CHIEF COMPLAINT: Pneumonia, Alcohol Withdrawal, Alcohol Dependence with Acute
Intoxication

PRESENT ILLNESS: 59 year old male with a history of polysubstance abuse and
chronic pain, recently discharged from the medical service for
alcohol withdrawal and pneumonia, who was brought in by EMS
after he was found intoxicated at a T-stop.  In the ED, the
patient sobered from his acute alcohol intoxication.  However,
he then went into withdrawal.  He began [**Doctor Last Name **] 22 on CIWA and
was given 3 doses of ativan.

MEDICAL HISTORY: - Benign Hypertension
- Alcohol abuse - 1qt vodka per day
- chronic pain on methadone
- h/o [**Doctor Last Name 8751**] with multiple traumatic injuries and subsequent
surgeries including splenectomy, fracture repairs, skin grafts
- h/o polysubstance abuse
-asplenia

MEDICATION ON ADMISSION: albuterol 90 mcg MDI 2 Puffs Q6H
methadone 10 mg PO TID
Toprol-XL 25 mg PO Daily
MVI Daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VSS: 98.6, 166/94, 68, 20, 96%2L
GEN: Cachectic, Uncomfortable, Tremulous
Pain: [**3-5**]
HEENT: EOMI, MMM, - OP Lesions, + tongue fasiculations
PUL: coarse b/l rhonchi on all fields, EE Wheezes
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, course tremor, CN II-XII grossly normal
.
DISCHARGE PHYSICAL EXAM:
GEN: awake, alert, intermittently follows commands (has to be
reminded to take deep breaths during lung exam)
HEENT: EOMI, MMM, - OP Lesions
PUL: mild diminished BS on b/l lower lobes
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: AOx3, mild course tremor, CN II-XII grossly normal

FAMILY HISTORY: Parents were alcoholics. He notes a significant family history
of cancer in his mother and father as well as his siblings. He
thinks most were esophageal cancer.

SOCIAL HISTORY: Currently homeless. Smokes 1ppd for the past 40 years. Drinks
about a pint of vodka daily with history of withdrawal. He
denies any IVDU.
Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Alcohol withdrawal,Bacterial pneumonia, unspecified,Acute alcoholic intoxication in alcoholism, continuous,Tobacco use disorder,Benign essential hypertension,Chronic airway obstruction, not elsewhere classified,Lack of housing,Swelling, mass, or lump in chest,Other diseases of trachea and bronchus,Other acquired absence of organ
Food/vomit pneumonitis,Acute respiratry failure,Alcohol withdrawal,Bacterial pneumonia NOS,Ac alcohol intox-contin,Tobacco use disorder,Benign hypertension,Chr airway obstruct NEC,Lack of housing,Chest swelling/mass/lump,Trachea & bronch dis NEC,Acq absence of organ NEC
Admission Date:  [**2171-3-14**]              Discharge Date:   [**2171-3-20**]

Date of Birth:  [**2111-9-22**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Pneumonia, Alcohol Withdrawal, Alcohol Dependence with Acute
Intoxication

Major Surgical or Invasive Procedure:
none


History of Present Illness:
59 year old male with a history of polysubstance abuse and
chronic pain, recently discharged from the medical service for
alcohol withdrawal and pneumonia, who was brought in by EMS
after he was found intoxicated at a T-stop.  In the ED, the
patient sobered from his acute alcohol intoxication.  However,
he then went into withdrawal.  He began [**Doctor Last Name **] 22 on CIWA and
was given 3 doses of ativan.

Of note, the patients last admission one month prior to this
presentation was complicated by pneumonia, for which he was
discharged on amoxicillin/clavulonate.  The patient continues to
note a persistent cough, although denies fever or chills.   He
underwent chest X-ray in the ED was concerning for either a
recurrence of his pneumonia or a persistence of the prior
pneumonia.

ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: + Dyspnea, + Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache


Past Medical History:
- Benign Hypertension
- Alcohol abuse - 1qt vodka per day
- chronic pain on methadone
- h/o [**Doctor Last Name 8751**] with multiple traumatic injuries and subsequent
surgeries including splenectomy, fracture repairs, skin grafts
- h/o polysubstance abuse
-asplenia

Social History:
Currently homeless. Smokes 1ppd for the past 40 years. Drinks
about a pint of vodka daily with history of withdrawal. He
denies any IVDU.


Family History:
Parents were alcoholics. He notes a significant family history
of cancer in his mother and father as well as his siblings. He
thinks most were esophageal cancer.

Physical Exam:
ADMISSION PHYSICAL EXAM:
VSS: 98.6, 166/94, 68, 20, 96%2L
GEN: Cachectic, Uncomfortable, Tremulous
Pain: [**3-5**]
HEENT: EOMI, MMM, - OP Lesions, + tongue fasiculations
PUL: coarse b/l rhonchi on all fields, EE Wheezes
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, course tremor, CN II-XII grossly normal
.
DISCHARGE PHYSICAL EXAM:
GEN: awake, alert, intermittently follows commands (has to be
reminded to take deep breaths during lung exam)
HEENT: EOMI, MMM, - OP Lesions
PUL: mild diminished BS on b/l lower lobes
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: AOx3, mild course tremor, CN II-XII grossly normal


Pertinent Results:
Admission Labs [**2171-3-15**] 06:45AM:

WBC-6.2 RBC-4.56* Hgb-14.5 Hct-47.0 MCV-103* MCH-31.7 MCHC-30.8*
RDW-14.2 Plt Ct-192
Neuts-51 Bands-0 Lymphs-34 Monos-10 Eos-5* Baso-0 Atyps-0
Metas-0 Myelos-0
PT-10.6 PTT-34.6 INR(PT)-1.0

Glucose-170* UreaN-9 Creat-0.6 Na-137 K-5.5* Cl-96 HCO3-31
AnGap-16
ALT-24 AST-25 LD(LDH)-198 CK(CPK)-105 AlkPhos-84 Amylase-920*
TotBili-0.3
Calcium-10.1 Phos-5.0* Mg-1.8

Discharge Labs:

WBC-4.6 RBC-4.26* Hgb-13.7* Hct-44.0 MCV-103* MCH-32.1*
MCHC-31.0 RDW-14.1 Plt Ct-242
Neuts-39* Bands-1 Lymphs-40 Monos-9 Eos-7* Baso-1 Atyps-3*
Metas-0 Myelos-0
PT-11.0 PTT-36.5 INR(PT)-1.0

Glucose-95 UreaN-13 Creat-0.6 Na-138 K-4.4 Cl-99 HCO3-32
AnGap-11
ALT-19 AST-23 LD(LDH)-199 AlkPhos-63 TotBili-0.3
Albumin-3.8 Calcium-9.4 Phos-3.5 Mg-1.8
Lactate-0.5

Micro:
Blood cultures 4/20, [**3-19**], [**3-20**] pending

CHEST (PA & LAT) Study Date of [**2171-3-14**] 9:29 PM
1. Continued right middle lobe opacification concerning for
pneumonia. As the findings appear similar when compared to prior
study, chest CT should be obtained to evaluate for the presence
of an obstructing central or endobronchial lesion.
2. Improved aeration of the left lower lobe with residual linear
opacities which may be reflective of atelectasis.

CT Chest non-con, [**3-16**]:
1. Right middle lobe collapse with bronchial obstruction. Right
lower lobe bronchus severely narrowed proximally with distal
reconstitution. In the setting of involvement of two adjacent
airways, lesion extrinsic to the airways is more likely than
endobronchial lesions, but evaluation is limited in the absence
of intravenous contrast. Repeat chest CT with intravenous
contrast could be performed for further evaluation.
Alternatively, direct visualization could be performed.
2. Prominent mediastinal and hilar lymph nodes.
3. Subcentimeter nodules and ground-glass opacity in the left
lower lobe, concerning for infection. In the presence of
centrilobular emphysema, close interval follow up is recommended
after treatment or within 3 months.
4. Mild anterior wedging of the T11 and T12 vertebral bodies.
5. Predominantly left-sided coronary artery calcifications.

CXR portable Study Date of [**2171-3-19**] 1:39 AM:
Mild-to-moderate bibasilar atelectasis has been present without
appreciable change since [**2-3**]. Previous small bilateral
pleural effusions have decreased. Upper lungs are clear. Heart
size is normal. There are no findings to suggest pneumonia
currently.

What appears to be a 5-cm long segment of catheter tubing
crosses the paramedian left hemithorax obliquely. In order to
clarify whether there is a retained catheter fragment, routine
chest radiograph should be obtained, and the radiologist
notified before the patient leaves the department.


Brief Hospital Course:
58 year old man with a history of polysubstance abuse, admitted
to the hospital with intoxication/withdrawal symptoms and
hypoxia; admission complicated by hypercarbic respiratory
failure.

# Hypercarbic and Hypoxic Respiratory failure:  On admission,
the patient was noted to be hypoxic. He also has chronic CO2
retention related to baseline COPD.  He underwent CT chest on
admission that showed RML collapse, likely by extrinsic
compression by mass.  He was started on ceftriaxone and
azithromycin for CAP coveraged.  He was evaluated by
interventional pulmonary with plan for bronchoscopy to further
evaluate bronchial obstruction.  However, with the use of
benzodiazepines for alcohol withdrawal (described below), he
became somnolent and began to go into hypercarbic and hypoxic
respiratory failure.  He was transferred to the MICU.  In the
ICU, the patient was reversed with 4 doses of flumazenil.  He
did not require invasive ventilation.  The benzodiazepines
cleared from his system, and he awoke.  He eloped from the
hospital prior to planned bronchoscopy.  The patient should
follow up with interventional pulmonology for further evaluation
of his right middle lobe collapse.

# Alcohol Withdrawal, Alcohol Dependence with Acute
Intoxication: The patient presented to the emergency department
with alcohol intoxication, and was admitted to the hospital
floor as he started to withdraw.  In the first 24 hours of his
hospital stay, he received >100mg valium.  By hospital day 3
symptoms of withdrawal had improved, however, the patient became
increasingly somnolent.  Respiratory drive was decreased by
cumulative effect of benzodiazepines, and the patient was
transferred to the MICU as above.

# Chronic Pain:  Per prior notes and patient report, he takes
methadone 10mg TID for chronic pain after a motor vehicle
accident. On admission, he was continued on methadone 10mg TID.
This medication was held on admission to the ICU, as the patient
experienced increasing somnolence.

# Benign Hypertension: The patient was continued on home
Toprol-XL 25mg daily.

# Lung nodules: CT chest showed "Subcentimeter nodules and
ground-glass opacity in the left lower lobe, concerning for
infection. In the presence of centrilobular emphysema, close
interval follow up is recommended after treatment or within 3
months."  The patient was recommended to follow up regarding
these findings in 3 months.  No follow-up was arranged for him,
as he eloped from the ICU.

================================================
TRANSITIONAL ISSUES:
Patient with RML collapse likely secondary to extrinsic
compression, and left lower lobe lung nodules.  Patient should
follow up with interventional pulmonology regarding these
findings and should undergo repeat CT scan chest in 3 months


Medications on Admission:
albuterol 90 mcg MDI 2 Puffs Q6H
methadone 10 mg PO TID
Toprol-XL 25 mg PO Daily
MVI Daily

Discharge Medications:
Patient eloped from the ICU prior to planned discharge

Discharge Disposition:
Home

Discharge Diagnosis:
Alcohol withdrawal
Bacterial pneumonia
Lung [**Hospital3 45395**] failure


Discharge Condition:
patient eloped from the hospital while admitted to the ICU


Discharge Instructions:
Patient was admitted with alcohol withdrawal and shortness of
breath. He was found to have pneumonia and a mass in his lung.
Admission complicated by ICU transfer for somnolence in the
setting of benzodiazepines used to treat alcohol withdrawal.
Benzodiazepines cleared, and the patient returned to baseline
mental status.  The patient insisted on leaving the hospital
against medical advice. Before the entire team had a chance to
speak with the patient about the full risks that he was facing,
he left the Unit without being observed.

During admission, patient was found to have lung nodules on a CT
scan of the chest.  He will need to have another CT scan of the
chest in 3 months to follow these nodules.

Followup Instructions:
The patient left the ICU against medical advice and  prior to
arranging followup for his outstanding problems.
{'Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Alcohol withdrawal,Bacterial pneumonia, unspecified,Acute alcoholic intoxication in alcoholism, continuous,Tobacco use disorder,Benign essential hypertension,Chronic airway obstruction, not elsewhere classified,Lack of housing,Swelling, mass, or lump in chest,Other diseases of trachea and bronchus,Other acquired absence of organ'}


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: Pneumonia, Alcohol Withdrawal, Alcohol Dependence with Acute
Intoxication

PRESENT ILLNESS: 59 year old male with a history of polysubstance abuse and
chronic pain, recently discharged from the medical service for
alcohol withdrawal and pneumonia, who was brought in by EMS
after he was found intoxicated at a T-stop.  In the ED, the
patient sobered from his acute alcohol intoxication.  However,
he then went into withdrawal.  He began [**Doctor Last Name **] 22 on CIWA and
was given 3 doses of ativan.

MEDICAL HISTORY: - Benign Hypertension
- Alcohol abuse - 1qt vodka per day
- chronic pain on methadone
- h/o [**Doctor Last Name 8751**] with multiple traumatic injuries and subsequent
surgeries including splenectomy, fracture repairs, skin grafts
- h/o polysubstance abuse
-asplenia

MEDICATION ON ADMISSION: albuterol 90 mcg MDI 2 Puffs Q6H
methadone 10 mg PO TID
Toprol-XL 25 mg PO Daily
MVI Daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VSS: 98.6, 166/94, 68, 20, 96%2L
GEN: Cachectic, Uncomfortable, Tremulous
Pain: [**3-5**]
HEENT: EOMI, MMM, - OP Lesions, + tongue fasiculations
PUL: coarse b/l rhonchi on all fields, EE Wheezes
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, course tremor, CN II-XII grossly normal
.
DISCHARGE PHYSICAL EXAM:
GEN: awake, alert, intermittently follows commands (has to be
reminded to take deep breaths during lung exam)
HEENT: EOMI, MMM, - OP Lesions
PUL: mild diminished BS on b/l lower lobes
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: AOx3, mild course tremor, CN II-XII grossly normal

FAMILY HISTORY: Parents were alcoholics. He notes a significant family history
of cancer in his mother and father as well as his siblings. He
thinks most were esophageal cancer.

SOCIAL HISTORY: Currently homeless. Smokes 1ppd for the past 40 years. Drinks
about a pint of vodka daily with history of withdrawal. He
denies any IVDU. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Alcohol withdrawal,Bacterial pneumonia, unspecified,Acute alcoholic intoxication in alcoholism, continuous,Tobacco use disorder,Benign essential hypertension,Chronic airway obstruction, not elsewhere classified,Lack of housing,Swelling, mass, or lump in chest,Other diseases of trachea and bronchus,Other acquired absence of organ'}
