CHIEF COMPLAINT: status epilepticus

PRESENT ILLNESS: This is a 84 y/o woman with h/o seizures starting in [**2178-9-20**],
HTN, spinal stenosis who was in her usual state of health this
morning, when she reported to her daughter a sudden onset of
headache followed by a "feeling of something bad".  Her daughter
took her to a pharmacy to get BP checked.  It was 222/104.

MEDICAL HISTORY: -seizures:  Her first seizure of record was in [**2178-9-20**] but was
not worked up fully.  In [**2178-3-21**], she had an episode similar
to today's episode starting with a HA and progressing to a
seizure (confused with repetitive movements and right arm
shaking, BP 233/110) and was brought to [**Hospital1 2025**] where she was
intubated for airway protection.  She had a full seizure workup
at [**Hospital1 2025**] with LP which was negative for infection, EEG which was
abnormal due to diffuse background slowing but showed no
epileptiform discharges, MRI which showed evidence for PRES, CTA
showed moderate narrowing of Right P2 segment and small areas of
hypodensity in occipital and parietal lobes.
.
-HTN
-hypercholesterolemia
-gout
-anxiety
-spinal stenosis

MEDICATION ON ADMISSION: keppra 500 mg [**Hospital1 **]
lasix 20 qd
lipitor 40mg qd
diovan 160 qd
metoprolol 100 tid
klonopin 1mg TID PRN
FA

ALLERGIES: Dilantin

PHYSICAL EXAM: Vitals: T 102.8; BP 170/75; P 70; O2- 100% ventilated (CMV, TV-
500, PEEP 5, Rate 12)
.
General: lying in bed intubated
HEENT: NCAT, moist mucous membranes
Neck: supple
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
.
Neurological Exam:
Mental status: unersponsive on arrival to ED, no spontaneous
movements, no purposeful withdrawal from pain, no doll-eye
movement with eyes fixed forward gaze, pupils 2mm unreactive
bilaterally,
.
Motor: Normal bulk. Normal tone.  No adventitious movements.

FAMILY HISTORY: n/a

SOCIAL HISTORY: lives with daughter at home.  Questionable medication
compliance.
Hypertensive encephalopathy,Malignant essential hypertension,Grand mal status,Acidosis,Pure hypercholesterolemia,Anxiety state, unspecified,Spinal stenosis, unspecified region,Unspecified disorder of kidney and ureter,Other specified cardiac dysrhythmias,Hypercalcemia,Iron deficiency anemia, unspecified,Other persistent mental disorders due to conditions classified elsewhere,Unspecified psychosis,Intravenous anesthetics causing adverse effects in therapeutic use
Hypertens encephalopathy,Malignant hypertension,Grand mal status,Acidosis,Pure hypercholesterolem,Anxiety state NOS,Spinal stenosis NOS,Renal & ureteral dis NOS,Cardiac dysrhythmias NEC,Hypercalcemia,Iron defic anemia NOS,Mental disor NEC oth dis,Psychosis NOS,Adv eff intraven anesth
Admission Date:  [**2178-7-25**]              Discharge Date:   [**2178-7-31**]


Service: NEUROLOGY

Allergies:
Dilantin

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
status epilepticus


Major Surgical or Invasive Procedure:
Intubation
CT
MRI
Lumbar Puncture


History of Present Illness:
This is a 84 y/o woman with h/o seizures starting in [**2178-9-20**],
HTN, spinal stenosis who was in her usual state of health this
morning, when she reported to her daughter a sudden onset of
headache followed by a "feeling of something bad".  Her daughter
took her to a pharmacy to get BP checked.  It was 222/104.

Upon returning home, the pt. started with an automatism, but was
verbalizing appropriately.  Daughter called EMS and patient was
seizing by the time EMS arrived.  Her daughter described the
seizure as face contortion.  The [**Hospital1 **] ED attending reported a
generalized seizure with R > L movements and R-sided gaze.

She was initially given 4 mg ativan in the ED which temporarily
stopped seizure activity, but she resumed seizing shortly
thereafter.  An additional 4mg ativan was given, which again
worked temporarily.  A final dose of 4 mg ativan was given, for
a total of 12 mg, and propofol was started, given her allergy to
dilantin.

She was intubated for airway protection.

Past Medical History:
-seizures:  Her first seizure of record was in [**2178-9-20**] but was
not worked up fully.  In [**2178-3-21**], she had an episode similar
to today's episode starting with a HA and progressing to a
seizure (confused with repetitive movements and right arm
shaking, BP 233/110) and was brought to [**Hospital1 2025**] where she was
intubated for airway protection.  She had a full seizure workup
at [**Hospital1 2025**] with LP which was negative for infection, EEG which was
abnormal due to diffuse background slowing but showed no
epileptiform discharges, MRI which showed evidence for PRES, CTA
showed moderate narrowing of Right P2 segment and small areas of
hypodensity in occipital and parietal lobes.
.
-HTN
-hypercholesterolemia
-gout
-anxiety
-spinal stenosis


Social History:
lives with daughter at home.  Questionable medication
compliance.

Family History:
n/a


Physical Exam:
Vitals: T 102.8; BP 170/75; P 70; O2- 100% ventilated (CMV, TV-
500, PEEP 5, Rate 12)
.
General: lying in bed intubated
HEENT: NCAT, moist mucous membranes
Neck: supple
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
.
Neurological Exam:
Mental status: unersponsive on arrival to ED, no spontaneous
movements, no purposeful withdrawal from pain, no doll-eye
movement with eyes fixed forward gaze, pupils 2mm unreactive
bilaterally,
.
Motor: Normal bulk. Normal tone.  No adventitious movements.

unable to assess strength
.
Reflexes: Bic T Br Pa Ac
Right      2  2 2  2  2
Left       2  2 2  2  2
Toes mute bilaterally.


Pertinent Results:
[**2178-7-25**] 08:58PM   CK-MB-5 cTropnT-0.04*
[**2178-7-25**] 12:12PM   CK(CPK)-304*
[**2178-7-25**] 04:58AM   TYPE-ART PO2-207* PCO2-33* PH-7.48* TOTAL
CO2-25 BASE XS-2
[**2178-7-25**] 03:30AM   GLUCOSE-111* UREA N-10 CREAT-0.9 SODIUM-141
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
[**2178-7-25**] 03:30AM   ALT(SGPT)-10 AST(SGOT)-18 LD(LDH)-252*
CK(CPK)-217* ALK PHOS-72 TOT BILI-0.4
[**2178-7-25**] 03:30AM   VIT B12-294
[**2178-7-25**] 03:30AM   %HbA1c-5.8 [Hgb]-DONE [A1c]-DONE
[**2178-7-25**] 03:30AM   TSH-2.4
[**2178-7-25**] 03:30AM   WBC-13.1* RBC-3.74* HGB-9.7* HCT-27.8*
MCV-74* MCH-25.8* MCHC-34.8 RDW-17.5*
[**2178-7-24**] 09:00PM CEREBROSPINAL FLUID (CSF)  PROTEIN-71*
GLUCOSE-76
[**2178-7-24**] 09:00PM CEREBROSPINAL FLUID (CSF)  WBC-1 RBC-57*
POLYS-17 LYMPHS-60 MONOS-22 ATYPS-1
[**2178-7-24**] 09:00PM CEREBROSPINAL FLUID (CSF)  WBC-3 RBC-1370*
POLYS-57 LYMPHS-31 MONOS-10 ATYPS-2
.
Head CT: No intracranial hemorrhage or mass effect is
identified.
.
MRI with/without Gad: Bilateral posterior foci and
supratentorial signal changes predominantly in the subcortical
region with a distribution suggestive of posterior reversible
encephalopathy/hypertensive encephalopathy. No evidence of slow
diffusion or abnormal enhancement seen in these regions. No mass
effect or hydrocephalus
.
EEG [**7-25**]: This is a moderately abnormal EEG due to the presence
of a
slow background with occasional bifrontal slow waves seen. This
pattern
is consistent with an encephalopathy of toxic, metabolic, or
anoxic
etiology, or can be seen with disorders affecting midline or
bilateral
white matter areas, particularly in the frontal lobes.
Occasionally,
patients with raised intracranial pressure can have bifrontal
slow
waves. Clinical correlation is recommended. No evidence of
ongoing
or potential epileptogenesis is seen at this time
.
EEG [**7-29**]:
BACKGROUND: Included a well-formed 9 Hz alpha frequency in
posterior areas bilaterally during wakefulness. There was a
faster superimposed beta rhythm as well.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: The patient appeared to remain awake or minimally drowsy
throughout the recording.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Mildly abnormal EEG in the waking state due to the
frequent but brief theta slowing in the left temporal region.
There were no areas of more persistent focal slowing, and there
were no epileptiform features.


Brief Hospital Course:
ICU Course
Neuro:
Intubated in the ED for airway protection.  After an initial
examination, she was sent for a STAT head CT which showed no new
hemorrhage or major territorial infarction (see results above).
Following this, an LP was performed as there was concern for CNS
infection as seizure source based on her fever.  LP findings
negative except as traumatic tap (see results above).

MRI performed later the following morning showed findings
consistent with hypertensive leukoencephalopathy.  This was felt
to be the etiology of her seizure, as pt. had no evidence of
other pathology, such as stroke or mass, on her MRI.  Patient
was extubated on [**7-26**] without complications.  Passed a speech and
swallow for solids and thickened liquids on [**7-27**] and was
transferred to the floor.
.
Seizure prophylaxis was maintained with propofol and Keprra
1000mg NG [**Hospital1 **].  After extubation, only Keppra was continued.
.
CVS:
Blood pressure in the ICU was managed with patient's home
medication regimen: Metoprolol 100mg PO TID, Valsartan 180mg
Daily, Lasix 10mg IV (takes 20 PO at home) as well as addition
of prn Hydralazine IV for SBP greater than 160.
.
ID:
Febrile on admission, but defervesced quickly.  Blood cultures
sent on admission and within 20 minutes of IV Vancomycin and
Ceftriaxone starting.  CSF sent for cultures, GS and HSV PCR,
all of which returned negative.  Initially covered broadly with
empiric doses of ABX for suspected CNS infection with IV
Ampicillin, Vancomycin, Ceftriaxone.  Also treated with
Acyclovir at CNS infection doses (10mg /kg Q8 hrs).  These were
d/ced as cultures came back negative.
.
Renal: Some renal insufficiency on admission which resolved with
IV fluids.  Received extra fluid boluses with each dose of
Acyclovir.
.
Floor Course:
Neuro: Pt. was initially continued on Keppra 1000 [**Hospital1 **], and had
no further seizures.  Pt. became more confused on her second day
on the floor.  Infection was considered, however pt. was
afebrile and CXR, UA, Urine Cx and blood cx were negative.  NCSE
was considered, however repeat EEG was negative.  Med effect was
considered, and symptoms resolved with decreasing Keppra dose to
750 [**Hospital1 **] and d/cing Acyclovir when CSF HSV came back negative.
Of note, BP control improved as MS improved it was felt that
this may also have contributed.  Pt. was seen by PT and OT, who
recommended acute rehab given weakness below baseline.
.
CV: BP control was continued as above (see ICU course)  Pt. was
noted to have several episodes of narrow complex tachycardia
with rates of 140s-160s on telemetry.  These were asymptomatic
and not associated with hypotension, although pt. was noted to
have ST depressions in inferior and lateral leads during the
episodes that resolved when her rhythm returned to baseline.
Acute episodes responded to 10 mg IV Diltiazem and did not recur
after Diltiazem 30 mg PO QID was started and Metoprolol titrated
up to 125 TID per recommendation of the cardiology service.
Diltiazem was increased to 60 QID on [**7-31**] given inadequate BP
control on lower doses, and should continue to be titrated as
necessary at Rehab.  Once dosing is stable pt. could be
converted to once a day long-acting CCB.  Cardiology recommended
a TTE, which was performed on the day of discharge.  Results of
this were pending at time of discharge and should be followed up
by pt's physician at [**Name9 (PRE) **].  The Echo lab here can be reached
at [**Telephone/Fax (1) 3312**].


Medications on Admission:
keppra 500 mg [**Hospital1 **]
lasix 20 qd
lipitor 40mg qd
diovan 160 qd
metoprolol 100 tid
klonopin 1mg TID PRN
FA


Discharge Medications:
1. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
4. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Hypertensive Encephalopathy
Generalized Tonic Clonic Seizure [**1-22**] hypertensive encephalopathy
Hypertension, poorly controlled


Discharge Condition:
Improved- no further seizures, tolerating medications, BP
controlled 130s-150s.


Discharge Instructions:
Please call your doctor or go to the ER if you have any further
seizures, headache, nausea, vomiting, fevers, chills, numbness,
weakness, or any other symptoms that concern you.
.
Please take all medications as prescribed

Followup Instructions:
Primary Care: Please call Dr. [**Last Name (STitle) 69676**] at [**Telephone/Fax (1) 31553**] to set
up a follow up appointment for 1-2 weeks after you are
discharged from [**Hospital1 **].

Cardiology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**]
Date/Time:[**2178-9-23**] 9:40


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

Completed by:[**2178-7-31**]

Name:  [**Known lastname 5339**],[**Known firstname 11852**]                     Unit No:   [**Numeric Identifier 11853**]

Admission Date:  [**2178-7-25**]              Discharge Date:   [**2178-7-31**]

Date of Birth:  [**2093-7-29**]             Sex:   F

Service: NEUROLOGY

Allergies:
Dilantin

Attending:[**First Name3 (LF) 3326**]
Addendum:
TTE read: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and systolic function (LVEF>55%). Regional left ventricular wall
motion is normal. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen.  The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-22**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened.  There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]

                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 3327**]

Completed by:[**2178-7-31**]
{'Hypertensive encephalopathy,Malignant essential hypertension,Grand mal status,Acidosis,Pure hypercholesterolemia,Anxiety state, unspecified,Spinal stenosis, unspecified region,Unspecified disorder of kidney and ureter,Other specified cardiac dysrhythmias,Hypercalcemia,Iron deficiency anemia, unspecified,Other persistent mental disorders due to conditions classified elsewhere,Unspecified psychosis,Intravenous anesthetics causing adverse effects in therapeutic use'}


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: status epilepticus

PRESENT ILLNESS: This is a 84 y/o woman with h/o seizures starting in [**2178-9-20**],
HTN, spinal stenosis who was in her usual state of health this
morning, when she reported to her daughter a sudden onset of
headache followed by a "feeling of something bad".  Her daughter
took her to a pharmacy to get BP checked.  It was 222/104.

MEDICAL HISTORY: -seizures:  Her first seizure of record was in [**2178-9-20**] but was
not worked up fully.  In [**2178-3-21**], she had an episode similar
to today's episode starting with a HA and progressing to a
seizure (confused with repetitive movements and right arm
shaking, BP 233/110) and was brought to [**Hospital1 2025**] where she was
intubated for airway protection.  She had a full seizure workup
at [**Hospital1 2025**] with LP which was negative for infection, EEG which was
abnormal due to diffuse background slowing but showed no
epileptiform discharges, MRI which showed evidence for PRES, CTA
showed moderate narrowing of Right P2 segment and small areas of
hypodensity in occipital and parietal lobes.
.
-HTN
-hypercholesterolemia
-gout
-anxiety
-spinal stenosis

MEDICATION ON ADMISSION: keppra 500 mg [**Hospital1 **]
lasix 20 qd
lipitor 40mg qd
diovan 160 qd
metoprolol 100 tid
klonopin 1mg TID PRN
FA

ALLERGIES: Dilantin

PHYSICAL EXAM: Vitals: T 102.8; BP 170/75; P 70; O2- 100% ventilated (CMV, TV-
500, PEEP 5, Rate 12)
.
General: lying in bed intubated
HEENT: NCAT, moist mucous membranes
Neck: supple
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
.
Neurological Exam:
Mental status: unersponsive on arrival to ED, no spontaneous
movements, no purposeful withdrawal from pain, no doll-eye
movement with eyes fixed forward gaze, pupils 2mm unreactive
bilaterally,
.
Motor: Normal bulk. Normal tone.  No adventitious movements.

FAMILY HISTORY: n/a

SOCIAL HISTORY: lives with daughter at home.  Questionable medication
compliance. 

### Response:
{'Hypertensive encephalopathy,Malignant essential hypertension,Grand mal status,Acidosis,Pure hypercholesterolemia,Anxiety state, unspecified,Spinal stenosis, unspecified region,Unspecified disorder of kidney and ureter,Other specified cardiac dysrhythmias,Hypercalcemia,Iron deficiency anemia, unspecified,Other persistent mental disorders due to conditions classified elsewhere,Unspecified psychosis,Intravenous anesthetics causing adverse effects in therapeutic use'}
