CHIEF COMPLAINT: status epilepticus

PRESENT ILLNESS: [**Known firstname 3403**] [**Known lastname 110699**] is a 47 year-old man with a history of severe
intellectual disabilty (non-verbal at baseline) who was
transferred from home to [**Hospital 8641**] Hospital in NH after reportedly
having whole body shaking (unknown duration). Records indicate
that he was given 1 mg of Ativan in addition to a load of
Fosphenytoin at 1200 PE x1. He continued to having shaking
movements and was intubated and sedated on propofol and
medflighted to [**Hospital1 18**]. In the ED off of propofol he continues to
have rhythmic shaking of his left arm more than the right.

MEDICAL HISTORY: Severe intellectual disability - nonverbal, reportedly
understands when spoken to.
Hydrocephalus
? Stroke in [**2153**] - unknown details
Total colectomy and end ileostomy
Scoliosis
Osteoarthritis
Anemia
Endocardial cushion defect
Hypogonadism
Vitiligo
Hiatal Hernia
GERD
Chronic UTIs
Narcolepsy
Polydipsia
MRSA infections

MEDICATION ON ADMISSION: Zyprexa
Citalopram 10 daily
Provigil 100 mg daily
Nexium 40 mg QHS
Nexium
Miralax
Vit D
MVI
Tylenol PRN

ALLERGIES: Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: At admission:
Vitals: 98.3 P 72 BP 134/82 R 16 SpO2 100%
General: intubated and sedated wi rhythmic movement of left arm
off sedation
HEENT: macrocephalic, patchy discoloration of hair
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: coarse breath sounds
Cardiac: RRR, no murmurs
Abdomen: colostomy bag, soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.

FAMILY HISTORY: unknown and unable to obtain

SOCIAL HISTORY: Lives with his [**Doctor Last Name **] mother. Nonverbal at baseline. Able to
walk
short distances to wheelchair.
Grand mal status,Urinary tract infection, site not specified,Methicillin resistant pneumonia due to Staphylococcus aureus,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Severe intellectual disabilities,Mixed acid-base balance disorder,Foreign body in main bronchus,Endocardial cushion defect, unspecified type,Obstructive hydrocephalus,Diverticulum of bladder,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Ileostomy status,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Esophageal reflux,Leukocytosis, unspecified,Anemia, unspecified,Other testicular hypofunction,Vitiligo,Narcolepsy, without cataplexy,Scoliosis [and kyphoscoliosis], idiopathic,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation,Physical restraints status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history, urinary (tract) infection,Acquired absence of intestine (large) (small),Other postprocedural status,Arthrodesis status
Grand mal status,Urin tract infection NOS,Meth res pneu d/t Staph,Acute respiratry failure,Food/vomit pneumonitis,Sev intellect disability,Mixed acid-base bal dis,Foreign body bronchus,Endocard cushion def NOS,Obstructiv hydrocephalus,Diverticulum of bladder,Pseudomonas infect NOS,Ileostomy status,Osteoarthros NOS-unspec,Esophageal reflux,Leukocytosis NOS,Anemia NOS,Testicular hypofunc NEC,Vitiligo,Narcolepsy w/o cataplexy,Idiopathic scoliosis,Resp obstr-inhal obj NEC,Physical restrain status,Hx TIA/stroke w/o resid,Personal history UTI,Acquire absnce intestine,Post-proc states NEC,Arthrodesis status
Admission Date:  [**2155-3-21**]              Discharge Date:   [**2155-4-12**]

Date of Birth:  [**2108-1-7**]             Sex:   M

Service: NEUROLOGY

Allergies:
Sulfa(Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 17813**]
Chief Complaint:
status epilepticus


Major Surgical or Invasive Procedure:
intubation and extubation


History of Present Illness:
[**Known firstname 3403**] [**Known lastname 110699**] is a 47 year-old man with a history of severe
intellectual disabilty (non-verbal at baseline) who was
transferred from home to [**Hospital 8641**] Hospital in NH after reportedly
having whole body shaking (unknown duration). Records indicate
that he was given 1 mg of Ativan in addition to a load of
Fosphenytoin at 1200 PE x1. He continued to having shaking
movements and was intubated and sedated on propofol and
medflighted to [**Hospital1 18**]. In the ED off of propofol he continues to
have rhythmic shaking of his left arm more than the right.

Neurosurgery was consulted regarding his VP shunt and could not
palpate a reservoir. A shunt series was ordered, but CT from
outside showed a stable level of hydrocephalus from prior
images.

A stat portable EEG was done in the ED which showed frequent
rhythmic right fronto-temporal discharges. ED ordered Flagyl and
Levaquin in the ED - but these infusions were stopped prior to
administration. He was started on Vancomycin and ceftriaxone.

In the chart it indicates that he was most recently admitted to
[**Location (un) 8641**] with a pseudomonas UTI. He has no known history of
seizures and is not currently on any AEDs as per medical
records.


Past Medical History:
Severe intellectual disability - nonverbal, reportedly
understands when spoken to.
Hydrocephalus
? Stroke in [**2153**] - unknown details
Total colectomy and end ileostomy
Scoliosis
Osteoarthritis
Anemia
Endocardial cushion defect
Hypogonadism
Vitiligo
Hiatal Hernia
GERD
Chronic UTIs
Narcolepsy
Polydipsia
MRSA infections


Social History:
Lives with his [**Doctor Last Name **] mother. Nonverbal at baseline. Able to
walk
short distances to wheelchair.


Family History:
unknown and unable to obtain


Physical Exam:
At admission:
Vitals: 98.3 P 72 BP 134/82 R 16 SpO2 100%
General: intubated and sedated wi rhythmic movement of left arm
off sedation
HEENT: macrocephalic, patchy discoloration of hair
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: coarse breath sounds
Cardiac: RRR, no murmurs
Abdomen: colostomy bag, soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: some movements of head and grimacing to sternal
rub

-Cranial Nerves:
pupils 2 - 1.5 b/l, + Doll's eyes, + corneals, + gag

-Motor: rhythmic movements of the left arm off of propofol. Some
spontaneous movement of the right arm. Wasting of LE b/l with
increased flexor tone.

-Sensory: some withdrawal to pinch on the right, no withdrawal
on
the left.

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2  2    2    2   1
R  2  2    2    2   1
Plantar response was flexor bilaterally.

-Coordination: unable to test
-Gait: unable to test

At transfer out of NeuroICU:
Doesn't react well with male examiners (hx of trauma by males in
past), macrocephaly/dysmorphic facial features. Eyes spon open,
track occasionally, dysconjugate gaze, nonverbal and does not
follow commands. moves b/l arms and feet spontaneously, resists
passive leg movement (appear spastic, may be realted to trauma
hx) but pt is able to move legs voluntarily, bilateral hands
also spastic.

AT DISPO:
Vitals: 98.2, 106/59, 60, 19, 93% on RA
General: sitting in bed in NAD
HEENT: macrocephalic, patchy discoloration of hair
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: coarse breath sounds
Cardiac: RRR, no murmurs
Abdomen: colostomy bag, soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: tracks examiner, smiles, follows some commands
-Cranial Nerves: pupils 2 - 1.5 b/l, EOMI, face baseline
asymetrical with missing teeth bilaterally
-Motor: MAEE, hands appear spastic
-Sensory: intact to tickle on feet and hands

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2  2    2    2   1
R  2  2    2    2   1
Plantar response was flexor bilaterally.

-Coordination: reaches for examiner bilaterally
-Gait: unable to test


Pertinent Results:
[**2155-3-21**] 02:35PM BLOOD WBC-7.4 RBC-3.88* Hgb-12.0* Hct-40.0
MCV-103* MCH-30.8 MCHC-29.9* RDW-14.6 Plt Ct-220
[**2155-3-21**] 02:35PM BLOOD Neuts-86.7* Lymphs-7.8* Monos-4.5 Eos-0.9
Baso-0.1
[**2155-3-21**] 02:35PM BLOOD Plt Ct-220
[**2155-3-21**] 11:29PM BLOOD Glucose-86 UreaN-18 Creat-0.6 Na-142
K-3.7 Cl-103 HCO3-37* AnGap-6*
[**2155-3-22**] 04:16AM BLOOD Glucose-83 UreaN-17 Creat-0.7 Na-139
K-4.3 Cl-102 HCO3-29 AnGap-12
[**2155-3-21**] 02:35PM BLOOD ALT-29 AST-37 AlkPhos-110 TotBili-0.2
[**2155-3-21**] 02:35PM BLOOD Lipase-28
[**2155-3-21**] 02:51PM BLOOD cTropnT-<0.01
[**2155-3-21**] 02:35PM BLOOD Albumin-3.8 Calcium-9.4 Phos-2.2* Mg-1.8
[**2155-3-29**] 01:53AM BLOOD 25VitD-22*
[**2155-3-26**] 06:20AM BLOOD Vanco-19.1
[**2155-3-22**] 04:16AM BLOOD Phenyto-12.0
[**2155-3-31**] 03:51AM BLOOD Phenyto-4.4*
[**2155-3-21**] 02:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2155-3-21**] 02:47PM BLOOD Type-ART PEEP-5 pO2-39* pCO2-59* pH-7.42
calTCO2-40* Base XS-10 -ASSIST/CON Intubat-INTUBATED
[**2155-3-22**] 04:57AM BLOOD Type-ART Rates-14/0 Tidal V-500 PEEP-5
FiO2-50 pO2-81* pCO2-44 pH-7.48* calTCO2-34* Base XS-8
Intubat-INTUBATED
[**2155-4-2**] 09:23AM BLOOD Type-ART Temp-36.5 O2 Flow-2 pO2-58*
pCO2-56* pH-7.46* calTCO2-41* Base XS-13 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2155-3-21**] 02:47PM BLOOD Lactate-2.9*
[**2155-3-23**] 02:07AM BLOOD freeCa-1.20
[**2155-3-21**] 02:35PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.017
[**2155-3-21**] 02:35PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-LG
[**2155-3-21**] 02:35PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-LG
[**2155-3-21**] 02:35PM URINE RBC-2 WBC-119* Bacteri-FEW Yeast-NONE
Epi-0
[**2155-3-29**] 11:46AM URINE CastHy-10*
[**2155-4-2**] 02:44AM URINE Hours-RANDOM Creat-46 Na-143 K-38 Cl-121
[**2155-4-2**] 02:44AM URINE Osmolal-479
[**2155-3-21**] 02:35PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG

[**2155-3-21**] 2:35 pm URINE     Site: NOT SPECIFIED

                            **FINAL REPORT [**2155-3-23**]**

   URINE CULTURE (Final [**2155-3-23**]):
      MORGANELLA MORGANII.    >100,000 ORGANISMS/ML..
         Piperacillin/tazobactam sensitivity testing available
on request.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             MORGANELLA MORGANII
                             |
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------   128 R
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----  =>16 R

[**2155-3-21**] 7:30 pm MRSA SCREEN      Source: Nasal swab.

                            **FINAL REPORT [**2155-3-23**]**

   MRSA SCREEN (Final [**2155-3-23**]):
      POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.

[**2155-3-23**] 4:47 am SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2155-3-29**]**

   GRAM STAIN (Final [**2155-3-23**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS.

   RESPIRATORY CULTURE (Final [**2155-3-29**]):
      SPARSE GROWTH Commensal Respiratory Flora.
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .
         VANCOMYCIN Sensitivity testing performed by Etest.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S

[**2155-3-25**] 12:50 am BRONCHOALVEOLAR LAVAGE

                            **FINAL REPORT [**2155-3-27**]**

   GRAM STAIN (Final [**2155-3-25**]):
      3+  (5-10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2155-3-27**]):
      10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
      STAPH AUREUS COAG +.    10,000-100,000 ORGANISMS/ML..
         SENSITIVITIES PERFORMED ON CULTURE # 344-8753W ON
[**2155-3-23**].

[**2155-3-29**] 11:46 am URINE      Source: Catheter.

                            **FINAL REPORT [**2155-3-31**]**

   URINE CULTURE (Final [**2155-3-31**]):
      PSEUDOMONAS AERUGINOSA.    10,000-100,000 ORGANISMS/ML..
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |
CEFEPIME--------------     2 S
CEFTAZIDIME-----------   <=1 S
CIPROFLOXACIN---------     1 S
GENTAMICIN------------     2 S
MEROPENEM-------------     1 S
PIPERACILLIN/TAZO-----       S
TOBRAMYCIN------------   <=1 S

EEG LTM: [**Date range (1) 110700**]
[**3-21**]:
FINDINGS:
ABNORMALITY #1: This 30 minute recording, the primary background
was
low, at about 7 Hz posteriorly. There was also a superimposition
of
widespread faster activity. There were a few bursts of
generalized
slowing.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping patterns were evident.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Abnormal EEG due to a mild slowing of the background

posteriorly, indicating a widespread encephalopathy. There were
also
widespread faster rhythms, suggesting medication effect. There
were no
prominent focal abnormalities but encephalopathies and
medications may
obscure such findings. There were no clearly epileptiform
features or
any electrographic seizures in this recording.
[**3-22**]:
IMPRESSION: This telemetry captured no pushbutton activations.
It
showed a slow background through most of the beginning of the
recording
and then a very widespread rapid rhythm during the early hours
of [**3-23**]. Both signify a widespread encephalopathy. The faster
widespread
rhythms, especially toward the end of the recording, are
primarily
suggestive of medication effect. There were no areas of
prominent focal
slowing but encephalopathies may obscure focal findings. There
were no
epileptiform features or electrographic seizures.
[**3-23**]:
IMPRESSION: This telemetry captured no pushbutton activations.
The
background remained with a very slow base and with superimposed
faster
beta activity throughout. The widespread faster activity
generally
indicates medication effect. There were no areas of prominent
focal
slowing, but encephalopathies may obscure focal findings. There
were no
epileptiform features or electrographic seizures.
[**3-24**]:
IMPRESSION: This telemetry captured no pushbutton activations.
It
showed a slow and low to moderate voltage background throughout
indicating a widespread encephalopathy. There was minimal
additional
slowing in the right hemisphere. The faster beta and alpha
rhythms with
a widespread distribution generally indicate medication effect.
There
were no clearly epileptiform features, and no electrographic
seizures
were recorded.
[**3-25**]:
IMPRESSION: This telemetry captured no pushbutton activations.
The
background remained slow and of low voltage throughout,
especially after
10:30 on the morning of the 17th. This suggests medication
effect. The
bradycardia began around the same time. There were no clearly
epileptiform features or any electrographic seizures in the
recording.
[**3-26**]:
IMPRESSION: This telemetry captured no pushbutton activations.
The
background rhythm was usually mildly slow or consisted of faster
alpha
and beta rhythms with a widespread distribution. The faster
rhythms
usually represent medication effect. There were some more
suppressed
periods. There were no epileptiform features or electrographic
seizures. The bradycardia was noted for most of the recording.
[**3-27**]:
IMPRESSION: This telemetry captured no pushbutton activations.
It
showed an encephalopathic background throughout. The early
rapid, beta
activity is strongly suggestive of medication effect. Later,
other
widespread uniform frequencies were also reflective of an
encephalopathy. There were no prominent focal findings. There
were no
clearly epileptiform features or any electrographic seizures.
[**3-28**]:
IMPRESSION: This is an abnormal EEG telemetry with no pushbutton

activations. It showed occasional isolated bifrontal or
generalized
epileptic discharges indicative of several areas of cortical
irritability. In addition, background was disorganized and
diffusely
slow indicative of moderate encephalopathy. No electrographic
seizures
were present.
[**3-29**]:
IMPRESSION: This is an abnormal EEG telemetry with one
pushbutton
activation for right shoulder twitching with no electrographic
seizures.
There were occasional isolated independent bifrontal or
generalized
epileptic discharges indicative of areas of cortical
irritability. In
addition, background was disorganized and diffusely slow
suggestive of
moderate encephalopathy with non-specific etiology. No
electrographic
seizures were present. Compared to prior day's recording, there
are no
significant differences.
[**3-30**]:
IMPRESSION: There were two pushbutton events for similar
trembling of
the right shoulder and forearm which clinically appeared likely
to be
seizure activity but did not have an identifiable EEG correlate.
The
record itself continues to show moderately severe diffuse
encephalopathy.
[**3-31**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of the continued presence of a diffuse encephalopathy. The
trends
analysis tends to suggest that the right hemisphere was slightly
more
involved than the left. Additionally, isolated interictal
epileptic
activity was seen from the right frontal and, to a lesser
degree, left
frontal regions. Short duration bursts of rhythmic activity were
also
seen that may represent projected abnormalities or briefly
limited
electrographic seizure activity with no clear clinical
accompaniments.
Additionally, the staff detected possible seizures clinically
that did
not appear to have a clear electrographic correlate even though
they
appeared to be highly suggestive of a clinical seizure activity.

Compared to the prior day's recording, there were no significant

changes.
[**4-1**]:
IMPRESSION: This is an abnormal waking EEG because of diffuse
slowing
of background activity compatible with a diffuse encephalopathic

process. Superimposed upon this were relatively focal interictal

epileptic spike and spike wave discharges in the right frontal
region.

ECG:
Sinus rhythm. Rightward axis. Baseline artifact.
Intraventricular conduction
delay. No previous tracing available for comparison.
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
67 176 116 372/384 60 86 65

[**3-21**] CXR:
IMPRESSION: Hazy appearance of left upper lung with suspected
volume loss, an appearance suggesting extensive atelectasis of
the left upper lobe.

[**3-21**] Shunt series Xray:
IMPRESSION:
1. Per patient's history, patient has a VA (ventricular atrial)
shunt;
however, tubing is only seen to the level of the distal right
neck. No tubing seen over the thorax.
2. Interval removal of nasogastric tube with now marked gaseous
distention of the stomach.

[**3-25**] CXR:
There is unchanged evidence of a relatively extensive left lung
parenchymal opacity that is exaggerated on today's radiograph
given patient positioning. The pre-existing right middle and
lower lung opacity is constant. Unchanged position of the
vertebral stabilization devices. The contour of the cardiac
silhouette cannot be delineated on the current image.

[**3-26**] NCHCT:
IMPRESSION:
Study limited by patient motion and positioning.
Right posterior approach ventriculostomy catheter tip projects
in the right lateral ventricle. Ventriculomegaly may be
unchanged compared to the prior examination, however, difficult
to get accurate measurements at reliable comparable levels given
differences in positioning between this study and the outside
hospital CT of [**2155-3-21**]. Findings discussed with Dr.
[**Last Name (STitle) 110701**] at 4:48 a.m. on [**2154-3-25**] via telephone.

[**3-28**] CT Chest without contrast:
IMPRESSION: Moderate-to-severe upper mediastinal
lymphadenopathy. Extensive left lung consolidation with
subsequent volume loss, moderate left pleural effusion.
Mild-to-moderate right pleural effusion with dependent
atelectasis and several non-characteristic ground-glass nodules
in the upper-to-mid lung. Moderate dilatation of the pulmonary
artery, potentially indicative of pulmonary hypertension.
Moderate cardiomegaly without evidence of relevant coronary
calcifications. Status post vertebral fixation devices.
Assessment of the lung parenchyma is limited by severe
respiratory motion artifacts.

[**4-2**] Video Oropharyngeal swallow:
FINDINGS: Barium passed freely through the oropharynx and
esophagus without evidence of obstruction. There was penetration
with thin liquids but no gross aspiration. For details, please
refer to speech and swallow division note in OMR.
IMPRESSION: Penetration with thin liquids, no evidence of gross
aspiration.


Brief Hospital Course:
[**Known firstname 3403**] [**Known lastname 110699**] is a 47 year-old man with severe intellectual
disabilty, VP shunt for hydrocephalus, and chronic UTIs who was
at home and had a generalized seizure reported as whole body
shaking by his [**Doctor Last Name **] mother. [**Name (NI) **] was taken to [**Hospital 8641**] hospital
loaded with fosphenytoin and intubated, then medflighted to
[**Hospital1 18**]. In the ED he had persistent left arm shaking and a
stat-net which showed right frontal rhythmic discharges. He was
loaded with Keppra and propofol was uptitrated to motor
supression. His exam off propofol was notable for macrocephaly,
dysmorphic facial features, intact cranial nerves, and rhythmic
left arm shaking. His CT done at [**Location (un) 8641**] showed stable
hydrocephalus. His labs were grossly positive for a UTI. Given
the current infection and poor substrate it is possible that
these seizures were purely in the setting of infection. There
was a questionable history of a stroke in [**2153**] which would also
be a plausible explanation for seizure focus, although infection
was more likely. During his 12 day NeuroICU course, the patient
was primarily seizure free until a short R shoulder twitching
witnessed on [**3-31**] prior to transfer to the floor. His primary
issue was pulmonary with mucus plugging when attempted
extubation. Patient again self-extubated [**3-31**] (for the 3rd time)
and after this his respiratory status remained stable and he was
able to be transferred to the regular neuro floor.
.
# Neuro: Given pt had been primarily seizure free during his
stay, he was started to be weaned off pheyntoin.  On [**3-31**] 3am
the only seizure activity that was seen involved right shoulder
twitching with probable EEG correlate which was limited and
self-resolved.  His phenytoin was held at 100mg [**Hospital1 **] with plans
to possibly wean in the future.  He was continued on keppra
1,000mg TID, which was transitioned to 1500mg [**Hospital1 **].  However, on
[**4-5**] he again had some twitching of his R shoulder that
self-resolved after 5-10 seconds.  His phenytoin level was
checked and it was <0.6.  Therefore, he was given a loading dose
and his mantenance was increased to 150mg [**Hospital1 **].  His level
increased, but on [**4-7**] he had another very brief episode of R
shoulder twitching and his phenytoin level was again very low.
He was given a nother loading dose and his maintenance was
increased to 200mg [**Hospital1 **].  However, his level on [**4-9**] was 8.2 so he
was increased to 250/250mg of phenytoin and has done well.
He will need his phenytoin level checked 3 days after dispo.

# ID: pt remained afebrile throughout most of his course, but
during his ICU stay he had a Morganella UTI, MRSA PNA and a
psuedomonas UTI all of which were treated with ABx the cultures
showed sensitivities to prior to his being discharged from the
hospital.
.
# Renal: patient was noted on admission to have etabolic
alkalosis with compensatory resp CO2 retainment. We suspected a
chronic etiology as patient's HCO3 elevated at admission and on
prior labs obtained from OSH. Per PCP, HCO3 has ranged 29-38 for
the past year. We consulted renal, who had some fluid recs, but
once it becema apparent that this was likely a chronic issue,
they recommended that pt f/u with a nephrologist closer to NH as
an outpatient. In addition, we got a renal US that showed a
small kidney, which they recommended could be followed as an
outpatient also.

# Pulm: Pt self-extubated for 3rd time on [**3-31**] and thereafter
remained stable on NC, then was weaned to RA successfully
without incident.
.
#GI: patient passed a speech and swallow video for a diet of
nectar thick liquid and puree.  He was initially on TF's ntil he
could take in enough calories on the above regimen, which were
then stopped once he met the required calorie counts.

# CODE/CONTACT: full code as per [**Doctor Last Name **] mother [**Name (NI) **]
([**Telephone/Fax (1) 110702**]

PENDING RESULTS:
None

TRANSITIONAL CARE ISSUES:
Patient will need his phenytoin level checked 3 days after
discharge to ensure that he isn't sub or supratherapeutic.


Medications on Admission:
Zyprexa
Citalopram 10 daily
Provigil 100 mg daily
Nexium 40 mg QHS
Nexium
Miralax
Vit D
MVI
Tylenol PRN


Discharge Disposition:
Home With Service

Facility:
Amedisys NH HH & Hospice

Discharge Diagnosis:
Seizure
Mucous Plugging
Pneumonia
UTI


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mr. [**Known lastname 110699**],
You were seen in the hospital for seizures.  You were admitted
to the ICU because you had to be intubated to stop your
seizures.  There, it was difficult to extubate you.  However,
once you were successfully extubated you did well and were able
to be sent home.

We made the following changes to your medications:
1) We STOPPED your PROVIGIL.
2) We STOPPED your ZYPREXA.
3) We STARTED you on KEPPRA 1500mg twice a day.
4) We STARTED you on PHENYTON 250mg every 12 hours.

Please continue to take your other medications as previously
prescribed.

If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.

It was a pleasure taking care of you on this hospitalization.

Please follow these seizure safety guidelines:
SEIZURE SAFETY
________________________________________________________________

The following tips will help you to make your home and
surroundings as safe as possible during or following a seizure.
Some people with epilepsy will not need to make any of these
changes.  Use this list to balance your safety with the way you
want to live your life.

Make sure that everyone in your family and in your home knows:
- what to expect when you have a seizure
- correct seizure first aid
- first aid for choking
- when it is (and isn't) necessary to call for emergency help

Avoid things that are known to increase the risk of a seizure:
- forgetting to take medications
- not getting enough sleep
- drinking a lot of alcohol
- using illegal drugs

In the kitchen:
- As much as possible, cook and use electrical appliances only
when someone else is in the house.
- Use a microwave if possible.
- Use the back burners of the stove. Turn handles of pans toward
the back of the stove.
- Avoid carrying hot pans; serve hot food and liquids directly
from the stove onto plates.
- Use pre-cut foods or use a blender or food processor to limit
the need for sharp knives.
- Wear rubber gloves when handling knives or washing dishes or
glasses in the sink.
- Use plastic cups, dishes, and containers rather than breakable
glass.

In the living room:
- Avoid open fires.
- Avoid trailing wires and clutter on the floor.
- Lay a soft, easy-to-clean carpet.
- Put safety glass in windows and doors.
- Pad sharp corners of tables and other furniture, and buy
furniture with rounded corners.
- Avoid smoking or lighting fires when you're by yourself.
- Try to avoid climbing up on chairs or ladders, especially when
alone.
- If you wander during seizures, make sure that outside doors
are
securely locked and put safety gates at the top of steep stairs.

In the bedroom:
- Choose a wide, low bed.
- Avoid top bunks.
- Place a soft carpet on the floor.

In the bathroom:
- Unless you live on your own, tell a family member or [**Name2 (NI) 8317**]
before you take a bath or shower.
- Hang the bathroom door so it opens outward, so it can be
opened
if you have a seizure and fall against it.
- Don't lock the bathroom door.  Hang an "Occupied"  sign on the
outside handle instead.
- Set the water temperature low so you won't be hurt if you have
a seizure while the water is running.
- Showers are generally safer than baths.  Consider using a
hand-
held shower nozzle.
- If taking a bath, keep the water shallow and make sure you
turn
off the tap before getting in.
- Put non-skid strips in the tub.
- Avoid using electrical appliances in the bathroom or near
water.
- Use shatterproof glass for mirrors.

At work:
- Consider telling your co-workers that you have epilepsy and
the
correct first aid for seizures.
- Climb only as high as you can fall without injuring yourself.
- When working around machinery, make sure that safety features
are in place, and consider wearing protective clothing.
- Try to keep consistent work hours so you don't have to go a
long time without sleep.
- Try to limit your exposure to flashing lights if this can
trigger your seizures.

Out and about:
- Carry only as many medications with you as you will need, and
2
spare doses.
- Wear a medical alert bracelet to let emergency workers and
others know that you have epilepsy.
- Stand well back from the road when waiting for the bus and
away
from the platform edge when taking the subway.
- If you wander during a seizure, take a friend along.
- Don't let fear of a seizure keep you at home.

Sports:
- Use common sense to decide which sports are reasonable.
- Exercise on soft surfaces.
- Wear a life vest when you are close to water.
- Avoid swimming alone.  Make sure someone with you can swim
well
enough to help you if you need it.
- Wear head protection when playing contact sports or when there
is a risk of falling.
- When riding a bicycle or rollerblading, wear a helmet, knee
pads, and elbow pads.  Avoid high traffic areas; ride or skate
on
side roads or bike paths.

Driving:
- You may not drive in [**State 350**] unless you have been
seizure- free for at least 6 months.
- Always wear a seatbelt.

Parenting:
- Childproof your home as much as possible.
- If you are nursing a baby, sit on the floor or bed with your
back supported so the baby will not fall far if you should lose
consciousness.
- Feed the baby while he or she is seated in an infant seat.
- Dress, change, and sponge bathe the baby on the floor.
- Move the baby around in a stroller or small crib.
- Keep a young baby in a playpen when you are alone, and a
toddler in an indoor play yard, or childproof one room and use
safety gates at the doors.
- When out of the house, use a bungee-type cord or restraint
harness so your child cannot wander away if you have a seizure
that affects your awareness.
- Explain your seizures to your child when he or she is old
enough to understand.


Followup Instructions:
Department: NEUROLOGY
When: WEDNESDAY [**2155-5-14**] at 1 PM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Please also call your PCP to have him arrange an appointment
with a nephrologist (a kidney doctor) near to your home.
{'Grand mal status,Urinary tract infection, site not specified,Methicillin resistant pneumonia due to Staphylococcus aureus,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Severe intellectual disabilities,Mixed acid-base balance disorder,Foreign body in main bronchus,Endocardial cushion defect, unspecified type,Obstructive hydrocephalus,Diverticulum of bladder,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Ileostomy status,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Esophageal reflux,Leukocytosis, unspecified,Anemia, unspecified,Other testicular hypofunction,Vitiligo,Narcolepsy, without cataplexy,Scoliosis [and kyphoscoliosis], idiopathic,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation,Physical restraints status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history, urinary (tract) infection,Acquired absence of intestine (large) (small),Other postprocedural status,Arthrodesis status'}


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: status epilepticus

PRESENT ILLNESS: [**Known firstname 3403**] [**Known lastname 110699**] is a 47 year-old man with a history of severe
intellectual disabilty (non-verbal at baseline) who was
transferred from home to [**Hospital 8641**] Hospital in NH after reportedly
having whole body shaking (unknown duration). Records indicate
that he was given 1 mg of Ativan in addition to a load of
Fosphenytoin at 1200 PE x1. He continued to having shaking
movements and was intubated and sedated on propofol and
medflighted to [**Hospital1 18**]. In the ED off of propofol he continues to
have rhythmic shaking of his left arm more than the right.

MEDICAL HISTORY: Severe intellectual disability - nonverbal, reportedly
understands when spoken to.
Hydrocephalus
? Stroke in [**2153**] - unknown details
Total colectomy and end ileostomy
Scoliosis
Osteoarthritis
Anemia
Endocardial cushion defect
Hypogonadism
Vitiligo
Hiatal Hernia
GERD
Chronic UTIs
Narcolepsy
Polydipsia
MRSA infections

MEDICATION ON ADMISSION: Zyprexa
Citalopram 10 daily
Provigil 100 mg daily
Nexium 40 mg QHS
Nexium
Miralax
Vit D
MVI
Tylenol PRN

ALLERGIES: Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: At admission:
Vitals: 98.3 P 72 BP 134/82 R 16 SpO2 100%
General: intubated and sedated wi rhythmic movement of left arm
off sedation
HEENT: macrocephalic, patchy discoloration of hair
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: coarse breath sounds
Cardiac: RRR, no murmurs
Abdomen: colostomy bag, soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.

FAMILY HISTORY: unknown and unable to obtain

SOCIAL HISTORY: Lives with his [**Doctor Last Name **] mother. Nonverbal at baseline. Able to
walk
short distances to wheelchair. 

### Response:
{'Grand mal status,Urinary tract infection, site not specified,Methicillin resistant pneumonia due to Staphylococcus aureus,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Severe intellectual disabilities,Mixed acid-base balance disorder,Foreign body in main bronchus,Endocardial cushion defect, unspecified type,Obstructive hydrocephalus,Diverticulum of bladder,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Ileostomy status,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Esophageal reflux,Leukocytosis, unspecified,Anemia, unspecified,Other testicular hypofunction,Vitiligo,Narcolepsy, without cataplexy,Scoliosis [and kyphoscoliosis], idiopathic,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation,Physical restraints status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history, urinary (tract) infection,Acquired absence of intestine (large) (small),Other postprocedural status,Arthrodesis status'}
