CHIEF COMPLAINT: bilateral leg weakness and dysesthesia (ED transfer: "r/o spinal
abscess")

PRESENT ILLNESS: [**Known firstname **] [**Known lastname 88805**] is a 22y F with no significant PMH who p/w
fever, diarrhea, and one day of progressive lower extremity
paresthesias and weakness to the point that now she cannot
stand. She was in her USOH until 3d PTA, when she developed
persistent LLQ abdominal pain, which has continued through the
day of admission. It gets worse in waves. There was no diarrhea
initially, but today she has had diarrhea x9. No one else she
knows has experienced these symptoms. Last night, she became
febrile to 103F and she developed a mild HA and her legs began
feeling "achy." She also developed mild low back pain over the
last 2-3 days. This morning, she awoke with paresthesias, this
morning her legs felt tingly like after they've been asleep in
her words, and mild weakness, that progressed rapidly to the
point that she could not walk. She went to an OSH ED where she
was given Vancomycin and Ceftriaxone IV; an abdominal CT with
PO+IV contrast was reportedly unremarkable. She was transferred
to [**Hospital1 18**] ED for "r/o spinal abscess."

MEDICAL HISTORY: 1. G2P2, both spontaneous vaginal deliveries with epidurals and
uncomplicated/uneventful, healthy kids.

MEDICATION ON ADMISSION: none

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: < ON ADMISSION: >

FAMILY HISTORY: No Hx of autoimmune/[**Last Name (un) 18183**]/vasculitic disease. No FH of Neurologic
disease.
+Cancer Hx (colon-mom's aunt; breast; prostate-[**Doctor Last Name 22583**])
+ paternal GPA died 56 of "heart problems", and paternal uncle
of
the same at 36y/o.

SOCIAL HISTORY: Lives at home in Glouchester with 2kids and sister and mother
and
father. [**Name (NI) 1403**] at a Candy store in [**Location (un) 28318**] and Raises her kids.
Lives in a non-wooded area. Two dogs that do not visit
wooded/tick-containing areas to her knowledge (only their
backyard/deck and indoors. Denies EtOH except rarely. Denies
tobacco or illicit drug use. No recent immunizations, no recent
flu vaccine.
Intestinal infection due to other organism, not elsewhere classified,Unspecified hereditary and idiopathic peripheral neuropathy,Other musculoskeletal symptoms referable to limbs,Disturbance of skin sensation,Abnormality of gait
Viral enteritis NOS,Idio periph neurpthy NOS,Muscskel sympt limb NEC,Skin sensation disturb,Abnormality of gait
Admission Date:  [**2176-7-20**]              Discharge Date:   [**2176-7-22**]

Date of Birth:  [**2154-3-12**]             Sex:   F

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 21193**]
Chief Complaint:
bilateral leg weakness and dysesthesia (ED transfer: "r/o spinal
abscess")

Major Surgical or Invasive Procedure:
none


History of Present Illness:
[**Known firstname **] [**Known lastname 88805**] is a 22y F with no significant PMH who p/w
fever, diarrhea, and one day of progressive lower extremity
paresthesias and weakness to the point that now she cannot
stand. She was in her USOH until 3d PTA, when she developed
persistent LLQ abdominal pain, which has continued through the
day of admission. It gets worse in waves. There was no diarrhea
initially, but today she has had diarrhea x9. No one else she
knows has experienced these symptoms. Last night, she became
febrile to 103F and she developed a mild HA and her legs began
feeling "achy." She also developed mild low back pain over the
last 2-3 days. This morning, she awoke with paresthesias, this
morning her legs felt tingly like after they've been asleep in
her words, and mild weakness, that progressed rapidly to the
point that she could not walk. She went to an OSH ED where she
was given Vancomycin and Ceftriaxone IV; an abdominal CT with
PO+IV contrast was reportedly unremarkable. She was transferred
to [**Hospital1 18**] ED for "r/o spinal abscess."

She arrived in our ED with temp 98.4F HR 138 and BP 118/57. RR
16 and SaO2 99%. The ED thought her exam was notable for
profound symmetric LE weakness with absent patellar tendon
reflexes and symmetric LE sensory loss. She was also c/o her
"eyelids are tired" and mild intermittend SOB.

Sick contacts include only her two children, 2.5y daughter and
11mos son, both of whom had a febrile illness (+lethargy, but no
diarrhea or other symptoms), self-limited, lasting a few days
and resolving in the last 1-3d. No toxic exposures, specifically
no known tickbites or exposure to wooded/tick-infested areas. No
FH of vasculitis.

On ROS, the pt loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. Denies
bowel or bladder incontinence or retention, although a Foley was
placed at the OSH ED due to inability to get up and use commode
independently. No recent weight loss or gain. Denies cough. only
mild shortness of breath.  Mild pharyngitis. Denies chest pain
or tightness. +feels heart racing (HR 120-130s).  Denies nausea,
vomiting. +diarrhea, abd pain. No recent constipation.  No
recent change in bladder habits or UTIs. No dysuria. Denies
rash. Legs are painful.

Past Medical History:
1. G2P2, both spontaneous vaginal deliveries with epidurals and
uncomplicated/uneventful, healthy kids.

Social History:
Lives at home in Glouchester with 2kids and sister and mother
and
father. [**Name (NI) 1403**] at a Candy store in [**Location (un) 28318**] and Raises her kids.
Lives in a non-wooded area. Two dogs that do not visit
wooded/tick-containing areas to her knowledge (only their
backyard/deck and indoors. Denies EtOH except rarely. Denies
tobacco or illicit drug use. No recent immunizations, no recent
flu vaccine.

Family History:
No Hx of autoimmune/[**Last Name (un) 18183**]/vasculitic disease. No FH of Neurologic
disease.
+Cancer Hx (colon-mom's aunt; breast; prostate-[**Doctor Last Name 22583**])
+ paternal GPA died 56 of "heart problems", and paternal uncle
of
the same at 36y/o.

Physical Exam:
< ON ADMISSION: >

General: Lying in bed in moderate distress, tachypneic,
tachycardic. +Rigors. 4th, then 5th L of NS running, with steady
clear UOP (900cc at that time)
HEENT: Normocephalic and atraumatic. No scleral icterus. Mucous
membranes are moist. No lesions noted in oropharynx, but poorly
visualized.
Neck: Supple, with full range of motion and no nuchal rigidity.
No lymphadenopathy was appreciated.
Pulmonary: Lungs CTA bilaterally. Voice is soft and patient's
respirations seem mildly labored (but No retractions).
Cardiac: Tachy, loud S1/S2, no M/R/G.
Abdomen: Moderately overweight. Soft, non-distended, hypoactive
BS. Tender to palpation over LLQ, but not jumping off the bed
with decent pressure.
Extremities: Cool (vs. trunk) and somewhat dusky. No clubbing,
cyanosis, or edema. 2+ radial, DP pulses bilaterally.
Skin: no rashes or lesions noted except + stretch marks at lower
abdomen from pregnancies, and small scabs/dots at lower shins
(?shaving injuries).

*****************
Neurologic examination:

Mental Status exam:
Grossly normal MS -- AOx3. Able to relate history without
difficulty. Attentive, and able to name [**Doctor Last Name 1841**] backward without
difficulty. Speech was soft, but not dysarthric. Language is
fluent with intact repetition and comprehension, normal prosody,
and normal affect. There were no paraphasic errors. There was no
evidence of apraxia or neglect

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL, 4 to 2mm and brisk. No RAPD Visual fields are full on
gross bedside exam. No papilledema, exudates, or hemorrhages on
fundoscopic examination.
III, IV, VI: EOMs full and conjugate. No nystagmus.
V: Facial sensation intact and subjectively symmetric to light
touch V1-V2-V3.
VII: Symmetric, but weak facial movements. No ptosis, no
flattening of either nasolabial fold. Brow elevation is
symmetric. Eye closure is symmetrically weak. Symmetric facial
elevation with smile. Weak buccinators (cheek puffing). Can
purse/whistle, but weak.
VIII: Hearing intact and subjectively equal to finger-rub
bilaterally.
IX, X: Palate elevates symmetrically with phonation.
[**Doctor First Name 81**]: 4+/5 equal strength in trapezii bilaterally.
XII: Tongue protrusion is midline.

-Motor:
Bilateral step-wise pronator with rigors. Rigors in
arms/chest/jaw. Normal to slightly decreased tone bilaterally in
UEs, LEs.

 Delt Bic Tri WE  FF  FE IO | IP   Q   Ham  TA  [**Last Name (un) 938**] Gastroc
L  4-  4+  4-  5  4+   4  4    2   4-   3    3   3     4
R  4-  4+  4-  5  4+   4  4    2   4-   3    3   4     4

-Sensory:
- Patient reports complete anesthesia to pinprick, temperature
sensation, light touch, and vibration in both lower extremities
up to a somewhat inconsistent sensory level at the
groin/inguinal
ligament. Normal/intact sensation above this level in the trunk
and arms/hands/face.
- The aforementioned area of sensory anesthesia, however, spares
the inner [**2-12**] of both calves (symmetrically), wrapping around to
the medial portion of the popliteal fossa, where she says she
can
perceive pinprick, light touch, and cold metal. Also, she can
perceive vibration 128Hz at the medial malleoli of each ankle,
but not at the MTPs and not at either knee.

-Reflex examination (left; right):
Biceps (+++;+++) (+distal spread from pec/delt bilaterally)
Triceps  (++;++)
Brachioradialis (++;++)
Quadriceps / patellar (++;++)
Gastroc-soleus / achilles (+;+)
Plantar response was indeterminate bilaterally.

-Coordination:
Finger-nose-finger testing was slow, but no dysmetria or tremor.
Slowed finger tapping bilaterally, and very slow/weak
toe-tapping. Mirroring finger/hand behavior was normal, with no
overshoot.

-Gait:
Not tested; patient required assistance just pulling to a seated
position, and cannot stand to walk.

Pertinent Results:
[**2176-7-19**] 02:30AM BLOOD WBC-7.3 RBC-3.95* Hgb-12.1 Hct-36.0
MCV-91 MCH-30.6 MCHC-33.6 RDW-12.6 Plt Ct-164
[**2176-7-19**] 02:30AM BLOOD Neuts-85.0* Lymphs-11.0* Monos-3.7
Eos-0.2 Baso-0.1
[**2176-7-19**] 02:30AM BLOOD PT-15.3* PTT-26.7 INR(PT)-1.3*
[**2176-7-19**] 02:30AM BLOOD Glucose-122* UreaN-10 Creat-0.6 Na-138
K-3.3 Cl-106 HCO3-21* AnGap-14
[**2176-7-19**] 02:30AM BLOOD ALT-9 AST-14 AlkPhos-68 TotBili-0.3
[**2176-7-19**] 02:30AM BLOOD Albumin-4.0 Calcium-7.3* Phos-2.7 Mg-1.8
[**2176-7-19**] 02:30AM BLOOD CRP-44.0*
[**2176-7-19**] 02:30AM BLOOD CRP-44.0*
[**2176-7-19**] 11:14PM BLOOD Lactate-1.0
[**2176-7-20**] 03:48AM BLOOD GQ1B IGG ANTIBODIES-PND
[**2176-7-20**] 03:48AM BLOOD CAMPYLOBACTER JEJUNI ANTIBODY, [**Doctor First Name **]-PND
**[**2176-7-20**] 01:30AM CEREBROSPINAL FLUID (CSF)  PROTEIN-18
GLUCOSE-66
**[**2176-7-20**] 01:30AM CEREBROSPINAL FLUID (CSF)  WBC-0 RBC-0
POLYS-0 LYMPHS-43 MONOS-57
[**2176-7-20**] 12:10AM URINE  UCG-NEGATIVE
[**2176-7-20**] 12:10AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.030
[**2176-7-20**] 12:10AM URINE  BLOOD-SM  NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2176-7-20**] 12:10AM URINE  RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
[**2176-7-20**] 12:10AM URINE  MUCOUS-RARE
[**2176-7-19**] 11:14PM   LACTATE-1.0
[**2176-7-19**] 02:30AM   SED RATE-16
[**2176-7-19**] 02:30AM   LIPASE-23

**MRI of the C/T/L spine**
(with and without IV gadolinium contrast dye)
  -FINDINGS: The alignment, configuration and signal intensity
throughout the cervical, thoracic and lumbar vertebral bodies
appears normal. The signal intensity throughout the cervical and
thoracic spinal cord appears
unremarkable with no evidence of focal or diffuse lesions. The
conus
medullaris is normal and terminates at the level of T12. There
is no evidence of spinal canal stenosis or neural foraminal
narrowing. With gadolinium contrast, there is no evidence of
abnormal enhancement to indicate leptomeningeal disease. The
visualized paravertebral structures are grossly unremarkable.
  - IMPRESSION: Essentially normal MRI of the cervical, thoracic
and lumbar spine with no evidence of spinal canal stenosis,
neural foraminal narrowing or nerve root impingement, there is
no evidence of abnormal enhancement to indicate leptomeningeal
disease. The signal intensity throughout the spinal cord is
normal.


Brief Hospital Course:
[**Known firstname **] [**Known lastname 88805**] is a 22y F, G2P2 with no significant PMH and
taking no home medications who was admitted in the midst of a
febrile illness with LLQ discomfort and diarrhea. During the
same day she developed fever and diarrhea she also complained of
aching/tingling in both legs, followed by numbness and weakness.
She was admitted to the Neurology service with complaints of leg
weakness and sensory changes, out of concern for possible GBS or
paraspinal abscess. Her exam on admission was in part poorly
localizing, and there was primarily give-way weakness in the
morning following admission, when her rigors and fever had
subsided and her HR and BP had normalized after 5L of IVF
between the OSH and our ED.

She had no intensive care needs, and was breathing comfortably
shortly after admission, so was transferred from the ICU to the
floor. She remained afebrile and HDS and in NAD throughout her
stay here at [**Hospital1 18**]. An MRI of the full spine was normal, with no
e/o paraspinal abscess. LP in the ED resulted in normal CSF
routine studies (see above). Her vital signs and laboratory
studies were largely normal with the exception of a low Ca++ of
7.3 (normal albumin 4.0), which normalized by the day of
discharge (iCa on [**7-22**] was 1.18). Lyme serology was negative.
Rapid strep throat test was negative. UA was normal. Urine,
blood, and CSF cultures were NG at the time of discharge. Her
calcium level was slightly low on arrival to the ED, but by the
time you left the hospital, it returned to a normal level
(ionized calcium 1.18) after fluids and food and rest.

Her General examination was normal on the day of discharge (her
abdominal tenderness and tachycardia resolved) and she only had
one more episode of diarrhea the day before (evening of [**7-21**]).
Her Neurological examination remained difficult to interpret,
with a non-localizing pattern of complete sensory anesthesia in
the lower extremities (see below) and a hesitant gait (Romberg
negative) and give-way weakness in the hamstrings and TAs.
Physical Therapy evaluated her and decided that she was safe to
return home (with support from family), but that she should use
a walker on discharge until her gait normalizes. She also c/o
intermittent lightheadedness and headache, for which we
encouraged fluid intake and acetaminophen PRN. Follow-up was
arranged in [**Hospital 878**] clinic [**8-1**] ([**Month/Year (2) 54849**]/[**Doctor Last Name 1206**]).

Tests pending at discharge:
1. Gq1b, clostridium jejuni serum antibodies.
2. West Nile virus CSF antibody.
3. Final reports on blood and CSF cultures.

Medications on Admission:
none

Discharge Medications:
none

Discharge Disposition:
Home

Discharge Diagnosis:
1. viral gastroenteritis/diarrheal illness
2. non-localizing sensory changes with mild weakness of
uncertain etiology


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Stands with good balance; takes
hesitant steps.

Neurologic examination still with subjective loss of all
sensation in bilateral LEs except for patchy/inconsistent region
of inner thighs, medial calves. Still some give-way weakness in
TAs, EHLs, FEs and intrinsic finger muscles.


Discharge Instructions:
You were admitted to [**Hospital1 18**] out of concern for leg weakness and
sensory changes. You had a diarrheal illness with fever, which
was probably a viral (vs. possibly bacterial) gastrointestinal
infection. During the same 24-36 hour period that you developed
fever and then diarrhea, you also developed aching/tingling, and
then numbness, in your legs, and you began feeling weak in your
legs.

We admitted you to the hospital on our Neurology service in
order to test you for serious or life-threatening conditions.
One such condition (an infection that presses on your spinal
cord or spinal nerve roots) was ruled out by MR imaging of your
spinal cord, which was normal. Another condition ([**Last Name (un) 4584**]-[**Location (un) **]
syndrome) is unlikely due to the rapid progression and then
regression of your symptoms as well as the preservation of your
knee and ankle reflexes and the prominent sensory changes (not
just weakness) already present when you arrived. To err on the
safe side, we also obtained cerebrospinal fluid (CSF, by spinal
tap) in addition to routine bloodwork, laboratory studies, and
cultures. Your initial tests are largely normal. The CSF and
labs and cultures are normal. A test for strep throat was
negative. A blood test for exposure to Lyme disease (from
tickbites) was negative. Your calcium level was slightly low on
arrival to the ED, but by the time you left the hospital, it
returned to a normal level (ionized calcium 1.18) after fluids
and food and rest.

Our physical therapists evaluated you and they agree it is safe
for you to return home if you use a walker initially for your
unsteady gait. You still had intermittent lightheadedness and
headache, so please drink plenty of fluids (at least six glasses
of fluid, along with salty foods) to replace the volume you lost
during your diarrheal illness. If your headaches persist, please
use over-the-counter acetaminophen (Tylenol) for pain relief as
needed, at a dose of 500-650mg with doses spaced apart by 6
hours or more (use as directed).

It was a pleasure taking care of you here at [**Hospital1 18**]. Best of luck
in the future, Ms. [**Known lastname 88805**]!

Followup Instructions:
Plan to follow up with Dr. [**Last Name (STitle) 54849**] and Dr. [**Last Name (STitle) 1206**] [**8-1**] in
[**Hospital 878**] clinic ([**Hospital1 18**] [**Hospital Ward Name **], [**Hospital Ward Name 23**] Clinical Center).
Please call [**Telephone/Fax (1) 2756**] and ask for [**Hospital 878**] clinic to confirm
appointment scheduling for this day.


                             [**Name6 (MD) 3523**] [**Name8 (MD) 3524**] MD [**MD Number(2) 21196**]

Completed by:[**2176-7-22**]
{'Intestinal infection due to other organism, not elsewhere classified,Unspecified hereditary and idiopathic peripheral neuropathy,Other musculoskeletal symptoms referable to limbs,Disturbance of skin sensation,Abnormality of gait'}


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: bilateral leg weakness and dysesthesia (ED transfer: "r/o spinal
abscess")

PRESENT ILLNESS: [**Known firstname **] [**Known lastname 88805**] is a 22y F with no significant PMH who p/w
fever, diarrhea, and one day of progressive lower extremity
paresthesias and weakness to the point that now she cannot
stand. She was in her USOH until 3d PTA, when she developed
persistent LLQ abdominal pain, which has continued through the
day of admission. It gets worse in waves. There was no diarrhea
initially, but today she has had diarrhea x9. No one else she
knows has experienced these symptoms. Last night, she became
febrile to 103F and she developed a mild HA and her legs began
feeling "achy." She also developed mild low back pain over the
last 2-3 days. This morning, she awoke with paresthesias, this
morning her legs felt tingly like after they've been asleep in
her words, and mild weakness, that progressed rapidly to the
point that she could not walk. She went to an OSH ED where she
was given Vancomycin and Ceftriaxone IV; an abdominal CT with
PO+IV contrast was reportedly unremarkable. She was transferred
to [**Hospital1 18**] ED for "r/o spinal abscess."

MEDICAL HISTORY: 1. G2P2, both spontaneous vaginal deliveries with epidurals and
uncomplicated/uneventful, healthy kids.

MEDICATION ON ADMISSION: none

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: < ON ADMISSION: >

FAMILY HISTORY: No Hx of autoimmune/[**Last Name (un) 18183**]/vasculitic disease. No FH of Neurologic
disease.
+Cancer Hx (colon-mom's aunt; breast; prostate-[**Doctor Last Name 22583**])
+ paternal GPA died 56 of "heart problems", and paternal uncle
of
the same at 36y/o.

SOCIAL HISTORY: Lives at home in Glouchester with 2kids and sister and mother
and
father. [**Name (NI) 1403**] at a Candy store in [**Location (un) 28318**] and Raises her kids.
Lives in a non-wooded area. Two dogs that do not visit
wooded/tick-containing areas to her knowledge (only their
backyard/deck and indoors. Denies EtOH except rarely. Denies
tobacco or illicit drug use. No recent immunizations, no recent
flu vaccine. 

### Response:
{'Intestinal infection due to other organism, not elsewhere classified,Unspecified hereditary and idiopathic peripheral neuropathy,Other musculoskeletal symptoms referable to limbs,Disturbance of skin sensation,Abnormality of gait'}
