CHIEF COMPLAINT: Altered Mental Status

PRESENT ILLNESS: The patient is a 27 yoM w/ h/o bipolar disorder presenting with
mania and delerium sent in from his psychiatrist's office.  The
patient is currently providing an unreliable history however per
his brother in law and his sister the patient has had recent
poor adherence to his medications and is has had erratic bizarre
behavior x 3 months.  Since then he has stopped taking his meds,
per his sister he seems like he was "on speed" and never sleeps.
 The patient was evaluated by psychiatry in the ER who thought
the patient had delerious or psychotic mania and had some
catatonic features such as echolalia.  He has hallucinations as
well.  Given delerium (not oriented to place or time) he was
admitted to medicine service to rule out toxic metabolic cause
prior to psychiatric inpt admission.
.
In the ED, initial VS: T 100.3 HR 127 BP 152/97 RR 18 O2 sat:
100% RA.   In the ER he rec'd valium 10mg IV and 2mg IV ativan x
4 doses.  He also was combative in the ER and jumped out of bed,
ran into the hallway and attempted to grab a nurse by the neck.
  Due to low grade temp there was a plan for LP but given his
combativeness was unable, so he was given vanc/ceftriaxone and
acyclovir.  Prior to his transfer to the floor his VS were: HR
92 BP 119/57  RR 14  O2 sat: 97% on RA.
.
Currently the patient has complaints of low back pain x 7 days,
no other complaints.  He is asking for food from legal sea foods
and occasionally yells non-sense phrases out but during other
times is sleeping heavily.  He is unable to provide adequate
history.

MEDICAL HISTORY: PSYCHIATRIC HISTORY (INCLUDE PRIOR HOSPITALIZATIONS, OUTPATIENT
TREATMENTS, MEDICATION/ECT HISTORY, RESPONSE TO TREATMENT,
HISTORY OF HOMICIDAL/SUICIDAL/ASSAULTIVE BEHAVIOR):
-[**First Name3 (LF) 8372**]: diagnosed in teens, "major downturn in college," has been
stabilized on Lithium in the past
-ADHD
-No previous psychiatric hospitalizations
-No previous SA
.
PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES,
OR OTHER NEUROLOGIC ILLNESS):
-s/p assault in HS (?skull fracture)
-severed ulnar nerve s/p repair

MEDICATION ON ADMISSION: Seroquel
Ambien
Lexapro

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: Vitals - T: 98.9 BP: 106/63 HR: 66 RR: 15 02 sat:  94% RA
GENERAL:  sleeping, AOx1 (person), thinks he is at the [**Hospital1 112**] and
thinks it is [**2108-3-10**].  He is unaware of why he is in the
hospital.
HEENT:  OP clear, JVP 8cm
CARDIAC:  RRR, no m/r/g
LUNG:  CTAB
ABDOMEN:  BS+, soft, NT, ND, no masses or organomegaly
EXT:  WWP, no c/c/e
NEURO:  somnolent, occasionally yells out phrases that are
non-sense, answers questions appropriately sometimes, AOx1,
occasional agitation. PERRL (3mm --> 2mm).  able to follow
commands, [**4-25**] grip stregnth bilaterally, [**4-25**] LE stregnth.  no
spinous process tenderness.  no myoclonus.  unable to cooperate
with rest of neuro exam.
DERM:  flush, bilateral hand abrasions with dorsal surface
erythema- blanching, blanching erythema of the knees bilaterally

FAMILY HISTORY: (per OMR) 2 brothers: both with [**Name (NI) 8372**], 1 with schizophrenia.
Father: depression.   Paternal aunt: depression s/p ECT.

SOCIAL HISTORY: (per OMR)  Lives alone. Is a 2nd year law student at NE. Likes
to go to bars, frequent barfights. Had 1 arrest for assaultive
behavior while at U Mich [**Hospital1 69333**]. Had 1 arrest for assault
within the past year (case dismissed after community service).
No history of physical or sexual abuse.  H/o cocaine, heroin
(per family no known h/o IVDU) and ETOH abuse.
Bipolar I disorder, single manic episode, severe, specified as with psychotic behavior,Cellulitis and abscess of hand, except fingers and thumb,Lumbago,Unspecified psychosis
Bipo I sin man-sev w psy,Cellulitis of hand,Lumbago,Psychosis NOS
Name:  [**Known lastname 12251**],[**Known firstname **]                 Unit No:   [**Numeric Identifier 12252**]

Admission Date:  [**2136-3-8**]              Discharge Date:   [**2136-3-9**]

Date of Birth:  [**2108-10-26**]             Sex:   M

Service: EMERGENCY

Allergies:
No Drug Allergy Information on File

Attending:[**First Name3 (LF) 11940**]
Addendum:
# Question of hand cellulitis given bilateral hand erythema and
several abrasions.  Erythema was likely secondary to patient's
struggle against restraints as the erythema resolved with
sedation.  He was treated with clindaymycin for 36 hours and
then discontinued as no active sign of infection.  Recommend
close monitoring of hands and abrasions.  Would restart a 7 day
course of clindamycin should patient develop signs of infection.

# Etoh abuse: Per patient and family he has been binge drinking
recently in the setting of his manic symptoms, but they deny any
history of etoh dependence or withdrawal symptoms so unlikely to
have withdrawal and low risk for Wernicke's.  However, would
continue to monitor withdrawal and provide daily banana bags
with thiamine particulary if patient remains too
sedated/agitated to tolerate po diet.


Discharge Disposition:
Extended Care

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11942**] MD [**MD Number(2) 11943**]

Completed by:[**2136-3-9**]

Admission Date:  [**2136-3-8**]              Discharge Date:   [**2136-3-9**]

Date of Birth:  [**2108-10-26**]             Sex:   M

Service: EMERGENCY

Allergies:
No Drug Allergy Information on File

Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Altered Mental Status

Major Surgical or Invasive Procedure:
None


History of Present Illness:
The patient is a 27 yoM w/ h/o bipolar disorder presenting with
mania and delerium sent in from his psychiatrist's office.  The
patient is currently providing an unreliable history however per
his brother in law and his sister the patient has had recent
poor adherence to his medications and is has had erratic bizarre
behavior x 3 months.  Since then he has stopped taking his meds,
per his sister he seems like he was "on speed" and never sleeps.
 The patient was evaluated by psychiatry in the ER who thought
the patient had delerious or psychotic mania and had some
catatonic features such as echolalia.  He has hallucinations as
well.  Given delerium (not oriented to place or time) he was
admitted to medicine service to rule out toxic metabolic cause
prior to psychiatric inpt admission.
.
In the ED, initial VS: T 100.3 HR 127 BP 152/97 RR 18 O2 sat:
100% RA.   In the ER he rec'd valium 10mg IV and 2mg IV ativan x
4 doses.  He also was combative in the ER and jumped out of bed,
ran into the hallway and attempted to grab a nurse by the neck.
  Due to low grade temp there was a plan for LP but given his
combativeness was unable, so he was given vanc/ceftriaxone and
acyclovir.  Prior to his transfer to the floor his VS were: HR
92 BP 119/57  RR 14  O2 sat: 97% on RA.
.
Currently the patient has complaints of low back pain x 7 days,
no other complaints.  He is asking for food from legal sea foods
and occasionally yells non-sense phrases out but during other
times is sleeping heavily.  He is unable to provide adequate
history.

Past Medical History:
PSYCHIATRIC HISTORY (INCLUDE PRIOR HOSPITALIZATIONS, OUTPATIENT
TREATMENTS, MEDICATION/ECT HISTORY, RESPONSE TO TREATMENT,
HISTORY OF HOMICIDAL/SUICIDAL/ASSAULTIVE BEHAVIOR):
-[**First Name3 (LF) 8372**]: diagnosed in teens, "major downturn in college," has been
stabilized on Lithium in the past
-ADHD
-No previous psychiatric hospitalizations
-No previous SA
.
PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES,
OR OTHER NEUROLOGIC ILLNESS):
-s/p assault in HS (?skull fracture)
-severed ulnar nerve s/p repair


Social History:
(per OMR)  Lives alone. Is a 2nd year law student at NE. Likes
to go to bars, frequent barfights. Had 1 arrest for assaultive
behavior while at U Mich [**Hospital1 69333**]. Had 1 arrest for assault
within the past year (case dismissed after community service).
No history of physical or sexual abuse.  H/o cocaine, heroin
(per family no known h/o IVDU) and ETOH abuse.


Family History:
(per OMR) 2 brothers: both with [**Name (NI) 8372**], 1 with schizophrenia.
Father: depression.   Paternal aunt: depression s/p ECT.


Physical Exam:
Vitals - T: 98.9 BP: 106/63 HR: 66 RR: 15 02 sat:  94% RA
GENERAL:  sleeping, AOx1 (person), thinks he is at the [**Hospital1 112**] and
thinks it is [**2108-3-10**].  He is unaware of why he is in the
hospital.
HEENT:  OP clear, JVP 8cm
CARDIAC:  RRR, no m/r/g
LUNG:  CTAB
ABDOMEN:  BS+, soft, NT, ND, no masses or organomegaly
EXT:  WWP, no c/c/e
NEURO:  somnolent, occasionally yells out phrases that are
non-sense, answers questions appropriately sometimes, AOx1,
occasional agitation. PERRL (3mm --> 2mm).  able to follow
commands, [**4-25**] grip stregnth bilaterally, [**4-25**] LE stregnth.  no
spinous process tenderness.  no myoclonus.  unable to cooperate
with rest of neuro exam.
DERM:  flush, bilateral hand abrasions with dorsal surface
erythema- blanching, blanching erythema of the knees bilaterally


Pertinent Results:
[**2136-3-8**] 04:00AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2136-3-8**] 04:00AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2136-3-8**] 04:00AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2136-3-8**] 04:00AM URINE  RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0
[**2136-3-7**] 08:51PM   LACTATE-1.0
[**2136-3-7**] 08:45PM   GLUCOSE-163* UREA N-19 CREAT-1.1 SODIUM-137
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-26 ANION GAP-14
[**2136-3-7**] 08:45PM   ALT(SGPT)-46* AST(SGOT)-56* LD(LDH)-220
CK(CPK)-864* ALK PHOS-66 TOT BILI-0.5
[**2136-3-7**] 08:45PM   LIPASE-36
[**2136-3-7**] 08:45PM   ALBUMIN-4.6 CALCIUM-9.3 PHOSPHATE-2.5*
MAGNESIUM-2.1
[**2136-3-7**] 08:45PM   TSH-1.7
[**2136-3-7**] 08:45PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2136-3-7**] 08:45PM   WBC-8.0 RBC-4.77 HGB-14.3 HCT-41.1 MCV-86
MCH-29.9 MCHC-34.7 RDW-12.0
[**2136-3-7**] 08:45PM   NEUTS-71.1* LYMPHS-21.6 MONOS-5.0 EOS-1.5
BASOS-0.8
[**2136-3-7**] 08:45PM   PLT COUNT-278
.
[**2136-3-7**] Hand A&P: No acute fracture, dislocation, or foreign
body of the left or right hand.
.
[**2136-3-7**] CXR: No acute intrathoracic abnormality
.
[**2136-3-8**] Head CT: No acute intracranial hemorrhage or edema.

Brief Hospital Course:
The patient is a 27 yoM w/ h/o bipolar disorder presenting with
mania and delerium.
.
# Altered mental status: Patient was not oriented on
presentation and was very aggressive. He became oriented to
person and place over the first 12 hours but his alertness has
waxed and waned with the the administration of sedating
medications.  Patient remained significantly agitated and
aggressive. Due to his aggression and attempted assault of
hospital staff he was maintained in four point restraints.
Initial disorientation was concerning for delirium.  Patient's
subsequent infectious and metabolic work up was negative. Head
CT was also negative for evidence of brain trauma. His serum and
urine toxicology screens were negative making acute intoxication
less likely.  He was monitored closely for evidence of
withdrawal. Patient's disorientation most likely represented
psychosis related to his underlying psychiatric illness.  Family
reports recent history of mania in the setting of not adhering
to his bipolar medication regimen. Psychiatry was consulted.
Per their recommendations he was started on zyprexa, cogentin,
and haldol. His home psychiatric medications of ambien, lexapro
and seroquel were held. He required several boluses of haldol
for extreme agitation.  He was medically cleared and discharged
for further psychiatric treatment to an inpatient psychiatric
facility.
.
# Fever: Low grade temp of 100.6 on admission with normal WBC
count and normal differential. Etiology unclear likely secondary
to agitation or intoxication as his infectious work up remained
negative and temperatures returned to [**Location 213**].  Due to erythema
of bilateral hands with several small abrasions he was started
on clindamycin for possible cellulitis.  After 24 hours erythema
resolved and showed no evidence of active infection.
Antibiotics were discontinued.
.
# Chronic back pain: Per patient and family, he does not use IV
drugs making osteomyelitis less likely and does not need to be
worked up immediately.
.
# Mild transaminse elevation: Unclear baseline, reports of
increased etoh use in the last week.  Recommend out patient work
up including hepatitis serologies.
.
# CODE:  FULL
# CONTACT:  Mother
# ICU CONSENT: Signed
# DISPO: Psychiatric inpatient facility ([**Hospital1 **] 4)

Medications on Admission:
Seroquel
Ambien
Lexapro

Discharge Medications:
1. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
2. Benztropine 2 mg/2 mL Solution Sig: One (1) mg Injection [**Hospital1 **]
(2 times a day) as needed for when he receives haldol.
3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO BID (2 times a day).
4. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) mg
Injection IV DRIP (via continous IV drip): 1 mg per hour.
5. Multivitamin injection/thiamine 100 mg IV once per day
(banana bag)particularly while not taking PO


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Bipolar Disorder with acute mania
Psychosis NOS


Discharge Condition:
Hemodynamically stable, altered alertness, oriented to person
and place.


Discharge Instructions:
You presented to the Emergency Department with extreme agitation
and confusion.  Because of your aggressive behavior you required
significant sedation and the decision was made to monitor you in
the ICU.  During your ICU admission you were evaluated for
underlying illness and infection to account for your altered
mental status.  No underlying infection or metabolic abnormality
was identified.  The psychiatry team was consulted and they
recommended admission to a psychiatric facility for further
management of your symptoms and titration of medications.

Followup Instructions:
Please follow up with your primary care provider within two
weeks of discharge to have your liver function monitored.
{'Bipolar I disorder, single manic episode, severe, specified as with psychotic behavior,Cellulitis and abscess of hand, except fingers and thumb,Lumbago,Unspecified psychosis'}


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: The patient is a 27 yoM w/ h/o bipolar disorder presenting with
mania and delerium sent in from his psychiatrist's office.  The
patient is currently providing an unreliable history however per
his brother in law and his sister the patient has had recent
poor adherence to his medications and is has had erratic bizarre
behavior x 3 months.  Since then he has stopped taking his meds,
per his sister he seems like he was "on speed" and never sleeps.
 The patient was evaluated by psychiatry in the ER who thought
the patient had delerious or psychotic mania and had some
catatonic features such as echolalia.  He has hallucinations as
well.  Given delerium (not oriented to place or time) he was
admitted to medicine service to rule out toxic metabolic cause
prior to psychiatric inpt admission.
.
In the ED, initial VS: T 100.3 HR 127 BP 152/97 RR 18 O2 sat:
100% RA.   In the ER he rec'd valium 10mg IV and 2mg IV ativan x
4 doses.  He also was combative in the ER and jumped out of bed,
ran into the hallway and attempted to grab a nurse by the neck.
  Due to low grade temp there was a plan for LP but given his
combativeness was unable, so he was given vanc/ceftriaxone and
acyclovir.  Prior to his transfer to the floor his VS were: HR
92 BP 119/57  RR 14  O2 sat: 97% on RA.
.
Currently the patient has complaints of low back pain x 7 days,
no other complaints.  He is asking for food from legal sea foods
and occasionally yells non-sense phrases out but during other
times is sleeping heavily.  He is unable to provide adequate
history.

MEDICAL HISTORY: PSYCHIATRIC HISTORY (INCLUDE PRIOR HOSPITALIZATIONS, OUTPATIENT
TREATMENTS, MEDICATION/ECT HISTORY, RESPONSE TO TREATMENT,
HISTORY OF HOMICIDAL/SUICIDAL/ASSAULTIVE BEHAVIOR):
-[**First Name3 (LF) 8372**]: diagnosed in teens, "major downturn in college," has been
stabilized on Lithium in the past
-ADHD
-No previous psychiatric hospitalizations
-No previous SA
.
PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES,
OR OTHER NEUROLOGIC ILLNESS):
-s/p assault in HS (?skull fracture)
-severed ulnar nerve s/p repair

MEDICATION ON ADMISSION: Seroquel
Ambien
Lexapro

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: Vitals - T: 98.9 BP: 106/63 HR: 66 RR: 15 02 sat:  94% RA
GENERAL:  sleeping, AOx1 (person), thinks he is at the [**Hospital1 112**] and
thinks it is [**2108-3-10**].  He is unaware of why he is in the
hospital.
HEENT:  OP clear, JVP 8cm
CARDIAC:  RRR, no m/r/g
LUNG:  CTAB
ABDOMEN:  BS+, soft, NT, ND, no masses or organomegaly
EXT:  WWP, no c/c/e
NEURO:  somnolent, occasionally yells out phrases that are
non-sense, answers questions appropriately sometimes, AOx1,
occasional agitation. PERRL (3mm --> 2mm).  able to follow
commands, [**4-25**] grip stregnth bilaterally, [**4-25**] LE stregnth.  no
spinous process tenderness.  no myoclonus.  unable to cooperate
with rest of neuro exam.
DERM:  flush, bilateral hand abrasions with dorsal surface
erythema- blanching, blanching erythema of the knees bilaterally

FAMILY HISTORY: (per OMR) 2 brothers: both with [**Name (NI) 8372**], 1 with schizophrenia.
Father: depression.   Paternal aunt: depression s/p ECT.

SOCIAL HISTORY: (per OMR)  Lives alone. Is a 2nd year law student at NE. Likes
to go to bars, frequent barfights. Had 1 arrest for assaultive
behavior while at U Mich [**Hospital1 69333**]. Had 1 arrest for assault
within the past year (case dismissed after community service).
No history of physical or sexual abuse.  H/o cocaine, heroin
(per family no known h/o IVDU) and ETOH abuse. 

### Response:
{'Bipolar I disorder, single manic episode, severe, specified as with psychotic behavior,Cellulitis and abscess of hand, except fingers and thumb,Lumbago,Unspecified psychosis'}
