) 40076**]) in the next 1-2 weeks. You should discuss
your kidney function to him at this time.

Also, you had a slight abdnormality on your EKG which normalized
when checked again. This should be discussed with your primary
care doctor, and you should discuss whether or not a cardiac
stress test is indicated.

No changes were made to your medications. Please continue to
take them as previously prescribed.

Followup Instructions:
Please follow up with your primary care physician in the next
1-2 weeks. His name is [**Name (NI) 333**] [**Name (NI) 40075**] and his number to set
the appointment up is [**Telephone/Fax (1) 40076**].



Completed by:[**2110-2-5**]
{'Mechanical complication due to insulin pump,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Leukocytosis, unspecified,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Insulin pump status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}


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: Diabetic Ketoacidosis

PRESENT ILLNESS: Mr. [**Known lastname 7518**] is a 51 year old man with a lifelong history of
IDDM who presented with hyperglycemia and nausea after his puppy
bit through the tubing of his insulin pump and he is now
transferred to the [**Hospital Unit Name 153**] for insulin drip. The patient reports he
was playing with his puppy last night and when he awoke this
morning he did not feel himself. He felt progressively worse
with increasing nausea throughout the morning and vomited 4
times. He subsequently checked his blood glucose level and found
it was 400 mg/dL. He attempted to bolus himself using his
insulin pump with no effect. After a second bolus attempt he
realized the tubing from his pump was broken. He called 911. On
EMS arrival he reported only nausea and hyperglycemia and denied
any other complaints.
.
In the ED, initial vs were: T 96 P 97 BP 155/90 R 16 O2 sat 100.
Labs were initially hemolyzed and repeat set was notable for
potassium 5.5. EKG showed sinus tach without peaked T-waves.
Patient was given 2 L NS, zofran, 8 U regular insulin and 8 U/hr
insulin gtt.

MEDICAL HISTORY: IDDM (last HbA1C 6.1) occasional hypoglycemia to 20's w/o
symptoms
hyperlipidemia - controlled on medication
hypothyroid
depression

MEDICATION ON ADMISSION: Insulin pump
Levoxil 25 mg PO daily
Simvastatin 20 mg PO daily
Zoloft 25 mg PO daily
Folic acid 1 mg PO daily
Multivitamin 1 tab PO daily

ALLERGIES: Penicillins

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not appreciated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, systolic
crescendo-decrescendo flow murmur at L upper sternal border. No
rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Maternal grandmother and great ??????grandmother with Type I IDDM,
father with MI at 72, sister with lung CA at 39.

SOCIAL HISTORY: Lives on [**Hospital3 **] with wife and their six children. Also has
3 dogs (beagles). Works [**Street Address(1) 4736**] as VP in real estate
finance. Exercises regularly.
- Tobacco: None
- Alcohol: Occasional
- Illicits: None 

### Response:
{'Mechanical complication due to insulin pump,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Leukocytosis, unspecified,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Insulin pump status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}
