CHIEF COMPLAINT: obtundation, respiratory distress

PRESENT ILLNESS: (All information below is according to mother, however patient
not able to answer questions. No family present. I tried to call
left for the day).
.
26M with history of drug abuse who is an OSH transfer for
obtundation, drug abuse, and concern for suicide attempt.
.
According to mother (although per OSH, she had changed the story
several times), pt was assaulted at a store yesterday and was
choked with the [**Doctor Last Name **] of his sweatshirt by 2 people assaulting
him. He was also sprayed in the face with mace and wallet
stollen. Later in the day, he was apparently cleaning a roasting
pan and cut his wrist on a knife that was in the pan while
reaching into it. Mother noticed he was acting different and
slurring his speech, he seems like "he aws on something" so she
called EMS and sent pt to OSH ED where he appeared "obtunded."
His initial vitals were BP 94/27, HR 72, RR 14, 93%RA. He was
intubated for airway protection. While at OSH ED, he had head CT
and CXR, CT cervical spine which were unremarkable. He was given
narcan x2 with minimal improvement in arrousal. Trop 0.03, [**Doctor First Name **]
neg, ETOH neg. Lactate 0.8. He was transfered to our ED for
further care.
.
In the [**Hospital1 18**] ED inital vitals were T 96.5, BP 102/46, HR 39-57,
18 Assist control, 500 TV, 5 PEEP, 18 F, Ppeak 21. GLASCOW
initialy 15 in [**Last Name (LF) **], [**Name8 (MD) **] RN report. FAST neg. Given bolues of
fent/versed. Given 3L IVF with 300cc total UO. He had CT
Cervical which was overall unremarkable. He had left wrist
laceration sp 6 sutures and tetanus vaccine. On exam, he was
found to have ligature mark on neck from likely recent
strangulation as well as what appeared to be cigerette burns
around his penis.
EKG and Tele notable for sinus bradycardia with HR 39-50s. He
was planned to be given 1g Ca Gluconate for possible BB/CCB
overdose but not given [**Name8 (MD) **] RN.
Urine positive for benzos, opiates, cocaine. (he was likely
given benzos and opiates for intubation, but cocaine is likely
recent intoxication). Recent vent settings: Assist control FiO2
50%, PEEP 5, Gas: 7.34/42/233/24.
.
On arrival to the ICU, pt follows commands, responds to his
name, opens his eyes, GLASCOW=15. He appears comfortable,
intubated. Has bruises/blood smear on knees bilaterally, neck
with sign of recent strangulation, left wrist with 6 stitches.

MEDICAL HISTORY: HCV
Drug abuser since age 19- heroin and cocaine (in a drug abuse
program x 14 mo)
Hospitalized 4 yrs ago for drug overdose
?Nerve damage
Genital Warts

MEDICATION ON ADMISSION: Neurontin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam
Vitals: BP: 115/57 P: 55 R: 18 O2:100%: AC, TV 500, FiO2 40%,
PEEP 4, Rate 19, PPeak 19.
General: responds/follows commands and name, no acute distress
HEENT: Sclera anicteric, MMM, intubated, neck with signs of
strangulation (rope mark).
Neck: supple, JVP not elevated, no LAD
Lungs: Bilateral breath sounds. Clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: Regular rate (bradycardic) 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: foley with urine output- 300 cc since arrival to ED. Has
genital warts on penis. Also with lesions on base of penis and
suprapubic area- chancre appearance.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: denied

SOCIAL HISTORY: -prior heroin and cocaine use, supposedly clean x 14 mo. Drug
abuse x 7 yrs.
-hospitalized 4 yrs ago for overdose
Spent some time in prison.
Poisoning by cocaine,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute respiratory failure,Drug-induced delirium,Poisoning by heroin,Poisoning by benzodiazepine-based tranquilizers,Poisoning by other antihypertensive agents,Open wound of wrist, without mention of complication,Hypoxemia,Cocaine abuse, unspecified,Chronic hepatitis C without mention of hepatic coma,Anemia, unspecified,Need for prophylactic vaccination and inoculation against tetanus toxoid alone,Condyloma acuminatum,Oliguria and anuria,Other specified cardiac dysrhythmias,Accidental poisoning by central nervous system stimulants,Accidental poisoning by heroin,Accidental poisoning by benzodiazepine-based tranquilizers,Accidental poisoning by agents primarily affecting cardiovascular system,Opioid type dependence, unspecified,Accidents caused by knives, swords, and daggers
Poisoning by cocaine,Pneumococcal pneumonia,Acute respiratry failure,Drug-induced delirium,Poisoning-heroin,Pois-benzodiazepine tran,Pois-antihyperten agent,Open wound of wrist,Hypoxemia,Cocaine abuse-unspec,Chrnc hpt C wo hpat coma,Anemia NOS,Tetanus toxoid inoculat,Condyloma acuminatum,Oliguria & anuria,Cardiac dysrhythmias NEC,Acc poison-cns stimulant,Acc poison-heroin,Acc poisn-benzdiaz tranq,Acc poisn-cardiovasc agt,Opioid dependence-unspec,Knife/sword/dagger acc
Admission Date:  [**2137-2-3**]              Discharge Date:   [**2137-2-8**]

Date of Birth:  [**2110-9-27**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 633**]
Chief Complaint:
obtundation, respiratory distress

Major Surgical or Invasive Procedure:
Intubation
suture of wrist laceration


History of Present Illness:
(All information below is according to mother, however patient
not able to answer questions. No family present. I tried to call
left for the day).
.
26M with history of drug abuse who is an OSH transfer for
obtundation, drug abuse, and concern for suicide attempt.
.
According to mother (although per OSH, she had changed the story
several times), pt was assaulted at a store yesterday and was
choked with the [**Doctor Last Name **] of his sweatshirt by 2 people assaulting
him. He was also sprayed in the face with mace and wallet
stollen. Later in the day, he was apparently cleaning a roasting
pan and cut his wrist on a knife that was in the pan while
reaching into it. Mother noticed he was acting different and
slurring his speech, he seems like "he aws on something" so she
called EMS and sent pt to OSH ED where he appeared "obtunded."
His initial vitals were BP 94/27, HR 72, RR 14, 93%RA. He was
intubated for airway protection. While at OSH ED, he had head CT
and CXR, CT cervical spine which were unremarkable. He was given
narcan x2 with minimal improvement in arrousal. Trop 0.03, [**Doctor First Name **]
neg, ETOH neg. Lactate 0.8. He was transfered to our ED for
further care.
.
In the [**Hospital1 18**] ED inital vitals were T 96.5, BP 102/46, HR 39-57,
18 Assist control, 500 TV, 5 PEEP, 18 F, Ppeak 21. GLASCOW
initialy 15 in [**Last Name (LF) **], [**Name8 (MD) **] RN report. FAST neg. Given bolues of
fent/versed. Given 3L IVF with 300cc total UO. He had CT
Cervical which was overall unremarkable. He had left wrist
laceration sp 6 sutures and tetanus vaccine. On exam, he was
found to have ligature mark on neck from likely recent
strangulation as well as what appeared to be cigerette burns
around his penis.
EKG and Tele notable for sinus bradycardia with HR 39-50s. He
was planned to be given 1g Ca Gluconate for possible BB/CCB
overdose but not given [**Name8 (MD) **] RN.
Urine positive for benzos, opiates, cocaine. (he was likely
given benzos and opiates for intubation, but cocaine is likely
recent intoxication). Recent vent settings: Assist control FiO2
50%, PEEP 5, Gas: 7.34/42/233/24.
.
On arrival to the ICU, pt follows commands, responds to his
name, opens his eyes, GLASCOW=15. He appears comfortable,
intubated. Has bruises/blood smear on knees bilaterally, neck
with sign of recent strangulation, left wrist with 6 stitches.

Past Medical History:
HCV
Drug abuser since age 19- heroin and cocaine (in a drug abuse
program x 14 mo)
Hospitalized 4 yrs ago for drug overdose
?Nerve damage
Genital Warts


Social History:
-prior heroin and cocaine use, supposedly clean x 14 mo. Drug
abuse x 7 yrs.
-hospitalized 4 yrs ago for overdose
Spent some time in prison.

Family History:
denied

Physical Exam:
Admission Exam
Vitals: BP: 115/57 P: 55 R: 18 O2:100%: AC, TV 500, FiO2 40%,
PEEP 4, Rate 19, PPeak 19.
General: responds/follows commands and name, no acute distress
HEENT: Sclera anicteric, MMM, intubated, neck with signs of
strangulation (rope mark).
Neck: supple, JVP not elevated, no LAD
Lungs: Bilateral breath sounds. Clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: Regular rate (bradycardic) 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: foley with urine output- 300 cc since arrival to ED. Has
genital warts on penis. Also with lesions on base of penis and
suprapubic area- chancre appearance.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
[**2137-2-8**] 06:40AM BLOOD WBC-7.1 RBC-4.28* Hgb-12.9* Hct-37.7*
MCV-88 MCH-30.0 MCHC-34.1 RDW-13.4 Plt Ct-355
[**2137-2-7**] 06:40AM BLOOD WBC-8.6 RBC-4.34* Hgb-13.1* Hct-38.7*
MCV-89 MCH-30.1 MCHC-33.8 RDW-13.2 Plt Ct-316
[**2137-2-6**] 05:08AM BLOOD WBC-9.4 RBC-4.09* Hgb-12.3* Hct-36.1*
MCV-88 MCH-29.9 MCHC-33.9 RDW-12.8 Plt Ct-268
[**2137-2-5**] 04:13AM BLOOD WBC-8.3 RBC-4.10* Hgb-12.3* Hct-36.6*
MCV-89 MCH-30.0 MCHC-33.6 RDW-12.9 Plt Ct-240
[**2137-2-4**] 05:25AM BLOOD WBC-12.8*# RBC-4.11* Hgb-12.4* Hct-36.9*
MCV-90 MCH-30.1 MCHC-33.6 RDW-13.0 Plt Ct-246
[**2137-2-3**] 06:13AM BLOOD WBC-7.6 RBC-3.71* Hgb-11.5* Hct-34.0*
MCV-92 MCH-31.0 MCHC-33.8 RDW-13.1 Plt Ct-240
[**2137-2-3**] 01:33AM BLOOD WBC-10.6 RBC-4.41* Hgb-13.4* Hct-38.8*
MCV-88 MCH-30.4 MCHC-34.6 RDW-13.1 Plt Ct-273
[**2137-2-4**] 05:25AM BLOOD Neuts-74.8* Lymphs-19.1 Monos-5.8 Eos-0.2
Baso-0.1
[**2137-2-3**] 06:13AM BLOOD Neuts-65.6 Lymphs-28.6 Monos-5.1 Eos-0.4
Baso-0.3
[**2137-2-3**] 06:13AM BLOOD PT-13.4* PTT-32.6 INR(PT)-1.2*
[**2137-2-3**] 01:33AM BLOOD PT-12.6* PTT-30.9 INR(PT)-1.2*
[**2137-2-3**] 01:33AM BLOOD Fibrino-235
[**2137-2-8**] 06:40AM BLOOD Glucose-90 UreaN-11 Creat-1.1 Na-140
K-4.2 Cl-109* HCO3-23 AnGap-12
[**2137-2-7**] 06:40AM BLOOD Glucose-92 UreaN-12 Creat-1.1 Na-141
K-4.0 Cl-108 HCO3-24 AnGap-13
[**2137-2-6**] 05:08AM BLOOD Glucose-108* UreaN-11 Creat-1.1 Na-142
K-3.8 Cl-111* HCO3-24 AnGap-11
[**2137-2-4**] 05:25AM BLOOD Glucose-83 UreaN-13 Creat-1.2 Na-139
K-3.9 Cl-109* HCO3-24 AnGap-10
[**2137-2-3**] 05:16PM BLOOD Glucose-92 UreaN-15 Creat-1.2 Na-140
K-3.8 Cl-110* HCO3-22 AnGap-12
[**2137-2-3**] 06:13AM BLOOD Glucose-119* UreaN-13 Creat-1.0 Na-140
K-4.7 Cl-114* HCO3-20* AnGap-11
[**2137-2-6**] 05:08AM BLOOD ALT-62* AST-38 LD(LDH)-173 AlkPhos-51
TotBili-0.4
[**2137-2-5**] 04:13AM BLOOD ALT-59* AST-33 LD(LDH)-177 AlkPhos-50
TotBili-0.4
[**2137-2-4**] 05:25AM BLOOD ALT-67* AST-35 LD(LDH)-168 CK(CPK)-120
AlkPhos-50 TotBili-0.4
[**2137-2-3**] 06:13AM BLOOD ALT-67* AST-31 LD(LDH)-132 CK(CPK)-90
AlkPhos-46 Amylase-42 TotBili-0.4
[**2137-2-3**] 01:33AM BLOOD ALT-86* AST-39 LD(LDH)-152 AlkPhos-54
TotBili-0.3
[**2137-2-3**] 06:13AM BLOOD Lipase-22
[**2137-2-3**] 01:33AM BLOOD Lipase-23
[**2137-2-4**] 05:25AM BLOOD CK-MB-3 cTropnT-<0.01
[**2137-2-3**] 06:13AM BLOOD CK-MB-2 cTropnT-<0.01
[**2137-2-8**] 06:40AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.9
[**2137-2-6**] 05:08AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.8
[**2137-2-5**] 04:13AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.0
[**2137-2-4**] 05:25AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.2
[**2137-2-3**] 05:16PM BLOOD Calcium-8.1* Phos-2.3* Mg-1.6
[**2137-2-3**] 06:13AM BLOOD Albumin-3.2* Calcium-7.9* Phos-3.1 Mg-1.9
[**2137-2-3**] 06:13AM BLOOD TSH-0.83
[**2137-2-5**] 04:13AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2137-2-5**] 04:13AM BLOOD HIV Ab-NEGATIVE
[**2137-2-3**] 06:13AM BLOOD Digoxin-LESS THAN
[**2137-2-3**] 06:13AM BLOOD Lithium-LESS THAN
[**2137-2-3**] 01:33AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2137-2-5**] 04:13AM BLOOD HCV Ab-POSITIVE*
[**2137-2-5**] 04:13AM BLOOD HCV Ab-POSITIVE*
[**2137-2-3**] 11:41AM BLOOD Type-ART Temp-36.1 FiO2-66 pO2-47*
pCO2-40 pH-7.31* calTCO2-21 Base XS--5 Intubat-NOT INTUBA
[**2137-2-3**] 02:12AM BLOOD Type-ART Tidal V-500 PEEP-5 FiO2-50
pO2-233* pCO2-42 pH-7.34* calTCO2-24 Base XS--2 -ASSIST/CON
Intubat-INTUBATED
[**2137-2-3**] 02:12AM BLOOD O2 Sat-98.
.
MICROBIOLOGY:
[**2137-2-7**] SPUTUM ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY INPATIENT prelim neg
[**2137-2-7**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT -neg
[**2137-2-6**] SPUTUM ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY INPATIENT-prelim neg
[**2137-2-5**] SPUTUM ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PENDING INPATIENT -prelim neg
[**2137-2-5**] IMMUNOLOGY HIV-1 Viral
Load/Ultrasensitive-FINAL INPATIENT -negative
[**2137-2-4**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-FINAL; Respiratory Viral Antigen
Screen-FINAL INPATIENT -negative
[**2137-2-4**] Influenza A/B by DFA NOT PROCESSED
INPATIENT
[**2137-2-4**] URINE Legionella Urinary Antigen -FINAL
INPATIENT negative
[**2137-2-4**] SPUTUM ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY INPATIENT prelim neg
[**2137-2-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2137-2-3**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-FINAL; Respiratory Viral Antigen
Screen-FINAL INPATIENT
[**2137-2-3**] URINE NEISSERIA GONORRHOEAE (GC), NUCLEIC
ACID PROBE, WITH AMPLIFICATION-FINAL; Chlamydia trachomatis,
Nucleic Acid Probe, with Amplification-FINAL INPATIENT  negative
[**2137-2-3**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {STREPTOCOCCUS PNEUMONIAE}; LEGIONELLA
CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY {PAECILOMYCES
SPECIES, STEMPHYLIUM SP.} INPATIENT
[**2137-2-3**] URINE URINE CULTURE-FINAL INPATIENT
[**2137-2-3**] SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL  INPATIENT  negative
[**2137-2-3**] SEROLOGY/BLOOD LYME SEROLOGY-FINAL INPATIENT
 negative
[**2137-2-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2137-2-3**] MRSA SCREEN MRSA SCREEN-FINAL
.
EKG [**2-3**]:
Ectopic atrial rhythm. Low QRS voltage in the limb leads.
Compared to the
previous tracing of [**2137-2-3**] P wave axis is now altered consistent
with an
ectopic atrial rhythm.
.
CXR [**2137-2-4**]:
IMPRESSION:
1. Standard position of lines and tubes. No pneumothorax.
2. Bibasilar consolidation, left greater than right, possible
atelectasis,
though aspiration or pneumonia should be considered in the
appropriate
clinical circumstances.
3. Mild cardiomegaly.
.
CTA neck [**2137-2-3**]:
IMPRESSION:
1. Patent cervical and intracranial vasculature.
2. Several tiny foci of air external to the trachea. These are
felt most
likely to represent small foci of air within small superficial
veins. Injury to the trachea is felt to be less likely.
NOTE ADDED AT ATTENDING REVIEW: Incompletely imaged, there
appears to be at least partial left lower lobe collapse with air
bronchograms. This revised finding was discussed by telephone
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] by Dr. [**Last Name (STitle) **] at 5:53 pm on [**2137-2-3**].
.
CXR [**2137-2-3**]:
There are low inspiratory volumes. Allowing for this, there is
increased
density at the left base, suspicious for worsening left lower
lobe collapse and/or consolidation. A small left effusion would
be difficult to exclude.
The cardiac silhouette, pulmonary hila, and interstitial
markings are all
prominent -- while these findings could relate to
cardiopulmonary failure,
they are likely also accentuated by low lung volumes. No
pneumothorax
detected.
Compared with earlier the same day, the left base opacity is
greater. The
inspiratory volumes are lower and, associated with this, and the
vascular
markings and hila are more prominent.
.
CT chest [**2137-2-4**]:
IMPRESSION:
1. Complete consolidation of the left lower lobe and the medial
base of the right lower lobe consistent with pneumonia.
Multifocal ground-glass opacities in the upper lobes indicates
spread of infection.
.
[**2-4**] EKG:
Sinus rhythm. Within normal limits. Compared to the previous
tracing
P wave axis is now consisent with sinus rhythm.
.
CXR [**2137-2-6**]:
IMPRESSION: AP chest compared to [**2-3**] through 3:
Large scale consolidation in both lower lobes, left greater than
right, is
improving. Pleural effusion small on the left, also decreased.
Heart size
normal. Mild pulmonary edema on [**2-3**] has not recurred. No
pneumothorax.


Brief Hospital Course:
26M with PMH of HCV is an OSH transfer for obtundation, cocaine
abuse, sinus bradycardia, and concern for suicide attempt, found
to have severe strep pneumo pneumonia.

# Respiratory distress/PNA: Patient was intubated for
respiratory distress. Patient's CT showed dense consolidation of
LLL and medial RLL, scattered ground glass opacities suggestive
of significant PNA. Sputum grew Strep pneumo, blood cultures
were NGTD. Patient was initially treated with Ceftriaxone,
Azithro and Vancomycin (d/c??????d on [**2137-2-5**]), however narrowed to
ceftriaxone given culture results. In the ICU, pt required
significant amounts of O2 with high flow mask, however improved
to 5L NC satting 99% just prior to transfer to the floor.
Induced sputum for AFB smear was negative X 4. Urine legionella
negative. Viral culture negative. HIV negative. Pt's symptoms
markedly improved upon transfer to the medical floor. He was on
room air by morning of floor transfer and remained on room air
without any signs of respiratory distress during the remainder
of his hospitalization. On day of discharge, strep culture was
noted to be resistant to PCN. However, given his marked
improvement on ceftriaxone, he was continued on cefopodoxime
400mg [**Hospital1 **] to complete a total of 14 days of therapy.
.
# Hemoptysis: Developed shortly after extubation. Possibly due
to frequent coughing, trauma from recent intubation, hemorrhage
from pneumonia (more often with staph PNA but can also see strep
PNA). Markedly improved during admission. HCT remained stable
and pt remained on room air. AFB neg x4.

# Obtundation/drug overdose- Concern for suicide attempt in
young male with signs of neck strangulation, wrist laceration
and drug abuse. However, per mother, there is concern for
assault. Urine positive for cocaine. Urine also pos for benzos
and opiates, although unclear if this is from his sedating meds
given during intubation. OSH records were positive for cocaine
and opiates, neg for benzos, suggesting he probably consumed
opiates and cocaine. Commonly abused drugs include: ethyl
alcohol, acetaminophen, opiates, benzodiazepines, barbiturates,
salicylates, cocaine, amphetamines, ethylene glycol, and
methanol. Patient's only presenting signs include: obtundation.
On trasnfer, pt was bradycardic in the 40-50s.  Urine and tox
screen remarkable for cocaine, benzos and opiates. Remainder all
negative. Intubated for airway protection. Patient with small
osmolar gap (<10 normal), which has since resolved. Would expect
to see pos gap in methanol, ethylene glycol, sorbitol, mannitol.
Patient was weaned off sedation and extubated without issues on
the first day in the ICU.
.
#Bradycardia: Sinus bradycardia on EKG, HR 39-50s. Differential
includes: tox ingestion such as BB/ CCB/
methyldopa/lithium/Digoxin/ clonidine/ amiordarone/
antiarrythmics; withdrawal from cocaine; sick sinus syndrome
although unlikely in otherwise health young male with no prior
arrythmias; vasovagal less likely since that is often self
limited and transient; hypothermia was of consideration; carotid
pressure upon strangulation although would expect that to be
self limited; hypothyroidism; increased intracranial pressure
(Cushings reflex) although head CT from OSH negative for signs
of increased pressure; inferior infarct in pt with recent
cocaine intox although no ST changes or TWI on EKG; severe
prolonged hypoxia although pt appeared to have preserved O2 sat
from OSH and was intubated for obtundation only, infections such
as legionella/Typhoid fever/lyme/viral myocarditis/endocarditis
can also present like this, although no description of recent
febrile/URI like illnesses and no clinical signs such as
olser/janeaway/splinter hemorrhage. Lithium level, dig level
negative. TSH normal. Troponin, CK, MB (trop neg at OSH) all
normal. Lyme titer negative. Patient's bradycardia resolved and
upon transfer HR was 67. Patient stated that he thinks he took
clonidine. Transient bradycardia most likely due to clonidine
overdose +-  benzo/opiates or withdrawal from prior stimulants
causing excess parasympathetic effect.

# Possible suicide attempt: Initial concern for suicide attempt
given signs of neck strangulation, wrist laceration and drug
abuse. On talking to the patient, sounds like he was trying to
get high by taking all these meds rather than kill himself.
Lesion on neck is from strangulation during mugging rather than
suicide attempt, cut on wrist was reportedly an accident while
washing dishes per him and his mother. Psych was consulted and
saw patient. Patient was initially section 12 with a 1:1 sitter,
however, psych spoke with the patient further and decided he
does not meet criteria for Section 12. Sitter was stopped.
Patient was monitored with plan for Bentyl 20 mg PO q4h prn
abdominal pain and robaxin 750 mg q 6 hrs prn muscle cramps
(neither of which were needed), and ibuprofen 600 mg q 6 hrs prn
muscle pain which may occur if opiate withdrawal develops.
Additionally, CIWA used for withdrawal symptoms, however never
showed signs of ETOH/benzodiazepine withdrawal. Psychiatry and
Social work followed the patient closely during admission to
assess for safety and suicidality. Pt repeatedly reported that
he was not trying to harm himself and was simply trying to get
high as his girlfriend wanted to "party" on New Year's for her
bday. Repeatedly said that the neck wound was from being
strangled when he was "trying to get his girlfriend (who uses
drugs) out of a crack house. He reported that wrist wound due to
accidentally injury at home. Psychiatry deemed that he was not a
candidate for section 12 nor did he warrant inpatient
psychiatric admission. They believed him to be in the
"pre-contemplative" phase. He has a scheduled appointment with
an outpatient psychiatrist, soonest available 3/[**2137**]. Of note,
pt has served alot of jail time due to drugs and his long-term
girlfriend uses drugs. Recently, released from prison.
.
#anxiety-pt reports "anxiety" as a trigger to his substance use.
Requests clonidine and benzos. This was no given, given pt's
reported history of missuse and overdose on these substances.
This was explained to patient. Pt reported he uses his home
neurontin for "anxiety". Told patient that best option for him
would be an SSRI and continued therapy. He was not interested in
SSRI therapy and requested benzos. This was not offered.
.
# Anemia: (hemoptysis was minimal per report). Guaiac'd stools.
Trended hct. Could be due to PNA. Remained stable during
admission. HCT 37.7 on day of discharge. This can be further
followed in the outpatient setting.
.
# Transaminitis: Mildly elevated ALT likely related to chronic
HCV. No fever or leukocytosis. Would consider outpatient GI
evaluation.
.
#wrist lac-s/p suture in ED and tetanus shot.  Pt was given
wound care and dressing changes. He is to have suture removal in
[**8-13**] days after placed ([**2137-2-3**]). PCP f/u scheduled.
.
#Wrist neuropathy-continued neurontin per outpt regimen. Pt
reports followed by a [**Month/Day/Year 850**] at [**Hospital1 2177**] and prescribed
neurontin. Pt requested rx for this, however called pharmacy-
CVS [**Location **]. Pt got 600mg TID neurontin on [**1-17**] #90. This
was not prescribed upon DC.
.
# Decreased urine output: UOP initially decreased upon hospital
transfer. FENa 0.54%, consistent with pre-renal state.  Cr
normal, no sign of renal dysfunction. UOP was trended and
responsive to IVFs. Resolved.

# Wrist laceration: Mother and patient report this was an
accident from washing dishes. Now s/p suture in ED and tetanus
shot. Daily dressings applied. Sutures to be removed 7-10 days
from placement (D1= [**2137-2-3**]). Pt was set up with PCP appointment
for this.

# HCV: Not currently on treatment. HIV and HBV negative. Pt can
follow up as an outpatient to consider need for treatment.
Currently, unlikely to be a good candidate.

# Penile lesions: Per patient, he had genital warts frozen at a
health clinic last week. Urine gonorrhea/chlamydia and RPR
negative.

Medications on Admission:
Neurontin

Discharge Medications:
1. Neurontin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
2. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO twice a day
for 9 days.
Disp:*36 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
-Strep pneumo pneumonia
-drug overdose (heroin, cocaine, benzodiazepines, clonidine)
-L.wrist injury with suture repair.
-anemia


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


Discharge Instructions:
You were admitted with an unintential overdose of multiple drugs
and you were found to have a severe pneumonia. Due to this, you
were intubated (placed on artifical breathing) and admitted to
the ICU. You were monitored by psychiatry, social work and
infectious diseases. Your pneumonia improved and you will be
discharged to complete your course of antibiotic therapy. In
addition, you were seen by psychiatry and social work to help
you with resources for anxiety and substance abuse. It is of
extreme importance that you stop using drugs in order to avoid
further harm to your body including death. In addition, this
will help to keep you out of jail. Please follow up with your
PCP, [**Name10 (NameIs) 850**], and psychiatry after discharge.  You reported
that you did not intentionally harm yourself or have any plans
to harm yourself. However, should this change, call 911 or go to
the nearest ER immediately.
.
You will need to have your stitches removed by your PCP at your
scheduled follow up.
.
Medication changes: NONE, your pharmacy reports that you
recently received a prescription for neurontin that will be good
until your next follow up appointment.
.
Please follow up with the appointments below and take all of
your medications as prescribed.

Followup Instructions:
Name: [**Last Name (LF) 72224**],[**Name6 (MD) **] E MD
Location: [**Hospital **] COMMUNITY HEALTH CENTER
Address: 409 [**Location (un) 61346**], [**Location **],[**Numeric Identifier 46146**]
Phone: [**Telephone/Fax (1) 6511**]
Appt:  [**Last Name (LF) 2974**], [**2-15**] at 4:50pm

Name: [**Last Name (LF) **], [**Name8 (MD) 50768**]  MD
Location: BU NEUROLOGY ASSOCIATES
Address: [**Location (un) **]. SUTIE 7B, [**Location (un) **],[**Numeric Identifier 13108**]
Phone: [**Telephone/Fax (1) 25666**]
Appt:  [**4-12**] at 10am
***You have also been placed on the wait list for a sooner appt.
 If you are unable to make this appt, PLEASE call the office
within 48 hours of appt to cancel. (your prior [**Month (only) 850**] is no
longer at this practice)

Name: [**Last Name (LF) 77879**], [**First Name5 (NamePattern1) 17**] [**Last Name (NamePattern1) 92617**]
Location: [**Hospital **] COMMUNITY HEALTH CENTER
Address: 386 [**Location (un) 61346**], [**Location **],[**Numeric Identifier 46146**]
Phone: [**Telephone/Fax (1) 6511**]
Appt:  [**5-2**] at 12pm
{'Poisoning by cocaine,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute respiratory failure,Drug-induced delirium,Poisoning by heroin,Poisoning by benzodiazepine-based tranquilizers,Poisoning by other antihypertensive agents,Open wound of wrist, without mention of complication,Hypoxemia,Cocaine abuse, unspecified,Chronic hepatitis C without mention of hepatic coma,Anemia, unspecified,Need for prophylactic vaccination and inoculation against tetanus toxoid alone,Condyloma acuminatum,Oliguria and anuria,Other specified cardiac dysrhythmias,Accidental poisoning by central nervous system stimulants,Accidental poisoning by heroin,Accidental poisoning by benzodiazepine-based tranquilizers,Accidental poisoning by agents primarily affecting cardiovascular system,Opioid type dependence, unspecified,Accidents caused by knives, swords, and daggers'}


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: obtundation, respiratory distress

PRESENT ILLNESS: (All information below is according to mother, however patient
not able to answer questions. No family present. I tried to call
left for the day).
.
26M with history of drug abuse who is an OSH transfer for
obtundation, drug abuse, and concern for suicide attempt.
.
According to mother (although per OSH, she had changed the story
several times), pt was assaulted at a store yesterday and was
choked with the [**Doctor Last Name **] of his sweatshirt by 2 people assaulting
him. He was also sprayed in the face with mace and wallet
stollen. Later in the day, he was apparently cleaning a roasting
pan and cut his wrist on a knife that was in the pan while
reaching into it. Mother noticed he was acting different and
slurring his speech, he seems like "he aws on something" so she
called EMS and sent pt to OSH ED where he appeared "obtunded."
His initial vitals were BP 94/27, HR 72, RR 14, 93%RA. He was
intubated for airway protection. While at OSH ED, he had head CT
and CXR, CT cervical spine which were unremarkable. He was given
narcan x2 with minimal improvement in arrousal. Trop 0.03, [**Doctor First Name **]
neg, ETOH neg. Lactate 0.8. He was transfered to our ED for
further care.
.
In the [**Hospital1 18**] ED inital vitals were T 96.5, BP 102/46, HR 39-57,
18 Assist control, 500 TV, 5 PEEP, 18 F, Ppeak 21. GLASCOW
initialy 15 in [**Last Name (LF) **], [**Name8 (MD) **] RN report. FAST neg. Given bolues of
fent/versed. Given 3L IVF with 300cc total UO. He had CT
Cervical which was overall unremarkable. He had left wrist
laceration sp 6 sutures and tetanus vaccine. On exam, he was
found to have ligature mark on neck from likely recent
strangulation as well as what appeared to be cigerette burns
around his penis.
EKG and Tele notable for sinus bradycardia with HR 39-50s. He
was planned to be given 1g Ca Gluconate for possible BB/CCB
overdose but not given [**Name8 (MD) **] RN.
Urine positive for benzos, opiates, cocaine. (he was likely
given benzos and opiates for intubation, but cocaine is likely
recent intoxication). Recent vent settings: Assist control FiO2
50%, PEEP 5, Gas: 7.34/42/233/24.
.
On arrival to the ICU, pt follows commands, responds to his
name, opens his eyes, GLASCOW=15. He appears comfortable,
intubated. Has bruises/blood smear on knees bilaterally, neck
with sign of recent strangulation, left wrist with 6 stitches.

MEDICAL HISTORY: HCV
Drug abuser since age 19- heroin and cocaine (in a drug abuse
program x 14 mo)
Hospitalized 4 yrs ago for drug overdose
?Nerve damage
Genital Warts

MEDICATION ON ADMISSION: Neurontin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam
Vitals: BP: 115/57 P: 55 R: 18 O2:100%: AC, TV 500, FiO2 40%,
PEEP 4, Rate 19, PPeak 19.
General: responds/follows commands and name, no acute distress
HEENT: Sclera anicteric, MMM, intubated, neck with signs of
strangulation (rope mark).
Neck: supple, JVP not elevated, no LAD
Lungs: Bilateral breath sounds. Clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: Regular rate (bradycardic) 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: foley with urine output- 300 cc since arrival to ED. Has
genital warts on penis. Also with lesions on base of penis and
suprapubic area- chancre appearance.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: denied

SOCIAL HISTORY: -prior heroin and cocaine use, supposedly clean x 14 mo. Drug
abuse x 7 yrs.
-hospitalized 4 yrs ago for overdose
Spent some time in prison. 

### Response:
{'Poisoning by cocaine,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute respiratory failure,Drug-induced delirium,Poisoning by heroin,Poisoning by benzodiazepine-based tranquilizers,Poisoning by other antihypertensive agents,Open wound of wrist, without mention of complication,Hypoxemia,Cocaine abuse, unspecified,Chronic hepatitis C without mention of hepatic coma,Anemia, unspecified,Need for prophylactic vaccination and inoculation against tetanus toxoid alone,Condyloma acuminatum,Oliguria and anuria,Other specified cardiac dysrhythmias,Accidental poisoning by central nervous system stimulants,Accidental poisoning by heroin,Accidental poisoning by benzodiazepine-based tranquilizers,Accidental poisoning by agents primarily affecting cardiovascular system,Opioid type dependence, unspecified,Accidents caused by knives, swords, and daggers'}
