CHIEF COMPLAINT: alcohol withdrawal

PRESENT ILLNESS: The patient is a 61 year old male with a history of
polysubstance abuse, Hepatitis C infection, CAD s/p stent in
[**2163**], and distant left arm amputation who presented to the ED
requesting detox last night on [**2165-6-26**].  He reported that his
last drink was at 3:00 PM earlier that day.  He was recently
admitted to [**Hospital1 18**] from [**2165-5-22**] to [**2165-5-24**] for alcohol withdrawal
and suicidal ideation.
.
During his previous admission, he remained hemodynamically
stable, but continued to require Diazepam approximately every 2
hours per CIWA scale, receiving a total of 170 mg over three
days.  His CIWA [**Doctor Last Name **] was driven primarily by anxiety and
agitation.  It was not clear whether his symptoms were entirely
due to alcohol withdrawal or his underlying psychiatric
condition.  Psychiatry was consulted, and was placed on Section
12.  He was discharged to the [**Hospital1 1680**] inpatient psychiatric unit
for further evaluation and treatment.
.
In the ED, initial vital signs were T 99.2, BP 167/96, HR 101,
RR 16, and SpO2 96% on RA.  Exam showed signs of alcohol
withdrawal with tremor, agitation, and headache.  EKG showed NSR
at 93 bpm with small R waves in III and aVF unchanged from prior
and no acute ischemic changes.  He received Diazepam 10 mg PO
twice in the early morning.  He continued to show signs of
withdrawal and received an additional Diazepam 10 mg IV three
times.  He was given Thiamine 100 mg, Folic acid 1 mg, and a
Multivitamin.  Labs were checked at 07:00 with serum ethanol
level 96 and otherwise negative serum tox screen.  No urine tox
screen was performed.  His electrolyte panel showed bicarb 25
and anion gap 15, but was otherwise unremarkable.  His WBC count
was elevated to 12.2 with normal diff except for 1% metas.  He
denied any localizing symptoms of infection and no infection
workup was started.  His platelets were low at 100, and
significantly down from 229 on [**2165-5-24**].  His Hct was 43.3,
slightly up from his baseline.
.
He continued to have withdrawal symptoms despite receiving a
total of Diazepam 50 mg in the ED with CIWA remaining elevated
primarily for agitation, tremor, and headache.  He remained
hemodynamically stable in the ED and was alert, oriented, and
conversant.  There was no evidence of seizure activity,
delirium, or hallucination.  He was admitted to the ICU for
continued monitoring and treatment of his withdrawal.  Vitals
prior to transfer were T afebrile, BP 140/70, HR 110, and SpO2
100% on RA.
.
Once in the ICU, he continued to score on CIWA and reported
anxiety, tremor, and headache.  He was hemodynamically stable
with HR in the 90s and BP in the 130s-140s.  He spiked a fever
to 101.2 on arrival.  He reported that he had been drinking
about 0.5 gallons of vodka daily since shortly after discharge
from [**Hospital1 1680**].  He also reported that he has recently been taking
6-8 mg of Klonopin and Xanax daily, as well as [**3-5**] Vicodin
daily.  He denied any injection drug use in several years since
a prior suicide attempt.  He denied any current active suicidal
ideation.  He says that he has been trying to take his Aspirin,
but sometimes forgets.  His chief complaint was headache for
which he requested narcotic pain medications or Tramadol.

MEDICAL HISTORY: - Polysubstance abuse, including heroin>40 years and multiple
BZDs
- Hit by a car at the age of 4 and suffered extensive injuries
including a skull fracture, bilateral broken legs and required
above the elbow amputation of the left arm.
- Hepatitis C diagnosed 10-15 years ago, never treated
- Right hip arthritis
- Cellulitis
- CAD s/p stent in [**2163**]

MEDICATION ON ADMISSION: (per last discharge [**2165-5-24**] in OMR)
Aspirin 325 mg PO daily -- taking intermittently
Acetaminophen 650 mg PO Q6H PRN pain -- not taking
Olanzapine 2.5 mg PO TID PRN agitation -- not taking
Diazepam 10 mg Taper -- completed at [**Hospital1 1680**]

ALLERGIES: All allergies / adverse drug reactions previously recorded have
been deleted

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T 101.2, BP 140/79, HR 98, RR 17, SpO2 96% on RA
General: Alert, attentive, oriented x3, agitated with tremor, no
nystagmus
HEENT: Sclera anicteric, dry MMs, oropharynx clear, dentures
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally.  Initial rhonchi in
upper lung fields that cleared with cough.
CV: Regular rate and rhythm. Normal S1, S2.  Early peaking C-D
murmur at RUSB and LLSB without radiation.
Abdomen: Bowel sounds present.  Soft, non-tender, mildly
distended and tympanic.  No rebound tenderness or guarding.
GU: No foley
Ext: Warm, well perfused.  Left arm amputated above elbow and
atrophied.  Distal pulses 2+. No cyanosis, clubbing, or edema.
Skin: Healing abrasion on right lower leg.

FAMILY HISTORY: No family history of seizure, stroke, SCD.

SOCIAL HISTORY: Originally from [**Location (un) **].  No family in the area. Currently
homeless.  Spent 17 years total in prison.
# Tobacco: Has smoked [**12-2**] PPD for over 40 years.
# Alcohol: Multiple admissions for detox. Currently reports
drinking 0.5 gallons vodka daily.
# Illicits: Polysubstance abuse with narcotics including heroine
and multiple benzodiazepines. Prior 40 year history of IVDU.
Alcohol withdrawal,Acidosis,Thrombocytopenia, unspecified,Suicidal ideation,Unspecified viral hepatitis C without hepatic coma,Acute alcoholic hepatitis,Tobacco use disorder,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Unspecified level upper limb amputation status
Alcohol withdrawal,Acidosis,Thrombocytopenia NOS,Suicidal ideation,Hpt C w/o hepat coma NOS,Ac alcoholic hepatitis,Tobacco use disorder,Crnry athrscl natve vssl,Status-post ptca,Status amput up lmb NOS
Admission Date:  [**2165-6-27**]              Discharge Date:   [**2165-6-28**]

Date of Birth:  [**2103-7-13**]             Sex:   M

Service: MEDICINE

Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
alcohol withdrawal

Major Surgical or Invasive Procedure:
none

History of Present Illness:
The patient is a 61 year old male with a history of
polysubstance abuse, Hepatitis C infection, CAD s/p stent in
[**2163**], and distant left arm amputation who presented to the ED
requesting detox last night on [**2165-6-26**].  He reported that his
last drink was at 3:00 PM earlier that day.  He was recently
admitted to [**Hospital1 18**] from [**2165-5-22**] to [**2165-5-24**] for alcohol withdrawal
and suicidal ideation.
.
During his previous admission, he remained hemodynamically
stable, but continued to require Diazepam approximately every 2
hours per CIWA scale, receiving a total of 170 mg over three
days.  His CIWA [**Doctor Last Name **] was driven primarily by anxiety and
agitation.  It was not clear whether his symptoms were entirely
due to alcohol withdrawal or his underlying psychiatric
condition.  Psychiatry was consulted, and was placed on Section
12.  He was discharged to the [**Hospital1 1680**] inpatient psychiatric unit
for further evaluation and treatment.
.
In the ED, initial vital signs were T 99.2, BP 167/96, HR 101,
RR 16, and SpO2 96% on RA.  Exam showed signs of alcohol
withdrawal with tremor, agitation, and headache.  EKG showed NSR
at 93 bpm with small R waves in III and aVF unchanged from prior
and no acute ischemic changes.  He received Diazepam 10 mg PO
twice in the early morning.  He continued to show signs of
withdrawal and received an additional Diazepam 10 mg IV three
times.  He was given Thiamine 100 mg, Folic acid 1 mg, and a
Multivitamin.  Labs were checked at 07:00 with serum ethanol
level 96 and otherwise negative serum tox screen.  No urine tox
screen was performed.  His electrolyte panel showed bicarb 25
and anion gap 15, but was otherwise unremarkable.  His WBC count
was elevated to 12.2 with normal diff except for 1% metas.  He
denied any localizing symptoms of infection and no infection
workup was started.  His platelets were low at 100, and
significantly down from 229 on [**2165-5-24**].  His Hct was 43.3,
slightly up from his baseline.
.
He continued to have withdrawal symptoms despite receiving a
total of Diazepam 50 mg in the ED with CIWA remaining elevated
primarily for agitation, tremor, and headache.  He remained
hemodynamically stable in the ED and was alert, oriented, and
conversant.  There was no evidence of seizure activity,
delirium, or hallucination.  He was admitted to the ICU for
continued monitoring and treatment of his withdrawal.  Vitals
prior to transfer were T afebrile, BP 140/70, HR 110, and SpO2
100% on RA.
.
Once in the ICU, he continued to score on CIWA and reported
anxiety, tremor, and headache.  He was hemodynamically stable
with HR in the 90s and BP in the 130s-140s.  He spiked a fever
to 101.2 on arrival.  He reported that he had been drinking
about 0.5 gallons of vodka daily since shortly after discharge
from [**Hospital1 1680**].  He also reported that he has recently been taking
6-8 mg of Klonopin and Xanax daily, as well as [**3-5**] Vicodin
daily.  He denied any injection drug use in several years since
a prior suicide attempt.  He denied any current active suicidal
ideation.  He says that he has been trying to take his Aspirin,
but sometimes forgets.  His chief complaint was headache for
which he requested narcotic pain medications or Tramadol.


Past Medical History:
- Polysubstance abuse, including heroin>40 years and multiple
BZDs
- Hit by a car at the age of 4 and suffered extensive injuries
including a skull fracture, bilateral broken legs and required
above the elbow amputation of the left arm.
- Hepatitis C diagnosed 10-15 years ago, never treated
- Right hip arthritis
- Cellulitis
- CAD s/p stent in [**2163**]


Social History:
Originally from [**Location (un) **].  No family in the area. Currently
homeless.  Spent 17 years total in prison.
# Tobacco: Has smoked [**12-2**] PPD for over 40 years.
# Alcohol: Multiple admissions for detox. Currently reports
drinking 0.5 gallons vodka daily.
# Illicits: Polysubstance abuse with narcotics including heroine
and multiple benzodiazepines. Prior 40 year history of IVDU.


Family History:
No family history of seizure, stroke, SCD.

Physical Exam:
Admission Physical Exam:
Vitals: T 101.2, BP 140/79, HR 98, RR 17, SpO2 96% on RA
General: Alert, attentive, oriented x3, agitated with tremor, no
nystagmus
HEENT: Sclera anicteric, dry MMs, oropharynx clear, dentures
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally.  Initial rhonchi in
upper lung fields that cleared with cough.
CV: Regular rate and rhythm. Normal S1, S2.  Early peaking C-D
murmur at RUSB and LLSB without radiation.
Abdomen: Bowel sounds present.  Soft, non-tender, mildly
distended and tympanic.  No rebound tenderness or guarding.
GU: No foley
Ext: Warm, well perfused.  Left arm amputated above elbow and
atrophied.  Distal pulses 2+. No cyanosis, clubbing, or edema.
Skin: Healing abrasion on right lower leg.

ICU Discharge Exam:
Patient left AMA.

Pertinent Results:
[**2165-6-27**] 07:00AM   ASA-NEG ETHANOL-96* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
[**2165-6-27**] 07:00AM   WBC-12.2*# RBC-4.68 HGB-15.1 HCT-43.3 MCV-93
MCH-32.2* MCHC-34.8 RDW-14.1
[**2165-6-27**] 07:00AM   NEUTS-70 BANDS-0 LYMPHS-24 MONOS-3 EOS-2
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2165-6-27**] 07:00AM   PLT SMR-LOW PLT COUNT-100*#
.
[**2165-6-27**] 07:00AM   GLUCOSE-87 UREA N-11 CREAT-0.9 SODIUM-143
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-25 ANION GAP-19
[**2165-6-27**] 07:00AM   ALBUMIN-4.2 CALCIUM-8.6 PHOSPHATE-3.2
MAGNESIUM-1.7
.
[**2165-6-27**] 07:00AM   ALT(SGPT)-43* AST(SGOT)-106* LD(LDH)-434* ALK
PHOS-100 TOT BILI-0.7
.
MICRO: none

IMAGING:
CXR [**6-27**]: IMPRESSION: Given striking finding of increased size
of the mediastinal compared with chest film only one month ago,
we communicated to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10936**] that a PA and lateral chest
radiograph was recommended to better assess mediastinal widening
and cardiac size as well as likely aspiration pneumonia.

CXR [**6-28**]: IMPRESSION: Aspiration pneumonia with multifocal
pneumonia in the right middle and both lower lobes. Mild
cardiomegaly has developed in the last month.


Brief Hospital Course:
The patient is a 61 year old male with a history of
polysubstance abuse, Hepatitis C infection, CAD s/p stent in
[**2163**], and left arm amputation who presented to the ED requesting
detox with last drink at 3:00 PM on [**2165-6-26**].  He required
significant amounts of Diazepam in the ED with continued
withdrawal symptoms, but remained HD stable.
.
# Alcohol Withdrawal: Pt has had multiple admissions for alcohol
detox, several with an apparent mixed withdrawal picture due to
his concurrent narcotic and benzodiazepine abuse. He scored on
CIWA for agitation, anxiety, and tremor, but as with prior
admission there was a question of whether his symptoms were
truly due to withdrawal versus underlying psychiatric conditions
or pt desire for benzodiazepines, as total body tremor present
on exam was not observed when patient was sleeping or not being
actively observed. He was ordered for Diazepam 10 mg PO Q1H PRN
CIWA >10, receiving a total of 120mg of Diazepam. He received
maintenance IVF, zofran for nausea, and multivitamin, thiamine
and folate. The patient left AMA after a psychiatry consult
found no psychiatric contraindication to discharge and that he
was compentent.
.
# Suicidal Ideation: While trying to obtain ICU consent from the
patient, he voluntarily admitted to having suicidal ideation.
Psychiatry was consulted and found no psychiatric
contraindication to discharge. Patient left AMA.
.
# Polysubstance Abuse: He has a history of narcotics and benzo
abuse in addition to alcohol, and has previously had admissions
with mixed withdrawal states.  Serum tox screen in the ED was
negative except for ethanol, but urine tox screen was not
performed. Urine tox screen was positive for benzodiazepenes,
but otherwise negative.
.
# Leukocytosis:  His WBC count was elevated to 12.2 on admission
with diff showing 70% neutrophils, no bands, and 1% metas.  He
denied any current localizing symptoms of infection, and has
been afebrile.  He has shown similar mild leukocytosis on prior
admissions for detox, and is unlikely to have an acute
infection, but a portable CXR and UA would be a reasonable
screen given his ICU admission. CXR showed possible aspiration
pneumonitis, now resolved. UA was ordered but not sent.

# Thrombocytopenia:  His platelet count was down to 100 on
admission from a prior baseline in the mid 200s.  He has never
had similar low counts in the past.  The differential includes
medication effects (uncertain what he received at recent psych
admission), alcohol toxicity, bone marrow process, or liver
disease.  His diff did show 1% metas, which is of uncertain
significance.  He has not received heparin recently. Platelet
counts trended up.
.
# Anion Gap: He had an elevated anion gap of 15 on admission
with normal bicarb 25.  This likely represents a combined anion
gap metabolic acidosis from his alcohol abuse and possibly a
respiratory alkalosis from hyperventilation or metabolic
alkalosis related to volume depletion. Anion gap resolved on
subsequent labs.
.
# Hepatitis C Infection: He has a reported history of HCV
infection due to IVDU.  He reports that he has not been treated,
but that he has seen a liver specialist in the past and
vaccinated against HAV and HBV. LFTs were elevated on admission
but trended down to within normal limits thereafter, with
residual AST/ALT ratio 2:1 suggestive of alcoholic hepatitis but
no other active liver pathology.
.
# CAD: He has a history of CAD with stent in [**2163**] and several
recent ED visits for chest pain with negative workup, including
negative exercise stress test on [**2165-4-23**].  He currently denies
any symptoms concerning for ACS.  EKG in the ED showed no acute
ischemic changes. Monitored on telemetry without events.
Continued home Aspirin 325 mg PO daily.
.


Medications on Admission:
(per last discharge [**2165-5-24**] in OMR)
Aspirin 325 mg PO daily -- taking intermittently
Acetaminophen 650 mg PO Q6H PRN pain -- not taking
Olanzapine 2.5 mg PO TID PRN agitation -- not taking
Diazepam 10 mg Taper -- completed at [**Hospital1 1680**]


Discharge Medications:
(Patient left AMA)
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).



Discharge Disposition:
Home

Discharge Diagnosis:
Alcohol Withdrawal
Hepatitis C


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


Discharge Instructions:
You were admitted to the hospital for treatment of alcohol
withdrawal.  You were takent to the ICU due to frequent
monitoring requirement. You were treated with diazepam for your
withdrawal. You were having suicidal thoughts during your
hospitalization. The psychiatry doctors saw [**Name5 (PTitle) **] and deemed you
competent, not suicidal and ok to discharge.  You decided to
leave against medical advice.

Followup Instructions:
Please follow up with your primary care doctor next week and ask
about potential detox facilities as well as social work
referral.
{'Alcohol withdrawal,Acidosis,Thrombocytopenia, unspecified,Suicidal ideation,Unspecified viral hepatitis C without hepatic coma,Acute alcoholic hepatitis,Tobacco use disorder,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Unspecified level upper limb amputation status'}


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: alcohol withdrawal

PRESENT ILLNESS: The patient is a 61 year old male with a history of
polysubstance abuse, Hepatitis C infection, CAD s/p stent in
[**2163**], and distant left arm amputation who presented to the ED
requesting detox last night on [**2165-6-26**].  He reported that his
last drink was at 3:00 PM earlier that day.  He was recently
admitted to [**Hospital1 18**] from [**2165-5-22**] to [**2165-5-24**] for alcohol withdrawal
and suicidal ideation.
.
During his previous admission, he remained hemodynamically
stable, but continued to require Diazepam approximately every 2
hours per CIWA scale, receiving a total of 170 mg over three
days.  His CIWA [**Doctor Last Name **] was driven primarily by anxiety and
agitation.  It was not clear whether his symptoms were entirely
due to alcohol withdrawal or his underlying psychiatric
condition.  Psychiatry was consulted, and was placed on Section
12.  He was discharged to the [**Hospital1 1680**] inpatient psychiatric unit
for further evaluation and treatment.
.
In the ED, initial vital signs were T 99.2, BP 167/96, HR 101,
RR 16, and SpO2 96% on RA.  Exam showed signs of alcohol
withdrawal with tremor, agitation, and headache.  EKG showed NSR
at 93 bpm with small R waves in III and aVF unchanged from prior
and no acute ischemic changes.  He received Diazepam 10 mg PO
twice in the early morning.  He continued to show signs of
withdrawal and received an additional Diazepam 10 mg IV three
times.  He was given Thiamine 100 mg, Folic acid 1 mg, and a
Multivitamin.  Labs were checked at 07:00 with serum ethanol
level 96 and otherwise negative serum tox screen.  No urine tox
screen was performed.  His electrolyte panel showed bicarb 25
and anion gap 15, but was otherwise unremarkable.  His WBC count
was elevated to 12.2 with normal diff except for 1% metas.  He
denied any localizing symptoms of infection and no infection
workup was started.  His platelets were low at 100, and
significantly down from 229 on [**2165-5-24**].  His Hct was 43.3,
slightly up from his baseline.
.
He continued to have withdrawal symptoms despite receiving a
total of Diazepam 50 mg in the ED with CIWA remaining elevated
primarily for agitation, tremor, and headache.  He remained
hemodynamically stable in the ED and was alert, oriented, and
conversant.  There was no evidence of seizure activity,
delirium, or hallucination.  He was admitted to the ICU for
continued monitoring and treatment of his withdrawal.  Vitals
prior to transfer were T afebrile, BP 140/70, HR 110, and SpO2
100% on RA.
.
Once in the ICU, he continued to score on CIWA and reported
anxiety, tremor, and headache.  He was hemodynamically stable
with HR in the 90s and BP in the 130s-140s.  He spiked a fever
to 101.2 on arrival.  He reported that he had been drinking
about 0.5 gallons of vodka daily since shortly after discharge
from [**Hospital1 1680**].  He also reported that he has recently been taking
6-8 mg of Klonopin and Xanax daily, as well as [**3-5**] Vicodin
daily.  He denied any injection drug use in several years since
a prior suicide attempt.  He denied any current active suicidal
ideation.  He says that he has been trying to take his Aspirin,
but sometimes forgets.  His chief complaint was headache for
which he requested narcotic pain medications or Tramadol.

MEDICAL HISTORY: - Polysubstance abuse, including heroin>40 years and multiple
BZDs
- Hit by a car at the age of 4 and suffered extensive injuries
including a skull fracture, bilateral broken legs and required
above the elbow amputation of the left arm.
- Hepatitis C diagnosed 10-15 years ago, never treated
- Right hip arthritis
- Cellulitis
- CAD s/p stent in [**2163**]

MEDICATION ON ADMISSION: (per last discharge [**2165-5-24**] in OMR)
Aspirin 325 mg PO daily -- taking intermittently
Acetaminophen 650 mg PO Q6H PRN pain -- not taking
Olanzapine 2.5 mg PO TID PRN agitation -- not taking
Diazepam 10 mg Taper -- completed at [**Hospital1 1680**]

ALLERGIES: All allergies / adverse drug reactions previously recorded have
been deleted

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T 101.2, BP 140/79, HR 98, RR 17, SpO2 96% on RA
General: Alert, attentive, oriented x3, agitated with tremor, no
nystagmus
HEENT: Sclera anicteric, dry MMs, oropharynx clear, dentures
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally.  Initial rhonchi in
upper lung fields that cleared with cough.
CV: Regular rate and rhythm. Normal S1, S2.  Early peaking C-D
murmur at RUSB and LLSB without radiation.
Abdomen: Bowel sounds present.  Soft, non-tender, mildly
distended and tympanic.  No rebound tenderness or guarding.
GU: No foley
Ext: Warm, well perfused.  Left arm amputated above elbow and
atrophied.  Distal pulses 2+. No cyanosis, clubbing, or edema.
Skin: Healing abrasion on right lower leg.

FAMILY HISTORY: No family history of seizure, stroke, SCD.

SOCIAL HISTORY: Originally from [**Location (un) **].  No family in the area. Currently
homeless.  Spent 17 years total in prison.
# Tobacco: Has smoked [**12-2**] PPD for over 40 years.
# Alcohol: Multiple admissions for detox. Currently reports
drinking 0.5 gallons vodka daily.
# Illicits: Polysubstance abuse with narcotics including heroine
and multiple benzodiazepines. Prior 40 year history of IVDU. 

### Response:
{'Alcohol withdrawal,Acidosis,Thrombocytopenia, unspecified,Suicidal ideation,Unspecified viral hepatitis C without hepatic coma,Acute alcoholic hepatitis,Tobacco use disorder,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Unspecified level upper limb amputation status'}
