CHIEF COMPLAINT: Severe depression with ETOH withdrawal state.

PRESENT ILLNESS: 60 year old man, previously a fully functioning nurse, has been
suffering from drug abuse for the last several years. He has
been
in treatment with Dr. [**Last Name (STitle) 1681**] (terminated in [**2102-8-27**]) related to
his wish to drive (and Dr. [**Last Name (STitle) 1681**]??????s disagreement with it). He had
gone to get a written permission from another psychiatrist and
would not let the two doctors [**Name5 (PTitle) **]. He also felt that Dr.
[**Last Name (STitle) 1681**] had been strict regarding his substance abuse and that he
could not handle that level of strictness so he would not follow
up with her treatment. So after several attempts by Dr. [**Last Name (STitle) 1681**] to
get him to abstain from treatment and his failure to do so,
patient was asked to seek another doctor. He was also reassigned
a new PCP, [**Name10 (NameIs) 1023**] he never followed up with.
Overall this man has been drinking quite a lot and without
break.
He also takes methadone. He doesn??????t want to go the Suboxone
route, (for ??????it will get me off my methadone clinic life, which
gives me structure and a sense of belonging??????).

MEDICAL HISTORY: PPH:
- No current treaters. Terminated from outpt psychiatrist by Dr.
[**Last Name (STitle) 1681**] [**9-5**] wi plan for pt to obtain coordinated mental health/
substance treatment.
- Multiple med trials in past as per OMR notes referenced above.

MEDICATION ON ADMISSION: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam:
Vitals: T: 96.2 BP: 140/101 P: 82 R: 15 O2: 100% RA
General: Middle-aged Caucasian male, tremulous, appears
uncomfortable.
HEENT: Sclera anicteric, MM dry, oropharynx with thick, dry
secretions.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, mildly tender periumbilically and in the
epigastrium, no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&O, CNII-XII intact, PERRL (4->2), moves all extremities

FAMILY HISTORY: FH: + depression, + substance use

SOCIAL HISTORY: Pt today states he is youngest of three; in past has reported he
is oldest of three. Lives alone in [**Last Name (un) **], having financial
problems, has three cats. No friends, no relationships. States
graduated high school, worked, used drugs, then eventually when
got clean got nursing bachelor's degree but after relapse lost
license. I did not verify this information with outside source.
Drug withdrawal,Encephalopathy, unspecified,Pulmonary collapse,Unspecified pleural effusion,Urinary tract infection, site not specified,Hypoxemia,Opioid type dependence, continuous,Anemia, unspecified,Unspecified sleep apnea,Other and unspecified hyperlipidemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Unspecified essential hypertension,Dysthymic disorder,Alcohol withdrawal,Epilepsy, unspecified, without mention of intractable epilepsy,Mitral valve disorders,Chronic hepatitis C without mention of hepatic coma
Drug withdrawal,Encephalopathy NOS,Pulmonary collapse,Pleural effusion NOS,Urin tract infection NOS,Hypoxemia,Opioid dependence-contin,Anemia NOS,Sleep apnea NOS,Hyperlipidemia NEC/NOS,Osteoarthros NOS-unspec,Hypertension NOS,Dysthymic disorder,Alcohol withdrawal,Epilep NOS w/o intr epil,Mitral valve disorder,Chrnc hpt C wo hpat coma
Admission Date:  [**2102-3-30**]              Discharge Date:   [**2102-4-4**]

Date of Birth:  [**2041-6-6**]             Sex:   M

Service: PSYCHIATRY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2116**]
Chief Complaint:
Severe depression with ETOH withdrawal state.

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
60 year old man, previously a fully functioning nurse, has been
suffering from drug abuse for the last several years. He has
been
in treatment with Dr. [**Last Name (STitle) 1681**] (terminated in [**2102-8-27**]) related to
his wish to drive (and Dr. [**Last Name (STitle) 1681**]??????s disagreement with it). He had
gone to get a written permission from another psychiatrist and
would not let the two doctors [**Name5 (PTitle) **]. He also felt that Dr.
[**Last Name (STitle) 1681**] had been strict regarding his substance abuse and that he
could not handle that level of strictness so he would not follow
up with her treatment. So after several attempts by Dr. [**Last Name (STitle) 1681**] to
get him to abstain from treatment and his failure to do so,
patient was asked to seek another doctor. He was also reassigned
a new PCP, [**Name10 (NameIs) 1023**] he never followed up with.
Overall this man has been drinking quite a lot and without
break.
He also takes methadone. He doesn??????t want to go the Suboxone
route, (for ??????it will get me off my methadone clinic life, which
gives me structure and a sense of belonging??????).

Pt terminated treatment with Dr. [**Last Name (STitle) 1681**] in [**2102-8-27**], due to
his
continuing to obtain meds and alternative treatment through a
separate psychiatrist, a Dr. [**First Name (STitle) 4223**], with whom he would not
allow contact. Pt did not f/u with plan to seek coordinated
substance/ mental health treatment. Relapsed about a week ago on
alcohol; level was 34 in ED. Also states he has been using
Klonopin to self taper, which he got on street or from other
physician. [**Name10 (NameIs) **] then patient has been very depressed. He
initially reported he made a suicide attempt by standing on
chair, hanging self, kicking chair, and then fixture in ceiling
collapsed, then brought self to ED via taxi. Now pt denies this,
but states he needs help because he is so very depressed. In ED,
there were no ligature marks on neck. He states he had not had
any substances for several months prior to relapse. He received
40 mg Valium IV in ED and then 50 mg IV in [**Hospital Unit Name 153**] and does not
feel
he is withdrawing. Chronic sleep problems, hopeless, continues
suicidal with no plan to harm self here in [**Hospital Unit Name 153**], restless, poor
appetite, poor concentration. Denies sx of psychosis, panic, or
mania. Denies hx self injurious behavior during this interview,
specifically cutting, burning, or eating d/o behavior, but in
past reported cut self.

Past Medical History:
PPH:
- No current treaters. Terminated from outpt psychiatrist by Dr.
[**Last Name (STitle) 1681**] [**9-5**] wi plan for pt to obtain coordinated mental health/
substance treatment.
- Multiple med trials in past as per OMR notes referenced above.

- Multiple hospitalizations; states last was here at [**Hospital1 18**], but
cannot recall date; by our records, most recent hospitalization
here was [**2100-4-20**].
- Harm to self: multiple suicide attempts including overdose of
prescribed meds, two prior hangings, and reported ingestion of
rat poisoning, one stabbing. Today he does not report the exact
same incidents. Not clear to me from notes that any of these
were
independently documented.

PMH:
1. Reiter's syndrome
2. HCV
3. Hx IVDU, in methadone program, recent relapses
4. Hx Suicidality
5. Depression and anxiety
6. Mitral valve prolapse
7. Osteoarthritis, chronic pain
8. Hypertension
9. Bell's palsy
10. s/p Left lis franc ORIF


Social History:
Pt today states he is youngest of three; in past has reported he
is oldest of three. Lives alone in [**Last Name (un) **], having financial
problems, has three cats. No friends, no relationships. States
graduated high school, worked, used drugs, then eventually when
got clean got nursing bachelor's degree but after relapse lost
license. I did not verify this information with outside source.

Family History:
FH: + depression, + substance use

-Mother has [**Name (NI) 2481**] and reportedly lives in her house with
assistance. Father deceased. [**Name2 (NI) **] contact with siblings.

Mother had an alcohol problem until she was 48 and has since
been sober. Mother also had colon cancer. Per OMR, depression in
maternal relatives.


Physical Exam:
Physical Exam:
Vitals: T: 96.2 BP: 140/101 P: 82 R: 15 O2: 100% RA
General: Middle-aged Caucasian male, tremulous, appears
uncomfortable.
HEENT: Sclera anicteric, MM dry, oropharynx with thick, dry
secretions.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, mildly tender periumbilically and in the
epigastrium, no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&O, CNII-XII intact, PERRL (4->2), moves all extremities

MSE:
No tremor, diaphoresis. Declines to ambulate, but heel to shin
intact. Good strength bilateral UE. Tongue midline. No abnormal
movements. Speech no pressure, slightly indistinct but has
upper/lower plates in. [**Name2 (NI) **] "I''m terribly terribly depressed."
Affect: [**Name2 (NI) **] congruent. TP: linear without loose associations.
TC: + SI but states he is not having any thoughts of harm to
self
here in the hospital. Denies AH, VH, HI, PI. No IOR. I/J: both
very poor. Cognitive: alert, oriented to full name, full
location, full date. Attn [**12-8**] one omission. Calculations
intact. Language fluent with intact naming, repetition,
comprehension. Memory: [**4-30**] registration, [**3-2**] recall at 5', [**4-30**]
with category prompts. Fund of knowledge: poor, unable to name
current events, play by [**Last Name (un) 16528**], equilateral triangle. Did
name president.


Pertinent Results:
[**2102-3-30**] 05:53AM   GLUCOSE-99 UREA N-12 CREAT-1.0 SODIUM-138
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-26 ANION GAP-11
[**2102-3-30**] 05:53AM   ALBUMIN-3.5 CALCIUM-8.7 PHOSPHATE-4.9*
MAGNESIUM-1.9
[**2102-3-30**] 05:53AM   VIT B12-394 FOLATE-6.8
[**2102-3-30**] 05:53AM   FREE T4-1.1
[**2102-3-30**] 05:53AM   WBC-5.1 RBC-3.64* HGB-11.4* HCT-32.9* MCV-90
MCH-31.5 MCHC-34.8 RDW-13.5
[**2102-3-30**] 05:53AM   PLT COUNT-196
[**2102-3-29**] 03:44AM   CK(CPK)-88
[**2102-3-29**] 03:44AM   CALCIUM-8.1* PHOSPHATE-4.2 MAGNESIUM-2.0
[**2102-3-29**] 03:44AM   TSH-5.1*
[**2102-3-29**] 03:44AM   VALPROATE-<3*

Brief Hospital Course:
1.	EtOH withdrawel - upon transfer from IM, the pt remained on
both standing and PRN Valium per CIWA scale due to subjective
si/sx of withdrawel.
--on [**3-31**], after discussion with the pt and with clinical staff,
standing Valium was d/c'd to initiate D4 standard withdrawel
protocol of Valium 10mg PO q1h PRN CIWA>10.
--as of [**4-3**], PRN only CIWA extended to q6h with good control of
sx.
--on the day of discharge, the pt showed no si/sx of EtOH
withdrawel.
However, when approached by IM consultant, pt statedm "I found
some
extra methadone in my bed and took it." He appeared obtunded at
that
time, and the decision was made to transfer the pt to MICU.

2.	[**Name (NI) **] - pt endorsed significant depressive [**Name (NI) **] sx with vague
passive SI upon admission, while retracting his original CC of
trying to hang himself, "I just said that to get help." He also
reported about 1m off Effexor and Wellbutrin SR 2ndary to,
"running out."
--on [**3-31**], d/w pt risks/benefits of Cymbalta trial (reduce
polypharmacy and possible additive analgesia), and he agreed to
begin trial at 20mg daily. Will monitor for AE/SE/efficacy.
--as of [**4-3**], Cymbalta tolerated well without AE/SE, pt agreed to
increase dose as noted below.
--on the day of discharge, the pt denied any significant [**Date Range **]
sx,
although conversation was limited due to his expressed, general
malaise and hypersomnulence. His [**Date Range **] sx should be addressed
further
via Psych C/L service.

3.	Medications ?????? upon transfer, pt had been re-started (renal
adjusted) on Depakote and Neurontin after 1m without either.
--on [**3-31**], raised Depakote from 250mg qDay to [**Hospital1 **], Neurontin to
remain at 600mg TID. As above, Cymbalta 20mg qAM trial began.
--on [**4-3**], Cymbalta increased to 30mg daily. Will monitor for
AE/SE.
--on the day of discharge, no medication changes were made, and
his
current regimen was tolerated without AE/SE.

4.	Risk and safety assessment ?????? upon transfer, pt retracted
previous statement re: attempting to hang himself, however
endorsed marked hopelessness, helplessness, recent EtOH relapse,
all taken in context still place him at risk for acute harm to
self and a gross functional inability.
--on [**3-31**], the pt continued to express marked hopelessness,
helplessness, and abulia, however denying SI/HI/SIB and agreeing
to safety plan in hospital.
--as of [**4-3**], pt expressed decreased hopelessness, helplessness,
and abulia, and continued to deny SI/HI/SIB and agreeing to
safety plan in hospital.
--on the day of discharge, since the pt was found obtunded
likely
from surreptitious opiate abuse, he was deemed to be an acutely
high
safety risk with respect of harm to self, and was placed on CO.

5.	Psychosocial/Family - upon transfer, pt lacked PCP and MH
multiple MD's without allowing communication b/w each.
--from 3/5-8, SW to investigate obtaining new providers.
--on the day of discharge, these matters were still pending, and
should
be further addressed by the Psych C/L service or MICU SW.

6.	Legal/Checks ?????? CV, on CO upon discharge

7.      Disposition - due to the pt's lack of medical stability,
the pt was transferred to the [**Hospital1 18**] MICU for further medical
attention. The pt should be followed by the Psych C/L service,
and they should be paged at [**Pager number 105302**] or
[**Pager number 105303**] to initiate C/L follow-up.

Medications on Admission:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).


3. Risperidone 2 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).


4. Methadone 10 mg Tablet Sig: Seventy Five (75) MG PO DAILY
(Daily): can be given in divided doses.
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day:
to be restarted at the time of discharge.
7. Multivitamin     Tablet Sig: One (1) Tablet PO once a day.
8. Valium 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours: with taper.
9. Valium 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for anxiety, s/s of etoh w/d.

Discharge Medications:
-diazepam 10mg TID (please attempt taper in MICU)
-Cymbalta 30 qAM (may titrate to 60 when stable)
-Risperdal 3 mg po qhs
-Methadone 75 mg po qday (dose verified by [**Hospital Unit Name 153**] team)
-venlafaxine XR 75 mg 3 tabs qday
-Valproate DR 250mg po Bid
-trazodone 50 mg qhs PRN - insomnia
-Neurontin 600 tid
-omeprazole 40 qD
-simvastatin 80 qD
-Nystatin 500k q8h s&s
-thiamine, folate, B12, MVI, docusate 100 [**Hospital1 **]

Discharge Disposition:
Extended Care

Facility:
MICU

Discharge Diagnosis:
     AXIS I: Polysubstance dependance, in partial remission
     AXIS II: opiate-induced AMS
     AXIS III: r/o liver damage; HCV, Reiter??????s syndrome
     AXIS IV: moderate psychosocial stressors
     AXIS V: (current): 35

Discharge Condition:
fair

Discharge Instructions:
*This pt should be called into the Psych C/L service for
continuing care.*

Followup Instructions:
Please take medication as prescribed and keep all follow-up
appointments as scheduled.

Please call your providers, dial 911, or go to your nearest
emergency room if the concerns that brought you to the hospital
return or worsen, if you feel unsafe in any way, if SI/HI
emerges, or if you have any immediate concerns.


Completed by:[**2102-4-4**]

Admission Date:  [**2102-4-4**]              Discharge Date:   [**2102-4-9**]

Date of Birth:  [**2041-6-6**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
obtundation

Major Surgical or Invasive Procedure:
none

History of Present Illness:
60 y/o M with long-hx substance abuse, including EtOH with
multiple suicide attempts, Hep C, Reiters syndrome, MVP, hx of
seizure, admitted to [**Hospital Unit Name 153**] on [**3-28**] for a suicide attempt after
attempting to hang himself, medically stabilized in [**Hospital Unit Name 153**] (given
Valium for alcohol withdrawal) and was transferred to [**Hospital1 **] 4 on
[**3-30**]. On [**4-4**], a Medicine Consult was called for 'patient not
looking well'. Stated to have stable VS. Found by Medicine
consult team to be obtunded with vomit/secretions coming from
mouth and incontinent of urine, arousable to physical contact.
Exam vitals BP 96/64 HR 85, on recheck temp 98.4, O2 sat 97% RA,
HR 80, BP 115/76. Non-focal neurological exam, 3mm pupils
reactive, no nystagus, + marked asterixis, no ankle clonus. Exam
with CV RRR, Pulm with bibasilar crackles, Abd S/NT/ND/NABS. Ext
with wrist swelling. At the time, the patient admitted to
finding "extra methadone on his bed" that he took this am (" 2
tabs of methadone 4" which Medicine consult believed translated
to 40 mg), however he has since retracted this statement and
denies that he took any meds that were not prescribed and given
by nurses. The patient had been on standing benzodiazepines
since [**4-2**] was previously on a CIWA scale until [**2102-4-2**] for Valium
but then it was transitioned to standing dosing).  The patient
was transferred to the Medical ICU for close airway monitoring
for likely methadone and benzo overdose with plan that he may
need CXR to assess aspiration, CT head to evaluate for new
intracranial process, and potentially Narcan administration.
.
Upon admission to the MICU, patient was sedated but opened eyes
to his name being called.  His VS were T 98.4, HR 74, BP 94/57,
RR 14, 91% on RA, which improved to 98% on 5L NC.  In the MICU,
the pt was given Narcan 0.2mg x 2 doses, after which he
spontaneously awoke.  His ABG revealed hypoxemia, and a CXR was
performed, revealing likely atalectasis with a question of a
small effusion that could be consistent with a pneumonia on the
R side.  CT of the head was negative for any mass or hemorrhage,
and EEG revealed an abnormal diffusely slow background (mixed
theta frequencies, [**7-3**] Hz) consistent with moderate
encephalopathy.  He was transferred to the floor at 6pm on [**4-5**]
after it was deemed that he no longer needed close monitoring.
.
On transfer to the floor, his vitals were T 98.1, BP 108/75, HR
68, RR 18, O2sat 93% on RA.  When asked why he was transferred
from the psychiatry unit to the ICU floor, he says that "they
overmedicated me on Valium, and I became congested and started
vomiting" and denies having taken any additional methadone.  He
does not believe he had a seizure.  He thinks he is withdrawing
from alcohol, saying the "has the shakes" and also reports
auditory hallucinations while in the [**Hospital Unit Name 153**] which he thinks were
an episode of delirium tremens.  Before presenting to the
hospital on [**3-28**], he had been on a drinking binge of [**1-28**]-gallon
of vodka per night, including the night of [**3-27**], after which he
self-medicated with Klonopin bought off the street in order to
overcome withdrawal symptoms.  He endorses palpitations,
diaphoresis, nausea, chills, and a poor appetite and denies any
chest pain, shortness of breath, or diarrhea/constipation.  He
has had a cough productive of yellow sputum for the past [**5-1**]
days.
.
Review of systems:
(+) Per HPI, also endorses pain in L leg
(-) as per above


Past Medical History:
Substance abuse with IVDU - heroin, last use was years ago
Alcohol abuse - actively abuses, + history of DTs and seizures
Multiple suicide attempts - 3 prior attempts
Hepatitis C - transiently treated w ribavirin 10 years ago but
stopped
Reiters syndrome - 10 years ago
Mitral valve prolapse
History of seizure in the setting of withdrawal
Depression and Anxiety
HTN
OA, chronic pain
Bell's palsy - 8 years ago, treated with steroids
s/p Left ORIF


Social History:
Lives alone in [**First Name4 (NamePattern1) 3340**] [**Last Name (NamePattern1) 19128**] w three cats. Former nurse
(substance abuse treatment nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 882**]) who began abusing
drugs on the job, currently on disability.  No tobacco.  [**1-30**] -
[**1-28**] gallon EtOH daily.  Denies any recent illicit druge use but
has past history of heroin use.  State he bought Klonipin 2 mg
#15 tabs off the street and took them all the weekend prior to
admission to 'help me come down'.


Family History:
FH: + depression, + substance use

Mother had an alcohol problem until she was 48 and has since
been sober. Mother also with colon cancer. Per OMR, depression
in maternal relatives.


Physical Exam:
Physical Exam on admission:
Vitals: 98.4, 74, 94/57, 14, 91% --> 98/5L NC
General: Somnolent, rousable to sternal rub & loud voice
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils equal and
reactive
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses DP, no clubbing, cyanosis or
edema
.
Physical Exam on transfer to [**Wardname 27095**]:
Vitals: T 98.1, BP 108/75, HR 68, RR 18, O2sat 93% on RA
General: AAOx3, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils equal and
reactive, no nystagmus
Neck: supple, JVP not elevated, no LAD but some mild tenderness
with palpation of cervical nodes
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses DP, no clubbing, cyanosis or
edema
Neuro: CN II-XII grossly intact with some mild facial muscle
weakness
MSE: Patient appears slightly dissheveled, behavior appropriate
and cooperative, [**Wardname **] "I want to break out of my skin", affect
flat.  Endorses passive SI, no HI, no hallucination.  Memory-
registers [**3-29**] objects with difficulty, recalls 0/3.  Attention-
months of year backwards with 2 errors, calculations normal,
lacks abstract thinking.
.
Physical exam on transfer from [**Wardname 27095**]:
Vitals: T 95.6, BP 115/62, HR 56, RR 18, O2sat 96% on RA
General: AAOx3, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils equal and
reactive, no nystagmus
Neck: supple, JVP not elevated, no LAD but some mild tenderness
with palpation of cervical nodes
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses DP, no clubbing, cyanosis or
edema
Neuro: Trace right facial weaknes. CN II-XII otherwise grossly
intact
MSE: Patient appears slightly dissheveled, behavior mostly
cooperative, [**Wardname **] "good," affect flat.  Denies SI, HI,
hallucinations.  Oriented to person, [**Hospital1 18**], date.  Memory -
registers [**3-29**] objects, recalls [**1-29**].  Attention - days of week
backwards with no errors, difficulty with calculations, lacks
abstract thinking.

Pertinent Results:
LABS AND MICROBIOLOGY-

On admission to MICU:

[**2102-4-4**] 07:20AM BLOOD WBC-7.2 RBC-3.85* Hgb-11.7* Hct-33.8*
MCV-88 MCH-30.3 MCHC-34.5 RDW-14.2 Plt Ct-159
[**2102-4-4**] 07:20AM BLOOD Neuts-76.9* Lymphs-18.1 Monos-3.7 Eos-1.0
Baso-0.3
[**2102-4-4**] 07:20AM BLOOD Glucose-111* UreaN-14 Creat-1.0 Na-137
K-4.4 Cl-100 HCO3-28 AnGap-13
[**2102-4-3**] 06:50AM BLOOD ALT-16 AST-26 AlkPhos-69 TotBili-0.6
[**2102-4-3**] 06:50AM BLOOD Albumin-3.9
[**2102-4-4**] 07:20AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.0
[**2102-4-3**] 06:50AM BLOOD Ammonia-37
[**2102-4-4**] 07:20AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS
Barbitr-NEG Tricycl-NEG
.
On admission to [**Wardname 27095**]:

Chemistry-
[**2102-4-5**] 03:43AM BLOOD Glucose-121* UreaN-12 Creat-0.8 Na-137
K-4.3 Cl-100 HCO3-34* AnGap-7*
[**2102-4-5**] 03:43AM BLOOD Calcium-8.6 Phos-4.6* Mg-2.1
[**2102-4-4**] 11:15AM BLOOD freeCa-1.22

Hematology-
[**2102-4-5**] 03:43AM BLOOD WBC-6.4 RBC-3.54* Hgb-11.5* Hct-31.9*
MCV-90 MCH-32.6* MCHC-36.2* RDW-13.9 Plt Ct-171
[**2102-4-4**] 07:20AM BLOOD Neuts-76.9* Lymphs-18.1 Monos-3.7 Eos-1.0
Baso-0.3

Toxicology-
[**2102-4-4**] 07:20AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS
Barbitr-NEG Tricycl-NEG
[**2102-4-4**] 11:35AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-POS

Urine-
[**2102-4-4**] 11:35AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.023
[**2102-4-4**] 11:35AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG
[**2102-4-4**] 11:35AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
TransE-<1
.
OTHER
.
[**2102-4-4**] 07:20AM BLOOD ALT-23 AST-51* AlkPhos-69
[**2102-4-3**] 06:50AM BLOOD Ammonia-37
[**2102-4-4**] 07:20AM BLOOD Valproa-42*
[**2102-4-4**] 11:15AM BLOOD Type-ART pO2-73* pCO2-51* pH-7.38
calTCO2-31* Base XS-3 Intubat-NOT INTUBA
[**2102-4-4**] 11:15AM BLOOD Lactate-0.8
.
MICRO:
.
RAPID PLASMA REAGIN TEST (Final [**2102-3-31**]): NONREACTIVE.
.
SPUTUM GRAM STAIN (Final [**2102-4-5**]):
>25 PMNs and >10 epithelial cells/100X field. Gram stain
indicates extensive contamination with upper  respiratory
secretions. Bacterial culture results are invalid. PLEASE SUBMIT
ANOTHER SPECIMEN.
.
HCV VIRAL LOAD (Final [**2102-4-5**]): 6,010,000 IU/mL.
.
[**2102-4-4**] MRSA SCREEN (Final [**2102-4-6**]):    No MRSA isolated.
.
[**2102-4-8**] 6:56 pm URINE CULTURE (Pending):
.
On discharge from [**Wardname 27095**]:

[**2102-4-8**] U/A: Yellow / Clear / 1.030 / 6.0 / Urobil >12 / Bili
Sm / Leuk Tr / Bld Tr / Nitr Neg / Prot Tr / Glu Neg / Ket 10 /
RBC 2 / WBC 17 / Bact None / Yeast None / Epi <1 / RenalEp: <1 /
Mucous: Rare

[**2102-4-8**] 07:50a

140  104  17  91
------------< 91 Agap11
3.7  29  1.0
Ca: 8.7 Mg: 2.1 P: 4.8

    11.4
4.9 >--<  199  mcv 85
   32.5
.
IMAGES-

CT HEAD W/O CONTRAST ([**2102-3-28**]):
1. No acute intracranial process.
2. Mild paranasal sinus disease.
CT C-SPINE W/O CONTRAST Study Date of [**2102-3-28**]
No evidence of acute fracture.
CTA NECK W&W/OC & RECONS Study Date of [**2102-3-28**]
Patent major arteries of the head and neck as described above;
atherosclerotic disease involving the common carotid artery
bifurcation and proximal cervical ICA without flow-limiting
stenosis. MRA with fat sat sequences is more sensitive if there
is contineud clinical concern for dissection, if not
contra-indicated.
.
EEG ([**2102-4-4**]):
IMPRESSION: This is an abnormal routine EEG in the waking and
drowsy
states due to a diffusely slow background consisting of mixed
theta
frequencies which, at times, reached [**7-3**] Hz. There were no focal
or
lateralized abnormalities and there were no epileptiform
features.
Overall, this background is consistent with a moderate
encephalopathy. Encephalopathies can be caused by medications,
metabolic derangements, or infection.
.
CXR ([**2102-4-5**]):
FINDINGS: In comparison with the study of [**4-4**], there is
persistent
opacification at the bases. Although this most likely represents
atelectasis with possible small effusion, in view of the
clinical symptoms, the possibility of supervening pneumonia must
be considered, especially on the right. A lateral view would be
helpful if the condition of the patient permits.
.
CT HEAD w/o CONTRAST ([**2102-4-4**]):
IMPRESSION: No evidence of acute intracranial hemorrhage or mass
effect.
.
EKG ([**2102-4-4**]): SR 66 bpm, slight LAD (-16'), normal intervals,
Q-wave in ?III, AVF; TW flattening in V1; unchanged compared to
[**2101-5-13**].
.
ECG [**2102-4-6**]  6:44:42 AM Sinus rhythm. Consider prior inferior
myocardial infarction although is non-diagnostic. Tracing is
otherwise probably within normal limits. Clinical correlation is
suggested. Since the previous tracing of [**2102-4-4**] low precordial
lead QRS voltage has improved but there may be no significant
change.
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
67 174 90 416/428 56 -14 12



Brief Hospital Course:
60 yo M with h/o EtOH/polysubstance abuse, seizure disorder;
admitted to [**Hospital Unit Name 153**] [**2102-3-28**] with attempted hanging, transferred to
inpatient psych [**3-30**], found to be obtunded morning of [**4-4**] with
possible methadone overdose; tranferred to MICU for monitoring,
found to be hypoxemic, obtundation improved s/p Narcan x 2, and
patient was transferred to [**Wardname 27095**] on [**4-5**] once deemed stable for
continued management.
.
# Obtundation: There are many potential etiologies for his
altered mental status.  Given history of seeking out medications
and report by patient (to Medicine Consult, patient has since
retracted this report) that he took an additional 80 mg of
Methadone and was on standing Valium 10mg TID on Deac4 since the
day prior to his altered mental status, this was very possibly a
medication effect with overdose of benzodiazepines and/or
narcotics.  His symptoms and physical exam, including an episode
of bradycardia to 39 in the early morning of [**4-6**] as well as
some tremors, anxiety, and sedation, were more suggestive of
benzodiazepine toxicity than withdrawal, as discussed with
psychiatry.  An intracranial process was ruled out with CT scan.
 Sedating and deleriogenic meds were held, including gabapentin
(D/C'ed on [**4-4**]) and Valium and methadone (D/C'ed on [**4-6**]).  The
patient remained delirious on [**4-7**], but his somnolence and
orientation had improved slightly.  His physical symptoms of
opiate withdrawal were treated with dicyclomine 20mg Q6H:PRN for
stomach cramps, methocarbamol 1000mg Q6H:PRN for muscle aches,
and ibuprofen 600mg Q8H:PRN for pain, per psychiatry recs.  On
[**4-8**], the patient's mental status had improved considerably, as
he was oriented x 3 with improved attention and abstraction.
Psychiatry recommended transfer to [**Hospital1 **] 4.  The patient was
able to ambulate without assistance, as determined by physical
therapy.  The patient's mental status was stable to improved
(alert, oriented x 3, cooperative, improved concentration and
attention, [**Hospital1 **] "good," no SI/HI) on the day of discharge.
.
# Seizure disorder: Patient cannot report last seizure, none
while inpatient.  While he was found to be incontinent by
Medicine consult, there were no reports of seizure like
activity, and his altered mental status was 7 days after his
last alcoholic drink, beyond the time-frame expected for alcohol
withdrawal seizures.  Benzodiazepine withdrawal does, however,
remain a possibility and could make this patient susceptible to
seizures.  Hence, his valproate does was changed from 500mg TID
to 750mg PO BID for ease of dosing.  EEG was negative for
epileptiform activity.  It remains unknown whether this patient
does indeed have a seizure history, as his self-reported history
has been inconsistent.
.
# Hypoxemia: In MICU, ABG showed hypoxemia with hypercarbia
(7.38/51/73), A-a gradient of 14mm Hg, suggestive of
hypoventilation in clinical setting of obtundation.  Chest X-ray
showed atalectasis with a question of a right pleural effusion
which could have resulted from an aspiration event, however the
patient's oxygen saturations remained >92% on room air while on
[**Wardname 27095**] with no oxygen requirement, and his physical exam and
symptoms did not support a diagnosis of aspiration pneumonia.
No antibiotics were administered.
.
# Polysubstance abuse:  Pt has a history of frequent relapses
and is on methadone at home for withdrawal from heroin, which he
used chronically until a few years ago.  His methadone was held
on [**4-6**], and the patient has been complaining of muscle aches,
abdominal pain, and diaphoresis but has denied diarrhea,
nausea/vomiting.  His opiate withdrawal symptoms were treated as
described above, and thiamine/folate/vitamin B12 were continued
given his active alcohol abuse.
.
# Suicide attempt: Patient denied any active suicidality while
on [**Wardname 27095**].  On [**4-5**] he reported wanted to "jump out of this room"
but said he had no plan to kill himself.  On [**4-6**], he reported
that he "wanted to live" and that he had no plans to harm
himself.  He had a 1:1 sitter throughout this hospitalization.
.
# UTI - A urinalysis was sent on [**4-8**] in the setting of
waxing/[**Doctor Last Name 688**] mental status, which demonstrated WBC 17 and trace
leukesterase.  The patient was started on a 10 day course of
empiric ciprofloxacin 500 mg [**Hospital1 **], as speciation was pending at
the time of discharge.  Please follow up cultures and
sensitivities on the morning of [**4-10**] and adjust antibiotics if
necessary.
.
# Anemia: Hematocrit has been stable since admission. His
B12/Folate were normal while inpatient.
.
# Hepatitis C: History of partial treatment.  Tried interferon
10 years ago but stopped due to side effects.  HCV viral load
was >6 million.  No treatment was rendered on this admission.
.
# Sleep Apnea: Per PCP, [**Name10 (NameIs) **] has refused diagnositic study
given he would not want mask.  The patient has not been on CPAP
during this hospital stay.
.
# Hyperlipidemia / CAD: Simvastatin and aspirin was briefly
discontinued during his episode of obtundation but restarted
after mental status improved.

Medications on Admission:
Buproprion SR 150 mg daily
Divalproex 500 mg TID
Gabapentin 800 mg TID
Methadone 74 mg daily
Omeprazole 40 mg daily
Risperidone 3 mg QHS
Simvastatin 80 mg daily
Trazodone 100 mg QHS (not taking)
Venlafaxine 225 mg daily
Aspirin 325 mg daily


Discharge Medications:
1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for muscle aches.
10. Dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) as needed for stomach cramps.
11. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
12. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): 10 day course ending [**2102-4-18**].


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary:
Altered mental status/delirium
Suicide attempt/suicidal ideation
Polysubstance abuse
Benzodiazepine intoxication
Alcohol withdrawal
Opiate withdrawal

Secondary:
Anemia
Hepatitis C
Sleep apnea
Hyperlipidemia


Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Lethargic but arousable
Activity Status: Ambulatory - Independent


Discharge Instructions:
Several changes were made to your medication regimen.  Please
take all of your medications as prescriibed.

Followup Instructions:
Please make a follow-up appointment with your primary care
provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**], within two weeks of discharge.  His
phone number is [**Telephone/Fax (1) 250**].



Completed by:[**2102-4-9**]
{'Drug withdrawal,Encephalopathy, unspecified,Pulmonary collapse,Unspecified pleural effusion,Urinary tract infection, site not specified,Hypoxemia,Opioid type dependence, continuous,Anemia, unspecified,Unspecified sleep apnea,Other and unspecified hyperlipidemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Unspecified essential hypertension,Dysthymic disorder,Alcohol withdrawal,Epilepsy, unspecified, without mention of intractable epilepsy,Mitral valve disorders,Chronic hepatitis C without mention of hepatic coma'}


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: Severe depression with ETOH withdrawal state.

PRESENT ILLNESS: 60 year old man, previously a fully functioning nurse, has been
suffering from drug abuse for the last several years. He has
been
in treatment with Dr. [**Last Name (STitle) 1681**] (terminated in [**2102-8-27**]) related to
his wish to drive (and Dr. [**Last Name (STitle) 1681**]??????s disagreement with it). He had
gone to get a written permission from another psychiatrist and
would not let the two doctors [**Name5 (PTitle) **]. He also felt that Dr.
[**Last Name (STitle) 1681**] had been strict regarding his substance abuse and that he
could not handle that level of strictness so he would not follow
up with her treatment. So after several attempts by Dr. [**Last Name (STitle) 1681**] to
get him to abstain from treatment and his failure to do so,
patient was asked to seek another doctor. He was also reassigned
a new PCP, [**Name10 (NameIs) 1023**] he never followed up with.
Overall this man has been drinking quite a lot and without
break.
He also takes methadone. He doesn??????t want to go the Suboxone
route, (for ??????it will get me off my methadone clinic life, which
gives me structure and a sense of belonging??????).

MEDICAL HISTORY: PPH:
- No current treaters. Terminated from outpt psychiatrist by Dr.
[**Last Name (STitle) 1681**] [**9-5**] wi plan for pt to obtain coordinated mental health/
substance treatment.
- Multiple med trials in past as per OMR notes referenced above.

MEDICATION ON ADMISSION: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam:
Vitals: T: 96.2 BP: 140/101 P: 82 R: 15 O2: 100% RA
General: Middle-aged Caucasian male, tremulous, appears
uncomfortable.
HEENT: Sclera anicteric, MM dry, oropharynx with thick, dry
secretions.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, mildly tender periumbilically and in the
epigastrium, no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&O, CNII-XII intact, PERRL (4->2), moves all extremities

FAMILY HISTORY: FH: + depression, + substance use

SOCIAL HISTORY: Pt today states he is youngest of three; in past has reported he
is oldest of three. Lives alone in [**Last Name (un) **], having financial
problems, has three cats. No friends, no relationships. States
graduated high school, worked, used drugs, then eventually when
got clean got nursing bachelor's degree but after relapse lost
license. I did not verify this information with outside source. 

### Response:
{'Drug withdrawal,Encephalopathy, unspecified,Pulmonary collapse,Unspecified pleural effusion,Urinary tract infection, site not specified,Hypoxemia,Opioid type dependence, continuous,Anemia, unspecified,Unspecified sleep apnea,Other and unspecified hyperlipidemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Unspecified essential hypertension,Dysthymic disorder,Alcohol withdrawal,Epilepsy, unspecified, without mention of intractable epilepsy,Mitral valve disorders,Chronic hepatitis C without mention of hepatic coma'}
