CHIEF COMPLAINT: alcohol withdrawal

PRESENT ILLNESS: 42 year old man with history of alcohol abuse, who was admitted
status post fall and ankle fracture. He underwent ORIF of right
ankle [**11-7**] and was transferred to floor without complication
that day. The following afternoon he was found to be hypoxic to
80's with witnessed vomiting/seizure activity. Code blue called
and ativan was given, oxygen saturations recovered. Patient was
transferred to trauma SICU service. Had to be managed in PACU
because of bed availabilty. Since then, requiring 20mg IV
ativan/12 hours and very agitated. He did appear to be off
benzodiazepines for several hours and, at the end of this
period, he escalated--requiring multiple people to restrain him.

MEDICAL HISTORY: Alcohol abuse
Born premature; reports he had a feeding tube as a baby

MEDICATION ON ADMISSION: None.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Temp: BP: 133/79 HR: 112 RR: 16 O2sat 100 on room air
Gen: Somnolent but arousable, mildly agitated. Follows commands,
largely non verbal
Eyes: Sclerae injected, pupils reactive
Mouth: MM dry
Neck: Obese
Chest: CTA b/l with good air movement throughout
Cor: Tachycardic, regular, S1 and S2 wnl, no m/r/g
Abd: Obese, non-distended, +b/s, soft, nt, no masses or
hepatosplenomegaly
Ext: No edema, warm, good pulses
Neuro: Somnolent

FAMILY HISTORY: Not available

SOCIAL HISTORY: Per chart 4 drinks a day. No known smoking history or drug
abuse.
Bimalleolar fracture, open,Alcohol withdrawal,Other and unspecified alcohol dependence, unspecified,Other convulsions,Kyphosis (acquired) (postural),Benign essential hypertension,Anemia of other chronic disease,Other abnormal glucose,Other fall,Accidents occurring in unspecified place
Fx bimalleolar-open,Alcohol withdrawal,Alcoh dep NEC/NOS-unspec,Convulsions NEC,Kyphosis NOS,Benign hypertension,Anemia-other chronic dis,Abnormal glucose NEC,Fall NEC,Accident in place NOS
Admission Date:  [**2196-11-6**]              Discharge Date:   [**2196-11-18**]

Date of Birth:  [**2154-6-21**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
alcohol withdrawal

Major Surgical or Invasive Procedure:
Right ankle ORIF.


History of Present Illness:
42 year old man with history of alcohol abuse, who was admitted
status post fall and ankle fracture. He underwent ORIF of right
ankle [**11-7**] and was transferred to floor without complication
that day. The following afternoon he was found to be hypoxic to
80's with witnessed vomiting/seizure activity. Code blue called
and ativan was given, oxygen saturations recovered. Patient was
transferred to trauma SICU service. Had to be managed in PACU
because of bed availabilty. Since then, requiring 20mg IV
ativan/12 hours and very agitated. He did appear to be off
benzodiazepines for several hours and, at the end of this
period, he escalated--requiring multiple people to restrain him.

Per previous history, he claimed only to be consuming 4 drinks a
day.

Past Medical History:
Alcohol abuse
Born premature; reports he had a feeding tube as a baby

PCP:  [**Name Initial (NameIs) **]

All:  NKDA


Social History:
Per chart 4 drinks a day. No known smoking history or drug
abuse.

Family History:
Not available

Physical Exam:
VS: Temp: BP: 133/79 HR: 112 RR: 16 O2sat 100 on room air
Gen: Somnolent but arousable, mildly agitated. Follows commands,
largely non verbal
Eyes: Sclerae injected, pupils reactive
Mouth: MM dry
Neck: Obese
Chest: CTA b/l with good air movement throughout
Cor: Tachycardic, regular, S1 and S2 wnl, no m/r/g
Abd: Obese, non-distended, +b/s, soft, nt, no masses or
hepatosplenomegaly
Ext: No edema, warm, good pulses
Neuro: Somnolent

Pertinent Results:
[**2196-11-6**] 09:58PM BLOOD WBC-6.7 RBC-4.01* Hgb-14.1 Hct-41.5
MCV-103* MCH-35.1* MCHC-33.9 RDW-13.1 Plt Ct-24*
[**2196-11-12**] 06:45AM BLOOD WBC-7.0 RBC-2.68* Hgb-9.3* Hct-27.5*
MCV-103* MCH-34.8* MCHC-33.9 RDW-13.2 Plt Ct-124*
[**2196-11-6**] 09:58PM BLOOD PT-14.0* PTT-30.0 INR(PT)-1.2*
[**2196-11-6**] 09:58PM BLOOD Glucose-133* UreaN-6 Creat-0.8 Na-139
K-3.4 Cl-97 HCO3-26 AnGap-19
[**2196-11-12**] 06:45AM BLOOD Glucose-117* UreaN-10 Creat-0.6 Na-137
K-3.3 Cl-104 HCO3-26 AnGap-10
[**2196-11-10**] 04:18AM BLOOD ALT-35 AST-178* LD(LDH)-379* AlkPhos-83
Amylase-55 TotBili-2.6*
[**2196-11-10**] 06:00PM BLOOD ALT-41* AST-245* LD(LDH)-473* AlkPhos-91
Amylase-75 TotBili-2.9*
[**2196-11-11**] 10:01AM BLOOD ALT-45* AST-260* AlkPhos-91 TotBili-2.9*
[**2196-11-12**] 06:45AM BLOOD ALT-43* AST-187* LD(LDH)-308* AlkPhos-101
TotBili-2.0*
[**2196-11-10**] 04:18AM BLOOD Lipase-146*
[**2196-11-10**] 06:00PM BLOOD Lipase-190*
[**2196-11-7**] 09:04PM BLOOD Calcium-8.5 Phos-1.1* Mg-1.5*
[**2196-11-12**] 06:45AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.0 Mg-2.0
[**2196-11-6**] 09:58PM BLOOD ASA-NEG Ethanol-428* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2196-11-7**] 08:25PM BLOOD Type-ART pO2-294* pCO2-50* pH-7.28*
calTCO2-24 Base XS--3
[**2196-11-8**] 12:11PM BLOOD Type-ART pO2-74* pCO2-40 pH-7.48*
calTCO2-31* Base XS-5
[**2196-11-6**] 09:55PM BLOOD Lactate-4.1*
[**2196-11-8**] 06:42AM BLOOD Lactate-1.4 K-3.8

EKG [**11-6**]:
Sinus rhythm. Borderline left axis deviation. Possible left
anterior
fascicular block.

Imaging:

R Knee and Ankle films [**11-6**]:
Oblique right distal fibular fracture and transverse right
medial
malleolar fracture with disruption of the ankle mortise.

CT Head without contrast [**11-7**]:
1. No hemorrhage or mass effect.
2. Prominent ventricles and cerebral sulci, likely related to
parenchymal volume loss; NPH is another possibility given the
greater dilation of the ventricles.

CXR [**11-7**]:
Aside from a mild atelectasis in the right lower lung accounting
for elevation of the lung base, the lungs are clear on the
frontal view. On the lateral view detail is obscured by motion,
probably respiratory. There is no pleural effusion. Heart is
mildly enlarged but there is no vascular congestion in the lungs
or in the mediastinum compared to mediastinal venous engorgement
that was present two hours earlier. The lateral view suggests
substantial compression of at least one lower thoracic vertebral
body with kyphosis. Clinical correlation advised.

ORIF fluoro images [**11-7**]:
Six fluoroscopic images from the operating room shows placement
of a lateral fibular fracture plate and interfragmentary screw
and two lag screws through the right medial malleolus. The
fracture lines are faintly visualized. There is good anatomic
alignment. There are no signs for hardware related
complications. Please refer to the operative note for additional
details.

CXR [**11-10**]:
No relevant interval changes. No pneumonia.

ON DISCHARGE

[**2196-11-17**] 09:10AM BLOOD WBC-10.0 RBC-3.35* Hgb-11.5* Hct-34.0*
MCV-102* MCH-34.5* MCHC-34.0 RDW-13.5 Plt Ct-400
[**2196-11-14**] 09:40AM BLOOD PT-14.2* PTT-29.8 INR(PT)-1.2*
[**2196-11-17**] 09:10AM BLOOD Glucose-94 UreaN-10 Creat-0.7 Na-135
K-3.5 Cl-98 HCO3-29 AnGap-12
[**2196-11-12**] 06:45AM BLOOD ALT-43* AST-187* LD(LDH)-308* AlkPhos-101
TotBili-2.0*
[**2196-11-12**] 06:45AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.0 Mg-2.0

Brief Hospital Course:
42yo gentleman with h/o alcohol abuse admitted with R ankle
fracture s/p ORIF who developed alcohol withdrawal seizures and
DTs during admission.

1) Alcohol withdrawal with Delerium Tremens and Alcohol
Withdrawal Seizures
Patient had witnessed alcohol withdrawal seizures during his
hospitalization.  He became hypoxic and improved with ativan, at
which point he was transferred to the MICU.  His vital signs
were labile and he was treated for delirium tremens with valium
IV.  He was eventually transferred to the floor when he no
longer needed IV benzodiazepines for withdrawal.  Clonidine
patch was given as well as IV fluids with thiamine, folate, and
multivitamin. The clonidine patch was discontinued, and the
patient was started on oral thiamin, folate and multivitamin.
Social work followed the patient to assist with resources for
quitting his addiction.
.
2) Open Right ankle fracture
ORIF was performed by orthopedics [**2196-11-7**].  His pain was
well-controlled and he was given lovenox for DVT prophylaxis.
He is touchdown weight bearing in his right lower extremity, and
the patient was followed by physical therapy. He was given a
prescription for outpatient physical therapy and provided with
orthopedics follow-up. After discharge he lost his prescription
for lovenox, which is documented in a separate note.
.
3) Thrombocytopenia:
Platelets were 24 on admission, and increased on their own
during his stay.  His platelets were most likely low secondary
to his alcohol abuse.  Orthopedics felt that it was safe to
continue lovenox despite his thrombocytopenia. At discharge his
platelets were 400.
.
4) Benign Hypertension:
It was unclear whether the patient has HTN or if his blood
pressure was elevated in the setting of withdrawal.  He was
treated with metoprolol [**Hospital1 **] to control his BP.  His blood
pressure remained controlled on metoprolol and he was felt to
have essential hypertension. On discharge, maintained on
metoprolol [**Hospital1 **] with good control of his blood pressure.
.
5) Anemia of chronic disease:
Patient had a stable, macrocytic anemia.  This is likely due to
the patient's alcohol abuse.  Folate and B12 were within normal
limits.
.
6) Hyperglycemia:
Patient had some transient hyperglycemia while in the MICU.  He
was treated with a sliding scale of insulin.  His sugars
normalized on their own during his hospital course.
.
7) Disposition: home with family, wheelchair provided by PT,
home PT, orthopedics follow-up, social work provided help in
arranging medication assistance.

Medications on Admission:
None.

Discharge Medications:
1. Multivitamin,Tx-Minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
6. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 14 days: until follow up with orthopedics.
Disp:*56 Capsule(s)* Refills:*0*
7. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1)  Subcutaneous
Q12H (every 12 hours) for 5 doses.
Disp:*5 syringe* Refills:*0*
8. Outpatient Physical Therapy
Please evaluate patient for outpatient physical therapy after
ORIF for right ankle fracture [**11-7**].


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
1. Right ankle fracture status post repair
2. Alcohol withdrawal
3. Hypertension
4. Wound infection
.
Secondary:
Alcohol abuse


Discharge Condition:
Afebrile, vital signs stable.


Discharge Instructions:
You were admitted with a right ankle fracture.  This was
repaired by orthopedics.  You should take antibiotics as below
for potential wound infection until follow up with orthopedics.
You should take aspirin 325 mg daily for one month to prevent a
blood clot including lovenox injections for the next 4 days from
discharge.  You should follow-up with Dr. [**Last Name (STitle) **] in 10 days
from discharge as below.
.
Please change the dressing on your ankle once a day.  Remove the
gauze, cleanse the area with normal saline, apply triple
antibiotic cream and re-wrap with dry gauze.
.
You were provided with a prescription for outpatient physical
therapy. Please call ([**Telephone/Fax (1) 30541**] to set up an appointment.
You may only touch your foot to the floor, you may not put any
weight on your right ankle.
.
During admission you had alcohol withdrawal and needed admission
to the intensive care unit.  You should continue a multivitamin,
thiamine, and folate for alcohol abuse.  You should abstain from
alcohol in the future.
.
Please contact a physician if you experience fevers, chills,
chest pain, shortness of breath, worsening ankle pain, or any
other concerning symptoms.
.
Please take your medications as below.
- You should take lovenox 30 mg twice daily for five doses to
prevent blood clots.
- You should take aspirin 325 mg daily for two weeks after
lovenox is complete to prevent blood clots.
- You should take keflex for 2 weeks to treat a wound infection
(or until follow up with orthopedics).
- You were started on a multivitamin, thiamine, and folate for
alcohol abuse.  These can be purchased at your local pharmacy
- You were started on metoprolol for high blood pressure.
.
Please keep your follow-up appointments as below.

Followup Instructions:
Follow-up with orthopedics:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2196-11-29**] 9:00
Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2196-11-29**] 9:20
{'Bimalleolar fracture, open,Alcohol withdrawal,Other and unspecified alcohol dependence, unspecified,Other convulsions,Kyphosis (acquired) (postural),Benign essential hypertension,Anemia of other chronic disease,Other abnormal glucose,Other fall,Accidents occurring in unspecified place'}


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: 42 year old man with history of alcohol abuse, who was admitted
status post fall and ankle fracture. He underwent ORIF of right
ankle [**11-7**] and was transferred to floor without complication
that day. The following afternoon he was found to be hypoxic to
80's with witnessed vomiting/seizure activity. Code blue called
and ativan was given, oxygen saturations recovered. Patient was
transferred to trauma SICU service. Had to be managed in PACU
because of bed availabilty. Since then, requiring 20mg IV
ativan/12 hours and very agitated. He did appear to be off
benzodiazepines for several hours and, at the end of this
period, he escalated--requiring multiple people to restrain him.

MEDICAL HISTORY: Alcohol abuse
Born premature; reports he had a feeding tube as a baby

MEDICATION ON ADMISSION: None.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Temp: BP: 133/79 HR: 112 RR: 16 O2sat 100 on room air
Gen: Somnolent but arousable, mildly agitated. Follows commands,
largely non verbal
Eyes: Sclerae injected, pupils reactive
Mouth: MM dry
Neck: Obese
Chest: CTA b/l with good air movement throughout
Cor: Tachycardic, regular, S1 and S2 wnl, no m/r/g
Abd: Obese, non-distended, +b/s, soft, nt, no masses or
hepatosplenomegaly
Ext: No edema, warm, good pulses
Neuro: Somnolent

FAMILY HISTORY: Not available

SOCIAL HISTORY: Per chart 4 drinks a day. No known smoking history or drug
abuse. 

### Response:
{'Bimalleolar fracture, open,Alcohol withdrawal,Other and unspecified alcohol dependence, unspecified,Other convulsions,Kyphosis (acquired) (postural),Benign essential hypertension,Anemia of other chronic disease,Other abnormal glucose,Other fall,Accidents occurring in unspecified place'}
