CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 55 year old
female with a history of hemorrhagic cerebrovascular
accident, seizure disorder, hypertension, and hydrocephalus
who was admitted to the Medical Intensive Care Unit on [**4-30**], after being found unresponsive at the nursing home with a
temperature of 102.4.

MEDICAL HISTORY: 1.  Hemorrhagic cerebrovascular
accident with residual left hemiparesis eight years ago; 2.
Seizures disorder after the hemorrhagic cerebrovascular
accident; 3.  Hydrocephalus with high intracranial pressure
by lumbar puncture in [**2171-11-30**] with opening pressure of
25, evaluated by Neurosurgery for ventriculoperitoneal shunt,
but the patient declined.  4.  Hypertension; 5.
Hypercholesterolemia; 6.  Depression; 7.  Status post
gastrostomy.

MEDICATION ON ADMISSION: 

ALLERGIES: Sulfa, Thiazide, diuretics, and Enalapril.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: She is a [**Location 11785**] native and lives at
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Nursing Home.
Meningitis due to gram-negative bacteria, not elsewhere classified,Obstructive hydrocephalus,Other convulsions,Infection and inflammatory reaction due to other vascular device, implant, and graft,Cerebral artery occlusion, unspecified with cerebral infarction,Acute kidney failure, unspecified,Disseminated candidiasis,Other late effects of cerebrovascular disease
Mningts gram-neg bct NEC,Obstructiv hydrocephalus,Convulsions NEC,React-oth vasc dev/graft,Crbl art ocl NOS w infrc,Acute kidney failure NOS,Disseminated candidiasis,Late effect CV dis NEC
Admission Date:  [**2175-4-30**]       Discharge Date: [**2175-5-11**]

Date of Birth:   [**2109-4-6**]       Sex:  F

Service:

HISTORY OF PRESENT ILLNESS:  The patient is a 55 year old
female with a history of hemorrhagic cerebrovascular
accident, seizure disorder, hypertension, and hydrocephalus
who was admitted to the Medical Intensive Care Unit on [**4-30**], after being found unresponsive at the nursing home with a
temperature of 102.4.

In the Emergency Department her temperature remained 102.4,
her blood pressure was 210/100, her pulse was 132, her
respiratory rate 42 and she was 100% on 100% nonrebreather.
She was given Tylenol and Nitroglycerin paste, insulin drip,
tuberous normal saline Nipride drip, Rocephin, a triple lumen
was placed in the right groin.  She was given Decadron 10 mg
intravenously.  Ceftriaxone and Vancomycin were also given.
Head computerized tomography scan revealed new left
frontoparietal infarct.

She was admitted to the Medicine Intensive Care Unit.
Medicine Intensive Care Unit course was notable for:  1.
Infectious disease - Lumbar puncture was performed, 20,000
white blood cells, 4+ polys, 4+ gram negative rods, 909
protein, 0 glucose, consistent with bacterial meningitis. In
addition 1 out of 4 bottles of blood culture grew out gram
positive cocci.  She was started on Ceftriaxone and Meropenem
to double cover for the gram negative rods as well as
Vancomycin to cover for the gram positive cocci in the blood.
She had an echocardiogram on [**5-1**] revealing no vegetations.
She also had a right upper quadrant ultrasound because of
possible sludge of the gallbladder.  HIDA scan as well as
negative.  Vancomycin was discontinued after four days
because the 1 out of 4 bottles of blood cultures grew out
coagulase negative Staphylococcus and it was felt to be a
contaminate.  She spiked a temperature to 101.7 on [**5-4**].
Her femoral line at that point was discontinued and
Vancomycin was restarted.  She had no repeat lumbar puncture
per the family's wishes as they decided not to be aggressive.
Ceftriaxone and Vancomycin were discontinued because the
patient spiked through them anyway.  She was continued on
Meropenem for gram negative rod meningitis.  Femoral line
grew back [**Female First Name (un) 564**] and she was started on Fluconazole.

2.  Neurological - Bacterial meningitis and cerebrovascular
accident.  Blood pressure maintained goal 170.  Her head
computerized tomography scan revealed no left frontoparietal
infarct.  She was unable to tolerate the magnetic resonance
given patient movement.  She was continued on Dilantin given
her history of seizure disorder.  Head computerized
tomography scan was repeated on [**5-4**] showing hydrocephalus
with prominent mass effect.  Circulation Service suggested
multiple studies and neurosurgery evaluation but the
patient's family declined.  Electroencephalogram showed
encephalopathy.

3.  Oncology - Abdominal ultrasound was performed and it
showed a question of ovarian cancer with an ovarian mass.
This was discussed with the family and the decision was not
to proceed with further workup.

4.  Heme - Her hematocrit decreased to 27 without obvious
source.  Her stool guaiacs were negative.

5.  Cardiovascular system - Hypertension, the patient with
systolic blood pressures elevated throughout the hospital
course.  Initially she was treated with Labetalol and then
her Metoprolol was increased and Norvasc was added.

6.  Endocrine - Diabetes mellitus, she was started on an
insulin drip and then changed to NPH and regular insulin
sliding scale.

7.  Fluids, electrolytes and nutrition - She was started on
tube feeds via nasogastric tube.  She was given free water
boluses.  The patient was cleared to the floor on [**2175-5-5**].

PAST MEDICAL HISTORY:  1.  Hemorrhagic cerebrovascular
accident with residual left hemiparesis eight years ago; 2.
Seizures disorder after the hemorrhagic cerebrovascular
accident; 3.  Hydrocephalus with high intracranial pressure
by lumbar puncture in [**2171-11-30**] with opening pressure of
25, evaluated by Neurosurgery for ventriculoperitoneal shunt,
but the patient declined.  4.  Hypertension; 5.
Hypercholesterolemia; 6.  Depression; 7.  Status post
gastrostomy.

ALLERGIES:  Sulfa, Thiazide, diuretics, and Enalapril.

MEDICATIONS ON TRANSFER:  NPH and regular insulin sliding
scales.  Fluconazole, Aspirin, Meropenem, Lansoprazole,
Senna, Talwin, Colace and Metoprolol.

SOCIAL HISTORY:  She is a [**Location 11785**] native and lives at
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Nursing Home.

PHYSICAL EXAMINATION:  Examination on transfer to floor,
temperature 99.2, 198/82, 68, 11, 100% on 2 liters,
unresponsive.  Eyes opened, right sided gaze.  Moving right
arm.  Pupils 3 cm and sluggish, reactive to light.  Regular
rate and rhythm, no murmurs, rubs or gallops appreciated.
Coarse breathsounds anteriorly.  No wheezes, no crackles.
Soft, moderately distended, hyperactive bowel sounds.
Positive upper extremity edema bilaterally, no lower
extremity edema.  Neurological, left neglect, left pupil
deviation, no purposeful movements, no gag.

LABORATORY DATA:  Laboratory data on admission revealed white
blood cell count 11.5, hematocrit 34.2, platelets 278, INR
1.4, 76% neutrophils, 8% bands, 10% lymphocytes, 4%
monocytes, 2% atypical study, 140,000, 4.6 potassium,
chloride 108, carbon dioxide 18, BUN 38, creatinine 2.8.
Blood cultures from [**4-30**] to [**Month (only) **] no blood cultures to date.
Micro data [**4-30**], cerebrospinal fluid, white blood count
20,000, red blood count 217, polymorphonuclear lymphocytes
93, bands 2, lymphocytes 3, monocytes 2, protein 909 and
glucose 0.  Cerebrospinal fluid culture, 4% polys, 2% gram
negative rods, culture ultimately grew Klebsiella which was
Meropenem sensitive.

HOSPITAL COURSE:  After being admitted to the Medical
Intensive Care Unit the patient was transferred to the floor
on [**2175-5-5**].  She continued to spike fevers despite being
on Meropenem and Fluconazole.  Her culture from her
cerebrospinal fluid grew out Klebsiella that was sensitive to
Meropenem.  Family meeting was performed with Neurology
present.  The decision was made to make the patient
comfort-measures-only, to withdraw antibiotics, intravenous
lines and drains and to continue to only treat with seizure
prophylaxis.  The patient remained stable, continued to spike
fevers and was starting on standing Acetaminophen and was
continued on Dilantin.  Of note, she did have seizure
activity on [**2175-5-6**].  She was given a bolus of Dilantin
and her seizure ceased at that time.  Her standing Dilantin
level was increased to 150 mg p.o. t.i.d.  The decision was
made to discontinue her intravenous medications and she was
discharged on intramuscular Fosphenytoin b.i.d. and Diastat
p.r. prn for seizure activities as well as sublingual
Morphine.

CONDITION ON DISCHARGE:  Poor.

DISCHARGE STATUS:  Discharged to hospice.

FINAL DIAGNOSIS:
1.  Seizure without status
2.  Tachycardia
3.  Hypertension
4.  Klebsiella
5.  Meningitis
6.  Cerebrovascular accident

DISCHARGE MEDICATIONS:
1.  Acetaminophen 650 mg p.r. q. 6 hours
2.  Fosphenytoin 225 mg intramuscularly b.i.d., alternate
arms
3.  Morphine Sulfate 1 to 5 mg sublingual q. 2 to 3 hours as
needed
4.  Diazepam p.r. 15 mg q.d. as needed for seizures




                            [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D.  [**MD Number(1) 29803**]

Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36

D:  [**2175-5-11**]  14:39
T:  [**2175-5-11**]  15:30
JOB#:  [**Job Number 29804**]


Admission Date:  [**2175-4-30**]       Discharge Date:  [**2175-5-15**]

Date of Birth:   [**2109-4-6**]       Sex:  F

Service:

ADDENDUM:  The patient remained hospitalized until [**2175-5-15**]
when she was discharged to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] with hospice.

DISCHARGE MEDICATIONS:
1. Tylenol 650 mg p.r. q. 6 hours.
2. Fosphenytoin 225 mg intramuscular b.i.d. alternate arms.
3. Diastat 2.5 mg p.r. q. 10 minutes p.r.n. seizures until
seizing stops.
4. Morphine elixir 20 mg per mL 5 mg sublingual q. 1 hour
p.r.n. for minimal distress.
5. Morphine sulfate 20 mg per mL solution, 10 mg sublingual
q. 1 hour as needed for moderate distress.
6. Morphine sulfate 20 mg sublingual q. 1 hour as needed for
severe distress.
7. Ativan 1 mg p.o. q. 3 hours, please give sublingual.
8. Ativan 1 mg p.o. q. 1 hour as needed for agitation,
respiratory distress.
9. Scopolamine patch q. 72 hours.





                            [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D.  [**MD Number(1) 29803**]

Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36

D:  [**2175-5-15**]  14:05
T:  [**2175-5-15**]  15:23
JOB#:  [**Job Number 29805**]
{'Meningitis due to gram-negative bacteria, not elsewhere classified,Obstructive hydrocephalus,Other convulsions,Infection and inflammatory reaction due to other vascular device, implant, and graft,Cerebral artery occlusion, unspecified with cerebral infarction,Acute kidney failure, unspecified,Disseminated candidiasis,Other late effects of cerebrovascular disease'}


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: 

PRESENT ILLNESS: The patient is a 55 year old
female with a history of hemorrhagic cerebrovascular
accident, seizure disorder, hypertension, and hydrocephalus
who was admitted to the Medical Intensive Care Unit on [**4-30**], after being found unresponsive at the nursing home with a
temperature of 102.4.

MEDICAL HISTORY: 1.  Hemorrhagic cerebrovascular
accident with residual left hemiparesis eight years ago; 2.
Seizures disorder after the hemorrhagic cerebrovascular
accident; 3.  Hydrocephalus with high intracranial pressure
by lumbar puncture in [**2171-11-30**] with opening pressure of
25, evaluated by Neurosurgery for ventriculoperitoneal shunt,
but the patient declined.  4.  Hypertension; 5.
Hypercholesterolemia; 6.  Depression; 7.  Status post
gastrostomy.

MEDICATION ON ADMISSION: 

ALLERGIES: Sulfa, Thiazide, diuretics, and Enalapril.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: She is a [**Location 11785**] native and lives at
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Nursing Home. 

### Response:
{'Meningitis due to gram-negative bacteria, not elsewhere classified,Obstructive hydrocephalus,Other convulsions,Infection and inflammatory reaction due to other vascular device, implant, and graft,Cerebral artery occlusion, unspecified with cerebral infarction,Acute kidney failure, unspecified,Disseminated candidiasis,Other late effects of cerebrovascular disease'}
