CHIEF COMPLAINT: Altered Mental Status

PRESENT ILLNESS: 40 year old woman with a PMH alcohol abuse, depression, anxiety,
admitted for loss of consciousness after falling onto a stopped
bus.  The patient was found by EMS unresponsive, slumped against
a poll.  On arrival to the ED, the patient had a GSC of 3, and
was intubated for airway protection.  Following intubation,
large amounts of blood were suctioned from the ED tube.  Blood
subsequently decresed to the point patient is producing
blood-tinged sputum.
.
In the ED, VS:  130s/80s, HR 80-90;  RR 18 O2 100% on FIO2 100%,
Vt 500, PEEP 5.  Patient received 2L IVF.  Patient underwent
Head CT that showed general atrophy with calcifications in
frontal lobe (confirmed w/neurosurg no sign of ICH).  C-spine CT
negative.  CXR clear.  Stox/Utox significant for EtOH of 519.
.
On transfer, VS:  96.9  118/71  80 20 100% CMV 40% FIO2; RR 20;
PEEP 5.  Patient intubated and mildly sedated, but awake and
following commands.  Denies pain.  Denies history of past
admissions for alcohol intoxication or withdrawal seizures.
However, patient has had several ED visits in past 6 months for
alcohol intoxication.  Per siblings, patient was a social
drinker until [**2161-1-17**], when she started having panic
attacks and worsening depression.  She began to see a
psychiatrist and was started on lorazepam and celexa for
depression.  Depression has recently worsened, and patient has
begun drinking to the point that friends have reached out to
siblings to notify them of her alcohol abuse.  She endorses one
episode of visual hallucinations and dry heaving in setting of
trial of abstinance from alcohol.  Per sister, the patient has
never endorsed SI.  No past psych hospitalizations.

MEDICAL HISTORY: Depression, Panic disorder;  one episode of visual
hallucinations associated with alcohol abstinence;  guttate
psoriasis;  recent cyclical dry-heaving related to menstrual
cycles (mid-workup with outpatient physician); surgical
correction of amblyopia as child

MEDICATION ON ADMISSION: Celexa 50 mg daily
Lorazepam 0.5 mg [**Hospital1 **] PRN anxiety

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
VS:  96.9  118/71  80 20 100% CMV FIO2 40% RR 20 PEEP 5
Gen:  Intubated, mildly sedated;  neck collar in place;  small
amount of blood in ET tube;  opens eyes and moves spontaneously
HEENT:  no scleral icterus
Card:  normal S1, S2, no murmurs, rubs or gallops
Resp:  Clear to auscultation bilterally
Abd:  Soft, non-tender, non-distended; no organomegaly; + BS
Ext:  Non-edematous;  DP and PT pulses 2+
Neuro:  Mild ansiocoria L 4mm, R 3mm;  Pupils reactive to light;
EOMI; squeezes eyes shut to command;  Upper ext 4-5/5 strength
(unable to assess fully due to restraints);  Lower ext [**5-21**]
Skin:  Pinpoint round macules with scale on arms, legs and
around umbilicus;  3x5 cm scraped lesion on left forhead,
bleeding;  small bleeding scrapes on knees bilaterally

FAMILY HISTORY: No history of lung problems; family hx of hypothyroidism

SOCIAL HISTORY: Lives alone.  Works at health club as spa masseuse.  Smokes
cigarettes (quantity unknown - per sister);  since [**Month (only) 404**], has
started drinking large quantities of EtOH;  multiple ED visits
for intoxication.  Family unaware of recreational drug use.
Acute alcoholic intoxication in alcoholism, continuous,Disorders of phosphorus metabolism,Altered mental status,Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection,Dysthymic disorder,Other iatrogenic hypotension,Intravenous anesthetics causing adverse effects in therapeutic use,Nausea with vomiting,Other psoriasis,Anemia, unspecified,Noncollision motor vehicle traffic accident while boarding or alighting injuring passenger in motor vehicle other than motorcycle
Ac alcohol intox-contin,Dis phosphorus metabol,Altered mental status,Abrasion head,Dysthymic disorder,Iatrogenc hypotnsion NEC,Adv eff intraven anesth,Nausea with vomiting,Other psoriasis,Anemia NOS,Mv acc board/alight-psgr
Admission Date:  [**2161-9-1**]              Discharge Date:   [**2161-9-3**]

Date of Birth:  [**2117-12-5**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Altered Mental Status

Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
40 year old woman with a PMH alcohol abuse, depression, anxiety,
admitted for loss of consciousness after falling onto a stopped
bus.  The patient was found by EMS unresponsive, slumped against
a poll.  On arrival to the ED, the patient had a GSC of 3, and
was intubated for airway protection.  Following intubation,
large amounts of blood were suctioned from the ED tube.  Blood
subsequently decresed to the point patient is producing
blood-tinged sputum.
.
In the ED, VS:  130s/80s, HR 80-90;  RR 18 O2 100% on FIO2 100%,
Vt 500, PEEP 5.  Patient received 2L IVF.  Patient underwent
Head CT that showed general atrophy with calcifications in
frontal lobe (confirmed w/neurosurg no sign of ICH).  C-spine CT
negative.  CXR clear.  Stox/Utox significant for EtOH of 519.
.
On transfer, VS:  96.9  118/71  80 20 100% CMV 40% FIO2; RR 20;
PEEP 5.  Patient intubated and mildly sedated, but awake and
following commands.  Denies pain.  Denies history of past
admissions for alcohol intoxication or withdrawal seizures.
However, patient has had several ED visits in past 6 months for
alcohol intoxication.  Per siblings, patient was a social
drinker until [**2161-1-17**], when she started having panic
attacks and worsening depression.  She began to see a
psychiatrist and was started on lorazepam and celexa for
depression.  Depression has recently worsened, and patient has
begun drinking to the point that friends have reached out to
siblings to notify them of her alcohol abuse.  She endorses one
episode of visual hallucinations and dry heaving in setting of
trial of abstinance from alcohol.  Per sister, the patient has
never endorsed SI.  No past psych hospitalizations.

Past Medical History:
Depression, Panic disorder;  one episode of visual
hallucinations associated with alcohol abstinence;  guttate
psoriasis;  recent cyclical dry-heaving related to menstrual
cycles (mid-workup with outpatient physician); surgical
correction of amblyopia as child

Social History:
Lives alone.  Works at health club as spa masseuse.  Smokes
cigarettes (quantity unknown - per sister);  since [**Month (only) 404**], has
started drinking large quantities of EtOH;  multiple ED visits
for intoxication.  Family unaware of recreational drug use.

Family History:
No history of lung problems; family hx of hypothyroidism


Physical Exam:
Admission Physical Exam:
VS:  96.9  118/71  80 20 100% CMV FIO2 40% RR 20 PEEP 5
Gen:  Intubated, mildly sedated;  neck collar in place;  small
amount of blood in ET tube;  opens eyes and moves spontaneously
HEENT:  no scleral icterus
Card:  normal S1, S2, no murmurs, rubs or gallops
Resp:  Clear to auscultation bilterally
Abd:  Soft, non-tender, non-distended; no organomegaly; + BS
Ext:  Non-edematous;  DP and PT pulses 2+
Neuro:  Mild ansiocoria L 4mm, R 3mm;  Pupils reactive to light;
EOMI; squeezes eyes shut to command;  Upper ext 4-5/5 strength
(unable to assess fully due to restraints);  Lower ext [**5-21**]
Skin:  Pinpoint round macules with scale on arms, legs and
around umbilicus;  3x5 cm scraped lesion on left forhead,
bleeding;  small bleeding scrapes on knees bilaterally

Discharge Physical Exam:
VS: BP 142/88 HR 88 R 18 T 100% O2 RA
Gen: Patient sleeping comfortably, alert to verbal stimuli,
oriented x 3 with sad affect
HEENT: no scleral icterus
Card: normal S1, S2, no murmurs, rubs or gallops
Resp: Clear to auscultation bilterally
Abd: Soft, non-tender, non-distended; no organomegaly
Ext: No clubbing/cyanosis/edema
Neuro: PERRL, EOMI, CN II-XII intact, 5/5 strength all
extremities, no tactile hallucinations or sensory deficits, no
tremors appreciated
Skin: Some facial sweating, pinpoint round macules with scale on
arms, legs and around umbilicus from psoriasis at baseline; 3x5
cm lesion on left forhead, small bleeding scrapes on knees
bilaterally


Pertinent Results:
[**2161-9-1**] 02:44PM BLOOD WBC-8.4 RBC-3.70* Hgb-11.7* Hct-34.4*
MCV-93 MCH-31.5 MCHC-34.0 RDW-16.1* Plt Ct-239
[**2161-9-2**] 02:49AM BLOOD WBC-8.5 RBC-3.21* Hgb-10.4* Hct-29.9*
MCV-93 MCH-32.3* MCHC-34.7 RDW-16.1* Plt Ct-194
[**2161-9-1**] 02:44PM BLOOD Plt Ct-239
[**2161-9-1**] 02:44PM BLOOD PT-11.4 PTT-24.5 INR(PT)-0.9
[**2161-9-1**] 02:44PM BLOOD PT-11.4 PTT-24.5 INR(PT)-0.9
[**2161-9-1**] 02:44PM BLOOD Glucose-107* UreaN-10 Creat-0.5 Na-140
K-3.9 Cl-108 HCO3-27 AnGap-9
[**2161-9-2**] 02:49AM BLOOD Glucose-91 UreaN-9 Creat-0.5 Na-145 K-4.0
Cl-114* HCO3-26 AnGap-9
[**2161-9-1**] 02:44PM BLOOD ALT-22 AST-24 AlkPhos-72 TotBili-0.2
[**2161-9-2**] 02:49AM BLOOD ALT-24 AST-29 AlkPhos-60 TotBili-0.2
[**2161-9-1**] 02:44PM BLOOD Albumin-4.1 Calcium-8.0* Phos-3.6 Mg-1.9
[**2161-9-2**] 02:49AM BLOOD Albumin-3.6 Calcium-7.3* Phos-2.6* Mg-1.7
[**2161-9-1**] 02:44PM BLOOD ASA-NEG Ethanol-519* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2161-9-1**] 02:43PM BLOOD Type-ART Rates-/16 Tidal V-500 FiO2-100
pO2-318* pCO2-57* pH-7.26* calTCO2-27 Base XS--2 AADO2-341 REQ
O2-62 Intubat-INTUBATED Vent-CONTROLLED
[**2161-9-1**] 06:31PM BLOOD Type-ART Rates-16/ Tidal V-500 PEEP-5
FiO2-40 pO2-169* pCO2-37 pH-7.38 calTCO2-23 Base XS--2
Intubat-INTUBATED Vent-CONTROLLED

CT head [**2161-9-1**]:  1. Foci of hyperdensity along the anterior
medial left frontal lobe may represent vascular malformation,
prior trauma, or underlying lesion- less likely to represent
acute intraparenchymal hemorrhage (though not excluded).
Recommend short interval repeat CT to assess for stability. If
lesion does not demonstrate typical evolution of blood products,
could be further assessed with MRI. 2. Prior infarct in left
internal capsule. 3. Global atrophy.

CT neck [**2161-9-1**]:  1. No fracture or malalignment evident. 2.
Multilevel degenerative change identified. 3. Left thyroid
nodule. Further evaluation with non-emergent outpatient thyroid
ultrasound is recommended.

ECG [**2161-9-1**]: Sinus rhythm. Normal tracing. No previous tracing
available for comparison.

CXR [**2161-9-1**]:  IMPRESSION: Endotracheal tube in ostium of the
right mainstem bronchus. Retraction noted on a short interval
subsequent study suggesting clinical team noted abnormality
prior to official radiology interpretation.

MICROBIOLOGY:
- Blood culture [**2161-9-1**]: No growth
- Blood culture [**2161-9-1**]: No growth
- MRSA screen [**2161-9-1**]: No MRSA isolated

Brief Hospital Course:
40 year old woman with unknown PMH admitted for AMS/+LOC after
falling off a stopped bus, found to have blood EtOH of 519.
Intubated and sedated, but hemodynamically stable. She was
extubated soon after admission to the ICU and called out to the
general medical wards the next day. She was noted to have flat
affect but denied suicidal ideation and was otherwise well.  She
was discharged with a plan to follow up with her [**Month/Day/Year **] and
PCP.

#AMS:  Patient was intubated in the ED for GCS of 3, s/p fall
with +LOC.  Upon transfer to the floor, the patient was
intubated but awake and alert.  She self-extubated the night of
admission while on a spontaneous breathing trial and was stable,
with good saturations on room air.  EtOH level found to be 519,
otherwise tox screen negative.  Elevated alcohol was found to be
source of AMS.  Glucose within normal limits.  EKG without
evidence of acute ischemia.  Patient afebrile, with normal WBC
count, normal CXR, and normal U/A.  Therefore, infection
unlikely source of AMS.  Patient's mental status cleared within
sevaral hours of admission. She remained clear following callout
to the general medical wards.

#Elevated EtOH:  Patient admitted with acute alcohol
intoxication in the setting of 3 years of chronic alcohol abuse.
 Per family, the patient has had recent visual hallucinations in
the setting of alcohol abstinence.  On laboratory data and
physical exam, no evidence of chronic liver disease.  No anion
gap to suggest injestion of other toxic EtOH, such as methanol
or ethylene glycol.  Patient was started on thiamine, folate,
and CIWA scale for alcohol withdrawal.  She was seen by social
work, who felt that she was in the precontemplative stage of
alcohol cessation. She did not exhibit symptoms of alcohol
withdrawal, so home lorazepam was restarted after callout from
the ICU. She had an otherwise uneventful course as far as
withdrawal. She agreed that she would contact her outpatient
[**Month/Day/Year **] for follow up within one week.

#History of depression/Panic attacks: Chronic, but worsening
over the past several months.  Patient has had recent outpatient
increase in celexa and lorazepam.  No history of past
hospitalizations for psychiatric issues.  The patient denies SI.
 On admission, she was restarted on her home celexa.  Lorazepam
was initially held, as patient was put on CIWA scale for alcohol
withdrawal, but restarted when patient was called out to the
general medical wards. She agreed that she would contact her
outpatient [**Month/Day/Year **] for follow up within one week.

#Transitional issues:
- Patient found to have thyroid incidentaloma on lateral neck
CT.  Recommended outpatient ultrasound.
- Head CT findings concerning for calcification - unlikely ICH.
However, recommended repeat scan to f/u.
- Code status:  full code (discussed with patient)


Medications on Admission:
Celexa 50 mg daily
Lorazepam 0.5 mg [**Hospital1 **] PRN anxiety

Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. citalopram 20 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. CLOBEX 0.05 % Spray, Non-Aerosol Sig: One (1)  Topical as
directed as needed for psoriasis.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
- Altered mental status
- Inability to protect airway; intubation
- Alcohol intoxication

Secondary:
- Depresssion
- Anxiety
- Panic disorder


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


Discharge Instructions:
Dear Ms. [**Known lastname **],

It was a pleasure to care for you during this hospitalization.
You were admitted to [**Hospital1 69**] after
you were found unresponsive and intoxicated with alcohol. You
were initially intubated to help your breathing, and as a result
of this procedure you had some bleeding from trauma to your
airway. You recovered well in the ICU and the breathing tube was
removed without complication. You spoke with our social worker
about resources to help you control your alcohol intake, and you
were otherwise medically stable.

We have made the following changes to your medication regimen:
- Begin taking thiamine 100 mg by mouth daily
- Begin taking folic acid 1 mg by mouth daily

Please follow up with your doctor [**First Name (Titles) **] [**Last Name (Titles) **] as reommended
below.

Followup Instructions:
1. PRIMARY CARE
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Apartment Address(1) 89809**], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 26774**]
Appointment: Tuesday [**2161-9-8**] 1:45pm
- Ask your doctor if you feel you need additional resources or
support to help you stop drinking alcohol

2. MENTAL HEALTH
- Please call your outpatient [**Year (4 digits) **] and arrange to be seen
this coming Thursday to discuss this hospitalization and other
sources of stress.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]

Completed by:[**2161-9-12**]
{'Acute alcoholic intoxication in alcoholism, continuous,Disorders of phosphorus metabolism,Altered mental status,Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection,Dysthymic disorder,Other iatrogenic hypotension,Intravenous anesthetics causing adverse effects in therapeutic use,Nausea with vomiting,Other psoriasis,Anemia, unspecified,Noncollision motor vehicle traffic accident while boarding or alighting injuring passenger in motor vehicle other than motorcycle'}


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: 40 year old woman with a PMH alcohol abuse, depression, anxiety,
admitted for loss of consciousness after falling onto a stopped
bus.  The patient was found by EMS unresponsive, slumped against
a poll.  On arrival to the ED, the patient had a GSC of 3, and
was intubated for airway protection.  Following intubation,
large amounts of blood were suctioned from the ED tube.  Blood
subsequently decresed to the point patient is producing
blood-tinged sputum.
.
In the ED, VS:  130s/80s, HR 80-90;  RR 18 O2 100% on FIO2 100%,
Vt 500, PEEP 5.  Patient received 2L IVF.  Patient underwent
Head CT that showed general atrophy with calcifications in
frontal lobe (confirmed w/neurosurg no sign of ICH).  C-spine CT
negative.  CXR clear.  Stox/Utox significant for EtOH of 519.
.
On transfer, VS:  96.9  118/71  80 20 100% CMV 40% FIO2; RR 20;
PEEP 5.  Patient intubated and mildly sedated, but awake and
following commands.  Denies pain.  Denies history of past
admissions for alcohol intoxication or withdrawal seizures.
However, patient has had several ED visits in past 6 months for
alcohol intoxication.  Per siblings, patient was a social
drinker until [**2161-1-17**], when she started having panic
attacks and worsening depression.  She began to see a
psychiatrist and was started on lorazepam and celexa for
depression.  Depression has recently worsened, and patient has
begun drinking to the point that friends have reached out to
siblings to notify them of her alcohol abuse.  She endorses one
episode of visual hallucinations and dry heaving in setting of
trial of abstinance from alcohol.  Per sister, the patient has
never endorsed SI.  No past psych hospitalizations.

MEDICAL HISTORY: Depression, Panic disorder;  one episode of visual
hallucinations associated with alcohol abstinence;  guttate
psoriasis;  recent cyclical dry-heaving related to menstrual
cycles (mid-workup with outpatient physician); surgical
correction of amblyopia as child

MEDICATION ON ADMISSION: Celexa 50 mg daily
Lorazepam 0.5 mg [**Hospital1 **] PRN anxiety

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
VS:  96.9  118/71  80 20 100% CMV FIO2 40% RR 20 PEEP 5
Gen:  Intubated, mildly sedated;  neck collar in place;  small
amount of blood in ET tube;  opens eyes and moves spontaneously
HEENT:  no scleral icterus
Card:  normal S1, S2, no murmurs, rubs or gallops
Resp:  Clear to auscultation bilterally
Abd:  Soft, non-tender, non-distended; no organomegaly; + BS
Ext:  Non-edematous;  DP and PT pulses 2+
Neuro:  Mild ansiocoria L 4mm, R 3mm;  Pupils reactive to light;
EOMI; squeezes eyes shut to command;  Upper ext 4-5/5 strength
(unable to assess fully due to restraints);  Lower ext [**5-21**]
Skin:  Pinpoint round macules with scale on arms, legs and
around umbilicus;  3x5 cm scraped lesion on left forhead,
bleeding;  small bleeding scrapes on knees bilaterally

FAMILY HISTORY: No history of lung problems; family hx of hypothyroidism

SOCIAL HISTORY: Lives alone.  Works at health club as spa masseuse.  Smokes
cigarettes (quantity unknown - per sister);  since [**Month (only) 404**], has
started drinking large quantities of EtOH;  multiple ED visits
for intoxication.  Family unaware of recreational drug use. 

### Response:
{'Acute alcoholic intoxication in alcoholism, continuous,Disorders of phosphorus metabolism,Altered mental status,Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection,Dysthymic disorder,Other iatrogenic hypotension,Intravenous anesthetics causing adverse effects in therapeutic use,Nausea with vomiting,Other psoriasis,Anemia, unspecified,Noncollision motor vehicle traffic accident while boarding or alighting injuring passenger in motor vehicle other than motorcycle'}
