CHIEF COMPLAINT: Seizure, altered mental status.

PRESENT ILLNESS: History obtained from [**Name (NI) 401**] [**Name (NI) 25766**] HCP and neuro notes

MEDICAL HISTORY: DM1 since age 38, insulin pump requiring. HbA1C 9.6 on [**2190-11-25**]
Hypertension
Diastolic Heart Failure
Hyerplipidemia
CKD ([**2190-11-25**] Cr of 3.0)
h/o Acute pancreatitis
h/o DKA with associated hypoxic brain injury and prolonged ICU
stay requiring Trach & PEG (now weaned from trach but PEG in
place)

MEDICATION ON ADMISSION: Miconazole TP
Ranitidine 150mg [**Hospital1 **]
Amlodipine 10mg daily
Heparin 5000u sc tid
Insulin Humolog SS
Labetalol 600mg TID
Calcium Acetate 667mg
Nitroglycerin patch
Lasix 100mg [**Hospital1 **]
Lantus 16units daily
Metolazone 2.5mg daily
Hydralazine 50mg q6hr
Tylenol/percocet prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: 99.5 BP 169/74 HR 74 RR 3-12 Sats 95% on RA
Gen: Lying in bed, somnolent but arousable, not following
commands and reports pain when touched anywhere
HEENT: NC/AT, dry mucosa
Neck: supple
CV: RRR, NL S1 and S2, no murmurs/gallops/rubs
Lung: not compliant with exam but subtle inspiratory crackles at
bases bilaterally
Abd: Soft, mildly TTP diffusely, no rebound/guarding, NABS.
Lower Ext: no edema, warm, good DPulses
RUE: warm, erythematous, edematous

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Used to work as an [**Company 2318**] mechanic, but had to stop working when
he lost driver's license after repeated episodes of
hypoglycemia. Not married. Pt has been living at [**Hospital1 9494**] Rehab since admission in [**Month (only) **]/[**2190**].
Other convulsions,Acute kidney failure, unspecified,Encephalopathy, unspecified,Nutritional marasmus,Chronic diastolic heart failure,Alkalosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes with other specified manifestations, type I [juvenile type], uncontrolled,Obstructive sleep apnea (adult)(pediatric)
Convulsions NEC,Acute kidney failure NOS,Encephalopathy NOS,Nutritional marasmus,Chr diastolic hrt fail,Alkalosis,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,DMI oth uncntrld,Obstructive sleep apnea
Admission Date:  [**2191-4-13**]              Discharge Date:   [**2191-4-23**]

Date of Birth:  [**2138-6-3**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
Seizure, altered mental status.

Major Surgical or Invasive Procedure:
Lumbar puncture ([**4-14**]).

History of Present Illness:
History obtained from [**Name (NI) 401**] [**Name (NI) 25766**] HCP and neuro notes

52 y/o M with PMHx of Type I DM, HTN, CKD and DKA c/b hypoxic
brain injury who had a witnessed generalized tonic clonic
seizure today this morning which lasted approximately 1 minute.
Per report, he was then noted to be postictal and yawning but
"he was moving all 4 extremities at the time" and BS was >200.
The rehab team cannot tell if there was a gaze deviation or
bowel incontinence. He did not receive any meds. [**Name (NI) **]
brother reports that at baseline the patient is able to converse
and comprehend, but has difficulty with naming. At baseline
patient is able to walk with assist using a belt and a person
following with a wheelchair. Has recently been able to
walk up 16 stairs. Per patient's brother/HCP, pt's blood glucose
levels have been fluctuating recently and he reportedly had an
episode of hypoglycemia yesterday with a glucose POC of 24
because the patient missed a meal. Brother saw patient last
night at which time he was able to discuss his children and his
retirement. Pt had a UTI last week which was treated with
ceftriaxone, last dose ~48 hours ago. Of note, he has had a
foley in since admission to the NH.  HCP reported that he has
had recurrent infections while at rehab and recently treated for
CDiff (stopped Abx for Cdiff on [**4-8**]).

Initial VS on arrival to the ED: T 97.6 BP 173/94 RR 18 Sats
95%2L NC.
Given new onset seizure and mental status changes, pt was given
Ativan 2mg IV and there were multiple unsuccessful attempts at
lumbar puncture. Head CT did not show any acute changes from
baseline. Neuro was consulted and pt was empirically treated
with Ceftriaxone 2grams, Vancomycin 1gram, Ampicillin 2grams,
Acyclovir 1gram. Pt was given IVF but this was stopped after CXR
showed increased pulm edema.

On arrival to the MICU, pt was somnolent but arousable to
stimuli.  Pt would shout out in clear language to stop and says
"[**Last Name (un) **]" but otherwise, he does not follow commands. Of note, he
falls to sleep and exhibits cheynes [**Doctor Last Name 6056**] breathing.

Family provided additional ROS: Pt has been c/o chills at night
but denies fevers. Good appetite, some diarrhea, recent UTI, no
significant cough or shortness of breath. Improving with swallow
function, advanced to regular diet approx [**2-10**] wks ago. No nausea
or vomiting.

Past Medical History:
DM1 since age 38, insulin pump requiring. HbA1C 9.6 on [**2190-11-25**]
Hypertension
Diastolic Heart Failure
Hyerplipidemia
CKD ([**2190-11-25**] Cr of 3.0)
h/o Acute pancreatitis
h/o DKA with associated hypoxic brain injury and prolonged ICU
stay requiring Trach & PEG (now weaned from trach but PEG in
place)

Social History:
Used to work as an [**Company 2318**] mechanic, but had to stop working when
he lost driver's license after repeated episodes of
hypoglycemia. Not married. Pt has been living at [**Hospital1 9494**] Rehab since admission in [**Month (only) **]/[**2190**].

Family History:
Non-contributory.

Physical Exam:
PE: 99.5 BP 169/74 HR 74 RR 3-12 Sats 95% on RA
Gen: Lying in bed, somnolent but arousable, not following
commands and reports pain when touched anywhere
HEENT: NC/AT, dry mucosa
Neck: supple
CV: RRR, NL S1 and S2, no murmurs/gallops/rubs
Lung: not compliant with exam but subtle inspiratory crackles at
bases bilaterally
Abd: Soft, mildly TTP diffusely, no rebound/guarding, NABS.
Lower Ext: no edema, warm, good DPulses
RUE: warm, erythematous, edematous

Pertinent Results:
Labs at Admission:
[**2191-4-13**] 08:15AM BLOOD WBC-8.5 RBC-4.68# Hgb-13.6*# Hct-41.9#
MCV-90 MCH-29.1 MCHC-32.5 RDW-17.1* Plt Ct-230
[**2191-4-13**] 08:15AM BLOOD Neuts-82.0* Lymphs-11.7* Monos-4.3
Eos-1.5 Baso-0.5
[**2191-4-13**] 08:15AM BLOOD PT-11.1 PTT-26.9 INR(PT)-0.9
[**2191-4-13**] 08:15AM BLOOD Glucose-202* UreaN-61* Creat-5.6*# Na-137
K-4.2 Cl-94* HCO3-32 AnGap-15
[**2191-4-13**] 08:13PM BLOOD ALT-22 AST-21 LD(LDH)-269* AlkPhos-126
TotBili-0.3
[**2191-4-13**] 08:15AM BLOOD Calcium-10.0 Phos-5.4* Mg-2.3
[**2191-4-14**] 04:15AM BLOOD Osmolal-308
[**2191-4-13**] 08:15AM BLOOD TSH-5.5*
[**2191-4-13**] 08:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2191-4-13**] 08:22AM BLOOD Lactate-1.4

CSF Fluid Analysis:
-WBC-2 RBC-2* Polys-1 Lymphs-56 Monos-43
-TotProt-75* Glucose-136 LD(LDH)-38
-HERPES SIMPLEX VIRUS PCR- pending

Micro Data:
-[**4-13**] BCx: Pending
-[**4-13**] UCx: Negative
-[**4-14**] CSF HSV PCR: negative
-[**4-14**] CSF: Cryptococcal antigen NEGATIVE
   GRAM STAIN (Final [**2191-4-14**]): NO PMNs. NO MICROORGANISMS.
   FLUID CULTURE (Preliminary):    NO GROWTH.
   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
   VIRAL CULTURE (Preliminary):
-[**4-15**] C. diff: negative
-[**4-17**] UCx: negative

Imaging Studies:
-[**4-13**] ECG: Sinus rhythm. Borderline prolonged/upper limits of
normal QTc interval is non-specific. Otherwise, tracing is
within normal limits. Clinical correlation is suggested. Since
the previous tracing of [**2190-12-20**] the rate is slower and low
amplitude T wave changes have decreased.
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 126 94 444/449 59 18 70
.
-[**4-13**] CT Head: 1. No acute intracranial process. 2. Unchanged old
infarctions.
-[**4-13**] CXR: 1. Mild CHF. 2. Left retrocardiac opacity, most likely
representing atelectasis, pneumonia cannot be excluded.
-[**4-13**] Abd X-ray: No evidence of bowel obstruction. No free
intraperitoneal air.
-[**4-14**] EEG: Abnormal portable EEG due to the slow and disorganized

background and frequent bursts of generalized slowing. These
findings
indicate a widespread encephalopathy affecting both cortical and

subcortical structures. There were some sharp features before
the
generalized slowing, but they were not simple spike or sharp and
slow
wave complexes, and they appeared repetitively for only a few
seconds at a time. The tracing cannot rule out the occurrence of
seizures at other times, but the bursts of slowing and even
sharp waves appeared more likely related to the encephalopathy.
If clinical suspicion for
seizures persists, a repeat tracing or longer monitoring could
be
helpful. There were no areas of persistent focal slowing, but
encephalopathies may obscure focal findings.
-[**4-16**] Renal U/S: Echogenic kidneys suggesting underlying medical
renal disease.  There is no nephrolithiasis, hydronephrosis, or
renal mass lesion
-[**4-17**] Right UE U/S: No right upper extremity DVT.

Brief Hospital Course:
# Seizure/Altered Mental Status: Neuro exam was generally
non-focal aside from right sided and lower extremity weakness,
which had reportedly been stable since his hypoxic brain injury
several months ago. He was empirically treated with Vanc,
Ceftriaxone, Ampicillin and Acyclovir for possible meningitis.
LP was eventually obtained after an initially unsuccesful
attempt. CSF was not concerning for infection, and
antibiotics/antivirals were discontinued.  Neuro was consulted
and recommended starting Keppra. In the MICU, his toxic
metabolic work up revealed a mildly elevated TSH and normal free
T4. Infectious workup was unrevealing. Pt was initially
continued on empiric metronidazole for possible C Diff given his
history of recurrent Cdiff, recent Abx course and elevated WBC
count, but this was discontinued when his toxin assay came back
negative.  EEG was performed and showed findings likely related
to encephalopathy. Mental status was improved by day 2 of
admission and pt was called out to the floor. He did not have
any further seizures, and his mental status improved to his
baseline mental status from prior to the seizure, according to
his brothers. [**Name (NI) **] will follow up with neurology as an outpatient.

# Acute on chronic renal failure: Pt has CKD with baseline
creatinine of 3.5-3.9 and presented with a creatinine of 5.8 and
a hemoconcentrated CBC. His creatinine had a variable result to
volume repletion, but eventually improved to 5.0. Nephrology was
consulted. A family meeting was held between the patient,
brothers, and the renal service, during which the brothers were
told that hemodialysis may not have a significant benefit in the
patient's quality of life. The family may consider seeing a
local nephrologist to further discuss the risks/benefits of
hemodialysis.

# Diastolic CHF: The patient was generally euvolemic during the
hospitalization. He was intermittently given IV fluids to treat
his [**Last Name (un) **], and did not have significant edema, oxygen
desaturation, or other signs of significant volume overload,
despite holding diuretics. His respiratory status was stable. He
was continued on Hydralazine, Amlodipine and Labetalol for BP
control.

# TypeI DM: Pt with h/o labile BS and severe episode of DKA
complicated by hypoxic brain injury.  Of note, his BS after the
seizure was >170 though his family had been feeding him his
meals and the day prior to admission, his BS was 24 due to
missing a meal. Given the lability of his blood sugars, the
patient was given tube feeds at a low rate, and his initial
insulin regimen was conservative to avoid repeat episodes of
hypoglycemia. Upon transfer to the floor, though, his blood
sugars were somewhat labile, especially after the
re-introduction of a diet. He was seen by [**Last Name (un) **] who recommended
adding bedtime glargine, and his fingersticks were subsequently
better controlled. His insulin doses will likely have to be
adjusted further as his oral diet and tube feeds are adjusted.
.
# Obstructive sleep apnea: The patient underwent a sleep study
as recommended by the neurology service. The neurology attending
planned to evaluate the sleep study. The patient was recommended
to sleep on his side.
.
# FEN: The patient was given tube feeds. On [**4-18**], he was seen by
speech and swallow therapy. He was written for a regular diet,
which he tolerated, but did not have sufficient PO intake to
warrant discontinuation of his tube feeds.
.
# CODE: The patient was full code for the duration of the
hospitalization, as confirmed with the Health Care Proxy [**First Name4 (NamePattern1) 401**]
[**Last Name (NamePattern1) 25766**] ([**Telephone/Fax (1) 62573**] C; [**Telephone/Fax (1) 62574**] H)

Medications on Admission:
Miconazole TP
Ranitidine 150mg [**Hospital1 **]
Amlodipine 10mg daily
Heparin 5000u sc tid
Insulin Humolog SS
Labetalol 600mg TID
Calcium Acetate 667mg
Nitroglycerin patch
Lasix 100mg [**Hospital1 **]
Lantus 16units daily
Metolazone 2.5mg daily
Hydralazine 50mg q6hr
Tylenol/percocet prn

Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for axilla .
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 Units
Injection TID (3 times a day).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

5. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
6. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
Units Subcutaneous QAM.
7. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) Units
Subcutaneous at bedtime.
8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
10. Insulin Lispro  Subcutaneous


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Hospital1 8**]

Discharge Diagnosis:
Primary:
Seizure
Acute on chronic kidney injury
Diabetes Mellitus
.
Secondary:
History of hypoxic brain injury
Hypertension
Diastolic Heart Failure
Hyerplipidemia


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Mr. [**Name13 (STitle) 25766**],
You were admitted with a seizure. You were found to be
hypogylcemic (low blood sugar) and this was treated. You had a
lumbar puncture to evaluate for an infection in your spinal
fluid. The lumbar puncture results did not show infection. You
had worsening kidney function, which is now stable. Your
diabetes was difficult to control, but your blood sugars are now
more stable. You have had some swelling of your right arm, but
your ultrasound was negative for a blood clot.

We made the following changes to your medications:
-Started LEVETIRACETAM 500 mg tabs, one tab by mouth twice daily
-Changed your insulin regimen: please see the attached sheet for
your new regimen

Followup Instructions:
Please follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 850**]
after you are discharged from rehab.

Department: NEUROLOGY
When: WEDNESDAY [**2191-5-11**] at 1 PM
With: DRS. [**Name5 (PTitle) 540**] & [**Doctor Last Name **] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Other convulsions,Acute kidney failure, unspecified,Encephalopathy, unspecified,Nutritional marasmus,Chronic diastolic heart failure,Alkalosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes with other specified manifestations, type I [juvenile type], uncontrolled,Obstructive sleep apnea (adult)(pediatric)'}


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, altered mental status.

PRESENT ILLNESS: History obtained from [**Name (NI) 401**] [**Name (NI) 25766**] HCP and neuro notes

MEDICAL HISTORY: DM1 since age 38, insulin pump requiring. HbA1C 9.6 on [**2190-11-25**]
Hypertension
Diastolic Heart Failure
Hyerplipidemia
CKD ([**2190-11-25**] Cr of 3.0)
h/o Acute pancreatitis
h/o DKA with associated hypoxic brain injury and prolonged ICU
stay requiring Trach & PEG (now weaned from trach but PEG in
place)

MEDICATION ON ADMISSION: Miconazole TP
Ranitidine 150mg [**Hospital1 **]
Amlodipine 10mg daily
Heparin 5000u sc tid
Insulin Humolog SS
Labetalol 600mg TID
Calcium Acetate 667mg
Nitroglycerin patch
Lasix 100mg [**Hospital1 **]
Lantus 16units daily
Metolazone 2.5mg daily
Hydralazine 50mg q6hr
Tylenol/percocet prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: 99.5 BP 169/74 HR 74 RR 3-12 Sats 95% on RA
Gen: Lying in bed, somnolent but arousable, not following
commands and reports pain when touched anywhere
HEENT: NC/AT, dry mucosa
Neck: supple
CV: RRR, NL S1 and S2, no murmurs/gallops/rubs
Lung: not compliant with exam but subtle inspiratory crackles at
bases bilaterally
Abd: Soft, mildly TTP diffusely, no rebound/guarding, NABS.
Lower Ext: no edema, warm, good DPulses
RUE: warm, erythematous, edematous

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Used to work as an [**Company 2318**] mechanic, but had to stop working when
he lost driver's license after repeated episodes of
hypoglycemia. Not married. Pt has been living at [**Hospital1 9494**] Rehab since admission in [**Month (only) **]/[**2190**]. 

### Response:
{'Other convulsions,Acute kidney failure, unspecified,Encephalopathy, unspecified,Nutritional marasmus,Chronic diastolic heart failure,Alkalosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes with other specified manifestations, type I [juvenile type], uncontrolled,Obstructive sleep apnea (adult)(pediatric)'}
