CHIEF COMPLAINT: intubated - seizure

PRESENT ILLNESS: Patient is a 30 yo M who was at work earlier today, reportedly
witnessed to bend down, then have a tonic clonic seizure.

MEDICAL HISTORY: EtOH abuse, No h/o withdrawal seizures.
Tobacco use
pancytopenia

MEDICATION ON ADMISSION: folic acid 1 mg daily
multivitamin
thiamine
omeprazole 20 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PE on Admission to MICU
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

FAMILY HISTORY: unknown

SOCIAL HISTORY: + Hx of EtOH abuse - QUIT 2 months ago ([**5-/2169**]) - was
hospitalized for detox and had not had EtOH since.
Per PCP recs, patient originally from El [**Country 19118**].  In US since
[**2157**].  Unmarried, limited english.
Epilepsy, unspecified, without mention of intractable epilepsy,Acute respiratory failure,Other pancytopenia,Alcoholic cirrhosis of liver,Cerebellar or brain stem contusion without mention of open intracranial wound, with loss of consciousness of unspecified duration,Urinary tract infection, site not specified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Other and unspecified alcohol dependence, in remission,Cervicalgia,Fall resulting in striking against other object,Hypersplenism,Unspecified essential hypertension,Tobacco use disorder
Epilep NOS w/o intr epil,Acute respiratry failure,Other pancytopenia,Alcohol cirrhosis liver,Cerebell contus-coma NOS,Urin tract infection NOS,Enterococcus group d,Alcoh dep NEC/NOS-remiss,Cervicalgia,Fall striking object NEC,Hypersplenism,Hypertension NOS,Tobacco use disorder
Admission Date:  [**2169-8-4**]              Discharge Date:   [**2169-8-8**]

Date of Birth:  [**2138-10-10**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
intubated - seizure

Major Surgical or Invasive Procedure:
Intubation


History of Present Illness:
Patient is a 30 yo M who was at work earlier today, reportedly
witnessed to bend down, then have a tonic clonic seizure.

EMS witnessed two seizures per report in transport, observed R
eye deviation. Patient was take to [**Hospital1 18**] and intubated upon
arrival. Per ER report, prior to intubation the patient was
withdrawing all 4 extremities to noxious stim. He was taken to
CT where his head CT showed a punctate hemorrhage on the left
posterior vertex. Neurosurgery was called to evaluate. They
recommended Neuro c/s, EEG, dilantin loading. Pt also had INR 2
and was given FFP. Neuro consulted, recommended changing
sedation to benzos, as thought this likely withdrawal related.

Labs notable for plt 50, INR 2, pos urine benzos. Anion gap 17.
ABG after intubation was 7.36/32/453/19 on AC 100% FIO2. Patient
given dilantin 250, banana bag, propofol, midaz, fentanyl and
naloxone. Ordered for 2 units ffp, did not get prior to
transfer.

On arrival to the MICU, patient intubated and sedated, unable to
provide further information.


Past Medical History:
EtOH abuse, No h/o withdrawal seizures.
Tobacco use
pancytopenia


Social History:
+ Hx of EtOH abuse - QUIT 2 months ago ([**5-/2169**]) - was
hospitalized for detox and had not had EtOH since.
Per PCP recs, patient originally from El [**Country 19118**].  In US since
[**2157**].  Unmarried, limited english.

Family History:
unknown


Physical Exam:
PE on Admission to MICU
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

PE on DISCHARGE:
VS 98.7 90 120/68 18 100%RA
Gen: awake, alert, NAD
CV: RRR, no m/r/g
Resp: CTAB
Abd: soft/NT/ND
Ext - WWP, no c/c/e


Pertinent Results:
Labs on Admission:
[**2169-8-4**] 08:41AM   WBC-8.3 RBC-4.35* HGB-14.3 HCT-42.6 MCV-98
MCH-33.0* MCHC-33.7 RDW-19.7*
[**2169-8-4**] 08:41AM   PLT COUNT-50*
[**2169-8-4**] 08:41AM   PT-21.2* PTT-39.9* INR(PT)-2.0*
[**2169-8-4**] 08:41AM   FIBRINOGE-175*
[**2169-8-4**] 08:41AM URINE  bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2169-8-4**] 09:00AM   GLUCOSE-105 NA+-141 K+-3.2* CL--111* TCO2-13*
[**2169-8-4**] 08:39PM   PLT COUNT-31*

Labs on Discharge:
[**2169-8-8**] 08:05AM BLOOD WBC-2.0* RBC-3.27* Hgb-10.7* Hct-30.8*
MCV-94 MCH-32.6* MCHC-34.6 RDW-19.4* Plt Ct-38*
[**2169-8-7**] 08:25AM BLOOD PT-22.9* PTT-36.5 INR(PT)-2.2*
[**2169-8-6**] 01:39PM BLOOD Fibrino-220
[**2169-8-7**] 08:25AM BLOOD Glucose-100 UreaN-7 Creat-0.8 Na-137
K-3.7 Cl-105 HCO3-26 AnGap-10
[**2169-8-8**] 08:05AM BLOOD ALT-20 AST-41* AlkPhos-54 TotBili-3.1*
[**2169-8-7**] 08:25AM BLOOD Albumin-2.7* Calcium-7.9* Phos-2.6*
Mg-1.6

Imaging:
[**8-4**] CT head: L posterior vertex small hemorrhage/contusion, no
calvarial fracture, soft tissue swelling overlying R orbit,
chronic nasal bone fx

[**8-4**] CT Cspine: Linear lucency through anterior aspect of C5
transverse foramen (102:164),likely congenital non-fusion and
less likely fracture. No acute alignmentabnormality or
prevertebral soft tissue abnormality (in setting of intubation).

[**8-4**] CT Maxillo: Soft tissue edema overlying right orbit. No
underlying orbital fracture.  Chronic-appearing minimally
displaced nasal bone fractures.

EEG [**2169-8-5**]: IMPRESSION: This is an abnormal continuous ICU
monitoring study because of low voltage and moderate diffuse
background slowing with excess diffuse beta activity. These
findings are indicative of moderate diffuse cerebral dysfunction
which is etiologically non-specific. Excessive beta activity is
likely a medication effect. The focal attenuation of faster
frequencies and intermittent focal slowing over the left
hemisphere is less prominent on today's study than yesterday.
This is indicative of focal cerebral dysfunction involving
cortical and subcortical structures on the left. No epileptiform
discharges or electrographic seizures are present. Compared to
the prior day's study, beta activity is less prominent, and the
hemispheric asymmetry is also less prominent.

CT Head [**8-5**]: IMPRESSION:
1.  Slight interval increase in size of punctate hemorrhages in
the left
parietal lobe, without mass effect.
2.  Interval increase in fluid within the left mastoid air cells
and left
middle ear cavity, though no fracture is seen.
NOTE ADDED IN ATTENDING REVIEW: The three punctate hemorrhagic
foci, located at the left frontoparietovertex [**Doctor Last Name 352**]-white matter
junction may reflect diffuse axonal ("shear") injury, and should
be correlated with the patient's neurologic status. If warranted
on clinical grounds, and feasible, these might be further
characterized by non-enhanced MR examination.

CT Head [**8-7**]:
IMPRESSION:
1. No significant change in left parietal lobe intraparenchymal
hemorrhages since [**2169-8-5**]. No new hemorrhage. If the etiology of
these hemorrhages is unknown then an MR examination may be
helpful. These may reflect small hemorrhagic infarctions,
cortical venous thrombosis, or a neoplastic lesion.
2. Global atrophy, more than expected for patient's age.

PENDING:
EEG [**8-8**]

Brief Hospital Course:
30 yo M with Hx of EtOH abuse, found down at work, reported to
have witnessed seizure activity and cerebral hemorrhage that
required intubation.

Active Issues:
#Acute respiratory failure-resolved:
Pt required intubated given altered mental status in the setting
of seizures. Pt extubated after one day on the vent, without
issue. He was discharged off of supplemental oxygen and
clinically stable from a respiratory perspective. Pt was
transferred to the floor where he remained stable through
discharge.

#Cerebral hemorrhage: Pt most likely hit his head during his
seizing episodes.  He was seen withdrawing extremities to
noxious stimuli only.  Head CT showed 2 Small left punctate
hemorrhages in posterior vertex.  Neurosurgery was consulted and
recommended no acute interventions.  Pt received Vitamin K and
FFP to normalize his elevated INR.  Also, received 1 unit PLTs
in setting of thrombocytopenia. Pt was only mildly responsive to
FFP and Vit K. It is thought that this is due to significant
cirrhosis (see below).

# Witnessed seizures:
Pt had 2 witnessed seizures with right eye deviation that
required intubation for airway protection for one day without
complications.  Without history, it was assumed that pt was
seizing due to EtOH withdrawal. However, upon stabilization and
transfer to the floor, pt reports that he has not had anything
to drink for the last two months and was detoxed while
hospitalized.  Pt also reports seizure one month prior to
admission for which he went to outside hospital, was "scanned"
and "they said I could leave." Neurology re-consulted and
recommended starting Keppra 1g [**Hospital1 **] for possible new-onset
seizure disorder. Pt to follow-up with neuro as outpt.

#C-spine trauma: Pt reported neck pain s/p seizure and c-collar
placement.  During his MICU stay, we were unable to safely clear
his C-spine clinically. His C-spine CT did not show any acute
bone pathology. Upon transfer to the floor, C-spine was able to
be cleared clinicially without any further studies. C-spine CT
showed linear lucency through the anterior aspect of the right
C5 transverse foramen, likely congenital nonfusion, less likely,
fracture.  No acute alignment abnormality or prevertebral soft
tissue abnormality.  This abnormality was discussed with
neurosurgery who felt there was no acute issue to be addressed
and recommmended follow-up in the [**Hospital **] clinic with Dr. [**First Name (STitle) **].

#Thrombocytopenia: Most likely due to hypersplenism from EtOH
cirrhosis seen on imaging from OSH.  He received plts x1.   EtOH
abuse-last admission for withdrawal in [**6-/2169**], h/o withdrawal
seizures (questionable), has been going to AA (corroborated by
family report to RN); essential hypertension not on meds;
cirrhosis-had been on spironolactone, nadolol for varices, lasix
as of [**6-/2169**] discharge but not on med list from [**2169-7-11**].

#Anemia: Thought initially to be dilutional anemia and the
setting of multiple IVF boluses. There was no clinical evidence
of acute blood loss. Trended his H/H daily, followed his
hemodynamics and no transfusions were necessary. H/H remained
stable through discharge.

Chronic Diagnoses
#Cirrhosis: Pt has a significant history of EtOH abuse and
ultrasonographic evidence of cirrhosis. He would benefit
subsequent management for underlying liver disease (Nadolol,
Lasix, Spironolactone, etc.) with PCP and hepatology jointly
managing (per PCP [**Name Initial (PRE) **]).

#h/o EtOH abuse: Continued encouragement of attendance at AA,
family support. SW was consulted during admission who
recommended same.

***********Transitional Issues****************
#Outstanding issues:
PENDING - EEG [**2169-8-8**]
F/u with PCP who may consider referral to Hepatology for
cirrhosis.

#Family: contacts [**Name (NI) 25812**] (step-father, [**Name (NI) 483**] speaking)
[**Telephone/Fax (1) 112525**]; [**Name (NI) 92428**] (mother, spanish-speaking but is
decision-maker if needed) ([**Telephone/Fax (1) 112526**]

Medications on Admission:
folic acid 1 mg daily
multivitamin
thiamine
omeprazole 20 mg daily


Discharge Disposition:
Home

Discharge Diagnosis:
Seizure
Presumed cirrhosis


Discharge Condition:
Stable.


Discharge Instructions:
Dear Mr. [**Known lastname **],

You were admitted after having had a seizure.  When you came
into the emergency room by ambulance, you required a breathing
tub (you were intubated) and were monitored in the ICU.  They
were soon able to remove the breathing tube and you were
transferred to the floor. Because you described another episode
of seizure a month prior to this admission, the neurology
service (doctors [**First Name (Titles) 1023**] [**Last Name (Titles) **] in the brain and seizures) was
consulted. They recommended that you start a medication to help
prevent seizures and also an additional scan of your brain to be
done as an outpatient.

Additionally you were found to have a possible infection of your
urinary tract. You were started on antibiotics to clear this
infection.

Finally, your blood counts were found to be low.  This is likely
due to damage to your liver from your previous alcohol intake.
Please continue to abstain from alcohol.  You primary care
doctor might want you to see a Hepatologist (a doctor [**First Name (Titles) 1023**] [**Last Name (Titles) 44055**]s in the liver).

New medications:
START Keppra 1g PO BID
START Ampicillin 500mg PO q6hrs x 4 days

Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital **] [**Hospital **] COMMUNITY HEALTH CENTER
Address: [**Location (un) 72188**], [**Hospital1 **],[**Numeric Identifier 26661**]
Phone: [**Telephone/Fax (1) 31372**]
When: Thursday, [**2169-8-17**]:00 PM

We are working on follow up appointments in the Neurology
department with both Dr. [**First Name (STitle) 437**] and Dr. [**First Name (STitle) **].  You will be
called at home with appointments.   If you have not heard or
have questions, please call [**Telephone/Fax (1) 2928**] for Dr. [**First Name (STitle) 437**] and Dr.
[**First Name (STitle) **] at [**Telephone/Fax (1) 1690**].
.
{'Epilepsy, unspecified, without mention of intractable epilepsy,Acute respiratory failure,Other pancytopenia,Alcoholic cirrhosis of liver,Cerebellar or brain stem contusion without mention of open intracranial wound, with loss of consciousness of unspecified duration,Urinary tract infection, site not specified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Other and unspecified alcohol dependence, in remission,Cervicalgia,Fall resulting in striking against other object,Hypersplenism,Unspecified essential hypertension,Tobacco use disorder'}


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: intubated - seizure

PRESENT ILLNESS: Patient is a 30 yo M who was at work earlier today, reportedly
witnessed to bend down, then have a tonic clonic seizure.

MEDICAL HISTORY: EtOH abuse, No h/o withdrawal seizures.
Tobacco use
pancytopenia

MEDICATION ON ADMISSION: folic acid 1 mg daily
multivitamin
thiamine
omeprazole 20 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PE on Admission to MICU
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

FAMILY HISTORY: unknown

SOCIAL HISTORY: + Hx of EtOH abuse - QUIT 2 months ago ([**5-/2169**]) - was
hospitalized for detox and had not had EtOH since.
Per PCP recs, patient originally from El [**Country 19118**].  In US since
[**2157**].  Unmarried, limited english. 

### Response:
{'Epilepsy, unspecified, without mention of intractable epilepsy,Acute respiratory failure,Other pancytopenia,Alcoholic cirrhosis of liver,Cerebellar or brain stem contusion without mention of open intracranial wound, with loss of consciousness of unspecified duration,Urinary tract infection, site not specified,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Other and unspecified alcohol dependence, in remission,Cervicalgia,Fall resulting in striking against other object,Hypersplenism,Unspecified essential hypertension,Tobacco use disorder'}
