CHIEF COMPLAINT: Altered mental status

PRESENT ILLNESS: 43 yo male with history of IDDM, prior SI, was admitted to [**First Name3 (LF) **]
on [**2112-4-23**].  Per the patient's wife, the patient was admitted to
[**Name (NI) **] after an anxiety attack during family counciling.  He
initially presented to [**Hospital3 **] for medical clearance, and was
found to have normal labs including BUN 30, Crn 1.2.  He has a
history of SI, but denies any ingestions at this time.  The wife
reports he had no symptoms on the day of admission to [**Hospital3 **] other
than anxiety.  Over the course of days, he began to complain of
nausea, vomiting, abdominal pain and fatigue starting on [**Hospital3 766**]
with progressive worsening.  He also reported worsening vision.
Per [**Hospital3 **], the patient has not urinated in 3 days and has had
worsening mental status changes.  It appears his BG have been
fluctuating over the course of the day as low as 40.
.
In the ED, initial vs were: T: 95.2 HR: 110 BP: 175/102 RR: 32
SatO2: 100% 10L NRB.  Initially found to have EKG with wide
sinusoidal pattern concerning for hyperkalemia v. TCA or other
med overdose.  He was treated with 5 amps of calcium gluconate
for empiric hyperkalemia prior to lab return.  He was then found
to have a profound acidosis of 6.8, K of 9.3, lactate of 12.4,
phos 16.4, Crn of 13.7.  He was subsequently treated with
boluses of bicarb as well as a drip at 250cc/hr.  A right fem
line was placed, however concern for arterial placement after
ABG sent from the line with PO2 of 189.  He was also given
vanc/zosyn as unclear etiology of acidosis.  He was also started
on insulin drip.  Toxicology was consulted and recommended high
dose thiamine as well as fomepizol which were given in the ED
for possible methanol/ethylene glycol toxicity.  Renal was
consulted and recommended emergent dialysis for severe anion gap
metabolic acidosis.  Has remained 100% on NRB, but RR increasing
and becoming more somnolent.  The patient went to CT prior to
arrival in the MICU.
.
On the floor, the patient is somnolent but arousable.  He denies
any ingestions.  He complains of neck pain, but otherwise does
not have any complaints.
.
Upon discussing the patient's condition with the family, the
wife asked to speak with me separately.  She endoresed that they
are separated, and he has been living with his mother.  She
expressed concern that his mother may want to "find blame" in
someone for her son's condition.  His wife expressed she does
not want excessive "investigation" into the cause of his illness
as he has been "poked" enough.  She has also asked for the
medical team to clarify who has right to autopsy, and has asked
as HCP that she would decline at this time, despite the fact
that patient's condition is critical but stable.

MEDICAL HISTORY: -depression
-suicidal ideation
-diabetes
-hypertension
-arthritis
-chronic fatigue
-fibromyalgia
-sleep apnea: he does not wear his CPAP regularly.
-s/p back surgery

MEDICATION ON ADMISSION: -abilify 2.5 mg PO BID
-effexor 37.5 mg po daily
-metformin 1000 mg po BID
-simvastatin 80 mg po qhs
-lisinopril 40 mg po daily
-topamax 50 mg [**Hospital1 **]
-lamictal 25 mg po qhs
-klonopin 0.5 mg po daily
-klonopin 1 mg po qhs anxiety
-tigan 300 mg po q4 prn emesis
-tigan 200 mg im q4 prn emesis
-imodium 2 mg po prn diarrhea
-insulin lantus 80 units sc qhs
-insulin regular sliding scale
-wellbutrin sr 150 mg po daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:
=============
Vitals: T: BP: 128/59  P:  R: 18 O2:
General:  Somnolent, but arousable, orientedx2, delirious
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
Lungs: Coarse breath sounds bl, no wheezes, rales, ronchi
CV:  irregularly irregular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
On discharge:
=============
Vitals:97.9(98)-134/77-71-18-95%RA.
General:Alert and Oriented x 3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
Lungs: Coarse breath sounds bl, no wheezes, rales, ronchi
CV: Regular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley.
Ext: warm, well perfused, 2+ pulses, no cce.

FAMILY HISTORY: -mother: heart disease
-father: depression

SOCIAL HISTORY: Works at the [**Company 3596**] cleaning towels, has two daughters and is
separated from his wife.
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
Poisoning by insulins and antidiabetic agents,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Acidosis,Bipolar I disorder, most recent episode (or current) depressed, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Accidents occurring in residential institution,Accidental poisoning by hormones and synthetic substitutes,Myalgia and myositis, unspecified,Obstructive sleep apnea (adult)(pediatric),Personal history of noncompliance with medical treatment, presenting hazards to health,Other iatrogenic hypotension,Sarcoidosis,Diarrhea,Anemia, unspecified
Poison-insulin/antidiab,Ac kidny fail, tubr necr,Acute respiratry failure,Acidosis,Bipol I cur depres NOS,DMII wo cmp nt st uncntr,Pure hypercholesterolem,Accid in resident instit,Acc poison-hormones,Myalgia and myositis NOS,Obstructive sleep apnea,Hx of past noncompliance,Iatrogenc hypotnsion NEC,Sarcoidosis,Diarrhea,Anemia NOS
Admission Date:  [**2112-4-27**]              Discharge Date:   [**2112-5-5**]

Date of Birth:  [**2069-2-20**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:
1) Intubation
2) Central venous catheterization times two (one for temporary
dialysis)


History of Present Illness:
43 yo male with history of IDDM, prior SI, was admitted to [**First Name3 (LF) **]
on [**2112-4-23**].  Per the patient's wife, the patient was admitted to
[**Name (NI) **] after an anxiety attack during family counciling.  He
initially presented to [**Hospital3 **] for medical clearance, and was
found to have normal labs including BUN 30, Crn 1.2.  He has a
history of SI, but denies any ingestions at this time.  The wife
reports he had no symptoms on the day of admission to [**Hospital3 **] other
than anxiety.  Over the course of days, he began to complain of
nausea, vomiting, abdominal pain and fatigue starting on [**Hospital3 766**]
with progressive worsening.  He also reported worsening vision.
Per [**Hospital3 **], the patient has not urinated in 3 days and has had
worsening mental status changes.  It appears his BG have been
fluctuating over the course of the day as low as 40.
.
In the ED, initial vs were: T: 95.2 HR: 110 BP: 175/102 RR: 32
SatO2: 100% 10L NRB.  Initially found to have EKG with wide
sinusoidal pattern concerning for hyperkalemia v. TCA or other
med overdose.  He was treated with 5 amps of calcium gluconate
for empiric hyperkalemia prior to lab return.  He was then found
to have a profound acidosis of 6.8, K of 9.3, lactate of 12.4,
phos 16.4, Crn of 13.7.  He was subsequently treated with
boluses of bicarb as well as a drip at 250cc/hr.  A right fem
line was placed, however concern for arterial placement after
ABG sent from the line with PO2 of 189.  He was also given
vanc/zosyn as unclear etiology of acidosis.  He was also started
on insulin drip.  Toxicology was consulted and recommended high
dose thiamine as well as fomepizol which were given in the ED
for possible methanol/ethylene glycol toxicity.  Renal was
consulted and recommended emergent dialysis for severe anion gap
metabolic acidosis.  Has remained 100% on NRB, but RR increasing
and becoming more somnolent.  The patient went to CT prior to
arrival in the MICU.
.
On the floor, the patient is somnolent but arousable.  He denies
any ingestions.  He complains of neck pain, but otherwise does
not have any complaints.
.
Upon discussing the patient's condition with the family, the
wife asked to speak with me separately.  She endoresed that they
are separated, and he has been living with his mother.  She
expressed concern that his mother may want to "find blame" in
someone for her son's condition.  His wife expressed she does
not want excessive "investigation" into the cause of his illness
as he has been "poked" enough.  She has also asked for the
medical team to clarify who has right to autopsy, and has asked
as HCP that she would decline at this time, despite the fact
that patient's condition is critical but stable.


Past Medical History:
-depression
-suicidal ideation
-diabetes
-hypertension
-arthritis
-chronic fatigue
-fibromyalgia
-sleep apnea: he does not wear his CPAP regularly.
-s/p back surgery

Social History:
Works at the [**Company 3596**] cleaning towels, has two daughters and is
separated from his wife.
- Tobacco: denies
- Alcohol: denies
- Illicits: denies


Family History:
-mother: heart disease
-father: depression


Physical Exam:
On admission:
=============
Vitals: T: BP: 128/59  P:  R: 18 O2:
General:  Somnolent, but arousable, orientedx2, delirious
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
Lungs: Coarse breath sounds bl, no wheezes, rales, ronchi
CV:  irregularly irregular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
On discharge:
=============
Vitals:97.9(98)-134/77-71-18-95%RA.
General:Alert and Oriented x 3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
Lungs: Coarse breath sounds bl, no wheezes, rales, ronchi
CV: Regular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley.
Ext: warm, well perfused, 2+ pulses, no cce.


Pertinent Results:
Admission labs:
===============
[**2112-4-27**] 10:15PM BLOOD WBC-15.9* RBC-4.61 Hgb-13.6* Hct-43.7
MCV-95 MCH-29.6 MCHC-31.2 RDW-13.2 Plt Ct-357
[**2112-4-27**] 10:15PM BLOOD Neuts-79.9* Lymphs-15.4* Monos-4.1
Eos-0.2 Baso-0.3
[**2112-4-28**] 01:20AM BLOOD PT-13.9* PTT-29.4 INR(PT)-1.2*
[**2112-4-27**] 10:15PM BLOOD Glucose-214* UreaN-122* Creat-13.7*
Na-132* K->10 Cl-91* HCO3-<5
[**2112-4-27**] 10:15PM BLOOD ALT-60* AST-138* CK(CPK)-567* AlkPhos-89
TotBili-0.3
[**2112-4-27**] 10:15PM BLOOD Lipase-222*
[**2112-4-27**] 10:15PM BLOOD cTropnT-0.15*
[**2112-4-28**] 01:20AM BLOOD CK-MB-6 cTropnT-0.23*
[**2112-4-28**] 07:32AM BLOOD cTropnT-0.26*
[**2112-4-27**] 11:15PM BLOOD Calcium-9.9 Phos-16.3* Mg-2.4
[**2112-4-28**] 11:06AM BLOOD Hapto-195
[**2112-4-27**] 11:15PM BLOOD Osmolal-358*
[**2112-4-28**] 11:06AM BLOOD Cortsol-23.0*
[**2112-4-28**] 11:06AM BLOOD Vanco-6.8*
[**2112-4-27**] 10:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2112-4-27**] 11:22PM BLOOD Type-ART pO2-138* pCO2-18* pH-6.80*
calTCO2-3* Base XS--33
[**2112-4-28**] 12:03AM BLOOD Type-ART pO2-77* pCO2-22* pH-6.80*
calTCO2-4* Base XS--33
[**2112-4-28**] 12:19AM BLOOD Type-ART pO2-391* pCO2-12* pH-6.86*
calTCO2-2* Base XS--32
[**2112-4-28**] 03:09AM BLOOD Type-ART Temp-35.0 pO2-84* pCO2-32*
pH-7.04* calTCO2-9* Base XS--21 Intubat-INTUBATED
[**2112-4-28**] 05:13AM BLOOD Type-ART Temp-36.8 Tidal V-550 PEEP-5
FiO2-50 pO2-71* pCO2-34* pH-7.34* calTCO2-19* Base XS--6
Intubat-INTUBATED
[**2112-4-28**] 06:59AM BLOOD Type-ART Rates-26/ Tidal V-550 PEEP-10
FiO2-60 pO2-88 pCO2-37 pH-7.37 calTCO2-22 Base XS--3 -ASSIST/CON
Intubat-INTUBATED
[**2112-4-28**] 07:36PM BLOOD Type-ART pO2-106* pCO2-45 pH-7.39
calTCO2-28 Base XS-1
[**2112-4-29**] 12:39PM BLOOD Type-ART Temp-38.4 pO2-118* pCO2-39
pH-7.26* calTCO2-18* Base XS--8 Intubat-INTUBATED
[**2112-4-30**] 08:11AM BLOOD Type-ART Temp-37.2 PEEP-10 pO2-159*
pCO2-37 pH-7.48* calTCO2-28 Base XS-4 -ASSIST/CON
Intubat-INTUBATED
[**2112-5-1**] 02:28AM BLOOD Type-ART Temp-36.9 Rates-/12 Tidal V-600
PEEP-5 FiO2-40 pO2-112* pCO2-52* pH-7.36 calTCO2-31* Base XS-3
Intubat-INTUBATED Vent-SPONTANEOU
[**2112-5-2**] 03:06AM BLOOD Type-ART Temp-37.1 pO2-84* pCO2-43
pH-7.45 calTCO2-31* Base XS-4 Intubat-NOT INTUBA
[**2112-4-27**] 10:20PM BLOOD Glucose-184* Lactate-11.2* Na-137 K-8.6*
Cl-102 calHCO3-3*
[**2112-4-28**] 12:03AM BLOOD Glucose-293* Lactate-11.8* K-8.4*
[**2112-4-28**] 12:59AM BLOOD ALCOHOL PROFILE-negative
[**2112-4-28**] 01:22AM BLOOD ETHYLENE GLYCOL-negative
[**2112-4-28**] 03:14AM BLOOD CYANIDE-negative

Imaging:
========
[**4-27**] ECG: Irregular tachy-arrhythmia of uncertain mechanism but
may be atrial fibrillation or possible multifocal atrial
tachycardia. Intraventricular conduction delay. ST-T wave
changes with prominent and peaked T waves. Findings raise the
consideration of hyperkalemia. Clinical correlation is
suggested. No previous tracing available for comparison.
.
[**4-28**] TTE: Normal left ventricular cavity size and wall thickness
with low-normal global left ventricular systolic function.
Extensive network in right atrium consistent with likely Chiari
network, as well as probable visualization of catheter tip
within the right atrium, but no discrete mass or vegetation
appreciated. No clinically significant valvular disease. Normal
pulmonary artery systolic hypertension.
.
[**4-28**] CT head: Study limited due to artifacts. No large focus of
acute intracranial hemrorhage. Vague dense foci in the upper
cervical cord and in the brain parenchyma are likely
artifactual. Consider followup study for better assessment or MR
if nto CI, if there is continued concern for abnormality.
.
[**4-28**] Renal U/S:
1. No hydroureteronephrosis or stones.
2. Major renal vasculature patent with normal waveforms. No
evidence of
renal venous thrombosis.
3. Echogenic liver, incompletely evaluated, most compatible with
diffuse
fatty change, but other forms of liver disease or advanced liver
disease
including fibrosis or cirrhosis cannot be excluded.
.
[**4-30**] CXR:
Tip of endotracheal tube now terminates 4.2 cm above the carina.
Right internal jugular catheter continues to terminate within
the right atrium. Improving atelectasis in both lower lobes with
residual patchy and linear atelectasis remaining.
.

[**2112-5-5**] 07:15AM BLOOD WBC-7.6 RBC-3.28* Hgb-9.9* Hct-28.5*
MCV-87 MCH-30.2 MCHC-34.7 RDW-13.0 Plt Ct-356
[**2112-5-5**] 07:15AM BLOOD Glucose-109* UreaN-35* Creat-2.8* Na-144
K-3.9 Cl-106 HCO3-25 AnGap-17
[**2112-4-30**] 03:15AM BLOOD ALT-37 AST-16 AlkPhos-77 TotBili-0.3

Brief Hospital Course:
43 yM h/o IDDM, depression with history of SI, admitted for
severe anion gap metabolic acidosis.

#  Severe anion gap metabolic acidosis:  On admission pH was
6.73 and patient had altered mental status and vision changes.
He was intubated for airway protection. Lactic acidosis
differential included metformin-associated (given ARF as below)
and ingestion though ethylene glycol, cyanide, methanol, and tox
panel was negative. He was initially started on fomipezole as an
antidote but this was stopped after negative results. Toxicology
and renal were consulted and patient was emergently dialyzed
with improvement in pH. He required 2 HD sessions on admission
with no further HD given improving acidosis and normal lactate.
Patient's HCO3 and pH continued to be acidotic for 3 days but
lactate was normal and HD was not continued. He was
hyperventilated on assist control ventilation and acidosis
resolved. Pt was successfully extubated on [**5-1**] and was patient
was transferred to the medical floor for further management of
his ARF (see below). He had large volume diuresis, and was
encouraged to take PO fluids. His kidney function continued to
improve.

#  ARF: Patient's Cr had been worsening slowly prior to
admission (documented to be 0.7 at baseline and 1.2 on [**4-23**]), Cr
13.7 on admission and slowly improved to 6.1 on transfer from
MICU after 2 sessions of HD. Most likely etiology was poor PO
intake with diarrhea/vomiting prior while patient was still
taking lisinopril.  Pt presented with oliguric ATN and likely
metformin-associated lactic acidosis given ongoing metformin
use. Renal ultrasound with Doppler did not show any flow
abnormalities. Patient had high urine output at time of
transfer. His metformin and lisinopril were being held. While on
the medical floor, his creatinine continued to trend down
towards the normal range. He continued to have increased urine
output and we were repleting his electrolytes as needed, with
BUN/Creatinine trending towards normal range.   Pt is scheduled
to follow up with renal team to ensure that his function returns
to baseline.

#  Respiratory failure: secondary to severe acidosis and altered
mental status, patient was intubated on admission for airway
protection. CXR shows some evidence of volume overload vs. ARDS
with no consolidations suggestive of pneumonia. He was initially
started on azithromycin, vanco, and zosyn. He completed a 5-day
course of azithromycin and vanco/zosyn were discontinued given
patient had negative sputum cx, afebrile and no leukocytosis and
no clinical evidence of pneumonia. Patient was successfully
extubated with no complications.

#  DM: In MICU his glucose was controlled with insulin drip and
sliding scale. Metformin was held given above. Patient and his
family would like to follow up at [**Hospital **] clinic on discharge. On
the floor he was on a sliding scale. He will follow up with
[**Hospital **] clinic on discharge. He will be sent home on Lantus with
an insulin sliding scale and instructions not to take metformin.

#  Psych:  On admission, home regimen of abilify, effexor,
wellbutrin, topomax, klonopin, and lamictal were all held given
AMS.  On the medicine floor, pt was restarted on Clonazepam,
Wellbutrin and prn abilify with the psychiatry consult service
following.  The Psychiatry team felt that he was safe to return
home with outpt follow up and recommended holding the rest of
his home psychiatric medications until he is seen by his primary
outpt Psychiatrist.
.
#  HLD: Restarted simvastatin 80 prior to discharge.
.
#  HTN:  Held lisinopril given dense renal failure. This may
need to be restarted once his renal function normalizes.

----
TRANSITIONAL ISSUES:
1. Psych - will be followed closely in an outpatient treatment
program near his home. His medications will need to be
re-evaluated and/or restarted at some point.
2. HTN - given hypotension in the unit, and renal failure these
were adjusted inpatient. These will need to be restarted once
renal function normalizes.
3. DM - patient left on insulin sliding scale.


Medications on Admission:
-abilify 2.5 mg PO BID
-effexor 37.5 mg po daily
-metformin 1000 mg po BID
-simvastatin 80 mg po qhs
-lisinopril 40 mg po daily
-topamax 50 mg [**Hospital1 **]
-lamictal 25 mg po qhs
-klonopin 0.5 mg po daily
-klonopin 1 mg po qhs anxiety
-tigan 300 mg po q4 prn emesis
-tigan 200 mg im q4 prn emesis
-imodium 2 mg po prn diarrhea
-insulin lantus 80 units sc qhs
-insulin regular sliding scale
-wellbutrin sr 150 mg po daily


Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
2. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
4. Outpatient Lab Work
please draw blood for CBC, Chem 10 on or around [**2112-5-9**].
Please fax results to Dr.[**Last Name (STitle) 4920**] at ([**Telephone/Fax (1) 81523**]
5. insulin lispro 100 unit/mL Insulin Pen Sig: sliding scale
units Subcutaneous three times a day.
Disp:*1 pen* Refills:*0*
6. prescription
glucometer test strips - one months supply for three times a day
testing - total of 90.
7. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
8. aripiprazole 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as
needed for agitation/racing thoughts .
9. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Forty
(40) units Subcutaneous at bedtime.
Disp:*1 pen* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnoses:
1)Metabolic Acidosis
2)Acute Renal Failure
Secondary Diagnoses:
1)Bipolar Disorder
2)Depression


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


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

You were admitted to our hospital with complaints of
nausea/vomiting, diarrhea, altered mental status.
You were briefly in our intensive care unit, intubated to reduce
severe metabolic derangements that we have found in your blood.
You were eventually extubated and transferred to the medical
floor. Your kidney function has improved greatly since your
admission.

The following changes were made to your medications:

MENTAL HEALTH MEDICATIONS
STOP Effexor, Topomax, Lamictal
CONTINUE klonipin, wellbutrin
CHANGE Abilify 2.5 mg to once daily AS NEEDED for racing
thoughts or agitation
These will have to be carefully adjusted with your psychiatrist
at some point.

OTHER MEDICATIONS
STOP Metformin - you may need to restart this medication once
your kidney function normalizes. Please discuss this with your
primary care doctor.

START Carvedilol - take 1 tablet twice a day to control your
blood pressure.
STOP lisinopril,imodium

You will need your blood drawn to evaluate your kidney function
on [**Last Name (LF) 766**], [**2112-5-9**].

Followup Instructions:
Please follow up with your psychiatrist and primary care doctor
within 4-8 days after leaving the hospital.

[**Doctor Last Name **] DAY PROGRAM: Go to [**Location (un) **] ([**Hospital 1263**] Hospital),
[**Last Name (LF) 766**], [**5-9**] at  9 am at  - [**Location (un) 861**] Psychiatric Unit. Lunch
will be served.

Name: [**Last Name (LF) 81524**],[**First Name3 (LF) 6811**] A.
Location: CARITAS PHYSICIAN NETWORK
Address: [**Street Address(2) 8727**] STE 105W, [**Hospital1 **],[**Numeric Identifier 9647**]
Phone: [**Telephone/Fax (1) 33743**]
*Dr. [**Last Name (STitle) **] is working on an appointment for you within one
week.  If you dont hear from him by [**Last Name (STitle) 766**], please call his
office directly.

Name: [**Last Name (LF) 1557**], [**First Name3 (LF) **] PA
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: [**Telephone/Fax (1) 766**] [**5-9**] at 1:30PM

Dr. [**Last Name (STitle) 4920**] - [**6-17**] at 10AM
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
YOU WILL BE CONTACT[**Name (NI) **] BY DR.[**Doctor Last Name 81525**] Office regarding earlier
appointment.



Completed by:[**2112-5-6**]
{'Poisoning by insulins and antidiabetic agents,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Acidosis,Bipolar I disorder, most recent episode (or current) depressed, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Accidents occurring in residential institution,Accidental poisoning by hormones and synthetic substitutes,Myalgia and myositis, unspecified,Obstructive sleep apnea (adult)(pediatric),Personal history of noncompliance with medical treatment, presenting hazards to health,Other iatrogenic hypotension,Sarcoidosis,Diarrhea,Anemia, unspecified'}


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: 43 yo male with history of IDDM, prior SI, was admitted to [**First Name3 (LF) **]
on [**2112-4-23**].  Per the patient's wife, the patient was admitted to
[**Name (NI) **] after an anxiety attack during family counciling.  He
initially presented to [**Hospital3 **] for medical clearance, and was
found to have normal labs including BUN 30, Crn 1.2.  He has a
history of SI, but denies any ingestions at this time.  The wife
reports he had no symptoms on the day of admission to [**Hospital3 **] other
than anxiety.  Over the course of days, he began to complain of
nausea, vomiting, abdominal pain and fatigue starting on [**Hospital3 766**]
with progressive worsening.  He also reported worsening vision.
Per [**Hospital3 **], the patient has not urinated in 3 days and has had
worsening mental status changes.  It appears his BG have been
fluctuating over the course of the day as low as 40.
.
In the ED, initial vs were: T: 95.2 HR: 110 BP: 175/102 RR: 32
SatO2: 100% 10L NRB.  Initially found to have EKG with wide
sinusoidal pattern concerning for hyperkalemia v. TCA or other
med overdose.  He was treated with 5 amps of calcium gluconate
for empiric hyperkalemia prior to lab return.  He was then found
to have a profound acidosis of 6.8, K of 9.3, lactate of 12.4,
phos 16.4, Crn of 13.7.  He was subsequently treated with
boluses of bicarb as well as a drip at 250cc/hr.  A right fem
line was placed, however concern for arterial placement after
ABG sent from the line with PO2 of 189.  He was also given
vanc/zosyn as unclear etiology of acidosis.  He was also started
on insulin drip.  Toxicology was consulted and recommended high
dose thiamine as well as fomepizol which were given in the ED
for possible methanol/ethylene glycol toxicity.  Renal was
consulted and recommended emergent dialysis for severe anion gap
metabolic acidosis.  Has remained 100% on NRB, but RR increasing
and becoming more somnolent.  The patient went to CT prior to
arrival in the MICU.
.
On the floor, the patient is somnolent but arousable.  He denies
any ingestions.  He complains of neck pain, but otherwise does
not have any complaints.
.
Upon discussing the patient's condition with the family, the
wife asked to speak with me separately.  She endoresed that they
are separated, and he has been living with his mother.  She
expressed concern that his mother may want to "find blame" in
someone for her son's condition.  His wife expressed she does
not want excessive "investigation" into the cause of his illness
as he has been "poked" enough.  She has also asked for the
medical team to clarify who has right to autopsy, and has asked
as HCP that she would decline at this time, despite the fact
that patient's condition is critical but stable.

MEDICAL HISTORY: -depression
-suicidal ideation
-diabetes
-hypertension
-arthritis
-chronic fatigue
-fibromyalgia
-sleep apnea: he does not wear his CPAP regularly.
-s/p back surgery

MEDICATION ON ADMISSION: -abilify 2.5 mg PO BID
-effexor 37.5 mg po daily
-metformin 1000 mg po BID
-simvastatin 80 mg po qhs
-lisinopril 40 mg po daily
-topamax 50 mg [**Hospital1 **]
-lamictal 25 mg po qhs
-klonopin 0.5 mg po daily
-klonopin 1 mg po qhs anxiety
-tigan 300 mg po q4 prn emesis
-tigan 200 mg im q4 prn emesis
-imodium 2 mg po prn diarrhea
-insulin lantus 80 units sc qhs
-insulin regular sliding scale
-wellbutrin sr 150 mg po daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:
=============
Vitals: T: BP: 128/59  P:  R: 18 O2:
General:  Somnolent, but arousable, orientedx2, delirious
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
Lungs: Coarse breath sounds bl, no wheezes, rales, ronchi
CV:  irregularly irregular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
On discharge:
=============
Vitals:97.9(98)-134/77-71-18-95%RA.
General:Alert and Oriented x 3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
Lungs: Coarse breath sounds bl, no wheezes, rales, ronchi
CV: Regular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley.
Ext: warm, well perfused, 2+ pulses, no cce.

FAMILY HISTORY: -mother: heart disease
-father: depression

SOCIAL HISTORY: Works at the [**Company 3596**] cleaning towels, has two daughters and is
separated from his wife.
- Tobacco: denies
- Alcohol: denies
- Illicits: denies 

### Response:
{'Poisoning by insulins and antidiabetic agents,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Acidosis,Bipolar I disorder, most recent episode (or current) depressed, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Accidents occurring in residential institution,Accidental poisoning by hormones and synthetic substitutes,Myalgia and myositis, unspecified,Obstructive sleep apnea (adult)(pediatric),Personal history of noncompliance with medical treatment, presenting hazards to health,Other iatrogenic hypotension,Sarcoidosis,Diarrhea,Anemia, unspecified'}
