CHIEF COMPLAINT: Altered mental status

PRESENT ILLNESS: Ms. [**Known lastname 88363**] is a 55 year old female with a PMH significant for
HTN admitted for salicylate overdose. The patient was found this
morning by a friend to be confused and agitated with associated
tachypnea and tremors. She was brought to an urgent care clinic
in [**Hospital1 **], and immediately sent to [**Hospital1 18**] for concern of a
stroke.
.
In the [**Hospital1 18**] ED, initial VS 98.1 114/64 85 24 100%4lnc.  She was
reported to have been feeling unwell for the past week, for
which she had been taking daily doses of aspirin.  She denies
taking any other drugs or alchohol. She was found to have a
respiratory alkalosis with anion-gap metabolic acidosis and an
elevated ASA level. She received a 150 meq bolus of bicarb, and
had a RIJ placed and was started on levophed for hypotension
with a SBP 80s. She was then admitted to the [**Hospital Unit Name 153**] for further
management.
.
Currently, the patient is confused, but denies any CP/SOB or HA
but endorses tinnitus.

MEDICAL HISTORY: - HTN
- Obesity
- sp hysterectomy
- hx of esophageal stricture
- GERD

MEDICATION ON ADMISSION: Confirmed with CVS in [**Hospital1 **] on [**1-4**]
Norvasc 10 mg po daily
Lisinopril 20 mg
omeprazole 20 mg po daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION:
VS: 96.8 72 108/75 (0.18 lecophed) 16 100%2Lnc
Gen: Confused
HEENT: pupils 3->2mm reactive.
CV: Nl S1+S2
Pulm: Clear to auscultation anteriorly
Abd: Obese, S/NT. +bs
Ext: No c/c/e.
Neuro: Oriented to person and "hospital." CN II-XII grossly
intact.

FAMILY HISTORY: NC

SOCIAL HISTORY: lives alone, never married, no children, never smoked, EtOH, IV,
illicit or herbal drug use.
Poisoning by salicylates,Acute kidney failure, unspecified,Toxic encephalopathy,Acute diastolic heart failure,Alkalosis,Other and unspecified coagulation defects,Hypotension, unspecified,Accidental poisoning by salicylates,Unspecified essential hypertension,Obesity, unspecified,Esophageal reflux,Anemia, unspecified
Poisoning-salicylates,Acute kidney failure NOS,Toxic encephalopathy,Ac diastolic hrt failure,Alkalosis,Coagulat defect NEC/NOS,Hypotension NOS,Acc poison-salicylates,Hypertension NOS,Obesity NOS,Esophageal reflux,Anemia NOS
Admission Date:  [**2138-1-1**]              Discharge Date:   [**2138-1-7**]

Date of Birth:  [**2082-2-10**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:
RIJ CVL placement
Arterial line placement

History of Present Illness:
Ms. [**Known lastname 88363**] is a 55 year old female with a PMH significant for
HTN admitted for salicylate overdose. The patient was found this
morning by a friend to be confused and agitated with associated
tachypnea and tremors. She was brought to an urgent care clinic
in [**Hospital1 **], and immediately sent to [**Hospital1 18**] for concern of a
stroke.
.
In the [**Hospital1 18**] ED, initial VS 98.1 114/64 85 24 100%4lnc.  She was
reported to have been feeling unwell for the past week, for
which she had been taking daily doses of aspirin.  She denies
taking any other drugs or alchohol. She was found to have a
respiratory alkalosis with anion-gap metabolic acidosis and an
elevated ASA level. She received a 150 meq bolus of bicarb, and
had a RIJ placed and was started on levophed for hypotension
with a SBP 80s. She was then admitted to the [**Hospital Unit Name 153**] for further
management.
.
Currently, the patient is confused, but denies any CP/SOB or HA
but endorses tinnitus.


Past Medical History:
- HTN
- Obesity
- sp hysterectomy
- hx of esophageal stricture
- GERD

Social History:
lives alone, never married, no children, never smoked, EtOH, IV,
illicit or herbal drug use.


Family History:
NC

Physical Exam:
ADMISSION:
VS: 96.8 72 108/75 (0.18 lecophed) 16 100%2Lnc
Gen: Confused
HEENT: pupils 3->2mm reactive.
CV: Nl S1+S2
Pulm: Clear to auscultation anteriorly
Abd: Obese, S/NT. +bs
Ext: No c/c/e.
Neuro: Oriented to person and "hospital." CN II-XII grossly
intact.

Pertinent Results:
CXR ([**2138-1-1**]): Mild blunting of right costophrenic angle. RIJ
ending at cavoatrial junction.
.
CXR ([**2138-1-3**]):
FINDINGS: In comparison with the study of [**1-1**], the central
catheter has been removed and the patient has taken a better
inspiration. Dextroscoliosis of the thoracic spine is again
seen. There is continued enlargement of the cardiac silhouette
with mild fullness of pulmonary vessels that could reflect some
elevated pulmonary venous pressure. Some opacification at the
bases most likely represents atelectasis, though in the
appropriate clinical setting the possibility of pneumonia cannot
be definitely excluded.
.
CXR ([**2138-1-6**]):
FINDINGS: In comparison with the study of [**1-3**], there is little
overall
change. Continued enlargement of the cardiac silhouette with
prominence of
interstitial markings consistent with increased pulmonary venous
pressure.
Bibasilar atelectasis is again seen, though in the appropriate
clinical
situation, the possibility of pneumonia would have to be
considered.

ECG: Sinus with 1:1 conduction. NA-NI. LAA. No acute ST-T wave
changes.
.
Head CT-FINDINGS: There is no evidence of acute hemorrhage,
edema, mass effect, or large vessel territorial infarction. The
grey-white matter differentiation is well preserved. The
ventricles and sulci appear normal in size and configuration.
There are no fractures. The visualized portions of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION: No acute intracranial process.
.
[**2138-1-1**] 11:54PM   TYPE-ART PO2-70* PCO2-29* PH-7.51* TOTAL
CO2-24 BASE XS-0
[**2138-1-1**] 11:54PM   LACTATE-1.3
[**2138-1-1**] 11:35PM   ALT(SGPT)-10 AST(SGOT)-16 LD(LDH)-172 ALK
PHOS-35 TOT BILI-0.1
[**2138-1-1**] 11:35PM   HAPTOGLOB-175
[**2138-1-1**] 11:35PM   ASA-36.7*
[**2138-1-1**] 11:35PM   VoidSpec-UNABLE TO
[**2138-1-1**] 11:35PM   WBC-6.0 RBC-2.76* HGB-7.9* HCT-23.2* MCV-84
MCH-28.5 MCHC-34.0 RDW-15.6*
[**2138-1-1**] 11:35PM   I-HOS-AVAILABLE
[**2138-1-1**] 11:35PM   PLT COUNT-239
[**2138-1-1**] 11:35PM   PT-36.6* PTT-32.9 INR(PT)-3.8*
[**2138-1-1**] 11:35PM   FDP-0-10
[**2138-1-1**] 11:35PM   FIBRINOGE-321
[**2138-1-1**] 09:23PM   TYPE-ART PO2-78* PCO2-21* PH-7.55* TOTAL
CO2-19* BASE XS--1
[**2138-1-1**] 09:23PM   LACTATE-1.0
[**2138-1-1**] 09:10PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2138-1-1**] 09:10PM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
[**2138-1-1**] 09:10PM URINE  RBC-51* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2138-1-1**] 08:26PM   GLUCOSE-159* UREA N-39* CREAT-1.3*
SODIUM-147* POTASSIUM-3.6 CHLORIDE-115* TOTAL CO2-17* ANION
GAP-19
[**2138-1-1**] 08:26PM   ALT(SGPT)-11 AST(SGOT)-15 LD(LDH)-197 ALK
PHOS-44 TOT BILI-0.1
[**2138-1-1**] 08:26PM   ALBUMIN-3.5 CALCIUM-8.0* PHOSPHATE-3.5
MAGNESIUM-2.1
[**2138-1-1**] 08:26PM   ASA-43.0*
[**2138-1-1**] 08:26PM   WBC-8.5 RBC-3.19* HGB-9.3* HCT-26.9* MCV-84
MCH-29.0 MCHC-34.4 RDW-15.5
[**2138-1-1**] 08:26PM   PLT COUNT-307
[**2138-1-1**] 08:26PM   PT-31.1* PTT-32.2 INR(PT)-3.1*
[**2138-1-1**] 05:15PM URINE  HOURS-RANDOM
[**2138-1-1**] 05:15PM URINE  UCG-NEG OSMOLAL-515
[**2138-1-1**] 05:15PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2138-1-1**] 05:15PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2138-1-1**] 05:15PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2138-1-1**] 04:50PM   TYPE-[**Last Name (un) **] TEMP-36.7 RATES-/22 O2-100 O2 FLOW-2
PO2-52* PCO2-27* PH-7.40 TOTAL CO2-17* BASE XS--5 AADO2-634 REQ
O2-100 INTUBATED-NOT INTUBA
[**2138-1-1**] 04:45PM   GLUCOSE-175* UREA N-42* CREAT-1.4*
SODIUM-148* POTASSIUM-4.2 CHLORIDE-119* TOTAL CO2-16* ANION
GAP-17
[**2138-1-1**] 04:45PM   ALBUMIN-3.2* CALCIUM-7.4* PHOSPHATE-3.6#
MAGNESIUM-2.1
[**2138-1-1**] 04:45PM   ASA-46.4*
[**2138-1-1**] 01:26PM   TYPE-ART PO2-214* PCO2-17* PH-7.37 TOTAL
CO2-10* BASE XS--12 COMMENTS-GREEN TOP
[**2138-1-1**] 01:26PM   LACTATE-0.9 K+-5.3
[**2138-1-1**] 12:24PM   K+-6.3*
[**2138-1-1**] 11:05AM   GLUCOSE-169* SODIUM-148* POTASSIUM-4.1
CHLORIDE-119*
[**2138-1-1**] 11:05AM   GLUCOSE-97 UREA N-47* CREAT-1.7* SODIUM-143
POTASSIUM-6.5* CHLORIDE-114* TOTAL CO2-10* ANION GAP-26*
[**2138-1-1**] 11:05AM   estGFR-Using this
[**2138-1-1**] 11:05AM   ALT(SGPT)-14 AST(SGOT)-24 LD(LDH)-366* ALK
PHOS-47 TOT BILI-0.1
[**2138-1-1**] 11:05AM   CALCIUM-8.9 PHOSPHATE-5.5* MAGNESIUM-2.4
[**2138-1-1**] 11:05AM   ASA-55.8* ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2138-1-1**] 11:05AM   WBC-8.2 RBC-3.58* HGB-10.0* HCT-30.4* MCV-85
MCH-27.9 MCHC-32.9 RDW-16.2*
[**2138-1-1**] 11:05AM   NEUTS-77* BANDS-0 LYMPHS-16* MONOS-4 EOS-3
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2138-1-1**] 11:05AM   HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
OVALOCYT-OCCASIONAL BURR-OCCASIONAL ELLIPTOCY-OCCASIONAL
[**2138-1-1**] 11:05AM   PLT SMR-NORMAL PLT COUNT-305
[**2138-1-1**] 11:05AM   PT-24.8* PTT-27.9 INR(PT)-2.4*
.
Labs at time of discharge:
[**2138-1-7**]:  WBC 5.8 Hct 27.8 Plt 218
[**2138-1-7**]: Na 138 K 4.0 Cl 104 HCO3 28 BUN 13 Cr 0.7
[**2138-1-3**]: TIBC 278 Vit B12 305 Folate 12.5 Ferritin 41
[**2138-1-3**]: TSH 0.11 FT4 0.89

Brief Hospital Course:
Ms. [**Known lastname 88363**] is a 55 year old female with a PMH significant for
HTN admitted for salicylate overdose.  The patient was treated
with a bicarbonate drip and was given charcoal.  Her aspirin
level decreased and her mental status improved.  The remainder
of her hospital course will be summarized below by problem.
.
#. Salicylate overdose: Patient presented with respiratory
alkalosis and anion-gap metabolic acidosis, tinnitus, and
elevatd salicylate level >50 consisetn with salicylate overdose,
which was complicated by distributive physiology causing
hypotension requiring pressor support.  She was also
coagulopathic at the time of her admission. She was treated with
a bicarb drip, and her ASA level came down. After her bicarb
drip was stopped, her repeat salicylate level further decreased
to 16.4. Her mental status improved and returned to baseline,
and she states that she had been taking [**2-27**] baby aspirins [**2-27**]
times a day for a least a week because she "felt unwell." She
denies any active or passive suicidal ideation.  She was unable
to further expand on her symptoms that prompted her to take
aspirin.
.
#. Hypotension: Patient required levophed for pressor support on
hospital day 1. This was felt to be due to distributive
physiology and related to her ASA overdose. She was successfully
weaned off pressors prior to transfer out of the MICU.  She did
not have any further episodes of hypotension during her
admission.  She has a history of hypertension and normally takes
lisinopril and norvasc.  However, she was normotensive during
her admission and these medications were not restarted.  We
recommended that she see her primary care doctor prior to
restarting these medications.
.
#. toxic metabolic encephalopathy/tremor: Most likely this is
from ASA overdose, but given coagulopathy and refractory
hypotension, there was concern for alternative etiology.
However, she improved as the aspirin level decreased.  She was
initially given one dose of antibiotics to cover for question
meningitis but this was discontinued as the etiology of her
delta MS was most likely the aspirin toxicity.
.
#. tremor -- this was also likely due to aspirin toxicity.  TFTs
were checked and revealed a low TSH of 0.11 uIU/mL (normal range
was 0.27-4.2).  The free T4 was 0.89 ng/dL (normal range was
0.93-1.7).  This is most likely consistent with sick euthyroid.
She should have her thyroid function tests repeated as an
outpatient.
.
#. Coaulopathy: Resolved during her course of admission. Felt to
be due to salicylate overdose.
.
#. Acid-base: Patient presented with a mixed acide base picture
- gap, non-gap metabolic acidosis and a respiratory alkalosis
consistent with salicylate overdose and fluid rescucitation.
Acid base status normalized by the time of discharge.
.
#. Hypernatremia: This was likely secondary to fluid
resuscitation and resolved by the time of discharge.
.
#. Acute renal failure: Resolved with aggressive fluid
resucitation during admission. Likely due to intravascular
volume depletion. Creatinine on discharge was 0.7.
.
#. Anemia: Her hematocrit was stable at 26-28 and was
normocytic.  Her ferritin was 41, folic acid was 12.5 and
vitamin B12 was 305.  Further work-up deferred to primary care.
.
#. Volume overload:  She was edematous and this was likely due
to her volume resuscitation in the intensive care unit.  She was
diuresed with lasix and her edema was nearly normalized at the
time of discharge.  I suspect that she will be able to mobilize
the remainder of the excess volume without further medication.
Her chest xray did show prominence of interstitial markings
consistent wtih increased pulmonary venous pressure.
Consideration for an echocardiogram to be performed as an
outpatient is recommended.
.
Prophylaxis: Patient received heparin products during admission.

Medications on Admission:
Confirmed with CVS in [**Hospital1 **] on [**1-4**]
Norvasc 10 mg po daily
Lisinopril 20 mg
omeprazole 20 mg po daily

Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
VNA Carenetwork

Discharge Diagnosis:
salicylate toxicity
toxic metabolic encephalopathy
normocytic anemia


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


Discharge Instructions:
You were admitted with confusion and low blood pressure from an
overdose of aspirin. For this, you were monitored in the ICU,
had IV fluids and medications to help your body get rid of this
medication.  Your symptoms improved and you were transferred to
the regular floor. You had some extra volume on board and were
treated with a water pill to remove this.  You will likely
continue to see the swelling decrease.  If it does not continue
to decrease or it gets worse, please call your primary care
physician.
.
In the future, it is best to see your doctor if there is
something that is bothering you and you are taking medication
several times a day for it.  If you do need to take something
for mild pain, you can take Tylenol (acetaminophen), which is an
over the counter medication.  Please do not take any more than 6
pills of tylenol in a 24-hour period.  If you are having
symptoms that are requiring you to take Tylenol more than a few
times in a row, please see your primary care doctor.
.
Medication changes:
- STOP taking your blood pressure pills (lisinopril and norvasc)
until you see your primary care physician.
[**Name Initial (NameIs) **] DO not take any aspirin
.
Please take all of your medications as prescribed and follow up
with the appointments below

Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Address: [**Location (un) **], 2ND FL, [**Hospital1 88364**],[**Numeric Identifier 26328**]
Phone: [**Telephone/Fax (1) 26318**]
Appointment: Monday [**1-13**] at 1:45pm
{'Poisoning by salicylates,Acute kidney failure, unspecified,Toxic encephalopathy,Acute diastolic heart failure,Alkalosis,Other and unspecified coagulation defects,Hypotension, unspecified,Accidental poisoning by salicylates,Unspecified essential hypertension,Obesity, unspecified,Esophageal reflux,Anemia, 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: Altered mental status

PRESENT ILLNESS: Ms. [**Known lastname 88363**] is a 55 year old female with a PMH significant for
HTN admitted for salicylate overdose. The patient was found this
morning by a friend to be confused and agitated with associated
tachypnea and tremors. She was brought to an urgent care clinic
in [**Hospital1 **], and immediately sent to [**Hospital1 18**] for concern of a
stroke.
.
In the [**Hospital1 18**] ED, initial VS 98.1 114/64 85 24 100%4lnc.  She was
reported to have been feeling unwell for the past week, for
which she had been taking daily doses of aspirin.  She denies
taking any other drugs or alchohol. She was found to have a
respiratory alkalosis with anion-gap metabolic acidosis and an
elevated ASA level. She received a 150 meq bolus of bicarb, and
had a RIJ placed and was started on levophed for hypotension
with a SBP 80s. She was then admitted to the [**Hospital Unit Name 153**] for further
management.
.
Currently, the patient is confused, but denies any CP/SOB or HA
but endorses tinnitus.

MEDICAL HISTORY: - HTN
- Obesity
- sp hysterectomy
- hx of esophageal stricture
- GERD

MEDICATION ON ADMISSION: Confirmed with CVS in [**Hospital1 **] on [**1-4**]
Norvasc 10 mg po daily
Lisinopril 20 mg
omeprazole 20 mg po daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION:
VS: 96.8 72 108/75 (0.18 lecophed) 16 100%2Lnc
Gen: Confused
HEENT: pupils 3->2mm reactive.
CV: Nl S1+S2
Pulm: Clear to auscultation anteriorly
Abd: Obese, S/NT. +bs
Ext: No c/c/e.
Neuro: Oriented to person and "hospital." CN II-XII grossly
intact.

FAMILY HISTORY: NC

SOCIAL HISTORY: lives alone, never married, no children, never smoked, EtOH, IV,
illicit or herbal drug use. 

### Response:
{'Poisoning by salicylates,Acute kidney failure, unspecified,Toxic encephalopathy,Acute diastolic heart failure,Alkalosis,Other and unspecified coagulation defects,Hypotension, unspecified,Accidental poisoning by salicylates,Unspecified essential hypertension,Obesity, unspecified,Esophageal reflux,Anemia, unspecified'}
