CHIEF COMPLAINT: Valproic acid overdose

PRESENT ILLNESS: This is a 32 year old woman w/ h/o bipolar disorder, anxiety,
ETOH, heroin abuse transferred from OSH for valproic acid
overdose.
.
She was initially found unresponsive in the bathroom by her
father.  She had vomited and was laying on the ground. She was
not answering questions and EMS was called. An empty bottle of
valproic acid was found.  She was taken to OSH, where her labs
were notable for: Valproic acid 170, bicarbonate 16, ammonia was
1359, ETOH 48, salicalyte/tylenol negative and anion gap of 21.
She received lactulose and ativan, and was transferred to [**Hospital1 18**].

MEDICAL HISTORY: -Depression
-ETOH dependence
-Marijuana Abuse
-Tobacco Abuse
-s/p 2 c-sections
-s/p internal anal sphincterotomy

MEDICATION ON ADMISSION: Unclear which medications patient is taking, the following have
been noted:
Geodon
Lithium
Valproic acid
Chlorpromazine
Benztropine
Cymbalta
Naltrexone
Seroquel
Propranolol

ALLERGIES: SSRI

PHYSICAL EXAM: Adm PE:
General: intubated
HEENT: Sclera anicteric, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
.
Discharge PE:
Vitals: 98.2 95/49 55 18 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, PERRL, oropharynx with erythema,
few palatal hemorrhages likely related to recent intubation
Neck: supple, mild cervical [**Doctor First Name **], some tenderness of
submandibular area.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mild tenderness to palpation in epigastric
region.  non-distended, bowel sounds present, no organomegaly,
no peritoneal signs, no rebound or guarding.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes

FAMILY HISTORY: Alcoholism, no history of gallstones

SOCIAL HISTORY: - Tobacco: [**1-25**] PPD
- Alcohol: Drinks 2 pints per day, most recent drink on Sunday
per the pt.
- Illicits: iv heroin has been documented in past, pt denies
current use.
Poisoning by other and unspecified anticonvulsants,Alcohol withdrawal,Drug-induced delirium,Disorders of urea cycle metabolism,Acidosis,Other alteration of consciousness,Suicide and self-inflicted poisoning by other specified drugs and medicinal substances,Bipolar disorder, unspecified,Opioid abuse, unspecified,Hypocalcemia,Other and unspecified alcohol dependence, unspecified,Throat pain,Tension headache,Abdominal pain, epigastric,Other postprocedural status
Pois-anticonvul NEC/NOS,Alcohol withdrawal,Drug-induced delirium,Dis urea cycle metabol,Acidosis,Other alter consciousnes,Poison-drug/medicin NEC,Bipolar disorder NOS,Opioid abuse-unspec,Hypocalcemia,Alcoh dep NEC/NOS-unspec,Throat pain,Tension headache,Abdmnal pain epigastric,Post-proc states NEC
Admission Date:  [**2150-11-15**]              Discharge Date:   [**2150-11-18**]

Date of Birth:  [**2118-6-9**]             Sex:   F

Service: MEDICINE

Allergies:
SSRI

Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Valproic acid overdose

Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
This is a 32 year old woman w/ h/o bipolar disorder, anxiety,
ETOH, heroin abuse transferred from OSH for valproic acid
overdose.
.
She was initially found unresponsive in the bathroom by her
father.  She had vomited and was laying on the ground. She was
not answering questions and EMS was called. An empty bottle of
valproic acid was found.  She was taken to OSH, where her labs
were notable for: Valproic acid 170, bicarbonate 16, ammonia was
1359, ETOH 48, salicalyte/tylenol negative and anion gap of 21.
She received lactulose and ativan, and was transferred to [**Hospital1 18**].

.
At [**Hospital1 18**] ED, initial VS were: HR 92, RR 17, BP 113/62, 100% RA.
She was intubated for airway protection. Toxicology was
consulted who recommended activated charcoal, l-carnatine. Her
ECG was sinus tachycardia, Qtc 428. Her labs were notable for:
ammonia 59, inr 1.3, alt/ast [**10-8**], tbili 0.2, hco 18, AG 19,
serium tox neg for asa/etoh/tylenol/benzo/barb/tca, valproate
150, abg 7.37/32/511, lactate 4.9. She received 20gm activated
charcoal, loading dose of l-carnatine iv, and NS. Current vent
settings: FiO2 100%, 450, 20, 5.
.
In the MICU, pt l-carnatine was continued, and Toxicology
recommended stopping after ammonia and valproate levels
continued to trend downward.  She had an elevated lactate that
improved with IVF.  She was successfully extubated on [**11-16**], and
she was placed on an ativan CIWA scale and given a bannana bag
given her h/o Etoh abuse.  A psychiatry consult was ordered, and
the patient was started on a 1:1.
.
On the floor, patient complaining of some throat pain that has
been present since extubation. She also notes some mild
epigastric discomfort. When asked to describe the pain, she
states that it feels more like she wants to throw up than it
does actual pain.  She denies fevers/chills, congestion.  She
states she had not been feeling sick recently.


Past Medical History:
-Depression
-ETOH dependence
-Marijuana Abuse
-Tobacco Abuse
-s/p 2 c-sections
-s/p internal anal sphincterotomy


Social History:
- Tobacco: [**1-25**] PPD
- Alcohol: Drinks 2 pints per day, most recent drink on Sunday
per the pt.
- Illicits: iv heroin has been documented in past, pt denies
current use.

Family History:
Alcoholism, no history of gallstones

Physical Exam:
Adm PE:
General: intubated
HEENT: Sclera anicteric, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
.
Discharge PE:
Vitals: 98.2 95/49 55 18 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, PERRL, oropharynx with erythema,
few palatal hemorrhages likely related to recent intubation
Neck: supple, mild cervical [**Doctor First Name **], some tenderness of
submandibular area.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mild tenderness to palpation in epigastric
region.  non-distended, bowel sounds present, no organomegaly,
no peritoneal signs, no rebound or guarding.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes


Pertinent Results:
Adm labs:
[**2150-11-15**] 08:45PM   PLT COUNT-199
[**2150-11-15**] 08:45PM   NEUTS-76.9* LYMPHS-18.3 MONOS-3.7 EOS-0.2
BASOS-0.8
[**2150-11-15**] 08:45PM   WBC-10.3# RBC-4.54# HGB-14.2# HCT-39.5
MCV-87# MCH-31.3 MCHC-36.0*# RDW-12.9
[**2150-11-15**] 08:45PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-11-15**] 08:45PM   VALPROATE-150*
[**2150-11-15**] 08:45PM   CALCIUM-9.1 PHOSPHATE-3.0 MAGNESIUM-1.8
[**2150-11-15**] 08:45PM   ALT(SGPT)-9 AST(SGOT)-15 LD(LDH)-195 ALK
PHOS-57 TOT BILI-0.2
[**2150-11-15**] 08:45PM   estGFR-Using this
[**2150-11-15**] 08:45PM   GLUCOSE-88 UREA N-10 CREAT-0.9 SODIUM-143
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-18* ANION GAP-23*
[**2150-11-15**] 09:09PM   PT-14.7* PTT-20.6* INR(PT)-1.3*
[**2150-11-15**] 09:09PM   AMMONIA-59
[**2150-11-15**] 09:12PM URINE  RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-1
[**2150-11-15**] 09:12PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2150-11-15**] 09:12PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2150-11-15**] 09:12PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2150-11-15**] 09:12PM URINE  UCG-NEGATIVE
[**2150-11-15**] 09:12PM URINE  HOURS-RANDOM
[**2150-11-15**] 09:21PM   LACTATE-4.9*
[**2150-11-15**] 09:21PM   TYPE-ART TEMP-36.8 RATES-/20 TIDAL VOL-450 O2
FLOW-100 PO2-511* PCO2-32* PH-7.37 TOTAL CO2-19* BASE XS--5
INTUBATED-INTUBATED VENT-CONTROLLED
.
Discharge labs:
[**2150-11-17**] 06:50AM BLOOD WBC-7.3 RBC-3.69* Hgb-11.1* Hct-32.5*
MCV-88 MCH-30.1 MCHC-34.1 RDW-12.1 Plt Ct-168
[**2150-11-16**] 12:39AM BLOOD PT-14.0* INR(PT)-1.2*
[**2150-11-17**] 06:50AM BLOOD Glucose-95 UreaN-5* Creat-0.6 Na-139
K-3.5 Cl-106 HCO3-23 AnGap-14
[**2150-11-15**] 08:45PM BLOOD ALT-9 AST-15 LD(LDH)-195 AlkPhos-57
TotBili-0.2
[**2150-11-17**] 06:50AM BLOOD Amylase-37
[**2150-11-17**] 06:50AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.8
[**2150-11-17**] 06:50AM BLOOD Ammonia-33
[**2150-11-17**] 06:50AM BLOOD Valproa-30*
[**2150-11-16**] 05:20AM BLOOD Type-ART pO2-146* pCO2-31* pH-7.41
calTCO2-20* Base XS--3
.
Studies:
Chest xray: The endotracheal tube is above the thoracic inlet,
6.6 cm above the carina and can be advanced for more optimal
placement. An enteric feeding tube terminates within the mid
esophagus and should be advanced for more optimal positioning.
The lungs are clear. There are no pleural effusions or
pneumothorax. The cardiomediastinal and hilar contours are
normal. Pulmonary vascularity is normal.

IMPRESSION: Support lines as described with endotracheal tube
above the
thoracic inlet and enteric feeding tube within the mid
esophagus, both of
which could be advanced for more optimal positioning.
.


Brief Hospital Course:
Summary: 32 yo F w/ h/o bipolar disorder, anxiety, ETOH abuse
transferred from OSH for valproic acid overdose.
.
# Overdose, unresponsiveness: In the MICU, Valproic acid and
ammonia levels trended down after patient received L-carnitine.
Remainder of tox screen was negative.  Lactate, AG acidosis
trended down after getting ivfs.  Patient was extubated on
hospital day 2 and transferred to the floor, where her ammonia
and valproic acid levels continued to decline.  Patient denies
any memory of ingesting anything.
.
# Suicide Attempt / Bipolar disorder with predominant
depression:  Initially medications were held at the
recommendation of the consult psychiatry team.  Seroquel was
started on hospital day 3.  The pt was kept section 12 with a
1:1 sitter.  She was transferred to a psychiatry floor when
medically stable, for further treatment of her depression.
.
# Etoh abuse: Pt with significant alcohol use.  CIWA protocol
was used, pt intially [**Doctor Last Name **] for withdrawal, later for anxiety
related to her underlying psychiatry diagnosis and a headache
felt to be tension headache.  Thiamine, folate, and MVI were
initiated. She will continue to be monitored for withdrawal on
the psychiatry unit.
.
# Epigastric pain:  Gerd/gastritis were possibilities.  Was
improving with tylenol.  Amylase and lipase were normal, and she
tolerated a full diet prior to discharge to psychiatry.
.
# Headache: Tension headache, improved with tylenol. Initially
treated with ibuprofen as well as tylenol, but this was stopped
given the concern for gastritis.
.
----
Transitional issues:
.
# O/D:  Pt does not remember taking, does have history of
suicide attempt in past.
.
# Abdominal pain: Likely related to gastritis or reflux, treated
conservatively with tylenol. Try to avoid NSAID use given
gastritis concern.  Started on ranitidine, consider stopping
when symptoms have resolved.
.
# Tension Headache:  Treated with tylenol.
.
# Alcohol withdrawal:  Intially in withdrawal, later was [**Doctor Last Name **]
on CIWA for anxiety and headache, likely unrelated to alcohol
withdrawal.
.
# Medication reconcilliation:  Unclear what regimen pt was
currently on.  She will need titration of her psychiatric
medications while on the psychiatry floor.  At the consult
team's rec, pt received seroquel 150mg QHS to help with sleep.

Medications on Admission:
Unclear which medications patient is taking, the following have
been noted:
Geodon
Lithium
Valproic acid
Chlorpromazine
Benztropine
Cymbalta
Naltrexone
Seroquel
Propranolol


Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. quetiapine 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
5. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.

7. Valium 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as
needed for CIWA >10.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] 4

Discharge Diagnosis:
Valproic Acid overdose
Alcohol abuse and withdrawal
Bipolar disorder


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


Discharge Instructions:
You were admitted after an overdose of valproic acid.  We gave
you medications to lower these levels.  You required a breathing
tube because of your sleepiness and to protect your airway
(breathing).
.
You were also withdrawing from alcohol, so we gave you
medication to treat this.
.
You were transferred to a psychiatry floor to help with your
bipolar disorder, and to help make sure to get you on the right
medications to best help you feel better.
.
For your abdominal pain, you should START
-Ranitidine 150mg daily
-Tylenol 1g every 6 hours as needed for belly pain or headache.
Do NOT take more than 4g daily.
-Thiamine, a multivitamin, and folic acid.  These medications
will help supplement your nutrition.

Followup Instructions:
Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week of being discharged
from the hospital.


Completed by:[**2150-11-18**]
{'Poisoning by other and unspecified anticonvulsants,Alcohol withdrawal,Drug-induced delirium,Disorders of urea cycle metabolism,Acidosis,Other alteration of consciousness,Suicide and self-inflicted poisoning by other specified drugs and medicinal substances,Bipolar disorder, unspecified,Opioid abuse, unspecified,Hypocalcemia,Other and unspecified alcohol dependence, unspecified,Throat pain,Tension headache,Abdominal pain, epigastric,Other postprocedural status'}


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: Valproic acid overdose

PRESENT ILLNESS: This is a 32 year old woman w/ h/o bipolar disorder, anxiety,
ETOH, heroin abuse transferred from OSH for valproic acid
overdose.
.
She was initially found unresponsive in the bathroom by her
father.  She had vomited and was laying on the ground. She was
not answering questions and EMS was called. An empty bottle of
valproic acid was found.  She was taken to OSH, where her labs
were notable for: Valproic acid 170, bicarbonate 16, ammonia was
1359, ETOH 48, salicalyte/tylenol negative and anion gap of 21.
She received lactulose and ativan, and was transferred to [**Hospital1 18**].

MEDICAL HISTORY: -Depression
-ETOH dependence
-Marijuana Abuse
-Tobacco Abuse
-s/p 2 c-sections
-s/p internal anal sphincterotomy

MEDICATION ON ADMISSION: Unclear which medications patient is taking, the following have
been noted:
Geodon
Lithium
Valproic acid
Chlorpromazine
Benztropine
Cymbalta
Naltrexone
Seroquel
Propranolol

ALLERGIES: SSRI

PHYSICAL EXAM: Adm PE:
General: intubated
HEENT: Sclera anicteric, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
.
Discharge PE:
Vitals: 98.2 95/49 55 18 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, PERRL, oropharynx with erythema,
few palatal hemorrhages likely related to recent intubation
Neck: supple, mild cervical [**Doctor First Name **], some tenderness of
submandibular area.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mild tenderness to palpation in epigastric
region.  non-distended, bowel sounds present, no organomegaly,
no peritoneal signs, no rebound or guarding.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes

FAMILY HISTORY: Alcoholism, no history of gallstones

SOCIAL HISTORY: - Tobacco: [**1-25**] PPD
- Alcohol: Drinks 2 pints per day, most recent drink on Sunday
per the pt.
- Illicits: iv heroin has been documented in past, pt denies
current use. 

### Response:
{'Poisoning by other and unspecified anticonvulsants,Alcohol withdrawal,Drug-induced delirium,Disorders of urea cycle metabolism,Acidosis,Other alteration of consciousness,Suicide and self-inflicted poisoning by other specified drugs and medicinal substances,Bipolar disorder, unspecified,Opioid abuse, unspecified,Hypocalcemia,Other and unspecified alcohol dependence, unspecified,Throat pain,Tension headache,Abdominal pain, epigastric,Other postprocedural status'}
