CHIEF COMPLAINT: Altered MS

PRESENT ILLNESS: Pt is a 51 year old African American woman with PMH sig for HTN
and hyperlipid with a remote hx of depression who was admitted
on [**2150-5-1**] after she was found unresponsive by her husband at
their home [**Name (NI) 2974**] evening. She reportedly went to her room that
evening to take a nap, which was not unusual, at around 5pm per
her children. Her husband checked on her at 8:15 pm and found
her unresponsive and (per medical chart)"foaming at the mouth."
She reportedly had multiple pill bottles out, but it was unclear
at that point how much she had taken. Pt psych who went through
the pills with the patient's husband, there were approx 70
Klonipin tabs missing, in addition to Nifedipine and
Amytriptiline tabs missing.
.
In the ED, VS HR 60s SBP 110-130s (No temp taken at that time).
Noted to be very lethargic and vomiting, and subsequently
intubated for airway protection. No ABG taken prior to
intubation. Pt given propofol for intubation. Pt had NG tube
placed, and charcoal was given. Labs were notable for a urine
tox (+) for benzodiazepines and TCAs. ABG taken after intubation
7.24/67/304 (Vent AC 550 x 15/PEEP 5/FiO2 100%). Pt then
transferred to the MICU. In the MICU she remained intubated for
obtundation. She was extubated on [**5-2**]. She then had a witnessed
aspiration and was started on Levo and Flagyl.
.
The patient is still unable to give a consistent story of why
she is in the hospital.  She reports that she fell off of a step
stool and hit her head. She also reports that she is in th
hospital for her pneumonia.  She ademently denies any overdose
on her medications as the reason she was admitted.  She denies
taking too many of her pills.  Per patient's nurse in the ICU,
who has been working with her for several days, after she was
extubated 2 days ago,
she did say that she took too many pills, but since then has
also stated that she took too many pills because she was having
pain in her foot which she broke one year ago.

MEDICAL HISTORY: HTN
Hyperchol
? depression/ anxiety
s/p surgical repaier for foot ankle fx. C/b staph infection.

MEDICATION ON ADMISSION: Amitriptyline
Clonidine
Lipitor
ASA
Nifedipine CR
Ambien
Toprol
Nitro tab
HCTZ
Tramadol

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS:
General: awake and alert. Pleasant and talkative. Obese.
HEENT: pupils 3mm b/l and reactive. anicteric, pink
conjunctivae. No LAD.
Heart: RRR s1 s2; no m/g/r
Lungs: Audible exp wheeze. Bronchial BS. No rales or rhonchi on
exam.
Abd: obese, soft, NT, ND, slightly hypoactive BS
Ext: warm, 1(+) radial/DP pulses B. R foot with well healed
scars and 1+ edema. L foot with trace edema.
Neuro: Awake and alert.
- Oriented x3
- CN II-12 intact
- Able to recall [**2-26**] objects
- Unable to spell world or perform serial 7 or 3's.
- Able to count backwards from 10.
- Aware of [**Country 2451**] war and current President. States former
President was [**Last Name (un) 38492**].

FAMILY HISTORY: DM

SOCIAL HISTORY: Lives with husband and 3 kids. Occ ETOH. 3 cig/d x 4 months. No
IVDU/no illicit drug use. Does not work.
Poisoning by benzodiazepine-based tranquilizers,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Acidosis,Other alteration of consciousness,Accidental poisoning by benzodiazepine-based tranquilizers,Anemia, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia
Pois-benzodiazepine tran,Acute respiratry failure,Food/vomit pneumonitis,Acidosis,Other alter consciousnes,Acc poisn-benzdiaz tranq,Anemia NOS,Hypertension NOS,Hyperlipidemia NEC/NOS
Admission Date:  [**2150-4-30**]              Discharge Date:   [**2150-5-6**]

Date of Birth:  [**2099-3-17**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Altered MS

Major Surgical or Invasive Procedure:

R subclavian central line placement
Intubation- no complications.


History of Present Illness:
Pt is a 51 year old African American woman with PMH sig for HTN
and hyperlipid with a remote hx of depression who was admitted
on [**2150-5-1**] after she was found unresponsive by her husband at
their home [**Name (NI) 2974**] evening. She reportedly went to her room that
evening to take a nap, which was not unusual, at around 5pm per
her children. Her husband checked on her at 8:15 pm and found
her unresponsive and (per medical chart)"foaming at the mouth."
She reportedly had multiple pill bottles out, but it was unclear
at that point how much she had taken. Pt psych who went through
the pills with the patient's husband, there were approx 70
Klonipin tabs missing, in addition to Nifedipine and
Amytriptiline tabs missing.
.
In the ED, VS HR 60s SBP 110-130s (No temp taken at that time).
Noted to be very lethargic and vomiting, and subsequently
intubated for airway protection. No ABG taken prior to
intubation. Pt given propofol for intubation. Pt had NG tube
placed, and charcoal was given. Labs were notable for a urine
tox (+) for benzodiazepines and TCAs. ABG taken after intubation
7.24/67/304 (Vent AC 550 x 15/PEEP 5/FiO2 100%). Pt then
transferred to the MICU. In the MICU she remained intubated for
obtundation. She was extubated on [**5-2**]. She then had a witnessed
aspiration and was started on Levo and Flagyl.
.
The patient is still unable to give a consistent story of why
she is in the hospital.  She reports that she fell off of a step
stool and hit her head. She also reports that she is in th
hospital for her pneumonia.  She ademently denies any overdose
on her medications as the reason she was admitted.  She denies
taking too many of her pills.  Per patient's nurse in the ICU,
who has been working with her for several days, after she was
extubated 2 days ago,
she did say that she took too many pills, but since then has
also stated that she took too many pills because she was having
pain in her foot which she broke one year ago.


Past Medical History:
HTN
Hyperchol
? depression/ anxiety
s/p surgical repaier for foot ankle fx. C/b staph infection.

Social History:
Lives with husband and 3 kids. Occ ETOH. 3 cig/d x 4 months. No
IVDU/no illicit drug use. Does not work.


Family History:
DM

Physical Exam:
VITALS:
General: awake and alert. Pleasant and talkative. Obese.
HEENT: pupils 3mm b/l and reactive. anicteric, pink
conjunctivae. No LAD.
Heart: RRR s1 s2; no m/g/r
Lungs: Audible exp wheeze. Bronchial BS. No rales or rhonchi on
exam.
Abd: obese, soft, NT, ND, slightly hypoactive BS
Ext: warm, 1(+) radial/DP pulses B. R foot with well healed
scars and 1+ edema. L foot with trace edema.
Neuro: Awake and alert.
- Oriented x3
- CN II-12 intact
- Able to recall [**2-26**] objects
- Unable to spell world or perform serial 7 or 3's.
- Able to count backwards from 10.
- Aware of [**Country 2451**] war and current President. States former
President was [**Last Name (un) 38492**].


Pertinent Results:
[**2150-4-30**] 10:00PM   GLUCOSE-128* UREA N-11 CREAT-1.1 SODIUM-139
POTASSIUM-5.7* CHLORIDE-104 TOTAL CO2-27 ANION GAP-14
[**2150-4-30**] 10:00PM   ALT(SGPT)-47* AST(SGOT)-60* CK(CPK)-276* ALK
PHOS-68 AMYLASE-116* TOT BILI-0.3
[**2150-4-30**] 10:00PM   LIPASE-26
[**2150-4-30**] 10:00PM   CK-MB-4 cTropnT-<0.01
[**2150-4-30**] 10:00PM   ALBUMIN-4.0 CALCIUM-7.9* PHOSPHATE-5.3*
MAGNESIUM-2.0
[**2150-4-30**] 10:00PM   ASA-NEG ETHANOL-NEG ACETMNPHN-6.0
bnzodzpn-NEG barbitrt-NEG tricyclic-POS
[**2150-4-30**] 10:00PM URINE  HOURS-RANDOM
[**2150-4-30**] 10:00PM URINE  UCG-NEGATIVE
[**2150-4-30**] 10:00PM URINE  bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2150-4-30**] 10:00PM   WBC-10.2 RBC-3.94* HGB-11.2* HCT-34.3*
MCV-87.1 MCH-28.3 MCHC-32.5 RDW-15.2
[**2150-4-30**] 10:00PM   NEUTS-82* BANDS-0 LYMPHS-14* MONOS-2 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2150-4-30**] 10:00PM   PLT SMR-NORMAL PLT COUNT-331
[**2150-4-30**] 10:00PM   PT-13.6* PTT-23.2 INR(PT)-1.2
[**2150-4-30**] 10:00PM   D-DIMER-288
[**2150-4-30**] 10:00PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2150-4-30**] 10:00PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.016
.
.
CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: No acute
intracranial hemorrhage is identified. There is no mass effect
or shift of normally midline structures. The lateral ventricles
are symmetric and nondilated. The [**Doctor Last Name 352**]-white differentiation is
preserved. There are tiny basal ganglia lacunes.

Bone windows demonstrate no evidence of fracture within the
surrounding osseous structures. The mastoid air cells are
normally pneumatized. There is a small amount of fluid within
the ethmoid air cells, and minimal mucosal thickening within the
right maxillary sinus. There appears to be proptosis.

IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Minimal mucosal thickening within the maxillary sinus and
fluid in the ethmoid sinuses, findings that could possibly
relate to mild sinusitis.
.
.
Post extubation CXR: The endotracheal tube and NG tube have both
been removed. A right subclavian central venous catheter remains
in place. There is an unusual sharp turn and a kink seen within
the mid portion of the line in the brachiocephalic vein.

There is mild cardiomegaly. Mediastinal contours are normal. The
aorta is slightly unfolded and tortuous. The lungs are clear.
Pulmonary vasculature is normal. There is no pneumothorax. The
osseous structures are unremarkable.

IMPRESSION:

Mild cardiomegaly with no radiographic evidence of acute
cardiopulmonary process. Interval extubation.
.
.


Brief Hospital Course:
ASSESSMENT:  A 51-year-old female admitted after found down with
respiratory failure, question benzo overdose, now stable with a
question of delirium.

1.  Respiratory failure:  The patient was intubated for airway
protection on admission secondary to question of an overdose.
AVG on admission was consistent with respiratory acidosis from
hyperventilation.  The patient had a questionable history of
asthma versus COPD.  She had an audible wheeze, but no wheeze on
exam.  The patient was continued on her albuterol and Atrovent
inhalers during her admission.  She was extubated after
approximately 48 hours.  After this, she had a witnessed
aspiration for which she was treated with levofloxacin and
Flagyl for 5 days.  Her respiratory status markedly improved by
the time of discharge and she was requiring no further
medications.  The patient states that she does not take inhalers
at home and therefore these were discontinued on discharge.

2.  Mental status changes/overdose:  On admission, the patient
had a positive tox screen for benzodiazepines, which were most
concerning for mental status changes.  The patient also had
positive tox screens for tricyclic acids, which she was known to
be taking for sleep.  An EKG was done in the ICU, which showed
mild QT prolongation, which resolved by the time of transfer to
a medicine floor.  All narcotics were held in both the ICU and
after the patient was transferred to the medicine floor.  Mental
status improved, however, the patient continued to deny the fact
that she overdosed.  The patient states after she awoke in the
ICU, that she had tripped on a stool in her bedroom and that is
why she was found down.  However, per reports from EMS, there
were pills all over the patient's bed.  The patient states that
these pills spilled when husband dragged her across the bed.
The patient's story persisted with multiple different interviews
by different physicians.  The patient was seen by psychiatry,
who felt that initially the patient was delirious; however, by
the time of discharge, she was no longer delirious and
maintained her story that she did not accidentally or
intentionally overdose on pills.  She states that occasionally
she will take extra Klonopin when she gets anxious.  She was
recently given the Klonopin for her anxiety by a psychiatrist
that she sees in the outpatient.  The patient was monitored by
psychiatry service throughout her admission, and felt that she
did not require an inpatient admission after she was medically
stable.  Her mental status did improve and per her family she
was at her baseline at the time of discharge.  The patient was
not discharged on any narcotics or benzodiazepines and was asked
to follow up with her outpatient psychiatrist for further
evaluation of the need for antianxiety medications.  The patient
denied any psych history and states that she was only taking the
Klonopin on rare occasion.

3.  LFTs abnormality:  Patient had elevated LFTs on admission,
but they trended down to normal on transfer from the ICU.  It
was felt that this may have been due to an element of shock
liver, and hypoperfusion while the patient was down.  Her
acetaminophen level was 6.

4.  Hypertension.  Patient has an extensive list of blood
pressure medications including clonidine 0.2 mg p.o. b.i.d.,
Lopressor 50 mg p.o. b.i.d., nifedipine 30 mg sustained release
p.o. once daily., and hydrochlorothiazide 20 mg p.o. once daily.
 The patient was maintained on this regimen and her blood
pressure was well controlled throughout her admission.

5.  Hyperlipidemia:  After her LFTs normalized, the patient was
restarted on her home dose of Lipitor.

6.  Status post foot surgery:  Upon further investigation of
this, the patient reports that she broke her foot approximately
1 year ago and the incision of the repair became infected.  She
was on a course of antibiotics and had severe pain.  She was
receiving pain medication for a while after this procedure,
however, she does report that she no longer takes pain
medications for it, however, still has pain in her foot.  All
pain medications were held during this admission due to her
mental status changes.  The patient also did not request further
pain medications during this admission.

7.  FEN.  The patient was maintained on a cardiac diet and her
electrolytes were repeated as needed.

The patient was a full code during this admission.


Medications on Admission:
Amitriptyline
Clonidine
Lipitor
ASA
Nifedipine CR
Ambien
Toprol
Nitro tab
HCTZ
Tramadol


Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Clonidine HCl 0.2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Home

Discharge Diagnosis:
Benzodiazepine overdose
Delirium


Discharge Condition:
Stable

Discharge Instructions:
Please return to the hospital if you experience shortness of
breath, chest pain, severe nausea/vomiting/diarrhea or any other
severe symptoms. Please return to the hospital or call your
doctor if you are feeling any symptoms of depression. Please
call your doctor is you have any questions about your symptoms.
- Please go to your follow-up appointment with Dr. [**First Name (STitle) 4135**] on
[**2150-5-7**] at 11am.

Followup Instructions:
Please follow-up with your Psychiatrist on [**2150-5-7**] at
11am.
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**12-28**] weeks.
{'Poisoning by benzodiazepine-based tranquilizers,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Acidosis,Other alteration of consciousness,Accidental poisoning by benzodiazepine-based tranquilizers,Anemia, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}


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 MS

PRESENT ILLNESS: Pt is a 51 year old African American woman with PMH sig for HTN
and hyperlipid with a remote hx of depression who was admitted
on [**2150-5-1**] after she was found unresponsive by her husband at
their home [**Name (NI) 2974**] evening. She reportedly went to her room that
evening to take a nap, which was not unusual, at around 5pm per
her children. Her husband checked on her at 8:15 pm and found
her unresponsive and (per medical chart)"foaming at the mouth."
She reportedly had multiple pill bottles out, but it was unclear
at that point how much she had taken. Pt psych who went through
the pills with the patient's husband, there were approx 70
Klonipin tabs missing, in addition to Nifedipine and
Amytriptiline tabs missing.
.
In the ED, VS HR 60s SBP 110-130s (No temp taken at that time).
Noted to be very lethargic and vomiting, and subsequently
intubated for airway protection. No ABG taken prior to
intubation. Pt given propofol for intubation. Pt had NG tube
placed, and charcoal was given. Labs were notable for a urine
tox (+) for benzodiazepines and TCAs. ABG taken after intubation
7.24/67/304 (Vent AC 550 x 15/PEEP 5/FiO2 100%). Pt then
transferred to the MICU. In the MICU she remained intubated for
obtundation. She was extubated on [**5-2**]. She then had a witnessed
aspiration and was started on Levo and Flagyl.
.
The patient is still unable to give a consistent story of why
she is in the hospital.  She reports that she fell off of a step
stool and hit her head. She also reports that she is in th
hospital for her pneumonia.  She ademently denies any overdose
on her medications as the reason she was admitted.  She denies
taking too many of her pills.  Per patient's nurse in the ICU,
who has been working with her for several days, after she was
extubated 2 days ago,
she did say that she took too many pills, but since then has
also stated that she took too many pills because she was having
pain in her foot which she broke one year ago.

MEDICAL HISTORY: HTN
Hyperchol
? depression/ anxiety
s/p surgical repaier for foot ankle fx. C/b staph infection.

MEDICATION ON ADMISSION: Amitriptyline
Clonidine
Lipitor
ASA
Nifedipine CR
Ambien
Toprol
Nitro tab
HCTZ
Tramadol

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS:
General: awake and alert. Pleasant and talkative. Obese.
HEENT: pupils 3mm b/l and reactive. anicteric, pink
conjunctivae. No LAD.
Heart: RRR s1 s2; no m/g/r
Lungs: Audible exp wheeze. Bronchial BS. No rales or rhonchi on
exam.
Abd: obese, soft, NT, ND, slightly hypoactive BS
Ext: warm, 1(+) radial/DP pulses B. R foot with well healed
scars and 1+ edema. L foot with trace edema.
Neuro: Awake and alert.
- Oriented x3
- CN II-12 intact
- Able to recall [**2-26**] objects
- Unable to spell world or perform serial 7 or 3's.
- Able to count backwards from 10.
- Aware of [**Country 2451**] war and current President. States former
President was [**Last Name (un) 38492**].

FAMILY HISTORY: DM

SOCIAL HISTORY: Lives with husband and 3 kids. Occ ETOH. 3 cig/d x 4 months. No
IVDU/no illicit drug use. Does not work. 

### Response:
{'Poisoning by benzodiazepine-based tranquilizers,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Acidosis,Other alteration of consciousness,Accidental poisoning by benzodiazepine-based tranquilizers,Anemia, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}
