CHIEF COMPLAINT: Mental status change.

PRESENT ILLNESS: This is a 41 year old male with
a history of alcohol abuse and recent decreased alcohol
intake, who presented on [**8-17**] with a questionable
history of a seizure.  The last ten days, the patient's wife
noted that the patient had only taken in two to ten beers a
day, down from his normal of 18 to 24 beers a day.  The day
prior to admission, she witnessed only one beer.  In
addition, on the day of admission, the patient's wife heard a
thud and found the husband thrashing on the floor.  It was
unclear whether this was tonic/clonic seizure.  This
continued for about 15 minutes until EMS arrived and gave
intravenous Ativan.

MEDICAL HISTORY: 1.  History of alcohol abuse.
2.  Low back pain.
3.  Chronic anxiety.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Coronary artery disease and diabetes
mellitus.

SOCIAL HISTORY: One to two packs per day of tobacco and
alcohol 24 beers a day.  The patient owns a large business of
restaurants and has increased stress in his job recently.
Babesiosis,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Opioid abuse, unspecified,Acquired hemolytic anemia, unspecified,Alcohol withdrawal,Other and unspecified alcohol dependence, unspecified,Other disorders of muscle, ligament, and fascia
Babesiosis,Acute kidney failure NOS,Hyposmolality,Opioid abuse-unspec,Acq hemolytic anemia NOS,Alcohol withdrawal,Alcoh dep NEC/NOS-unspec,Muscle/ligament dis NEC
Admission Date:  [**2173-8-17**]       Discharge Date:  [**2173-8-23**]

Date of Birth:   [**2131-12-9**]       Sex:  M

Service:  [**Hospital1 **]

CHIEF COMPLAINT:   Mental status change.

HISTORY OF PRESENT ILLNESS:  This is a 41 year old male with
a history of alcohol abuse and recent decreased alcohol
intake, who presented on [**8-17**] with a questionable
history of a seizure.  The last ten days, the patient's wife
noted that the patient had only taken in two to ten beers a
day, down from his normal of 18 to 24 beers a day.  The day
prior to admission, she witnessed only one beer.  In
addition, on the day of admission, the patient's wife heard a
thud and found the husband thrashing on the floor.  It was
unclear whether this was tonic/clonic seizure.  This
continued for about 15 minutes until EMS arrived and gave
intravenous Ativan.

In the Emergency Department at an outside hospital, the
patient received Haldol and Ativan for agitation and was
oriented only to himself and described a loss of vision.  He
was diaphoretic and had blood pressures of systolic 120 to
130 and a heart rates of 100 to 130.  Out there, he had a
hematocrit that was measured at 25 and LDH was greater than
[**2170**].  He was intubated and sedated for transfer to [**Hospital1 1444**] via Life Flight and a
cervical collar was also applied for travel.  During that
flight, the patient received Fentanyl, Etomidate,
Apifloxemide, Vecuronium and Versed as well as Ativan.

In the [**Hospital1 69**] Emergency
Department, the patient's head CT scan was negative and a
chest x-ray was negative for acute cardiopulmonary process
and 12 mgs of Ativan were given intravenously.

Of note, the patient did say that he had had shakes in the
past due to alcohol, but no seizures.  Also of note, the
patient repeatedly said, "I'm sorry" and seemed to recoil
from imaginary things in the room during this episode on the
day of admission.  There was also a question of a right
facial droop.  The patient was able to talk during this
episode and was quite agitated.

PAST MEDICAL HISTORY:
1.  History of alcohol abuse.
2.  Low back pain.
3.  Chronic anxiety.

ALLERGIES:   No known drug allergies.

MEDICATIONS:
1.  Naprosyn.
2.  Ephedrine.
3.  Xanax.
4.  Percocet.
5.  Viagra.

SOCIAL HISTORY:  One to two packs per day of tobacco and
alcohol 24 beers a day.  The patient owns a large business of
restaurants and has increased stress in his job recently.

FAMILY HISTORY:  Coronary artery disease and diabetes
mellitus.

PHYSICAL EXAMINATION:  Upon presentation, temperature 99.4
F.; pulse 106; blood pressure 103/71; respirations 25 and the
patient was intubated at 100% FIMV of blood pressure support.
In general, the patient was intubated and sedated with an
abrasion over his left eye.  The pupils were 1 mm bilaterally
and not reactive.  There were moist mucous membranes and they
were pale.  On HEENT examination also, there was cervical
spine collar.  Lungs were coarse throughout.  The
cardiovascular examination was notable for tachycardia but a
regular rhythm, with normal S1 and S2.  The abdomen was
benign with 3 cm hepatomegaly.  Guaiac was negative.
Extremities showed no cyanosis, clubbing or edema and two
plus dorsalis pedis and posterior tibial pulses.
Dermatologic examination revealed no rashes or petechiae.
Neurologic examination revealed a person who is agitated,
moving all four extremities with brisk deep tendon reflexes
throughout.

LABORATORY:  Upon presentation, white blood cell count was
5.2, hematocrit was 21.8, platelet count was 151.  Sodium was
122, potassium 4.1, chloride 89, bicarbonate 23, BUN 28,
creatinine 1.1, magnesium of 2.8.  Liver function tests were
normal as well as cardiac enzymes.

A urine toxicology was positive for benzodiazepines and
opiates.  Serum toxicology was negative.

Peripheral smear revealed negative schistocytes, negative
intracytoplasmic inclusions and positive polychromasia.

A cervical spine x-ray was negative for fracture.  Chest
x-ray was negative for pneumonia or effusions.  A head CT
scan again was negative for hemorrhage, masses or ischemic
changes.

An EKG was done which revealed sinus tachycardia at 105, with
a slightly increased PR interval at 0.24 seconds with a
normal axis, left atrial abnormality and peaked T waves.
There were some diffuse ST elevations, likely J-point
elevation in lead I, II, AVL, V3, V4, V5 and V6.

HOSPITAL COURSE:  The patient was admitted to the Medical
Intensive Care Unit and was intubated for his decreased
mental status.  By systems:
1.  Neurologic:  The patient had agitation, hallucinations
and delirium and Neurologic was consulted to help as to the
etiology of the mental status change.  It was felt that the
patient might have been undergoing seizure activity due to
alcohol withdrawal or acute alcohol delirium.  The patient's
sodium was noted to be low and he was treated and later
became normonatremic.

In addition, a lumbar puncture was done and was clear and
colorless revealing only a protein of 31, a glucose of 66,
one white cell and zero red cells, with 7% polys, 87% lymphs
and 6% monos.  The patient was checked for babesiosis on
peripheral smear and was found to have babesiosis, and the
mental status was attributed to either alcohol withdrawal and
babesiosis contributing to it, or just alcohol withdrawal.

The mental status started to improve on day three.  When it
was felt that he could be extubated, he was extubated and
tolerated it well.  The patient remained moderately sedated
but was alert and oriented times three, reporting some pain
in both of his arms.

On neurological examination, it was noted that he did have a
right sided facial droop thought to be possibly Bell's Palsy
or a new onset event.  However, he continued to be agitated
and was kept on Ativan for ethanol withdrawal.  On day four
of his hospitalization, he was transferred to [**Hospital1 139**] Medicine
when it was felt that his mental status had improved and he
was able to ambulate and tolerate p.o.

2.  Infectious Disease:  The patient was treated for
babesiosis with Atovaquone and Azithromycin starting on day
one of his admission.  He was also started on Doxycycline for
concern of Lyme but was discontinued when that test returned
negative.  In addition, he had an HIV test which turned out
to be negative during his hospital course.  Infectious
Disease was consulted and recommended at least a ten day
course of Atovaquone and erythromycin.  Ehrlichieae was sent
out but was still pending as of this dictation.

The patient continued to do well on the Atovaquone and the
Azithromycin and was told to follow-up with Infectious
Disease in Clinic one week post discharge for all final
laboratory results.

3.  Hematologic:  The patient had a drop in hematocrit with
decreased haptoglobin and increased LDH, indicating hemolysis
from babesiosis.  However, it was somewhat puzzling why the
patient had such a significant hemolysis without much
parasite burden noted to be only 0.1% on the peripheral
smear.  The patient had a Hematology consultation and they
recommended transfusion for red blood cells to support his
low hematocrit which had dropped as low as 18 on the day of
admission.  After three blood transfusions, by the fourth
hospital day, the patient's hematocrit was rebounding on its
own.

4.  Renal:  The patient had some slight renal insufficiency
with a prerenal component with a BUN and creatinine ratio of
greater than 20 and a FEna of less than 1%.  The patient did
have blood in his urine and myoglobinuria was considered.
The patient was continued on intravenous fluid hydration and
the creatinine slowly corrected to his baseline.  Upon
discharge, his creatinine was 0.5 with a BUN of 5.0.   A
creatinine kinase was checked and was as high as 1797,
however, this was a decrease from 3,990 on the day prior to
discharge.  This attempted to support an episode of
rhabdomyolysis status post shaking on the day of admission.

5.  Pulmonary:  The patient was intubated and sedated for
agitation and decreased mental status for airway protection
and post-extubation did well and oxygenated well on room air.

6.  Cardiovascular:  The patient was tachycardic during his
hospital course and this was thought to be secondary to
anemia, anxiety as well as alcohol withdrawal.  The patient
was asymptomatic with this tachycardia and upon the day of
discharge, his heart rate was approximately 84.

7.  Fluids, Electrolytes:  The patient's sodium, as I
mentioned, had corrected from 122 to 135 over the course of
seven hospital days.

CONDITION AT DISCHARGE:   Good.

DISCHARGE STATUS:  To home.

DISCHARGE DIAGNOSES:
1.  Babesiosis.
2.  History of alcohol abuse and apparent alcohol withdrawal
while on this admission.
3.  Transient renal failure secondary to prerenal causes.
4.  Low back pain.
5.  Anxiety.

DISCHARGE MEDICATIONS:
1.  Atovaquone 750 mg p.o. twice a day.
2.  Azithromycin 600 mg p.o. q. day.
3.  Ativan.
4.  Ibuprofen.

DISCHARGE INSTRUCTIONS:
1.  The patient is to follow-up in Infectious Disease Clinic
one week post discharge and the patient was to make this
appointment on his own.

                            [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2400**], M.D.  [**MD Number(1) 2401**]

Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36

D:  [**2173-8-25**]  17:12
T:  [**2173-8-31**]  14:46
JOB#:  [**Job Number 44400**]
{'Babesiosis,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Opioid abuse, unspecified,Acquired hemolytic anemia, unspecified,Alcohol withdrawal,Other and unspecified alcohol dependence, unspecified,Other disorders of muscle, ligament, and fascia'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Mental status change.

PRESENT ILLNESS: This is a 41 year old male with
a history of alcohol abuse and recent decreased alcohol
intake, who presented on [**8-17**] with a questionable
history of a seizure.  The last ten days, the patient's wife
noted that the patient had only taken in two to ten beers a
day, down from his normal of 18 to 24 beers a day.  The day
prior to admission, she witnessed only one beer.  In
addition, on the day of admission, the patient's wife heard a
thud and found the husband thrashing on the floor.  It was
unclear whether this was tonic/clonic seizure.  This
continued for about 15 minutes until EMS arrived and gave
intravenous Ativan.

MEDICAL HISTORY: 1.  History of alcohol abuse.
2.  Low back pain.
3.  Chronic anxiety.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Coronary artery disease and diabetes
mellitus.

SOCIAL HISTORY: One to two packs per day of tobacco and
alcohol 24 beers a day.  The patient owns a large business of
restaurants and has increased stress in his job recently. 

### Response:
{'Babesiosis,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Opioid abuse, unspecified,Acquired hemolytic anemia, unspecified,Alcohol withdrawal,Other and unspecified alcohol dependence, unspecified,Other disorders of muscle, ligament, and fascia'}
