CHIEF COMPLAINT: The patient was found down.

PRESENT ILLNESS: This is a 56 year old white male
with a past medical history of seizure disorder on Tegretol and
mental retardation among others.  The patient was found down at
home today by EMS.  Per the patient's brother, the patient lives
alone and the family periodically "checks in with him".  No one
has heard from the patient for three days so the EMS broke the
door down.  The patient was found down unconscious, covered in
emesis as well as blood (question nosebleed).  The patient was
noted to have multiple abrasions over his body.

MEDICAL HISTORY: 1.  Mental retardation.
2.  Hypertension.
3.  Seizure disorder secondary to meningitis as a child.
4.  Hypercholesterolemia.
5.  Fecal incontinence.
6.  Recent upper gastrointestinal bleed secondary to erosive
esophagitis.
7.  Status post coronary artery bypass graft in [**2094**].
8.  Atrial fibrillation.

MEDICATION ON ADMISSION: 1.  Tegretol.
2.  Pravachol.
3.  Atenolol.
4.  Zantac.
5.  Fluconazole

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Non contributory.

SOCIAL HISTORY: The patient denies alcohol or tobacco use. He
lives alone in an apartment in [**Hospital1 8**], [**State 350**] and is
able to care for himself.  Once awake, he described how he takes
the subway to see his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 102851**], at [**Hospital 14852**], and described how he gets there.  He also
reports that he walks to the grocery store and buys his own
groceries.  He keeps in close contact with a social worker, [**Name (NI) **]
[**Name (NI) 12130**], that works in his building.  His brother, [**Name (NI) **] [**Name (NI) 13304**],
lives in [**Name (NI) 3844**] and checks in with the patient
periodically.
Poisoning by other and unspecified anticonvulsants,Poisoning by other specified drugs and medicinal substances, undetermined whether accidentally or purposely inflicted,Pneumonitis due to inhalation of food or vomitus,Other disorders of muscle, ligament, and fascia,Other convulsions,Unspecified intellectual disabilities,Unspecified essential hypertension,Pure hypercholesterolemia,Aortocoronary bypass status
Pois-anticonvul NEC/NOS,Undet pois-med agnt NEC,Food/vomit pneumonitis,Muscle/ligament dis NEC,Convulsions NEC,Intellect disability NOS,Hypertension NOS,Pure hypercholesterolem,Aortocoronary bypass
Admission Date:  [**2100-11-2**]       Discharge Date:  [**2100-11-17**]

Date of Birth:   [**2044-8-21**]       Sex:  M

Service:  MEDICINE - [**Company 191**] firm
CHIEF COMPLAINT:  The patient was found down.

HISTORY OF PRESENT ILLNESS:  This is a 56 year old white male
with a past medical history of seizure disorder on Tegretol and
mental retardation among others.  The patient was found down at
home today by EMS.  Per the patient's brother, the patient lives
alone and the family periodically "checks in with him".  No one
has heard from the patient for three days so the EMS broke the
door down.  The patient was found down unconscious, covered in
emesis as well as blood (question nosebleed).  The patient was
noted to have multiple abrasions over his body.

Little is known about the patient's other history.  He was
admitted to [**Hospital1 336**] last week with a change in mental status. His
mental status there was described as awake, alert, but minimally
attentive.  His course was complicated by an upper
gastrointestinal bleed.  Esophagogastroduodenoscopy showed
severe erosive esophagitis, question of [**Female First Name (un) 564**], and small
gastric polyps.  The patient was discharged on Fluconazole,
Tegretol, Prilosec, and Loperamide.

Apparently, the patient's father died on [**Holiday 1451**] one year
ago and the patient was depressed related to this.  Many empty
pill bottles were found next to him.

The patient was brought to [**Hospital1 69**]
Emergency Department where his GCS was 6 with oxygen saturation
in the 80s.  The patient was intubated.  He was hemodynamically
stable with blood pressure in the 120s and heart rate in the 90s.
Left groin line was placed.  Chest x-ray showed a right lower
lobe pneumonia and bilateral apical opacities.  CT of the head
was negative.  CT of the spine was negative for any cervical
spine fractures.  The patient was transferred to the Medical
Intensive Care Unit for further evaluation and treatment.

PAST MEDICAL HISTORY:
1.  Mental retardation.
2.  Hypertension.
3.  Seizure disorder secondary to meningitis as a child.
4.  Hypercholesterolemia.
5.  Fecal incontinence.
6.  Recent upper gastrointestinal bleed secondary to erosive
esophagitis.
7.  Status post coronary artery bypass graft in [**2094**].
8.  Atrial fibrillation.

MEDICATIONS ON ADMISSION:
1.  Tegretol.
2.  Pravachol.
3.  Atenolol.
4.  Zantac.
5.  Fluconazole

ALLERGIES:  No known drug allergies.

FAMILY HISTORY:  Non contributory.

SOCIAL HISTORY: The patient denies alcohol or tobacco use. He
lives alone in an apartment in [**Hospital1 8**], [**State 350**] and is
able to care for himself.  Once awake, he described how he takes
the subway to see his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 102851**], at [**Hospital 14852**], and described how he gets there.  He also
reports that he walks to the grocery store and buys his own
groceries.  He keeps in close contact with a social worker, [**Name (NI) **]
[**Name (NI) 12130**], that works in his building.  His brother, [**Name (NI) **] [**Name (NI) 13304**],
lives in [**Name (NI) 3844**] and checks in with the patient
periodically.

REVIEW OF SYSTEMS:  Unknown.

PHYSICAL EXAMINATION:  Vital signs revealed blood pressure of
90/45, temperature maximum 102.4, heart rate 96 to 110,
respiratory rate 16 to 21, oxygen saturation 95 to 98% on
"many" liters of oxygen.  General - The patient is not responsive
but moving in athetotic pattern.  Skin - multiple abrasions on
bilateral lower extremities (DIP of all toes, lateral malleoli
and dorsum of feet).  No petechiae.  No jaundice.  Head, eyes,
ears, nose and throat examination - The pupils are 2.0
millimeters and reactive bilaterally. Unable to assess
extraocular movements.  Bilateral periorbital erythema and edema.
Right eye with subconjunctival hemorrhage superior to pupil.  No
Battle sign.  Respiratory is clear to auscultation anteriorly.
Examination limited due to the patient's unresponsiveness.
Cardiovascular - regular rate and rhythm, no murmurs, rubs or
gallops.  Abdomen is soft, normoactive bowel sounds, nontender,
nondistended, no organomegaly.  Extremities - no cyanosis,
clubbing or edema, pulses 2+ bilaterally. Abrasions on lateral
malleoli bilaterally and dorsum of feet. Rectal is guaiac
negative.  Neurologically, the patient is moving all four
extremities, withdraws to pain, no posturing, no corneal or gag
reflex (but on Propofol).  Toes downgoing.

LABORATORY DATA:  White blood cell count 17.6, hematocrit
34.3, platelets 364,000, neutrophils 71%, bands 18%, lymphocytes
6%.  Urinalysis is nitrite positive, protein trace, bilirubin
small, pH 5.0, blood negative, red blood cells 0 per high power
field, white blood cells 0-2 per high power field, bacteria rare.
Chem7 revealed sodium 141, potassium 4.4, chloride 105,
bicarbonate 13, blood urea nitrogen 56, creatinine 4.2, glucose
100, anion gap 23.  CPK [**Numeric Identifier 40281**], MB 91, index 0.8.  Toxicology
screen - Aspirin negative, ETOH negative, Tylenol negative,
benzodiazepines negative, barbiturates negative, TCAs negative.
Carbamazepine 33 ([**3-18**]).

Electrocardiogram revealed normal sinus rhythm, PR interval
204 consistent with first degree AV block, left atrial
enlargement, QRS 140, Q-Tc 450, peaked T waves, 1.0 to 2.[**Street Address(2) 27948**] elevation in V1, V2, but pattern is left bundle
branch block, no T wave inversions, Q wave only in lead III.

IMAGING STUDIES:  CT of the head revealed cerebellar atrophy,
mucosal thickening of maxillary and ethmoid sinus.  CT spine
revealed normal alignment of vertebra, no fractures, no
subluxation, positive degenerative changes in C4-C5, C5-C6,
C6-C7.  Chest x-ray revealed hazy opacities in the bilateral
apices and right lower lobe - ? aspiration.

HOSPITAL COURSE:
1.  Toxicology - The patient was noted to have elevated
Carbamazepine levels.  Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from toxicology
recommended charcoal for absorption of the toxin. Carbamazepine
levels were monitored q3hours.  Activated charcoal 30 grams were
given at the time of arrival to the Medical Intensive Care Unit
and three hours afterwards and need for further doses was
evaluated in the a.m. after admission.  The patient most likely
had a Carbamazepine overdose (question intentional or confused
or due to interaction with fluconazole, recently begun for
candidiasis). The levels were reduced to therapeutic range with
charcoal treatment and intravenous hydration.  They were
monitored for a couple days after that, however, remained in
normal limits for the duration of the hospital course.

2.  Cardiology - The patient had a new widening of the QRS on
initial electrocardiogram and this was likely related to sodium
channel blocking activity of Tegretol.  One amp of bicarbonate
was pushed and the electrocardiogram was rechecked.  QRS
prolongation resolved rapidly after the bicarbonate and
resolution of the patient's acidemia.

3.  Pulmonary - Due to the patient's findings on chest x-ray
of right lower lobe and bilateral apical opacities, he was
assumed to have suffered an aspiration event causing aspiration
pneumonia.  He was started on Levofloxacin 500 mg intravenously
q.d. and Clindamycin 300 mg t.i.d. intravenously which was
continued for fourteen days.  While in the Medical Intensive Care
Unit, he was kept on the ventilator with full support, however,
once he improved, on [**2100-11-8**], he was extubated.  No
complications after extubation.  The Levofloxacin and Clindamycin
were continued for a fourteen day course and discontinued
starting on [**2100-11-17**].  The patient's lung findings improved
rapidly over the course of the stay and for the last six days he
was clear to auscultation bilaterally with normal oxygen
saturation and no signs or symptoms, i.e., cough.

4.  Renal - Initially the patient's creatinine was increased to
4.2.  He also had elevated creatinine kinase enzyme levels around
10,000.  This was most likely rhabdomyolysis and resolved with
hydration and bicarbonate and eventually the CKs trended
downward.  The elevated creatinine normalized within the first
couple of days around [**2100-11-4**], and was postulated to be due to
acute renal failure secondary to severe hydration.  His decreased
potassium was also suspected to be secondary to diarrhea,
gastrointestinal losses.

5.  Gastrointestinal - His recent gastrointestinal bleed at [**Hospital 14852**] secondary to erosive esophagitis prompted
nasogastric tube lavage on admission in the Emergency Department
which was clear.  He was treated with intravenous Protonix for
the duration of his hospital course up until discharge.  Multiple
Clostridium difficile toxin assays were sent which were negative.
His abdominal examination continued to appear benign.

6.  Neurology - The patient's altered mental status was likely
secondary to the Tegretol overdose.  His CT of the head was
negative for any acute process.  Cerebrospinal fluid cultures for
HSV and urine toxicology screens were negative, not consistent
with these as possible etiologies of altered mental status.  The
patient was also while intubated on Propofol and thus not
allowing assessment of his current mental status.  A few days
later, a CT was done of the head again which showed minimal
intraventricular and subarachnoid blood.

Neurology recommendations included electroencephalogram and
magnetic resonance scan to further workup altered mental status.
Two lumbar punctures were also done, one at admission and one
later on.  Both were bloody with increased protein, however, CT
of the head initially did not reveal an acute bleed.  The repeat
CT on [**2100-11-4**], is stated above. Neurology did not feel that
these were large enough to be treated and thus would resolve on
their own.  Follow-up CT will need to be obtained one week after
discharge.

7.  Hematology - The patient's hematocrit was 34.3 on admission
and dropped to 26.7 on hospital day number one.  He was
transfused with two units after which his hematocrit remained
stable for the duration of the admission.

8.  Trauma - He was seen by trauma surgery to be evaluated for
cervical spine instability; they recommended that he be kept in a
cervical collar even though he had no fracture, since ligamentous
injury was not ruled out at the time. Later on in the course of
the hospitalization when he was moved to the floor, flexion and
extension spine films were done and approved by neurosurgery as
clear and thus the collar was removed.  He will follow-up with
neurosurgery a week or two after discharge when he will be
reevaluated with flexion and extension films as well as a head CT
to follow his subarachnoid blood and intraventricular blood seen
on CT of the head on [**2100-11-4**].

9.  Dermatology - The patient was also seen by dermatology while
in the Medical Intensive Care Unit for his multiple abrasions on
bilateral malleoli and forehead.  Initially, it was felt that
these may be trauma induced erosions versus herpetic erosions.
DFA for HSV type I and type II as well as ZBZ were negative
except for an HSV type I DFA which was positive.  All other
cultures of the wound were negative and Acyclovir, which was
started empirically when dermatology first saw him for HSV, was
discontinued when these cultures and DFA came back negative.
These abrasions were treated with Bacitracin Ointment and wound
dressing changes b.i.d.

10. Psychiatry - While in the Medical Intensive Care Unit, the
patient was also seen by psychiatry who was unable to fully
evaluate him while he was sedated.  They recommended an
electroencephalogram and magnetic resonance scan to evaluate
mental status if this did not improve once he was extubated.
They also were questioning the fact that his Carbamazepine
level of 33 implied overingestion, suggesting possible assault or
possible suicide attempt.  The hypothesis that was generated was
that perhaps the patient had a seizure and overdosed with
Tegretol during postictal confusion.

Later on in the hospitalization, they revisited the patient when
he was alert, awake and oriented.  The patient disclosed that he
had had a seizure on the day of admission.  He did not know
anything about the overingestion of the Tegretol, however, he did
deny assault or suicidal attempts.  At the time of discharge, the
patient was not considered to have any psychiatric issues as he
was cheerful and responsive to questions.  The psychiatry team
felt that it was reasonable that he was going to be discharged to
a temporary rehabilitation facility prior to returning home to
care for himself.

11. Hospital floor course - The patient was extubated on
[**2100-11-8**], and moved to the floor on [**2100-11-9**]. His respiratory
status was stable and oxygen was in the process of being weaned.
His issues of Tegretol overdose as well as rhabdomyolysis were
resolved and levels of Tegretol as well as CKs were trending
downward towards normal limits.

As aspiration pneumonia continued to be treated with Levofloxacin
and Clindamycin for a fourteen day course.  The patient continued
to improve respiratory wise with good oxygen saturation, good
respiratory rate and clear lung examination.

Neurology: he had a repeat head CT done on the day of transfer
from the Medical Intensive Care Unit to the floor which was not
different from the [**2100-11-4**] study and was notable for perhaps a
slightly larger bleed ("subdural fluid collection").  It was
decided that a repeat CT would be done one to two weeks after
discharge when following up with neurosurgery unless there was
significant clinical deterioration.  During his continued
hospital course, he had no neurological deficits, no signs of
central nervous system infection.  Magnetic resonance scan and
electroencephalogram were postponed as the patient's mental
status continued to improve progressively and once he was awake,
was alert and oriented times three.

Eventually as stated previously, his cervical collar was removed
once he was clinically cleared with extension and flexion
cervical spine films.

He was continued on Lopresor 100 mg b.i.d. for his hypertension
and was switched to Atenolol 100 mg q.d. on discharge.

Nutrition - The patient had a nasogastric tube in since the
Medical Intensive Care Unit stay and due to aspiration pneumonia
history as well as neck instability, tube feeds were started on
this patient two days after he reached the floor in efforts to
give him nutrition.  Swallow specialist was consulted.  For the
first couple of days, he failed the swallow studies with signs
and symptoms of aspiration upon taking thin liquids. Eventually,
he did better with liquids and was started on soft solids and
thick liquids. This continued to be his diet upon discharge.  He
remains on aspiration precautions.

His hematocrit remained stable during his hospital floor course
and his abrasions on his extremities continued to be treated with
Bacitracin Ointment application to the wounds with dressing
changes twice a day.

Of note, the patient's brother visited him once during his
Medical Intensive Care Unit stay at which time he was unable to
talk to the patient.  His brother visited one more time while he
was on the floor.  He described the patient was slowly returning
to his baseline and at baseline the patient talks and is fully
functional, transports himself around the city, and is very
meticulous about his medication regimen by taking the right
amount at the right time, never over or under.

DISPOSITION:  To subacute/acute rehabilitation facility until
function returns to baseline.  [**Hospital **] [**Hospital **] Rehab -
[**Telephone/Fax (1) 106748**].

PCP:  [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. [**Last Name (STitle) 102851**] ([**Hospital1 336**]) [**Telephone/Fax (1) 106749**]

CONDITION ON DISCHARGE:  Stable.

MEDICATIONS ON DISCHARGE:
1.  Tegretol 200 mg p.o. t.i.d.
2.  Atenolol 100 mg p.o. q.d.
3.  Bacitracin Ointment apply b.i.d. to wounds.




                            [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(2) 4814**]

Dictated By:[**Name8 (MD) 106750**]
MEDQUIST36

D:  [**2100-11-16**]  16:36
T:  [**2100-11-16**]  16:49
JOB#:  [**Job Number 40852**]
{'Poisoning by other and unspecified anticonvulsants,Poisoning by other specified drugs and medicinal substances, undetermined whether accidentally or purposely inflicted,Pneumonitis due to inhalation of food or vomitus,Other disorders of muscle, ligament, and fascia,Other convulsions,Unspecified intellectual disabilities,Unspecified essential hypertension,Pure hypercholesterolemia,Aortocoronary bypass 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: The patient was found down.

PRESENT ILLNESS: This is a 56 year old white male
with a past medical history of seizure disorder on Tegretol and
mental retardation among others.  The patient was found down at
home today by EMS.  Per the patient's brother, the patient lives
alone and the family periodically "checks in with him".  No one
has heard from the patient for three days so the EMS broke the
door down.  The patient was found down unconscious, covered in
emesis as well as blood (question nosebleed).  The patient was
noted to have multiple abrasions over his body.

MEDICAL HISTORY: 1.  Mental retardation.
2.  Hypertension.
3.  Seizure disorder secondary to meningitis as a child.
4.  Hypercholesterolemia.
5.  Fecal incontinence.
6.  Recent upper gastrointestinal bleed secondary to erosive
esophagitis.
7.  Status post coronary artery bypass graft in [**2094**].
8.  Atrial fibrillation.

MEDICATION ON ADMISSION: 1.  Tegretol.
2.  Pravachol.
3.  Atenolol.
4.  Zantac.
5.  Fluconazole

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Non contributory.

SOCIAL HISTORY: The patient denies alcohol or tobacco use. He
lives alone in an apartment in [**Hospital1 8**], [**State 350**] and is
able to care for himself.  Once awake, he described how he takes
the subway to see his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 102851**], at [**Hospital 14852**], and described how he gets there.  He also
reports that he walks to the grocery store and buys his own
groceries.  He keeps in close contact with a social worker, [**Name (NI) **]
[**Name (NI) 12130**], that works in his building.  His brother, [**Name (NI) **] [**Name (NI) 13304**],
lives in [**Name (NI) 3844**] and checks in with the patient
periodically. 

### Response:
{'Poisoning by other and unspecified anticonvulsants,Poisoning by other specified drugs and medicinal substances, undetermined whether accidentally or purposely inflicted,Pneumonitis due to inhalation of food or vomitus,Other disorders of muscle, ligament, and fascia,Other convulsions,Unspecified intellectual disabilities,Unspecified essential hypertension,Pure hypercholesterolemia,Aortocoronary bypass status'}
