CHIEF COMPLAINT: change in mental status

PRESENT ILLNESS: 48 year old woman with chronic back, leg pain, on multiple meds
for pain syndrome who was found by her daughter on [**7-25**] to be
somnolent. Called EMS and in ED found to be lethargic in setting
of taking [**7-18**] Vicodin and an unknown amount of trazadone,
Seroquel, and Neurotin. Due to slurred speech and somnolence in
ED, patient was intubated for airway protection. Before being
intubated, she denied suicidal ideation, although per patient's
sister, history of suicidal ideation.  In the ED, temperature
97, HR 116, BP 140/87, RR 17, and oxygen saturation 98% on room
air. Tylenol level was 80 and her urine was positive for
benzodiazepines, opiates, and amphetamines. Her EKG was
unremarkable. She had minimal response to 0.4mg of Narcan, given
twice. She received 50 mg of charcoal and was started on 13gm
(14mg/kg) of NAC by mouth.

MEDICAL HISTORY: -Status post gastric bypass surgery in [**2176**]
-Hypothyroid
-Asthma, with normal PFTs in [**2178**]
-Status post subtotal colectomy
-History of lower back pain, leg pain, foot pain
-Suicidal ideations, per sister

MEDICATION ON ADMISSION: -Percocet
-Neurontin
-MVI
-Vicodin
-Albuterol 90 mcg INH [**2-11**] q6HR PRN
-Xanax XR 3mg daily
-Synthroid 100mg daily
-Lamictal 100 mg daily
-Prilosec 20mg [**Hospital1 **]
-Topiramate 50 mg [**Hospital1 **]
-Sertraline 100 mg daily
-Trazodone 200 mg qHS
-Quetiapine 300 mg qHS
-Flonase 50 mcg INH 2puffs [**Hospital1 **]
-Flovent HFA 220 mcg INH 2-4 puffs [**Hospital1 **]
-Imitrex 50 mg PO q1h PRN (maximum 4 per day)
-Acetaminophn-Isometh-Dichloral 325-65-100 mg TWO capsules [**Hospital1 **]
PRN

ALLERGIES: Compazine / Terbutaline / Morphine / Iodine; Iodine Containing /
Adhesive Tape

PHYSICAL EXAM: Physical exam on admission:
T:98.5 BP:147/86 HR:104 RR:23 O2saturation:94%
Gen: Overweight, intubated middle aged woman.
HEENT: Pupils equal round and reactive. 6-->2mm. No conjunctival
pallor. No icterus. Moist mucous membranes.
NECK: Supple. No cervical lymphadenopathy. No JVD.
CV: RRR. Normal S1 and S2. No murmurs, rubs or [**Last Name (un) 549**]
appreciated.
LUNGS: Clear to auscultation bilaterally. Decreased breath
sounds in lower lung fields, bilaterally. No wheezes, crackles,
or rhonci appreciated.
ABD: Protuberant. Normal active bowel sounds in all four
quadrants. Soft. Nontender and nondistended. No guarding or
rebound. Liver edge not palpated.
EXT: Warm and well perfused. No clubbing or cyanosis. No lower
extremity edema, bilaterally. 2+ dorsalis pedis and radial
pulses, bilaterally.
NEURO: Intubated and sedated. Movements not purposeful. Responds
to noxious stimuli.

FAMILY HISTORY: colon cancer in grandmother, uncle

SOCIAL HISTORY: Stay at home mom.  Daughter 17yo.  [**Name2 (NI) **] tob/etoh/IVDU.
Poisoning by aromatic analgesics, not elsewhere classified,Acute respiratory failure,Other alteration of consciousness,Bipolar disorder, unspecified,Chronic pain syndrome,Unspecified acquired hypothyroidism,Asthma, unspecified type, unspecified,Anemia, unspecified,Bariatric surgery status,Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics
Pois-arom analgesics NEC,Acute respiratry failure,Other alter consciousnes,Bipolar disorder NOS,Chronic pain syndrome,Hypothyroidism NOS,Asthma NOS,Anemia NOS,Bariatric surgery status,Poison-analgesics
Admission Date:  [**2183-7-26**]              Discharge Date:   [**2183-7-29**]

Date of Birth:  [**2134-8-16**]             Sex:   F

Service: MEDICINE

Allergies:
Compazine / Terbutaline / Morphine / Iodine; Iodine Containing /
Adhesive Tape

Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
change in mental status

Major Surgical or Invasive Procedure:
endotracheal intubation


History of Present Illness:
48 year old woman with chronic back, leg pain, on multiple meds
for pain syndrome who was found by her daughter on [**7-25**] to be
somnolent. Called EMS and in ED found to be lethargic in setting
of taking [**7-18**] Vicodin and an unknown amount of trazadone,
Seroquel, and Neurotin. Due to slurred speech and somnolence in
ED, patient was intubated for airway protection. Before being
intubated, she denied suicidal ideation, although per patient's
sister, history of suicidal ideation.  In the ED, temperature
97, HR 116, BP 140/87, RR 17, and oxygen saturation 98% on room
air. Tylenol level was 80 and her urine was positive for
benzodiazepines, opiates, and amphetamines. Her EKG was
unremarkable. She had minimal response to 0.4mg of Narcan, given
twice. She received 50 mg of charcoal and was started on 13gm
(14mg/kg) of NAC by mouth.

Past Medical History:
-Status post gastric bypass surgery in [**2176**]
-Hypothyroid
-Asthma, with normal PFTs in [**2178**]
-Status post subtotal colectomy
-History of lower back pain, leg pain, foot pain
-Suicidal ideations, per sister

Social History:
Stay at home mom.  Daughter 17yo.  [**Name2 (NI) **] tob/etoh/IVDU.


Family History:
colon cancer in grandmother, uncle

Physical Exam:
Physical exam on admission:
T:98.5 BP:147/86 HR:104 RR:23 O2saturation:94%
Gen: Overweight, intubated middle aged woman.
HEENT: Pupils equal round and reactive. 6-->2mm. No conjunctival
pallor. No icterus. Moist mucous membranes.
NECK: Supple. No cervical lymphadenopathy. No JVD.
CV: RRR. Normal S1 and S2. No murmurs, rubs or [**Last Name (un) 549**]
appreciated.
LUNGS: Clear to auscultation bilaterally. Decreased breath
sounds in lower lung fields, bilaterally. No wheezes, crackles,
or rhonci appreciated.
ABD: Protuberant. Normal active bowel sounds in all four
quadrants. Soft. Nontender and nondistended. No guarding or
rebound. Liver edge not palpated.
EXT: Warm and well perfused. No clubbing or cyanosis. No lower
extremity edema, bilaterally. 2+ dorsalis pedis and radial
pulses, bilaterally.
NEURO: Intubated and sedated. Movements not purposeful. Responds
to noxious stimuli.


Pertinent Results:
Laboratory studies on admission:
[**2183-7-25**]
WBC-7.2 HGB-10.6* HCT-30.9* MCV-91 RDW-15.9* PLT COUNT-400
NEUTS-31* BANDS-0 LYMPHS-52* MONOS-9 EOS-8* BASOS-0
GLUCOSE-136* UREA N-18 CREAT-1.0 SODIUM-137 POTASSIUM-4.0
CHLORIDE-104 TOTAL CO2-24
ALT(SGPT)-9 AST(SGOT)-15 ALK PHOS-90 TOT BILI-0.1
Utox: bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG
amphetmn-POS mthdone-NEG
Stox: ASA-NEG ETHANOL-NEG ACETMNPHN-80.6* bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG

Laboratory studies on discharge:
[**2183-7-29**]
WBC-9.4 Hgb-12.2 Hct-37.0 MCV-94 RDW-15.6* Plt Ct-307
Glucose-111* UreaN-16 Creat-0.6 Na-141 K-3.5 Cl-102 HCO3-22

Other labs:
Iron-103 calTIBC-464 VitB12-415 Folate-18.1 Ferritn-15 TRF-357
TSH-2.0

EKG [**7-25**]: Sinus tachycardia, rate 103. Since the previous
tracing of [**2183-3-31**] the heart rate is faster. Technical artifacts
are present. Minimal increase in ST-T wave abnormalities is
present

Radiology:
[**7-25**] CXR: An ET tube has been placed with tip 6.3 cm above the
carina, above the level of the clavicular heads. The tube could
be advanced approximately 3 cm to ensure proper positioning. An
NG tube traverses below the diaphragm with tip off the field of
view. The lungs are grossly clear and there is no evidence of
consolidations or edema. The cardiac silhouette is enlarged
compared to the prior exam, though this may be due to technique.
Mediastinal and hilar contours are unremarkable. There is no
evidence of pneumothorax.

[**7-26**] Head CT w/o contrast: There is no intracranial hemorrhage.
There is no mass effect, shift of normally midline structures,
hydrocephalus, or acute vascular territorial infarct. The
density values of the brain parenchyma are normal, and the
ventricles and basal cisterns are unremarkable. Fluid secretions
within the posterior nasopharynx and oropharynx are likely
related to patient's intubated status. Visualized paranasal
sinuses and mastoid air cells are otherwise normally aerated.

[**7-27**] CXR: Comparison with the previous study done [**2183-7-26**]. The
lungs remain clear. The heart and mediastinal structures are
unremarkable. The left hemidiaphragm is mildly elevated. An
endotracheal tube and nasogastric tube have been removed.

Brief Hospital Course:
48 year old female with chronic pain (back, leg, foot) initially
admitted [**7-26**] to [**Hospital Unit Name 153**] after being found somnolent in the setting
of multiple drug ingestion (Vicodin, trazodone, Seroquel,
Neurontin).

1) Polysubstance overdose: Patient is on multiple psychiatric
meds (see admission med list), in addition to Vicodin and
neurontin. Urine tox screen was positive for amphetamines,
opiates, and benzodiazepines, and serum tox was notable for a
Tylenol level of 80. A toxicology consult was obtained and the
patient was started on N-acetylcysteine for Tylenol overdose and
a dose of charcoal. She was intubated in the emergency room and
transferred to the intensive care unit. She was extubated on
[**2183-7-26**] without difficulty. Her liver function tests remained
normal, and N-acetylcysteine was discontinued. She was
transferred to the general medical floor on [**2183-7-28**]. Psychiatry
followed the patient closely throughout her hospital stay.
Although the patient denies intentional overdose, she
acknowledges multiple recent social stressors and passive
suicidality, raising concern that this overdose represented a
suicide attempt. Psychiatry therefore recommended section 12 and
psychiatric admission.

2) Bipolar disorder: As recommended by psychiatry, all of the
patient's psychiatric medications were discontinued. Her
psychiatric medications will be re-started/titrated once she is
transferred to a psychiatric facility.

3) Hypothyroidism: The patient was continued on levothyroxine;
recent TSH wnl

4) Asthma: The patient has a chronic cough attributed to asthma.
CXR was without infiltrate. She was continued on flovent and
albuterol and was started on atrovent. She may benefit from
outpatient PFTs (last obtained in [**2178**]).

5) Anemia: At time of discharge, the patient's hematocrit was
stable. Although ferritin was low at 15, iron/TIBC were normal.
This should be monitored as an outpatient and further work-up of
occult bleeding pursued at the discretion of the patient's
primary care physician. [**Name Initial (NameIs) **] B12 and folate were normal.

6) Disposition:  The patient is medically stable for transfer to
psychiatric facility.

Medications on Admission:
-Percocet
-Neurontin
-MVI
-Vicodin
-Albuterol 90 mcg INH [**2-11**] q6HR PRN
-Xanax XR 3mg daily
-Synthroid 100mg daily
-Lamictal 100 mg daily
-Prilosec 20mg [**Hospital1 **]
-Topiramate 50 mg [**Hospital1 **]
-Sertraline 100 mg daily
-Trazodone 200 mg qHS
-Quetiapine 300 mg qHS
-Flonase 50 mcg INH 2puffs [**Hospital1 **]
-Flovent HFA 220 mcg INH 2-4 puffs [**Hospital1 **]
-Imitrex 50 mg PO q1h PRN (maximum 4 per day)
-Acetaminophn-Isometh-Dichloral 325-65-100 mg TWO capsules [**Hospital1 **]
PRN

Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for nausea.
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary: polysubstance overdose
Secondary: bipolar disorder, asthma, anemia


Discharge Condition:
The patient is medically stable for transfer to a psychiatric
facility


Discharge Instructions:
You were admitted with a polysubatance overdose. You are now
being transferred to a psychiatric facility for further
treatment.
1) Please follow-up as indicated below
2) Please see your primary care physician or come to the
emergency room if you develop abdominal pain, nausea, vomiting,
or other symptoms that concern you.

Followup Instructions:
1) Primary Care:
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Date/Time:[**2183-10-21**] 10:20
2) Orthopedics
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2183-9-9**] 3:05
3) Psychiatry: Please follow-up as directed following
psychiatric admissions


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]

Completed by:[**2183-7-29**]
{'Poisoning by aromatic analgesics, not elsewhere classified,Acute respiratory failure,Other alteration of consciousness,Bipolar disorder, unspecified,Chronic pain syndrome,Unspecified acquired hypothyroidism,Asthma, unspecified type, unspecified,Anemia, unspecified,Bariatric surgery status,Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics'}


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: change in mental status

PRESENT ILLNESS: 48 year old woman with chronic back, leg pain, on multiple meds
for pain syndrome who was found by her daughter on [**7-25**] to be
somnolent. Called EMS and in ED found to be lethargic in setting
of taking [**7-18**] Vicodin and an unknown amount of trazadone,
Seroquel, and Neurotin. Due to slurred speech and somnolence in
ED, patient was intubated for airway protection. Before being
intubated, she denied suicidal ideation, although per patient's
sister, history of suicidal ideation.  In the ED, temperature
97, HR 116, BP 140/87, RR 17, and oxygen saturation 98% on room
air. Tylenol level was 80 and her urine was positive for
benzodiazepines, opiates, and amphetamines. Her EKG was
unremarkable. She had minimal response to 0.4mg of Narcan, given
twice. She received 50 mg of charcoal and was started on 13gm
(14mg/kg) of NAC by mouth.

MEDICAL HISTORY: -Status post gastric bypass surgery in [**2176**]
-Hypothyroid
-Asthma, with normal PFTs in [**2178**]
-Status post subtotal colectomy
-History of lower back pain, leg pain, foot pain
-Suicidal ideations, per sister

MEDICATION ON ADMISSION: -Percocet
-Neurontin
-MVI
-Vicodin
-Albuterol 90 mcg INH [**2-11**] q6HR PRN
-Xanax XR 3mg daily
-Synthroid 100mg daily
-Lamictal 100 mg daily
-Prilosec 20mg [**Hospital1 **]
-Topiramate 50 mg [**Hospital1 **]
-Sertraline 100 mg daily
-Trazodone 200 mg qHS
-Quetiapine 300 mg qHS
-Flonase 50 mcg INH 2puffs [**Hospital1 **]
-Flovent HFA 220 mcg INH 2-4 puffs [**Hospital1 **]
-Imitrex 50 mg PO q1h PRN (maximum 4 per day)
-Acetaminophn-Isometh-Dichloral 325-65-100 mg TWO capsules [**Hospital1 **]
PRN

ALLERGIES: Compazine / Terbutaline / Morphine / Iodine; Iodine Containing /
Adhesive Tape

PHYSICAL EXAM: Physical exam on admission:
T:98.5 BP:147/86 HR:104 RR:23 O2saturation:94%
Gen: Overweight, intubated middle aged woman.
HEENT: Pupils equal round and reactive. 6-->2mm. No conjunctival
pallor. No icterus. Moist mucous membranes.
NECK: Supple. No cervical lymphadenopathy. No JVD.
CV: RRR. Normal S1 and S2. No murmurs, rubs or [**Last Name (un) 549**]
appreciated.
LUNGS: Clear to auscultation bilaterally. Decreased breath
sounds in lower lung fields, bilaterally. No wheezes, crackles,
or rhonci appreciated.
ABD: Protuberant. Normal active bowel sounds in all four
quadrants. Soft. Nontender and nondistended. No guarding or
rebound. Liver edge not palpated.
EXT: Warm and well perfused. No clubbing or cyanosis. No lower
extremity edema, bilaterally. 2+ dorsalis pedis and radial
pulses, bilaterally.
NEURO: Intubated and sedated. Movements not purposeful. Responds
to noxious stimuli.

FAMILY HISTORY: colon cancer in grandmother, uncle

SOCIAL HISTORY: Stay at home mom.  Daughter 17yo.  [**Name2 (NI) **] tob/etoh/IVDU. 

### Response:
{'Poisoning by aromatic analgesics, not elsewhere classified,Acute respiratory failure,Other alteration of consciousness,Bipolar disorder, unspecified,Chronic pain syndrome,Unspecified acquired hypothyroidism,Asthma, unspecified type, unspecified,Anemia, unspecified,Bariatric surgery status,Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics'}
