CHIEF COMPLAINT: S/P Fall with Agitation

PRESENT ILLNESS: The paitent is an 87 year old man with a history of HTN, CKD,
CHF (EF>55%) who presented from an outside hospital (OSH) with
suspected meningitis. He was in his usual state of health until
[**2169-3-16**], one week prior to admission to this hospital
when he developed a rash on the upper portion of his right face.
He then went to his primary doctor, who diagnosed him with
facial Zoster and prescribed him Valtrex 1 g TID. Later that
day, per his wife, he began having intermittent visual and
auditory hallucinations along with progressive and intermittent
confusion. He also had a stiff neck. There were no fevers,
chills or rigors. He was seen by an ophthomologist on [**3-21**], [**2168**], with a reportedly normal exam.

MEDICAL HISTORY: CHF ([**9-/2168**]: EF 60-65%), CKD (Baseline Cr 2.7-2.7) S/P LUE AVF
(In Prep for HD), Hypothyroidism, Gout, Emphysema/COPD, Anxiety,
S/P R THR x 2.

MEDICATION ON ADMISSION: 1) Levoxyl 125 mg PO DAILY
2) Allopurinol 100 mg PO DAILY
3) Lasix 80 mg PO DAILY
4) Valtrex 1 g PO TID
5) Azmacort
6) Lorazepam 0.5 mg PO DAILY PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T98 HR53 BP128/62 RR17 OS100% (AC: TV 500, Rate 16; FIO2 40%,
PEEP 5)
GEN - ELDERLY APPEARING. ADENTULOUS. INTUBATED AND SEDATED.
SKIN - RIGHT UPPER FACIAL CRUSTED VESICULAR LESIONS WITH
UNDERLYING ERYTHEMA (NO CROSSING OF THE MIDLINE).
HEENT - ANICTERIC. B/L CONJ INJECTION. NO LAD. MM DRY.
NECK - STIFF.
RESP - COARSE BS AT B/L BASES. GOOD FLOW WITHOUT ADVENTIOUS BS
ELSEWHERE.
CV - BRADY AND REGULAR. NML S1/S2. NO MGR.
ABD - S/NT/ND. POS BS. NO HSM.
EXT - NO CCE. WARM. DP1+. LEFT UUE WITH AVF (PALP THRILL AND
AUDIBLE BRUIT).
NEURO - SEDATE. RIGHT PUPIL AT 2MM, LEFT PUPIL AT 1.5MM WITH B/L
REACTIVITY. FACIAL GRIMACE SYM. GAG INTACT. WITHDRAWS UE, BUT
NOT LE, TO PAIN STIMULUS. TOE DOWNGOING. DTR 2+ BICEPS, 2+ (MORE
BRISK THAN UE, BUT NO SPREAD) PATELLAR.

FAMILY HISTORY: Not obtained.

SOCIAL HISTORY: He lived with his wife and was a prior smoker. There was not
history of excessive ETOH use or illicit drug use.
Postvaricella encephalitis,Pneumonia, organism unspecified,Chronic airway obstruction, not elsewhere classified,Cellulitis and abscess of foot, except toes,Hyperosmolality and/or hypernatremia,Secondary iridocyclitis, infectious,Unspecified acquired hypothyroidism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified
Postvaricella encephalit,Pneumonia, organism NOS,Chr airway obstruct NEC,Cellulitis of foot,Hyperosmolality,Secondry iritis, infect,Hypothyroidism NOS,Hy kid NOS w cr kid I-IV
Admission Date:  [**2169-3-23**]              Discharge Date:   [**2169-4-4**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
S/P Fall with Agitation

Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation.

History of Present Illness:
The paitent is an 87 year old man with a history of HTN, CKD,
CHF (EF>55%) who presented from an outside hospital (OSH) with
suspected meningitis. He was in his usual state of health until
[**2169-3-16**], one week prior to admission to this hospital
when he developed a rash on the upper portion of his right face.
He then went to his primary doctor, who diagnosed him with
facial Zoster and prescribed him Valtrex 1 g TID. Later that
day, per his wife, he began having intermittent visual and
auditory hallucinations along with progressive and intermittent
confusion. He also had a stiff neck. There were no fevers,
chills or rigors. He was seen by an ophthomologist on [**3-21**], [**2168**], with a reportedly normal exam.

On the night prior to admission to this hospital, he had an
unwitnessed fall with head trauma (but no loss of consiousness
or reported seizure-like activity). His wife called EMS and he
was transported to an OSH emergency [**Hospital1 **]. He was noted to be
agitated and was then intubated for airway protection and for
lumbar puncture. A Head CT was negative. His CSF had 11 WBC, 280
RBC, 58 Glucose, TP 82 (it was deemed a possible traumatic tap
as he was status-post multiple attempts). An opening pressure
was not recorded. He was covered empirically with Ceftriaxone as
well as Azithromycin for a possible right lower lobe pneumonia.
He was then transferred to the [**Hospital1 18**] MICU for further care.

[**Hospital1 18**] ED: He arrived intubated with a temperature of 102.8.
Acyclovir and Vancomycin were added to his regimen.

Past Medical History:
CHF ([**9-/2168**]: EF 60-65%), CKD (Baseline Cr 2.7-2.7) S/P LUE AVF
(In Prep for HD), Hypothyroidism, Gout, Emphysema/COPD, Anxiety,
S/P R THR x 2.

Social History:
He lived with his wife and was a prior smoker. There was not
history of excessive ETOH use or illicit drug use.


Family History:
Not obtained.

Physical Exam:
T98 HR53 BP128/62 RR17 OS100% (AC: TV 500, Rate 16; FIO2 40%,
PEEP 5)
GEN - ELDERLY APPEARING. ADENTULOUS. INTUBATED AND SEDATED.
SKIN - RIGHT UPPER FACIAL CRUSTED VESICULAR LESIONS WITH
UNDERLYING ERYTHEMA (NO CROSSING OF THE MIDLINE).
HEENT - ANICTERIC. B/L CONJ INJECTION. NO LAD. MM DRY.
NECK - STIFF.
RESP - COARSE BS AT B/L BASES. GOOD FLOW WITHOUT ADVENTIOUS BS
ELSEWHERE.
CV - BRADY AND REGULAR. NML S1/S2. NO MGR.
ABD - S/NT/ND. POS BS. NO HSM.
EXT - NO CCE. WARM. DP1+. LEFT UUE WITH AVF (PALP THRILL AND
AUDIBLE BRUIT).
NEURO - SEDATE. RIGHT PUPIL AT 2MM, LEFT PUPIL AT 1.5MM WITH B/L
REACTIVITY. FACIAL GRIMACE SYM. GAG INTACT. WITHDRAWS UE, BUT
NOT LE, TO PAIN STIMULUS. TOE DOWNGOING. DTR 2+ BICEPS, 2+ (MORE
BRISK THAN UE, BUT NO SPREAD) PATELLAR.

Pertinent Results:
CXR ([**2169-3-23**]): IMPRESSION: ET tube in satisfactory position. No
evidence of pneumonia or CHF. Interstitial opacities that may
represent chronic lung disease.

HEAD CT ([**2169-3-26**]): There is a small amount of hyperdensity seen
in both right and left parietal lobes series 3, image 30 and 31.
This is likely due to volume averaging from the surrounding
osseous structures. No other areas of increased attenuation are
seen to suggest intracranial hemorrhage. [**Doctor Last Name **]-white matter
differentiation is preserved. There is no hydrocephalus or shift
of normally midline structures. The osseous structures are
unremarkable. Circumferential mucosal thickening is seen within
the sphenoid sinus. The remaining visualized paranasal sinuses
and mastoid air cells are clear. Soft tissues are unremarkable.
Motion artifact somewhat limits the most inferior images.

VIDEO OROPHARYNGEAL SWALLOW ([**2169-3-30**]): IMPRESSION: Trace
penetration and aspiration with thin liquid. For a detailed
discussion of the swallowing specialist's evaluation and
treatmet recommendations, please see the notes section of the
patient's online medical record.

EEG ([**2169-3-27**]): IMPRESSION - This is an abnormal routine EEG due
to the slow and disorganized background rhythm and bursts of
generalized slowing. These
findings indicate a widespread encephalopathic condition
affecting both
cortical and subcortical structures. Medications, metabolic
disease,
and infection are among the most common causes. There were no
focal
abnormalities. Also, encephalopathies might obscure focal
findings.
There were no epileptiform features.
[**2169-3-23**] 12:23PM BLOOD Lactate-0.9
[**2169-3-23**] 10:53AM BLOOD Type-ART Rates-[**10-4**] Tidal V-550 PEEP-5
FiO2-100 pO2-596* pCO2-40 pH-7.36 calHCO3-24 Base XS--2 AADO2-99
REQ O2-27 Intubat-

INTUBATED
[**2169-3-23**] 12:05PM BLOOD calTIBC-209* VitB12-398 Folate-4.2
Ferritn-198 TRF-161*
[**2169-3-23**] 12:05PM BLOOD TSH-3.2
[**2169-3-24**] 03:45AM BLOOD Vanco-7.8*
[**2169-3-23**] 12:05PM BLOOD Albumin-3.5 Calcium-8.8 Phos-4.2 Mg-2.1
Iron-20*
[**2169-4-1**] 06:25AM BLOOD Calcium-9.5 Mg-2.3
[**2169-3-23**] 12:05PM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2169-3-24**] 03:45AM BLOOD CK-MB-5 cTropnT-0.18*
[**2169-3-23**] 12:05PM BLOOD Lipase-47
[**2169-3-23**] 12:05PM BLOOD ALT-8 AST-17 CK(CPK)-77 AlkPhos-103
Amylase-179*
[**2169-3-23**] 12:05PM BLOOD Glucose-123* UreaN-78* Creat-2.9* Na-142
K-4.5 Cl-107 HCO3-24 AnGap-16
[**2169-4-1**] 06:25AM BLOOD Glucose-92 UreaN-86* Creat-2.4* Na-141
K-4.9 Cl-110* HCO3-22 AnGap-14
[**2169-3-23**] 12:05PM BLOOD PT-14.1* PTT-35.8* INR(PT)-1.3
[**2169-4-1**] 06:25AM BLOOD Plt Ct-217
[**2169-3-23**] 12:05PM BLOOD Neuts-81.1* Lymphs-13.3* Monos-4.4
Eos-0.8 Baso-0.4
[**2169-3-23**] 12:05PM BLOOD WBC-5.2 RBC-2.90* Hgb-9.3* Hct-27.7*
MCV-95 MCH-32.0 MCHC-33.6 RDW-14.2 Plt Ct-123*
[**2169-4-1**] 06:25AM BLOOD WBC-5.7 RBC-3.10* Hgb-9.8* Hct-30.6*
MCV-99* MCH-31.6 MCHC-32.0 RDW-14.6 Plt Ct-217

Brief Hospital Course:
Mr [**Known lastname 60914**] was admitted to the MICU and then transferred to
Medicine with a presumed Varicella-Zoster Virus
meningoencephalitis. He made dramatic neurologic recovery, on
acyclovir, over his hospital stay. His presentation was
complicated by a left lower lobe pneumonia and a right lower
extremity cellulitis.

87M H/O HTN, CKD, CHF (EF>55%) with facial VZV infection and
obtundation S/P ICU/Intubation Course for presumed viral
meningitis - also with LLL PNA and RLE cellulitis; continues to
make dramatic clinical improvement re: MS, but still dysarthric.

1) Meningoencephalitis: He presented with a change in mental
status, and concominant hallucinations. Given his extrememely
depressed consiousness on presentation to the outside hospital,
he was intubated for airway protection. Given his facial Zoster,
an infection and extension into the CNS was presumed. Head CT
showed only hyperdensities right and left parietal lobes (likely
artifact per Rads report). An EEG was consistent with
encephalopathy. An RPR, TSH and B12 were negative or normal. The
initial CSF was only mildly inflammatory (WBC of 11, TP of
82)which could have been consistent with a  possible VZV
meningitis (and encephilitis). HSV or alternate viral agents
were also possible. The OSH was not able to run CSF for viral
studies, but he was treated empirically for HSV and VZV with a
two week course of Acyclovir 800 mg IV Q24H. He was followed by
the ID service. Other bacterial agents were initially covered.
As mentioned, over the early and middle part of his course, he
was only arousable to painful stimuli and showed signs of
brainstem dysfunction (alternating tachynpea and bradypnea,
possible intermittent decorticate posturing, and asymmetric
pupils). He made dramatic improvement over a period of two to
three days and soon became oriented to person, place, time, was
able to follow all commands, joked with the medical team, passed
a swallowing evaluation, and participated (ambulated) with
physical therapy.

2) LLL PNA: The patient arrived to [**Hospital1 18**] intubated (mainly for
airway protection) and not respiratory failure. An incidental
PNA was noted at the OSH and had a modest O2 requirement for the
first half of his course. He was extubated a few days into his
course. He was soon comfortable on RA. He was continued on
Levofloxacin 250 mg PO Q24H and Metronidazole 500 mg PO Q8H for
CAP/Aspiration PNA coverage for a ten day course.

4) R Facial(CNV-V1)/Ophtho VZV: This also improved with ACV. He
was seen by ophthalmology VZV eye-involvement. He was started on
Dorzolamide 2% Ophth. Soln. 1 DROP OD TID and Prednisolone
Acetate 1% Ophth. Susp. 1 DROP OD QID and was set-up with
outpatient follow-up.

5) CKD: He had a baseline creatinine of 2.1 to 2.7. He was S/P
LUE AVF (in preparatuib for HD). He remained at his baseline for
most of his course.

6) Hypothyroidism: He was continued on his home dose of
Levothyroxine Sodium 125 mcg PO DAILY. Again, his TSH was
normal.

7) Anemia: His HCT was in the low 30's and stable for most of
the course and intiatlly nadired at 27. He had an unknown
baseline. The etiology was likely a combination of
EPO-deficiency and an anemia of chronic inflammation. His iron
studies, B12 and folate were essentially normal.

8) FEN: After IV hydration early in his course, he was mainted
on PPN. After passing the swallow evaluation, he was give the
following diet: Consistency: Ground; Thin liquids.

9) Code: He was full code, which was confirmed with his wife.

Medications on Admission:
1) Levoxyl 125 mg PO DAILY
2) Allopurinol 100 mg PO DAILY
3) Lasix 80 mg PO DAILY
4) Valtrex 1 g PO TID
5) Azmacort
6) Lorazepam 0.5 mg PO DAILY PRN

Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic  QID (4 times a day) as needed for uveitis: Please
take until seen by an eye doctor, for your scheduled
appointment.
3. Dorzolamide HCl 2 % Drops Sig: One (1) Drop Ophthalmic  TID
(3 times a day): Please take until seen by an eye doctor, for
your scheduled appointment.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) for 2 days.
11. Acyclovir Sodium 500 mg Recon Soln Sig: Eight Hundred (800)
mg Intravenous  Q24H (every 24 hours) for 2 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]

Discharge Diagnosis:
Primary Diagnsosis:
1) Varicella-Zoster Virus Meningoencephalitis.
2) Left Lower Lobe Pneumonia.
3) Right Foot Cellulitis.

Secondary Diagnosis:
4) Chronic Kidney Disease.
5) Hypertension.


Discharge Condition:
Fair/Stable

Discharge Instructions:
1) Please call your doctor if you have a rash, fevers, chills,
confusion, or any other concenring symptoms.

2) Please speak to you primary doctor about receiving the
Pneumococcal vaccine to protect you from a certain type of
Pneumonia. You will also need to speak to your primary doctor
about restarting your Lasix and possibly adding an ACE-inhibitor
to your regimen.

3) Take your medicines as instructed.

Followup Instructions:
1) Please see your doctor (LITTLE,[**Doctor Last Name **] C. [**Telephone/Fax (1) 60915**]) in the
week following your discharge from the rehab.

2) Please see the ophthalmologists at [**Hospital1 18**] ([**Telephone/Fax (1) 253**]) for
the following appointment:

Provider [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Where: [**Hospital6 29**] [**Hospital1 37213**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2169-4-18**] 9:00.


                             [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
{'Postvaricella encephalitis,Pneumonia, organism unspecified,Chronic airway obstruction, not elsewhere classified,Cellulitis and abscess of foot, except toes,Hyperosmolality and/or hypernatremia,Secondary iridocyclitis, infectious,Unspecified acquired hypothyroidism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}


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: S/P Fall with Agitation

PRESENT ILLNESS: The paitent is an 87 year old man with a history of HTN, CKD,
CHF (EF>55%) who presented from an outside hospital (OSH) with
suspected meningitis. He was in his usual state of health until
[**2169-3-16**], one week prior to admission to this hospital
when he developed a rash on the upper portion of his right face.
He then went to his primary doctor, who diagnosed him with
facial Zoster and prescribed him Valtrex 1 g TID. Later that
day, per his wife, he began having intermittent visual and
auditory hallucinations along with progressive and intermittent
confusion. He also had a stiff neck. There were no fevers,
chills or rigors. He was seen by an ophthomologist on [**3-21**], [**2168**], with a reportedly normal exam.

MEDICAL HISTORY: CHF ([**9-/2168**]: EF 60-65%), CKD (Baseline Cr 2.7-2.7) S/P LUE AVF
(In Prep for HD), Hypothyroidism, Gout, Emphysema/COPD, Anxiety,
S/P R THR x 2.

MEDICATION ON ADMISSION: 1) Levoxyl 125 mg PO DAILY
2) Allopurinol 100 mg PO DAILY
3) Lasix 80 mg PO DAILY
4) Valtrex 1 g PO TID
5) Azmacort
6) Lorazepam 0.5 mg PO DAILY PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T98 HR53 BP128/62 RR17 OS100% (AC: TV 500, Rate 16; FIO2 40%,
PEEP 5)
GEN - ELDERLY APPEARING. ADENTULOUS. INTUBATED AND SEDATED.
SKIN - RIGHT UPPER FACIAL CRUSTED VESICULAR LESIONS WITH
UNDERLYING ERYTHEMA (NO CROSSING OF THE MIDLINE).
HEENT - ANICTERIC. B/L CONJ INJECTION. NO LAD. MM DRY.
NECK - STIFF.
RESP - COARSE BS AT B/L BASES. GOOD FLOW WITHOUT ADVENTIOUS BS
ELSEWHERE.
CV - BRADY AND REGULAR. NML S1/S2. NO MGR.
ABD - S/NT/ND. POS BS. NO HSM.
EXT - NO CCE. WARM. DP1+. LEFT UUE WITH AVF (PALP THRILL AND
AUDIBLE BRUIT).
NEURO - SEDATE. RIGHT PUPIL AT 2MM, LEFT PUPIL AT 1.5MM WITH B/L
REACTIVITY. FACIAL GRIMACE SYM. GAG INTACT. WITHDRAWS UE, BUT
NOT LE, TO PAIN STIMULUS. TOE DOWNGOING. DTR 2+ BICEPS, 2+ (MORE
BRISK THAN UE, BUT NO SPREAD) PATELLAR.

FAMILY HISTORY: Not obtained.

SOCIAL HISTORY: He lived with his wife and was a prior smoker. There was not
history of excessive ETOH use or illicit drug use. 

### Response:
{'Postvaricella encephalitis,Pneumonia, organism unspecified,Chronic airway obstruction, not elsewhere classified,Cellulitis and abscess of foot, except toes,Hyperosmolality and/or hypernatremia,Secondary iridocyclitis, infectious,Unspecified acquired hypothyroidism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}
