CHIEF COMPLAINT: TCA overdose

PRESENT ILLNESS: The patient was brought to [**Hospital 4199**] Hospital by his friends after
he ingested "7 yellow pills," later identified as doxepin. He
was responsive at [**Last Name (un) 4199**] and started on a bicarbonate infusion.
He was apparently given Narcan without improvement. On arrival
to the ER, his respiratory rate was 5 with a GSC of 7 so he was
intubated.  Mother states that he also takes suboxone and
gabapentin, but isn't sure on how much.  Serum and utox (+) for
TCA.

MEDICAL HISTORY: - Peptic Ulcer Disease
- h/o ankle fracture

MEDICATION ON ADMISSION: - Meds per Dr.[**Name (NI) 89235**] office:
-- Suboxone 8 mg tablet [**2-10**] tab (4 mg) TID
-- Trazodone 100 mg QHS for sleep
-- Omeprazole PRN for PUD diagnosed while in prison [**2102**]
-- Acyclovir 400 mg PO BID suppressive therapy for HSV2
-- Viagra PRN for ED, though had negative endocrine w/u with
normal testosterone
- [**Street Address(1) **] Pharmacy [**Telephone/Fax (1) 89236**]: No record of any TCA or other
antidepressant
-- Suboxone 8/2 tablets [**2-10**] tab PO TID (#44 on [**2104-7-21**])
-- Trazodone 100 mg PO QHS (#30 on [**2104-7-16**])
-- Viagra 425 mg PO PRN (#2 > 1 month ago)
-- Prilosec 20 mg PO PRN
-- Acyclovir 400 mg PO BID (#60 on [**2104-7-11**])

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission PE:

FAMILY HISTORY: 

SOCIAL HISTORY: - MD [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20137**] at [**Location (un) 6188**] Health Center [**Telephone/Fax (1) 11329**]
contact[**Name (NI) **]; he sees this patient for substance abuse (chiefly PCP
and snorted heroin, no IVDU) and prescribes suboxone. He had
been seen n this practice about 3 years ago but resurfaced in
[**Month (only) 404**] and since then has been seen regularly. Updated social
history: Struggles with substance abuse but especially with PCP.
[**Name10 (NameIs) **] not had a positive drug screen since [**Month (only) 958**] (5 negatives
since) and has seemd motivated in this program and thought to be
doing well. He has been in prison for "11 out of 12" years since
turning 18, but most recently has had a full time job as a scrap
metal worker. Other medical history: HSV2 on suppressive
therapy, PUD, umbilical hernia repair x 2 while in prison. No
documented depression or TCA use.
Poisoning by tricyclic antidepressants,Acute respiratory failure,Accidental poisoning by antidepressants,Accidents occurring in unspecified place,Opioid abuse, in remission,Depressive disorder, not elsewhere classified
Pois tricyclc antidepres,Acute respiratry failure,Acc poison-antidepressnt,Accident in place NOS,Opioid abuse-in remiss,Depressive disorder NEC
Admission Date:  [**2104-8-4**]              Discharge Date:   [**2104-8-5**]

Date of Birth:  [**2073-12-27**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
TCA overdose

Major Surgical or Invasive Procedure:
AMA

History of Present Illness:
The patient was brought to [**Hospital 4199**] Hospital by his friends after
he ingested "7 yellow pills," later identified as doxepin. He
was responsive at [**Last Name (un) 4199**] and started on a bicarbonate infusion.
He was apparently given Narcan without improvement. On arrival
to the ER, his respiratory rate was 5 with a GSC of 7 so he was
intubated.  Mother states that he also takes suboxone and
gabapentin, but isn't sure on how much.  Serum and utox (+) for
TCA.

Per mother, pt does not have depression and isnt prescribed
doxepin.  No one in their household is apparently prescribed
doxepin.  She states that her son thought he was taking 300mg
gabapentin prior to going to a meeting (he took 7 pills).
States that he was ataxic and drowsy, fumbling for objects.
Also states that she knew it was doxepin because her son's
girlfriend obtained one of the pills and had her friend [**Name (NI) 89234**]
the pill, which they determined was 50mg doxepin.

In the [**Hospital1 18**] ED, initial VS: 98.2 70 122/74 16 100%
Toxicology was consulted and recommended continuing the bicarb
gtt and checking serial lytes, pH, and EKG.


Past Medical History:
- Peptic Ulcer Disease
- h/o ankle fracture

Social History:
- MD [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20137**] at [**Location (un) 6188**] Health Center [**Telephone/Fax (1) 11329**]
contact[**Name (NI) **]; he sees this patient for substance abuse (chiefly PCP
and snorted heroin, no IVDU) and prescribes suboxone. He had
been seen n this practice about 3 years ago but resurfaced in
[**Month (only) 404**] and since then has been seen regularly. Updated social
history: Struggles with substance abuse but especially with PCP.
[**Name10 (NameIs) **] not had a positive drug screen since [**Month (only) 958**] (5 negatives
since) and has seemd motivated in this program and thought to be
doing well. He has been in prison for "11 out of 12" years since
turning 18, but most recently has had a full time job as a scrap
metal worker. Other medical history: HSV2 on suppressive
therapy, PUD, umbilical hernia repair x 2 while in prison. No
documented depression or TCA use.


Physical Exam:
Admission PE:

VS: Temp: BP: / HR: RR: O2sat
GEN: intubated, sedated, comfortable, NAD
HEENT: PERRL, anicteric, MMM, no supraclavicular or cervical
lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or
thyroid nodules
CV: RR, S1 and S2 wnl, no m/r/g
RESP: CTA b/l with good air movement throughout
ABD: nd, +b/s, soft, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: sedated, PERRL pupils nml size, -clonus

Pertinent Results:
Admission labs:

[**2104-8-4**] 10:55PM BLOOD WBC-9.7 RBC-4.91 Hgb-15.4 Hct-45.2 MCV-92
MCH-31.3 MCHC-34.0 RDW-13.2 Plt Ct-534*
[**2104-8-4**] 10:55PM BLOOD Neuts-52.8 Lymphs-40.7 Monos-3.2 Eos-2.7
Baso-0.6
[**2104-8-4**] 10:55PM BLOOD PT-12.4 PTT-23.0 INR(PT)-1.0
[**2104-8-4**] 10:55PM BLOOD Glucose-117* UreaN-13 Creat-0.7 Na-143
K-5.4* Cl-106 HCO3-27 AnGap-15
[**2104-8-5**] 04:03AM BLOOD ALT-13 AST-14 LD(LDH)-191 AlkPhos-75
TotBili-0.3
[**2104-8-5**] 04:03AM BLOOD Lipase-16
[**2104-8-5**] 04:03AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.1
[**2104-8-4**] 10:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
[**2104-8-5**] 02:39AM BLOOD Type-ART Temp-36.3 Rates-16/ Tidal V-550
PEEP-5 FiO2-50 pO2-48* pCO2-47* pH-7.44 calTCO2-33* Base XS-6
-ASSIST/CON Intubat-INTUBATED
[**2104-8-5**] 04:07AM BLOOD Glucose-97 Lactate-1.1 K-4.0
[**2104-8-4**] 11:33PM BLOOD O2 Sat-97
[**2104-8-5**] 04:07AM BLOOD freeCa-1.22

Imaging:
[**8-5**] CXR:AP chest compared to [**8-5**], 6:49 a.m.: Large areas of
consolidation at both lung bases persist, with some improvement
on the right. These could be either regions of pneumonia or
atelectasis,
presumably due to aspiration. Heart is mildly enlarged. ET tube
is in
standard placement. Nasogastric tube ends in the upper stomach.
Pleural
effusions are small if any and probably on the left side. No
pneumothorax.

Discharge labs:

[**2104-8-5**] 04:03AM BLOOD WBC-13.2* RBC-4.32* Hgb-14.1 Hct-40.2
MCV-93 MCH-32.6* MCHC-35.1* RDW-12.8 Plt Ct-493*
[**2104-8-5**] 04:03AM BLOOD Neuts-73.4* Lymphs-21.6 Monos-2.8 Eos-1.6
Baso-0.6
[**2104-8-5**] 04:03AM BLOOD Glucose-107* UreaN-12 Creat-0.7 Na-143
K-4.3 Cl-105 HCO3-32 AnGap-10
[**2104-8-5**] 06:27AM BLOOD Type-ART Temp-36.8 Rates-20/ Tidal V-600
PEEP-8 FiO2-60 pO2-81* pCO2-39 pH-7.51* calTCO2-32* Base XS-6
-ASSIST/CON Intubat-INTUBATED

Brief Hospital Course:
ICU Course:

30yoM with TCA +/- sedative/hypnotic ingestion. His borderline
prolonged QRS and terminal R in aVR suggests this is most likely
TCA toxicity.

#Overdose: Patient presenting with overdose, presumed to doxepin
ingestion. Due to low RR and GSC 7, pt was intubated. Serum and
urine tox (+) for TCA consistent with history from friends; in
addition, serum and urine tox (-) for other substances.
Toxicology was consulted, and their recommendations were
followed:  HCO3 gtt to 75 cc/hr x 2 hours, then stop. Check EKG
15 min after rate decreased, and 15 min after gtt stopped. Check
hourly EKG x 6 hours after gtt stopped. Bolus HCO3 for QRS
widening if needed. Patient improved, and was extubated without
problem.  [**Name (NI) **] then signed out AMA.

After interviews by several members of the team, the patient was
deemed competent and not an immediate risk of harm to himself or
others.

Medications on Admission:
- Meds per Dr.[**Name (NI) 89235**] office:
-- Suboxone 8 mg tablet [**2-10**] tab (4 mg) TID
-- Trazodone 100 mg QHS for sleep
-- Omeprazole PRN for PUD diagnosed while in prison [**2102**]
-- Acyclovir 400 mg PO BID suppressive therapy for HSV2
-- Viagra PRN for ED, though had negative endocrine w/u with
normal testosterone
- [**Street Address(1) **] Pharmacy [**Telephone/Fax (1) 89236**]: No record of any TCA or other
antidepressant
-- Suboxone 8/2 tablets [**2-10**] tab PO TID (#44 on [**2104-7-21**])
-- Trazodone 100 mg PO QHS (#30 on [**2104-7-16**])
-- Viagra 425 mg PO PRN (#2 > 1 month ago)
-- Prilosec 20 mg PO PRN
-- Acyclovir 400 mg PO BID (#60 on [**2104-7-11**])


Discharge Medications:
-- Suboxone 8 mg tablet [**2-10**] tab (4 mg) TID
-- Trazodone 100 mg QHS for sleep
-- Omeprazole PRN for PUD diagnosed while in prison [**2102**]
-- Acyclovir 400 mg PO BID suppressive therapy for HSV2
-- Viagra PRN for ED, though had negative endocrine w/u with
normal testosterone

Discharge Disposition:
Home

Discharge Diagnosis:
Drug overdose (Tricyclic antidepressant Doxepin)
Leaving AMA

Discharge Condition:
AMA

Discharge Instructions:
Mr [**Known lastname 1169**],
You were admitted after you took too many pills. You experienced
a drug toxicity due to taking too many pills. We talked with you
and your family and you made it clear that this was not a
suicide attempt. Your heart rate and rhythm were monitored, and
you were treated with a medication called bicarbonate to help
your heart rate. When you took too many pills you may have
aspirated. If you develop cough, start having phlegm or fevers,
please contact your primary care doctor. You are leaving against
medical advice.

All of your medications remain the same. Please do not take
drugs, alcohol or cigarettes again.

Followup Instructions:
AMA
{'Poisoning by tricyclic antidepressants,Acute respiratory failure,Accidental poisoning by antidepressants,Accidents occurring in unspecified place,Opioid abuse, in remission,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: TCA overdose

PRESENT ILLNESS: The patient was brought to [**Hospital 4199**] Hospital by his friends after
he ingested "7 yellow pills," later identified as doxepin. He
was responsive at [**Last Name (un) 4199**] and started on a bicarbonate infusion.
He was apparently given Narcan without improvement. On arrival
to the ER, his respiratory rate was 5 with a GSC of 7 so he was
intubated.  Mother states that he also takes suboxone and
gabapentin, but isn't sure on how much.  Serum and utox (+) for
TCA.

MEDICAL HISTORY: - Peptic Ulcer Disease
- h/o ankle fracture

MEDICATION ON ADMISSION: - Meds per Dr.[**Name (NI) 89235**] office:
-- Suboxone 8 mg tablet [**2-10**] tab (4 mg) TID
-- Trazodone 100 mg QHS for sleep
-- Omeprazole PRN for PUD diagnosed while in prison [**2102**]
-- Acyclovir 400 mg PO BID suppressive therapy for HSV2
-- Viagra PRN for ED, though had negative endocrine w/u with
normal testosterone
- [**Street Address(1) **] Pharmacy [**Telephone/Fax (1) 89236**]: No record of any TCA or other
antidepressant
-- Suboxone 8/2 tablets [**2-10**] tab PO TID (#44 on [**2104-7-21**])
-- Trazodone 100 mg PO QHS (#30 on [**2104-7-16**])
-- Viagra 425 mg PO PRN (#2 > 1 month ago)
-- Prilosec 20 mg PO PRN
-- Acyclovir 400 mg PO BID (#60 on [**2104-7-11**])

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission PE:

FAMILY HISTORY: 

SOCIAL HISTORY: - MD [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20137**] at [**Location (un) 6188**] Health Center [**Telephone/Fax (1) 11329**]
contact[**Name (NI) **]; he sees this patient for substance abuse (chiefly PCP
and snorted heroin, no IVDU) and prescribes suboxone. He had
been seen n this practice about 3 years ago but resurfaced in
[**Month (only) 404**] and since then has been seen regularly. Updated social
history: Struggles with substance abuse but especially with PCP.
[**Name10 (NameIs) **] not had a positive drug screen since [**Month (only) 958**] (5 negatives
since) and has seemd motivated in this program and thought to be
doing well. He has been in prison for "11 out of 12" years since
turning 18, but most recently has had a full time job as a scrap
metal worker. Other medical history: HSV2 on suppressive
therapy, PUD, umbilical hernia repair x 2 while in prison. No
documented depression or TCA use. 

### Response:
{'Poisoning by tricyclic antidepressants,Acute respiratory failure,Accidental poisoning by antidepressants,Accidents occurring in unspecified place,Opioid abuse, in remission,Depressive disorder, not elsewhere classified'}
