CHIEF COMPLAINT: Fevers

PRESENT ILLNESS: Pt is a 71 yo F w/ h/o seizures who was recently admitted to the
neuro service with herpes encephalitis who presents with fevers
and hypotension.  She had completed the course of acyclovir on
[**12-12**] and was currently at [**Hospital 15303**] Rehab after recent [**Hospital1 18**]
stay.  New "baseline" per daughters included repeating herself,
decreased short-term memory, restlessness, and agitation
sometimes at night (ie, pulling tubes).  Yesterday, she fell and
hit her head while trying to climb out of bed, she was cleared
by doctor at facility but no head scan done.  She then developed
fever to 104, vomiting, headache this evening and had
"seizure-like" activity witnessed by nurse at rehab.  Otherwise
at this time patient unable to give any history.
.
In the ED, the patient received Vanco 1g, Decadron 10mg, CTx 2g,
Acyclovir 700mg, flagyl 500 mg.  Her pressure had dropped to
80/36, still with high O2 requirement.  Labs rechecked and
Hemoglobin down to 7.8 from 9.1, though lactate slightly lower.
Had brief episode of aflutter.  Sepsis protocol initiated;
levophed started to increase sbp to goal 90s.

MEDICAL HISTORY: -recent herpes simplex type 1 encephalitis- treated w/
acyclovir- PCR from [**12-8**] negative
-seizure disorder since [**91**]; had 3 GTC seizures; also partial
complex seizures: would stare, not respond and make circling
movement with her R-arm for example on the table in front of her
(per family); followed by Dr. [**Last Name (STitle) **]
[**Name (STitle) 15304**] problems, followed by Dr. [**Last Name (STitle) **]
[**Name (STitle) **]/p knee fracture

MEDICATION ON ADMISSION: Paroxetine HCl 10 mg qday, Acetaminophen prn, Senna [**Hospital1 **],
Phenobarbital 45mg tid, Phenytoin 100mg [**Hospital1 **], colace [**Hospital1 **], RISS,
Heparin SC tid, Phenytoin 175mg qpm, Pantoprazole 40 mg qday,
Decadron 8 mg q6hrs, started on Augment [**12-19**] for possible UTI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 97.7 BP 101/45 HR 77 RR 22 O2sats 100% NRB
SvO2 92 CVP 10
Gen: Lethergic, responds to noxious stimuli
HEENT: PERRL, anicteric, dry mm
Neck: No JVD
Lungs: Tubular breath sounds in RUL, + exp wheezes
Heart: RRR no m/r/g
Abd: Soft, NT, ND + BS
Ext: no edema, no cyanosis
Neuro: Letheragic, responds to noxious stimuli, moving all 4
extremities
.

FAMILY HISTORY: N/C

SOCIAL HISTORY: Denies tobacco, ETOH, illicit drug use. Married, 4 healthy
daughters
Unspecified septicemia,Pneumonia, organism unspecified,Herpetic meningoencephalitis,Urinary tract infection, site not specified,Other convulsions,Sepsis,Anemia of other chronic disease,Pure hypercholesterolemia
Septicemia NOS,Pneumonia, organism NOS,Herpetic encephalitis,Urin tract infection NOS,Convulsions NEC,Sepsis,Anemia-other chronic dis,Pure hypercholesterolem
Admission Date:  [**2101-12-20**]              Discharge Date:   [**2101-12-26**]

Date of Birth:  [**2030-10-2**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
Fevers

Major Surgical or Invasive Procedure:
Lumbar puncture [**2100-12-21**]

History of Present Illness:
Pt is a 71 yo F w/ h/o seizures who was recently admitted to the
neuro service with herpes encephalitis who presents with fevers
and hypotension.  She had completed the course of acyclovir on
[**12-12**] and was currently at [**Hospital 15303**] Rehab after recent [**Hospital1 18**]
stay.  New "baseline" per daughters included repeating herself,
decreased short-term memory, restlessness, and agitation
sometimes at night (ie, pulling tubes).  Yesterday, she fell and
hit her head while trying to climb out of bed, she was cleared
by doctor at facility but no head scan done.  She then developed
fever to 104, vomiting, headache this evening and had
"seizure-like" activity witnessed by nurse at rehab.  Otherwise
at this time patient unable to give any history.
.
In the ED, the patient received Vanco 1g, Decadron 10mg, CTx 2g,
Acyclovir 700mg, flagyl 500 mg.  Her pressure had dropped to
80/36, still with high O2 requirement.  Labs rechecked and
Hemoglobin down to 7.8 from 9.1, though lactate slightly lower.
Had brief episode of aflutter.  Sepsis protocol initiated;
levophed started to increase sbp to goal 90s.

Past Medical History:
-recent herpes simplex type 1 encephalitis- treated w/
acyclovir- PCR from [**12-8**] negative
-seizure disorder since [**91**]; had 3 GTC seizures; also partial
complex seizures: would stare, not respond and make circling
movement with her R-arm for example on the table in front of her
(per family); followed by Dr. [**Last Name (STitle) **]
[**Name (STitle) 15304**] problems, followed by Dr. [**Last Name (STitle) **]
[**Name (STitle) **]/p knee fracture

Social History:
Denies tobacco, ETOH, illicit drug use. Married, 4 healthy
daughters

Family History:
N/C

Physical Exam:
T 97.7 BP 101/45 HR 77 RR 22 O2sats 100% NRB
SvO2 92 CVP 10
Gen: Lethergic, responds to noxious stimuli
HEENT: PERRL, anicteric, dry mm
Neck: No JVD
Lungs: Tubular breath sounds in RUL, + exp wheezes
Heart: RRR no m/r/g
Abd: Soft, NT, ND + BS
Ext: no edema, no cyanosis
Neuro: Letheragic, responds to noxious stimuli, moving all 4
extremities
.

Pertinent Results:
CXR [**12-20**]
1. Satisfactory left subclavian line placement.
2. Right upper lobe pneumonia.
3. Interval development of volume overload/CHF.
.
ECG- Sinus tachy, 100, normal axis, normal intervals,
non-specific ST changes in V5-V6
.
CT head- [**12-20**]
1. No acute intracranial hemorrhage or fracture.
2. Stable areas of edema in the right temporal and frontal
lobes, unchanged from study of four days prior.
.
Hip/knee X-ray [**12-20**]
No definite evidence for acute traumatic injury to the right hip
or right knee.
.
CXR [**12-23**]
1. Improving pulmonary edema.
2. Worsening bibasilar opacities, likely due to a combination of
atelectasis and effusion.
3. Improving right upper lobe opacity, which may be due to
asymmetric edema or improving pneumonia.
.

[**2101-12-19**] 11:54PM BLOOD WBC-15.4*# RBC-2.77* Hgb-9.1* Hct-25.1*
MCV-91 MCH-32.9* MCHC-36.3* RDW-17.9* Plt Ct-249
[**2101-12-22**] 04:45AM BLOOD WBC-9.6 RBC-2.72* Hgb-9.0* Hct-25.8*
MCV-95 MCH-33.0* MCHC-34.9 RDW-18.9* Plt Ct-252
[**2101-12-26**] 05:06AM BLOOD WBC-5.1 RBC-4.10*# Hgb-13.6# Hct-38.8#
MCV-95 MCH-33.2* MCHC-35.0 RDW-19.1* Plt Ct-178
[**2101-12-20**] 05:00AM BLOOD Neuts-84* Bands-7* Lymphs-5* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2101-12-19**] 11:54PM BLOOD PT-14.2* PTT-29.8 INR(PT)-1.4
[**2101-12-20**] 05:00AM BLOOD PT-14.4* PTT-32.3 INR(PT)-1.4
[**2101-12-19**] 11:54PM BLOOD Glucose-139* UreaN-9 Creat-0.6 Na-136
K-3.4 Cl-100 HCO3-24 AnGap-15
[**2101-12-26**] 05:06AM BLOOD Glucose-78 UreaN-7 Creat-0.4 Na-136 K-4.1
Cl-100 HCO3-26 AnGap-14
[**2101-12-19**] 11:54PM BLOOD ALT-19 AST-17 CK(CPK)-71 AlkPhos-82
Amylase-23 TotBili-0.6
[**2101-12-20**] 05:00AM BLOOD LD(LDH)-211
[**2101-12-19**] 11:54PM BLOOD Lipase-13
[**2101-12-19**] 11:54PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2101-12-19**] 11:54PM BLOOD Albumin-3.3* Calcium-7.7* Phos-2.7
Mg-1.2*
[**2101-12-26**] 05:06AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.5*
[**2101-12-19**] 11:54PM BLOOD Cortsol-28.8*
[**2101-12-20**] 09:40AM BLOOD Cortsol-32.7*
[**2101-12-19**] 11:54PM BLOOD CRP-239.0*
[**2101-12-19**] 11:54PM BLOOD Phenoba-21.9 Phenyto-18.8
[**2101-12-24**] 06:27AM BLOOD Phenyto-10.4 Phenyfr-PND
[**2101-12-19**] 11:59PM BLOOD Lactate-1.9
[**2101-12-20**] 05:22AM BLOOD Lactate-1.7
[**2101-12-20**] 01:42AM BLOOD Hgb-7.8* calcHCT-23 O2 Sat-95
[**2101-12-20**] 05:22AM BLOOD freeCa-1.04*
.
[**2101-12-19**] 11:30 pm BLOOD CULTURE

                            **FINAL REPORT [**2101-12-26**]**

   AEROBIC BOTTLE (Final [**2101-12-26**]):    NO GROWTH.

   ANAEROBIC BOTTLE (Final [**2101-12-26**]):    NO GROWTH.
.
[**2101-12-19**] 11:15 pm URINE

                            **FINAL REPORT [**2101-12-21**]**

   URINE CULTURE (Final [**2101-12-21**]):
      CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).    >100,000
ORGANISMS/ML..
      GRAM POSITIVE BACTERIA.    10,000-100,000 ORGANISMS/ML..
         Alpha hemolytic colonies consistent with alpha
streptococcus or
         Lactobacillus sp.
.
[**2101-12-21**] 2:03 pm CSF;SPINAL FLUID      Source: LP.

                            **FINAL REPORT [**2101-12-24**]**

   GRAM STAIN (Final [**2101-12-21**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Final [**2101-12-24**]):    NO GROWTH.


Brief Hospital Course:
A/P 71 yo F w/ h/o seizure, recent herpes encephalitis p/w
fevers and ?seizure like activity prior to presentation to the
ED.
.
# [**Name (NI) 15305**] Pt with several possible sources for sepsis given + UA
and likely PNA on CXR and recent herpes encephalitis. Initially
febrile, with hypotension requiring pressors.  Lactate normal
although most likely cause of hypotension thought to be
pneumonia.  She was started on sepsis protocol in the ED, with
Goal CVP>8, Goal MAP>60, Goal SvO2>70.  On day of admission her
hct was 23 and she was given 1 unit prbc.  [**Last Name (un) **] stim was done
which showed good response.  She was started on vancomycin and
zosyn.  Acyclovir was also started given recent hsv encephalitis
admission.  She was also started on Insulin gtt for goal glucose
80-120.  She improved during her admission requiring less O2 per
day and with good blood pressure.  Levophed was weaned off, she
remained afebrile in the ICU after the initial temperature of
104.  Antibiotics were changed to levo/flagyl to treat her RUL
pneumonia after the blood cx were negative; her CXR on [**12-23**]
showed resolving infection although her atelectasis/effusion did
not improve.  She will finish 7 more days of levo/flagyl and
taper quickly off the dexamethasone in the week after discharge.
 Acyclovir was discontinued after her CSF PCR was negative.  She
is hemodynamically stable, afebrile w/ normal WBC and appears
well.
.
# Mental status changes - [**Month (only) 116**] be secondary to sepsis vs
recurrent herpes encephalitis vs post ictal from seizures vs
stroke.  Pt also had fall at rehab in the day prior to admission
and then developed HA and vomiting, which was also concerning
for possible SDH.  CT scan showed no ICH.  LP was done which had
wbc count; however it was mainly lymphocytic.  HSV PCR was
ordered, and she was empirically treated w/ acyclovir until the
results came back negative.  She was continued on decadron per
neuro recs who followed pt during her stay in the icu.  Her
mental status returned to baseline with resolving infection and
hemodynamic stability.
.
# Seizure disorder- On regimen of phenobarbital and phenytoin as
outpatient.  Phenytoin level at 24 based on albumin of 3.3 on
admission.  Decreased phenytoin to 100mg tid and levels within
therapeutic range prior to discharge.  She did not have any
episodes of seizure like activity during her admission.
.
# Knee pain - pt complained of knee pain 1 day after admission,
plain films of hip and knee were done which showed no acute
fracture.  Pain likely secondary to her fall prior to
admisssion, tylenol prn with good affect.
.
# Agitation - per family pt has had a new baseline after the hsv
encephalitis where she was more agitated.  She required zyprexa
prn at nights; however per neurorecs,  ativan should be used
instead of zyprexa for agitation as zyprexa can lower seizure
threshhold.  She has not needed any ativan in the last several
days.
.
# Rhythm - Pt had brief episode of Aflutter on admission; no
events since on tele.  No further work-up recommended.
# FEN- PO diet, replete lytes prn.
# PPX- Heparin SC, PPI, tylenol prn
# Code- DNR/DNI
# Communication:  Daughter:  [**First Name8 (NamePattern2) **] [**Known lastname 5850**], [**Telephone/Fax (1) 15306**];
[**Telephone/Fax (1) 15307**].
# Dispo:  to rehab facility

Medications on Admission:
Paroxetine HCl 10 mg qday, Acetaminophen prn, Senna [**Hospital1 **],
Phenobarbital 45mg tid, Phenytoin 100mg [**Hospital1 **], colace [**Hospital1 **], RISS,
Heparin SC tid, Phenytoin 175mg qpm, Pantoprazole 40 mg qday,
Decadron 8 mg q6hrs, started on Augment [**12-19**] for possible UTI

Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two
(2) Packet PO BID (2 times a day).
9. Insulin Regular Human 100 unit/mL Solution Sig: see insulin
sliding scale  Injection ASDIR (AS DIRECTED).
10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO Q8H (every 8 hours).
11. Phenobarbital 15 mg Tablet Sig: Three (3) Tablet PO Q8H
(every 8 hours).
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days. Tablet(s)
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  TID
(3 times a day) as needed.
15. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
16. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Two (2)
mg Injection Q8H (every 8 hours) for 2 days.
17. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Two (2)
mg Injection every twelve (12) hours for 2 days: please give
after completing 2 days of dexamethasone 2mg IV Q8.
18. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: One (1)
mg Injection every twelve (12) hours for 2 days: Give after
completing 2mg q12 dose.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Primary:
hypotension and fever consistent w/ sepsis
urinary tract infection
RUL pneumonia
.
Secondary:
?herpes encephalitis
seizure disorder
anemia of chronic disease
knee pain s/p fall


Discharge Condition:
good


Discharge Instructions:
Please return for further care if you have fever, chills,
confusion, chest pain, shortness of breath, dizziness, seizure
or any other symptom that is concerning to you.
.
Please take all your medications as directed.
.
You should keep the appointments scheduled for you - the details
are listed below.

Followup Instructions:
Provider: [**Name10 (NameIs) 42**] [**Name11 (NameIs) 43**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2102-1-25**] 4:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. Date/Time:[**2102-4-19**] 10:30



Completed by:[**2101-12-26**]
{'Unspecified septicemia,Pneumonia, organism unspecified,Herpetic meningoencephalitis,Urinary tract infection, site not specified,Other convulsions,Sepsis,Anemia of other chronic disease,Pure hypercholesterolemia'}


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: Fevers

PRESENT ILLNESS: Pt is a 71 yo F w/ h/o seizures who was recently admitted to the
neuro service with herpes encephalitis who presents with fevers
and hypotension.  She had completed the course of acyclovir on
[**12-12**] and was currently at [**Hospital 15303**] Rehab after recent [**Hospital1 18**]
stay.  New "baseline" per daughters included repeating herself,
decreased short-term memory, restlessness, and agitation
sometimes at night (ie, pulling tubes).  Yesterday, she fell and
hit her head while trying to climb out of bed, she was cleared
by doctor at facility but no head scan done.  She then developed
fever to 104, vomiting, headache this evening and had
"seizure-like" activity witnessed by nurse at rehab.  Otherwise
at this time patient unable to give any history.
.
In the ED, the patient received Vanco 1g, Decadron 10mg, CTx 2g,
Acyclovir 700mg, flagyl 500 mg.  Her pressure had dropped to
80/36, still with high O2 requirement.  Labs rechecked and
Hemoglobin down to 7.8 from 9.1, though lactate slightly lower.
Had brief episode of aflutter.  Sepsis protocol initiated;
levophed started to increase sbp to goal 90s.

MEDICAL HISTORY: -recent herpes simplex type 1 encephalitis- treated w/
acyclovir- PCR from [**12-8**] negative
-seizure disorder since [**91**]; had 3 GTC seizures; also partial
complex seizures: would stare, not respond and make circling
movement with her R-arm for example on the table in front of her
(per family); followed by Dr. [**Last Name (STitle) **]
[**Name (STitle) 15304**] problems, followed by Dr. [**Last Name (STitle) **]
[**Name (STitle) **]/p knee fracture

MEDICATION ON ADMISSION: Paroxetine HCl 10 mg qday, Acetaminophen prn, Senna [**Hospital1 **],
Phenobarbital 45mg tid, Phenytoin 100mg [**Hospital1 **], colace [**Hospital1 **], RISS,
Heparin SC tid, Phenytoin 175mg qpm, Pantoprazole 40 mg qday,
Decadron 8 mg q6hrs, started on Augment [**12-19**] for possible UTI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 97.7 BP 101/45 HR 77 RR 22 O2sats 100% NRB
SvO2 92 CVP 10
Gen: Lethergic, responds to noxious stimuli
HEENT: PERRL, anicteric, dry mm
Neck: No JVD
Lungs: Tubular breath sounds in RUL, + exp wheezes
Heart: RRR no m/r/g
Abd: Soft, NT, ND + BS
Ext: no edema, no cyanosis
Neuro: Letheragic, responds to noxious stimuli, moving all 4
extremities
.

FAMILY HISTORY: N/C

SOCIAL HISTORY: Denies tobacco, ETOH, illicit drug use. Married, 4 healthy
daughters 

### Response:
{'Unspecified septicemia,Pneumonia, organism unspecified,Herpetic meningoencephalitis,Urinary tract infection, site not specified,Other convulsions,Sepsis,Anemia of other chronic disease,Pure hypercholesterolemia'}
