CHIEF COMPLAINT: 

PRESENT ILLNESS: Ms [**Known lastname **] is an 18 year old female
transferred from [**Hospital6 33**] for further management
here at [**Hospital6 256**].  She had
previously been a very healthy 18 year old who is very active
in her school and sports.  Approximately four days prior to
admission she began feeling nauseated, vomiting and had
diarrhea (greenish) for several episodes.  She was feeling so
poorly that she stayed home from school one day, and felt
that she was very lethargic.  During that time period, she
was also having her menses.  When she was on day #4 of her
menses, she was feeling so poorly, that she stayed in bed,
and did not change her tampon for approximately 16 to 24
hours.  However, on menses day #1 through 3, she had been
changing her tampons regularly.  During the 24 hours prior to
admission, she noted an acute onset of lethargy, headaches,
and fevers.  She was brought to [**Hospital6 33**]
approximately 3 AM by her parents.  About that time, she had
diffuse erythroderma noted over her face, and chest.  She
complained of a sore throat and headache for greater than 24
hours, but did not have a stiff neck.  She was found to have
severe oropharynx injection with exudate and tonsillar
inflammation.  A rapid Streptococcus was negative.  She has a
history of multiple prior episodes of Streptococcus
pharyngitis.  Blood cultures times two were sent.  Urine
culture was sent.  Vaginal examination revealed a tampon in
place, and that was sent to Microbiology.  Her temperature at
[**Hospital6 33**] was 102.8, heartrate was in the 170s and
her initial systolic blood pressure was approximately 100.
However, within a short amount of time, her systolic blood
pressure dropped to the 70s, and she was only minimally
responsive to intravenous fluids.  She was given 8 liters of
fluid and her systolic blood pressure increased only to the
80s.  At that point in time, Dopamine was started.  In
addition, an lumbar puncture was done to rule out meningitis,
and it revealed two white blood cells, 13 red blood cells,
normal glucose and normal protein.  Initial chest x-ray was
reportedly unremarkable, but the patient had a significant
oxygen requirement (she was on a nonrebreather and face
mask).  Arterial blood gases done was 7.34/26/80.  Other
notable laboratory data included a white blood cell count of
19,000 (32% bands), creatinine 1.5, normal liver function
tests and her coags were increased to an INR of 2.6, PTT 60
with positive fibrin split products (FSP).  At [**Hospital6 3426**], she received 2 gm of Ceftriaxone, 2 gm of
Oxacillin, 500 mg of Azithromycin, 600 mg of Clindamycin.
She was then transferred to [**Hospital6 2018**] for further management.

MEDICAL HISTORY: 1.  Psoriasis, 2.  History of
Streptococcus pharyngitis.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is an 18 year old student,
senior in high school.  She lives at home with her family,
and has not had any recent travels.  She has had no sick
contacts.  She is an avid basketball player and is the
captain of her basketball team.  She was last sexually active
several months ago, and reports consistent condom use.  She
has a remote naval ring and tongue piercing.  She has a
tattoo on her lower back as well.  Positive tanning bed use.
Toxic shock syndrome,Acute and subacute necrosis of liver,Other pulmonary insufficiency, not elsewhere classified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Foreign body in vulva and vagina,Methicillin susceptible Staphylococcus aureus septicemia,Pulmonary congestion and hypostasis
Toxic shock syndrome,Acute necrosis of liver,Other pulmonary insuff,Mth sus Stph aur els/NOS,Foreign bdy vulva/vagina,Meth susc Staph aur sept,Pulm congest/hypostasis
Admission Date:  [**2178-5-9**]       Discharge Date: [**2178-5-14**]

Date of Birth:   [**2159-5-21**]       Sex:  F

Service:

ADDENDUM:  This Addendum goes to Job #[**Numeric Identifier 48840**].

HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED):

1.  MOBILITY ISSUES:  The patient was significantly
deconditioned after transfer from the Medical Intensive Care
Unit to the floor.

A Physical Therapy consultation was obtained, and Physical
Therapy worked with the patient for two days.  On the first
day, she was very weak and required assistance with walking.
On the second day of physical therapy, she was doing very
well.  She was able to walk up and down two flights of stairs
and ambulate without assistance.  Physical Therapy felt that
she was safe for discharge, as she was ambulating and walking
without assistance and doing well.




                         DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AFC


Dictated By:[**Last Name (NamePattern1) 14484**]
MEDQUIST36

D:  [**2178-5-14**]  15:25
T:  [**2178-5-14**]  18:00
JOB#:  [**Job Number 48841**]


Admission Date:  [**2178-5-9**]       Discharge Date:  [**2178-5-14**]

Date of Birth:   [**2159-5-21**]       Sex:  F

Service:  [**Location (un) 2655**]

HISTORY OF PRESENT ILLNESS:  Ms [**Known lastname **] is an 18 year old female
transferred from [**Hospital6 33**] for further management
here at [**Hospital6 256**].  She had
previously been a very healthy 18 year old who is very active
in her school and sports.  Approximately four days prior to
admission she began feeling nauseated, vomiting and had
diarrhea (greenish) for several episodes.  She was feeling so
poorly that she stayed home from school one day, and felt
that she was very lethargic.  During that time period, she
was also having her menses.  When she was on day #4 of her
menses, she was feeling so poorly, that she stayed in bed,
and did not change her tampon for approximately 16 to 24
hours.  However, on menses day #1 through 3, she had been
changing her tampons regularly.  During the 24 hours prior to
admission, she noted an acute onset of lethargy, headaches,
and fevers.  She was brought to [**Hospital6 33**]
approximately 3 AM by her parents.  About that time, she had
diffuse erythroderma noted over her face, and chest.  She
complained of a sore throat and headache for greater than 24
hours, but did not have a stiff neck.  She was found to have
severe oropharynx injection with exudate and tonsillar
inflammation.  A rapid Streptococcus was negative.  She has a
history of multiple prior episodes of Streptococcus
pharyngitis.  Blood cultures times two were sent.  Urine
culture was sent.  Vaginal examination revealed a tampon in
place, and that was sent to Microbiology.  Her temperature at
[**Hospital6 33**] was 102.8, heartrate was in the 170s and
her initial systolic blood pressure was approximately 100.
However, within a short amount of time, her systolic blood
pressure dropped to the 70s, and she was only minimally
responsive to intravenous fluids.  She was given 8 liters of
fluid and her systolic blood pressure increased only to the
80s.  At that point in time, Dopamine was started.  In
addition, an lumbar puncture was done to rule out meningitis,
and it revealed two white blood cells, 13 red blood cells,
normal glucose and normal protein.  Initial chest x-ray was
reportedly unremarkable, but the patient had a significant
oxygen requirement (she was on a nonrebreather and face
mask).  Arterial blood gases done was 7.34/26/80.  Other
notable laboratory data included a white blood cell count of
19,000 (32% bands), creatinine 1.5, normal liver function
tests and her coags were increased to an INR of 2.6, PTT 60
with positive fibrin split products (FSP).  At [**Hospital6 3426**], she received 2 gm of Ceftriaxone, 2 gm of
Oxacillin, 500 mg of Azithromycin, 600 mg of Clindamycin.
She was then transferred to [**Hospital6 2018**] for further management.

PAST MEDICAL HISTORY:  1.  Psoriasis, 2.  History of
Streptococcus pharyngitis.

PAST SURGICAL HISTORY:  None.

MEDICATIONS AS AN OUTPATIENT:  1.  Orthotricyclin; 2.
Antibiotics prn.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  The patient is an 18 year old student,
senior in high school.  She lives at home with her family,
and has not had any recent travels.  She has had no sick
contacts.  She is an avid basketball player and is the
captain of her basketball team.  She was last sexually active
several months ago, and reports consistent condom use.  She
has a remote naval ring and tongue piercing.  She has a
tattoo on her lower back as well.  Positive tanning bed use.

PHYSICAL EXAMINATION:  Vital signs on transfer to [**Hospital6 1760**], temperature maximum was
102.8, temperature currently 97.2, blood pressure 78/40s,
heartrate 130s, respiratory rate in the 20s, oxygen
saturation 96% on 100% nonrebreather.  On physical
examination this is in general a young woman in acute
distress.  Head, eyes, ears, nose and throat:  Conjunctival
hyperemia, extraocular movements intact, pupils equal, round
and reactive to light, anicteric.  Chest:  Rales at the right
one-third base, left lung was clear.  Cardiovascular:
Regular rhythm, tachycardiac with a rate in the 130s.
Abdomen, soft, nontender, nondistended, positive bowel
sounds.  Skin:  Diffuse erythema on the face, chest and arms.

LABORATORY DATA:  On admission (from the outside hospital)
white blood cell count 18.7, hematocrit 40.4, platelets 205,
61% neutrophils, 32% bands, sodium 134, potassium 3.6,
chloride 99, bicarbonate 18, BUN 30, creatinine 1.5, glucose
115, calcium 8.9, AST 39, ALT 22, total protein 6.7, albumin
3.7, alkaline phosphatase 53, total bilirubin 1.2, amylase
51, mono screen negative.  Cerebrospinal fluid, white blood
cells 2, red blood cells 3, cell count 3, glucose 72, total
protein 18.  Arterial blood gases, 7.34/26/80 on 2 liters of
nasal cannula, 95% oxygen saturation.

IMPRESSION:  An 18 year old female, previously healthy, who
had some sort of a viral gastroenteritis on her menstruation
days 1 through 3.  On the fourth day of her menstruation she
was feeling so ill from her gastroenteritis that she did not
change her tampon for approximately 16 to 24 hours.  She now
presents with an apparent toxic shock syndrome, with
hypotension, tachycardia, and erythroderma, febrile to 102
degrees.

HOSPITAL COURSE:  The patient was admitted to the Medical
Intensive Care Unit (MICU) and infectious disease consult was
obtained.  The patient was started on antibiotics with
Clindamycin and Oxacillin as well as vaginal Oxacillin.  She
was given intravenous immunoglobulin for her toxic shock
syndrome antibodies.  Blood cultures were drawn, and vaginal
vault cultures were drawn as well.  Otorhinolaryngology
evaluated her and their evaluation ruled out any
peritonsillar abscess or neck abscess.  On hospital day #2,
the patient continued to be very tachypneic with respiratory
rate in the 40s and blood gas revealed a pH of 7.1.  At this
point in time she was intubated.  She was kept on the
ventilator for one day, with resolution of her acidemia, and
her pH returned to 7.38, and a carbon dioxide of 30.  She was
extubated without event, and was observed in the Medical
Intensive Care Unit and then was transferred to the floor.
She was given voluminous amounts of  fluids to support her
hypertension.  At a certain point in the Medical Intensive
Care Unit she was on three pressors, (Dopamine,
Neo-Synephrine, Vasopressin), to support her blood pressure
in addition to the fluids.  After transfer to the floor, she
auto-diuresed and her urine output was very brisk.  While she
was in the Medical Intensive Care Unit her chest x-ray showed
interstitial increase in her edema, likely secondary to fluid
overload, however, after being on the floor, repeat chest
x-ray was obtained and showed significant resolution of
interstitial edema, this is likely secondary to the fact that
the patient is auto-diuresing and urine output was good, and
her pulmonary status was good.  She was breathing 96 to 97%
on room air and was very comfortable.

1.  Infectious disease - Vaginal vault swab was obtained and
a pelvic examination was done.  Speculum examination revealed
cervix with a closed os.  Mucopurulent appearing drainage in
the vaginal vault.  No foreign bodies noted.  Bimanual
examination revealed no cervical motion tenderness, no
adnexal tenderness, and no foreign body was felt.  The
vaginal vault as well was sent off for micro studies and they
subsequently revealed positive Staphylococcus aureus,
positive Escherichia coli.  Staphylococcus aureus was
sensitive to Clindamycin, sensitive to Methicillin and
resistant to Ampicillin.  Escherichia coli was pansensitive.
Infectious disease consultation was obtained, and they
recommended intravenous antibiotics of Oxacillin 2 gm
intravenously q. 4 hours, Clindamycin 900 mg intravenously q.
8 hours, Ceftriaxone 2 gm intravenously q. day.  The patient
was given his antibiotics and was also given intravenous
immunoglobulin for the treatment of Staphylococcal and
Streptococcal toxic shock syndrome.  In addition, [**Hospital 48862**]
Hospital sent to [**Hospital6 256**] the
patient's culture from the tampon.  These cultures have been
forwarded to the CDC to check for toxic production by the
Staphylococcus.  These are still pending at the time of
discharge.  On the day of discharge the patient was on day #6
of her antibiotics.  She is to start Dicloxacillin 500 mg
p.o. q.i.d. times eight days to complete a 14 day course of
antibiotics.  She is to follow up with Infectious Disease,
(Dr. [**Last Name (STitle) 48863**] on [**4-23**], at 10 AM.  She has been instructed
to not use tampons until further advised.  At the time of her
follow up appointment with Infectious Disease in one month,
she will have repeat serologies (convalescent) for antibodies
drawn.  We have discussed the risk of relapse with [**Known firstname 11709**]
and it is 30% in all patient's and the risk of relapse is
decreased if she is treated with Betalactam antibiotic as she
was.  Ultimately, whether or not she can use tampons will
depend on whether or not she forms antibodies to the toxic
shock syndrome toxin.  Until these convalescent titers are
drawn she has been instructed to not use tampons.

2.  Hypotension - Hypotension is likely secondary to toxic
shock syndrome toxin.  The patient was placed on pressors,
Neo-Synephrine, Vasopressin, as well as Dopamine during her
Medical Intensive Care Unit.  She was given voluminous
amounts of fluids to support her blood pressure as well.
After the intravenous immunoglobulin and antibiotics were
given she appeared to be less hypotensive and pressors were
weaned off.  After weaning off of pressors, she has been able
to maintain her blood pressure quite well with systolic 100
to 120s without events.

3.  Cardiovascular - Electrocardiogram showed some
rate-related ST depressions.  At that point in time her rate
was between the 140s to 150s.  Her creatinine kinases were
cycled and it was noted that she did have a troponin leak
with troponins in the range of 1 to 8 and her creatinine
kinases were in the range of 100 to 600, and MB fraction was
in the range of 2 to 20.  An echocardiogram was done and it
revealed decreased ejection fraction of 35%.  Her right
ventricle had a moderate global hypokinesis, her right
ventricle size and free wall motion were normal.  The
impression was there was moderate global left ventricular
global hypokinesis with a normal right ventricle.  There was
no pericardial effusion and no vegetations were seen.  This
was likely secondary to the toxic shock syndrome antibody and
toxic metabolic state, toxic metabolic assault to her
myocardium.  It is recommended that she have a repeat
echocardiogram done in three weeks after discharge.  This has
been discussed with her primary care physician, [**Name10 (NameIs) **] her
primary care physician will schedule [**Name Initial (PRE) **] follow up
echocardiogram in three to four weeks.

4.  Diarrhea - The patient had diarrhea prior to admission,
likely secondary to gastroenteritis.  In addition she also
had diarrhea during her hospital admission.  There is
question whether this was antibiotic-induced or not.
Clostridium difficile was sent off on [**2178-5-10**] and this
was negative, however, the patient continued to have diarrhea
and another Clostridium difficile was sent off on [**2178-5-14**], on the day of discharge.  The patient has been
instructed if she continues to have diarrhea to tell her
primary care physician and another Clostridium difficile will
be sent.  We will follow up on the Clostridium difficile
results here, and if it is positive, we will notify the
patient as well as her primary care physician.  [**Name10 (NameIs) **] negative,
no one will be notified.

5.  ? Pregnancy - The urine ACG as well as urine HCG were
negative.

6.  Culture data - Sputum culture showed contamination with
oropharyngeal secretions.  Respiratory culture showed no
predominance of any respiratory pathogens (no Streptococcus
pneumonia, no Hemophilus influenza, no M-Catarrhalis
evidence). Catheter tip (this was done after her right
internal jugular central line was taken out) showed
preliminarily no significant growth at the time of discharge.
 Blood cultures, at the time of discharge, blood cultures
showed no growth, this was still a preliminary result.  Urine
cultures, no growth.  Stool test, negative for Clostridium
difficile on [**2178-5-10**].  Vaginal cultures, negative for
Group B Beta Streptococcus.  Throat swab, negative for
Neisseria, Gonorrhea.  Throat swab, negative for Beta
Streptococcus Group A, with moderate growth of oropharyngeal
Flora.  Cultures from the vaginal swab from [**Hospital6 3426**] showed Staphylococcus aureus:  sensitive to
Clindamycin, sensitive to Methicillin, resistant to
Ampicillin.  It also grew out Escherichia coli pansensitive
to everything.

7.  Liver - As regards the toxic shock syndrome, the patient
also suffered an assault to her liver.  At various points
during her hospital admission, her liver enzymes were
elevated, with a high bilirubin up to 2.2, AST to 108, ALT
143, and LDH up to 503.  It was advised that the patient have
repeat liver function tests done in one week, to evaluate the
resolution.  She does not complain of any right upper
quadrant pain, and it is not tender to palpation in this
area.

8.  Pulmonary -  The patient was intubated on the evening of
[**2178-5-9**] (on the evening of hospital day #1) and was
subsequently extubated on [**2178-5-10**].  Serial chest
x-rays were done on the patient which initially showed
diffuse infiltrates, consistent with fluid overload or
pneumonic infiltrates or adult respiratory distress syndrome.
They also showed diffuse alveolar infiltrates as well.  After
she was extubated and breathing well on her own, a repeat
chest x-ray showed a significant interval improvement in her
pulmonary edema with just minimal interstitial edema
persistent.  There was still some patchy bibasilar
infiltrates, and a very small pleural effusion, but these
were both significantly improved.  At the day of discharge,
the patient was breathing quite well, sating 96 to 98% on
room air and was not dyspneic on exertion.  With the patient
auto-diuresed with her urine output being so brisk, she was
diuresing much of the fluid off and she should have full
resolution of the minimal pulmonary edema and pleural
effusions.  I suggest repeat chest x-ray in one to two weeks
with her primary care physician to evaluate the resolution.

9.  Hematology - It is a question of whether the patient had
heparin-induced thrombocytopenia.  The patient's initial
platelet counts were in the 200 range on the day of
admission, and subsequently decreased to 94,000 on [**2178-5-12**].  Heparin-induced thrombocytopenia (HIT) antibodies were
sent, which were positive.  At this point in time, the
patient was not given any more heparin.  The heparin
dependent antibodies were negative, PM4 antibody by [**Doctor First Name **].
This was a low positive result and it may represent
interference due to recent intravenous immunoglobulin
administration.  It is recommended to repeat the evaluation
by serotonin release assay.  This will be deferred to the
primary care physician, [**Last Name (NamePattern4) **] ? recheck heparin dependent
antibodies.

10.  Viral antibody panels - Ebstein-[**Doctor Last Name **] virus IgG positive,
Ebstein-[**Doctor Last Name **] virus IgM negative.  These results are
interpreted as indicative of a past Ebstein-[**Doctor Last Name **] virus
infection.  Monospot test was negative as well.  At the time
of discharge, the toxic shock antibody panel is pending.
When the patient follows up with Infectious Disease, the
toxic shock antibody panel results will be reviewed.  In
addition, at this point in time, the results from the CDC
(whether the Staphylococcus aureus culture produces toxins)
will also be reviewed.  The correlation between the antibody
production as well as toxin production, will be reviewed by
infectious disease to advise the patient on future management
options.

11.  Dermatology - The patient had diffuse erythroderma on
her chest, arms and face.  This slowly resolved throughout
the course of her admission.  On the day of discharge, she
was doing well with no evidence for erythroderma.  She was
cautioned that her hands and feet may declamate in the next
one to two weeks.  This should be expected and is not
abnormal.

DISPOSITION:  On the day of discharge, the patient is
afebrile, breathing very well, oxygen saturation 96 to 97% on
room air, hemodynamically stable.  Repeat chest x-ray
significantly improved.  She is ambulating and eating and she
is discharged in good condition.

MEDICATIONS ON DISCHARGE:
1.  Dicloxacillin 500 mg p.o. q.i.d. for eight days (from
[**2178-5-15**] through [**2178-5-22**])
2.  Dextromethorphan 5 to 10 cc q. 12 hours prn as needed for
cough

DISCHARGE DIAGNOSIS:
1.  Toxic shock syndrome
2.  Sepsis secondary to Staphylococcus aureus toxin
3.  Liver shock
4.  Cardiac dysfunction (globally depressed left ventricular
function), ejection fraction 35%
5.  Pulmonary edema secondary to capillary leak, secondary to
sepsis
6.  ? Heparin-induced thrombocytopenia.

FOLLOW UP APPOINTMENTS:
1.  The patient should follow up with her primary care
physician (Dr. [**First Name (STitle) **] in one week.  At her follow up
appointment she should have liver function tests (ALT, AST,
total bilirubin, alkaline phosphatase, her LDH) as well as
PT, PTT, and INR drawn to check for resolution/down trend.
If the patient's diarrhea/loose stools persist she is to tell
her primary care physician and have her Clostridium difficile
checked.  In addition, the patient needs a repeat
echocardiogram in three weeks, to evaluate her left
ventricular function.
2.  Follow up with Infectious Disease, (Kassuto) on [**2178-6-23**] at 10 AM.  At this point in time she will have
convalescent titers for antibodies drawn.

DISCHARGE INSTRUCTIONS:  The patient had fevers, chills,
lightheadedness and she is to return to the Emergency
Department.  The patient has been instructed to not use
tampons again until further instructions.  She will have her
laboratory data drawn in one month, and at that time,
Infectious Disease will be following her and will instruct
her whether or not she may use tampons again.  She is to take
her medications as prescribed.  If she continues to have
loose stools or diarrhea, she is to notify her primary care
physician and to have her stools tested for Clostridium
difficile.  In addition the skin on her hands and feet may
begin to peel off in one to two weeks, this is to be expected
and is not abnormal.


                            [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 48864**]

Dictated By:[**Name8 (MD) 48865**]
MEDQUIST36

D:  [**2178-5-14**]  15:32
T:  [**2178-5-14**]  18:02
JOB#:  [**Job Number 48840**]
{'Toxic shock syndrome,Acute and subacute necrosis of liver,Other pulmonary insufficiency, not elsewhere classified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Foreign body in vulva and vagina,Methicillin susceptible Staphylococcus aureus septicemia,Pulmonary congestion and hypostasis'}


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: Ms [**Known lastname **] is an 18 year old female
transferred from [**Hospital6 33**] for further management
here at [**Hospital6 256**].  She had
previously been a very healthy 18 year old who is very active
in her school and sports.  Approximately four days prior to
admission she began feeling nauseated, vomiting and had
diarrhea (greenish) for several episodes.  She was feeling so
poorly that she stayed home from school one day, and felt
that she was very lethargic.  During that time period, she
was also having her menses.  When she was on day #4 of her
menses, she was feeling so poorly, that she stayed in bed,
and did not change her tampon for approximately 16 to 24
hours.  However, on menses day #1 through 3, she had been
changing her tampons regularly.  During the 24 hours prior to
admission, she noted an acute onset of lethargy, headaches,
and fevers.  She was brought to [**Hospital6 33**]
approximately 3 AM by her parents.  About that time, she had
diffuse erythroderma noted over her face, and chest.  She
complained of a sore throat and headache for greater than 24
hours, but did not have a stiff neck.  She was found to have
severe oropharynx injection with exudate and tonsillar
inflammation.  A rapid Streptococcus was negative.  She has a
history of multiple prior episodes of Streptococcus
pharyngitis.  Blood cultures times two were sent.  Urine
culture was sent.  Vaginal examination revealed a tampon in
place, and that was sent to Microbiology.  Her temperature at
[**Hospital6 33**] was 102.8, heartrate was in the 170s and
her initial systolic blood pressure was approximately 100.
However, within a short amount of time, her systolic blood
pressure dropped to the 70s, and she was only minimally
responsive to intravenous fluids.  She was given 8 liters of
fluid and her systolic blood pressure increased only to the
80s.  At that point in time, Dopamine was started.  In
addition, an lumbar puncture was done to rule out meningitis,
and it revealed two white blood cells, 13 red blood cells,
normal glucose and normal protein.  Initial chest x-ray was
reportedly unremarkable, but the patient had a significant
oxygen requirement (she was on a nonrebreather and face
mask).  Arterial blood gases done was 7.34/26/80.  Other
notable laboratory data included a white blood cell count of
19,000 (32% bands), creatinine 1.5, normal liver function
tests and her coags were increased to an INR of 2.6, PTT 60
with positive fibrin split products (FSP).  At [**Hospital6 3426**], she received 2 gm of Ceftriaxone, 2 gm of
Oxacillin, 500 mg of Azithromycin, 600 mg of Clindamycin.
She was then transferred to [**Hospital6 2018**] for further management.

MEDICAL HISTORY: 1.  Psoriasis, 2.  History of
Streptococcus pharyngitis.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is an 18 year old student,
senior in high school.  She lives at home with her family,
and has not had any recent travels.  She has had no sick
contacts.  She is an avid basketball player and is the
captain of her basketball team.  She was last sexually active
several months ago, and reports consistent condom use.  She
has a remote naval ring and tongue piercing.  She has a
tattoo on her lower back as well.  Positive tanning bed use. 

### Response:
{'Toxic shock syndrome,Acute and subacute necrosis of liver,Other pulmonary insufficiency, not elsewhere classified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Foreign body in vulva and vagina,Methicillin susceptible Staphylococcus aureus septicemia,Pulmonary congestion and hypostasis'}
