CHIEF COMPLAINT: 

PRESENT ILLNESS: Patient is a 47-year-old female
with history of polysubstance abuse and asthma as well as
question of a seizure disorder secondary to head injury
greater than 10 years ago, history of depression and anxiety
admitted to the Medical Intensive Care Unit from the outside
hospital on [**2150-5-22**] for a Klonopin/Dilaudid overdose
complicated by rhabdomyolysis and transaminitis, change in
mental status, and intubated for airway protection and
hypercarbic respiratory failure who was transferred to the
floor on [**2150-5-24**] after extubation for further management.

MEDICAL HISTORY: 1. Asthma.
2. Polysubstance abuse with questionable history of heroin
   use in the past.  Patient has been on Methadone in the
   past but unclear when last taken.
3. Status post GYN surgery.
4. Lower back pain.
5. Depression and anxiety.
6. Question of seizure disorder secondary to head injury
   greater than 10 years ago.  Per the patient's sister the
   patient was apparently on Dilantin which had since been
   discontinued for unknown reasons.
7. Endometriosis status post hysterectomy at age 21.
8. Questionable history of lupus with a positive [**Doctor First Name **] but no
   therapy.  This history was also given by the patient's
   sister.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: Patient is married.  Her husband's name is
[**Name (NI) 122**] [**Name (NI) 55404**] and his phone number is [**Telephone/Fax (1) 55405**].  She also
has a sister, [**Name (NI) **] [**Name (NI) 55406**], phone number [**Telephone/Fax (1) 55407**].  Per
the patient's sister patient had recently lost her pet dog
and from the trauma of this loss, the patient's husband and
her made this suicide pact.  [**Name (NI) **] husband at the time of
this dictation is currently discharged from the hospital but
had been hospitalized at [**Hospital 5503**] [**Hospital 7637**] Hospital
with question of transfer to the CCU for management of
cardiac issues.  He is currently doing well.
Toxic encephalopathy,Rhabdomyolysis,Acute respiratory failure,Other convulsions,Acute and subacute necrosis of liver,Acquired coagulation factor deficiency,Pneumonitis due to inhalation of food or vomitus,Other, mixed, or unspecified drug abuse, unspecified,Cerebral edema
Toxic encephalopathy,Rhabdomyolysis,Acute respiratry failure,Convulsions NEC,Acute necrosis of liver,Acq coagul factor defic,Food/vomit pneumonitis,Drug abuse NEC-unspec,Cerebral edema
Admission Date: [**2150-5-22**]        Discharge Date: [**2150-6-5**]

Date of Birth:  [**2102-12-1**]        Sex:  F

Service:  MED

HISTORY OF PRESENT ILLNESS:  Patient is a 47-year-old female
with history of polysubstance abuse and asthma as well as
question of a seizure disorder secondary to head injury
greater than 10 years ago, history of depression and anxiety
admitted to the Medical Intensive Care Unit from the outside
hospital on [**2150-5-22**] for a Klonopin/Dilaudid overdose
complicated by rhabdomyolysis and transaminitis, change in
mental status, and intubated for airway protection and
hypercarbic respiratory failure who was transferred to the
floor on [**2150-5-24**] after extubation for further management.

Patient apparently had a suicide pact with her husband two
days prior to admission on [**2150-5-20**] and overdosed on
Dilaudid 300 mg (150, 2 mg tabs) and Klonopin 200 mg (50, 4
mg tabs).

Patient was found unresponsive by the patient's sister-in-law
who found both her husband and the patient lying on the
floor.  Patient was brought to the emergency department at
the outside hospital and received Narcan with good effect.
Patient did not receive charcoal and was given intravenous N-
acetyl cysteine for question of Tylenol overdose (although
unlikely) and Ceftriaxone 2 mg intravenous times one.

Per the outside hospital records head CT and chest x-ray were
normal and urine toxicology screen was positive for
benzodiazepines and opiates.  Labs at the outside hospital
showed an increased creatinine of 15, AST of 4600, ALT of
[**2146**], CPK of [**2146**], CPK of 25,000.

In the Emergency Department at [**Hospital1 188**] patient was arousable, satting 100 percent on
nonrebreather with an ABG of 7.36/67/167.  The patient,
however, was intubated later on [**2150-5-22**] for hypercarbia
with an ABG of 7.15, PCO2 of 108, and PAO2 of 96.

Patient was seen by the Liver service, as well, and it was
agreed that patient should continue with N-acetyl cysteine
for five more days for hepato protective effects and a
question of ischemic liver injury.  Patient was extubated on
[**2150-5-23**] and was satting well on 2 liters nasal cannula and
had slightly improved mental status upon transfer to the
Medicine floor on [**2150-5-24**].

Patient was also seen by Toxicology while in the Medical
Intensive Care Unit and it was agreed to continue with
anacetylcysteine since patient had increased liver function
tests and an increased total bilirubin.

On transfer to the Medicine floor patient complained of some
lower back pain which is chronic and bilateral knee pain but
otherwise was breathing comfortably.

PAST MEDICAL HISTORY:
1. Asthma.
2. Polysubstance abuse with questionable history of heroin
   use in the past.  Patient has been on Methadone in the
   past but unclear when last taken.
3. Status post GYN surgery.
4. Lower back pain.
5. Depression and anxiety.
6. Question of seizure disorder secondary to head injury
   greater than 10 years ago.  Per the patient's sister the
   patient was apparently on Dilantin which had since been
   discontinued for unknown reasons.
7. Endometriosis status post hysterectomy at age 21.
8. Questionable history of lupus with a positive [**Doctor First Name **] but no
   therapy.  This history was also given by the patient's
   sister.

MEDICATIONS PRIOR TO HOSPITALIZATION:
1. Klonopin.
2. Dilaudid.
3. Asthma inhalers.

MEDICATIONS ON TRANSFER TO THE FLOOR:
1. IV fluids, normal saline at 250 cc an hour.
2. Humalog insulin sliding scale.
3. Heparin 5000 units subq b.i.d.
4. Famotidine 20 mg IV b.i.d.
5. Thiamine 100 mg IV q.d.
6. Folic acid 1 mg IV q.d.
7. Salmeterol Diskus b.i.d.
8. Flovent inhaler b.i.d.
9. Albuterol nebulizers q. 4 hours.
10.      Atrovent nebulizers q. 4 hours.
11.      Clindamycin 600 mg p.o. t.i.d. day number one
   (patient had previously been on Flagyl and Ceftriaxone for
   the last two days prior to transfer).
12.      N-acetyl cysteine times eight doses intravenous.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  Patient is married.  Her husband's name is
[**Name (NI) 122**] [**Name (NI) 55404**] and his phone number is [**Telephone/Fax (1) 55405**].  She also
has a sister, [**Name (NI) **] [**Name (NI) 55406**], phone number [**Telephone/Fax (1) 55407**].  Per
the patient's sister patient had recently lost her pet dog
and from the trauma of this loss, the patient's husband and
her made this suicide pact.  [**Name (NI) **] husband at the time of
this dictation is currently discharged from the hospital but
had been hospitalized at [**Hospital 5503**] [**Hospital 7637**] Hospital
with question of transfer to the CCU for management of
cardiac issues.  He is currently doing well.

Also of note, patient's new primary care physician is [**Last Name (NamePattern4) **].
[**Last Name (STitle) 55408**], phone number [**Telephone/Fax (1) 55409**].  Previous primary care
physician was Dr. [**Last Name (STitle) 4610**].

PHYSICAL EXAMINATION ON TRANSFER:  Temperature 98.1, BP
134/73, pulse 86, respirations 17, satting 96 percent on 2
liters nasal cannula.  ABG checked the morning of [**2150-5-24**],
was 7.54, PCO2 of 38, and PAO2 of 109.  In general, patient
is alert and oriented times two to person and year although
did not know the month, and patient knew that she was in a
"hospital" but did not know the name of the hospital.  HEENT:
Pupils equal, round, and reactive to light.  Extraocular
movements intact.  Oropharynx is clear with moist mucous
membranes but poor dentition.  Neck:  Cool and supple;
nontender; no jugular venous distention.  Pulmonary:  Clear
to auscultation bilaterally with poor inspiratory effort.
Cardiovascular:  Regular rate and rhythm with no murmurs,
rubs, or gallops.  Abdomen:  Soft, nontender, nondistended,
with good bowel sounds.  Femoral line was in place, clean,
dry, and intact.  Extremities:  No edema, no calf tenderness,
with 2 plus dorsalis pedis pulses present bilaterally.

LABS ON TRANSFER:  White blood cell count 8.5, hematocrit
34.1, platelets 120.  Chem-7:  Sodium of 146, potassium of
2.3, chloride 108, bicarbonate 32, BUN 7, creatinine 0.3,
glucose 84, magnesium 1.4, calcium 7.5, phosphorus 1.4, ALT
649, AST 640, CK 16,278, alkaline phosphatase 44, total
bilirubin 2.3 mostly, indirect at 1.4, direct bilirubin 0.9,
PTT 38, INR 2.0, troponin less than 0.01, CK-MB of 20, lipase
37, HCV antibody negative, Dilantin level less than 0.06, D-
Dimer at 3258.

Chest x-ray on [**2150-5-22**] showed persistent small peripheral
opacity in the right lower lobe, small right pleural effusion
versus pleural thickening.

Abdominal ultrasound showed patent pleural vein with no
lesions, no obstruction, positive echogenic kidneys with
appropriate flow, normal liver.  Gallbladder showed
thickening but no signs of cholecystitis,.  No ascites.

CT of the head showed no hemorrhage, normal ventricles and
sulci.  There was a focal region of encephalomalacia in the
right frontal lobe, but otherwise unremarkable.

ASSESSMENT:  47-year-old female with history of substance
abuse and question of seizure disorder in the past, asthma
status post Dilaudid and Klonopin overdose who was admitted
to the Medical Intensive Care Unit with mental status change,
rhabdomyolysis, transaminitis, and hypercarbic respiratory
failure now transferred to the Medicine floor after
extubation, improved, for further management.

HOSPITAL COURSE:
1. Medication overdose/Psychiatry:  On transfer to the
   Medicine floor patient was maintained on a one-to-one
   sitter and was followed by Psychiatry throughout her
   hospitalization.  Given her mental status change she was
   not restarted on her antidepressants.  Psych and
   Toxicology both were following the patient.

As far as from a Toxicology standpoint, patient shortly had
her N-acetyl cysteine discontinued on transfer to the
Medicine floor since her liver function tests began to trend
downward.  It was unlikely that patient overdosed on Tylenol,
but the N-acetyl cysteine was kept on per Toxicology
recommendations for hepato protective effects.  Patient
showed no signs of benzodiazepine withdrawal and was
maintained on a Clinical Institute Withdrawal Assessment
scale for several days and required no Ativan per CIWA scale.
The CIWA scale was subsequently discontinued after events on
[**2150-3-27**], which will be discussed below.  The patient
showed no signs of narcotics withdrawal with no nausea,
vomiting, or any other associated symptoms.  Currently at
time of this dictation patient is awaiting inpatient
psychiatric treatment either at a rehab facility or at [**Hospital1 1444**].

1. Mental status change:  Initially on transfer to the
   Medicine floor patient's mental status seemed slightly
   improved, although patient still was disoriented and
   somewhat confused.  It was thought initially that patient
   most likely had a toxic metabolic encephalopathy from her
   overdose.  Initial EEG, which was checked on [**2150-5-24**],
   was consistent with a diffuse encephalopathy.  Given
   patient's very high liver function tests, decision was
   made to hold off on Dilantin loading on transfer on
   [**2150-5-24**] given possible hepatotoxic effects on Dilantin
   and a questionable history of seizure disorder in the past
   but no evidence of seizures at the time of transfer.

Over the next several days from [**2150-5-25**] to [**2150-5-26**]
patient began to appear more lethargic and her mental status
declined.  She received no Valium to explain her mental
status change, and the Valium per CIWA scale was
discontinued.  A head CT was checked on [**2150-5-25**] to rule
out anoxic brain injury and results showed bilateral
hypodense zones in the main inferior orbital portion of both
frontal lobes as well as a 2 cm triangular area of decreased
absorption in the right frontal lobe suggesting chronic
malasic change in frontal lobes.  Dictation suggested a
questionable history of prior trauma, and thus it was thought
that her head CT was stable.  It was most likely chronic
change from previous head injury.  It was thought that
patient still may likely have a toxic metabolic
encephalopathy.

However, during the course on [**2150-5-26**] patient began to
manifest a worsening mental status and stopped following
commands and was not responding even to sternal rub.  At the
same time patient spiked fevers to 102 and 103.  At 5 p.m. on
[**2150-5-26**] patient became tachycardiac in the 100s.  Systolic
blood pressure rose to the 160s when they had previously been
in the low 100s and temperature rose to 102 with a
respiratory rate of 40.  HEENT exam showed dilated pupils
that were minimally active, scleral icterus with bulging
sclerae.  Funduscopic exam was performed which showed no
papilledema.  Neuro exam:  As mentioned above, patient was
not responding to sternal rub and no withdrawal to pain.  She
was not opening her eyes or following commands.  Her deep
tendon reflexes were still 2 plus throughout with downgoing
Babinski's.

With the mental status change and fever, it was concerning
that patient was either suffering from a seizure,
benzodiazepine withdrawal, or some other neurologic process.
Patient was given 1 mg of Ativan times one for question of
seizure and benzodiazepine withdrawal but with no effect.
Stat chest x-ray showed a question of an aspiration pneumonia
in the right lower lobe, but this was most likely secondary
to mental status change and not the cause of recurrent fever
and mental status.  Blood cultures were drawn which showed no
growth.  Urinalysis was negative.

At this point it was attempted to perform an lumbar puncture.
Head CT had just been performed the night before and there
was no papilledema on funduscopic exam.  It was felt
comfortable to perform the lumbar puncture.  Several attempts
were made by two differential physicians and lumbar puncture
was unsuccessful on the evening of [**2150-5-26**] with no fluid
retrieval.  There were no complications at the attempts.

ABG was also checked at that time and it was 7.54, PCO2 of
29, and PAO2 of 99, suggesting a respiratory alkylosis.  Of
note, patient was also given two units of fresh frozen plasma
for an elevated INR of 1.7 prior to lumbar puncture.

Since patient was and the lumbar puncture was unsuccessful on
the evening of [**2150-5-26**] patient was empirically placed on
Ceftriaxone 2 grams q.d., Vancomycin, and Flagyl for coverage
of aspiration pneumonia.

The patient continued to spike fevers throughout the night of
[**2150-5-27**] and on [**2150-5-28**] patient was not responding to
sternal rub, following commands, or responding to any pain.
Her white count was elevated at 15,000.  A tox screen was
checked which was negative.

At 9 a.m. on [**2150-5-27**] patient had a grand mal seizure with
tonic-clonic movements that were generalized and witnessed by
the nursing staff.  The seizure resolved after a few seconds.
Patient was given Ativan 2 mg times one, but the seizure had
already resolved.  Her temperature was 103 at that time and
her saturations were initially at 95 percent on 2 liters, but
they decreased to 70 percent 4 liters.  Patient was put on
100 percent nonrebreather with only an O2 saturation at 94
percent on nonrebreather.  Anesthesia was called to intubate
the patient for airway protection.  They performed a
nasotracheal intubation most probably secondary to mouth
rigidity.  Patient was emergently transferred to the Medical
Intensive Care Unit after intubation.

Repeat head CT at the MICU showed extensive cerebral edema
primarily in the white matter in a pattern consistent with
reversible leukoencephalopathy syndrome.  There were open
ventricles and the basal cisternal  spaces remain visualized.
Neurosurgery was consulted and it was felt that patient would
most likely benefit from some type of intracranial monitoring
device.  Patient was given Mannitol q. 6 hours to keep serum
osms less than 320, four units of fresh frozen plasma, and
had an intracerebral pressure monitor placed as well as an
external ventriculostomy drain.  Patient had cerebrospinal
fluid sample sent from this drain which showed no signs of
infection.  CSF showed only 1 white blood cell and normal
glucose and total protein.

Patient had the drain placed for one day and intracerebral
pressures remained stable and the drain was discontinued on
[**2150-5-29**] by Neurosurgery.  Repeat EEG still showed just
diffuse encephalopathy.  MRI of the head was unrevealing.
Patient was initially started on Dilantin and then
transitioned to Keppra for ease of usage and no monitoring.
Patient was also treated with meningitis doses of Ceftriaxone
2 grams q. day for a total of a seven-day course completed on
[**2150-6-2**] for empiric coverage of meningitis since LP could
not be performed in the acute setting, and patient had
received 24 hours of antibiotics prior to shunt placement and
retrieval of CSF.

Even at the time of this dictation it is still unclear why
patient had this diffuse cerebral edema, and there have been
no clear hypotheses as to why this may have occurred.
Patient was transferred from the ICU back to the Medicine
floor after improvement of her mental status and
discontinuation of the intracerebral pressure monitoring and
patient has been alert, lucid, and her mental status has been
stable.  She is alert enough to give a thorough history and
is aware of her surroundings as well as her caretakers, which
is quite different from her initial presentation.  As far as
her seizure disorder, she will continue with the Keppra and
has not manifested any further seizures.

Fevers:  It is unclear whether patient may have had an
   aspiration pneumonia so she was treated briefly with a
   course of Clindamycin which was subsequently discontinued
   after her second transfer to the Medicine floor since her
   chest x-ray from [**2150-5-28**] was entirely clear.  The
   patient did complete a full course of seven days for a
   treatment of meningitis with Ceftriaxone 2 grams per day
   since it was unclear what precipitated her event.

Patient had a mild low-grade fever on [**2150-6-4**], but this
has resolved and she has had no further infectious issues at
the time of this dictation.  She is currently on no
antibiotics.

Transaminitis:  Patient's liver function tests continued
   to decline and it was thought likely that patient's
   transaminitis and increased INR were secondary to ischemic
   liver injury from her initial event.  These AST and ALT
   are almost at normal levels at the time of this dictation.

Rhabdomyolysis:  Patient's rhabdomyolysis also continued
   to improve throughout the course of her hospitalization.
   At the time of this dictation her CK level is now down to
   500 from a peak of 26,000, and it is felt there is no need
   to follow these since they have continued to trend
   downwards.  Patient was maintained on aggressive
   intravenous hydration at first and now is continuing on
   maintenance fluids since she continues to have poor p.o.
   intake.

Nutrition goal:  Patient initially presented with
   decreased mental status and was not able to take
   nutrition, but since her mental status has improved
   patient has passed a speech and swallow evaluation and is
   tolerating good Pos.  Would continue to encourage fluid
   intake.

Access:  Patient had a right femoral groin line placed
   initially when she was in the Unit and this was
   subsequently discontinued on her first transfer to the
   Medicine floor.  However, when she decompensated with a
   grand mal seizure and was intubated, she had a left IJ
   placed in the MICU.  This left IJ remained in place until
   [**2150-6-4**] when it was discontinued.  The catheter check
   has been sent for culture since the line site was somewhat
   erythematous.  The culture data is still pending at the
   time of this dictation.

DISPOSITION:  Patient has been working with Physical Therapy
and has been regaining her strength daily.  She still
requires some assistance with moving around, but this is felt
that it would likely improve with further strengthening.  The
decision is currently being made at the time of this
dictation whether to transfer the patient to the inpatient
psychiatric unit or to discharge the patient to psychiatric
unit at [**Hospital1 69**].  It has been
confirmed that patient does indeed have insurance, Medicare.

DISCHARGE CONDITION:  Stable.

DISCHARGE STATUS:  Still unknown at the time of this
dictation but likely to an inpatient psychiatric facility
with a rehab potential.

A discharge addendum will be added to cover the medications
and follow-up plans.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 27875**]

Dictated By:[**Name8 (MD) 5706**]
MEDQUIST36
D:  [**2150-6-4**] 20:14:55
T:  [**2150-6-4**] 22:39:26
Job#:  [**Job Number 55410**]
{'Toxic encephalopathy,Rhabdomyolysis,Acute respiratory failure,Other convulsions,Acute and subacute necrosis of liver,Acquired coagulation factor deficiency,Pneumonitis due to inhalation of food or vomitus,Other, mixed, or unspecified drug abuse, unspecified,Cerebral edema'}


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: 

PRESENT ILLNESS: Patient is a 47-year-old female
with history of polysubstance abuse and asthma as well as
question of a seizure disorder secondary to head injury
greater than 10 years ago, history of depression and anxiety
admitted to the Medical Intensive Care Unit from the outside
hospital on [**2150-5-22**] for a Klonopin/Dilaudid overdose
complicated by rhabdomyolysis and transaminitis, change in
mental status, and intubated for airway protection and
hypercarbic respiratory failure who was transferred to the
floor on [**2150-5-24**] after extubation for further management.

MEDICAL HISTORY: 1. Asthma.
2. Polysubstance abuse with questionable history of heroin
   use in the past.  Patient has been on Methadone in the
   past but unclear when last taken.
3. Status post GYN surgery.
4. Lower back pain.
5. Depression and anxiety.
6. Question of seizure disorder secondary to head injury
   greater than 10 years ago.  Per the patient's sister the
   patient was apparently on Dilantin which had since been
   discontinued for unknown reasons.
7. Endometriosis status post hysterectomy at age 21.
8. Questionable history of lupus with a positive [**Doctor First Name **] but no
   therapy.  This history was also given by the patient's
   sister.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: Patient is married.  Her husband's name is
[**Name (NI) 122**] [**Name (NI) 55404**] and his phone number is [**Telephone/Fax (1) 55405**].  She also
has a sister, [**Name (NI) **] [**Name (NI) 55406**], phone number [**Telephone/Fax (1) 55407**].  Per
the patient's sister patient had recently lost her pet dog
and from the trauma of this loss, the patient's husband and
her made this suicide pact.  [**Name (NI) **] husband at the time of
this dictation is currently discharged from the hospital but
had been hospitalized at [**Hospital 5503**] [**Hospital 7637**] Hospital
with question of transfer to the CCU for management of
cardiac issues.  He is currently doing well. 

### Response:
{'Toxic encephalopathy,Rhabdomyolysis,Acute respiratory failure,Other convulsions,Acute and subacute necrosis of liver,Acquired coagulation factor deficiency,Pneumonitis due to inhalation of food or vomitus,Other, mixed, or unspecified drug abuse, unspecified,Cerebral edema'}
