CHIEF COMPLAINT: mental status change

PRESENT ILLNESS: Patient came to MICU intubated. Per report, presented after a
witnessed fall with head strike yesterday evening. ETOH level
314 (4 hours after presentation). Head CT showed a tiny L
frontal SAH. He was initially alert but not very cooperative and
subsequently became increasingly agitated and combative and was
ultimately intubated for airway protection. He was started on
fentanyl/versed but was still not adequately sedated.
Subsequently he was noted to be biting ETT and reportedly had
shaking movements of b/l UE lasting 30-60 seconds concerning for
seizure activity. On  exam by neuro at that time  he had just
been rebolused with fentanyl/versed but appeared uncomfortable
and restless, with writhing movements of all extremities and
intermittent non-rhythmic shaking of his head as well as his
arms which is suppressible ([**Name8 (MD) **] RN similar to episode witnessed
earlier). He was not following commands but moved all
extremities purposefully and, per report, there was no activity
consistent with seizure during my assessment. Repeat head CT
appears stable. Overall low suspicion for seizure given
non-rhythmic and suppressible movements, as well as the fact
that his ETOH level is still high and he has received multiple
medications that would suppress any potential risk for seizure
(ativan, fentanyl, versed, propofol).

MEDICAL HISTORY: Alcohol abuse
HTN
Hyperlipidemia
nicotine addiction
Depression

MEDICATION ON ADMISSION: ASPIRIN - aspirin 81 mg tablet,delayed release
1 Tablet, Delayed Release (E.C.)(s) by mouth daily
DIPHENHYDRAMINE HCL [NIGHTTIME SLEEP AID (DIPHEN)] - NightTime
Sleep Aid (diphenhydramine) 25 mg tablet
1 Tablet(s) by mouth once at night as needed for insomnia take
one tablet at night, 1 hour before desired sleeping time
MULTIVITAMIN - multivitamin tablet
1 Tablet(s) by mouth daily
THIAMINE HCL - thiamine 100 mg tablet
1 Tablet(s) by mouth once a day

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission:
General: intubated.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: intubated and sedated

FAMILY HISTORY: He is adopted.

SOCIAL HISTORY: Alcohol abuse, unclear at this time how much pt drinks. Several
[**Last Name (un) 20934**] in the past. Also smokes, unclear amount. He denies any
illicit drug use. Pt lives in [**Location **] in an apartment by
himself, wife and child reportedly died in a car accident
Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Open wound of forehead, without mention of complication,Alcohol abuse, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Fall from other slipping, tripping, or stumbling
Traum subarachnoid hem,Open wound of forehead,Alcohol abuse-unspec,Hypertension NOS,Hyperlipidemia NEC/NOS,Fall from slipping NEC
Admission Date:  [**2179-10-18**]              Discharge Date:   [**2179-10-21**]

Date of Birth:  [**2120-1-9**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
mental status change

Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
Patient came to MICU intubated. Per report, presented after a
witnessed fall with head strike yesterday evening. ETOH level
314 (4 hours after presentation). Head CT showed a tiny L
frontal SAH. He was initially alert but not very cooperative and
subsequently became increasingly agitated and combative and was
ultimately intubated for airway protection. He was started on
fentanyl/versed but was still not adequately sedated.
Subsequently he was noted to be biting ETT and reportedly had
shaking movements of b/l UE lasting 30-60 seconds concerning for
seizure activity. On  exam by neuro at that time  he had just
been rebolused with fentanyl/versed but appeared uncomfortable
and restless, with writhing movements of all extremities and
intermittent non-rhythmic shaking of his head as well as his
arms which is suppressible ([**Name8 (MD) **] RN similar to episode witnessed
earlier). He was not following commands but moved all
extremities purposefully and, per report, there was no activity
consistent with seizure during my assessment. Repeat head CT
appears stable. Overall low suspicion for seizure given
non-rhythmic and suppressible movements, as well as the fact
that his ETOH level is still high and he has received multiple
medications that would suppress any potential risk for seizure
(ativan, fentanyl, versed, propofol).

On arrival to the MICU, patient was intubated and sedated.
Covered in dried blood.


Past Medical History:
Alcohol abuse
HTN
Hyperlipidemia
nicotine addiction
Depression

Social History:
Alcohol abuse, unclear at this time how much pt drinks. Several
[**Last Name (un) 20934**] in the past. Also smokes, unclear amount. He denies any
illicit drug use. Pt lives in [**Location **] in an apartment by
himself, wife and child reportedly died in a car accident


Family History:
He is adopted.

Physical Exam:
Admission:
General: intubated.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: intubated and sedated

DISCHARGE EXAM
Vitals: 98.5118/68 58 16 95RA
General: Deshoveled caucasian male, 2 lacerations over left
forehead, in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, mild guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moving all 4 limbs spontaneously


Pertinent Results:
admission:

[**2179-10-18**] 10:34PM BLOOD WBC-8.7 RBC-4.36* Hgb-14.5 Hct-42.8
MCV-98 MCH-33.3* MCHC-33.9 RDW-14.1 Plt Ct-226
[**2179-10-18**] 10:34PM BLOOD PT-9.7 PTT-35.1 INR(PT)-0.9
[**2179-10-18**] 10:34PM BLOOD Glucose-79 UreaN-10 Creat-0.9 Na-143
K-4.0 Cl-105 HCO3-31 AnGap-11
[**2179-10-18**] 10:34PM BLOOD ASA-NEG Ethanol-314* Acetmnp-NEG
Bnzodzp-NEG Tricycl-NEG

Pertinent:
[**2179-10-19**] 12:05AM BLOOD Type-ART Temp-36.7 Rates-14/ Tidal V-500
PEEP-5 FiO2-100 pO2-460* pCO2-41 pH-7.39 calTCO2-26 Base XS-0
AADO2-218 REQ O2-44 -ASSIST/CON Intubat-INTUBATED

[**2179-10-20**] 02:49AM BLOOD WBC-9.9 RBC-4.07* Hgb-13.6* Hct-39.6*
MCV-97 MCH-33.6* MCHC-34.5 RDW-13.7 Plt Ct-199
[**2179-10-19**] 08:42AM BLOOD Neuts-78.4* Lymphs-13.3* Monos-6.8
Eos-1.2 Baso-0.4
[**2179-10-19**] 08:42AM BLOOD PT-9.4 PTT-32.3 INR(PT)-0.9

Imaging:
[**10-18**] CT head
FINDINGS:  There is a tiny quantity of high density material
within a left
frontal lobe sulcus (400b:32), likely secondary to subarachnoid
hemorrhage.
There is no additional intracranial hemorrhage, edema, shift of
normally
midline structures, hydrocephalus, or acute large vascular
territorial
infarction.  Prominence of the ventricles and sulci is similar
in appearance
compared to the prior study from [**2179-2-5**], consistent
with global
atrophy.  Periventricular white matter hypodensities, seen
particularly in the
left cerebral hemisphere, are a nonspecific finding that can be
seen in the
setting of chronic small vessel ischemic disease, not
significantly changed in
appearance.  The imaged portions of the orbits are unremarkable.
 There is
opacification of the majority of the right ethmoidal air cells
and scattered
opacification of left ethmoidal air cells, not significantly
changed.  Mucosal
thickening is seen within both maxillary sinuses.  There is also
mucosal
thickening within the right frontal sinus and left sphenoid
sinus.  The
mastoid air cells are well aerated.  Deformity of the right
nasal bone has not
been fully imaged on multiple prior head CTs, but given the lack
of associated
overlying soft tissue swelling, may be an old injury.  The
remaining imaged
osseous structures are intact.  Marked calcifications of the
bilateral
internal and cavernous carotid arteries are noted.

IMPRESSION:

1.  Minimal left frontal lobe subarachnoid hemorrhage.

2.  Deformity of the right nasal bone, possibly acute on
chronic.  Recommend
correlation with physical exam.

3.  Extensive paranasal sinus disease, as described above, not
significantly
changed.

[**10-19**] CT head
FINDINGS:  There has been interval resolution of the previously
seen
subarachnoid hemorrhage.  There is no new hemorrhage, edema,
mass effect or
acute large vascular territory infarction.  Mild to moderately
prominent
ventricles and sulci indicate cerebral atrophy. Mild
periventricular white
matter hypodensities are consistent with chronic small vessel
ischemic
disease.  The basal cisterns appear patent.

No acute fracture is identified.  Again seen is the chronic
comminuted right
nasal bone fracture and left anterior nasal bone fracture, as
seen previously
on [**2177-9-23**].  There is bilateral moderate maxillary sinus mucosal
thickening.
There is near-complete right anterior ethmoidal opacification as
well as mild
left anterior ethmoidal mucosal thickening.  There is also mild
bilateral
posterior ethmoid mucosal thickening.  A mucous retention cyst
is seen in the
left sphenoid sinus, and mild right sphenoid mucosal thickening.
 There are
new secretions in the nasopharynx, likely secondary to
endotracheal
intubation.

Left periorbital soft tissue swelling is again noted.

CONCLUSION:

Interval resolution of the previously seen subarachnoid
hemorrhage.  No new
hemorrhage.


DISCHARGE LABS

[**2179-10-21**] 07:45AM BLOOD WBC-6.7 RBC-3.81* Hgb-12.7* Hct-36.3*
MCV-95 MCH-33.2* MCHC-34.8 RDW-14.3 Plt Ct-187
[**2179-10-21**] 07:45AM BLOOD Glucose-90 UreaN-12 Creat-0.6 Na-143
K-3.4 Cl-106 HCO3-27 AnGap-13
[**2179-10-21**] 07:45AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9

Brief Hospital Course:
59-year-old male with hx of HTN, HLD, EtOH abuse presents s/p
fall, found to have small SAH, required intubation and MICU
care, clinically stable upon transfer to the medical floor.

In the ED:
Head CT showed a tiny L frontal SAH. He was initially alert but
not very cooperative and subsequently became increasingly
agitated and combative and was ultimately intubated for airway
protection. He was started on fentanyl/versed but was still not
adequately sedated. Subsequently he was noted to be biting ETT
and reportedly had shaking movements of b/l UE lasting 30-60
seconds concerning for seizure activity. Neurosurgery and
Neurology were consulted. NO surgical intervention was needed
for the small SAH and Neurology felt that pt was not having any
seizure activity.

IN the MICU:
Pt came to the MICU intubated and sedated. Sedation was weaned
and pt was extubated with out any issues. He was given a
multivitamin and placed on a CIWA scale protocol. Follow up head
CT saw resolution of tiny SAH. Pt had frequent neuro checks
which were normal. Pt was called out to the floor.

#Subarachnoid hemmorhage: given that patient has no residual
hemmorhage on recent CT Head and per neurosurgery consultation,
patient does not have an active SAH.  Benign neuro exam, no
seizure activity on EEG previously.

#EtOH Withdrawal: patient with high EtOH level, however was
sober nearly 2 months ago.  During hospitalization had no
signs/symptoms of EtOH withdrawal.  He was placed on CIWA scale
but did not score, did not receive PRN Diazepam.  Patient was
advised numerous times to follow up with his therapists and
psychiatrist regarding alcohol cessation.

TRANSITIONAL ISSUES
-should follow up with PCP regarding EtOH abuse

Medications on Admission:
ASPIRIN - aspirin 81 mg tablet,delayed release
1 Tablet, Delayed Release (E.C.)(s) by mouth daily
DIPHENHYDRAMINE HCL [NIGHTTIME SLEEP AID (DIPHEN)] - NightTime
Sleep Aid (diphenhydramine) 25 mg tablet
1 Tablet(s) by mouth once at night as needed for insomnia take
one tablet at night, 1 hour before desired sleeping time
MULTIVITAMIN - multivitamin tablet
1 Tablet(s) by mouth daily
THIAMINE HCL - thiamine 100 mg tablet
1 Tablet(s) by mouth once a day


Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Simvastatin 40 mg PO DAILY
4. Thiamine 100 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. naltrexone *NF* 50 mg Oral qd
7. NIFEdipine CR 30 mg PO DAILY


Discharge Disposition:
Home

Discharge Diagnosis:
small subarachnoid hemorrhage
Alcohol intoxication/abuse


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


Discharge Instructions:
Dear Mr. [**Known lastname 49586**],

You were admitted at [**Hospital1 18**] for a bleed in your head after you
fell while you were intoxicated.  Your CT scan did not show any
bleeding most recently.  You should decrease your alcohol intake
and follow up with your primary doctor.

Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2179-10-28**] at 4:30 PM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
*This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider.  [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

Completed by:[**2179-10-22**]
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Open wound of forehead, without mention of complication,Alcohol abuse, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Fall from other slipping, tripping, or stumbling'}


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: mental status change

PRESENT ILLNESS: Patient came to MICU intubated. Per report, presented after a
witnessed fall with head strike yesterday evening. ETOH level
314 (4 hours after presentation). Head CT showed a tiny L
frontal SAH. He was initially alert but not very cooperative and
subsequently became increasingly agitated and combative and was
ultimately intubated for airway protection. He was started on
fentanyl/versed but was still not adequately sedated.
Subsequently he was noted to be biting ETT and reportedly had
shaking movements of b/l UE lasting 30-60 seconds concerning for
seizure activity. On  exam by neuro at that time  he had just
been rebolused with fentanyl/versed but appeared uncomfortable
and restless, with writhing movements of all extremities and
intermittent non-rhythmic shaking of his head as well as his
arms which is suppressible ([**Name8 (MD) **] RN similar to episode witnessed
earlier). He was not following commands but moved all
extremities purposefully and, per report, there was no activity
consistent with seizure during my assessment. Repeat head CT
appears stable. Overall low suspicion for seizure given
non-rhythmic and suppressible movements, as well as the fact
that his ETOH level is still high and he has received multiple
medications that would suppress any potential risk for seizure
(ativan, fentanyl, versed, propofol).

MEDICAL HISTORY: Alcohol abuse
HTN
Hyperlipidemia
nicotine addiction
Depression

MEDICATION ON ADMISSION: ASPIRIN - aspirin 81 mg tablet,delayed release
1 Tablet, Delayed Release (E.C.)(s) by mouth daily
DIPHENHYDRAMINE HCL [NIGHTTIME SLEEP AID (DIPHEN)] - NightTime
Sleep Aid (diphenhydramine) 25 mg tablet
1 Tablet(s) by mouth once at night as needed for insomnia take
one tablet at night, 1 hour before desired sleeping time
MULTIVITAMIN - multivitamin tablet
1 Tablet(s) by mouth daily
THIAMINE HCL - thiamine 100 mg tablet
1 Tablet(s) by mouth once a day

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission:
General: intubated.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: intubated and sedated

FAMILY HISTORY: He is adopted.

SOCIAL HISTORY: Alcohol abuse, unclear at this time how much pt drinks. Several
[**Last Name (un) 20934**] in the past. Also smokes, unclear amount. He denies any
illicit drug use. Pt lives in [**Location **] in an apartment by
himself, wife and child reportedly died in a car accident 

### Response:
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Open wound of forehead, without mention of complication,Alcohol abuse, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Fall from other slipping, tripping, or stumbling'}
