CHIEF COMPLAINT: FUO, altered MS

PRESENT ILLNESS: Ms. [**Known lastname 13304**] is a 63 yo F with a h/o EtOH abuse,
hemochromatosis, and recent hospitalization for ETOH
pancreatitis, who was transferred to the ED from rehab with
acute altered mental status.  According to her husband she was
in her usual state of health when he last spoke to her at 9pm on
the evening of admission.  He was called by the rehab 2 hours
later and informed that she was not making sense and that she
was being sent to ED for further evaluation.  He reported that
when he saw her in the ED she was speaking non-sensically; he
had never seen her like this before.

MEDICAL HISTORY: #. Pancreatitis-- hospitalization [**4-29**] - [**2138-5-22**], on
levo/flagyl; MICU stay w/intubation
#. EtOH abuse-- heavy drinking of [**1-21**] to whole bottle of wine
per
day every day for 4-5 years; unclear if she has been drinking
since recent discharge from hospital
#. Peptic ulcer disease
#. Hemochromatosis-- requiring therapeutic phlebotomy (no h/o
organ dysfunction)
#. OSA-- per sleep study on [**2138-4-2**], patient should be started
on auto CPAP with a pressure ranging from 6-10 cm of water;
however she hasn't started using CPAP at home yet
#. Cognitive impairment-- per husbands report she has been
reporting short term memory impairment x3 years; h/o abnormal
neuropsych testing

MEDICATION ON ADMISSION: -Acetaminophen 1000 mg Capsule Sig: [**11-20**] Capsules PO every [**2-23**]
hours as needed for pain.
-Heparin 5000 SQ TID
-Quetiapine 50 mg Tablet PO at bedtime
-Oxycodone 5 mg Tablet PO Q4H prn for pain.
-Folic Acid 1 mg Tablet PO DAILY
-Thiamine HCl 100 mg PO DAILY
-Loperamide 2 mg PO QID prn for diarrhea.
-Fentanyl 25 mcg/hr Patch Q72 hr
-Aspirin 81 mg PO once a day
-Omeprazole 20 mg po daily
-Venlafaxine 75 mg PO daily
-Amlodipine 7.5mg po qhs
-psyllium powder 3.7gm [**Hospital1 **] prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS in the [**Hospital Unit Name 153**]: T 103.2, HR 121, BP 155/67, RR 30, 99% NC
Gen: appears agitated, non purposeful movements, muttering,
moans in response to questions/exam
Skin: warm, flushed, no rashes or lesions noted
HEENT: pupils 3mm, equal, sluggisly reactive, roving eye
movements, will not open mouth, dried blood on tongue/[**Last Name (LF) **], [**First Name3 (LF) **]
not open mouth for examination
Neck: supple, no LAD, no thyromegaly or thyroid nodules
CV: tachycardic, regular rhythm, no appreciable murmur
Lungs: unable to cooperate with exam, CTAB
Abd: soft, appears to be tender to deep palpation primarily in
RLQ, +Bowel sounds, no guarding
Ext: no pedal edema

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Up until the past month she had been drinking 1 whole bottle of
wine per day +/- scotch every day for 4-5 years.  Last drink was
[**2138-4-26**], husband denies any access to alcohol since.  No h/o
tobacco or drug use.  Prior to her recent pancreatitis she had
been working part time as a therapist, previously as a
professor.  Lives with husband who does not drink.
Hypertensive encephalopathy,Grand mal status,Cyst and pseudocyst of pancreas,Anemia, unspecified,Depressive disorder, not elsewhere classified,Other and unspecified alcohol dependence, continuous,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Obstructive sleep apnea (adult)(pediatric),Chronic peptic ulcer of unspecified site without mention of hemorrhage or perforation, without mention of obstruction
Hypertens encephalopathy,Grand mal status,Pancreat cyst/pseudocyst,Anemia NOS,Depressive disorder NEC,Alcoh dep NEC/NOS-contin,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Obstructive sleep apnea,Chronic peptic ulcer NOS
Admission Date:  [**2138-5-26**]              Discharge Date:   [**2138-6-5**]

Date of Birth:  [**2075-3-15**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 552**]
Chief Complaint:
FUO, altered MS


Major Surgical or Invasive Procedure:
intubation

History of Present Illness:
Ms. [**Known lastname 13304**] is a 63 yo F with a h/o EtOH abuse,
hemochromatosis, and recent hospitalization for ETOH
pancreatitis, who was transferred to the ED from rehab with
acute altered mental status.  According to her husband she was
in her usual state of health when he last spoke to her at 9pm on
the evening of admission.  He was called by the rehab 2 hours
later and informed that she was not making sense and that she
was being sent to ED for further evaluation.  He reported that
when he saw her in the ED she was speaking non-sensically; he
had never seen her like this before.

On [**2138-5-22**] she was discharged from [**Hospital1 18**] to rehab after a
month-long hospitalization, including intubation, for severe
alcoholic pancreatitis.

In the ED, VS were T 97.6, HR 104, BP 156/88, RR 20, 100% on NC.
 She was initially evaluated for stroke, noted to have B/L
mydriasis, sluggishly reactive to light; but no evidence of
herniation/hemorrhage or other acute process on head CT.
Negative tox screen except for benzos which were given in the
ED.  She spiked a fever to 102.4 in ED and had an LP performed,
which was normal.  She was treated with vanco 1g IV x1,
levofloxacin 750mg IV x1, flagyl 500mg IV x1.  She was also
given NS IV x2L, Bannana bag, mag 2g IV x1, 1mg Ativan x2,
tylenol 1g PR, ASA 325.


Past Medical History:
#. Pancreatitis-- hospitalization [**4-29**] - [**2138-5-22**], on
levo/flagyl; MICU stay w/intubation
#. EtOH abuse-- heavy drinking of [**1-21**] to whole bottle of wine
per
day every day for 4-5 years; unclear if she has been drinking
since recent discharge from hospital
#. Peptic ulcer disease
#. Hemochromatosis-- requiring therapeutic phlebotomy (no h/o
organ dysfunction)
#. OSA-- per sleep study on [**2138-4-2**], patient should be started
on auto CPAP with a pressure ranging from 6-10 cm of water;
however she hasn't started using CPAP at home yet
#. Cognitive impairment-- per husbands report she has been
reporting short term memory impairment x3 years; h/o abnormal
neuropsych testing


Social History:
Up until the past month she had been drinking 1 whole bottle of
wine per day +/- scotch every day for 4-5 years.  Last drink was
[**2138-4-26**], husband denies any access to alcohol since.  No h/o
tobacco or drug use.  Prior to her recent pancreatitis she had
been working part time as a therapist, previously as a
professor.  Lives with husband who does not drink.


Family History:
non-contributory

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS in the [**Hospital Unit Name 153**]: T 103.2, HR 121, BP 155/67, RR 30, 99% NC
Gen: appears agitated, non purposeful movements, muttering,
moans in response to questions/exam
Skin: warm, flushed, no rashes or lesions noted
HEENT: pupils 3mm, equal, sluggisly reactive, roving eye
movements, will not open mouth, dried blood on tongue/[**Last Name (LF) **], [**First Name3 (LF) **]
not open mouth for examination
Neck: supple, no LAD, no thyromegaly or thyroid nodules
CV: tachycardic, regular rhythm, no appreciable murmur
Lungs: unable to cooperate with exam, CTAB
Abd: soft, appears to be tender to deep palpation primarily in
RLQ, +Bowel sounds, no guarding
Ext: no pedal edema


Pertinent Results:
ADMISSION LABS:
Na 132 K 3 CL 102 HCO 26 BUN
AST 22 ALT 12 AP 155  Lip 13
CK 36  MB - Trop 0.02
WBC 7.7 HCT 28.1 PLT 390
Serum Tox negative

Lactate 1

[**5-26**] CSF 3WBC 7RBC 29protein 76glucose
CSF HSV PCR: pending
CSF gram stain: no PMN's or microorganisms
CSF bacterial/viral cultures: pending

Urine Tox positive for benzos (which were given in the ED),
otherwise negative
UA: trace blood, occ bacteria otherwise neg

[**2138-5-26**] BCx: Coag negative staph in [**11-22**] vials
[**2138-5-27**] BCx:
[**2138-5-28**] BCx:

[**2138-5-26**] PICC catheter tip: NGTD

C. Diff Toxin A: negative on three samples
C. Diff Toxin B: pending
[**2138-5-26**] Stool Cx: negative

Imaging:
[**2138-5-26**] CXR:  No acute intrathoracic process. PICC tip in
standard location. Limited evaluation fue to low lung volumes.

[**2138-5-25**] Head CT: No acute intracranial process.

[**2138-5-28**] TTE:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. Trace aortic regurgitation
may be present (clip [**Clip Number (Radiology) **]). The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2138-5-19**],
the findings are similar.

[**2138-5-28**] Bilateral LE US:

[**2138-5-28**] Torso CT with Contrast:

Brief Hospital Course:
63 yo WF w/ ETOH abuse, hemachromatosis, PUD w recent admission
for severe pancreatitis/ARDS/intubation/MICU transfer was
re-admitted on [**5-26**] with acute mental status change. Pt underwent
CT head (neg), and LP in ED and was transferred to MICU. LP
revealed only 3 WBC w/ lymphocytic predominance, 7 RBCs, 29 pro
and 76 gluc. CSF Cx were NGTD. Pt was empirically given one dose
of Vanc, levaquin, flagyl. Pt had fever and workup revealed
pancreatic pseudocyst w >30% necrosis and levaquin/flagyl were
continued. Pt also had resp distress/inability  to protect
airway and was intubated but quickly extubated within 48 hrs.
Due to persistent MS change, pt underwent EEG which showed NCSE
and she was loaded on Keppra. Pt's MS improved. MRI showed
changes consistent with PRES.  Pt was transferred to floor:
.
1. Acute mental status change - LP neg for infection. EEG did
show seizure activity, therefore loaded on keppra.  Recent MRI
shows changes of Posterior Reversible Leukoencephalopathy
(PRES). Per Neuro, pt will need repeat MRI in 8 weeks and outpt
FU w/ Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] at the same time. Of note, per pt's husband
and notes, even prior to admission for pancreatitis, pt did have
some issues with short term memory and word finding. On the day
of discharge pt was alert and oriented X3 and not showing signs
of obvious confusion. Given the HTN may have been the underlying
etiology behind PRES, pt started on Norvasc and Metoprolol and
BP under reasonable range after that. Neurology also wanted
Keppra continued.
2. Pancreatic pseudocyst w/ necrosis - CT guided aspirate shows
no growth so far. Per GI, pt will be given total 10 d course of
Levaquin/Flagyl. Also, [**Name (NI) 653**], Resident on Surgery, and given
that Cx is sterile, they do not recommend further interventions
for the pseudocyst.
4. Diarrhea - Stool C&S, campy, O&P, and Cdiff X 3 NGTD.  [**Month (only) 116**] be
related to pancreatitis. Is on pancreatic enzyme replacement.
Since infectious workup was neg, and pt was afebrile w nl WBC,
pt was started on imodium and improvement in diarrhea was noted.
5. Anemia - Pt had stable anemia noted and had no active signs
of bleeding. Pt's stool guaiac was neg X1. Pt has had a
colonoscopy in [**2135**] which was neg.
6. Hx depression  - Initially pts psych meds were held as
diagnosis was unclear and given fever, seretonin syndrome was on
differential but these were later restarted.
7. Renal insufficiency - Before admission in [**Month (only) **] cr 0.8-0.9. Cr
worsened initially during ICU stay likely [**12-21**] hypotension and
improved and stabilized around 1.1-1.2
8. Abnormal thyroid function - Pt had high tSH (19) and low ft2
(0.73). In the setting of recent criticall illness, this likely
represents sick euthyroid and therefore, will not start
synthroid. Will need recheck in a few weeks by PCP.
[**Name10 (NameIs) **] was sent home w/ home services and follow up appt w/ PCP, [**Name10 (NameIs) **]
and Neuro

Medications on Admission:
-Acetaminophen 1000 mg Capsule Sig: [**11-20**] Capsules PO every [**2-23**]
hours as needed for pain.
-Heparin 5000 SQ TID
-Quetiapine 50 mg Tablet PO at bedtime
-Oxycodone 5 mg Tablet PO Q4H prn for pain.
-Folic Acid 1 mg Tablet PO DAILY
-Thiamine HCl 100 mg PO DAILY
-Loperamide 2 mg PO QID prn for diarrhea.
-Fentanyl 25 mcg/hr Patch Q72 hr
-Aspirin 81 mg PO once a day
-Omeprazole 20 mg po daily
-Venlafaxine 75 mg PO daily
-Amlodipine 7.5mg po qhs
-psyllium powder 3.7gm [**Hospital1 **] prn

Discharge Medications:
1. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: [**11-20**] Caps PO TID W/MEALS (3 TIMES A
DAY WITH MEALS): This medication is to help with diarrhea, which
pt with pancreatitis can have.
Disp:*120 Cap(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours):
This is for history of Acid Reflux.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
For blood pressure.
Disp:*60 Tablet(s)* Refills:*2*
4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for loose stools.
Disp:*60 Capsule(s)* Refills:*0*
5. Psyllium     Packet Sig: One (1) Packet PO TID (3 times a
day) as needed: for loose stools.
Disp:*30 Packet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day): For Blood Pressure.
Disp:*60 Tablet(s)* Refills:*2*
7. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed.
Disp:*15 Tablet(s)* Refills:*0*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Antibiotic. finish course.
Disp:*9 Tablet(s)* Refills:*0*
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): Antibiotic. Finish course.
Disp:*3 Tablet(s)* Refills:*0*
12. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): For Seizures.
Disp:*120 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
RPLS. Reversible Posterior Leukoencephalopathy Syndrome
Pancreatic pseudocyst
Alcohol abuse
Hemachromatosis
hx of PUD


Discharge Condition:
Good


Discharge Instructions:
You were admitted to the hospital with mental status change. You
were admitted to the ICU and briefly needed to be put on
mechanical ventilation. You were found to have findings on MRI
consistent with RPLS, reversible posterior leukoencephalopathy
syndrome, which can sometimes be associated with high blood
pressure. the EEG also revealed that you were having seizures,
so you were started on an anti-epileptic.  Neurology wants the
MRI to be repeated in ~8 weeks and would like to see you after
the MRI. These appointments have been made. You are doing much
better from mental status point but should there be any changes,
please return to ED
You were found to have a pseudocyst around your pancreas. This
is a complication from your recent attack of pancreatitis. This
was aspirated and it did not show any infection.
Gasteroenterology and Surgery were consulted and they
recommended 10d antibiotic course but no interventions. You have
been made appointment with your GI doctor to follow up on this.
You also developed some diarrhea in the hospital but workup did
not show any signs of infection. Your diarrhea appears to be
slowing down, you may take imodium to help but if your diarrhea
worsens or you notice blood in stool or abdominal pain or
fevers, please return to ED
We checked thyroid function in you. It was mildly abnormal but
likely does not represent true thyroid disease. Please have your
PCP recheck them in [**4-27**] weeks.

Followup Instructions:
Please follow up w/ your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2472**] on Tuesday [**2140-6-9**]:45am at [**Hospital3 **]. Please also follow up w/ appts below

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2138-6-24**] 1:00
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2138-7-24**]
10:35
Provider: [**Name10 (NameIs) 640**] [**Name11 (NameIs) 747**] [**Name12 (NameIs) **], M.D. Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2138-7-24**] 1:00
{'Hypertensive encephalopathy,Grand mal status,Cyst and pseudocyst of pancreas,Anemia, unspecified,Depressive disorder, not elsewhere classified,Other and unspecified alcohol dependence, continuous,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Obstructive sleep apnea (adult)(pediatric),Chronic peptic ulcer of unspecified site without mention of hemorrhage or perforation, without mention of obstruction'}


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: FUO, altered MS

PRESENT ILLNESS: Ms. [**Known lastname 13304**] is a 63 yo F with a h/o EtOH abuse,
hemochromatosis, and recent hospitalization for ETOH
pancreatitis, who was transferred to the ED from rehab with
acute altered mental status.  According to her husband she was
in her usual state of health when he last spoke to her at 9pm on
the evening of admission.  He was called by the rehab 2 hours
later and informed that she was not making sense and that she
was being sent to ED for further evaluation.  He reported that
when he saw her in the ED she was speaking non-sensically; he
had never seen her like this before.

MEDICAL HISTORY: #. Pancreatitis-- hospitalization [**4-29**] - [**2138-5-22**], on
levo/flagyl; MICU stay w/intubation
#. EtOH abuse-- heavy drinking of [**1-21**] to whole bottle of wine
per
day every day for 4-5 years; unclear if she has been drinking
since recent discharge from hospital
#. Peptic ulcer disease
#. Hemochromatosis-- requiring therapeutic phlebotomy (no h/o
organ dysfunction)
#. OSA-- per sleep study on [**2138-4-2**], patient should be started
on auto CPAP with a pressure ranging from 6-10 cm of water;
however she hasn't started using CPAP at home yet
#. Cognitive impairment-- per husbands report she has been
reporting short term memory impairment x3 years; h/o abnormal
neuropsych testing

MEDICATION ON ADMISSION: -Acetaminophen 1000 mg Capsule Sig: [**11-20**] Capsules PO every [**2-23**]
hours as needed for pain.
-Heparin 5000 SQ TID
-Quetiapine 50 mg Tablet PO at bedtime
-Oxycodone 5 mg Tablet PO Q4H prn for pain.
-Folic Acid 1 mg Tablet PO DAILY
-Thiamine HCl 100 mg PO DAILY
-Loperamide 2 mg PO QID prn for diarrhea.
-Fentanyl 25 mcg/hr Patch Q72 hr
-Aspirin 81 mg PO once a day
-Omeprazole 20 mg po daily
-Venlafaxine 75 mg PO daily
-Amlodipine 7.5mg po qhs
-psyllium powder 3.7gm [**Hospital1 **] prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS in the [**Hospital Unit Name 153**]: T 103.2, HR 121, BP 155/67, RR 30, 99% NC
Gen: appears agitated, non purposeful movements, muttering,
moans in response to questions/exam
Skin: warm, flushed, no rashes or lesions noted
HEENT: pupils 3mm, equal, sluggisly reactive, roving eye
movements, will not open mouth, dried blood on tongue/[**Last Name (LF) **], [**First Name3 (LF) **]
not open mouth for examination
Neck: supple, no LAD, no thyromegaly or thyroid nodules
CV: tachycardic, regular rhythm, no appreciable murmur
Lungs: unable to cooperate with exam, CTAB
Abd: soft, appears to be tender to deep palpation primarily in
RLQ, +Bowel sounds, no guarding
Ext: no pedal edema

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Up until the past month she had been drinking 1 whole bottle of
wine per day +/- scotch every day for 4-5 years.  Last drink was
[**2138-4-26**], husband denies any access to alcohol since.  No h/o
tobacco or drug use.  Prior to her recent pancreatitis she had
been working part time as a therapist, previously as a
professor.  Lives with husband who does not drink. 

### Response:
{'Hypertensive encephalopathy,Grand mal status,Cyst and pseudocyst of pancreas,Anemia, unspecified,Depressive disorder, not elsewhere classified,Other and unspecified alcohol dependence, continuous,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Obstructive sleep apnea (adult)(pediatric),Chronic peptic ulcer of unspecified site without mention of hemorrhage or perforation, without mention of obstruction'}
