CHIEF COMPLAINT: Suicide attempt with tylenol overdose

PRESENT ILLNESS: 45 y/o female with schizoaffective d/o transferred from [**Hospital 7188**]
Hospital to [**Hospital1 18**] for further care due to deteriorating liver
function. The patient states that on  Wed at 10:15 am she took
100 tylenol PM (acetaminophen, and diphenhydramine)  and 3
tablets of Nyquil  (dextromethorphan, pseudoephedrine,
acetaminophen, doxylamine). The patient reports that she wanted
to die and fell asleep after taking all the pills. Patient was
suprised to wake-up and went to her day program on Thurs am (30
hours after the tylenol ingestion). At her day program at
[**Location (un) **]Mental Health Program she told her psychiatrist
about her suicide attempt and was immediately transferred to
[**Hospital 7188**] Hospital. In ED she was started on oral Mucomyst (N-AC)
which she vomited. She was then stated on Mucomyst 18.4gm
loading, 6.1 gm for 4 hours, then 12.3gms until transfer to
[**Hospital1 18**]. The patient was in the [**Hospital 7188**] Hospital ICU where labs
progressed INR 1.2 to 1.9 and ALT 244 to 1783, AST 265 to 1851,
and Biliribin 1.7 on transfer. Her plasma tylenol level at
transfer was 89 mcg/mL (40-fold in the toxic range according to
the RIMAC nomogram). She was transferred to [**Hospital1 18**] for further
care due to non-resolving LFTs.

MEDICAL HISTORY: Schizoaffective Disorder

MEDICATION ON ADMISSION: Risperdal Consta 50mg q2week last dose [**2159-8-28**]
Nexium 40mg daily

ALLERGIES: Phenothiazines / Lithobid

PHYSICAL EXAM: Gen: NAD, resting in bed
HEENT: anicteric scerla, PERRL 5mm-3mm b/l, EOMI, no nystagmus,
CN II??????XII intact
Neck: No JVD, supple
Pulm: CTA b/l, mild rales at bases b/l cleared with breathing
Cardiac: Brady, regular rhythm, no m/r/g, nl S1, S2
Abdomen: hypoactive bowel sounds, mildly distended abdomen,
diffusely tender without rebound or guarding.
Extremities: warm well perfused
Peripheral Vascular: Radial pulses 2+ bilaterally.
Skin:  No jaundice, no rashes
Neurologic: Responds to: voice, alert and oriented *3, Movement:
[**5-7**] biceps, triceps, deltoids, hip flexion, knee flexion and
extension, wrist extensors, dorsi/plantarflexion, noted to fine
resting tremor b/l hands, (+) asterixis, Tone: wnl, Sensation:
intact to light touch *4 extremities, Reflexes: 1+
brachioradialis, 1+ biceps, absent patellar and ankle b/l,
Coordination: finger to nose intact and heel to shin
bilaterally. Patient also able to spell world backwards and do
serial 7s.
Psych: flat affect, attentive

FAMILY HISTORY: No hx of CAD, Cancer, DM, HTN, HL.

SOCIAL HISTORY: Occupation:unemployed
Drugs: no
Tobacco: no
Alcohol: no
Other: attends psychiatric day program, lives home alone by
herself.
Poisoning by aromatic analgesics, not elsewhere classified,Drug-induced psychotic disorder with hallucinations,Urinary tract infection, site not specified,Acidosis,Poisoning by antitussives,Poisoning by sympathomimetics [adrenergics],Hepatitis, unspecified,Retention of urine, unspecified,Schizoaffective disorder, unspecified,History of physical abuse,Bipolar disorder, unspecified,Esophageal reflux,Other constipation,Suicide and self-inflicted poisoning by other specified drugs and medicinal substances
Pois-arom analgesics NEC,Drug psy dis w hallucin,Urin tract infection NOS,Acidosis,Poisoning-antitussives,Poison-sympathomimetics,Hepatitis NOS,Retention urine NOS,Schizoaffective dis NOS,Hx of physical abuse,Bipolar disorder NOS,Esophageal reflux,Constipation NEC,Poison-drug/medicin NEC
Admission Date:  [**2159-9-7**]              Discharge Date:   [**2159-9-12**]

Date of Birth:  [**2113-10-18**]             Sex:   F

Service: MEDICINE

Allergies:
Phenothiazines / Lithobid

Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
Suicide attempt with tylenol overdose

Major Surgical or Invasive Procedure:
None.


History of Present Illness:
45 y/o female with schizoaffective d/o transferred from [**Hospital 7188**]
Hospital to [**Hospital1 18**] for further care due to deteriorating liver
function. The patient states that on  Wed at 10:15 am she took
100 tylenol PM (acetaminophen, and diphenhydramine)  and 3
tablets of Nyquil  (dextromethorphan, pseudoephedrine,
acetaminophen, doxylamine). The patient reports that she wanted
to die and fell asleep after taking all the pills. Patient was
suprised to wake-up and went to her day program on Thurs am (30
hours after the tylenol ingestion). At her day program at
[**Location (un) **]Mental Health Program she told her psychiatrist
about her suicide attempt and was immediately transferred to
[**Hospital 7188**] Hospital. In ED she was started on oral Mucomyst (N-AC)
which she vomited. She was then stated on Mucomyst 18.4gm
loading, 6.1 gm for 4 hours, then 12.3gms until transfer to
[**Hospital1 18**]. The patient was in the [**Hospital 7188**] Hospital ICU where labs
progressed INR 1.2 to 1.9 and ALT 244 to 1783, AST 265 to 1851,
and Biliribin 1.7 on transfer. Her plasma tylenol level at
transfer was 89 mcg/mL (40-fold in the toxic range according to
the RIMAC nomogram). She was transferred to [**Hospital1 18**] for further
care due to non-resolving LFTs.

Upon arrival, the patient endorsed diffuse abdominal pain. The
patient regrets her suicide attempt. She reports she is
currently not suicidal.  Patient reports after OD visual
hallucinations of people, but states she does not currently have
them. Patient confirms the drugs she took to OD and denies
taking any other medications.

Past Medical History:
Schizoaffective Disorder

- per patient h/o intentional OD in the past,

- Dr. [**Last Name (STitle) 79948**] [**Telephone/Fax (1) 74416**]

- per Dr. [**Last Name (STitle) **] psychiatrist for 16 yrs, but not past [**3-6**] yrs,
who was on-call is not aware of any suicide attempts on
emergency line [**Telephone/Fax (1) 79949**]

- mostly manic, few depressive episodes, mild paranoia

- prior hx of needing mobile treatment team twice a day to
assist with medications, currently goes to psych center to pick
up meds twice a week

- per [**Doctor First Name **], case manager at [**Company **]Health. Ms. [**Known lastname 79950**]
has been psychiatrically hospitalized in [**2135**], 4x from 88-89 at
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11309**] or RI state,  [**7-7**] for psychotic symptoms, [**2-7**]
for self defeating behavior, intrusive thoughts that maker her
feel unsafe, regression, [**2-7**] for SI and HI, [**5-8**] for SI.

h/o sexual abuse at group home circa 90-92

GERD

s/p Hernia Repair

s/p tonsillectomy

s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4675**] Cyst

Social History:
Occupation:unemployed
Drugs: no
Tobacco: no
Alcohol: no
Other: attends psychiatric day program, lives home alone by
herself.

Family History:
No hx of CAD, Cancer, DM, HTN, HL.

Physical Exam:
Gen: NAD, resting in bed
HEENT: anicteric scerla, PERRL 5mm-3mm b/l, EOMI, no nystagmus,
CN II??????XII intact
Neck: No JVD, supple
Pulm: CTA b/l, mild rales at bases b/l cleared with breathing
Cardiac: Brady, regular rhythm, no m/r/g, nl S1, S2
Abdomen: hypoactive bowel sounds, mildly distended abdomen,
diffusely tender without rebound or guarding.
Extremities: warm well perfused
Peripheral Vascular: Radial pulses 2+ bilaterally.
Skin:  No jaundice, no rashes
Neurologic: Responds to: voice, alert and oriented *3, Movement:
[**5-7**] biceps, triceps, deltoids, hip flexion, knee flexion and
extension, wrist extensors, dorsi/plantarflexion, noted to fine
resting tremor b/l hands, (+) asterixis, Tone: wnl, Sensation:
intact to light touch *4 extremities, Reflexes: 1+
brachioradialis, 1+ biceps, absent patellar and ankle b/l,
Coordination: finger to nose intact and heel to shin
bilaterally. Patient also able to spell world backwards and do
serial 7s.
Psych: flat affect, attentive

Pertinent Results:
[**2159-9-7**] 06:31PM BLOOD WBC-9.1 RBC-4.38 Hgb-13.2 Hct-38.4 MCV-88
MCH-30.2 MCHC-34.4 RDW-13.8 Plt Ct-249
[**2159-9-10**] 06:05AM BLOOD WBC-8.7 RBC-4.16* Hgb-12.6 Hct-36.7
MCV-88 MCH-30.2 MCHC-34.2 RDW-14.0 Plt Ct-229
[**2159-9-7**] 06:31PM BLOOD PT-19.7* PTT-35.3* INR(PT)-1.8*
[**2159-9-11**] 06:10AM BLOOD PT-13.5* INR(PT)-1.2*
[**2159-9-7**] 06:31PM BLOOD Glucose-89 UreaN-18 Creat-1.3* Na-144
K-3.6 Cl-112* HCO3-23 AnGap-13
[**2159-9-12**] 05:45AM BLOOD Glucose-91 UreaN-20 Creat-1.0 Na-147*
K-4.1 Cl-115* HCO3-23 AnGap-13
[**2159-9-7**] 06:31PM BLOOD ALT-5685* AST-4482* AlkPhos-54 Amylase-58
TotBili-1.1
[**2159-9-9**] 03:06AM BLOOD ALT-2507* AST-527* LD(LDH)-264*
AlkPhos-46 TotBili-0.8
[**2159-9-12**] 05:45AM BLOOD ALT-695* AST-52*

[**2159-9-9**] 03:06AM BLOOD Acetmnp-NEG
[**2159-9-8**] 03:22AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2159-9-8**] 03:22AM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2159-9-8**] 03:22AM URINE RBC-[**3-7**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-[**3-7**]

[**9-8**] Blood cx: NGTD
[**2159-9-8**] 5:08 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2159-9-10**]**

   URINE CULTURE (Final [**2159-9-10**]):
      CITROBACTER KOSERI.    >100,000 ORGANISMS/ML..
         This organism may develop resistance to third
generation
         cephalosporins during prolonged therapy. Therefore,
isolates that
         are initially susceptible may become resistant within
three to
         four days after initiation of therapy.  For serious
infections,
         repeat culture and sensitivity testing may therefore be
warranted
         if third generation cephalosporins were used.
      GRAM POSITIVE BACTERIA.    10,000-100,000 ORGANISMS/ML..
         Alpha hemolytic colonies consistent with alpha
streptococcus or
         Lactobacillus sp.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             CITROBACTER KOSERI
                             |
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------    32 S
PIPERACILLIN----------     8 R
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

CXR ([**9-8**]):
IMPRESSION: No radiographic evidence of pneumonia.

Brief Hospital Course:
1) Acetaminophen overdose:  The patient took over 100 pills of
Tylenol p.m. by her account. On presentation to [**Hospital 7188**] Hospital
30 hours after ingestion, she had an acetaminophen level of 89.9
mcg/mL, placing her at high risk for fulminant hepatic failure.
She was treated with N-acetylcysteine at [**Hospital 7188**] Hospital as
noted in HPI.  At [**Hospital1 18**], she was treated with N-acetylcysteine
50 mg/kg every 4 hours. She did well during her stay in the MICU
and was able to be called out to the floor on day 2. Her
transaminases continued to trend down and her INR remained
stable below 2.0 after peaking on the first hospital day, and
the N-acetylcysteine was stopped after 5 days of treatment. A
repeat serum acetaminophen level was negative. She had no
encephalopathy or other evidence of liver failure, and her mild
coagulopathy continually improved.

2) Diphenhydramine overdose:  The patient overdosed on Tylenol
p.m., which contains both acetaminophen and diphenhydramine.
Likely as a result of this ingestion, the patient experienced
sedation, urinary retention, and visual hallucination. However,
these symptoms had resolved by the time the patient was
transferred to [**Hospital1 18**] and her foley was discontinued.

3) Suicide attempt:  While at [**Hospital1 18**], the patient was followed by
the psychiatric consult service. She had a 1:1 sitter during her
first and second hospital days.  This was discontinued during
the second hospital day at the recommendation of the psychiatric
service. The patient's outpatient psychiatric providers were
contact[**Name (NI) **] to obtain collateral information, which is described
under PMH and in psychiatric consult notes. She currently denies
suicidal ideations, but will need inpatient psychiatric
placement now that she is medically cleared.

4) Renal dysfunction:  The patient presented with mildly
elevated creatinine and mild proteinuria. It is unclear if this
was acute or chronic. The patient's renal function was followed
closely during her hospitalization given the risk of kidney
injury from acetaminophen overdose. Her creatinine improved from
1.3 to 1.0 during admission.

5) UTI:  Complicated due to presence of foley early during her
hospitalization. Pt denies urinary symptoms, but initially had
mild suprapubic tenderness. Urine culture grew Citrobacter,
sensitive to ciprofloxacin. She is to complete a 7 day course of
ciprofloxacin.

6) Disposition: Patient is medically cleared for transfer to
inpatient psychiatry. This is evidenced by dramatic improvement
in her LFTs. Physical therapy has evaluated the patient and
believes she can ambulate independently.

Medications on Admission:
Risperdal Consta 50mg q2week last dose [**2159-8-28**]
Nexium 40mg daily

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: To complete course on [**9-15**].
5. Risperidone Microspheres 50 mg/2 mL Syringe Sig: Fifty (50)
mg Intramuscular Q2W (TU): Last dose 9/09.


Discharge Disposition:
Extended Care

Facility:
Deaconness IV

Discharge Diagnosis:
Primary: Acute tylenol-induced hepatitis, suicide attempt,
complicated UTI
Secondary: Schizoaffective disorder


Discharge Condition:
Patient is medically cleared for transfer to inpatient
psychiatry.


Discharge Instructions:
You were admitted to [**Hospital1 18**] after taking an overdose of tylenol.
We gave you a medicine to help counteract the toxic effects of
tylenol and monitored your liver function tests, which rapidly
improved. You will need to have an inpatient stay in a
psychiatric facility to help understand why you took the
overdose and what treatments are available.

Please keep all follow up appointments and take all medications
as prescribed. We are treating your urinary tract infection with
an antibiotic called ciprofloxacin. Please complete all doses of
this medication.

If you experience any severe depression or anxiety, thoughts of
suicide, fevers, chills, abdominal pain, or any other concerning
symptoms, please seek medical attention or come to the ER
immediately.

Followup Instructions:
Please call your primary care doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 36821**], at ([**Telephone/Fax (1) 79951**] for a follow up appointment upon your discharge from
the psychiatric facility.

Please also establish an appointment with your mental health
provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 79952**], at ([**Telephone/Fax (1) 79953**] after your
discharge.



Completed by:[**2159-9-12**]
{'Poisoning by aromatic analgesics, not elsewhere classified,Drug-induced psychotic disorder with hallucinations,Urinary tract infection, site not specified,Acidosis,Poisoning by antitussives,Poisoning by sympathomimetics [adrenergics],Hepatitis, unspecified,Retention of urine, unspecified,Schizoaffective disorder, unspecified,History of physical abuse,Bipolar disorder, unspecified,Esophageal reflux,Other constipation,Suicide and self-inflicted poisoning by other specified drugs and medicinal substances'}


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: Suicide attempt with tylenol overdose

PRESENT ILLNESS: 45 y/o female with schizoaffective d/o transferred from [**Hospital 7188**]
Hospital to [**Hospital1 18**] for further care due to deteriorating liver
function. The patient states that on  Wed at 10:15 am she took
100 tylenol PM (acetaminophen, and diphenhydramine)  and 3
tablets of Nyquil  (dextromethorphan, pseudoephedrine,
acetaminophen, doxylamine). The patient reports that she wanted
to die and fell asleep after taking all the pills. Patient was
suprised to wake-up and went to her day program on Thurs am (30
hours after the tylenol ingestion). At her day program at
[**Location (un) **]Mental Health Program she told her psychiatrist
about her suicide attempt and was immediately transferred to
[**Hospital 7188**] Hospital. In ED she was started on oral Mucomyst (N-AC)
which she vomited. She was then stated on Mucomyst 18.4gm
loading, 6.1 gm for 4 hours, then 12.3gms until transfer to
[**Hospital1 18**]. The patient was in the [**Hospital 7188**] Hospital ICU where labs
progressed INR 1.2 to 1.9 and ALT 244 to 1783, AST 265 to 1851,
and Biliribin 1.7 on transfer. Her plasma tylenol level at
transfer was 89 mcg/mL (40-fold in the toxic range according to
the RIMAC nomogram). She was transferred to [**Hospital1 18**] for further
care due to non-resolving LFTs.

MEDICAL HISTORY: Schizoaffective Disorder

MEDICATION ON ADMISSION: Risperdal Consta 50mg q2week last dose [**2159-8-28**]
Nexium 40mg daily

ALLERGIES: Phenothiazines / Lithobid

PHYSICAL EXAM: Gen: NAD, resting in bed
HEENT: anicteric scerla, PERRL 5mm-3mm b/l, EOMI, no nystagmus,
CN II??????XII intact
Neck: No JVD, supple
Pulm: CTA b/l, mild rales at bases b/l cleared with breathing
Cardiac: Brady, regular rhythm, no m/r/g, nl S1, S2
Abdomen: hypoactive bowel sounds, mildly distended abdomen,
diffusely tender without rebound or guarding.
Extremities: warm well perfused
Peripheral Vascular: Radial pulses 2+ bilaterally.
Skin:  No jaundice, no rashes
Neurologic: Responds to: voice, alert and oriented *3, Movement:
[**5-7**] biceps, triceps, deltoids, hip flexion, knee flexion and
extension, wrist extensors, dorsi/plantarflexion, noted to fine
resting tremor b/l hands, (+) asterixis, Tone: wnl, Sensation:
intact to light touch *4 extremities, Reflexes: 1+
brachioradialis, 1+ biceps, absent patellar and ankle b/l,
Coordination: finger to nose intact and heel to shin
bilaterally. Patient also able to spell world backwards and do
serial 7s.
Psych: flat affect, attentive

FAMILY HISTORY: No hx of CAD, Cancer, DM, HTN, HL.

SOCIAL HISTORY: Occupation:unemployed
Drugs: no
Tobacco: no
Alcohol: no
Other: attends psychiatric day program, lives home alone by
herself. 

### Response:
{'Poisoning by aromatic analgesics, not elsewhere classified,Drug-induced psychotic disorder with hallucinations,Urinary tract infection, site not specified,Acidosis,Poisoning by antitussives,Poisoning by sympathomimetics [adrenergics],Hepatitis, unspecified,Retention of urine, unspecified,Schizoaffective disorder, unspecified,History of physical abuse,Bipolar disorder, unspecified,Esophageal reflux,Other constipation,Suicide and self-inflicted poisoning by other specified drugs and medicinal substances'}
