CHIEF COMPLAINT: Found in apartment unresponsive.

PRESENT ILLNESS: A 44 year-old woman with
extensive psychiatric history who was found in her apartment
unconscious by emergency medical technicians who were
summoned by her family after they had not heard from her in
one day.  When the patient was found she had dried blood at
the nose and was incontinent of stool and urine.  There
appeared to be coffee ground emesis on the floor as well.
Initial laboratory work was significant for a sodium of 118.

MEDICAL HISTORY: Hypercholesterolemia, hypertension,
noninsulin dependent diabetes mellitus (diet controlled),
hypothyroidism, chronic renal insufficiency, bipolar
disorder, depression and suicidal ideation.  For the bipolar
disorder she had been on Lithium from [**2180**] until [**2184**].

MEDICATION ON ADMISSION: K-clor 10 mg b.i.d., Depakote [**2185**]
mg q.h.s., Lipitor 10 mg q.d., Celexa 40 mg q.d., Serzone 450
mg b.i.d., Risperdal 2 mg q.h.s., Levoxyl 50 micrograms q.d.,
Norvasc 5 mg q.d., Lasix 20 mg q.d.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: No drug or alcohol use.  No smoking.  She
lives alone in her apartment.  The patient functions
independently and a patient of the day hospital of the
[**State 350**] Mental Day Hospital.  She has a brother and
sister that she speaks with regularly and sees occasionally.
Hyposmolality and/or hyponatremia,Polydipsia,Nephrogenic diabetes insipidus,Other psychotropic agents causing adverse effects in therapeutic use,Pneumonitis due to inhalation of food or vomitus,Bipolar I disorder, most recent episode (or current) unspecified,Unspecified essential hypertension,Unspecified acquired hypothyroidism
Hyposmolality,Polydipsia,Nephrogen diabetes insip,Adv eff psychotropic NEC,Food/vomit pneumonitis,Bipolor I current NOS,Hypertension NOS,Hypothyroidism NOS
Name:  [**Known lastname **], [**Known firstname 4377**]                     Unit No:  [**Numeric Identifier 6771**]

Admission Date:  [**2188-1-27**]     Discharge Date:  [**2188-2-5**]

Date of Birth:   [**2143-2-4**]     Sex:  F

Service:  [**Hospital1 1098**]/

DISCHARGE SUMMARY ADDENDUM:

LABORATORY DATA: CBC significant for WBC falling to 10.2
gradually on [**2188-2-3**].  The hematocrit stabilized at 36 to
38. Differential 67 neutrophils, 27 bands, 6 lymphocytes, 0
monocytes.  On [**2188-1-27**] the sodium was 118 on admission two
P.M. on [**2188-1-27**] and was 132 on [**2188-1-28**] at one A.M. For the
remainder of the hospital it was 135 to 143 except when she
was fluid restricted on [**2188-1-29**] and [**2188-1-30**] when her sodium
was 151 and 150.

IMAGING STUDIES:

1.  Chest x-ray on [**2188-1-27**] - Lungs are clear. Heart is
normal size.

2. Chest x-ray on [**2188-1-29**]  - Large area of predominately air
space opacity in the right lung consistent with pneumonia /
aspiration.

3. CT scan of head on [**2188-1-27**] - Focal low density in the
posterior left frontal lobe subcortical region which could
represent a small focal infarct, inflammatory lesion or brain
abscess.  Ventricles are not remarkable.

4.  MRI of head on [**2188-1-29**] - Inappropriate prominence of
sulci and ventricles, a well defined area of T1 and flair
hypointensity and T1 hyperintensity seen adjacent to a sulcus
in the left frontal lobe which is unchanged from previus
study.

5.  MRI with gadolinium on [**2188-2-4**] - A well defined area of
T1 and flair hypointensity and T2 hyperintensity seen
adjacent to a sulcus in the left posterior frontal lobe which
is unchanged.

IMPRESSION:  Discreet lesion in the left posterior frontal
lobe, low on T1 and high on T2 consistent with a cystic area
without enhancement representing possibly the residue of an
inflammatory process, ischemic process or developmental
abnormality.  This appearance does not suggest a neoplasm at
this time.

Urine electrolytes on [**2188-1-27**] BUN 79, creatinine 13, sodium
less than 10, chloride less than 20.  On [**2188-2-1**] urine
creatinine 15, sodium 21. On [**2188-2-2**] urine creatinine 40,
sodium 23. On [**2188-2-4**] urine creatinine 30, sodium 19,
potassium 23, chloride 33.

HOSPITAL COURSE: Impression and plan for a 44 year-old woman
with extensive psychiatric history and history of lithium use
brought to the Emergency Department because of
unresponsiveness and because she was found to have a sodium
of 118.

The patient was nasotracheally intubated as she was only
minimally responsive upon arrival to the Emergency
Department.  Toxic ingestion was considered as a cause of her
mental state, however her tox screen was positive only for
benzodiazepines. From the Emergency Department she was
admitted initially to the Medical Intensive Care Unit where
she stayed until she was transferred to the floor on
[**2188-1-30**].

RENAL - The patient's hyponatremia of [**2188-1-18**] quickly
corrected to 130 on the day of admission and subsequently was
normal throughout the remainder of the hospitalization except
when she was fluid restricted and her sodium was 150 to 151.
The patient was noted to have extremely copious urine output
on [**2188-1-27**] in 3550 out 2660.  On [**2188-1-28**] in 10,597 out
8950.  On [**2188-1-29**] in 5714 out 7900. On [**2188-1-30**] in 1460 out
2540.

A trial of DDAVP was attempted but it did not increase the
concentration of her urine.  Based upon the patient's dilute
urine and her copious urine output and her lack of
responsiveness to DDAVP, she in all likelihood has
nephrogenic diabetes insipidus. Therefore she is unable to
concentrate her urine and she is required to take in a large
amount of fluids by mouth.  After the patient's mental status
had cleared she in fact reported a history of constantly
being thirsty at home. When the patient's fluid intake was
not restricted she continued to drink copious amounts of
water and her sodium remained at normal levels from 145 to
153.

The patient was becoming hypernatremic to 150 to 151 while
fluid restricted and continuing to produce copious urine at
this time also suggests diabetes insipidus.

It was felt that the patient's hyponatremia on admission was
probably due to psychogenic polydipsia.  In other words
excessive intake of water. Because of the patient's
nephrogenic diabetes insipidus she is at risk for
hypernatremia because of her constant water loss.  However
she appeared to be able to regulate her fluid intake
adequately at baseline.

INFECTIOUS DISEASE -  It is not clear what the patient's
initial fever on admission was.  She did have an elevated
high blood cell count which could be due either to infection
or to stress such as her likely seizure.  She was started on
a two week course of Levofloxacin and Flagyl on [**2188-1-29**].
She did not complain of any cough or any fever subsequently.
Based on her chest x-ray it is possible that she may have had
an aspiration pneumonia at the time of her initial event.

NEUROLOGIC - The patient's likely seizure was probably due to
a setting of hyponatremia as well as her fever.  The patient
was evaluated by the Neurology service and a head MRI was
performed to rule out pituitary mass as the cause of her
diabetes insipidus.  MRI findings as described above showed a
lesion that appeared to be old and did not appear to be a
mass. Given that the patient did not respond to DDAVP this
further suggests that her wasting water is due not to a CNS
problem but to a problem within her kidney.  Given that the
seizure occurred in the setting of hyponatremia and fever, it
was decided not to discharge her on an anti-seizure
medication.

PSYCHIATRIC - The patient was psychiatrically stable while
she was in the hospital. She was followed by her outpatient
psychiatric Dr. [**First Name8 (NamePattern2) 6772**] [**Last Name (NamePattern1) 6773**].  He recommended Serzone be
discontinued because it may lower the seizure threshold; its
discontinuation had already been planned as an outpatient.
He also recommended that Celexa be discontinued because it
may contribute to hyponatremia.  The Psychiatry service also
noted that her psychiatric history is significant for limited
intelligence, bipolar disorder and schizoaffective /
borderline disorder. They felt that she does appear depressed
but it does not appear that her unconsciousness was a result
of a suicide attempt nor is she currently suicidal. Of note
is that when she received her head MRI she did require
conscious sedation owing to anxiety.

On the day of discharge the patient was comfortable, was
ambulating, eating and drinking without any problems and was
mentally appropriate.

DISCHARGE CONDITION:  Stable.

DISCHARGE DIAGNOSIS:
1.  Hyponatremia - likely due to psychogenic polydipsia.
2.  Nephrogenic diabetes insipidus - probably due to lithium
toxicity.
3.  History of depression and bipolar disorder.

DISCHARGE MEDICATIONS:
1.  Norvasc 5 milligrams po q day.
2.  Lipitor 10 milligrams po q day.
3.  Levoxyl 50 micrograms q day.
4.  Risperidone 2 milligrams q HS.
5.  Flagyl 500 milligrams tid for six more days.
6.  Levofloxacin 500 milligrams q day for six more days.
7.  Depakote extended release 1,000 milligrams q day.

FOLLOW UP APPOINTMENTS:
1.  Dr. [**Last Name (STitle) 6773**] on [**2188-2-7**] at 3:45 P.M.  He is her
outpatient psychiatrist.
2.  Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4332**] on Monday, [**2188-2-11**] at two P.M.
at [**Hospital3 **] West, [**Telephone/Fax (1) 2253**]. He was her
resident during parts of her hospitalization and he will
follow up her sodium at that time.
3. The [**Hospital **] Clinic at the [**Hospital 616**] Clinic on [**2188-2-15**] at three
P.M. where she will see Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] for evaluation of
her diabetes.
4.  Follow up appointment with her primary care physician [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1403**] on [**2188-2-25**] at 4:30 P.M. [**Telephone/Fax (1) 6774**].



                          [**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D.  [**MD Number(1) 628**]

Dictated By:[**Name8 (MD) 2984**]

MEDQUIST36

D:  [**2188-2-5**]  16:28
T:  [**2188-2-8**]  10:50
JOB#:  [**Job Number 1691**]


Admission Date:  [**2188-1-27**]     Discharge Date:  [**2188-2-5**]

Date of Birth:   [**2143-2-4**]     Sex:  F

Service:  [**Hospital1 212**]/INTERNAL MEDICINE

CHIEF COMPLAINT:  Found in apartment unresponsive.

HISTORY OF PRESENT ILLNESS:  A 44 year-old woman with
extensive psychiatric history who was found in her apartment
unconscious by emergency medical technicians who were
summoned by her family after they had not heard from her in
one day.  When the patient was found she had dried blood at
the nose and was incontinent of stool and urine.  There
appeared to be coffee ground emesis on the floor as well.
Initial laboratory work was significant for a sodium of 118.

PAST MEDICAL HISTORY:  Hypercholesterolemia, hypertension,
noninsulin dependent diabetes mellitus (diet controlled),
hypothyroidism, chronic renal insufficiency, bipolar
disorder, depression and suicidal ideation.  For the bipolar
disorder she had been on Lithium from [**2180**] until [**2184**].

MEDICATIONS ON ADMISSION:  K-clor 10 mg b.i.d., Depakote [**2185**]
mg q.h.s., Lipitor 10 mg q.d., Celexa 40 mg q.d., Serzone 450
mg b.i.d., Risperdal 2 mg q.h.s., Levoxyl 50 micrograms q.d.,
Norvasc 5 mg q.d., Lasix 20 mg q.d.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  No drug or alcohol use.  No smoking.  She
lives alone in her apartment.  The patient functions
independently and a patient of the day hospital of the
[**State 350**] Mental Day Hospital.  She has a brother and
sister that she speaks with regularly and sees occasionally.

PHYSICAL EXAMINATION ON ADMISSION:  She was comatose and
intubated nasotracheally.  Vital signs temperature 101 to
104.8.  Pulse 76.  Blood pressure 130/76.  Respiratory rate
16.  Skin cool and dry peripherally.  HEENT pupils are equal,
round and reactive to light 3 to 2 mm.  No nystagmus.  Neck,
hirsute.  Lungs clear to auscultation bilaterally.
Cardiovascularly, regular rate and rhythm.  No murmurs, rubs
or gallops.  Abdomen obese.  No hepatosplenomegaly.
Extremities 2+ edema to mid tibia.  Neurological minimal
withdraw to pain.  Does not respond to voice.  Left toe
upgoing.  Right two downgoing.  No rigidity.

LABORATORIES ON ADMISSION:  White blood cell 16.7, hemoglobin
and hematocrit 18/53, platelets 233, sodium 118, potassium
2.8, chloride 80, CO2 19, BUN 14, creatinine 1.4, glucose
136, magnesium 1.3, INR 1.3, PT/PTT 13.4/24.6, ALT 33, AST
62, magnesium 2.2,k phosphate 3.0, albumin 2.8.  Serum
osmolarity 256, fibrinogen 320, lipase 37, CK 2058, alkaline
phosphatase 112, total bilirubin 0.8, lactate 2.4, amylase
39, free calcium 1.17.  Urinalysis positive for large blood
and for ketones.  No white blood cells.  Cerebral spinal
fluid 1 white blood cell, 1 red blood cell.  Serum toxicity
positive for benzodiazepines only.  Arterial blood gas
7.32/41/179.  Serial CK were 2058, 2110 and 2156 with MB
index negative at 2.9, 2.7 and 2.6 respectively.  TSH 0.84,
T4 5.5, T3 52, free T4 1.1, cortisol random 17, lithium level
undetectable.  Urine osmolality 60 on [**1-27**]. ...............






                          [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D.  [**MD Number(1) 4518**]

Dictated By:[**Name8 (MD) 4123**]

MEDQUIST36

D:  [**2188-2-5**]  15:59
T:  [**2188-2-8**]  06:52
JOB#:  [**Job Number 37646**]
{'Hyposmolality and/or hyponatremia,Polydipsia,Nephrogenic diabetes insipidus,Other psychotropic agents causing adverse effects in therapeutic use,Pneumonitis due to inhalation of food or vomitus,Bipolar I disorder, most recent episode (or current) unspecified,Unspecified essential hypertension,Unspecified acquired hypothyroidism'}


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: Found in apartment unresponsive.

PRESENT ILLNESS: A 44 year-old woman with
extensive psychiatric history who was found in her apartment
unconscious by emergency medical technicians who were
summoned by her family after they had not heard from her in
one day.  When the patient was found she had dried blood at
the nose and was incontinent of stool and urine.  There
appeared to be coffee ground emesis on the floor as well.
Initial laboratory work was significant for a sodium of 118.

MEDICAL HISTORY: Hypercholesterolemia, hypertension,
noninsulin dependent diabetes mellitus (diet controlled),
hypothyroidism, chronic renal insufficiency, bipolar
disorder, depression and suicidal ideation.  For the bipolar
disorder she had been on Lithium from [**2180**] until [**2184**].

MEDICATION ON ADMISSION: K-clor 10 mg b.i.d., Depakote [**2185**]
mg q.h.s., Lipitor 10 mg q.d., Celexa 40 mg q.d., Serzone 450
mg b.i.d., Risperdal 2 mg q.h.s., Levoxyl 50 micrograms q.d.,
Norvasc 5 mg q.d., Lasix 20 mg q.d.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: No drug or alcohol use.  No smoking.  She
lives alone in her apartment.  The patient functions
independently and a patient of the day hospital of the
[**State 350**] Mental Day Hospital.  She has a brother and
sister that she speaks with regularly and sees occasionally. 

### Response:
{'Hyposmolality and/or hyponatremia,Polydipsia,Nephrogenic diabetes insipidus,Other psychotropic agents causing adverse effects in therapeutic use,Pneumonitis due to inhalation of food or vomitus,Bipolar I disorder, most recent episode (or current) unspecified,Unspecified essential hypertension,Unspecified acquired hypothyroidism'}
