CHIEF COMPLAINT: alcohol withdrawal and witnessed seizure

PRESENT ILLNESS: 45 yom with h/o etoh abuse brought to ER after a witnessed GTC
by family at home. Fell back and hit his head. Patient has h/o
etoh abuse and has had seizures in the past.  Last drink was 1
nights ago by report from ED, although patient said on admit it
had been several days..

MEDICAL HISTORY: alcoholism

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Afebrile, VSS
Gen -- pleasant, interactive
HEENT -- unremarkable
Heart -- regular
Lungs -- clear
Abd -- benign
Ext -- no edema
Neuro -- grossly intact

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: drinks when he works, works as a carpenter.  Has been drinking
for ~25 years; states that he drinks about a pint a day of
vodka.
Alcohol withdrawal delirium,Urinary tract infection, site not specified,Hypertensive encephalopathy,Other convulsions,Other and unspecified alcohol dependence, unspecified,Acute alcoholic hepatitis,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Phlebitis and thrombophlebitis of upper extremities, unspecified,Other unspecified secondary hypertension
Delirium tremens,Urin tract infection NOS,Hypertens encephalopathy,Convulsions NEC,Alcoh dep NEC/NOS-unspec,Ac alcoholic hepatitis,Enterococcus group d,Phlbts vn NOS up extrm,Second hypertension NEC
Admission Date:  [**2149-4-6**]              Discharge Date:   [**2149-4-16**]

Date of Birth:  [**2103-8-22**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 358**]
Chief Complaint:
alcohol withdrawal and witnessed seizure

Major Surgical or Invasive Procedure:
none


History of Present Illness:
45 yom with h/o etoh abuse brought to ER after a witnessed GTC
by family at home. Fell back and hit his head. Patient has h/o
etoh abuse and has had seizures in the past.  Last drink was 1
nights ago by report from ED, although patient said on admit it
had been several days..

In the ER, vitals, 98.8 BP 160/108 HR 71 O2 100%RA.  FS was 94.
He was given 2 mg PO ativan and 1 mg IV ativan with no further
seizures.  He had a CT c-spine and CT head done and neuro was
consulted and they recommended treating EtOh withdrawl.

At time of transfer to the ICU, he denies any complaints.
Denies recent fevers, chills, nausea, vomiting.

Past Medical History:
alcoholism

Social History:
drinks when he works, works as a carpenter.  Has been drinking
for ~25 years; states that he drinks about a pint a day of
vodka.

Family History:
noncontributory

Physical Exam:
Afebrile, VSS
Gen -- pleasant, interactive
HEENT -- unremarkable
Heart -- regular
Lungs -- clear
Abd -- benign
Ext -- no edema
Neuro -- grossly intact

Pertinent Results:
[**2149-4-5**] 08:00PM   WBC-2.6* RBC-3.99* HGB-12.7* HCT-38.3* MCV-96
MCH-31.8 MCHC-33.2 RDW-14.8
[**2149-4-5**] 08:00PM   NEUTS-66.9 LYMPHS-29.0 MONOS-3.4 EOS-0.4
BASOS-0.4
[**2149-4-5**] 08:00PM   PLT SMR-VERY LOW PLT COUNT-62*
[**2149-4-5**] 08:00PM   PT-11.6 PTT-20.8* INR(PT)-1.0
[**2149-4-5**] 08:00PM   GLUCOSE-129* UREA N-11 CREAT-0.9 SODIUM-138
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-28 ANION GAP-17
[**2149-4-5**] 08:00PM   CALCIUM-9.7 PHOSPHATE-1.9* MAGNESIUM-1.6
[**2149-4-5**] 08:25PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2149-4-5**] 08:25PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-8.0 LEUK-NEG
[**2149-4-5**] 08:25PM URINE  RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2149-4-5**] 08:25PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2149-4-5**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2149-4-6**] 05:30AM BLOOD ALT-137* AST-320* LD(LDH)-371*
AlkPhos-127* TotBili-1.6*

CT Head:
1. Subtle widening of the extra-axial spaces overlying the
convexities bilaterally. This could be secondary to atrophy;
however, chronic subdural hematomas are possible. Consider MR
for further characterization as clinically indicated.
2. No acute intracranial process.

CT CERVICAL SPINE WITHOUT IV CONTRAST: The skull base through T2
is visualized, and there is normal alignment without evidence
for fractures or dislocations. The vertebral body and disc
height is preserved. There is no prevertebral soft tissue
swelling. Mastoid air cells and visualized paranasal sinuses are
clear. Interspinous distance is preserved. Lung apices are
clear.
===================
MRI head
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
FINDINGS: This exam was terminated early due to patient
agitation. There are no T2 sequences available for evaluation.
On the T1-weighted sequences, there are bilateral small
extra-axial fluid collections measuring up to 6 mm in diameter,
which likely represent subdural hematomas or hygromas. The [**Doctor Last Name 352**]-
white matter differentiation is normal and the ventricles are
normal in size. On the diffusion-weighted images, there is
increased signal on the ADC maps within the bilateral
occipital/parietal lobes, corresponding to the areas of
hypodensity seen on CT, which may represent T2 shine-through and
vasogenic edema, again supporting the suspicion of PRES. There
is also an area with ADC bright signal within the right
cerebellar hemisphere, corresponding to an area of prior
infarct. No evidence of acute infarction on the
diffusion-weighted images.

MRV OF THE BRAIN: The MRV is limited due to motion. The
visualized portions of the venous structures demonstrate no
gross abnormalities. The majority of the superior sagittal,
inferior sagittal, and transverse sinuses are visualized, with
no evidence of thrombosis.

Subcutaneous swelling over the occiput is again noted.

IMPRESSION:
1. Very limited study, with no T2-weighted images and
motion-limited MRV. High signal intensity within the occipital
and parietal lobes bilaterally on the ADC map suggests T2
shine-through/vasogenic edema, and would be consistent with a
diagnosis of PRES (posterior reversible encephalopathy
syndrome). No gross venous sinus thrombosis is identified,
though again this is limited by motion.

2. Old infarct within the right cerebellar hemisphere.

3. Bilateral subdural collections over the cerebral convexities.
==================

[**2149-4-16**] 05:50AM BLOOD WBC-5.5# RBC-3.27* Hgb-10.5* Hct-31.2*
MCV-96 MCH-32.2* MCHC-33.7 RDW-13.0 Plt Ct-336
[**2149-4-8**] 08:18AM BLOOD PT-12.3 PTT-21.1* INR(PT)-1.0
[**2149-4-16**] 05:50AM BLOOD Glucose-86 UreaN-11 Creat-0.8 Na-139
K-3.8 Cl-103 HCO3-28 AnGap-12
[**2149-4-6**] 05:30AM BLOOD Ret Aut-0.6*
[**2149-4-14**] 07:45AM BLOOD ALT-40 AST-35 AlkPhos-80 TotBili-0.4
[**2149-4-6**] 05:30AM BLOOD ALT-137* AST-320* LD(LDH)-371*
AlkPhos-127* TotBili-1.6*
[**2149-4-12**] 08:15AM BLOOD Albumin-3.7 Calcium-8.9 Phos-4.1 Mg-1.6
[**2149-4-6**] 05:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2149-4-5**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2149-4-6**] 05:30AM BLOOD HCV Ab-NEGATIVE
=================
 URINE CULTURE (Final [**2149-4-14**]):
      ENTEROCOCCUS SP..    >100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------   <=2 S
NITROFURANTOIN--------  <=16 S
TETRACYCLINE----------  =>16 R
VANCOMYCIN------------     2 S


Brief Hospital Course:
45 yom with h/o etoh abuse and seizures admitted after a
seizure.
.
# Etoh Abuse: Patient was admitted to the ICU for observation of
Etoh withdrawal and seizure.  Impression from Neurology was for
etoh withdrawal seizures and head CT at that time showed no
significant acute intracranial processes - ?small subdural
hematomas in frontal region.  Patient was started on standing
diazepam 5mg q8 H w/ CIWA q2H PRN.  He was observed in ICU for
24 hours and required no PRN diazepam on the CIWA scale, and was
hemodynamically stable.  Patient was called out to the floor.
Overnight on the floor he became agitated and delerious pulling
out IV's and with obvious hypertension suggesting acute
withdrawal.  He was readmited to the ICU for further management.
 On readmission patient was started on aggressive diazepam with
10mg IV q2 h with PRN on CIWA scale and required about 50-80mg
diazepam in a 12 hour shift.  Took almost 36 hours to fully
catch up on benzo requirements.  Patient had repeat head CT/MRI
that demonstrated PRES syndrome.  BP controlled with diazepam
and briefly with hydralazine.  Neurology was consulted
recommended BP control and treating diazepam PRN, and followed
throughout his course.  He was slowly weaned from scheduled
Valium through the rest of his course.  He was offered inpatient
and outpatient rehabilitation options, but at discharge he was
not interested.  He did take contact numbers for local AA
groups.
.
# PRES: see above, radiologic findings consistent with PRES in
the setting of hypertension related to EtOH withdrawal.  He did
not require antihypertensives after treatment with Valium and
brief hydralazine in the ICU.
.
# Abnml LFTs: AST and ALT elevated 2:1, consistent with
alcoholic liver disease. Discrimant function score is <<30 (PT
is normal and Tbili 1.6) so not fulminant alcoholic hepatitis
and no indication for steroids. As pt has not had prior work-up,
will send hepatitis serologies and check RUQ as well.
Hepatitis core ab positive, HCV negative.  LFTs returned to
[**Location 213**] prior to discharge.
.
# Pancytopenia: Suspect due to alcoholism.  Improved prior to
discharge.
.
# Enterococcus UTI: treated with ampicillin for 7 days.

Medications on Admission:
None

Discharge Medications:
1. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q8H
(every 8 hours) for 1 days.
Disp:*12 Capsule(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
1. delerium tremens
2. posterior reversible encephalopathy syndrome
3. hypertensive urgency


Discharge Condition:
stable, no evidence of persistent alcohol withdrawal


Discharge Instructions:
You were hospitalized with very high blood pressure and alcohol
withdrawal.  Do not drink alcohol, as it can kill you.  Please
follow up with your primary care doctor, which we have arranged
an appointment for you.  Return to the emergency department with
fever, chest pain, mental status changes, seizure, or any other
concerning symptoms.

Followup Instructions:
Please see the neurologists, Dr. [**Last Name (STitle) 78578**], on Wednesday [**7-9**] at 1pm.

Please see your primary care physician at [**Name9 (PRE) **] Health Center
[**2149-5-5**] at 9:30am.
{'Alcohol withdrawal delirium,Urinary tract infection, site not specified,Hypertensive encephalopathy,Other convulsions,Other and unspecified alcohol dependence, unspecified,Acute alcoholic hepatitis,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Phlebitis and thrombophlebitis of upper extremities, unspecified,Other unspecified secondary hypertension'}


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 withdrawal and witnessed seizure

PRESENT ILLNESS: 45 yom with h/o etoh abuse brought to ER after a witnessed GTC
by family at home. Fell back and hit his head. Patient has h/o
etoh abuse and has had seizures in the past.  Last drink was 1
nights ago by report from ED, although patient said on admit it
had been several days..

MEDICAL HISTORY: alcoholism

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Afebrile, VSS
Gen -- pleasant, interactive
HEENT -- unremarkable
Heart -- regular
Lungs -- clear
Abd -- benign
Ext -- no edema
Neuro -- grossly intact

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: drinks when he works, works as a carpenter.  Has been drinking
for ~25 years; states that he drinks about a pint a day of
vodka. 

### Response:
{'Alcohol withdrawal delirium,Urinary tract infection, site not specified,Hypertensive encephalopathy,Other convulsions,Other and unspecified alcohol dependence, unspecified,Acute alcoholic hepatitis,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Phlebitis and thrombophlebitis of upper extremities, unspecified,Other unspecified secondary hypertension'}
