CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: 25 yo gentleman with remote hx brain PNET s/p LS internal shunt
placement for increased ICP in [**2101**], who now presents to the ED
with AMS.  Per the pt's family, the patient had not been feeling
well starting last wed, with complaints c/w URI including cough,
fever, chills, myalgias, lethargy, diarrhea and decreased PO
intake which progressed throughout the week.  They also stated
that he had difficulty navigating around the house which he is
usually able to do despite legal blindness.  Several family
members have been ill with URI symptoms.  He did not feel well
enought for work/usual activities on Tuesday/Wed and therefore
stayed home.  When his parents left on Wed morning, he was
feeling sick and staying in bed, but MS was normal.  When they
returned Wed night, they found him down on the floor of his
room, altered and incontinent of urine and therefore called EMS.
 No seizure activity was observed.  He didrecieve his flu
vaccine this year.
.
In the ED, initial vs were: T102.9 P130 BP 111/67 R17-29 O2 sat
93% on 4L. CXR/chest CT performed and was concerning for a
R-sided PNA.  Neurosurgery was consulted out of concern for
infected shunt/meningitis and ceftriaxone, azithro and vanc were
started and he was given tylenol for fever.  After vancomycin
was administered, breathing became more difficult and stridorous
and pt was intubated and treated for anaphylactic reaction with
epipen, solumedrol, famotidine and benadryl.  LP was not done
given pulmonary source was thought to be more likely and pt
would require IR-guided tap given hx of shunt.  CT abd/pelvis
was performed and showed no evidence of infection.  A foley was
placed for a distended bladder and he was started on 5 L NC.  He
was also given 3-4 L IVF.
.
On arrival on the floor he is intubated and sedated, not
responsive to voice.
.
Review of systems (per father, pt unable to respond):
(+) Per HPI
(-) Denies headache, neck pain/stiffness, sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath, or
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies rashes or skin changes.  No confusion prior to
Wed evening.  Mild dizziness.

MEDICAL HISTORY: -Primitive Neuroectodermal Tumor dx'd at age 10, s/p radiation
treatment
-meningioma resection [**2111**]
-LS shunt last revised in [**2104**]
-CCY
-hernia repair
-appendectomy
-panhypopituitarism
-blindness, some residual peripheral vision
-OSA on CPAP
-Hearing loss, R> L, hearing aid in L eye
-hx steroid induced psychosis
-diastolic htn

MEDICATION ON ADMISSION: 1. citalopram 40 mg qAM
2. hydrocortisone 10 mg q AM, 5 q PM
3. omeprazole 20 mg q AM
4. testim 50 mg/5 g PRN
5. divalproex 500 mg [**Hospital1 **]
6. synthroid 175 daily
7. lopressor ER 25 q day
8. zyprexa 10 mg q PM
9. topiramate 50 mg q PM
10. fiber con
11. MV
12. Fish oil

ALLERGIES: Dilantin Kapseal / Vancomycin

PHYSICAL EXAM: ADMISSION PEx:
Vitals: T:101.6 BP:111/57 P:107 R:20 18 O2:99%
General: Intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils minimally
reactive
Neck: supple, JVP not elevated, no LAD, no rigidity
Lungs: ventilated, no rhonchi or rales
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sedated, unable to fully assess.  Reflexes diminished
throughout.  Babinski indeterminate.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: lives with mother and father.  Graduated high school, some
college, attends art programs.  Generally independent at
baseline.  Has been employed at [**Hospital3 **] delivering
meds. No tobacco, alcohol, or illicts.
Pneumonitis due to inhalation of food or vomitus,Other and unspecified mycoses,Other conditions of brain,Hyposmolality and/or hyponatremia,Other anaphylactic reaction,Acute respiratory failure,Pneumonia, organism unspecified,Examination of participant in clinical trial,Legal blindness, as defined in U.S.A.,Other specified antibiotics causing adverse effects in therapeutic use,Epilepsy, unspecified, without mention of intractable epilepsy,Iatrogenic pituitary disorders,Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Unspecified hearing loss,Personal history of malignant neoplasm of brain,Presence of cerebrospinal fluid drainage device,Anemia, unspecified
Food/vomit pneumonitis,Mycoses NEC & NOS,Brain conditions NEC,Hyposmolality,Other anaphylactic react,Acute respiratry failure,Pneumonia, organism NOS,Exam-clincal trial,Legal blindness-usa def,Adv eff antibiotics NEC,Epilep NOS w/o intr epil,Iatrogenic pituitary dis,Hypertension NOS,Depressive disorder NEC,Obstructive sleep apnea,Hearing loss NOS,Hx of brain malignancy,Ventricular shunt status,Anemia NOS
Admission Date:  [**2119-2-15**]              Discharge Date:   [**2119-2-28**]

Date of Birth:  [**2093-7-23**]             Sex:   M

Service: MEDICINE

Allergies:
Dilantin Kapseal / Vancomycin

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
-intubation/extubation
-bronchoscopy
-lumbar puncture
-placement/removal of arterial line, PICC line, central venous
line


History of Present Illness:
25 yo gentleman with remote hx brain PNET s/p LS internal shunt
placement for increased ICP in [**2101**], who now presents to the ED
with AMS.  Per the pt's family, the patient had not been feeling
well starting last wed, with complaints c/w URI including cough,
fever, chills, myalgias, lethargy, diarrhea and decreased PO
intake which progressed throughout the week.  They also stated
that he had difficulty navigating around the house which he is
usually able to do despite legal blindness.  Several family
members have been ill with URI symptoms.  He did not feel well
enought for work/usual activities on Tuesday/Wed and therefore
stayed home.  When his parents left on Wed morning, he was
feeling sick and staying in bed, but MS was normal.  When they
returned Wed night, they found him down on the floor of his
room, altered and incontinent of urine and therefore called EMS.
 No seizure activity was observed.  He didrecieve his flu
vaccine this year.
.
In the ED, initial vs were: T102.9 P130 BP 111/67 R17-29 O2 sat
93% on 4L. CXR/chest CT performed and was concerning for a
R-sided PNA.  Neurosurgery was consulted out of concern for
infected shunt/meningitis and ceftriaxone, azithro and vanc were
started and he was given tylenol for fever.  After vancomycin
was administered, breathing became more difficult and stridorous
and pt was intubated and treated for anaphylactic reaction with
epipen, solumedrol, famotidine and benadryl.  LP was not done
given pulmonary source was thought to be more likely and pt
would require IR-guided tap given hx of shunt.  CT abd/pelvis
was performed and showed no evidence of infection.  A foley was
placed for a distended bladder and he was started on 5 L NC.  He
was also given 3-4 L IVF.
.
On arrival on the floor he is intubated and sedated, not
responsive to voice.
.
Review of systems (per father, pt unable to respond):
(+) Per HPI
(-) Denies headache, neck pain/stiffness, sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath, or
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies rashes or skin changes.  No confusion prior to
Wed evening.  Mild dizziness.

Past Medical History:
-Primitive Neuroectodermal Tumor dx'd at age 10, s/p radiation
treatment
-meningioma resection [**2111**]
-LS shunt last revised in [**2104**]
-CCY
-hernia repair
-appendectomy
-panhypopituitarism
-blindness, some residual peripheral vision
-OSA on CPAP
-Hearing loss, R> L, hearing aid in L eye
-hx steroid induced psychosis
-diastolic htn

Social History:
lives with mother and father.  Graduated high school, some
college, attends art programs.  Generally independent at
baseline.  Has been employed at [**Hospital3 **] delivering
meds. No tobacco, alcohol, or illicts.


Family History:
non-contributory

Physical Exam:
ADMISSION PEx:
Vitals: T:101.6 BP:111/57 P:107 R:20 18 O2:99%
General: Intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils minimally
reactive
Neck: supple, JVP not elevated, no LAD, no rigidity
Lungs: ventilated, no rhonchi or rales
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sedated, unable to fully assess.  Reflexes diminished
throughout.  Babinski indeterminate.

DISCHARGE PEx:
VS: afebrile (Tm = 99.7), BP 108-123/70-89, 80-100,
20@97%(CPAP), 96-97%RA
Gen: NAD. Hard of hearing (deaf on R), blind.  Sleeping in bed,
wakes to voice but still sleepy.
HEENT: Sclera anicteric, pupils minimally reactive but PERRL.
Lungs: anteriorly and laterally clear to auscultation, poor
cooperation with air movement, coarse upper airway sounds
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley, groin rash that extends to buttocks and low back,
more erythemic confluence in groin, but patchy towards borders,
overlying desquamation but no purulence, fluctuance, weeping
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: follows commands, interactive.  Hard of hearing and eyes
as above.  Strength symmetric.


Pertinent Results:
ADMISSION LABS:
[**2119-2-16**] 12:40AM BLOOD WBC-7.1 RBC-3.88* Hgb-12.1* Hct-35.3*
MCV-91 MCH-31.3 MCHC-34.4 RDW-14.4 Plt Ct-151
[**2119-2-16**] 12:40AM BLOOD Neuts-60.9 Lymphs-31.9 Monos-5.9 Eos-0.6
Baso-0.7
[**2119-2-16**] 12:40AM BLOOD PT-14.0* PTT-28.9 INR(PT)-1.2*
[**2119-2-16**] 12:40AM BLOOD Glucose-83 UreaN-12 Creat-1.1 Na-131*
K-7.9* Cl-95* HCO3-29 AnGap-15
[**2119-2-16**] 05:52AM BLOOD ALT-71* AST-119* LD(LDH)-319*
CK(CPK)-4450* AlkPhos-61 TotBili-0.3
[**2119-2-16**] 12:40AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.9
.
PERTINENT LABS:
[**2119-2-16**] 05:52AM BLOOD CK-MB-9 cTropnT-<0.01
[**2119-2-16**] 03:07PM BLOOD Ammonia-57
.
LABS PRIOR TO DISCHARGE ([**2119-2-27**]):
White Blood Cells 11.3
Hemoglobin 10.4*
Hematocrit 30.8*
MCV 92
Platelet Count 207
Chem panel wnl
.
MICROBIOLOGY:
[**2119-2-16**] Blood Cx: negative
[**2119-2-16**] Urine Cx: negative
[**2119-2-16**] Urine Legionella: negative
[**2119-2-16**] Influenza DFA: negative
[**2119-2-16**] Rapid Viral Screen/Cx: negative
[**2119-2-16**] BAL:
   GRAM STAIN (Final [**2119-2-16**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
   RESPIRATORY CULTURE (Final [**2119-2-18**]):    NO GROWTH, <1000
CFU/ml.
   LEGIONELLA CULTURE (Final [**2119-2-23**]):    NO LEGIONELLA
ISOLATED.
   Immunoflourescent test for Pneumocystis jirovecii (carinii)
NEGATIVE
   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
[**2119-2-16**] CSF: negative
[**2119-2-17**] legionella sputum culture: negative
[**2119-2-18**] urine, blood culture x2: negative
.
IMAGING:
[**2119-2-15**] CXR: Right middle lobe pneumonia.
.
[**2119-2-15**] CT Head:
1. No acute intracranial hemorrhage or mass effect. Hypodense
areas may relate to prior radiation treatment or
microangiopathic changes. However, MR without and with contrast
can be considered if not contra-indicated for better assessment
of the parenchymal abnormalities and excluding acute conditions
such as infarction.
2. Mildly dilated ventricles- may relate to volume loss.
Attention on close folow up to exclude hydrocephalus given the
h/o Lumbar drain and altered mental status.
3. Diffuse cortical calcification along with basal ganglia and
cerebellar calcifications most likely represents mineralizing
microangiopathy from radiation therapy, or other etiology,
metabolic/infectious etiologies, etc. Correlate clinically.
.
[**2119-2-15**] CT C-Spine: Motion limited study. No gross fracture. If
there is concern for cord, ligamentous or neural injury,
consider MR if not contra-indicated. Thyroid not well seen-
correlate with hormone labs.
.
[**2119-2-16**] CT Abdomen/Pelvis:
1. Middle lobe consolidation as described.
2. Enlarged fatty liver.
3. Minimal pelvic free fluid which may be related to the shunt.
No localized fluid collection is seen.
.
[**2119-2-16**] CTA Chest:
1. No pulmonary embolism or acute aortic pathology.
2. Severe multifocal pneumonia predominantly in the right middle
lobe, mildly in the right upper lobe and minimally in the right
lower lobe.
3. Subtotal collapse of left lower lobe. Mild atelectasis in the
right lower lobe.
4. Severely and diffusely fatty liver. Bilateral gynecomastia.
.
[**2119-2-17**], EEG, IMPRESSION: This is an abnormal video EEG due to
the presence of a slow background which reached a 7 Hz maximum
representing a mild encephalopathy. It is also abnormal due to
the presence of delta
frequency slowing, greater appreciated on the right which
demonstrates
additional subcortical dysfunction, more focally severe on the
right
side. Excessive beta frequency activity was seen likely from
drug
effect from, most commonly, benzodiazepines or barbiturates.
There were
no clear epileptiform discharges or electrographic seizures
seen.
.
[**2119-2-17**] ECHO: The left atrium is normal in size. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast at rest. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
.
[**2119-2-17**] MRI Head: No evidence of acute infarct. Diffuse white
matter changes and calcification and mineralization as well as
several cystic areas likely related to prior radiation. Chronic
encephalomalacia, right frontal lobe. No definite enhancing mass
seen, but diffuse pachymeningeal enhancement is noted which
could be related to prior radiation and lumbar punctures. No
definite leptomeningeal enhancement is seen. A small 8-mm pineal
cyst is incidentally noted. Assessment for interval change is
limited in absence of prior images. Mild mucosal thickening and
soft tissue changes are seen within the paranasal sinuses, which
could be related to intubation.
.
[**2119-2-18**], EEG, IMPRESSION: This is an abnormal video EEG due to
the presence of a slow background reaching a maximum of 7 Hz
which represents a mild encephalopathy. It is also abnormal due
to the presence of superimposed R>L delta frequency slowing
which represents subcortical dysfunction. There were no
epileptiform discharges or electrographic seizures.
.
[**2119-2-19**], EEG, IMPRESSION: This is an abnormal video EEG due to
the presence of a slow background which reached a maximum of 7
Hz which represents a mild encephalopathy. Additionally, there
is R>L delta frequency slowing which represents subcortical
dysfunction, greater on the right than on the left. There were
no epileptiform discharges or electrographic seizures.
.
[**2119-2-23**], CXR, FINDINGS: As compared to the previous radiograph,
the patient has been extubated and the nasogastric tube has been
removed. A new right PICC line has been inserted. The course of
the line is unremarkable, the tip of the line is not clearly
visualized. However, the course of the line indicates that the
tip is located in the right atrium. The line should be pulled
back by 5 cm, then a repeat radiograph should be performed. The
PICC line team was paged for notification at the time of
dictation, 11:23, [**2119-2-23**]. There is no evidence of
complications, notably no pneumothorax. Improved transparency of
the lung parenchyma reflects improved ventilation, pre-existing
bilateral areas of atelectasis have resolved.

Brief Hospital Course:
HOSPITAL STATEMENT:
25 yo man with remote history of brain primary neuroectodermal
tumor and LP shunt who was brought to the ED for altered mental
status, found to have a multifocal pneumonia and questionable
post-ictal findings on EEG.

ACTIVE ISSUES:

# Pneumonia: On admission, the patient's recent prodromal
symptoms were suggestive of influenza with bacterial
superinfection. He was started on oseltamavir until viral screen
returned negative for flu.  CXR revealed R lobar pneumonia.
Patient was empirically started on vancomycin, azithromycin, and
ceftriaxone in the ED but developed an anaphylactic reaction,
likely to the vancomycin, requiring epinephrine, solumedrol,
famotidine, and benadryl, and ultimately intubation for airway
protection.  He was then continued on azithromycin and
ceftriaxone, and linezolid was added as well for better gram
positive coverage.  CT chest revealed multifocal pneumonia. A
bronchoscopy revealed gram positive cocci in pairs.  He finished
5 days of azithromycin on [**2-20**]. On [**2-21**], he was extubated and
his antibiotic regimen was narrowed only to Ceftriaxone.  He was
transferred to the floor on [**2-23**].  He completed a 10-day course
of Ceftriaxone, and at the time of discharge, had good
oxygenation on room air.

# Altered Mental Status: Neurology and neurosurgery were
consulted given AMS and wide differential in this patient with
prior CNS manipulation (shunt), tumor history, and seizure
disorder.  CSF negative for meningitis.  EEG done in the ICU was
without evidence of ongoing seizure activity, but there was some
concern for a post-inctal state.  CT head w/o evidence of
infection, though did show some hypodensities concerning for
possible CVA.  Therefore MRI was done, and showed some chronic
changes (likely from prior radiation therapy) but no acute
process.  Blood and urine cultures were negative.  The patient's
AMS was felt most likely due to his pneumonia and unclear
post-ictal state.  The patient's mental status continued to
clear throughout admission.  Dose of valproic acid increased to
500mg TID prior to discharge.

# Panhypopituitarism: Secondary to treatment of PNET.  Given
stress-dose steroids initially, but transitioned to oral home
steroid dose and synthroid prior to discharge.

# Groin rash, fungal: Patient was noted to have a groin rash
that was thought to be fungal in nature, especially given his
incontinence and bed-rest in the ICU.  He was given topical
antifungal powder/cream, and the rash improved slightly while on
the floor.  Discharged with topical antifungals.

# Diastolic HTN:  Patient's diastolic BPs were noted to be
elevated, so his lopressor (which he takes for migraine
prophylaxis) dose was increased to 50mg daily.

INACTIVE ISSUES:

# GERD: Continued omeprazole.

# Depression/history of steroid-induced psychosis: Continued
citalopram, zyprexa.

# Migraines: continued lopressor with above mentioned dose
adjustment.

# Code: full

Medications on Admission:
1. citalopram 40 mg qAM
2. hydrocortisone 10 mg q AM, 5 q PM
3. omeprazole 20 mg q AM
4. testim 50 mg/5 g PRN
5. divalproex 500 mg [**Hospital1 **]
6. synthroid 175 daily
7. lopressor ER 25 q day
8. zyprexa 10 mg q PM
9. topiramate 50 mg q PM
10. fiber con
11. MV
12. Fish oil

Discharge Medications:
1. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. olanzapine 10 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
3. hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
4. hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. citalopram 40 mg Tablet Sig: One (1) Tablet PO qAM.
7. topiramate 100 mg Tablet Sig: 0.5 Tablet PO QPM (once a day
(in the evening)).
8. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
10. clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for rash.
Disp:*1 bottle* Refills:*0*
11. multivitamin  Oral
12. FiberCon  Oral
13. Fish Oil  Oral
14. Testim 50 mg/5 gram (1 %) Gel Sig: One (1) appl Transdermal
as previously directed as needed for as previously directed.
15. nystatin 100,000 unit/g Powder Sig: One (1) appl Topical
twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Primary:
-Pneumonia
-Seizure disorder
-Allergic reaction (anaphylaxis)
-Fungal groin rash

Secondary:
-Migraines
-Hypertension (diastolic)
-Obstructive sleep apnea
-Hard of hearing
-Blind
-Pan-hypopituitarism


Discharge Condition:
Mental Status: Clear and coherent, but hard of hearing and
legally blind.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].  You were
admitted because you were confused, lethargic, and your parents
were concerned.  You were found to have a pneumonia, and were
treated initially with vancomycin (an antibiotic).  However, you
had a severe allergic reaction to this medication (anaphylaxis),
and needed to be intubated.  You initially went to the ICU, but
once you had the breathing tube removed and your oxygen levels
were good enough, you were transferred to the floor, where you
continued to get stronger.  You had a full course of antibiotics
while hospitalized.  We're still not sure if you had a seizure,
but the EEG that you had indicates that you may have.  The
neurologists, infectious disease doctors, and neurosurgeons saw
you while you were here.

The following changes were made to your medications:
-INCREASE valproic acid to 500mg THREE times a day
-INCREASE metoprolol to 50mg daily
-START clotrimazole cream and nystatin powder as needed for your
rash

Followup Instructions:
Please call your Primary Care Physician [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 2205**] to make
follow-up appointment within 1 week of leaving rehab.  Please
also call your neurologist to schedule follow-up after leaving
rehab.
{'Pneumonitis due to inhalation of food or vomitus,Other and unspecified mycoses,Other conditions of brain,Hyposmolality and/or hyponatremia,Other anaphylactic reaction,Acute respiratory failure,Pneumonia, organism unspecified,Examination of participant in clinical trial,Legal blindness, as defined in U.S.A.,Other specified antibiotics causing adverse effects in therapeutic use,Epilepsy, unspecified, without mention of intractable epilepsy,Iatrogenic pituitary disorders,Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Unspecified hearing loss,Personal history of malignant neoplasm of brain,Presence of cerebrospinal fluid drainage device,Anemia, 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: altered mental status

PRESENT ILLNESS: 25 yo gentleman with remote hx brain PNET s/p LS internal shunt
placement for increased ICP in [**2101**], who now presents to the ED
with AMS.  Per the pt's family, the patient had not been feeling
well starting last wed, with complaints c/w URI including cough,
fever, chills, myalgias, lethargy, diarrhea and decreased PO
intake which progressed throughout the week.  They also stated
that he had difficulty navigating around the house which he is
usually able to do despite legal blindness.  Several family
members have been ill with URI symptoms.  He did not feel well
enought for work/usual activities on Tuesday/Wed and therefore
stayed home.  When his parents left on Wed morning, he was
feeling sick and staying in bed, but MS was normal.  When they
returned Wed night, they found him down on the floor of his
room, altered and incontinent of urine and therefore called EMS.
 No seizure activity was observed.  He didrecieve his flu
vaccine this year.
.
In the ED, initial vs were: T102.9 P130 BP 111/67 R17-29 O2 sat
93% on 4L. CXR/chest CT performed and was concerning for a
R-sided PNA.  Neurosurgery was consulted out of concern for
infected shunt/meningitis and ceftriaxone, azithro and vanc were
started and he was given tylenol for fever.  After vancomycin
was administered, breathing became more difficult and stridorous
and pt was intubated and treated for anaphylactic reaction with
epipen, solumedrol, famotidine and benadryl.  LP was not done
given pulmonary source was thought to be more likely and pt
would require IR-guided tap given hx of shunt.  CT abd/pelvis
was performed and showed no evidence of infection.  A foley was
placed for a distended bladder and he was started on 5 L NC.  He
was also given 3-4 L IVF.
.
On arrival on the floor he is intubated and sedated, not
responsive to voice.
.
Review of systems (per father, pt unable to respond):
(+) Per HPI
(-) Denies headache, neck pain/stiffness, sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath, or
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies rashes or skin changes.  No confusion prior to
Wed evening.  Mild dizziness.

MEDICAL HISTORY: -Primitive Neuroectodermal Tumor dx'd at age 10, s/p radiation
treatment
-meningioma resection [**2111**]
-LS shunt last revised in [**2104**]
-CCY
-hernia repair
-appendectomy
-panhypopituitarism
-blindness, some residual peripheral vision
-OSA on CPAP
-Hearing loss, R> L, hearing aid in L eye
-hx steroid induced psychosis
-diastolic htn

MEDICATION ON ADMISSION: 1. citalopram 40 mg qAM
2. hydrocortisone 10 mg q AM, 5 q PM
3. omeprazole 20 mg q AM
4. testim 50 mg/5 g PRN
5. divalproex 500 mg [**Hospital1 **]
6. synthroid 175 daily
7. lopressor ER 25 q day
8. zyprexa 10 mg q PM
9. topiramate 50 mg q PM
10. fiber con
11. MV
12. Fish oil

ALLERGIES: Dilantin Kapseal / Vancomycin

PHYSICAL EXAM: ADMISSION PEx:
Vitals: T:101.6 BP:111/57 P:107 R:20 18 O2:99%
General: Intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils minimally
reactive
Neck: supple, JVP not elevated, no LAD, no rigidity
Lungs: ventilated, no rhonchi or rales
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sedated, unable to fully assess.  Reflexes diminished
throughout.  Babinski indeterminate.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: lives with mother and father.  Graduated high school, some
college, attends art programs.  Generally independent at
baseline.  Has been employed at [**Hospital3 **] delivering
meds. No tobacco, alcohol, or illicts. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Other and unspecified mycoses,Other conditions of brain,Hyposmolality and/or hyponatremia,Other anaphylactic reaction,Acute respiratory failure,Pneumonia, organism unspecified,Examination of participant in clinical trial,Legal blindness, as defined in U.S.A.,Other specified antibiotics causing adverse effects in therapeutic use,Epilepsy, unspecified, without mention of intractable epilepsy,Iatrogenic pituitary disorders,Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Unspecified hearing loss,Personal history of malignant neoplasm of brain,Presence of cerebrospinal fluid drainage device,Anemia, unspecified'}
