CHIEF COMPLAINT: cardiac arrest, seizure

PRESENT ILLNESS: 35 y/o female with hx of HCV s/p recent bowel perforation 1
month ago surrounding a complicated ERCP presents s/p report of
cardiac arrest and seizures.

MEDICAL HISTORY: Perforated bowel
Heroin Abuse
ERCP on [**2113-3-10**]
HCV
migraines
Chronic LBP
Anxiety/Depression
CBD stones
Cholilithiasis
History of sphincterotmy complicated by duodenal perforation

MEDICATION ON ADMISSION: lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY
acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR
alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID prn
acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID prn
gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H prn pain
amoxicillin-pot clavulanate 500-125 mg Tablet 1 po q12 (just
completed with this admission)
fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 10 days (just completed with this admission)
ZOFRAN ODT 4 mg Tablet 1 po q8hrs prn

ALLERGIES: Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: On admission to ICU:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Coarse to auscultation bilaterally. No wheezes
Abdomen: Abdominal scar located midline.  Abdominal distention
with respiratory effort.  Bowel sounds present, no organomegaly
appreciated. Purulent drainage from grenade drain on right.
GU: clear urine
Ext: cold to touch with mottled appearance.  2+ pulses.  Prior
IV site on dorsum of left hand.  PIVs in antecubital vv
bilaterally.
Neuro: Unconscious sedated on vent.  Gag reflex. Pupils from 6
to 2-3 mm with light.  Right corneal reflex intact, left not
brisk to corneal irritation.  Decerabrate posturing.  Down going
babinski's b/l with 2+ patellar/bicipital reflexes b/l.

FAMILY HISTORY: Mother and sister with symptomatic cholelithiasis requiring CCY.
 Father died in [**2107**] from MI, mother, alive, with alcoholic
cirrhoisis.

SOCIAL HISTORY: Unemployed and currently homeless, though she stays frequently
with her ex-husband/sister.  Two children ages 3 and 5. +Tobacco
use,
1PPD currently. Denies ETOH. Uses heroin, marijuana regularly.
Other postoperative infection,Other staphylococcal septicemia,Peritoneal abscess,Grand mal status,Cardiac arrest,Severe sepsis,Septic shock,Drug withdrawal,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Chronic hepatitis C without mention of hepatic coma,Lack of housing,Tobacco use disorder,Depressive disorder, not elsewhere classified,Opioid type dependence, unspecified,Urinary incontinence, unspecified,Diarrhea
Other postop infection,Staphylcocc septicem NEC,Peritoneal abscess,Grand mal status,Cardiac arrest,Severe sepsis,Septic shock,Drug withdrawal,Pseudomonas infect NOS,Chrnc hpt C wo hpat coma,Lack of housing,Tobacco use disorder,Depressive disorder NEC,Opioid dependence-unspec,Urinary incontinence NOS,Diarrhea
Admission Date:  [**2113-4-19**]              Discharge Date:   [**2113-5-9**]

Date of Birth:  [**2077-9-28**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa(Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
cardiac arrest, seizure


Major Surgical or Invasive Procedure:
- none


History of Present Illness:
35 y/o female with hx of HCV s/p recent bowel perforation 1
month ago surrounding a complicated ERCP presents s/p report of
cardiac arrest and seizures.

Per report, patient was at home with her sister when she
sufferred a seizure.  The patient has been feeling lethargic for
the last several days, and today was found by her sister to be
"shaking" on the couch with seizure like activity, clenching her
jaw with staring and rigid posturing.  Her sister called the
neighbor over who is an MA, and no pulse could be palpated so
CPR was intiated and 911 was called.   Emergency responders
arrived, the patient was placed on an AED and had reportedly two
shocks with return of spontaneous circulation.  During this
time, patient started to have seizues with bladder incontinence.
 She was taken to [**Hospital3 **] where vitals were BP 132/72, HR
131, satting 100% on RA with no recroded RR.  Patient was
intubated and given fosphenytoin, phenobarbital, diazepam, and
propfol without resolution of her seizures.  EKG at the OSH
showed sinus tachycardia to 133, normal axis, normal intervals,
flattened TW in AvL and V1 with good R wave progression in the
anterior leads. Labs were significant for an EtOH <10, WBC of
37.4 with 28.9 absolute PMN count, HCT of 39.5, plts of 502.
.
In the ED, nursing notes document patient seizing on arrival.
She was given 2 mg of midazolam  Initial VS were: temp 102.6,
Labs showed WBC of 24.5, H/H 10.7/33.7, K 2.6, lactate 2.4. ABG
showed 7.38/31/139.  Blood cultures were sent.  Given continued
sizure activity given another 2 mg of midazolam 10 minutes after
inital dose.  Neurology, surgery, and the Post-Arrest team were
consulted.  A propofol gtt was titrated to sedation to control
seizure activity.    Surgery rec'd a CT A/P which showed stable
positioning of patient's perc drain with minimal resolution of
prior fluid collection and no evidence of new collections or
abscesses.  Neuro rec'd to continue the cooling protocol with
EEG, check dilantin level and continue 100mg q8hrs, obtain LP to
eval for infectious source of fevers and seizure, and to
consider loading with Keppra or start midazolam drip if
continued seizures.  LP was done which showed no evidence of
infection.  Given fevers, she was given vancomycin 1gm, zosyn
4.5gm, acetaminophen 650mg PR, and IV potassium repletion and
sedated with fentanyl and versed. EKG showed shivering artifact
but evidence was ventricular bigeminy and sinus waves.  No
troponins were present at time of ICU admission.  Cooling
protocal initaited at 0350 hrs with temperature prob in foley
and rectum.  Patient was started on fentanyl and midazolam at
this time prior to transfer to the floor.  At 4:10 AM pt was
noted to be awake, pulling at lines and tubing with noted
seizure activity, moving extremities but not collowing commands.
 Midazolam gtt was uptitrated.
.
On arrival to the MICU, patient is intubated on the vent shaking
with Arctic Sun cooling being underway.  Rectal and bladder
temperature probes were affirmed by patient's nurse.


Past Medical History:
Perforated bowel
Heroin Abuse
ERCP on [**2113-3-10**]
HCV
migraines
Chronic LBP
Anxiety/Depression
CBD stones
Cholilithiasis
History of sphincterotmy complicated by duodenal perforation


Social History:
Unemployed and currently homeless, though she stays frequently
with her ex-husband/sister.  Two children ages 3 and 5. +Tobacco
use,
1PPD currently. Denies ETOH. Uses heroin, marijuana regularly.


Family History:
Mother and sister with symptomatic cholelithiasis requiring CCY.
 Father died in [**2107**] from MI, mother, alive, with alcoholic
cirrhoisis.


Physical Exam:
On admission to ICU:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Coarse to auscultation bilaterally. No wheezes
Abdomen: Abdominal scar located midline.  Abdominal distention
with respiratory effort.  Bowel sounds present, no organomegaly
appreciated. Purulent drainage from grenade drain on right.
GU: clear urine
Ext: cold to touch with mottled appearance.  2+ pulses.  Prior
IV site on dorsum of left hand.  PIVs in antecubital vv
bilaterally.
Neuro: Unconscious sedated on vent.  Gag reflex. Pupils from 6
to 2-3 mm with light.  Right corneal reflex intact, left not
brisk to corneal irritation.  Decerabrate posturing.  Down going
babinski's b/l with 2+ patellar/bicipital reflexes b/l.

Discharge Exam:
General: pt awake, NAD
Skin: PICC site no erythema, mild crusting, last changed on
[**5-1**].
HEENT: Sclera anicteric, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended. Surgical incision site intact, no
erythema, no drainage. mild tenderness to palpation over
incision site, tenderness over drain site improved.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: no focal deficits


Pertinent Results:
[**2113-4-19**] 02:25AM BLOOD WBC-24.5* RBC-3.69* Hgb-10.7* Hct-33.7*
MCV-92 MCH-28.9 MCHC-31.6 RDW-14.1 Plt Ct-386
[**2113-4-19**] 02:25AM BLOOD Neuts-81.0* Lymphs-13.3* Monos-5.3
Eos-0.2 Baso-0.2
[**2113-4-19**] 02:25AM BLOOD Plt Ct-386
[**2113-4-19**] 02:25AM BLOOD Fibrino-338
[**2113-4-19**] 06:28AM BLOOD Glucose-124* UreaN-3* Creat-0.7 Na-145
K-4.1 Cl-112* HCO3-17* AnGap-20
[**2113-4-19**] 02:25AM BLOOD ALT-17 AST-31 AlkPhos-107* TotBili-0.4
[**2113-4-19**] 02:25AM BLOOD Lipase-76*
[**2113-4-19**] 02:25AM BLOOD cTropnT-0.06*
[**2113-4-19**] 06:28AM BLOOD CK-MB-4 cTropnT-<0.01
[**2113-4-19**] 01:20PM BLOOD CK-MB-13* MB Indx-1.3 cTropnT-<0.01
[**2113-4-19**] 03:35PM BLOOD CK-MB-14* MB Indx-1.5 cTropnT-<0.01
[**2113-4-20**] 09:02AM BLOOD CK-MB-13* MB Indx-1.9 cTropnT-<0.01
[**2113-4-19**] 06:28AM BLOOD Calcium-7.1* Phos-3.8 Mg-1.1*
[**2113-4-20**] 07:37AM BLOOD HCG-<5
[**2113-4-20**] 06:00AM BLOOD Vanco-35.2*
[**2113-4-21**] 07:00AM BLOOD Vanco-8.5*
[**2113-4-22**] 06:48PM BLOOD Vanco-7.3*
[**2113-4-27**] 05:14AM BLOOD Vanco-46.1*
[**2113-4-27**] 01:07PM BLOOD Vanco-14.1
[**2113-5-1**] 07:45AM BLOOD Vanco-24.3*
[**2113-4-20**] 06:00AM BLOOD Phenyto-11.7
[**2113-4-30**] 10:20PM BLOOD Phenyto-11.5
[**2113-4-19**] 02:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-POS Tricycl-NEG
[**2113-4-19**] 03:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-POS Tricycl-NEG
[**2113-4-19**] 02:32AM BLOOD pO2-139* pCO2-31* pH-7.38 calTCO2-19*
Base XS--5
[**2113-4-19**] 02:32AM BLOOD Glucose-134* Lactate-2.4* Na-143 K-2.6*
Cl-117*
[**2113-4-19**] 02:32AM BLOOD Hgb-10.7* calcHCT-32 O2 Sat-98 COHgb-1
MetHgb-0
[**2113-4-19**] 02:25AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2113-4-19**] 02:25AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
[**2113-4-19**] 02:25AM URINE RBC-13* WBC-8* Bacteri-FEW Yeast-NONE
Epi-<1
[**2113-4-19**] 03:30AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0
Lymphs-25 Monos-75
[**2113-4-19**] 03:30AM CEREBROSPINAL FLUID (CSF) TotProt-37 Glucose-83
[**2113-5-9**] 04:41AM BLOOD WBC-10.4 RBC-3.44* Hgb-9.9* Hct-31.1*
MCV-90 MCH-28.9 MCHC-31.9 RDW-15.6* Plt Ct-389
[**2113-5-9**] 04:41AM BLOOD Glucose-109* UreaN-7 Creat-0.4 Na-138
K-4.0 Cl-102 HCO3-28 AnGap-12
[**2113-5-9**] 04:41AM BLOOD ALT-46* AST-37 AlkPhos-212* TotBili-0.2
[**2113-5-9**] 04:41AM BLOOD Calcium-8.4 Phos-5.1* Mg-1.7
.
MICROBIOLOGY
[**2113-5-1**] STOOL C. difficile DNA amplification
assay-NEGATIVE
[**2113-4-30**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
[**2113-4-30**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
[**2113-4-22**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
[**2113-4-21**] STOOL C. difficile DNA amplification
assay-NEGATIVE
[**2113-4-21**] STOOL C. difficile DNA amplification
assay-NEGATIVE
[**2113-4-21**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
[**2113-4-21**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
[**2113-4-20**] BLOOD CULTURE Blood Culture,
Routine-NEGATIVE
[**2113-4-19**] BILE GRAM STAIN-FINAL; FLUID
CULTURE-{PSEUDOMONAS AERUGINOSA, PSEUDOMONAS AERUGINOSA};
ANAEROBIC CULTURE-NO GROWH
[**2113-4-19**] URINE URINE CULTURE-NEGATIVE
[**2113-4-19**] MRSA SCREEN MRSA SCREEN-NEGATIVE
[**2113-4-19**] CSF;SPINAL FLUID GRAM STAIN-NO ORGANISM;
FLUID CULTURE-NO GROWTH
[**2113-4-19**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE, STAPHYLOCOCCUS
EPIDERMIDIS}; Aerobic Bottle Gram Stain-NO ORGANISM; Anaerobic
Bottle Gram Stain-NO GROWTH
[**2113-4-19**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram
Stain-NO ORGANISM; Anaerobic Bottle Gram Stain-NO GROWTH
.
IMAGING:
[**2113-4-26**]   Radiology MR HEAD W & W/O CONTRAST: No evidence of
intracranial mass, infarction, or infectious process.
Acute-on-chronic inflammatory disease in the left sphenoid air
cell; correlate clinically.

[**2113-4-25**]   Cardiovascular ECHO   [**2113-4-25**]: The estimated right
atrial pressure is 0-5 mmHg. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size is normal. with
borderline normal free wall function. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.

[**2113-4-21**]   Neurophysiology EEG   [**2113-4-21**]: This is an abnormal
continuous ICU monitoring study because of the presence of a few
isolated paroxysmal potential epileptiform transients in the
left central region. Compared to the prior day's recording, this
record shows improvement in background rhythms.

[**2113-4-20**]   Cardiovascular ECHO   [**2113-4-20**]: The left atrium and
right atrium are normal in cavity size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with hypokinesis
of the septum and the inferolateral wall. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels 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 structurally normal. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.

[**2113-4-20**]   Neurophysiology EEG   [**2113-4-20**]:  This is an abnormal
continuous ICU monitoring study because of the presence of a
diffuse severe encephalopathy. While the frequencies are in a
range that would suggest reasonable brain activity there
continues to be a reverse anterior posterior gradient. This may
still be the effect of medication and the cooling protocol
itself. It is necessary to monitor this to see if it evolves
into and alpha coma pattern. There also exists multifocal and
independent appearing interictal sharp transients. These also
should be monitored for detection of seizures. In comparison to
the previous today's recording, there does appear to be some
improvement in this record. There is more evident background
activity in the occipital poles. Near the end of the record
there appeared to be some variability to the background
suggesting some cyclic behavior.

[**2113-4-19**]   Radiology CT HEAD W/O CONTRAST: No acute intracranial
pathology.   Mucus-retention cyst with aerosolized secretions
within the left sphenoid air cell, with inflammatory changes in
the anterior ethmoidal air cells; correlate clinically.

[**2113-4-19**]   Radiology CT ABD & PELVIS WITH CO:Residual
rim-enhancing fluid collection in the right posterior perirenal
and pararenal spaces, slightly smaller since [**2113-4-6**].
Percutaneous pigtail drainage catheter is appropriately
positioned within this cavity.  No new fluid collections.

[**2113-4-19**]   Neurophysiology EEG   [**2113-4-19**]:This is an abnormal
continuous ICU monitoring study because of a severe diffuse
encephalopathy with some multifocal interictal epileptic
features. Additionally, there were short runs of semi- rhythmic
activity which may represent brief abortive seizure discharges.
None of them had clinical accompaniments.



Brief Hospital Course:
35 y/o female with Hep C and recent bowel/biliary perforation
s/p ERCP with drain in place who presents s/p reported cardiac
arrest with ROSC after 2 shocks in addition to seizure activity
and clinical pararamaters consistent with sepsis.

.

# Possible VF/VT arrest:  Pt was initially brought to OSH s/p
reported cardiac arrest.  Events surrounding the event was
unclear.  [**Name2 (NI) **] report, she had seizures prior to the arrest and
was found with loss of pulse with shockable rhythm.  She was
shocked twice.  EMS and police were contact[**Name (NI) **] to attempt to
discern her heart rhythm at the time but AED could not be
interrogated.  She was intubated at OSH.  Post-cardiac arrest
team was consulted. She was started on cooling protocol upon
arriving to [**Hospital1 18**] MICU and then re-warmed.  She was also on
neuromuscular blockade during this time.  Trop was initially
0.06 but then downtrended to <0.01.  CKs were elevated by MB was
largely unremarkable.  Initial TTE showed EF 35-40% with
moderate regional LV systolic dysfunction in a non-coronary
distribution.  However, this had been performed while pt was on
cooling protocol was likely unreliable.  TTE was later repeated
which showed normal functions in both ventricles.  Patient has
been stable since hospitalization.

.

#Sepsis:  On admission to MICU, pt met SIRS criteria with fever,
leukocytosis, and tachycardia and also had elevated lactate.
Concern was high for GI source of infection given recent history
of bowel perforation.  She had recently completed course of
augmentin/fluconazole prior to admission.  She was broadly
covered with vancomycin/zosyn initially.  Four sets of blood
cultures from [**2113-4-19**] grew staph epi and coag neg staph (not
sensitive to oxacillin).  Ob/gyn was also curbsided regarding
possible removal of IUD but did not feel IUD was source of
infection. Her JP drain was sent for culture and grew
pseudomonas sensitive to ciprofloxacin.  She was transitioned to
vancomycin and ciprofloxacin PO.  She was followed by surgery
for her JP drain.  JP drain fell out prior to transfer to
medicine floor; surgery recommended no replacement of drain or
reimaging unless patient was febrile. Patient was seen by ID
while on the floor who recommended her to be switched to IV
ceftazidime for 2 weeks.

Patient had mild increase in WBC and transaminitis during day 11
of hospitalization while on vancomycin and ceftazidime. Repeat
blood cultures and c.diff assay were sent which returned
negative. Patient was asymptomatic during this period and
remained afebrile. Patient completed a 14 day course of
vancomycin on [**5-3**] and 2 weeks of IV ceftazidime on [**5-9**] with
appropriate decreased in WBC and LFTs. See below for abdominal
abcess.

.

# Seizure - No history of seizures in the past.  Urine tox was
positive for barbs and benzos which she had received at OSH.
There was no evidence of IC mass/process on stat head CT.
Lumbar puncture showed no growth in CSF fluid.  She was kept on
continuous EEG monitoring initially.  This did not show
seizures.  She was followed by neurology who recommended
initiation of dilantin 100mg q8H. On week 2 of hospitalization,
patient??????s dilantin level was found to be subtherapeutic and she
was loaded with 1000mg of Dilantin to therapeutic level. Patient
was maintained on 100mg q8H.  She will need to follow up with
neurology in 4 weeks.

.

# Bowel perforation - Etiology was due to duodenal perforation
after ERCP.  She had been treated with Perc drain in perinephric
space and abx course recently completed.  CT A/P in the ED
showed drain in appropriate place and no new evidence for
abdominal catastrophe.  Surgery consulted in ED and followed pt
on floor.  She was kept on vanc/zosyn initially and switched to
vanc/cipro when JP drain culture grew pseudomonas sensitive to
cipro.  JP Drain fell out on [**2113-4-23**]; surgery recommended no
replacement of drain unless patient is febrile. Patient finished
a 2-week course of IV ceftazidime on [**5-9**]. Repeat CT of the
abdomen showed only slight decrease in the size of the abdominal
fluid collection.  Given this ID and surgery were reconsulted
and recommended drainage.  The patient refused to stay in the
hospital for this procedure even after explaining her the high
risk for spreading of the infection, her becoming septic again
and potentially dying from this.  She refused to stay as she was
very upset she had to be here for so long and this was not found
earlier.  Prior to discharge she was given a prescription for
ciprofloxacin 500 mg [**Hospital1 **] until she is instructed otherwise by
her PCP or Dr. [**Last Name (STitle) 468**].  Appointments were made with these
doctors.

.

# Hep C - last month VL at 72,762 IU/mL. Stable, with LFT's WNL.

.

# Diarrhea: After extubation, pt developed diarrhea associated
with profound electrolyte abnormalities that required frequent
monitoring and repletion. C.diff was negative.  She was treated
with loperamide.  Diarrhea may have been due to narcotic
withdrawal. She was continued on her home dilaudid for chronic
abdominal pain. Patient??????s diarrhea resolved on its own 4 days
after being on the floor and patient remained asymptomatic off
of loperamide.

.

# Psych: Addictions/social work consult was obtained for
polysubstance abuse, including active IVDU. She appeared quite
depressed with flat affect, had issues with polydipsia (drinking
liters of water daily), and had anorexia.  Psych was consulted
who did not think she was at acute risk of harming herself and
her anorexia in the ICU was most likely appetite related.
Patient was initially maintained on a 1.5L fluid restriction but
given well-compensated kidneys and normonatremia, the fluid
restriction was lifted with no issues. Patient??????s appetite
improved progressively during her hospitalization. She was seen
by nutrition who initially recommended ensure puddings then
multivitamins.

.

# IV Access: Pt had difficult IV access. She was maintained on
peripheral IVs while at ICU and ordered for IR guided PICC
placement while on the floor for the completion of her
antibiotic course.  The PICC line was taken out prior to
discharge.


Medications on Admission:
lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY
acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR
alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID prn
acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID prn
gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H prn pain
amoxicillin-pot clavulanate 500-125 mg Tablet 1 po q12 (just
completed with this admission)
fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 10 days (just completed with this admission)
ZOFRAN ODT 4 mg Tablet 1 po q8hrs prn


Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*16 Tablet(s)* Refills:*0*
2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO Q8H (every 8 hours).
Disp:*90 Capsule(s)* Refills:*0*
3. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
- Cardiac Arrest
- Seizure
- Intra-abdominal abscess
- Bacteremia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
It was a pleasure to be involved in your care. You were admitted
because your heart stopped and had a seizure.
.
You were initially intubated in the intensive care unit where
you were given medication and cooled to stop your seizures. You
did not have any further seizures during your hospitalization.
You will need to follow up with neurologist (brain doctors) 4
weeks after discharge.
.
Initial image of your heart showed slowing of activities but
that was in the setting of you going through cooling for your
seizures.  You had a repeat image after you left the intensive
care unit which showed normal function of your heart.
.
You also had blood cultures which showed a bacteria in your
blood.  You were given antibiotics to treat that for 14 days.
You completed your course on [**2113-5-3**].
.
You were also found to have an infection in your stomach from
your prior intestine performation. You were given antibiotics
for the infection and you finished that course on [**5-9**]. You had
a repeat CAT scan of your stomach which showed that the
infection was not completely gone.  We recommended you stay in
the hospital for a procedure to drain this infection but you
decided you wanted to be discharged against our advice.  We
explained that in doing so this infection might worsen and it
can be catastrophic for your health.  Please take the
antibiotics prescribed, see your PCP and Dr. [**Last Name (STitle) 468**] from
general surgery to have this draining procedure arranged soon.

Medication Changes:
Start:  ciprofloxacin 500 mg [**Hospital1 **] until told to stop by your PCP
or Dr. [**Last Name (STitle) 468**].
Start:  phenytoin 100 mg three times a day


Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital 22163**] MEDICAL PRIMARY CARE
Address: [**Street Address(2) 66034**]. STE #200, [**Location (un) **],[**Numeric Identifier 66035**]
Phone: [**Telephone/Fax (1) 66036**]
Appt:  [**5-15**] at 6pm

***The Neurology Department is working on an appointment for you
within the month and they will call you at home with the appt.
If you dont hear back from them by Wednesday, please call the
office directly to book at [**Telephone/Fax (1) 110633**]

Department: SURGICAL SPECIALTIES
When: MONDAY [**2113-5-22**] at 9:00 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
{'Other postoperative infection,Other staphylococcal septicemia,Peritoneal abscess,Grand mal status,Cardiac arrest,Severe sepsis,Septic shock,Drug withdrawal,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Chronic hepatitis C without mention of hepatic coma,Lack of housing,Tobacco use disorder,Depressive disorder, not elsewhere classified,Opioid type dependence, unspecified,Urinary incontinence, unspecified,Diarrhea'}


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: cardiac arrest, seizure

PRESENT ILLNESS: 35 y/o female with hx of HCV s/p recent bowel perforation 1
month ago surrounding a complicated ERCP presents s/p report of
cardiac arrest and seizures.

MEDICAL HISTORY: Perforated bowel
Heroin Abuse
ERCP on [**2113-3-10**]
HCV
migraines
Chronic LBP
Anxiety/Depression
CBD stones
Cholilithiasis
History of sphincterotmy complicated by duodenal perforation

MEDICATION ON ADMISSION: lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY
acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR
alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID prn
acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID prn
gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H prn pain
amoxicillin-pot clavulanate 500-125 mg Tablet 1 po q12 (just
completed with this admission)
fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 10 days (just completed with this admission)
ZOFRAN ODT 4 mg Tablet 1 po q8hrs prn

ALLERGIES: Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: On admission to ICU:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Coarse to auscultation bilaterally. No wheezes
Abdomen: Abdominal scar located midline.  Abdominal distention
with respiratory effort.  Bowel sounds present, no organomegaly
appreciated. Purulent drainage from grenade drain on right.
GU: clear urine
Ext: cold to touch with mottled appearance.  2+ pulses.  Prior
IV site on dorsum of left hand.  PIVs in antecubital vv
bilaterally.
Neuro: Unconscious sedated on vent.  Gag reflex. Pupils from 6
to 2-3 mm with light.  Right corneal reflex intact, left not
brisk to corneal irritation.  Decerabrate posturing.  Down going
babinski's b/l with 2+ patellar/bicipital reflexes b/l.

FAMILY HISTORY: Mother and sister with symptomatic cholelithiasis requiring CCY.
 Father died in [**2107**] from MI, mother, alive, with alcoholic
cirrhoisis.

SOCIAL HISTORY: Unemployed and currently homeless, though she stays frequently
with her ex-husband/sister.  Two children ages 3 and 5. +Tobacco
use,
1PPD currently. Denies ETOH. Uses heroin, marijuana regularly. 

### Response:
{'Other postoperative infection,Other staphylococcal septicemia,Peritoneal abscess,Grand mal status,Cardiac arrest,Severe sepsis,Septic shock,Drug withdrawal,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Chronic hepatitis C without mention of hepatic coma,Lack of housing,Tobacco use disorder,Depressive disorder, not elsewhere classified,Opioid type dependence, unspecified,Urinary incontinence, unspecified,Diarrhea'}
