CHIEF COMPLAINT: Alcohol Withdrawal

PRESENT ILLNESS: 59 year old man with past medical history significant for
diabetes, hypertension, EtOH abuse, presenting with acute
abdominal pain, nausea, vomiting, and diarrhea for the past day.

MEDICAL HISTORY: - HYPERTENSION
- DIABETES
- ETOH ABUSE (Never been treated)

MEDICATION ON ADMISSION: Metformin 500mg [**Hospital1 **]
Glyburide 7.5mg daily
Lisinopril 5mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GEN:The patient is in no distress and appears comfortable
SKIN:No rashes or skin changes noted
HEENT:No JVD, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted.
CHEST:Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES:no peripheral edema, warm without cyanosis
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**4-26**], and BLE [**4-26**] both proximally and distally. No pronator
drift. Reflexes were symmetric. Downward going toes

FAMILY HISTORY: 

SOCIAL HISTORY: Lives with wife, [**Name (NI) 47658**] off since last [**Month (only) 116**]. Does not smoke, 10
beer per night alcohol use, no illicit drugs
Alcohol-induced persisting amnestic disorder,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Other and unspecified manifestations of thiamine deficiency,Acute alcoholic hepatitis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Acute alcoholic intoxication in alcoholism, continuous,Dysphagia, unspecified
Alcohol amnestic disordr,Hyposmolality,Urin tract infection NOS,Thiamine defic NEC/NOS,Ac alcoholic hepatitis,DMII wo cmp nt st uncntr,Hypertension NOS,Ac alcohol intox-contin,Dysphagia NOS
Admission Date:  [**2180-1-28**]              Discharge Date:   [**2180-2-9**]

Date of Birth:  [**2120-10-25**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Alcohol Withdrawal

Major Surgical or Invasive Procedure:
None

History of Present Illness:
59 year old man with past medical history significant for
diabetes, hypertension, EtOH abuse, presenting with acute
abdominal pain, nausea, vomiting, and diarrhea for the past day.

.
Patient is very confused at time of interview and history is
obtained from the wife. She reports patient has developed a 10
beer per day drinking habit for the past 2 years. She also
reports he has been [**First Name3 (LF) 47658**] off last [**Month (only) 116**] and since has stayed home
all day. For the past 2 weeks, she states patient has had very
poor PO intake, and one day prior to admission started vomiting.
On the day of admission, she reports patient was very anxious,
agitated and tremulous. Patient is able to confirm he has been
having vomiting and has not been able to drink in the past two
days.
.
They deny any fevers, chills, chest pain, shortness of breath or
other associated symptoms. Vomitus is described and clear and
without blood or dark contents. Pts wife did however report he
has been having some memory problems, making up stories about
family members (talking about recently seeing deceased
relatives) and has been having worsening balance stumbling
although not falling.
.
.
In the ED, vital signs were initially: Pain [**4-1**] T 99.0 104
153/92 16 100%. Patient received Thiamine, Folic Acid,
multivitamin and 10mg Diazepam along with 3L NS and 1
multivitamin bag. Chest x-ray revealed no acute process. Lipase
and amylase were found to be elevated, surgery was consulted and
felt patient could be monitored closely on medical service.
Given high risk of withdrawal, patient was admitted to MICU.


Past Medical History:
- HYPERTENSION
- DIABETES
- ETOH ABUSE (Never been treated)


Social History:
Lives with wife, [**Name (NI) 47658**] off since last [**Month (only) 116**]. Does not smoke, 10
beer per night alcohol use, no illicit drugs

Physical Exam:
GEN:The patient is in no distress and appears comfortable
SKIN:No rashes or skin changes noted
HEENT:No JVD, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted.
CHEST:Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES:no peripheral edema, warm without cyanosis
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**4-26**], and BLE [**4-26**] both proximally and distally. No pronator
drift. Reflexes were symmetric. Downward going toes


Pertinent Results:
[**2180-1-28**] 02:00PM BLOOD WBC-4.6 RBC-4.53* Hgb-14.8 Hct-42.0
MCV-93 MCH-32.8* MCHC-35.3* RDW-13.9 Plt Ct-83*
[**2180-1-28**] 02:00PM BLOOD Neuts-76.9* Lymphs-16.9* Monos-4.8
Eos-0.6 Baso-0.7
[**2180-1-28**] 06:15PM BLOOD PT-12.3 PTT-31.1 INR(PT)-1.0
[**2180-1-28**] 02:00PM BLOOD Glucose-213* UreaN-7 Creat-1.0 Na-126*
K-3.5 Cl-87* HCO3-19* AnGap-24*
[**2180-1-28**] 02:00PM BLOOD ALT-131* AST-304* LD(LDH)-341*
AlkPhos-221* TotBili-2.2*
[**2180-1-28**] 02:00PM BLOOD Lipase-487*
[**2180-2-2**] 05:20AM BLOOD CK-MB-2 cTropnT-<0.01
[**2180-1-28**] 02:00PM BLOOD Albumin-3.6 Calcium-9.1 Phos-3.2 Mg-2.0
[**2180-2-2**] 05:20AM BLOOD VitB12-1693*
[**2180-1-29**] 02:37PM BLOOD %HbA1c-9.6* eAG-229*
[**2180-1-28**] 08:52PM BLOOD Triglyc-72
[**2180-1-28**] 02:00PM BLOOD Acetone-NEG Osmolal-268*
[**2180-2-2**] 05:20AM BLOOD TSH-1.5
[**2180-1-29**] 04:56AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2180-1-28**] 08:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2180-1-29**] 04:56AM BLOOD HCV Ab-NEGATIVE
[**2180-1-28**] 06:07PM BLOOD Lactate-2.4*
[**2180-1-29**] 05:20AM BLOOD freeCa-0.99*
[**2180-2-2**] 10:51AM BLOOD Lactate-0.8
[**2180-2-8**] 07:05AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.7
[**2180-1-31**] 03:41AM BLOOD Lipase-211*
[**2180-2-4**] 07:00AM BLOOD ALT-58* AST-57* LD(LDH)-245 AlkPhos-174*
TotBili-1.7*
[**2180-2-8**] 07:05AM BLOOD Glucose-116* UreaN-4* Creat-0.6 Na-140
K-3.6 Cl-101 HCO3-28 AnGap-15
[**2180-2-6**] 06:05AM BLOOD PT-11.0 PTT-27.6 INR(PT)-0.9
[**2180-2-8**] 07:05AM BLOOD WBC-5.2 RBC-3.73* Hgb-12.4* Hct-36.5*
MCV-98 MCH-33.2* MCHC-33.9 RDW-15.1 Plt Ct-385

[**2180-2-1**]  URINE CULTURE- STAPHYLOCOCCUS, COAGULASE NEGATIVE.
[**2180-1-28**]  MRSA SCREEN - NEG
[**2180-1-28**]  BLOOD CULTURE - NEG
[**2180-1-28**]  BLOOD CULTURE - NEG
HBsAg - HBsAb + HBcAb - HAV Ab +
.
MRI of HEAD: The repeat study confirms the enhancement of the
mamillary bodies which is suggestive of Wernicke's
encephalopathy. No acute infarct is seen.
.
CT HEAD - IMPRESSION: No evidence of intracranial bleed. If
there is clinical suspicion for subacute/chronic stroke or
Wernicke encephalopathy, MR imaging can be ordered.
.
CHEST (PA & LAT) [**2180-2-2**]:  No acute cardiopulmonary process.
Persistent right middle and lower lobe atelectases.
.
CHEST X-RAY:
UPRIGHT AP AND LATERAL VIEWS OF THE CHEST: No free
intraperitoneal air. Subsegmental atelectasis in the right lung
base. Elevation of the right hemidiaphragm.
.
RIGHT UPPER QUADRANT ULTRASOUND: No biliary dilatation. Normal
gallbladder.
.
ECG: [**2180-1-28**] 14:35
NSR at 98 bpm, poor baseline with low voltage at V1, non
specific anteroseptal T wave flattening and rightward axis. PR
interval is borderline prolonged.


Brief Hospital Course:
59 year old man with past medical history significant for
diabetes, hypertension, EtOH abuse, presenting with abdominal
pain and EtOH withdrawal, found to have pancreatitis, ETOH
hepatitis, and Werneckies-Korsakoff syndrome.
.
# ETOH ABUSE: Patient had approximately 10drinks/day though may
be significantly underestimated given he is home alone all day.
He had withdrawal symptoms on arrival to ER as his last drink
was >24hours PTA. He was admitted to the MICU and treated with
valium. Given his agittation, he also recieved haldol. He was
dischared on thiamine/folate/mvi (see below). SW saw pt as well
for his ETOH abuse. he will be discharged to [**Hospital1 1501**] so will not be
exposed to ETOH. Given his severe ETOH over past 8months, he did
have evidence of refeeding and lytes were repleted aggressively.
Also, he had hyponatremia on admission, likely combinition of
volume depletion (vomiting) and SIADH (nausea) and beer
protomenia (low solute intake). this improved at time of
discharge.
.
# acute delirium/Wernicke's encephalopthy: Pt was noted to be
agitated on arrival, however, this was thought to be [**1-25**] etoh
withdrawal as his last drink was >24hours before. After being
treated with large doses of valium and haldol in ICU, he was
somnolent. Upon transfer to floor and as he became more alert,
it was clear that he had ongoing memory deficits and severe gait
ataxia (fell X2 here). CT head repeated and was negative.
Further history from family revealed a recent history of
confabualtion, ataxia, memory problems. [**Name (NI) **] also had some
horizontal nystagmus here. While he did recieve empiric IV
thiamine with bannana bag in ER and another dose of IV thiamine
in ICU, the diagnosis of Werneckies was not clear until later
([**2-2**]) when he was transfered to floor and his etoh withdrawal
was no longer confounding the picture. At this point, he was
treated with 5days of IV thiamine 100mg (dose thought to be
adequate per neuro and pharm). Of note, he did undergo MRI head
which showed typical pattern c/w Wernekies.  In addition to PO
thiamine/folate,  B complex vitamis were also added given his
overall malnutrition and likely other vitamin deficiencies (had
dermatitis on face which may be related to vitamin def).  He had
some improvement in his confusion, agitation, ataxia but was
still severely impaired at time of discharge. Given he likely
has korsakoff (continued memory lapse/confabulation), unclear
how much of this is reversible. He also has some dysphagia
related to this, which is slowly improving. He will need
aggressive PT and close monitoring for recovery. He should have
neuropsych testing in few months to see if extent of cognitive
deficits. Can consider repeat MRI to see if mamillary bodies
regress but not sure if this would change long term management.
After discussion with family regarding his new need for closer
monitoring, they aggreed to rehab. He was discharged to [**Hospital1 1501**] for
ongoing rehab for ataxia, dysphagia, cognitive/memory deficits.
.
# ETOH Pancreatitis/hepatitis: abdominal pain, nausea/vomiting
on admission->found ot have pancreatitis and hepatitis. RUQ US
neg, CT a/p unremarkable, likely [**1-25**] ETOH. treated
conservatively with fluids, bowel rest, pain control. improved
and tolerating PO at time of discharge. Hep serologies A c/w
prior exposure, hep B c/w vaccination, hep C neg. LFTs much
improved at time of discharge. for hepatitits, was mild and did
not start trental/steroids.
.
# UTI: CONS. He was placed on Cephalexin. He remained afebrile
and asymptomatic at the time of discharge.  Planned course of
antibiotics is 10 days (Cephalexin 500 mg PO/NG Q6H with Day 1 =
[**2180-2-4**]).
.
# dysphagia: likely [**1-25**] wernekies/korsakoff:was improving at
time of discharge. speech/swallow reccommended continued
aspiration precautions, PO diet of ground solids and nectar
thick liquids, Meds were crushed in puree; TID oral care; 1:1
supervision with meals to maintain aspiration precautions
including: -assist with feeding -alternate bites and sips -cue
to swallow before speaking.  Recommend swallow f/u with SLP and
formal aphasia evaluation.
.
# DIABETES: Patient is on metformin (500 [**Hospital1 **]) /glyburide (7.5QD)
at home.  However, during the hospitalization, these were held
and an insulin sliding scale was used.  HgB A1C is noted to be
9.6. these were resumed on discharge
.
#. THROMBOCYTOPENIA/LEUKOPENIA: Likely from bone marrow
suppression [**1-25**] ETOH toxicity; improved at time of discharge.
.
# HYPERTENSION: Patient only on lisinopril as outpatient,
normotensive since arrival.  Lisinopril was held but can be
considered as outpt

# CODE:  Full, discussed
# CONTACT:  wife [**Numeric Identifier 86428**] / [**Numeric Identifier 86429**] HCP daughter [**Numeric Identifier 86430**]
/ [**Telephone/Fax (3) 86431**] / [**Telephone/Fax (3) 86432**]


Medications on Admission:
Metformin 500mg [**Hospital1 **]
Glyburide 7.5mg daily
Lisinopril 5mg daily


Discharge Medications:


1. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1)  PO BID (2
times a day).
2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
4. Cephalexin 500 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H (every
6 hours) for 6 days: end day is [**2180-2-14**].
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).

7. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
8. Multivitamin     Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).

9. B Complex Vitamins     Capsule [**Last Name (STitle) **]: One (1) Cap PO DAILY
(Daily).
10. Erythromycin 5 mg/g Ointment [**Last Name (STitle) **]: One (1)  Ophthalmic QID (4
times a day).
11. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Last Name (STitle) **]: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
12. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
Subcutaneous ASDIR (AS DIRECTED).
13. Glyburide 5 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO once a day.
14. Metformin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.



Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]

Discharge Diagnosis:
wernicke's encephalopathy
alcohol withdraw
alcohol pancreatitis
alcohol hepatitis
DM
HTN
Thrombocytopenia


Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair


Discharge Instructions:
You came to the hospital with alcoholic pancreatitis due to the
alcohol use.  We found that your liver was inflamed as well.
You were undergoing withdrawal and we had to provide you with
medication to treat the withdrawal symptoms.  Your liver and
pancreas recovered; however, we found that you did not have
appropriate recovery in your mental status.  It appears that you
have suffered significant neurological damage called
Wernekies/Korsakoff syndrome.  We provided you with appropriate
vitamin supplement in the hope to reverse the damage.  You will
need to follow up with your doctor in the next couple of month
to evaluate your progress.  You were discharged in stable
condition to rehab.

Please follow up with you doctors listed below.

Please note we made the following changes to your medications.
STOPPED:
Lisinopril 5mg daily

STARTED:
1. Docusate Sodium  50 mg/5 mL Liquid  [**Location (un) **]:  One (1) PO BID (2
times a day).
2. Senna  8.6 mg Tablet  [**Location (un) **]:  One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Heparin (Porcine)  5,000 unit/mL Solution  [**Location (un) **]:  One (1)
Injection TID (3 times a day).
4. Cephalexin  500 mg Capsule  [**Location (un) **]:  One (1) Capsule PO Q6H
(every 6 hours) for 6 days: end day is [**2180-2-14**].
5. Lansoprazole  30 mg Tablet,Rapid Dissolve, DR  [**Last Name (STitle) **]:  One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Folic Acid  1 mg Tablet  [**Last Name (STitle) **]:  One (1) Tablet PO DAILY
(Daily).
7. Thiamine HCl  100 mg Tablet  [**Last Name (STitle) **]:  One (1) Tablet PO DAILY
(Daily).
8. Multivitamin   Tablet  [**Last Name (STitle) **]:  One (1) Tablet PO DAILY (Daily).

9. B Complex Vitamins   Capsule  [**Last Name (STitle) **]:  One (1) Cap PO DAILY
(Daily).
10. Erythromycin  5 mg/g Ointment  [**Last Name (STitle) **]:  One (1) Ophthalmic QID
(4 times a day).
11. White Petrolatum-Mineral Oil  42.5-56.8 % Ointment  [**Last Name (STitle) **]:
One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
12. Insulin Lispro  100 unit/mL Solution  [**Last Name (STitle) **]:  One (1)
Subcutaneous ASDIR (AS DIRECTED).
13. Metformin 500mg [**Hospital1 **]
14. Glyburide 7.5mg daily

Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in the next 2 weeks.
Please call [**Numeric Identifier 86433**] to make the appointment.

Please call ([**Telephone/Fax (1) 2528**] to confirm an appointment to follow
up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], neurologist, on Tuesday
[**2180-4-18**] at 2:30 PM - Shipiro [**Location (un) **].

Please call ([**Telephone/Fax (1) 1703**] to confirm an appointment to follow
up with neuro-psych evaluation, Tuesday, [**2180-4-4**] at 1:00pm -
Cognitive Neurology in [**Hospital Ward Name 860**] Building [**Hospital1 18**].
{'Alcohol-induced persisting amnestic disorder,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Other and unspecified manifestations of thiamine deficiency,Acute alcoholic hepatitis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Acute alcoholic intoxication in alcoholism, continuous,Dysphagia, unspecified'}


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

PRESENT ILLNESS: 59 year old man with past medical history significant for
diabetes, hypertension, EtOH abuse, presenting with acute
abdominal pain, nausea, vomiting, and diarrhea for the past day.

MEDICAL HISTORY: - HYPERTENSION
- DIABETES
- ETOH ABUSE (Never been treated)

MEDICATION ON ADMISSION: Metformin 500mg [**Hospital1 **]
Glyburide 7.5mg daily
Lisinopril 5mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GEN:The patient is in no distress and appears comfortable
SKIN:No rashes or skin changes noted
HEENT:No JVD, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted.
CHEST:Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES:no peripheral edema, warm without cyanosis
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**4-26**], and BLE [**4-26**] both proximally and distally. No pronator
drift. Reflexes were symmetric. Downward going toes

FAMILY HISTORY: 

SOCIAL HISTORY: Lives with wife, [**Name (NI) 47658**] off since last [**Month (only) 116**]. Does not smoke, 10
beer per night alcohol use, no illicit drugs 

### Response:
{'Alcohol-induced persisting amnestic disorder,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Other and unspecified manifestations of thiamine deficiency,Acute alcoholic hepatitis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Acute alcoholic intoxication in alcoholism, continuous,Dysphagia, unspecified'}
