CHIEF COMPLAINT: CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
Intubation

PRESENT ILLNESS: The history was taken using the night-float notes and using the
medicine resident as an interpreter.

MEDICAL HISTORY: 1.) EtOH - Per pt's sister, has had numerous admissions to [**Hospital **] in past for EtOH intoxication and
?withdrawl. Unknown h/o withdrawl szs.

MEDICATION ON ADMISSION: ASA daily
Multivitamin daily
.
NKDA

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: PE:
Vitals: T 98.3, BP 140/80, HR 79, RR 20, O2 97% RA.
Gen: Awake, alert, non-tremulous, NAD
HEENT: anicteric sclerae, MMM
Lungs: CTA b/l, no wheezes, no rhonchi, no rales.
Card: regular rhythm, slightly tachycardic, Nl S1, S2, no
murmurs appreciated
Abd: normoactive BS, soft, NT/ND, no HSM, no ascites.
Ext: no edema, DP 2+ b/l
Skin: no telangiectasias or spider angiomas.  2 cm x 3 cm scab
on R chest.

FAMILY HISTORY: FH: unknown

SOCIAL HISTORY: SH: Pt lives with sister, who is "fed up" with his drinking.
Long h/o EtOH abuse. No tobacco or illicits.
Alcohol withdrawal,Hyperosmolality and/or hypernatremia,Thrombocytopenia, unspecified,Acute alcoholic hepatitis
Alcohol withdrawal,Hyperosmolality,Thrombocytopenia NOS,Ac alcoholic hepatitis
Admission Date:  [**2109-8-24**]              Discharge Date:   [**2109-8-26**]

Date of Birth:  [**2053-12-14**]             Sex:   M

Service: MEDICINE

Allergies:
No Drug Allergy Information on File

Attending:[**First Name3 (LF) 358**]
Chief Complaint:
CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
The history was taken using the night-float notes and using the
medicine resident as an interpreter.

HPI: This patient is a 50 yo spanish speaking man with h/o EtOH
abuse, no other known PMH, who initially presented on [**2109-8-24**]
after being found down.
The patient was found down in the hallway of an apartment
building and does not remember falling down.  Per report on the
field, he was minimally/non-responsive, had had urinary
incontinence, but was breathing spontaneously. He was brought to
the ED.
In the ED, the pt had HR 84, bp 150/p, RR 16-20, SaO2 98% on 2L,
was intubated for airway protection. Labs notable for EtOH level
of 627, mild transaminitis. Other w/u included head CT which was
negative, C-spine showed rotation of C1 and C2 which was likely
positional but patient was placed in a hard collar. FAST U/S was
negative. He received 4L banana bag, versed 10mg IV x 1 and was
admitted to MICU.



Past Medical History:
1.) EtOH - Per pt's sister, has had numerous admissions to [**Hospital **] in past for EtOH intoxication and
?withdrawl. Unknown h/o withdrawl szs.

Social History:
SH: Pt lives with sister, who is "fed up" with his drinking.
Long h/o EtOH abuse. No tobacco or illicits.

Family History:
FH: unknown

Physical Exam:
PE:
Vitals: T 98.3, BP 140/80, HR 79, RR 20, O2 97% RA.
Gen: Awake, alert, non-tremulous, NAD
HEENT: anicteric sclerae, MMM
Lungs: CTA b/l, no wheezes, no rhonchi, no rales.
Card: regular rhythm, slightly tachycardic, Nl S1, S2, no
murmurs appreciated
Abd: normoactive BS, soft, NT/ND, no HSM, no ascites.
Ext: no edema, DP 2+ b/l
Skin: no telangiectasias or spider angiomas.  2 cm x 3 cm scab
on R chest.


Pertinent Results:
[**2109-8-26**] 06:20AM BLOOD WBC-4.6 RBC-4.21* Hgb-13.6* Hct-39.3*
MCV-93 MCH-32.4* MCHC-34.7 RDW-14.5 Plt Ct-98*
[**2109-8-25**] 04:08AM BLOOD Neuts-75.4* Lymphs-20.0 Monos-3.4 Eos-1.0
Baso-0.3
[**2109-8-25**] 04:08AM BLOOD PT-12.3 PTT-28.9 INR(PT)-1.1
[**2109-8-24**] 01:30PM BLOOD Fibrino-256
[**2109-8-26**] 06:20AM BLOOD Glucose-87 UreaN-10 Creat-0.7 Na-139
K-3.3 Cl-98 HCO3-30 AnGap-14
[**2109-8-26**] 06:20AM BLOOD ALT-40 AST-74* CK(CPK)-519*
[**2109-8-25**] 04:08AM BLOOD Lipase-91*
[**2109-8-25**] 11:59AM BLOOD CK-MB-20* MB Indx-3.5 cTropnT-0.01
[**2109-8-25**] 04:08AM BLOOD CK-MB-15* MB Indx-3.5 cTropnT-<0.01
[**2109-8-24**] 10:02PM BLOOD cTropnT-0.02*
[**2109-8-26**] 06:20AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.0
[**2109-8-24**] 10:02PM BLOOD Triglyc-83
[**2109-8-24**] 01:30PM BLOOD ASA-NEG Ethanol-627* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2109-8-24**] 10:14PM BLOOD Type-ART Temp-37.2 pO2-220* pCO2-47*
pH-7.41 calTCO2-31* Base XS-4 Intubat-INTUBATED
[**2109-8-24**] 10:14PM BLOOD Lactate-2.3*
.
CT Spine ([**8-24**]): IMPRESSION:
1. No evidence of fracture.
2. Rotation of C1 on C2 which may be positional but must be
clinically correlated.
3. Cystic structure lateral to the left massator muscle may
represent a sebaceous cyst but it should be clinically
correlated.
.
CT head ([**8-24**]): IMPRESSION:
1. No hemorrhage or mass effect.
2. Mild paranasal sinus mucosal disease.
.
Urine Culture: No growth
.
Blood Culture: pending

Brief Hospital Course:
Pt is a 50 yo man with h/o EtOH, found down with EtOH
intoxication, initially intubated for airway protection and
admitted to MICU.
.
# EtOH: Pt presented after being found down, presumably from
EtOH intoxication as EtOH level was 627 on presentation.  CT
head showed to intracranial hemorrhage or mass effect.  He was
initially intubated for airway protection, and was sent to the
MICU where he remained stable.  He was then extubated, and
continued to be awake and alert. He was monitored for alcohol
withdrawal (he reports his last drink was on Thursday) and was
maintained on a CIWA scale.  His CIWA had gone up to 11
overnight in the MICU, and he only required [**12-29**] doses of
diazepam for some tremulousness and mild tachycardia (HR low
100's).  He was given 4 L of a banana bag in the ED, which was
changed to MVI, thiamine and folic acid PO once the patient was
transferred to the floor.  Social Work was consulted for his
EtOH abuse and family relations (sister is "fed up" with pt's
EtOH use, and patient lives w/ his sister).  The patient was
referred to a [**Month/Day (3) 32231**] Partial Program at [**Hospital1 1680**]/[**Location (un) 538**]
from Monday - Friday, which will start the day following his
discharge.  The patient reports he is willing to join AA.
.
# Elevated CK: Pt presented wtih elevated CK, but had flat MB
and trop. CK initially trended up to 671, now at 519. This is
likely secondary to him being found down, and was not in the
range consistent with rhabdomyolysis. The patient did not need
high rate IVF for this the elevated CKs.
.
# Transaminitis: Pt w/ mildly elevated LFTs on presentation
which appear stable. The transaminitis is likely due to
alcoholic liver disease.  HepBsAG negative and HepBsAb negative.
Otherwise, the patient had no other signs of synthetic
dysfunction as his albumin and coags were within normal limits.

.
# Thrombocytopenia: Pt presented with mild thrombocytopenia
(down to 98) on CBC. This is likely secondary to marrow
suppression vs splenic sequestration from EtOH.
.
# Malrotation of C1-C2: Pt had C-spine film that demonstrated
rotation of C1 and C2, which may be positional.  It also showed
a cystic structure lateral to the left massator muscle may
represent a sebaceous cyst but it should be clinically
correlated.  The patient was placed in a hard C-collar.
Neurosurgery cleared his neck and the hard collar was removed.
The patient is scheduled for a repeat cervical CT scan in 6
weeks, and a follow up appointment with Dr. [**Last Name (STitle) 548**] in
neurosurgery.


Medications on Admission:
ASA daily
Multivitamin daily
.
NKDA

Discharge Medications:
1. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
Cap(s)
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY
1. Alcohol intoxication
2. Mild transaminitis, likely ETOH-related
3. Thrombocytopenia, likely alcohol-related
SECONDARY
1. Alcohol Abuse


Discharge Condition:
afebrile, tolerating POs


Discharge Instructions:
1. Take all medications as prescribed
2. Make all follow-up appointments
3. If you develop fevers, chills, nausea, vomiting or any other
concerning symptoms, please contact your provider or report to
the Emergency Department
4. Refrain from alcohol use

Followup Instructions:
We have contact[**Name (NI) **] your primary care provider [**Last Name (NamePattern4) **]. [**First Name (STitle) 17832**]
[**Name (STitle) 16365**] at [**Hospital3 33953**] Community Health Center and they will
be contacting you with an appointment. They are aware of your
admission and your follow-up issues. If you do not hear from
them, their number is [**Telephone/Fax (1) 17826**].
.
Our social worker has set you up with the [**Name (NI) 32231**] Partial Program
at [**Hospital1 1680**]/[**Location (un) 538**] from Monday - Friday. Please report to
the location provided beginning tomorrow morning.
{'Alcohol withdrawal,Hyperosmolality and/or hypernatremia,Thrombocytopenia, unspecified,Acute alcoholic hepatitis'}


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: CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
Intubation

PRESENT ILLNESS: The history was taken using the night-float notes and using the
medicine resident as an interpreter.

MEDICAL HISTORY: 1.) EtOH - Per pt's sister, has had numerous admissions to [**Hospital **] in past for EtOH intoxication and
?withdrawl. Unknown h/o withdrawl szs.

MEDICATION ON ADMISSION: ASA daily
Multivitamin daily
.
NKDA

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: PE:
Vitals: T 98.3, BP 140/80, HR 79, RR 20, O2 97% RA.
Gen: Awake, alert, non-tremulous, NAD
HEENT: anicteric sclerae, MMM
Lungs: CTA b/l, no wheezes, no rhonchi, no rales.
Card: regular rhythm, slightly tachycardic, Nl S1, S2, no
murmurs appreciated
Abd: normoactive BS, soft, NT/ND, no HSM, no ascites.
Ext: no edema, DP 2+ b/l
Skin: no telangiectasias or spider angiomas.  2 cm x 3 cm scab
on R chest.

FAMILY HISTORY: FH: unknown

SOCIAL HISTORY: SH: Pt lives with sister, who is "fed up" with his drinking.
Long h/o EtOH abuse. No tobacco or illicits. 

### Response:
{'Alcohol withdrawal,Hyperosmolality and/or hypernatremia,Thrombocytopenia, unspecified,Acute alcoholic hepatitis'}
