CHIEF COMPLAINT: nausea and vomiting x 4 days

PRESENT ILLNESS: Ms. [**Known lastname **] is a 47 year old female with medical history
significant for Type I Diabetes with ESRD s/p renal transplant
in [**2118**] on chronic immunosuppressive agents, who presents with
nausea and vomiting of 4 days' duration. Pt stated that this
episode was more severe that her usual gastroparesis, and that
while her vomiting has eased up in the last two days, she has
not been able to tolerate any POs including water, causing her
to miss all of her medications since [**2125-8-20**]. Pt also had loose
stools x 4 since yesterday. She had chills, but no fevers that
she knows of.
.
In the ED, she complained of substernal chest pain that felt
like pressure with no radiation. Vitals were: 97.7  123  144/72
28  100% on RA. Pt was started on IVF 200cc/hr, Insulin drip 6
units/hr with Q 1hr FS, was given [**Month/Day/Year **] 750 mg IV x 1, ASA
325 mg PO x 1, and Zofran 4 mg IV x 1. U cx and B cx were sent.
EKG showed demand ischemia (was faxed to Cards fellow for
review). CK and Trop sent. Kidney U/S showed mild pelviectasis.
CXR demonstrated no acute process.
.
ROS: Positive for SOB, worse with activity; unintentional weight
loss of [**5-26**] pounds in 3 months; worsening visual acuity; mild
abdominal pain in lower quadrants. Negative for melena,
hematochezia, chest pain, orthopnea, PND, lower extremity edema,
cough, urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes, headache,
rash or skin changes.
.

MEDICAL HISTORY: Diabetes Type 1, s/p renal transplant in [**2118**], with a history of
episodes of diabetic ketoacidosis.
Gastroparesis secondary to DM.
Hypertension.
Hypercholesterolemia.
Coronary artery disease with an ejection fraction of 55%
in [**2118**], MI x2 and a three-vessel CABG in [**2116**].
Left below the knee amputation in [**2118**].
Vascular procedures on the right lower extremity.
Heel ulcers due to diabetes, s/p bypass graft surgeries
Peripheral neuropathy
CVA x2.
S/p cholecystectomy
S/p cataract surgery
Depression.

MEDICATION ON ADMISSION: Cymbalta, hydromorphone, furosemide, prednisone, nitroglycerin,
Isordil, Plavix, Prograf, glyburide, tramadol, metoprolol,
CellCept, gabapentin, ASA, piroxicam, Lipitor, and insulin.

ALLERGIES: Demerol / Iodine / Augmentin

PHYSICAL EXAM: Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.

FAMILY HISTORY: Uncle with diabetes
Sister died of colon CA
Mother died of brain CA

SOCIAL HISTORY: The patient smokes [**3-20**] of a pack of [**State 622**] slim lights. Has
been smoking ~1ppd since age 14. No alcohol or IVDU.  She is
married.  She lives in [**Location **] with her husband, [**Name (NI) 1158**].
Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Coronary atherosclerosis of autologous vein bypass graft,Kidney replaced by transplant,Hyposmolality and/or hyponatremia,Gastroparesis,Background diabetic retinopathy,Polyneuropathy in diabetes,Ulcer of other part of foot,Unspecified essential hypertension,Old myocardial infarction,Pure hypercholesterolemia,Depressive disorder, not elsewhere classified,Below knee amputation status,Other postprocedural status,Long-term (current) use of insulin,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Subendo infarct, initial,Acute kidney failure NOS,DMI ketoacd uncontrold,Crn ath atlg vn bps grft,Kidney transplant status,Hyposmolality,Gastroparesis,Diabetic retinopathy NOS,Neuropathy in diabetes,Ulcer other part of foot,Hypertension NOS,Old myocardial infarct,Pure hypercholesterolem,Depressive disorder NEC,Status amput below knee,Post-proc states NEC,Long-term use of insulin,Hx TIA/stroke w/o resid
Admission Date:  [**2125-8-23**]              Discharge Date:   [**2125-8-28**]

Date of Birth:  [**2074-6-22**]             Sex:   F

Service: MEDICINE

Allergies:
Demerol / Iodine / Augmentin

Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
nausea and vomiting x 4 days

Major Surgical or Invasive Procedure:
[**2125-8-27**] Cardiac catherization


History of Present Illness:
Ms. [**Known lastname **] is a 47 year old female with medical history
significant for Type I Diabetes with ESRD s/p renal transplant
in [**2118**] on chronic immunosuppressive agents, who presents with
nausea and vomiting of 4 days' duration. Pt stated that this
episode was more severe that her usual gastroparesis, and that
while her vomiting has eased up in the last two days, she has
not been able to tolerate any POs including water, causing her
to miss all of her medications since [**2125-8-20**]. Pt also had loose
stools x 4 since yesterday. She had chills, but no fevers that
she knows of.
.
In the ED, she complained of substernal chest pain that felt
like pressure with no radiation. Vitals were: 97.7  123  144/72
28  100% on RA. Pt was started on IVF 200cc/hr, Insulin drip 6
units/hr with Q 1hr FS, was given [**Month/Day/Year **] 750 mg IV x 1, ASA
325 mg PO x 1, and Zofran 4 mg IV x 1. U cx and B cx were sent.
EKG showed demand ischemia (was faxed to Cards fellow for
review). CK and Trop sent. Kidney U/S showed mild pelviectasis.
CXR demonstrated no acute process.
.
ROS: Positive for SOB, worse with activity; unintentional weight
loss of [**5-26**] pounds in 3 months; worsening visual acuity; mild
abdominal pain in lower quadrants. Negative for melena,
hematochezia, chest pain, orthopnea, PND, lower extremity edema,
cough, urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes, headache,
rash or skin changes.
.


Past Medical History:
Diabetes Type 1, s/p renal transplant in [**2118**], with a history of
episodes of diabetic ketoacidosis.
Gastroparesis secondary to DM.
Hypertension.
Hypercholesterolemia.
Coronary artery disease with an ejection fraction of 55%
in [**2118**], MI x2 and a three-vessel CABG in [**2116**].
Left below the knee amputation in [**2118**].
Vascular procedures on the right lower extremity.
Heel ulcers due to diabetes, s/p bypass graft surgeries
Peripheral neuropathy
CVA x2.
S/p cholecystectomy
S/p cataract surgery
Depression.


Social History:
The patient smokes [**3-20**] of a pack of [**State 622**] slim lights. Has
been smoking ~1ppd since age 14. No alcohol or IVDU.  She is
married.  She lives in [**Location **] with her husband, [**Name (NI) 1158**].


Family History:
Uncle with diabetes
Sister died of colon CA
Mother died of brain CA

Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.


Pertinent Results:
Labs (blood)
[**2125-8-23**] 03:30PM WBC-14.7 Hgb-12.6 Hct-41.1 MCV-92 MCH-28.3
MCHC-30.7 RDW-13.7 Plt Ct-333
Neuts-92* Bands-0 Lymphs-5.0* Monos-3 Eos-0 Baso-0
PT-11.5 PTT-24.2 INR(PT)-1.0
Glucose-759* UreaN-49* Creat-1.7* Na-130* K-5.6* Cl-86* HCO3-11*
Calcium-9.6 Phos-4.2# Mg-2.3
ALT-18 AST-16 LD(LDH)-181 CK(CPK)-77 AlkPhos-213* TotBili-0.5
Lipase-12
cTropnT-0.10*
Acetone-LARGE
ASA-4 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
pH-7.31* Glucose-GREATER TH Lactate-3.0* Na-132* K-5.4* Cl-93*
calHCO3-11* freeCa-1.04*
.
Labs (urine)
[**2125-8-23**] 04:20PM Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.022
Blood-LG Nitrite-NEG Protein-TR Glucose-1000 Ketone-150
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
RBC-21-50* WBC-[**3-21**] Bacteri-FEW Yeast-NONE Epi-[**3-21**]
UTox: bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
.
[**2125-8-23**] renal transplant ultrasound
FINDINGS: A transplanted kidney is visualized in the right lower
quadrant of the abdomen and measures 10.8 cm in length. The
corticomedullary differentiation is preserved. Mild pelviectasis
is noted which appears new compared to the most recent prior
study in [**2117**]. Doppler assessment demonstrates resistive indices
of the upper, mid and lower poles of 0.8, 1.0, and 1.0. Normal
venous flow is demonstrated in the main renal vein. While the
arterial upstroke is good in the main renal artery there is
minimal diastolic flow.
Limited images of the bladder are unremarkable.
IMPRESSION: Right lower quadrant transplanted kidney with mild
new pelviectasis. Elevated resistive indices as described.
Clinical correlation is recommended.
.
[**2125-8-23**] CXR
FINDINGS: The lungs are clear without consolidation or edema.
There is evidence of prior median sternotomy and CABG. There is
convexity involving the AP window which is stable from the prior
exam. The cardiac silhouette size is within normal limits. Again
seen is minimal blunting of the left costophrenic angle possibly
due to the scarring or small effusion. No pneumothorax is noted.
The bones are diffusely osteopenic but otherwise unremarkable.
The patient has had prior cholecystectomy.
IMPRESSION: Relatively stable radiographic examination
demonstrating no acute process.
.
[**2125-8-23**] ECG:  Sinus tachycardia at 127 bpm, nl axis, nl PR, QRS,
and QT intervals, fair R-wave progress, 2mm ST depression in
V4-6.
.
[**2125-8-27**] Cardiac cath: 1. Selective coronary angiography of this
left dominant system revealed 3 vessel coronary artery disease.
The LMCA was normal. The LAD had mild luminal irregularities
proximally with a total mid-segment occlusion. D1 was patent
with moderate diffuse disease. The LCX is a dominant vessel with
mild luminal irregularities. The non-dominant RCA had moderate
diffuse disease.
2. Graft arteriography revealed a patent LIMA-LAD, and stump
occluded SVGs to OM1 and PDA.
3. Limited resting hemodynamics revealed systemic arterial
hypertension with aortic pressures of 178/64 and mildly elevated
left sided filling pressures with LVEDP of 17. There was no
transaortic pressure gradient on pullback of catheter from LV to
aorta.
4. Left ventriculography was not performed.
.
[**2125-8-28**] L femoral U/S
No evidence of pseudoaneurysm.
.


Brief Hospital Course:
Ms. [**Known lastname **] is a 47 year old female with medical history
significant for Type I Diabetes with ESRD s/p renal transplant
in [**2118**] on chronic immunosuppressive agents, who presents with
nausea and vomiting of 4 days' duration, and found to be in DKA.


1) DKA: Anion gap closed with aggressive hydration and insulin
drip per DKA protocol. Pt was started on subcutaneous Insulin
coverage once gap had closed, with frequent finger sticks.
Potassium was repleted PRN. Differential for precipitating
factors included diarrhea, gastroparesis, c.diff, MI, infection,
or viral gastroenteritis (given pt's lower abdominal discomfort
on admission).  Pt also may have had TSS with history that a
tampon was left in place for 5 days (this history was revealed
on a few days after admission). Pt received a single dose of
Levoquin in ED on admission, which was not continued in the ICU
given that she had borderline high normal WBC and afebrile.
Tachycardia resolved with hydration. Upon discovery of retained
tampon during hospital stay, vancomycin was started, however,
this too was discontinued based on the absence of clinical
symptoms and signs.

2) Unstable angina:
Pt complained of substernal chest pain in the ED. EKG changes
were initially felt to be consistent with demand ischemia due to
tachycardia. Pt had cardiac enzyme elevation that peaked then
slowly trended down. Pt continued to have short episodes of
chest tightness, and cardiac enzymes were cycled. ASA, statin
(80 mg daily rather than 10 mg daily, which is her home dose),
metoprolol, isosorbide dinitrate (later switched to isosorbide
mononitrate extended release) were continued. Heparin gtt were
used intermittently with her symptoms. Pt underwent cardiac
catherization on [**2125-8-27**], which showed diffusely diseased
vessels and two out of three occluded grafts (which were
previously seen in [**2117**]). No interventions were made.

3) DM, type 1
[**Last Name (un) **] followed the patient during her stay. Pt's insulin
regimen were optimized according to blood sugar checks. Pt was
encouraged to take part in sliding scale insulin administration.
Pt was discharged home on Glyburide 5 mg daily, Lantus 18 units
at dinner time, and short-acting insulin with carbohydrate
counting. Pt has an appointment to follow up at [**Last Name (un) **].

4) ARF:  Cr 1.7 on admission. Improved to 0.7 with aggressive
hydration. U/S of transplanted kidney showed mild pelviectasis.
Because pt received dye for cardiac cath, pt was instructed to
get a check of BUN and Cr when she follows up with her PMD.

5) Lower abdominal tenderness: unclear etiology. UCG was neg.
Resolved shortly after admission.

6) S/p renal transplant:
Pt's regular immunosuppressive therapy was continued. Renal team
followed pt as inpatient. Pt was advised not to miss [**First Name (Titles) 691**] [**Last Name (Titles) 26642**]n medications (may open capsules and take the
powder sublingually if unable to tolerate PO due to nausea).
Pt's Prograf levels were in the lower limits of therapeutic
range when checked during hospitalization. Pt was instructed to
get a repeat level at her PMD's office when she goes for her
follow-up appointment.

7)  Right heel ulcer
She regularly sees a podiatrist as outpatient for foot care.
Podiatry was consulted as inpatient, who recommended that
adaptic and guaze dressing be continued, as the ulcer is healing
well.

8) Depression: stable
- continued cymbalta

9) Code: DNR, but do wish to be intubated if necessary. Husband
[**Name (NI) 1158**] is her health care proxy.


Medications on Admission:
Cymbalta, hydromorphone, furosemide, prednisone, nitroglycerin,
Isordil, Plavix, Prograf, glyburide, tramadol, metoprolol,
CellCept, gabapentin, ASA, piroxicam, Lipitor, and insulin.


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Primary:
Diabetic ketoacidosis
Non ST-elevation myocardial infarction
Right foot ulcer
.
Secondary:
Diabetes Type 1, s/p renal transplant
Gastroparesis secondary to diabetes.
Hypertension.
Hypercholesterolemia.
Left below the knee amputation
Vascular procedures on the right lower extremity.
Peripheral neuropathy
cerebrovascular accident x2.
S/p cholecystectomy
S/p cataract surgery
Depression.


Discharge Condition:
Good, stable. Tolerating POs well


Discharge Instructions:
You were admitted to the hospital because you were extremely
dehydrated and had high blood sugars. We treated you with
intravenous fluids and insulin drip, which resolved the acidosis
of your blood caused by high sugar.
.
You had episodes of chest pain during this hospitalization, with
elevation of cardiac enzymes. We performed cardiac catherization
to evaluate the cause of these frequent chest pains. It showed
that your heart arteries are diffusely narrow, with blockage of
two out of three bypass grafts, which were also previously seen
in [**2117**]. No interventions were made.
.
The following changes were made to your medication regimen:
Isordil 20 mg twice a day --> Imdur 60 mg daily
Lipitor 10 mg daily --> Lipitor 80 mg daily
Aspirin 81 mg daily --> Aspirin 325 mg daily
Please resume all of your other medications. It is very
important that you take all medications, especially your
immunosuppression medications (CellCept, Tacrolimus,
Prednisone).
.
Please attend all of your follow-up appointments.
.
If you have severe chest pain, nausea/vomiting, shortness of
breath, palpitations, or any other concerning symptoms, please
call your primary care physician or return to the emergency
room.
.
***For today, [**2125-8-28**], please take 12 units of Lantus
with dinner. Starting tomorrow, you can resume taking 18 units
of Lantus once a day with dinner, along with Glyburide and
carbohydrate counting for short-acting insulin.***


Followup Instructions:
Please attend the following appointments that have been made for
you:
[**2125-9-6**] 3:30 PM with Dr. [**Last Name (STitle) 17887**] (tel [**Telephone/Fax (1) 6699**])
Please have labs (electrolytes including BUN and Cr, and prograf
level) drawn during your appointment with Dr. [**Last Name (STitle) 17887**], and have
the result be faxed to Dr. [**Last Name (STitle) **] also (fax: [**Telephone/Fax (1) 26643**]).
[**2125-9-3**] 2 pm at [**Hospital **] Clinic to meet with nurse practitioner
[**2125-9-21**] 3 pm with Dr.[**Doctor Last Name 4849**] (Nephrology-kidney)
[**2125-10-3**] 3:30 pm with Dr. [**Last Name (STitle) **] (Diabetes)
.
You will also want to continue foot ulcer care with your
podiatrist.



Completed by:[**2125-8-28**]
{'Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Coronary atherosclerosis of autologous vein bypass graft,Kidney replaced by transplant,Hyposmolality and/or hyponatremia,Gastroparesis,Background diabetic retinopathy,Polyneuropathy in diabetes,Ulcer of other part of foot,Unspecified essential hypertension,Old myocardial infarction,Pure hypercholesterolemia,Depressive disorder, not elsewhere classified,Below knee amputation status,Other postprocedural status,Long-term (current) use of insulin,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}


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: nausea and vomiting x 4 days

PRESENT ILLNESS: Ms. [**Known lastname **] is a 47 year old female with medical history
significant for Type I Diabetes with ESRD s/p renal transplant
in [**2118**] on chronic immunosuppressive agents, who presents with
nausea and vomiting of 4 days' duration. Pt stated that this
episode was more severe that her usual gastroparesis, and that
while her vomiting has eased up in the last two days, she has
not been able to tolerate any POs including water, causing her
to miss all of her medications since [**2125-8-20**]. Pt also had loose
stools x 4 since yesterday. She had chills, but no fevers that
she knows of.
.
In the ED, she complained of substernal chest pain that felt
like pressure with no radiation. Vitals were: 97.7  123  144/72
28  100% on RA. Pt was started on IVF 200cc/hr, Insulin drip 6
units/hr with Q 1hr FS, was given [**Month/Day/Year **] 750 mg IV x 1, ASA
325 mg PO x 1, and Zofran 4 mg IV x 1. U cx and B cx were sent.
EKG showed demand ischemia (was faxed to Cards fellow for
review). CK and Trop sent. Kidney U/S showed mild pelviectasis.
CXR demonstrated no acute process.
.
ROS: Positive for SOB, worse with activity; unintentional weight
loss of [**5-26**] pounds in 3 months; worsening visual acuity; mild
abdominal pain in lower quadrants. Negative for melena,
hematochezia, chest pain, orthopnea, PND, lower extremity edema,
cough, urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes, headache,
rash or skin changes.
.

MEDICAL HISTORY: Diabetes Type 1, s/p renal transplant in [**2118**], with a history of
episodes of diabetic ketoacidosis.
Gastroparesis secondary to DM.
Hypertension.
Hypercholesterolemia.
Coronary artery disease with an ejection fraction of 55%
in [**2118**], MI x2 and a three-vessel CABG in [**2116**].
Left below the knee amputation in [**2118**].
Vascular procedures on the right lower extremity.
Heel ulcers due to diabetes, s/p bypass graft surgeries
Peripheral neuropathy
CVA x2.
S/p cholecystectomy
S/p cataract surgery
Depression.

MEDICATION ON ADMISSION: Cymbalta, hydromorphone, furosemide, prednisone, nitroglycerin,
Isordil, Plavix, Prograf, glyburide, tramadol, metoprolol,
CellCept, gabapentin, ASA, piroxicam, Lipitor, and insulin.

ALLERGIES: Demerol / Iodine / Augmentin

PHYSICAL EXAM: Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.

FAMILY HISTORY: Uncle with diabetes
Sister died of colon CA
Mother died of brain CA

SOCIAL HISTORY: The patient smokes [**3-20**] of a pack of [**State 622**] slim lights. Has
been smoking ~1ppd since age 14. No alcohol or IVDU.  She is
married.  She lives in [**Location **] with her husband, [**Name (NI) 1158**]. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Diabetes with ketoacidosis, type I [juvenile type], uncontrolled,Coronary atherosclerosis of autologous vein bypass graft,Kidney replaced by transplant,Hyposmolality and/or hyponatremia,Gastroparesis,Background diabetic retinopathy,Polyneuropathy in diabetes,Ulcer of other part of foot,Unspecified essential hypertension,Old myocardial infarction,Pure hypercholesterolemia,Depressive disorder, not elsewhere classified,Below knee amputation status,Other postprocedural status,Long-term (current) use of insulin,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}
