CHIEF COMPLAINT: Altered mental status

PRESENT ILLNESS: Mr. [**Known lastname **] is a 69yo M with history of atrial fibrillation on
warfarin and hyperlipidemia who presents with altered mental
status.  Patient has had sinus congestion and drainage for the
past 4-5 days and saw his PCP for this who prescribed
azithromycin and decongestant.  He started these medications
yesterday and developed a severe headache on the night of
admission with temperature of 100.7.  He was confused so his
wife brought him to [**Location (un) **] Cope Hospital.
.
In the ER there, he continued to be confused and had CT of his
head which showed opacificiation of his sphenoid sinus with
concern for epidural abscess vs subdural empyema.  No LP was
performed given this concern but he was given vancomycin,
ceftriaxone and flagyl and transferred to [**Hospital1 18**] for further
care.
.
In the ED, initial vs were: T 99.2 P 86 BP 118/79 R 16 O2 sat
93% RA. Patient's CT was reviewed by neurosurgery here who felt
there was no CNS extension of the sinus opacification.  Patient
was alerted and oriented to person only.  He withdraws to pain
but does not follow commands.  Neurology reviewed the film with
her CT with radiology and agrees there does not appear to be any
signs of empyema or abscess.  Ampicillin 1g was given for
listeria meningitis coverage and patient also received 10mg IV
Zyprexa for agitation.  LP was recommended by deferred given INR
of 3.0.  Patient was transferred to the MICU with vitals of 78,
120/84, 19, 99% RA.
.
In the ICU, patient is not answering questions or following
commands.
.
Review of systems: Unable to obtain secondary to confusion

MEDICAL HISTORY: Hyperlipidemia
Atrial fibrillation
Hypothyroidism
CAD s/p Cypher DES in [**2129-7-13**] and CABG with porcine AVR in
[**1-/2135**], all at [**Hospital3 **]

MEDICATION ON ADMISSION: warfarin
gemfibrozil
pravastatin
colace
levothyroxine
multaq
aspirin 81 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL:
Vitals: T: 100.6 BP: 139/84 P: 90 R: 18 O2: 97 2L NC
General: Somnolent, spontaneously opens eyes, not following
commands
HEENT: NC/AT, PEERL with 1.5mm pupils, sclera anicteric, MM dry,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, some wincing with abdominal palpitation,
non-distended, bowel sounds present, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Unable to obtain

SOCIAL HISTORY: Unable to obtain
Streptococcal meningitis,Acute respiratory failure,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Other encephalopathy,Other disorders of neurohypophysis,Delirium due to conditions classified elsewhere,Atrial flutter,Bacteremia,Encephalocele,Acute sphenoidal sinusitis,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Long-term (current) use of anticoagulants,Aortocoronary bypass status,Heart valve replaced by transplant
Streptococcal meningitis,Acute respiratry failure,Pneumococcal pneumonia,Encephalopathy NEC,Neurohypophysis dis NEC,Delirium d/t other cond,Atrial flutter,Bacteremia,Encephalocele,Ac sphenoidal sinusitis,Pure hypercholesterolem,Hypothyroidism NOS,Long-term use anticoagul,Aortocoronary bypass,Heart valve transplant
Admission Date:  [**2135-5-7**]              Discharge Date:   [**2135-5-15**]

Date of Birth:  [**2065-9-14**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:
intubation/sedation
femoral central venous catheterization


History of Present Illness:
Mr. [**Known lastname **] is a 69yo M with history of atrial fibrillation on
warfarin and hyperlipidemia who presents with altered mental
status.  Patient has had sinus congestion and drainage for the
past 4-5 days and saw his PCP for this who prescribed
azithromycin and decongestant.  He started these medications
yesterday and developed a severe headache on the night of
admission with temperature of 100.7.  He was confused so his
wife brought him to [**Location (un) **] Cope Hospital.
.
In the ER there, he continued to be confused and had CT of his
head which showed opacificiation of his sphenoid sinus with
concern for epidural abscess vs subdural empyema.  No LP was
performed given this concern but he was given vancomycin,
ceftriaxone and flagyl and transferred to [**Hospital1 18**] for further
care.
.
In the ED, initial vs were: T 99.2 P 86 BP 118/79 R 16 O2 sat
93% RA. Patient's CT was reviewed by neurosurgery here who felt
there was no CNS extension of the sinus opacification.  Patient
was alerted and oriented to person only.  He withdraws to pain
but does not follow commands.  Neurology reviewed the film with
her CT with radiology and agrees there does not appear to be any
signs of empyema or abscess.  Ampicillin 1g was given for
listeria meningitis coverage and patient also received 10mg IV
Zyprexa for agitation.  LP was recommended by deferred given INR
of 3.0.  Patient was transferred to the MICU with vitals of 78,
120/84, 19, 99% RA.
.
In the ICU, patient is not answering questions or following
commands.
.
Review of systems: Unable to obtain secondary to confusion


Past Medical History:
Hyperlipidemia
Atrial fibrillation
Hypothyroidism
CAD s/p Cypher DES in [**2129-7-13**] and CABG with porcine AVR in
[**1-/2135**], all at [**Hospital3 **]


Social History:
Unable to obtain


Family History:
Unable to obtain


Physical Exam:
ADMISSION PHYSICAL:
Vitals: T: 100.6 BP: 139/84 P: 90 R: 18 O2: 97 2L NC
General: Somnolent, spontaneously opens eyes, not following
commands
HEENT: NC/AT, PEERL with 1.5mm pupils, sclera anicteric, MM dry,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, some wincing with abdominal palpitation,
non-distended, bowel sounds present, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

On discharge:
Vitals: A 106/70 85 16 95%RA.
Gen: sitting in bed, no acute discomfort but generally holding
head while lying in bed. Appears to have some headache.
CV: RRR s1s2, slightly distant, no murmurs, no rubs or gallops
L: CTA b/l -slight crackles in bases
Abd: soft, nt, nd, +bs
Extremities: warm, well perfused, no edema
.
Neuro:
Alert/oriented X3
comprehension/repetition/naming intact. Attention: able to count
down from 20 without mistakes. Overall does not appear as sharp
and interactive as yesterday.

Patient reports seeing intermittent small black "flies" moving
in the distance, pt also reports intermittent "colored moving
sparkles" when he closes his eyes.

Pertinent Results:
ADMISSION LABS:
[**2135-5-7**] 03:51AM   PT-31.0* PTT-35.1* INR(PT)-3.0*
[**2135-5-7**] 03:51AM   PLT COUNT-248
[**2135-5-7**] 03:51AM   NEUTS-90.9* LYMPHS-4.1* MONOS-4.6 EOS-0.2
BASOS-0.2
[**2135-5-7**] 03:51AM   WBC-17.2* RBC-4.38* HGB-13.3* HCT-37.3*
MCV-85 MCH-30.3 MCHC-35.5* RDW-13.5
[**2135-5-7**] 03:51AM   estGFR-Using this
[**2135-5-7**] 03:51AM   GLUCOSE-129* UREA N-14 CREAT-0.7 SODIUM-134
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-26 ANION GAP-14
[**2135-5-7**] 04:03AM   LACTATE-1.2
[**2135-5-7**] 09:19AM URINE  MUCOUS-RARE
[**2135-5-7**] 09:19AM URINE  RBC-18* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2135-5-7**] 09:19AM URINE  BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2135-5-7**] 09:19AM URINE  COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.024
[**2135-5-7**] 09:19AM   PT-30.2* PTT-33.2 INR(PT)-3.0*
[**2135-5-7**] 09:19AM   PLT COUNT-254
[**2135-5-7**] 09:19AM   WBC-16.2* RBC-4.80 HGB-14.3 HCT-41.5 MCV-87
MCH-29.7 MCHC-34.3 RDW-13.6
[**2135-5-7**] 09:19AM   TSH-2.2
[**2135-5-7**] 09:19AM   CALCIUM-9.2 PHOSPHATE-2.8 MAGNESIUM-2.1
[**2135-5-7**] 09:19AM   CK-MB-3 cTropnT-<0.01
[**2135-5-7**] 09:19AM   LIPASE-19
[**2135-5-7**] 09:19AM   ALT(SGPT)-14 AST(SGOT)-29 ALK PHOS-62
AMYLASE-18 TOT BILI-0.5
[**2135-5-7**] 09:19AM   GLUCOSE-107* UREA N-13 CREAT-0.7 SODIUM-136
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-23 ANION GAP-18
[**2135-5-7**] 09:43AM   freeCa-1.05*
[**2135-5-7**] 09:43AM   GLUCOSE-116* LACTATE-1.7
[**2135-5-7**] 09:43AM   TYPE-[**Last Name (un) **] TEMP-38.1 PO2-63* PCO2-33* PH-7.40
TOTAL CO2-21 BASE XS--2 INTUBATED-NOT INTUBA COMMENTS-GREEN TOP
[**2135-5-7**] 11:43AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2135-5-7**] 11:43AM URINE  HOURS-RANDOM
[**2135-5-7**] 11:44AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2135-5-7**] 07:02PM   CALCIUM-7.9* PHOSPHATE-2.2* MAGNESIUM-2.0
[**2135-5-7**] 07:02PM   GLUCOSE-124* UREA N-12 CREAT-0.6 SODIUM-135
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-14
[**2135-5-7**] 07:03PM   PT-28.4* PTT-36.4* INR(PT)-2.7*
[**2135-5-7**] 07:03PM   PLT COUNT-250
[**2135-5-7**] 07:03PM   WBC-15.2* RBC-3.93* HGB-11.6* HCT-33.6*
MCV-85 MCH-29.6 MCHC-34.7 RDW-13.6
[**2135-5-7**] 07:15PM   LACTATE-0.6
[**2135-5-7**] 07:15PM   TYPE-ART TEMP-38.3 PO2-363* PCO2-37 PH-7.46*
TOTAL CO2-27 BASE XS-3 INTUBATED-INTUBATED

.
STUDIES:
CXR [**2135-5-7**]:
IMPRESSION:
No active pulmonary disease.
.
SKULL X-RAY [**2135-5-7**]:
Two views of the skull, two views of the neck and two views of
the abdomen are submitted for report. Positioningis suboptimal
and there is motion artifact on the view of the upper abdomen.
There is metal in the patient's teeth consistent with dental
work. Sternotomy wires are present in the upper chest and there
are surgical clips in the vertebral quadrant. There is no other
metallic foreign body.
.
MRI HEAD [**2135-5-7**]:
IMPRESSION:
1. Large meningocele involving bilateral sphenoid and left
posterior ethmoid
sinuses.

2. Pus completely opacifying the inferior sphenoid sinuses,
including the
left pterygoid recess, as well as the right frontal and
maxillary sinuses.  Fluid level in the left maxillary sinus.
These findings are consistent with acute sinusitis.

3. Small focus of dural thickening and enhancement in the medial
left middle cranial fossa, along the sphenoid sinus, without
evidence of a drainable fluid collection.

4. Diffuse leptomeningitis.

5. Ventriculitis with pus in the ventricles.

6. Foci of high T2 signal in the supratentorial white matter,
without
contrast enhancement, most likely representing chronic
microvascular infarcts, given the patient's age and history of
coronary artery disease. Small chronic microhemorrhage in the
right frontal cortex, which could be hypertensive or related to
amyloid angiopathy.

7. Unremarkable head MRA. Please note that MRA has a poor
sensitivity for
mycotic aneurysms as they tend to affect the distal vasculature.


8. Unremarkable head MRV. Please note that MRV does not detect
cavernous
sinus thrombosis.
.
CTAP [**2135-5-7**]:
IMPRESSION:

1. Left lower lobe airspace disease.
2. Extensive atherosclerosis.
3. No evidence of abscess, as questioned.

.
MICRO:
BCX [**2135-5-7**]: PENDING
BCX [**2135-5-8**]: PENDING

UCX [**2135-5-7**]: PENDING
.
[**2135-5-7**] 3:27 pm ASPIRATE      Source: Sinus.

   GRAM STAIN (Final [**2135-5-7**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   RESPIRATORY CULTURE (Final [**2135-5-11**]):
      RARE GROWTH Commensal Respiratory Flora.
      STREPTOCOCCUS PNEUMONIAE.    SPARSE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # 320-7381S ON
[**2135-5-7**].
      MORAXELLA CATARRHALIS.    RARE GROWTH.
.
ECHO
[**2135-5-8**]
A patent foramen ovale is present. A right-to-left shunt across
the interatrial septum is seen at rest. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. A bioprosthetic
aortic valve prosthesis is present. The prosthetic aortic valve
leaflets appear normal. No masses or vegetations are seen on the
aortic valve. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.

IMPRESSION: No vegetations seen. Normal-appearing aortic valve
bioprosthesis. Small stretched PFO.
.
.

.
.
CXR
[**2135-5-12**]
FINDINGS: As compared to the previous radiograph, there is
slightly improved ventilation at both lung bases. No newly
appeared focal parenchymal opacities. The pre-existing areas of
slightly increased density at both lung bases, interpreted as
atelectasis, have decreased. Unchanged size of the cardiac
silhouette. No evidence of pleural effusions.
.
.
Labs at discharge:
.
INR 2.1
Na+ 133
K+ 4.1
Bicarb 26

WBC 8.8
HCT 30.5
Plt 293


Brief Hospital Course:
HOSPITAL COURSE:
Mr. [**Known lastname **] is a 69yo M with atrial fibrillation presenting
with altered mental status in setting of sinus infection. Pt was
found to have meningitis & ventriculitis. He was treated in the
MICU with antibiotics and neurosurgery and ENT were consulted
who recommended conservative management.
.
# Meningitis/Ventriculitis: Pt presented with AMS and fevers.
Per discussion with neuro, no clear findings on CT head of CNS
extension but given severity of sinus disease and proximity to
CNS, will aggressively workup. MRI head demonstrated
ventriculitis. He was started on Vanc, CTX, Acyclovir, and
Ampicillin initially for broad coverage of meningitis. LP was
considered, but not pursued given elevated INR. ENT was
consulted, and recommended continuing abx without other
intervention. Neurosurg was consulted and recommended no
surgical intervention. CTAP was checked given abdominal pain,
with no significant findings and no evidence of abscess. Abx
were peeled back to CTX/Vancomycin and eventually to CTX. He had
two low grade fevers following this but remained afebrile>24hrs
prior to discharge. ID recommended 4 weeks of IV ceftriaxone
with follow MRI. They also requested weekly CBC/CHEM7/LFTs to be
faxed to [**Telephone/Fax (1) 109365**]. He should have a follow up with Dr. [**First Name8 (NamePattern2) 47034**]
[**Last Name (NamePattern1) **] (to be scheduled) in [**2-17**] weeks. He also has a follow up
MRI scheduled for [**6-3**] at [**Hospital1 18**] (please see follow up). If
this MRI- appointment cannot be made, it should be reschedule at
a more appropriate time/location in conjuction with the patient.
.
# Strep pneumo bacteremia: Pt found to be growing GPC's from
OSH. He was continued on Vancomycin, OSH culture data showed
strep pneumo. Serial BCx were sent and were pending on transfer
to the medicine floor. At time of discharge, cultures were
either "no growth" or pending.
.
# Sinusitis: He has had sinus symptoms with CT findings of
sphenoid opacification.  As above, ENT consulted, and
recommended continuing on current abx regimen. Sinus sampling
grew strep pneumo and moraxella catarrhalis. He was continued on
CTX.
.
# CAP: As suggested by imaging, and fevers. Continued on abx as
mentioned above.
.
# Atrial fibrillation: He has known atrial fibrillation and is
therapeutic on warfarin on admission. Warfarin was held given
possible pending procedures. He was started on heparin gtt for
bridge with daily PT/INR's checked. He developed atrial
flutter/fib with rapid rate in setting of fevers. He was started
on a dilt gtt, and converted. In the MICU, he was placed on
metoprolol for rate control and restarted on home dronaderone.
He will be discharged with both metroprolol and dronedarone for
rate/rhythm control. He will also be discharged with coumadin
4mg daily for goal inr of [**2-17**]. His INR on discharge was 2.1.
.
# Hyponatremia: Initially attributed to hypovolemia given
continued fevers and insensible losses. However, Na remained
low, and attributed to SIADH related either to meningitis or PNA
as discussed above. Pt was fluid restricted, and Na improved to
133 on discharge. He should continue on the fluid restriction of
1500cc/day until Na+ normalizes. This should be followed as
SIADH might the result of transient inflammation/infection of
brain parenchyma.
.
# Hyperlipidemia: Held statin initially given NPO. This was
restarted in hospital and on discharge.
.
# Hypothyroidism: Held levothyroxine initially given NPO, and
home dose was restarted once tolerating diet. He was discharged
on this medication.

#################

Transitional issues:

1. Meningitis: patient should continue Ceftriaxone IV through
PICC line for total 4 weeks until [**2135-6-4**]. He should have weekly
blood draws as above. He should have outpatient ID appointment
scheduled. He should also have PCP [**Name9 (PRE) 702**] with possible
Neurosurgery referal for intervention on his Meningocele.
2. SIADH: likely [**2-16**] brain inflammation/infection, continue
fluid restriction until Na+ normalizes. He should have follow
-up serial CHEM7
3. Afib: currently in sinus, pt started on metoprolol in
addition to home multaq. He had borderline low BP in house (SBP
low 100s), but claimed he always had borderline low BPs. If he
remains in sinus, his metoprolol should perhaps be discontinued.


Medications on Admission:
warfarin
gemfibrozil
pravastatin
colace
levothyroxine
multaq
aspirin 81 mg daily


Discharge Medications:
1. Please be aware
1) Patient will need [**Hospital1 **] IV abx as written. 2) Patient is
deconditioned from critical illness and requires physical
therapy. 3) Patient had significant brain inflammation and will
have chronic headaches, please be sure to provide the pain
medications as written. 3) Patient has "black spots" or "flees"
in vision likely as a consequence of meningitis. Please be
aware.
2. dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. levothyroxine 75 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).

5. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1) unit Intravenous Q12H (every 12 hours): last day is
[**2135-6-4**].
6. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours: provide standing.
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): Consider weaning this medicine to [**Hospital1 **] and then QD
and then discontinue. He needed extra rate control before we
restarted his dronederone.
9. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain: can consider giving standing if
headaches are persistent.
10. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
11. PICC care
12. Aspirin 81mg daily
Provide PICC care as per usual


Discharge Disposition:
Extended Care

Facility:
[**Male First Name (un) 4542**] Nursing Center - [**Hospital1 1562**]

Discharge Diagnosis:
Primary:
-Pneumococcal Meningitis
Secondary:
- Meningocoel
- Atrial Fibrillation
- Bioprosthetic Aortic Valve ([**2135-2-15**])


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were seen at the [**Hospital3 **] Medical center for altered
mental status and were found to have Meningitis. Given the
serious nature of your infection, you were intubated and given
broad-spectrum antibiotics in the intensive care unit. You
improved and were transfered to the floor. You antibiotics were
narrowed down to Ceftriaxone. You should continue taking this
medication through your IV line for 4 weeks after you leave the
hospital. You will need to have an MRI prior to your appointment
with the infectious disease doctors. We have scheduled you one
at [**Hospital1 18**] for [**6-3**]. If you choose to have one elsewhere,
please arrange this through your PCP and be sure to have the
results and images available for our infectious disease doctors.
You will need weekly blood checks while you undergo treatment
with this medication. The results of these tests should be faxed
to [**Telephone/Fax (1) 109365**].

Given your high sodium level, you have been placed on a fluid
restriction that should be maintained at 1500cc per day until
otherwise instructed by your health care providers.

NEW MEDICATIONS
1. Ceftriaxone - an antibtiotic, you must take this medication
for 4 weeks after discharge.
2. Tylenol and Ibuprophen - pain medications to help with your
headache.
3. Metoprolol - we have you on this heart rate medicine to
control your heart rate but this may be discontinued at the
rehab.

You should take all your other medications as prescribed by your
physicians.

Please call your doctor if you experience worsening headaches,
worsening visual changes, loss of consciousness.


Followup Instructions:
MRI -Brain: [**Last Name (LF) 2974**], [**6-3**] @ 4:40pm --> Please go to the [**Hospital Ward Name 12837**] Clinical center

Department: MRI
When: [**Hospital Ward Name **] [**2135-6-3**] at 5:00 PM
With: MRI [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Hospital 1422**]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

PLEASE MAKE AN APPOINTMENT WITH INFECTIOUS DISEASE DOCTORS:
.
Please call the Infectious Disease Department to book a follow
up appointment of your hospitalization. You need to have an
appointment with Dr. [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **] within 2 weeks. The office
phone number is [**Telephone/Fax (1) 457**].

You should contact your Primary care physician and book [**Name Initial (PRE) **]
follow-up appointment. You should discuss the possible need for
referal for surgical intervention regarding your meningocele.
{'Streptococcal meningitis,Acute respiratory failure,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Other encephalopathy,Other disorders of neurohypophysis,Delirium due to conditions classified elsewhere,Atrial flutter,Bacteremia,Encephalocele,Acute sphenoidal sinusitis,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Long-term (current) use of anticoagulants,Aortocoronary bypass status,Heart valve 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: Altered mental status

PRESENT ILLNESS: Mr. [**Known lastname **] is a 69yo M with history of atrial fibrillation on
warfarin and hyperlipidemia who presents with altered mental
status.  Patient has had sinus congestion and drainage for the
past 4-5 days and saw his PCP for this who prescribed
azithromycin and decongestant.  He started these medications
yesterday and developed a severe headache on the night of
admission with temperature of 100.7.  He was confused so his
wife brought him to [**Location (un) **] Cope Hospital.
.
In the ER there, he continued to be confused and had CT of his
head which showed opacificiation of his sphenoid sinus with
concern for epidural abscess vs subdural empyema.  No LP was
performed given this concern but he was given vancomycin,
ceftriaxone and flagyl and transferred to [**Hospital1 18**] for further
care.
.
In the ED, initial vs were: T 99.2 P 86 BP 118/79 R 16 O2 sat
93% RA. Patient's CT was reviewed by neurosurgery here who felt
there was no CNS extension of the sinus opacification.  Patient
was alerted and oriented to person only.  He withdraws to pain
but does not follow commands.  Neurology reviewed the film with
her CT with radiology and agrees there does not appear to be any
signs of empyema or abscess.  Ampicillin 1g was given for
listeria meningitis coverage and patient also received 10mg IV
Zyprexa for agitation.  LP was recommended by deferred given INR
of 3.0.  Patient was transferred to the MICU with vitals of 78,
120/84, 19, 99% RA.
.
In the ICU, patient is not answering questions or following
commands.
.
Review of systems: Unable to obtain secondary to confusion

MEDICAL HISTORY: Hyperlipidemia
Atrial fibrillation
Hypothyroidism
CAD s/p Cypher DES in [**2129-7-13**] and CABG with porcine AVR in
[**1-/2135**], all at [**Hospital3 **]

MEDICATION ON ADMISSION: warfarin
gemfibrozil
pravastatin
colace
levothyroxine
multaq
aspirin 81 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL:
Vitals: T: 100.6 BP: 139/84 P: 90 R: 18 O2: 97 2L NC
General: Somnolent, spontaneously opens eyes, not following
commands
HEENT: NC/AT, PEERL with 1.5mm pupils, sclera anicteric, MM dry,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, some wincing with abdominal palpitation,
non-distended, bowel sounds present, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Unable to obtain

SOCIAL HISTORY: Unable to obtain 

### Response:
{'Streptococcal meningitis,Acute respiratory failure,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Other encephalopathy,Other disorders of neurohypophysis,Delirium due to conditions classified elsewhere,Atrial flutter,Bacteremia,Encephalocele,Acute sphenoidal sinusitis,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Long-term (current) use of anticoagulants,Aortocoronary bypass status,Heart valve replaced by transplant'}
