CHIEF COMPLAINT: Altered Mental Status

PRESENT ILLNESS: Mr. [**Known lastname 18403**] is a 48 year old man with h/o seizure d/o, HIV
([**2145-10-26**] CD4 692, VL undetected), HTN, DM, mild MR, who
presented to the hospital with lightheadedness and became
somnolent in the ED.
.
The patient was recently admitted to the hospital for
nausea/vomiting, attributed to possible seizure, noted to have
elevated phenobarb level (65), and was discharged home the day
prior to admission with level 42. Today, he reportedly noted
some lightheadedness, so was brought back to the ED. EMS reports
that he was talking and joking with them in the ambulance. Only
complaint was lightheadedness. Pt was instructed to restart
Phenobarb at lower dose today, after phenobarb was held during
hospitalization x3days.
.
As per the patient's epilepsy doctor, the patient is able to
communicate at baseline, albeit with delayed, slurred speech. No
h/o waxing/[**Doctor Last Name 688**] MS.
.
In the ED, initial vs were: T 98.0 P 85 BP 108/56 RR 18 O2sat
100%. The patient was very somnolent upon initial exam in th ED
- he was responsive only to painful stimuli, moved all 4
extremities. Labs notable for positive serum phenobarb, level
106. CT head was unremarkable. CXR was a limited exam, acute PNA
cannot be ruled out. Patient was given Narcan with no effect. He
was evaluated by Neuro, who was able to document brain stem
reflexes. Toxicology evaluated the patient as well, and the
patient was started on a bicarb gtt. Vitals prior to transfer:
BP 123/71 P 75 RR 22 O2sat 100%RA.
.
Initially on the floor, the patient remained obtunded. He was
able to follow simple commands and mumble, but unable to speak
intelligibly.

MEDICAL HISTORY: - epilepsy (followed by Dr. [**Last Name (STitle) 2442**]
- mental retardation (thought to be secondary to lead poisoning)

MEDICATION ON ADMISSION: Colace 100mg PO BID
Abacavir 300mg PO BID
Lopinavir-Ritonavir 200-50mg 2tabs PO BID
Stavudine 30mg PO q12h
Nabumetone 500mg PO qAM 1-2tabs
Zonisamide 300mg PO BID
Keppra 2000mg PO qAM, 2500mg PO qPM
Lisinopril 20mg PO daily
Diltiazem 120mg PO daily
Atorvastatin 20mg PO daily
Phenobarbital 120mg PO BID
IV Iron infusions

ALLERGIES: Penicillins

PHYSICAL EXAM: Initial Physical exam in MICU:
Physical Exam:
Vitals: T 97.7 P 90 BP 127/73 RR 20 O2sat 100%RA
General: obtunded, tries to open eyes to voice, wiggles toes and
squeezes fingers, mumbles unintelligible answers
HEENT: dry MM, PERRL
Neck: supple
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi
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
GU: foley
Ext: 2+ pulses, no clubbing, cyanosis or edema

FAMILY HISTORY: No seizure disorders in family.

SOCIAL HISTORY: Patient lives in a local group home ([**Street Address(2) 18402**], [**Location (un) 669**]).
Single and no children.
- Tobacco: none
- Alcohol: none
- Illicits: none
Poisoning by barbiturates,Pneumonitis due to inhalation of food or vomitus,Other encephalopathy,Other alteration of consciousness,Accidental poisoning by barbiturates,Epilepsy, unspecified, without mention of intractable epilepsy,Asymptomatic human immunodeficiency virus [HIV] infection status,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Mild intellectual disabilities,Iron deficiency anemia, unspecified,Sprain of ankle, unspecified site
Poisoning-barbiturates,Food/vomit pneumonitis,Encephalopathy NEC,Other alter consciousnes,Acc poison-barbiturates,Epilep NOS w/o intr epil,Asymp hiv infectn status,Hypertension NOS,DMII wo cmp nt st uncntr,Mild intellect disabilty,Iron defic anemia NOS,Sprain of ankle NOS
Admission Date:  [**2145-11-1**]              Discharge Date:   [**2145-11-10**]

Date of Birth:  [**2097-5-27**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Altered Mental Status

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname 18403**] is a 48 year old man with h/o seizure d/o, HIV
([**2145-10-26**] CD4 692, VL undetected), HTN, DM, mild MR, who
presented to the hospital with lightheadedness and became
somnolent in the ED.
.
The patient was recently admitted to the hospital for
nausea/vomiting, attributed to possible seizure, noted to have
elevated phenobarb level (65), and was discharged home the day
prior to admission with level 42. Today, he reportedly noted
some lightheadedness, so was brought back to the ED. EMS reports
that he was talking and joking with them in the ambulance. Only
complaint was lightheadedness. Pt was instructed to restart
Phenobarb at lower dose today, after phenobarb was held during
hospitalization x3days.
.
As per the patient's epilepsy doctor, the patient is able to
communicate at baseline, albeit with delayed, slurred speech. No
h/o waxing/[**Doctor Last Name 688**] MS.
.
In the ED, initial vs were: T 98.0 P 85 BP 108/56 RR 18 O2sat
100%. The patient was very somnolent upon initial exam in th ED
- he was responsive only to painful stimuli, moved all 4
extremities. Labs notable for positive serum phenobarb, level
106. CT head was unremarkable. CXR was a limited exam, acute PNA
cannot be ruled out. Patient was given Narcan with no effect. He
was evaluated by Neuro, who was able to document brain stem
reflexes. Toxicology evaluated the patient as well, and the
patient was started on a bicarb gtt. Vitals prior to transfer:
BP 123/71 P 75 RR 22 O2sat 100%RA.
.
Initially on the floor, the patient remained obtunded. He was
able to follow simple commands and mumble, but unable to speak
intelligibly.


Past Medical History:
- epilepsy (followed by Dr. [**Last Name (STitle) 2442**]
- mental retardation (thought to be secondary to lead poisoning)

- HIV (VL undetectable, CD4 692 on [**10-26**])
- Type 2 diabetes mellitus
- hypercholesterolemia
- Benign Hypertension
- anxiety

Social History:
Patient lives in a local group home ([**Street Address(2) 18402**], [**Location (un) 669**]).
Single and no children.
- Tobacco: none
- Alcohol: none
- Illicits: none

Family History:
No seizure disorders in family.

Physical Exam:
Initial Physical exam in MICU:
Physical Exam:
Vitals: T 97.7 P 90 BP 127/73 RR 20 O2sat 100%RA
General: obtunded, tries to open eyes to voice, wiggles toes and
squeezes fingers, mumbles unintelligible answers
HEENT: dry MM, PERRL
Neck: supple
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi
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
GU: foley
Ext: 2+ pulses, no clubbing, cyanosis or edema

Pertinent Results:
Labs/Studies:
.
[**2145-11-8**] 06:15AM BLOOD WBC-7.8 RBC-4.19* Hgb-8.4* Hct-29.0*
MCV-69* MCH-19.9* MCHC-28.9* RDW-21.1* Plt Ct-415
[**2145-11-10**] 06:20AM BLOOD Glucose-101* UreaN-17 Creat-0.8 Na-134
K-4.1 Cl-106 HCO3-18* AnGap-14
[**2145-11-10**] 06:20AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.0
.
[**2145-11-6**] 07:25AM BLOOD ALT-21 AST-43* AlkPhos-90 TotBili-0.2
[**2145-10-31**] 08:15AM BLOOD Phenoba-41.6*
[**2145-11-1**] 11:53PM BLOOD Phenoba-120*
[**2145-11-9**] 06:35AM BLOOD Phenoba-23.3
.
[**11-1**] Blood culture: NGTD
.
Keppra and Zonisamide levels were within the normal range.
.
[**11-4**] CXR:
PA AND LATERAL CHEST RADIOGRAPH: Cardiac, mediastinal and hilar
contours are
unremarkable. Both lungs appear grossly clear with no focal
consolidation,
pleural effusion or pneumothorax. In the interim since [**11-2**], [**2145**],
there has been resolution of retrocardiac opacity.

IMPRESSION: No acute cardiopulmonary process. Interval
resolution of
retrocardiac opacification.
.
[**11-1**] Head CT:
IMPRESSION:
No acute intracranial findings.
.
[**11-4**] Ankle Xray:
FINDINGS: No previous images. No evidence of acute fracture or
dislocation.
Small bony opacifications that are well corticated are seen
inferior to the
lateral malleolus, possibly related to previous trauma. Indeed,
deformity of
the distal portion of the fibula suggests that there has been a
previous
fracture in the region.

The ankle mortise is quite well maintained. There is mild
inferior and dorsal
hypertrophic spurring.
.
[**11-2**] EEG:
IMPRESSION: This is an abnormal routine EEG in the waking and
drowsy
states due to the appearance of rare rightsided frontal and
temporal
spikes which may represent epileptogenic cortex. It is also
abnormal
due to left hemisphere delta and theta slowing which may
represent
underlying focal lesion such as due to ischemia, infection, or
mass. It
is also abnormal due to generalized slowing which may be due to
encephalopathy. There were no organized epileptiform discharges
or
electrographic seizures seen.


Brief Hospital Course:
Mr. [**Known lastname 18403**] is a 48 year old man with h/o seizure d/o on
multiple medications, HIV (well controlled), DM, HTN, HLD, [**Doctor First Name **],
who presents with coma.
.
#. Coma:
Pt presented with acute onset of unresponsiveness, preceded by
lightheadedness. Head CT was negative. EEG showed no seizure.
Presentation most likely [**2-9**] to phenobarbital intoxication, as
the patient was found to have severely elevated phenobarbital
level of 106, which later peaked at 120 on [**11-1**].  Unclear why
the patient's level was so high, given that his level was 42 the
day prior to admission, and that his dose was lowered as well.
This issue was investigated by social work and the case
managers. It was determined that the pharmacy places the
patient's medications into blister packs but that the patient
takes his own medications. It was not confirmed, but likely that
the patient took his medication incorrectly. He was started on a
sodium bicarbonate drip to alkalinize the urine and increase
excretion.  His phenobarbital level and urine pH were monitored
closely. Phenobarbital level decreased to 23.3 the day prior to
discharge.  HAART was restarted once the patient's phenobarbital
level was less than 40. He had a normal neurological exam while
on the floor. His phenobarbital was stopped because of the 2
admissions with supratherapeutic doses. His pharmacy was
notified of the change. His group home was notified of the
change and arrangements were made for the patient to have
assistance administering his medications.
.
#. Epilepsy:
Pt with h/o epilepsy. Altered mental status could have been
precipitated by a seizure but this was believed to be unlikely
given the high phenobarbital level.  Phenobarbital was held but
he was continued on his other anti-epileptics.  EEG was obtained
that showed no seizure activity. He was discharged on his home
Zonisamide and Keppra dosages with neuro follow-up. The patient
had no seizures during this admission.
.
#. HIV:
Last CD4 692, VL undetected on [**2145-10-26**].  HAART medications were
held until phenobarbital levels decreased but were restarted on
their normal dosages prior to discharge.
.
#. Anemia:
Pt with microcytic anemia, HCT 29 on admission, which seems to
be his baseline for the last 6 months. Recent iron studies with
very low iron and ferritin (2.8) levels. Dark stools on last
admission were guaiac negative. Pt was hemodynamically stable
and did not appear to be actively bleeding. Was set up with IV
Iron infusions as an outpatient for the next 7 weeks. He should
continue this therapy and should be scheduled for outpatient
colonoscopy and further work-up for his profound iron
deficiencies.
.
#Ankle pain: The patient complained of left ankle pain. Xrays
showed no acute fracture. An ACE wrap was placed and physical
therapy was consulted. He walked well with a walker and should
continue to use the walker until his ankle feels more stable.
.
#Pneumonia: The patient developed an elevated white count along
with CXR findings concerning for pneumonia. He completed a 7-day
course of Levaquin and CXR showed resolution of the infiltrate
prior to discharge.
.
#The patient was continued on SubQ heparin for DVT prophylaxis.
He remained full code during this admission. Contact was with
his mother [**Name (NI) 18404**] at [**Telephone/Fax (1) 18405**].


Medications on Admission:
Colace 100mg PO BID
Abacavir 300mg PO BID
Lopinavir-Ritonavir 200-50mg 2tabs PO BID
Stavudine 30mg PO q12h
Nabumetone 500mg PO qAM 1-2tabs
Zonisamide 300mg PO BID
Keppra 2000mg PO qAM, 2500mg PO qPM
Lisinopril 20mg PO daily
Diltiazem 120mg PO daily
Atorvastatin 20mg PO daily
Phenobarbital 120mg PO BID
IV Iron infusions

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. stavudine 15 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
5. nabumetone 500 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for pain.
6. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
7. levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO QAM (once
a day (in the morning)).
8. levetiracetam 500 mg Tablet Sig: Five (5) Tablet PO QPM (once
a day (in the evening)).
9. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. diltiazem HCl 120 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
11. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day:
You should restart this medication in 1 week on [**11-15**]. .
12. iron sucrose  Intravenous


Discharge Disposition:
Home with Service

Facility:
Group home ([**Street Address(2) 18402**], [**Location (un) 669**])

Discharge Diagnosis:
Primary:
Accidental Phenobarbital overdose
aspiration pneumonia
Epilepsy
.
Secondary:
HIV
DM
HL
HTN
Mental retardation
iron deficiency anemia of undetermined etiology


Discharge Condition:
Mental Status: Clear and coherent - slow to respond, but
oriented
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr. [**Known lastname 18403**],
It was a pleasure caring for you at [**Hospital1 827**]. You were admitted for tiredness and were found
nearly unconscious in the Emergency Department. We found that
the phenobarbital level in your blood was dangerously high. We
gave you fluids to help remove the drug from your system and you
improved. We also treated you with antibiotics for pneumonia.
.
We made the following changes to your medications:
We STOPPED Phenobarbital.
You HELD Atorvastatin while you were in the hospital. You should
restart this medication in 1 week on [**11-15**].
.
Your follow-up appointments are listed below. You should be
careful at home and should use your walker when you are moving
about your apartment - at least until your ankle feels better.
If you continue to have ankle pain, please call Dr. [**Last Name (STitle) **] and
let her know.

Followup Instructions:
Name: [**Last Name (LF) **], [**First Name3 (LF) **] R. MD
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 18406**]
Phone: [**Telephone/Fax (1) 3581**]
Appointment: Wednesday [**11-10**] at 2:30PM

Name: [**Last Name (LF) 2442**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: B.I.D.M.C. - [**Hospital Ward Name **]
Address: [**Location (un) **], [**Hospital Ward Name **] 8, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3506**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) 2442**]
within 1-2 weeks. You will be called at home with the
appointment. If you have not heard from the office or have any
questions, please call the number above.**

Department: NEUROLOGY
When: TUESDAY [**2146-1-18**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 3506**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
{'Poisoning by barbiturates,Pneumonitis due to inhalation of food or vomitus,Other encephalopathy,Other alteration of consciousness,Accidental poisoning by barbiturates,Epilepsy, unspecified, without mention of intractable epilepsy,Asymptomatic human immunodeficiency virus [HIV] infection status,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Mild intellectual disabilities,Iron deficiency anemia, unspecified,Sprain of ankle, unspecified site'}


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: Mr. [**Known lastname 18403**] is a 48 year old man with h/o seizure d/o, HIV
([**2145-10-26**] CD4 692, VL undetected), HTN, DM, mild MR, who
presented to the hospital with lightheadedness and became
somnolent in the ED.
.
The patient was recently admitted to the hospital for
nausea/vomiting, attributed to possible seizure, noted to have
elevated phenobarb level (65), and was discharged home the day
prior to admission with level 42. Today, he reportedly noted
some lightheadedness, so was brought back to the ED. EMS reports
that he was talking and joking with them in the ambulance. Only
complaint was lightheadedness. Pt was instructed to restart
Phenobarb at lower dose today, after phenobarb was held during
hospitalization x3days.
.
As per the patient's epilepsy doctor, the patient is able to
communicate at baseline, albeit with delayed, slurred speech. No
h/o waxing/[**Doctor Last Name 688**] MS.
.
In the ED, initial vs were: T 98.0 P 85 BP 108/56 RR 18 O2sat
100%. The patient was very somnolent upon initial exam in th ED
- he was responsive only to painful stimuli, moved all 4
extremities. Labs notable for positive serum phenobarb, level
106. CT head was unremarkable. CXR was a limited exam, acute PNA
cannot be ruled out. Patient was given Narcan with no effect. He
was evaluated by Neuro, who was able to document brain stem
reflexes. Toxicology evaluated the patient as well, and the
patient was started on a bicarb gtt. Vitals prior to transfer:
BP 123/71 P 75 RR 22 O2sat 100%RA.
.
Initially on the floor, the patient remained obtunded. He was
able to follow simple commands and mumble, but unable to speak
intelligibly.

MEDICAL HISTORY: - epilepsy (followed by Dr. [**Last Name (STitle) 2442**]
- mental retardation (thought to be secondary to lead poisoning)

MEDICATION ON ADMISSION: Colace 100mg PO BID
Abacavir 300mg PO BID
Lopinavir-Ritonavir 200-50mg 2tabs PO BID
Stavudine 30mg PO q12h
Nabumetone 500mg PO qAM 1-2tabs
Zonisamide 300mg PO BID
Keppra 2000mg PO qAM, 2500mg PO qPM
Lisinopril 20mg PO daily
Diltiazem 120mg PO daily
Atorvastatin 20mg PO daily
Phenobarbital 120mg PO BID
IV Iron infusions

ALLERGIES: Penicillins

PHYSICAL EXAM: Initial Physical exam in MICU:
Physical Exam:
Vitals: T 97.7 P 90 BP 127/73 RR 20 O2sat 100%RA
General: obtunded, tries to open eyes to voice, wiggles toes and
squeezes fingers, mumbles unintelligible answers
HEENT: dry MM, PERRL
Neck: supple
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi
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
GU: foley
Ext: 2+ pulses, no clubbing, cyanosis or edema

FAMILY HISTORY: No seizure disorders in family.

SOCIAL HISTORY: Patient lives in a local group home ([**Street Address(2) 18402**], [**Location (un) 669**]).
Single and no children.
- Tobacco: none
- Alcohol: none
- Illicits: none 

### Response:
{'Poisoning by barbiturates,Pneumonitis due to inhalation of food or vomitus,Other encephalopathy,Other alteration of consciousness,Accidental poisoning by barbiturates,Epilepsy, unspecified, without mention of intractable epilepsy,Asymptomatic human immunodeficiency virus [HIV] infection status,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Mild intellectual disabilities,Iron deficiency anemia, unspecified,Sprain of ankle, unspecified site'}
