CHIEF COMPLAINT: Gastroparesis

PRESENT ILLNESS: 40 y/o woman with PMH notable for type I DM complicated by
gastroparesis with multiple prior admissions for abdominal pain
who presented to [**Hospital3 **] earlier this evening due to
ongoing nausea/vomiting, epigastric abdominal pain, and
inability to tolerate po. At [**Hospital1 392**], KUB showing no obstruction,
guaiac neg. Went to [**Hospital1 34**] 3 days ago. Received IV dilaudid, able
to tol PO, recommended DC home. Insisted on IV pain meds and tx
to [**Hospital1 18**]. Dr. [**Last Name (STitle) 8840**] felt not medically necessary, while
attempting xfer, pt eloped with portocath accessed, in lobby
took out portocath needle and left ama-without signing papers,
without flushing.

MEDICAL HISTORY: - Diabetes (Type 1): Diagnosed in [**2145**] at the age of 17,
complicated by mild retinopathy. Severe gastroparesis. Her DM is
managed with insulin, Lantus and NovoLog by Dr. [**Last Name (STitle) 10088**] at
[**Last Name (un) **].
- Gastroparesis. Required a feeding tube as recently as '[**65**].
Prior Botox injection in [**2164**], s/p gastric pacemaker placement
in [**2164-6-19**]. She is followed very closely by Dr. [**Last Name (STitle) 10689**].
- Hypertension.
- Panic attacks.
- h/o Anemia
- Genital herpes.
- Anal dysplasia followed by the infectious disease clinic.
- Fibromyalgia.
- Diabetic mastopathy. She is followed by Dr. [**Last Name (STitle) **] [**Name (STitle) 22283**] in
the [**Hospital **] [**Hospital **] Clinic through [**Hospital6 33**]. She
underwent a lumpectomy in [**2167-2-19**] and was diagnosed with
diabetic mastopathy. This lumpectomy was of the right breast.
- h/o SBO

MEDICATION ON ADMISSION: [**Month/Year (2) **] 81 mg daily
atenolol 50 mg daily
ativan 2 mg QAM prn
buspirone 20 mg TID
cleocin gel
clonidine 0.1 mg [**Hospital1 **]
dicyclomine (uses infequently)
duloxetine 20 mg [**Hospital1 **]
flonase 1-2 puffs [**Hospital1 **]
dilaudid 2 mg [**Hospital1 **] prn pain - taking infrequently at home
lantus 13 U [**Hospital1 **]
loestrin 1.5/30 daily
novolog four times daily
NULEV (never uses)
omeprazole 20 mg daily
zofran prn

ALLERGIES: Phenergan / Compazine / Reglan / Haldol

PHYSICAL EXAM: VS: afebrile, HR 102, BP 127/62
Gen: NAD, pleasant
HEENT: No oropharyngeal erythema or exudate.
CV: RRR, no m/r/g.
Pulm: CTAB.
Abd: +BS. Soft, moderate tenderness diffusely. No guarding or
rebound.
Extrem: No c/c/e.

FAMILY HISTORY: Her father has type 2 diabetes mellitus. Her mother has
[**Name (NI) 2481**] disease. Her brother has diabetes and her sister
suffers from [**Name (NI) 4522**] disease. A maternal uncle and maternal
grandmother both died from MIs at age 50.

SOCIAL HISTORY: Currently not working, but former sales manager for [**Company 22280**].
Takes care of her mother with [**Name (NI) 2481**] disease during the
day. Not married and no children. Denies alcohol, tobacco, and
drug use.
Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Gastroparesis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Background diabetic retinopathy,Other postprocedural status,Anemia of other chronic disease,Myalgia and myositis, unspecified,Other chest pain,Panic disorder without agoraphobia,Hypotension, unspecified
DMI ketoacd uncontrold,Chronic kidney dis NOS,Long-term use of insulin,Gastroparesis,Hy kid NOS w cr kid I-IV,Diabetic retinopathy NOS,Post-proc states NEC,Anemia-other chronic dis,Myalgia and myositis NOS,Chest pain NEC,Panic dis w/o agorphobia,Hypotension NOS
Admission Date:  [**2168-12-8**]              Discharge Date:   [**2168-12-15**]

Date of Birth:  [**2128-7-21**]             Sex:   F

Service: MEDICINE

Allergies:
Phenergan / Compazine / Reglan / Haldol

Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Gastroparesis

Major Surgical or Invasive Procedure:
EGD

History of Present Illness:
40 y/o woman with PMH notable for type I DM complicated by
gastroparesis with multiple prior admissions for abdominal pain
who presented to [**Hospital3 **] earlier this evening due to
ongoing nausea/vomiting, epigastric abdominal pain, and
inability to tolerate po. At [**Hospital1 392**], KUB showing no obstruction,
guaiac neg. Went to [**Hospital1 34**] 3 days ago. Received IV dilaudid, able
to tol PO, recommended DC home. Insisted on IV pain meds and tx
to [**Hospital1 18**]. Dr. [**Last Name (STitle) 8840**] felt not medically necessary, while
attempting xfer, pt eloped with portocath accessed, in lobby
took out portocath needle and left ama-without signing papers,
without flushing.

.
In our ED, initial vs were: 98.6 86 137/87 100%ra. Patient was
given ativan 1 mg IV X 1, zofran 4 mg IV X 1, dilaudid 1 mg IV X
1. She was also treated with pyridium 100 mg PO X 1 and levaquin
500 mg PO X 1 as well as benadryl 25 mg IV X 1. Urine pregnancy
test was negative. Pt had transient episode of hypotension to
80's after pain medication. CT abdomen performed/no obstruction.
Secondary to elevated glucose, AG gap pt needing insulin gtt
(s/p 20 units IV insulin, gap to 15. Also, s/p 4L IVF. SBP
90-100's, pulse 100s.


Past Medical History:
- Diabetes (Type 1): Diagnosed in [**2145**] at the age of 17,
complicated by mild retinopathy. Severe gastroparesis. Her DM is
managed with insulin, Lantus and NovoLog by Dr. [**Last Name (STitle) 10088**] at
[**Last Name (un) **].
- Gastroparesis. Required a feeding tube as recently as '[**65**].
Prior Botox injection in [**2164**], s/p gastric pacemaker placement
in [**2164-6-19**]. She is followed very closely by Dr. [**Last Name (STitle) 10689**].
- Hypertension.
- Panic attacks.
- h/o Anemia
- Genital herpes.
- Anal dysplasia followed by the infectious disease clinic.
- Fibromyalgia.
- Diabetic mastopathy. She is followed by Dr. [**Last Name (STitle) **] [**Name (STitle) 22283**] in
the [**Hospital **] [**Hospital **] Clinic through [**Hospital6 33**]. She
underwent a lumpectomy in [**2167-2-19**] and was diagnosed with
diabetic mastopathy. This lumpectomy was of the right breast.
- h/o SBO


Social History:
Currently not working, but former sales manager for [**Company 22280**].
Takes care of her mother with [**Name (NI) 2481**] disease during the
day. Not married and no children. Denies alcohol, tobacco, and
drug use.

Family History:
Her father has type 2 diabetes mellitus. Her mother has
[**Name (NI) 2481**] disease. Her brother has diabetes and her sister
suffers from [**Name (NI) 4522**] disease. A maternal uncle and maternal
grandmother both died from MIs at age 50.

Physical Exam:
VS: afebrile, HR 102, BP 127/62
Gen: NAD, pleasant
HEENT: No oropharyngeal erythema or exudate.
CV: RRR, no m/r/g.
Pulm: CTAB.
Abd: +BS. Soft, moderate tenderness diffusely. No guarding or
rebound.
Extrem: No c/c/e.


Pertinent Results:
Admission Labs:
[**2168-12-8**] 02:18AM   WBC-7.8# RBC-3.91* HGB-11.4* HCT-34.8* MCV-89
MCH-29.2 MCHC-32.8 RDW-14.8
[**2168-12-8**] 02:18AM   GLUCOSE-458* UREA N-25* CREAT-1.4* SODIUM-136
POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-20* ANION GAP-24*
[**2168-12-8**] 02:18AM   ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-64 TOT
BILI-0.6
[**2168-12-8**] 02:18AM   LIPASE-16
[**2168-12-8**] 02:18AM   ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-4.5#
MAGNESIUM-1.8
[**2168-12-8**] 02:18AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2168-12-8**] 02:18AM   PLT COUNT-444*
[**2168-12-8**] 02:18AM URINE  RBC-[**6-28**]* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0
.
CT ABD:
IMPRESSION: No evidence of obstruction or perforation. No acute
intra-
abdominal pathology. Similar-appearing CT scan when compared to
[**2166-11-13**].
<br>

[**12-12**] EGD:

Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated her
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
conscious sedation. Supplemental oxygen was used. The patient
was placed in the left lateral decubitus position and an
endoscope was introduced through the mouth and advanced under
direct visualization until the third part of the duodenum was
reached. Careful visualization of the upper GI tract was
performed. The procedure was not difficult. The patient
tolerated the procedure well. There were no complications.
Findings: Esophagus: Normal esophagus.
Stomach:
 Contents: Clear, slightly bilious fluid was seen in the stomach
body.
 Mucosa: Normal mucosa was noted in the whole stomach. Cold
forceps biopsies were performed for histology at the stomach
antrum.
Duodenum:
 Mucosa: Normal mucosa was noted. Cold forceps biopsies were
performed for histology at the second part of the duodenum.
Impression: Retained fluids in stomach
Normal mucosa in the duodenum (biopsy)
Normal mucosa in the whole stomach (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: A letter with the biopsy results will be sent
to you in [**11-1**] days.
Discontinue Protonix IV. Switch to ranitidine 150 mg [**Hospital1 **].

<br>

EGD Bx:

DIAGNOSIS:

Gastrointestinal mucosal biopsies, two:

A.  Antrum:

Antrum/fundic mucosa, within normal limits.

B.  Duodenum:

Within normal limits.


Brief Hospital Course:
40 yo female with a PMH of DM1 with severe gastroparesis who
presents with abdominal pain and dysuria found to be in DKA and
having severe gastroparesis.  DKA treated with gap closed as
below, prolonged hospitalization for severe gastroparesis -
including EGD eval with nml mucosa including nml antral/duodenal
bx (random bx).  Slow coarse for recovery, noted difficult to
control DM with [**Last Name (un) **] following.  Pt stable at time of d/c and
wished to return home.  Will need close f/u with [**Hospital 387**] clinic.
<br>

# DKA/AG acidosis/DM1, uncontrolled with complications: Pt with
an acidosis based on HCO3 level upon admission. Initially had a
gap with elevated glucose. The patient was initiated on an
Insulin drip and was fluid resuscitated. The patient was
subsequently transitioned to SQ Insulin following her BS<200.
The patient was not taking good POs in the ICU, however her GAP
remained close.
On the medicine service, her diet was advanced.  The [**Last Name (un) **]
consult service agreed with her current home regimen initially.
Pt later given gastroparesis wished for more a full liquid [**Doctor First Name **]
diet, but occasionally would have toast/light solids.  Nutrition
was also consulted to aide pt with home education on such a
diet. At end pt tolerated solid foods but more conservative
diet.
- final DM regime [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations were for Lantus 10u
am, 9u pm, with humolog with all meals based on insulin:carb
ratio 1:15 at breakfast and lunch, and 1:20 at dinner with
sensitivity factor 1:50.  Pt has both adequate supplies of
lantus and humologue at home.  Please not pt's BS very difficult
to control, when regime was 13/12 had noted am hypoglycemic
level at upper 50s on am - so regime titrated from there (lantus
reduced but more pm SSI adjusted).  Pt will need close f/u, may
need insulin pump in future?
<br>

# Acute mental status change/chest pain - [**12-14**] pt with
increased [**Month/Year (2) **] - not feeling her self and out of control,
with clouded thought process - consistant with prior use of
reglan - gets effects occasionally.  Overall feel reglan has
exacerbated her underlying [**Month/Year (2) **] disorder with this metabolic
effect.  Pt's CP on that day also most likely related to [**Month/Year (2) **]
- given DM checked EKG.  Note pt was r/o for MI [**2-20**] to
tachycardia when pt initially was admitted - EKG re-checked
[**12-14**] -no changes.
-d/c reglan on [**12-14**] with pt's mental status returning to
baseline on [**12-15**] and stable
-ekg checked an without changes
<br>

# Gastroparesis:  Etiology of the patients severe abdominal
pain. similar to past episodes of gastroparesis. Treated with
dilaudid (for pain control), ativan, zofran. The patient was
seen by the GI service and Dr. [**Last Name (STitle) 10689**] and she was started on
Erythromycin IV in-patient initially, given Dilaudid (which was
rapidly downtitrated and converted to po) and ativan for pain
and [**Last Name (STitle) **]. In addition she was written for Zofran for nausea.
The patient underwent EGD on [**12-12**] that grossly was unremarkable
with nml mucosa - bx taken of duodendum and stomach (duodendum
with prior concern of possible sprue), both bx came back with
nml mucosa.
-d/ced protonix and started H2 blocker po bid as without any
evid of ulcers on EGD on [**12-12**] (Rx given)
-d/c IV erythromycin on [**12-12**]
-started reglan 10mg qid for 2 wk course with f/u with Dr.
[**Last Name (STitle) 10689**]/PCP following on [**12-12**], however given AMS as above - d/ced
reglan [**12-14**]
-d/c stool softeners [**12-14**] with pt with loose stools - resolved
at time of d/c
-sx stable, though vary - pt prefers to cont her care at home -
feels can control with po meds
<br>

# UTI?: UA positive; culture not sent from ED. She has had
E.coli resistant to cipro in the past (but several years ago).
She was given levoflox in the ED but likely vomited this up.
Antibiotics were later discontinued. Repeat U/A and urine cx
checked - no evid of UTI.
<br>

# Hypertension: Held atenolol, clonidine given hypotension on
admission.  These were restarted, BP subsequently controlled
when pain also controlled.  Atentolol currently [**1-20**] home dose,
but BP currently controlled - pt to be d/c on full dose with BPs
in upper nml range at time of d/c with HR in 90s.  PCP to [**Name Initial (PRE) **]/u in
[**1-20**] weeks.
<br>

# [**Date Range **]/fibromyalgia: Continue ativan as above. Continue
duloxetine and buspirone.  Patient needs close outpatient psych
f/u.  Returned to home dose of ativan at 2mg qam on [**12-14**] - to
cont as outpt with PCP to further adjust.


Medications on Admission:
[**Month/Year (2) **] 81 mg daily
atenolol 50 mg daily
ativan 2 mg QAM prn
buspirone 20 mg TID
cleocin gel
clonidine 0.1 mg [**Hospital1 **]
dicyclomine (uses infequently)
duloxetine 20 mg [**Hospital1 **]
flonase 1-2 puffs [**Hospital1 **]
dilaudid 2 mg [**Hospital1 **] prn pain - taking infrequently at home
lantus 13 U [**Hospital1 **]
loestrin 1.5/30 daily
novolog four times daily
NULEV (never uses)
omeprazole 20 mg daily
zofran prn


Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) tab PO BID (2
times a day).
2. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. [**Hospital1 9766**] EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. Buspirone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. Ativan 2 mg Tablet Sig: One (1) Tablet PO qAM as needed for
[**Hospital1 **].
Disp:*30 Tablet(s)* Refills:*0*
8. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain: For breakthrough pain.
9. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**1-20**] nasal
puffs Nasal twice a day.
10. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO once a
day: USE DOSE AND FREQUENCY AS NEEDED BY PRIOR INSTRCUTIONS FROM
DR. [**Last Name (STitle) **].
11. Cleocin T 1 % Gel Sig: One (1) application Topical once a
day: As needed per prior home regimen.
12. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
qAM.
13. Lantus 100 unit/mL Solution Sig: Nine (9) units Subcutaneous
Qpm.
14. Humalog 100 unit/mL Solution Sig: One (1) units Subcutaneous
four times a day: Use per sliding scale with 1:15 insulin:carb
for breakfast and lunch, and 1:20 for dinner, and 1:50 for
sensitivity factor.
15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
16. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q3H (every 3
hours) as needed for pain.
17. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Diabetic Ketoacidosis
Gastroparesis
[**Last Name (STitle) **] with hx of panic attacks
HTN
Fibromyalgia
h/o SBO


Discharge Condition:
Vital Signs Stable


Discharge Instructions:
Return to ED if unable to hold down any pills or fluids, high
fevers, significant abdominal distention, high blood sugars that
do not improve with home sliding scale and increased water
intake.  And if your abdominal pain is not controlled with your
po dilaudid at home.
<br>

Please note and make close follow-up appointments as below.
<br>

If you require dilaudid medication for pain - you can NOT
operate any heavy machinary including a car or use any alcohol
products concurrently during that time period of use (nothing
within 24hour of use).

Followup Instructions:
Please call your PCP: [**Name10 (NameIs) 2879**],[**Name11 (NameIs) 2878**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] and set-up a
f/u appointment in [**1-20**] weeks for f/u for your blood pressure and
gastroparesis sx - they can also assist along with [**Hospital **] clinic
for your DM.
<br>

Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3014**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2168-12-28**]
1:30
Provider: [**Name10 (NameIs) 306**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2169-1-3**] 4:00
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2169-1-27**] 1:55


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]

Completed by:[**2168-12-15**]
{'Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Gastroparesis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Background diabetic retinopathy,Other postprocedural status,Anemia of other chronic disease,Myalgia and myositis, unspecified,Other chest pain,Panic disorder without agoraphobia,Hypotension, 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: Gastroparesis

PRESENT ILLNESS: 40 y/o woman with PMH notable for type I DM complicated by
gastroparesis with multiple prior admissions for abdominal pain
who presented to [**Hospital3 **] earlier this evening due to
ongoing nausea/vomiting, epigastric abdominal pain, and
inability to tolerate po. At [**Hospital1 392**], KUB showing no obstruction,
guaiac neg. Went to [**Hospital1 34**] 3 days ago. Received IV dilaudid, able
to tol PO, recommended DC home. Insisted on IV pain meds and tx
to [**Hospital1 18**]. Dr. [**Last Name (STitle) 8840**] felt not medically necessary, while
attempting xfer, pt eloped with portocath accessed, in lobby
took out portocath needle and left ama-without signing papers,
without flushing.

MEDICAL HISTORY: - Diabetes (Type 1): Diagnosed in [**2145**] at the age of 17,
complicated by mild retinopathy. Severe gastroparesis. Her DM is
managed with insulin, Lantus and NovoLog by Dr. [**Last Name (STitle) 10088**] at
[**Last Name (un) **].
- Gastroparesis. Required a feeding tube as recently as '[**65**].
Prior Botox injection in [**2164**], s/p gastric pacemaker placement
in [**2164-6-19**]. She is followed very closely by Dr. [**Last Name (STitle) 10689**].
- Hypertension.
- Panic attacks.
- h/o Anemia
- Genital herpes.
- Anal dysplasia followed by the infectious disease clinic.
- Fibromyalgia.
- Diabetic mastopathy. She is followed by Dr. [**Last Name (STitle) **] [**Name (STitle) 22283**] in
the [**Hospital **] [**Hospital **] Clinic through [**Hospital6 33**]. She
underwent a lumpectomy in [**2167-2-19**] and was diagnosed with
diabetic mastopathy. This lumpectomy was of the right breast.
- h/o SBO

MEDICATION ON ADMISSION: [**Month/Year (2) **] 81 mg daily
atenolol 50 mg daily
ativan 2 mg QAM prn
buspirone 20 mg TID
cleocin gel
clonidine 0.1 mg [**Hospital1 **]
dicyclomine (uses infequently)
duloxetine 20 mg [**Hospital1 **]
flonase 1-2 puffs [**Hospital1 **]
dilaudid 2 mg [**Hospital1 **] prn pain - taking infrequently at home
lantus 13 U [**Hospital1 **]
loestrin 1.5/30 daily
novolog four times daily
NULEV (never uses)
omeprazole 20 mg daily
zofran prn

ALLERGIES: Phenergan / Compazine / Reglan / Haldol

PHYSICAL EXAM: VS: afebrile, HR 102, BP 127/62
Gen: NAD, pleasant
HEENT: No oropharyngeal erythema or exudate.
CV: RRR, no m/r/g.
Pulm: CTAB.
Abd: +BS. Soft, moderate tenderness diffusely. No guarding or
rebound.
Extrem: No c/c/e.

FAMILY HISTORY: Her father has type 2 diabetes mellitus. Her mother has
[**Name (NI) 2481**] disease. Her brother has diabetes and her sister
suffers from [**Name (NI) 4522**] disease. A maternal uncle and maternal
grandmother both died from MIs at age 50.

SOCIAL HISTORY: Currently not working, but former sales manager for [**Company 22280**].
Takes care of her mother with [**Name (NI) 2481**] disease during the
day. Not married and no children. Denies alcohol, tobacco, and
drug use. 

### Response:
{'Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Gastroparesis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Background diabetic retinopathy,Other postprocedural status,Anemia of other chronic disease,Myalgia and myositis, unspecified,Other chest pain,Panic disorder without agoraphobia,Hypotension, unspecified'}
