CHIEF COMPLAINT: Alcohol intoxication

PRESENT ILLNESS: This is a 54 M who was found down outside a restaurant where he
reportedly works as a dishwasher and was brought to the ED. BAL
was 509. He had stepped outside about five minutes before he was
found unresponsive. Pt was noted to be posturing and foaming at
the mouth per EMS. No signs of trauma. C-collar was placed. FSBG
normal per EMS.

MEDICAL HISTORY: Alcohol abuse
HTN
Hyperlipidemia
Tobacco abuse
Depression

MEDICATION ON ADMISSION: HCTZ 25 mg PO daily
Percocet PRN
Zocor 20 mg PO daily
Trazodone 50 mg PO QHS PRN insomnia
ASA 81 mg PO daily
Colace
MVI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: Per Metavision
GEN: Appears unkempt, NAD.
HEENT: NC/AT. MMM. OP clear.
NECK: No JVD.
CV: RRR, no M/G/R, normal S1 S2, radial pulses +2.
PULM: Lungs CTAB, no W/R/R.
ABD: Soft, NT, ND, +BS, no HSM, no masses.
EXT: No C/C/E, no palpable cords.
NEURO: Oriented to person and place. Able to move all four
extremities. Sensation grossly intact.

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.
Acute alcoholic intoxication in alcoholism, continuous,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Depressive disorder, not elsewhere classified,Spinal stenosis in cervical region
Ac alcohol intox-contin,Hypertension NOS,Hyperlipidemia NEC/NOS,Tobacco use disorder,Depressive disorder NEC,Cervical spinal stenosis
Admission Date:  [**2176-2-9**]              Discharge Date:   [**2176-2-10**]

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

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Alcohol intoxication

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is a 54 M who was found down outside a restaurant where he
reportedly works as a dishwasher and was brought to the ED. BAL
was 509. He had stepped outside about five minutes before he was
found unresponsive. Pt was noted to be posturing and foaming at
the mouth per EMS. No signs of trauma. C-collar was placed. FSBG
normal per EMS.

In the ED, vitals on presentation were T 98 HR 90 BP 133/70 RR
15 100%NRB. Head CT was negative. CT C-spine revealed grade 1
retrolisthesis
of C4 on C5 and disc bulge at C4-5 causing moderate canal
narrowing.
He was given a banana bag and 325 mg PR ASA. Weaned to 2L NC,
100% sats. EKG revealed ST at a rate of 111, normal axis, normal
intervals, and STD in V3-V6, II.

Upon arrival to the ICU, pt was able to spell his name but he
had no identification on him. He could not remember any of his
PMH or his medications. Pt clearly states when asked who is PCP
[**Last Name (NamePattern4) **], "Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]." After further investigation, his full
name and MR#[**Medical Record Number **]were able to be obtained.




Past Medical History:
Alcohol abuse
HTN
Hyperlipidemia
Tobacco abuse
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.


Family History:
He is adopted.

Physical Exam:
Vitals: Per Metavision
GEN: Appears unkempt, NAD.
HEENT: NC/AT. MMM. OP clear.
NECK: No JVD.
CV: RRR, no M/G/R, normal S1 S2, radial pulses +2.
PULM: Lungs CTAB, no W/R/R.
ABD: Soft, NT, ND, +BS, no HSM, no masses.
EXT: No C/C/E, no palpable cords.
NEURO: Oriented to person and place. Able to move all four
extremities. Sensation grossly intact.

Pertinent Results:
[**2176-2-9**] 01:45AM   GLUCOSE-122* UREA N-17 CREAT-0.9 SODIUM-141
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-20* ANION GAP-20
[**2176-2-9**] 01:45AM   CK(CPK)-180*
[**2176-2-9**] 01:45AM   CK-MB-5 cTropnT-<0.01
[**2176-2-9**] 01:45AM   ASA-NEG ETHANOL-509* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2176-2-9**] 01:45AM   WBC-9.3 RBC-4.33* HGB-14.9 HCT-42.1 MCV-97
MCH-34.5* MCHC-35.4* RDW-14.1
[**2176-2-9**] 01:45AM   NEUTS-76.6* LYMPHS-18.4 MONOS-3.5 EOS-1.1
BASOS-0.5
[**2176-2-9**] 01:45AM   PT-11.9 PTT-25.3 INR(PT)-1.0

[**2176-2-9**] 04:45AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2176-2-9**] 04:45AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2176-2-9**] 08:21AM   TRIGLYCER-122 HDL CHOL-68 CHOL/HDL-3.7
LDL(CALC)-161*
[**2176-2-9**] 08:21AM   ALT(SGPT)-33 AST(SGOT)-37 CK(CPK)-218* ALK
PHOS-56 TOT BILI-0.2
[**2176-2-9**] 08:21AM   CK-MB-7 cTropnT-<0.01
[**2176-2-9**] 08:21AM   CALCIUM-7.7* PHOSPHATE-3.8 MAGNESIUM-1.9
CHOLEST-253*
[**2176-2-9**] 02:26PM   CK(CPK)-240*
[**2176-2-9**] 02:26PM   CK-MB-8 cTropnT-0.05*
[**2176-2-9**] 08:06PM   CK(CPK)-252*
[**2176-2-9**] 08:06PM   CK-MB-7 cTropnT-0.07*

Imaging:
CT C-spine [**2-9**]: No evidence of acute fracture or mal-alignment,
however grade 1 retrolisthesis of C4 on C5 is of unknown
chronicity and and disc bulge at C4-5 causes moderate canal
narrowing. MRI is recommended for further evaluation if concern
for cord injury persists.

Head CT [**2-9**]: No acute intracranial process.

MRI C-spine [**2-9**]: (prelim) Central disc protrusion at C4-C5 with
mild central canal stenosis. There is no significant cord
compression or cord contusion.


Brief Hospital Course:
54 M who was found down acutely intoxicated, found to have a BAL
of 509, and admitted to the ICU for alcohol intoxication.

# Alcohol intoxication - The patient was found down acutely
intoxicated. Unclear the amount that patient drank although can
estimate based on BAL. Pt with known history of alcohol abuse.
He was monitored overnight in the ICU on telemetry without
event.  He had no signs of alcohol withdrawal.  He was alert and
oriented the morning after admission and wished to be discharged
home.  He was counceled to refrain from alcohol and will follow
up with his primary doctor, Dr. [**First Name (STitle) **].

# EKG changes - No baseline available for comparison. Lateral ST
changes may be [**2-26**] to profound alcohol intoxication. No symptoms
of CP or SOB.  His CE's were cycled and his CK's were mildly
elevated in the 200's (likely due to muscle break down from his
fall) and his troponins ranged between <0.01 to 0.07.  On
recheck, his EKG changes had resolved.  Due to concern for
possible cardiac disease he was started on 25 mg of metoprolol
[**Hospital1 **] and his zocor was increased to 40 mg daily.  He was
continued on his outpatient ASA.  He was ordered for an
outpatient stress test and will follow up with his primary
doctor after the stress test.

# CT C-spine findings: The patient underwent a C-spine CT given
his history of a fall which was re-read as showing a large
midline protrusion of the intervertebral disk at C4-5 with
concern for cord compression so neurosurgery was called to
evaluate the patient in the ED.  He underwent a MRI of his
C-spine which showed Central disc protrusion at C4-C5 with mild
central canal stenosis and no significant cord compression or
cord contusion.  Neurosurgery stated that he did not need to
wear a collar or have follow up with them as an outpatient.

# Code: Full code

Medications on Admission:
HCTZ 25 mg PO daily
Percocet PRN
Zocor 20 mg PO daily
Trazodone 50 mg PO QHS PRN insomnia
ASA 81 mg PO daily
Colace
MVI


Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Colace  Oral
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary -
Alcohol Intoxication
Mild central cervical spinal canal stenosis

Secondary -
Hypertension
Hyperlipidemia


Discharge Condition:
Stable, detoxed.


Discharge Instructions:
You were admitted to the hospital because you were found to have
fallen while intoxicated with alcohol.  You had imaging of your
head and spine which showed no injury.  Neurosurgery evaluated
you in the ED and felt that you had no spinal injury.

While you were evaluated in the emergency room your EKG (imaging
of the forces in your heart) showed changes concerning for
cardiac disease.  These resolved when your heart rate decreased.
 You will need to undergo a stress test as an outpatient.

You should refrain from drinking alcohol in the future.

Medication changes:
1.  You were started on metoprolol 25 mg twice daily.
2.  Your zocor was increased to 40 mg daily.

Otherwise continue to take your outpatient medications as
prescribed.

Go to the emergency room or call your primary doctor if you
experience fevers, chills, chest pain, shortness of breath,
blood in your stool, black stool, new onset numbness, tingling,
or weakness.

Followup Instructions:
You will need to follow up with with your primary doctor, Dr.
[**First Name (STitle) **].  Call [**Telephone/Fax (1) 250**] to schedule this appointment.
Appointment should be in [**8-2**] days

You will also need to follow up with your social worker, [**Name (NI) **]
[**Name (NI) 41140**].  Call [**Telephone/Fax (1) 250**] to schedule this appointment.
Appointment should be in [**8-2**] days

Call [**Telephone/Fax (1) 62**] to schedule your stress test.  Please try to
complete this test before following up with Dr. [**First Name (STitle) **].  It is
very important that you undergo this test to see if their is
problems with the vessels in your heart.



Completed by:[**2176-2-10**]
{'Acute alcoholic intoxication in alcoholism, continuous,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Depressive disorder, not elsewhere classified,Spinal stenosis in cervical region'}


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 intoxication

PRESENT ILLNESS: This is a 54 M who was found down outside a restaurant where he
reportedly works as a dishwasher and was brought to the ED. BAL
was 509. He had stepped outside about five minutes before he was
found unresponsive. Pt was noted to be posturing and foaming at
the mouth per EMS. No signs of trauma. C-collar was placed. FSBG
normal per EMS.

MEDICAL HISTORY: Alcohol abuse
HTN
Hyperlipidemia
Tobacco abuse
Depression

MEDICATION ON ADMISSION: HCTZ 25 mg PO daily
Percocet PRN
Zocor 20 mg PO daily
Trazodone 50 mg PO QHS PRN insomnia
ASA 81 mg PO daily
Colace
MVI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: Per Metavision
GEN: Appears unkempt, NAD.
HEENT: NC/AT. MMM. OP clear.
NECK: No JVD.
CV: RRR, no M/G/R, normal S1 S2, radial pulses +2.
PULM: Lungs CTAB, no W/R/R.
ABD: Soft, NT, ND, +BS, no HSM, no masses.
EXT: No C/C/E, no palpable cords.
NEURO: Oriented to person and place. Able to move all four
extremities. Sensation grossly intact.

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. 

### Response:
{'Acute alcoholic intoxication in alcoholism, continuous,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Depressive disorder, not elsewhere classified,Spinal stenosis in cervical region'}
