CHIEF COMPLAINT: mental status changes and fever

PRESENT ILLNESS: 39 y.o. female with Schizoaffective disorder, CKD presents to
[**Hospital1 18**] ER from [**Hospital **] [**Hospital **] Hospital with new onset of drooling,
mutism, diaphoresis and diffuse weakness.  According to the
records from the [**Hospital1 **], she was "talking" and "out of bed...with
no difficulty communicating."   Today she had acute onset of arm
stiffness and she was mute.  At [**Hospital1 **], Temp:100.9, BP:120/100,
P:140, RR:40, O2:99 RA.  At [**Hospital1 18**], T:99.1, BP:102/70, P:100,
O2:100 RA.   She was noted to be A/O x 3, with slow speech.  She
had intermittent rigors.  WBC was 15.4 with no bands, Lactate
2.8.  Head CT (-).  She was noted to have 3 abscesses behind the
right ear and she underwent I&D with 5-10 cc foul smelling pus.
 Urine and serum tox (-).  CK found to be 5675. In the ER, she
was given 1 liter of fluid.  Neurology and psychiatry were
consulted and thought that her clinical picture might be
consistent with Neuroleptic Malignant Syndrome.  She was
admitted to the MICU for further evaluation.

MEDICAL HISTORY: 1) Schizophrenia, Bipolar Type, on Geodon and Haldol.  Had SI in
the past with O.D. on pills.  Also with HI towards her mother.
[**Name (NI) **] racing thoughts.
2) HTN
3) Secondary Amenorrhea
4) Hirsutism
5) Acne Vulgaris
6) h/o sexual assault

MEDICATION ON ADMISSION: Lactobacillus (when on antibiotics)
Ciprofloxacin 500mg po bid (to be completed on [**12-7**])
Geodon 80mg po bid (stopped [**11-28**])
Haldol 5mg po tid (held on [**11-30**])
Propanolol 20mg po qid
Haldol 5mg po q4h prn
Ativan 2mg po q4h prn
Benadadryl 50mg po q4h prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp:98.0  BP:110/66   HR:100   RR:20   O2:100 RA
Gen: Hypophonic.  Slow speech.  A/O x 3.
HEENT: PEARLA. EOMI.  Exophthalmos b/l.  No icterus.  Moist mm.
OP: tongue fasiculations [**8-5**] Hz.  Right posterior abscess s/p
drainage w/o pain.  No LAD
CV: RR. S1>S2.  No M
Pulm: CTA b/l
ABD: Soft. NT. ND.  No HSM
Ext: b/l tremor at hands no edema. 1+ DP/PT
Neuro: Somwhat rigid b/l.  No cogwheeling.  Motor [**4-30**] in all
flex/ex.  [**Last Name (un) **]: GI.  CN II-XII GI.  Brisk reflexes b/l.  Affect
blunted.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: From [**Country **], came to U.S. at age 8.  Divorced, no children.  No
EtOH/smoking/IVDU.
Neuroleptic malignant syndrome,Other specified types of schizophrenia, unspecified,Acute kidney failure, unspecified,Rhabdomyolysis,Hyperosmolality and/or hypernatremia,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use,Infective otitis externa, unspecified,Nephrogenic diabetes insipidus,Unspecified essential hypertension,Suicidal ideation
Neuroleptic malgnt synd,Schizophrenia NEC-unspec,Acute kidney failure NOS,Rhabdomyolysis,Hyperosmolality,Adv eff antipsychotc NEC,Infec otitis externa NOS,Nephrogen diabetes insip,Hypertension NOS,Suicidal ideation
Admission Date:  [**2189-12-1**]              Discharge Date:   [**2189-12-8**]

Date of Birth:  [**2150-7-24**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
mental status changes and fever

Major Surgical or Invasive Procedure:
Lumbar Puncture


History of Present Illness:
39 y.o. female with Schizoaffective disorder, CKD presents to
[**Hospital1 18**] ER from [**Hospital **] [**Hospital **] Hospital with new onset of drooling,
mutism, diaphoresis and diffuse weakness.  According to the
records from the [**Hospital1 **], she was "talking" and "out of bed...with
no difficulty communicating."   Today she had acute onset of arm
stiffness and she was mute.  At [**Hospital1 **], Temp:100.9, BP:120/100,
P:140, RR:40, O2:99 RA.  At [**Hospital1 18**], T:99.1, BP:102/70, P:100,
O2:100 RA.   She was noted to be A/O x 3, with slow speech.  She
had intermittent rigors.  WBC was 15.4 with no bands, Lactate
2.8.  Head CT (-).  She was noted to have 3 abscesses behind the
right ear and she underwent I&D with 5-10 cc foul smelling pus.
 Urine and serum tox (-).  CK found to be 5675. In the ER, she
was given 1 liter of fluid.  Neurology and psychiatry were
consulted and thought that her clinical picture might be
consistent with Neuroleptic Malignant Syndrome.  She was
admitted to the MICU for further evaluation.

Past Medical History:
1) Schizophrenia, Bipolar Type, on Geodon and Haldol.  Had SI in
the past with O.D. on pills.  Also with HI towards her mother.
[**Name (NI) **] racing thoughts.
2) HTN
3) Secondary Amenorrhea
4) Hirsutism
5) Acne Vulgaris
6) h/o sexual assault

Social History:
From [**Country **], came to U.S. at age 8.  Divorced, no children.  No
EtOH/smoking/IVDU.

Family History:
Unknown

Physical Exam:
Temp:98.0  BP:110/66   HR:100   RR:20   O2:100 RA
Gen: Hypophonic.  Slow speech.  A/O x 3.
HEENT: PEARLA. EOMI.  Exophthalmos b/l.  No icterus.  Moist mm.
OP: tongue fasiculations [**8-5**] Hz.  Right posterior abscess s/p
drainage w/o pain.  No LAD
CV: RR. S1>S2.  No M
Pulm: CTA b/l
ABD: Soft. NT. ND.  No HSM
Ext: b/l tremor at hands no edema. 1+ DP/PT
Neuro: Somwhat rigid b/l.  No cogwheeling.  Motor [**4-30**] in all
flex/ex.  [**Last Name (un) **]: GI.  CN II-XII GI.  Brisk reflexes b/l.  Affect
blunted.


Pertinent Results:
ABG  7.39/31/114.
LACTATE-1.6
O2 SAT-98
freeCa-1.32
URINE TOX:  bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
U/A:  BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG  RBC-0-2 WBC-0-2
BACTERIA-NONE YEAST-NONE EPI-0

142  110  14
-------------<
4.3   17  1.8

ALT(SGPT)-34 AST(SGOT)-110* LD(LDH)-466* CK(CPK)-5675* ALK
PHOS-88 AMYLASE-54 TOT BILI-0.3

CK(CPK)-5633*

 LIPASE-32,   CK-MB-112* MB INDX-2.0
 ALBUMIN-4.2, TSH-0.58,  FREE T4-1.7

SERUM TOX  ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG

WBC-15.4* HCT-40.4, Plt:205

NEUTS-77.3* BANDS-0 LYMPHS-17.8* MONOS-4.6 EOS-0.1 BASOS-0.2

CALCIUM-9.4 PHOSPHATE-3.4 MAGNESIUM-2.0

CSF: Prot:32  Gluc:77
CSF: WBC:2, RBC:1

CXR: No CP processes.

EKG: NSR at 85.  nl axis/int.  no ST-T changes


Brief Hospital Course:
1) Mental status / Neuroleptic Malignant Syndrome: Pt had
recently been started on geodon and haldol with a functional
basline. However, on the day of admission, she was found to be
fatigued, drooling, febrile, and with rigidity. A CK in the ED
was 5000 and diagnosis of NMS was made. Pt had blood and urine
cultures which were negative. She also had a lumbar puncture and
CT of the head, both of which were negative as well. Pt was seen
by psychiatry and neurology. Antipsychotics were held and
patient was placed on valium q2h per CIWA scale. Pt was admitted
to MICU and on the first evening of hospitalization, her CK rose
to 55,000. She was hydrated aggressively and her urine
alkalinized. Her mental status slowly improved, and her CK
trended downward. At the time of discharge, she had been weened
off valium, was alert, oriented, and answering questions
appropriately.
.
2) Acute renal failure: Pt had a rise in her creatinine to a max
of 1.8, presumed [**1-28**] to rhabdomyolysis from NMS. She was
hydrated aggressively with IV fluids as above, and urine
alkalinized with bicarbonate. Her creatinine trended down and
was 1.1-1.3 at the time of discharge.
.
3) Diabetes Insipidus: Pt found to have nephrogenic DI, presumed
[**1-28**] previous lithium therapy. Pt's serum sodium was monitored
closely and remained in the high 140s. She was hydrated
aggressively as above, using D5W with 1 amp of bicarb to
alkalinize the urine. She was provided ample water at bedside to
drink for thirst. A DDAVP trial was performed during
hospitalization, which was consistent with nephrogenic DI.
.
4) Schizoaffective Disorder: Pt had been on geodon and haldol at
the time of presentation. However, they were stopped for concern
of NMS. She was seen by the psychiatry consult liaison service
who recommended placing the patient on valium q2h per CIWA
scale. This was initially given IV, and then switched to PO when
patient's mental status cleared. With clearing of her mental
status, patient also began expressing suicidal and homicidal
ideation with auditory hallucinations. She admitted to hearing
voices telling her to kill herself by overdosing on pills, as
well as voices telling her to hurt others, though no one in
particular. She was assigned a 1:1 sitter, and she was without
incident throughout hospitalization. After stabilization of her
medical issues, she was transferred back to her psychiatric
facility.
.
5) Right ear abscess s/p I&D: Pt had bedside incision and
drainage of several right ear abscesses in the ED. She was
emperically given a dose each of ceftriaxone and vancomycin in
the ED. Her antibiotics were changed to dicloxicillin and a
seven day course was established, with last dose to be given on
[**12-9**]. She subsequently remained afebrile with clinical
improvement of her abscess sites.
.
6) HTN: On admission, pt had been on propranolol for
hypertension. This was stopped during hospitalization, and pt's
blood pressure subsequently remained under good control off
antihypertensives.
.
7) Contact: [**Name (NI) 1094**] medical condition was communicated with mother
[**Name (NI) 65225**] at [**Telephone/Fax (1) 65226**] as well as her HCP, [**Name (NI) **] [**Name (NI) **] at
[**Telephone/Fax (5) 65227**].

Medications on Admission:
Lactobacillus (when on antibiotics)
Ciprofloxacin 500mg po bid (to be completed on [**12-7**])
Geodon 80mg po bid (stopped [**11-28**])
Haldol 5mg po tid (held on [**11-30**])
Propanolol 20mg po qid
Haldol 5mg po q4h prn
Ativan 2mg po q4h prn
Benadadryl 50mg po q4h prn

Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed.
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical  DAILY (Daily).
4. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 2 days: Continue through [**2189-12-9**].
Disp:*8 Capsule(s)* Refills:*0*
5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 1680**] Hospital - [**Location (un) 538**]

Discharge Diagnosis:
Neuroleptic malignant syndrome
Nephrogenic diabetes insipidus
Hypertension
Schizophrenia, Bipolar Type


Discharge Condition:
Stable


Discharge Instructions:
Please take all medications as listed in the discharge
paperwork.  Also please make all appointments as listed.  If the
patient has chest pain, shortness of breath, dizziness, nausea,
vomitting, diarrhea, abdominal pain, or other concerning

Make sure that patient has access to as much water as she wants.
 She has Diabetes Insipidus and needs to drink frequently to
maintain her sodium.  If she is unconscious or confused and
stops drinking she needs to have her electrolytes drawn and be
seen by a doctor.

Followup Instructions:
Follow up with your psychiatrist as indicated.

Follow up with your primary care provider.
[**Name Initial (NameIs) 2169**]: [**First Name8 (NamePattern2) 640**] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 250**] Date/Time:[**2189-12-29**]
3:30

Please follow up with the Renal doctors.
[**Telephone/Fax (1) 60**]
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D. Date/Time:[**2190-1-21**] 3:00
{'Neuroleptic malignant syndrome,Other specified types of schizophrenia, unspecified,Acute kidney failure, unspecified,Rhabdomyolysis,Hyperosmolality and/or hypernatremia,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use,Infective otitis externa, unspecified,Nephrogenic diabetes insipidus,Unspecified essential hypertension,Suicidal ideation'}


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: mental status changes and fever

PRESENT ILLNESS: 39 y.o. female with Schizoaffective disorder, CKD presents to
[**Hospital1 18**] ER from [**Hospital **] [**Hospital **] Hospital with new onset of drooling,
mutism, diaphoresis and diffuse weakness.  According to the
records from the [**Hospital1 **], she was "talking" and "out of bed...with
no difficulty communicating."   Today she had acute onset of arm
stiffness and she was mute.  At [**Hospital1 **], Temp:100.9, BP:120/100,
P:140, RR:40, O2:99 RA.  At [**Hospital1 18**], T:99.1, BP:102/70, P:100,
O2:100 RA.   She was noted to be A/O x 3, with slow speech.  She
had intermittent rigors.  WBC was 15.4 with no bands, Lactate
2.8.  Head CT (-).  She was noted to have 3 abscesses behind the
right ear and she underwent I&D with 5-10 cc foul smelling pus.
 Urine and serum tox (-).  CK found to be 5675. In the ER, she
was given 1 liter of fluid.  Neurology and psychiatry were
consulted and thought that her clinical picture might be
consistent with Neuroleptic Malignant Syndrome.  She was
admitted to the MICU for further evaluation.

MEDICAL HISTORY: 1) Schizophrenia, Bipolar Type, on Geodon and Haldol.  Had SI in
the past with O.D. on pills.  Also with HI towards her mother.
[**Name (NI) **] racing thoughts.
2) HTN
3) Secondary Amenorrhea
4) Hirsutism
5) Acne Vulgaris
6) h/o sexual assault

MEDICATION ON ADMISSION: Lactobacillus (when on antibiotics)
Ciprofloxacin 500mg po bid (to be completed on [**12-7**])
Geodon 80mg po bid (stopped [**11-28**])
Haldol 5mg po tid (held on [**11-30**])
Propanolol 20mg po qid
Haldol 5mg po q4h prn
Ativan 2mg po q4h prn
Benadadryl 50mg po q4h prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp:98.0  BP:110/66   HR:100   RR:20   O2:100 RA
Gen: Hypophonic.  Slow speech.  A/O x 3.
HEENT: PEARLA. EOMI.  Exophthalmos b/l.  No icterus.  Moist mm.
OP: tongue fasiculations [**8-5**] Hz.  Right posterior abscess s/p
drainage w/o pain.  No LAD
CV: RR. S1>S2.  No M
Pulm: CTA b/l
ABD: Soft. NT. ND.  No HSM
Ext: b/l tremor at hands no edema. 1+ DP/PT
Neuro: Somwhat rigid b/l.  No cogwheeling.  Motor [**4-30**] in all
flex/ex.  [**Last Name (un) **]: GI.  CN II-XII GI.  Brisk reflexes b/l.  Affect
blunted.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: From [**Country **], came to U.S. at age 8.  Divorced, no children.  No
EtOH/smoking/IVDU. 

### Response:
{'Neuroleptic malignant syndrome,Other specified types of schizophrenia, unspecified,Acute kidney failure, unspecified,Rhabdomyolysis,Hyperosmolality and/or hypernatremia,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use,Infective otitis externa, unspecified,Nephrogenic diabetes insipidus,Unspecified essential hypertension,Suicidal ideation'}
