CHIEF COMPLAINT: status post fall, alcohol withdrawal

PRESENT ILLNESS: This is a 48 year old male with history of depression was found
by EMS lying half on and half off the sidewalk incontinent of
urine and stool.  En route he was consfused and confabulating.
After a round a bout converation, he admitted to falling down 14
stairs today.  He also stated that 4 days prior he was hit in
the back of the head by robbers.  He also endorsed cocaine and
MJ use that may be been contaminated as recently as Friday.
.
.
In the ED vs were 98.1   142   154/97   19   100.  GCS was 14,
hard collar was placed.  Left shoulder with edema and accymoses.
 CT of the head/neck/abdomen were performed without serious
abnormality.  CXR of the left shoulder showed a displaced
fracture of the humerus.  Ortho evaulated, and patient is on the
schedule for OR on [**10-28**].  While in the [**Name (NI) **], pt showed signs of
withdrawl.  He was given 1L IV Thiamine, Folate, MVI, 70mg
Valium, 40meq K, Mg 2gm.  He also received 9L NS for a CK of
6000.  Vs on transfer:  T98.1 HR142 BP 154/97  RR19 100.
.
On the floor, pt is unable to cooperate with a coherent history.
Mother was [**Name (NI) 653**] for more information.  She is aware that
[**Doctor Last Name **] has been drinking, but unclear about when he restarted and
if he has had problems with ETOH in the past.

MEDICAL HISTORY: hx "mild depression per pt, treated by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 111598**]
(addictions psychologist) and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 111599**] as PCP at [**Name9 (PRE) 778**]
Health. PCP prescribes psych meds, no psychiatrrist he says. no
prior admissions, no SA/SI/SIB, no hx assualtive or violent
behavior

MEDICATION ON ADMISSION: Fexofenadine 60mg [**Hospital1 **]
Quetiapine 100 mg qAM, 300mg qPM

ALLERGIES: Mold Extracts / Codeine / Percocet

PHYSICAL EXAM: Admission Physical Exam:
Vitals: 99.5  120  147/120  17  100% RA
General: Alert, oriented, no acute distress
HEENT: PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear,
blood on back of head, no open laceration, cervical hard collar
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, few rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, old ecchymoses on chest
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Neuro: alert and oriented to person, hospital, tremor.  Able to
give details from long term memory but not acutely.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.  LUE
with bruising, hematoma, tenderness, and edema

FAMILY HISTORY: mother with three alcoholic brothers

SOCIAL HISTORY: single, gay male, BU graduate with associates degree.
Lives in [**Location 86**] at the Braemore.
h/o ETOH dependence, sober since [**2138-11-30**].  Unclear when he
started drinking again.
h/o cocaine in the [**2109**], now claims he has been using cocaine
and
denies IVD, opioids, any other drug use.
Closed fracture of surgical neck of humerus,Encephalopathy, unspecified,Acute kidney failure, unspecified,Rhabdomyolysis,Acidosis,Alcohol withdrawal delirium,Other and unspecified manifestations of thiamine deficiency,Accidental fall on or from other stairs or steps,Hypotension, unspecified,Depressive disorder, not elsewhere classified,Other alteration of consciousness,Other and unspecified alcohol dependence, continuous,Other B-complex deficiencies,Folate-deficiency anemia,Unspecified essential hypertension,Tachycardia, unspecified,Tobacco use disorder,Fall from other slipping, tripping, or stumbling,Rotator cuff (capsule) sprain,Essential thrombocythemia,Open wound of scalp, without mention of complication,Cervical spondylosis without myelopathy
Fx surg nck humerus-clos,Encephalopathy NOS,Acute kidney failure NOS,Rhabdomyolysis,Acidosis,Delirium tremens,Thiamine defic NEC/NOS,Fall on stair/step NEC,Hypotension NOS,Depressive disorder NEC,Other alter consciousnes,Alcoh dep NEC/NOS-contin,B-complex defic NEC,Folate-deficiency anemia,Hypertension NOS,Tachycardia NOS,Tobacco use disorder,Fall from slipping NEC,Sprain rotator cuff,Essntial thrombocythemia,Open wound of scalp,Cervical spondylosis
Admission Date:  [**2139-10-27**]              Discharge Date:   [**2139-11-9**]

Date of Birth:  [**2091-4-15**]             Sex:   M

Service: MEDICINE

Allergies:
Mold Extracts / Codeine / Percocet

Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
status post fall, alcohol withdrawal

Major Surgical or Invasive Procedure:
ORIF/K-Rod of left shoulder ([**2139-10-28**]) and repair ([**11-4**])
Posterior scalp laceration repair with staples

History of Present Illness:
This is a 48 year old male with history of depression was found
by EMS lying half on and half off the sidewalk incontinent of
urine and stool.  En route he was consfused and confabulating.
After a round a bout converation, he admitted to falling down 14
stairs today.  He also stated that 4 days prior he was hit in
the back of the head by robbers.  He also endorsed cocaine and
MJ use that may be been contaminated as recently as Friday.
.
.
In the ED vs were 98.1   142   154/97   19   100.  GCS was 14,
hard collar was placed.  Left shoulder with edema and accymoses.
 CT of the head/neck/abdomen were performed without serious
abnormality.  CXR of the left shoulder showed a displaced
fracture of the humerus.  Ortho evaulated, and patient is on the
schedule for OR on [**10-28**].  While in the [**Name (NI) **], pt showed signs of
withdrawl.  He was given 1L IV Thiamine, Folate, MVI, 70mg
Valium, 40meq K, Mg 2gm.  He also received 9L NS for a CK of
6000.  Vs on transfer:  T98.1 HR142 BP 154/97  RR19 100.
.
On the floor, pt is unable to cooperate with a coherent history.
Mother was [**Name (NI) 653**] for more information.  She is aware that
[**Doctor Last Name **] has been drinking, but unclear about when he restarted and
if he has had problems with ETOH in the past.

Past Medical History:
hx "mild depression per pt, treated by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 111598**]
(addictions psychologist) and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 111599**] as PCP at [**Name9 (PRE) 778**]
Health. PCP prescribes psych meds, no psychiatrrist he says. no
prior admissions, no SA/SI/SIB, no hx assualtive or violent
behavior

PMH- psoriasis, kidney stones

Social History:
single, gay male, BU graduate with associates degree.
Lives in [**Location 86**] at the Braemore.
h/o ETOH dependence, sober since [**2138-11-30**].  Unclear when he
started drinking again.
h/o cocaine in the [**2109**], now claims he has been using cocaine
and
denies IVD, opioids, any other drug use.

Family History:
mother with three alcoholic brothers

Physical Exam:
Admission Physical Exam:
Vitals: 99.5  120  147/120  17  100% RA
General: Alert, oriented, no acute distress
HEENT: PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear,
blood on back of head, no open laceration, cervical hard collar
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, few rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, old ecchymoses on chest
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Neuro: alert and oriented to person, hospital, tremor.  Able to
give details from long term memory but not acutely.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.  LUE
with bruising, hematoma, tenderness, and edema

Pertinent Results:
I. Labs

A. Admission

[**2139-10-27**] 04:02PM BLOOD WBC-9.9 RBC-3.60* Hgb-12.6* Hct-37.2*
MCV-103* MCH-34.9* MCHC-33.8 RDW-15.1 Plt Ct-150
[**2139-10-27**] 04:02PM BLOOD Neuts-83.8* Lymphs-10.7* Monos-5.1
Eos-0.3 Baso-0.2
[**2139-10-27**] 04:02PM BLOOD PT-10.7 PTT-19.6* INR(PT)-0.9
[**2139-10-27**] 04:02PM BLOOD Glucose-206* UreaN-23* Creat-2.2* Na-141
K-3.2* Cl-96 HCO3-15* AnGap-33*
[**2139-10-27**] 04:02PM BLOOD CK(CPK)-6623*
[**2139-10-27**] 04:02PM BLOOD CK-MB-9
[**2139-10-27**] 07:30PM BLOOD cTropnT-0.01
[**2139-10-27**] 10:27PM BLOOD cTropnT-0.01
[**2139-10-27**] 04:02PM BLOOD Calcium-10.3 Phos-3.8 Mg-1.4*
[**2139-10-30**] 07:20AM BLOOD calTIBC-137* Ferritn-1166* TRF-105*
[**2139-11-2**] 06:50AM BLOOD TSH-4.6*
[**2139-11-2**] 06:50AM BLOOD T4-4.5*
[**2139-10-27**] 04:35PM BLOOD Glucose-201* Lactate-8.3* Na-143 K-3.3*
Cl-100 calHCO3-15*
[**2139-10-27**] 07:39PM BLOOD Lactate-1.4
[**2139-10-29**] 07:01PM BLOOD Lactate-1.3
[**2139-10-28**] 09:42AM BLOOD METHYLMALONIC ACID-Test

B. Discharge

[**2139-11-9**] 07:00AM BLOOD WBC-9.4 RBC-2.83* Hgb-9.1* Hct-28.0*
MCV-99* MCH-32.3* MCHC-32.6 RDW-16.8* Plt Ct-1090*
[**2139-11-9**] 07:00AM BLOOD Plt Ct-1090*
[**2139-11-9**] 07:00AM BLOOD Glucose-107* UreaN-7 Creat-0.7 Na-138
K-4.6 Cl-105 HCO3-25 AnGap-13
[**2139-11-6**] 06:45AM BLOOD ALT-39 AST-31 LD(LDH)-317* CK(CPK)-217
AlkPhos-114 TotBili-0.7
[**2139-11-9**] 07:00AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.1
[**2139-10-29**] 07:01PM BLOOD Lactate-1.3
[**2139-11-7**] 02:28PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.004
[**2139-11-7**] 02:28PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2139-11-7**] 02:28PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2139-10-27**] 04:22PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG

C. Genetic Testing
[**2139-11-9**] 07:00 JAK2 MUTATION (V617F) ANALYSIS, PLASMA BASED
Results Pending

II. Microbiology
[**2139-11-7**] URINE URINE CULTURE-FINAL INPATIENT
URINE CULTURE (Final [**2139-11-8**]):
      MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
      AND/OR GENITAL CONTAMINATION.
[**2139-11-7**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2139-11-7**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2139-11-5**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2139-11-5**] URINE URINE CULTURE-FINAL INPATIENT
[**2139-11-5**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2139-11-1**] SEROLOGY/BLOOD LYME SEROLOGY-FINAL INPATIENT

LYME SEROLOGY (Final [**2139-11-5**]):
      NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA.
      Reference Range:  No antibody detected.
      Negative results do not rule out B. burgdorferi infection.
 Patients
      in early stages of infection or on antibiotic therapy may
not produce
      detectable levels of antibody.  Patients with clinical
history and/or
      symptoms suggestive of lyme disease should be retested in
[**3-4**] weeks.

[**2139-10-30**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2139-10-30**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2139-10-29**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2139-10-29**] URINE URINE CULTURE-FINAL INPATIENT
[**2139-10-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2139-10-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2139-10-27**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT

III. Neurophysiology

FINDINGS:
BACKGROUND: A well-formed 9-9.5 Hz alpha rhythm background was
observed
throughout the record.
HYPERVENTILATION: Did not produce activation of the record.
INTERMITTENT PHOTIC STIMULATION: Did not produce activation of
the
record.
SLEEP: The patient remained awake throughout the entire record.
CARDIAC MONITOR: Showed a generally regular rhythm between
90-100 bpm.
IMPRESSION: This is a normal routine EEG in the awake state.
There were
no focal abnormalities or epileptiform features present.

IV. Cardiology

A. EKG
Sinus tachycardia. Otherwise, tracing is within normal limits.
No diagnostic
interim change.
TRACING #2


Read by: [**Last Name (LF) **],[**First Name3 (LF) **] V.

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
115 128 90 330/426 42 10 24


B. ECHO
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.

IMPRESSION: Normal global and regional biventricular systolic
function. No pulmonary hypertension or clinically-significant
valvular disease seen

V. Radiology

A. Head MRI
EXAM: MRI of the brain.

CLINICAL INFORMATION: Patient with persistent memory and
cognitive problems
status post head trauma and alcoholism and family history of
multiple
sclerosis.

TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion
axial images were obtained before gadolinium. T1 axial and
MP-RAGE sagittal
images acquired following gadolinium.

FINDINGS: Diffusion images demonstrate no evidence of acute
infarct. Subtle
hyperintensities on diffusion images in the brainstem appear to
be secondary
to T2 shine-through from mild T2 hyperintensities in the region
from small
vessel disease.

There is no evidence of periventricular signal abnormalities. A
few scattered
nonspecific hyperintensities are seen in the white matter
indicating minimal
changes of small vessel disease. The appearances are not typical
for
demyelinating process. However, clinical correlation
recommended. Following
gadolinium, no evidence of abnormal parenchymal, vascular or
meningeal
enhancement seen.

There is mild prominence of sylvian fissures identified but
there is no
evidence of dilatation of the temporal horns to indicate medial
temporal
atrophy. On the coronal MP-RAGE images there is no evidence of
atrophy of the
hippocampi visualized or atrophy of the medial temporal lobe
structure seen.

Following gadolinium, no evidence of abnormal parenchymal,
vascular or
meningeal enhancement seen.

IMPRESSION:
Except for a few non-specific scattered foci of T2
hyperintensity in the white
matter, no other significant abnormalities are seen. The
appearances are not
typical for demyelinating disease but clinical correlation
recommended. No
enhancing brain lesions are seen. No evidence of medial temporal
atrophy.

B. CXR
CHEST RADIOGRAPH

INDICATION: Status post left shoulder repair.

COMPARISON: [**2139-10-30**].

FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Normal size of the cardiac silhouette. No pleural
effusions. No
pneumothorax. Minimal atelectasis in the retrocardiac lung
areas. Otherwise, the lung parenchyma is unremarkable. There is
no evidence of focal parenchymal opacity suggesting pneumonia.
No evidence of pulmonary edema and no pleural effusions. The
hilar and mediastinal contours are unremarkable

C. Left Shoulder
HISTORY: ORIF.

FINDINGS: Single image from the operating suite shows extensive
metallic
fixation device about previous fracture of the proximal humerus.
The humeral
head is somewhat inferiorly displaced in relation to the glenoid
fossa.

D. UE Doppler ([**11-1**])
IMPRESSION: Right basilic vein clot (this is a SUPERFICIAL
vein). Limited evaluation of the right cephalic and left
brachial veins.

E. MRI C-spine ([**2139-10-29**])
IMPRESSION:
1. Cervical spondylosis with posterior disc protrusions at C3-C4
through
C6-C7. The posterior disc protrusion indents the cervical cord
at C4-C5 and C5-C6. The cervical cord, C3 through C7, does
demonstrate subtle T2
hyperintense signal, possibly related to myelomalacia.
2. The right neural foraminal of C6-C7 is severely narrowed due
to the above mentioned disc protrusion.
2. No definite acute abnormality identified.

F. Left shoulder plain film
HISTORY: ORIF left proximal humerus.
Fluoroscopic assistance provided to the surgeon in the OR
without the
radiologist present. Four spot views obtained. Fluoro time
recorded as 49.5
seconds on the electronic requisition. Views demonstrate
hardware related to
a left proximal humeral fracture. Correlation with real-time
findings and
when appropriate conventional radiographs are recommended for
full assessment.

G. C-spine
HISTORY: 43-year-old male with altered mental status and head
strike.

COMPARISON: Concurrent head CT.

TECHNIQUE: Non-contrast cervical spine CT was obtained.
Multiplanar
reformatted images were generated.

FINDINGS: There is reversal of the normal cervical lordosis
centered at C4.
Minimal, grade I retrolisthesis of the C5 on C6 is likely
degenerative. There
is no fracture of the cervical spine and no prevertebral soft
tissue edema or
hematoma.

Posterior osteophytes result in mild spinal canal narrowing at
C6-7, C5-6 and
C4-5 consisitent with degenerative changes of the cervical
spine. At C6-7,
osteophytes result in neural foraminal narrowing, right greater
than left.
The lung apices are clear.

IMPRESSION:
1. No fracture of the cervical spine.
2. Multilevel degenerative changes of the cervical spine with
mild canal
stenosis at C4-5, C5-6 and C6-7, which could predispose to cord
injury in the
setting of minor trauma. MRI is recommended if there is concern
for
ligamentous injury.


Brief Hospital Course:
48-year-old male with alcohol abuse that presents with resolved
polysubstance withdrawal, confabulation, resolved delirium,
resolved acute kidney injury secondary to pre-renal etiology and
elevated CK, baseline tachycardia at 100 that is status post
left proximal humerus ORIF/K-Rod ([**2139-10-28**]) and repair
([**2139-11-4**]) secondary to repeat fall vs. non-adherence to sling.

ICU Course:
Patient was admitted for ETOH withdrawal in the setting of left
humeral fracture, having hallucinations and being minimally
responsive. He was resuscitated in the ICU with fluids with
subsequent transfer to the floor.

# Altered mental status/delirium (resolved) secondary to
polysubstance abuse/underlying medical issues
In first twelve hours, the patient scored frequently on the CIWA
scale.  He was noted to be broadly confabulating.  In subsequent
24 hours he received only 10mg valium.  However, he continued to
lack orientation to time and continued to confabulate.  He was
also unable to tell a consistent story of what happened to him
prior to admission.  There was concern for thiamine deficiency
and Wernicke-Korsakoff syndrome and aggressive thiamine
repletion was undertaken.  He also has a history of psychosis
although this is questionable upon record review. His home
quetiapine was restarted. It was thought that he may have
delirium. Various issue have been ruled out for his delirium.
Given left humerus fracture, polytrauma was ruled out with CT
Head not suggestive of bleed, CXR showed no evidence of
traumatic injury, MRI of C-spine showed cervical spondylosis
with a variety of abnormalities not suggestive of acute
abnormality. His mental status has improved and now resolving
with normal EEG. As his medical issues resolve, he remains
rather odd, which is normal per family. He has had intermittent
alcohol sobriety periods in past year. He has had issues with
attending medical appointments. He has been working with
addiction specialists at [**Hospital1 778**] but dropped out last Fall. There
was no evidence of organic brain disease on MRI. He was given
appropriate nutrition, weaned off delirium-causing medications,
and psychiatry was consulted for assessment. He was initially
placed on seroquel that caused orthostatic issues. He was
subsequently switched to abilify 5 mg with good effect and
resolution of orthostasis. His delirium had resolved. He does
have poor insight at times about his alcohol habits.

# Orthostatic hypotension with tachycardia and gait instability
The patient had a mechanical fall prompting admission and felt
dizzy getting out of bed in the radiology suite with subsequent
fall. His baseline heart rate is 100 per old records. During his
earlier hospital course, he was triggered for tachycardia to 140
consistent with sinus tachycardia. He also has had tachycardia
on exertion elevated to 140 on exertion that is non-paroxsymal
in nature per telemetry. PT/OT evaluation showed orthostatic
hypotension with tachycardia to 160. Previously in his hospital
course, considerations were hypovolemia with heart rate
responding to boluses. Given this current issue, medication side
effect with seroquel was found to be the likely etiology
resulting in orthostasis. In addition, he has had new gait
instability since [**Month (only) 216**] per his mother. [**Name (NI) 227**] confusing
picture, neurology was consulted and felt based on additional
imaging (MRI brain) that he had the sequela of chronic
alcoholism. His seroquel was changed to abilify.

# Tachycardia with trigger on [**10-30**]
His heart rate was 100s-130s and as high as 160 during first the
first 48 hours of hospitalization with SBPs 110s-160s.
Differential included pain, surgery, and alcohol withdrawal.
Heart rate and blood pressure were not noted to respond to
diazepam. There was a concern for thiamine deficiency leading to
beriberi prompted echocardiogram with reported attached. The
patient was triggered on [**10-30**] for sinus tachycardia to the 130s
responsive to fluids. His tachycardia has likely been
multifactorial and the etiology remains unknown definitively
except that orthostasis may have played a role. His heart is 100
at baseline per old records. It was initially suspected that he
may be withdrawing, but outside of this period, he still
continued to have issues. TSH and other factors were examined
and negative. It was likely attributed to a medication side
effect.

# Left humerus fracture status post ORIF ([**2139-10-28**]) and status
post repair ([**2139-11-4**]) after fall
The patient had suffered a left humerus fracture from his fall.
He was made non-weight bearing on his LUE with a shoulder
immobilization device. He subsequently fell in the radiology
suite with ? injury from the fall vs. non-adherence with his
splint. He was again taken to the OR on [**11-4**] for subsequent
repair. He refused to wear his shoulder sling during his
hospitalization and was warned about further injury. He was
discharged on motrin for pain.

# Recurrent pyrexia
The patient was febrile in both the ICU and on the floor. The
patient was pan-cultured with multiple negative studies. He
stated that at times he has fever at home spontaneously and that
it is "normal" for him. In the post-op period, aspiration
pneumonia and UTI were ruled out in addition to wound
infection.There has been no identifiable source of infection
with cultures, and UE US for DVT has been negative given Left >
Right upper extremity swelling. Withdrawal was also considered
but unlikely given he was out of the normal period.

# Left extremity swelling and erythema
Given warm and left greater than right upper extremity swelling,
surgery was called to re-evaulate wound on initial surgery.
Upper extremity US to rule out DVT showed superficial basilic
clot. He extremity edema has nearly resolved on discharge.

# Acute kidney injury secondary to elevated CPKs, pre-renal,
resolved
Cr at admission of 2.21 now down to baseline with CK and volume
depletion likely contributers. Issue is resolved.

# Neck pain, resolved
The patient had complained of neck pain and was placed in a
c-spine collar. MRI was performed given point tenderness over
spinous processes. MRI of the spine showed no acute abnormality
but some anatomical issues. It is perhaps possible that he may
have had ligamentous strain from fall. This pain subsequently
resolved after a few days.

# Anemia with thrombocytosis
The patient had anemia on admission (Hgb 13) likely secondary to
nutritional disorder, blood loss, and marrow-supressive effect
of alcohol. He had a nadir to 9.1 with subsequent transfusion of
2pRBC before going to the OR with interval climb of 10.2. He had
mild blood loss during both procedures. His stools have been
hemoccult negative. The etiology of his anemia is unknown. He
also had development of thrombocytosis. The patient has no
apparent malignancy, so the thrombocytosis may be reactive in
the post-operative period. A JAK2 mutation was ordered to rule
out underlying myleoproliferative disease, and he was placed on
aspirin given platelets greater than 1090.

In addition given macrocytosis and B12 < 400, he was empirically
treated for B12 deficiency in setting of folate therapy in order
to avoid masking underlying neurological symptoms. His MMA
returned low. B12 can be continued on an outpatient basis and
re-tested.

# Transaminitis: The patient has initial LFT elevation on
admission (ALT 89 AST 260 LDH 459 CPK 4207 ALP 79 Tot Bili 1)
with subsequent downtrend to normal range with remaining
isolated LDH elevation. Suspect acute alcohol ingestion along
with component of muscle damage given concomitant CK. Issue has
resolved.

# Tobacco abuse
Patient was counseled about tobacco abuse and given nicotine
patch.

# Pending tests - BCx x 2 ([**11-7**]), Bcx x 2 ([**11-5**]), JAK2
mutation

# Outpatient considerations
- Uptitration of Abilify to 15 mg based on symptoms (akathisia
would be main side effect that can be treated with ativan).
- re-check outpatient TSH as suggestive of sick euthyroid
- re-check nutritional studies
- outpatient substance abuse program or Alcoholics Anonymous
- repeat liver enzymes
- consider outpatient psychiatry

Medications on Admission:
Fexofenadine 60mg [**Hospital1 **]
Quetiapine 100 mg qAM, 300mg qPM

Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2857**] - [**Location (un) 9188**]

Discharge Diagnosis:
1. Left humerus fracture s/p ORIF and repair
2. Alcohol withdrawal
3. Thrombocytosis
4. Anemia


[**Hospital 16392**] rehab stay less than 30 days


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Use left shoulder splint.


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

You were admitted after falling onto your left shoulder. Your
left shoulder was repaired by the orthopedic doctors.  You were
also lightheaded and unstable on your feet. You fell again, and
unfortunately had to return to the operating room to have your
shoulder fixed a second time. By decreasing your Seroquel dose
and starting a new medication, Abilify, your walking improved.
You are now ready to go to rehab to continue working on your
walking.

New medications:
Aripiprazole 5 mg PO DAILY
Aspirin 325 mg PO DAILY
Cyanocobalamin 1000 mcg PO DAILY
FoLIC Acid 1 mg PO DAILY
Ibuprofen 400 mg PO every 8 hours as needed for pain
Multivitamins 1 TAB PO daily
Thiamine 100 mg PO DAILY

Followup Instructions:
Please call your primary care doctor:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10747**]
[**Location (un) 57122**], [**Numeric Identifier 57123**]
([**Telephone/Fax (1) 10757**]


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
{'Closed fracture of surgical neck of humerus,Encephalopathy, unspecified,Acute kidney failure, unspecified,Rhabdomyolysis,Acidosis,Alcohol withdrawal delirium,Other and unspecified manifestations of thiamine deficiency,Accidental fall on or from other stairs or steps,Hypotension, unspecified,Depressive disorder, not elsewhere classified,Other alteration of consciousness,Other and unspecified alcohol dependence, continuous,Other B-complex deficiencies,Folate-deficiency anemia,Unspecified essential hypertension,Tachycardia, unspecified,Tobacco use disorder,Fall from other slipping, tripping, or stumbling,Rotator cuff (capsule) sprain,Essential thrombocythemia,Open wound of scalp, without mention of complication,Cervical spondylosis without myelopathy'}


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: status post fall, alcohol withdrawal

PRESENT ILLNESS: This is a 48 year old male with history of depression was found
by EMS lying half on and half off the sidewalk incontinent of
urine and stool.  En route he was consfused and confabulating.
After a round a bout converation, he admitted to falling down 14
stairs today.  He also stated that 4 days prior he was hit in
the back of the head by robbers.  He also endorsed cocaine and
MJ use that may be been contaminated as recently as Friday.
.
.
In the ED vs were 98.1   142   154/97   19   100.  GCS was 14,
hard collar was placed.  Left shoulder with edema and accymoses.
 CT of the head/neck/abdomen were performed without serious
abnormality.  CXR of the left shoulder showed a displaced
fracture of the humerus.  Ortho evaulated, and patient is on the
schedule for OR on [**10-28**].  While in the [**Name (NI) **], pt showed signs of
withdrawl.  He was given 1L IV Thiamine, Folate, MVI, 70mg
Valium, 40meq K, Mg 2gm.  He also received 9L NS for a CK of
6000.  Vs on transfer:  T98.1 HR142 BP 154/97  RR19 100.
.
On the floor, pt is unable to cooperate with a coherent history.
Mother was [**Name (NI) 653**] for more information.  She is aware that
[**Doctor Last Name **] has been drinking, but unclear about when he restarted and
if he has had problems with ETOH in the past.

MEDICAL HISTORY: hx "mild depression per pt, treated by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 111598**]
(addictions psychologist) and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 111599**] as PCP at [**Name9 (PRE) 778**]
Health. PCP prescribes psych meds, no psychiatrrist he says. no
prior admissions, no SA/SI/SIB, no hx assualtive or violent
behavior

MEDICATION ON ADMISSION: Fexofenadine 60mg [**Hospital1 **]
Quetiapine 100 mg qAM, 300mg qPM

ALLERGIES: Mold Extracts / Codeine / Percocet

PHYSICAL EXAM: Admission Physical Exam:
Vitals: 99.5  120  147/120  17  100% RA
General: Alert, oriented, no acute distress
HEENT: PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear,
blood on back of head, no open laceration, cervical hard collar
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, few rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, old ecchymoses on chest
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Neuro: alert and oriented to person, hospital, tremor.  Able to
give details from long term memory but not acutely.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.  LUE
with bruising, hematoma, tenderness, and edema

FAMILY HISTORY: mother with three alcoholic brothers

SOCIAL HISTORY: single, gay male, BU graduate with associates degree.
Lives in [**Location 86**] at the Braemore.
h/o ETOH dependence, sober since [**2138-11-30**].  Unclear when he
started drinking again.
h/o cocaine in the [**2109**], now claims he has been using cocaine
and
denies IVD, opioids, any other drug use. 

### Response:
{'Closed fracture of surgical neck of humerus,Encephalopathy, unspecified,Acute kidney failure, unspecified,Rhabdomyolysis,Acidosis,Alcohol withdrawal delirium,Other and unspecified manifestations of thiamine deficiency,Accidental fall on or from other stairs or steps,Hypotension, unspecified,Depressive disorder, not elsewhere classified,Other alteration of consciousness,Other and unspecified alcohol dependence, continuous,Other B-complex deficiencies,Folate-deficiency anemia,Unspecified essential hypertension,Tachycardia, unspecified,Tobacco use disorder,Fall from other slipping, tripping, or stumbling,Rotator cuff (capsule) sprain,Essential thrombocythemia,Open wound of scalp, without mention of complication,Cervical spondylosis without myelopathy'}
