CHIEF COMPLAINT: Overdose

PRESENT ILLNESS: 49M with past medical history significant for asthma, GERD,
multiple psychiatric problems, heavy alcoholism and new lung
nodule presents from outside hospital in rhabdomyolysis, renal
failure, shock requiring 2 pressors of unknown etiology, as well
as depressed mental status.
.
Interval history reveals that apparently the wife found him this
morning lying in the bathtub, where he apparently slept
overnight after being involved in a domestic dispute. She found
that he had taken more doses of his prescription meds than
should, including all of his fluoxetine, ativan, ambien, and
Neurontin, and naproxen, and doxepin [**1-3**] pills and he was again
not responsive. He was taken to outside hospital where he was
unresponsive and so was intubated for airway protection. Trauma
CXR pelv there negative, as were head and C-spine CT (unknown
whether trauma was involved initially). His labs there showed an
anion gap acidosis, with rhabdomyolysis (CK of about 10,000),
potassium of 7.1 EKG changes for which he was given calcium,
insulin, bicarbonate.
.
Arrived to our emergency department on dopamine and we have fed,
with a wide complex EKG (QRS 170) and potassium of 6.5. He
required 2 amps of calcium, bicarbonate, and after bicarbonate
his QRS narrowed dramatically.
.
Bedside echocardiogram and shock ultrasound revealed
hyperdynamic ventricular function, normal caliber aorta, IVC
which appeared very compressible with respiratory variability
indicating under resuscitation. He was aggressively fluid
resuscitated and subsequently weaned off the dopamine during his
ED stay.
.
Prior to transfer he dropped his pressures and was restarted on
dopamine and levophed.
.
.
On arrival to the MICU, he is intubated and sedated.
.
Wife says he has had no access to over the counter medications
specifically denying benadryl.

MEDICAL HISTORY: asthma
GERD
multiple psychiatric problems
heavy alcoholism
recently discovered lung nodule undergoing work up
lung abcess

MEDICATION ON ADMISSION: Gabapentin 900mg QHS
Fluoxeptine 60mg QD
Doxepin 150mg QHS
Omeprazole
Ambien 10mg QHS
Ativan 1mg [**Hospital1 **]
Flomax
Naproxen

ALLERGIES: Codeine

PHYSICAL EXAM: Admission
Vitals: P107 Bp 137/75 98% Intubated
General: Intuabted and sedated
HEENT: Sclera anicteric, ETT in place, NGT in place pupils round
and reactive.
Neck: supple, JVP not elevated, no LAD
CV:Tachycardia RRR no MRG
Lungs: Bilateral breathsounds CTA
Abdomen: soft, non-tender, non-distended, absent bowel sounds
GU: Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Lung cancer on his mothers side

SOCIAL HISTORY: - Tobacco: 40 pack year history
- Alcohol: Heavy at times unknown daily quantitiy
- Illicits: Not to his wife knowledge [**Name2 (NI) 91896**] he has been
hanging out with people his wife feels to be unsavory
Poisoning by tricyclic antidepressants,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Pneumonitis due to inhalation of food or vomitus,Cerebral embolism with cerebral infarction,Sepsis,Streptococcal septicemia,Rhabdomyolysis,Mixed acid-base balance disorder,Other acute and subacute forms of ischemic heart disease, other,Aphasia,Hemiplegia, unspecified, affecting unspecified side,Urinary tract infection, site not specified,Unspecified intestinal obstruction,Bloodstream infection due to central venous catheter,Poisoning by other sedatives and hypnotics,Poisoning by other and unspecified anticonvulsants,Poisoning by propionic acid derivatives,Suicide and self-inflicted poisoning by tranquilizers and other psychotropic agents,Acute alcoholic intoxication in alcoholism, unspecified,Other early complications of trauma,Other accidents,Encounter for change or removal of surgical wound dressing,Below knee amputation status,Solitary pulmonary nodule,Atrial fibrillation,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Chronic obstructive asthma, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Other alteration of consciousness,Depressive disorder, not elsewhere classified
Pois tricyclc antidepres,Acute respiratry failure,Ac kidny fail, tubr necr,Food/vomit pneumonitis,Crbl emblsm w infrct,Sepsis,Streptococcal septicemia,Rhabdomyolysis,Mixed acid-base bal dis,Ac ischemic hrt dis NEC,Aphasia,Unsp hemiplga unspf side,Urin tract infection NOS,Intestinal obstruct NOS,Blood inf dt cen ven cth,Pois-sedative/hypnot NEC,Pois-anticonvul NEC/NOS,Pois-propionic acid derv,Poison-psychotropic agt,Ac alcohol intox-unspec,Early complic trauma NEC,Accident NEC,Attn rem surg dressing,Status amput below knee,Solitary pulmonry nodule,Atrial fibrillation,Abn react-procedure NEC,Accid in resident instit,Chronic obst asthma NOS,Chr blood loss anemia,Other alter consciousnes,Depressive disorder NEC
Admission Date:  [**2189-1-7**]              Discharge Date:   [**2189-1-27**]

Date of Birth:  [**2139-8-14**]             Sex:   M

Service: MEDICINE

Allergies:
Codeine

Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Overdose

Major Surgical or Invasive Procedure:
Mechanical ventilation and intubation
Central venous line placement
Tunneled line placement
Hemodialysis
Fasciotomies x 2


History of Present Illness:
49M with past medical history significant for asthma, GERD,
multiple psychiatric problems, heavy alcoholism and new lung
nodule presents from outside hospital in rhabdomyolysis, renal
failure, shock requiring 2 pressors of unknown etiology, as well
as depressed mental status.
.
Interval history reveals that apparently the wife found him this
morning lying in the bathtub, where he apparently slept
overnight after being involved in a domestic dispute. She found
that he had taken more doses of his prescription meds than
should, including all of his fluoxetine, ativan, ambien, and
Neurontin, and naproxen, and doxepin [**1-3**] pills and he was again
not responsive. He was taken to outside hospital where he was
unresponsive and so was intubated for airway protection. Trauma
CXR pelv there negative, as were head and C-spine CT (unknown
whether trauma was involved initially). His labs there showed an
anion gap acidosis, with rhabdomyolysis (CK of about 10,000),
potassium of 7.1 EKG changes for which he was given calcium,
insulin, bicarbonate.
.
Arrived to our emergency department on dopamine and we have fed,
with a wide complex EKG (QRS 170) and potassium of 6.5. He
required 2 amps of calcium, bicarbonate, and after bicarbonate
his QRS narrowed dramatically.
.
Bedside echocardiogram and shock ultrasound revealed
hyperdynamic ventricular function, normal caliber aorta, IVC
which appeared very compressible with respiratory variability
indicating under resuscitation. He was aggressively fluid
resuscitated and subsequently weaned off the dopamine during his
ED stay.
.
Prior to transfer he dropped his pressures and was restarted on
dopamine and levophed.
.
.
On arrival to the MICU, he is intubated and sedated.
.
Wife says he has had no access to over the counter medications
specifically denying benadryl.

Past Medical History:
asthma
GERD
multiple psychiatric problems
heavy alcoholism
recently discovered lung nodule undergoing work up
lung abcess


Social History:
- Tobacco: 40 pack year history
- Alcohol: Heavy at times unknown daily quantitiy
- Illicits: Not to his wife knowledge [**Name2 (NI) 91896**] he has been
hanging out with people his wife feels to be unsavory


Family History:
Lung cancer on his mothers side


Physical Exam:
Admission
Vitals: P107 Bp 137/75 98% Intubated
General: Intuabted and sedated
HEENT: Sclera anicteric, ETT in place, NGT in place pupils round
and reactive.
Neck: supple, JVP not elevated, no LAD
CV:Tachycardia RRR no MRG
Lungs: Bilateral breathsounds CTA
Abdomen: soft, non-tender, non-distended, absent bowel sounds
GU: Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Discharge:
General: patient alert and oriented in no acute distress
HEENT: sclera anicterica, PEARLA, EOMI
CV: No MRG
lungs: CTAB
Abdomen: soft, non-tender, non-distended
Neuro: CN 2-12 intact, strength 5/5 in the left upper ext,
strength 4/5 in the right upper ext with proximal muscles weaker
than distal, right lower ext [**3-5**] with proximal weaker than
distal

Pertinent Results:
Pertinent Labs:
[**2189-1-7**] 01:48PM BLOOD WBC-15.9* RBC-4.27* Hgb-11.6* Hct-36.5*
MCV-86 MCH-27.3 MCHC-31.9 RDW-15.5 Plt Ct-285
[**2189-1-7**] 06:04PM BLOOD Neuts-82* Bands-0 Lymphs-12* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2189-1-7**] 01:48PM BLOOD PT-12.6* PTT-32.9 INR(PT)-1.2*
[**2189-1-7**] 06:04PM BLOOD Glucose-249* UreaN-35* Creat-3.5* Na-139
K-6.0* Cl-99 HCO3-20* AnGap-26*
[**2189-1-7**] 09:04PM BLOOD ALT-214* AST-751* CK(CPK)-[**Numeric Identifier 91897**]*
TotBili-0.5
[**2189-1-7**] 06:04PM BLOOD Calcium-7.1* Phos-6.7* Mg-2.1
[**2189-1-16**] 01:03AM BLOOD Hapto-403*
[**2189-1-19**] 04:31AM BLOOD calTIBC-224* Ferritn-240 TRF-172*
[**2189-1-17**] 03:45PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-POSITIVE
[**2189-1-7**] 01:48PM BLOOD ASA-NEG Ethanol-26* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
[**2189-1-17**] 03:45PM BLOOD HCV Ab-POSITIVE*
[**2189-1-7**] 02:58PM BLOOD Type-ART pO2-122* pCO2-36 pH-7.25*
calTCO2-17* Base XS--10
[**2189-1-7**] 01:49PM BLOOD Glucose-182* Lactate-6.4* Na-140 K-6.5*
Cl-108 calHCO3-13*
[**2189-1-9**] 11:24PM BLOOD Glucose-170* Lactate-2.0 K-6.4*
[**2189-1-7**] 06:58PM BLOOD freeCa-0.97*
[**2189-1-7**] 02:11PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2189-1-23**] 05:27AM BLOOD HIV Ab-NEGATIVE.
.
**FINAL REPORT [**2189-1-22**]**

   WOUND CULTURE (Final [**2189-1-22**]):
      ENTEROCOCCUS SP..    >15 colonies.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------  =>32 R
LINEZOLID-------------     2 S
PENICILLIN G----------  =>64 R
VANCOMYCIN------------  =>32 R

.
ECG [**1-7**]: Wide complex tachycardia with left bundle-branch block
morphology and left superior axis suggestive of supraventricular
tachycardia with intraventricular conduction delay. However,
cannot exclude ventricular tachycardia or accelerated
idioventricular rhythm. No previous tracing available for
comparison.
.
ECG [**1-12**]: Sinus tachycardia with atrial premature beats. Low QRS
voltage in the limb leads. Compared to tracing #1 atrial ectopy
is new. QRS voltage in the precordial leads is increased.
.
LENI [**1-9**]:  No evidence of deep vein thrombosis seen in either
leg. Note is
made of some fluid tracking in the region of the left popliteal
fossa. Note
is also made of prior left lower leg amputation.
.
Head CT [**1-11**]: 1. New hypodensity in the genu of the left
internal capsule is suggestive of an acute infarction. A
dedicated brain MRI is recommended for further evaluation. 2.
Ethmoidal and sphenoidal mucosal thickening with air-fluid
levels and aerosolized secretions is suggestive of acute
sinusitis.
.
TTE [**1-12**]: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. Right atrial appendage
ejection velocity is good (>20 cm/s). No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast at restx2 (late bubbles are seen at 5 beats c/w
transpulmonic passage). Global left ventricular systolic
function is normal. There are simple atheroma in the aortic arch
and descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. No
discrete vegetations are seen. Trace aortic regurgitation is
seen. The anterior mitral valve leaflet is mildly thickened, but
without discrete vegetation. Physiologic mitral regurgitation is
seen (within normal limits). There is no pericardial effusion.

IMPRESSION: No echocardiographic evidence of endocarditis seen.
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast at rest. Normal biventricular
function.
.
Carotid U/S [**1-13**]: Duplex was performed of bilateral carotid
arteries. No significant plaque is seen bilaterally.
.
CT Abdomen [**1-15**]
1. Small bowel obstruction with a transition point in the right
lower
quadrant. No evidence for free air or bowel ischemia.
2. Nodular consolidative opacities seen at the right lung base
are likely
representative of developing pneumonia.
3. Distended gallbaldder with enhancing wall and surrounding
fluid may be
related to volume status. However, if there is clinical concern
for
cholecystitis a HIDA scan should be obtained.
4. Small trace bilateral pleural effusions with adjacent
compressive
atelectasis.
.
CT Chest/Abdomen/Pelvis [**1-18**]
1. Widespread multifocal pneumonia involving primarily right
lung but also
left upper lobe.
2. Small bilateral pleural effusions.
3. Segment [**Doctor First Name 690**] liver hypodensity too small to fully
characterize.
4. Interval improvement of small-bowel obstruction.
5. Right lung base pleural calcifications.


Brief Hospital Course:
49M with past medical history significant for asthma, GERD,
multiple psychiatric problems, heavy alcoholism and new lung
nodule (being worked up for malignancy, +PET, no bx yet)
presents from outside hospital with TCA overdose who initially
presented with rhabdomyolysis, renal failure and shock initially
requiring 2 pressors now weaned off pressors. ICU course has
been complicated by oliguric/anuric renal failure requiring
continued CVVH/HD, compartment syndrome s/p fasciotomies x 2,
new finding of stroke, SBO (now resolved), and persistent
leukocytosis and fever.

1. Ingestion/Overdose with resulting respiratory failure
requiring mechanical ventilation: Patient found down with empty
pill bottles by his side. Tox screen was positive for TCAs and
EtOH and otherwise negative. Initially presented with AMS,
metabolic acidosis, hypotension and QRS >100 suggestive of TCA
overdose. He was started on intravenous bicarbonate infusion and
his QRS narrowed appropriately. He was started on neosynephrine
and levophed for his hypotension (presumed to be more likely
drug effect than sepsis) which was successfully weaned on [**1-10**].
Serial ECGs showed no signs of widening. Patient was initially
intubated for airway protection. Extubation was attempted on
[**1-15**] but failed due to massive bilious emesis and concurrent
aspiration. He was successfully extubated on [**1-18**]. Circumstances
of ingestion are unclear. Appears to have occurred after night
of drinking in the context of domestic dispute. Per family,
patient had been under increased stress for the past several
months as he was in the process of being worked up for potential
lung cancer. When patient had regained his speech capabilities,
psychiatry was reconsulted and they felt that he should be
started on anti-depressant monotherapy after the course of
linezolid is completed.

2. Sepsis secondary to pneumonia and CVL: Though patient
intially presented with leukocytosis, he showed no signs of
infection on first presentation. Then from [**1-13**] onwards,
patient's temperature was noted to be gradually increasing in
tandem with his white count until he finally became febrile to
102 on [**1-15**]. Patient was empirically started on vanc, zosyn, and
flagyl. His lines were discontinued and foley was changed. The
patient??????s gallbladder was visualized and no cholecystitis was
seen. There was concern for C.diff given patient's concurrent
abdominal distention so he was empirically started on treatment
for C.diff with concurrent PO vanc, which was discontinued after
negative C. diff PCR. CT Chest indicated multifocal pneumonia
likely from aspiration event during first attempted extubation
(see below). Plan for antibiotics was to continue vanc and zosyn
for PNA for an eight day course until [**1-22**] and azithromycin for
a five day course (added for atypical coverage of PNA) until
[**1-23**]. On [**1-22**], culture tip from catheter was positive for VRE.
Patient was switched to linezolid on [**1-22**] for 14 day course and
vancomycin was discontinued.  Blood cultures showed no growth
after.  HIV serologies negative. On discharge patient had
completed the antibiotic course for his pneumonia and is on
linezolid for the VRE+ central line culture.

3. Acute renal failure / acute tubular necrosis - Renal failure
secondary to rhabdomyolysis, with peak CK in the 60,000 range.
Patient initially with elevated potassium and phosphate and low
calcium requiring agressive correction. Pt was started on CVVH
then transitioned to HD for Monday, Wednesday, Friday sessions
after tunneled line was placed by IR. Per renal, chance of renal
recovery remains slim.  Per renal, recommendations on discharge
include measure interdialytic CR and obtain a 24 hour urine
collection for a urea and creatinine clearance once urine
outpute is > 400. On the day of his discharge patient had a
urine output of around 200cc and will continue HD at his [**Hospital1 1501**].

4. Small Bowel Obstruction: On [**1-15**], the day of his first
extubation attempt, patient experienced copious bilious vomiting
with likely aspiration of bilious material. Patient had been
having some stool output prior but worsening abdominal
distention was noted. Subsequent CT scan showed small bowel
obstruction with transition point in the RLQ. Cause felt to be
likely ileus but infection was a concern as well so Cdiff
treatment was initiated. ACS was consulted who felt there was no
need for acute surgical intervention so patient was kept NPO
with an NG tube in place. Repeat imaging showed improvement of
the obstruction so patient's diet was slowly advanced as
tolerated.

5. Compartment Syndrome due to rhabdomyolysis: Patient had been
found down in a bathtub. On presentation, noted to have tense
right upper arm and right upper thigh. Evaluated by orthopedics
who noted that pressures in both compartments were elevated
necessitating urgent fasciotomies the night of admission. Wounds
were closed on [**1-12**] and wound vacs were placed until drainage
ceased. Ortho recommended starting ancef for prophylaxis for one
weeks but this was discontinued once broad-spectrum antibiotics
were initiated. Sutures were removed on [**1-24**]. Ortho will
follow-up with patient 2-4 weeks after discharge.

6. Acute stroke: Though patient presented with a negative Head
CT on admission, patient was noted to have decreased movement of
his right side and repeat Head CT showed a hypodensity in the
internal capsule in the geniculate on the left side. LENIs were
negative for clot and TEE was without vegetation or PFO.
Neurology was consulted who recommended ASA and carotid
ultrasounds which were negative. The patient did have a single
episode of afib on [**1-11**] which may be related to etiology of
stroke.  MRI showed evidence of acute left subcortical infarct
in the posterior frontal and anterior parietal lobes.  MRA head
and neck showed no evidence of occlusion or aneurysm. Neurology
recommended anticoagulation with coumadin.  Patient was bridged
with heparin and had therapuetic INR on discharge

7. Atrial fibrillation with RVR: One episode in the AM of [**1-11**].
The patient had a non-sustained interval of afib with RVR with
accompanying hypotension. It responded well to diltiazem bolus
and patient remained in sinus rhythm for the remainder of his
stay.  Started on anticoagulation per neurology recommendations
as above.

TRANSITIONAL ISSUES
- Patient will need further work-up of his underlying lung
nodules which are PET positive.
- Patient was found to be HCV positive on bloodwork here. Will
require liver follow-up as outpatient
- Renal recommendations as above: interdialytic CR and obtain a
24 hour urine collection for a urea and creatinine clearance
once urine outpute is > 400


Medications on Admission:
Gabapentin 900mg QHS
Fluoxeptine 60mg QD
Doxepin 150mg QHS
Omeprazole
Ambien 10mg QHS
Ativan 1mg [**Hospital1 **]
Flomax
Naproxen


Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily): give after hemodialysis.
8. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. linezolid 600 mg/300 mL Parenteral Solution Sig: Three
Hundred (300) mL Intravenous twice a day.
13. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
14. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]

Discharge Diagnosis:
Primary Diagnoses:
Tricyclic antidepressant overdose
Acute respiratory failure requiring mechanical ventilation
Rhabdomyolysis
Acute kidney failure requiring hemodialysis
Compartment syndrome s/p fasciotomies x 2
Embolic Stroke wirh right sided hemiparesis and aphasia
Multifocal pneumonia
Small bowel obstruction
Atrial Fibrillation

Secondary diagnoses:
Depression
Alcohol abuse
Lung nodules


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mr. [**Last Name (Titles) 91898**],

You were admitted to the [**Hospital1 69**]
after you overdosed on prescription medications. You needed to
be admitted to the intensive care unit and were initially
dependent on a mechanical ventilator. You developed severe
kidney failure requiring hemodialysis which you will continue
after discharge. You also required surgeries on your right arm
and right leg to help relieve the pressure that had built up
there while you were unconscious. Unfortunately, you also
developed a stroke during your stay and will require continued
rehab and anticoagulation as you regain your strength and
speech.
.
We have made the following changes to your medications:
# START coumadin 2mg daily by mouth with goal INR [**1-2**]
# START linezolid 600mg every 12 hours IV for 9 more days
# START nephrocaps 1 daily
# START sevelamer 1600mg three times daily
# START thiamine 100mg daily
# START senna 8.6mg twice daily as needed for constipation
# START bisacodyl 10mg daily as needed for constipation
# START nicotine patch to be tapered over 2 weeks
# START advair twice daily
# DECREASE gabapentin to 300mg daily after hemodialysis
# STOP fluoxetine
# STOP doxepin

You will need ongoing psychiatric care and once the antibiotics
stop, you may be able to start a low dose antidepressant.

Followup Instructions:
Orthopedics: please follow up in 2-4wks with Dr. [**Last Name (STitle) **].
Please call [**Numeric Identifier 18919**] to make an appointment.

Department: INFECTIOUS DISEASE
When: TUESDAY [**2189-2-10**] at 10:00 AM
With: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: NEUROLOGY
When: TUESDAY [**2189-3-24**] at 8:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
*You have also been placed on a cancellation list for this
appointment. The office will contact you at home when a sooner
appointment becomes available.

Name: [**Last Name (LF) **],[**First Name3 (LF) **] Z.
Address: [**Doctor Last Name 90140**], [**Hospital1 **],[**Numeric Identifier 26407**]
Phone: [**Telephone/Fax (1) 78940**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
{'Poisoning by tricyclic antidepressants,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Pneumonitis due to inhalation of food or vomitus,Cerebral embolism with cerebral infarction,Sepsis,Streptococcal septicemia,Rhabdomyolysis,Mixed acid-base balance disorder,Other acute and subacute forms of ischemic heart disease, other,Aphasia,Hemiplegia, unspecified, affecting unspecified side,Urinary tract infection, site not specified,Unspecified intestinal obstruction,Bloodstream infection due to central venous catheter,Poisoning by other sedatives and hypnotics,Poisoning by other and unspecified anticonvulsants,Poisoning by propionic acid derivatives,Suicide and self-inflicted poisoning by tranquilizers and other psychotropic agents,Acute alcoholic intoxication in alcoholism, unspecified,Other early complications of trauma,Other accidents,Encounter for change or removal of surgical wound dressing,Below knee amputation status,Solitary pulmonary nodule,Atrial fibrillation,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Chronic obstructive asthma, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Other alteration of consciousness,Depressive disorder, not elsewhere classified'}


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: Overdose

PRESENT ILLNESS: 49M with past medical history significant for asthma, GERD,
multiple psychiatric problems, heavy alcoholism and new lung
nodule presents from outside hospital in rhabdomyolysis, renal
failure, shock requiring 2 pressors of unknown etiology, as well
as depressed mental status.
.
Interval history reveals that apparently the wife found him this
morning lying in the bathtub, where he apparently slept
overnight after being involved in a domestic dispute. She found
that he had taken more doses of his prescription meds than
should, including all of his fluoxetine, ativan, ambien, and
Neurontin, and naproxen, and doxepin [**1-3**] pills and he was again
not responsive. He was taken to outside hospital where he was
unresponsive and so was intubated for airway protection. Trauma
CXR pelv there negative, as were head and C-spine CT (unknown
whether trauma was involved initially). His labs there showed an
anion gap acidosis, with rhabdomyolysis (CK of about 10,000),
potassium of 7.1 EKG changes for which he was given calcium,
insulin, bicarbonate.
.
Arrived to our emergency department on dopamine and we have fed,
with a wide complex EKG (QRS 170) and potassium of 6.5. He
required 2 amps of calcium, bicarbonate, and after bicarbonate
his QRS narrowed dramatically.
.
Bedside echocardiogram and shock ultrasound revealed
hyperdynamic ventricular function, normal caliber aorta, IVC
which appeared very compressible with respiratory variability
indicating under resuscitation. He was aggressively fluid
resuscitated and subsequently weaned off the dopamine during his
ED stay.
.
Prior to transfer he dropped his pressures and was restarted on
dopamine and levophed.
.
.
On arrival to the MICU, he is intubated and sedated.
.
Wife says he has had no access to over the counter medications
specifically denying benadryl.

MEDICAL HISTORY: asthma
GERD
multiple psychiatric problems
heavy alcoholism
recently discovered lung nodule undergoing work up
lung abcess

MEDICATION ON ADMISSION: Gabapentin 900mg QHS
Fluoxeptine 60mg QD
Doxepin 150mg QHS
Omeprazole
Ambien 10mg QHS
Ativan 1mg [**Hospital1 **]
Flomax
Naproxen

ALLERGIES: Codeine

PHYSICAL EXAM: Admission
Vitals: P107 Bp 137/75 98% Intubated
General: Intuabted and sedated
HEENT: Sclera anicteric, ETT in place, NGT in place pupils round
and reactive.
Neck: supple, JVP not elevated, no LAD
CV:Tachycardia RRR no MRG
Lungs: Bilateral breathsounds CTA
Abdomen: soft, non-tender, non-distended, absent bowel sounds
GU: Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Lung cancer on his mothers side

SOCIAL HISTORY: - Tobacco: 40 pack year history
- Alcohol: Heavy at times unknown daily quantitiy
- Illicits: Not to his wife knowledge [**Name2 (NI) 91896**] he has been
hanging out with people his wife feels to be unsavory 

### Response:
{'Poisoning by tricyclic antidepressants,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Pneumonitis due to inhalation of food or vomitus,Cerebral embolism with cerebral infarction,Sepsis,Streptococcal septicemia,Rhabdomyolysis,Mixed acid-base balance disorder,Other acute and subacute forms of ischemic heart disease, other,Aphasia,Hemiplegia, unspecified, affecting unspecified side,Urinary tract infection, site not specified,Unspecified intestinal obstruction,Bloodstream infection due to central venous catheter,Poisoning by other sedatives and hypnotics,Poisoning by other and unspecified anticonvulsants,Poisoning by propionic acid derivatives,Suicide and self-inflicted poisoning by tranquilizers and other psychotropic agents,Acute alcoholic intoxication in alcoholism, unspecified,Other early complications of trauma,Other accidents,Encounter for change or removal of surgical wound dressing,Below knee amputation status,Solitary pulmonary nodule,Atrial fibrillation,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Chronic obstructive asthma, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Other alteration of consciousness,Depressive disorder, not elsewhere classified'}
