CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 36-year-old
gravida 2/para 2 who was sent to GYN triage following a
telephone call reporting a headache to the office. The
patient was sent to GYN triage after she reported that she
had been seen the previous day by her primary care provider
who had done an evaluation; including a blood pressure that
had been 120/60, and because of the persistent headache the
patient was sent to the GYN triage area to be evaluated.
Additionally, the attending anesthesiologist was [**Year (4 digits) 653**] by
telephone by the primary obstetrician, and this headache was
discussed while the patient was en route to GYN triage
regarding the proper approach to evaluation. The attending
anesthesiologist on labor and delivery that day indicated
that it sounded as though it may be a postural or spinal
anesthesia related headache, and so the plan was formulated
that the patient would be evaluated in a GYN triage area for
obstetrical as well as anesthesia related condition with the
possibility of the placement of a blood patch.

MEDICAL HISTORY: Negative.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Other complications of puerperium, postpartum condition or complication,Other encephalopathy,Infections of genitourinary tract in pregnancy, postpartum condition or complication,Urinary tract infection, site not specified
Puerp compl NEC-postpart,Encephalopathy NEC,Gu infection-postpartum,Urin tract infection NOS
Admission Date: [**2144-4-21**]        Discharge Date: [**2144-4-28**]
Admission Diagnosis: Headache

Discharge Diagnosis: Posterior Reversible Leukoencephalopathy
Syndrome

Date of Birth:  [**2107-11-11**]        Sex:  F

Service:  NME (this summmary dictated by Obstetrics Service)

HISTORY OF PRESENT ILLNESS:  The patient is a 36-year-old
gravida 2/para 2 who was sent to GYN triage following a
telephone call reporting a headache to the office. The
patient was sent to GYN triage after she reported that she
had been seen the previous day by her primary care provider
who had done an evaluation; including a blood pressure that
had been 120/60, and because of the persistent headache the
patient was sent to the GYN triage area to be evaluated.
Additionally, the attending anesthesiologist was [**Year (4 digits) 653**] by
telephone by the primary obstetrician, and this headache was
discussed while the patient was en route to GYN triage
regarding the proper approach to evaluation. The attending
anesthesiologist on labor and delivery that day indicated
that it sounded as though it may be a postural or spinal
anesthesia related headache, and so the plan was formulated
that the patient would be evaluated in a GYN triage area for
obstetrical as well as anesthesia related condition with the
possibility of the placement of a blood patch.

The patient arrived to GYN triage and was evaluated by the
chief resident in GYN triage. The patient had had a repeat
elective cesarean delivery on [**2144-4-10**] and had an
uneventful antepartum as well as postpartum course. The
patient reported that she had been taking Percocet for
incisional pain
since returning from the hospital after her discharge from
her delivery on [**4-14**] but that she had gradually decreased
the amount of Percocet that she was using for her incisional
pain, and coincident with the decrease in the amount of
Percocet that she was taking she noticed that her headache
had progressively been getting worse. At the time of the
initial interview in GYN triage the patient denied any visual
changes or abdominal pain, and the patient described her
headache on the scale of 10 as [**9-28**] and stated that the main
area where it hurt her was over her eyes. She had taken 1
Motrin approximately 3 hours prior to her arrival at GYN
triage. She denied any symptoms of neck stiffness, and she
reported that she got some relief from the headache in a
supine position.

PAST OBSTETRICAL HISTORY:  Notable for a low transverse
cesarean delivery previously in [**2143-2-18**]. This was done
emergently for the indication of a nonreassuring fetal heart
rate tracing leading to a subsequent planned repeat cesarean
delivery on [**2144-4-10**].

PAST MEDICAL HISTORY:  Negative.

PAST SURGICAL HISTORY:  Notable for only for her previous
history of cesarean delivery twice as well as wisdom teeth
operation.

MEDICATIONS:  At the time of her initial evaluation included
only Motrin.

ALLERGIES:  The patient has no known drug allergies.

PHYSICAL EXAMINATION:  At the time of her evaluation in GYN
triage included a temperature of 99.0, a heart rate of 54, a
respiratory rate of 16, and blood pressures as follows. Blood
pressure at 12:15 p.m. was 141/78, and the nursing notes
indicate that the patient states her vision is okay and she
has no epigastric pain and no pedal edema. Repeat blood
pressure was 151/83. At 12:50 p.m. her blood pressure was
172/90. At 1:30 p.m. her blood pressure was 164/86, and at
1:55 p.m. her blood pressure was 138/83, and at 4:00 p.m. her
blood pressure was 141/74 (per nursing notes). The patient
was evaluated by the chief resident. Preeclampsia labs were
sent, and physical exam was performed. The physical exam
revealed that her heart was regular in rate and rhythm. The
chest was clear to auscultation. The abdomen was soft and
nontender. There were no masses. The incision was clean, dry,
and intact. There was scant lochia noted. On her extremities
there were 1+ deep tendon reflexes noted throughout, and her
extremities were nontender. Her neurologic exam at that point
was normal, revealing extraocular movements intact, no nuchal
rigidity, a supple neck, anicteric sclerae, and cranial
nerves II through XII were grossly intact without focal
deficits.

LABORATORY DATA:  Laboratory exams were sent, and they
revealed the following. The times of these laboratory tests
were 1:00 p.m. White blood cell count was 8.5, hemoglobin was
13.8, hematocrit was 39.0, and platelet count was 330,000. A
urine test was sent, and the urine test revealed trace
proteinuria, a large amount of blood (likely due to
contamination from lochia), and negative for ketones. The
liver function tests were normal revealing an ALT of 23 and a
uric acid of 4.7. The protein/creatinine ratio that was sent
at 1:00 o'clock in the afternoon revealed a
protein/creatinine ratio of 0.3, and serum creatinine was
0.5.

HOSPITAL COURSE:  Upon her initial evaluation, the patient
had relative hypertension and her laboratory exam showing
normal preeclampsia labs. Therefore, the decision was made to
have the patient evaluated by both neurology as well as
anesthesiology staff to determine more clearly the etiology of
headache.  Initial evaluation by anesthesiology was suspicious
for spinal headache, and therefore, a plan was formulated to
administer a blood patch.  However, when anesthesia staff
began making preparations for blood patch, the patient began
reporting visual changes, and therefore, neurology was asked
to evaluate the patient as soon as possible.
Neurology staff arrived promptly and began their evaluation.
In the course of performing a funduscopic exam on the patient
the patient was noted to have generalized tonic-clonic
seizure activity. The patient was attended by the neurologist
during the seizure. The patient's primary obstetrician was
being covered on this day by another attending on Labor and
Delivery; however, the primary obstetrician was coincidentally
on labor and delivery attending to another urgent issue and
was called in and was made aware of the events in GYN triage,
and additional nursing as well as anesthesia staff were
summoned for. The patient had had an IV line placed. However,
this IV line was functioning very poorly. As the patient was
noted to have seizure activity, magnesium sulfate was called
for urgently.
However, the IV site that had been placed previously was
noted to be nonfunctioning. As soon as the seizure activity
ceased the patient had a postictal state that was combative,
and there was concern for the patient hurting herself.
Additionally, as the neurology staff was in attendance at
this time, neurology felt strongly that the patient needed to
- as a top priority - go to the CT scan area in order to
determine the cause of the headache and seizure, and most
importantly determine whether the patient urgently needed to
go to the operating room. In view of the patient's combative
postictal state, the decision was made with obstetrician as
well as together with neurology to administer Ativan
intramuscularly as it was impossible to control the patient
without sedating her. Simultaneously, the ICU staff was
summoned for and arrived quickly. The ICU staff, the
anesthesia staff, the neurology staff, as well as obstetrical
staff chief resident and several nurses were present trying
to prepare the patient for the neurologist recommendation for
immediate CT scan. Consideration was made for transferring
the patient to the intensive care unit; however, the
intensive care unit staff felt that she needed to be sedated
prior to this transfer. The anesthesia staff tried very hard
to insert IV access in order to be able to give the patient
intravenous medications including magnesium, however, this
was extremely difficult to do given the patient's postictal
state and the very strong movements of her arms and legs. For
this reason - and again in conjunction with the other
services - the decision was made to give the patient Ativan
to try to get her postictal state under control; and as a
second priority to get the patient to the CT scanner in order
to get imaging performed. We planned on giving the patient
magnesium sulfate, however, it was impossible to do this
given the fact that there was no IV access at that point.

The patient went to CT scan and had a 22-gauge IV placed
after 10 mg of Ativan were given. A 22-gauge IV was able to
be placed in the patient's arm, and the patient was urgently
brought to CT scan so that contrast could be infused through
this only intravenous access in order to determine whether
the patient needed to urgently go to the operating room.
There was additional concern that before the patient arrived
in the ICU that given the fact that the patient had received
a total of 10 mg of Ativan in order to sedate her that the
addition of magnesium without adequate IV access could
unacceptably increase the risk for respiratory depression in
this patient. The patient had received the majority of this
Ativan intramuscularly and there was concern that with
the poor intravenous access that the patient could become
heavily sedated respiratory wise and that we wanted to make
sure that the patient was in the intensive care unit setting
before giving additional medication that could sedate her
respiratory system.

The patient was brought to the CT scan suite, contrast was
infused, and the neurosurgeons were called. The [**Location (un) 1131**] on
the initial CT scan showed that there was a question of a
subarachnoid hemorrhage. The patient was seen by neurosurgery
and neurology, and the patient was immediately transferred to
the intensive care unit. At this point, there was a
discussion among the obstetrical staff. The chairman of the
obstetrical department was [**Name (NI) 653**], and there was a
discussion regarding the further management of this patient.
The impression of the neurology staff and the intensive care
unit staff was that the images and the clinical picture were
consistent with posterior reversible leukoencephalopathy
syndrome, and neurology felt strongly that the patient should
receive prophylaxis for further seizures using Dilantin. On
arrival in the intensive care unit Dilantin was begun, and
the patient received central line access. Further tests were
completed in the intensive care unit including a lumbar
puncture that eventually showed negative results, except that
there was some blood in the cerebrospinal fluid which was
consistent with a subarachnoid hemorrhage.

The impression was that the clinical picture was
consistent with posterior reversible encephalopathy syndrome,
and we discussed once again the decision for magnesium
prophylaxis. The decision was made at that point (in
collaboration with neurology, intensive care unit staff,
maternal fetal medicine, and general obstetrics staff) to not
give magnesium sulfate as the suspicion at this time was that
the patient had posterior reversible encephalopathy syndrome.
The patient was intubated prophylactically in the intensive
care unit as she had received Ativan and there was concern
about airway protection.

On the second day of admission, the neurology staff requested
that the obstetrical staff consider that the patient be
transferred to the neurological ICU (which is on the [**Hospital Ward Name **]). Opinion was sought from the chairman of the
obstetrical department, the maternal fetal medicine
consultant, Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. A detailed conference
was undertaken with Dr.
[**Last Name (STitle) **] of neuroradiology regarding his most specific
impression of the differential diagnosis, and together the
impression was that the patient had posterior reversible
encephalopathy syndrome, and therefore the decision was made
that the patient should be transferred to the neurology
intensive care unit so that she could have continuous EEG
monitoring and intensive neurological oversight. The patient
was transferred on the 2nd day of her hospitalization to the
neurology ICU on the [**Hospital Ward Name **] and was observed to have no
further seizure activity.

The following day,the patient was extubated. Upon extubation
did report that she still had a headache and also noted some
persistent visual deficits. The patient continued to improve
and was transferred to the stepdown unit after the 4th day.
The patient continued to improve and had a subsequent MRI
that showed that the initial changes on the MRI were
resolving. The patient was discharged home on [**4-28**] with
followup by visiting nurse and also with the obstetrical
social worker. The final [**Location (un) 1131**] on the MRI that was done on
admission showed extensive cortical and subcortical white
matter lesions which could be a manifestation of reversible
leukoencephalopathy; though infectious and even neoplastic
etiologies could be considered. The final [**Location (un) 1131**] on the MRI
the day before discharge from the hospital showed in the
interval since the prior/previous examination there had been
marked improvement in most areas of prominent T2
hyperintensity involving high bilateral frontal, right
parietal, bilateral occipital lobes, and cerebellum; although
a residual amount of T2 hyperintensity remained. The
impression showed marked improvement of diffuse white matter
hyperintensity with residual amount remaining and showed
evidence of residual blood within the sulci on flare images.

DISCHARGE DISPOSITION:  The patient was discharged home on
[**2144-4-28**].

CONDITION ON DISCHARGE:  Noted to be in good condition.

DISCHARGE FOLLOW-UP PLANS:  To follow up with neurology as
well as with her primary obstetrician the following week
after discharge.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 50701**], M.D.  [**MD Number(1) 50702**]

Dictated By:[**Last Name (NamePattern4) 50703**]
MEDQUIST36
D:  [**2144-5-5**] 17:58:59
T:  [**2144-5-6**] 14:38:58
Job#:  [**Job Number 50704**]
{'Other complications of puerperium, postpartum condition or complication,Other encephalopathy,Infections of genitourinary tract in pregnancy, postpartum condition or complication,Urinary tract infection, site not specified'}


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: 

PRESENT ILLNESS: The patient is a 36-year-old
gravida 2/para 2 who was sent to GYN triage following a
telephone call reporting a headache to the office. The
patient was sent to GYN triage after she reported that she
had been seen the previous day by her primary care provider
who had done an evaluation; including a blood pressure that
had been 120/60, and because of the persistent headache the
patient was sent to the GYN triage area to be evaluated.
Additionally, the attending anesthesiologist was [**Year (4 digits) 653**] by
telephone by the primary obstetrician, and this headache was
discussed while the patient was en route to GYN triage
regarding the proper approach to evaluation. The attending
anesthesiologist on labor and delivery that day indicated
that it sounded as though it may be a postural or spinal
anesthesia related headache, and so the plan was formulated
that the patient would be evaluated in a GYN triage area for
obstetrical as well as anesthesia related condition with the
possibility of the placement of a blood patch.

MEDICAL HISTORY: Negative.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Other complications of puerperium, postpartum condition or complication,Other encephalopathy,Infections of genitourinary tract in pregnancy, postpartum condition or complication,Urinary tract infection, site not specified'}
