CHIEF COMPLAINT: Fall

PRESENT ILLNESS: 62 year old man with CAD in [**2138**] s/p RCA stenting, depression,
and alcoholism who was brought to [**Hospital1 18**] on [**2143-7-24**] after a
witnessed fall down stairs while intoxicated. Patient was unable
to recall the fall and denied LOC. CT findings demonstrated a
subarachnoid and left parietal lobe intraparenchymal hemorrhage.
Patient was also found to have alcohol withdrawl and
thrombocytopenia.

MEDICAL HISTORY: - MI s/p cardiac catheterization and stenting, [**2138**]
 - HTN
- Alcohol abuse
- Hx anterior cervical spinal fusion

MEDICATION ON ADMISSION: .  Information was obtained from .
1. Metoprolol Tartrate 12.5 mg PO BID
2. Escitalopram Oxalate 20 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
O: T:  98.6  BP: 140/80         HR:  110  R   18    O2Sats 99RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:    PERRLA     EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death, DM, HTN.

SOCIAL HISTORY: EtOH abuse, 40 pack year smoking history
Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Alcohol withdrawal,Cachexia,Acidosis,Thrombocytopenia, unspecified,Other emphysema,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Depressive disorder, not elsewhere classified,Accidental fall on or from other stairs or steps,Other chronic nonalcoholic liver disease,Solitary pulmonary nodule,Old myocardial infarction,Unspecified essential hypertension,Tobacco use disorder,Other and unspecified alcohol dependence, continuous
Subarachnoid hem-no coma,Alcohol withdrawal,Cachexia,Acidosis,Thrombocytopenia NOS,Emphysema NEC,Crnry athrscl natve vssl,Status-post ptca,Depressive disorder NEC,Fall on stair/step NEC,Chronic liver dis NEC,Solitary pulmonry nodule,Old myocardial infarct,Hypertension NOS,Tobacco use disorder,Alcoh dep NEC/NOS-contin
Admission Date:  [**2143-7-24**]              Discharge Date:   [**2143-7-30**]

Date of Birth:  [**2081-5-28**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

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

Major Surgical or Invasive Procedure:
Diagnostic cerebral angiogram

History of Present Illness:
62 year old man with CAD in [**2138**] s/p RCA stenting, depression,
and alcoholism who was brought to [**Hospital1 18**] on [**2143-7-24**] after a
witnessed fall down stairs while intoxicated. Patient was unable
to recall the fall and denied LOC. CT findings demonstrated a
subarachnoid and left parietal lobe intraparenchymal hemorrhage.
Patient was also found to have alcohol withdrawl and
thrombocytopenia.

Patient was initially admitted to intensive care under the
Neurosurgical service. ETOH withdrawl was treated with Ativan.
Cerebral bleeds were stable on CT although mental status has
waxed and waned. CT torso showed emphysema and a 5mm RLL nodule,
fatty liver, soft plaque in the descending aorta causing 40%
stenosis, 50% stenosis of the right common iliac artery.
Hematology was consulted for thrombocytopenia who felt that it
was most likely secondary to bone marrow suppression.

The patient was transferred to medicine for further managment of
his thrombocytopenia and alcohol withdrawl.  Vitals signs upon
transfer to medicine: BP-106/59, HR NSR in 60's 98% RA. He was
alert and oriented x3 and able to recount the events leading to
his admission. He was drinking while staying at his sister's
house and slipped at the top of the stairs and fell down the
entire flight. Currently denies pain, headache, tremor,
palpiations, diaphoresis. He is anxious to leave the hospital.

Past Medical History:
 - MI s/p cardiac catheterization and stenting, [**2138**]
 - HTN
- Alcohol abuse
- Hx anterior cervical spinal fusion


Social History:
EtOH abuse, 40 pack year smoking history

Family History:
There is no family history of premature coronary artery disease
or sudden death, DM, HTN.

Physical Exam:
On Admission:
O: T:  98.6  BP: 140/80         HR:  110  R   18    O2Sats 99RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:    PERRLA     EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.

Neuro:
Mental status: Somnolent but arousable, cooperative with exam,
normal affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-9**] objects at 5 minutes.
Language: Speech slightly slurred with good comprehension and
repetition.  No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-11**] throughout. No pronator drift

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Reflexes: B T Br Pa Ac
Right intact
Left  intact

Toes downgoing bilaterally
Coordination: normal on finger-nose-finger

On Discharge:
GENERAL: Awake, oriented, NAD. Multiple large, dark purple
bruises on back. torso, and limbs.
LUNGS: CTAB, no W/R/R
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly, no ascites
EXTREMITIES: No c/c/e, extemities wasted
NEUROLOGIC: A+OX3, no tremor or asterixis. CN II-XII intact.
Strength 5/5.

Pertinent Results:
ADMISSION LABS:

[**2143-7-23**] 10:35PM   PLT SMR-VERY LOW PLT COUNT-63*#
[**2143-7-23**] 10:35PM   PT-8.5* PTT-30.3 INR(PT)-0.8*
[**2143-7-23**] 10:35PM   WBC-8.5 RBC-4.43* HGB-15.3 HCT-44.0 MCV-99*
MCH-34.5* MCHC-34.8 RDW-14.9
[**2143-7-23**] 10:35PM   ASA-NEG ETHANOL-365* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2143-7-23**] 10:35PM   GLUCOSE-96 UREA N-17 CREAT-0.7 SODIUM-135
POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-20* ANION GAP-26*
[**2143-7-25**] 03:59AM BLOOD ALT-84* AST-69* AlkPhos-101 TotBili-1.0

STUDIES:

[**7-23**] CT head
1.  Subarachnoid hemorrhage in the right sylvian fissure and
suprasellar cistern.
2.  Intraparenchymal hemorrhage in the left parietal lobe in the
vertex and tiny punctate focus in the body of the right corpus
callosum.

[**7-23**] chest Xray: The lungs are well expanded and show a left
lower lobe mild patchy opacity, likely Atelectasis.  The
cardiomediastinal silhouette and hilar contours are normal.  No
pleural effusion or pneumothorax is present.  Partially imaged
is an anterior cervical fusion device. No displaced rib
fractures are noted.

[**7-23**] CT Cervical Spine: No acute fracture or malalignment.
As above, there is no acute abnormality.
However, there is circumferential lucency about the paired
screws in the C5 and C6, but no the C4 vertebral body, and, in
the absence of previous studies, loosening is a consideration.
Also noted is significant bilateral neural foraminal narrowing
at the C5/6 and C6/7 levels, with possible exiting neural
impingement.

[**7-24**] CT c/a/p:
IMPRESSION:
1.  No acute fracture.  Mild stranding in the subcutaneous
tissues overlying the left gluteal muscles.
2.  Fatty liver.
3.  5-mm right lower lobe nodule needs followup in 12 months if
the patient is low risk for malignancy and followup CT in six
months if the patient is high risk for malignancy.
4.  Diffuse calcific and non-calcific plaque causing 40%
narrowing of the
distal descending thoracic aorta, 50% stenosis of the celiac
artery and 50% stenosis of the right common iliac artery.

[**7-24**] CT head
IMPRESSION:
1.  Slight increase in size of the small parenchymal hemorrhage
at the left pareitovertex [**Doctor Last Name 352**]-white matter junction.
2.  No significant short-interval change in the amount or
distribution of the subarachnoid hemorrhage, predominantly in
the right basal cisterns.

[**7-24**] Cerebral angiogram
No aneurysm no apparent etiology to subarachnoid and parenchymal
hemorrhage.  Incidental notes include an infundibulum at the
origin of the left posterior communicating artery.

[**7-25**] CT head: stable hemorrhages, note made of left
frontoparietal subdural hygroma

DISCHARGE LABS:

[**2143-7-30**] 07:40AM BLOOD WBC-6.3 RBC-3.88* Hgb-13.3* Hct-39.4*
MCV-102* MCH-34.2* MCHC-33.7 RDW-15.3 Plt Ct-195#
[**2143-7-30**] 07:40AM BLOOD Glucose-107* UreaN-14 Creat-0.7 Na-141
K-3.8 Cl-102 HCO3-26 AnGap-17
[**2143-7-28**] 08:10AM BLOOD ALT-55* AST-43*
[**2143-7-30**] 07:40AM BLOOD Calcium-9.5 Phos-4.6* Mg-1.6
[**2143-7-25**] 02:07PM BLOOD calTIBC-212* VitB12-567 Folate-GREATER TH
Hapto-24* Ferritn-1759* TRF-163*


Brief Hospital Course:
Mr [**Name13 (STitle) **]  is a 62-year-old man with CAD in [**2138**] s/p RCA
stenting, depression, and alcoholism who was brought to [**Hospital1 18**] on
[**2143-7-24**] after a witnessed fall down stairs, developing a
subarachnoid and left parietal lobe intraparenchymal hemorrhage.


ACTIVE ISSUES THIS HOSPITALIZATION:

1. Intracranial bleed: Patient sustained but a traumatic
subarachnoid hemorrhage and a left parietal lobe
intraparenchymal hemorrhage during his fall. He was admitted to
the neurosurgical ICU for q4H neuro checks and SBP control <
140. His left parietal lobe intraparenchymal hemorrhage remained
stable on CT and his neuro exam remained non-focal. He did not
require surgical intervention. Patient was started on Keppra for
seizure prophylaxis. Upon transfer to the floor, his neuro exam
remained unremarkable and he was evaluated by PT and OT, who
recommended he make a visit with cognitive neurology. Patient
will follow up with Neurosurgery in 4 weeks. He will obtain head
CT prior to appointment.

2. Thrombocytopenia: Patient was noted to have low platelets,
with initial values in the 60's and a nadir in the low 40's.
Heparin-based products were held and patient received
pneumoboots for DVT prophylaxis. Hematology was consulted who
determined the thrombocytopenia was most likely secondary to
bone marrow suppression secondary to alcohol use. The patient
did not have signs of cirrhosis. His platelets trended up to
120's upon discharge without intervention, and he was counseled
extensively on alcohol cessation and the risk of recurrent bone
marrow suppression should he continue to drink.

3. ETOH abuse: Patient was maintained on CIWA protocol,
requiring up to 40mg IV ativan on [**2143-7-26**]. He last scored on
CIWA on [**2143-7-27**]. Upon transfer to medicine, patient was no
longer exhibiting signs of withdrawl. He received thiamine,
folate, and a multivitamin. He was counseled extensively on the
implications of his EtOH use and the importance of pursuing
outpatient treatment and enrolling in AA. Over the course of
hospitalization, patient's insight into the ramifications of his
drinking improved. He declined inpatient rehab placement but was
provided with a list of day treatment programs and planned to
take a month off from work to dedicate himself to sobriety.

4. Incidental CT finding: On [**7-23**] CT C-spine, lucency was noted
near screws of anterior cervical fusions, read as possible
loosening. This finding was followed up with lateral c-spine
flexion and extension x-rays, which showed minimal lucency
around the screws of C6, which might represent some loosening.
Otherwise, moderate degenerative changes more pronounced at
C6-C7, but no fracture, malalignment or dynamic instability.
Patient will follow up with neurosurgery as an outpatient.

5. Incidental CT finding: 5mm RLL nodule.  Recommended follow-up
CT in 6 months for high risk patients.

CHRONIC ISSUES:

1. HLD: Patient was continued on atorvastatin

2. HTN: Patient was continued on metoprolol and lisinopril with
goal SBP <140 as per neurosurgery recommendations.

3. Depression: Patient was continued on escitalopram

TRANSITIONAL ISSUES:
- Monitor for new neurological deficits and follow up head CT to
ensure improvement
- Trend platelets
- Follow up alcohol cessation
- Follow-up CT for incidental 5mm RLL lung nodule in 6 months
- Continue to monitor for signs of instability at anterior
cervical fusion site

Medications on Admission:
.  Information was obtained from .
1. Metoprolol Tartrate 12.5 mg PO BID
2. Escitalopram Oxalate 20 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY


Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Escitalopram Oxalate 20 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. LeVETiracetam 500 mg PO BID
RX *Keppra 500 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*2
7. Multivitamins 1 TAB PO DAILY
RX *Daily Multi-Vitamin   1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
8. Nicotine Patch 21 mg TD DAILY
RX *Nicoderm CQ 21 mg/24 hour Wear on patch once a day Disp #*14
Unit Refills:*0
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0


Discharge Disposition:
Home

Discharge Diagnosis:
Intracranial hemorrahge
Thrombocytopenia
Alcohol withdrawal


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


Discharge Instructions:
Dear Mr. [**Name13 (STitle) 12101**],

It was a pleasure caring for you during your admission to [**Hospital 61**]. As you know, you were admitted for a bleed in your brain
after having a fall in the setting of alcohol intoxication. Your
bleed was monitored and you were treated for alcohol withdrawal.
You were also found to have low platelets, which resolved and
which were most likely due to your alcohol use.

General Instructions from the Neurosurgical Team:
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
??????	You have been prescribed Keppra for anti-seizure medicine,
take it as prescribed.
?????? Call your doctor immediately for:
-	New onset of tremors or seizures.
??????	Any confusion, lethargy or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.
??????	New onset of the loss of function, or decrease of function on
one whole side of your body.

You were also seen by Occupational Therapy, who recommended you
set up an appointment with Cognitive Neurology at [**Hospital1 18**] at
[**Telephone/Fax (1) 6335**].

We strongly recommend that you enroll in an outpatient alcohol
treatment program and attend AA meetings at least once per day.
We have also booked you a follow-up appointment with Dr. [**Last Name (STitle) **]
for [**8-6**].

You had a lung nodule on your CT scan (5-mm right lower lobe
nodule) and should have follow up CT scan in 6 months. This
nodule has a risk of malignancy, so it is very important to
follow up with your primary doctor.

Once again, it was a pleasure caring for you and we wish you the
best,

[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51079**], MD

Followup Instructions:
Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.

You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.

We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment, please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].

We have established an appointment for you with your primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], for Tuesday, [**2143-8-6**] at
3:15pm. His contact information is below if you need to change
the appointment:
Name: [**Last Name (LF) **],[**First Name3 (LF) 251**] T.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Fax: [**Telephone/Fax (1) 29683**]
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Alcohol withdrawal,Cachexia,Acidosis,Thrombocytopenia, unspecified,Other emphysema,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Depressive disorder, not elsewhere classified,Accidental fall on or from other stairs or steps,Other chronic nonalcoholic liver disease,Solitary pulmonary nodule,Old myocardial infarction,Unspecified essential hypertension,Tobacco use disorder,Other and unspecified alcohol dependence, continuous'}


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: Fall

PRESENT ILLNESS: 62 year old man with CAD in [**2138**] s/p RCA stenting, depression,
and alcoholism who was brought to [**Hospital1 18**] on [**2143-7-24**] after a
witnessed fall down stairs while intoxicated. Patient was unable
to recall the fall and denied LOC. CT findings demonstrated a
subarachnoid and left parietal lobe intraparenchymal hemorrhage.
Patient was also found to have alcohol withdrawl and
thrombocytopenia.

MEDICAL HISTORY: - MI s/p cardiac catheterization and stenting, [**2138**]
 - HTN
- Alcohol abuse
- Hx anterior cervical spinal fusion

MEDICATION ON ADMISSION: .  Information was obtained from .
1. Metoprolol Tartrate 12.5 mg PO BID
2. Escitalopram Oxalate 20 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
O: T:  98.6  BP: 140/80         HR:  110  R   18    O2Sats 99RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:    PERRLA     EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death, DM, HTN.

SOCIAL HISTORY: EtOH abuse, 40 pack year smoking history 

### Response:
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Alcohol withdrawal,Cachexia,Acidosis,Thrombocytopenia, unspecified,Other emphysema,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Depressive disorder, not elsewhere classified,Accidental fall on or from other stairs or steps,Other chronic nonalcoholic liver disease,Solitary pulmonary nodule,Old myocardial infarction,Unspecified essential hypertension,Tobacco use disorder,Other and unspecified alcohol dependence, continuous'}
