CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: 43 y/o male with suicidal ideation in the past, h/o depression
presents with altered mental status. Apparently he stated on
that presentation that he was given a prescription for 55 pills
of clonazepam two days prior to admission. Patient endorsed
taking more than he should have, and was found with only 4 left,
but can't recall how many he took during this event. He states
that he was trying to get high, and not trying to kill himself,
and says he did not take anything else.
.
In the ED, initial VS were T 97.1 P 95 BP 110/82 Sat 94% ra.
Patient was found to be bradypneic to 6 and hypoxic to the 80's
soon after arrival. He was given a dose of narcan, and perked up
a little in bed. Tylenol level was 29 and ethanol 14, and serum
tox was negative, urine tox pending. Toxicology was consulted
and recommended supportive care and continouous O2. ABG was
performed and was 7.32/48/106/26, with a lactate of 2.9. Before
transfer, patient was noted to be somewhat conversant, but then
was found to be less responsive. Vital signs prior to transfer
were P 104 BP 139/66 R 24 Sat 100%RA.
.
On the floor, patient denies taking clonazepam, and states that
he got the bottle from a friend, who was supposedly attempting
to overdose on the medication, and he took it from her. The
clonazepam bottle does have the name of another person on it. He
states that he has been taking medication for his kidney stone
pain, but can't identify what this is or what quantity he took.
He cannot recall if he drank alcohol prior to presentation. He
does not recall the events that happened prior to coming to the
ED in an ambulance.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: PSYCHIATRIC HISTORY:
--Over 20 psychiatric hospitalizations over the past 5 years
most recently in [**9-/2131**] at [**Hospital1 18**]).
--Depression first started in [**2127**] when his daughter was in a
coma for 9 days.
--ECT courses x 3 (most recently [**9-/2131**] with 4 bilateral and 3
unilateral treatments).
--DBT treatment at MMHC since [**10/2131**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
resident, and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18741**], attending, are his
treaters).
--Patient reports dx'es that range from MDD to bipolar to
borderline personality disorder depending on the inpatient
facility (he denies symptoms of mania).
--Denies history of violence or SIB.
--States his only suicide attempt was in 9/[**2131**].
.
PAST MEDICAL HISTORY:
--PUD
--Migraines (every 3-4 years): he's taken Fiorinal, Fiorocet,
Imitrex, and a beta blocker in the past; Fiorinal has been most

MEDICATION ON ADMISSION: Confirmed by phone with [**Company 4916**] pharmacy:
Fioricet
Oxycodone 5mg from [**2133-5-19**] - prescribed by Dr. [**First Name (STitle) 24425**] for 5 day
supply
Gabapentin 800mg TID
Omeprazole 20mg [**Hospital1 **]
Mirtazapine 15mg Daily
MVI
Levothyroxine 0.175mg Daily
Sertraline 150mg Daily
Hydroxyzine
Buproprion XR 200mg Daily
Vicodin 7.5/750mg Q6h from [**2133-5-29**] - prescribed by Dr. [**Last Name (STitle) **]
[**Name (STitle) 6382**]

ALLERGIES: Haloperidol / Prochlorperazine

PHYSICAL EXAM: ICU Admission Physical Exam
Vitals: T: 98.3 BP: 120/98 P: 70 R: 16 O2: 98%
General: Somnolent, oriented x 2, not to date, no acute
distress, cooperative
HEENT: NCAT, sclera anicteric, pupils bilaterally at 2 mm, MMM,
oropharynx clear with no lesions noted
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, with no wheezes,
rales, rhonchi audible
CV: Regular 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
Back: + right CVA tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Mother and brother have EtOH dependence and depression.

SOCIAL HISTORY: Pt born/raised in [**Location (un) 620**], MA. Parents divorced. Denies
childhood abuse. Completed law school at NE School of Law. "Gave
up" his license in [**2130**] [**2-11**] malpractice/not being able to "keep
mind straight." Reports being addicted to fentanyl in [**2128**]; went
to detox and then was on Suboxone for 6 months. Divorced.
Daughter is 6 y/o. He is unemployed.
Poisoning by benzodiazepine-based tranquilizers,Toxic encephalopathy,Acute kidney failure, unspecified,Accidental poisoning by benzodiazepine-based tranquilizers,Anemia, unspecified,Depressive disorder, not elsewhere classified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Unspecified acquired hypothyroidism,Other, mixed, or unspecified drug abuse, unspecified,Bariatric surgery status
Pois-benzodiazepine tran,Toxic encephalopathy,Acute kidney failure NOS,Acc poisn-benzdiaz tranq,Anemia NOS,Depressive disorder NEC,Migrne unsp wo ntrc mgrn,Hypothyroidism NOS,Drug abuse NEC-unspec,Bariatric surgery status
Admission Date:  [**2133-6-5**]              Discharge Date:   [**2133-6-9**]

Date of Birth:  [**2089-11-25**]             Sex:   M

Service: MEDICINE

Allergies:
Haloperidol / Prochlorperazine

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
None


History of Present Illness:
43 y/o male with suicidal ideation in the past, h/o depression
presents with altered mental status. Apparently he stated on
that presentation that he was given a prescription for 55 pills
of clonazepam two days prior to admission. Patient endorsed
taking more than he should have, and was found with only 4 left,
but can't recall how many he took during this event. He states
that he was trying to get high, and not trying to kill himself,
and says he did not take anything else.
.
In the ED, initial VS were T 97.1 P 95 BP 110/82 Sat 94% ra.
Patient was found to be bradypneic to 6 and hypoxic to the 80's
soon after arrival. He was given a dose of narcan, and perked up
a little in bed. Tylenol level was 29 and ethanol 14, and serum
tox was negative, urine tox pending. Toxicology was consulted
and recommended supportive care and continouous O2. ABG was
performed and was 7.32/48/106/26, with a lactate of 2.9. Before
transfer, patient was noted to be somewhat conversant, but then
was found to be less responsive. Vital signs prior to transfer
were P 104 BP 139/66 R 24 Sat 100%RA.
.
On the floor, patient denies taking clonazepam, and states that
he got the bottle from a friend, who was supposedly attempting
to overdose on the medication, and he took it from her. The
clonazepam bottle does have the name of another person on it. He
states that he has been taking medication for his kidney stone
pain, but can't identify what this is or what quantity he took.
He cannot recall if he drank alcohol prior to presentation. He
does not recall the events that happened prior to coming to the
ED in an ambulance.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.


Past Medical History:
PSYCHIATRIC HISTORY:
--Over 20 psychiatric hospitalizations over the past 5 years
most recently in [**9-/2131**] at [**Hospital1 18**]).
--Depression first started in [**2127**] when his daughter was in a
coma for 9 days.
--ECT courses x 3 (most recently [**9-/2131**] with 4 bilateral and 3
unilateral treatments).
--DBT treatment at MMHC since [**10/2131**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
resident, and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18741**], attending, are his
treaters).
--Patient reports dx'es that range from MDD to bipolar to
borderline personality disorder depending on the inpatient
facility (he denies symptoms of mania).
--Denies history of violence or SIB.
--States his only suicide attempt was in 9/[**2131**].
.
PAST MEDICAL HISTORY:
--PUD
--Migraines (every 3-4 years): he's taken Fiorinal, Fiorocet,
Imitrex, and a beta blocker in the past; Fiorinal has been most

effective
--s/p Gastric bypass
--s/p Hernia repair
--hypothyroidism


Social History:
Pt born/raised in [**Location (un) 620**], MA. Parents divorced. Denies
childhood abuse. Completed law school at NE School of Law. "Gave
up" his license in [**2130**] [**2-11**] malpractice/not being able to "keep
mind straight." Reports being addicted to fentanyl in [**2128**]; went
to detox and then was on Suboxone for 6 months. Divorced.
Daughter is 6 y/o. He is unemployed.

Family History:
Mother and brother have EtOH dependence and depression.

Physical Exam:
ICU Admission Physical Exam
Vitals: T: 98.3 BP: 120/98 P: 70 R: 16 O2: 98%
General: Somnolent, oriented x 2, not to date, no acute
distress, cooperative
HEENT: NCAT, sclera anicteric, pupils bilaterally at 2 mm, MMM,
oropharynx clear with no lesions noted
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, with no wheezes,
rales, rhonchi audible
CV: Regular 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
Back: + right CVA tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema


Pertinent Results:
Admission Labs:

[**2133-6-5**] 05:30PM BLOOD WBC-6.3 RBC-4.36* Hgb-12.6* Hct-36.4*
MCV-84 MCH-28.9 MCHC-34.7 RDW-16.5* Plt Ct-234
[**2133-6-6**] 05:23AM BLOOD WBC-4.1 RBC-3.78* Hgb-10.7* Hct-32.0*
MCV-85 MCH-28.4 MCHC-33.5 RDW-16.8* Plt Ct-172
[**2133-6-5**] 05:30PM BLOOD Neuts-70.6* Lymphs-19.9 Monos-3.6
Eos-4.5* Baso-1.4
[**2133-6-5**] 05:30PM BLOOD PT-12.6 PTT-21.5* INR(PT)-1.1
[**2133-6-5**] 05:30PM BLOOD Plt Ct-234
[**2133-6-6**] 05:23AM BLOOD Plt Ct-172
[**2133-6-5**] 05:30PM BLOOD Glucose-93 UreaN-17 Creat-1.6* Na-145
K-4.2 Cl-110* HCO3-22 AnGap-17
[**2133-6-6**] 05:23AM BLOOD Glucose-85 UreaN-13 Creat-0.9 Na-145
K-3.9 Cl-114* HCO3-24 AnGap-11
[**2133-6-6**] 05:23AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.1
[**2133-6-5**] 05:30PM BLOOD calTIBC-449 VitB12-810 Folate-15.5
Ferritn-29* TRF-345
[**2133-6-5**] 05:30PM BLOOD TSH-5.2*
[**2133-6-5**] 05:30PM BLOOD ASA-NEG Ethanol-14* Acetmnp-29
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2133-6-5**] 05:50PM BLOOD Glucose-76 Lactate-2.9* Na-146 K-4.2
Cl-110 calHCO3-23
[**2133-6-5**] 05:50PM BLOOD Hgb-13.2* calcHCT-40

Tox Screen
Benzodiazepine Screen, Urine POS
Barbiturate Screen, Urine POS
Opiate Screen, Urine POS
  OPIATE IMMUNOASSAY SCREEN DOES NOT DETECT SYNTHETIC
OPIOIDS;SUCH AS METHADONE, OXYCODONE, FENTANYL, BUPRENORPHINE,
TRAMADOL,;NALOXONE, MEPERIDINE. SEE ONLINE LAB MANUAL FOR
DETAILS
Cocaine, Urine NEG
Amphetamine Screen, Urine NEG
  TRAZODONE METABOLITE [**Month (only) **] CAUSE FALSE POSITIVE AMPHETAMINE
RESULT
Methadone, Urine NEG
  METHADONE ASSAY DETECTS ONLY METHADONE (NOT OTHER
OPIATES/OPIOIDS)

Blood Tox
Salicylate NEG 2 - 25 mg/dL
Ethanol 14* 10 - 10 mg/dL
  80 (THESE UNITS) = 0.08 (% BY WEIGHT)
Acetaminophen 29 10 - 30 ug/mL
Benzodiazepine Screen NEG
Barbiturate Screen NEG
Tricyclic Antidepressant Screen NEG

CHEST (PORTABLE AP) Study Date of [**2133-6-5**] 5:42 PM
SEMI-UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette
remains mildly
enlarged. The mediastinal and hilar contours are relatively
stable. Lungs
are clear. No focal consolidation, pleural effusion or
pneumothorax is
identified. No acute osseous findings are seen.
IMPRESSION: No acute cardiopulmonary abnormality.


Brief Hospital Course:
43 y/o male with suicidal ideation in the past, h/o depression
presents with altered mental status after ingesting undetermined
amount of clonazepam.
.
# Toxidrome/toxic-metabolic encephalopathy: Presentation was
consistent with benzodiazepine toxicity given generally normal
vital signs with CNS depression. Patient inconsistent in his
report of what he took, amount of drinking, etc. Ethanol level
was 14, slightly elevated, which could raise some concern for
respiratory depression. Urine tox was positive for benzos,
barbiturates, and opiates. Patient only slightly responded to
Narcan dosing in the ED. Flumazenil was not indicated given that
patient already takes bupropion which lowers seizure threshold.
Patient with slight anion gap, likely due to elevated lactate.
Pt's was closely monitored in ICU, did not require intubation
and mental status gradually improved. Pt was seen by psych who
sectioned pt. Pt placed on suicide precautions and called out to
floor given clinical improvement.  He recovered to baseline,
there was no evidence of any intoxication as of [**2133-6-8**].  He was
accepted for inpatient psychiatry admisssion on discharge.
.
# Acute kidney injury: The patient presented with acute renal
failure. After IVFs, Cr improved from 1.6 to 0.9 by AM.
.
# Anemia: iron studies and vitamin B12/folate last checked in
[**2131**], hematocrit appears to be at baseline. He had normal B12
and folate levels on this admission.
.
# Depression: The patient was restarted on his home medication
regimen after he was able to give a reliable medication list.
.
# Hypothyroidism: The patient was continued on his home
levothyroxine.
.
# History of kidney stones. The patient has a history of kidney
stones and is undergoing definitive therapy in the urology
clinics. He asked multiple times for continuation of narcotic
pain medications that he takes at home and it was confirmed that
he received small volume (20 pills) of oxycodone on [**2133-5-19**] and
vicodin on [**2133-6-3**]. He had no objective source for pain that
would require narcotic pain medications and given his history of
suicidality with intentional overdose it seemed appropriate to
try non-narcotic pain control.

Medications on Admission:
Confirmed by phone with [**Company 4916**] pharmacy:
Fioricet
Oxycodone 5mg from [**2133-5-19**] - prescribed by Dr. [**First Name (STitle) 24425**] for 5 day
supply
Gabapentin 800mg TID
Omeprazole 20mg [**Hospital1 **]
Mirtazapine 15mg Daily
MVI
Levothyroxine 0.175mg Daily
Sertraline 150mg Daily
Hydroxyzine
Buproprion XR 200mg Daily
Vicodin 7.5/750mg Q6h from [**2133-5-29**] - prescribed by Dr. [**Last Name (STitle) **]
[**Name (STitle) 6382**]

Discharge Medications:
1. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. bupropion HCl 100 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO BID (2 times a day).
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
6. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain or fever.


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary Diagnosis
- Benzodiazepine Overdose
- Polysubstance Abuse
- Depression
- Hypothyroidism


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


Discharge Instructions:
You were brought to the emergency department after you were
found to be confused and sedated. Your lab work was positive for
alcohol, tylenol, and several other medications. Given your
level of sedation, you were admitted to the ICU for close
respiratory monitoring. You improved overnight and were
evaluated by the psychiatry service. You are now being
discharged to an inpatient psychiatry facility for further
treatment.

There were no changes to your medications during this
hospitalization.

Followup Instructions:
You should follow up with your primary care physician and your
psychiatrist within the next 2 days.
{'Poisoning by benzodiazepine-based tranquilizers,Toxic encephalopathy,Acute kidney failure, unspecified,Accidental poisoning by benzodiazepine-based tranquilizers,Anemia, unspecified,Depressive disorder, not elsewhere classified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Unspecified acquired hypothyroidism,Other, mixed, or unspecified drug abuse, unspecified,Bariatric surgery status'}


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 y/o male with suicidal ideation in the past, h/o depression
presents with altered mental status. Apparently he stated on
that presentation that he was given a prescription for 55 pills
of clonazepam two days prior to admission. Patient endorsed
taking more than he should have, and was found with only 4 left,
but can't recall how many he took during this event. He states
that he was trying to get high, and not trying to kill himself,
and says he did not take anything else.
.
In the ED, initial VS were T 97.1 P 95 BP 110/82 Sat 94% ra.
Patient was found to be bradypneic to 6 and hypoxic to the 80's
soon after arrival. He was given a dose of narcan, and perked up
a little in bed. Tylenol level was 29 and ethanol 14, and serum
tox was negative, urine tox pending. Toxicology was consulted
and recommended supportive care and continouous O2. ABG was
performed and was 7.32/48/106/26, with a lactate of 2.9. Before
transfer, patient was noted to be somewhat conversant, but then
was found to be less responsive. Vital signs prior to transfer
were P 104 BP 139/66 R 24 Sat 100%RA.
.
On the floor, patient denies taking clonazepam, and states that
he got the bottle from a friend, who was supposedly attempting
to overdose on the medication, and he took it from her. The
clonazepam bottle does have the name of another person on it. He
states that he has been taking medication for his kidney stone
pain, but can't identify what this is or what quantity he took.
He cannot recall if he drank alcohol prior to presentation. He
does not recall the events that happened prior to coming to the
ED in an ambulance.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: PSYCHIATRIC HISTORY:
--Over 20 psychiatric hospitalizations over the past 5 years
most recently in [**9-/2131**] at [**Hospital1 18**]).
--Depression first started in [**2127**] when his daughter was in a
coma for 9 days.
--ECT courses x 3 (most recently [**9-/2131**] with 4 bilateral and 3
unilateral treatments).
--DBT treatment at MMHC since [**10/2131**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
resident, and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18741**], attending, are his
treaters).
--Patient reports dx'es that range from MDD to bipolar to
borderline personality disorder depending on the inpatient
facility (he denies symptoms of mania).
--Denies history of violence or SIB.
--States his only suicide attempt was in 9/[**2131**].
.
PAST MEDICAL HISTORY:
--PUD
--Migraines (every 3-4 years): he's taken Fiorinal, Fiorocet,
Imitrex, and a beta blocker in the past; Fiorinal has been most

MEDICATION ON ADMISSION: Confirmed by phone with [**Company 4916**] pharmacy:
Fioricet
Oxycodone 5mg from [**2133-5-19**] - prescribed by Dr. [**First Name (STitle) 24425**] for 5 day
supply
Gabapentin 800mg TID
Omeprazole 20mg [**Hospital1 **]
Mirtazapine 15mg Daily
MVI
Levothyroxine 0.175mg Daily
Sertraline 150mg Daily
Hydroxyzine
Buproprion XR 200mg Daily
Vicodin 7.5/750mg Q6h from [**2133-5-29**] - prescribed by Dr. [**Last Name (STitle) **]
[**Name (STitle) 6382**]

ALLERGIES: Haloperidol / Prochlorperazine

PHYSICAL EXAM: ICU Admission Physical Exam
Vitals: T: 98.3 BP: 120/98 P: 70 R: 16 O2: 98%
General: Somnolent, oriented x 2, not to date, no acute
distress, cooperative
HEENT: NCAT, sclera anicteric, pupils bilaterally at 2 mm, MMM,
oropharynx clear with no lesions noted
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, with no wheezes,
rales, rhonchi audible
CV: Regular 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
Back: + right CVA tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Mother and brother have EtOH dependence and depression.

SOCIAL HISTORY: Pt born/raised in [**Location (un) 620**], MA. Parents divorced. Denies
childhood abuse. Completed law school at NE School of Law. "Gave
up" his license in [**2130**] [**2-11**] malpractice/not being able to "keep
mind straight." Reports being addicted to fentanyl in [**2128**]; went
to detox and then was on Suboxone for 6 months. Divorced.
Daughter is 6 y/o. He is unemployed. 

### Response:
{'Poisoning by benzodiazepine-based tranquilizers,Toxic encephalopathy,Acute kidney failure, unspecified,Accidental poisoning by benzodiazepine-based tranquilizers,Anemia, unspecified,Depressive disorder, not elsewhere classified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Unspecified acquired hypothyroidism,Other, mixed, or unspecified drug abuse, unspecified,Bariatric surgery status'}
