CHIEF COMPLAINT: pna, AMS

PRESENT ILLNESS: Mr. [**Name14 (STitle) 85524**] is a 27 yo male with PMH of bipolar disorder,
narcotics addiction on methadone, remote motorcycle accident
with resulting seizure disorder on dilantin until 6 months ago,
who presented to [**Hospital3 **] on one week ago in respiratory
failure.  He initially had a sore throat but then developed
productive cough, DOE, which was followed by fever and then
respiratory distress.
.
In the ED there, they felt he was septic and he was intubated.
He had large bilateral consolidations and sputum grew group A
strep and strep pneumoniae.  A CT chest without contrast on [**6-15**]
showed confluent consolidation with associated air bronchogram
involving both lower lobes and there is also involvement of the
middle lobe with patchyinfiltrate in the upper lobes, pleural
fluid on the right and left.  He was on norepinephrine for BP
support which was weaned on the days following admission as he
received aggressive IV hydration.  He received a dose of IVIG
because of his history of splenectomy and was placed on
quadruple antibiotics with levoquin, clindamycin, ceftriaxone,
and vanc until the speciation and sensitivities returned, at
which time he was placed on ceftriaxone for a planned 14 day
course.  Legionella urinary antigen also returned negative so
his levofloxacin was stopped.  An HIV test was reportedly
negative.  HCV was positive.  He required large doses of
fentanyl and versed to remain comfortable on the vent and
remained on his home methadone.  On Thursday, he was extubated.
He has been afebrile since [**6-21**] and his O2 sat has been in the
mid 90s on [**7-7**] liters.
.
His MS was noted to be off and he had a reported seizure on
Saturday described as his eyes rolling back into his head with a
short episode of LOC.  He was started on dilantin 100mg TID.
Since then, his physician describes episodes where his eyes will
roll back in his head and he will have tremors, but he will come
out of it if he is spoken to.  A CT head was normal over the
weekend.  For that reason, he is being transferred to [**Hospital1 18**].  He
is currently on 10L O2, but there has not been much effort to
wean his O2.
.
His WBC prior to transfer was 23 with 51 neutrophils, 10 bands,
15 lymphs, HCT 35.5.
.
.
On the floor, he is tachycardic, alert but only intermittently
following commands.  He can not give a history because he is not
talking.

MEDICAL HISTORY: narcotics addiction on methadone.
motorcycle accident
seizure disorder on dilantin up until 6 months ago
bipolar disease
hepatitis C
s/p splenectomy

MEDICATION ON ADMISSION: methadone 150mg qday
seroquel 200mg qhs
clonazepam 1mg [**Hospital1 **]
clonidine 0.3mg [**Hospital1 **]
effexor 75 mg tid
zofran 4mg q 6 hrs

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.6  BP:157/82  P:98 R: 18 O2: 96% on 8L --> low 90s
on 4L
General: Awake, following some simple commands
HEENT: Sclera anicteric, MMM, pupils dilated [**7-4**].  No nystagmus.
Neck: supple, JVP not elevated, no LAD
Lungs: scattered rhonchi bilaterally R>L, no wheezes, rales
CV: regular and tachy, normal S1 + S2, no murmurs, rubs, gallops
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
skin: blanching erythematous rash on back with small papules.
Right subclavian line site without erythema or pus.
neuro: awake, tracks with eyes.  He does not respond with voice.
 Follows some simple commands like squeezing fingers and stick
out tongue, but not all commands.  Grip strength wnl, unable to
assess strength elsewhere.  Reflexes 3+ throughout.  + myoclonus
in his LEs.  5-8 beats of clonus in his LEs.  Mild rigidity in
his UEs.

FAMILY HISTORY: no early CA or MI.

SOCIAL HISTORY: engaged to be married. active.
- Tobacco: 1 ppd for many years
- Alcohol: denies
- Illicits: IVDU until 4 yrs ago
unemployed and lives with his parents.
Pneumonia due to Streptococcus, group A,Chronic hepatitis C with hepatic coma,Opioid type dependence, continuous,Drug withdrawal,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Bipolar disorder, unspecified,Acute poliomyelitis, unspecified, poliovirus, unspecified type
Pneumonia strptococcus a,Chrnc hpt C w hepat Coma,Opioid dependence-contin,Drug withdrawal,Pneumococcal pneumonia,Bipolar disorder NOS,Ac polio NOS-type NOS
Admission Date:  [**2139-6-22**]              Discharge Date:   [**2139-6-28**]

Date of Birth:  [**2111-8-14**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
pna, AMS

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr. [**Name14 (STitle) 85524**] is a 27 yo male with PMH of bipolar disorder,
narcotics addiction on methadone, remote motorcycle accident
with resulting seizure disorder on dilantin until 6 months ago,
who presented to [**Hospital3 **] on one week ago in respiratory
failure.  He initially had a sore throat but then developed
productive cough, DOE, which was followed by fever and then
respiratory distress.
.
In the ED there, they felt he was septic and he was intubated.
He had large bilateral consolidations and sputum grew group A
strep and strep pneumoniae.  A CT chest without contrast on [**6-15**]
showed confluent consolidation with associated air bronchogram
involving both lower lobes and there is also involvement of the
middle lobe with patchyinfiltrate in the upper lobes, pleural
fluid on the right and left.  He was on norepinephrine for BP
support which was weaned on the days following admission as he
received aggressive IV hydration.  He received a dose of IVIG
because of his history of splenectomy and was placed on
quadruple antibiotics with levoquin, clindamycin, ceftriaxone,
and vanc until the speciation and sensitivities returned, at
which time he was placed on ceftriaxone for a planned 14 day
course.  Legionella urinary antigen also returned negative so
his levofloxacin was stopped.  An HIV test was reportedly
negative.  HCV was positive.  He required large doses of
fentanyl and versed to remain comfortable on the vent and
remained on his home methadone.  On Thursday, he was extubated.
He has been afebrile since [**6-21**] and his O2 sat has been in the
mid 90s on [**7-7**] liters.
.
His MS was noted to be off and he had a reported seizure on
Saturday described as his eyes rolling back into his head with a
short episode of LOC.  He was started on dilantin 100mg TID.
Since then, his physician describes episodes where his eyes will
roll back in his head and he will have tremors, but he will come
out of it if he is spoken to.  A CT head was normal over the
weekend.  For that reason, he is being transferred to [**Hospital1 18**].  He
is currently on 10L O2, but there has not been much effort to
wean his O2.
.
His WBC prior to transfer was 23 with 51 neutrophils, 10 bands,
15 lymphs, HCT 35.5.
.
.
On the floor, he is tachycardic, alert but only intermittently
following commands.  He can not give a history because he is not
talking.


Past Medical History:
narcotics addiction on methadone.
motorcycle accident
seizure disorder on dilantin up until 6 months ago
bipolar disease
hepatitis C
s/p splenectomy

Social History:
engaged to be married. active.
- Tobacco: 1 ppd for many years
- Alcohol: denies
- Illicits: IVDU until 4 yrs ago
unemployed and lives with his parents.

Family History:
no early CA or MI.

Physical Exam:
Vitals: T: 98.6  BP:157/82  P:98 R: 18 O2: 96% on 8L --> low 90s
on 4L
General: Awake, following some simple commands
HEENT: Sclera anicteric, MMM, pupils dilated [**7-4**].  No nystagmus.
Neck: supple, JVP not elevated, no LAD
Lungs: scattered rhonchi bilaterally R>L, no wheezes, rales
CV: regular and tachy, normal S1 + S2, no murmurs, rubs, gallops
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
skin: blanching erythematous rash on back with small papules.
Right subclavian line site without erythema or pus.
neuro: awake, tracks with eyes.  He does not respond with voice.
 Follows some simple commands like squeezing fingers and stick
out tongue, but not all commands.  Grip strength wnl, unable to
assess strength elsewhere.  Reflexes 3+ throughout.  + myoclonus
in his LEs.  5-8 beats of clonus in his LEs.  Mild rigidity in
his UEs.

Pertinent Results:
[**2139-6-22**] 11:30PM BLOOD WBC-22.6* RBC-4.04* Hgb-11.7* Hct-35.7*
MCV-88 MCH-28.8 MCHC-32.7 RDW-16.1* Plt Ct-389
[**2139-6-23**] 05:59AM BLOOD WBC-22.0* RBC-3.89* Hgb-11.1* Hct-34.5*
MCV-89 MCH-28.5 MCHC-32.2 RDW-16.8* Plt Ct-390
[**2139-6-23**] 05:59AM BLOOD PT-13.4 PTT-23.7 INR(PT)-1.1
[**2139-6-22**] 11:30PM BLOOD Glucose-114* UreaN-21* Creat-0.6 Na-141
K-3.6 Cl-102 HCO3-30 AnGap-13
[**2139-6-23**] 05:59AM BLOOD Glucose-115* UreaN-21* Creat-0.6 Na-142
K-3.9 Cl-105 HCO3-28 AnGap-13
[**2139-6-22**] 11:30PM BLOOD ALT-25 AST-24 LD(LDH)-302* AlkPhos-105
TotBili-0.4
[**2139-6-22**] 11:30PM BLOOD Albumin-3.2* Calcium-8.8 Phos-4.0 Mg-2.2
[**2139-6-23**] 04:15PM BLOOD Phenyto-5.0*

Lab results day of discharge:
[**2139-6-28**] 06:13AM BLOOD WBC-12.6* RBC-3.44* Hgb-10.1* Hct-31.4*
MCV-91 MCH-29.3 MCHC-32.1 RDW-16.7* Plt Ct-501*
[**2139-6-28**] 09:59AM BLOOD Hct-35.1*
[**2139-6-28**] 06:13AM BLOOD Plt Ct-501*
[**2139-6-28**] 06:13AM BLOOD Glucose-97 UreaN-11 Creat-0.6 Na-142
K-3.4 Cl-104 HCO3-26 AnGap-15
[**2139-6-28**] 11:59AM BLOOD Phenyto-10.5

[**2139-6-26**] PA&Lat CXR: IMPRESSION:
1. Right PICC in satisfactory position with tip in mid SVC.
2. Left lower lobe opacification and small left effusion most
compatible with
pneumonia.

[**2139-6-22**] ECG: Baseline artifact. Sinus tachycardia. Diffuse T
wave changes that are non-specific. No previous tracing
available for comparison.

[**2139-6-23**] EEG: IMPRESSION: This telemetry captured no pushbutton
activations; however, it captured several events suggestive of
ongoing seizure activity bifrontally with a left predominance
which became much less frequent in the second half of the
recording. There were several sharp waves seen in the left
temporal area suggestive of increased irritability in this
region. The background activity improved substantially over the
time of the recording suggestive of a resolving mild to moderate
encephalopathy.

Brief Hospital Course:
Mr. [**Name14 (STitle) 85524**] is a 27 yo male with PMH of seizure disorder [**3-3**]
head trauma, narcotic addiction, who was transferred from [**Hospital1 6591**] for further management of seizures and altered mental
status following a group A strep/strep pneumo pna requiring
intubation.
.
# respiratory failure: respiratory failure in the setting of
group A strep and strep pneumo pna.  He was extubated on [**6-18**]
still required 10L O2 by NC on transfer, though little previous
attempt was made to wean.  Severe strep pneumo pna is uncommon
in healthy 27 [**Last Name (LF) **], [**First Name3 (LF) **] underlying immunocompromise may be
considered, but he also grew group A strep which can cause a
severe pna in young immunocompetent individuals.  He was HIV
negative during his OSH stay. Continued ceftriaxone during his
micu stay, and fever curve decreased. His O2 was progressively
weaned down as his mental status improved, but he did require
occasional aggressive chest PT to mobilize secretions.  He was
weaned to room air and was able to ambulate without supplemental
oxygen. He completed a 2 week course of IV ceftriaxone after a
PICC was placed.  The PICC was removed prior to discharge.
.
# MS changes/seizure: Reported seizure at OSH 2 days prior to
transfer, was started on dilantin.  He has a history of a
seizure disorder [**3-3**] head trauma from motocycle accident. He
presented to [**Hospital1 18**] with markedly dilated pupils, decreased
interraction and intermittent command following, hyperreflexia
with LE clonus, very concerning for acute withdrawal state, with
possible intermittent seizures. He had been getting large doses
of versed and fentanyl while intubated at OSH (up to
40mg/400mcg/hr!, and his home methadone has been reduced
recently. Neuro and psychiatry were consulted and agreed with
withdrawal picture. His methadone dose was doubled, and he was
put on standing ativan and clonidine. He was also loaded with
dilantin (low levels here) and monitored on EEGs, which were
reported are markedly encephalopathic with possible intermittent
seizures. Over his MICU course his mental status markedly
improved with the above measures, making withdrawal and
intermittent seizures the working diagnosis.  He was put back on
his home dose of 150mg methadone daily, and given several extra
doses of Dilantin to get his level to a therapeutic level. He
was also restarted on his home Klonopin, clonidine and Seroquel.
 He was eventually discharged on Dilantin 100/200/200 mg daily,
for a total of 500mg a day split into separate doses.  We
discussed the dilantin dosing with his PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29247**], who
will monitor the blood levels.  He continued to have dilated,
reactive pupils, which he reports is his baseline.
.
# narcotics addiction: see above, methadone resumed at home oral
dose of 150mg daily.
.
# seizure disorder: see above, loaded with dilantin, followed by
neuro.
.
# bipolar: eventually restarted home regimen (venlafaxine,
clonazepam and quetiapine)

Medications on Admission:
methadone 150mg qday
seroquel 200mg qhs
clonazepam 1mg [**Hospital1 **]
clonidine 0.3mg [**Hospital1 **]
effexor 75 mg tid
zofran 4mg q 6 hrs


Discharge Medications:
1. Methadone 10 mg Tablet Sig: Fifteen (15) Tablet PO DAILY
(Daily).
2. Seroquel 200 mg Tablet Sig: 0.5 (half) Tablet PO at bedtime.

3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Phenytoin Sodium Extended 100 mg Capsule Sig: As directed
Capsule PO every eight (8) hours: Take 1 pills at 8am, 2 pills
at 2pm and 2 pills at 10pm.
Disp:*120 Capsule(s)* Refills:*2*
6. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO three times a
day.


Discharge Disposition:
Home

Discharge Diagnosis:
Severe Group A Strep and Strep Pneumonia pneumonia
Altered mental status
Seizures
Narcotic and benzodiazepene withdrawal


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
It was a pleasure caring for you Mr. [**Known lastname 13144**]. You were
transferred to the [**Hospital1 18**] intensive care unit because your mental
status was persistently altered.  You were likely withdrawing
from your sedative medications and pain killers and having
seizures.  Your mental status has improved after restarting your
home medications and starting Dilantin (phenytoin), an
anti-seizure medication.  Your pneumonia continued to improve,
and you completed a two-week course of ceftriaxone, an
antibiotic.  You are now ready to go home.
.
You were started on Dilantin (phenytoin) three times a day. Take
1 pill at 8am, 2 pills at 2pm and 2 pills at 10pm for a total of
5 pills a day. It is very important that you continue taking
this medication to prevent seizures.  The Dilantin levels in
your blood need to be monitored to be sure they stay in the
right range.  Dr. [**Last Name (STitle) 29247**] will check these levels.

Followup Instructions:
Primary Care [**First Name8 (NamePattern2) **]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29247**]
Tuesday, [**6-30**] at 10am
You can call [**Telephone/Fax (1) 29248**] to confirm or re-schedule this
appointment.



Completed by:[**2139-6-30**]
{'Pneumonia due to Streptococcus, group A,Chronic hepatitis C with hepatic coma,Opioid type dependence, continuous,Drug withdrawal,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Bipolar disorder, unspecified,Acute poliomyelitis, unspecified, poliovirus, unspecified type'}


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: pna, AMS

PRESENT ILLNESS: Mr. [**Name14 (STitle) 85524**] is a 27 yo male with PMH of bipolar disorder,
narcotics addiction on methadone, remote motorcycle accident
with resulting seizure disorder on dilantin until 6 months ago,
who presented to [**Hospital3 **] on one week ago in respiratory
failure.  He initially had a sore throat but then developed
productive cough, DOE, which was followed by fever and then
respiratory distress.
.
In the ED there, they felt he was septic and he was intubated.
He had large bilateral consolidations and sputum grew group A
strep and strep pneumoniae.  A CT chest without contrast on [**6-15**]
showed confluent consolidation with associated air bronchogram
involving both lower lobes and there is also involvement of the
middle lobe with patchyinfiltrate in the upper lobes, pleural
fluid on the right and left.  He was on norepinephrine for BP
support which was weaned on the days following admission as he
received aggressive IV hydration.  He received a dose of IVIG
because of his history of splenectomy and was placed on
quadruple antibiotics with levoquin, clindamycin, ceftriaxone,
and vanc until the speciation and sensitivities returned, at
which time he was placed on ceftriaxone for a planned 14 day
course.  Legionella urinary antigen also returned negative so
his levofloxacin was stopped.  An HIV test was reportedly
negative.  HCV was positive.  He required large doses of
fentanyl and versed to remain comfortable on the vent and
remained on his home methadone.  On Thursday, he was extubated.
He has been afebrile since [**6-21**] and his O2 sat has been in the
mid 90s on [**7-7**] liters.
.
His MS was noted to be off and he had a reported seizure on
Saturday described as his eyes rolling back into his head with a
short episode of LOC.  He was started on dilantin 100mg TID.
Since then, his physician describes episodes where his eyes will
roll back in his head and he will have tremors, but he will come
out of it if he is spoken to.  A CT head was normal over the
weekend.  For that reason, he is being transferred to [**Hospital1 18**].  He
is currently on 10L O2, but there has not been much effort to
wean his O2.
.
His WBC prior to transfer was 23 with 51 neutrophils, 10 bands,
15 lymphs, HCT 35.5.
.
.
On the floor, he is tachycardic, alert but only intermittently
following commands.  He can not give a history because he is not
talking.

MEDICAL HISTORY: narcotics addiction on methadone.
motorcycle accident
seizure disorder on dilantin up until 6 months ago
bipolar disease
hepatitis C
s/p splenectomy

MEDICATION ON ADMISSION: methadone 150mg qday
seroquel 200mg qhs
clonazepam 1mg [**Hospital1 **]
clonidine 0.3mg [**Hospital1 **]
effexor 75 mg tid
zofran 4mg q 6 hrs

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.6  BP:157/82  P:98 R: 18 O2: 96% on 8L --> low 90s
on 4L
General: Awake, following some simple commands
HEENT: Sclera anicteric, MMM, pupils dilated [**7-4**].  No nystagmus.
Neck: supple, JVP not elevated, no LAD
Lungs: scattered rhonchi bilaterally R>L, no wheezes, rales
CV: regular and tachy, normal S1 + S2, no murmurs, rubs, gallops
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
skin: blanching erythematous rash on back with small papules.
Right subclavian line site without erythema or pus.
neuro: awake, tracks with eyes.  He does not respond with voice.
 Follows some simple commands like squeezing fingers and stick
out tongue, but not all commands.  Grip strength wnl, unable to
assess strength elsewhere.  Reflexes 3+ throughout.  + myoclonus
in his LEs.  5-8 beats of clonus in his LEs.  Mild rigidity in
his UEs.

FAMILY HISTORY: no early CA or MI.

SOCIAL HISTORY: engaged to be married. active.
- Tobacco: 1 ppd for many years
- Alcohol: denies
- Illicits: IVDU until 4 yrs ago
unemployed and lives with his parents. 

### Response:
{'Pneumonia due to Streptococcus, group A,Chronic hepatitis C with hepatic coma,Opioid type dependence, continuous,Drug withdrawal,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Bipolar disorder, unspecified,Acute poliomyelitis, unspecified, poliovirus, unspecified type'}
