CHIEF COMPLAINT: Abdominal pain

PRESENT ILLNESS: This is a 44yo male with DM, bipolar disorder, possible seizure
disorder vs pseudoseizures, recent cholecystectomy/appendectomy,
who presents with persistent hypoglycemia. This started 1 week
ago with blood glucose in the 40s and multiple syncopal
episodes. He stopped his inuslin use 5 days ago, although an OMR
note mentions he took 4 units humalog on [**10-2**]. He has been
eating and drinking normally, with sugars transiently increasing
to 330, 130, but has otherwise remained hypoglycemic until
presentation. Has had nausea, subjective fevers, and sweats.
Also, he fell 2 days ago onto his right side, and has since had
RUQ pain at the site of his recent cholecystectomy.
.
Upon arrival to the ED, his vital signs were: 97.6 153/94 138 24
100%. He was given 4 amps of D50 and 3L of D5 1/2 NS. His sugars
have transiently improved to ~70-120s, but between glucose
boluses have fallen back to the 40s. In the ED, he had a
possible pseudoseizure x1-2min with stable vitals and FS 128.
Imaging including CXR and CT abdomen were unremarkable. His WBC
count is elevated, but labs were otherwise normal. He was given
2mg hydromorphone for abdominal pain. He also received
octreotide for his persistent hypoglycemia and is being admitted
to the ICU for close blood sugar monitoring. His most recent
vital signs are: 157/92 95 20 100%,2L FS 128.
.
Review of systems is positive for nausea/vomiting 2 days ago,
diaphoresis usually in context of low blood sugars, abdominal
pain extending from hypogastrium around R side to the back that
is not new, chronic low back pain that is currently 9.5/10.
Negative for chest pain/pressure, SOB, rhinorrhea, diarrhea.
.

MEDICAL HISTORY: 1. Hypertension
2. Type 2 Diabetes Mellitus - diagnosed at 40 years old, but
states that he was told for years that he had sugar in his urine

MEDICATION ON ADMISSION: 

ALLERGIES: Depakote / Keppra / Oxycodone / Paxil / Sulfacetamide / Zoloft /
Bactrim / Seroquel

PHYSICAL EXAM: GENERAL: Pleasant, appears uncomfortable in bed, mildly
diaphoreticD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2
physiologically split. No murmurs, rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally. No wheezes or
crackles
ABDOMEN: Appears mildly distended, soft, tender to palp in
hypogastrium to umbilicus extending to RUQ and R flank. NABS. No
HSM detected. Healing laparoscopy sites noted without erythema
or signs of infection.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. WWP.
SKIN: No rashes/lesions other than healing laparoscopy sites as
noted, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout, except R straight
leg raise limited by pain. Normal coordination, finger-nose
testing intact, sensation limited in upper extremities due to
h/o fractures/burns per pt, no asterixis, no pronator drift.
Gait assessment deferred
PSYCH: Listens and responds to questions appropriately,
pleasant. Appears anxious.

FAMILY HISTORY: Mom - epilepsy, stroke, HTN, DM.

SOCIAL HISTORY: He lives with his wife and step son (24) in [**Location (un) 14840**] and is a
retired [**Company 2318**] worker.  He has smoked 1 pack per day for over 30
years (current
smoker). States that he is not currently interested in quitting.
He is currently abstinent from alcohol since [**2175**]. He denies
IVDU.
Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Chronic pancreatitis,Bipolar disorder, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Posttraumatic stress disorder,Alcohol abuse, in remission,Lumbago,Other chronic pain,Other postprocedural status
DMII oth uncntrld,Chronic pancreatitis,Bipolar disorder NOS,Epilep NOS w/o intr epil,Posttraumatic stress dis,Alcohol abuse-in remiss,Lumbago,Chronic pain NEC,Post-proc states NEC
Name:  [**Known lastname 13043**],[**Known firstname 77**] C                  Unit No:   [**Numeric Identifier 13044**]

Admission Date:  [**2178-10-5**]              Discharge Date:   [**2178-10-8**]

Date of Birth:  [**2134-1-12**]             Sex:   M

Service: MEDICINE

Allergies:
Depakote / Keppra / Oxycodone / Paxil / Sulfacetamide / Zoloft /
Bactrim / Seroquel

Attending:[**First Name3 (LF) 9498**]
Addendum:
Patient's C-peptide and Insulin levels were both low. Patients
with excess exogenous Insulin have elevated blood Insulin and
suppressed C-peptide levels when hypoglycemic. The cause of his
hypoglycemia remains unclear but could be related to either lack
of glucagon secretion from chronic pancreatitis or factitious
disease. Insulinoma resuls in elevated C-Peptide levels and is
unlikely (negative MRCP).

Discharge Disposition:
Home

                             [**First Name4 (NamePattern1) **] [**Name8 (MD) **] MD [**Last Name (un) 9499**]

Completed by:[**2178-10-12**]

Admission Date:  [**2178-10-5**]              Discharge Date:   [**2178-10-8**]

Date of Birth:  [**2134-1-12**]             Sex:   M

Service: MEDICINE

Allergies:
Depakote / Keppra / Oxycodone / Paxil / Sulfacetamide / Zoloft /
Bactrim / Seroquel

Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Abdominal pain

Major Surgical or Invasive Procedure:
None

History of Present Illness:
This is a 44yo male with DM, bipolar disorder, possible seizure
disorder vs pseudoseizures, recent cholecystectomy/appendectomy,
who presents with persistent hypoglycemia. This started 1 week
ago with blood glucose in the 40s and multiple syncopal
episodes. He stopped his inuslin use 5 days ago, although an OMR
note mentions he took 4 units humalog on [**10-2**]. He has been
eating and drinking normally, with sugars transiently increasing
to 330, 130, but has otherwise remained hypoglycemic until
presentation. Has had nausea, subjective fevers, and sweats.
Also, he fell 2 days ago onto his right side, and has since had
RUQ pain at the site of his recent cholecystectomy.
.
Upon arrival to the ED, his vital signs were: 97.6 153/94 138 24
100%. He was given 4 amps of D50 and 3L of D5 1/2 NS. His sugars
have transiently improved to ~70-120s, but between glucose
boluses have fallen back to the 40s. In the ED, he had a
possible pseudoseizure x1-2min with stable vitals and FS 128.
Imaging including CXR and CT abdomen were unremarkable. His WBC
count is elevated, but labs were otherwise normal. He was given
2mg hydromorphone for abdominal pain. He also received
octreotide for his persistent hypoglycemia and is being admitted
to the ICU for close blood sugar monitoring. His most recent
vital signs are: 157/92 95 20 100%,2L FS 128.
.
Review of systems is positive for nausea/vomiting 2 days ago,
diaphoresis usually in context of low blood sugars, abdominal
pain extending from hypogastrium around R side to the back that
is not new, chronic low back pain that is currently 9.5/10.
Negative for chest pain/pressure, SOB, rhinorrhea, diarrhea.
.


Past Medical History:
1. Hypertension
2. Type 2 Diabetes Mellitus - diagnosed at 40 years old, but
states that he was told for years that he had sugar in his urine

3. PTSD [**1-19**] work on [**Company 2318**] and seeing co-workers injured/killed
4. Bipolar disorder
5. History of alcohol abuse (sober since [**2175**])
6. Chronic pancreatitis--likely alcoholic
Recently, he has undergone multiple procedures for pancreatitis

summarized below:
[**2178-2-11**]: ERCP - pancreatic duct sphincterotomy, stone removal,
stent placement
[**2178-3-23**]: ERCP - pancreatic duct stone removal, dilatation of 5mm

genu stricture, stent replacement
[**2178-4-12**]: ERCP - stent removed due to persistent/increased
R-sided pain
7. Seizure disorder (although recent suggestion of
pseudoseizures).
8. Diabetic gastroparesis, resolved now spontaneously
9. History of LUE DVT
10. Chronic low back pain
11. Hyperlipidemia
12. History of electrocution 15 years prior.
13. Patient states he was stabbed on 14 different occasions in
multiple places on his body.
14. S/p cholecystectomy and appendectomy [**8-26**]
15. H/o apnea on depakote requiring intubation


Social History:
He lives with his wife and step son (24) in [**Location (un) 14840**] and is a
retired [**Company 2318**] worker.  He has smoked 1 pack per day for over 30
years (current
smoker). States that he is not currently interested in quitting.
He is currently abstinent from alcohol since [**2175**]. He denies
IVDU.


Family History:
Mom - epilepsy, stroke, HTN, DM.

Physical Exam:
GENERAL: Pleasant, appears uncomfortable in bed, mildly
diaphoreticD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2
physiologically split. No murmurs, rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally. No wheezes or
crackles
ABDOMEN: Appears mildly distended, soft, tender to palp in
hypogastrium to umbilicus extending to RUQ and R flank. NABS. No
HSM detected. Healing laparoscopy sites noted without erythema
or signs of infection.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. WWP.
SKIN: No rashes/lesions other than healing laparoscopy sites as
noted, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout, except R straight
leg raise limited by pain. Normal coordination, finger-nose
testing intact, sensation limited in upper extremities due to
h/o fractures/burns per pt, no asterixis, no pronator drift.
Gait assessment deferred
PSYCH: Listens and responds to questions appropriately,
pleasant. Appears anxious.


Brief Hospital Course:
44 year old man with DM type 2, bipolar disorder, seizure
disorder vs pseudoseizures, and recent cholecystectomy with
appendectomy who presented with multiple syncopal episodes,
diaphoresis, and persistent hypoglycemia and was initially
admitted to the ICU for close glycemic monitoring. The patient
had a history of DM Type 2 on Humulog 2 units [**Hospital1 **] (unusual
treatment of diabetes!). Potential etiologies included increased
exogenous administration of insulin or hypoglycemic medications
(self induced specially in light of history of pseudoseizures),
increased endogenous production of insulin, or impaired
gluconeogenesis. He stated that he had not taken insulin for [**3-22**]
days and had prescription only for Humalog (short-acting
insulin). Surreptitious administration remained a strong
possibility. CT scan and old MRCP did not reveal tumor such as
an insulinoma. INR and liver enzymes were normal, which argued
against impaired gluconeogenesis in the liver.  Insulin,
C-peptide, BHB, and cortisol were sent. The insulin and
C-peptide were still pending at the time of discharge but his
cortisol stimulation test was completely normal. The patient was
discharge on Metformin [**Hospital1 **] to avoid hypoglycemia. He was
instructed not to take insulin and to follow up with [**Hospital **]
clinic for future management of his diabetes. The final
diagnosis depends on the C-peptide and Insulin levels but we
strongly suspected factitious disease. His fasting and
postprandial glucose remained normal or elevated during more
than 3 days monitoring on the hospital floor with out any
glucose supplementation. Total discharge time 45 minutes.



Discharge Medications:
1. Ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
11. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet
Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS).

12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Hypoglycemia

Discharge Condition:
Excellent

Discharge Instructions:
You had low blood sugars so please do not take any insulin
products. Please take Metformin to manage your diabetes. Please
follow up with [**Hospital **] clinic for future management of your
diabetes.

Followup Instructions:
[**Last Name (un) **] Follow Up.  Please call if questions ([**Telephone/Fax (1) 4847**]:
[**2178-10-23**] - 2:00 PM - Eye exam
[**2178-10-23**] - 2:30 PM - Appointment with Dr. [**Last Name (STitle) 81354**]
[**2178-10-23**] - 3:30 PM - Appointment with Nurse educator.
{'Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Chronic pancreatitis,Bipolar disorder, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Posttraumatic stress disorder,Alcohol abuse, in remission,Lumbago,Other chronic pain,Other postprocedural status'}


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: Abdominal pain

PRESENT ILLNESS: This is a 44yo male with DM, bipolar disorder, possible seizure
disorder vs pseudoseizures, recent cholecystectomy/appendectomy,
who presents with persistent hypoglycemia. This started 1 week
ago with blood glucose in the 40s and multiple syncopal
episodes. He stopped his inuslin use 5 days ago, although an OMR
note mentions he took 4 units humalog on [**10-2**]. He has been
eating and drinking normally, with sugars transiently increasing
to 330, 130, but has otherwise remained hypoglycemic until
presentation. Has had nausea, subjective fevers, and sweats.
Also, he fell 2 days ago onto his right side, and has since had
RUQ pain at the site of his recent cholecystectomy.
.
Upon arrival to the ED, his vital signs were: 97.6 153/94 138 24
100%. He was given 4 amps of D50 and 3L of D5 1/2 NS. His sugars
have transiently improved to ~70-120s, but between glucose
boluses have fallen back to the 40s. In the ED, he had a
possible pseudoseizure x1-2min with stable vitals and FS 128.
Imaging including CXR and CT abdomen were unremarkable. His WBC
count is elevated, but labs were otherwise normal. He was given
2mg hydromorphone for abdominal pain. He also received
octreotide for his persistent hypoglycemia and is being admitted
to the ICU for close blood sugar monitoring. His most recent
vital signs are: 157/92 95 20 100%,2L FS 128.
.
Review of systems is positive for nausea/vomiting 2 days ago,
diaphoresis usually in context of low blood sugars, abdominal
pain extending from hypogastrium around R side to the back that
is not new, chronic low back pain that is currently 9.5/10.
Negative for chest pain/pressure, SOB, rhinorrhea, diarrhea.
.

MEDICAL HISTORY: 1. Hypertension
2. Type 2 Diabetes Mellitus - diagnosed at 40 years old, but
states that he was told for years that he had sugar in his urine

MEDICATION ON ADMISSION: 

ALLERGIES: Depakote / Keppra / Oxycodone / Paxil / Sulfacetamide / Zoloft /
Bactrim / Seroquel

PHYSICAL EXAM: GENERAL: Pleasant, appears uncomfortable in bed, mildly
diaphoreticD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2
physiologically split. No murmurs, rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally. No wheezes or
crackles
ABDOMEN: Appears mildly distended, soft, tender to palp in
hypogastrium to umbilicus extending to RUQ and R flank. NABS. No
HSM detected. Healing laparoscopy sites noted without erythema
or signs of infection.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. WWP.
SKIN: No rashes/lesions other than healing laparoscopy sites as
noted, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout, except R straight
leg raise limited by pain. Normal coordination, finger-nose
testing intact, sensation limited in upper extremities due to
h/o fractures/burns per pt, no asterixis, no pronator drift.
Gait assessment deferred
PSYCH: Listens and responds to questions appropriately,
pleasant. Appears anxious.

FAMILY HISTORY: Mom - epilepsy, stroke, HTN, DM.

SOCIAL HISTORY: He lives with his wife and step son (24) in [**Location (un) 14840**] and is a
retired [**Company 2318**] worker.  He has smoked 1 pack per day for over 30
years (current
smoker). States that he is not currently interested in quitting.
He is currently abstinent from alcohol since [**2175**]. He denies
IVDU. 

### Response:
{'Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Chronic pancreatitis,Bipolar disorder, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Posttraumatic stress disorder,Alcohol abuse, in remission,Lumbago,Other chronic pain,Other postprocedural status'}
