CHIEF COMPLAINT: Seizures

PRESENT ILLNESS: 86 F with hx of dementia, HTN, AF not on coumadin, prior stroke,
had been living at a NH, and was noted to have a GTC seizure
x3-4 minutes at about 4:30 pm [**2121-3-24**]. This was noted to be
preceded by right gaze deviation. She received ativan at the NH
after the seizure. Afterward her eyes were open but she was
non-verbal. She was transported via EMS to an OSH ER, where she
proceded to have a second GTC seizure, also lasting minutes. She
was intubated for airway protection, given more ativan and
started on a propofol gtt. She was subsequently transferred to
[**Hospital1 18**]. She had been on Leqaquin for a UTI. Though there is no hx
of seizure per se. She is DNR, but not DNI.

MEDICAL HISTORY: HTN
dementia
prior stroke
(likely prior seizure as came in on Keppra)
AF - not on coumadin

MEDICATION ON ADMISSION: Levaquin 250 mg Qday x 9 days started [**2121-3-18**]
Keppra 500 mg [**Hospital1 **]
Ativan 0.5 mg PRN
Nitropaste PRN
Seroquel 25 mg [**Hospital1 **] and 25 mg PRN agitation
Simvastatin 20 mg Qday
ASA 81 mg Qday
Prevacid 15 mg Qday
Dulcolax 10 mg PR PRN constipation
MOM 30 mL PRN constipation
Colace 100 mg TID
Neutraphos 4 packets Qday
MVI
Vit D

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T- 97.4 F BP- 150/90 HR- 85 RR- 14 O2Sat 98% intubated
Gen: Lying in bed, intubated, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: irreg irreg,  no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no c/c/e; equal radial and pedal pulses B/L

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Does not walk or talk at baseline, sings to herself, and does
not recognize her sons. She lives in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Nursing Home.
Other convulsions,Other encephalopathy,Other amyloidosis,Urinary tract infection, site not specified,Other persistent mental disorders due to conditions classified elsewhere,Atrial fibrillation,Unspecified essential hypertension,Dehydration,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Convulsions NEC,Encephalopathy NEC,Amyloidosis NEC,Urin tract infection NOS,Mental disor NEC oth dis,Atrial fibrillation,Hypertension NOS,Dehydration,Hx TIA/stroke w/o resid
Admission Date:  [**2121-3-25**]              Discharge Date:   [**2121-3-29**]


Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Seizures

Major Surgical or Invasive Procedure:
Lumbar puncture
Intubation/Extubation


History of Present Illness:
86 F with hx of dementia, HTN, AF not on coumadin, prior stroke,
had been living at a NH, and was noted to have a GTC seizure
x3-4 minutes at about 4:30 pm [**2121-3-24**]. This was noted to be
preceded by right gaze deviation. She received ativan at the NH
after the seizure. Afterward her eyes were open but she was
non-verbal. She was transported via EMS to an OSH ER, where she
proceded to have a second GTC seizure, also lasting minutes. She
was intubated for airway protection, given more ativan and
started on a propofol gtt. She was subsequently transferred to
[**Hospital1 18**]. She had been on Leqaquin for a UTI. Though there is no hx
of seizure per se. She is DNR, but not DNI.


Past Medical History:
HTN
dementia
prior stroke
(likely prior seizure as came in on Keppra)
AF - not on coumadin


Social History:
Does not walk or talk at baseline, sings to herself, and does
not recognize her sons. She lives in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Nursing Home.

Family History:
Non-contributory

Physical Exam:
T- 97.4 F BP- 150/90 HR- 85 RR- 14 O2Sat 98% intubated
Gen: Lying in bed, intubated, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: irreg irreg,  no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no c/c/e; equal radial and pedal pulses B/L

Neurologic examination:
Mental status: off propofol for 10 minutes, she remains
non-responsive to verbal stim; some mvmt of LE to tactile stim,

Cranial Nerves:
Pupils equally round and reactive to light, 5 to 2 mm
bilaterally. Left retina with sharp disc margin, right poorly
visualized. Corneals present B/L, very weak on L (weaker than
R). No BTT B/L. (+) VOR. (+) cough.

Motor:
Normal bulk bilaterally. increased tone in the UE B/L, left
greater than right. No mvmt of UE at all, even to noxious.
Mildly withdraws LE B/L to noxious

Sensation: withdraws LE to noxious in LE. In UE, noxious stim
causes withdrawal of LE.

Reflexes:
+2 and symmetric throughout the UE. At the Patellae, L is far
brisker than R (3 vs 1). 0 at Achilles B/L.  Toes upgoing
bilaterally

Pertinent Results:
LABS:
[**2121-3-25**] 02:45AM BLOOD WBC-11.8* RBC-4.43 Hgb-13.3 Hct-40.5
MCV-92 MCH-29.9 MCHC-32.7 RDW-14.0 Plt Ct-343
[**2121-3-26**] 03:09AM BLOOD WBC-12.0* RBC-4.37 Hgb-13.2 Hct-39.5
MCV-91 MCH-30.1 MCHC-33.3 RDW-14.0 Plt Ct-310
[**2121-3-25**] 02:45AM BLOOD Neuts-78.4* Lymphs-15.8* Monos-4.8
Eos-0.3 Baso-0.7
[**2121-3-25**] 02:05AM BLOOD PT-14.0* PTT-21.2* INR(PT)-1.2*
[**2121-3-25**] 02:05AM BLOOD Glucose-149* UreaN-32* Creat-1.3* Na-150*
K-3.5 Cl-114* HCO3-25 AnGap-15
[**2121-3-26**] 03:09AM BLOOD Glucose-135* UreaN-23* Creat-1.1 Na-146*
K-3.2* Cl-114* HCO3-23 AnGap-12
[**2121-3-25**] 08:11AM BLOOD ALT-12 AST-20 CK(CPK)-67 AlkPhos-106
TotBili-0.6
[**2121-3-25**] 02:43PM BLOOD CK(CPK)-56
[**2121-3-25**] 10:29PM BLOOD CK(CPK)-42
[**2121-3-25**] 08:11AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2121-3-25**] 02:43PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2121-3-25**] 10:29PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2121-3-25**] 08:11AM BLOOD TotProt-6.6 Albumin-3.8 Globuln-2.8
Calcium-9.0 Phos-3.1 Mg-2.4
[**2121-3-25**] 08:11AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2121-3-25**] 08:11AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025
[**2121-3-25**] 08:11AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2121-3-25**] 08:11AM URINE RBC-[**1-23**]* WBC-[**4-30**]* Bacteri-FEW Yeast-NONE
Epi-0 TransE-[**1-23**]
[**2121-3-25**] 05:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.028
[**2121-3-25**] 05:15PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2121-3-25**] 05:15PM URINE RBC-0-2 WBC-[**4-30**]* Bacteri-FEW Yeast-NONE
Epi-0-2
[**2121-3-25**] 08:11AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2121-3-25**] 06:11PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-3* Polys-0
Lymphs-56 Monos-42 Basos-2
[**2121-3-25**] 06:11PM CEREBROSPINAL FLUID (CSF) TotProt-113*
Glucose-97
CSF HSV [**11-22**] PCR not detected

MICRO:
Blood Cx ([**3-25**]): NGTD x2
Urine Cx ([**3-25**]): ESCHERICHIA COLI.    10,000-100,000
ORGANISMS/ML.
CSF Cx ([**3-25**]):
   GRAM STAIN (Final [**2121-3-25**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Preliminary):    NO GROWTH.

IMAGING:
Head CT ([**3-25**]): IMPRESSION:
1. Diffuse white matter hypodensity for which the differential
includes
vasogenic edema secondary to metastases, posterior reversible
encephalopathy syndrome (associated with seizures), reversible
leukoencephalopathy syndrome (associated with hypertension), or
a diffuse demyelinating process. Correlate clinically. Recommend
MR for further characterization.
2. Small hyperdense foci in the posterior parietal region may be
small
hemorrhagic foci vs. calcifications.
3. Right parietal hyperdense lesion at the convexity possibly
consistent with a hemorrhagic focus vs. meningioma correlation
with MRI of the head with and without contrast is recommended.

EEG ([**3-25**]): IMPRESSION: This is an abnormal portable EEG
recording due to the slow background which was not reactive to
different stimuli and the runs of somewhat more rhythmic
triphasic waves. The first abnormality suggests a moderate to
severe encephalopathy. Metabolic disturbances, medications, and
infection are the most common causes. The second abnormality may
be part of the same pattern of encephalopathy described above
but it may also evolve into a build-up of rhythmic activity
suggestive of epileptic activity. Long-term monitoring of this
patient for 24-48 hours may reveal the existence of subclinical
seizures. Of note is that although lateralized features were not
seen in this recording, this may be obscured by the severe
slowing of the background.

CXR ([**3-25**]): IMPRESSION:
1. ET tube in right mainstem bronchus. Needs retraction.
Orogastric tube
standard postion.
2. Likely right lower lobe atelectasis

MR [**Name13 (STitle) 430**] ([**3-25**]): IMPRESSION:
1. Multiple foci of magnetic susceptibility as described above,
raising the possibility of amyloid angiopathy, and multiple
microbleeds. No diffusion abnormalities are detected, the
subcortical white matter is diffusely hyperintense on T2 and
FLAIR, raising the possibility of chronic hypertensive
leukoencephalopathy or severe chronic microangiopathy. Mild
mucosal thickening identified in the mastoid and ethmoidal air
cells.

2. The right parietal lesion is not enhancing and demonstrates
hemorrhagic changes on the gradient echo sequence.

Brief Hospital Course:
The patient is an 86 year old woman with a history of dementia,
atrial fibrillation not on Coumadin, and hypertension who
presented with new onset seizures. She was intubated at an OSH,
placed on propofol, and started on Keppra. Physical exam on
admission showed that she was intubated, no eye opening, did not
follow any simple commands, PERRL but roving eye movements. Head
CT on admission showed diffuse white matter hypodensity for
which the differential includes vasogenic edema secondary to
metastases, posterior reversible encephalopathy syndrome
(associated with seizures), reversible leukoencephalopathy
syndrome (associated with hypertension), or a diffuse
demyelinating process. MRI brain showed multiple foci of
magnetic susceptibility
raising the possibility of amyloid angiopathy, and multiple
microbleeds, no diffusion abnormalities are detected, the
subcortical white matter is diffusely hyperintense on T2 and
FLAIR raising the possibility of chronic hypertensive
leukoencephalopathy or severe chronic microangiopathy. EEG
showed slow background suggestive of moderate to severe
encephalopathy, and runs of somewhat more rhythmic triphasic
waves consistent with encephalopathy or epileptic activity. LP
showed 2 WBC, CSF culture showed no growth (prelim), and HSV 1
and 2 were negative.

While in the NeuroICU, the team spoke with [**First Name8 (NamePattern2) 717**] [**Last Name (NamePattern1) 9449**], NP at
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] NH, who mentioned that at baseline the patient needed
1:1 assistance, did not talk, had recurrent UTIs, sodiums were
around 147, she also had HTN and anxiety. Recently, her Prozac
had been weaned down, she also had swelling in her hands. She
was DNR/DNI and [**Last Name (NamePattern1) 3225**] in light of her advanced dementia, however,
her sons reversed the [**Name (NI) 3225**] after the new onset seizures.

After being admitted to the neuro ICU service for 24 hours, she
spontaneously opened her eyes but did not move her limbs in any
purposeful manner. After further discussions with both Mrs. [**Known lastname 82750**] sons [**Name2 (NI) **] and [**Name (NI) **]), her sons decided to make her
comfort measures only in light of her advanced dementia, and her
physical deterioration.

Palliative care was consulted, and recommended Morphine SL and
Tylenol PR prn. She was also prescribed Scopolamine patch.


Medications on Admission:
Levaquin 250 mg Qday x 9 days started [**2121-3-18**]
Keppra 500 mg [**Hospital1 **]
Ativan 0.5 mg PRN
Nitropaste PRN
Seroquel 25 mg [**Hospital1 **] and 25 mg PRN agitation
Simvastatin 20 mg Qday
ASA 81 mg Qday
Prevacid 15 mg Qday
Dulcolax 10 mg PR PRN constipation
MOM 30 mL PRN constipation
Colace 100 mg TID
Neutraphos 4 packets Qday
MVI
Vit D


Discharge Medications:
1. Morphine Concentrate 5 mg/0.25 mL Solution Sig: 5-10 mg PO
Q1H (every hour) as needed for pain, agitation: to be given
sublingual.
2. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72 HOURS PRN () as needed for excess secretions.
3. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain: TO BE GIVEN PR.


Discharge Disposition:
Extended Care

Facility:
[**Doctor First Name **] [**Doctor First Name **] nursing care center

Discharge Diagnosis:
PRIMARY
Seizure likely due to underlying strokes, hypertension, or
amyloid angiopathy
PRES
Hypertension
Dementia

SECONDARY
Atrial fibrillation
Recurrent UTI


Discharge Condition:
Stable


Discharge Instructions:
You were admitted to the hospital with seizures, which was
likely due to your prior strokes, hypertension, or underlying
amyloid angiopathy. After discussion with your family, you were
made [**Doctor First Name 3225**]. Palliative care was consulted, and gave
recommendations to help keep you comfortable. You will be
discharged back to your nursing home.

Followup Instructions:
None


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
{'Other convulsions,Other encephalopathy,Other amyloidosis,Urinary tract infection, site not specified,Other persistent mental disorders due to conditions classified elsewhere,Atrial fibrillation,Unspecified essential hypertension,Dehydration,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}


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: Seizures

PRESENT ILLNESS: 86 F with hx of dementia, HTN, AF not on coumadin, prior stroke,
had been living at a NH, and was noted to have a GTC seizure
x3-4 minutes at about 4:30 pm [**2121-3-24**]. This was noted to be
preceded by right gaze deviation. She received ativan at the NH
after the seizure. Afterward her eyes were open but she was
non-verbal. She was transported via EMS to an OSH ER, where she
proceded to have a second GTC seizure, also lasting minutes. She
was intubated for airway protection, given more ativan and
started on a propofol gtt. She was subsequently transferred to
[**Hospital1 18**]. She had been on Leqaquin for a UTI. Though there is no hx
of seizure per se. She is DNR, but not DNI.

MEDICAL HISTORY: HTN
dementia
prior stroke
(likely prior seizure as came in on Keppra)
AF - not on coumadin

MEDICATION ON ADMISSION: Levaquin 250 mg Qday x 9 days started [**2121-3-18**]
Keppra 500 mg [**Hospital1 **]
Ativan 0.5 mg PRN
Nitropaste PRN
Seroquel 25 mg [**Hospital1 **] and 25 mg PRN agitation
Simvastatin 20 mg Qday
ASA 81 mg Qday
Prevacid 15 mg Qday
Dulcolax 10 mg PR PRN constipation
MOM 30 mL PRN constipation
Colace 100 mg TID
Neutraphos 4 packets Qday
MVI
Vit D

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T- 97.4 F BP- 150/90 HR- 85 RR- 14 O2Sat 98% intubated
Gen: Lying in bed, intubated, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: irreg irreg,  no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no c/c/e; equal radial and pedal pulses B/L

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Does not walk or talk at baseline, sings to herself, and does
not recognize her sons. She lives in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Nursing Home. 

### Response:
{'Other convulsions,Other encephalopathy,Other amyloidosis,Urinary tract infection, site not specified,Other persistent mental disorders due to conditions classified elsewhere,Atrial fibrillation,Unspecified essential hypertension,Dehydration,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}
