CHIEF COMPLAINT: weakness

PRESENT ILLNESS: 49 year-old male with mental retardation, intractable seizures,
non-verbal at baseline, recurrent subclinical seizures
presenting with weakness, gait instability, and decreased
engagement with staff at group home. Noticed over past 2-3 days
by staff. Requiring assistance with ambulation, whereas usually
independent. No falls. He was not having fevers, chills, cough.
Appetite at baseline.
.
Of note, he was admitted [**Date range (1) 15126**] and [**Date range (1) 15127**]/11 for
similar complaint. During both admissions he had increased
seizure activity (described as subclinical tonic seizures,
suspected left temporal lobe in origin) due to infection -
pneumonia during the first admission, UTI during the second. He
was discharged on Vimpat, but due to difficulty tolerating
medication stopped on [**2187-2-28**].
.
In the ED, 85.5/90 axillary 52 103/62 18 99%__. Systolic blood
pressure dropped to 80s, initially fluid responsive. Physical
examination notable for recurrent seizures with lateral gaze
deviation. Laboratory data significant for platelet count 64,
WBC 4.1 with left shift, transaminitis, lipase 1438, and chem10
within normal limits; UA with trace leukocyte esterase, nitrite
positive, moderate bacteria. Lactate 1.4. CXR 1V "acutely
worsening right lower lobe opacification." RUQ ultrasound with
patent portal vein, gallbladder sludge, liver cysts, CBD 0.4cm;
note of poor study quality. CT head without contrast without
acute hemorrhage, stable periventricular leukomalacia. Seen by
neurology - concerning for seizures due to underlying infection;
recommended restart Vimpat 100 mg QAM and ordering 24 hour
bedside EEG. He was intubated for airway protection. RIJ placed,
sterile position; Levophed initiated. Received Ativan 1mg IV
x4-5 for seizures; 5L IVF; vancomycin, Zosyn for suspected UTI,
pneumonia; midazolam for sedation. On transfer to MICU, 109,
131/60, 99% AC 500x16 , PEEP 10, FiO2 100%.
.
In the MICU, patient is intubated and sedated.

MEDICAL HISTORY: - static encephalopathy after prolonged status epilepticus,
possible anoxic injury at age 7 or 8 years.
- Intractable epilepsy.
- Per neurology note "He had mild developmental delay as a
child, and then at age 7 or 8 years had prolonged (greater than
24 hours) status epilepticus with probable anoxic brain injury
in the setting of a febrile illness. Subsequently, he had severe
static encephalopathy and intractable epilepsy. He currently
resides in a group home. He is nonverbal, but does understand
some language. He requires assistance with most activities of
daily living. He has some obstinate behavior, but no aggression
or agitated behavior recently.
His typical seizures are of 2 types: #1) episodes of rapid eye
blinking, staring, and urinary incontinence, unclear frequency,
and #2) episodes of facial grimacing, stiffening of his limbs,
some lip smacking, and incontinence of urine and stool,
occurring 3-4 times pack-year."

MEDICATION ON ADMISSION: Gabapentin 1200mg PO AM; 2400mg PO QHS
Clonazepam 5mg PO QHS
Zonisamide 300mg PO QAM; 400mg PO QHS
Peridex oral rinse [**12-31**] cap [**Hospital1 **]
Oxcarbazepine 600mg PO TID
MVI
Vimpat was discontinued on [**2187-3-1**]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ON ADMISSION:
97.7, 105, 116/67, 24, 99% AC 500x24, PEEP10, FiO2 100%
General: Intubated, sedated; not responsive to verbal stimuli
HEENT: Sclera anicteric, moist mucous membranes
Neck: Supple
Lungs: Anterior auscultation, clear to auscultation bilaterally
without wheezes, rales, or rhonchi
CV: Tachycardic; regular rhythm; normal S1/S2, no murmurs
appreciated
Abdomen: Hypoactive bowel sounds; soft, nontender (sedated), not
distended; no guarding
GU: Foley in place
Ext: Warm, well-perfused; radial, DP pulses 2+, symmetric; no
lower extremity edema
Neuro: Pupils equally round and reactive to light; does not
respond to verbal stimuli; withdraws to painful stimuli; biceps,
patellar reflexes 2+, symmetric
.
ON DISCHARGE:
Tm 97.6, 108/62 54 12 98% RA
Gen: awake, alert, no acute distress
HEENT: sclera anicteric, EOMI
CV: RRR, S1/S2, no murmurs or extra sounds appreciated
Pulm: Anterior fields CTA bilaterally
Abd: + BS, soft, non-tender, non-distended
Ext: warm, no edema, moves all extremities spontaneously

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives in group home. Does not use tobacco, alcohol, or illicit
drugs.
Septicemia due to escherichia coli [E. coli],Acute respiratory failure,Septic shock,Encephalopathy, unspecified,Pneumonia, organism unspecified,Acute pancreatitis,Urinary tract infection, site not specified,Epilepsy, unspecified, with intractable epilepsy,Intestinal infection due to Clostridium difficile,Severe sepsis,Thrombocytopenia, unspecified,Unspecified intellectual disabilities
E coli septicemia,Acute respiratry failure,Septic shock,Encephalopathy NOS,Pneumonia, organism NOS,Acute pancreatitis,Urin tract infection NOS,Epilepsy NOS w intr epil,Int inf clstrdium dfcile,Severe sepsis,Thrombocytopenia NOS,Intellect disability NOS
Admission Date:  [**2187-3-3**]              Discharge Date:   [**2187-4-20**]

Date of Birth:  [**2137-10-23**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
weakness

Major Surgical or Invasive Procedure:
intubation

History of Present Illness:
49 year-old male with mental retardation, intractable seizures,
non-verbal at baseline, recurrent subclinical seizures
presenting with weakness, gait instability, and decreased
engagement with staff at group home. Noticed over past 2-3 days
by staff. Requiring assistance with ambulation, whereas usually
independent. No falls. He was not having fevers, chills, cough.
Appetite at baseline.
.
Of note, he was admitted [**Date range (1) 15126**] and [**Date range (1) 15127**]/11 for
similar complaint. During both admissions he had increased
seizure activity (described as subclinical tonic seizures,
suspected left temporal lobe in origin) due to infection -
pneumonia during the first admission, UTI during the second. He
was discharged on Vimpat, but due to difficulty tolerating
medication stopped on [**2187-2-28**].
.
In the ED, 85.5/90 axillary 52 103/62 18 99%__. Systolic blood
pressure dropped to 80s, initially fluid responsive. Physical
examination notable for recurrent seizures with lateral gaze
deviation. Laboratory data significant for platelet count 64,
WBC 4.1 with left shift, transaminitis, lipase 1438, and chem10
within normal limits; UA with trace leukocyte esterase, nitrite
positive, moderate bacteria. Lactate 1.4. CXR 1V "acutely
worsening right lower lobe opacification." RUQ ultrasound with
patent portal vein, gallbladder sludge, liver cysts, CBD 0.4cm;
note of poor study quality. CT head without contrast without
acute hemorrhage, stable periventricular leukomalacia. Seen by
neurology - concerning for seizures due to underlying infection;
recommended restart Vimpat 100 mg QAM and ordering 24 hour
bedside EEG. He was intubated for airway protection. RIJ placed,
sterile position; Levophed initiated. Received Ativan 1mg IV
x4-5 for seizures; 5L IVF; vancomycin, Zosyn for suspected UTI,
pneumonia; midazolam for sedation. On transfer to MICU, 109,
131/60, 99% AC 500x16 , PEEP 10, FiO2 100%.
.
In the MICU, patient is intubated and sedated.


Past Medical History:
- static encephalopathy after prolonged status epilepticus,
possible anoxic injury at age 7 or 8 years.
- Intractable epilepsy.
- Per neurology note "He had mild developmental delay as a
child, and then at age 7 or 8 years had prolonged (greater than
24 hours) status epilepticus with probable anoxic brain injury
in the setting of a febrile illness. Subsequently, he had severe
static encephalopathy and intractable epilepsy. He currently
resides in a group home. He is nonverbal, but does understand
some language. He requires assistance with most activities of
daily living. He has some obstinate behavior, but no aggression
or agitated behavior recently.
His typical seizures are of 2 types: #1) episodes of rapid eye
blinking, staring, and urinary incontinence, unclear frequency,
and #2) episodes of facial grimacing, stiffening of his limbs,
some lip smacking, and incontinence of urine and stool,
occurring 3-4 times pack-year."


Social History:
Lives in group home. Does not use tobacco, alcohol, or illicit
drugs.

Family History:
Noncontributory

Physical Exam:
ON ADMISSION:
97.7, 105, 116/67, 24, 99% AC 500x24, PEEP10, FiO2 100%
General: Intubated, sedated; not responsive to verbal stimuli
HEENT: Sclera anicteric, moist mucous membranes
Neck: Supple
Lungs: Anterior auscultation, clear to auscultation bilaterally
without wheezes, rales, or rhonchi
CV: Tachycardic; regular rhythm; normal S1/S2, no murmurs
appreciated
Abdomen: Hypoactive bowel sounds; soft, nontender (sedated), not
distended; no guarding
GU: Foley in place
Ext: Warm, well-perfused; radial, DP pulses 2+, symmetric; no
lower extremity edema
Neuro: Pupils equally round and reactive to light; does not
respond to verbal stimuli; withdraws to painful stimuli; biceps,
patellar reflexes 2+, symmetric
.
ON DISCHARGE:
Tm 97.6, 108/62 54 12 98% RA
Gen: awake, alert, no acute distress
HEENT: sclera anicteric, EOMI
CV: RRR, S1/S2, no murmurs or extra sounds appreciated
Pulm: Anterior fields CTA bilaterally
Abd: + BS, soft, non-tender, non-distended
Ext: warm, no edema, moves all extremities spontaneously



Pertinent Results:
=========
Labs (UPDATED THROUGH MICU COURSE)
=========
[**2187-3-3**] 12:30PM BLOOD Lipase-1438*
[**2187-3-4**] 04:27AM BLOOD Lipase-566*
[**2187-3-5**] 03:49AM BLOOD Lipase-98*
[**2187-3-7**] 05:34AM BLOOD Lipase-98*
[**2187-3-8**] 04:40AM BLOOD Lipase-389*
[**2187-3-9**] 03:24AM BLOOD Lipase-397*
[**2187-3-10**] 03:42AM BLOOD Lipase-297*
[**2187-3-11**] 04:11AM BLOOD Lipase-241*
[**2187-3-12**] 04:02AM BLOOD Lipase-282*
[**2187-3-14**] 03:00AM BLOOD Lipase-279*
[**2187-3-15**] 04:06AM BLOOD Lipase-298*
[**2187-3-16**] 02:24AM BLOOD Lipase-262*
[**2187-3-17**] 03:12AM BLOOD Lipase-250*
.
[**2187-3-3**] 12:30PM BLOOD WBC-4.1 RBC-3.61* Hgb-11.8* Hct-35.4*
MCV-98 MCH-32.7* MCHC-33.3 RDW-15.8* Plt Ct-64*#
[**2187-3-4**] 04:27AM BLOOD WBC-8.4# RBC-3.14* Hgb-10.2* Hct-30.8*
MCV-98 MCH-32.5* MCHC-33.1 RDW-15.9* Plt Ct-54*
[**2187-3-5**] 03:49AM BLOOD WBC-13.3*# RBC-2.93* Hgb-9.5* Hct-28.3*
MCV-97 MCH-32.6* MCHC-33.7 RDW-16.0* Plt Ct-46*
[**2187-3-6**] 05:23AM BLOOD WBC-12.6* RBC-3.01* Hgb-9.9* Hct-28.8*
MCV-96 MCH-33.0* MCHC-34.5 RDW-16.0* Plt Ct-44*
[**2187-3-7**] 05:34AM BLOOD WBC-9.7 RBC-2.76* Hgb-9.1* Hct-26.5*
MCV-96 MCH-32.8* MCHC-34.2 RDW-15.8* Plt Ct-51*
[**2187-3-8**] 04:40AM BLOOD WBC-3.9*# RBC-3.20* Hgb-10.5* Hct-30.9*
MCV-97 MCH-32.7* MCHC-33.9 RDW-15.6* Plt Ct-55*
[**2187-3-9**] 03:24AM BLOOD WBC-1.5*# RBC-2.63* Hgb-8.6* Hct-25.6*
MCV-97 MCH-32.8* MCHC-33.8 RDW-15.4 Plt Ct-72*
[**2187-3-9**] 03:24AM BLOOD WBC-1.5*# RBC-2.63* Hgb-8.6* Hct-25.6*
MCV-97 MCH-32.8* MCHC-33.8 RDW-15.4 Plt Ct-72*
[**2187-3-10**] 03:42AM BLOOD WBC-3.0*# RBC-2.57* Hgb-8.4* Hct-24.8*
MCV-97 MCH-32.6* MCHC-33.8 RDW-15.3 Plt Ct-117*#
[**2187-3-10**] 03:45PM BLOOD WBC-3.8* RBC-2.70* Hgb-8.8* Hct-26.2*
MCV-97 MCH-32.6* MCHC-33.6 RDW-15.2 Plt Ct-198#
[**2187-3-11**] 04:11AM BLOOD WBC-4.2 RBC-2.12* Hgb-6.9* Hct-20.7*
MCV-98 MCH-32.4* MCHC-33.2 RDW-14.9 Plt Ct-233
[**2187-3-11**] 05:48AM BLOOD WBC-4.4 RBC-2.51* Hgb-8.1* Hct-24.6*
MCV-98 MCH-32.1* MCHC-32.8 RDW-14.8 Plt Ct-244
[**2187-3-12**] 04:02AM BLOOD WBC-5.0 RBC-2.70* Hgb-8.7* Hct-26.6*
MCV-98 MCH-32.2* MCHC-32.7 RDW-14.6 Plt Ct-332
[**2187-3-12**] 03:53PM BLOOD WBC-4.9 RBC-2.60* Hgb-8.2* Hct-25.4*
MCV-98 MCH-31.5 MCHC-32.3 RDW-14.5 Plt Ct-435
[**2187-3-13**] 04:14AM BLOOD WBC-4.7 RBC-2.41* Hgb-7.8* Hct-23.5*
MCV-98 MCH-32.3* MCHC-33.2 RDW-14.7 Plt Ct-448*
[**2187-3-14**] 03:00AM BLOOD WBC-5.2 RBC-2.51* Hgb-8.0* Hct-24.5*
MCV-98 MCH-31.9 MCHC-32.7 RDW-14.7 Plt Ct-600*
[**2187-3-15**] 04:06AM BLOOD WBC-6.8 RBC-2.21* Hgb-7.0* Hct-21.5*
MCV-97 MCH-31.6 MCHC-32.5 RDW-14.6 Plt Ct-661*
[**2187-3-16**] 02:24AM BLOOD WBC-5.5 RBC-2.55* Hgb-8.3* Hct-24.7*
MCV-97 MCH-32.5* MCHC-33.5 RDW-14.7 Plt Ct-688*
[**2187-3-17**] 03:12AM BLOOD WBC-5.2 RBC-2.56* Hgb-8.3* Hct-24.7*
MCV-96 MCH-32.3* MCHC-33.5 RDW-14.9 Plt Ct-657*
.
[**2187-3-4**] 04:27AM BLOOD PT-14.1* PTT-37.2* INR(PT)-1.2*
[**2187-3-5**] 03:49AM BLOOD PT-15.9* PTT-42.2* INR(PT)-1.4*
[**2187-3-7**] 05:34AM BLOOD PT-15.2* PTT-41.4* INR(PT)-1.3*
[**2187-3-11**] 04:11AM BLOOD PT-16.0* PTT-34.1 INR(PT)-1.4*
[**2187-3-12**] 04:02AM BLOOD PT-16.9* PTT-34.7 INR(PT)-1.5*
[**2187-3-15**] 04:06AM BLOOD PT-16.7* PTT-33.8 INR(PT)-1.5*
[**2187-3-16**] 02:24AM BLOOD PT-16.3* PTT-30.7 INR(PT)-1.4*
[**2187-3-17**] 03:12AM BLOOD PT-14.5* PTT-21.2* INR(PT)-1.3*
.
[**2187-3-3**] Glucose-104* UreaN-20 Creat-0.8 Na-141 K-3.9 Cl-105
HCO3-27 [**2187-3-4**] Glucose-69* UreaN-17 Creat-0.8 Na-142 K-3.9
Cl-114* HCO3-21* [**2187-3-5**] Glucose-75 UreaN-16 Creat-0.8 Na-141
K-3.5 Cl-113* HCO3-22 [**2187-3-6**] Glucose-86 UreaN-15 Creat-0.8
Na-142 K-3.1* Cl-110* HCO3-24 [**2187-3-6**] Glucose-86 UreaN-16
Creat-0.9 Na-143 K-3.4 Cl-109* HCO3-24 [**2187-3-7**] Glucose-100
UreaN-17 Creat-0.9 Na-139 K-3.2* Cl-107 HCO3-28 [**2187-3-7**]
Glucose-122* UreaN-20 Creat-0.8 Na-142 K-3.6 Cl-110* HCO3-30
[**2187-3-8**] Glucose-99 UreaN-19 Creat-0.7 Na-142 K-3.7 Cl-107
HCO3-28 AnGap-11
[**2187-3-8**] Glucose-118* UreaN-22* Creat-0.8 Na-144 K-3.5 Cl-107
HCO3-30 [**2187-3-9**] Glucose-123* UreaN-24* Creat-0.7 Na-142 K-3.6
Cl-105 HCO3-31 [**2187-3-9**] Glucose-96 UreaN-27* Creat-0.7 Na-144
K-4.0 Cl-106 HCO3-31 [**2187-3-10**] Glucose-85 UreaN-28* Creat-0.6
Na-145 K-3.7 Cl-107 HCO3-30 [**2187-3-10**] Glucose-106* UreaN-28*
Creat-0.7 Na-144 K-3.5 Cl-106 HCO3-31 [**2187-3-11**] Glucose-93
UreaN-24* Creat-0.6 Na-145 K-3.2* Cl-111* HCO3-28 [**2187-3-11**]
Glucose-98 UreaN-26* Creat-0.6 Na-142 K-3.7 Cl-106 HCO3-29
[**2187-3-12**] Glucose-105* UreaN-27* Creat-0.6 Na-144 K-4.0 Cl-107
HCO3-28 [**2187-3-13**] Glucose-89 UreaN-26* Creat-0.6 Na-144 K-4.1
Cl-105 HCO3-31 [**2187-3-14**] Glucose-116* UreaN-25* Creat-0.6 Na-144
K-3.4 Cl-103 HCO3-35* [**2187-3-14**] Glucose-125* UreaN-26* Creat-0.7
Na-141 K-4.5 Cl-104 HCO3-35* [**2187-3-15**] Glucose-107* UreaN-25*
Creat-0.6 Na-141 K-3.9 Cl-104 HCO3-32 [**2187-3-16**] Glucose-98
UreaN-25* Creat-0.5 Na-143 K-4.1 Cl-108 HCO3-30 [**2187-3-17**]
Glucose-104* UreaN-27* Creat-0.6 Na-142 K-4.6 Cl-109* HCO3-27
.
[**2187-3-3**] ALT-53* AST-52* LD(LDH)-274* AlkPhos-147* TotBili-0.1
[**2187-3-7**] ALT-34 AST-67* AlkPhos-101 TotBili-0.4
[**2187-3-8**] ALT-40 AST-78* AlkPhos-122 Amylase-360* TotBili-0.4
[**2187-3-9**] Amylase-378*
[**2187-3-10**] ALT-55* AST-92* AlkPhos-106 TotBili-0.3
[**2187-3-12**] ALT-43* AST-50* AlkPhos-126 TotBili-0.4
.
=========
Radiology
=========
[**3-3**] CT Head: No acute hemorrhage. No significant change in
appearance
compared with the MRI of [**2187-1-26**].
.
[**3-3**] CXR: Persistent patchy opacification in the right lower lobe
is
nonspecific, may represent atelectasis, though acute
infection/aspiration is not excluded.
.
[**3-3**] RUQ u/s: Sludge within the gallbladder, but no evidence of
cholecystitis or cholelithiasis.
.
CXR [**3-7**]: In comparison with the study of [**3-6**], the monitoring and
support devices are essentially unchanged. Diffuse bilateral
pulmonary opacifications persist. This apparently is consistent
with bilateral pneumonia combined with congestive failure and
bilateral pleural effusions, and is again more prominent on the
right.
.
CT Head [**3-8**]: No acute intracranial hemorrhage or mass effect.
Persistent moderate dilation of the lateral ventricles along
with evidence of volume loss as on the prior study. 2. No large
obvious hypodense area to suggest acute infarct. However,
assessment is somewhat limited due to artifacts from the leads.
If there is continued concern for small acute infarcts, consider
MR if not contraindicated.
.
CT Abd [**3-8**]: No evidence of complications related to
pancreatitis. Dense consolidative and patchy opacity at the
bilateral lung bases, right slightly greater than left, most
likely represents aspiration but infection cannot be excluded.
.
CXR [**3-10**]: Current study demonstrates unchanged appearance of the
ET tube and NG tube. Widespread parenchymal consolidations are
unchanged except for right lower lung where they appear to be
progressed and they might be accompanied by bilateral pleural
effusion. No interval development of pneumothorax or other new
findings have been demonstrated.
.
CXR [**3-15**]: In comparison with the studies of [**3-12**] and [**3-13**],
there is little overall change in the diffuse bilateral
pulmonary opacifications involving almost all of the right lung
and much of the left lung. This represents some undetermined
combination of pneumonia, pulmonary edema, hemorrhage, and
possibly even ARDS.
.
==========
Micro
==========
   URINE CULTURE (Final [**2187-3-6**]):
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].
         WARNING! This isolate is an extended-spectrum
beta-lactamase
         (ESBL) producer and should be considered resistant to
all
         penicillins, cephalosporins, and aztreonam. Consider
Infectious
         Disease consultation for serious infections caused by
         ESBL-producing species.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMIKACIN--------------     4 S
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------  =>64 R
CEFEPIME--------------       R
CEFTAZIDIME-----------       R
CEFTRIAXONE-----------  =>64 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------  =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------    64 I
PIPERACILLIN/TAZO-----       S
TOBRAMYCIN------------  =>16 R
TRIMETHOPRIM/SULFA----  =>16 R
.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2187-3-7**]):
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2187-4-2**]):
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
Blood cultures [**Date range (1) 15128**], no growth on final cultures.
==========
Cards
==========
TTE [**3-6**]: The left atrium is elongated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve is not well seen. There is no
aortic valve stenosis. There is mild posterior leaflet mitral
valve prolapse. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
=========
Neuro
=========
EEG [**3-4**]: This is an abnormal continuous EEG due to the presence
of
14 electrographic seizures characterized by a generalized
electrodecrement, followed by a higher amplitude rhythmic [**12-11**]
Hz activity beginning over the bifrontocentral regions with
secondary generalization, usually lasting between 40-50 seconds.
There was an extended seizure which lasted for 15 minutes
occuring at 00:21 am. In addition, the [**6-5**] Hz theta rhythm
background with bursts of generalized theta slowing is
consistent with a mild diffuse encephalopathy, commonly seen
with medication effect, metabolic disturbance, or infection. In
addition, there were frequent interictal sharp discharges,
greatest over the right frontocentral region (with phase
reversal at C4/T4), but also seen over the left frontocentral
region (with phase reversal at F3/C3), and rarely
bifrontocentrally, consistent with multiple regions with
epileptogenic potential.
.
EEG [**3-5**]: This is an abnormal continuous EEG due to the presence
of 10 electrographic seizures characterized by higher amplitude
rhythmic [**12-11**] Hz activity beginning over the bifrontocentral
regions with secondary generalization, usually lasting between
10-20 seconds. Compared to the previous tracing, the
electrographic seizures are fewer in frequency and shorter in
duration. In addition, the [**6-5**] Hz theta rhythm background with
bursts of generalized theta slowing is consistent with a mild
diffuse encephalopathy, commonly seen with medication effect,
metabolic disturbance, or infection. In addition, there were
less frequent interictal sharp discharges, although still
occasionally seen over the right frontocentral region (with
phase reversal at C4/T4), left frontocentral region (with phase
reversal at F3/C3), and rarely bifrontocentrally. Compared to
the previous tracing, there is a significant improvement in the
frequency of seizures and epileptiform activity.
.
EEG [**3-6**]: This is an abnormal continuous EEG due to the presence
of 5 brief electrographic seizures characterized by higher
amplitude rhythmic [**12-11**] Hz activity beginning over the
bifrontocentral regions with secondary generalization, usually
lasting between 5-20 seconds. Compared to the previous tracing,
the electrographic seizures are fewer in frequency and shorter
in duration. In addition, the [**6-5**] Hz theta rhythm background
seen during the most awake portions of the record is consistent
with a mild diffuse encephalopathy, commonly seen with
medication effect, metabolic disturbance, or infection. In
addition, there were occasional low amplitude interictal sharp
discharges, seen over the right frontocentral region (with phase
reversal at C4/T4), left frontocentral region (with phase
reversal at F3/C3), and rarely bifrontocentrally. Compared to
the previous tracing, there is a significant improvement in
seizure frequency and background slowing.
.
EEG [**3-7**]: This is an abnormal continuous EEG due to the presence
of 3 brief electrographic seizures characterized by higher
amplitude rhythmic [**12-11**] Hz activity beginning over the
bifrontocentral regions with secondary generalization, usually
lasting approximately 10 seconds. Compared to the previous
tracing, the electrographic seizures are fewer in frequency and
shorter in duration. There are also multiple brief bursts of
similar appearing activity, lasting between 3-5 seconds each,
which likely constitute epileptiform bursts. In addition, the
[**6-5**] Hz theta rhythm background seen during the most awake
portions of the record is consistent with a mild diffuse
encephalopathy, commonly seen with medication effect, metabolic
disturbance, or infection. In addition, there were occasional
low amplitude interictal sharp discharges, seen over the right
frontocentral region (with phase reversal at C4/T4), left
frontocentral region (with phase reversal at F3/C3), and rarely
bifrontocentrally. Compared to the previous tracing, there is no
significant change.
.
EEG [**3-8**]: This is an abnormal continuous EEG due to the presence
of 3 brief electrographic seizures characterized by higher
amplitude rhythmic [**12-11**] Hz activity beginning over the
bifrontocentral regions with secondary generalization, usually
lasting between 10-15 seconds. There are also multiple brief
bursts of similar appearing activity, lasting between [**3-3**]
seconds each, which represent epileptiform bursts. In addition,
the [**7-6**] Hz theta rhythm background seen during the most awake
portions of the record is consistent with a mild diffuse
encephalopathy, commonly seen with medication effect, metabolic
disturbance, or infection. In addition, there were occasional
low amplitude interictal sharp discharges, seen over the right
frontocentral region (with phase reversal at C4/T4), left
frontocentral region (with phase reversal at F3/C3), and rarely
bifrontocentrally. Compared to the previous tracing, there is no
significant change.

Brief Hospital Course:
49M with mental retardation, intractable seizures admitted with
lethargy and gait instability in context of hypothermia and
hypotension, and found to have pancreatitis, pneumonia, UTI and
ongoing seizure activity. He improved and remained clinically
stable, but stayed on the medical floor for 4 weeks awaiting
guardianship for discharge to a rehabilitation facility.
.
#. Sepsis: Defined based on hypothermia and tachycardia on
admission, in setting of pulmonary and urinary infectious
processes. Patient was initially managed on Vanco and Zosyn for
UTI given a history of resistant pathogens, and urine eventually
grew out ESBL E coli. Zosyn was transitioned to Meropenem, and
patient completed a 10 day course of Vanco and Meropenem. CXR
showed bilateral consolidations, which may have been due to
pneumonia or chemical pneumonitis. Sputum culture was
unremarkable, and patient completed 10 day course of broad
antibiotics for UTI. Patient received fluid resusication during
his septic physiology state, and was later diuresed to help with
his respiratory status (see below). After coming to the floor,
he was hemodynamically stable and afebrile. His blood cultures
from [**Date range (1) 15128**] did not have any growth. He had no leukocytosis
of localizing symptoms or signs of infection for the remainder
of the hospitalization.
.
#. Respiratory failure: Initial CXR concerning for bilateral
pneumonia, which may have developed in setting of aspiration
event during seizure. Imaging also consistent with fluid
overload from aggressive resuscitation. Sputum cultures have
been negative. Patient has completed course of meropenem, and
was extubated successfully on [**3-15**]. Vancomycin was initially on
board for HCAP, but was stopped for concerns of worsening
thrombocytopenia. Patient aggressively diuresed, and diuresis
continued after extubation with IV Lasix 20 mg because CXR was
still consistent with edema and patient was over 8 liters
positive for length of stay. On transfer from the ICU, patient
was saturating well on 3L NC. He was able to be weaned off
oxygen quickly without additional diuresis. He was maintaining
normal oxygen saturations on room air at time of discharge.
.
#. Acute Pancreatitis: Lipase 1438 on admission, and downtrended
rapidly. He met 0/5 [**Last Name (un) **] criteria on admission. No
choledolcholithiasis found on ultrasound. CT abdomen without
signs of complications from pancreatitis. Patient was initially
fed via postpyloric dobhoff, which was discontinued upon
transfer to the floor. He was transitioned to a low fat regular
diet, which he tolerated well.
.
#. Seizure disorder: Patient had presumed seizure activity in
the ED, and multiple seizures on 24 hour EEG monitoring. Patient
is well known to have increased seizure activity with infection.
In addition, patient had recently been tapered off of Vimpat,
possibly in error. Vimpat was restarted, and other home
antiepileptic meds were continued. Seizure activity improved
with new regimen and treatment of infections as above. He was
discharged on  Gabapentin (1200 mg daily, 2400 mg nightly),
Oxcarbazepine (600 mg TID), Lacosamide (Vimpat) (100 mg qhs),
and Zonisamide (300 mg daily, 400 mg nightly).
.
#. Urinary Tract Infection: Urine culture on [**3-3**] positive for
ESBL E. coli. Patient completed 10-day course of meropenem,
though repeat urine culture positive for yeast. Foley changed
and patient started on fluconazole, as unable to assess whether
patient symptomatic. Treated with fluconazole to complete 3 day
course ([**Date range (1) 8975**]). Foley was removed and patient had successful
voiding trial.
.
#. Clostridium difficile infection: No complications of colitis
seen on abdominal CT. Given leukocytosis, C diff. specimen was
sent on [**3-6**] and was positive. Patient was started on PO vanco
and IV flagyl through [**2187-3-20**]. He had resolution of symptoms but
began to have increased frequency of stool on [**4-1**] with 4/5 assay
positive for C diff. He was treated for recurrence with a 2-week
course of vancomycin which he completed on [**4-18**]. He did not have
any recurrence of symptoms, fevers, or abdominal pain and was
having 1 formed stool daily at time of discharge.
.
#. Thrombocytopenia/Thrombocytosis: Platelet count in [**2186**] has
ranged between 60 and 600. Concern for DIC given
infection/pancreatitis, although coags within normal limits.
Platelets improved with infection treatment and even rose to
thrombocytotic range (likely reactive in nature), which trended
down at time of discharge.
.
#. Fever: Patient had temperature of 103 rectal on [**3-18**] and was
pan-cultured. Urinalysis and culture were negative for
infection. [**1-2**] blood cultures (anaerobic bottle) grew
coagulase-negative staph, likely a skin contaminant.
Surveillance blood cultures are pending, no growth to date. The
patient remained afebrile and developed no other signs or
symptoms localizing infection. His LFTs were normal, lipase was
trending down, and abdominal exam benign. The exact etiology of
his one fever is unclear; however, he clinically appeared well
for 4 days after and was thought suitable for discharge. He
remained in the hospital for several weeks awaiting guardianship
paperwork and was afebrile for the remainder of the stay with no
signs/symptoms of infection (other than C diff recurrence as
above).
.
# Disposition: Evaluated by Physical Therapy and thought
appropriate for discharge to rehabilitative center for continued
strength training.
.
TRANSITION OF CARE:
===================
# Patient will return to his group home after rehabilitation
stay. He will have an appointment with his PCP scheduled after
discharge.

Medications on Admission:
Gabapentin 1200mg PO AM; 2400mg PO QHS
Clonazepam 5mg PO QHS
Zonisamide 300mg PO QAM; 400mg PO QHS
Peridex oral rinse [**12-31**] cap [**Hospital1 **]
Oxcarbazepine 600mg PO TID
MVI
Vimpat was discontinued on [**2187-3-1**]


Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain, fever.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
3. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
4. clonazepam 1 mg Tablet Sig: Five (5) Tablet PO QHS (once a
day (at bedtime)).
5. gabapentin 250 mg/5 mL Solution Sig: 2400 (2400) mg PO HS (at
bedtime).
6. gabapentin 250 mg/5 mL Solution Sig: 1200 (1200) mg PO DAILY
(Daily).
7. oxcarbazepine 300 mg/5 mL Suspension Sig: Six Hundred (600)
mg PO TID (3 times a day).
8. lacosamide 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO QAM.
10. zonisamide 100 mg Capsule Sig: Four (4) Capsule PO QHS (once
a day (at bedtime)).
11. multivitamin     Capsule Sig: One (1) Capsule PO once a day.

12. Peridex 0.12 % Mouthwash Sig: 0.5 cap full Mucous membrane
twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] LivingCenter - [**Hospital1 8218**] - [**Location (un) **]

Discharge Diagnosis:
respiratory failure
pneumonia
clostridium difficile colitis
urinary tract infection
acute pancreatitis
seizures


Discharge Condition:
Mental Status: Non-verbal.
Level of Consciousness: Alert. Minimally interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr. [**Known lastname **],

You were recently admitted to [**Hospital1 1170**] where you were treated for pneumonia, a colon infection,
seizures, and a urinary tract infection. You first spent time in
the intensive care unit, then were transferred to the floor. You
were evaluated by physical therapy, who felt you would benefit
by going to a rehab center for more strength building.
.
We have made some changes to your medication regimen, which are
listed in detail in your discharge packet.
.
It was a pleasure taking care of you during this admission.

Followup Instructions:
Please schedule a follow up appointment with your Primary Care
Physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 4775**]) after discharge.



Completed by:[**2187-4-20**]
{'Septicemia due to escherichia coli [E. coli],Acute respiratory failure,Septic shock,Encephalopathy, unspecified,Pneumonia, organism unspecified,Acute pancreatitis,Urinary tract infection, site not specified,Epilepsy, unspecified, with intractable epilepsy,Intestinal infection due to Clostridium difficile,Severe sepsis,Thrombocytopenia, unspecified,Unspecified intellectual disabilities'}


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: weakness

PRESENT ILLNESS: 49 year-old male with mental retardation, intractable seizures,
non-verbal at baseline, recurrent subclinical seizures
presenting with weakness, gait instability, and decreased
engagement with staff at group home. Noticed over past 2-3 days
by staff. Requiring assistance with ambulation, whereas usually
independent. No falls. He was not having fevers, chills, cough.
Appetite at baseline.
.
Of note, he was admitted [**Date range (1) 15126**] and [**Date range (1) 15127**]/11 for
similar complaint. During both admissions he had increased
seizure activity (described as subclinical tonic seizures,
suspected left temporal lobe in origin) due to infection -
pneumonia during the first admission, UTI during the second. He
was discharged on Vimpat, but due to difficulty tolerating
medication stopped on [**2187-2-28**].
.
In the ED, 85.5/90 axillary 52 103/62 18 99%__. Systolic blood
pressure dropped to 80s, initially fluid responsive. Physical
examination notable for recurrent seizures with lateral gaze
deviation. Laboratory data significant for platelet count 64,
WBC 4.1 with left shift, transaminitis, lipase 1438, and chem10
within normal limits; UA with trace leukocyte esterase, nitrite
positive, moderate bacteria. Lactate 1.4. CXR 1V "acutely
worsening right lower lobe opacification." RUQ ultrasound with
patent portal vein, gallbladder sludge, liver cysts, CBD 0.4cm;
note of poor study quality. CT head without contrast without
acute hemorrhage, stable periventricular leukomalacia. Seen by
neurology - concerning for seizures due to underlying infection;
recommended restart Vimpat 100 mg QAM and ordering 24 hour
bedside EEG. He was intubated for airway protection. RIJ placed,
sterile position; Levophed initiated. Received Ativan 1mg IV
x4-5 for seizures; 5L IVF; vancomycin, Zosyn for suspected UTI,
pneumonia; midazolam for sedation. On transfer to MICU, 109,
131/60, 99% AC 500x16 , PEEP 10, FiO2 100%.
.
In the MICU, patient is intubated and sedated.

MEDICAL HISTORY: - static encephalopathy after prolonged status epilepticus,
possible anoxic injury at age 7 or 8 years.
- Intractable epilepsy.
- Per neurology note "He had mild developmental delay as a
child, and then at age 7 or 8 years had prolonged (greater than
24 hours) status epilepticus with probable anoxic brain injury
in the setting of a febrile illness. Subsequently, he had severe
static encephalopathy and intractable epilepsy. He currently
resides in a group home. He is nonverbal, but does understand
some language. He requires assistance with most activities of
daily living. He has some obstinate behavior, but no aggression
or agitated behavior recently.
His typical seizures are of 2 types: #1) episodes of rapid eye
blinking, staring, and urinary incontinence, unclear frequency,
and #2) episodes of facial grimacing, stiffening of his limbs,
some lip smacking, and incontinence of urine and stool,
occurring 3-4 times pack-year."

MEDICATION ON ADMISSION: Gabapentin 1200mg PO AM; 2400mg PO QHS
Clonazepam 5mg PO QHS
Zonisamide 300mg PO QAM; 400mg PO QHS
Peridex oral rinse [**12-31**] cap [**Hospital1 **]
Oxcarbazepine 600mg PO TID
MVI
Vimpat was discontinued on [**2187-3-1**]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ON ADMISSION:
97.7, 105, 116/67, 24, 99% AC 500x24, PEEP10, FiO2 100%
General: Intubated, sedated; not responsive to verbal stimuli
HEENT: Sclera anicteric, moist mucous membranes
Neck: Supple
Lungs: Anterior auscultation, clear to auscultation bilaterally
without wheezes, rales, or rhonchi
CV: Tachycardic; regular rhythm; normal S1/S2, no murmurs
appreciated
Abdomen: Hypoactive bowel sounds; soft, nontender (sedated), not
distended; no guarding
GU: Foley in place
Ext: Warm, well-perfused; radial, DP pulses 2+, symmetric; no
lower extremity edema
Neuro: Pupils equally round and reactive to light; does not
respond to verbal stimuli; withdraws to painful stimuli; biceps,
patellar reflexes 2+, symmetric
.
ON DISCHARGE:
Tm 97.6, 108/62 54 12 98% RA
Gen: awake, alert, no acute distress
HEENT: sclera anicteric, EOMI
CV: RRR, S1/S2, no murmurs or extra sounds appreciated
Pulm: Anterior fields CTA bilaterally
Abd: + BS, soft, non-tender, non-distended
Ext: warm, no edema, moves all extremities spontaneously

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives in group home. Does not use tobacco, alcohol, or illicit
drugs. 

### Response:
{'Septicemia due to escherichia coli [E. coli],Acute respiratory failure,Septic shock,Encephalopathy, unspecified,Pneumonia, organism unspecified,Acute pancreatitis,Urinary tract infection, site not specified,Epilepsy, unspecified, with intractable epilepsy,Intestinal infection due to Clostridium difficile,Severe sepsis,Thrombocytopenia, unspecified,Unspecified intellectual disabilities'}
