CHIEF COMPLAINT: Tylenol, lithium overdos

PRESENT ILLNESS: Ms. [**Known lastname 18170**] is a 27 year-old female with a history of depression
who presents with lithium and acetaminophen overodose.

MEDICAL HISTORY: Depression

MEDICATION ON ADMISSION: MEDICATIONS (not confirmed; based on mother's recollection)
1. Klonopin
2. Xanax
3. Zoloft
4. Inhaler

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals - BP 103/61, HR 85, RR
gen - Intubated with a bear-hugger on.
heent - Anicteric sclera. No conjunctival palor. ETT in place.
cv - Regular. No murmurs.
pulm - Clear. No wheeze/rales.
abd - Soft. Non-tender. Non-distended.
ext - Warm. Pneumoboots applied. No edema.
neuro - Intubated. Does not respond to voice. Pupils 4mm -->
3.5mm and sluggish. Resonds to painful stimuli (nailbed pressure
and a-line placement). Otherwise unable to obtain.
skin - No stigmata of liver disease. No rashes

FAMILY HISTORY: Maternal grand-mother with [**Name (NI) 77359**] anemia and CAD

SOCIAL HISTORY: Per mother: [**Name (NI) **] currently lives alone; previously with
husband who is now in jail. She has no children. Previously
worked as a crime analyst, but not currently. No tobacco. Drinks
alcohol (unsure of amount). Uses cocaine
Toxic effect of other specified metals,Acute respiratory failure,Urinary tract infection, site not specified,Other and unspecified infection due to central venous catheter,Cellulitis and abscess of upper arm and forearm,Hyperosmolality and/or hypernatremia,Poisoning by aromatic analgesics, not elsewhere classified,Suicide and self-inflicted poisoning by other and unspecified solid and liquid substances,Major depressive affective disorder, recurrent episode, unspecified
Toxic effect metals NEC,Acute respiratry failure,Urin tract infection NOS,Oth/uns inf-cen ven cath,Cellulitis of arm,Hyperosmolality,Pois-arom analgesics NEC,Poison-solid/liquid NEC,Recurr depr psychos-unsp
Name:  [**Last Name (LF) 12540**],[**Known firstname **]                    Unit No:   [**Numeric Identifier 12541**]

Admission Date:  [**2123-5-9**]              Discharge Date:   [**2123-5-19**]

Date of Birth:  [**2095-6-6**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5520**]
Addendum:
please note: wound culture grew MSSA, this pt has NO history of
MRSA!!!

Discharge Disposition:
Home

                             [**Name6 (MD) **] [**Last Name (NamePattern4) 5521**] MD [**MD Number(2) 5522**]

Completed by:[**2123-5-20**]

Admission Date:  [**2123-5-9**]              Discharge Date:   [**2123-5-19**]

Date of Birth:  [**2095-6-6**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Tylenol, lithium overdos

Major Surgical or Invasive Procedure:
Endotracheal Intubation
Arterial Line Placement
Central Line Placement


History of Present Illness:
Ms. [**Known lastname 18170**] is a 27 year-old female with a history of depression
who presents with lithium and acetaminophen overodose.

Mother reports depression for "years" with acute worsening over
the last few months, in the setting of the patient's father
dying (7 months prior to admission) and the patient's husband
being placed in jail (one month prior to admission). The mother
reports that the patient is currently seeing a psychiatrist,
though she is unsure of what medications she is on.

The mother last spoke with the patient the morning prior to
admission. Plans were made for the two to get together for
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1017**]. On the day of admission, the mother reports going
to the patient's home in the afternoon and banging on the door
without answer. At 5pm, a neighbor/friend broke a window to the
patient's home and found her unresponsive. He called EMS.

Per the OSH records, "pt found uncon/unresp by P2 with vomitus
in airway. Pt was last seen at 4am today. Pt has hx of
depression. Pt was intub with 7.0 ETT at 20cm LL." Notes also
indicate: "...found next to her bed with large bottles of
tylenol pm and lithium next to her bedside. There were only
agonal repsirations and she was intubated by the paramedics. She
is unresponsive. There is a hx of substance abuse. Family says
she has been very derpessed since the death of her father 8
months ago. She is known to be on zoloft and a benzodiazipine.
She was last seen yesterday."

At the outside hospital her labs showed positive cocaine and
benzoes and a lithium level of 13.1. An ABG showed 7.47/34/325.


In the ED here, T 95.5, BP of 104/74, HR 70. She was given
sodium bicarbonate and 2mg versed.


Past Medical History:
Depression

Social History:
Per mother: [**Name (NI) **] currently lives alone; previously with
husband who is now in jail. She has no children. Previously
worked as a crime analyst, but not currently. No tobacco. Drinks
alcohol (unsure of amount). Uses cocaine

Family History:
Maternal grand-mother with [**Name (NI) 77359**] anemia and CAD

Physical Exam:
Vitals - BP 103/61, HR 85, RR
gen - Intubated with a bear-hugger on.
heent - Anicteric sclera. No conjunctival palor. ETT in place.
cv - Regular. No murmurs.
pulm - Clear. No wheeze/rales.
abd - Soft. Non-tender. Non-distended.
ext - Warm. Pneumoboots applied. No edema.
neuro - Intubated. Does not respond to voice. Pupils 4mm -->
3.5mm and sluggish. Resonds to painful stimuli (nailbed pressure
and a-line placement). Otherwise unable to obtain.
skin - No stigmata of liver disease. No rashes


Pertinent Results:
Chemistries:
[**2123-5-9**] 10:25PM   GLUCOSE-55* UREA N-17 CREAT-1.1 SODIUM-135
POTASSIUM-6.3* CHLORIDE-110* TOTAL CO2-20* ANION GAP-11
[**2123-5-9**] 10:25PM   ALT(SGPT)-116* AST(SGOT)-156* CK(CPK)-347*
ALK PHOS-48 TOT BILI-1.6*
[**2123-5-9**] 10:25PM   LIPASE-109*
[**2123-5-9**] 10:25PM   ALBUMIN-4.8 CALCIUM-9.1 PHOSPHATE-1.0*
MAGNESIUM-2.4
[**2123-5-9**] 10:25PM   LITHIUM-7.1*
[**2123-5-19**] 06:33AM BLOOD Glucose-112* UreaN-18 Creat-0.7 Na-140
K-4.6 Cl-106 HCO3-24 AnGap-15
[**2123-5-11**] 11:24PM BLOOD ALT-[**2094**]* AST-1249* LD(LDH)-568*
AlkPhos-54 TotBili-0.7
[**2123-5-19**] 06:33AM BLOOD ALT-155* AST-34 LD(LDH)-195 AlkPhos-73
TotBili-0.4
[**2123-5-11**] 04:55AM BLOOD Lipase-18
[**2123-5-19**] 06:33AM BLOOD Albumin-3.8 Calcium-9.3 Phos-3.4 Mg-1.9
[**2123-5-12**] 03:54AM BLOOD VitB12-GREATER TH Folate-13.2
[**2123-5-12**] 03:54AM BLOOD TSH-2.2
[**2123-5-12**] 03:54AM BLOOD Lithium-0.9
[**2123-5-12**] 03:54AM BLOOD Acetmnp-5.3

Hematology:
[**2123-5-9**] 10:25PM   WBC-11.2* RBC-5.15 HGB-15.8 HCT-45.0 MCV-87
MCH-30.7 MCHC-35.2* RDW-13.9
[**2123-5-9**] 10:25PM   NEUTS-87.7* LYMPHS-7.4* MONOS-3.6 EOS-0.9
BASOS-0.3
[**2123-5-9**] 10:25PM   PLT COUNT-366
[**2123-5-19**] 06:33AM BLOOD WBC-9.1 RBC-3.65* Hgb-11.1* Hct-32.3*
MCV-89 MCH-30.5 MCHC-34.4 RDW-14.1 Plt Ct-751*

Urinalysis:
[**2123-5-9**] 10:25PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2123-5-9**] 10:25PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-8.0 LEUK-NEG
[**2123-5-9**] 10:25PM URINE  bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG

Cardiac Enzymes:
[**2123-5-9**] 10:25PM BLOOD CK-MB-9
[**2123-5-9**] 10:25PM BLOOD cTropnT-<0.01

Arterial Blood Gasses:
[**2123-5-10**] 02:36AM BLOOD Type-ART Temp-37.0 pO2-173* pCO2-30*
pH-7.47* calTCO2-22 Base XS-0
[**2123-5-11**] 11:43PM BLOOD Type-ART FiO2-70 pO2-110* pCO2-31*
pH-7.44 calTCO2-22 Base XS--1 Intubat-NOT INTUBA

EGK [**2123-5-9**]: Sinus rhythm. Non-specific anterior ST-T wave
changes. No previous tracing available for comparison.

Imaging:
NON-CONTRAST CT OF THE SPINE [**2123-5-9**]:
There is no evidence of acute fracture or malalignment.
Vertebral body heights are maintained and there is no
prevertebral soft tissue swelling. Visualized epidural space and
the contour of the thecal sac appear unremarkable. Soft tissues
in the neck are normal, although the endotracheal tube cuff
appears slightly overdistended. There is moderate amount of
layering secretions within the oral and nasopharynx. Visualized
lung apices display faint centrilobular nodules, bilaterally,
right greater than left.

NON-CONTRAST HEAD CT [**2123-5-9**]:
No priors are available. There is no evidence of intracranial
hemorrhage, mass effect, shift of midline structures,
hydrocephalus, or acute major vascular territorial infarct.
[**Doctor Last Name **]-white matter differentiation is well preserved with no
underlying edema noted. Soft tissues and osseous structures
appear unremarkable. Paranasal sinuses and mastoid air cells are
well aerated.

SUPINE PORTABLE CHEST RADIOGRAPH [**2123-5-9**]:
The lungs are clear and without evidence of edema, pneumothorax,
effusions, or focal consolidation. Endotracheal tube terminates
3 cm from the carina and tip of nasogastric tube terminates in
the distal esophagus proximal to the GE junction. Mild gaseous
distention of stomach is likely related to recent intubation.

Microbiology:

Blood Cultures [**2123-5-11**] x2, [**2123-5-13**] x2 - no growth to date

[**2123-5-11**] 12:33 am URINE      Source: Catheter.

                            **FINAL REPORT [**2123-5-13**]**

   URINE CULTURE (Final [**2123-5-13**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    >100,000
ORGANISMS/ML..
         Please contact the Microbiology Laboratory ([**8-/2421**])
immediately if
         sensitivity to clindamycin is required on this
patient's isolate.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.
      GRAM NEGATIVE ROD(S).    ~3000/ML.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPHYLOCOCCUS, COAGULASE NEGATIVE
                             |
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN--------  <=16 S
OXACILLIN-------------<=0.25 S

[**2123-5-11**] 4:34 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2123-5-13**]**

   URINE CULTURE (Final [**2123-5-13**]):
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

[**2123-5-12**] 3:54 am SEROLOGY/BLOOD      Source: Line-aline.

                            **FINAL REPORT [**2123-5-13**]**

   RAPID PLASMA REAGIN TEST (Final [**2123-5-13**]):
      NONREACTIVE.
      Reference Range: Non-Reactive.

[**2123-5-17**] 4:30 pm SWAB      Source: r wrist.

   GRAM STAIN (Final [**2123-5-17**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   WOUND CULTURE (Preliminary):
      STAPH AUREUS COAG +.    RARE GROWTH.


Brief Hospital Course:
ASSESSMENT/PLAN: 27 year-old female with poorly treated
depression who presents with lithium and acetaminophen overdose.

Suicide attempt:  The patient was admitted following a serious
overdose.  She was seen by the psychiatric consult service
during this admission.  She has a history of depression.  The
psychiatric consult service recommended starting the patient on
seroquel for her anxiety.  They filed section 12 papers and
placed the patient on a 1:1 sitter.  At the time of discharge
she was taking standing seroquel 50 mg QHS and 25 mg PRN for
anxiety.  At the time of discharge she denied suicidal or
homicidal ideations.  She is being discharged to an inpatient
psychiatric facility to further manage her mood disorder.

Acetaminophen Overdose:  The patient presented after an overdose
with acetaminophen and lithium.  Her acetaminophen level was 346
on admission and the time of ingestion was unclear.  On
presentation her transaminase were in the 100s with an INR of
1.4 and her total bilirubin was 1.6.  NAC was started on the
emergency room.  Her ALT peaked at 1900, AST at 1200, total
bilirubin at 1.7 and INR at 1.8.  Her transaminases subsequently
trended down and her hepatic function improved to near normal
levels at the time of discharge.

Lithium toxicity: As above, the patient initially presented
after an acetaminophen and lithium overdose.  Initial lithium
level at the outside hospital was 13.1.  On arrival to this
hospital she was started on CVVH which was successful in
reducing her lithium level to non-toxic levels.

TCA overdose vs Benadryl overdose: On presentation the patient's
serum was positive for tricyclics but she was found with a
bottle of tylenol PM.  It was unclear whether she also overdosed
on TCAs or whether her toxicology screen was falsely positive
for TCAs in the setting of benadryl overdose.  Her initial EKG
did show a widened QRS complex with a large R wave in AVR which
would be concerning for tricyclic overdose.  A bicarbonate drip
was started in the emergency room and her EKG changes
normalized.

Respiratory failure: The patient was found having agonal
respirations and was intubated in the field for mental status
changes and aspiration.  On presentation her CXR showed no
evidence of pulmonary infiltrates.  Once her metabolic
abnormalities were controlled she was extubated without
difficulty.

Right Forearm Abscess:  The patient's hospitalization course was
complicated by the development of a right forearm abscess at the
site of her previous arterial line. The surgery service
performed an incision and drainage of the abscess. Given concern
for possible MRSA colonization she was started on IV vancomycin
for her infection with immediate improvement.  She will complete
a 7 day course of antibiotics for her infection on [**2123-5-20**].  It
was not felt that linezolid would be an appropriate alternative
antibiotic given potential interactions with her psychiatric
medications.  Wound culture was pending at the time of
discharge.

Dilutional Anemia:  On presentation the patient's hematocrit was
45 in the setting of lack of PO intake and severe metabolic
abnormalities resulting in a hemoconcentrated state.  After
aggressive volume resuscitation and fluid shifts her hematocrit
dropped to a nadir of 25 without any evidence of bleeding.  Over
the remainder of her hospitalization her hematocrit rebounded
nicely.  On discharge her hematocrit was 32.

Urinary Tract Infection:  The patient was noted to have an e.
coli urinary tract infection during this hospitalization.  The
organism was pan-sensitive.  She was treated with a 3 day course
of ciprofloxacin.

Code: Full

Communication: Mother [**Name (NI) **] [**Name (NI) 18170**] - (c) [**Telephone/Fax (1) 77360**]; (h)
[**Telephone/Fax (1) 77361**]

Disposition: Inpatient psychiatry

Medications on Admission:
MEDICATIONS (not confirmed; based on mother's recollection)
1. Klonopin
2. Xanax
3. Zoloft
4. Inhaler


Discharge Medications:
1. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
3. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram  Intravenous twice a day for 1 days.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Overdose
Major Depression
Right Forearm Abscess
Urinary Tract Infection


Discharge Condition:
Stable.  Ambulating without assistance. Breathing comfortably on
room air.


Discharge Instructions:
You were seen and evalauted because you were unresponsive.  This
was likely from an overdose.  You required treatment in the
intensive care unit.  You were seen by the psychiatry service
who recommended inpatient psychiatric hospitalization.

Please take all your medications as prescribed.  The following
changes were made to your medication regimen.

Please keep all your follow up appointments as scheduled.

Please seek immediate medical attention if you experiene any
fevers > 101.5 degrees, worsening pain or swelling at the site
of your wrist infection or any other concerning symptoms.

Followup Instructions:
Please follow up with your primary care physician within one
week of discharge from inpatient psychiatry.
{'Toxic effect of other specified metals,Acute respiratory failure,Urinary tract infection, site not specified,Other and unspecified infection due to central venous catheter,Cellulitis and abscess of upper arm and forearm,Hyperosmolality and/or hypernatremia,Poisoning by aromatic analgesics, not elsewhere classified,Suicide and self-inflicted poisoning by other and unspecified solid and liquid substances,Major depressive affective disorder, recurrent episode, unspecified'}


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: Tylenol, lithium overdos

PRESENT ILLNESS: Ms. [**Known lastname 18170**] is a 27 year-old female with a history of depression
who presents with lithium and acetaminophen overodose.

MEDICAL HISTORY: Depression

MEDICATION ON ADMISSION: MEDICATIONS (not confirmed; based on mother's recollection)
1. Klonopin
2. Xanax
3. Zoloft
4. Inhaler

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals - BP 103/61, HR 85, RR
gen - Intubated with a bear-hugger on.
heent - Anicteric sclera. No conjunctival palor. ETT in place.
cv - Regular. No murmurs.
pulm - Clear. No wheeze/rales.
abd - Soft. Non-tender. Non-distended.
ext - Warm. Pneumoboots applied. No edema.
neuro - Intubated. Does not respond to voice. Pupils 4mm -->
3.5mm and sluggish. Resonds to painful stimuli (nailbed pressure
and a-line placement). Otherwise unable to obtain.
skin - No stigmata of liver disease. No rashes

FAMILY HISTORY: Maternal grand-mother with [**Name (NI) 77359**] anemia and CAD

SOCIAL HISTORY: Per mother: [**Name (NI) **] currently lives alone; previously with
husband who is now in jail. She has no children. Previously
worked as a crime analyst, but not currently. No tobacco. Drinks
alcohol (unsure of amount). Uses cocaine 

### Response:
{'Toxic effect of other specified metals,Acute respiratory failure,Urinary tract infection, site not specified,Other and unspecified infection due to central venous catheter,Cellulitis and abscess of upper arm and forearm,Hyperosmolality and/or hypernatremia,Poisoning by aromatic analgesics, not elsewhere classified,Suicide and self-inflicted poisoning by other and unspecified solid and liquid substances,Major depressive affective disorder, recurrent episode, unspecified'}
