CHIEF COMPLAINT: Suicide attempt/benzodiazepene overdose

PRESENT ILLNESS: 41 year-old male with depression and hypothyroidism admitted
following benzodiazepene overdose. Patient took clonazepam 1mg
PO x30 over one hour while at a friend's house earlier this
afternoon. He presented to [**Hospital1 18**] ED within 40 minutes of
ingestion.
.
On admission to ED, 97.5 77 118/64 16 100% RA. Patient was given
activated charcoal. He was also given a total of 3L IVF and
Zofran IV x1. Toxicology was consulted and recommended close
monitoring of airway status with evaluation by psychiatry after
6 hours. During ED stay, patient became bradycardic to 30s with
systolic BP 90s, despite fluid resuscitation. He was given
glucagon IV x1 given concern for beta-blocker overdose. EKG
reportedly showed 1st degree AV block with few PVCs. Patient was
noted to be asymptomatic during this time; he remained
conversant and with full orientation. Patient was transferred to
[**Hospital Unit Name 153**] for further hemodynamic monitoring. On transfer to the
[**Hospital Unit Name 153**], 97.6, 40, 99/57 (after 3L NS), 10, 99% RA.
.
On arrival in the [**Hospital Unit Name 153**], patient complains of feeling very
depressed. He reports frustration with not being successful with
suicide attempt today. He reports feeling suicidal currently,
but admits to not having a plan. Regarding his hemodynamic
status, he reports he has a slow heart rate and low blood
pressure at baseline (numbers unknown). He denies chest pain,
shortness of breath, palpitations.
.
Review of Sytems:
(+) Per HPI. Reports 30 lb weightloss over 2 month period.
Reports migraine headache currently.
(-) Denies fever, chills, night sweats. Denies sinus tenderness,
rhinorrhea, or nasal congestion. Denie cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias

MEDICAL HISTORY: Depression with ?catatonic episodes in the past
Hypothyroidism
Migraine headaches
Gastric ulcer (EGD with Dr. [**Last Name (STitle) 41956**]
s/p gastric bypass ([**12/2122**])
s/p hernia repair x 3 ([**2092**]-inguinal, [**7-18**]-ventral)

MEDICATION ON ADMISSION: none

ALLERGIES: Haloperidol / Prochlorperazine

PHYSICAL EXAM: afebrile  120/80  49  16  97RA  (HR on tele 40's-109 past 24
hrs)
General:  Alert, oriented, tearful at times
HEENT:  Sclera anicteric, pupils equal and reactive to light,
moist mucous membrnaes, oropharynx clear
Neck:  Supple, JVP not elevated
Lungs:  Clear to auscultation bilaterally; no wheezes, rales,
ronchi
CV:  Bradycardic; regular rhythm; normal S1/S2; no murmurs,
rubs, gallops
Abdomen:  Normoactive bowel sounds; soft, nontender, not
distended
Ext:  Warm, well-perfused; 2+ radial and DP pulses; no clubbing,
cyanosis, or edema
Psych:  Appropriate responses, flat affect, mild psychomotor
slowing, AOx3

FAMILY HISTORY: Did not obtain

SOCIAL HISTORY: Former criminal defense attorney. Has 1 daughter, now 5.
Divorced. Lost law license, privileges for seeing daughter due
to depression. Denies alcohol, tobacco, or illicit drug use, now
or in the past.
Poisoning by benzodiazepine-based tranquilizers,Major depressive affective disorder, recurrent episode, severe, without mention of psychotic behavior,Other specified cardiac dysrhythmias,Suicide and self-inflicted poisoning by tranquilizers and other psychotropic agents,Iron deficiency anemia, unspecified,Neutropenia, unspecified,Other vitamin B12 deficiency anemia,Unspecified acquired hypothyroidism,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Hypopotassemia,Disorders of phosphorus metabolism,Bariatric surgery status
Pois-benzodiazepine tran,Recur depr psych-severe,Cardiac dysrhythmias NEC,Poison-psychotropic agt,Iron defic anemia NOS,Neutropenia NOS,B12 defic anemia NEC,Hypothyroidism NOS,Migrne unsp wo ntrc mgrn,Hypopotassemia,Dis phosphorus metabol,Bariatric surgery status
Admission Date:  [**2131-9-8**]              Discharge Date:   [**2131-9-13**]

Date of Birth:  [**2089-11-25**]             Sex:   M

Service: MEDICINE

Allergies:
Haloperidol / Prochlorperazine

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Suicide attempt/benzodiazepene overdose


Major Surgical or Invasive Procedure:
none

History of Present Illness:
41 year-old male with depression and hypothyroidism admitted
following benzodiazepene overdose. Patient took clonazepam 1mg
PO x30 over one hour while at a friend's house earlier this
afternoon. He presented to [**Hospital1 18**] ED within 40 minutes of
ingestion.
.
On admission to ED, 97.5 77 118/64 16 100% RA. Patient was given
activated charcoal. He was also given a total of 3L IVF and
Zofran IV x1. Toxicology was consulted and recommended close
monitoring of airway status with evaluation by psychiatry after
6 hours. During ED stay, patient became bradycardic to 30s with
systolic BP 90s, despite fluid resuscitation. He was given
glucagon IV x1 given concern for beta-blocker overdose. EKG
reportedly showed 1st degree AV block with few PVCs. Patient was
noted to be asymptomatic during this time; he remained
conversant and with full orientation. Patient was transferred to
[**Hospital Unit Name 153**] for further hemodynamic monitoring. On transfer to the
[**Hospital Unit Name 153**], 97.6, 40, 99/57 (after 3L NS), 10, 99% RA.
.
On arrival in the [**Hospital Unit Name 153**], patient complains of feeling very
depressed. He reports frustration with not being successful with
suicide attempt today. He reports feeling suicidal currently,
but admits to not having a plan. Regarding his hemodynamic
status, he reports he has a slow heart rate and low blood
pressure at baseline (numbers unknown). He denies chest pain,
shortness of breath, palpitations.
.
Review of Sytems:
(+) Per HPI. Reports 30 lb weightloss over 2 month period.
Reports migraine headache currently.
(-) Denies fever, chills, night sweats. Denies sinus tenderness,
rhinorrhea, or nasal congestion. Denie cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias

Past Medical History:
Depression with ?catatonic episodes in the past
Hypothyroidism
Migraine headaches
Gastric ulcer (EGD with Dr. [**Last Name (STitle) 41956**]
s/p gastric bypass ([**12/2122**])
s/p hernia repair x 3 ([**2092**]-inguinal, [**7-18**]-ventral)

Social History:
Former criminal defense attorney. Has 1 daughter, now 5.
Divorced. Lost law license, privileges for seeing daughter due
to depression. Denies alcohol, tobacco, or illicit drug use, now
or in the past.


Family History:
Did not obtain

Physical Exam:
afebrile  120/80  49  16  97RA  (HR on tele 40's-109 past 24
hrs)
General:  Alert, oriented, tearful at times
HEENT:  Sclera anicteric, pupils equal and reactive to light,
moist mucous membrnaes, oropharynx clear
Neck:  Supple, JVP not elevated
Lungs:  Clear to auscultation bilaterally; no wheezes, rales,
ronchi
CV:  Bradycardic; regular rhythm; normal S1/S2; no murmurs,
rubs, gallops
Abdomen:  Normoactive bowel sounds; soft, nontender, not
distended
Ext:  Warm, well-perfused; 2+ radial and DP pulses; no clubbing,
cyanosis, or edema
Psych:  Appropriate responses, flat affect, mild psychomotor
slowing, AOx3


Pertinent Results:
URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
.
EKG [**9-8**] Sinus rhythm. Prolonged P-R interval. Compared to the
previous tracing of [**2131-7-29**] the P-R interval is now prolonged.

EKG [**9-9**] Sinus rhythm. P-R interval prolongation. Borderline low
QRS voltage. Intraventricular conduction delay. Since the
previous tracing of [**2131-9-8**] the rate has increased. Premature
beats are no longer seen. The QRS width is prolonged, as is the
P-R interval. Clinical correlation is suggested.

Micro: MRSA screen negative
.
Imaging: none

[**2131-9-8**] 04:50PM BLOOD WBC-3.1* RBC-4.37* Hgb-9.9* Hct-31.5*
MCV-72* MCH-22.7*# MCHC-31.4 RDW-16.7* Plt Ct-253
[**2131-9-10**] 07:15AM BLOOD WBC-3.0* RBC-4.04* Hgb-9.4* Hct-29.4*
MCV-73* MCH-23.1* MCHC-31.8 RDW-17.1* Plt Ct-197
[**2131-9-8**] 04:50PM BLOOD Neuts-63.2 Lymphs-28.2 Monos-2.8 Eos-5.2*
Baso-0.7
[**2131-9-10**] 07:15AM BLOOD Glucose-84 UreaN-8 Creat-1.1 Na-146*
K-3.7 Cl-112* HCO3-29 AnGap-9
[**2131-9-12**] 09:25AM BLOOD Glucose-210* UreaN-10 Creat-1.1 Na-142
K-3.1* Cl-106 HCO3-28 AnGap-11
[**2131-9-10**] 07:15AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.1
[**2131-9-12**] 09:25AM BLOOD Calcium-8.7 Phos-1.4*# Mg-2.0
[**2131-9-8**] 04:50PM BLOOD CK-MB-3 cTropnT-<0.01
[**2131-9-9**] 03:52AM BLOOD CK-MB-4 cTropnT-<0.01
[**2131-9-8**] 04:50PM BLOOD ALT-13 AST-14 LD(LDH)-169 CK(CPK)-120
AlkPhos-69 TotBili-0.4
[**2131-9-9**] 03:52AM BLOOD CK(CPK)-95

[**2131-9-9**] 03:52AM BLOOD calTIBC-326 VitB12-149* Folate-7.4
Ferritn-5.5* TRF-251
[**2131-9-9**] 03:52AM BLOOD Calcium-7.4* Phos-2.9 Mg-2.0 Iron-28*

[**2131-9-8**] 04:50PM BLOOD TSH-5.8*
[**2131-9-9**] 03:52AM BLOOD Free T4-0.53*

[**2131-9-9**] 03:52AM BLOOD Digoxin-<0.2*
[**2131-9-9**] 03:52AM BLOOD Lithium-0.2*
[**2131-9-8**] 04:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Brief Hospital Course:
41M with depression, hypothyroidism admitted with benzodiazepene
overdose, and bradycardia into the 30's. Despite this level of
bradycardia, pt remained hemodynamically stable.  He was
initially monitored in the ICU, and was subsequently called out
to the medical floor for further management.  Toxicology was
consulted via the ED, and followed initially in the ICU and
floor.  Per recommendations, pacer pads were initially left on
the patient in case of symptomatic bradycardia, and atropine was
kept available on the floor; neither of which were used during
the admission.
.
#. Benzodiazepene overdose: Pt ingested Clonazepam 30-40mg PO
over 1 hour period. t([**1-12**]) 30-40 hours (Micromedix); hepatic
metabolism.
HR was significantly bradycardic for several days, with slow
trend towards improvement. On record review, it appears that his
baseline HR is likely mid-60's. Based upon T1/2 of 30-40 hrs, 3
half lives = 4.3 days. At 3 half lives, would expect medication
88% eliminated. Pt is currently on Day 4 post-ingestion. HR now
showing significant signs of improvement, with HR trending
towards 50s to more recently 70's; brief excursion into low
100's, which is a good sign for medication clearance.  Pt is now
considered medically cleared from benzodiazepine overdose.
- transfer to inpatient psychiatry
- continue 1:1 sitter for SI, with seclusion for active SI.
.
#. Bradycardia: HR improving; see above. There may also have
been a contribution from hypothyroidism, as pt had not been
taking his synthroid recently. Further history from patient
revealed that his most recent dose of synthroid was 175 mcg/day,
and pt's dose was increased accordingly.
- Continue tele until transferred to psych.
- pacer pads discontinued
- d/c atropine; doses were not required.
.
# Hypokalemia/ hypophosphatemia
On evening of [**9-11**]-2, increased ventricular ectopy was noted on
telemetry, and thus a chemistry panel was rechecked.  It was
noted that pt had developed hypokalemia and hypophosphatemia
over the 2 days that labs were not checked.
Pt was provided potassium and phos repletion, and will need
further electrolyte monitoring/repletion while on the psychiatry
service.
- while the patient's history is not entirely clear, this could
represent a mild refeeding syndrome vs current inadequate oral
intake.  Pt notes that he had been drinking carnation instant
breakfast prior to his admission.
.
#. Depression: Severe with suicide attempt. Per patient's
report, has undergone multiple medication therapies and
prolonged treatment with ECT without relief at [**Location (un) 745**]-[**Location (un) 3678**].
Currently with suicidal ideation without plan.
Pt was maintained on suicide precautions with 1:1 sitter and
seclusion.  Remained  Section 12 via Psych.  Pt being admitted
to inpatient psychiatry for further management of his
depression.
.
#. Hypothyroidism: Formerly on Synthroid. Patient stopped
abruptly several years ago. Pt clarified this am that his most
recent synthroid dose was acutally 175 mcg, and he reports that
he had been compliant with his synthroid in the months prior to
that dosing.  Pt's hypothyroidism is likely contributing to his
bradycardia, and will likely improve with treatment with
Synthroid.
TSH 5.8 with free T4 0.53.
- increased synthroid to 175 mcg/day
.
#. Anemia and mild neutropenia: Borderline microcytic (MCV 72)
and large RDW. Hematocrit 29-32 in previous bloodwork. No prior
anemia workup or endoscopies in OMR; patient reports gastric
ulcer diagnosed by recent previous EGD.  Labs show evidence of
iron deficiency and B12 deficiency which can account for low H/H
and low WBC.  Pt had no episodes of bleeding during the
hospialization, he was maintained on oral ppi considering his
history of gastric ulcer in the past.  He was provided a B12 SQ
injection (1000 mcg) for 2 days, and will be provided high-dose
oral B12 supplements.  He was also treated with oral iron
sulfate supplements, which he should continue for 2 months.  He
will need to follow up with his primary care physician after
discharge from psychiatry for possible further evaluation of his
anemia, and reevaluation of his supplementation.
His oral B12 should be administered as follows:
  B12 1000mcg po q day x 7 days, then qWeek x 4 weeks. Pt should
then be reevaluated by PCP to determine if patient needs further
supplementation.
.
# Hypokalemia/hypophosphatemia:
Nutritional vs refeeding syndrome vs electrolyte consumption
post-B12 injection (consumption for cell synthesis)
- Pt repleted with Po KCl, and given dose of KPhos, with
normalization of labs.
- Recommend follow lytes and replete prn
.
Code status: FULL CODE (suicidal patient)
.
Communication: Patient wishes that no friends/family members be
made aware of his hospitalization.
Dispo: Patient is medically clear for Psychiatric admission;
although he will need electrolyte monitoring and repletion prn.

Medications on Admission:
none

Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day for 2 months.
2. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Synthroid 175 mcg Tablet Sig: One (1) Tablet PO once a day:
do not administer iron at same time as synthroid.
5. K Phos Di & Mono-Sod Phos Mono 250 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day) for 2 days.
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day)
for 2 doses.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for Constipation.
9. Cyanocobalamin 1,000 mcg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day for as dir weeks:
Take 1 tab po q day x 7 days, then 1 tab po q week x 4 weeks.
10. Multivitamin     Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
Deacones 4 ([**Hospital1 18**] [**Hospital Ward Name 517**])

Discharge Diagnosis:
# Suicide attempt ingestion
# Benzodiazepine overdose; clonazepam
# Bradycardia
# Hypothyroidism
# Severe depression
# Anemia, B12 and iron deficiency
# Mild neutropenia; likely d/t B12 deficiency


Discharge Condition:
medically stable for admission to psychiatry.


Discharge Instructions:
You were admitted to medicine following an overdose of
clonazepam, and now that you are medically stable from this
overdose, you are being admitted to inpatient Psychiatry
service.
Please take medications only as prescribed.

Followup Instructions:
Please follow up with your primary care provider [**Last Name (NamePattern4) **] [**1-13**] weeks
after discharge from psychiatry for further evaluation of your
anemia, your iron deficiency, your B12 deficiency, and you
should have your thyroid replacements (Synthroid) reevaluated as
appropriate.

Please follow electrolytes over the next several days, and
replete electrolytes as needed.
{'Poisoning by benzodiazepine-based tranquilizers,Major depressive affective disorder, recurrent episode, severe, without mention of psychotic behavior,Other specified cardiac dysrhythmias,Suicide and self-inflicted poisoning by tranquilizers and other psychotropic agents,Iron deficiency anemia, unspecified,Neutropenia, unspecified,Other vitamin B12 deficiency anemia,Unspecified acquired hypothyroidism,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Hypopotassemia,Disorders of phosphorus metabolism,Bariatric surgery 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: Suicide attempt/benzodiazepene overdose

PRESENT ILLNESS: 41 year-old male with depression and hypothyroidism admitted
following benzodiazepene overdose. Patient took clonazepam 1mg
PO x30 over one hour while at a friend's house earlier this
afternoon. He presented to [**Hospital1 18**] ED within 40 minutes of
ingestion.
.
On admission to ED, 97.5 77 118/64 16 100% RA. Patient was given
activated charcoal. He was also given a total of 3L IVF and
Zofran IV x1. Toxicology was consulted and recommended close
monitoring of airway status with evaluation by psychiatry after
6 hours. During ED stay, patient became bradycardic to 30s with
systolic BP 90s, despite fluid resuscitation. He was given
glucagon IV x1 given concern for beta-blocker overdose. EKG
reportedly showed 1st degree AV block with few PVCs. Patient was
noted to be asymptomatic during this time; he remained
conversant and with full orientation. Patient was transferred to
[**Hospital Unit Name 153**] for further hemodynamic monitoring. On transfer to the
[**Hospital Unit Name 153**], 97.6, 40, 99/57 (after 3L NS), 10, 99% RA.
.
On arrival in the [**Hospital Unit Name 153**], patient complains of feeling very
depressed. He reports frustration with not being successful with
suicide attempt today. He reports feeling suicidal currently,
but admits to not having a plan. Regarding his hemodynamic
status, he reports he has a slow heart rate and low blood
pressure at baseline (numbers unknown). He denies chest pain,
shortness of breath, palpitations.
.
Review of Sytems:
(+) Per HPI. Reports 30 lb weightloss over 2 month period.
Reports migraine headache currently.
(-) Denies fever, chills, night sweats. Denies sinus tenderness,
rhinorrhea, or nasal congestion. Denie cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias

MEDICAL HISTORY: Depression with ?catatonic episodes in the past
Hypothyroidism
Migraine headaches
Gastric ulcer (EGD with Dr. [**Last Name (STitle) 41956**]
s/p gastric bypass ([**12/2122**])
s/p hernia repair x 3 ([**2092**]-inguinal, [**7-18**]-ventral)

MEDICATION ON ADMISSION: none

ALLERGIES: Haloperidol / Prochlorperazine

PHYSICAL EXAM: afebrile  120/80  49  16  97RA  (HR on tele 40's-109 past 24
hrs)
General:  Alert, oriented, tearful at times
HEENT:  Sclera anicteric, pupils equal and reactive to light,
moist mucous membrnaes, oropharynx clear
Neck:  Supple, JVP not elevated
Lungs:  Clear to auscultation bilaterally; no wheezes, rales,
ronchi
CV:  Bradycardic; regular rhythm; normal S1/S2; no murmurs,
rubs, gallops
Abdomen:  Normoactive bowel sounds; soft, nontender, not
distended
Ext:  Warm, well-perfused; 2+ radial and DP pulses; no clubbing,
cyanosis, or edema
Psych:  Appropriate responses, flat affect, mild psychomotor
slowing, AOx3

FAMILY HISTORY: Did not obtain

SOCIAL HISTORY: Former criminal defense attorney. Has 1 daughter, now 5.
Divorced. Lost law license, privileges for seeing daughter due
to depression. Denies alcohol, tobacco, or illicit drug use, now
or in the past. 

### Response:
{'Poisoning by benzodiazepine-based tranquilizers,Major depressive affective disorder, recurrent episode, severe, without mention of psychotic behavior,Other specified cardiac dysrhythmias,Suicide and self-inflicted poisoning by tranquilizers and other psychotropic agents,Iron deficiency anemia, unspecified,Neutropenia, unspecified,Other vitamin B12 deficiency anemia,Unspecified acquired hypothyroidism,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Hypopotassemia,Disorders of phosphorus metabolism,Bariatric surgery status'}
