CHIEF COMPLAINT: Alcohol Withdrawal

PRESENT ILLNESS: The patient is a 53 year old male with a history of bipolar
disorder with psychotic features, alcohol/benzo abuse who was
transferred from [**Hospital1 **] for tachycardia, tremors,
agitation/combative behaviors, and hallucinations.  Minimal
medical records were provided from [**Hospital1 **].  Per EMS, he has
a history of bipolar disorder with psychosis, and was at
[**Hospital1 **] for alcohol abuse (from [**Hospital1 2436**] ED).  He is
reportedly noncompliant with his psychiatric medications because
he "doesn't like pills", but has been purchasing Xanax and
Klonopin off the street.  At [**Hospital1 **] prior to ED transfer, he
reportedly received Thorazine 100 mg for agitation, followed by
Haldol 10 mg IM and Ativan 2 mg IM for assaultive behavior, then
Librium 100 mg and Valium 5 mg PO.

MEDICAL HISTORY: - Bipolar Disorder with Psychosis
- Alcohol Abuse
- Chronic ear infections, s/p surgery at [**Hospital 13128**]
- Substance abuse, with benzos

MEDICATION ON ADMISSION: Home Medications:
-not taking any home meds

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: Tcurrent: 36.1 ??????C (97 ??????F)
HR: 98 (90 - 111) bpm
BP: 118/74(84) {91/64(76) - 134/110(116)} mmHg
RR: 25 (15 - 25) insp/min
SpO2: 96%
General: completely disoriented, difficult to keep attention,
flight of ideas and inappropriate answers to questions,
tremulous, writhing
HEENT: Sclera anicteric, MMM, could not assess oropharynx [**2-20**]
mouth clenching
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1/S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro/Psych: AAO x 0, unable to respond to questions, very
agitated and tremulous; in 4-point restraints

FAMILY HISTORY: unable to obtain due to mental status

SOCIAL HISTORY: (per [**Hospital1 **]):
- Tobacco: <1ppd x 40 years
- Alcohol: last drink "last weekend", drinking heavily since age
14 (16 ounces beer daily)
- Illicits: occasional marijuana, no IVDU
Alcohol withdrawal delirium,Sedative, hypnotic or anxiolytic dependence, continuous,Other and unspecified alcohol dependence, continuous,Contusion of toe,Anemia, unspecified,Tobacco use disorder,Unspecified psychosis,Leukocytosis, unspecified,Cerebral cysts,Microscopic hematuria,Volume depletion, unspecified
Delirium tremens,Sed,hyp,anxiolyt dep-con,Alcoh dep NEC/NOS-contin,Contusion of toe,Anemia NOS,Tobacco use disorder,Psychosis NOS,Leukocytosis NOS,Cerebral cysts,Microscopic hematuria,Volume depletion NOS
Admission Date:  [**2137-8-17**]              Discharge Date:   [**2137-8-20**]

Date of Birth:  [**2084-3-30**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Alcohol Withdrawal

Major Surgical or Invasive Procedure:
none


History of Present Illness:
The patient is a 53 year old male with a history of bipolar
disorder with psychotic features, alcohol/benzo abuse who was
transferred from [**Hospital1 **] for tachycardia, tremors,
agitation/combative behaviors, and hallucinations.  Minimal
medical records were provided from [**Hospital1 **].  Per EMS, he has
a history of bipolar disorder with psychosis, and was at
[**Hospital1 **] for alcohol abuse (from [**Hospital1 2436**] ED).  He is
reportedly noncompliant with his psychiatric medications because
he "doesn't like pills", but has been purchasing Xanax and
Klonopin off the street.  At [**Hospital1 **] prior to ED transfer, he
reportedly received Thorazine 100 mg for agitation, followed by
Haldol 10 mg IM and Ativan 2 mg IM for assaultive behavior, then
Librium 100 mg and Valium 5 mg PO.

According to his girlfriend, he has been abusing benzos for
about a month now and continues to drink.  He has been seen
numerous times at the [**Hospital1 2436**] ED and treated for
"dehydration".  This last time, he was section 12'ed and sent to
[**Hospital1 **]/dual diagnosis bed.
.
In the ED, initial vital signs were T 97.9, BP 151/136, HR 140,
RR 16, SpO2 % on RA.  On exam, he was found to be tachycardic,
agitated, and confabulating, but neurologically nonfocal.  His
symptoms were thought due to alcohol withdrawal with a likely
contribution of his underlying psychiatric disease.  He was
afebrile and had no evidence of infection, no focal neurologic
deficits, and no nuchal rigidity to suggest meningitis.  He was
given an Diazepam 20 mg IV shortly after arrival followed by
another 10 mg later in the morning.  Head CT was performed to
rule out acute processes, and showed only an incidental
choroidal fissure cyst and chronic small vessel disease. He was
agitated and not able to provide any helpful history in the ED.

.
After receiving the Diazepam in the ED, he became calmer and
more somnolent, possibly due to the Librium starting to take
effect.  He was arousable to voice and maintaining his airway.
He was placed on capnography for continual assessment of
respiratory status.  He received a total of [**2126**] ml IV fluids,
with another 1000 ml hanging.  He was admitted to the ICU for
close monitoring of his withdrawal and respiratory status.
Vitals prior to transfer were T 97.7, BP 117/69, HR 97, RR 18,
SpO2 100% on RA, and ETCO2 27.
.
In the ICU, he is very difficult to focus, agitated, but
breathing well and protecting his airway.  His speech is
nonsensical and it is impossible to get a reliable history from
him.
.
Review of systems:
(+) Per HPI, otherwise unable to obtain reliably


Past Medical History:
- Bipolar Disorder with Psychosis
- Alcohol Abuse
- Chronic ear infections, s/p surgery at [**Hospital 13128**]
- Substance abuse, with benzos


Social History:
(per [**Hospital1 **]):
- Tobacco: <1ppd x 40 years
- Alcohol: last drink "last weekend", drinking heavily since age
14 (16 ounces beer daily)
- Illicits: occasional marijuana, no IVDU

Family History:
unable to obtain due to mental status

Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Tcurrent: 36.1 ??????C (97 ??????F)
HR: 98 (90 - 111) bpm
BP: 118/74(84) {91/64(76) - 134/110(116)} mmHg
RR: 25 (15 - 25) insp/min
SpO2: 96%
General: completely disoriented, difficult to keep attention,
flight of ideas and inappropriate answers to questions,
tremulous, writhing
HEENT: Sclera anicteric, MMM, could not assess oropharynx [**2-20**]
mouth clenching
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1/S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro/Psych: AAO x 0, unable to respond to questions, very
agitated and tremulous; in 4-point restraints

ICU DISCHARGE EXAM:
VS: Tc36.4 ??????C HR: 87 BP: 125/74(84) RR: 20 SpO2: 98% /RA
General: oriented and able to answer questions, contrite about
alcohol use
HEENT: Sclera anicteric, MMM, OP clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1/S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema


Pertinent Results:
====================
ADMISSION LABS:
====================
[**2137-8-17**] 08:36AM   PLT COUNT-295
[**2137-8-17**] 08:36AM   NEUTS-75.8* LYMPHS-15.2* MONOS-6.9 EOS-0.7
BASOS-1.4
[**2137-8-17**] 08:36AM   WBC-13.0* RBC-4.34* HGB-14.6 HCT-41.3 MCV-95
MCH-33.7* MCHC-35.5* RDW-13.2
[**2137-8-17**] 08:36AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2137-8-17**] 08:36AM   ALBUMIN-4.6 MAGNESIUM-2.3
[**2137-8-17**] 08:36AM   ALT(SGPT)-27 AST(SGOT)-67* ALK PHOS-65 TOT
BILI-1.0
[**2137-8-17**] 08:36AM   estGFR-Using this
[**2137-8-17**] 08:36AM   GLUCOSE-91 UREA N-19 CREAT-1.2 SODIUM-142
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-28 ANION GAP-16
[**2137-8-17**] 09:02AM URINE  MUCOUS-RARE
[**2137-8-17**] 09:02AM URINE  HYALINE-25*
[**2137-8-17**] 09:02AM URINE  RBC-3* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2137-8-17**] 09:02AM URINE  BLOOD-SM  NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2137-8-17**] 09:02AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2137-8-17**] 09:02AM URINE  bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2137-8-17**] 09:02AM URINE  HOURS-RANDOM

MICRO: none

IMAGING:
CT HEAD [**2137-8-17**]
FINDINGS: There is no evidence of hemorrhage, edema, large mass,
mass effect, or acute infarct. The ventricles and sulci are
normal in size and
configuration. No fractures are identified. The mastoid air
cells, middle
ear cavities, and included paranasal sinuses are clear. No soft
tissue
swelling identified.

IMPRESSION: Normal non-contrast head CT.

NOTE ADDED IN ATTENDING REVIEW: There is a well-defined 14 x
10mm
CSF-attenuation structure, interposed between the right lateral
ventricular temporal [**Doctor Last Name 534**] and that perimesencephalic cistern
(2a:13); this is a typical location and appearance for an
incidental choroidal fissure cyst. Also noted is relatively mild
and ill-defined low-attenuation in periventricular white matter,
likely the sequelae of chronic small vessel disease.
.
EKG-[**Known lastname 90552**],[**Known firstname 1955**] [**Medical Record Number 90553**] M  53  [**2084-3-30**]
Cardiology Report ECG Study Date of [**2137-8-17**]  8:15:26 AM
Baseline artifact precludes analysis. Sinus tachycardia. Poor R
wave
progression probably a normal variant. ST segment interpretation
is not
possible due to baseline artifact.



Brief Hospital Course:
The patient is a 53 year old male with a history of bipolar
disorder with psychosis and alcohol abuse who was transferred
from [**Hospital1 **] for tachycardia, tremors, agitation, and
hallucinations.  He was placed on capnography in the ED for
monitoring of his respiratory status and admitted to the ICU for
further monitoring of his alcohol withdrawal.
.
# Alcohol Withdrawal/benzodiazepine withdrawal/Delerium Tremens-
Current clinical status upon presentation was concerning for
delirium tremens, given his vital signs abnormalities and
hallucinosis (though this is complicated by his hx of bipolar
disorder, for which he is not taking his meds).  He received
significant amounts of benzos as well as antipsychotics at
[**Hospital1 **] prior to admission, as well as some additional IV
diazepam in the ED with mild effect. Urine tox was positive for
benzos, but otherwise negative and serum tox was negative for
EtOH.  His respiratory status was stable at time of ICU
admission, but agitation and delirium were difficult to control.
He was monitored on a q1H CIWA scale and received a total of 40
mg valium. He fell asleep and slept through the night. Upon
awakening after day in ICU, he was asymptomatic with normal
vitals, no tremors or anxiety. Morning labs were within normal
limits with the exception of an elevated AST. He did not receive
any antipsychotic medications in the ICU. He was continued on
Thiamine and Folate. Pt was evaluated by social work/addiction
specialist to determine safe discharge plan for the patient. Pt,
was section 12 from [**Hospital1 2436**] to [**Hospital1 **]. However, he was
discharged from [**Hospital1 **] prior to admission to [**Hospital1 18**] and pt
did not want to return to that facility. Pt has been seeing a SW
in [**Location (un) **] who apparently was not aware of pt's carried
diagnosis of bipolar disorder. She stated that pt had not been
on psychiatric medications for some time and never has displayed
symptoms of mania. While on the medical floor, pt was placed on
the CIWA scale and did not display signs of withdrawal nor did
he require valium on the medical floor. Pt and his girlfriend
(who is involved in his care) agree that patient needs further
help. Addiction counseling was provided to patient. He has been
set up at [**University/College 23633**] Mental Health for pre-admissions intake
on [**2137-8-22**] and urged to continue to follow up with his PCP for
ongoing care. He did not express or display signs of suicidality
or depression during admission.
.
# Leukocytosis:  His WBC count was elevated to 13.0 on admission
with diff showing 75.8% neutrophils and no bands.  Pt remained
afebrile without any localizing sources of infection such as
cough, rhinorrhea, headache, diarrhea, dysuria, during
admission.  U/A was unremarkable for infection.  WBCs may be
secondary to generalized inflammatory process and relatively
non-specific with a normal differential. Resolved
.
#R. 4th toe ecchymoses-Pt reports log fell on foot a while ago.
Reports improved symptoms and that xray at [**Hospital1 2436**] was
negative for fx, only showing a "bone bruise". Pt ambulated
without difficulty. xray ordered, but pt has been declining exam
stating that xray at OSH was negative. This should be monitored
for continued improvement.
.
#Hypertension: likely related to withdrawal as above. Resolved
during admission.
.
#Choroidal Cyst: incidentally found on head CT, no focal
neurologic signs. Pt was instructed to follow up with his PCP
after discharge.
.
#normocytic anemia-mild, no signs of active bleeding. HCT 39 day
prior to discharge. Pt should have screening colonoscopy as
outpatient.
.
#mild transaminitis-likely related to ETOH/benzo. Pt should have
LFTs checked at PCP office after discharge to ensure
downtrending.
.
#microscopic hematuria-seen on initial u/a. Could have been due
to foley placement. Should repeat u/a in outpatient setting and
if still present refer to urology for consideration of
cystoscopy as pt is a current smoker.
.
#bipolar disorder-Pt had not been taking any psych medications
in a long time per pt. He was being followed by a SW in [**Location (un) 11507**], who expressed that patient never expressed mania. Pt set
up at [**University/College 23633**] Mental Health for intake on [**2137-8-22**]. He did
not display signs of depression/mania while admitted.
.
# Volume Depletion:  He received NS IVF 3L total in the ED.  His
creatinine was 1.2 on admission with unknown baseline.

# Tobacco use: nicotine patch while in house


Medications on Admission:
Home Medications:
-not taking any home meds

[**Hospital1 **] meds:
-Ativan 1mg TID + PRN
-Folic acid 1mg daily
-Zyprexa 5mg qhs
-thiamine 100mg daily
-MVI
-trazodone 50mg PRN (x1 if needed)
-mylanta, milk of mag, ibuprofen PRN
-nicotine gum
-librium 25mg x4 this AM for agitation
-thorazine 100mg PO x1
-valium 5mg PO x1
-haldol 10mg IM x1
-ativan 2mg IM x1

Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
alcohol and benzodiazepine withdrawal
bipolar disorder
choroidal cyst
R.4th toe ecchymoses


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to [**Hospital1 18**] with significant withdrawal from
alcohol and benzodiazepine medication and initially admitted to
the ICU. You were given medication and your symptoms improved.
You should stop drinking alcohol and you should NEVER take
medications that are not prescribed to you. If you abuse alcohol
and take benzodiazepine medication and suddenly stop doing this,
you could have a seizure or die. Please continue to seek help
with your drug and alcohol abuse. See below.
.
You were found to have a cyst noted on your head CT scan. There
are currently no concerning findings, but this should be
followed up with your PCP.
.
If you develop increasing pain in your R.foot, please see your
PCP.
.
Medication changes:
1.start folic acid and thiamine.
.
Please take all of your medications as prescribed and follow up
with the appointments below.

Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD
When: Wednesday [**2137-8-28**] at 15:30 AM
Address: [**Apartment Address(1) 90554**] [**Last Name (un) **]
[**Location (un) 2199**], MA
Phone: [**Telephone/Fax (1) 31302**]
.
Psychiatry
[**University/College 23633**] Mental Health
[**Last Name (NamePattern1) 29381**]
[**Location (un) **], MA
1-[**Telephone/Fax (1) **]
appointment is [**Last Name (un) **] [**8-22**] at 4pm.
{'Alcohol withdrawal delirium,Sedative, hypnotic or anxiolytic dependence, continuous,Other and unspecified alcohol dependence, continuous,Contusion of toe,Anemia, unspecified,Tobacco use disorder,Unspecified psychosis,Leukocytosis, unspecified,Cerebral cysts,Microscopic hematuria,Volume depletion, 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: The patient is a 53 year old male with a history of bipolar
disorder with psychotic features, alcohol/benzo abuse who was
transferred from [**Hospital1 **] for tachycardia, tremors,
agitation/combative behaviors, and hallucinations.  Minimal
medical records were provided from [**Hospital1 **].  Per EMS, he has
a history of bipolar disorder with psychosis, and was at
[**Hospital1 **] for alcohol abuse (from [**Hospital1 2436**] ED).  He is
reportedly noncompliant with his psychiatric medications because
he "doesn't like pills", but has been purchasing Xanax and
Klonopin off the street.  At [**Hospital1 **] prior to ED transfer, he
reportedly received Thorazine 100 mg for agitation, followed by
Haldol 10 mg IM and Ativan 2 mg IM for assaultive behavior, then
Librium 100 mg and Valium 5 mg PO.

MEDICAL HISTORY: - Bipolar Disorder with Psychosis
- Alcohol Abuse
- Chronic ear infections, s/p surgery at [**Hospital 13128**]
- Substance abuse, with benzos

MEDICATION ON ADMISSION: Home Medications:
-not taking any home meds

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: Tcurrent: 36.1 ??????C (97 ??????F)
HR: 98 (90 - 111) bpm
BP: 118/74(84) {91/64(76) - 134/110(116)} mmHg
RR: 25 (15 - 25) insp/min
SpO2: 96%
General: completely disoriented, difficult to keep attention,
flight of ideas and inappropriate answers to questions,
tremulous, writhing
HEENT: Sclera anicteric, MMM, could not assess oropharynx [**2-20**]
mouth clenching
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1/S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro/Psych: AAO x 0, unable to respond to questions, very
agitated and tremulous; in 4-point restraints

FAMILY HISTORY: unable to obtain due to mental status

SOCIAL HISTORY: (per [**Hospital1 **]):
- Tobacco: <1ppd x 40 years
- Alcohol: last drink "last weekend", drinking heavily since age
14 (16 ounces beer daily)
- Illicits: occasional marijuana, no IVDU 

### Response:
{'Alcohol withdrawal delirium,Sedative, hypnotic or anxiolytic dependence, continuous,Other and unspecified alcohol dependence, continuous,Contusion of toe,Anemia, unspecified,Tobacco use disorder,Unspecified psychosis,Leukocytosis, unspecified,Cerebral cysts,Microscopic hematuria,Volume depletion, unspecified'}
