CHIEF COMPLAINT: fever

PRESENT ILLNESS: Ms. [**Known lastname 32457**] is a 37 yo F with h/o Ulcerative Colitis, Primary
sclerosing cholangitis with ESLD s/p 2 liver transplants in
[**2161-3-26**], with the second transplant complicated by
neurocognificant defects attributed to cerebral edema, and
biopsy in [**2165**] performed for increasing alk phos showing PSC
recurrence. She was transferred from Eastern [**Hospital 1727**] Hospital at
the request of transplant surgery for persistent fevers of
unknown origin.
.
This is Ms. [**Known lastname 32461**] third hospital admission for fevers in the
last 2 months. Her first admission was at [**Hospital6 8432**]
Center [**Date range (1) 32462**] when she presented with vomiting and
diarrhea thought to be from viral gastroenteritis. All cultures
and tests were negative and she improved from the
gastroenteritis. After discharge she developed upper respiratory
symptoms. She was given 10 days of tamiflu for recent outbreak
at her rehab. She reportedly did not have any mental status
changes, new rash or changes in PO intake. She then was admitted
at Eastern [**State 1727**] for a second time on [**3-20**] - [**3-25**] with fever
104.5 and blood pressure 90/50. She was empirically started on
antibiotics given her immunocompromised state but cultures were
negative. She did eventually grow RSV, which was the only
pathogen detected to cause her fevers.  At that time, she did
not have new rashes, HA, change in mental status, and was only
battling respiratory symptoms.
.
She continued in her usual state until 2 days prior to her
current presentation when she was noted to be more lethargic and
had fevers again to 102. Yesterday she was brought back from
rehab to [**Hospital6 8432**] Center. There the workup
reportedly included: neg u/a, WBC=6.9, Hct 35.4, cchem
139/4.5/24/22/0.76. CXR and Head CT were both negative (however,
reports are not with patient). She has baseline loose stools,
but unclear whether they have been increasing in quantity,
frequency, or caliber.  No blood.  Per patient's husband and
HCP, a decision was made to transfer her to [**Hospital1 18**] where her
transplant was performed for further work up of her fevers.
.
In the ED at [**Hospital1 18**], initial VS: 99.0, 84, 118/67, 16 99 RA. Labs
were unable to be obtained. CT scan showed bowel wall thickening
involving mainly the sigmoid and rectum, and to a lesser degree
the cecum and ascending colon in addition to small locules of
air in liver which may represent pneumobilia.

MEDICAL HISTORY: * ESLD secondary to primary sclerosing cholangitis, s/p living
unrelated donor transplant in [**3-/2161**] which failed (thrombosed)
leading to second transplant complicated by tracheostomy,
feeding tube, and cerebral edema requiring VP shunt
* IBD - UC diagnosed [**2156**] after p/w bloody stools
* cognitive defecits from anoxic brain injury [**1-27**] respiratory
arrest
* h/o cerebral edema s/p VP shunt
* h/o prolonged mechanical ventilation and tracheostomy
* h/o dysphagia and aspiration PNA with G tube placement (now
removed)
* h/o seizures, on anticonvulsants
* Ulcerative colitis
* h/o dysphagia
* h/o aspiration PNA
* H/o UTIs
* Psoriasis
* h/o DVT in post-op period
* Hypothyroidism, on Synthroid

MEDICATION ON ADMISSION: Risperidone 0.25 mg once a day
Ursodiol 300 mg Cap 2 Capsule(s) two times a day
Levetiracetam 750 mg Tab 1 Tablet twice a day
Tacrolimus 1 mg Cap 1 Capsule twice a day
Lexapro 10 mg Tab once a day
Vitamin D-3 400 unit Tab 2 Tablet once a day
Calcium Carbonate 500 mg (1,250 mg)1 Tablet four times a day
Potassium Chloride SR 20 mEq Tab twice a day
Asacol 400 mg Tab 4 Tablet three times a day
Levothyroxine 25 mcg Tab once a day
Methylphenidate 5 mg Tab once a day
Multivitamin Cap 1 (One) Capsule once a day
Fluticasone 50 mcg/Actuation Nasal Spray

ALLERGIES: Morphine Sulfate

PHYSICAL EXAM: ADMISSION PEx:
VS:  101.1, 112/74, 115, 24@94%(RA)
GENERAL: Female in NAD laying in fetal position in bed, agitated
when examined, speaking in one-word statements such as "juice,"
"drink"
HEENT: NC/AT, NGT in place, PERRL, EOMI, sclerae anicteric, MMM,
OP clear.
NECK: Supple, no JVD.
HEART: Tachycardic, regular, no MRG, nl S1-S2.
LUNGS: Respirations unlabored, non-coperative with exam, ie.
will not take deep breaths, thus moving poor amounts or air and
cannot appreciate r/rh/wh.
ABDOMEN: Soft/ND, some TTP in lower quadrant (L>R), but unclear
if patient simply agitated by exam, no guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: Non-jaundiced, no rashes or lesions.  Abdominal scar.
LYMPH: No cervical LAD appreciated.
NEURO: MS as above, AOxself, child-like interactions.  CNs
II-XII grossly intact, moving all extremities, non-cooperativ
with sensation coordinaiton, and relaxing for DTR testing.

FAMILY HISTORY: One brother with [**Name (NI) 4522**] disease or ulcerative colitis s/p bowel
resection.  Mother with breast cancer (d. [**2164**])

SOCIAL HISTORY: Living at [**Hospital 32458**] rehab facility following anoxic brain injury in
[**2161**]. Husband is power of attorney, married since [**2155**]. No
history of tobacco or alcohol use. Full code.
Foreign body accidentally left during a procedure,Epilepsy, unspecified, without mention of intractable epilepsy,Tracheostomy status,Infection and inflammatory reaction due to nervous system device, implant, and graft,Meningitis due to gram-negative bacteria, not elsewhere classified,Acute respiratory failure,Ulcerative colitis, unspecified,Urinary tract infection, site not specified,Liver replaced by transplant
FB left during procedure,Epilep NOS w/o intr epil,Tracheostomy status,React-nerv sys dev/graft,Mningts gram-neg bct NEC,Acute respiratry failure,Ulceratve colitis unspcf,Urin tract infection NOS,Liver transplant status
Admission Date:  [**2168-4-5**]              Discharge Date:   [**2168-4-19**]

Date of Birth:  [**2129-8-16**]             Sex:   F

Service: SURGERY

Allergies:
Morphine Sulfate

Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
fever

Major Surgical or Invasive Procedure:
[**2168-4-8**] Removal of ventriculoperitoneal shunt and repair
of colon.
Picc line placement


History of Present Illness:
Ms. [**Known lastname 32457**] is a 37 yo F with h/o Ulcerative Colitis, Primary
sclerosing cholangitis with ESLD s/p 2 liver transplants in
[**2161-3-26**], with the second transplant complicated by
neurocognificant defects attributed to cerebral edema, and
biopsy in [**2165**] performed for increasing alk phos showing PSC
recurrence. She was transferred from Eastern [**Hospital 1727**] Hospital at
the request of transplant surgery for persistent fevers of
unknown origin.
.
This is Ms. [**Known lastname 32461**] third hospital admission for fevers in the
last 2 months. Her first admission was at [**Hospital6 8432**]
Center [**Date range (1) 32462**] when she presented with vomiting and
diarrhea thought to be from viral gastroenteritis. All cultures
and tests were negative and she improved from the
gastroenteritis. After discharge she developed upper respiratory
symptoms. She was given 10 days of tamiflu for recent outbreak
at her rehab. She reportedly did not have any mental status
changes, new rash or changes in PO intake. She then was admitted
at Eastern [**State 1727**] for a second time on [**3-20**] - [**3-25**] with fever
104.5 and blood pressure 90/50. She was empirically started on
antibiotics given her immunocompromised state but cultures were
negative. She did eventually grow RSV, which was the only
pathogen detected to cause her fevers.  At that time, she did
not have new rashes, HA, change in mental status, and was only
battling respiratory symptoms.
.
She continued in her usual state until 2 days prior to her
current presentation when she was noted to be more lethargic and
had fevers again to 102. Yesterday she was brought back from
rehab to [**Hospital6 8432**] Center. There the workup
reportedly included: neg u/a, WBC=6.9, Hct 35.4, cchem
139/4.5/24/22/0.76. CXR and Head CT were both negative (however,
reports are not with patient). She has baseline loose stools,
but unclear whether they have been increasing in quantity,
frequency, or caliber.  No blood.  Per patient's husband and
HCP, a decision was made to transfer her to [**Hospital1 18**] where her
transplant was performed for further work up of her fevers.
.
In the ED at [**Hospital1 18**], initial VS: 99.0, 84, 118/67, 16 99 RA. Labs
were unable to be obtained. CT scan showed bowel wall thickening
involving mainly the sigmoid and rectum, and to a lesser degree
the cecum and ascending colon in addition to small locules of
air in liver which may represent pneumobilia.

Past Medical History:
* ESLD secondary to primary sclerosing cholangitis, s/p living
unrelated donor transplant in [**3-/2161**] which failed (thrombosed)
leading to second transplant complicated by tracheostomy,
feeding tube, and cerebral edema requiring VP shunt
* IBD - UC diagnosed [**2156**] after p/w bloody stools
* cognitive defecits from anoxic brain injury [**1-27**] respiratory
arrest
* h/o cerebral edema s/p VP shunt
* h/o prolonged mechanical ventilation and tracheostomy
* h/o dysphagia and aspiration PNA with G tube placement (now
removed)
* h/o seizures, on anticonvulsants
* Ulcerative colitis
* h/o dysphagia
* h/o aspiration PNA
* H/o UTIs
* Psoriasis
* h/o DVT in post-op period
* Hypothyroidism, on Synthroid

Social History:
Living at [**Hospital 32458**] rehab facility following anoxic brain injury in
[**2161**]. Husband is power of attorney, married since [**2155**]. No
history of tobacco or alcohol use. Full code.

Family History:
One brother with [**Name (NI) 4522**] disease or ulcerative colitis s/p bowel
resection.  Mother with breast cancer (d. [**2164**])

Physical Exam:
ADMISSION PEx:
VS:  101.1, 112/74, 115, 24@94%(RA)
GENERAL: Female in NAD laying in fetal position in bed, agitated
when examined, speaking in one-word statements such as "juice,"
"drink"
HEENT: NC/AT, NGT in place, PERRL, EOMI, sclerae anicteric, MMM,
OP clear.
NECK: Supple, no JVD.
HEART: Tachycardic, regular, no MRG, nl S1-S2.
LUNGS: Respirations unlabored, non-coperative with exam, ie.
will not take deep breaths, thus moving poor amounts or air and
cannot appreciate r/rh/wh.
ABDOMEN: Soft/ND, some TTP in lower quadrant (L>R), but unclear
if patient simply agitated by exam, no guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: Non-jaundiced, no rashes or lesions.  Abdominal scar.
LYMPH: No cervical LAD appreciated.
NEURO: MS as above, AOxself, child-like interactions.  CNs
II-XII grossly intact, moving all extremities, non-cooperativ
with sensation coordinaiton, and relaxing for DTR testing.


Pertinent Results:
LABS: On Admission: [**2168-4-5**]
GLUCOSE-87 UREA N-11 CREAT-0.7 SODIUM-138 POTASSIUM-4.5
CHLORIDE-101 TOTAL CO2-26 ANION GAP-16
ALT(SGPT)-33 AST(SGOT)-19 ALK PHOS-191* TOT BILI-0.5
CALCIUM-9.2 PHOSPHATE-3.2 MAGNESIUM-1.4*
tacroFK-4.2*
WBC-8.8 RBC-4.17* HGB-12.1 HCT-37.1 MCV-89 MCH-29.0 MCHC-32.7
RDW-15.0
PLT COUNT-233
PT-14.2* PTT-27.1 INR(PT)-1.2*
UCG-NEGATIVE
Urinalysis: COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.017
BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM
RBC-58* WBC-10* BACTERIA-FEW YEAST-NONE EPI-30 TRANS EPI-<1
MUCOUS-RARE
.
IMAGING:
.
CT head                           Date: [**2168-4-8**]
1. Status post ventriculostomy shunt removal with resulting air
in the
ventricle, and along the shunt course. However, no hemorrhage.
Stable
ventriculomegaly.
.
CXR (confirm placement of PICC)   Date: [**2168-4-10**]
Frontal view of the chest compared to multiple prior
examinations.
Endotracheal tube has been removed. Nasogastric tube is removed.
Right PICC terminates in the superior vena cava. Lungs are
clear. Cardiomediastinal silhouette is unremarkable. Multiple
EKG leads are present. Results communicated with [**Doctor First Name 8513**] of the IV
team at 10:40 a.m. on [**2168-4-10**] by telephone by Dr. [**Last Name (STitle) **].
.
EEG studies: pending
.
MRI                                 Date: [**2168-4-14**]
IMPRESSION:
1. There is FLAIR hyperintensity, slow diffusion and enhancement
in the
subarachnoid space overlying the right posterior frontal and
parietal lobes. This is concerning for subarachnoid empyema with
menengitis and encephalitis.
2. There is a thin subdural collection overlying the right
hemisphere which demonstrates FLAIR hyperintensity and
enhancement without slow diffusion which may represent a
subdural hemorrhage, or dural thickening/fluid related to the
previous shunt manipulation. Infection cannot be excluded in
this compartment.
3. Severe enlargement of the lateral and third ventricles,
similar to the
prior CT five days ago with patent aqueduct of sylvius. The
pneumocephalus
present [**4-8**] (CT head) has resolved.


Brief Hospital Course:
36 h/o UC, PSC with ESLD s/p 2 liver transplants [**2161-3-29**] c/b
graft failure and cerebral edema with permanent anoxic brain
injury s/p VP shunt who is chronically immunosupressed after
transplants p/w fevers (to 102) and found to have question of
colitis on CT.
.
Upon admission, fever was of unclear etiology, but given
immunocompromised state, differential was very broad.
Differenials included IBD flare, especially with pancolotis on
colonoscopy.  CMV, O&P, C.dif, stool studies were negative.  CT
abd/pel showed signs of colitis on admission, but no abscess.
CXR was negative at OSH.  She completed a course of Influenza
prophylaxis prior to admission, and had no respiratory symptoms.
 Drug fever was considered, but there were no recent medication
changes making this less likely.  CNS infection was considered,
but no change in MS per husband, no rashes, and no CT head
findings to increase suspicion.  Post-transplant
lymphoproliferative disorder was also considered, but patient
was then found to have potential sources with UTI and VP shunt
that traversed the bowel wall.

Colonoscopy on HD3 revealed pancolitis, as well as unclear
foreign object that seemed to be embedded in the bowel wall.
Radiology was then contact[**Name (NI) **] to review the abdominal imaging
with the foreign object in mind, and the team was notified that
the patient's VP shunt perforated the bowel wall in the region
of the transverse colon.  Neurosurgery was notified and elected
to remove the VP shunt in conjunction with transplant surgery to
repair the bowel wall on [**2168-4-8**].  CSF studies were sent at
that time, and revealed E. Coli. The VP shunt revealed
enterococcus. ID was also consulted given immunocompromised
state and unusual anatomy early in hospitalization, prior to OR,
and recommended coverage with CefePIME, Vancomycin,
MetRONIDAZOLE (FLagyl), at least until further data could be
obtained regarding tissue cultures.  Transplant surgery and
hepatology were involved in her care during the hospitalization.
 She received a course of antibiotics to treat her UTI (see
below). However, when the sensitivities from her CSF and VP
shunt returned she was switched to intravenous meropenem and
vancomycin. ID followed and recommended continuing this
antibiotic regimen for three weeks with the end date of [**2168-4-30**]. They contact[**Name (NI) **] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from [**Hospital6 8432**]
Center to ensure close follow-up.
.
Malpositioned VP shunt: The VP shunt was extracted from the
transverse colon with the help of neurosurgery and the
transplant surgery team on [**2168-4-8**]. She tolerated the procedure
well. The VP shunt was sent for culture and grew out
Enterococcus, a species that was sensitive to vancomycin.
Neurosurgery continued to follow during her hospital stay and
removed the staples on [**2168-4-15**]. They recommended follow-up in 4
weeks with a non-contrast head CT prior to her next visit.
Vancomycin required adjustment based on levels. On [**4-18**],
vancomycin trough was 36.7 on 1 gram [**Hospital1 **]. Vanco was held and
level checked [**4-19**] am. Give a dose if it is less than 18 and
continue 1gm IV q24h.
.
UTI: patient was diagnosed with a UTI based on urine culture.
She was initially given a dose of ciprofloxacin, however, given
past sensitivities and concern for concomitant infection once it
was learned that she had VP shunt connection with bowel flora,
she was switched to broad coverage with CefePIME, Vancomycin,
MetRONIDAZOLE (FLagyl).  ID continued to follow as indicated
above.
.
ESLD/PSC s/p liver transplants ([**2160**]) c/b graft failure, then
s/p repeat transplant ([**2160**]): as discussed above, hepatology and
the transplant service cared for the patient throughout her
hospitalization.  Her tacrolimus dose was continued based on
levels, as well as her home dose Ursodiol.
.
Ulcerative colitis with pan-colitis on colonoscopy: this in
itself could have been contributing to her cyclical fevers.
Trigger for flare may have been bowel wall irritation with CSF
from VP shunt.  Mesalamine 1600 mg TID (max dose) was continued.
 Steroids were deferred in the immediate post-colonoscopy
hospitalization.
.
Pneumobilia: in post-operative liver transplant patient with
some gut-liver connection, not a surprising finding on CT.  The
transplant team was involved in her care.
.
Hx of seizures and anoxic brain injury: no SZ activity during
first part of hospitalization (she had been continued on her
home dose of Keppra), however, she was transferred to the ICU on
the day prior to her OR date for removal of her VP shunt for
status epilepticus. She had a reported 4 minute and then 15
minute
seizure prior to ICU transfer. She received Ativan and her
seizure activity subsided. She had a second seizure that
persisted for 15 minutes, despite Ativan, until she received
sedatives for intubation. Post-operatively, she had 24 hour EEG
monitoring. Her dose of Keppra was titrated up to 2gm [**Hospital1 **]. She
continued to have frequent discharges on EEG and was started on
Vimpat 100mg [**Hospital1 **]. She had decreased discharges with the addition
of vimpat and was eventually increased to vimpat 200mg [**Hospital1 **]. She
will continue on both medications
.
Hypothyroid: She was continued on her home dose Synthroid
throughout her hospitalization.
.
h/o dysphagia with regular diet at rehab: when patient was not
NPO, she was given a regular diet with aspiration precautions.
She was resumed on a regular diet post-operatively.
.
Code: FULL

Medications on Admission:
Risperidone 0.25 mg once a day
Ursodiol 300 mg Cap 2 Capsule(s) two times a day
Levetiracetam 750 mg Tab 1 Tablet twice a day
Tacrolimus 1 mg Cap 1 Capsule twice a day
Lexapro 10 mg Tab once a day
Vitamin D-3 400 unit Tab 2 Tablet once a day
Calcium Carbonate 500 mg (1,250 mg)1 Tablet four times a day
Potassium Chloride SR 20 mEq Tab twice a day
Asacol 400 mg Tab 4 Tablet three times a day
Levothyroxine 25 mcg Tab once a day
Methylphenidate 5 mg Tab once a day
Multivitamin Cap 1 (One) Capsule once a day
Fluticasone 50 mcg/Actuation Nasal Spray


Discharge Medications:
1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
3. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
5. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea.
7. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. ursodiol 300 mg Capsule Sig: Three (3) Capsule PO QAM (once a
day (in the morning)).
9. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QHS (once a
day (at bedtime)).
10. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
17. lacosamide 50 mg Tablet Sig: Three (3) Tablet PO bid ().
18. meropenem 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 10 days: End date [**4-30**].
19. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
20. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
21. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gm
Intravenous Q 24H (Every 24 Hours) for 12 days: Day 1 = [**4-7**]
Trough Goal range 15-20.  End date [**4-30**] .
Disp:*qs * Refills:*0*
22. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).


Discharge Disposition:
Extended Care

Facility:
Eastern Main Medical Acute Rehab Unit

Discharge Diagnosis:
Meningitis
Perforated Colon
Pancolitis
Seizures
UTI


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive with baseline
deficit.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Requires FALL PRECAUTIONS


Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
seizure activity, change in mental status, head/abdominal
incision sites appear red or have drainage.
Continue IV antibiotics via PICC line
Follow Vanco level
Please follow trough Prograf levels at least weekly. Call the
transplant center for help with dosing, keep trough levels 6 -
8, call for advice regarding dosing regimen
CD with most recent MRI and Head CT has been sent with patient

Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the [**Hospital **] clinic at
[**Hospital6 8432**] Center. The office phone number is
([**Telephone/Fax (1) 32463**]. Our ID physicians will be in contact with Dr.
[**Last Name (STitle) **]. An appointment will be arranged and they should contact
you. If you do not hear from their office, please call their
office directly.
.
Please follow-up with Dr. [**Last Name (STitle) 739**] in 4 weeks. Your
appointment is scheduled for [**2168-5-18**] at 11am. You will
need to have a non-contrast head CT scan completed prior to your
office visit at 10am at the [**Location (un) 591**] Radiology
department at [**Hospital1 32464**]. Please call the office phone
number at [**Telephone/Fax (1) 1669**] with any questions.
.
You will also need to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from the
epilepsy division. Your appointment is scheduled for Wednesday,
[**2168-5-18**] at 1pm. Their office phone number is ([**Telephone/Fax (1) 32465**].
.
Please follow-up with Dr. [**Last Name (STitle) **] [**2168-5-18**] at 2:40pm on
the [**Location (un) 436**] of the [**Hospital Unit Name **].



Completed by:[**2168-4-18**]

Name:  [**Known lastname 5620**],[**Known firstname **]                Unit No:   [**Numeric Identifier 5621**]

Admission Date:  [**2168-4-5**]              Discharge Date:   [**2168-4-19**]

Date of Birth:  [**2129-8-16**]             Sex:   F

Service: SURGERY

Allergies:
Morphine Sulfate

Attending:[**First Name3 (LF) 3999**]
Addendum:
Prograf dose: 1.5mg [**Hospital1 **]

Discharge Disposition:
Extended Care

Facility:
Eastern Main Medical Acute Rehab Unit

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4000**] MD [**MD Number(2) 4001**]

Completed by:[**2168-4-19**]

Name:  [**Known lastname 5620**],[**Known firstname **]                Unit No:   [**Numeric Identifier 5621**]

Admission Date:  [**2168-4-5**]              Discharge Date:   [**2168-4-19**]

Date of Birth:  [**2129-8-16**]             Sex:   F

Service: SURGERY

Allergies:
Morphine Sulfate

Attending:[**First Name3 (LF) 3999**]
Addendum:
Lacosamide dose: 200mg [**Hospital1 **]

Discharge Disposition:
Extended Care

Facility:
Eastern Main Medical Acute Rehab Unit

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4000**] MD [**MD Number(2) 4001**]

Completed by:[**2168-4-19**]
{'Foreign body accidentally left during a procedure,Epilepsy, unspecified, without mention of intractable epilepsy,Tracheostomy status,Infection and inflammatory reaction due to nervous system device, implant, and graft,Meningitis due to gram-negative bacteria, not elsewhere classified,Acute respiratory failure,Ulcerative colitis, unspecified,Urinary tract infection, site not specified,Liver replaced by transplant'}


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: fever

PRESENT ILLNESS: Ms. [**Known lastname 32457**] is a 37 yo F with h/o Ulcerative Colitis, Primary
sclerosing cholangitis with ESLD s/p 2 liver transplants in
[**2161-3-26**], with the second transplant complicated by
neurocognificant defects attributed to cerebral edema, and
biopsy in [**2165**] performed for increasing alk phos showing PSC
recurrence. She was transferred from Eastern [**Hospital 1727**] Hospital at
the request of transplant surgery for persistent fevers of
unknown origin.
.
This is Ms. [**Known lastname 32461**] third hospital admission for fevers in the
last 2 months. Her first admission was at [**Hospital6 8432**]
Center [**Date range (1) 32462**] when she presented with vomiting and
diarrhea thought to be from viral gastroenteritis. All cultures
and tests were negative and she improved from the
gastroenteritis. After discharge she developed upper respiratory
symptoms. She was given 10 days of tamiflu for recent outbreak
at her rehab. She reportedly did not have any mental status
changes, new rash or changes in PO intake. She then was admitted
at Eastern [**State 1727**] for a second time on [**3-20**] - [**3-25**] with fever
104.5 and blood pressure 90/50. She was empirically started on
antibiotics given her immunocompromised state but cultures were
negative. She did eventually grow RSV, which was the only
pathogen detected to cause her fevers.  At that time, she did
not have new rashes, HA, change in mental status, and was only
battling respiratory symptoms.
.
She continued in her usual state until 2 days prior to her
current presentation when she was noted to be more lethargic and
had fevers again to 102. Yesterday she was brought back from
rehab to [**Hospital6 8432**] Center. There the workup
reportedly included: neg u/a, WBC=6.9, Hct 35.4, cchem
139/4.5/24/22/0.76. CXR and Head CT were both negative (however,
reports are not with patient). She has baseline loose stools,
but unclear whether they have been increasing in quantity,
frequency, or caliber.  No blood.  Per patient's husband and
HCP, a decision was made to transfer her to [**Hospital1 18**] where her
transplant was performed for further work up of her fevers.
.
In the ED at [**Hospital1 18**], initial VS: 99.0, 84, 118/67, 16 99 RA. Labs
were unable to be obtained. CT scan showed bowel wall thickening
involving mainly the sigmoid and rectum, and to a lesser degree
the cecum and ascending colon in addition to small locules of
air in liver which may represent pneumobilia.

MEDICAL HISTORY: * ESLD secondary to primary sclerosing cholangitis, s/p living
unrelated donor transplant in [**3-/2161**] which failed (thrombosed)
leading to second transplant complicated by tracheostomy,
feeding tube, and cerebral edema requiring VP shunt
* IBD - UC diagnosed [**2156**] after p/w bloody stools
* cognitive defecits from anoxic brain injury [**1-27**] respiratory
arrest
* h/o cerebral edema s/p VP shunt
* h/o prolonged mechanical ventilation and tracheostomy
* h/o dysphagia and aspiration PNA with G tube placement (now
removed)
* h/o seizures, on anticonvulsants
* Ulcerative colitis
* h/o dysphagia
* h/o aspiration PNA
* H/o UTIs
* Psoriasis
* h/o DVT in post-op period
* Hypothyroidism, on Synthroid

MEDICATION ON ADMISSION: Risperidone 0.25 mg once a day
Ursodiol 300 mg Cap 2 Capsule(s) two times a day
Levetiracetam 750 mg Tab 1 Tablet twice a day
Tacrolimus 1 mg Cap 1 Capsule twice a day
Lexapro 10 mg Tab once a day
Vitamin D-3 400 unit Tab 2 Tablet once a day
Calcium Carbonate 500 mg (1,250 mg)1 Tablet four times a day
Potassium Chloride SR 20 mEq Tab twice a day
Asacol 400 mg Tab 4 Tablet three times a day
Levothyroxine 25 mcg Tab once a day
Methylphenidate 5 mg Tab once a day
Multivitamin Cap 1 (One) Capsule once a day
Fluticasone 50 mcg/Actuation Nasal Spray

ALLERGIES: Morphine Sulfate

PHYSICAL EXAM: ADMISSION PEx:
VS:  101.1, 112/74, 115, 24@94%(RA)
GENERAL: Female in NAD laying in fetal position in bed, agitated
when examined, speaking in one-word statements such as "juice,"
"drink"
HEENT: NC/AT, NGT in place, PERRL, EOMI, sclerae anicteric, MMM,
OP clear.
NECK: Supple, no JVD.
HEART: Tachycardic, regular, no MRG, nl S1-S2.
LUNGS: Respirations unlabored, non-coperative with exam, ie.
will not take deep breaths, thus moving poor amounts or air and
cannot appreciate r/rh/wh.
ABDOMEN: Soft/ND, some TTP in lower quadrant (L>R), but unclear
if patient simply agitated by exam, no guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: Non-jaundiced, no rashes or lesions.  Abdominal scar.
LYMPH: No cervical LAD appreciated.
NEURO: MS as above, AOxself, child-like interactions.  CNs
II-XII grossly intact, moving all extremities, non-cooperativ
with sensation coordinaiton, and relaxing for DTR testing.

FAMILY HISTORY: One brother with [**Name (NI) 4522**] disease or ulcerative colitis s/p bowel
resection.  Mother with breast cancer (d. [**2164**])

SOCIAL HISTORY: Living at [**Hospital 32458**] rehab facility following anoxic brain injury in
[**2161**]. Husband is power of attorney, married since [**2155**]. No
history of tobacco or alcohol use. Full code. 

### Response:
{'Foreign body accidentally left during a procedure,Epilepsy, unspecified, without mention of intractable epilepsy,Tracheostomy status,Infection and inflammatory reaction due to nervous system device, implant, and graft,Meningitis due to gram-negative bacteria, not elsewhere classified,Acute respiratory failure,Ulcerative colitis, unspecified,Urinary tract infection, site not specified,Liver replaced by transplant'}
