CHIEF COMPLAINT: Altered mental status
Seizures

PRESENT ILLNESS: The patient is an 83 year old female with history significant
for DM/HTN who presented to the ED BIB family for increasingly
not being herself for possibly the last couple weeks. Per
family, pt with increasing decline in cognitive functioning
since her L hip arthroplasty in [**12-2**]. Changes notable for
garbled speech, not able to follow simple commands, not
registering information, not understanding information,
increasing confusion, a tendency to lean to her left. Pt started
haldol a few weeks ago. Most recently, she was diagnosed with a
UTI and was started on Macrobid.

MEDICAL HISTORY: -Hypertension (HTN)
-Diabetes Mellitus Type II (DM2)
-CKD baseline of 2.2 to 2.4
-Recurrent Urinary tract infeciton (UTI)
-Status-post Hemiarthroplasty left hip on [**12-2**]
-Left knee replacement at NEB [**2178**]
-Right elbow surgery
-Breast cancer status-post bilateral partial mastectomies
-Cholelithiasis
-Glaucoma

MEDICATION ON ADMISSION: Arimidez 1 mg po qd
Atenolol 50mg po qd
Calcitriol - 0.25 mcg po qd
LATANOPROST
Protonix 40mg po qd
Ursodiol 300 mg po bid
Coumadin 4 mg po qd
ASA 81mg qd
Calcium Carbonate TID
VITAMIN D3 800u qd
Colace
Iron 325 mg po qd
Senna

ALLERGIES: Penicillins / Codeine

PHYSICAL EXAM: On admission:
Gen: Elderly woman lying in bed in no acute distress, not
interactive
HEENT: PERRL, R eye with e/o iridectomy, pupils [**2-24**] bilat. MMM
Neck: supple, no JVD, no carotid bruit
CV: Regular, 2/6 systolic murmur best heard at RUSB
Abd: +bs, soft, non-distended, non-tender, no HSM, no guarding
or rebound tenderness
Ext: no edema, 1+ DP bilaterally.
Neuro: Does not open eyes spontaneously. Moving all extremities

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Married. She lives with her husband. [**Name (NI) **] history of alcohol
consumption or smoking.
Hip joint replacement,Personal history of malignant neoplasm of breast,Other convulsions,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Dehydration,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Joint replaced hip,Hx of breast malignancy,Convulsions NEC,Acute kidney failure NOS,Urin tract infection NOS,Dehydration,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,DMII wo cmp nt st uncntr
Admission Date:  [**2183-4-2**]              Discharge Date:   [**2183-4-10**]

Date of Birth:  [**2099-7-31**]             Sex:   F

Service: NEUROLOGY

Allergies:
Penicillins / Codeine

Attending:[**Doctor Last Name 15044**]
Chief Complaint:
Altered mental status
Seizures

Major Surgical or Invasive Procedure:
Nasogastric tube placement, [**2183-4-4**]

History of Present Illness:
The patient is an 83 year old female with history significant
for DM/HTN who presented to the ED BIB family for increasingly
not being herself for possibly the last couple weeks. Per
family, pt with increasing decline in cognitive functioning
since her L hip arthroplasty in [**12-2**]. Changes notable for
garbled speech, not able to follow simple commands, not
registering information, not understanding information,
increasing confusion, a tendency to lean to her left. Pt started
haldol a few weeks ago. Most recently, she was diagnosed with a
UTI and was started on Macrobid.

In ED, vitals 98.6 235/102 69 22 100%. Rectal temp noted to be
101. Patient slow in responding on command. Work-up significant
for nml WBC, Cr 2.9 from baseline 2.2-2.4, U/A +UTI (per records
pt had previously been treated for UTI at end of last month with
Macrobid). CT head no ICH but calcified meningioma along the
right anterior frontal bone, old lacunar infarct. CXR negative.
Patient was given CTX/vanco and 1L NS and plan was to admit to
the floor for UTI. Upon transfer to ambulance gurney pt noted to
have a clonic-tonic seizure x30 seconds which broke
spontaneously. She had another tonic-clonic seizure lasting 2
minutes an hour later which was broken with 2mg ativan. Repeat
head CT was negative. An LP was negative, after which she had
her third seizure and was given another 1mg ativan. Pt has never
had a seizure in the past. Neuro evaluated the patient in the ED
who witnessed a focal left sided seizure. Pt was loaded with
dilantin with cessation of seizing. Admit to ICU.

Past Medical History:
-Hypertension (HTN)
-Diabetes Mellitus Type II (DM2)
-CKD baseline of 2.2 to 2.4
-Recurrent Urinary tract infeciton (UTI)
-Status-post Hemiarthroplasty left hip on [**12-2**]
-Left knee replacement at NEB [**2178**]
-Right elbow surgery
-Breast cancer status-post bilateral partial mastectomies
-Cholelithiasis
-Glaucoma


Social History:
Married. She lives with her husband. [**Name (NI) **] history of alcohol
consumption or smoking.

Family History:
Noncontributory.

Physical Exam:
On admission:
Gen: Elderly woman lying in bed in no acute distress, not
interactive
HEENT: PERRL, R eye with e/o iridectomy, pupils [**2-24**] bilat. MMM
Neck: supple, no JVD, no carotid bruit
CV: Regular, 2/6 systolic murmur best heard at RUSB
Abd: +bs, soft, non-distended, non-tender, no HSM, no guarding
or rebound tenderness
Ext: no edema, 1+ DP bilaterally.
Neuro: Does not open eyes spontaneously. Moving all extremities

At discharge:
Pt answers questions, follows most commands, some perseveration,
oriented to hospital, not name of hospital, not date. Pupils
surgical. Moves extremities symmetrically without focal
weakness, no cranial nerve deficits.

Pertinent Results:
Labs on admission:
[**2183-4-2**] 04:55PM BLOOD WBC-8.5 RBC-3.83* Hgb-12.1 Hct-35.9*
MCV-94 MCH-31.6 MCHC-33.7 RDW-13.3 Plt Ct-298
[**2183-4-2**] 04:55PM BLOOD Neuts-58.7 Lymphs-30.5 Monos-5.9 Eos-4.1*
Baso-0.9
[**2183-4-2**] 04:55PM BLOOD PT-17.0* PTT-23.4 INR(PT)-1.5*
[**2183-4-2**] 04:55PM BLOOD Glucose-159* UreaN-45* Creat-2.9* Na-134
K-4.1 Cl-102 HCO3-21* AnGap-15
[**2183-4-3**] 02:37AM BLOOD ALT-10 AST-14 LD(LDH)-205 CK(CPK)-106
AlkPhos-96 TotBili-0.4
[**2183-4-2**] 04:55PM BLOOD cTropnT-0.01
[**2183-4-3**] 02:37AM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.8 Mg-1.5*
[**2183-4-3**] 11:55AM BLOOD VitB12-240
[**2183-4-3**] 02:37AM BLOOD Phenyto-9.3*
[**2183-4-3**] 10:15AM BLOOD Type-ART pO2-176* pCO2-41 pH-7.36
calTCO2-24 Base XS--1
[**2183-4-2**] 05:09PM BLOOD Lactate-1.4 K-4.6

Chest x-ray [**2183-4-2**]: Low lung volumes, but otherwise no acute
pulmonary process.

CT head [**2183-4-2**]:
1. No acute intracranial hemorrhage.
2. Old lacunar infarcts.

MRA/MRV Brain [**2183-4-3**]:
There is unchanged small ossified lesion in the right frontal
bone. There is unchanged small vessel ischemic sequela in the
brain. The ventricles and sulci are prominent but age
appropriate. There is no evidence for acute ischemia. MRA of the
brain is markedly motion degraded. There appears to be
hypoplastic right A1 segment. The proximal intracranial
vasculature appears to be patent. The distal branches cannot be
assessed on this examination due to motion artifact. There is
hypoplasia of the right distal vertebral artery. MRV of the
brain demonstrates no evidence of dural venous sinus thrombosis.
Significantly limited study due to motion. No significant change
compared to the prior examination. No evidence of venous sinus
thrombosis. Markedly limited MRA.

EEG: Abnormal EEG due to the slowing of the background in the
most alert-appearing portions of the record. This indicates a
widespread encephalopathy. Medications, metabolic disturbances,
and
infection are among the most common causes. There were no focal
abnormalities or epileptiform features. The relatively
normal-appearing
sleep pattern suggests a lessened severity of the
encephalopathy.


Brief Hospital Course:
This is an 83 year old female with history of HTN, DM2, CKD,
breast cancer, coming in to the ED with altered mental status,
found to have UTI, given Ceftriaxone, subsequent seizure (4
total) in ED, and admitted to ICU.  Transferred to neurology
service after began to wake up.

# Altered mental status: Unclear etiology for patients
progressive decline in cognitive functioning since her Left hip
arthoplasty but most current decline could be related to
infectious vs. ischemic vs epileptic.  Urinalysis in ED
suggested UTI, and she was previously treated recently with
Macrobid.  CT head was negative for bleed. She had a normal WBC.
 LP in ED negative for infection, cultures were sent, and she
was given Acyclovir, though this was not continued as it was
felt to be unlikley though HSV PCR was sent. Cardiac enzymes
were negative. MRI/MRV head did not show clear acute cause of
seizure/AMS. An EEG did show evidence of encephalopathy but no
further seizures. She was given Ceftriaxone for her UTI. Her B12
level was found to be at the lower level of normal and this was
repleted.  Her mental status improved with time although she
remains quite confused.  She had multiple nights of agitation
and agression requiring restraints and ativan which made her
quite sleepy in the am but did not help much acutely.  Seroquel
25 mg hs was started [**4-8**] with drastic improvement in agitation
and no residual somnolence in the am.  She was also started on
aricept for her cognitive decline.

# Seizure:  The patient had three episodes of generalized
tonic-clonic and 1 left sided focal clonic seizure witnessed in
ED during work-up.  No prior history of seizures.  She was
loaded with dilantin in ED. Neurology was consulted and
recommended MRI, Dilatin 100mg IV TID (converted to PO after NG
tube placement), Ativan PRN, CSF cultures, HSV PCR, cytology,
EEG, and seizure precautions. MRI did show a calcified
Meningioma however no clear structural reason for seizure.  CSF
studies were not revealing.  She was transitioned from dilantin
to po keppra w/ final dose of 250/500mg (kept low due to renal
failure).  No further seizures during admission.  She should not
receive haldol or floroquinolones which lower the seizure
threshold.

# UTI:  Per notes, the patient had a recent UTI diagnosed on
[**3-24**], with a prescription for Macrobid called in.  In ED, her UA
was significant for persistent UTI, and she was started on
Ceftriaxone.  Urine culture grew multiple bacteria and was read
as contaminated but we believe this was pathologic and related
to her seizures.  A 7 day course of ceftriaxone was completd.

# Renal failure: Her baseline Cr is 2.2-2.4, and was found to be
elevated to 2.9 on admission. This was felt to likely be
pre-renal and she was given IV fluid to maintain goal UOP of
50-100cc/hr.  Her Cr fluctuated between 2.0 and 2.5 before
discharge.  She continues on IVF to maintain her hydration
although she is taking food well.

# HTN: She has hypertension noted at baseline. Her Atenolol was
started after NGT placement on [**2183-4-4**] but BP control was poor
and required IV hydralazine daily for BP over 190.  We switched
her to metolprolol and titrated up to 50/50/75mg by [**4-10**] with BP
currently in the 130-180s range.  Her pulse pressure is wide.
Further titration may be necessary.

# Anticoagulation:  She has been on Coumadin for orthopedic
surgery for DVT prophylaxis, however her treatment course was
not clear and Coumadin was held on this admission.  Discussed
coumadin with orthopedics who agree that she no longer needs
this for post-op prophylaxis.  She was kept on subQ heparin and
pneumoboots for DVT prophylaxis while not mobile during
hospitalization.  We anticipate pt can go home off
anticoagulation.

# Diabetes Type II:  Pt maintained on insulin sliding scale with
glucose fluctuation from 100s to over 300.  Started lantus
10untils qAM on [**4-9**] after discussion with [**Last Name (un) **] consultant.
This was increased to 12units on [**4-10**] for sugars in the 200s in
the evenings.  CKD limits po options.  Lantus may need further
up titration.  HbA1C 6.6 and has been in the 6-7s range for 10
years.

Medications on Admission:
Arimidez 1 mg po qd
Atenolol 50mg po qd
Calcitriol - 0.25 mcg po qd
LATANOPROST
Protonix 40mg po qd
Ursodiol 300 mg po bid
Coumadin 4 mg po qd
ASA 81mg qd
Calcium Carbonate TID
VITAMIN D3 800u qd
Colace
Iron 325 mg po qd
Senna


Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2)  PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Keppra 250 mg Tablet Sig: One (1) Tablet PO qam: Brand name
only, no substitutions.
15. Keppra 250 mg Tablet Sig: Two (2) Tablet PO qpm: Brand name
only, no substitutions.
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous once a day: started at 10 untis [**4-9**], increased to
12 units [**5-10**], may need up titration.
18. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection four times a day.
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day) as needed for while
sedentary, hospitalized.
20. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
21. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime).


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] - [**Location (un) **]

Discharge Diagnosis:
Seizures
Cognitive decline
Urinary tract infection
Hypertension
Diabetes melitus
Acute on chronic renal failure

Secondary:
Chronic kidney disease
Urinary urgency and incontinence
Hemiarthroplasty of left hip
Left knee replacement
Right elbow surgery
Breast cancer
Cholelithiasis
Glaucoma
Cataract


Discharge Condition:
Improved


Discharge Instructions:
You were brought to the hospital for change in level of
alertness.  After arrival you had 3 generalized siezures and 1
focal seizure for which you were treated with anti-epileptic
medications.  You will be discharged on keppra which is one of
these medications.  You were also started on aricept to help
with the cognitive problems you'[**Name2 (NI) **] been having and seroquel to
help with agitation and confusion.
.
Please take all medications as perscribed.  If you have concerns
about the medications, please call your PCP before changing the
doses.
.
Please call your PCP or return to the emergency room if you
experience any worsening in your symptoms or have other
concerns.

Followup Instructions:
Dr. [**Last Name (STitle) **] in behavioral neurology on [**2183-5-23**] at 2pm.  Call his
office at [**Telephone/Fax (1) 108085**] with any questions.  Apointment will be
on the [**Location (un) **] of the [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **]
COMPLEX).

Call your primary care doctor for a follow up appointment after
discharge from the skilled nursing facility.  Dr. [**Last Name (STitle) 172**] or [**Doctor Last Name 131**]
- [**Telephone/Fax (1) 133**]



Completed by:[**2183-4-10**]
{'Hip joint replacement,Personal history of malignant neoplasm of breast,Other convulsions,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Dehydration,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: Altered mental status
Seizures

PRESENT ILLNESS: The patient is an 83 year old female with history significant
for DM/HTN who presented to the ED BIB family for increasingly
not being herself for possibly the last couple weeks. Per
family, pt with increasing decline in cognitive functioning
since her L hip arthroplasty in [**12-2**]. Changes notable for
garbled speech, not able to follow simple commands, not
registering information, not understanding information,
increasing confusion, a tendency to lean to her left. Pt started
haldol a few weeks ago. Most recently, she was diagnosed with a
UTI and was started on Macrobid.

MEDICAL HISTORY: -Hypertension (HTN)
-Diabetes Mellitus Type II (DM2)
-CKD baseline of 2.2 to 2.4
-Recurrent Urinary tract infeciton (UTI)
-Status-post Hemiarthroplasty left hip on [**12-2**]
-Left knee replacement at NEB [**2178**]
-Right elbow surgery
-Breast cancer status-post bilateral partial mastectomies
-Cholelithiasis
-Glaucoma

MEDICATION ON ADMISSION: Arimidez 1 mg po qd
Atenolol 50mg po qd
Calcitriol - 0.25 mcg po qd
LATANOPROST
Protonix 40mg po qd
Ursodiol 300 mg po bid
Coumadin 4 mg po qd
ASA 81mg qd
Calcium Carbonate TID
VITAMIN D3 800u qd
Colace
Iron 325 mg po qd
Senna

ALLERGIES: Penicillins / Codeine

PHYSICAL EXAM: On admission:
Gen: Elderly woman lying in bed in no acute distress, not
interactive
HEENT: PERRL, R eye with e/o iridectomy, pupils [**2-24**] bilat. MMM
Neck: supple, no JVD, no carotid bruit
CV: Regular, 2/6 systolic murmur best heard at RUSB
Abd: +bs, soft, non-distended, non-tender, no HSM, no guarding
or rebound tenderness
Ext: no edema, 1+ DP bilaterally.
Neuro: Does not open eyes spontaneously. Moving all extremities

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Married. She lives with her husband. [**Name (NI) **] history of alcohol
consumption or smoking. 

### Response:
{'Hip joint replacement,Personal history of malignant neoplasm of breast,Other convulsions,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Dehydration,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
