CHIEF COMPLAINT: episode of confusion

PRESENT ILLNESS: 22 year old right handed woman who was transferred from
[**Location (un) 47**], for assessment for an acute change in mental status
around 2 pm this afternoon. She had recently been discharged
from
[**Hospital1 **] [**Location (un) 21601**] after treatment for a viral meningitis, her main
symptoms were bitemporal pulsatile headaches with photophobia.
Notably, her work-up in [**Hospital1 **] [**Location (un) 21601**] was negative for HIV, Lyme,
Ehrlichia, Syphilis, but she was EBV positive. Her initial LP
on
[**10-29**] when she was admitted over there showed 400 white cells
with
a 95% lymphocytic predominance, 0 red cells, 45 glucose, and 106
total protein. Two days before she was discharged on [**11-3**], her
LP
showed the following: 571 white cells, 14 red cells, 1
neutrophil, 91 lymphocytes. She was treated empirically with
Rocephin+Vanc+Acyclovir, and the Acyclovir was discontinued when
the HSV PCR came back negative, on the initial CSF tap on [**10-29**].
She was seen by neurologist Dr [**Last Name (STitle) **] at the OSH. She was febrile
up to 104 during her hospital stay, until about two days before
her discharge. Since her discharge home, she has been staying
with her mother in [**Name (NI) 1411**] who mentioned that her daughter barely
drank much in terms of fluids, and would eat a few fruit loops.
At 2pm today she started acting extremely confused, not
agitated,
but not knowing where she was, what date it was, or being able
to
identify various family members. She had a CT head at
[**Location (un) 47**],
which was unremarkable (apart from movement artifact) and she
received a dose of Acyclovir, and was transferred to [**Hospital1 18**] for
neurological care. Her mother mentioned that she had urinary
retention, and had left lower quadrant abdominal pain.

MEDICAL HISTORY: HUS age 5
Recurrent PNA
HPV

MEDICATION ON ADMISSION: OCP stopped in her recent hospital admission at [**Hospital1 **], [**Location (un) 21601**]
Ibuprofen 600 mg Q6h, prn
Tylenol prn

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: initial exam:

FAMILY HISTORY: NC

SOCIAL HISTORY: No tobacco, rare ETOH, no IVDU. Boyfriend.
Unprotected sexual contacts with single male partner x several
years. No tick bites, rash, joint pain. No h/o HSV known.  Cat.
No travel. No contacts who are ill. Intern for magazine.
Other enterovirus diseases of central nervous system,Other specified cardiac dysrhythmias,Dehydration,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Unspecified essential hypertension,Other convulsions,Retention of urine, unspecified
Oth enteroviral cns dis,Cardiac dysrhythmias NEC,Dehydration,DMII wo cmp nt st uncntr,Obesity NOS,Hypertension NOS,Convulsions NEC,Retention urine NOS
Admission Date:  [**2166-11-15**]              Discharge Date:   [**2166-11-21**]

Date of Birth:  [**2144-4-15**]             Sex:   F

Service: NEUROLOGY

Allergies:
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 20506**]
Chief Complaint:
episode of confusion

Major Surgical or Invasive Procedure:
LP - [**2166-11-14**]

History of Present Illness:
22 year old right handed woman who was transferred from
[**Location (un) 47**], for assessment for an acute change in mental status
around 2 pm this afternoon. She had recently been discharged
from
[**Hospital1 **] [**Location (un) 21601**] after treatment for a viral meningitis, her main
symptoms were bitemporal pulsatile headaches with photophobia.
Notably, her work-up in [**Hospital1 **] [**Location (un) 21601**] was negative for HIV, Lyme,
Ehrlichia, Syphilis, but she was EBV positive. Her initial LP
on
[**10-29**] when she was admitted over there showed 400 white cells
with
a 95% lymphocytic predominance, 0 red cells, 45 glucose, and 106
total protein. Two days before she was discharged on [**11-3**], her
LP
showed the following: 571 white cells, 14 red cells, 1
neutrophil, 91 lymphocytes. She was treated empirically with
Rocephin+Vanc+Acyclovir, and the Acyclovir was discontinued when
the HSV PCR came back negative, on the initial CSF tap on [**10-29**].
She was seen by neurologist Dr [**Last Name (STitle) **] at the OSH. She was febrile
up to 104 during her hospital stay, until about two days before
her discharge. Since her discharge home, she has been staying
with her mother in [**Name (NI) 1411**] who mentioned that her daughter barely
drank much in terms of fluids, and would eat a few fruit loops.
At 2pm today she started acting extremely confused, not
agitated,
but not knowing where she was, what date it was, or being able
to
identify various family members. She had a CT head at
[**Location (un) 47**],
which was unremarkable (apart from movement artifact) and she
received a dose of Acyclovir, and was transferred to [**Hospital1 18**] for
neurological care. Her mother mentioned that she had urinary
retention, and had left lower quadrant abdominal pain.


Past Medical History:
HUS age 5
Recurrent PNA
HPV


Social History:
No tobacco, rare ETOH, no IVDU. Boyfriend.
Unprotected sexual contacts with single male partner x several
years. No tick bites, rash, joint pain. No h/o HSV known.  Cat.
No travel. No contacts who are ill. Intern for magazine.


Family History:
NC

Physical Exam:
initial exam:

T-98.4 BP-130/89 HR-86 RR-16 O2Sat-99%
Gen: Lying in bed, complaining of not being able to pass urine,
when the Foley was inserted she voided>300 ml of urine
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, suprapubic fullness
Skin: no rashes
ext: no edema

Neurologic examination:
Mental status: Confused, inattentive. Is calling her family
members incorrect rooms. Thinks her cat is blue in color, and
thinks that her boyfriend in her cat. Looking around the room,
and sees multiple images of everything. Uses neologisms. Her
speech is fluent, and she is intermittently following commands.

Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Not allowing me to do fundoscopy. Keeps
perseverating on the number of fingers in each quadrant. Tracks
normally, with nystagmus. Corneal reflexes in tact bilaterally.
Facial excursion is symmetric. Gag is intact.

Motor:
Her calves seemed deconditioned. Tone normal. No observed
myoclonus or tremor
Can hold each limb up for 1 minute without fatiguing, but she
cannot comply with formal strength testing.

Sensation: moves all 4 limbs away from tickle or noxious stimuli

Reflexes:
2 and symmetric throughout.
Toes downgoing bilaterally

Coordination and Gait could not be assessed

follow up exam (next day):
Neuro: MS: alert and oriented x3, intact naming, repetition,
knowledge, fluency, comprehension, follows crossed body
commands,
able to say world backwards, no apraxia, [**4-8**] IR and [**4-8**] SR
CN: PERRLA, EOMI, intact light touch and facial strength
bilaterally, intact t/u/p, [**6-10**] SCM, VFFTC, no extinction to DSS
stimuli
Motor: normal tone and bulk of all four ext. 5/5 Strength of all
four ext
Sensory: intact lt of all four ext
Reflexes: 2+ symmetric of UE and LE, toes are downgoing
bilaterally
Coord: Intact fnf and hs bilaterally
Gait: deferred



Pertinent Results:
[**2166-11-14**] 09:00PM   PT-12.5 PTT-26.4 INR(PT)-1.1
[**2166-11-14**] 09:00PM   PLT COUNT-420
[**2166-11-14**] 09:00PM   WBC-16.2* RBC-4.49 HGB-12.9 HCT-37.1 MCV-83
MCH-28.8 MCHC-34.9 RDW-13.4
[**2166-11-14**] 09:00PM   CALCIUM-10.0 PHOSPHATE-4.0 MAGNESIUM-2.0
[**2166-11-14**] 09:00PM   LIPASE-115*
[**2166-11-14**] 09:00PM   ALT(SGPT)-15 AST(SGOT)-13 CK(CPK)-43 ALK
PHOS-39 TOT BILI-0.5
[**2166-11-14**] 09:50PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2166-11-14**] 11:50PM CEREBROSPINAL FLUID (CSF)  WBC-73 RBC-1*
POLYS-0 LYMPHS-91 MONOS-4 EOS-3 BASOS-1 ATYPS-1
[**2166-11-14**] 11:50PM CEREBROSPINAL FLUID (CSF)  WBC-101 RBC-1*
POLYS-0 LYMPHS-90 MONOS-4 EOS-2 BASOS-1 ATYPS-3
[**2166-11-14**] 11:50PM CEREBROSPINAL FLUID (CSF)  PROTEIN-105*
GLUCOSE-43
[**2166-11-15**] 03:11AM   WBC-10.7 RBC-4.25 HGB-11.8* HCT-34.8* MCV-82
MCH-27.7 MCHC-33.8 RDW-13.9
[**2166-11-15**] 03:11AM   RHEU FACT-<3
[**2166-11-15**] 03:11AM   dsDNA-NEGATIVE
[**2166-11-15**] 03:11AM   ANCA-NEGATIVE B
[**2166-11-15**] 03:11AM   TSH-0.77
[**2166-11-15**] 11:02AM URINE  UCG-NEGATIVE

From OSH:
SH:nml, dsDNA:- RF<3, ANCA:- [**Doctor First Name **]:- RPR: - CSF syph:- CSF Cx:-
HSV PCR:-, CSF Cx:-, CSF [**Country **] ink:- AFB: - cocksackie:- viral
cx:-
from blood: HIV:- Babesia:- Erlichia:- Ricketsia: - Adenosine
deaminase(from CSF):1.7  CMV:-, viral throat swap:- flu:-

CT C/A/P: Normal study, gallstones noted

MRI ([**2166-11-16**])
1. Redemonstration of the restricted diffusion in the genu of
the corpus
callosum, the significance of this finding is uncertain, given
the lack of
corresponding abnormality on the color maps of fractional
anisotropy.

2. Faint foci of increased FLAIR hyperintensity in the posterior
parts of the
thalami on both sides, again of uncertain significance.

3. Very subtle possible enhancement in the optic nerves, without
obvious
increased signal on the STIR sequence. Hence, the significance
of these
subtle findings is uncertain, ? related to fat suppression of
the adjacent fat
than an abnormality, being bilateral and symmetric, thin and
linear.

Followup evaluation in a few days/weeks can be considered based
on the
patient's condition/progression to evaluate the
stability/progression of the
above-mentioned equivocal abnormalities.


MRI ([**2166-11-14**]):
1. Restricted diffusion is seen within the genu of corpus
callosum which
can be seen in ischemia or demyelination.

2. Subtle signal abnormalities in medulla, pons and thalami need
further
confirmation with repeat sagittal FLAIR and T2 and axial FLAIR
(without
gadolinium).

3. FLAIR signal abnormalities along sulci and along the surface
of the
brain are consistent with meningeal inflammation.

4. Subtle signal changes are seen on diffusion images within
both optic nerves
and subtle enhancement is suspected on post- gadolinium images.
However, this
could not be confirmed, and if clinically indicated, a dedicated
MRI of the
orbit can help for further assessment.

5. Findings discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].

MRV:

The head MRV demonstrates normal flow in the superior sagittal
and transverse
sinuses as well as in the deep venous system.

IMPRESSION: Normal MRV of the head.

EEG ([**2166-11-18**])
 Normal EEG in wakefulness and sleep. There were no focal
abnormalities or epileptiform features.

EEG ([**2166-11-15**]):
Abnormal EEG due to bursts of focal slowing from the left
temporal and central regions with secondary generalization
indicative of
some degree of focal irritation involving primarily the left
hemisphere
and primarily the left temporal and central structures
independently
and, at times, synchronously with secondary spread. No frank
epileptiform discharges were, however, seen. A focal infectious
etiology cannot be absolutely excluded and this pattern can be
seen in
the early stages of a typical viral encephalitis or
encephalopathy.


Echo: ([**2166-11-18**]):
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Transmitral
Doppler and tissue velocity imaging are consistent with normal
LV diastolic function. Right ventricular chamber size and free
wall motion are normal. The number of aortic valve leaflets
cannot be determined. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.


Brief Hospital Course:
The patient was admitted with an episode of confusion after a
diagnosis of viral meningitis that was made at a hospital in [**Location (un) 7349**]
([**Hospital1 **] [**Location (un) 21601**]).  This confusion was short (less than 6 hours)
but was concerning enough given the recent history to warrant an
ICU admission and a repeat spinal tap was done (as well as
obtaining the records from the prior hospitalization.  The LP
still showed a lymphocytic pleocytosis but it was improving from
the last hospitalization.

The confusion rapidly resolved and the patient was at baseline
the next morning after admission and she was transferred out of
the ICU.  She was initially placed on antibiotics for empiric
treatment of meningitis, however these were discontinued after a
day with the results of the gram stain and culture of the LP.
She was maintained on Acylovir for the time period before
another HSV PCR could be obtained.  Imaging showed some mild
FLAIR hyperintensity in the thalamus b/l, that was thought to be
consistent with the patients recent viral meningo/encephalitis.
 It was thought that this breif episode of confusion could have
been a result of a seizure brought about by the patient's
underlying illness.  An EEG was obtained that was abnormal
showing: focal slowing from the left temporal and central
regions with secondary generalization indicative of some degree
of focal irritation involving primarily the left hemisphere and
primarily the left temporal and central structures independently
and the patient was started on Keppra.  The HSV PCR was negative
and acyclovir was discontinued.  The patient had persistent
headaches throughout the admission but these improved with
Toradol, and appeared to improve as the hospital course went on.


The patient was also had some brief hypertension and
tachycardia, that were likely secondary to pain, and resolved
with pain treatment, and were at baseline on d/c.  She was
briefly treated with a beta blocker but this was discontinued.

Medications on Admission:
OCP stopped in her recent hospital admission at [**Hospital1 **], [**Location (un) 21601**]
Ibuprofen 600 mg Q6h, prn
Tylenol prn

Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Possible seizure after viral meningitis.


Discharge Condition:
Good: MS: intact CN: intact, no deficits, Motor/Sensory: no
deficits Reflexes: 2+ throughout Gait: normal


Discharge Instructions:
You were admitted with an episode of confusion after you were
given a diagnosis of viral meningitis at an outside hospital in
[**Location (un) **].  You had been improving over a week that you were
discharged from the other hospital but had another breif episode
of confusion.  You were brought to [**Hospital1 18**] where you were placed
in the ICU and another workup was done, including LP and blood
work and imaging.  Your confusion rapidly resolved. You were
transferred out of the ICU. The workup at the [**Hospital 8050**] hospital
was negative, as well as the workup here.  You had another HSV
PCR which was shown to be negative.  There is a Bartonella test
still pending which you will follow up with infectious disease
in about 3 weeks.  At this time please also follow-up on results
pending from [**Hospital3 **] in [**Location (un) **] including EEE and WNV.
You had an EEG which showed some abnormailites, and based on
your recent infection and episode of confusion you were started
on an anti-epileptic medication Keppra.  You tolerated the
medication well.

Please take all medicine as prescribed
Please ensure you keep all follow up appointments
If you have any worsening of your symptoms, such as new
confusion, please call your doctor or return to the nearst ER.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2166-12-16**] 9:00

Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**], MD Please call
for an appointment within 1 month [**Telephone/Fax (1) 2100**]
{'Other enterovirus diseases of central nervous system,Other specified cardiac dysrhythmias,Dehydration,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Unspecified essential hypertension,Other convulsions,Retention of urine, 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: episode of confusion

PRESENT ILLNESS: 22 year old right handed woman who was transferred from
[**Location (un) 47**], for assessment for an acute change in mental status
around 2 pm this afternoon. She had recently been discharged
from
[**Hospital1 **] [**Location (un) 21601**] after treatment for a viral meningitis, her main
symptoms were bitemporal pulsatile headaches with photophobia.
Notably, her work-up in [**Hospital1 **] [**Location (un) 21601**] was negative for HIV, Lyme,
Ehrlichia, Syphilis, but she was EBV positive. Her initial LP
on
[**10-29**] when she was admitted over there showed 400 white cells
with
a 95% lymphocytic predominance, 0 red cells, 45 glucose, and 106
total protein. Two days before she was discharged on [**11-3**], her
LP
showed the following: 571 white cells, 14 red cells, 1
neutrophil, 91 lymphocytes. She was treated empirically with
Rocephin+Vanc+Acyclovir, and the Acyclovir was discontinued when
the HSV PCR came back negative, on the initial CSF tap on [**10-29**].
She was seen by neurologist Dr [**Last Name (STitle) **] at the OSH. She was febrile
up to 104 during her hospital stay, until about two days before
her discharge. Since her discharge home, she has been staying
with her mother in [**Name (NI) 1411**] who mentioned that her daughter barely
drank much in terms of fluids, and would eat a few fruit loops.
At 2pm today she started acting extremely confused, not
agitated,
but not knowing where she was, what date it was, or being able
to
identify various family members. She had a CT head at
[**Location (un) 47**],
which was unremarkable (apart from movement artifact) and she
received a dose of Acyclovir, and was transferred to [**Hospital1 18**] for
neurological care. Her mother mentioned that she had urinary
retention, and had left lower quadrant abdominal pain.

MEDICAL HISTORY: HUS age 5
Recurrent PNA
HPV

MEDICATION ON ADMISSION: OCP stopped in her recent hospital admission at [**Hospital1 **], [**Location (un) 21601**]
Ibuprofen 600 mg Q6h, prn
Tylenol prn

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: initial exam:

FAMILY HISTORY: NC

SOCIAL HISTORY: No tobacco, rare ETOH, no IVDU. Boyfriend.
Unprotected sexual contacts with single male partner x several
years. No tick bites, rash, joint pain. No h/o HSV known.  Cat.
No travel. No contacts who are ill. Intern for magazine. 

### Response:
{'Other enterovirus diseases of central nervous system,Other specified cardiac dysrhythmias,Dehydration,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Unspecified essential hypertension,Other convulsions,Retention of urine, unspecified'}
