CHIEF COMPLAINT: Unresponsiveness

PRESENT ILLNESS: Pt is a 32-yo woman with h/o IVDA recently started on Methadone,
who is admitted after being found unresponsive. The pt was found
unresponsive of unknown duration at her group home, lying supine
in bed. She had reportedly last been seen normal at ~1500 this
afternoon, approx 1-2 hours prior to being found unresponsive.
Reportedly, she had started on methadone on Monday, with an
increase in her dose from 45mg to 50mg yesterday. She also had
been vomiting for the past few days. She was initiated on
ventilation by BLS until EMS arrived. She was noted by EMS to
have pinpoint pupils, so she received Narcan 2mg IM + 2mg IV,
without significant effect except for a slight increase in
pupillary diameter. She was then intubated by rapid sequence
intubation and transported to [**Hospital3 20284**] Center.
.
At [**Hospital3 20284**] Center, she was noted to be pale, cool, and
dry, smelling of foul urine, with coffee-grounds from her NGT
and thick brown secretions from her ETT. GCS was 3 and she was
thought to have decorticate posturing and possibly intermittent
seizing, without change to Ativan 2mg IV x2 and Fosphenytoin.
Head CT showed diffuse cerebral edema with loss of white-[**Doctor Last Name 352**]
matter c/w anoxic brain injury, so she received Decadron 10mg IV
x1. ABG was 7.28/48.4/361.9, and CXR showed bilateral lower lobe
atelectasis and mild pulmonary vascular congestion. WBC was
elevated at 33.9 as well, so she received Levofloxacin 750mg IV
x1 and was ordered for Vancomycin 1gram IV x1. She also received
Protonix 40mg IV x1 and a 500cc NS IVF bolus. Urine tox was only
positive for methadone. She was transferred to [**Hospital1 18**] ED for
further evaluation.
.
In the ED, VS - BP 123/82, HR 76, R 18, SaO2 100% RA. She
remained intubated but was awake, moving her eyes and arms
purposefully, so she was sedated with midazolam and fentanyl
gtts. ECG and CXR were unremarkable, and NCHCT showed no ICH or
infarct. She is being admitted to the MICU for further care.
.
On arrival to the MICU, she was noted to desaturate while being
suctioned...

MEDICAL HISTORY: IVDU
Depression

MEDICATION ON ADMISSION: Paxil 20mg Daily
Methadone per clinic dosing

ALLERGIES: Aspirin / Cefuroxime Axetil

PHYSICAL EXAM: intubated, following commands, moving purposefully
NC/AT, PERRL/EOMI, sclera anicteric
supple, no LAD
lungs CTA bilat, no r/rh/wh
heart RRR, nl S1-S2, no MRG
abd +bs, soft/nt/nd, obese
extrem wwp no c/c/e
Diffuse scabs reflecting excoriations.

FAMILY HISTORY: NC

SOCIAL HISTORY: Homeless, Boyfriend.
Hx of IVDU currently in [**Hospital 2514**] clinic
Poisoning by methadone,Cerebral edema,Acute respiratory failure,Pneumonia, organism unspecified,Hematemesis,Opioid type dependence, continuous,Poisoning by analgesics, antipyretics, and antirheumatics, undetermined whether accidentally or purposely inflicted,Home accidents,Altered mental status,Depressive disorder, not elsewhere classified,Open wound of tongue and floor of mouth, without mention of complication,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Anemia, unspecified
Poisoning-methadone,Cerebral edema,Acute respiratry failure,Pneumonia, organism NOS,Hematemesis,Opioid dependence-contin,Undeterm pois-analgesics,Accident in home,Altered mental status,Depressive disorder NEC,Opn wnd tongue/mouth flr,Acc cut in med care NEC,Elev transaminase/ldh,Anemia NOS
Admission Date:  [**2143-7-25**]              Discharge Date:   [**2143-7-28**]

Date of Birth:  [**2110-12-30**]             Sex:   F

Service: MEDICINE

Allergies:
Aspirin / Cefuroxime Axetil

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Unresponsiveness

Major Surgical or Invasive Procedure:
Intubation


History of Present Illness:
Pt is a 32-yo woman with h/o IVDA recently started on Methadone,
who is admitted after being found unresponsive. The pt was found
unresponsive of unknown duration at her group home, lying supine
in bed. She had reportedly last been seen normal at ~1500 this
afternoon, approx 1-2 hours prior to being found unresponsive.
Reportedly, she had started on methadone on Monday, with an
increase in her dose from 45mg to 50mg yesterday. She also had
been vomiting for the past few days. She was initiated on
ventilation by BLS until EMS arrived. She was noted by EMS to
have pinpoint pupils, so she received Narcan 2mg IM + 2mg IV,
without significant effect except for a slight increase in
pupillary diameter. She was then intubated by rapid sequence
intubation and transported to [**Hospital3 20284**] Center.
.
At [**Hospital3 20284**] Center, she was noted to be pale, cool, and
dry, smelling of foul urine, with coffee-grounds from her NGT
and thick brown secretions from her ETT. GCS was 3 and she was
thought to have decorticate posturing and possibly intermittent
seizing, without change to Ativan 2mg IV x2 and Fosphenytoin.
Head CT showed diffuse cerebral edema with loss of white-[**Doctor Last Name 352**]
matter c/w anoxic brain injury, so she received Decadron 10mg IV
x1. ABG was 7.28/48.4/361.9, and CXR showed bilateral lower lobe
atelectasis and mild pulmonary vascular congestion. WBC was
elevated at 33.9 as well, so she received Levofloxacin 750mg IV
x1 and was ordered for Vancomycin 1gram IV x1. She also received
Protonix 40mg IV x1 and a 500cc NS IVF bolus. Urine tox was only
positive for methadone. She was transferred to [**Hospital1 18**] ED for
further evaluation.
.
In the ED, VS - BP 123/82, HR 76, R 18, SaO2 100% RA. She
remained intubated but was awake, moving her eyes and arms
purposefully, so she was sedated with midazolam and fentanyl
gtts. ECG and CXR were unremarkable, and NCHCT showed no ICH or
infarct. She is being admitted to the MICU for further care.
.
On arrival to the MICU, she was noted to desaturate while being
suctioned...

Past Medical History:
IVDU
Depression

Social History:
Homeless, Boyfriend.
Hx of IVDU currently in [**Hospital 2514**] clinic

Family History:
NC

Physical Exam:
intubated, following commands, moving purposefully
NC/AT, PERRL/EOMI, sclera anicteric
supple, no LAD
lungs CTA bilat, no r/rh/wh
heart RRR, nl S1-S2, no MRG
abd +bs, soft/nt/nd, obese
extrem wwp no c/c/e
Diffuse scabs reflecting excoriations.

Pertinent Results:
Labs On Admission:
[**2143-7-25**] 09:50PM BLOOD WBC-22.6* RBC-5.19 Hgb-12.3 Hct-41.1
MCV-79* MCH-23.7* MCHC-30.0* RDW-15.9* Plt Ct-391
[**2143-7-25**] 09:50PM BLOOD Neuts-93.9* Lymphs-3.7* Monos-1.0*
Eos-1.2 Baso-0.1
[**2143-7-25**] 09:50PM BLOOD PT-14.9* PTT-29.5 INR(PT)-1.3*
[**2143-7-25**] 09:50PM BLOOD Glucose-110* UreaN-13 Creat-0.9 Na-140
K-4.2 Cl-99 HCO3-26 AnGap-19
[**2143-7-25**] 09:50PM BLOOD ALT-91* AST-181* AlkPhos-129* TotBili-0.4
[**2143-7-26**] 02:53AM BLOOD CK-MB-11* MB Indx-1.6 cTropnT-<0.01
[**2143-7-26**] 02:53AM BLOOD Albumin-3.8 Calcium-8.6 Phos-2.7 Mg-1.9
[**2143-7-26**] 02:53AM BLOOD Osmolal-285
[**2143-7-25**] 09:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2143-7-25**] 09:55PM BLOOD Lactate-4.0*
.
Labs On Discharge:
[**2143-7-28**] 06:40AM BLOOD WBC-13.3* RBC-4.25 Hgb-10.2* Hct-32.9*
MCV-77* MCH-24.0* MCHC-31.0 RDW-16.5* Plt Ct-415
[**2143-7-28**] 06:40AM BLOOD Neuts-67.3 Lymphs-27.3 Monos-3.4 Eos-1.3
Baso-0.6
[**2143-7-28**] 06:40AM BLOOD PT-14.2* PTT-33.6 INR(PT)-1.2*
[**2143-7-28**] 06:40AM BLOOD Glucose-71 UreaN-6 Creat-0.7 Na-140 K-4.1
Cl-104 HCO3-26 AnGap-14
[**2143-7-26**] 02:53AM BLOOD ALT-81* AST-147* LD(LDH)-766*
CK(CPK)-684* AlkPhos-108* TotBili-0.3
[**2143-7-28**] 06:40AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.8
.
Microbiology:
Blood Cultures ([**6-24**] - 20): No Growth Pending
.
Images:
CT Head: No acute hemorrhage. No midline shift. No cerebral
edema
appreciated
.
CXR ([**7-25**]):  ET tube and orogastric tube in standard location.
Retrocardiac
opacification may be atelectasis or pneumonitis from infection
or aspiration and follow up chest radiograph is recommended.
.
CXR ([**7-26**]): 1. Endotracheal tube terminates at least 1.3 cm
above the carina, should be withdrawn 3cm. No pneumothorax. 2.
Slightly worse mild bibasilar atelectasis.
.
CXR ([**7-27**]):  Bibasilar linear atelectasis


Brief Hospital Course:
ASSESSMENT / PLAN: 32-yo woman with h/o IVDA recently started on
Methadone, found unresponsive at her group home and intubated,
also thought to have anoxic brain injury with decorticate
posturing and/or seizures, elevated WBC, coffee-ground emesis,
and thick secretions.
.
#. Unresponsiveness: Pt found unresponsive at home, thought to
be due to overdose, possibly combination of increased dose of
methadone with other ingestions although history very unclear.
Did not respond initially to Narcan, and neuro exams previously
concerning per OSH records, including decorticate posturing,
question of intermittent seizures, and reportedly Head CT c/w
anoxic brain injury. At [**Hospital1 18**] extubation patient is responsive
and purposeful without sedation. Repeat NCHCT here without
concerning findings. Tox screen positive only for methadone. No
concerning deficits on neurologic exam. Psych evaluated patient
and felt there was no concern for suicide attempt.
.
#. Coffee-ground emesis: Reported at OSH. Likely secondary to
injury to lateral tongue during intubation. HCT remained stable
during hospitalization and no further coffee-ground emesis was
identified.
.
#. Leukocytosis: Thought to be secondary to acute stress
response. Initially started on Vancomycin, Levofloxacin, and
Flagyl. These were discontinued when transfered to general
medicine floor. Patient remained afebrile and leukocytosis
trended down.
.
#. Transaminitis: Very mild transaminitis during
hospitalization. Unclear if this is secondary to recent acute
illness, med effect, or more chronic process such as a viral
hepatitis. Transaminases trending down prior to discharge. These
will need to be followed as an outpatient after discharge.
Further, testing for hepatitis should be performed. Asymptomatic
at time of discharge.

Medications on Admission:
Paxil 20mg Daily
Methadone per clinic dosing

Discharge Medications:
1. Paxil 20 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Unresponsiveness NOS
Depression
Insomnia
Hx of Drug Abuse


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


Discharge Instructions:
Dear Ms. [**Known lastname 85002**],

It was a pleasure caring for you while you were admitted with
unresponsiveness. You were initially intubated to support your
breathing. It is unclear what led to this episode of
unresponsiveness. It may have been secondary to your recent
increase in Methadone dosing. We will contact your methadone
clinic regarding a lower methadone dose.
.
Please contact your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 8516**] [**Last Name (NamePattern1) 85003**]
([**Telephone/Fax (1) 85004**]) regarding a follow up appointment in the next
two weeks. Further, return to your methadone clinic on Monday
for continued care.
.
No changes were made to your medications regimen. Your Methadone
clnic should decrease your methadone dose, given concern that
this may have contributed to your medication regimen.
.
Again, it was a pleasure participating in your care.

Followup Instructions:
Please contact your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 8516**] [**Last Name (NamePattern1) 85003**]
([**Telephone/Fax (1) 85004**]) regarding a follow up appointment in the next
two weeks.
{'Poisoning by methadone,Cerebral edema,Acute respiratory failure,Pneumonia, organism unspecified,Hematemesis,Opioid type dependence, continuous,Poisoning by analgesics, antipyretics, and antirheumatics, undetermined whether accidentally or purposely inflicted,Home accidents,Altered mental status,Depressive disorder, not elsewhere classified,Open wound of tongue and floor of mouth, without mention of complication,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Anemia, unspecified'}


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: Unresponsiveness

PRESENT ILLNESS: Pt is a 32-yo woman with h/o IVDA recently started on Methadone,
who is admitted after being found unresponsive. The pt was found
unresponsive of unknown duration at her group home, lying supine
in bed. She had reportedly last been seen normal at ~1500 this
afternoon, approx 1-2 hours prior to being found unresponsive.
Reportedly, she had started on methadone on Monday, with an
increase in her dose from 45mg to 50mg yesterday. She also had
been vomiting for the past few days. She was initiated on
ventilation by BLS until EMS arrived. She was noted by EMS to
have pinpoint pupils, so she received Narcan 2mg IM + 2mg IV,
without significant effect except for a slight increase in
pupillary diameter. She was then intubated by rapid sequence
intubation and transported to [**Hospital3 20284**] Center.
.
At [**Hospital3 20284**] Center, she was noted to be pale, cool, and
dry, smelling of foul urine, with coffee-grounds from her NGT
and thick brown secretions from her ETT. GCS was 3 and she was
thought to have decorticate posturing and possibly intermittent
seizing, without change to Ativan 2mg IV x2 and Fosphenytoin.
Head CT showed diffuse cerebral edema with loss of white-[**Doctor Last Name 352**]
matter c/w anoxic brain injury, so she received Decadron 10mg IV
x1. ABG was 7.28/48.4/361.9, and CXR showed bilateral lower lobe
atelectasis and mild pulmonary vascular congestion. WBC was
elevated at 33.9 as well, so she received Levofloxacin 750mg IV
x1 and was ordered for Vancomycin 1gram IV x1. She also received
Protonix 40mg IV x1 and a 500cc NS IVF bolus. Urine tox was only
positive for methadone. She was transferred to [**Hospital1 18**] ED for
further evaluation.
.
In the ED, VS - BP 123/82, HR 76, R 18, SaO2 100% RA. She
remained intubated but was awake, moving her eyes and arms
purposefully, so she was sedated with midazolam and fentanyl
gtts. ECG and CXR were unremarkable, and NCHCT showed no ICH or
infarct. She is being admitted to the MICU for further care.
.
On arrival to the MICU, she was noted to desaturate while being
suctioned...

MEDICAL HISTORY: IVDU
Depression

MEDICATION ON ADMISSION: Paxil 20mg Daily
Methadone per clinic dosing

ALLERGIES: Aspirin / Cefuroxime Axetil

PHYSICAL EXAM: intubated, following commands, moving purposefully
NC/AT, PERRL/EOMI, sclera anicteric
supple, no LAD
lungs CTA bilat, no r/rh/wh
heart RRR, nl S1-S2, no MRG
abd +bs, soft/nt/nd, obese
extrem wwp no c/c/e
Diffuse scabs reflecting excoriations.

FAMILY HISTORY: NC

SOCIAL HISTORY: Homeless, Boyfriend.
Hx of IVDU currently in [**Hospital 2514**] clinic 

### Response:
{'Poisoning by methadone,Cerebral edema,Acute respiratory failure,Pneumonia, organism unspecified,Hematemesis,Opioid type dependence, continuous,Poisoning by analgesics, antipyretics, and antirheumatics, undetermined whether accidentally or purposely inflicted,Home accidents,Altered mental status,Depressive disorder, not elsewhere classified,Open wound of tongue and floor of mouth, without mention of complication,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Anemia, unspecified'}
