CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: 57F w/ ESRD on hemodialysis and HCV cirrhosis who presents with
altered mental status. Family unable to get in touch with her,
called 911. Found lying in bed lethargic, responsive but
somnolent, last HD Monday did not get HD today, no c/o pain,
gluc=171. EMS brought to ED.
.
In the ED on arrival VS were T 98, HR 80, BP 163/95, RR 16, SpO2
100%/RA. She was unresponsive on exam. ABG was normal. Narcan
given without improvement. Labs significant for K 5.7, BUN/Cr
36/7.5, lactate 2.2, hct 31.1. EKG: SR at 78, NA/NI, TWI in III
and aVF, TWI V1-V5, c/w prior. CXR, CT Head and CT abdomen
showed no acute pathology. Renal was called, and plan to take
her for HD tomorrow. She was given vanc/zosyn for possible
infectious cause of AMS. After several hours in ED, patient woke
up, and is now droswy but arousable, AAO x 3, and answering
questions appropriately. VS on transfer were 97.3 78 125/70 16
100/ra.
.
On the floor, patient is alert and coversant. She complains of
back which is chronic. She also has some nasal congestion and
thinks she is getting a cold.

MEDICAL HISTORY: -HTN
-ESRD on hemodialysis
-HCV cirrhosis
-spinal stenosis with back pain
-seizure disorder
-depression
-hypothyroidism
-substance abuse
-Lumbar laminectomy
-status post failed renal transplant
-cholecystectomy
-thyroidectomy
-Rt ovarian mass

MEDICATION ON ADMISSION: 1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS - Temp 98.1 F, BP 135/72, HR 73, R 18, O2-sat 100% RA
GENERAL - pt is lethargic but a well-appearing female in NAD,
comfortable
HEENT - NC/AT, EOMI
NECK - supple, no JVD, no carotid bruits, RIJ CVL in place
LUNGS - CTA bilat, no abnormal breath sounds appreciated, good
air movement, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft, mild ttp in rlq, ruq, bs +
EXTREMITIES - no clubbing, cyanosis, edema, RUE AVF.
SKIN - no rashes or lesions
NEURO - awake but lethargic, A&Ox3, CNs II-XII grossly intact,
+ asterixis
.
Discharge:
GENERAL - pt is lethargic but a well-appearing female in NAD,
comfortable
HEENT - NC/AT, EOMI
NECK - supple, no JVD, no carotid bruits, RIJ CVL in place
LUNGS - CTA bilat, no abnormal breath sounds appreciated, good
air movement, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft, mild ttp in rlq, ruq, bs +
EXTREMITIES - no clubbing, cyanosis, edema, RUE AVF.
SKIN - no rashes or lesions
NEURO - awake but lethargic, A&Ox3, CNs II-XII grossly intact,
no asterixis

FAMILY HISTORY: Father: ESRD and hypertension
Mother: lung cancer

SOCIAL HISTORY: Retired special education teacher. Widowed, lives at home with
sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy.
# Tobacco: 3 packs per week since teenager
# Alcohol: Denies
# Drugs: Past IVDU, but not in several years
Toxic encephalopathy,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Complications of transplanted kidney,Other alteration of consciousness,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Other opiates and related narcotics causing adverse effects in therapeutic use,Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use,Unspecified drug or medicinal substance causing adverse effects in therapeutic use,Renal dialysis status,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Spinal stenosis, unspecified region,Epilepsy, unspecified, without mention of intractable epilepsy,Depressive disorder, not elsewhere classified,Postsurgical hypothyroidism,Opioid type dependence, in remission,Neoplasm of unspecified nature of other genitourinary organs,Tobacco use disorder
Toxic encephalopathy,End stage renal disease,Hyp kid NOS w cr kid V,Compl kidney transplant,Other alter consciousnes,Adv eff antconvl NEC/NOS,Adv eff opiates,Adv eff benzodiaz tranq,Adv eff medicinal NOS,Renal dialysis status,Abn react-org transplant,Hpt C w/o hepat coma NOS,Cirrhosis of liver NOS,Spinal stenosis NOS,Epilep NOS w/o intr epil,Depressive disorder NEC,Postsurgical hypothyroid,Opioid dependence-remiss,Other gu neoplasm NOS,Tobacco use disorder
Admission Date:  [**2129-8-31**]              Discharge Date:   [**2129-9-2**]

Date of Birth:  [**2072-5-1**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Doctor First Name 2080**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
R IJ central line placement


History of Present Illness:
57F w/ ESRD on hemodialysis and HCV cirrhosis who presents with
altered mental status. Family unable to get in touch with her,
called 911. Found lying in bed lethargic, responsive but
somnolent, last HD Monday did not get HD today, no c/o pain,
gluc=171. EMS brought to ED.
.
In the ED on arrival VS were T 98, HR 80, BP 163/95, RR 16, SpO2
100%/RA. She was unresponsive on exam. ABG was normal. Narcan
given without improvement. Labs significant for K 5.7, BUN/Cr
36/7.5, lactate 2.2, hct 31.1. EKG: SR at 78, NA/NI, TWI in III
and aVF, TWI V1-V5, c/w prior. CXR, CT Head and CT abdomen
showed no acute pathology. Renal was called, and plan to take
her for HD tomorrow. She was given vanc/zosyn for possible
infectious cause of AMS. After several hours in ED, patient woke
up, and is now droswy but arousable, AAO x 3, and answering
questions appropriately. VS on transfer were 97.3 78 125/70 16
100/ra.
.
On the floor, patient is alert and coversant. She complains of
back which is chronic. She also has some nasal congestion and
thinks she is getting a cold.


Past Medical History:
-HTN
-ESRD on hemodialysis
-HCV cirrhosis
-spinal stenosis with back pain
-seizure disorder
-depression
-hypothyroidism
-substance abuse
-Lumbar laminectomy
-status post failed renal transplant
-cholecystectomy
-thyroidectomy
-Rt ovarian mass

Social History:
Retired special education teacher. Widowed, lives at home with
sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy.
# Tobacco: 3 packs per week since teenager
# Alcohol: Denies
# Drugs: Past IVDU, but not in several years


Family History:
Father: ESRD and hypertension
Mother: lung cancer


Physical Exam:
VS - Temp 98.1 F, BP 135/72, HR 73, R 18, O2-sat 100% RA
GENERAL - pt is lethargic but a well-appearing female in NAD,
comfortable
HEENT - NC/AT, EOMI
NECK - supple, no JVD, no carotid bruits, RIJ CVL in place
LUNGS - CTA bilat, no abnormal breath sounds appreciated, good
air movement, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft, mild ttp in rlq, ruq, bs +
EXTREMITIES - no clubbing, cyanosis, edema, RUE AVF.
SKIN - no rashes or lesions
NEURO - awake but lethargic, A&Ox3, CNs II-XII grossly intact,
+ asterixis
.
Discharge:
GENERAL - pt is lethargic but a well-appearing female in NAD,
comfortable
HEENT - NC/AT, EOMI
NECK - supple, no JVD, no carotid bruits, RIJ CVL in place
LUNGS - CTA bilat, no abnormal breath sounds appreciated, good
air movement, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft, mild ttp in rlq, ruq, bs +
EXTREMITIES - no clubbing, cyanosis, edema, RUE AVF.
SKIN - no rashes or lesions
NEURO - awake but lethargic, A&Ox3, CNs II-XII grossly intact,
no asterixis


Brief Hospital Course:
57F w/ ESRD on hemodialysis and HCV cirrhosis who presents with
altered mental status. Family unable to get in touch with her,
called 911. Found lying in bed lethargic, responsive but
somnolent, admitted and ms improved.
.
#ACUTE METABOLIC ENCEPHALOPATHY: Pt was initially found
unresponsive by EMS with  pinpoint pupils, garbled speech and
hypotensive. Concern that this was due to possible opioid
overdose given clinical improvement with narcan in the ED,
however improvement was not immediate (took over an hour post
narcan administration) and pt did not exhibit withdrawal
symptoms after narcan.  Pt does have history of seizures and it
is possible that she had a seizure and AMS was a post ictal
state.  She denies missing any doses of keppra.  Most likely
explanation is polypharmacy in the setting of ESRD.  She has
been prescribed many sedating medications (gabapentin,
hydromorphone, clonazepam, trazadone) in the past.  Infectious
workup was negative and pt was not hypoxic.  Electrolytes were
remarkable for K 5.7, BUN/Cr 36/7.5, lactate 2.2, hct 31.1. EKG:
SR at 78, NA/NI, TWI in III and aVF, TWI V1-V5, and CE were
flat, repeat ekg was normal and repeat CE unchanged. CXR, CT
Head and CT abdomen showed no acute pathology.  After dialysis
and day in hospital pt's mental status was at baseline.  She is
encouraged to only take medications as prescribed from discharge
medication list.  She was also sent home with VNA services to
assist with discarding non-active medications.  A letter was
sent to pt's methadone clinic to inform them of hospitalization.

.
#SEIZURE DISORDER:  Pt could have had a seizure and post-ictal
state caused her to be somnolent and difficult to arouse as
discussed above.  She reports that she has been taking home
Keppra dose and has not missed any doses.  A follow up appt with
neurology was made and pt was encouraged not to operate a motor
vehicle for at least 6 months or until she gets clearance from
her neurologist.
.
#RENAL FAILURE/CKD V: Pt's BUN:Cr were extremely elevated on
admission as would be expected for someone that missed dialysis
the prior day.  Pt's nephrologist reports that he does not
believe that AMS was from euremia, rather it is more likely [**2-16**]
polypharmacy as mentioned above.  Pt's renal function improved
after dialysis and she was discharged on home medications and
normal dialysis schedule.
.
#CHRONIC BACK/LEG PAIN: chronic back pain for years with
multiple back surgeries.  Pt's pain and use of pain medications
likely is contributing to her AMS.  At time of discharge she was
continued on home gabapentin renally dosed.
.
Transitional:
Pt will need to follow up with PCP and neurology within next
several weeks.
Will have VNA assist in removing non-active medications from
home

Medications on Admission:
1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:

One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every

48 hours).
5. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. levothyroxine 100 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. levothyroxine 88 mcg Capsule Sig: One (1) Capsule PO once a
day.
8. methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble

PO once a day.
9. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).

Discharge Medications:
1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. levothyroxine 100 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. levothyroxine 88 mcg Capsule Sig: One (1) Capsule PO once a
day.
7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. methadone 10 mg/mL Concentrate Sig: Forty Six (46) mg PO
DAILY (Daily): being tapered, managed at methadone clinic.
[**Telephone/Fax (1) 10953**].
9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO q48h.


Discharge Disposition:
Home With Service

Facility:
Care Group VNA

Discharge Diagnosis:
altered mental status
polypharmacy
ESRD


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


Discharge Instructions:
Dear Mrs [**First Name8 (NamePattern2) **] [**Known lastname 3671**],

It was a pleasure taking care of you.  You were admitted to the
hospital because you were found by EMS and you were confused and
difficult to arouse.  We believe that this happened because you
might not be taking your medications properly.  We have reviewed
your medication list and noticed that you have been prescibed
some very sedating medications in the past.  Given that you are
on dialysis, many of these medications can build up in your
blood and cause confusion or oversedation.
.
We have provided you with a list of medications below.
DO NOT TAKE MEDICATIONS NOT ON THIS LIST. Don't take clonazepam,
trazodone or hydromorphone. These medications have been
discontinued because we are concerned that they are contributing
to your altered mental status.
.
There is a possibility that you could have had a seizure as
well.  We have set you up with a neurology appointment so that
your medications can be properly dosed.  Please do not operate a
car or heavy machinery for at least six months.
.
We will be giving you a letter to present to [**Location (un) 86**] Independent
Care in efforts to speed up the process of attaining services
from them.
.
Please bring all of this paperwork with you to the methadone
clinic when you go there next.

Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2129-9-8**] at 2:20 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: NEUROLOGY
When: THURSDAY [**2129-9-15**] at 1 PM
With: [**First Name11 (Name Pattern1) 4092**] [**Last Name (NamePattern1) 4093**], MD [**Telephone/Fax (1) 2574**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Toxic encephalopathy,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Complications of transplanted kidney,Other alteration of consciousness,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Other opiates and related narcotics causing adverse effects in therapeutic use,Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use,Unspecified drug or medicinal substance causing adverse effects in therapeutic use,Renal dialysis status,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Spinal stenosis, unspecified region,Epilepsy, unspecified, without mention of intractable epilepsy,Depressive disorder, not elsewhere classified,Postsurgical hypothyroidism,Opioid type dependence, in remission,Neoplasm of unspecified nature of other genitourinary organs,Tobacco use disorder'}


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: altered mental status

PRESENT ILLNESS: 57F w/ ESRD on hemodialysis and HCV cirrhosis who presents with
altered mental status. Family unable to get in touch with her,
called 911. Found lying in bed lethargic, responsive but
somnolent, last HD Monday did not get HD today, no c/o pain,
gluc=171. EMS brought to ED.
.
In the ED on arrival VS were T 98, HR 80, BP 163/95, RR 16, SpO2
100%/RA. She was unresponsive on exam. ABG was normal. Narcan
given without improvement. Labs significant for K 5.7, BUN/Cr
36/7.5, lactate 2.2, hct 31.1. EKG: SR at 78, NA/NI, TWI in III
and aVF, TWI V1-V5, c/w prior. CXR, CT Head and CT abdomen
showed no acute pathology. Renal was called, and plan to take
her for HD tomorrow. She was given vanc/zosyn for possible
infectious cause of AMS. After several hours in ED, patient woke
up, and is now droswy but arousable, AAO x 3, and answering
questions appropriately. VS on transfer were 97.3 78 125/70 16
100/ra.
.
On the floor, patient is alert and coversant. She complains of
back which is chronic. She also has some nasal congestion and
thinks she is getting a cold.

MEDICAL HISTORY: -HTN
-ESRD on hemodialysis
-HCV cirrhosis
-spinal stenosis with back pain
-seizure disorder
-depression
-hypothyroidism
-substance abuse
-Lumbar laminectomy
-status post failed renal transplant
-cholecystectomy
-thyroidectomy
-Rt ovarian mass

MEDICATION ON ADMISSION: 1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS - Temp 98.1 F, BP 135/72, HR 73, R 18, O2-sat 100% RA
GENERAL - pt is lethargic but a well-appearing female in NAD,
comfortable
HEENT - NC/AT, EOMI
NECK - supple, no JVD, no carotid bruits, RIJ CVL in place
LUNGS - CTA bilat, no abnormal breath sounds appreciated, good
air movement, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft, mild ttp in rlq, ruq, bs +
EXTREMITIES - no clubbing, cyanosis, edema, RUE AVF.
SKIN - no rashes or lesions
NEURO - awake but lethargic, A&Ox3, CNs II-XII grossly intact,
+ asterixis
.
Discharge:
GENERAL - pt is lethargic but a well-appearing female in NAD,
comfortable
HEENT - NC/AT, EOMI
NECK - supple, no JVD, no carotid bruits, RIJ CVL in place
LUNGS - CTA bilat, no abnormal breath sounds appreciated, good
air movement, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft, mild ttp in rlq, ruq, bs +
EXTREMITIES - no clubbing, cyanosis, edema, RUE AVF.
SKIN - no rashes or lesions
NEURO - awake but lethargic, A&Ox3, CNs II-XII grossly intact,
no asterixis

FAMILY HISTORY: Father: ESRD and hypertension
Mother: lung cancer

SOCIAL HISTORY: Retired special education teacher. Widowed, lives at home with
sister, who is primary caregiver. [**Name (NI) **] one son, who is healthy.
# Tobacco: 3 packs per week since teenager
# Alcohol: Denies
# Drugs: Past IVDU, but not in several years 

### Response:
{'Toxic encephalopathy,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Complications of transplanted kidney,Other alteration of consciousness,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Other opiates and related narcotics causing adverse effects in therapeutic use,Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use,Unspecified drug or medicinal substance causing adverse effects in therapeutic use,Renal dialysis status,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Spinal stenosis, unspecified region,Epilepsy, unspecified, without mention of intractable epilepsy,Depressive disorder, not elsewhere classified,Postsurgical hypothyroidism,Opioid type dependence, in remission,Neoplasm of unspecified nature of other genitourinary organs,Tobacco use disorder'}
