CHIEF COMPLAINT: tylenol overdose
acute intoxication

PRESENT ILLNESS: This 28 yo man with h/o depression presented to the ED s/p OD on
'blue pills with PM on them', thought to be excedrin PM. Tox.
screen positive for acetominphen (unknown time of ingestion-?
0100-0200), and etoh. He resides in CT but was in [**Location (un) 86**]
visiting his girlfriend. She left to return a shirt to a friend
approx 0100 and that is when this OD occured. Per his parents he
had an episode of binge drinking 2 months prior where he was
hospitalized for detox (3 days) and treated with benzos but no
noted withdrawl/seizures. He rec'd 1.5 days counceling but did
not follow-up for further treatment. Around that time his PCP
started him on Paxil and he seemed to improve initially but has
been worse over the past 6 weeks. He arrived in [**Location (un) 86**] 1 week
prior to visit his ex-girlfriend and things were going well
until [**6-26**] when he started to drink heavily. Per his parents the
ex-girlfriend called last night stating he was drunk and
difficult, shortly after which he told her he took 20 pills
(excedrin pm?). Per his parents no known close friends/family
memebers with completed suicide, though a peer in high school
died by hanging. His parents came from CT and brought him to the
ED.
.
On arrival to the ED VS: T 98.7 HR 120 BP 157/96 RR 18 Sat 95%
on RA. Sat fell to 92% on RA. He was noted to be
confused/lethargic so intubated for airway protection. He was
given activated charcoal PO. narcan 0.4mg given with no effect.
Toxicology was consulted and he was admitted to the ICU.

MEDICAL HISTORY: OSA on home CPAP
Hypertension: not known to be on medications
Depression: on paroxitene, ?compliance, no previous suicide
attempts known
GERD
Recent L wrist fracture w/metal pins placed (2 weeks prior), in
splint
h/o tremor since childhood

MEDICATION ON ADMISSION: paxil 20mg qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ON ADMIT
VS: T 99.5 oral, 100.6 rectal BP 155/96 HR 101 AC
500(500)/16(23)/0.5/5 98%
General: Intubated, sedated but arouses, nods yes/no to
questions, follows commands, NAD, withdraws to pain
HEENT: OP with charcoal, otherwise clear, PERRL 5->3mm bilat
Neck: Wide, JVP 6cm, no LAD
Resp: CTAB, no wheezes, rales, rhonchi
CV: Tachycardic but regular rhythm, no m/r/g; 2+ radial/DP/PT
pulses B
Abdomen: soft, NT, ND, +BS, no masses or HSM
Ext: L wrist in splint; no c/c/e
Skin: Multiple tattoos, no rashes or erythema, warm and moist to
touch
Neuro: PERRL 5->3mm bilaterally, + horizontal nystagmus both
directions; DTR's 2+ biceps B, brachioradialis R; 3+ patellar
reflexes bilaterally, babinski down-going bilaterally, +[**3-28**]
beats of clonus in ankles bilaterally, no rigidity or tremor

FAMILY HISTORY: nc

SOCIAL HISTORY: Works as a restaurant manager in CT, here visiting his
girlfriend. + EtOH (recent heavy use as above) and tobacco use
(1 PPD, had quit 5 years ago but restarted 6-8 months ago).
Possible MJ use, no other known drug use per parents.
Poisoning by aromatic analgesics, not elsewhere classified,Other and unspecified alcohol dependence, unspecified,Pneumonitis due to inhalation of food or vomitus,Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics,Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified,Esophageal reflux,Tobacco use disorder
Pois-arom analgesics NEC,Alcoh dep NEC/NOS-unspec,Food/vomit pneumonitis,Poison-analgesics,Obstructive sleep apnea,Depressive disorder NEC,Esophageal reflux,Tobacco use disorder
Admission Date:  [**2176-6-30**]              Discharge Date:   [**2176-7-3**]

Date of Birth:  [**2148-6-27**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
tylenol overdose
acute intoxication

Major Surgical or Invasive Procedure:
intubation, mechanical ventilation


History of Present Illness:
This 28 yo man with h/o depression presented to the ED s/p OD on
'blue pills with PM on them', thought to be excedrin PM. Tox.
screen positive for acetominphen (unknown time of ingestion-?
0100-0200), and etoh. He resides in CT but was in [**Location (un) 86**]
visiting his girlfriend. She left to return a shirt to a friend
approx 0100 and that is when this OD occured. Per his parents he
had an episode of binge drinking 2 months prior where he was
hospitalized for detox (3 days) and treated with benzos but no
noted withdrawl/seizures. He rec'd 1.5 days counceling but did
not follow-up for further treatment. Around that time his PCP
started him on Paxil and he seemed to improve initially but has
been worse over the past 6 weeks. He arrived in [**Location (un) 86**] 1 week
prior to visit his ex-girlfriend and things were going well
until [**6-26**] when he started to drink heavily. Per his parents the
ex-girlfriend called last night stating he was drunk and
difficult, shortly after which he told her he took 20 pills
(excedrin pm?). Per his parents no known close friends/family
memebers with completed suicide, though a peer in high school
died by hanging. His parents came from CT and brought him to the
ED.
.
On arrival to the ED VS: T 98.7 HR 120 BP 157/96 RR 18 Sat 95%
on RA. Sat fell to 92% on RA. He was noted to be
confused/lethargic so intubated for airway protection. He was
given activated charcoal PO. narcan 0.4mg given with no effect.
Toxicology was consulted and he was admitted to the ICU.

For tylenol overdose he was given acetylcysteine based on 80kg
wt, (IV) 9800 mg (140mg/kg load) with 5600mg (70mg/kg) q4 iv for
24 hours-rec'd at 1000, 1400 prior to transfer. Toxicology
following: 1-2 beats of clonus, no hyperreflexia noted. He rec'd
1.7 L NS then approx 500cc D51/2NS. UOP 600cc when foley placed,
then total 1160 for 9 hours.


Past Medical History:
OSA on home CPAP
Hypertension: not known to be on medications
Depression: on paroxitene, ?compliance, no previous suicide
attempts known
GERD
Recent L wrist fracture w/metal pins placed (2 weeks prior), in
splint
h/o tremor since childhood


Social History:
Works as a restaurant manager in CT, here visiting his
girlfriend. + EtOH (recent heavy use as above) and tobacco use
(1 PPD, had quit 5 years ago but restarted 6-8 months ago).
Possible MJ use, no other known drug use per parents.

Family History:
nc

Physical Exam:
ON ADMIT
VS: T 99.5 oral, 100.6 rectal BP 155/96 HR 101 AC
500(500)/16(23)/0.5/5 98%
General: Intubated, sedated but arouses, nods yes/no to
questions, follows commands, NAD, withdraws to pain
HEENT: OP with charcoal, otherwise clear, PERRL 5->3mm bilat
Neck: Wide, JVP 6cm, no LAD
Resp: CTAB, no wheezes, rales, rhonchi
CV: Tachycardic but regular rhythm, no m/r/g; 2+ radial/DP/PT
pulses B
Abdomen: soft, NT, ND, +BS, no masses or HSM
Ext: L wrist in splint; no c/c/e
Skin: Multiple tattoos, no rashes or erythema, warm and moist to
touch
Neuro: PERRL 5->3mm bilaterally, + horizontal nystagmus both
directions; DTR's 2+ biceps B, brachioradialis R; 3+ patellar
reflexes bilaterally, babinski down-going bilaterally, +[**3-28**]
beats of clonus in ankles bilaterally, no rigidity or tremor


Brief Hospital Course:
A/P: 28 yo man with depression presents with EtOH intoxication,
suicide attempt via acetaminophen/diphenhydramine/? paroxetine
overdose.
.
# Acetaminophen overdose: Pt given NAC in the ED. Toxicology
consulted. Initial LFTs normal. completed treatment with NAC.
LFTS remained normal.
.
# Diphenhydramine overdose: Likely contributing to confusion,
monitored for hyperthermia, cutaneous vasodilation,
decreased/absent bowel sounds, pupillary dilation, tachycardia,
prolonged QTc, seizures as signs of anticholinergic toxicity and
all were within the normal in the initial 24 hours.
.
# Possible paroxetine overdose: Per pharmacy did not get
prescription refilled after [**5-27**], has one pill remaining so
likely not strictly compliant. Patient had mild hyper-reflexia,
clonus on exam, also tachycardic and with low-grade fever, ?
serotonin syndrome given on paroxetine, toxicology was
reconsulted. received supportive care and no intervention
needed.
.
# Suicide attempt: Psychiatry consulted, and followed throughout
hospitalization. initially on 1:1 sitter which was discontinued.
Ultimately, intensive outpatient counseling and therapy was
recommended and was agreeable to the patient and family.
Social work and addiction counseling saw the patient and helped
arrange follow-up closer to home in CT.
.
# EtOH intoxication: monitored on CIWA q 4 hours for withdrawal,
no signs or symptoms. Complete abstinence recommended and AA was
rec'd by psych.
.
#DEPRESSION -psychiatry consulted, continued on Paxil 20mg qd,
psychiatry established plan for safe care and follow up with
patient and family. Social work will follow up to help arrange
outpatient follow-up.

Medications on Admission:
paxil 20mg qd

Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Home

Discharge Diagnosis:
Tylenol PM overdose
alcohol intoxication
depression


Discharge Condition:
improved


Discharge Instructions:
call or seek medical attention if any questions or concerns.

Followup Instructions:
follow up with outpatient counseling and your primary care
doctor.
social work will be in contact tomorrow to confirm follow-up for
counseling.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]

Completed by:[**2176-7-5**]
{'Poisoning by aromatic analgesics, not elsewhere classified,Other and unspecified alcohol dependence, unspecified,Pneumonitis due to inhalation of food or vomitus,Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics,Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified,Esophageal reflux,Tobacco use disorder'}


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: tylenol overdose
acute intoxication

PRESENT ILLNESS: This 28 yo man with h/o depression presented to the ED s/p OD on
'blue pills with PM on them', thought to be excedrin PM. Tox.
screen positive for acetominphen (unknown time of ingestion-?
0100-0200), and etoh. He resides in CT but was in [**Location (un) 86**]
visiting his girlfriend. She left to return a shirt to a friend
approx 0100 and that is when this OD occured. Per his parents he
had an episode of binge drinking 2 months prior where he was
hospitalized for detox (3 days) and treated with benzos but no
noted withdrawl/seizures. He rec'd 1.5 days counceling but did
not follow-up for further treatment. Around that time his PCP
started him on Paxil and he seemed to improve initially but has
been worse over the past 6 weeks. He arrived in [**Location (un) 86**] 1 week
prior to visit his ex-girlfriend and things were going well
until [**6-26**] when he started to drink heavily. Per his parents the
ex-girlfriend called last night stating he was drunk and
difficult, shortly after which he told her he took 20 pills
(excedrin pm?). Per his parents no known close friends/family
memebers with completed suicide, though a peer in high school
died by hanging. His parents came from CT and brought him to the
ED.
.
On arrival to the ED VS: T 98.7 HR 120 BP 157/96 RR 18 Sat 95%
on RA. Sat fell to 92% on RA. He was noted to be
confused/lethargic so intubated for airway protection. He was
given activated charcoal PO. narcan 0.4mg given with no effect.
Toxicology was consulted and he was admitted to the ICU.

MEDICAL HISTORY: OSA on home CPAP
Hypertension: not known to be on medications
Depression: on paroxitene, ?compliance, no previous suicide
attempts known
GERD
Recent L wrist fracture w/metal pins placed (2 weeks prior), in
splint
h/o tremor since childhood

MEDICATION ON ADMISSION: paxil 20mg qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ON ADMIT
VS: T 99.5 oral, 100.6 rectal BP 155/96 HR 101 AC
500(500)/16(23)/0.5/5 98%
General: Intubated, sedated but arouses, nods yes/no to
questions, follows commands, NAD, withdraws to pain
HEENT: OP with charcoal, otherwise clear, PERRL 5->3mm bilat
Neck: Wide, JVP 6cm, no LAD
Resp: CTAB, no wheezes, rales, rhonchi
CV: Tachycardic but regular rhythm, no m/r/g; 2+ radial/DP/PT
pulses B
Abdomen: soft, NT, ND, +BS, no masses or HSM
Ext: L wrist in splint; no c/c/e
Skin: Multiple tattoos, no rashes or erythema, warm and moist to
touch
Neuro: PERRL 5->3mm bilaterally, + horizontal nystagmus both
directions; DTR's 2+ biceps B, brachioradialis R; 3+ patellar
reflexes bilaterally, babinski down-going bilaterally, +[**3-28**]
beats of clonus in ankles bilaterally, no rigidity or tremor

FAMILY HISTORY: nc

SOCIAL HISTORY: Works as a restaurant manager in CT, here visiting his
girlfriend. + EtOH (recent heavy use as above) and tobacco use
(1 PPD, had quit 5 years ago but restarted 6-8 months ago).
Possible MJ use, no other known drug use per parents. 

### Response:
{'Poisoning by aromatic analgesics, not elsewhere classified,Other and unspecified alcohol dependence, unspecified,Pneumonitis due to inhalation of food or vomitus,Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics,Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified,Esophageal reflux,Tobacco use disorder'}
