CHIEF COMPLAINT: transfered for status epilepticus

PRESENT ILLNESS: The pt is a 23 year-old right-handed man with a PMH of GTC who
was transferred from an OSH after being found in status.

MEDICAL HISTORY: -GTC since age 18, treated with dilantin monotherapy and briefly
with Lamictal as well, likely noncompliant. Apparently he saw
his
Neurologist (Dr. [**Last Name (STitle) 74474**] at [**Location (un) 12021**]) on [**2-14**] and his
dilantin dose was decreased from 400mg PO BID to 300mg PO BID.
-GERD

MEDICATION ON ADMISSION: ? dilantin 600mg PO QD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 97.3 P: 80 R: 16 BP: 116/50 SaO2: 100% on AC
General: intubated, sedated, intermittently fighting the vent
HEENT: NC/AT, no scleral icterus noted, however has injected
conjunctiva bilaterally
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally anteriorly
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: no rashes or edema

FAMILY HISTORY: -Mother: [**Name (NI) **], none in several years
-Cousin: [**Name (NI) **]

SOCIAL HISTORY: -Unemployed, lives with his girlfriend
-[**Name (NI) 1139**]: 2ppd
-Etoh: girlfriend denies use
-Drugs: intermittent Marijuana use, also has been taking unknown
doses of ativan in unknown frequencies which he does not obtain
from his physician
Grand mal status,Pneumonitis due to inhalation of food or vomitus,Tobacco use disorder,Personal history of noncompliance with medical treatment, presenting hazards to health,Other diseases of trachea and bronchus
Grand mal status,Food/vomit pneumonitis,Tobacco use disorder,Hx of past noncompliance,Trachea & bronch dis NEC
Admission Date:  [**2116-3-4**]              Discharge Date:   [**2116-3-7**]

Date of Birth:  [**2092-10-17**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2927**]
Chief Complaint:
transfered for status epilepticus


Major Surgical or Invasive Procedure:
LP
Intubation


History of Present Illness:
The pt is a 23 year-old right-handed man with a PMH of GTC who
was transferred from an OSH after being found in status.

Per report, he was seen driving at about 5 mph in the parking
lot of [**Company **]. He then struck a pole and EMS was called. On
arrival, he was noted to be having a GTC, agonal breathing and
incontinent of stool and urine. His vitals on the scene were
96.5 117 186/90 87% RA. He was given Valium 5mg IM and then
2.5mg [**Known lastname **] twice without effect.

He was then transferred to [**Hospital 8641**] hospital where he was
reportedly still seizing. He underwent RSI was given Cerebyx
1000mg, Ativan 1mg x 3, Etomidate 20mg [**Known lastname **], Succ 150mg [**Known lastname **],
Pavulon 10mg [**Known lastname **] and propofol ggt. Screening labs at [**Location (un) 8641**]
showed the following:

29.1\16.7/459 w/ left shift
     50.4

6.[**Telephone/Fax (3) 76646**]

C&: remarkable for Cr 1.2 and Gluc 293 NH4 231
Dilantin <5
Tegretol <0.5
Depakote <3

Per the ED he was loaded with fosphenytoin their, however there
was no documentation of this. He was then transferred by med
flight to [**Hospital1 18**]. In the ED at [**Hospital1 18**] he was afebrile and no
longer convulsing. His ED course was complicated by an initially
normal CXR. The repeat CXR showed a L lung opacification and
mediastinal
shift. This was shown on a repeat CXR again. Purulent sputum was
suctioned from his ET tube and he was sent to CT which showed
persistent opacification of the L lung. He was pan cultured and
started on empiric antibiotics for meningitis with acyclovir,
CXT and Vanco. A bedside EEG in the ED showed that he was not
seizing. A stat repeat dilantin level was 7.7 so he was
reloaded.


Past Medical History:
-GTC since age 18, treated with dilantin monotherapy and briefly
with Lamictal as well, likely noncompliant. Apparently he saw
his
Neurologist (Dr. [**Last Name (STitle) 74474**] at [**Location (un) 12021**]) on [**2-14**] and his
dilantin dose was decreased from 400mg PO BID to 300mg PO BID.
-GERD


Social History:
-Unemployed, lives with his girlfriend
-[**Name (NI) 1139**]: 2ppd
-Etoh: girlfriend denies use
-Drugs: intermittent Marijuana use, also has been taking unknown
doses of ativan in unknown frequencies which he does not obtain
from his physician


Family History:
-Mother: [**Name (NI) **], none in several years
-Cousin: [**Name (NI) **]

Physical Exam:
Vitals: T: 97.3 P: 80 R: 16 BP: 116/50 SaO2: 100% on AC
General: intubated, sedated, intermittently fighting the vent
HEENT: NC/AT, no scleral icterus noted, however has injected
conjunctiva bilaterally
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally anteriorly
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: no rashes or edema

Neurologic:
-Mental Status: sedated but responds purposefully to nox stim,
grabbing with both arms, does not follow commands

-Cranial Nerves: Olfaction not tested.  PERRL 3 to 2mm and
brisk. There is no ptosis bilaterally. Fundus not visualized due
to small pupils. No occulcephalics. No facial droop, facial
musculature symmetric.

-Motor: moves all extremities symmetrically

-Sensory: exam performed after propofol bolus. No withdrawal to
nox stim in any extremity

-Coordination: unable to test

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2   2   2    2   1
R  2   2   2    2   1

Toes were upgoing bilaterally.

-Gait: unable to test


Pertinent Results:
[**2116-3-4**] 01:54PM BLOOD WBC-20.8* RBC-4.96 Hgb-15.5 Hct-42.7
MCV-86 MCH-31.3 MCHC-36.4* RDW-13.2 Plt Ct-259
[**2116-3-6**] 06:30AM BLOOD WBC-13.3* RBC-4.83 Hgb-14.9 Hct-41.0
MCV-85 MCH-30.8 MCHC-36.3* RDW-13.2 Plt Ct-234
[**2116-3-4**] 01:54PM BLOOD Plt Smr-NORMAL Plt Ct-259
[**2116-3-4**] 01:54PM BLOOD Glucose-120* UreaN-10 Creat-0.9 Na-140
K-3.8 Cl-106 HCO3-25 AnGap-13
[**2116-3-6**] 06:30AM BLOOD Glucose-85 UreaN-6 Creat-0.8 Na-142 K-3.8
Cl-104 HCO3-27 AnGap-15
[**2116-3-4**] 01:54PM BLOOD ALT-53* AST-35 LD(LDH)-250 AlkPhos-130*
TotBili-0.3
[**2116-3-4**] 01:54PM BLOOD Lipase-25
[**2116-3-5**] 02:33AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.7
[**2116-3-6**] 06:30AM BLOOD Albumin-4.0 Calcium-9.3 Phos-3.2 Mg-2.0
[**2116-3-4**] 02:50PM BLOOD Ammonia-33
[**2116-3-4**] 01:54PM BLOOD Phenyto-7.7* Valproa-<3.0*
[**2116-3-6**] 10:38AM BLOOD Phenyto-19.1
[**2116-3-4**] 01:54PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2116-3-4**] 02:04PM BLOOD Glucose-116* Lactate-2.0 Na-139 K-3.6
Cl-103

UA: negative

CT C-Spine:
1. No acute fracture or subluxation of the cervical spine.
2. Large focal area of opacification present at the left lung
apex, incompletely imaged, could represent aspiration. Please
refer to concurrent chest CT for further assessment of finding.
3. A few foci of pneumocephalus adjacent to the trachea of
uncertain clinical significance

CT Chest:
1. Large left lung consolidation and minimal involvement of the
right lung are consistent with extensive pneumonia or
aspiration. The atelectasis demonstrated on chest radiograph
preceding the chest CT has resolved.
2. Minimal pneumomediastinum of unknown clinical ethiology and
significance. No pneumothorax.

CT Head:
No acute intracranial process.

EEG [**3-4**]:
This is an abnormal portable EEG due to the abnormal
background of disorganized, low voltage fast beta frequency
activity
admixed with bursts of generalized delta frequency slowing. The
fast
beta frequency activity likely reflects medication effects due
to
benzodiazepine or barbiturate administration. The admixed
generalized
delta frequency slowing is consistent with an encephalopathy due
to
dysfunction of bilateral subcortical or deep midline structures.
There
were no areas of prominent focal slowing. There were no
epileptiform
features. No electrographic seizure activity was noted.

EEG [**3-5**]:
This telemetry captured 10 pushbutton activations. None
were associated with any epileptiform activity. Routine sampling
and
spike and seizure detection programs were notable for a fast
widespread
beta frequency rhythm, likely related to medication effects from

benzodiazepine or barbiturate administration. There were no
areas of
prominent focal slowing. There were no epileptiform features. No

electrographic seizure activity was noted.

EEG: [**3-6**]:
This telemetry captured no pushbutton activations. Routine
sampling and spike and seizure detection programs showed a
normal alpha
frequency posterior dominant rhythm in wakefulness. There were
no areas
of prominent focal slowing. There were no epileptiform features.
No
electrographic seizure activity was noted.

[**3-7**] chest xray:
COMPARISONS: [**2116-3-5**].

FRONTAL AND LATERAL VIEWS OF CHEST: There has been near-complete
resolution of left basilar opacity. There is no effusion or
pneumothorax. Cardiac silhouette is normal.

IMPRESSION: Near-complete resolution of left basilar opacity.

Brief Hospital Course:
Mr. [**Known lastname 41465**] was med-flighted to [**Hospital1 18**]. In the ED he was no
longer seizing but required high doses of propofol and versed to
achieve sedation. His hospital course by problem is as follows:

Neuro:
He had a head CT in the ED which was unremarkable. Afterwards he
was connected to EEG monitoring and found not to be in status.
He was then LP'd and started on empiric vancomycin, CTX and
acyclovir for meningitis. His LP was unremarkable. The following
day, the antibiotics for meningitis were stopped. His seizures
were treated with a dilantin load in the ED followed by a
maintenance dose of 300mg QD. His dilantin level was therapeutic
and he his EEG normalized. He had no further seizures.

Multiple clinicians discussed medication non-compliance with Mr.
[**Known lastname 41465**]. He denied not taking medications, but admitted that he
does have difficutlies with his memory at times. He was
therefore counseled to use a pill-box to monitor his medications
and follow-up with Dr. [**Last Name (STitle) 74474**], his primary Neurologist, for
close blood level monitoring. He aggreed to do this. Dr.
[**Last Name (STitle) 74474**] was also called and the patients hospital course was
discussed. He stated that Mr. [**Known lastname 41465**] is often non-compliant.
We are recommending generic zonisamide as a possible alternative
to Dilantin, as Zonisamide can be taken once per day (long
acting) and due to its long half-life, noncompliant patients
often have enough coverage to miss an occasional dose.
Furthermore, it does not seem to have levels affected by smoking
or drinking alcohol, nor are frequent level checks required.

Mr. [**Known lastname 41465**] was also counseled multiple times that he is not
allowed to drive for one year in accordance with [**Location (un) **]
law, as he has had a seizure. He agreed not to drive.

RESP:
He was initially well ventilated, but a repeat CXR showed
opacification of the L lung, concerning for a mucous plug. He
was aggressively suctioned and purulent sputum was removed. He
was then reimaged and had persistent opacification. A CT chest
was therefore done and his lung was noted to be down. He was
therefore treated with aggressive PEEP and his lung was
sucessfully aerated.
He was extubated without difficulty the following day and
treated with clinda and CTX for aspiration PNA.  Repeat chest
xray showed interval improvement, suggesting an aspiration
pneumonitis, but he was nonetheless discharged on clindamycin
alone to finish a course for aspiration pneumonia (seven days).

ID:
His initial empiric treatment for meningitis and PNA are
described above. On admission, blood cultures were also drawn.
He was found to have [**2-14**] sets of blood cultures with GPCs. He
was therefore started on vancomycin.  Speciation showed coag
negative staph, and as only 1/4 bottles were positive, with
surveillance cultures negative preliminarily, this was
discontinued at discharge.

Medications on Admission:
? dilantin 600mg PO QD

Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO DAILY (Daily): brand name only; do not substitute.
2. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 4 days.
Disp:*32 Capsule(s)* Refills:*0*
3. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Outpatient Lab Work
Dilantin level - please draw in late afternoon as trough if
taking dilantin every night.  Results should be sent to
neurologist Dr. [**Last Name (STitle) 74474**] - ([**Telephone/Fax (1) 76647**].


Discharge Disposition:
Home

Discharge Diagnosis:
Seizures
Pneumonia


Discharge Condition:
Stable, no focal neurological deficits


Discharge Instructions:
1. Please take all medications as prescribed
2. Please follow-up with your Neurologist and primary care
doctor
3. DO NOT DRIVE FOR ONE YEAR AFTER YOUR LAST SEIZURE, PER NH LAW

Followup Instructions:
Please see Dr. [**Last Name (STitle) 74474**] in the next week to have your dilantin
level checked; call to set this up:
[**Location (un) 511**] Neurological Associates
[**Hospital1 76648**], [**Numeric Identifier 76649**]

Phone:  ([**Telephone/Fax (1) 76647**]

We recommend an alternative medication called 'Zonisamide,'
which can be taken once a day.  Please discuss this with your
neurologist.



Completed by:[**2116-3-7**]
{'Grand mal status,Pneumonitis due to inhalation of food or vomitus,Tobacco use disorder,Personal history of noncompliance with medical treatment, presenting hazards to health,Other diseases of trachea and bronchus'}


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: transfered for status epilepticus

PRESENT ILLNESS: The pt is a 23 year-old right-handed man with a PMH of GTC who
was transferred from an OSH after being found in status.

MEDICAL HISTORY: -GTC since age 18, treated with dilantin monotherapy and briefly
with Lamictal as well, likely noncompliant. Apparently he saw
his
Neurologist (Dr. [**Last Name (STitle) 74474**] at [**Location (un) 12021**]) on [**2-14**] and his
dilantin dose was decreased from 400mg PO BID to 300mg PO BID.
-GERD

MEDICATION ON ADMISSION: ? dilantin 600mg PO QD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 97.3 P: 80 R: 16 BP: 116/50 SaO2: 100% on AC
General: intubated, sedated, intermittently fighting the vent
HEENT: NC/AT, no scleral icterus noted, however has injected
conjunctiva bilaterally
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally anteriorly
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: no rashes or edema

FAMILY HISTORY: -Mother: [**Name (NI) **], none in several years
-Cousin: [**Name (NI) **]

SOCIAL HISTORY: -Unemployed, lives with his girlfriend
-[**Name (NI) 1139**]: 2ppd
-Etoh: girlfriend denies use
-Drugs: intermittent Marijuana use, also has been taking unknown
doses of ativan in unknown frequencies which he does not obtain
from his physician 

### Response:
{'Grand mal status,Pneumonitis due to inhalation of food or vomitus,Tobacco use disorder,Personal history of noncompliance with medical treatment, presenting hazards to health,Other diseases of trachea and bronchus'}
