CHIEF COMPLAINT: Transfer from [**Hospital3 15174**] for treatment of
altered mental status.

PRESENT ILLNESS: The patient is a 52 year old woman with past medical history
significant for chronic pain on narcotics and benzodiazepines,
malabsorption syndrome due to complications of gastric bypass
surgery, and severe osteoporosis.  Three days prior to her
admission to the outside hospital, the patient presented to her
PCP's office for evaluation of ~20 pound weight loss that had
occurred over the past 6-8 weeks.  The patient was found to have
a urinary tract infection, and she was prescribed Ciprofloxacin.
 The patient took two doses of the antibiotic.  The following
day, the patient's husband noted that his wife seemed very
nervous and agitated.  He called the PCP, [**Name10 (NameIs) 1023**] advised the
patient to discontinue the Ciprofloxacin.  That evening, the
patient's husband noted that the patient was laughing
inappropriately while she watched TV.  She thought the TV was
"talking to her."  The patient's husband called 911, but by the
time the EMTs arrived at their home, the patient was able to
answer questions correctly, and she refused to go to the
hospital.  The following morning, the patient was noted to be
more agitated, paranoid, and delusional, so her huaband called
911 again.  This time, the patient was taken to
[**Hospital3 15174**].
   On presentation to the outside hospital, the patient was
noted to have a low grade temperature (100.2). Her neurologic
exam was reported as "non-focal," and a non-contrast head CT was
negative for bleed. The patient's tox screen was negative for
ETOH.  Her other laboratory data was unremarkable.  The patient
was admitted to the hospital for treatment of narcotic
withdrawal.
   During her 36 hour hospitalization, the patient was given two
doses of Buprenex.  Subsequently, the patient became lethargic,
confused, combative, and agitated.  She was transferred to the
ICU for further management.  She was given a few doses of Haldol
and Ativan for her agitation.  Lumbar puncture was unsuccessful.
 Given her persistent agitation and concern for narcotic
withdrawal, the patient was transferred to [**Hospital1 18**] MICU for
further management.

MEDICAL HISTORY: Motor vehicle accident, complicated by R ankle injury and rib
fractures, [**2151**]

MEDICATION ON ADMISSION: [**Doctor First Name **] 180 mg PO daily
Premarin 1.25 mg PO daily
Maxair prn
Oxycontin 160 mg PO 8x/daily
Neurontin 600 mg PO daily
Percocet 325-650 mg PO q4-6hours prn pain
Valium 20 mg qid prn pain

ALLERGIES: Ciprofloxacin

PHYSICAL EXAM: GEN: Agitated, diaphoretic, cachectic appearing female lying in
bed. Patient appears tremulous.
VS: T: 98.8  HR: 122  BP: 140/69  RR: 18  O2sat: 98% RA
HEENT:  NC/AT. PERRL. EOMI. Pupils dilated ~3 mm.  Edentulous.
MM dry. OP clear.
NECK: Supple. No nuchal rigidity. Palpable thyroid.
CVS: Tachycardic. S1, S2. No murmurs, rubs, or gallops.
LUNGS: CTAB. No rales, wheezes, or crackles.
ABD: Scaphoid, non-tender, non-distended, +BS.
EXT: Right stump without c/c/e. Left leg without c/c/e.
Extremities warm, well-perfused.
SKIN: No rashes or lesions.
NEURO: Patient thinks the year is "[**2162**]," knows she is in a
hospital, and thinks "[**Last Name (un) 2450**]" is the president.  +Tremor. Strength
[**5-13**] in all extremities.  Finger-to-nose intact.  Reflexes 2+
throughout.

FAMILY HISTORY: Mother with alcoholism.

SOCIAL HISTORY: The patient lives at home with her husband. She has three
children.  Her husband states that she does not abuse tobacco,
alcohol, or illicit drugs.  The patient is currently on SSI.
Drug withdrawal,Other and unspecified postsurgical nonabsorption,Multiple sclerosis,Nutritional marasmus,Combinations of opioid type drug with any other drug dependence, continuous,Other and unspecified anti-infectives causing adverse effects in therapeutic use,Below knee amputation status,Iron deficiency anemia, unspecified,Depressive disorder, not elsewhere classified,Osteoporosis, unspecified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus
Drug withdrawal,Intest postop nonabsorb,Multiple sclerosis,Nutritional marasmus,Opioid/other dep-contin,Adv eff antinfct NEC/NOS,Status amput below knee,Iron defic anemia NOS,Depressive disorder NEC,Osteoporosis NOS,Migrne unsp wo ntrc mgrn
Admission Date:  [**2161-11-22**]              Discharge Date:   [**2161-11-27**]

Date of Birth:  [**2109-6-15**]             Sex:   F

Service: MEDICINE

Allergies:
Ciprofloxacin

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Transfer from [**Hospital3 15174**] for treatment of
altered mental status.

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
The patient is a 52 year old woman with past medical history
significant for chronic pain on narcotics and benzodiazepines,
malabsorption syndrome due to complications of gastric bypass
surgery, and severe osteoporosis.  Three days prior to her
admission to the outside hospital, the patient presented to her
PCP's office for evaluation of ~20 pound weight loss that had
occurred over the past 6-8 weeks.  The patient was found to have
a urinary tract infection, and she was prescribed Ciprofloxacin.
 The patient took two doses of the antibiotic.  The following
day, the patient's husband noted that his wife seemed very
nervous and agitated.  He called the PCP, [**Name10 (NameIs) 1023**] advised the
patient to discontinue the Ciprofloxacin.  That evening, the
patient's husband noted that the patient was laughing
inappropriately while she watched TV.  She thought the TV was
"talking to her."  The patient's husband called 911, but by the
time the EMTs arrived at their home, the patient was able to
answer questions correctly, and she refused to go to the
hospital.  The following morning, the patient was noted to be
more agitated, paranoid, and delusional, so her huaband called
911 again.  This time, the patient was taken to
[**Hospital3 15174**].
   On presentation to the outside hospital, the patient was
noted to have a low grade temperature (100.2). Her neurologic
exam was reported as "non-focal," and a non-contrast head CT was
negative for bleed. The patient's tox screen was negative for
ETOH.  Her other laboratory data was unremarkable.  The patient
was admitted to the hospital for treatment of narcotic
withdrawal.
   During her 36 hour hospitalization, the patient was given two
doses of Buprenex.  Subsequently, the patient became lethargic,
confused, combative, and agitated.  She was transferred to the
ICU for further management.  She was given a few doses of Haldol
and Ativan for her agitation.  Lumbar puncture was unsuccessful.
 Given her persistent agitation and concern for narcotic
withdrawal, the patient was transferred to [**Hospital1 18**] MICU for
further management.

Past Medical History:
Motor vehicle accident, complicated by R ankle injury and rib
fractures, [**2151**]

Chronic pain syndrome since motor vehicle accident

s/p R leg BKA due to R ankle injury in above MVA, [**2154**]

Malabsorption syndrome, s/p gastric bypass surgery for morbid
obesity, ~22 years ago

Asthma. Patient has been hospitalized for asthma exacerbations,
but she has never been intubated.

Relapsing-remitting multiple sclerosis, questionable diagnosis
~8 years ago.  Patient given diagnosis based on problems with
motor coordination.

Depression. Hospitalized in [**2141**] at [**Hospital3 3765**] for
psychiatric illness.

Migraine

Social History:
The patient lives at home with her husband. She has three
children.  Her husband states that she does not abuse tobacco,
alcohol, or illicit drugs.  The patient is currently on SSI.

Family History:
Mother with alcoholism.

Physical Exam:
GEN: Agitated, diaphoretic, cachectic appearing female lying in
bed. Patient appears tremulous.
VS: T: 98.8  HR: 122  BP: 140/69  RR: 18  O2sat: 98% RA
HEENT:  NC/AT. PERRL. EOMI. Pupils dilated ~3 mm.  Edentulous.
MM dry. OP clear.
NECK: Supple. No nuchal rigidity. Palpable thyroid.
CVS: Tachycardic. S1, S2. No murmurs, rubs, or gallops.
LUNGS: CTAB. No rales, wheezes, or crackles.
ABD: Scaphoid, non-tender, non-distended, +BS.
EXT: Right stump without c/c/e. Left leg without c/c/e.
Extremities warm, well-perfused.
SKIN: No rashes or lesions.
NEURO: Patient thinks the year is "[**2162**]," knows she is in a
hospital, and thinks "[**Last Name (un) 2450**]" is the president.  +Tremor. Strength
[**5-13**] in all extremities.  Finger-to-nose intact.  Reflexes 2+
throughout.


Pertinent Results:
[**2161-11-22**] 07:36PM   WBC-10.0 RBC-3.68* HGB-8.5* HCT-27.6* MCV-75*
MCH-23.1* MCHC-30.8* RDW-22.6*
Labs on admission:

[**2161-11-22**] 07:36PM   NEUTS-85.8* LYMPHS-10.0* MONOS-3.8 EOS-0.3
BASOS-0.1
[**2161-11-22**] 07:36PM   PLT COUNT-878*
[**2161-11-22**] 07:36PM   GLUCOSE-97 UREA N-7 CREAT-0.3* SODIUM-139
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13
[**2161-11-22**] 07:36PM   ALT(SGPT)-10 AST(SGOT)-17 ALK PHOS-89 TOT
BILI-0.2
[**2161-11-22**] 07:36PM   ALBUMIN-3.1* CALCIUM-8.3* PHOSPHATE-3.0
MAGNESIUM-1.8
[**2161-11-22**] 07:36PM   PT-13.1 PTT-26.9 INR(PT)-1.1
[**2161-11-22**] 07:36PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2161-11-22**] 07:36PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2161-11-22**] 10:12PM CEREBROSPINAL FLUID (CSF)  PROTEIN-28
GLUCOSE-76
[**2161-11-22**] 10:12PM CEREBROSPINAL FLUID (CSF)  WBC-7 RBC-370*
POLYS-20 LYMPHS-76 MONOS-4
[**2161-11-22**] 10:12PM CEREBROSPINAL FLUID (CSF)  WBC-10 RBC-2500*
[**2161-11-23**] 02:53AM BLOOD calTIBC-384 Ferritn-7.5* TRF-295
[**2161-11-22**] 07:36PM BLOOD VitB12-GREATER TH Folate-GREATER TH
[**2161-11-22**] 07:36PM BLOOD TSH-0.62
[**2161-11-22**] 07:36PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG


EKG:
(OSH)
Sinus tachycardia, 96 bpm. Nl int, nl axis. No ST/TW changes.

CXR:
No infiltrates or consolidations.

Labs on discharge:

[**2161-11-26**] 05:59AM BLOOD WBC-9.6 RBC-3.82* Hgb-8.6* Hct-29.0*
MCV-76* MCH-22.6* MCHC-29.8* RDW-22.5* Plt Ct-657*
[**2161-11-26**] 05:59AM BLOOD Plt Ct-657*
[**2161-11-26**] 05:59AM BLOOD Glucose-108* UreaN-12 Creat-0.3* Na-142
K-4.8 Cl-108 HCO3-32* AnGap-7*
[**2161-11-26**] 05:59AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.0
[**2161-11-25**] 07:51AM BLOOD tTG-IgA-DONE
[**2161-11-25**] 07:51AM BLOOD ENDOMYSIAL ANTIBODIES-PND

Brief Hospital Course:
1. MICU COURSE ([**Date range (1) 12258**]): Pt had an LP and the results of
the CSF analysis were unremarkable. Her mental status improved
in ICU and she became much more alert and was oriented by the
morning of the second hospital day. While in the ICU, the
chronic pain service was consulted. Their recommendations are
noted below.

2. Altered mental status: As above, the pt. underwent a lumbar
puncture, the results of which were not suggestive of CNS
infection as the cause of her encephalopathy.  A TSH, B12 and
electrolytes were sent which were all within normal limits. An
RPR was sent and was nonreactive. Upon further discussion with
the pt. when she became more alert, it was discovered that after
taking the first two doses of ciprofloxacin the week prior to
admission, the pt. became extremely nauseous and had episodes of
emesis and diarrhea.  This led the pt. to stop taking her
narcotics which she is on chronically for pain.  Thus, it was
believed that the pt's. altered mental status was secondary to
narcotics withdrawal.  It should be noted, however, that
ciprofloxacin has been associated with acute psychosis,
seizures, and acute delirium.

3. Chronic pain: The pt. reported that she had been on large
doses of oxycontin, valium and neurontin for pain in her right
shoulder, back and legs prior to admission.  In the context of
her heavy narcotics use, a chronic pain service consult was
obtained while the pt. was in the intensive care unit.  They
recommended stopping oxycontin and decreasing the dose of
valium.  In addition, they recommended continuing neurontin and
adding methadone.  The pt. initially tolerated this regimen
well.  However, on the fourth hospital day, the pt. continued to
complain of leg spasms.  Baclofen was introduced with some
success in relieving her spasms.
The pain service also recommended that the pt. be started on
celecoxib for musculoskeletal pain but this was held over the
concern of possible upper gastrointestinal bleeding in the
setting of iron deficiency anemia of yet uncertain etiology.

4. Iron deficiency anemia:  The pt. was found to have profound
iron deficiency anemia on admission.  Further discussion with
the pt. and her PCP revealed that the pt. has known iron
deficiency and has received supplementation in the past.  A
gastroenterology consult was called.  They had recommended
performing both colonoscopy to examine for occult malignancy
(especially in the face of recent unintentional weight loss and
cachexia) and an EGD to evaluate the anatomy of her upper GI
tract in light of her prior gastric bypass.  The pt. did not
desire to undergo these procedures during this inpatient
hospitalization, but agreed to follow-up for these studies on an
outpatient basis.  The importance of following-up regarding this
issue was explicitly stressed to the pt. prior to discharge.
She was discharged on 325mg of ferrous sulfate once per day.

5. Weight loss/cachexia/?malabsorption:  In light of the pt's.
~20 pounds over the 6 to 8 weeks prior to admission, a nutrition
consult was obtained.  They had recommended TPN in addition to
encouraging the pt. to increase her p.o. intake.  The pt. did
received three days of TPN through a PICC line in addition to a
regular diet.  There was, again, concern over occult malignancy
which further prompted the desire to perform a colonoscopy.  A
breast exam was also performed as a part of a malignancy work-up
and was unremarkable.  The pt. stated that she has had a
"negative" mammography within the last year.
The gastroenterology service also raised the possibility of
celiac disease and tTG-IgA and endomysial antibodies were sent
and were pending at the time of discharge.
There is also the possibility that her weight loss is secondary
to her profound depression with vegetative symptoms.

6. Depression: The pt. admitted to severe depression in the
months prior to admission.  As such, the psychiatry service was
consulted.  They recommended re-starting fluoxetine which was
done at a dose of 20mg per day.

7. Osteoporosis: The pt. was started on calcium and vitamin D
supplementation.

8. Migraine Headaches: The pt. complained of headache suggestive
of typical (not classical) migraine.  Her pain was not relieved
with acetaminophen.  A trial of subcutaneous sumatriptan,
however, did provide relief.  She was discharged with a
prescription for subcutaneous sumatriptan with instructions to
stop taking the medication if she experienced flushing,
dizziness, fatigue (suggestive of serotonin syndrome due to
concomitant use of fluoxetine).

Medications on Admission:
[**Doctor First Name **] 180 mg PO daily
Premarin 1.25 mg PO daily
Maxair prn
Oxycontin 160 mg PO 8x/daily
Neurontin 600 mg PO daily
Percocet 325-650 mg PO q4-6hours prn pain
Valium 20 mg qid prn pain

Discharge Medications:
1. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
2. Methadone HCl 5 mg Tablet Sig: 0.5 Tablet PO QID (4 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
3. Diazepam 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
Disp:*120 Capsule(s)* Refills:*2*
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
9. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Sumatriptan Succinate 6 mg/0.5 mL Kit Sig: One (1)
Subcutaneous Q1H PRN as needed for headache not controlled by
tylenol: [**Month (only) 116**] repaat after one hour if headache not controlled by
first dose.  Do NOT take more than 12mg in a 24 hour time
period.
Disp:*60 syringes* Refills:*2*
12. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
-acute delirium, likely secondary to narcotics withdrawal vs.
reaction to ciprofloxacin, resolved.
-iron deficiency anemia
-depression
-chronic pain
-osteoporosis
-migraine headache


Discharge Condition:
The pt. was alert and completely oriented.  She was tolerating a
p.o. diet and eating well.  She was ambulating with the
assistance of a walker.

Discharge Instructions:
Please take all of your medications as perscribed.  Please
notice that you have had many medication changes.  Please be
sure to attend all of your follow-up appointments.  If you
experience any concerning symptoms, including dizziness,
flushing or confusion, please call your primary care doctor or
come to the emergency department for evaluation.

Followup Instructions:
Please call your primary care doctor, Dr. [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) 59655**]
at [**Telephone/Fax (1) 26677**], to schedule a follow-up appointment regarding
this hospitalization within one week.  It is strongly
recommmended that you undergo a colonoscopy and
esophagogastroduodenoscopy to investigate the cause of your
anemia and weight loss.


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
{'Drug withdrawal,Other and unspecified postsurgical nonabsorption,Multiple sclerosis,Nutritional marasmus,Combinations of opioid type drug with any other drug dependence, continuous,Other and unspecified anti-infectives causing adverse effects in therapeutic use,Below knee amputation status,Iron deficiency anemia, unspecified,Depressive disorder, not elsewhere classified,Osteoporosis, unspecified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus'}


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: Transfer from [**Hospital3 15174**] for treatment of
altered mental status.

PRESENT ILLNESS: The patient is a 52 year old woman with past medical history
significant for chronic pain on narcotics and benzodiazepines,
malabsorption syndrome due to complications of gastric bypass
surgery, and severe osteoporosis.  Three days prior to her
admission to the outside hospital, the patient presented to her
PCP's office for evaluation of ~20 pound weight loss that had
occurred over the past 6-8 weeks.  The patient was found to have
a urinary tract infection, and she was prescribed Ciprofloxacin.
 The patient took two doses of the antibiotic.  The following
day, the patient's husband noted that his wife seemed very
nervous and agitated.  He called the PCP, [**Name10 (NameIs) 1023**] advised the
patient to discontinue the Ciprofloxacin.  That evening, the
patient's husband noted that the patient was laughing
inappropriately while she watched TV.  She thought the TV was
"talking to her."  The patient's husband called 911, but by the
time the EMTs arrived at their home, the patient was able to
answer questions correctly, and she refused to go to the
hospital.  The following morning, the patient was noted to be
more agitated, paranoid, and delusional, so her huaband called
911 again.  This time, the patient was taken to
[**Hospital3 15174**].
   On presentation to the outside hospital, the patient was
noted to have a low grade temperature (100.2). Her neurologic
exam was reported as "non-focal," and a non-contrast head CT was
negative for bleed. The patient's tox screen was negative for
ETOH.  Her other laboratory data was unremarkable.  The patient
was admitted to the hospital for treatment of narcotic
withdrawal.
   During her 36 hour hospitalization, the patient was given two
doses of Buprenex.  Subsequently, the patient became lethargic,
confused, combative, and agitated.  She was transferred to the
ICU for further management.  She was given a few doses of Haldol
and Ativan for her agitation.  Lumbar puncture was unsuccessful.
 Given her persistent agitation and concern for narcotic
withdrawal, the patient was transferred to [**Hospital1 18**] MICU for
further management.

MEDICAL HISTORY: Motor vehicle accident, complicated by R ankle injury and rib
fractures, [**2151**]

MEDICATION ON ADMISSION: [**Doctor First Name **] 180 mg PO daily
Premarin 1.25 mg PO daily
Maxair prn
Oxycontin 160 mg PO 8x/daily
Neurontin 600 mg PO daily
Percocet 325-650 mg PO q4-6hours prn pain
Valium 20 mg qid prn pain

ALLERGIES: Ciprofloxacin

PHYSICAL EXAM: GEN: Agitated, diaphoretic, cachectic appearing female lying in
bed. Patient appears tremulous.
VS: T: 98.8  HR: 122  BP: 140/69  RR: 18  O2sat: 98% RA
HEENT:  NC/AT. PERRL. EOMI. Pupils dilated ~3 mm.  Edentulous.
MM dry. OP clear.
NECK: Supple. No nuchal rigidity. Palpable thyroid.
CVS: Tachycardic. S1, S2. No murmurs, rubs, or gallops.
LUNGS: CTAB. No rales, wheezes, or crackles.
ABD: Scaphoid, non-tender, non-distended, +BS.
EXT: Right stump without c/c/e. Left leg without c/c/e.
Extremities warm, well-perfused.
SKIN: No rashes or lesions.
NEURO: Patient thinks the year is "[**2162**]," knows she is in a
hospital, and thinks "[**Last Name (un) 2450**]" is the president.  +Tremor. Strength
[**5-13**] in all extremities.  Finger-to-nose intact.  Reflexes 2+
throughout.

FAMILY HISTORY: Mother with alcoholism.

SOCIAL HISTORY: The patient lives at home with her husband. She has three
children.  Her husband states that she does not abuse tobacco,
alcohol, or illicit drugs.  The patient is currently on SSI. 

### Response:
{'Drug withdrawal,Other and unspecified postsurgical nonabsorption,Multiple sclerosis,Nutritional marasmus,Combinations of opioid type drug with any other drug dependence, continuous,Other and unspecified anti-infectives causing adverse effects in therapeutic use,Below knee amputation status,Iron deficiency anemia, unspecified,Depressive disorder, not elsewhere classified,Osteoporosis, unspecified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus'}
