CHIEF COMPLAINT: Somnolence

PRESENT ILLNESS: 67-yo morbidly obese woman transferred from [**Hospital3 **] w/
hypotension and atrial fib.  Last night, she took 10 percocet
tablets for acute on chronic low back pain.  This AM, she was
discovered by her son to be lethargic and unresponsive.  He
called EMS, who administered Narcan in the field resulting in
rapid improvement in the pt's mental status.  Upon arrival to
[**Hospital3 **] ED, she was in atrial fibrillation w/ HR 120s,
BP 104/70, groggy but responsive.  EKG showed ST changes thought
to be ST elevations in V1-V2.  She was treated w/ ASA 324 mg,
heparin gtt, and diltiazem 30 mg IV followed by 5 mg/hr gtt,
resulting in BP decrease to 66/40 and HR decrease to 80s.  She
was then treated w/ phenylephrine gtt for BP support through a
peripheral IV.  She is now transferred to the [**Hospital1 18**] CCU for
ongoing care.
.
Currently, she is on phenylephrine, diltiazem, and heparin gtt.
She denies any recent chest pain, palpitations, dyspnea,
presyncope, or syncope.  Further history is unavailable at
present due to pt's lethargy.

MEDICAL HISTORY: - DM type 2:  formerly on metformin, now diet controlled
- hyperlipidemia
- COPD
- Barrett's esophagus
- Chronic low back pain

MEDICATION ON ADMISSION: - losartan 25 mg daily
- simvastatin 40 mg daily
- lasix 40 mg [**Hospital1 **]
- tylenol 650 mg prn
- rabeprazole 20 mg [**Hospital1 **]
- omeprazole 20 mg [**Hospital1 **]
- percocet prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T  99.2, BP 119/83 (without phenylephrine), HR 82, RR 9, O2
96% 2L/m
Gen:  morbidly obese woman lying flat in bed, lethargic,
arousable but falls asleep during the interview.
HEENT: NCAT. Sclera anicteric. PERRL (3mm --> 2mm), EOMI.
Conjunctiva were pink.  OP clear w/ MMM
Neck: no visible JVD.
CV:  faint irreg irreg S1, S2.  No s3/s4/m/r
Pulm:  exam limited by body habitus; coarse exp rhonchi
anteriorly b/l, no crackles or wheezes.
Abd:  obese, +BS, large vertical supraumbilical surgical scar,
soft, NTND.
Ext:  warm, + non-pitting edema to mid-leg b/l, 2+ DP b/l, 8cm x
5cm erythematous woody area of skin over right anterior leg w/
no tenderness or fluctuance; 3 x 4 cm erythematous patch of skin
over left anterior leg w/ no tenderness or fluctuance.
Neuro:  lethargic, rousable, oriented to person and place only,
inattentive, strength 5/5 handgrip b/l, moving all 4 extremities
spontaneously and withdraws to pain from legs b/l.

FAMILY HISTORY: NC

SOCIAL HISTORY: significant for the absence of current tobacco use; smoked 3
packs daily for unknown number of years, but quit "many" years
ago. There is no history of alcohol abuse.
Poisoning by other opiates and related narcotics,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Other thalassemia,Accidental poisoning by other opiates and related narcotics,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia,Morbid obesity,Esophageal reflux,Lumbago,Other chronic pain
Poisoning-opiates NEC,Atrial fibrillation,Chr airway obstruct NEC,Thalassemia NEC,Acc poison-opiates NEC,DMII wo cmp nt st uncntr,Hypertension NOS,Pure hypercholesterolem,Morbid obesity,Esophageal reflux,Lumbago,Chronic pain NEC
Admission Date:  [**2194-4-14**]              Discharge Date:   [**2194-4-16**]

Date of Birth:  [**2126-7-8**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Somnolence

Major Surgical or Invasive Procedure:
None

History of Present Illness:
67-yo morbidly obese woman transferred from [**Hospital3 **] w/
hypotension and atrial fib.  Last night, she took 10 percocet
tablets for acute on chronic low back pain.  This AM, she was
discovered by her son to be lethargic and unresponsive.  He
called EMS, who administered Narcan in the field resulting in
rapid improvement in the pt's mental status.  Upon arrival to
[**Hospital3 **] ED, she was in atrial fibrillation w/ HR 120s,
BP 104/70, groggy but responsive.  EKG showed ST changes thought
to be ST elevations in V1-V2.  She was treated w/ ASA 324 mg,
heparin gtt, and diltiazem 30 mg IV followed by 5 mg/hr gtt,
resulting in BP decrease to 66/40 and HR decrease to 80s.  She
was then treated w/ phenylephrine gtt for BP support through a
peripheral IV.  She is now transferred to the [**Hospital1 18**] CCU for
ongoing care.
.
Currently, she is on phenylephrine, diltiazem, and heparin gtt.
She denies any recent chest pain, palpitations, dyspnea,
presyncope, or syncope.  Further history is unavailable at
present due to pt's lethargy.


Past Medical History:
- DM type 2:  formerly on metformin, now diet controlled
- hyperlipidemia
- COPD
- Barrett's esophagus
- Chronic low back pain

Social History:
significant for the absence of current tobacco use; smoked 3
packs daily for unknown number of years, but quit "many" years
ago. There is no history of alcohol abuse.


Family History:
NC

Physical Exam:
VS: T  99.2, BP 119/83 (without phenylephrine), HR 82, RR 9, O2
96% 2L/m
Gen:  morbidly obese woman lying flat in bed, lethargic,
arousable but falls asleep during the interview.
HEENT: NCAT. Sclera anicteric. PERRL (3mm --> 2mm), EOMI.
Conjunctiva were pink.  OP clear w/ MMM
Neck: no visible JVD.
CV:  faint irreg irreg S1, S2.  No s3/s4/m/r
Pulm:  exam limited by body habitus; coarse exp rhonchi
anteriorly b/l, no crackles or wheezes.
Abd:  obese, +BS, large vertical supraumbilical surgical scar,
soft, NTND.
Ext:  warm, + non-pitting edema to mid-leg b/l, 2+ DP b/l, 8cm x
5cm erythematous woody area of skin over right anterior leg w/
no tenderness or fluctuance; 3 x 4 cm erythematous patch of skin
over left anterior leg w/ no tenderness or fluctuance.
Neuro:  lethargic, rousable, oriented to person and place only,
inattentive, strength 5/5 handgrip b/l, moving all 4 extremities
spontaneously and withdraws to pain from legs b/l.


Pertinent Results:
Admission labs:
137  102  25
--------------< 167
6.2  21  2.1
** Hemolyzed **
CK: 2405  MB: 40  MBI: 1.7  Trop-T: 0.29
Ca: 8.8 Mg: 2.4 P: 7.1
TSH:3.9
.
      13.4
17.4 >----<  337
      43.6
N:84.2 L:11.6 M:3.8 E:0.2 Bas:0.4
.
PT: 13.4  PTT: 61.2  INR: 1.2
.
EKG demonstrated atrial fib w/ rate 85, nl axis, 1-2mm ST
elevations V1-V2, no ST changes I/avL.
.
CXR ([**2194-4-14**] from [**Hospital3 **]):  increased soft tissue
density diffusely, no signs of pleural effusion or infiltrates.
.
Trends:
WBC 17.4 - 12.5
Hct: 43.6 - 35.5
INR: 1.2 - 1.1
Creatinine 1.3 - 0.7
[**2194-4-14**] 02:07PM BLOOD CK(CPK)-2405*
[**2194-4-14**] 07:55PM BLOOD CK(CPK)-381*
[**2194-4-15**] 05:25AM BLOOD CK(CPK)-519*
[**2194-4-14**] 02:07PM BLOOD CK-MB-40* MB Indx-1.7 cTropnT-0.29*
[**2194-4-14**] 07:55PM BLOOD CK-MB-39* MB Indx-10.2* cTropnT-0.25*
[**2194-4-15**] 05:25AM BLOOD CK-MB-23* MB Indx-4.4 cTropnT-0.23*
.
Radiology:
[**4-15**] VQ Scan
No perfusion/ventilation mismatches identified.
Findings suggest possibility of a compressive mass lesion in the
left hilar
region and CT chest is recommended for further evaluation.
.
[**4-15**] CT Angio Chest:
CT CHEST WITH IV CONTRAST: There are no filling defects in the
pulmonary arterial vasculature. Small peripheral lung nodule (2,
24) measuring 3 mm is seen in the right upper lobe. A second
larger nodule measuring 4.5 mm (2, 23 is also seen in the right
upper lobe. There are coronary artery calcifications present.
Smooth interlobular septal thickening with areas of ground-glass
opacity are seen throughout both lung fields with tiny bilateral
pleural effusions, right greater than left and associated
atelectasis at the lung bases. Findings are consistent with
fluid overload. Few images through the upper abdomen are normal.
The airways are patent at the level of the segmental bronchi
bilaterally. No enlarged axillary, mediastinal, or hilar lymph
nodes are present. Small hilar lymph nodes on the right measure
8 mm (2,22).
IMPRESSION: 1) No lung mass seen. Small pulmonary nodules as
described above. If there is a history of smoking or other risk
factors, a follow up chest CT in 12 months is recommended to
document stability.
.
[**4-15**]: Echo:
Conclusions:
The left atrium is normal in size. The estimated right atrial
pressure is
16-20 mmHg. Left ventricular wall thickness, cavity size, and
systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The right ventricular cavity is dilated with moderate
global free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Right ventricular cavity enlargement with free wall
hypokinesis c/w primary pulmonary process (COPD, pulmonary
embolism, etc.). Preserved global left ventricular systolic
function.


Brief Hospital Course:
67-yo-woman w/ DM2, HTN, hyperlipidemia, COPD, low back pain
transferred from OSH w/ lethargy, hypotension, and atrial
fibrillation after percocet overdose.  Hospital course by
problem:
.
#) Hypotension: Etiology likely iatrogenic from diltiazem w/
contribution from opioid overdose. There were no signs of
infection; no reason to suspect adrenal insufficiency or
significant volume depletion. Was briefly on neosynephrine but
this was quickly weaned.  We restarted losartan and beta blocker
and she was normotensive for >24 hours prior to discharge.
.
#) Atrial fibrillation: Initially, this appeared to be a new dx
of atrial fib. Possible causes in this case include COPD,
cardiac ischemia, hypoxia, and thyroid disease. We rate
controlled first with dilt then metoprolol (given slight
troponin leak).  She spontaneously converted to NSR on [**4-14**].  We
treated first with heparin gtt.  On further questioning, patient
reports that she may have been told that she had an irregular
heartbeat in the past.  Given this possible recurrence of Afib,
we recommend treatment with coumadin.  We discharged the patient
on coumadin in addition to her BB and ask that she have an INR
check two days following discharge.  She had direct instructions
from us to go to her PCP's office for a lab draw.
- We have set her up to see a cardiologist in [**Hospital1 **] as
mentioned below.  We will provide his office with this summary.
.
#) Cards ischemic: patient had slight enzyme leak as above.
This was likely in the setting of a tachycardia and her enzymes
were trending downward prior to discharge.  We performed an echo
which showed RV free wall hypokinesis and RA pressures which
were 16-20mm Hg.  There was no regional wall motion abnl of the
left ventricle.  We discharged patient on BB with close
followup.
- also started ASA prior to discharge
.
#) respiratory: patient was able to tolerate room air.  However,
given the above mentioned findings on echo, we performed a V/Q
scan to assess for PE.  There was no evidence of a PE.
- patient with likely sleep apnea given body habitus.  We would
recommend a sleep study within the near future.
.
#) Pulmonary nodules: The V/Q scan demonstarted a possible
mediastinal mass which prompted the above mentioned CT scan.  It
did not confirm such a mass.  However, pulm nodules were noted
as above.  We recommend a followup CT scan in 12 months as per
the radiologists recommendation to assess for interval change.
.
#) Percocet overdose: this is likely the cause of her somnolence
and resp depression by history; utox was positive for opioids.
This was seemingly an unintentional overdose.  Patient however
had a flat affect and we consulted with the social
worker/addiction counselor.  They recommend the following:
-Suggest psycho pharm consult as outpatient
We also recommend close followup with the PCP to monitor for any
signs or symptoms of depression.  Prior to discharge, the
patient reported that it was not a suicide attempt and she did
not have any SI or HI.
.
#) Cellulitis: RLE was erythematous and slightly tender,
possible due to venous stasis changes. Leukocytosis but afebrile
and changes chronic; thus decided not to treat for cellulitis.
.
#) DM type 2: controlled w/ diet as outpt.
- follow FS QID
- cover w/ RISS
.
#) Kidney disease: she had creat 1.3 w/ unknown baseline.  this
improved to 0.7 prior to discharge.
.
#) COPD: unknown severity.
- albuterol INH prn for wheezing
.
#) HTN: controlled w/ losaratan as outpt;  Also added on BB as
above.
.
#) Hyperlipidemia: controlled w/ simvastatin; we continued.
.
#) GERD: controlled w/ PPI; we continued.
.
#) Full code
.
#) Dispo status: fair understanding of the events leading up to
hospitalization as well as discharge instructions.  She will f/u
with PCP in two days for an INR check.  We will also contact PCP
to discuss hospital course.


Medications on Admission:
- losartan 25 mg daily
- simvastatin 40 mg daily
- lasix 40 mg [**Hospital1 **]
- tylenol 650 mg prn
- rabeprazole 20 mg [**Hospital1 **]
- omeprazole 20 mg [**Hospital1 **]
- percocet prn


Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*14 Tablet(s)* Refills:*0*
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Have your INR checked on [**Hospital1 2974**] [**2194-4-18**]


Discharge Disposition:
Home

Discharge Diagnosis:
Percocet Overdose
.
Atrial Fibrillation
Diet Controlled Non-Insulin Dependent Diabetes Mellitus
COPD
Hyperlipidemia
Hypertension


Discharge Condition:
stable


Discharge Instructions:
Please take all medications as prescribed. Please attend all
follow up appointments. It is very important that you follow up
with your primary care physician so that your symptoms and
laboratory tests may be monitored.  You have also been scheduled
an appointment with a cardiologist that it is very important
that you keep.  You have a new diagnosis of atrial fibrillation.
You were started on coumadin, a blood thinning medicine for
this. It is important that you have your lab work checked by
your primary care doctor to measure how thin your blood is.

Followup Instructions:
Please go to your primary care physician's office (Dr.[**Name (NI) 72943**]
office [**Telephone/Fax (1) 18325**]) on [**Last Name (LF) 2974**], [**4-18**] at 10:15AM - you have
an appointment to see him, and you will have your INR (a level
of how thin your blood is) checked at this time, and your
coumadin dose adjusted.  You can bring the provided prescription
for lab work to this appointment.
.
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 18323**] at ([**Telephone/Fax (1) 72944**] to make a follow up appointment in the next 1 week, for
follow up after hospitalization.
.
We have scheduled an appointment for you with a cardiologist in
[**Hospital1 **], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**], phone number [**Telephone/Fax (1) 72945**].  Your
appointment is on [**2194-4-28**] at 2:00pm.  The Fax number is:
[**Telephone/Fax (1) 29683**].
{'Poisoning by other opiates and related narcotics,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Other thalassemia,Accidental poisoning by other opiates and related narcotics,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia,Morbid obesity,Esophageal reflux,Lumbago,Other chronic pain'}


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: Somnolence

PRESENT ILLNESS: 67-yo morbidly obese woman transferred from [**Hospital3 **] w/
hypotension and atrial fib.  Last night, she took 10 percocet
tablets for acute on chronic low back pain.  This AM, she was
discovered by her son to be lethargic and unresponsive.  He
called EMS, who administered Narcan in the field resulting in
rapid improvement in the pt's mental status.  Upon arrival to
[**Hospital3 **] ED, she was in atrial fibrillation w/ HR 120s,
BP 104/70, groggy but responsive.  EKG showed ST changes thought
to be ST elevations in V1-V2.  She was treated w/ ASA 324 mg,
heparin gtt, and diltiazem 30 mg IV followed by 5 mg/hr gtt,
resulting in BP decrease to 66/40 and HR decrease to 80s.  She
was then treated w/ phenylephrine gtt for BP support through a
peripheral IV.  She is now transferred to the [**Hospital1 18**] CCU for
ongoing care.
.
Currently, she is on phenylephrine, diltiazem, and heparin gtt.
She denies any recent chest pain, palpitations, dyspnea,
presyncope, or syncope.  Further history is unavailable at
present due to pt's lethargy.

MEDICAL HISTORY: - DM type 2:  formerly on metformin, now diet controlled
- hyperlipidemia
- COPD
- Barrett's esophagus
- Chronic low back pain

MEDICATION ON ADMISSION: - losartan 25 mg daily
- simvastatin 40 mg daily
- lasix 40 mg [**Hospital1 **]
- tylenol 650 mg prn
- rabeprazole 20 mg [**Hospital1 **]
- omeprazole 20 mg [**Hospital1 **]
- percocet prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T  99.2, BP 119/83 (without phenylephrine), HR 82, RR 9, O2
96% 2L/m
Gen:  morbidly obese woman lying flat in bed, lethargic,
arousable but falls asleep during the interview.
HEENT: NCAT. Sclera anicteric. PERRL (3mm --> 2mm), EOMI.
Conjunctiva were pink.  OP clear w/ MMM
Neck: no visible JVD.
CV:  faint irreg irreg S1, S2.  No s3/s4/m/r
Pulm:  exam limited by body habitus; coarse exp rhonchi
anteriorly b/l, no crackles or wheezes.
Abd:  obese, +BS, large vertical supraumbilical surgical scar,
soft, NTND.
Ext:  warm, + non-pitting edema to mid-leg b/l, 2+ DP b/l, 8cm x
5cm erythematous woody area of skin over right anterior leg w/
no tenderness or fluctuance; 3 x 4 cm erythematous patch of skin
over left anterior leg w/ no tenderness or fluctuance.
Neuro:  lethargic, rousable, oriented to person and place only,
inattentive, strength 5/5 handgrip b/l, moving all 4 extremities
spontaneously and withdraws to pain from legs b/l.

FAMILY HISTORY: NC

SOCIAL HISTORY: significant for the absence of current tobacco use; smoked 3
packs daily for unknown number of years, but quit "many" years
ago. There is no history of alcohol abuse. 

### Response:
{'Poisoning by other opiates and related narcotics,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Other thalassemia,Accidental poisoning by other opiates and related narcotics,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia,Morbid obesity,Esophageal reflux,Lumbago,Other chronic pain'}
