CHIEF COMPLAINT: concern for alcohol withdrawal

PRESENT ILLNESS: 50 yo M with DM unknown medical history, who was admitted to
[**Hospital 1562**] hospital for EtOH withdrawal, episodes of nonbloody
nonbilious emesis and abdominal pain, who is transferred from
[**Hospital1 1562**] to [**Hospital1 18**] for frequent monitoring of etoh withdrawal
since their ICU was full and they could not handle the patient
on the floor.

MEDICAL HISTORY: Alcohol abuse
Arthritis
Anxiety
Gout
Hyperlipidemia
Hypertension

MEDICATION ON ADMISSION: Per RiteAid pharmacy in [**Hospital1 1562**], MA:
Metoprolol tartrate 37.5mg daily
Pantoprazole 40mg daily
Glyburide 2.5mg daily
Amlodipine 5mg daily
Gemfibrozil 600mg [**Hospital1 **]
Sertraline 50mg qAM
Allopurinol 300mg daily (last filled [**2118-1-20**])
Famotidine 20mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission physical exam:
General: Awake, disoriented no acute distress
HEENT: Sclera anicteric, dMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: RR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
There is ulnar deviation of RUE and less so LUE, none in LEs.
MSK: no joint effusions in UEs or LEs.
Neuro:
MS: Awake, moving around in bed, follows axial and appendicular
commands only for [**12-6**] steps.  Naming intact, [**Location (un) 1131**] intact, as
is repetition. Impaired Registration and recall.  Unable to
perform DOWb.  Unable to perform Luria.  President is [**Last Name (un) 2753**] and
his wife is [**Name (NI) **]. It's [**2118**], fall, according to patient.
CNII-XII:
VFF, 4-2mm b/l, horizontal nystagmus on left lateral gaze,
intrusion saccades, right sided gaze w/ difficulty adducting the
left eye and torsional jerk nystagmus at midline.  Face is
symmetric, tongue midline, palate elevates symmetrically.
UEs intact in UMN distribution, [**4-9**], same for LEs.
Normal tone, DTRs 2+ at [**Hospital1 **] and patella.
Toes down
No asterixis, intention tremor.

FAMILY HISTORY: Fa - MI at 61
Brothers - HTN
[**Name2 (NI) **] DM, Ca, or CVA

SOCIAL HISTORY: Former construction worker, now on disability and Medicare.
Homeless, no family.  Has friend in [**Name (NI) 1562**] who is aware of his
alcholism and willing to help him with treatment.  Drinks .5-1.5
pints vodka daily.  Has been in detox programs before and
willing to quit.  Does not smoke or use other drugs.
Alcohol withdrawal,Other and unspecified manifestations of thiamine deficiency,Acidosis,Unspecified protein-calorie malnutrition,Gout, unspecified,Other and unspecified hyperlipidemia,Lack of housing,Other and unspecified alcohol dependence, unspecified,Unspecified disorder of eye movements,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Iron deficiency anemia, unspecified,Unspecified essential hypertension,Anxiety state, unspecified,Depressive disorder, not elsewhere classified,Disorders of magnesium metabolism,Obstructive sleep apnea (adult)(pediatric),Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled
Alcohol withdrawal,Thiamine defic NEC/NOS,Acidosis,Protein-cal malnutr NOS,Gout NOS,Hyperlipidemia NEC/NOS,Lack of housing,Alcoh dep NEC/NOS-unspec,Eye movemnt disorder NOS,Gstr/ddnts NOS w/o hmrhg,Iron defic anemia NOS,Hypertension NOS,Anxiety state NOS,Depressive disorder NEC,Dis magnesium metabolism,Obstructive sleep apnea,DMII wo cmp uncntrld
Admission Date:  [**2118-3-2**]              Discharge Date:   [**2118-3-7**]

Date of Birth:  [**2067-11-20**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 602**]
Chief Complaint:
concern for alcohol withdrawal

Major Surgical or Invasive Procedure:
None

History of Present Illness:
50 yo M with DM unknown medical history, who was admitted to
[**Hospital 1562**] hospital for EtOH withdrawal, episodes of nonbloody
nonbilious emesis and abdominal pain, who is transferred from
[**Hospital1 1562**] to [**Hospital1 18**] for frequent monitoring of etoh withdrawal
since their ICU was full and they could not handle the patient
on the floor.

Pt. is a poor historian.  Apparently was in USOH until this AM
when he deveoped acute episode of right sided abdominal pain
with emesis x3 (clear w/ food, no blood, no coffee grounds).
Given this, went to [**Hospital 18222**] hospital for an evaluation.  Also
reports intermittent nasal congestion, but no cough, fevers,
chills, post nasal gtt, sore throat, dysphagia.  No
dysuria/constipation.  No back pain. He does note 20 lb weight
loss in the past 1 yr, not intentiontal, no nightsweats.

Notes that his last drink was on AM of admission.  He drinks 1
pint per day of vodka. Denies withdrawal szs or DTs.  Has been
hospitalized 1 wk ago for EtOH withdrawal and another hospital.


At [**Hospital 18222**] hospital EtOH level was 170, bicarbonate 14, with AG
29.   AST 68, ALT 38, nl Tbili, elevated GGT, lipase 24, AP 86,
alb. 4.3.  CT abd + showed no acute process, thickening of the
distal esophagus.  At Falmough he received a total of 9 mg of
Ativan, 40mg Protonix, 10mg Reglan and 8mg Zofran.

In the ED, initial VS were:  98.0 106 154/89 18 95% RA. Pt.
underwent CT head which showed no ICH, CXR w/o acute process,
labs notable for HCT of 38, lactate of 2.3, Utox/Stox were
negative.  Pt. received 4mg IV ativan, 5mg Valium PO, MVI,
Folate and Thiamine 100mg IV, 2mg IV Mg.  Current CIWA scale
scores in [**9-18**] range.  He received 3L NS.  At time of transfer,
HR 120, BP 149/81 18 97% RA.
.
On arrival to the MICU, NAD, confused.


Past Medical History:
Alcohol abuse
Arthritis
Anxiety
Gout
Hyperlipidemia
Hypertension


Social History:
Former construction worker, now on disability and Medicare.
Homeless, no family.  Has friend in [**Name (NI) 1562**] who is aware of his
alcholism and willing to help him with treatment.  Drinks .5-1.5
pints vodka daily.  Has been in detox programs before and
willing to quit.  Does not smoke or use other drugs.


Family History:
Fa - MI at 61
Brothers - HTN
[**Name2 (NI) **] DM, Ca, or CVA


Physical Exam:
Admission physical exam:
General: Awake, disoriented no acute distress
HEENT: Sclera anicteric, dMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: RR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
There is ulnar deviation of RUE and less so LUE, none in LEs.
MSK: no joint effusions in UEs or LEs.
Neuro:
MS: Awake, moving around in bed, follows axial and appendicular
commands only for [**12-6**] steps.  Naming intact, [**Location (un) 1131**] intact, as
is repetition. Impaired Registration and recall.  Unable to
perform DOWb.  Unable to perform Luria.  President is [**Last Name (un) 2753**] and
his wife is [**Name (NI) **]. It's [**2118**], fall, according to patient.
CNII-XII:
VFF, 4-2mm b/l, horizontal nystagmus on left lateral gaze,
intrusion saccades, right sided gaze w/ difficulty adducting the
left eye and torsional jerk nystagmus at midline.  Face is
symmetric, tongue midline, palate elevates symmetrically.
UEs intact in UMN distribution, [**4-9**], same for LEs.
Normal tone, DTRs 2+ at [**Hospital1 **] and patella.
Toes down
No asterixis, intention tremor.

Discharge physical exam:
Vitals: T:98.0  BP:114-137/61-91  P:82-90 R:20 O2:98(RA)
General: Alert, oriented, cognitively slow, no acute distress
HEENT: mild scleral icterus, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, obese, non-tender, non-distended, no rebound
tenderness or guarding, possible splenomegaly on palpation
Ext: warm, well-perfused, 2+ pulses, right hand with joint
disfigurement/claw hand
Neuro: CNs2-12 intact, cerebellar exam with normal
finger-nose-finger, but very slow movements, no asterixis

Pertinent Results:
Admission labs:
[**2118-3-2**] 02:35PM   WBC-9.4 RBC-4.76 HGB-12.3* HCT-37.8* MCV-80*
MCH-25.9* MCHC-32.6 RDW-16.3*
[**2118-3-2**] 02:35PM   NEUTS-70.1* LYMPHS-20.3 MONOS-8.1 EOS-0.1
BASOS-1.3
[**2118-3-2**] 02:35PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2118-3-2**] 02:35PM   TSH-4.1
[**2118-3-2**] 02:35PM   CALCIUM-8.4 PHOSPHATE-2.3* MAGNESIUM-1.3*
[**2118-3-2**] 02:35PM   GLUCOSE-163* UREA N-13 CREAT-0.9 SODIUM-140
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-22 ANION GAP-23*
[**2118-3-2**] 02:42PM   LACTATE-2.3*
[**2118-3-2**] 03:33PM URINE  RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2118-3-2**] 03:33PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2118-3-2**] 03:33PM URINE  COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->1.050*
[**2118-3-2**] 03:33PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2118-3-2**] 10:40PM   %HbA1c-11.2* eAG-275*
.
[**2118-3-2**] Chest X-ray:
FINDINGS: Single frontal view of the chest was obtained. There
are low lung volumes and the patient is somewhat rotated to the
left. The left
costophrenic angle is not well seen, which may be due to
overlying soft
tissue, although a small left pleural effusion cannot be
excluded. However, in reference with abdomen and pelvis CT
performed at [**Hospital6 23316**] earlier the same date,
[**2118-3-2**], no left pleural effusion is seen. No focal
consolidation. The cardiac and mediastinal silhouettes are
unremarkable.
.
[**2118-3-2**] CT head:
IMPRESSION: No acute intracranial process. Prominent
bifrontoparietal
extra-axial CSF spaces most likely relates to parenchymal loss.
.
Labs on Discharge:
[**2118-3-7**] 06:50AM BLOOD WBC-5.5 RBC-4.62 Hgb-11.2* Hct-38.0*
MCV-82 MCH-24.3* MCHC-29.5* RDW-17.8* Plt Ct-206
[**2118-3-7**] 06:50AM BLOOD Glucose-180* UreaN-17 Creat-0.8 Na-134
K-3.9 Cl-101 HCO3-23 AnGap-14
[**2118-3-7**] 06:50AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.5*
.
Iron studies/B12/Folate/Retic:
[**2118-3-4**] 06:38AM BLOOD calTIBC-386 VitB12-449 Folate-15.6
Ferritn-74 TRF-297
[**2118-3-4**] 06:38AM BLOOD Iron-41*
[**2118-3-4**] 06:38AM BLOOD Ret Aut-1.5

Brief Hospital Course:
50 yo M with possible diabetes mellitus, hypertension,
hyperlipidemia, gout and alcohol abuse admitted with abdominal
pain and alcohol withdrawal complicated by encephalopathy and
thiamine deficiency.

Active Diagnoses:
#Alcohol dependence with withdrawal/ [**Last Name (un) 4897**] encephalopathy:
Patient presented on transfer from OSH with mild withdrawal.
EtOH level was 0. He was encephalopathic and had evidence of
ophthalmoplegia on admission.  CT did not show profound
hypodensities in thalamus, midbrain on PVW, but this is
insensitive.  Moreover, most Wernicke patients present only with
encephalopathy. Patient was continued on IV thiamine therapy
with cleraing of ophthalmoplegia and mental status the morning
after admission. He was subsequently transitioned to oral
thiamine which was continued on discharge. The patient also
received folate and multivitamins. He was placed on CIWA scale,
but did  not require any ativan.  On the floor, his mental
status improved daily, although he was still cognitively slow on
discharge.

#Abdominal pain: Patient was felt to most likely have alcoholic
gastritis or mild pancreatitis. LFTs drawn at OSH were all
normal including lipase except for mild transaminitis. By
morning after admission, patient no longer complaining of
abdominal pain.  Pain resolved by itself by HD2.
.
#Diabetes mellitus: The patient said he had diabetes at [**Hospital 1562**]
hospital and pharmacy says patient takes glyburide. A1c of 11.2.
Patient was maintained on insulin sliding scale in house.  He
was discharged with home dose of glyburide and also on new
medication of metformin. He was encouraged to follow up with his
PCP.
.
# Gastritis: Patient takes pantoprazole and famotidine at home,
which was continued.
.
# Anemia: Patient has anemia with evidence of iron deficiency
based on slightly low iron levels and low iron/TIBC ratio.
Patient had labs which were stable but patient was advised to
follow up with his PCP for further evaluation of his iron
deficiency. Based on suggestion of esophageal thickening noted
on CT from [**Hospital 1562**] Hospital and his age, in addition to iron
deficiency, the patient would benefit from GI evaluation (most
likely upper and lower endoscopy) in the near future in the
outpatient setting. The patient was not started on iron on this
admission.

#Hypertension: Patient has hx of hypertension, on metoprolol and
amlodipine at home.  Patient was maintained on metoprolol at
25bid and amlodipine at home dose of 5mg daily.
.
# Hyperlipidemia: Patient takes gemfibrozil, which was continued
at home dose of 600 [**Hospital1 **].
.
# Nocturnal hypoxia/Probable sleep apnea:  Noted in MICU on
countinuous monitoring; likely due to sleep apnea, that worsened
with benzodiazepines and etoh intoxication.  Patient will  need
outpatient sleep evaluation.

Transitional Issues/Disposition:
Discharged to rehab, and discharge summary will also be sent to
PCPs office for continuity of care.
Patient should receive outpatient sleep study and outpatient
upper and lower endoscopy.


Medications on Admission:
Per RiteAid pharmacy in [**Hospital1 1562**], MA:
Metoprolol tartrate 37.5mg daily
Pantoprazole 40mg daily
Glyburide 2.5mg daily
Amlodipine 5mg daily
Gemfibrozil 600mg [**Hospital1 **]
Sertraline 50mg qAM
Allopurinol 300mg daily (last filled [**2118-1-20**])
Famotidine 20mg daily

*Patient last refilled most in [**2117-12-5**].

Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).


Discharge Disposition:
Extended Care

Facility:
Teen Challenge [**Location (un) 511**]

Discharge Diagnosis:
Alcohol intoxication
Diabetes Mellitus Type 2
Hypertension
Anxiety
Depression


Discharge Condition:
Mental Status: Confused, sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Mr. [**Known lastname 110618**],
It was a pleasure taking care of you at [**Hospital1 18**].  You were
admitted to the hospital with alcohol intoxication and risk of
withdrawal.  While you were here, we monitored you and you did
not show any signs of withdrawal.  We were in touch with your
primary care doctor and were able to obtain records of the
medications you were on.  We feel that you are medically safe to
go to alcohol rehabilitation.
Please take all medications that you are prescribed on this
discharge.  Since it is uncertain if these are changes from your
previous medications, please follow the directions of what you
are being discharged with.

Followup Instructions:
After discharge from alcohol rehab, please follow-up with your
PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) 4768**], who is aware of your hospitalization.
 You can reach her office at [**Telephone/Fax (1) 110619**].



Completed by:[**2118-3-8**]
{'Alcohol withdrawal,Other and unspecified manifestations of thiamine deficiency,Acidosis,Unspecified protein-calorie malnutrition,Gout, unspecified,Other and unspecified hyperlipidemia,Lack of housing,Other and unspecified alcohol dependence, unspecified,Unspecified disorder of eye movements,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Iron deficiency anemia, unspecified,Unspecified essential hypertension,Anxiety state, unspecified,Depressive disorder, not elsewhere classified,Disorders of magnesium metabolism,Obstructive sleep apnea (adult)(pediatric),Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled'}


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: concern for alcohol withdrawal

PRESENT ILLNESS: 50 yo M with DM unknown medical history, who was admitted to
[**Hospital 1562**] hospital for EtOH withdrawal, episodes of nonbloody
nonbilious emesis and abdominal pain, who is transferred from
[**Hospital1 1562**] to [**Hospital1 18**] for frequent monitoring of etoh withdrawal
since their ICU was full and they could not handle the patient
on the floor.

MEDICAL HISTORY: Alcohol abuse
Arthritis
Anxiety
Gout
Hyperlipidemia
Hypertension

MEDICATION ON ADMISSION: Per RiteAid pharmacy in [**Hospital1 1562**], MA:
Metoprolol tartrate 37.5mg daily
Pantoprazole 40mg daily
Glyburide 2.5mg daily
Amlodipine 5mg daily
Gemfibrozil 600mg [**Hospital1 **]
Sertraline 50mg qAM
Allopurinol 300mg daily (last filled [**2118-1-20**])
Famotidine 20mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission physical exam:
General: Awake, disoriented no acute distress
HEENT: Sclera anicteric, dMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: RR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
There is ulnar deviation of RUE and less so LUE, none in LEs.
MSK: no joint effusions in UEs or LEs.
Neuro:
MS: Awake, moving around in bed, follows axial and appendicular
commands only for [**12-6**] steps.  Naming intact, [**Location (un) 1131**] intact, as
is repetition. Impaired Registration and recall.  Unable to
perform DOWb.  Unable to perform Luria.  President is [**Last Name (un) 2753**] and
his wife is [**Name (NI) **]. It's [**2118**], fall, according to patient.
CNII-XII:
VFF, 4-2mm b/l, horizontal nystagmus on left lateral gaze,
intrusion saccades, right sided gaze w/ difficulty adducting the
left eye and torsional jerk nystagmus at midline.  Face is
symmetric, tongue midline, palate elevates symmetrically.
UEs intact in UMN distribution, [**4-9**], same for LEs.
Normal tone, DTRs 2+ at [**Hospital1 **] and patella.
Toes down
No asterixis, intention tremor.

FAMILY HISTORY: Fa - MI at 61
Brothers - HTN
[**Name2 (NI) **] DM, Ca, or CVA

SOCIAL HISTORY: Former construction worker, now on disability and Medicare.
Homeless, no family.  Has friend in [**Name (NI) 1562**] who is aware of his
alcholism and willing to help him with treatment.  Drinks .5-1.5
pints vodka daily.  Has been in detox programs before and
willing to quit.  Does not smoke or use other drugs. 

### Response:
{'Alcohol withdrawal,Other and unspecified manifestations of thiamine deficiency,Acidosis,Unspecified protein-calorie malnutrition,Gout, unspecified,Other and unspecified hyperlipidemia,Lack of housing,Other and unspecified alcohol dependence, unspecified,Unspecified disorder of eye movements,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Iron deficiency anemia, unspecified,Unspecified essential hypertension,Anxiety state, unspecified,Depressive disorder, not elsewhere classified,Disorders of magnesium metabolism,Obstructive sleep apnea (adult)(pediatric),Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled'}
