CHIEF COMPLAINT: Medication overdose, altered mental status

PRESENT ILLNESS: This is an 85 year-old male with hx of CHF (EF <20%) s/p ICD and
pacemaker, Afib on Coumadin, and CKD who presents to the ED
after an accidental medication overdose. Per report, when taking
his morning medications, the patient took his entire day's worth
of medications at one time. Per his [**First Name3 (LF) 802**], she was called by the
VNA at 9:30 am who thought he just seemed a little "off," normal
vitals signs, afebrile at that time. The home health aide came
at 11am and found him to be confused, partially undressed and
incontinent of urine on his clothing and found that he had
emptied (and presumably taken) Thursday's medication contained.
He was referred to the emergency department.
.
In the ED, he was oriented to person though confused re: place
and time. His SBP ranged between 80s-90s, toxicology was
consulted and the patient received glucagon. He was mentating
well and heart rhythm V-paced in the 50s (usual setting).
.
On arrival to the ICU, the patient reports feeling tired and
increased urinary frequency but otherwise feels well. He denies
visual changes or headache.
.
Of note, he had a recent hospitalization [**8-7**] for a RLE
cellulitis and 3rd toe ulcer that was treated with Unasyn.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation, chest
pain, shortness of breath, lower extremity oedema, cough,
lightheadedness, gait unsteadiness, headache, rash or skin
changes.

MEDICAL HISTORY: -CHF EF <20%, s/p ICD for hx VT
-Severe tricuspid regurgitation, mild to moderate mitral
regurgitation
-Left Bundle Branch Block ([**2187**])
-Atrial fibrillation on anticoagulation
-BPH ([**2182**])
-Sigmoid polyps ([**2188**])
-Diverticulosis
-GI bleed ([**2188**])
-Chronic renal insufficiency 1.5-1.7
-Actinic keratosis
-Iron deficiency anemia
-Presyncope, Falls
-Allergic rhinitis
-Hearing Loss
-Gout
-Appendectomy
-Hernia Repair

MEDICATION ON ADMISSION: Digoxin 125 mcg PO DAILY
Tamsulosin 0.4 mg po qhd
Omeprazole 20 mg po daily
Warfarin 5 mg 3X/WEEK, 2.5mg 4X/WEEK
Ascorbic Acid 500 mg daily
Ferrous Sulfate 325 mg daily
Multivitamin daily
Vitamin E 400 unit daily
Acetaminophen prn
Docusate Sodium 100 mg po bid
Toprol XL 12.5 mg daily
Lisinopril 2.5 mg po daily
Spironolactone 25 mg po daily
Lasix 80 mg po daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tm 99.6 Tc 99.1  112/56  p60  R20  100%RA
Heart rhythm: V Paced

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: He lives alone in [**Hospital3 4634**]. Visiting Angels comes on MF,
and [**First Name8 (NamePattern2) 24979**] [**First Name8 (NamePattern2) 3146**] [**Location (un) 4628**] Elder Care Services comes on MWF to
help patient shower. Patient has groceries bought for him. His
nephew and [**Name2 (NI) 802**] [**First Name8 (NamePattern2) **] [**Name (NI) 13039**] - next of [**Doctor First Name **]) are quite active in
his care. He quit smoking over 40 years ago. No EtOH.
Poisoning by cardiotonic glycosides and drugs of similar action,Acute kidney failure, unspecified,Delirium due to conditions classified elsewhere,Chronic systolic heart failure,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Poisoning by other diuretics,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Atrial fibrillation,Chronic kidney disease, unspecified,Hypotension, unspecified,Pressure ulcer, stage II,Diverticulosis of colon (without mention of hemorrhage),Iron deficiency anemia, unspecified,Gout, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Long-term (current) use of anticoagulants,Automatic implantable cardiac defibrillator in situ,History of fall,Accidental poisoning by agents primarily affecting cardiovascular system
Poisoning-cardiotonics,Acute kidney failure NOS,Delirium d/t other cond,Chr systolic hrt failure,Urin tract infection NOS,Hyposmolality,Poisoning-diuretics NEC,Enterococcus group d,Hy kid NOS w cr kid I-IV,Atrial fibrillation,Chronic kidney dis NOS,Hypotension NOS,Pressure ulcer, stage II,Dvrtclo colon w/o hmrhg,Iron defic anemia NOS,Gout NOS,BPH w/o urinary obs/LUTS,Long-term use anticoagul,Status autm crd dfbrltr,Personal history of fall,Acc poisn-cardiovasc agt
Admission Date:  [**2192-11-22**]              Discharge Date:   [**2192-11-27**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Medication overdose, altered mental status

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is an 85 year-old male with hx of CHF (EF <20%) s/p ICD and
pacemaker, Afib on Coumadin, and CKD who presents to the ED
after an accidental medication overdose. Per report, when taking
his morning medications, the patient took his entire day's worth
of medications at one time. Per his [**First Name3 (LF) 802**], she was called by the
VNA at 9:30 am who thought he just seemed a little "off," normal
vitals signs, afebrile at that time. The home health aide came
at 11am and found him to be confused, partially undressed and
incontinent of urine on his clothing and found that he had
emptied (and presumably taken) Thursday's medication contained.
He was referred to the emergency department.
.
In the ED, he was oriented to person though confused re: place
and time. His SBP ranged between 80s-90s, toxicology was
consulted and the patient received glucagon. He was mentating
well and heart rhythm V-paced in the 50s (usual setting).
.
On arrival to the ICU, the patient reports feeling tired and
increased urinary frequency but otherwise feels well. He denies
visual changes or headache.
.
Of note, he had a recent hospitalization [**8-7**] for a RLE
cellulitis and 3rd toe ulcer that was treated with Unasyn.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation, chest
pain, shortness of breath, lower extremity oedema, cough,
lightheadedness, gait unsteadiness, headache, rash or skin
changes.


Past Medical History:
-CHF EF <20%, s/p ICD for hx VT
-Severe tricuspid regurgitation, mild to moderate mitral
regurgitation
-Left Bundle Branch Block ([**2187**])
-Atrial fibrillation on anticoagulation
-BPH ([**2182**])
-Sigmoid polyps ([**2188**])
-Diverticulosis
-GI bleed ([**2188**])
-Chronic renal insufficiency 1.5-1.7
-Actinic keratosis
-Iron deficiency anemia
-Presyncope, Falls
-Allergic rhinitis
-Hearing Loss
-Gout
-Appendectomy
-Hernia Repair

Social History:
He lives alone in [**Hospital3 4634**]. Visiting Angels comes on MF,
and [**First Name8 (NamePattern2) 24979**] [**First Name8 (NamePattern2) 3146**] [**Location (un) 4628**] Elder Care Services comes on MWF to
help patient shower. Patient has groceries bought for him. His
nephew and [**Name2 (NI) 802**] [**First Name8 (NamePattern2) **] [**Name (NI) 13039**] - next of [**Doctor First Name **]) are quite active in
his care. He quit smoking over 40 years ago. No EtOH.


Family History:
non-contributory

Physical Exam:
Tm 99.6 Tc 99.1  112/56  p60  R20  100%RA
Heart rhythm: V Paced

GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL
RESP: CTA B,
CV: RRR. No mrg.
Abd: benign.
Ext: No cee.

Pertinent Results:
[**2192-11-23**] 03:54AM BLOOD WBC-7.0 RBC-2.54* Hgb-8.8* Hct-25.6*
MCV-101* MCH-34.5* MCHC-34.3 RDW-14.3 Plt Ct-166
[**2192-11-23**] 03:54AM BLOOD PT-24.3* PTT-35.7* INR(PT)-2.4*
[**2192-11-23**] 03:54AM BLOOD Glucose-84 UreaN-63* Creat-2.1* Na-134
K-4.8 Cl-99 HCO3-24 AnGap-16
[**2192-11-22**] 08:32PM BLOOD ALT-14 AST-17 LD(LDH)-204 AlkPhos-62
TotBili-1.1
[**2192-11-23**] 03:54AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.3
[**2192-11-22**] 08:32PM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.9 Mg-2.8*
Iron-25*
[**2192-11-22**] 08:32PM BLOOD calTIBC-330 VitB12-1000* Folate-GREATER
TH Hapto-191 Ferritn-39 TRF-254
[**2192-11-22**] 08:32PM BLOOD TSH-0.58
[**2192-11-23**] 03:54AM BLOOD Digoxin-1.9
[**2192-11-22**] 01:15PM BLOOD Digoxin-2.4*
[**2192-11-22**] 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

CXR: [**11-22**]
IMPRESSION: No acute cardiopulmonary process.
.

[**2192-11-27**] 09:25AM BLOOD WBC-8.2 RBC-2.84* Hgb-9.5* Hct-28.9*
MCV-102* MCH-33.6* MCHC-33.0 RDW-14.2 Plt Ct-229
[**2192-11-27**] 09:25AM BLOOD PT-26.0* INR(PT)-2.6*
[**2192-11-27**] 09:25AM BLOOD Glucose-188* UreaN-42* Creat-1.6* Na-137
K-3.8 Cl-98 HCO3-26 AnGap-17
[**2192-11-27**] 09:25AM BLOOD Calcium-8.4 Phos-2.1* Mg-2.2
.
EKG: Ventricular paced rhythm at 55 beats per minute. Atrial
mechanism is
unclear but appears to be atrial fibrillation. One natively
conducted
QRS complex. Compared to the previous tracing of [**2191-3-24**] no
major change
is apparent.


Brief Hospital Course:
# Medication overdose: Per the patient's [**Date Range 802**] she states he
only took one day's worth of medications all at one time.
Toxicology was consulted in the ED.  The patient's was given
glucagon in the ED for possible BBlockers inotxication.  The
patient was not started on Digibind because he had a AICD and
pacemaker inplace.  The patient did not exhibit worsening
ventricular ectopy or arrhythmias. The patient's initial digoxin
level was 2.4 and returned to 1.9 the following day. He was
restarted on Digoxin when he arrived at floor. The patient was
back to his baseline mental status when he arrived in the ICU.
The rest of the patient's medications were held including his
BBlockers and diuretics and the patient was monitored for
adverse effects. The potassium level was elevated initially at
5.1, but reduced to 4.8 in the morning. His medications were
restarted gradually.  Due to ongoing renal failure (improving),
diuretics were held at discharge; to be evaluated at PCP follow
up.
.
# Altered mental status: The patient's family states that he is
usually very responsible about taking his medications as
directed. The patient may have become confused prior to taking
medications.  Unclear etiology of confusion; pt was given 2 days
of levofloxacin for concern of possible respiratory infection,
however, the evidence for this was limited and was subsequently
discontinued.  Pt was found to have a urinary tract infection
with >100k enterococcus; unclear if this was initial infection
that caused pt to be ill, or if this was a complication of a
foley catheter that he had in ICU (appears to have been d/c'd
[**11-23**]).  Treated with Augmentin, and switched to Ampicillin per
ID on discharge.
.
# Urinary tract infection; as above.
.
# Anemia: The patient's Hct was 26.3 on admission. Hct was
stable during his admission.  However, his baseline Hct is
usually around 30-32. Hemolysis labs were checked and negative.
Pt does have a h/o GI bleed in the past. The patient has been on
Fe supplementation and Fe studies were consistent with Fe
deficiency.
.
# Acute on chronic renal failure: The patient's creatinine on
admission was 2.7; Cr 1.7 at time of discharge, which appears
worse than baseline. Diuretics held at discharge; will need PCP
reevaluation within 1 week to evaluate for restarting diuretics.
.
# CHF: Most recent EF was <20% in [**2187**]. Patient's medications
were held secondary to potential overdose. SBP in 90-100s.
Medications restarted gradually; diuretics continued to be held
.
# Atrial fibrillation: On Coumadin. V-paced in 50s INR 2.4. he
was placed back on coumadin.
.
# Code: DNR/DNI



Medications on Admission:
Digoxin 125 mcg PO DAILY
Tamsulosin 0.4 mg po qhd
Omeprazole 20 mg po daily
Warfarin 5 mg 3X/WEEK, 2.5mg 4X/WEEK
Ascorbic Acid 500 mg daily
Ferrous Sulfate 325 mg daily
Multivitamin daily
Vitamin E 400 unit daily
Acetaminophen prn
Docusate Sodium 100 mg po bid
Toprol XL 12.5 mg daily
Lisinopril 2.5 mg po daily
Spironolactone 25 mg po daily
Lasix 80 mg po daily


Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 100 mg PO BID
(2 times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
13. Amoxicillin 500 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 7 days.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 1036**] - [**Location (un) 620**]

Discharge Diagnosis:
medication overdose
pneumonia
acute renal failure
Urinary tract infection


Discharge Condition:
stable


Discharge Instructions:
you took all your medications at one time. you were confused,
maybe because of pneumonia. we had to stop all your medication
because you had acute renal failure. we were able to restart
your medications gradully.  Weigh yourself every morning, [**Name8 (MD) 138**]
MD if weight > 3 lbs.
Adhere to 2 gm sodium diet. Fluid Restriction: [**2184**] ML daily.
continue the antibiotic for 7 days .

Followup Instructions:
[**Last Name (LF) 1576**],[**First Name3 (LF) 1575**] [**Telephone/Fax (1) 1579**]; you will be contact[**Name (NI) **] with an
appointment in approx 1 week. (office contact[**Name (NI) **] [**11-27**] for
appointment)
{'Poisoning by cardiotonic glycosides and drugs of similar action,Acute kidney failure, unspecified,Delirium due to conditions classified elsewhere,Chronic systolic heart failure,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Poisoning by other diuretics,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Atrial fibrillation,Chronic kidney disease, unspecified,Hypotension, unspecified,Pressure ulcer, stage II,Diverticulosis of colon (without mention of hemorrhage),Iron deficiency anemia, unspecified,Gout, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Long-term (current) use of anticoagulants,Automatic implantable cardiac defibrillator in situ,History of fall,Accidental poisoning by agents primarily affecting cardiovascular system'}


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: Medication overdose, altered mental status

PRESENT ILLNESS: This is an 85 year-old male with hx of CHF (EF <20%) s/p ICD and
pacemaker, Afib on Coumadin, and CKD who presents to the ED
after an accidental medication overdose. Per report, when taking
his morning medications, the patient took his entire day's worth
of medications at one time. Per his [**First Name3 (LF) 802**], she was called by the
VNA at 9:30 am who thought he just seemed a little "off," normal
vitals signs, afebrile at that time. The home health aide came
at 11am and found him to be confused, partially undressed and
incontinent of urine on his clothing and found that he had
emptied (and presumably taken) Thursday's medication contained.
He was referred to the emergency department.
.
In the ED, he was oriented to person though confused re: place
and time. His SBP ranged between 80s-90s, toxicology was
consulted and the patient received glucagon. He was mentating
well and heart rhythm V-paced in the 50s (usual setting).
.
On arrival to the ICU, the patient reports feeling tired and
increased urinary frequency but otherwise feels well. He denies
visual changes or headache.
.
Of note, he had a recent hospitalization [**8-7**] for a RLE
cellulitis and 3rd toe ulcer that was treated with Unasyn.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation, chest
pain, shortness of breath, lower extremity oedema, cough,
lightheadedness, gait unsteadiness, headache, rash or skin
changes.

MEDICAL HISTORY: -CHF EF <20%, s/p ICD for hx VT
-Severe tricuspid regurgitation, mild to moderate mitral
regurgitation
-Left Bundle Branch Block ([**2187**])
-Atrial fibrillation on anticoagulation
-BPH ([**2182**])
-Sigmoid polyps ([**2188**])
-Diverticulosis
-GI bleed ([**2188**])
-Chronic renal insufficiency 1.5-1.7
-Actinic keratosis
-Iron deficiency anemia
-Presyncope, Falls
-Allergic rhinitis
-Hearing Loss
-Gout
-Appendectomy
-Hernia Repair

MEDICATION ON ADMISSION: Digoxin 125 mcg PO DAILY
Tamsulosin 0.4 mg po qhd
Omeprazole 20 mg po daily
Warfarin 5 mg 3X/WEEK, 2.5mg 4X/WEEK
Ascorbic Acid 500 mg daily
Ferrous Sulfate 325 mg daily
Multivitamin daily
Vitamin E 400 unit daily
Acetaminophen prn
Docusate Sodium 100 mg po bid
Toprol XL 12.5 mg daily
Lisinopril 2.5 mg po daily
Spironolactone 25 mg po daily
Lasix 80 mg po daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tm 99.6 Tc 99.1  112/56  p60  R20  100%RA
Heart rhythm: V Paced

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: He lives alone in [**Hospital3 4634**]. Visiting Angels comes on MF,
and [**First Name8 (NamePattern2) 24979**] [**First Name8 (NamePattern2) 3146**] [**Location (un) 4628**] Elder Care Services comes on MWF to
help patient shower. Patient has groceries bought for him. His
nephew and [**Name2 (NI) 802**] [**First Name8 (NamePattern2) **] [**Name (NI) 13039**] - next of [**Doctor First Name **]) are quite active in
his care. He quit smoking over 40 years ago. No EtOH. 

### Response:
{'Poisoning by cardiotonic glycosides and drugs of similar action,Acute kidney failure, unspecified,Delirium due to conditions classified elsewhere,Chronic systolic heart failure,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Poisoning by other diuretics,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Atrial fibrillation,Chronic kidney disease, unspecified,Hypotension, unspecified,Pressure ulcer, stage II,Diverticulosis of colon (without mention of hemorrhage),Iron deficiency anemia, unspecified,Gout, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Long-term (current) use of anticoagulants,Automatic implantable cardiac defibrillator in situ,History of fall,Accidental poisoning by agents primarily affecting cardiovascular system'}
