CHIEF COMPLAINT: right shoulder twitching, altered
mentation

PRESENT ILLNESS: The patient is a [**Age over 90 **] year old woman with a recent history of
frequent seizures with right face and shoulder twitching who
returns to [**Hospital1 18**] with reports of altered mentation and
recurrence
of right shoulder twitches.

MEDICAL HISTORY: [] Neurologic - Seizures (s/p cardiac arrest, ? hypoxic brain
injury), Recent ? Posterior Reversible Leukoencephalopathy
Syndrome (clinical diagnosis at onset of seizures)
[] MSK - Left hip fracture (s/p ORIF)
[] Cardiovascular - Recent cardiac arrest, HTN, HL, reportedly
CAD
[] Pulmonary - Recent hypoxic respiratory failure
[] Endocrine - Multinodular goiter with papillary carcinoma (s/p
resection, discovered during difficult intubation)
[] Ophthalmologic - Corneal abrasion/chemosis

MEDICATION ON ADMISSION: ASA 325 Daily
Levetiracetam 1000 [**Hospital1 **] (solution),
Metoprolol tartrate 25 [**Hospital1 **],
Bisacodyl 10 daily,
Heparin SC, Potassium 40 mEq daily,
Acetaminophen PRN, Docusate/Senna, Multivitamin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At admission:
VS T: 98.7 HR: 67 BP: 123/64 RR: 17 SaO2: 100% RA
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilaterally, no crackles or wheezes
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses
Skin: No rashes or lesions

FAMILY HISTORY: Ovarian cancer (mother)

SOCIAL HISTORY: Until recently living independently, driving. Previously at [**Location (un) 22092**] on the [**Doctor Last Name **] but was at [**Hospital 38**] rehab post-[**Hospital1 **]
discharge. No tobacco, ETOH, or illicit drug use.
Epilepsy, unspecified, without mention of intractable epilepsy,Acute respiratory failure,Other encephalopathy,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute myocardial infarction of unspecified site, initial episode of care,Urinary tract infection, site not specified,Unspecified pleural effusion,Ventilator associated pneumonia,Hyperosmolality and/or hypernatremia,Cellulitis and abscess of upper arm and forearm,Hypotension, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Disorders of phosphorus metabolism,Personal history of sudden cardiac arrest,Personal history of malignant neoplasm of other sites,Do not resuscitate status,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Encounter for palliative care,Coronary atherosclerosis of native coronary artery,Personal history of traumatic fracture,History of fall
Epilep NOS w/o intr epil,Acute respiratry failure,Encephalopathy NEC,Meth sus pneum d/t Staph,AMI NOS, initial,Urin tract infection NOS,Pleural effusion NOS,Ventltr assoc pneumonia,Hyperosmolality,Cellulitis of arm,Hypotension NOS,Hypertension NOS,Hyperlipidemia NEC/NOS,Mth sus Stph aur els/NOS,Anemia NOS,Dis phosphorus metabol,Hx sudden cardiac arrest,Hx of malignancy NEC,Do not resusctate status,Abn react-procedure NEC,Encountr palliative care,Crnry athrscl natve vssl,Hx traumatic fracture,Personal history of fall
Admission Date:  [**2108-4-8**]              Discharge Date:   [**2108-5-2**]


Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
right shoulder twitching, altered
mentation


Major Surgical or Invasive Procedure:
intubation

History of Present Illness:
The patient is a [**Age over 90 **] year old woman with a recent history of
frequent seizures with right face and shoulder twitching who
returns to [**Hospital1 18**] with reports of altered mentation and
recurrence
of right shoulder twitches.

Her history from her recent admission is as follows: on [**2108-2-18**]
she was found down at her residence and was noted to be
bradycardic, hypotensive, hypothermic, and lethargic. She was
transported to an ED at Upstate [**Location (un) **] Hospital in NY where
she had a cardiopulmonary arrest and was intubated and
resuscitated. The intubation was difficult and she was found to
have a mediastinal mass (multinodular goiter with papillary
microcarcinoma, which was removed). She had a complicated
hospital course with hospital-associated pneumonia, lung
collapse
s/p bronchoscopy, sepsis, corneal abrasion/chemosis,
perioperative anemia from blood loss, and then confusion. She
was
started on quetiapine initially for suspected ICU-related
delirium. However, she started showing clinical signs of
seizures
(sudden behavioral arrest, blank stare, eye deviation to the
left
and down) which resolved with low dose of lorazepam. Despite
reportedly unremarkable head imaging, she was thought to
potentially has PRES (unclear what the blood pressure
measurements were at the time). She was started on Levetiracetam
750 mg [**Hospital1 **] for seizure prevention. An EEG done at that time
reportedly suggested potential epileptiform foci but no seizures
were seen. She was discharged to a rehab but per her family did
not return to her prior highly functional baseline mental
status.
On [**2108-3-21**], she was even more lethargic than usual and did not
respond promptly to sternal rub. She was observed as having
right
face and right shoulder twitches with associated bowel/bladder
incontinence which ceased with diazepam 2.5 mg given twice. She
had a normal blood sugar of 81 at that time and otherwise normal
vital signs after the episode. She was transferred to
[**Hospital1 **]
for further management where she was given two loading doses of
Fosphenytoin 500 mg with some improvement in the focal motor
activity. Neurology was consulted there and recommended
increasing Levetiracetam to 1000 mg [**Hospital1 **] and continuing
Phenytoin.
She had an unremarkable NCHCT. She was found to have a UTI and
was started on Ceftriaxone on [**3-21**]. She was thought to
potentially have pneumonia as well, but chest imaging did not
reveal an infiltrate so this was stopped. An EEG was obtained
which potentially showed frequent left parasagittal epileptiform
discharges, so she was transferred to [**Hospital1 18**] for further care.
Upon arrival, her mental status was already improving, so
further
changes to medications were not made at that time. Her EEG
showed
frequent GPEDS and PLEDs. She continue to improve in mental
status, eventually was transitioned to a single [**Doctor Last Name 360**] again
(Levetiracetam 1000 [**Hospital1 **]), and was sent to [**Hospital 38**] Rehab in
stable condition.


Past Medical History:
[] Neurologic - Seizures (s/p cardiac arrest, ? hypoxic brain
injury), Recent ? Posterior Reversible Leukoencephalopathy
Syndrome (clinical diagnosis at onset of seizures)
[] MSK - Left hip fracture (s/p ORIF)
[] Cardiovascular - Recent cardiac arrest, HTN, HL, reportedly
CAD
[] Pulmonary - Recent hypoxic respiratory failure
[] Endocrine - Multinodular goiter with papillary carcinoma (s/p
resection, discovered during difficult intubation)
[] Ophthalmologic - Corneal abrasion/chemosis


Social History:
Until recently living independently, driving. Previously at [**Location (un) 22092**] on the [**Doctor Last Name **] but was at [**Hospital 38**] rehab post-[**Hospital1 **]
discharge. No tobacco, ETOH, or illicit drug use.


Family History:
Ovarian cancer (mother)

Physical Exam:
At admission:
VS T: 98.7 HR: 67 BP: 123/64 RR: 17 SaO2: 100% RA
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilaterally, no crackles or wheezes
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses
Skin: No rashes or lesions

Neurologic Examination:
- Mental Status - Lethargic, but easily arouses to voice and
keeps her eyes open for about a minute if continuously
stimulated
by voice or non-noxious stimuli. Smiles. Inattentive. Follows
midline commands (opens/closes eyes, sticks out tongue) but not
appendicular commands consistently. No verbalization.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to threat.
[III, IV, VI] Tracks to the left but has difficult crossing
midline to the right. [V] Corneals present bilaterally. [VII] No
facial asymmetry at rest. [XII] Tongue midline.

- Motor - No tremor or asterixis or myoclonus currently. Extends
RUE to noxious. Flexion withdraws LUE to noxious. Triple flexes
both LE to noxious, R > L.

- Sensory - Response to noxious all four extremities.

- Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2      2      2      2        2
R 2      2      2      2        1
Plantar response extensor bilaterally.

- Coordination - Unable to assess at the time of examination.

- Gait - Unable to assess at the time of examination.

DISCHARGE:
deceased

Pertinent Results:
[**2108-4-8**] 04:20PM BLOOD WBC-7.1 RBC-3.73* Hgb-11.2* Hct-36.7
MCV-98 MCH-30.0 MCHC-30.5* RDW-15.7* Plt Ct-455*
[**2108-4-9**] 06:20AM BLOOD WBC-4.0 RBC-3.12* Hgb-9.6* Hct-30.6*
MCV-98 MCH-30.7 MCHC-31.4 RDW-15.8* Plt Ct-345
[**2108-4-8**] 04:20PM BLOOD Neuts-75.4* Lymphs-15.8* Monos-5.2
Eos-3.4 Baso-0.2
[**2108-4-9**] 12:20PM BLOOD PT-11.2 PTT-64.5* INR(PT)-1.0
[**2108-4-8**] 04:20PM BLOOD Glucose-64* UreaN-16 Creat-0.8 Na-145
K-4.8 Cl-109* HCO3-20* AnGap-21*
[**2108-4-9**] 12:20PM BLOOD ALT-13 AST-26 CK(CPK)-103 AlkPhos-113*
TotBili-0.3
[**2108-4-9**] 06:20AM BLOOD CK-MB-8 cTropnT-0.13*
[**2108-4-9**] 12:20PM BLOOD CK-MB-15* MB Indx-14.6* cTropnT-0.20*
[**2108-4-8**] 04:20PM BLOOD Calcium-10.4* Phos-2.9 Mg-1.5*
[**2108-4-9**] 06:20AM BLOOD Phenyto-16.7
[**2108-4-9**] 06:23AM BLOOD Phenyto-18.7
[**2108-4-9**] 02:15PM BLOOD Type-ART pO2-365* pCO2-39 pH-7.37
calTCO2-23 Base XS--2
[**2108-4-8**] 05:20PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012
[**2108-4-8**] 05:20PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2108-4-8**] 05:20PM URINE RBC-10* WBC-61* Bacteri-FEW Yeast-FEW
Epi-0
[**2108-4-8**] 05:20PM URINE CastHy-4*
[**2108-4-9**] 02:07PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2108-4-9**] 02:07PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2108-4-9**] 02:07PM URINE RBC-3* WBC-8* Bacteri-FEW Yeast-RARE
Epi-0
[**2108-4-9**] 02:07PM URINE CastHy-19*

MICRO data:
RESPIRATORY CULTURE (Preliminary):
      Further incubation required to determine the presence or
absence of
      commensal respiratory flora.
      STAPH AUREUS COAG +.    MODERATE GROWTH.

[**4-8**] CXR:
FINDINGS: Single portable frontal chest x-ray demonstrates no
acute
intrathoracic process. Blunting of the costophrenic angles with
fluid seen in the minor fissure represents trace bilateral
pleural effusions which are unchanged from prior study. The
cardiac silhouette is enlarged with stable left ventricular
predominance. Calcifications are again noted within the aortic
arch, as are clips within the left neck. There is no
pneumothorax.  There are no suspicious osseous lesions.
IMPRESSION: Probable tiny bilateral pleural effusions, unchanged
from prior.  No acute intrathoracic process.

[**4-9**] CXR:
IMPRESSION: AP chest compared to [**4-8**] at 4:21 p.m.:
New endotracheal tube ends at the level of the aortic apex,
between 4.5 cm from the carina, in standard placement. Lungs are
low in volume but clear.  Moderate cardiomegaly is stable. There
is no pleural abnormality or evidence of central lymph node
enlargement. Thoracic aorta is heavily calcified but not focally
dilated.

[**4-9**] NCHCT:
FINDINGS: There is mild brain atrophy seen. There is no evidence
of midline shift or hydrocephalus. No evidence of intra- or
extra-axial hemorrhage seen.
IMPRESSION: No acute abnormalities.

MICU imaging:
CXR [**4-19**]:NG tube tip is out of view below the diaphragm likely
in the stomach.  ET tube tip is in the standard position 3.9 cm
above the carina.  Left PICC tip is in the lower SVC.  There is
no pneumothorax.  Moderate-to-large right and small-to- moderate
left pleural effusion are grossly unchanged allowing the
difference in positioning of the patient.  Cardiomediastinal
contours are unchanged and there is mild vascular congestion.

CXR [**4-20**]: Endotracheal tube tip is 4 cm above the carina,
orogastric tube ends into the stomach, and left-sided PICC line
tip is in lower SVC.  Since [**2108-4-19**], mild right pleural
effusion has improved, while left lower lung opacity, probably a
combination of effusion and atelectasis is better.  Mild
pulmonary vascular engorgement is similar.  Mildly enlarged
heart size, mediastinal and hilar contours are unchanged.  No
new discrete opacities in the lungs

CXR [**4-21**]: IMPRESSION:
An enteric tube follows a course similar to the enteric tube in
place
yesterday, ending in the left upper quadrant, presumably but not
definitively in the stomach.  There is no pneumothorax.  Left
PIC line ends low in the SVC. Moderate cardiomegaly and small
bilateral pleural effusions have increased.  Atelectasis at both
lung bases is stable.


Brief Hospital Course:
Ms. [**Known lastname 110651**] is a [**Age over 90 **]F with hx of cardiopulmonary arrest c/b
seizures presents from rehab with unresponsiveness and muscle
twitches concerning for seizure activity. Found to have a UTI
which likely lowered seizure threshold. Shortly after admission
patient was seen to have ongoing twitching despite increase
keppra dose and was loaded with Fosphenytoin with resultant
hypotension/bradycardia and transfer to the NeuroICU.

Neuro ICU course:
In the NeuroICU, she was intubated and started on Levophed for
hypotension. Neuro exam significant for increased level of
arousal since starting AEDs, but has since declined again. She
continues to have decreased movement on the left compared to
RUE. NCHCT unrevealing, EEG shows PLEDs. On [**4-19**] the patient
continued to be lethargic. She was noted to be tachypneic and O2
sats decreased from 99% on RA to 82%. Face mask and then
non-rebreather were placed initially with good response, but
again decreased to 79% on non-rebreather. Anesthesia was called
stat and the patient was intubated prior to transfer to MICU for
further care. The patient's son was called prior to intubation
and he confirmed full code.

# Respiratory failure: While in the MICU, the patient was
experiencing hypoxic respiratory failure precipitated by volume
overload evidenced by history of IVF administration and presence
of pleural effusions, improving with diuresis. Oxygenation
improved with diuresis, but AMS may have led to airway
compromise as she was minimally responsive off of sedation.
Successfully extubated on [**4-21**] and maintained on face mask for
24 hours prior to call out from the MICU.

On the floor, the patient was maintained on 40% face mask.  She
initially remained DNR, but ok to intubate, but after
reassessing goals of care with the patient's son [**Name (NI) 382**], she was
made DNR/DNI and transitioned to CMO.  Face mask was continued
for comfort.

# PNA - patient spiked a temperature to 101 on morning of [**4-20**].
Patient was empirically started on vanc/cefepime on [**4-20**] for
HCAP and potentially ventilator associated PNA.  Sputum gram
stain grew out GPCs, and culture grew coagulase positive staph
aureus.  Patient was continued on vanc/cefepime.

The patient's antibiotics were discontinued on the medicine
floor after she was made CMO.

# Hypotension: Patient has had intermittent hypotensive episodes
treated with gentle fluid bolus and minimal pressor requirement.
Weaned off pressors on [**4-20**].  Likely in the setting of sepsis
from PNA.  Patient was treated with antibioitcs as above.
Patient was normotensive prior to transfer from MICU and
remained normotensive on the floor.

# Flash Pulmonary Edema: Prior to unit transfer, patient
received 2L IVF on the floor, overnight IVF and an additional
liter of IVF from meds given on the day of transfer. She
developed acute respiratory distress with sats to low 80's on
NRB. CXR showed worsening pleural effusions and pulmonary edema.
She received 20mg of IV lasix, was intubated, and transferred to
the unit. Recent Echo showed mild MR [**First Name (Titles) **] [**Last Name (Titles) **] 60%. Etiology of
pulmonary edema may be fluid overload in the setting of
diastolic dysfunction vs. acute MI, however CE down from
previous so unlikely.  Patient underwent gentle diruresis and
respiratory status improved.

While on the floor, the patient was gently diuresed.  However,
this was also stopped once the patient was made CMO.

# Seizure disorder: Patient is on valproate and levetiracetam
for seizure prophylaxis. She is also on continual EEG
monitoring. Balanced the therapeutic value of AED's with the
side affect of sedation/AMS.  Neuro continued to follow the
patient while on the floor and decreased her medication doses.
Once she was made CMO, her AED's were converted to IV and were
continued for her comfort.

# h/o Cardiac arrest with anoxic injury: Patient had cardiac
arrest in [**Month (only) 958**] of this year with anoxic injury and subsequent
development of seizure disorder. Etiology is unclear but cards
eval considered prolonged QT-syndrome.  QT prolonging agents
were avoided during this hospitalization.

# Hypernatremia: Patient with mildly elevated sodium levels
while in the MICU. Free water deficit calculated to be 1L.  Was
treated with gentle D5W hydration. While on the floor, her
sodium levels remained within normal limits.

# Goals of care: Patient has a poor prognosis from a medical
standpoint given the recent cardiac arrest and complicated
hospital course involving three intubations and ICU admissions
over the past few months. Discussed goals of care with son, and
the likely negative outcome of a repeat cardiac arrest and
resuscitation would be outside of patient's wishes, and agrees
to DNR.  The patient was ultimately also transitioned to DNI and
she was made CMO. Pall care consult was also obtained to help
optimize patient comfort.

Medications on Admission:
ASA 325 Daily
Levetiracetam 1000 [**Hospital1 **] (solution),
Metoprolol tartrate 25 [**Hospital1 **],
Bisacodyl 10 daily,
Heparin SC, Potassium 40 mEq daily,
Acetaminophen PRN, Docusate/Senna, Multivitamin


Discharge Medications:
NONE

Discharge Disposition:
Expired

Discharge Diagnosis:
primary diagnosis:
seizure disorder
hypoxic respiratory failure


Discharge Condition:
Deceased

Discharge Instructions:
N/A

Followup Instructions:
N/A


Completed by:[**2108-5-3**]
{'Epilepsy, unspecified, without mention of intractable epilepsy,Acute respiratory failure,Other encephalopathy,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute myocardial infarction of unspecified site, initial episode of care,Urinary tract infection, site not specified,Unspecified pleural effusion,Ventilator associated pneumonia,Hyperosmolality and/or hypernatremia,Cellulitis and abscess of upper arm and forearm,Hypotension, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Disorders of phosphorus metabolism,Personal history of sudden cardiac arrest,Personal history of malignant neoplasm of other sites,Do not resuscitate status,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Encounter for palliative care,Coronary atherosclerosis of native coronary artery,Personal history of traumatic fracture,History of fall'}


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: right shoulder twitching, altered
mentation

PRESENT ILLNESS: The patient is a [**Age over 90 **] year old woman with a recent history of
frequent seizures with right face and shoulder twitching who
returns to [**Hospital1 18**] with reports of altered mentation and
recurrence
of right shoulder twitches.

MEDICAL HISTORY: [] Neurologic - Seizures (s/p cardiac arrest, ? hypoxic brain
injury), Recent ? Posterior Reversible Leukoencephalopathy
Syndrome (clinical diagnosis at onset of seizures)
[] MSK - Left hip fracture (s/p ORIF)
[] Cardiovascular - Recent cardiac arrest, HTN, HL, reportedly
CAD
[] Pulmonary - Recent hypoxic respiratory failure
[] Endocrine - Multinodular goiter with papillary carcinoma (s/p
resection, discovered during difficult intubation)
[] Ophthalmologic - Corneal abrasion/chemosis

MEDICATION ON ADMISSION: ASA 325 Daily
Levetiracetam 1000 [**Hospital1 **] (solution),
Metoprolol tartrate 25 [**Hospital1 **],
Bisacodyl 10 daily,
Heparin SC, Potassium 40 mEq daily,
Acetaminophen PRN, Docusate/Senna, Multivitamin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At admission:
VS T: 98.7 HR: 67 BP: 123/64 RR: 17 SaO2: 100% RA
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilaterally, no crackles or wheezes
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses
Skin: No rashes or lesions

FAMILY HISTORY: Ovarian cancer (mother)

SOCIAL HISTORY: Until recently living independently, driving. Previously at [**Location (un) 22092**] on the [**Doctor Last Name **] but was at [**Hospital 38**] rehab post-[**Hospital1 **]
discharge. No tobacco, ETOH, or illicit drug use. 

### Response:
{'Epilepsy, unspecified, without mention of intractable epilepsy,Acute respiratory failure,Other encephalopathy,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute myocardial infarction of unspecified site, initial episode of care,Urinary tract infection, site not specified,Unspecified pleural effusion,Ventilator associated pneumonia,Hyperosmolality and/or hypernatremia,Cellulitis and abscess of upper arm and forearm,Hypotension, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Disorders of phosphorus metabolism,Personal history of sudden cardiac arrest,Personal history of malignant neoplasm of other sites,Do not resuscitate status,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Encounter for palliative care,Coronary atherosclerosis of native coronary artery,Personal history of traumatic fracture,History of fall'}
