CHIEF COMPLAINT: seizure

PRESENT ILLNESS: Patient is a 63 yo woman with PMH of HTN, DM, morbid obesity,
hemorrhagic stroke 2 yrs ago, afib off coumadin who presents
after episode of seizure vs. syncope with family. She and her
husband are in town from CT visiting son and had just gone to a
performance. Following this they went to a restaurant to get a
late night meal, and en route there noted her to be normal in
the car. Once they got to the restaurant, the patient ordered
her meal correctly, but hortly thereafter was not making sense
with her speech. This was around 11 PM. She was speaking actual
words and was not dysarthric but her peech didn't make sense.
They recall that one phrase was something about "ice cream" and
much of her speech was about food. Her son seemed to notice a
slight facial droop around this time and pointed it out to the
patient's husband. This non-sensical speech went on or about 45
minutes without any improvement and the patient seemed ompletely
unconcerned about this. The son asked his father if this sort of
behavior occured frequently with her. They tried asking her if
she had a headache and once she said yes, and another time said
o. Then, suddenly, she threw her head and body back in the
chair, onvulsed at the arms for seconds to a minute, and then
fell to the left. Her husband was able to break her fall and she
did not strike her head. Once on the ground she continued to
convulse briefly and then stopped. At this point she was
gurgling, and not moving. She was not speaking or following
commands.
.
She did have a seizure in the context of her ICH. Her son noted
an event over a year ago where on the phone she suddenly had
non-sensical speech similar to today's. That event resolved
spontaneously.
.
In the ED she was found to have persitent altered mental status
and wasintubated for airway protection. She was evaluated by the
neurology consult service who felt that the symptoms were
concerning for left sided stroke. The evalution was notable for
+UA for UTI. A chest Xray showed concern for widenen mediastinum
which prompted a CTA chest which was negative for dissection. A
CT head was negative for hemorrhage or mass effect. No MRI was
obtained
.
Pt was loaded with dilantin (1g IV x 1) although neuro suggested
1.5g. Pt got pre and post Ct hydration with bicarbonate.
.
ROS: patient cannot offer

MEDICAL HISTORY: 1. Hemorrhagic stroke 2 yrs ago. Patient had headache and went
to bed. Woke confused and en route to hospital became aphasic.
While there at the hospital coded according to husband and had
to
be intubated. He doesn't know it it was a cardiac vs.
respiratory failure. Following the stroke, she was noted to be
slightly weaker right than left.
2. DM, recent diagnosis
3. Morbid Obesity
4. afib off coumadin
5. OSA on CPAP
6. Depression
7. Diastolic heart failure
8. Hypertension

MEDICATION ON ADMISSION: atenolol 50 mg po daily
fluoxetine 20mg po daily
lasix 20mg po daily
prilosec 20mg po daily
lisinopril 5mg po daily
simvastatin 20mg po daily
folate 1g po daily
KCl 10 mEQ po daily

ALLERGIES: Tetracycline

PHYSICAL EXAM: VS: T 98.6 BP 130/80 P 50 100% on AC 500x14, peep 5, FiO2 60%
Gen: intubated and sedated
HEENT: left eye echymosis. Pupils 3-4 mm and equally reactive to
light. Thickened right cornea and injected sclera bilaterally
R>L. MMM.
Neck: unable to assess for JVD given size of neck and intubation

FAMILY HISTORY: mother had [**Name2 (NI) **] in late life and lived to 92.

SOCIAL HISTORY: Retired RN. Remote Tobacco. no ETOH. Lives with husband.
Other convulsions,Unspecified transient cerebral ischemia,Urinary tract infection, site not specified,Chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Obstructive sleep apnea (adult)(pediatric),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Atrial fibrillation,Morbid obesity
Convulsions NEC,Trans cereb ischemia NOS,Urin tract infection NOS,Chr diastolic hrt fail,Hyperosmolality,Obstructive sleep apnea,DMII wo cmp nt st uncntr,Hypertension NOS,Hx TIA/stroke w/o resid,Atrial fibrillation,Morbid obesity
Admission Date:  [**2199-9-25**]              Discharge Date:   [**2199-10-2**]

Date of Birth:  [**2130-3-19**]             Sex:   F

Service: MEDICINE

Allergies:
Tetracycline

Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
seizure

Major Surgical or Invasive Procedure:
intubation

History of Present Illness:
Patient is a 63 yo woman with PMH of HTN, DM, morbid obesity,
hemorrhagic stroke 2 yrs ago, afib off coumadin who presents
after episode of seizure vs. syncope with family. She and her
husband are in town from CT visiting son and had just gone to a
performance. Following this they went to a restaurant to get a
late night meal, and en route there noted her to be normal in
the car. Once they got to the restaurant, the patient ordered
her meal correctly, but hortly thereafter was not making sense
with her speech. This was around 11 PM. She was speaking actual
words and was not dysarthric but her peech didn't make sense.
They recall that one phrase was something about "ice cream" and
much of her speech was about food. Her son seemed to notice a
slight facial droop around this time and pointed it out to the
patient's husband. This non-sensical speech went on or about 45
minutes without any improvement and the patient seemed ompletely
unconcerned about this. The son asked his father if this sort of
behavior occured frequently with her. They tried asking her if
she had a headache and once she said yes, and another time said
o. Then, suddenly, she threw her head and body back in the
chair, onvulsed at the arms for seconds to a minute, and then
fell to the left. Her husband was able to break her fall and she
did not strike her head. Once on the ground she continued to
convulse briefly and then stopped. At this point she was
gurgling, and not moving. She was not speaking or following
commands.
.
She did have a seizure in the context of her ICH. Her son noted
an event over a year ago where on the phone she suddenly had
non-sensical speech similar to today's. That event resolved
spontaneously.
.
In the ED she was found to have persitent altered mental status
and wasintubated for airway protection. She was evaluated by the
neurology consult service who felt that the symptoms were
concerning for left sided stroke. The evalution was notable for
+UA for UTI. A chest Xray showed concern for widenen mediastinum
which prompted a CTA chest which was negative for dissection. A
CT head was negative for hemorrhage or mass effect. No MRI was
obtained
.
Pt was loaded with dilantin (1g IV x 1) although neuro suggested
1.5g. Pt got pre and post Ct hydration with bicarbonate.
.
ROS: patient cannot offer


Past Medical History:
1. Hemorrhagic stroke 2 yrs ago. Patient had headache and went
to bed. Woke confused and en route to hospital became aphasic.
While there at the hospital coded according to husband and had
to
be intubated. He doesn't know it it was a cardiac vs.
respiratory failure. Following the stroke, she was noted to be
slightly weaker right than left.
2. DM, recent diagnosis
3. Morbid Obesity
4. afib off coumadin
5. OSA on CPAP
6. Depression
7. Diastolic heart failure
8. Hypertension


Social History:
Retired RN. Remote Tobacco. no ETOH. Lives with husband.


Family History:
mother had [**Name2 (NI) **] in late life and lived to 92.


Physical Exam:
VS: T 98.6 BP 130/80 P 50 100% on AC 500x14, peep 5, FiO2 60%
Gen: intubated and sedated
HEENT: left eye echymosis. Pupils 3-4 mm and equally reactive to
light. Thickened right cornea and injected sclera bilaterally
R>L. MMM.
Neck: unable to assess for JVD given size of neck and intubation

Chest: ctab anteriorly without w/c
CV: bradycardic and irregularly irregular, no m/r/g
Abd: obese, s/nd/hypoactive bowel sounds. no appreciable
organomegaly
Ext: no c/c/e. pedal pulses 1+ and equal bilaterally
Skin: no rashes
Neuro: withdraws all four limbs to pain, shifts body with
sternal rub. reflexes 2+ RUE, 1+LUE, 1+ LE bilaterally. + gag
reflex, brain-stem reflexes intact. with propofol weaned was
interactive trying to speak over ventilator, moved all
extremities to command

Pertinent Results:
Urinalysis 21-50 whites, many bacteria, LE, N neg
.
Studies:
CXR - Apparent widening of the upper mediastinum. An aortic
injury cannot be excluded. Consider CT as indicated. Enlarged
cardiac silohuette with evidence of pulmonary edema as
described. ETT tube positioned low (1.3 cm above carina)
.
CT c-spine - Cervical spondylosis with anterior osteophytes are
most prominent at C5/6. no fracture or dislocation identified.
.
CTA chest - No aortic dissection, huge cardiomegaly with
coronary calcifications, Rt pleural effusion, bronchial
thickening with basilar consolidation versus atelectasis, some
diffuse ground glass pattern.
.
MRI/A head/neck: No evidence of hemorrhage, masses, mass effect,
edema or midline shift.  Bilateral periventricular white matter
demonstrates hyperintensity on FLAIR and T2-weighted imaging
suggestive of chronic microangiopathic ischemic disease.  The
sulci and the ventricles appear normal in caliber,
configuration, and morphology.  No hydrocephalus is noted.  No
diffusion abnormalities are noted.  No areas of abnormal
contrast enhancement are seen. Bilateral sphenoid sinus
demonstrates air-fluid levels suggestive of sinusitis.  Mucus
retention cysts are noted in bilateral maxillary sinuses. The
osseous, soft tissue structures and visualized portions of the
orbits are unremarkable.
.
EKG afib with bradycardia (rate 49), normal axis, QTc 540.
diffuse TWI.
.
Bedside EEG:  This is an abnormal portable EEG in the waking and
drowsy
states due to intermittent mixed frequency slowing noted broadly
over
the right hemisphere suggesting an underlying area of
subcortical
dysfunction in that region. In addition, the background was
mildly
slowed and disorganized, consistent with a mild encephalopathy,
suggesting bilateral subcortical or deep midline dysfunction.
Medications, metabolic disturbances, and infections are among
the common causes of encephalopathy. There were no epileptiform
features and no electrographic seizures were noted.
.
[**2199-9-25**] 04:07PM   GLUCOSE-101 UREA N-14 CREAT-1.0 SODIUM-136
POTASSIUM-2.8* CHLORIDE-99 TOTAL CO2-26 ANION GAP-14
[**2199-9-25**] 04:07PM   CALCIUM-8.5 PHOSPHATE-3.7 MAGNESIUM-1.8

Brief Hospital Course:
69 year old woman with history of L-sided hemorrhagic stroke,
DM2, atrial fibrillation, and obesity presenting with acute
altered mental status.
.
#Seizure: Pt admitted with seizure in the setting of presumed
[**Month/Day/Year **]. Symptoms of aphasia/werneke's type speech make L-sided
temporal [**Month/Day/Year **] likely with resultant seizure.  The patient was
intubated in the ED due to concern over airway protection and
loaded with dilantin.  MRI without stroke.  Upon arrival to the
ICU she had full motor strength and was attempting to
communicate over the ventilator which suggested against a large
territory stroke.  The patient had an MRI on HD 2 which did not
show stroke, and she was subsequently extubated.  Her dilantin
was changed to keppra for ease of administration.  Because of
her atrial fibrillation, the [**Month/Day/Year **] was presumed to be a result of
not being anticoagulated.  The patient was advised by the
neurology team that she should be on coumadin but the patient
declined and wanted to discuss this with her PCP first, she was
started instead on a full dose aspirin.

With regards to her seizure activity, this was felt to be [**12-21**]
[**Month/Day (2) **] or possibly due to her UTI causing a lowered seizure
threshold.  She was started on dilantin, which was changed to
keppra and she was treated with 3 days of augmentin.  Carotid
ultrasound was without significant stenosis b/l.

Follow up scheduled with her primary neurologist Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 75499**] of [**Last Name (un) 3407**] to discuss course of Keppra and to determine
driving restrictions.
.
# Cardiac: Atrial fibrillation with mild bradycardia likely from
atenolol. And after recovery from stroke, hr was stable in
60-80s on atenolol. She also ruled out for MIwith 3x cardiac
enzymes
.
# Pulmonary - Inititally, intubated for airway protection in
setting of change in mental status. Sucessfully extubated
without complication. However, she did have desaturations to 88%
while on NC 2-4L concerning for hypoventilation vs COPD. Chest
CT abnormal with suggestion of possible pulmonary edema and
atelectasis vs RLL infiltrate. Hypozia resolved with gentle
diuresis though she does at times require low level of oxygen
with aggressive physical therapy.  She should have an outpatient
chest CT in [**1-20**] months to evaluate for resolution and may need
work up for COPD with PFT's if she has persistent resting
desaturations.
.
# Diabetes Mellitus - New dx previously treated with diet and
exercise.  Continue insulin sliding scale with plan deferred to
[**Name8 (MD) 1501**] MD regarding starting oral hypoglycemics.

#OSA: Continue CPAP at 12cm/h2o
.
# UTI: may be responsible for seizure, fully treated with
augmenting.
# Prophy - SQ heparin, PPI
# Code - full


Medications on Admission:
atenolol 50 mg po daily
fluoxetine 20mg po daily
lasix 20mg po daily
prilosec 20mg po daily
lisinopril 5mg po daily
simvastatin 20mg po daily
folate 1g po daily
KCl 10 mEQ po daily


Discharge Disposition:
Extended Care

Facility:
Montowese skilled nursing facility

Discharge Diagnosis:
seizure
[**Name8 (MD) **]
CHF exacerbation


Discharge Condition:
stable


Discharge Instructions:
Please continue physical therapy and be sure to follow up with
your neurologist re: whether to start coumadin.  Return to ER
with seizure, weakness or other concerning symptoms.

Followup Instructions:
Chest CT in [**1-20**] months to ensure that infiltrates have resolved.

Please follow up with your primary neurologist Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 75499**] [**2199-10-9**] at 10:45am at the [**Location (un) 75500**], [**Location (un) **],
[**State 2748**] Phone: ([**Telephone/Fax (1) 75501**].  If family wants to change
appt to the [**Last Name (un) 3407**] office of Dr. [**Last Name (STitle) 75499**] they cal call
[**Telephone/Fax (1) 75502**].


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]

Completed by:[**2199-10-2**]
{'Other convulsions,Unspecified transient cerebral ischemia,Urinary tract infection, site not specified,Chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Obstructive sleep apnea (adult)(pediatric),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Atrial fibrillation,Morbid obesity'}


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: Patient is a 63 yo woman with PMH of HTN, DM, morbid obesity,
hemorrhagic stroke 2 yrs ago, afib off coumadin who presents
after episode of seizure vs. syncope with family. She and her
husband are in town from CT visiting son and had just gone to a
performance. Following this they went to a restaurant to get a
late night meal, and en route there noted her to be normal in
the car. Once they got to the restaurant, the patient ordered
her meal correctly, but hortly thereafter was not making sense
with her speech. This was around 11 PM. She was speaking actual
words and was not dysarthric but her peech didn't make sense.
They recall that one phrase was something about "ice cream" and
much of her speech was about food. Her son seemed to notice a
slight facial droop around this time and pointed it out to the
patient's husband. This non-sensical speech went on or about 45
minutes without any improvement and the patient seemed ompletely
unconcerned about this. The son asked his father if this sort of
behavior occured frequently with her. They tried asking her if
she had a headache and once she said yes, and another time said
o. Then, suddenly, she threw her head and body back in the
chair, onvulsed at the arms for seconds to a minute, and then
fell to the left. Her husband was able to break her fall and she
did not strike her head. Once on the ground she continued to
convulse briefly and then stopped. At this point she was
gurgling, and not moving. She was not speaking or following
commands.
.
She did have a seizure in the context of her ICH. Her son noted
an event over a year ago where on the phone she suddenly had
non-sensical speech similar to today's. That event resolved
spontaneously.
.
In the ED she was found to have persitent altered mental status
and wasintubated for airway protection. She was evaluated by the
neurology consult service who felt that the symptoms were
concerning for left sided stroke. The evalution was notable for
+UA for UTI. A chest Xray showed concern for widenen mediastinum
which prompted a CTA chest which was negative for dissection. A
CT head was negative for hemorrhage or mass effect. No MRI was
obtained
.
Pt was loaded with dilantin (1g IV x 1) although neuro suggested
1.5g. Pt got pre and post Ct hydration with bicarbonate.
.
ROS: patient cannot offer

MEDICAL HISTORY: 1. Hemorrhagic stroke 2 yrs ago. Patient had headache and went
to bed. Woke confused and en route to hospital became aphasic.
While there at the hospital coded according to husband and had
to
be intubated. He doesn't know it it was a cardiac vs.
respiratory failure. Following the stroke, she was noted to be
slightly weaker right than left.
2. DM, recent diagnosis
3. Morbid Obesity
4. afib off coumadin
5. OSA on CPAP
6. Depression
7. Diastolic heart failure
8. Hypertension

MEDICATION ON ADMISSION: atenolol 50 mg po daily
fluoxetine 20mg po daily
lasix 20mg po daily
prilosec 20mg po daily
lisinopril 5mg po daily
simvastatin 20mg po daily
folate 1g po daily
KCl 10 mEQ po daily

ALLERGIES: Tetracycline

PHYSICAL EXAM: VS: T 98.6 BP 130/80 P 50 100% on AC 500x14, peep 5, FiO2 60%
Gen: intubated and sedated
HEENT: left eye echymosis. Pupils 3-4 mm and equally reactive to
light. Thickened right cornea and injected sclera bilaterally
R>L. MMM.
Neck: unable to assess for JVD given size of neck and intubation

FAMILY HISTORY: mother had [**Name2 (NI) **] in late life and lived to 92.

SOCIAL HISTORY: Retired RN. Remote Tobacco. no ETOH. Lives with husband. 

### Response:
{'Other convulsions,Unspecified transient cerebral ischemia,Urinary tract infection, site not specified,Chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Obstructive sleep apnea (adult)(pediatric),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Atrial fibrillation,Morbid obesity'}
