allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain & blurry vision major surgical or invasive procedure: none history of present illness: ms. is a 45yo woman with a history of dm type i on home lantus and sliding scale who presented with abdominal pain & blurry vision. one day prior to admission, pt developed photophobia (tv bothering her eyes), blurry vision, sharp abdominal pain, shortness of breath, chest tightness & unsteady gait. also, (+) polyuria, polydypsia, nausea & vomiting. pt's family called ems & brought her to . . in , pt was found to have blood glucose in 800's. abg 6.9/17/60 hco3 5. ekg showed changes that were initially concerning for stemi and pt started on heparin gtt because of this. cardiology reportedly saw pt & reviewed ekg in ed and felt that pt was not having acs and that heparin was not indicated. (ekg changes actually j point elevation in v2-v4, which were unchanged from previous ekg. additionaly, other changes, including st depressions 1-2mm in i, v5, v6; twi in i, avl, biphasic t waves in v5-v6, were all unchanged from previous ekgs.) past medical history: 1. dm type i; a1c 8.2 in ; no h/o dka, but multiple ed visits for hypoglyemia 2. htn 3. depression 4. bartholin gland abscess s/p i and d social history: lives with her children. smokes 1/3ppd, drinks 1 beer/day. no known std's, has boyfriend. family history: history of htn; no dm, cad or cancer. physical exam: vs: tc 98.5f tmax 99.1f hr 69 (69-111) bp 176/97 (131-182/65-93) rr 19 100%ra gen: awake, alert, pleasant, sitting up eating dinner, nad heent: perrl, eomi, anicteric sclera, op clear, mmm, poor dentition neck: supple, no jvd cv: rrr, normal s1, s2 pulm: ctab abd: normoactive bowel sounds, soft, nd/nt ext: wwp, no edema pertinent results: admit labs: 07:05am glucose-848* urea n-38* creat-2.4*# sodium-126* potassium-greater th chloride-83* total co2-5* 07:05am wbc-31.2*# hct-39.0 12:57pm alt(sgpt)-15 ast(sgot)-23 ck(cpk)-276* alk phos-77 amylase-63 tot bili-0.1 03:57pm cerebrospinal fluid (csf) wbc-1 rbc-1* polys-2 bands-0 lymphs-70 monos-28 protein-28 glucose-345 12:57pm ck-mb-15* mb indx-5.4 ctropnt-0.08* 09:20pm ck-mb-21* mb indx-4.2 ctropnt-0.13* 04:01am ctropnt-0.09* . chest ap: the heart and mediastinum are normal. the lung fields are clear. the costophrenic angles are sharp. there is no evidence of failure or infiltrate. impression: normal chest . echo: ef > 75%. mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. no valvular pathology or pathologic flow identified. . stres mibi: tolerated 7.5 minutes of protocol without symptoms. resting ekg is notable for chronic anteroseptal q waves and left ventricular hypertrophy with stt wave abnormalities affecting the inferior leads and v4-v6. ekg during stress demonstrated frequent vpb's. the additional st segment changes seen during exercise and in recovery period are uninterpretable for ischemia in the presence of baseline abnormalities. heart rate response was adequate, achieving 85% of maximum predicted heart rate and a rate-pressure product of . blood pressure was hypertensive reaching 220/100 at peak exercise. impression: no angina-type symptoms with uninterpretable ekg for ischemia. below average exercise tolerance for age. resting hypertension exacerbated with exercise. interpretation: the image quality is good. left ventricular cavity size is normal. resting and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. gated images reveal normal wall motion. the calculated left ventricular ejection fraction is 65%. impression: normal myocardial perfusion study. brief hospital course: 45f with h/o type i diabetes mellitus who presents with dka. . # dka - dka likely resulted from medication non-compliance. pt reports to infrequent fsbs checks and had last checked her fsbs more than 36 hours prior to admission. she reports fsbs mostly running in high-200's. hgba1c nearly 12. infectious etiologies also considered as cause of dka although her cxr, ua, blood cultures and lp were all negative. the pt may have had cardiac event in the setting of dka; however, it is not thought that her dka was triggered by acs. her enzymes were elevated: troponin to 0.13 and ck index positive. the pt was treated with insulin drip and ivf. she was transitioned to humalog sliding scale and lantus 30units qpm. was consulted. the pt will follow-up with them as an outpatient. . # elevated cardiac enzymes: on presentation to the ed, the pt was found to have elevated ce's as well as ekg changes that were thought to be st elevations. because of this, she was started on a heparin gtt in the ed. the pt was reportedly seen by cardiology in the ed, who reportedly felt that the pt was not having acs, though there is no note documenting this. on further review, her ekg changes were interpreted as j-point elevations (not st elevations) and were noted to be old. her heparin was discontinued, as she was not felt to be having acute coronary syndrome. while in the micu, the pt had additional sets of enzymes checked. her enzymes peaked at a troponin of 0.13, ck of 502 and ck index of 5.4. the pt was treated with b-blocker, lisinopril, & aspirin. after being called out of the micu, the floor team consulted cardiology regarding her enzyme elevation and need for further evaluation. the cardiology team felt that the pt had in fact had an event based on her enzymes. given that she was >24 hours out from the event, catheterization was not undertaken. rather, the pt underwent a stress mibi, which showed normal myocardial perfusion study and calculated lvef of 65%. based on these results, the pt was treated medically with b-blocker, acei and aspirin. cardiology recommended a statin as well. this was not started as her pcp preferred to start it as an outpatient given concern that the discharging her with too many new medications might lead to non-compliance w/ them. (the pt has had medication compliance issues in past.) thus, a statin will likely be started as an outpatient once the pt has complied with her insulin regimen, which is the most critical of her medications at present. . # htn - metoprolol and lisinopril were titrated for bp & hr control. . # mental status changes - resolved following treatment of dka. likely the result of toxic-metabolic causes in setting of dka & acidemia. unlikely infection given all cultures negative. lp unremarkable. . # acute renal failure - due to dka and related dehydration causing prerenal azotemia. resolved with hydration. . # depression: pt seen by social work. they recommended she resume her outpatient therapy/counseling. pt planning on restarting counseling at following discharge. . # ppx - sc heparin, ppi . # code - full medications on admission: -lisinopril 40mg daily -lantus 40units daily -hiss discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 3. humalog 100 unit/ml solution sig: per sliding scale subcutaneous brkfast, lunch, dinner, bedtime. disp:*4 vials* refills:*5* 4. lantus 100 unit/ml solution sig: thirty (30) units subcutaneous at bedtime. disp:*2 vials* refills:*5* 5. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 6. insulin please take 34u lantus insulin every night. please also check your blood glucose four time/day and take humalog according to the humalog insulin sliding scale. discharge disposition: home discharge diagnosis: primary: diabetic ketoacidosis hypertension . secondary: depression discharge condition: good discharge instructions: you were admitted to the hospital with extremely elevated blood sugar levels. this happened because you were not taking your insulin as prescribed. as well, your diet likely contributed to this as well. . please contact dr. at or go to the emergency room if you develop fever, chills, abdominal pain, chest pain, shortness of breath, or any other concerning symptoms or change in your health. . please take your medications as prescribed. you will be starting on a new blood pressure medication called metoprolol. you should take this twice a day, once in the morning and once in the evening. . your insulin and lantus regimen has been changed. please follow the new sliding scale that you got at the time of discharge. followup instructions: you have the following appointments scheduled, please attend them: . please follow up at on (monday) at 9am with . please make a follow up appointment at clinic when you are there on monday. please see dr. at on (next thursday) at 1pm. Procedure: Spinal tap Incision of lung Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Acute kidney failure, unspecified Dehydration Rhabdomyolysis Diabetes with ketoacidosis, type I [juvenile type], uncontrolled