CHIEF COMPLAINT: Unresponsiveness/hypoglycemia

PRESENT ILLNESS: This is a 43yoM with history MEN1 s/p splenectomy and subtotal
pancreatectomy who presents after being found unresponsive.
Patient was intubated on arrival to MICU so history was obtained
from partner. Pt apparently was feeling more depressed over last
2 weeks. Yesterday apparently pt and partner got into an
argument. Pt was last seen at 10am on [**11-27**]. Pt was contact[**Name (NI) **]
via phone at 12pm on [**11-27**]. Patient was then found at home at
730pm and was unresponsive. Blood sugar was taken which was
"critically low." EMS was called who also found pt with low
blood sugar. Pt was given amp of D50 as well as narcan without
improvement of MS and was then intubated for "airway
protection."
.
In [**Name (NI) **], pt was found to be continually hypoglycemic. Started on
D10 gtt. Head CT was negative. Pt admitted for further work-up
.
In MICU, pt was intubated/sedated continued on glucose drip
until blood sugars had normalized and patient's mental status
had improved.  Post-extubation psychiatry was consulted given
patient's partner's concern for worsening of his depression a
sectioned 12 was placed and the patient was given a 1:1 sitter.
Patient now states that he had several appointments on the day
of admission adn was unable to eat and that was why his blood
sugar was low.  Has had several episodes of hypoglycemia in the
past, but never this severe.
.
Review of systems:  Patient currently feeling well with no HA,
dizziness, thirst, dysuria, change in bowel or bladder habits,
CP, SOB, abdominal pain nausea or vomitting.

MEDICAL HISTORY: PAST MEDICAL & SURGICAL HISTORY:
1. multiple endocrine neoplasia (type 1) - genetic testing
confirmed per medical records
2. metastatic gastrinoma, Zollinger-[**Doctor Last Name 9480**] syndrome
3. insulin dependent type 1 diabetes (diagnosed at age 16, h/o
DKA with hospitalizations)
4. stage II CKD (diabetic nephropathy) - baseline creatinine
1.4-1.6
5. s/p parathyroidectomy (x 3, [**2172**]-[**2176**]) with re-implantation
to arm
6. GERD/gastritis
7. unilateral right adrenalectomy (for pheochromocytoma with
adrencortical hyperplasia, [**11/2174**])
8. sub-total pancreatectomy (MD [**Location (un) 4223**] with pathology
demonstrating islet cell tumor, [**2174**])
9. s/p splenectomy ([**11/2174**])
10. depression

MEDICATION ON ADMISSION: Per OMR
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays(s) in each
nostril daily Can decrease to 1 spray daily in each nostril once
symptoms controlled
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth daily at
bedtime
INSULIN GLARGINE [LANTUS] -  (Dose adjustment - no new Rx) - 100
unit/mL Solution - 15 units SC every AM
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - per sliding
scale three times daily as directed
KETOTIFEN FUMARATE - 0.025 % Drops - 1 drop(s) in the affected
eye(s) twice a day as needed for allergy symptoms
LAMOTRIGINE - 100 mg Tablet - 1 Tablet(s) by mouth daily
LEVOTHYROXINE - 150 mcg Tablet - 9.5 Tablet(s) by mouth weekly
LIPASE-PROTEASE-AMYLASE [CREON] - 24,000 unit-[**Unit Number **],000
unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) - [**7-23**] Capsule(s) by mouth up
to 6 times daily before meals and snacks as directed: 8 caps
before meals 6 before snacks
LORAZEPAM - 1 mg Tablet - 1.5 Tablet(s) by mouth four times
daily
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth twice a day - No Substitution
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for insomnia ; may take additional dose if needed after
one hour

ALLERGIES: Levaquin in D5W

PHYSICAL EXAM: Physical Exam on Arrival to MICU
General Appearance: No acute distress, Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes :
)
Abdominal: Soft, Bowel sounds present, Tender: mildly,
throughout
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin:  Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed

FAMILY HISTORY: His father had an [**Name (NI) 58955**] and subsequent gastrinoma.  He denies
any other family history of malignancy.

SOCIAL HISTORY: He normally lives in [**Location 3615**], but has been staying with his
partner in [**Name (NI) 86**].  He smoked approximately two packs per week
from [**2172**] to [**2182**] and quit in [**2182**].  He denies any alcohol use.
He denies IV drug use.  He does smoke marijuana regularly.
Poisoning by insulins and antidiabetic agents,Diabetes with other coma, type I [juvenile type], not stated as uncontrolled,Major depressive affective disorder, recurrent episode, severe, without mention of psychotic behavior,Multiple endocrine neoplasia [MEN] type I,Other specified diseases of pancreas,Polyneuropathy in diabetes,Abnormality of secretion of gastrin,Accidental poisoning by hormones and synthetic substitutes,Long-term (current) use of insulin,Background diabetic retinopathy,Family history of multiple endocrine neoplasia [MEN] syndrome,Chronic kidney disease, Stage II (mild),Other acquired absence of organ,Acquired partial absence of pancreas,Personal history of tobacco use,Other postablative hypothyroidism,Unspecified cataract,Personal history of other specified diseases,History of physical abuse
Poison-insulin/antidiab,DMI o cm nt st uncntrld,Recur depr psych-severe,Mult endo neoplas type I,Pancreatic disease NEC,Neuropathy in diabetes,Abnorm secretion gastrin,Acc poison-hormones,Long-term use of insulin,Diabetic retinopathy NOS,Fam hx MEN syndrome,Chro kidney dis stage II,Acq absence of organ NEC,Acq part absnce pancreas,History of tobacco use,Postablat hypothyr NEC,Cataract NOS,Hx diseases NEC,Hx of physical abuse
Admission Date:  [**2188-11-27**]              Discharge Date:   [**2188-12-2**]

Date of Birth:  [**2144-12-16**]             Sex:   M

Service: MEDICINE

Allergies:
Levaquin in D5W

Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
Unresponsiveness/hypoglycemia

Major Surgical or Invasive Procedure:
-Mechanical Ventilation


History of Present Illness:
This is a 43yoM with history MEN1 s/p splenectomy and subtotal
pancreatectomy who presents after being found unresponsive.
Patient was intubated on arrival to MICU so history was obtained
from partner. Pt apparently was feeling more depressed over last
2 weeks. Yesterday apparently pt and partner got into an
argument. Pt was last seen at 10am on [**11-27**]. Pt was contact[**Name (NI) **]
via phone at 12pm on [**11-27**]. Patient was then found at home at
730pm and was unresponsive. Blood sugar was taken which was
"critically low." EMS was called who also found pt with low
blood sugar. Pt was given amp of D50 as well as narcan without
improvement of MS and was then intubated for "airway
protection."
.
In [**Name (NI) **], pt was found to be continually hypoglycemic. Started on
D10 gtt. Head CT was negative. Pt admitted for further work-up
.
In MICU, pt was intubated/sedated continued on glucose drip
until blood sugars had normalized and patient's mental status
had improved.  Post-extubation psychiatry was consulted given
patient's partner's concern for worsening of his depression a
sectioned 12 was placed and the patient was given a 1:1 sitter.
Patient now states that he had several appointments on the day
of admission adn was unable to eat and that was why his blood
sugar was low.  Has had several episodes of hypoglycemia in the
past, but never this severe.
.
Review of systems:  Patient currently feeling well with no HA,
dizziness, thirst, dysuria, change in bowel or bladder habits,
CP, SOB, abdominal pain nausea or vomitting.

Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. multiple endocrine neoplasia (type 1) - genetic testing
confirmed per medical records
2. metastatic gastrinoma, Zollinger-[**Doctor Last Name 9480**] syndrome
3. insulin dependent type 1 diabetes (diagnosed at age 16, h/o
DKA with hospitalizations)
4. stage II CKD (diabetic nephropathy) - baseline creatinine
1.4-1.6
5. s/p parathyroidectomy (x 3, [**2172**]-[**2176**]) with re-implantation
to arm
6. GERD/gastritis
7. unilateral right adrenalectomy (for pheochromocytoma with
adrencortical hyperplasia, [**11/2174**])
8. sub-total pancreatectomy (MD [**Location (un) 4223**] with pathology
demonstrating islet cell tumor, [**2174**])
9. s/p splenectomy ([**11/2174**])
10. depression


Social History:
He normally lives in [**Location 3615**], but has been staying with his
partner in [**Name (NI) 86**].  He smoked approximately two packs per week
from [**2172**] to [**2182**] and quit in [**2182**].  He denies any alcohol use.
He denies IV drug use.  He does smoke marijuana regularly.


Family History:
His father had an [**Name (NI) 58955**] and subsequent gastrinoma.  He denies
any other family history of malignancy.


Physical Exam:
Physical Exam on Arrival to MICU
General Appearance: No acute distress, Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes :
)
Abdominal: Soft, Bowel sounds present, Tender: mildly,
throughout
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin:  Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed

ON DISCHARGE:
Vitals:  97.3, 134/93, 70, 18, 16
I/O: NR
General: A and ox3
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: non-focal.

Pertinent Results:
[**2188-11-27**] 09:49PM BLOOD WBC-14.7*# RBC-4.50* Hgb-13.1* Hct-39.8*
MCV-88 MCH-29.1 MCHC-32.9 RDW-14.3 Plt Ct-393
ADMISSION LABS:
[**2188-11-27**] 09:49PM BLOOD Neuts-76.2* Lymphs-14.1* Monos-7.6
Eos-1.4 Baso-0.6
[**2188-11-27**] 09:49PM BLOOD PT-13.1 PTT-25.5 INR(PT)-1.1
[**2188-11-27**] 09:49PM BLOOD Glucose-16* UreaN-21* Creat-1.7* Na-143
K-3.9 Cl-110* HCO3-19* AnGap-18
[**2188-11-27**] 09:49PM BLOOD ALT-30 AST-33 AlkPhos-230* TotBili-0.2
[**2188-11-27**] 09:49PM BLOOD Calcium-10.2 Phos-2.5* Mg-1.9
[**2188-11-27**] 09:42PM BLOOD Lactate-2.7*
[**2188-11-27**] 09:49PM BLOOD Lipase-9
[**2188-11-28**] 01:23AM BLOOD TSH-0.54
[**2188-11-28**] 01:23AM BLOOD Cortsol-18.8
[**2188-11-28**] 01:23AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG

[**2188-11-28**] 12:48AM BLOOD C-PEPTIDE-PND

[**2188-11-27**]
- CT head w/o contrast: No acute intracranial hemorrhage, edema,
mass effect or major vascular territorial infarction. [**Doctor Last Name **]-white
matter differentiation is preserved. There is no shift of
normally midline structures. The ventricles and sulci are normal
in size and configuration. There is no fracture. Imaged
paranasal sinuses and mastoid air cells demonstrate mucus
retention cyst or polyp in the floor of the right maxillary
sinus is not completely imaged.  Right parietal scalp lipoma is
again noted.
IMPRESSION: No acute intracranial process.

DISCHARGE LABS
[**2188-11-30**] 06:40AM BLOOD WBC-10.2 RBC-4.28* Hgb-12.2* Hct-37.5*
MCV-88 MCH-28.5 MCHC-32.5 RDW-14.4 Plt Ct-388
[**2188-12-1**] 06:33AM BLOOD Glucose-155* UreaN-20 Creat-1.7* Na-138
K-5.1 Cl-103 HCO3-26 AnGap-14
[**2188-11-29**] 03:34AM BLOOD ALT-20 AST-21 AlkPhos-210* TotBili-0.3
[**2188-12-1**] 06:33AM BLOOD Calcium-10.3 Phos-3.8 Mg-1.9
[**2188-11-28**] 01:23AM BLOOD TSH-0.54
[**2188-11-28**] 01:23AM BLOOD Cortsol-18.8

Brief Hospital Course:
43 yoM with history of severe depression, MEN 1a s/p
pancreatectomy who presents after unresponsive episode.

# Unresponsive episode: patient was found unconscious at home by
his partner, EMS was called and found to have a SBG in the 40s
was given dextrose and naracan, intubated and brought to the ED.
 Patient was admitted to the ICU where he continued to recieve
dextrose gtt until alert enough for extubation 24 hours later.
Patient was transfered to the floor where he was followed by
[**Last Name (un) 387**] consult service and had his basal glargine titrated to 12
units QAM with a tighter humalog sliding scale.  Thyroid,
coritisol and c-peptide (pending) were sent as patient had
history of MEN1 all of which were normal.  Patient reports
hypoglycemia was unitentional and from forgetting to eat.
Psychiatry was consulted and felt patient lacked appropriate
insight into his illness and were concerned that his actions may
have been suicidial in intent.  Patient was secontioned 12 and
was to be admitted to inpatient psychiatry.  Patient was alert
and oriented and medically clear prior to transfer to
psycihatry.
.
# Leukocytosis: felt to be stress demargination and resolved by
MICU admission.
.
# Depression: Patient has signifcant history of depression under
outpatient management and past history of suicide attempts.
Psychiatry was consulted out of concern that patient's
hypoglycemia was intentional.  Patient continues to have an
increased level of risk given his demonstrating impaired
judgment and impulsiveness resulting in serious medical
consequences, his previous history of suicide
attempt, ongoing unchanged psychosocial stressors, and expressed
concerns about safety outside of the hospital by his outpatient
providers.  Patient was section 12'd and to be admitted to
inpaitent psychiatry.
.
# Diabetes:  Patient was seen by inpatient [**Last Name (un) **] service and
had his basal galargine titrated to 12 units daily with an
uptitrated sliding scale.  Paitent will continue to have [**Last Name (un) 387**]
consultation while in inpatient psychiatry and was medically
cleared for transfer to psychiatry.  His most reccent sliding
scale was
Glargine 12 units SC every AM
Humalog sliding scale to as below:
          Breakfast    Lunch     Dinner
71-110       4           5         5
111-150      5           6         6
151-200      7           7         7
[**Telephone/Fax (2) 58956**]51-400      9           9         9
>400 call your doctor
.
# Vomitting:  patient with 2 episodes of vomitting intact food
several hours after eating post extubation.  This was felt to be
from possible gastroperesis though patient without a known
history of these symptoms.  He was treated with Zofran PRN with
good effect and medically cleared for inpatient psychiatric
admission.
.
# MEN1:  patient with history of pheochromcytoma, gastrinoma and
hyperparathyroidism diagnosed as MEN1 syndrome status
post-pancreatectomy and spleenectomy.  Patient has insulin
diabetes as discussed above as well as peristantly elevated
gastrin levels.  he was maintained on his home regimen of
pantoparazole 40 mg [**Hospital1 **] with good effect and medically clear for
inpatient psychiatric admission.
.
# HYPOTHYROIDISM: secondary to idodine ablation of grave's
disease, stable on home regimen of levothyroxine 150 mcg for 9.5
doses weekly.
.
TRANSITIONAL ISSUES:
-patient is not on Ace/[**Last Name (un) **] for diabetic nephropathy due to
history of hyperkalemia - should followup as outpatient with his
nephrologist.
-consider having gastric emptying study to evaluate for
gastroperesis.

Medications on Admission:
Per OMR
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays(s) in each
nostril daily Can decrease to 1 spray daily in each nostril once
symptoms controlled
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth daily at
bedtime
INSULIN GLARGINE [LANTUS] -  (Dose adjustment - no new Rx) - 100
unit/mL Solution - 15 units SC every AM
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - per sliding
scale three times daily as directed
KETOTIFEN FUMARATE - 0.025 % Drops - 1 drop(s) in the affected
eye(s) twice a day as needed for allergy symptoms
LAMOTRIGINE - 100 mg Tablet - 1 Tablet(s) by mouth daily
LEVOTHYROXINE - 150 mcg Tablet - 9.5 Tablet(s) by mouth weekly
LIPASE-PROTEASE-AMYLASE [CREON] - 24,000 unit-[**Unit Number **],000
unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) - [**7-23**] Capsule(s) by mouth up
to 6 times daily before meals and snacks as directed: 8 caps
before meals 6 before snacks
LORAZEPAM - 1 mg Tablet - 1.5 Tablet(s) by mouth four times
daily
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth twice a day - No Substitution
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for insomnia ; may take additional dose if needed after
one hour

Medications - OTC
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] -   Strip - to be
used as directed up to five times daily
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 3 Capsule(s)
by mouth daily; to replace previous Vit D prescriptions


Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Ten (10) Capsule, Delayed
Release(E.C.) PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache.
4. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lorazepam 1 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day)
as needed for anxiety.
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. insulin glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: 12 units daily in the AM.
9. dextrose 50% in water (D50W)     Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.

10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
11. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed for nausea.
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
13. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
14. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
15. insulin glargine 100 unit/mL Solution Sig: One (1) 1
Subcutaneous once a day: 12 units daily.
16. levothyroxine 75 mcg Tablet Sig: Three (3) Tablet PO 1X/WEEK
(SA).
17. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO
2X/WEEK (MO,WE).
18. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,FR).
19. Humalog 100 unit/mL Solution Sig: One (1)  Subcutaneous
three times a day: CHANGE Glargine 15 units SC every AM to 12
units SC every AM
CHANGE Humalog sliding scale to as below:
          Breakfast    Lunch     Dinner
71-110       4           5         5
111-150      5           6         6
151-200      7           7         7
[**Telephone/Fax (2) 58956**]51-400      9           9         9
>400 call your doctor.


Discharge Disposition:
Extended Care

Facility:
 [**Hospital1 **] 4

Discharge Diagnosis:
PRIMARY:
Hypoglycemia

SECONDARY:
-MEN-1 status post surgical excision of gastrinomas, parathyroid
resection, right adrenalectomy for pheochromocytoma, splenectomy
in [**2174**],
-type 1 diabetes,
-pancreatic insufficiency on enzyme supplements
-[**Doctor Last Name **] disease s/p radioiodine ablation
-Hypothyroidism
-cataracts


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


Discharge Instructions:
Mr. [**Known lastname 58871**],

It was a pleasure taking care of you while you were in the
hospital. You were admitted for severe hypoglycemia requiring
intubation and a stay in the intensive care unit.  Your blood
sugar was aggressively treated we were able to stabilize you and
discharge you from the ICU.  You were seen by our diabetes
experts who have ajusted your sliding scale for better glucose
control.  You were also seen by our psychiatrists who felt you
should be observed in the inpatient setting for the time being.

The following changes were made to your medications:
CONTINUE Fluticasone - 50 mcg 2 sprays(s) in each  nostril daily

CONTINUE Gabapentin 300 mg before bed
CONTINUE Ketotifen 0.025% 1 drop(s) in the affected eye(s) twice
a day as needed for allergy symptoms
CONTINUE Lamotrigine 100 mg daily
CONTINUE Levothyroxine 150 mcg, 9.5 Tablet(s) by mouth weekly
CONTINUE Creon [**7-23**] Capsule up  to 6 times daily before meals and
snacks as directed: 8 caps before meals 6 before snacks
CONTINUE Lorazeopam 1 mg - 1.5 Tablet(s) by mouth four times
daily
CONTINUE Pantoprazole - 40 mg Tablet, Delayed Release twice
daily
CONTINUE Trazodone 50 mg as needed for insomnia
CHANGE Glargine 15 units SC every AM to 12 units SC every AM
CHANGE Humalog sliding scale to as below:
          Breakfast    Lunch     Dinner
71-110       4           5         5
111-150      5           6         6
151-200      7           7         7
[**Telephone/Fax (2) 58956**]51-400      9           9         9
>400 call your doctor

Followup Instructions:
Department: PSYCHIATRY
When: TUESDAY [**2188-12-2**] at 4:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST     Best Parking: Main Garage

Department: [**Location (un) 1947**]
When: WEDNESDAY [**2188-12-3**] at 10:40 AM
With: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: [**Hospital3 249**]
When: MONDAY [**2188-12-8**] at 9:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Poisoning by insulins and antidiabetic agents,Diabetes with other coma, type I [juvenile type], not stated as uncontrolled,Major depressive affective disorder, recurrent episode, severe, without mention of psychotic behavior,Multiple endocrine neoplasia [MEN] type I,Other specified diseases of pancreas,Polyneuropathy in diabetes,Abnormality of secretion of gastrin,Accidental poisoning by hormones and synthetic substitutes,Long-term (current) use of insulin,Background diabetic retinopathy,Family history of multiple endocrine neoplasia [MEN] syndrome,Chronic kidney disease, Stage II (mild),Other acquired absence of organ,Acquired partial absence of pancreas,Personal history of tobacco use,Other postablative hypothyroidism,Unspecified cataract,Personal history of other specified diseases,History of physical abuse'}


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: Unresponsiveness/hypoglycemia

PRESENT ILLNESS: This is a 43yoM with history MEN1 s/p splenectomy and subtotal
pancreatectomy who presents after being found unresponsive.
Patient was intubated on arrival to MICU so history was obtained
from partner. Pt apparently was feeling more depressed over last
2 weeks. Yesterday apparently pt and partner got into an
argument. Pt was last seen at 10am on [**11-27**]. Pt was contact[**Name (NI) **]
via phone at 12pm on [**11-27**]. Patient was then found at home at
730pm and was unresponsive. Blood sugar was taken which was
"critically low." EMS was called who also found pt with low
blood sugar. Pt was given amp of D50 as well as narcan without
improvement of MS and was then intubated for "airway
protection."
.
In [**Name (NI) **], pt was found to be continually hypoglycemic. Started on
D10 gtt. Head CT was negative. Pt admitted for further work-up
.
In MICU, pt was intubated/sedated continued on glucose drip
until blood sugars had normalized and patient's mental status
had improved.  Post-extubation psychiatry was consulted given
patient's partner's concern for worsening of his depression a
sectioned 12 was placed and the patient was given a 1:1 sitter.
Patient now states that he had several appointments on the day
of admission adn was unable to eat and that was why his blood
sugar was low.  Has had several episodes of hypoglycemia in the
past, but never this severe.
.
Review of systems:  Patient currently feeling well with no HA,
dizziness, thirst, dysuria, change in bowel or bladder habits,
CP, SOB, abdominal pain nausea or vomitting.

MEDICAL HISTORY: PAST MEDICAL & SURGICAL HISTORY:
1. multiple endocrine neoplasia (type 1) - genetic testing
confirmed per medical records
2. metastatic gastrinoma, Zollinger-[**Doctor Last Name 9480**] syndrome
3. insulin dependent type 1 diabetes (diagnosed at age 16, h/o
DKA with hospitalizations)
4. stage II CKD (diabetic nephropathy) - baseline creatinine
1.4-1.6
5. s/p parathyroidectomy (x 3, [**2172**]-[**2176**]) with re-implantation
to arm
6. GERD/gastritis
7. unilateral right adrenalectomy (for pheochromocytoma with
adrencortical hyperplasia, [**11/2174**])
8. sub-total pancreatectomy (MD [**Location (un) 4223**] with pathology
demonstrating islet cell tumor, [**2174**])
9. s/p splenectomy ([**11/2174**])
10. depression

MEDICATION ON ADMISSION: Per OMR
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays(s) in each
nostril daily Can decrease to 1 spray daily in each nostril once
symptoms controlled
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth daily at
bedtime
INSULIN GLARGINE [LANTUS] -  (Dose adjustment - no new Rx) - 100
unit/mL Solution - 15 units SC every AM
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - per sliding
scale three times daily as directed
KETOTIFEN FUMARATE - 0.025 % Drops - 1 drop(s) in the affected
eye(s) twice a day as needed for allergy symptoms
LAMOTRIGINE - 100 mg Tablet - 1 Tablet(s) by mouth daily
LEVOTHYROXINE - 150 mcg Tablet - 9.5 Tablet(s) by mouth weekly
LIPASE-PROTEASE-AMYLASE [CREON] - 24,000 unit-[**Unit Number **],000
unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) - [**7-23**] Capsule(s) by mouth up
to 6 times daily before meals and snacks as directed: 8 caps
before meals 6 before snacks
LORAZEPAM - 1 mg Tablet - 1.5 Tablet(s) by mouth four times
daily
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth twice a day - No Substitution
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for insomnia ; may take additional dose if needed after
one hour

ALLERGIES: Levaquin in D5W

PHYSICAL EXAM: Physical Exam on Arrival to MICU
General Appearance: No acute distress, Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes :
)
Abdominal: Soft, Bowel sounds present, Tender: mildly,
throughout
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin:  Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed

FAMILY HISTORY: His father had an [**Name (NI) 58955**] and subsequent gastrinoma.  He denies
any other family history of malignancy.

SOCIAL HISTORY: He normally lives in [**Location 3615**], but has been staying with his
partner in [**Name (NI) 86**].  He smoked approximately two packs per week
from [**2172**] to [**2182**] and quit in [**2182**].  He denies any alcohol use.
He denies IV drug use.  He does smoke marijuana regularly. 

### Response:
{'Poisoning by insulins and antidiabetic agents,Diabetes with other coma, type I [juvenile type], not stated as uncontrolled,Major depressive affective disorder, recurrent episode, severe, without mention of psychotic behavior,Multiple endocrine neoplasia [MEN] type I,Other specified diseases of pancreas,Polyneuropathy in diabetes,Abnormality of secretion of gastrin,Accidental poisoning by hormones and synthetic substitutes,Long-term (current) use of insulin,Background diabetic retinopathy,Family history of multiple endocrine neoplasia [MEN] syndrome,Chronic kidney disease, Stage II (mild),Other acquired absence of organ,Acquired partial absence of pancreas,Personal history of tobacco use,Other postablative hypothyroidism,Unspecified cataract,Personal history of other specified diseases,History of physical abuse'}
