CHIEF COMPLAINT: pneumonia, EtOH & benzodiazepine intoxication

PRESENT ILLNESS: 59 M with past medical history significant for heavy EtOH abuse,
COPD and multiple recent admissions for pneumonia and EtOH
withdrawal, found down today laying on a sofa. No report of
trauma. Yesterday the patient had a chest x-ray that showed
pneumonia; upon sobering he stated that he has been coughing and
was told to back to the ED for treatment of his pneumonia.

MEDICAL HISTORY: 1. EtOH abuse
2. COPD
3. h/o PNAs
4. s/p [**Hospital1 8751**] w/ multiple fractures, splenectomy, jaw repair in
[**2161**]
5. chronic pain [**12-27**] [**Month/Day (2) 8751**] injuries
6. h/o hypercarbic respiratory failure
7. S/p splenectomy [**2161**]
8. Tobacco abuse

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillins

PHYSICAL EXAM: ADMISSION EXAM
General: somnolent, oriented to person/place/month/year, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Very poor inspiratory effort (pt not cooperative), poor
air movemement, very faint crackles heard at the bases R>L
Abdomen: soft, non-distended, midline scar s/p splenectomy,
bowel sounds present, no organomegaly, no tenderness to
palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, no focal deficit, gait deferred, no
asterixis
Psych: Agitated, non-cooperative

FAMILY HISTORY: Mother died from breast cancer.  The father was a fireman and he
believes he died from lung cancer.

SOCIAL HISTORY: Currently homeless, living at the [**Hospital1 **] Shelter in [**Location (un) 14307**]. He has been staying there for several months. He smokes 1
ppd.  He drinks daily, at least 1 quart.  He says that he would
even fight to get his alcohol.  He says that he was sober for 10
years until both of his sons got into a car accident and died.
He used to be a roofer and helped to build many of the roofs of
the local hospitals in [**Location (un) 86**] area.
Other Staphylococcus pneumonia,Alcohol withdrawal,Obstructive chronic bronchitis with (acute) exacerbation,Tobacco use disorder,Lack of housing,Acute alcoholic intoxication in alcoholism, continuous,Chronic pain due to trauma
Staph pneumonia NEC,Alcohol withdrawal,Obs chr bronc w(ac) exac,Tobacco use disorder,Lack of housing,Ac alcohol intox-contin,Chronc pain d/t trauma
Admission Date:  [**2171-7-10**]              Discharge Date:   [**2171-7-11**]

Date of Birth:  [**2111-9-22**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
pneumonia, EtOH & benzodiazepine intoxication


Major Surgical or Invasive Procedure:
none

History of Present Illness:
59 M with past medical history significant for heavy EtOH abuse,
COPD and multiple recent admissions for pneumonia and EtOH
withdrawal, found down today laying on a sofa. No report of
trauma. Yesterday the patient had a chest x-ray that showed
pneumonia; upon sobering he stated that he has been coughing and
was told to back to the ED for treatment of his pneumonia.

In the ED, initial VS were T 98, HR 88, BP 95/48, RR 14, SpO2
88% RA. On arrival, the patient was intoxicated and observed
overnight until sobriety. Portable CXR showed RLL infiltrate
that appeared improved from prior CXR on [**7-4**]. Labs were notable
for a serum EtOH level 265, positive serum benzos, Na 149,
lactate 1.8, and elevated bicarb 35. This morning, the patient
was found to be hypoxic to 87-88% on 6L NC. He was placed on a
NRB for about 20 min; O2 sat improved, then he was switched back
to nasal cannula with O2 sat 94-95% on 6L NC. He received
levofloxacin and will receive flagyl. The ED team was concerned
that the pneumonia seen on CXR did not fully account for the
degree of hypoxia, and ordered a CTA to rule out PE, however,
patient became upset and refused CTA so it was not performed.
The complained of alcohol withdrawal symptoms and received
ativan 0.5mg IV.

Of note, the patient has been hospitalized at least four times
over the past month, leaving AMA and eloping on most of his
hospitalizations. Most recently he eloped from the ED 2 days ago
([**7-8**]) after being searched by [**Hospital1 18**] police and before being
seen by an ED attending. In the past, he has threatened nursing
staff "I will come back and shoot you" and "I want you dead." He
has used profanities toward staff, has been uncooperative
requiring security involvement, leather restraints and
pharmacologic interventions.

On arrival to the MICU, the patient is lethargic and somewhat
somnolent, but becomes irritated when he is asked questions. He
is cursing at staff, but answering questions. During the
interview, when notified that he would not be receiving
methadone, he pulled out his IV and threatened to leave AMA.
Upon standing and putting on his clothes, he reported that he
felt too weak to leave, and decided to stay.


Past Medical History:
1. EtOH abuse
2. COPD
3. h/o PNAs
4. s/p [**Hospital1 8751**] w/ multiple fractures, splenectomy, jaw repair in
[**2161**]
5. chronic pain [**12-27**] [**Month/Day (2) 8751**] injuries
6. h/o hypercarbic respiratory failure
7. S/p splenectomy [**2161**]
8. Tobacco abuse


Social History:
Currently homeless, living at the [**Hospital1 **] Shelter in [**Location (un) 14307**]. He has been staying there for several months. He smokes 1
ppd.  He drinks daily, at least 1 quart.  He says that he would
even fight to get his alcohol.  He says that he was sober for 10
years until both of his sons got into a car accident and died.
He used to be a roofer and helped to build many of the roofs of
the local hospitals in [**Location (un) 86**] area.


Family History:
Mother died from breast cancer.  The father was a fireman and he
believes he died from lung cancer.


Physical Exam:
ADMISSION EXAM
General: somnolent, oriented to person/place/month/year, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Very poor inspiratory effort (pt not cooperative), poor
air movemement, very faint crackles heard at the bases R>L
Abdomen: soft, non-distended, midline scar s/p splenectomy,
bowel sounds present, no organomegaly, no tenderness to
palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, no focal deficit, gait deferred, no
asterixis
Psych: Agitated, non-cooperative

PATIENT LEFT AMA

Pertinent Results:
[**2171-7-10**] 10:03AM BLOOD WBC-4.4 RBC-4.22* Hgb-13.9* Hct-43.3
MCV-103* MCH-32.9* MCHC-32.1 RDW-15.9* Plt Ct-159
[**2171-7-9**] 11:45PM BLOOD Glucose-126* UreaN-6 Creat-0.5 Na-149*
K-3.3 Cl-105 HCO3-35* AnGap-12
[**2171-7-9**] 11:45PM BLOOD ALT-52* AST-65* AlkPhos-120 TotBili-0.3
[**2171-7-9**] 11:45PM BLOOD Calcium-9.2 Phos-4.7* Mg-1.5*
[**2171-7-9**] 11:45PM BLOOD ASA-NEG Ethanol-265* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG

Brief Hospital Course:
# Pneumonia: Patient had been admitted recently for hypoxia and
pneumonia and had left on [**7-5**] after receiving only 2 days of
treatment with levofloxacin and flagyl. However, sputum culture
from that admission grew coagulase + staph resistant to
levofloxacin. CXR performed on admission did show improvement of
the RLL infiltrate previously see on [**7-4**]. In the ED, the patient
received a dose of levofloxacin and flagyl. After arriving to
the MICU, the patient complained of being subjectively short of
breath, although physical signs were unconcerning. Patient was
started on bactrim ds 1 tab po q12hr based on sensitivity
patterns from the sputum culture. Patient left AMA on hospital
and antibiotic day 2.

# COPD: Given shortness of breath as well as history of greenish
sputum production, consideration was paid to potential
contribution of COPD exacerbation. Patient was offered
ipatropium and albuterol nebs, which he refused. Patient left
AMA as above.

# Alcoholism: Patient was actively abusing alcohol and presented
to the ED intoxicated. During our interview, he threatened to
leave AMA to go drink. He also refused to speak with social
worker. Ciwa scale was initiated q2hr with diazepam. Patient
required 60 mg diazepam over the course of the first 24 hrs.
Patient then left AMA>

# Chronic pain: Patient reported a history of chronic pain in
the context of multiple MVAs and surgeries. He claimed to be on
methadone, but during his last admission [**Date range (1) 45401**], his PCP was
[**Name (NI) 653**] and states that he has not prescribed the patient
methadone in 1 month because of aberrant behavior and repeatedly
negative urine tox screens. When told that he would not be
receiving methadone, the patient decided to leave AMA, but then
changed his mind because he said he felt too weak. Subsequently,
he left AMA.

# Tobacco abuse: Smoking cessation counseling and nicotine patch
were offered. Patient refused. Patient subsequently left AMA.

Discharge Disposition:
Home

Facility:
Patient left AMA

Discharge Diagnosis:
Pneumonia, EtOH, & Benzodiazepine intoxication

Discharge Condition:
Left AMA

Discharge Instructions:
N/A
Patient left AMA

Followup Instructions:
N/A
Patient left AMA


Completed by:[**2171-7-11**]
{'Other Staphylococcus pneumonia,Alcohol withdrawal,Obstructive chronic bronchitis with (acute) exacerbation,Tobacco use disorder,Lack of housing,Acute alcoholic intoxication in alcoholism, continuous,Chronic pain due to trauma'}


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: pneumonia, EtOH & benzodiazepine intoxication

PRESENT ILLNESS: 59 M with past medical history significant for heavy EtOH abuse,
COPD and multiple recent admissions for pneumonia and EtOH
withdrawal, found down today laying on a sofa. No report of
trauma. Yesterday the patient had a chest x-ray that showed
pneumonia; upon sobering he stated that he has been coughing and
was told to back to the ED for treatment of his pneumonia.

MEDICAL HISTORY: 1. EtOH abuse
2. COPD
3. h/o PNAs
4. s/p [**Hospital1 8751**] w/ multiple fractures, splenectomy, jaw repair in
[**2161**]
5. chronic pain [**12-27**] [**Month/Day (2) 8751**] injuries
6. h/o hypercarbic respiratory failure
7. S/p splenectomy [**2161**]
8. Tobacco abuse

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillins

PHYSICAL EXAM: ADMISSION EXAM
General: somnolent, oriented to person/place/month/year, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Very poor inspiratory effort (pt not cooperative), poor
air movemement, very faint crackles heard at the bases R>L
Abdomen: soft, non-distended, midline scar s/p splenectomy,
bowel sounds present, no organomegaly, no tenderness to
palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, no focal deficit, gait deferred, no
asterixis
Psych: Agitated, non-cooperative

FAMILY HISTORY: Mother died from breast cancer.  The father was a fireman and he
believes he died from lung cancer.

SOCIAL HISTORY: Currently homeless, living at the [**Hospital1 **] Shelter in [**Location (un) 14307**]. He has been staying there for several months. He smokes 1
ppd.  He drinks daily, at least 1 quart.  He says that he would
even fight to get his alcohol.  He says that he was sober for 10
years until both of his sons got into a car accident and died.
He used to be a roofer and helped to build many of the roofs of
the local hospitals in [**Location (un) 86**] area. 

### Response:
{'Other Staphylococcus pneumonia,Alcohol withdrawal,Obstructive chronic bronchitis with (acute) exacerbation,Tobacco use disorder,Lack of housing,Acute alcoholic intoxication in alcoholism, continuous,Chronic pain due to trauma'}
