CHIEF COMPLAINT: seizure

PRESENT ILLNESS: per admitting resident:

MEDICAL HISTORY: -L parietal stroke [**2129**] peri-operative to AVR
-a fib - patient has been off coumadin for the past few days due
to hematuria
-A.comm aneurysm
-prostate ca s/p radiation
- Central and Obstructive sleep apnea, on CPAP

MEDICATION ON ADMISSION: Lasix 20/40mg AM/PM
Flomax 0.4mg - stopped by patient
Ditropan 5mg HS - stopped by patient
Lisinopril 20mg daily
Coumadin 5mg daily
Toprol XL 25mg daily
Simvastatin 40mg daily
ASA 81mg daily
Folic acid, Vitamin D, Viagra 100mg prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T-99.8 BP-196/106 HR-106 RR-20 100O2Sat
Gen: Lying in bed, intubated
HEENT: NC/AT, moist oral mucosa
CV: afib
Lung: Clear to auscultation bilaterally
aBd: +BS soft
ext: no edema

FAMILY HISTORY: NC

SOCIAL HISTORY: patient is a conductor, lives by himself, independent, no
tobbaco or alcohol
Grand mal status,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Hemoperitoneum (nontraumatic),Encephalopathy, unspecified,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Acidosis,Shock, unspecified,Atrial fibrillation,Diseases of tricuspid valve,Pulmonary valve disorders,Obstructive sleep apnea (adult)(pediatric),Long-term (current) use of anticoagulants,Malignant neoplasm of prostate,Nontraumatic hematoma of soft tissue,Heart valve replaced by other means
Grand mal status,Pneumonia, organism NOS,Ac kidny fail, tubr necr,Hemoperitoneum,Encephalopathy NOS,Food/vomit pneumonitis,Acute respiratry failure,Meth sus pneum d/t Staph,Late ef-hemplga side NOS,Acidosis,Shock NOS,Atrial fibrillation,Tricuspid valve disease,Pulmonary valve disorder,Obstructive sleep apnea,Long-term use anticoagul,Malign neopl prostate,Nontrauma hema soft tiss,Heart valve replac NEC
Admission Date:  [**2134-11-2**]              Discharge Date:   [**2134-11-23**]

Date of Birth:  [**2060-4-10**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 20506**]
Chief Complaint:
seizure

Major Surgical or Invasive Procedure:
cerebral angiogram

History of Present Illness:
per admitting resident:

74 year old man with PMH of L parietal stroke during
perioperative cardiac procedure 5 years ago, prostate ca s/p
radiation therapy, afib off coumadin for the past few days due
to
hematuria (INR subtherapeutic 1.2), hx a. comm aneurysm who p/w
status epilepticus.

Patient was well at barber shop at 2pm (baseline he is
independent, lives by himself). At 2:30pm he was noticed to have
dysarthria and soon after slumped on the floor, described to
have
right sided weakness by EMS report. On the floor he had GTC
seizure, he was given 2mg ativan and 5mg valium by EMS with no
significant response; BP 100/103 HR 100. On arrival at ED at 3pm
he was still seizing, described was tonic posture. BP 196/109 HR
106 Sat 100% on mask; he was intubated for airway protection and
received a bolus of propofol; his seizures were stopped. No
neurologic exam was documented before he was heavily sedated to
confirm right sided weakness reported by history. His BP dropped
down to SBP 80's and ED started him temporarily on phentanyl
gtt.
He was loaded with dilantin 1g.

Of note, his son reports that patient has had two seizures in
his
life; one of them when he had a stroke, perioperatively 5 years
ago and another one 2 years ago in the setting of hypertensive
encephalopathy.


Past Medical History:
-L parietal stroke [**2129**] peri-operative to AVR
-a fib - patient has been off coumadin for the past few days due
to hematuria
-A.comm aneurysm
-prostate ca s/p radiation
- Central and Obstructive sleep apnea, on CPAP


Social History:
patient is a conductor, lives by himself, independent, no
tobbaco or alcohol


Family History:
NC


Physical Exam:
T-99.8 BP-196/106 HR-106 RR-20 100O2Sat
Gen: Lying in bed, intubated
HEENT: NC/AT, moist oral mucosa
CV: afib
Lung: Clear to auscultation bilaterally
aBd: +BS soft
ext: no edema

Neurologic examination:
EXAM WAS LIMITED AS PATIENT WAS HEAVILY SEDATED ON PROPOFOL DUE
TO STATUS. IT SHOULD BE PERFORMED AGAIN ONCE HE IS STABLE AND
WEANED OFF PROPOFOL

Mental status: intubated, no movement was obtained on noxious
stimuli.

Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Normal doll's, normal corneal, face was symmetric,
tongue was midline

Motor:
Patient was heavily sedated; no spontaneous movement was
obtained. No retraction to noxious stimuli

Sensation: No retraction to noxious stimuli

Reflexes: B T Br Pa Pl
Right     0 0 0  0  0
Left      0 0 0  0  0
Toes were downgoing bilaterally.


Coordination: unable to examine

Gait: unable to examine


Pertinent Results:
Labs:

[**2134-11-2**] 03:19PM BLOOD WBC-16.0* RBC-5.71 Hgb-16.5 Hct-53.3*
MCV-93 MCH-29.0 MCHC-31.0 RDW-15.0 Plt Ct-240
[**2134-11-7**] 01:53AM BLOOD WBC-8.0 RBC-4.16* Hgb-12.2* Hct-35.2*
MCV-85 MCH-29.4 MCHC-34.8 RDW-16.3* Plt Ct-171

[**2134-11-2**] 08:08PM BLOOD Glucose-131* UreaN-20 Creat-1.6* Na-139
K-4.2 Cl-108 HCO3-18* AnGap-17
[**2134-11-4**] 12:53AM BLOOD Glucose-192* UreaN-27* Creat-2.4* Na-141
K-3.6 Cl-109* HCO3-22 AnGap-14
[**2134-11-7**] 01:53AM BLOOD Glucose-136* UreaN-28* Creat-1.4* Na-142
K-3.6 Cl-109* HCO3-23 AnGap-14

[**2134-11-2**] 03:19PM BLOOD ALT-17 AST-28 CK(CPK)-113 AlkPhos-48
TotBili-0.6

[**2134-11-3**] 01:59PM BLOOD CK(CPK)-1532*
[**2134-11-6**] 02:17AM BLOOD CK(CPK)-561*
[**2134-11-2**] 03:19PM BLOOD cTropnT-<0.01
[**2134-11-2**] 08:08PM BLOOD CK-MB-3 cTropnT-0.07*
[**2134-11-3**] 01:59PM BLOOD CK-MB-6 cTropnT-0.05*
[**2134-11-4**] 12:53AM BLOOD CK-MB-4 cTropnT-0.05*

[**2134-11-3**] 02:31AM BLOOD Albumin-3.4 Calcium-8.2* Phos-4.6* Mg-2.3

[**2134-11-2**] 03:19PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

[**2134-11-2**] 03:26PM BLOOD Glucose-198* Lactate-12.6* Na-143 K-4.4
Cl-99* calHCO3-20*
[**2134-11-3**] 07:27AM BLOOD Glucose-115* Lactate-1.4 K-1.9*

[**2134-11-2**] 05:53PM URINE RBC->50 WBC-[**10-15**]* Bacteri-OCC Yeast-NONE
Epi-0
[**2134-11-2**] 05:53PM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG

[**2134-11-3**] 08:05AM URINE CastGr-[**5-5**]* CastWBC-2*

Microbiology:

[**2134-11-5**] 	BLOOD CULTURE 	Blood Culture, Routine-PENDING
	INPATIENT
[**2134-11-5**] 	BLOOD CULTURE 	Blood Culture, Routine-PENDING
	INPATIENT

[**2134-11-4**] 	SPUTUM 	GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
	INPATIENT

[**2134-11-4**] 	SPUTUM 	- MSSA

[**2134-11-3**] 	BLOOD CULTURE 	Blood Culture, Routine-PENDING
	INPATIENT
[**2134-11-3**] 	URINE 	URINE CULTURE-no growth

[**2134-11-3**] 	BLOOD CULTURE 	Blood Culture, Routine-PENDING
	INPATIENT
[**2134-11-3**] 	URINE 	URINE CULTURE-no growth

[**2134-11-3**] 	SPUTUM 	GRAM STAIN - MSSA

[**2134-11-3**] 	BLOOD CULTURE 	Blood Culture, Routine-PENDING
	INPATIENT

[**2134-11-2**] 	Rapid Respiratory Viral Screen & Culture
	Respiratory Viral Culture-no growth
[**2134-11-2**] 	MRSA SCREEN 	negative
[**2134-11-2**] 	CSF;SPINAL FLUID 	- no growth

Imaging:

MRI/A of brain:

IMPRESSION:

1. Loss of flow-related enhancement of the distal right
vertebral artery
extending into the basilar artery, with corresponding increased
T2 and FLAIR hyperintensity. The findings are concerning for a
high-grade versus complete stenosis of the basilar artery.

2. Old left parietal and temporal infarct, with a tiny focus of
decreased
diffusion along its anterior margin that may represent a tiny
acute component.

However, there is no other area of definite decreased diffusion,
with no
evidence of infarct in the brainstem.

3. Extensive white matter hyperintensity, some of which
correlates with the
chronic infarct, while the remainder is in a nonspecific
distribution, likely representing the sequela of chronic
microangiopathy given the patient's age.

4. Stable 1-2 mm anterior communicating artery aneurysm.

CXR - IMPRESSION: Multifocal lung opacities, the larger one is
located in the left upper lobe. This could be aspiration
pneumonia.

Cerebral Angiogram:

Prelim - flow through right vertebral and basilar, normal.

..............


Brief Hospital Course:
74 year old man with PMH of L parietal stroke (perioperative
during AVR replacment [**2128**]), prostate ca s/p radiation therapy,
afib off coumadin for the past few days due to hematuria (INR
subtherapeutic 1.2), hx a. comm aneurysm, and two
previous episodes of seizures (first in the setting of his
stroke and second in the setting of hypertensive
encephalopathy), who was noted to have started talking
"gibberish and was confused" while getting a hair cut, attempted
to get out of chair but was unsteady with EMS called and noted
to slump to one side and have a "GTC" He was treated with
ativan/valim and transferred to ED at [**Hospital1 18**] where he was
intubated and had an episode of hypotension to 80s.  Patient was
admitted to Neurology service for further evaluation and
treatment.

1) Neuro:  He underwent a CT head revealing no new pathology and
EEG revealing mild encephalopathy.  He was loaded with Dilantin,
later converted to Keppra IV.  On HD#1 patient was noted to have
multiple episodes of low amplitude high frequency R > L
extremities shaking with extensor posturing.  Given clinical
concern for sz activity by the intensivist team, he was treated
with a total of 11mg of ativan. He did not have further seizures
on continuous EEG monitoring for the next two days.

Given being off anticoagulation, there was concern for an
embolic stroke, leading to a GTC.  He underwent an MRI/a of the
brain which showed a low flow at R vertebral and basilar, no
infarction in the brainstem and the old L parietal/temporal
infarct with chronic WMD. An urgent cerebral angiogram revealed
full flow in R vertebral and basilar arteries. At this time, he
was started on heparin gtt for atrial fibrillation.
Echocardiogram showed no evidence of an embolus.

Over HD#[**11-28**] patient was noted to have significant autonomic
instabilty (HTN, tachycardia, tachypnea, hypoxemia) along with
low amplitude high frequency R > L extremities shaking with
extensor posturing.  Given hx of exposure to two doses of celexa
an having taken Ginko Biloba as a supplement, along with
fluctuating examination of increased LE tone, hyperreflexia and
intermittent clonus > UE, a dx of serotonin syndrom was
considered, however, the exam was fluctuating and patient also
had an underlying PNA, which were felt to be the better
explanations for his symptoms, including possible temporary
basilar insufficiency, leading to b/l pontine symptoms (in
addition patient had disconjugate eye movements in vertical and
horizontal directions)

On [**2134-11-7**] the patient began to be much more responsive and
beagn to follow simple midline and appendicular commands.  He
was making purposeful movements initially only with his left arm
and leg, but soon recovered a small amount of function on his
right side as well.

On [**2134-11-13**] the patient was extubated and was able to follow
commands.  He was transferred to the neurology step-down unit on
[**2134-11-17**]. While on the step-down unit, he was awake and alert.
He was oriented to person and place and when asked more directly
can identify that it is winter and [**Month (only) 1096**].  He follows
commands and converses quite well. His neurologic exam on day of
transfer was also significant for residual right-sided
hemiparesis from his prior stroke.

Heme:
On [**2134-11-7**] the patient was noted to have become hypotensive and
began to require pressors.  At the same time his abdomen had
become distended and tense.  His hematocrit was noted to be
dropping.  A CT scan was ordered and the patient was found to
have had a large left sided RP bleed.  His heparin was stopped.
Surgery was called and they did not recommend any intervention
but would allow the bleed to tamponade on its own.  The patient
continued to lose blood over the next 3 days requiring 2U of
PRBC x 3.  By [**11-10**] the patient's Hgb had stabilized and his
renal function continued to improve.  Repeat abdominal CT done
on [**2134-11-22**] showed that the retroperitoneal hematoma.

2) CV: Atrial fibrillation with intermittent hypertension to
180s systolic.  Treated with esmolol gtt/metoprolol bridge and
hydralazine PO.  TTE showed LAD, EF 50-55% with mild dilatation
and mild aortic root dilatation with 2+MR, 3+ severe TR, and
significant PR.  ROMI was completed, with peak troponin of 0.05,
felt to be due to renal failure and w/o ekg correlate.

Regarding anticoagulation for his atrial fibrillation, he was
started on aspirin 325 mg daily after transfer to the neurology
step-down unit with the plan to transition to coumadin on
[**2134-11-28**] which is 3 weeks from the retroperitoneal bleed.

3) RESP.  Patient was intubated in the ED.  He was found to have
a LUL PNA on CXR, along with WBC/tachypnea and respiratory
distress, for which he was empirically treated with Vanco/Zosyn,
which was narrowed to Levofloxacin after organism on sputum was
identified as MSSA.  With his bleeding he again spiked fevers
and his antibiotic coverage was expanded to Vanco/Zosyn.  He was
extubated on [**2134-11-13**] and his antibiotics were changed to
Linezolid PO for a likely 10 day course.

4) RENAL.  Creatinine peaked at 2.4 and noted to have granular
casts on microscopic exam suggesting ATN.  Cr improved over next
3 days.  However his renal function again deteriorated when he
became hypotensive and was having blood loss.  In addition his
abdominal pressure was increased also contributing to renal
dysfunction.   At time of discharge, creatinine was 1.4 and BUN
was 23.

5)ID: Fever on admission to 105.6F and febrile through HD# 5 to
102F.  WBC count peaked at 16K.  LP showed 4 wBCs and 5 RBCs,
w/o growth, predominantly mono/lymphs.  Pt. was treated
empirically with one day of acyclovir.  He was noted to have an
LUL infiltrate on CXR and was treated for HAP as above, then
narrowed to coverage for MSSA.  On transfer to the floor, he was
on day 5 of 10 of Linezolid. He completed the 10 day course of
Linezolid on [**2134-11-22**]. UCx and BCx were negative.

Medications on Admission:
Lasix 20/40mg AM/PM
Flomax 0.4mg - stopped by patient
Ditropan 5mg HS - stopped by patient
Lisinopril 20mg daily
Coumadin 5mg daily
Toprol XL 25mg daily
Simvastatin 40mg daily
ASA 81mg daily
Folic acid, Vitamin D, Viagra 100mg prn

Pt. took one dose of Celexa stopped due to dizziness
Pt. also prescribed Provigil but reportedly never took it.


Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO QID (4 times
a day).
11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for flatulence.
12. HydrALAzine 15 mg IV Q4H:PRN If SBP>180


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Seizure
Atrial fibrillation
Pneumonia
History of left parietal stroke 5 years ago


Discharge Condition:
Mental Status: Awake, alert. Oriented to self, place.  When
asked, he knows it is winter and often knows it is [**Month (only) 1096**]
[**2133**]. Unable to state DOW. Can identify objects correctly.  Can
follow simple commands.
Neuro exam is significant for mild dysarthria, motor weakness
throughout (R>L), and has right pronator drift.
He is unable to ambulate without assistance.


Discharge Instructions:
You were admitted with seizure-like activity and fever.  You
were initially treated in the ICU.  You were started on Keppra
for seizure prophylaxis.  You were treated for antibiotics for
pneumonia.  You had bleeding within your abdomen and you
required blood transfusion.  Regarding anticoagulation for your
atrial fibrillation, you were started on aspirin which will be
transitioned to coumadin on [**2134-11-28**].

Please follow-up with your neurologist, Dr. [**First Name (STitle) **] as scheduled
on [**2134-11-29**] at 1:30 PM.

Followup Instructions:
Please follow-up with your neurologist, Dr. [**First Name8 (NamePattern2) 5036**] [**Last Name (NamePattern1) **], as
scheduled on [**2134-11-29**] at 1:30 PM. Phone: [**Telephone/Fax (1) 101198**].
Location: [**Hospital6 1597**].

Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1158**]
[**Last Name (NamePattern1) 43421**], for management of your anticoagulation.  Phone
([**Telephone/Fax (1) 101199**]. Location: [**Street Address(2) 101200**], [**Location (un) 538**], MA Zip
Code02130



Completed by:[**2134-11-23**]
{'Grand mal status,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Hemoperitoneum (nontraumatic),Encephalopathy, unspecified,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Acidosis,Shock, unspecified,Atrial fibrillation,Diseases of tricuspid valve,Pulmonary valve disorders,Obstructive sleep apnea (adult)(pediatric),Long-term (current) use of anticoagulants,Malignant neoplasm of prostate,Nontraumatic hematoma of soft tissue,Heart valve replaced by other means'}


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: seizure

PRESENT ILLNESS: per admitting resident:

MEDICAL HISTORY: -L parietal stroke [**2129**] peri-operative to AVR
-a fib - patient has been off coumadin for the past few days due
to hematuria
-A.comm aneurysm
-prostate ca s/p radiation
- Central and Obstructive sleep apnea, on CPAP

MEDICATION ON ADMISSION: Lasix 20/40mg AM/PM
Flomax 0.4mg - stopped by patient
Ditropan 5mg HS - stopped by patient
Lisinopril 20mg daily
Coumadin 5mg daily
Toprol XL 25mg daily
Simvastatin 40mg daily
ASA 81mg daily
Folic acid, Vitamin D, Viagra 100mg prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T-99.8 BP-196/106 HR-106 RR-20 100O2Sat
Gen: Lying in bed, intubated
HEENT: NC/AT, moist oral mucosa
CV: afib
Lung: Clear to auscultation bilaterally
aBd: +BS soft
ext: no edema

FAMILY HISTORY: NC

SOCIAL HISTORY: patient is a conductor, lives by himself, independent, no
tobbaco or alcohol 

### Response:
{'Grand mal status,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Hemoperitoneum (nontraumatic),Encephalopathy, unspecified,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Acidosis,Shock, unspecified,Atrial fibrillation,Diseases of tricuspid valve,Pulmonary valve disorders,Obstructive sleep apnea (adult)(pediatric),Long-term (current) use of anticoagulants,Malignant neoplasm of prostate,Nontraumatic hematoma of soft tissue,Heart valve replaced by other means'}
