<s>[INST] Hi I have diabetes and achalasha. Have reflux problems. Insulin resistant. Narrowed esphogus.high sugar levels rage from 300 to400. Cannot get under control. Recently have a fast pulse rate about 118 at rest. Swollen painful hands. Swelling in hands and feet with numbness in feet. Question is when do go to the er? How high a pulse rate should I worry about? I have a typical chest pain associated with the achalashia. Don't how to tell if having heart problems. I am 53 & a woman. Please advise [/INST] Dear madam, greetings from HCM.. Your sugar levels are very high .. By seeing your symptoms .. I feel that you need to get evaluated and change your medications .. Please get HbA1c, lipid profile, thyroid profile  and microalbuminuria done soon ... And later meet us or your doctor for change in diabetic medications ... You need to change lifestyle ... Medications alone will not be enough in diabetic s .. Take care and do contact us for more questions ... Thank you .... </s>