CHIEF COMPLAINT: dysphagia, vague chest discomfort

PRESENT ILLNESS: 33 yo female with h/o DM2 diagnosed 2 yrs ago who presented to
the ED [**2118-2-3**] with chest discomfort for 1 week. She was
initially worked up for PE or intrathoracic problem, but was
found to have abnormal labs suspicious for DKA. She is followed
at [**Last Name (un) **] but has not been seen for a long time. Notes that
lateley her blood glucose has been poorly controlled with sugars
in the 200-400s over the past 2 months. She also has had 65 lb
weight loss since this summer with polydipsia and polyuria. For
the past two days she has felt more fatigued and short of
breath. Three days ago she ran out of her Metformin and did not
get it filled. She otherwise denies fevers, chills, nausea,
diarrhea, upper URI symptoms, cough, dysuria, flank pain, recent
steroid use or other new medications, night sweats. She has had
slightly decreased PO intake from her recent dysphagia and feels
dehydrated.
.
As for the chest discomfort, the pt describes a vague discomfort
that becomes painful with swallowing both liquids and solids.
She endorses palpitations, weakness, nausea x 2 days, and left
sided abdominal discomfort. No radiation of the pain. No similar
sx in the past and no hx of GERD. Denies regurgitation of the
food, but feels like it gets "stuck." She admitted to increased
stress and feeling overwhelmed and has seen someone in psych
recently for this in the ED, but denied this during my
interview.
.
In th ED, the patient was noted to be tachycardic to 104, other
vital signs were: BP 155/100 RR 20, 100% RA, temp 97.9. The
patient initially was complaining of dysphagia (although she was
still able to tolerate PO water) and had a d-dimer and CXR to
r/o PE, which were both negative. Trop was also negative. EKG
showed NSR. Chem 7 revealed glucose 513, sodium 131, and bicarb
7 (anion gap = 30), K 5.2, but hemolyzed. Hct was elevated at
48.6. UA pos for ketones. The patient was given 500 cc bolus of
NS and ordered for 2 more L. She was started on insulin gtt at
5U/hr after being boluesed 10 units. She was changed to D5 [**1-22**]
NS prior to arrival. VS at time of transfer were: HR 109 SBP 144
RR 20 100% RA.

MEDICAL HISTORY: Diabetes - c/b nephropathy. Followed at [**Last Name (un) **]
Pylonephritis [**1-/2116**] (Admission to [**Hospital1 18**])
B12 defficiency
abnormal pap -has been missing appointments for colposcopy
hypothyroid

MEDICATION ON ADMISSION: metformin 500 mg [**Hospital1 **] (previously on humalog but not now)
.
prescribed but not taking: simvastatin 10 mg QHS

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: Temp: BP: 132/79 HR: 100 RR:20 100% O2sat
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, Thyroid
feels slightly full
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses
EXT: no c/c/e, thin legs
SKIN: xeroderma, hyperpigmented macules on dorsum of hands. no
jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.

FAMILY HISTORY: glaucoma - grandmother

SOCIAL HISTORY: Ms. [**Known lastname 103512**] is divorced, mother of 2, works in administration
at [**Hospital **] clinic, recently started school to be a medical
assistant. Smokes [**1-22**] cig a day, drinks 2-3 glasses etoh a week,
denies other drug use
Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Personal history of noncompliance with medical treatment, presenting hazards to health,Unspecified acquired hypothyroidism,Dysphagia, unspecified,Other B-complex deficiencies,Other and unspecified hyperlipidemia,Loss of weight,Disorders of phosphorus metabolism
DMI ketoacd uncontrold,Hyposmolality,Nephritis NOS in oth dis,Hx of past noncompliance,Hypothyroidism NOS,Dysphagia NOS,B-complex defic NEC,Hyperlipidemia NEC/NOS,Abnormal loss of weight,Dis phosphorus metabol
Admission Date:  [**2119-2-3**]              Discharge Date:   [**2119-2-8**]

Date of Birth:  [**2085-10-21**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Doctor First Name 2080**]
Chief Complaint:
dysphagia, vague chest discomfort

Major Surgical or Invasive Procedure:
None


History of Present Illness:
33 yo female with h/o DM2 diagnosed 2 yrs ago who presented to
the ED [**2118-2-3**] with chest discomfort for 1 week. She was
initially worked up for PE or intrathoracic problem, but was
found to have abnormal labs suspicious for DKA. She is followed
at [**Last Name (un) **] but has not been seen for a long time. Notes that
lateley her blood glucose has been poorly controlled with sugars
in the 200-400s over the past 2 months. She also has had 65 lb
weight loss since this summer with polydipsia and polyuria. For
the past two days she has felt more fatigued and short of
breath. Three days ago she ran out of her Metformin and did not
get it filled. She otherwise denies fevers, chills, nausea,
diarrhea, upper URI symptoms, cough, dysuria, flank pain, recent
steroid use or other new medications, night sweats. She has had
slightly decreased PO intake from her recent dysphagia and feels
dehydrated.
.
As for the chest discomfort, the pt describes a vague discomfort
that becomes painful with swallowing both liquids and solids.
She endorses palpitations, weakness, nausea x 2 days, and left
sided abdominal discomfort. No radiation of the pain. No similar
sx in the past and no hx of GERD. Denies regurgitation of the
food, but feels like it gets "stuck." She admitted to increased
stress and feeling overwhelmed and has seen someone in psych
recently for this in the ED, but denied this during my
interview.
.
In th ED, the patient was noted to be tachycardic to 104, other
vital signs were: BP 155/100 RR 20, 100% RA, temp 97.9. The
patient initially was complaining of dysphagia (although she was
still able to tolerate PO water) and had a d-dimer and CXR to
r/o PE, which were both negative. Trop was also negative. EKG
showed NSR. Chem 7 revealed glucose 513, sodium 131, and bicarb
7 (anion gap = 30), K 5.2, but hemolyzed. Hct was elevated at
48.6. UA pos for ketones. The patient was given 500 cc bolus of
NS and ordered for 2 more L. She was started on insulin gtt at
5U/hr after being boluesed 10 units. She was changed to D5 [**1-22**]
NS prior to arrival. VS at time of transfer were: HR 109 SBP 144
RR 20 100% RA.

Past Medical History:
Diabetes - c/b nephropathy. Followed at [**Last Name (un) **]
Pylonephritis [**1-/2116**] (Admission to [**Hospital1 18**])
B12 defficiency
abnormal pap -has been missing appointments for colposcopy
hypothyroid

Social History:
Ms. [**Known lastname 103512**] is divorced, mother of 2, works in administration
at [**Hospital **] clinic, recently started school to be a medical
assistant. Smokes [**1-22**] cig a day, drinks 2-3 glasses etoh a week,
denies other drug use

Family History:
glaucoma - grandmother

Physical Exam:
VS: Temp: BP: 132/79 HR: 100 RR:20 100% O2sat
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, Thyroid
feels slightly full
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses
EXT: no c/c/e, thin legs
SKIN: xeroderma, hyperpigmented macules on dorsum of hands. no
jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.

Pertinent Results:
Admssion labs:

[**2119-2-3**] 08:40PM BLOOD WBC-11.5*# RBC-4.76 Hgb-15.5 Hct-48.6*
MCV-102* MCH-32.6* MCHC-31.9 RDW-14.6 Plt Ct-311
[**2119-2-3**] 08:40PM BLOOD Neuts-77* Bands-2 Lymphs-15* Monos-4
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2119-2-3**] 08:40PM BLOOD Glucose-513* UreaN-4* Creat-1.1 Na-131*
K-5.2* Cl-94* HCO3-7* AnGap-35*
[**2119-2-4**] 12:40AM BLOOD Calcium-8.4 Phos-1.4*# Mg-1.7
.
Other labs:

[**2119-2-4**] 04:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2119-2-4**] 07:32AM BLOOD Cortsol-12.9
[**2119-2-4**] 07:32AM BLOOD TSH-4.4*
[**2119-2-3**] 08:40PM BLOOD Osmolal-317*
[**2119-2-4**] 12:40AM BLOOD Acetone-LARGE
[**2119-2-4**] 06:31AM BLOOD Triglyc-156* HDL-21 CHOL/HD-9.9
LDLcalc-156*
[**2119-2-3**] 08:40PM BLOOD D-Dimer-394
[**2119-2-4**] 07:32AM BLOOD VitB12-492 Folate-7.7
[**2119-2-3**] 08:40PM BLOOD cTropnT-<0.01
[**2119-2-4**] 06:31AM BLOOD cTropnT-<0.01
[**2119-2-4**] 06:31AM BLOOD ALT-7 AST-10 LD(LDH)-137 AlkPhos-57
TotBili-0.3
[**2119-2-4**] 03:59AM BLOOD Ret Man-.8
.
.
Urine:

[**2119-2-3**] 06:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.031
[**2119-2-3**] 06:15PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2119-2-3**] 06:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2119-2-3**] 06:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2119-2-4**] 03:02AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.018
[**2119-2-4**] 03:02AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose->1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.5
Leuks-NEG
[**2119-2-4**] 03:02AM URINE RBC-3* WBC-9* Bacteri-NONE Yeast-NONE
Epi-2
[**2119-2-4**] 03:02AM URINE CastHy-2*
[**2119-2-4**] 03:02AM URINE Mucous-RARE
.
.
Microbiology:
[**2119-2-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2119-2-4**] URINE URINE CULTURE-FINAL
[**2119-2-4**] MRSA SCREEN MRSA SCREEN-PENDING
.
.
Radiology:
XR CHEST (PA & LAT) Study Date of [**2119-2-3**] 7:37 PM
FINDINGS: The cardiomediastinal and hilar contours appear
normal. The lungs
are clear. There is no pleural effusion or pneumothorax. The
osseous
structures are intact. The retrotracheal is not well demarcated
on the
lateral view, most likely due to patient position and overlying
scapulae and
soft tissues. No mass effect seen on the trachea.

IMPRESSION: No acute cardiopulmonary process.

Brief Hospital Course:
33 YOF with type II diabetes who presented to the ED with
dysphagia and was found to be in diabetic ketoacidosis. She was
transferred to the ICU for further management of the DKA and
transferred to the [**Hospital1 **] on [**2-5**].
.
.
#  DKA: She is followed at [**Last Name (un) **] for what was thought to be
T2DM but had not been seen for a long time. The diagnosis of DKA
was made on routine labs during work-up for her chest pain. She
noted recent poor glycemic control with sugars in the 200-400s
over the past 2 months. She also noted 65 lb weight loss since
this summer with polydipsia and polyuria. She noted a 2 day hx
of fatigue and SOB and ran out of metformin 3 days prior to
admissioan dn did not get this refilled. Three days ago she ran
out of her Metformin and did not get it filled. She denied any
localising sx for infection by had slightly decreased PO intake
from her recent dysphagia and felt dehydrated. There was
evidence of rare bacteria on UA and no dysuria, CXR was clear.
The precipitant was felt to be likely medication noncompliance.
Labs on admission revealed Glc 513 Cl 94 HCO3 7 An Gap 35 and UA
pos for ketones. The patient was given 2.5L in the ED and
started on insulin IV infusion and transferred to the ICU on
[**2-3**].  She was managed on the ICU and received aggressive fluid
hydration receiving 6L whilst in the ICU. Potassiuma nd
Magnesium were repleted. We held antibiotics and pan-cultured,
urine and blood cultures were negtative at the time of writing.
She was initialy continued on an IV insulin sliding scale and
eventually by the evwning of [**2-4**] she was transitioned to a s/c
insulin scale and PO Lantus 25mg. She was reviewed by [**Last Name (un) **] who
recommended stopping metformin until stabilized, and hey felt
that given her presentation that her case was more in keeping
with T1DM. They further advised tranitioning to lantus when
taking. Her diet was slowly advanced and by [**2-5**] she was able to
take po and had eaten breakfast without issue. he wsa
transferred from the ICU to teh floor on [**2-5**] by which point her
anion gap had normalised to 15, her HCO3 was 15 and her Glc were
better controlled in the 200s. Ultimately pt will need better
outpatient management of her diabtes with better monitoring and
medication compliance.
- she was discharged on glargine 35units qHS in addition to HISS
.
# Pseudohyponatremia: Admission Na at 131 corrected to Na 140
when  blood glucose in the 500s was take into account.
.
# Metabolic acidosis: Likely from ketoacids. + ketones in urine.
There was no clinical suspicion for sepsis, althouh WBC elevated
with 2% bands so was monitored closely for evolving infection
and bandemia spontaneously resolved. Cultures are negative at
time of writing.
.
# Dysphagia: Etiology could include eophagitis, esophageal
spasm, GERD, or mechanical stricture.  Diabetic gastroparesis
unlikely to cause pain, more likely to cause discomfort.  EKG no
ischemic changes with two negative troponins. Ddimer also
effectively r/o PE.  No abnormalities were seen on CXR.  We
started omeprazole and this was continued. Pt will need
outpatient work up for this, possibly including upper GI
endoscopy.
.
# Macrocytic anemia:  B12 and folate were wnl and TSH was mildly
elevated at 4.4 but in the setting of acute illness. TSH should
be repeated as an o/p and this should be followed in the
community.
.
# HL: Pt volunteered that she was noncompliant with statin. Last
lipid panel in [**2113**] and repeat showed Chol 208 TGCs 156 HLD 21
LDL 156. Her statin was restarted and she was educated about
cardiovascular risk factors.
.
# ? hyperparathyroid: Seen in old record but pt was unaware of
diagnosis. Serum calcium was not elevated during this admission.
 Repeat PTH was normal.

Medications on Admission:
metformin 500 mg [**Hospital1 **] (previously on humalog but not now)
.
prescribed but not taking: simvastatin 10 mg QHS


Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
[**Hospital1 **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Glucagon Emergency 1 mg Kit Sig: One (1) MG Injection as
needed: inject into muscle/fat if blood sugar critically low
with symptoms and unable to eat.  [**Name6 (MD) 138**] your MD.
[**Last Name (Titles) **]:*1 syringes* Refills:*2*
4. Lantus 100 unit/mL Solution Sig: Thirty Five (35) units
Subcutaneous at bedtime.
[**Last Name (Titles) **]:*1 vial* Refills:*2*
5. Humalog 100 unit/mL Solution Sig: 1-30 units Subcutaneous
qAC: according to sliding scale with meals.
[**Last Name (Titles) **]:*7 vials* Refills:*2*
6. insulin syringe-needle,dispos. 0.5 mL 29 x [**1-22**]  Syringe Sig:
One (1) use Miscellaneous four times a day: with insulin.
[**Month/Day (2) **]:*1 month supply* Refills:*2*
7. One Touch Test     Strip Sig: One (1) strip Miscellaneous
four times a day.
[**Month/Day (2) **]:*1 box* Refills:*2*
8. Lancets,Thin     Misc Sig: One (1) lancet Miscellaneous four
times a day.
[**Month/Day (2) **]:*1 box* Refills:*2*
9. Ketostix     Strip Sig: One (1) strip Miscellaneous as
needed: for blood sugar >250.  call [**Last Name (un) 387**] if positive.
[**Last Name (un) **]:*1 box* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Diabetic ketoacidosis
Type 1 diabetes mellitus, uncontrolled
Dysphagia
Weight loss


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


Discharge Instructions:
You were admitted with chest pain and found to have high blood
sugars and diabetic ketoacidosis.  With IV fluids and insulin
your symptoms resolved.  You likely have "Type 1 diabetes"
meaning you MUST take insulin at all times to prevent this from
happening.  Please check your blood sugar and use the insulin
doses recommended every day as directed.  Please follow the
instructions provided by the [**Last Name (un) **] doctors regarding the use of
glucagon and high blood sugars.

Please follow up with your PCP and [**Name9 (PRE) **] doctor as soon as
scheduled

Followup Instructions:
Name: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**]  (works with [**Last Name (LF) 978**], [**First Name7 (NamePattern1) 7208**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **])
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appt: [**2-15**] at 3pm

Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: WEDNESDAY [**2119-2-15**] at 6:00 PM
With: [**First Name11 (Name Pattern1) 2801**] [**Last Name (NamePattern4) 14773**], NP [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site
{'Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Personal history of noncompliance with medical treatment, presenting hazards to health,Unspecified acquired hypothyroidism,Dysphagia, unspecified,Other B-complex deficiencies,Other and unspecified hyperlipidemia,Loss of weight,Disorders of phosphorus metabolism'}


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: dysphagia, vague chest discomfort

PRESENT ILLNESS: 33 yo female with h/o DM2 diagnosed 2 yrs ago who presented to
the ED [**2118-2-3**] with chest discomfort for 1 week. She was
initially worked up for PE or intrathoracic problem, but was
found to have abnormal labs suspicious for DKA. She is followed
at [**Last Name (un) **] but has not been seen for a long time. Notes that
lateley her blood glucose has been poorly controlled with sugars
in the 200-400s over the past 2 months. She also has had 65 lb
weight loss since this summer with polydipsia and polyuria. For
the past two days she has felt more fatigued and short of
breath. Three days ago she ran out of her Metformin and did not
get it filled. She otherwise denies fevers, chills, nausea,
diarrhea, upper URI symptoms, cough, dysuria, flank pain, recent
steroid use or other new medications, night sweats. She has had
slightly decreased PO intake from her recent dysphagia and feels
dehydrated.
.
As for the chest discomfort, the pt describes a vague discomfort
that becomes painful with swallowing both liquids and solids.
She endorses palpitations, weakness, nausea x 2 days, and left
sided abdominal discomfort. No radiation of the pain. No similar
sx in the past and no hx of GERD. Denies regurgitation of the
food, but feels like it gets "stuck." She admitted to increased
stress and feeling overwhelmed and has seen someone in psych
recently for this in the ED, but denied this during my
interview.
.
In th ED, the patient was noted to be tachycardic to 104, other
vital signs were: BP 155/100 RR 20, 100% RA, temp 97.9. The
patient initially was complaining of dysphagia (although she was
still able to tolerate PO water) and had a d-dimer and CXR to
r/o PE, which were both negative. Trop was also negative. EKG
showed NSR. Chem 7 revealed glucose 513, sodium 131, and bicarb
7 (anion gap = 30), K 5.2, but hemolyzed. Hct was elevated at
48.6. UA pos for ketones. The patient was given 500 cc bolus of
NS and ordered for 2 more L. She was started on insulin gtt at
5U/hr after being boluesed 10 units. She was changed to D5 [**1-22**]
NS prior to arrival. VS at time of transfer were: HR 109 SBP 144
RR 20 100% RA.

MEDICAL HISTORY: Diabetes - c/b nephropathy. Followed at [**Last Name (un) **]
Pylonephritis [**1-/2116**] (Admission to [**Hospital1 18**])
B12 defficiency
abnormal pap -has been missing appointments for colposcopy
hypothyroid

MEDICATION ON ADMISSION: metformin 500 mg [**Hospital1 **] (previously on humalog but not now)
.
prescribed but not taking: simvastatin 10 mg QHS

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: Temp: BP: 132/79 HR: 100 RR:20 100% O2sat
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, Thyroid
feels slightly full
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses
EXT: no c/c/e, thin legs
SKIN: xeroderma, hyperpigmented macules on dorsum of hands. no
jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.

FAMILY HISTORY: glaucoma - grandmother

SOCIAL HISTORY: Ms. [**Known lastname 103512**] is divorced, mother of 2, works in administration
at [**Hospital **] clinic, recently started school to be a medical
assistant. Smokes [**1-22**] cig a day, drinks 2-3 glasses etoh a week,
denies other drug use 

### Response:
{'Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Personal history of noncompliance with medical treatment, presenting hazards to health,Unspecified acquired hypothyroidism,Dysphagia, unspecified,Other B-complex deficiencies,Other and unspecified hyperlipidemia,Loss of weight,Disorders of phosphorus metabolism'}
