CHIEF COMPLAINT: Aggitation, fever.

PRESENT ILLNESS: This is a 31 yo man h/o polysubstance abuse who was at
[**Hospital1 **] for detox when he was noted to be aggitated and
confused, then somnolent. He was transferred to [**Hospital1 18**] [**7-19**] for
further evaluation. He was unresponsive per EMS so given narcan
x2. On arrival in the ED he was aggitated and appeared to be
responding to internal stimuli. He was also tachycardic and
febrile on arrival. He was given ativan and intubated with
propofal in the ED. He additonally underwent LP. His ECG showed
widened QRS and he was started on bicarbonate gtt for presumed
TCA toxicity (tox screen +). He had negative CXR and head CT. He
was covered empirically with vancomycin and ceftriaxone in the
ED but LP was negative for infection so these were stopped. He
was transferred to the ICU for further care.

MEDICAL HISTORY: -multiple admissions for substance detoxification since age 15
(heroin, cocaine, alcohol, benzodiazepines)

MEDICATION ON ADMISSION: Home medication per [**Hospital1 **], he also notes remeron and buspar
but may be old:
-MVI 1 tab PO qam
-thiamine 100mg PO qam
-folate 1mg PO qam
-seroquel 50mg QHS
-prozac 20mg qAM
-bentyl 20g PO BID
-depakote 500mg [**Hospital1 **] (7 day course with last day on [**2190-7-22**])
-clonidine PRN 0.1g PO BID
-ibuprofen 400mg PO q4h PRN pain
-mylanta 30cc PO q6h GI upset

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: VS: T 97.2 HR 102 BP 153/87 RR 19 Sat 100% RA
Gen: Disheveled appearing man in NAD
Eye: extra-occular movements intact, pupils equal round
8mm->5mm, reactive to light, sclera anicteric, not injected, no
exudates
ENT: mucus membranes moist, no ulcerations or exudates
Neck: no thyromegally, JVD: flat
Cardiovascular: tachycardic but regular rhythm, normal s1, s2,
no murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present, guaiac negative
Extremities: No cyanosis, clubbing, edema, joint swelling
Back: diffusely tender to palpation, especially at LP site and
lower paraspinous musculature
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, speech fluent
Integument: Warm, moist, no rash or ulceration, multiple tattoos

FAMILY HISTORY: Two sisters with a history of substance abuse and dependence.
Denies history of psychiatric illness in his family.

SOCIAL HISTORY: Polysubstance substance with heroin, benzodiazepines, cocaine,
and alcohol. He is currently unemployed and may be homeless, but
states he lives with parents. He may or may not be married
(denies it). He has a partner (wife, ex wife?) with whom he
shares a 4 year old son. Released from prison in [**10-26**]. In the
past he has worked as a car technician.
Poisoning by parasympatholytics (anticholinergics and antimuscarinics) and spasmolytics,Coma,Other pulmonary insufficiency, not elsewhere classified,Combinations of opioid type drug with any other drug dependence, continuous,Suicide and self-inflicted poisoning by other specified drugs and medicinal substances,Tachycardia, unspecified,Elevated blood pressure reading without diagnosis of hypertension,Long QT syndrome,Other and unspecified alcohol dependence, continuous,Myoclonus,Nystagmus, unspecified,Depressive disorder, not elsewhere classified,Lumbago,Tobacco use disorder,Lack of housing
Pois-parasympatholytics,Coma,Other pulmonary insuff,Opioid/other dep-contin,Poison-drug/medicin NEC,Tachycardia NOS,Elev bl pres w/o hypertn,Long QT syndrome,Alcoh dep NEC/NOS-contin,Myoclonus,Nystagmus NOS,Depressive disorder NEC,Lumbago,Tobacco use disorder,Lack of housing
Admission Date:  [**2190-7-19**]              Discharge Date:   [**2190-7-23**]

Date of Birth:  [**2159-5-3**]             Sex:   M

Service: MEDICINE

Allergies:
No Drug Allergy Information on File

Attending:[**First Name3 (LF) 20224**]
Chief Complaint:
Aggitation, fever.

Major Surgical or Invasive Procedure:
Lumbar puncture [**7-19**], endotracheal intubation and extubation.

History of Present Illness:
This is a 31 yo man h/o polysubstance abuse who was at
[**Hospital1 **] for detox when he was noted to be aggitated and
confused, then somnolent. He was transferred to [**Hospital1 18**] [**7-19**] for
further evaluation. He was unresponsive per EMS so given narcan
x2. On arrival in the ED he was aggitated and appeared to be
responding to internal stimuli. He was also tachycardic and
febrile on arrival. He was given ativan and intubated with
propofal in the ED. He additonally underwent LP. His ECG showed
widened QRS and he was started on bicarbonate gtt for presumed
TCA toxicity (tox screen +). He had negative CXR and head CT. He
was covered empirically with vancomycin and ceftriaxone in the
ED but LP was negative for infection so these were stopped. He
was transferred to the ICU for further care.

In the ICU he was maintained on bicarbonate gtt for goal pH of
7.5 (7.51-7.53). His ECG improved by [**7-20**] and the gtt was stopped
[**7-21**]. ECG remained improved. He was extubated without difficulty
[**7-20**]. He noted back pain at the sight of his LP, worse with
movement. He feels not entirely himself, jittery, cloudy in his
thinking. He does not recall being at [**Hospital1 **] for detox. He
does not recall the events prior to transfer that led him to the
ED. He does not recall taking a specific toxic ingestion and
states he had no intetion to kill himself. He does acknowledge
struggling with depressed mood in the past.

ROS: 10 point review of systems otherwise negative except as
noted above.

Past Medical History:
-multiple admissions for substance detoxification since age 15
(heroin, cocaine, alcohol, benzodiazepines)

Social History:
Polysubstance substance with heroin, benzodiazepines, cocaine,
and alcohol. He is currently unemployed and may be homeless, but
states he lives with parents. He may or may not be married
(denies it). He has a partner (wife, ex wife?) with whom he
shares a 4 year old son. Released from prison in [**10-26**]. In the
past he has worked as a car technician.

Family History:
Two sisters with a history of substance abuse and dependence.
Denies history of psychiatric illness in his family.

Physical Exam:
VS: T 97.2 HR 102 BP 153/87 RR 19 Sat 100% RA
Gen: Disheveled appearing man in NAD
Eye: extra-occular movements intact, pupils equal round
8mm->5mm, reactive to light, sclera anicteric, not injected, no
exudates
ENT: mucus membranes moist, no ulcerations or exudates
Neck: no thyromegally, JVD: flat
Cardiovascular: tachycardic but regular rhythm, normal s1, s2,
no murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present, guaiac negative
Extremities: No cyanosis, clubbing, edema, joint swelling
Back: diffusely tender to palpation, especially at LP site and
lower paraspinous musculature
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, speech fluent
Integument: Warm, moist, no rash or ulceration, multiple tattoos

Psychiatric: anxious, poor insight and judgement, unable to
recall details of recent events
Hematologic: no cervical or supraclavicular LAD

Pertinent Results:
Labs:
WBC: 7.3
Hgb: 13.9
HCT: 42.3
Plt: 235
N:61.8 L:32.1 M:4.5 E:1.3 Bas:0.3

145 109 14 AGap=12
------------- 104
3.4 27 0.8

Ca: 8.6 Mg: 2.2 P: 2.9
CK: 52 MB: Notdone Trop-T: <0.01
ABG: 7.51, PCO2: 39, PO2: 262, HCO3: 32
Serum: TCA positive
Serum: Negative for ASA, EtOH, Acetmnphn, Benzo, Barb
Serum Valproic Acid: 71
Urine: Positive for TCA. Negative for Benzos, Barbs, Opiates,
Cocaine, Amphet, Methadone
U/A Negative
Lactate 1.3

Micro:
Urine culture NG [**7-19**].
Blood cultures pending no growth to date [**7-19**] x4.
CSF gram stain: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO
MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):    NO GROWTH.
CSF: 3 WBC, 35 RBC, 31 protein, 68 glucose.

EKG: Rhythm is probably sinus tachycardia with A-V conduction
delay but rapid rate and unstable baseline make assessment
difficult. Intraventricular conduction delay. Prominent QRS
voltage. Late precordial QRS transition. ST-T wave
abnormalities.

CT Head [**7-19**]: No acute intracranial abnormality. If clinical
warranted, MRI may be a more sensitive study for hypoxia.

Chest xray [**7-21**] (portable): No acute pulmonary process.

Brief Hospital Course:
31 yo man with polysubstance abuse with aggitation and altered
mental status likely secondary to TCA toxicity.

1. TCA intoxication: unknown additonal co-ingestions but
possibly narcotics, benzos, and likley anticholinergics,
improved ECG with some residual tachycardia, s/p bicarbonate
treatment. His ECG remains improved with no further events on
telemetry, he is therefore deemed cleared for discharge from the
medical service as of [**2190-7-22**], with no further telemetry
monitoring. He was monitored for benzo withdrawl as well given
unknown co-ingestions with no evidence of withdrawl and low CIWA
scores. His  buspar, seroquel and remeron were all held.

2. Tachycardia: suspect [**12-21**] residual toxicity from
anticholinergics, this improved as well.

3. Suicide attempt: unclear intention but result was life
threatening over-dose, does not appear to appreciate the gravity
of his actions. He was seen by psychiatry who agreed with
section 12, monitored on 1:1 sitter with suicide precautions.

4. Depression: He was continued on fluoxetine and topomax, other
possible home medications were held.

5. Polysubstance abuse: This is a long-standing issue, multiple
agents including cocaine, alcohol, benzos, narcotics, nicotine,
heroin. SW was consulted to help with this. He was given
thiamine, folic acid and multivitamin.

6. Low back pain: This was thought related to his Lumbar
Puncture or musculoskeletal pain, treated with tylenol, he
refused NSAIDs, narcotics were avoided. A lumbar spine xray was
done but revealed no abnormality. This was improved by
discharge.

7. Headache: He complained of severe headache on hospital day 4,
per him responsive only to ativan or percocet. It was not
positional in nature and there were no associated neurologic
deficits so it was not thought to be a post-LP headache. He is a
coffee drinker to cafeine withdrawl is possible. Additionally
there was concern for narcotic/benzo drug seeking. He was given
tylenol, fioricet, and ibuprofen with intermittent relief. There
was no other evidence to support benzo or etoh withdrawl as an
etiology for the HA as there were no other signs or syptoms of
this.

Medications on Admission:
Home medication per [**Hospital1 **], he also notes remeron and buspar
but may be old:
-MVI 1 tab PO qam
-thiamine 100mg PO qam
-folate 1mg PO qam
-seroquel 50mg QHS
-prozac 20mg qAM
-bentyl 20g PO BID
-depakote 500mg [**Hospital1 **] (7 day course with last day on [**2190-7-22**])
-clonidine PRN 0.1g PO BID
-ibuprofen 400mg PO q4h PRN pain
-mylanta 30cc PO q6h GI upset

Medications on transfer:
Heparin 5000 UNIT SC TID
Multivitamins 1 TAB PO DAILY
Acetaminophen 325-650 mg PO Q6H:PRN pain
Divalproex (DELayed Release) 500 mg PO BID
Fluoxetine 20 mg PO DAILY
Thiamine 100 mg PO DAILY
FoLIC Acid 1 mg PO DAILY

Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
3. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for aggitation.
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain.
9. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**11-20**]
Tablets PO Q6H (every 6 hours) as needed for headache.


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary: TCA intoxication, suicide attempt, depression,
polysubstance abuse.
Secondary: Headache, nicotine dependence, low back pain.


Discharge Condition:
Stable vital signs, continued complaints of headache, normal
neurologic exam.


Discharge Instructions:
You were admitted with altered mental status after a toxic
ingestion including TCA's and other unknown substances. You
initially had cardiac toxicity related to this but improved with
treatment and your ECG returned to [**Location 213**]. You were monitored
for benzo and etoh withdrawl but showed no signs of this.

Followup Instructions:
Please follow up with your primary care doctor within 3 weeks of
discharge.
{'Poisoning by parasympatholytics (anticholinergics and antimuscarinics) and spasmolytics,Coma,Other pulmonary insufficiency, not elsewhere classified,Combinations of opioid type drug with any other drug dependence, continuous,Suicide and self-inflicted poisoning by other specified drugs and medicinal substances,Tachycardia, unspecified,Elevated blood pressure reading without diagnosis of hypertension,Long QT syndrome,Other and unspecified alcohol dependence, continuous,Myoclonus,Nystagmus, unspecified,Depressive disorder, not elsewhere classified,Lumbago,Tobacco use disorder,Lack of housing'}


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: Aggitation, fever.

PRESENT ILLNESS: This is a 31 yo man h/o polysubstance abuse who was at
[**Hospital1 **] for detox when he was noted to be aggitated and
confused, then somnolent. He was transferred to [**Hospital1 18**] [**7-19**] for
further evaluation. He was unresponsive per EMS so given narcan
x2. On arrival in the ED he was aggitated and appeared to be
responding to internal stimuli. He was also tachycardic and
febrile on arrival. He was given ativan and intubated with
propofal in the ED. He additonally underwent LP. His ECG showed
widened QRS and he was started on bicarbonate gtt for presumed
TCA toxicity (tox screen +). He had negative CXR and head CT. He
was covered empirically with vancomycin and ceftriaxone in the
ED but LP was negative for infection so these were stopped. He
was transferred to the ICU for further care.

MEDICAL HISTORY: -multiple admissions for substance detoxification since age 15
(heroin, cocaine, alcohol, benzodiazepines)

MEDICATION ON ADMISSION: Home medication per [**Hospital1 **], he also notes remeron and buspar
but may be old:
-MVI 1 tab PO qam
-thiamine 100mg PO qam
-folate 1mg PO qam
-seroquel 50mg QHS
-prozac 20mg qAM
-bentyl 20g PO BID
-depakote 500mg [**Hospital1 **] (7 day course with last day on [**2190-7-22**])
-clonidine PRN 0.1g PO BID
-ibuprofen 400mg PO q4h PRN pain
-mylanta 30cc PO q6h GI upset

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: VS: T 97.2 HR 102 BP 153/87 RR 19 Sat 100% RA
Gen: Disheveled appearing man in NAD
Eye: extra-occular movements intact, pupils equal round
8mm->5mm, reactive to light, sclera anicteric, not injected, no
exudates
ENT: mucus membranes moist, no ulcerations or exudates
Neck: no thyromegally, JVD: flat
Cardiovascular: tachycardic but regular rhythm, normal s1, s2,
no murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present, guaiac negative
Extremities: No cyanosis, clubbing, edema, joint swelling
Back: diffusely tender to palpation, especially at LP site and
lower paraspinous musculature
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, speech fluent
Integument: Warm, moist, no rash or ulceration, multiple tattoos

FAMILY HISTORY: Two sisters with a history of substance abuse and dependence.
Denies history of psychiatric illness in his family.

SOCIAL HISTORY: Polysubstance substance with heroin, benzodiazepines, cocaine,
and alcohol. He is currently unemployed and may be homeless, but
states he lives with parents. He may or may not be married
(denies it). He has a partner (wife, ex wife?) with whom he
shares a 4 year old son. Released from prison in [**10-26**]. In the
past he has worked as a car technician. 

### Response:
{'Poisoning by parasympatholytics (anticholinergics and antimuscarinics) and spasmolytics,Coma,Other pulmonary insufficiency, not elsewhere classified,Combinations of opioid type drug with any other drug dependence, continuous,Suicide and self-inflicted poisoning by other specified drugs and medicinal substances,Tachycardia, unspecified,Elevated blood pressure reading without diagnosis of hypertension,Long QT syndrome,Other and unspecified alcohol dependence, continuous,Myoclonus,Nystagmus, unspecified,Depressive disorder, not elsewhere classified,Lumbago,Tobacco use disorder,Lack of housing'}
