CHIEF COMPLAINT: seizure

PRESENT ILLNESS: CC: code stroke called at 7:26 pm, at the patient's bedside by
7:30 pm.

MEDICAL HISTORY: Left breast cancer(in records, but son unaware of any history)
asthma vs COPD.  Also remote hx of GYN cancer (s/p hysterectomy
in her 20s, further details unknown)
hypertension Benicar stopped a month ago according to her son
mild dementia on formal neuropsych testing(although son states
deficits are no longer mild)-seen by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6817**]
[**2167-11-11**] - Mild intrahepatic biliary dilatation on U/S,
Cholelithiasis w/o son[**Name (NI) 493**] evidence of acute cholecystitis &
she had a UTI.

MEDICATION ON ADMISSION: AZELASTINE [ASTELIN] -  (Prescribed by Other Provider) - 137 mcg
Aerosol, Spray -  twice daily
BECLOMETHASONE DIPROPIONATE [QVAR] -  (Prescribed by Other
Provider) - 80 mcg Aerosol -  twice daily
CITALOPRAM -  (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
DONEPEZIL [ARICEPT] - 10 mg Tablet - 1 Tablet(s) by mouth once a
day
MEMANTINE [NAMENDA] - 5 mg Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE -  (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day
OXYBUTYNIN CHLORIDE - 5 mg Tab,Sust Rel Osmotic Push 24hr - 1
Tab(s) by mouth daily

ALLERGIES: Sulfonamides

PHYSICAL EXAM: T-afebrile BP-in the field her systolic BP had been in the 212,
when she arrived in the ER it was 168/121, on propofol it was
140/71 HR-62 RR-16 O2Sat-100% (on vent)FS 177
Gen: Lying in bed, NAD
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, nontender
Breast: L breast scar noted, fullness noted in the left upper
outer quadrant.
ext: no edema

FAMILY HISTORY: Her sister died recently of emphysema

SOCIAL HISTORY: SH: Lives in [**Location **] with her son.  She goes out of the house
once a day to visit [**Company 2486**]. Capable of ADL's, but does
not
drive or balance a cheque book. Gave up smoking 20 years ago,
prior to that she had been a heavy smoker for 40 years. She does
not drink alcohol or use recreational drugs. She worked in a
cafeteria.
HCP/son [**Name (NI) **] [**Name (NI) 122**] [**Name (NI) 15427**] [**Telephone/Fax (1) 15429**], full code for now
PCP: [**Name10 (NameIs) **] [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2903**] ([**Hospital1 18**]-[**Location (un) **])
Subarachnoid hemorrhage,Cerebral edema,Other convulsions,Chronic obstructive asthma, unspecified,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Personal history of malignant neoplasm of breast,Acquired absence of both cervix and uterus,Personal history, urinary (tract) infection
Subarachnoid hemorrhage,Cerebral edema,Convulsions NEC,Chronic obst asthma NOS,Hypertension NOS,Mental disor NEC oth dis,Hx of breast malignancy,Acq absnce cervix/uterus,Personal history UTI
Admission Date:  [**2167-2-23**]              Discharge Date:   [**2167-2-27**]

Date of Birth:  [**2098-7-23**]             Sex:   F

Service: NEUROLOGY

Allergies:
Sulfonamides

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
seizure

Major Surgical or Invasive Procedure:
none

History of Present Illness:
CC: code stroke called at 7:26 pm, at the patient's bedside by
7:30 pm.

HPI: 68 year old left handed woman, with a history of dementia,
HTN, previous breast cancer, who around 6:00 pm became confused.
She had woken up from a nap, and was about to have a cup of tea
with her son, and complained of a headache, and feeling sick.
She
stated to her son that she was having a sinus headache, and had
complained of a headache before she went to bed the previous
night. Her son [**Name (NI) **] [**Name (NI) 15427**] was unable to describe the character
or exact location of the headache. She started to want to vomit
and began to gag. He seated his mother down on the couch, and
she
became more disoriented, so he called 911. By the time the EMS
arrived, she was completely confused as to what they were doing
in the room. A few minutes after they arrived around 6:20 pm,
she
started to slouch in the couch to the left, clench her hands and
started shaking them, her legs were straight out, and she
started
frothing at the mouth with a glazed expression. She was
unresponsive and mute. Prior to this, she had been able to
answer
and understand questions in her normal manner. The episode
lasted
10-15 minutes, and her son thought that she was having a
seizure.
The EMS placed an oxygen mask on her face, and she remained
unresponsive.

Of note she had taken Ibuprofen and Tylenol the previous night
for her headache, and when she woke up in the morning. Her son
had offered to take her to the ER in the morning, but she
mentioned that it was her usual sinus headache, which she saw
her
PCP [**Name Initial (PRE) **]. According to her son, yesterday, they went to [**Name (NI) 15428**] as usual, and she was at her baseline.

By the time that I saw her in the ER, she was already intubated
and paralyzed for airway protection. An ROS was unobtainable.
According to the ER physicians she had a flaccid right sided
paralysis on arrival, which was not appreciable after intubation
and paralysis.


Past Medical History:
Left breast cancer(in records, but son unaware of any history)
asthma vs COPD.  Also remote hx of GYN cancer (s/p hysterectomy
in her 20s, further details unknown)
hypertension Benicar stopped a month ago according to her son
mild dementia on formal neuropsych testing(although son states
deficits are no longer mild)-seen by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6817**]
[**2167-11-11**] - Mild intrahepatic biliary dilatation on U/S,
Cholelithiasis w/o son[**Name (NI) 493**] evidence of acute cholecystitis &
she had a UTI.

Past Surgical History:
Tonsillectomy, appendectomy, breast
surgery, hysterectomy, and some sort of bladder neck suspension.


Social History:
SH: Lives in [**Location **] with her son.  She goes out of the house
once a day to visit [**Company 2486**]. Capable of ADL's, but does
not
drive or balance a cheque book. Gave up smoking 20 years ago,
prior to that she had been a heavy smoker for 40 years. She does
not drink alcohol or use recreational drugs. She worked in a
cafeteria.
HCP/son [**Name (NI) **] [**Name (NI) 122**] [**Name (NI) 15427**] [**Telephone/Fax (1) 15429**], full code for now
PCP: [**Name10 (NameIs) **] [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2903**] ([**Hospital1 18**]-[**Location (un) **])


Family History:
Her sister died recently of emphysema



Physical Exam:
T-afebrile BP-in the field her systolic BP had been in the 212,
when she arrived in the ER it was 168/121, on propofol it was
140/71 HR-62 RR-16 O2Sat-100% (on vent)FS 177
Gen: Lying in bed, NAD
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, nontender
Breast: L breast scar noted, fullness noted in the left upper
outer quadrant.
ext: no edema

Neurologic examination:
Mental status: Intubated and sedated. Received Narcan (2) in the
field, then she was intubated by rapid sequence method
(etomidate+succ), and sedated with propofol (and also given some
versed)

Cranial Nerves:
Pupils 2 mm bilaterally, sluggishly responsive to light.
Corneals
in tact. Dolls head reflex normal. Gag in tact.

Motor:
Withdraws all 4 extremeties to noxious stimulus.

Reflexes:
2 and symmetric throughout, apart from Achilles jerks which are
+1s.
Right toe is upgoing

Coordination & gait could not be assessed

Labs:
pH 7.33 pCO2 44 pO2 484 HCO3 24 BaseXS -2

[**2167-2-23**]
7:33p
Green Top
Na:142
K:3.6
Cl:100
TCO2:17
Glu:191       freeCa:1.16
Lactate:10.7
pH:7.22
Hgb:15.4
CalcHCT:46

Serum tylenol 18.8, rest of serum and Utox unremarkable


Pertinent Results:
[**2167-2-23**] 07:26PM BLOOD WBC-13.1* RBC-4.86 Hgb-14.3 Hct-43.3
MCV-89 MCH-29.5 MCHC-33.1 RDW-12.5 Plt Ct-384
[**2167-2-24**] 02:46AM BLOOD WBC-17.6* RBC-4.31 Hgb-12.5 Hct-37.3
MCV-87 MCH-29.1 MCHC-33.6 RDW-12.9 Plt Ct-270
[**2167-2-23**] 07:26PM BLOOD PT-12.1 PTT-24.8 INR(PT)-1.0
[**2167-2-23**] 07:26PM BLOOD Fibrino-547*
[**2167-2-25**] 03:05AM BLOOD ESR-30*
[**2167-2-25**] 03:05AM BLOOD Glucose-94 UreaN-14 Creat-0.7 Na-142
K-3.1* Cl-109* HCO3-25 AnGap-11
[**2167-2-25**] 03:05AM BLOOD ALT-9 AST-22
[**2167-2-24**] 02:46AM BLOOD CK(CPK)-88
[**2167-2-24**] 02:46AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2167-2-24**] 02:46AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.6

CT head [**2167-2-23**]
1. Subarachnoid hemorrhage in the left posterior parietal cortex
at the
vertex.
2. No evidence of acute infarct. MRI is more sensitive for the
detection of acute ischemia.

MRI head, MRA / MRV [**2167-2-23**]

1. Extensive areas of signal abnormality with nodular
enhancement throughout
the brain, many of which are centered at the [**Doctor Last Name 352**]-white matter
junction, with
both supra- and infra-tentorial compartments involvement as well
as
involvement of deep [**Doctor Last Name 352**] nuclei.

Differential considerations include an infectious process, which
may be
related to septic emboli (although the lack of more widespread
associated
blood products and infarction is unusual, given the extent of
the
abnormalities), atypical infections such as tuberculosis,
neoplastic processes
such as metastatic disease or lymphoma, toxic metabolic
processes (given deep
[**Doctor Last Name 352**] structure involvement and somewhat bilateral diffuse
symmetric
appearance), as well as other more atypical patterns of emboli,
such as from
an atrial myxoma or bland endocarditis.

2. The left parietal blood products seen on the preceding CT
scan could be
due to septic or bland embolism, or an infectious process.
However, they
could also be indicative of venous ischemia secondary to the
underlying
pathologic process.

3. No evidence of venous sinus thrombosis. While the large
cortical veins
appear patent, MRV is not sensitive for evaluation of cortical
veins.

4. Unremarkable MRAs of the head and neck, without evidence of a

hemodynamically significant stenosis or aneurysm.

5. Areas of increased signal intensity within the left lobe of
thyroid gland,
incompletely characterized on the current study. Correlation
with thyroid
laboratory data and/or ultrasound is recommended.

TTE [**2167-2-24**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Left ventricular systolic function is hyperdynamic
(EF>75%). Right ventricular chamber size and free wall motion
are normal. 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 a trivial/physiologic pericardial effusion.
There is an anterior space which most likely represents a fat
pad.

IMPRESSION: Normal global and regional biventricular systolic
function.

[**2167-2-24**] CXR
FINDINGS: In comparison with the study of [**2-23**], the
endotracheal tube and
nasogastric tube have been removed. There is a vague suggestion
of an area of
increased opacification in the retrocardiac region on the left.
This could
merely reflect atelectasis or crowding of vessels. However, in
view of the
clinical symptoms, the possibility of a developing aspiration
must be
considered. This area should be closely checked on subsequent
radiographs.
On to recent studies, there is suggestion medial displacement of
the stomach,
which could be associated with enlargement of the spleen.

MR HEAD W & W/O CONTRAST Study Date of [**2167-2-26**] 9:53 PM

IMPRESSION: There has been significant interval improvement in
the extent of
T2/FLAIR-signal abnormality throughout the supra- and
infratentorial
compartments with a similar small volume of subarachnoid
hemorrhage, compared
to the prior study. The enhancement at these sites has resolved
completely.
The overall distribution and evolution strongly suggests the
possibility of
underlying PRES, which may be associated with both enhancement
and hemorrhage
in some cases. There is no associated infarct. Other toxic,
neoplastic or
metabolic etiologies as suggested in the report of the previous
exam remain in
the differential diagnosis, though are now considered
significantly less
likely.


Brief Hospital Course:
Ms. [**Known lastname 15427**] is a 68 year old left handed woman, with a history
of dementia, HTN, a remote history of GYN cancer (in her 20s,
s/p hysterectomy, further details unobtainable), presenting with
several day history of headache followed by sudden-onset
confusion, disorientation, and vomiting, with subsequent
10-minute GTC seizure.  She was intubated upon arrival to the
emergency department for airway protection and admitted to the
neurology ICU.
.
Hospital course by problem;
.
Neurology; A CT head revealed a right parietal subarachnoid
hemorrhage.  An MRI showed extensive areas of signal abnormality
with nodular enhancement throughout the brain on FLAIR and
post-contrast studies.  Given the clinical history, it was
thought these may represent transient post-seizure changes.  An
MRA and MRV were unremarkable.  She was transferred to the
neurology floor.

An MRI with and without contrast was repeated and showed
significant interval improvement in the extent of
T2/FLAIR-signal abnormality throughout the supra- and
infratentorial compartments with a similar small volume of
subarachnoid hemorrhage, compared to the prior study. The
enhancement at these sites has resolved completely.  The overall
distribution and evolution strongly suggests the possibility of
underlying PRES, which may be associated with both enhancement
and hemorrhage in some cases. There is no associated infarct.

The patient was started on keppra 750 mg [**Hospital1 **] for seizure
prophylaxis.
.
Respiratory; The patient was extubated on HD#1 and required a
facemask for oxygenation for the following day.  She was weaned
to room air.
.
ID; The patient had a Tmax of 101 on HD#1 and has been afebrile
since.  She also has a leukocytosis with WBC 17.  Blood
cultures, urine cultures, and CXR have showed no sign of
infectious process.  The patient has no nuchal rigidity.
.
CV; The patient was monitored on telemetry with no significant
events.  A TTE was unremarkable. She was started on simvastatin.
 She was instructed to restart Benicar at discharge.
.

Medications on Admission:
AZELASTINE [ASTELIN] -  (Prescribed by Other Provider) - 137 mcg
Aerosol, Spray -  twice daily
BECLOMETHASONE DIPROPIONATE [QVAR] -  (Prescribed by Other
Provider) - 80 mcg Aerosol -  twice daily
CITALOPRAM -  (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
DONEPEZIL [ARICEPT] - 10 mg Tablet - 1 Tablet(s) by mouth once a
day
MEMANTINE [NAMENDA] - 5 mg Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE -  (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day
OXYBUTYNIN CHLORIDE - 5 mg Tab,Sust Rel Osmotic Push 24hr - 1
Tab(s) by mouth daily

Medications - OTC
DOCUSATE SODIUM [COLACE] -  (OTC) - Dosage uncertain


Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Benicar HCT 40-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Memantine 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. Oxybutynin Chloride 5 mg Tab,Sust Rel Osmotic Push 24hr Sig:
One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
left parietal subarachnoid hemorrhage
seizure


Discharge Condition:
Mental Status: Awake, Alert, oriented x 2 (her baseline). Able
to say DOW forward
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent


Discharge Instructions:
You were admitted after you had a seizure.  You were found to a
left-sided parietal subarachnoid hemorrhage in your brain.  Your
brain imaging also shows areas of your brain that may have been
affected by high blood pressure in the setting of being off
Benicar for the past month.  Repeat imaging prior to your
discharge showed that these areas were improving.

You should re-start Benicar for blood pressure control.  We also
have started you on Simvastatin to help with your cholesterol
level.  In addition, since you had a seizure you have been
placed on Keppra 750 mg twice daily for seizure prophylaxis.
You should stay on Keppra for at least 6 months.

Please take all medications as prescribed.

Please follow-up with your neurologist, Dr. [**Last Name (STitle) **], as listed
below.

Should you develop any symptoms as listed below or concerning to
you, please call your doctor or go to the emergency room.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2167-3-31**] 5:30



Completed by:[**2167-3-7**]
{'Subarachnoid hemorrhage,Cerebral edema,Other convulsions,Chronic obstructive asthma, unspecified,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Personal history of malignant neoplasm of breast,Acquired absence of both cervix and uterus,Personal history, urinary (tract) infection'}


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: CC: code stroke called at 7:26 pm, at the patient's bedside by
7:30 pm.

MEDICAL HISTORY: Left breast cancer(in records, but son unaware of any history)
asthma vs COPD.  Also remote hx of GYN cancer (s/p hysterectomy
in her 20s, further details unknown)
hypertension Benicar stopped a month ago according to her son
mild dementia on formal neuropsych testing(although son states
deficits are no longer mild)-seen by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6817**]
[**2167-11-11**] - Mild intrahepatic biliary dilatation on U/S,
Cholelithiasis w/o son[**Name (NI) 493**] evidence of acute cholecystitis &
she had a UTI.

MEDICATION ON ADMISSION: AZELASTINE [ASTELIN] -  (Prescribed by Other Provider) - 137 mcg
Aerosol, Spray -  twice daily
BECLOMETHASONE DIPROPIONATE [QVAR] -  (Prescribed by Other
Provider) - 80 mcg Aerosol -  twice daily
CITALOPRAM -  (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
DONEPEZIL [ARICEPT] - 10 mg Tablet - 1 Tablet(s) by mouth once a
day
MEMANTINE [NAMENDA] - 5 mg Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE -  (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day
OXYBUTYNIN CHLORIDE - 5 mg Tab,Sust Rel Osmotic Push 24hr - 1
Tab(s) by mouth daily

ALLERGIES: Sulfonamides

PHYSICAL EXAM: T-afebrile BP-in the field her systolic BP had been in the 212,
when she arrived in the ER it was 168/121, on propofol it was
140/71 HR-62 RR-16 O2Sat-100% (on vent)FS 177
Gen: Lying in bed, NAD
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, nontender
Breast: L breast scar noted, fullness noted in the left upper
outer quadrant.
ext: no edema

FAMILY HISTORY: Her sister died recently of emphysema

SOCIAL HISTORY: SH: Lives in [**Location **] with her son.  She goes out of the house
once a day to visit [**Company 2486**]. Capable of ADL's, but does
not
drive or balance a cheque book. Gave up smoking 20 years ago,
prior to that she had been a heavy smoker for 40 years. She does
not drink alcohol or use recreational drugs. She worked in a
cafeteria.
HCP/son [**Name (NI) **] [**Name (NI) 122**] [**Name (NI) 15427**] [**Telephone/Fax (1) 15429**], full code for now
PCP: [**Name10 (NameIs) **] [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2903**] ([**Hospital1 18**]-[**Location (un) **]) 

### Response:
{'Subarachnoid hemorrhage,Cerebral edema,Other convulsions,Chronic obstructive asthma, unspecified,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Personal history of malignant neoplasm of breast,Acquired absence of both cervix and uterus,Personal history, urinary (tract) infection'}
