CHIEF COMPLAINT: seizure

PRESENT ILLNESS: Time of Code: 3:34pm
Neurology Resident present: 3:35pm
Last normal at ~ 11.30am
Patient intubated and sedated on arrival
NIHSS score of 19.
Not IVtPA candidate due to seizure at time of presentation.

MEDICAL HISTORY: - Stage IV SCLC, mets to brain (multiple lesions s/p XRT [**6-5**] -
[**7-6**]) and adrenals, completed chemo [**12-3**] (carboplatin,
VP16[etoposide])
- CAD, s/p CABG, AVR [**2197**]
- HTN
- HL
- ? CVA as above
- GERD
- COPD
- AS
- Basal cell cancer
- Right parotidectomy ([**Last Name (un) 86828**] tumor)

MEDICATION ON ADMISSION: - ASA 325mg
- Omeprazole 20mg
- simvastatin 80mg
- ativan 0.5mg prn anxiety

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T:97.8F  P:95  R: 12  BP:128/90  SaO2:100% on AC, FiO2
100%

FAMILY HISTORY: nc

SOCIAL HISTORY: Social Hx: Retired, lives with wife, currently staying at a
house
in ME where he is recovering from chemo and XRT.
Tobacco - quit 2 yrs ago, smoked ppd for "many many years"
EtOH - occasional
Drug use - denied by family.
Secondary malignant neoplasm of brain and spinal cord,Cerebral edema,Malignant neoplasm of upper lobe, bronchus or lung,Unspecified pleural effusion,Other convulsions,Atrial fibrillation,Encounter for palliative care,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Aortic valve disorders,Personal history of tobacco use,Anemia, unspecified
Sec mal neo brain/spine,Cerebral edema,Mal neo upper lobe lung,Pleural effusion NOS,Convulsions NEC,Atrial fibrillation,Encountr palliative care,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Hypertension NOS,Hyperlipidemia NEC/NOS,Hx TIA/stroke w/o resid,Aortic valve disorder,History of tobacco use,Anemia NOS
Admission Date:  [**2201-1-12**]              Discharge Date:   [**2201-1-14**]

Date of Birth:  [**2128-5-25**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
seizure

Major Surgical or Invasive Procedure:
extubation

History of Present Illness:
Time of Code: 3:34pm
Neurology Resident present: 3:35pm
Last normal at ~ 11.30am
Patient intubated and sedated on arrival
NIHSS score of 19.
Not IVtPA candidate due to seizure at time of presentation.

NIH Stroke Scale score was 19:
1a. Level of Consciousness: 3
1b. LOC Question: 1
1c. LOC Commands: 2
2. Best gaze: 0
3. Visual fields: UN
4. Facial palsy:   0
5a. Motor arm, left: 2
5b. Motor arm, right: 2
6a. Motor leg, left: 2
6b. Motor leg, right: 2
7. Limb Ataxia: 0
8. Sensory: 2
9. Language: 3
10. Dysarthria: UN
11. Extinction and Neglect: 0

HPI: The pt is an 72 year-old man with CAD (s/p CABG, AVR), HTN,
HL, SCLC metastatic to adrenals and brain (s/p WBXRT and chemo),
CVA (found on MRI on Cancer f/u [left upper convexity middle
cortical infarct]) who now presents with multiple seizures this
AM while in the car with wife (1st as head shaking and arm
shaking, last normal at 11.30am), then two more between EMS and
OSH, where he was intubated for unresponsiveness and
[**Last Name (un) 6055**]-[**Doctor Last Name **] respirations.  CT head was notable for a large L
temporal lobe hypodensity concerning for a CVA and was
transferred to [**Hospital1 18**]. He is reported as having been in ? afib at
OSH, but no EKG is available for review.

Hx obtained from wife who was w/ patient in car while driving.
She reports being scared and does not recall all the details of
the events.  Was in USOH until 11.30am when driving, noted to
have head shaking movement and stiffening of his arms.  He was
not responding to his wife at this time with duration of
minutes.
She pulled over at a rest stop, at which time he began to "come
to," slumped over, then was trying to lift his head.  After
several minutes, he again began to shake (head and arm
movements), eyes open, though exact character is not recalled by
wife.  EMS was called by a car next to them. Duration of second
episode again is noted as seconds to minutes.  Upon arrival,
apparently patient was confused and was trying to answer
questions.  Was noted to have bleeding from mouth.  Reportedly,
while in EMS [**Doctor Last Name **], he seized again, unclear whether received
AEDs,
and was intubated for concern of irregular breathing pattern and
difficulty maintaining airway.

Of note, has completed WBXRT in [**7-6**] and last dose of
chemotherapy [**2200-12-3**].  Reporteldy has been doing well.  He had
an incidental finding of a ? cortical stroke on last MRI
[**2200-10-13**]
at [**Hospital3 **] notable for with microvascular disease, small
infarct at left upper convexity middle cortical infarct (?
embolic).  Undergone ECHO w/ bubble results of which have not
been communicated to family.

Unable to obtain ROS as pt. intubated.


Past Medical History:
- Stage IV SCLC, mets to brain (multiple lesions s/p XRT [**6-5**] -
[**7-6**]) and adrenals, completed chemo [**12-3**] (carboplatin,
VP16[etoposide])
- CAD, s/p CABG, AVR [**2197**]
- HTN
- HL
- ? CVA as above
- GERD
- COPD
- AS
- Basal cell cancer
- Right parotidectomy ([**Last Name (un) 86828**] tumor)

Social History:
Social Hx: Retired, lives with wife, currently staying at a
house
in ME where he is recovering from chemo and XRT.
Tobacco - quit 2 yrs ago, smoked ppd for "many many years"
EtOH - occasional
Drug use - denied by family.


Family History:
nc

Physical Exam:
Vitals: T:97.8F  P:95  R: 12  BP:128/90  SaO2:100% on AC, FiO2
100%

General: intubated on propofol.  bloody discharged from OP.
HEENT: NC/AT, supple, no bruits.
Pulmonary: CTA bilaterally
Cardiac: RR, no M/R/G
Abdomen: soft, NT/ND, obese.
Extremities: warm, dry, b/l LE edema, 1+

Skin: no rashes or lesions noted.

Neurologic: exam 10 mins off propofol

-Mental Status: intubated, grimaces to noxious at supraorbital
notch b/l.

-Cranial Nerves:

No blink to threat.  PERRL 3->2mm b/l, no gaze deviation,
corneals intact, VOR intact, gag intact.

Increased tone in RUE vs. LUE.  moves b/l UE spontanously,
nonpurposeful, somewhat less vigorously on R vs. L.  [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
spont. movement, nl tone.

Withdraws flexor to noxious in UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**], but no
localization to noxious at clavicles.

DTRs 2 in UEs, 1 at patella and none at achilles.


Plantar response:
RIGHT - flexor
LEFT - flexor


Pertinent Results:
[**2201-1-12**] 03:45PM BLOOD WBC-11.8* RBC-3.80* Hgb-12.0* Hct-35.1*
MCV-92 MCH-31.5 MCHC-34.1 RDW-17.1* Plt Ct-207
[**2201-1-12**] 03:45PM BLOOD PT-12.6 PTT-25.0 INR(PT)-1.1
[**2201-1-12**] 03:45PM BLOOD Glucose-118* UreaN-10 Creat-1.1 Na-139
K-3.9 Cl-103 HCO3-16* AnGap-24*
[**2201-1-12**] 09:05PM BLOOD Glucose-109* UreaN-10 Creat-1.0 Na-140
K-3.5 Cl-108 HCO3-21* AnGap-15
[**2201-1-13**] 02:58AM BLOOD ALT-20 AST-37 LD(LDH)-549* CK(CPK)-131
AlkPhos-42 TotBili-0.4
[**2201-1-12**] 03:45PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2201-1-13**] 02:58AM BLOOD CK-MB-4 cTropnT-<0.01
[**2201-1-13**] 02:58AM BLOOD Calcium-7.5* Phos-3.7 Mg-1.6 Cholest-124
[**2201-1-13**] 02:58AM BLOOD %HbA1c-5.2 eAG-103
[**2201-1-13**] 02:58AM BLOOD Triglyc-2098* HDL-36 CHOL/HD-3.4
LDLmeas-LESS THAN

Imaging:

CTA/CTP head/neck [**1-12**]
IMPRESSION:

1. No evidence of cerebral ischemia on CT perfusion study.

2. Vasogenic edema in the left temporal lobe, insula, and
external capsule.
Intracranial metastatic disease is much better assessed on the
concurrent head
MRI.

3. Moderate, approximately 50% stenoses spanning relatively long
segments of
the proximal internal carotid arteries bilaterally.

4. No hemodynamically significant stenoses in the intracranial
circulation.

5. Spiculated mass at the right lung apex. Correlation with the
status of
the patient's lung cancer is recommended.

MRI:

[**1-13**]:

IMPRESSION:

1. Multiple intracranial metastases, many of which could be
either
superficial cortical or leptomeningeal.

2. Small left subdural collection. Tumor involvement of the dura
overlying
both the right and left cerebral convexities cannot be excluded.


3. No evidence of an acute infarction

CXR

MPRESSION:
1. Endotracheal tube and nasogastric tube in standard positions.

2. Layering left pleural effusion with retrocardiac density,
possibly
representing atelectasis but infection is not excluded.


Brief Hospital Course:
The pt is an 72 year-old man with CAD (s/p CABG, AVR), HTN, HL,
SCLC metastatic to adrenals and brain (s/p WBXRT and chemo), CVA
(found on MRI on Cancer f/u [left upper
convexity middle cortical infarct]) who now presented with
multiple seizures this AM while in the car with wife (1st as
head shaking and arm shaking, last normal at 11.30am), then two
more between EMS and OSH, where he was intubated for
unresponsiveness and [**Last Name (un) 6055**]-[**Doctor Last Name **] respirations.  CT head was
notable for a large
L temporal lobe hypodensity concerning for a CVA and was
transferred to [**Hospital1 18**]. He is recorded as having been in afib at
OSH.  Patient was DRN/I.

On arrival he was intubated and sedated on profol.  Exam w/
10mins off was
propofol notable for being comatose, intact pupillary, corneal,
VOR and gag reflexes, spontanous UE movements R < L,
non-localizing to pain at supraorbital notch, flx response to
nox in UEs and LEs.  EKG showing sinus tachycardia.

Repeat HCT and CTA showing a persistent hypodensity in the left
subcortial white matter in region of left temporal and parietal
lobes (MCA territory) and extensive plaque at bilateral carotid
bulbs, but no sigificant hemodynamic stenosis.  He was loaded
with 1g of Keppra for seizure control and admitted to NeuroICU.

NEURO.  Given history of afib, it initially appeared unclear
whether CT findings were consistent with an embolic infarction
versus the more likely metastatic disease leading to seizure.
Once CTP images were available, it was notable that there was no
perfusion deficit and majority of edema was vasogenic.  MRI of
the brain revealed multiple metastatic lesions
intraparenchymally as well as leptomenigial.

At this point discussion was held with family regarding goals of
care and what would have been patient's further wishes.  It was
clear that the preference would have been not to be intubated
and at this time no further treatment including chemotherapy,
radiation or steroids were desired.  Patient was extubated on
[**1-13**] and expired on [**1-14**].

Medications on Admission:
- ASA 325mg
- Omeprazole 20mg
- simvastatin 80mg
- ativan 0.5mg prn anxiety

Discharge Medications:
na

Discharge Disposition:
Expired

Discharge Diagnosis:
na

Discharge Condition:
na

Discharge Instructions:
na

Followup Instructions:
na

                             [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

Completed by:[**2201-1-14**]
{'Secondary malignant neoplasm of brain and spinal cord,Cerebral edema,Malignant neoplasm of upper lobe, bronchus or lung,Unspecified pleural effusion,Other convulsions,Atrial fibrillation,Encounter for palliative care,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Aortic valve disorders,Personal history of tobacco use,Anemia, unspecified'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: seizure

PRESENT ILLNESS: Time of Code: 3:34pm
Neurology Resident present: 3:35pm
Last normal at ~ 11.30am
Patient intubated and sedated on arrival
NIHSS score of 19.
Not IVtPA candidate due to seizure at time of presentation.

MEDICAL HISTORY: - Stage IV SCLC, mets to brain (multiple lesions s/p XRT [**6-5**] -
[**7-6**]) and adrenals, completed chemo [**12-3**] (carboplatin,
VP16[etoposide])
- CAD, s/p CABG, AVR [**2197**]
- HTN
- HL
- ? CVA as above
- GERD
- COPD
- AS
- Basal cell cancer
- Right parotidectomy ([**Last Name (un) 86828**] tumor)

MEDICATION ON ADMISSION: - ASA 325mg
- Omeprazole 20mg
- simvastatin 80mg
- ativan 0.5mg prn anxiety

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T:97.8F  P:95  R: 12  BP:128/90  SaO2:100% on AC, FiO2
100%

FAMILY HISTORY: nc

SOCIAL HISTORY: Social Hx: Retired, lives with wife, currently staying at a
house
in ME where he is recovering from chemo and XRT.
Tobacco - quit 2 yrs ago, smoked ppd for "many many years"
EtOH - occasional
Drug use - denied by family. 

### Response:
{'Secondary malignant neoplasm of brain and spinal cord,Cerebral edema,Malignant neoplasm of upper lobe, bronchus or lung,Unspecified pleural effusion,Other convulsions,Atrial fibrillation,Encounter for palliative care,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Aortic valve disorders,Personal history of tobacco use,Anemia, unspecified'}
