CHIEF COMPLAINT: Transferred to MICU for altered mental status

PRESENT ILLNESS: 20 y/o F w/no past med hx who originally presented to [**Hospital 39437**] Hospital on [**2100-8-29**] complaining of one week of nausea,
headache, ear pain, neck pain, and suprapubic pain.  Reportedly
the day before she had slept all day and c/o a generalized
headache.  She went to the ED, where she it was felt she had a
UTI (WBCs/bacturia) and otitis media ("bloody ear").  She was
treated with amoxicillin.  Her symptoms became progressively
worse, and she had fevers and chills.  She returned to the
emergency room the next day c/o suprapubic discomfort, fever,
n/v, headache, and back pain.  She had CVA tenderness and was
febrile to 101.1.  At that time she had no meningismus and a
normal mental status, nonfocal neuro exam.  Her WBC at that time
was 20, which was elevated from 9 the day prior.  She was
admitted with a diagnosis of pyelo and treated with ceftriaxone
and/or ciprofloxacin (unclr from notes which she received).  She
was given lorazepam 1 mg for anxiety.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: Medications on transfer:
Ativan gtt at 4 mg/hr
Phenytoin 100 q8h
Depakote 250 q8h
Ceftriaxone 2 g IV q12h
Ampicillin 2 g IV q6h
Vancomycin 1 g IV bid
Acyclovir 500 IV q8h
Protonix
SQ heparin
Insulin SS
Cipro ear gtt

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: 100.8  BP:  119/58  P: 105
Vent: AC 500x16  PEEP 5  FiO2 40%, SaO2 99%
Gen: intubated, sedated
HEENT:  EEG leads in place, tongue protruding, pupils deviated
inferiorly, sclerae anicteric, MMM
Neck: no lymphadenopathy, or thyromegaly
Chest:  lungs clear to auscultation bilaterally
CV: tachycardic, regular, no m/r/g
Abd: soft, nontender, nondistended.  hypoactive bowel sounds.
no hepatosplenomegaly.
Ext: warm, no edema.
Skin: diaphoretic, no rash

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives with her parents in [**Location (un) 745**], [**Location (un) 3844**].  Occasionally
uses her boyfriend's klonepin, also + ecstasy.  Tobacco unknown,
etoh unknown.  Works as a cashier at an auto dealer.
Eastern equine encephalitis,Acute respiratory failure,Other convulsions,Alkalosis
East equine encephalitis,Acute respiratry failure,Convulsions NEC,Alkalosis
Admission Date:  [**2100-8-31**]              Discharge Date:   [**2100-9-3**]

Date of Birth:  [**2080-8-6**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Transferred to MICU for altered mental status

Major Surgical or Invasive Procedure:
Intracranial Pressure Monitor placement
Central Venous Line placement

History of Present Illness:
20 y/o F w/no past med hx who originally presented to [**Hospital 39437**] Hospital on [**2100-8-29**] complaining of one week of nausea,
headache, ear pain, neck pain, and suprapubic pain.  Reportedly
the day before she had slept all day and c/o a generalized
headache.  She went to the ED, where she it was felt she had a
UTI (WBCs/bacturia) and otitis media ("bloody ear").  She was
treated with amoxicillin.  Her symptoms became progressively
worse, and she had fevers and chills.  She returned to the
emergency room the next day c/o suprapubic discomfort, fever,
n/v, headache, and back pain.  She had CVA tenderness and was
febrile to 101.1.  At that time she had no meningismus and a
normal mental status, nonfocal neuro exam.  Her WBC at that time
was 20, which was elevated from 9 the day prior.  She was
admitted with a diagnosis of pyelo and treated with ceftriaxone
and/or ciprofloxacin (unclr from notes which she received).  She
was given lorazepam 1 mg for anxiety.

Approximately 8 am on [**2100-8-31**], she was found by her nurse to be
unresponsive.  She was incontinent of stool and urine.  Her eyes
were open and deviated to the left.  She was responsive to pain.
 Hemodynamically, she was tachycardic in the 140s (sinus) and
febrile to 103.  BP 110/70.  Exam was otherwise unremarkable.
They felt she was postictal and she was given Ativan and loaded
with dilantin (1000 mg).  A noncontrast CT scan was negative.
She was given vancomycin, continued on ceftriaxone (2 g iv q12h)
and acyclovir.  An LP revealed an opening pressure of 380 (?mm).
 WBC 988, RBC 45.  Differential on WBC was 58 PMNs, 25 lymphs,
17 monos.  Gram stain negative for bacteria.  Glucose 80,
protein 167.  She also received Dexamethasone 10 mg IV given the
meningitis.  She continued to have deviation of her eyes as well
as lip smacking, and was transferred to [**Hospital1 18**] on the
Neurology/SICU service on [**2100-8-31**] for further management.

She was evaluated by Neurology on arrival who felt she had
encephalomeningitis and recommended an MRI.  She was intubated
for her mental status.  At that time, she was on dilantin,
propofol, and ativan gtt.  She continued to seize (w/occasional
decerebrate posturing, downward eye deviation) and was loaded
with depakote.  The MRI demonstrated enhancement of medial
temporal lobes, caudate, and thalamus bilaterally and
symmetrically.  MRV was negative for thrombosis.  She had a CT
scan of her sinuses (given hx of otitis) which revealed mucosal
thickening but no evidence of sinusitis, as well as a 5 mm dense
soft tissue mass which appeared to be adherent to her left
tympanic membrane, of unclear significance.  She was continued
on the aforementioned antibiotics and ampicillin was added.  ENT
evaluated her and felt that it was either a foreign body vs.
osteoma, and that it was not related to her meningoencephalitis.
 She was then transferred to the Medical ICU.

Past Medical History:
None

Social History:
Lives with her parents in [**Location (un) 745**], [**Location (un) 3844**].  Occasionally
uses her boyfriend's klonepin, also + ecstasy.  Tobacco unknown,
etoh unknown.  Works as a cashier at an auto dealer.

Family History:
Noncontributory

Physical Exam:
T: 100.8  BP:  119/58  P: 105
Vent: AC 500x16  PEEP 5  FiO2 40%, SaO2 99%
Gen: intubated, sedated
HEENT:  EEG leads in place, tongue protruding, pupils deviated
inferiorly, sclerae anicteric, MMM
Neck: no lymphadenopathy, or thyromegaly
Chest:  lungs clear to auscultation bilaterally
CV: tachycardic, regular, no m/r/g
Abd: soft, nontender, nondistended.  hypoactive bowel sounds.
no hepatosplenomegaly.
Ext: warm, no edema.
Skin: diaphoretic, no rash


Pertinent Results:
[**2100-8-31**] 06:37PM BLOOD WBC-25.8* RBC-4.13* Hgb-13.1 Hct-38.1
MCV-92 MCH-31.8 MCHC-34.5 RDW-11.9 Plt Ct-139*
[**2100-9-1**] 03:38AM BLOOD WBC-22.8* RBC-3.70* Hgb-11.6* Hct-33.5*
MCV-91 MCH-31.4 MCHC-34.7 RDW-12.0 Plt Ct-147*
[**2100-8-31**] 06:37PM BLOOD Neuts-88* Bands-4 Lymphs-1* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2100-8-31**] 06:37PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL
[**2100-9-1**] 03:38AM BLOOD Plt Ct-147*
[**2100-8-31**] 06:37PM BLOOD PT-12.8 PTT-26.3 INR(PT)-1.1
[**2100-8-31**] 06:37PM BLOOD Fibrino-527* D-Dimer-695*
[**2100-9-1**] 04:24PM BLOOD Glucose-92 UreaN-5* Creat-0.5 Na-145
K-3.4 Cl-112* HCO3-25 AnGap-11
[**2100-8-31**] 06:37PM BLOOD ALT-28 AST-30 LD(LDH)-194 AlkPhos-69
TotBili-0.2
[**2100-9-1**] 04:24PM BLOOD Calcium-7.9* Phos-1.4* Mg-1.8
[**2100-9-1**] 04:24PM BLOOD Phenyto-8.7* Valproa-71
[**2100-9-1**] 04:38PM BLOOD Type-ART pO2-196* pCO2-33* pH-7.48*
calHCO3-25 Base XS-2 Intubat-INTUBATED
[**2100-9-1**] 04:38PM BLOOD Lactate-2.0

MRI: MR [**First Name (Titles) **] [**Last Name (Titles) **]: There is abnormal, elevated T2/FLAIR
signal involving the medial temporal lobes, and continuing into
the tails and thr bodies of the caudate nuclei, and portions of
the thalamus bilaterally and symmetrically. There is
corresponding abnormal signal on the diffusion- weighted
sequences in these regions. An accompanying ADC map is not
available to distinguish true slowed diffusion from T2 shine-
through effect. There is no susceptibility artifact or abnormal
bright T1 signal to suggest hemorrhage. The brain parenchyma
demonstrates otherwise unremarkable signal intensity. The
ventricles, cisterns, and sulci are unremarkable. No definite
enhancement is noted in the areas of signal abnormality on the
post gadolinium-enhanced sequences.

MR [**First Name (Titles) **] [**Last Name (Titles) **]: The venous sinuses demonstrate no evidence
of thrombosis. There is mild asymmetry of the transverse and the
sigmoid sinuses which is likely developmental. Expected areas of
artifact on the 3D images without corresponding evidence of flow
abnormality/thrombus on the axial source data.

IMPRESSION:
1) Constellation of [**Last Name (Titles) 4493**] concerning for limbic encephalitis
involving the medial temporal lobes, basal ganglia, caudate, and
portions of the thalamus. Possible etiologies include viral,
Herpes, and Listeria encephalitis; less likely a paraneoplastic
syndrome. Correlate with clinical symptoms and lumbar puncture
results.
2) No evidence of venous sinus thrombosis.

CT: [**Last Name (Titles) **]: There is mild mucosal thickening of the maxillary,
ethmoid, and sphenoid sinuses. There are no air-fluid levels or
area of osseous destruction. There is more polypoid focal
thickening in the right maxillary sinus likely representing a
retention cyst. The mastoid processes and air cells are clear.
There is a small amount of cerumen in the right external
auditory canal but no evidence of an infectious process.
Centered on the left tympanic membrane is a focal, circular,
hyperdense soft tissue mass. It is difficult to definitively
localize this soft tissue mass; however, it appears adherent to
the tympanic membrane within the middle ear rather than within
the external auditory canal. There is a trace amount of
fluid/soft tissue adjacent to it. There is no associated osseous
destruction. The dentition and remaining osseous structures are
unremarkable. The orbits appear normal. The visualized brain
parenchyma is unremarkable.

IMPRESSION:
1) No evidence of mastoiditis.

2) Sinus polypoid and mucosal thickening without evidence to
suggest acute sinusitis.

3) 5mm focal, dense soft tissue mass, which is difficult to
definitively localize but appears adherent to the tympanic
membrane within the middle ear. This finding is of unclear
etiology and significance, and does not appear likely to
represent the source of the patient's clinically suspected
encephalomeningitis. There is no associated osseous destruction.
After treated for the acute process, an ENT consult may be
helpful.

CXR: no acute cardiopulmonary process. ETT at thoracic inlet.


Brief Hospital Course:
The pt was admitted to MICU on [**2100-9-1**] from the SICU service.
The following summarizes her MICU course (for SICU course, see
HPI).  She was admitted on an Ativan gtt, as well as depakote
and dilantin.  She continued to seize through this regimen,
despite reloading with both the dilantin and depakote.  She was
then placed on phenobarbitol (loading dose and daily dosing).
She was continued on the same antibiotic regimen (ceftriaxone,
vancomycin, ampicillin, acyclovir).  ID felt that the most
likely diagnosis was EEE given the clinical scenario and MRI
[**Date Range 4493**].  Unfortunately, the only treatment for this is
supportive care.  She continued to spike temperatures.  On
[**2100-9-2**], she began to have worsening hypernatremia.  She became
progressively hypotensive requiring pressors, including
norepinephrine and phenylephrine.  Her head CT revealed cerebral
edema.  She was given mannitol and an intracranial pressure
monitor was placed.  Her sodium continued to rise, to >180.  A
family meeting was held and the goals of care were changed to
comfort measures only, given the poor prognosis of her
encephalitis.  She was extubated, placed on a morphine drip, and
died peacefully with her family by her side.

Medications on Admission:
Medications on transfer:
Ativan gtt at 4 mg/hr
Phenytoin 100 q8h
Depakote 250 q8h
Ceftriaxone 2 g IV q12h
Ampicillin 2 g IV q6h
Vancomycin 1 g IV bid
Acyclovir 500 IV q8h
Protonix
SQ heparin
Insulin SS
Cipro ear gtt

Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
Encephalitis (likely Eastern Equine)

Discharge Condition:
expired

Discharge Instructions:
none

Followup Instructions:
none
{'Eastern equine encephalitis,Acute respiratory failure,Other convulsions,Alkalosis'}


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: Transferred to MICU for altered mental status

PRESENT ILLNESS: 20 y/o F w/no past med hx who originally presented to [**Hospital 39437**] Hospital on [**2100-8-29**] complaining of one week of nausea,
headache, ear pain, neck pain, and suprapubic pain.  Reportedly
the day before she had slept all day and c/o a generalized
headache.  She went to the ED, where she it was felt she had a
UTI (WBCs/bacturia) and otitis media ("bloody ear").  She was
treated with amoxicillin.  Her symptoms became progressively
worse, and she had fevers and chills.  She returned to the
emergency room the next day c/o suprapubic discomfort, fever,
n/v, headache, and back pain.  She had CVA tenderness and was
febrile to 101.1.  At that time she had no meningismus and a
normal mental status, nonfocal neuro exam.  Her WBC at that time
was 20, which was elevated from 9 the day prior.  She was
admitted with a diagnosis of pyelo and treated with ceftriaxone
and/or ciprofloxacin (unclr from notes which she received).  She
was given lorazepam 1 mg for anxiety.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: Medications on transfer:
Ativan gtt at 4 mg/hr
Phenytoin 100 q8h
Depakote 250 q8h
Ceftriaxone 2 g IV q12h
Ampicillin 2 g IV q6h
Vancomycin 1 g IV bid
Acyclovir 500 IV q8h
Protonix
SQ heparin
Insulin SS
Cipro ear gtt

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: 100.8  BP:  119/58  P: 105
Vent: AC 500x16  PEEP 5  FiO2 40%, SaO2 99%
Gen: intubated, sedated
HEENT:  EEG leads in place, tongue protruding, pupils deviated
inferiorly, sclerae anicteric, MMM
Neck: no lymphadenopathy, or thyromegaly
Chest:  lungs clear to auscultation bilaterally
CV: tachycardic, regular, no m/r/g
Abd: soft, nontender, nondistended.  hypoactive bowel sounds.
no hepatosplenomegaly.
Ext: warm, no edema.
Skin: diaphoretic, no rash

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives with her parents in [**Location (un) 745**], [**Location (un) 3844**].  Occasionally
uses her boyfriend's klonepin, also + ecstasy.  Tobacco unknown,
etoh unknown.  Works as a cashier at an auto dealer. 

### Response:
{'Eastern equine encephalitis,Acute respiratory failure,Other convulsions,Alkalosis'}
