CHIEF COMPLAINT: Seizures

PRESENT ILLNESS: The patient is a 60 year old woman with a hx of
paraimmunoblastic CLL, s/p MUD allo transplant 90 days post, hx
of DVTs and PE (heterozygous for the prothrombin gene mutation),
recently admitted to [**Hospital1 **] for SOB. Today she presents from
[**Hospital **] Rehab having had an acute onset of seizures involving
the left face, arm, and leg, accompanied by loss of
consciussness. This episode was witnessed by her niece and it
lasted about a minute. There was some urinary incontinence and
the patient became very confused after the episode and
essentially nonverbal, answering only yes or no. The patient had
never had a seizure before. In the ED, a CT scan w/o contrast
and an MRI/MRA showed possible posterior reversible
encephalopathy or old subacute infarcts, possibly embolic.
Neurology evaluated the patient and recommended seizure
precautions and meningitis dose of abx. She comes to the MICU
for further monitoring and management of her seizures. Her
doctor is Dr [**First Name (STitle) 1557**].

MEDICAL HISTORY: - Paraimmunoblastic CLL with chromosome 17P deletion, as above

MEDICATION ON ADMISSION: Acyclovir 400 mg [**Hospital1 **]
Albuterol prn
Aquaphor to post head
Citalopram 20 mg PO daily
Cyclosporin microemulsion 225 mg PO bid
Lovenox 60 mg sq q 12 hours
Erythromycin eye ointment qHS
Lopressor 75 mg PO BID
Remeron 22.5 mg PO qHS
Procardia XL 120 mg PO daily
Zofran 8 mg TID
Protonix 40 mg PO daily
Prednisone 10 mg daily
Bactrim DS Mo, W, Fr
Ursodiol 300 mg [**Hospital1 **]
Tylenol, atrovent,  prn

ALLERGIES: Coumadin / Codeine / Demerol

PHYSICAL EXAM: Vitals T 99, BP 110/50, HR 69, RR 22, O2 sat 95% on 4L
Gnl: NAD, does not answer questions except yes or no
HEENT: PERRLA, Anicteric.
CV: RRR, Normal S1 + S2, No murmurs, rubs or gallops
Resp: Crackles at bases bilaterally.
Abd: Soft, Nontender, NABS.
Extremities: no edema RLE and 1+ LLE, nonpitting
Neuro: Moves all 4 extremities spontaneously. Detailed exam
performed by Neurology consult showing normal and symmetrical
strength and sensation.

FAMILY HISTORY: Her mom died of blood clots at 76 (unknown etiology).  Her
father has HTN.

SOCIAL HISTORY: She quit smoking 30 yrs ago but has a 20-pack-year history. She
is administrative assistant, lives in [**Location 2498**]. She is married
and has one daughter. She lives with her husband, daughter,
son-in-law and four grandchildren. No ETOH.
Unspecified causes of encephalitis, myelitis, and encephalomyelitis,Toxic myopathy,Chronic lymphoid leukemia, without mention of having achieved remission,Peripheral stem cells replaced by transplant,Primary hypercoagulable state,Hypercalcemia,Unspecified essential hypertension,Hypovolemia,Tachycardia, unspecified,Anemia in neoplastic disease,Other specified paralytic syndrome,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Obstructive sleep apnea (adult)(pediatric),Adrenal cortical steroids causing adverse effects in therapeutic use,Personal history of venous thrombosis and embolism
Encephalitis NOS,Toxic myopathy,Ch lym leuk wo achv rmsn,Trspl sts-perip stm cell,Prim hypercoagulable st,Hypercalcemia,Hypertension NOS,Hypovolemia,Tachycardia NOS,Anemia in neoplastic dis,Oth spcf paralytic synd,Adv eff antineoplastic,Obstructive sleep apnea,Adv eff corticosteroids,Hx-ven thrombosis/embols
Admission Date:  [**2160-3-18**]              Discharge Date:   [**2160-4-2**]

Date of Birth:  [**2099-6-24**]             Sex:   F

Service: MEDICINE

Allergies:
Coumadin / Codeine / Demerol

Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Seizures

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is a 60 year old woman with a hx of
paraimmunoblastic CLL, s/p MUD allo transplant 90 days post, hx
of DVTs and PE (heterozygous for the prothrombin gene mutation),
recently admitted to [**Hospital1 **] for SOB. Today she presents from
[**Hospital **] Rehab having had an acute onset of seizures involving
the left face, arm, and leg, accompanied by loss of
consciussness. This episode was witnessed by her niece and it
lasted about a minute. There was some urinary incontinence and
the patient became very confused after the episode and
essentially nonverbal, answering only yes or no. The patient had
never had a seizure before. In the ED, a CT scan w/o contrast
and an MRI/MRA showed possible posterior reversible
encephalopathy or old subacute infarcts, possibly embolic.
Neurology evaluated the patient and recommended seizure
precautions and meningitis dose of abx. She comes to the MICU
for further monitoring and management of her seizures. Her
doctor is Dr [**First Name (STitle) 1557**].

Past Medical History:

- Paraimmunoblastic CLL with chromosome 17P deletion, as above

- Hiatal hernia
- Lymph edema, LLL since [**2141**] (unknown etiology)
- Cholecystectomy, [**2158-7-3**]
- h/o DVT and PEs diagnosed in [**12-8**] (treated with Lovenox x 6
months, patient reports allergic reaction to Coumadin)
- s/p IVC filter placement [**2159-12-28**]
- h/o Obstructive Sleep Apnea
- Chronic sinusitis
- Clivus mass treated with 7 weeks fungal abx and 3-4 weeks
meropenem without change, will need surgical bx at some point
- Labile blood pressure (history of both HTN and hypotension)
- h/o Depression
- Heterozygous for antithrombin gene


Social History:
She quit smoking 30 yrs ago but has a 20-pack-year history. She
is administrative assistant, lives in [**Location 2498**]. She is married
and has one daughter. She lives with her husband, daughter,
son-in-law and four grandchildren. No ETOH.


Family History:
Her mom died of blood clots at 76 (unknown etiology).  Her
father has HTN.


Physical Exam:

Vitals T 99, BP 110/50, HR 69, RR 22, O2 sat 95% on 4L
Gnl: NAD, does not answer questions except yes or no
HEENT: PERRLA, Anicteric.
CV: RRR, Normal S1 + S2, No murmurs, rubs or gallops
Resp: Crackles at bases bilaterally.
Abd: Soft, Nontender, NABS.
Extremities: no edema RLE and 1+ LLE, nonpitting
Neuro: Moves all 4 extremities spontaneously. Detailed exam
performed by Neurology consult showing normal and symmetrical
strength and sensation.


Pertinent Results:
[**2160-3-18**] 06:45PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2160-3-18**] 06:45PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5
LEUK-NEG
[**2160-3-18**] 02:41PM   TYPE-[**Last Name (un) **] PH-7.31*
[**2160-3-18**] 02:41PM   GLUCOSE-146* LACTATE-1.2 NA+-141 K+-3.8
CL--103 TCO2-32*
[**2160-3-18**] 02:41PM   freeCa-1.40*
[**2160-3-18**] 02:00PM   GLUCOSE-154* UREA N-18 CREAT-1.0 SODIUM-141
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-28 ANION GAP-12
[**2160-3-18**] 02:00PM   ALT(SGPT)-16 AST(SGOT)-24 ALK PHOS-99
AMYLASE-13 TOT BILI-0.7
[**2160-3-18**] 02:00PM   LIPASE-17
[**2160-3-18**] 02:00PM   TOT PROT-5.8* CALCIUM-11.0*
[**2160-3-18**] 02:00PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2160-3-18**] 02:00PM   WBC-6.2 RBC-3.84* HGB-11.4* HCT-33.4* MCV-87
MCH-29.6 MCHC-34.1 RDW-16.8*
[**2160-3-18**] 02:00PM   NEUTS-78* BANDS-7* LYMPHS-5* MONOS-4 EOS-5*
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2160-3-18**] 02:00PM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2160-3-18**] 02:00PM   PLT SMR-NORMAL PLT COUNT-160
[**2160-3-18**] 02:00PM   PT-13.0 PTT-31.5 INR(PT)-1.1
[**2160-3-18**] 01:09PM   CYCLSPRN-168

CT HEAD [**3-18**]
IMPRESSION:
1. Biparietal low intensity white matter foci. Differential
diagnosis
includes posterior reversible encephalopathy and venous
infarctions from
sagittal sinus thrombosis with tumor or infectious process.
Neurological
consultation and follow up MR study is recommended.
2. Large lytic mass in the clivus.
.
MRI [**3-18**]
IMPRESSION
New increased t2 and flair signal noted within posterior
pariteal lobes
superior to ventricles and within deep left frontal [**Male First Name (un) 4746**] as noted
on CT, with  slight increased signal on DWI, likely due to t2
shine through. Overall exam  limited by motion, but clival mass
and sinus thickening is without sign. changes. No sinus
thrombosis noted.

Diff dx includes Posterior reversible encephalopathy (is there
htn history),  or old subacute infarcts, possibly embolic given
lesion location.

CXR [**3-19**]
AP CHEST RADIOGRAPH: Compared to prior radiograph from [**2160-2-19**], there is no significant change. Again seen are low lung
volumes without
consolidation. Heart, mediastinum, hila, pulmonary vascularity
are within
normal limits. A right PICC line is present with tip overlying
the expected  region of the mid SVC. No pneumothorax is
identified. There is minimal  bibasilar atelectasis.

IMPRESSION: Persistent low lung volumes without evidence of
pneumonia

EEG [**3-19**]

IMPRESSION: This is an abnormal EEG due the occasional right and
left
central sharp waves, frequent large amplitude slow waves and the
slow
and disorganized background rhythm. The first abnormality
suggests a
right and left central focus of cortical hypersynchrony. The
second two
abnormalites suggest a moderate encephalopathy, which may be
seen with
toxic metabolic abnormalities, medication effect or infections
.
[**3-20**] CXR:  Low lung volumes without consolidation or effusion.



Brief Hospital Course:
This is a 60 year old woman with a hx of paraimmunoblastic CLL,
s/p MUD allo transplant ~ 90 days post, hx of DVTs and PE on
lovenox, who presented from [**Hospital **] Rehab having had an acute
onset of seizures. The following issues were addressed during
her hospitalization:

1. Seizure: Per the history, the patient had a partial complex
seizure with generalization, witnessed by her niece. No had
hypoglycemia or lyte abnormalities upon presentation to [**Hospital1 18**].
No bleed or mass was found on imaging.
An EEG showed encephalopathy, but no seizure activity. An LP was
done and shoed 14-28 WBC (90% lymphs) w/ nl glucose and protein.
CSF was negative on gram stain and also for crypto ag. MR
imaging of the brain was consistent with reversible posterior
leukocencephelopathy of the brain which can be associated with
seizures. Neurology was consulted and believed that the seizure
was a result of RPLE. PPLE is often induece by HTN. In Ms.
[**Known lastname 66500**] case, her HTN was likely secondary to cyclosporine
induce hypertension. The patient's BP was controlled with
metoprolol and nifedipine. She remained seizure free during her
hospitalization.
.
# Infectious/low grade temp: The patient presented with bandemia
and a low grade temperature. Urine grew yeast, for which the
patient was treated with one dose of fluconazole. CSF cultures
were negative to the time of discharge. Clinically there were no
signs of meningitis, however patient was treated with meningitis
doses of ceftriaxone, vancomycin and acyclovir. The antibiotics
were d/c after 48 hours. CXR was clear.
.
# dropping ANC and wbc ct: Prior to discharge it was noticed
that the patient's ANC was slowly dropping. DDx included med
effect vs graft rejection. Acyclovir, bactrim, and protonix were
discontinued due to their possible marrow related effects. Her
ANC stabilized and .....
.
# Tachycardia: The patient has a baseline heart rate in the 90s
in the last few months. She was volume depleted on admission and
tachycardia resolved with a 1Liter bolus of normal saline. EKG
was normal. Anemia also thought to be contributing to elevated
HR, and the patient received two units PRBCs in the MICU. The
issue then resolved.
.
# Hypoxia: The patient has a history of PEs. O2 sats were
consistently 92-94% on 2-4L O2. Upon transfer to the BMT
service, the patient was satting 97% RA.
.
# Hypercalcemia: this was thought to be mainly due to
dehydration. SPEP and UPEP were also abnormal, as was uric acid
(elevated). The patient did not have bone pain. The
hypercalcemia resolved with fluids.
.
# Anemia: The goal was Hct>30. The patient received two units
PRBCs while in the ICU. The Hct remained stable.
.
# AMS: The altered mental status was thought to be a combination
of her postictal state coupled with reversible posterior
encephalopathy and cyclosporin toxicity. The mental status
improved sometime after 48 hours in the ICU, with a decreased
level of cyclosporin. However, the patient remained somewhat
confused at the time of her transfer to the floor.
.
# CLL s/p allo transplant 90 days: the cyclosporin levels were
monitored on a daily basis and the patient was also maintained
on her outpatient dose of prednisone. The cyclosporin dose was
lowered from 225 mg [**Hospital1 **] to 175 mg [**Hospital1 **] to 75 mg [**Hospital1 **].
.
# Hypercoagulable state. Lovenox was briefly held for 12 hours
prior to the patient having a lumbar puncture. It was then
restarted at the therapeutic doses the patient usually takes
given her history of DVTs and PEs and heterozygosity for the
antithrombin gene.
.
# FEN. The patient had a speech and swallow evaluation and a
nutrition consult. She was placed on a ground solid/thin liquid
diet. Her lytes were repleted as needed, particularly magnesium,
which can be low with neoral.
.

#ACCESS - as she was afebrile and doing well, permanent vascular
access was secured via surgery with the placement of a
double-lumen port-a-cath. She was discharged to rehab following
this procedure.

Medications on Admission:
Acyclovir 400 mg [**Hospital1 **]
Albuterol prn
Aquaphor to post head
Citalopram 20 mg PO daily
Cyclosporin microemulsion 225 mg PO bid
Lovenox 60 mg sq q 12 hours
Erythromycin eye ointment qHS
Lopressor 75 mg PO BID
Remeron 22.5 mg PO qHS
Procardia XL 120 mg PO daily
Zofran 8 mg TID
Protonix 40 mg PO daily
Prednisone 10 mg daily
Bactrim DS Mo, W, Fr
Ursodiol 300 mg [**Hospital1 **]
Tylenol, atrovent,  prn


Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg
Subcutaneous Q12H (every 12 hours).
4. Cyclosporine 25 mg Capsule Sig: Two (2) Capsule PO twice a
day.
5. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
Q 8HR ().
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed.
9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed.
10. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain.


Discharge Disposition:
Extended Care

Facility:
LifeCare Center of [**Location (un) 5165**]

Discharge Diagnosis:
primary:
generalized seizure
Recurrent Polyleukoencephelopathy
steroid myopathy
.
secondary:
Paraimmunoblastic CLL
Clivus mass
h/o DVT and PEs


Discharge Condition:
Good.


Discharge Instructions:
Please return to the hospital if you experience any
lightheadedness, seizure activity, or any other symptoms that
concern you.
.
It is very important that your blood pressure remains well
controlled. Please take all medications as prescribed.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2160-4-4**] 2:30

Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2160-4-23**] 9:00


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
{'Unspecified causes of encephalitis, myelitis, and encephalomyelitis,Toxic myopathy,Chronic lymphoid leukemia, without mention of having achieved remission,Peripheral stem cells replaced by transplant,Primary hypercoagulable state,Hypercalcemia,Unspecified essential hypertension,Hypovolemia,Tachycardia, unspecified,Anemia in neoplastic disease,Other specified paralytic syndrome,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Obstructive sleep apnea (adult)(pediatric),Adrenal cortical steroids causing adverse effects in therapeutic use,Personal history of venous thrombosis and embolism'}


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: Seizures

PRESENT ILLNESS: The patient is a 60 year old woman with a hx of
paraimmunoblastic CLL, s/p MUD allo transplant 90 days post, hx
of DVTs and PE (heterozygous for the prothrombin gene mutation),
recently admitted to [**Hospital1 **] for SOB. Today she presents from
[**Hospital **] Rehab having had an acute onset of seizures involving
the left face, arm, and leg, accompanied by loss of
consciussness. This episode was witnessed by her niece and it
lasted about a minute. There was some urinary incontinence and
the patient became very confused after the episode and
essentially nonverbal, answering only yes or no. The patient had
never had a seizure before. In the ED, a CT scan w/o contrast
and an MRI/MRA showed possible posterior reversible
encephalopathy or old subacute infarcts, possibly embolic.
Neurology evaluated the patient and recommended seizure
precautions and meningitis dose of abx. She comes to the MICU
for further monitoring and management of her seizures. Her
doctor is Dr [**First Name (STitle) 1557**].

MEDICAL HISTORY: - Paraimmunoblastic CLL with chromosome 17P deletion, as above

MEDICATION ON ADMISSION: Acyclovir 400 mg [**Hospital1 **]
Albuterol prn
Aquaphor to post head
Citalopram 20 mg PO daily
Cyclosporin microemulsion 225 mg PO bid
Lovenox 60 mg sq q 12 hours
Erythromycin eye ointment qHS
Lopressor 75 mg PO BID
Remeron 22.5 mg PO qHS
Procardia XL 120 mg PO daily
Zofran 8 mg TID
Protonix 40 mg PO daily
Prednisone 10 mg daily
Bactrim DS Mo, W, Fr
Ursodiol 300 mg [**Hospital1 **]
Tylenol, atrovent,  prn

ALLERGIES: Coumadin / Codeine / Demerol

PHYSICAL EXAM: Vitals T 99, BP 110/50, HR 69, RR 22, O2 sat 95% on 4L
Gnl: NAD, does not answer questions except yes or no
HEENT: PERRLA, Anicteric.
CV: RRR, Normal S1 + S2, No murmurs, rubs or gallops
Resp: Crackles at bases bilaterally.
Abd: Soft, Nontender, NABS.
Extremities: no edema RLE and 1+ LLE, nonpitting
Neuro: Moves all 4 extremities spontaneously. Detailed exam
performed by Neurology consult showing normal and symmetrical
strength and sensation.

FAMILY HISTORY: Her mom died of blood clots at 76 (unknown etiology).  Her
father has HTN.

SOCIAL HISTORY: She quit smoking 30 yrs ago but has a 20-pack-year history. She
is administrative assistant, lives in [**Location 2498**]. She is married
and has one daughter. She lives with her husband, daughter,
son-in-law and four grandchildren. No ETOH. 

### Response:
{'Unspecified causes of encephalitis, myelitis, and encephalomyelitis,Toxic myopathy,Chronic lymphoid leukemia, without mention of having achieved remission,Peripheral stem cells replaced by transplant,Primary hypercoagulable state,Hypercalcemia,Unspecified essential hypertension,Hypovolemia,Tachycardia, unspecified,Anemia in neoplastic disease,Other specified paralytic syndrome,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Obstructive sleep apnea (adult)(pediatric),Adrenal cortical steroids causing adverse effects in therapeutic use,Personal history of venous thrombosis and embolism'}
