CHIEF COMPLAINT: headache

PRESENT ILLNESS: The patient is a 73 yo R-handed woman with CAD, GERD,
sinusitis, emphesema who presented with HA to the ED on [**8-9**] and
was admitted to Medicine service [**8-9**] for sinusitis.

MEDICAL HISTORY: -COPD, emphesema
-CAD
-anxiety
-GERD
-hyperlipidemia
-sinusitis
-head trauma, MVC in '[**08**]: since that time she has a tremor of
her
head and her hands

MEDICATION ON ADMISSION: -ADVAIR DISKUS
-ALBUTEROL
-ASPIRIN
-FLONASE
-FLOVENT
-IBUPROFEN
-LIPITOR
-NEXIUM
-NITROGLYCERIN
-SUDAFED
-TOPROL XL
-ZYRTEC

ALLERGIES: Codeine / Penicillins

PHYSICAL EXAM: EXAM ON ADMISSION
VITALS: T99.2 Tm 100.9 HR88 BP150/70 RR20  sO2 95 on 1L; 87 on
RA

FAMILY HISTORY: - siblings are healthy
-CAD
-grandma has something, but she cannot remember what

SOCIAL HISTORY: Occupation: currently does not work (stopped in '[**97**], not able to
get clear reason)
Smoking: [**1-22**] ppd; EthOH: occasional; drug abuse: no
Married, 2 children
Unspecified viral meningitis,Other emphysema,Esophageal reflux,Other and unspecified hyperlipidemia,Anxiety state, unspecified
Viral meningitis NOS,Emphysema NEC,Esophageal reflux,Hyperlipidemia NEC/NOS,Anxiety state NOS
Admission Date:  [**2125-8-9**]              Discharge Date:   [**2125-8-22**]

Date of Birth:  [**2052-2-27**]             Sex:   F

Service: NEUROLOGY

Allergies:
Codeine / Penicillins

Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
headache

Major Surgical or Invasive Procedure:
Lumbar puncture


History of Present Illness:
The patient is a 73 yo R-handed woman with CAD, GERD,
sinusitis, emphesema who presented with HA to the ED on [**8-9**] and
was admitted to Medicine service [**8-9**] for sinusitis.

[**6-19**], the patient presented to the ED  with a severe headache.
At that time, a CT head was normal and the patient refused an
LP.
At follow up she did "complain of stuffy nose and pain behind
her
right eye like an ice pick. She states that she also has a
pressure in her sinuses bilaterally." At that point (early [**Month (only) **])
she was given a 10 day course of Augmentin, and her symptoms
improved somewhat. They did never completely resolve. She did
have photo- and phonophobia at that time, no muscle aches. She
had some neckpain (does not remember the details).

She returned to the ED [**8-9**] as her headache had been getting
worse over about 2 weeks. She said the onset was sudden, though
that may not fit with the story that her headache never really
went away. The headache became progressively worse. She was
evaluated in the ED and a CT head was normal except for
sinusitis
involving the sphenoid sinus (maxillary sinuses not in view).
She
was started on CTX and Unasyn. The patient refused an LP in the
ED. Neurology was not consulted and she was admitted to
Medicine.
The Medicine attending persuaded her to undergo an LP, which had
increased WBC (Lymphocytic predominant). She was emperically
started on vanco, ampicillin, CTX and acyclovir.

She has been having night sweats, and a chronic cough. No
weightloss. No rash or itching. No insect bites. No jaw
claudication, but does remember scalp tenderness upon touch. No
transient visual loss. This morning she noted some neckpain at
the right. She also noted that she would say the wrong words
occasionally and that she had difficulties thinking smoothly
(this morning). Also some nausea this morning.

About 10 years ago, she had similar headaches, fever and was
diagnosed with sinusitis. Followed by ENT, but last time she was
seen was 2.5 years ago.

ROS:
denies any hearing changes, vomiting, dysphagia, weakness,
tingling, numbness, bowel-bladder dysfunction, chest pain,
shortness of breath, abdominal pain, dysuria, hematuria, or
bright red blood per rectum.

Past Medical History:
-COPD, emphesema
-CAD
-anxiety
-GERD
-hyperlipidemia
-sinusitis
-head trauma, MVC in '[**08**]: since that time she has a tremor of
her
head and her hands


Social History:
Occupation: currently does not work (stopped in '[**97**], not able to
get clear reason)
Smoking: [**1-22**] ppd; EthOH: occasional; drug abuse: no
Married, 2 children


Family History:
- siblings are healthy
-CAD
-grandma has something, but she cannot remember what

Physical Exam:
EXAM ON ADMISSION
VITALS: T99.2 Tm 100.9 HR88 BP150/70 RR20  sO2 95 on 1L; 87 on
RA

GEN: NAD, in bed
HEENT: mmm; no rash
NECK: no LAD; no carotid bruits; neck supple, no brudzinski;
palpation a bit tender R-paraspinally
LUNGS: bilateral wheezing
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: some clubbing, no cyanosis, ecchymosis, or edema

MENTAL STATUS:
Awake and alert, cooperative with exam, normal affect, very slow
thinking.
Oriented to place, month, day, and date, person.
Attention: MOYbw: unable; DOWbw slow but accurate
Memory: Registration: [**2-23**] items; Recall [**1-23**] at 5 min.
Language: fluent; repetition: intact; Naming: mistakes with low
frequency objects (cactus/hammock); Comprehension intact; mild
dysarthria, paraphasic errors: substitues wrong words (will
realize it). [**Location (un) **]: intact; Prosody: normal. 3D-construction:
poor clock, could not draw handles; did not want to proceed with
copying; No Apraxia. No Neglect.

CRANIAL NERVES:
II: Visual fields are full to confrontation, pupils equally
round
and reactive to light both directly and consensually, 3-->2 mm
bilaterally.
III, IV, VI: Extraocular movements intact without nystagmus.
Fixation and saccades are normal. No ptosis.
V: Facial sensation intact to light touch and pinprick.
VII: Facial movement symmetrical; R-nasiolabial fold somewhat
flat. Lev palp strong.
VIII: Hearing intact to finger rub bilaterally.
IX: Palate elevates in midline.
XII: Tongue protrudes in midline, no fasciculations.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.

MOTOR SYSTEM: Normal bulk and tone bilaterally in UE. Increased
tone in LE more on the R than the L. No adventitious movements,
no tremor, no asterixis.
      D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 5 4+5 5  5  5    5  5- 5  5 [**5-25**]  5  5 5
Left  5 4+5 5  5  5    4+ 5- 5  5 4+5  5  5 5
No pronator drift. No rebound.

SENSORY SYSTEM: Sensation intact to light touch. No extinction
to
DSS.
Temperature (cold), vibration, and proprioception unreliable:
not
able to tell movement, not even in bigger joints; did say she
felt vibration everywhere

REFLEXES:
B T Br Pa Pl
Right  2 2 2 3 2
Left   2 2 2 3 2 crossed adductor
Toes: downgoing bilaterally.

COORDINATION: Normal [**Last Name (LF) 11140**], [**First Name3 (LF) **], HTS. No dysmetria or
pastpointing.
However, slight action tremor bilaterally in UE. HTS slow.

GAIT: deferred

EXAM ON DISCHARGE: Unchanged, no neck tenderness, thinking
clear.

Pertinent Results:
Lactate:0.8

137  98  8  103    AGap=15
-----------<
3.9  28  0.8

ALT: 32 AP: 86 Tbili: 0.3 Alb: 3.9
AST: 42 LDH:  Dbili:  TProt:
[**Doctor First Name **]: 54 Lip: 31

WBC8.2  PLT309 Hct40.3
 N:68.8 L:22.3 M:6.0 E:1.6 Bas:1.2

PT: 11.3  PTT: 22.8  INR: 0.9

ESR 68 (not c/w temporal arteritis), RF wnl, SPEP negative

UA, Ucx: negative
Bcx: negative

CSF #1 ([**8-11**]): 63 wbc, lymphocyte predominant(WBC 93, RBC 9,
Poly 0, Lymph 88, Mono 12), protein 33 glucose 70 , GS negative,
culture negative, fungal culture negative, RPR negative, crypto
ag negative, Lyme AB negative, HSV [**1-22**] PCR negative, ACE, VZV
pcr negative. TB .

Cytology #2 and 3:Hypercellular specimen.
  Polymorphous population of lymphocytes and monocytes
  consistent with a reactive process.

[**2125-8-9**] 08:19PM CEREBROSPINAL FLUID (CSF) TotProt-63*
Glucose-56
[**2125-8-9**] 08:19PM CEREBROSPINAL FLUID (CSF) WBC-66 RBC-19*
Polys-0 Lymphs-90 Monos-10
[**2125-8-11**] 05:35PM CEREBROSPINAL FLUID (CSF) TotProt-33 Glucose-70
[**2125-8-11**] 05:35PM CEREBROSPINAL FLUID (CSF) WBC-75 RBC-460*
Polys-0 Lymphs-93 Monos-7
[**2125-8-11**] 05:35PM CEREBROSPINAL FLUID (CSF) WBC-93 RBC-9* Polys-0
Lymphs-88 Monos-12
[**2125-8-16**] 02:33AM CEREBROSPINAL FLUID (CSF) TotProt-31 Glucose-59
[**2125-8-16**] 02:33AM CEREBROSPINAL FLUID (CSF) WBC-51 RBC-23*
Polys-0 Lymphs-95 Monos-5
[**2125-8-16**] 02:33AM CEREBROSPINAL FLUID (CSF) WBC-40 RBC-6* Polys-0
Lymphs-96 Monos-4
[**2125-8-17**] 01:17PM CEREBROSPINAL FLUID (CSF) TotProt-32 Glucose-71
[**2125-8-17**] 01:17PM CEREBROSPINAL FLUID (CSF) WBC-76 RBC-18*
Polys-0 Lymphs-93 Monos-7
[**2125-8-17**] 01:17PM CEREBROSPINAL FLUID (CSF) WBC-63 RBC-2* Polys-0
Lymphs-97 Monos-3

FLOW CYTOMETRY IMMUNOPHENOTYPING

The following tests (antibodies) were performed:  Kappa, Lambda
and CD antigens 5, 19, 45.



RESULTS:



Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.

Majority of the cells are in the cell debris/lysed cell area.



A limited panel is performed to determine B cell clonality.
In the viable lymphoid gate, CD19 positive B-cells are extremely
scant (less than 1% of lymphoid gated events ) and clonality
cannot be reliably assessed.



CD5 positive T cells comprise 82% of lymphoid gate.



INTERPRETATION



Non-specific T cell dominant lymphoid profile.

B-cell clonality could not be reliably assessed due to scant
numbers.

Correlation with clinical findings and morphology is
recommended. Flow cytometry immunophenotyping may not detect all
lymphomas due to topography, sampling or artifacts of sample
preparation.

MR OF THE LUMBAR SPINE: The lumbar spine is imaged from T12
through L5. The vertebral body heights are normal and marrow
signal intensity values are within normal limits. There is
diffuse disc desiccation without evidence of disc bulge, spinal
stenosis, or foraminal narrowing. The signal intensity values of
the pre- and paravertebral soft tissues are within normal
limits. There is no evidence of abnormal signal within the conus
or cauda and no evidence of abnormal epidural collection. No
areas of abnormal enhancement are identified on post-gadolinium
images.

IMPRESSION: No evidence of epidural abscess. Multilevel
degenerative disc desiccation. Otherwise, normal MRI of the
lumbar spine.

MR [**Name13 (STitle) **]: FINDINGS: There is increased T2 signal on the FLAIR
sequence within the subdural space as well as pachymeningeal
enhancement. These findings could be due to a recent
intervention such as lumbar puncture, intracranial hypotension,
or meningitis. However, there is no evidence of intraaxial
enhancement. There is no midline shift, mass effect, or
hydrocephalus. There are multiple foci of increased T2 signal
within the periventricular and subcortical white matter of both
cerebral hemispheres consistent with chronic microvascular
infarcts. The size and shape of the lateral ventricles is
unchanged from [**2125-8-10**], the prior MRI. There are no areas
of significantly abnormal magnetic susceptibility. There is no
slow diffusion to indicate an acute infarct.

IMPRESSION: Bilateral increased T2 signal within the subdural
space with pachymeningeal enhancement is new from the prior
examination of [**2125-8-10**]. These findings could represent a
recent intervention such as a lumbar puncture. Intracranial
hypotension or meningitis could also give a similar appearance.

There is no evidence of an intraaxial enhancing lesion. There is
no acute infarct.

MRV negative

Hip x-ray: There are some mild degenerative changes with medial
joint space narrowing seen bilaterally and some osteophytes, but
no fractures identified.

Brief Hospital Course:
The patient is a 73 yo R-handed woman with CAD, GERD, sinusitis,
and emphesema who presented with HA to the ED on [**8-9**] for a
severe headache. Her LP (63 wbc, lymphocyte predominant, high
protein, low glucose, GS negative) has shown lymphocytic
pleocytosis and is overall suggestive of an aseptic meningitis.
She was initially covered with CTX/vanco/amp(tolerated augmentin
as outpatient)/acyclovir and dexamethasone. The dexamethasone
was discontinued on [**8-10**] given the low suspicion for a bacterial
process. The antibiotics were discontinued after the lab results
returned and were negative for bacteria and HSV. All studies
have returned negative, including gram stain, bacterial and
fungal cultures, RPR, crypto Ag, Lyme Ab, HSV [**1-22**] PCR, ACE, VZV,
and TB. Cytology showed a hypercellular specimen, most likely
reactive. Though her course was initially complicated by
increased encephalopathy over the [**8-13**] to [**8-15**], she improved and
was clear by discharge. Notable events in her course include
intubation for LP. She was also noted to have hip pain but x-ray
was negative other than degenerative disease. She is discharged
to rehab with neurology follow up.


Medications on Admission:
-ADVAIR DISKUS
-ALBUTEROL
-ASPIRIN
-FLONASE
-FLOVENT
-IBUPROFEN
-LIPITOR
-NEXIUM
-NITROGLYCERIN
-SUDAFED
-TOPROL XL
-ZYRTEC

Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
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 for constipation.
7. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
treatment Inhalation Q6H (every 6 hours) as needed.
9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
11. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 599**] of [**Location (un) 55**]

Discharge Diagnosis:
Aseptic meningitis


Discharge Condition:
Stable


Discharge Instructions:
Take all medications as prescribed.

Please attend your scheduled appointments.

Call your doctor or go to the emergency room if you have any
worsening headache, any fevers, chills, neck pain, change in
vision, weakness, numbness, tingling, change in bowel or bladder
function, change in thinking, unresponsiveness, or any other
concerning symptoms.


Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2125-9-27**] 2:25
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2125-9-27**] 2:45

Please follow up with Dr. [**Last Name (STitle) 7994**] in the neurology clinic
[**2125-10-5**] at 4:30 in [**Hospital Ward Name 23**]. Please call [**Telephone/Fax (1) 541**]
prior to your appointment.
{'Unspecified viral meningitis,Other emphysema,Esophageal reflux,Other and unspecified hyperlipidemia,Anxiety state, 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: headache

PRESENT ILLNESS: The patient is a 73 yo R-handed woman with CAD, GERD,
sinusitis, emphesema who presented with HA to the ED on [**8-9**] and
was admitted to Medicine service [**8-9**] for sinusitis.

MEDICAL HISTORY: -COPD, emphesema
-CAD
-anxiety
-GERD
-hyperlipidemia
-sinusitis
-head trauma, MVC in '[**08**]: since that time she has a tremor of
her
head and her hands

MEDICATION ON ADMISSION: -ADVAIR DISKUS
-ALBUTEROL
-ASPIRIN
-FLONASE
-FLOVENT
-IBUPROFEN
-LIPITOR
-NEXIUM
-NITROGLYCERIN
-SUDAFED
-TOPROL XL
-ZYRTEC

ALLERGIES: Codeine / Penicillins

PHYSICAL EXAM: EXAM ON ADMISSION
VITALS: T99.2 Tm 100.9 HR88 BP150/70 RR20  sO2 95 on 1L; 87 on
RA

FAMILY HISTORY: - siblings are healthy
-CAD
-grandma has something, but she cannot remember what

SOCIAL HISTORY: Occupation: currently does not work (stopped in '[**97**], not able to
get clear reason)
Smoking: [**1-22**] ppd; EthOH: occasional; drug abuse: no
Married, 2 children 

### Response:
{'Unspecified viral meningitis,Other emphysema,Esophageal reflux,Other and unspecified hyperlipidemia,Anxiety state, unspecified'}
