CHIEF COMPLAINT: Work-up of possible seizure disorder

PRESENT ILLNESS: 25 yo left-handed woman with seizures of unclear etiology since
[**2141**] in the setting of a history of drug and alcohol abuse and a
prior suicide attempt, and transferred here as a transfer from
[**Hospital 1562**] Hospital for evaluation and management of increasing
seizure frequency.  The history is obtained from the patient and
a review of records.  According to the patient, she had her
first
seizure at the end of [**2141**], in the context of drug abuse
("acid,"
cocaine, and marijuana).  However, she does not know any further
details regarding this event.  Records suggest that she may have
been seen in the ED in [**Location (un) 9101**] for seizures dating back to [**2141-7-21**].

MEDICAL HISTORY: Seizures as above
Drug and alcohol abuse (see below)
Has prior suicide attempt in 10th grade, overdose on Ibuprofen.

MEDICATION ON ADMISSION: Only on ortho-evra as outpatient

ALLERGIES: Sulfa (Sulfonamides) / Compazine / Keflex / Ativan

PHYSICAL EXAM: Afebrile
General: well nourished and in no acute distress
Neck: supple
Lungs: clear to auscultation
CV: regular rate and rhythm
Abdomen:  non-tender, non-distended, bowel sounds present
Ext: warm, no edema

FAMILY HISTORY: Family History: Years ago, her mother had several seizures as a
young adult, requiring hospitalization.  Little else known.

SOCIAL HISTORY: History of drug abuse including ecstasy, cocaine, acid, and
marijuana since [**2137**], but has reportedly abstained for 1.5
years.
No IVDU.  Alcohol consumption has continued, generally on
weekends "will have a few drinks."  Has been in rehab in both
10th grade and again in [**2142**].  Denies history of tobacco use.
Begins working full ime at animal hospital on Tuesday.
Other convulsions,Depressive disorder, not elsewhere classified,Other, mixed, or unspecified drug abuse, unspecified
Convulsions NEC,Depressive disorder NEC,Drug abuse NEC-unspec
Admission Date:  [**2143-11-13**]              Discharge Date:   [**2143-11-16**]

Date of Birth:  [**2118-7-7**]             Sex:   F

Service: NEUROLOGY

Allergies:
Sulfa (Sulfonamides) / Compazine / Keflex / Ativan

Attending:[**First Name3 (LF) 7573**]
Chief Complaint:
Work-up of possible seizure disorder

Major Surgical or Invasive Procedure:
None


History of Present Illness:
25 yo left-handed woman with seizures of unclear etiology since
[**2141**] in the setting of a history of drug and alcohol abuse and a
prior suicide attempt, and transferred here as a transfer from
[**Hospital 1562**] Hospital for evaluation and management of increasing
seizure frequency.  The history is obtained from the patient and
a review of records.  According to the patient, she had her
first
seizure at the end of [**2141**], in the context of drug abuse
("acid,"
cocaine, and marijuana).  However, she does not know any further
details regarding this event.  Records suggest that she may have
been seen in the ED in [**Location (un) 9101**] for seizures dating back to [**2141-7-21**].

She did not experience the next episode until [**2142**], when she
began having monthly episodes after undergoing drug
rehabilitation shortly after a close friend had died.  Prior to
these events, the patient describes an aura of nausea and
uneasiness.  While she does not recall the episodes, others have
told her that they involve shaking, eyes rolling back, foaming
at
the mouth, and occasionally associated with urinary
incontinence.
The events last a few minutes, and she awakens confused and
tired
for some time, able to speak but not move.
She had initially attributed these seizures to drug use and
possible subsequent withdrawal, but continued to have the single
events every few months.

She saw several physicians during [**2142**] (Dr. [**Last Name (STitle) 75768**] a
neurologist
in [**Location (un) 9101**] and Dr. [**First Name (STitle) **], a family physician in [**Name9 (PRE) 9188**]).  She
reports that she walked out of Dr.[**Name (NI) 75769**] office without
medications or testing early in [**2142**].  However, she reportedly
had a normal MRI and EEG there in [**2142-11-21**].  Dr. [**First Name (STitle) **]
prescribed depakote at some point, which caused her hair to fall
out.  Depakote was also too expensive and she stopped the
medication after 30 days, a period in which she was
seizure-free.
She also saw Dr. [**Last Name (STitle) 75770**] in [**Hospital1 112**], who performed a 24 hour
ambulatory EEG; records report "some abnormality" although the
patient reports a normal study.  She was not offered
anti-epileptic therapy at this time.  The patient refused 24
video-EEG monitoring, as she did not want to spend time away
from
her new puppy.  After she lost full-time work and thus her
health
insurance, she saw another physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], who gave her
valium as needed for sleep later in the year.

By early [**2143**], the seizures were occurring every few weeks.
She had been experiencing increasing seizure frequency since
[**Month (only) **]
or [**Month (only) 205**], for the first time experiencing "back to back"
episodes.
The events were similar as before; however, between these
consecutive episodes she can hear but not speak.  She apparently
reported to the ED in [**Hospital1 1562**] with her boyfriend on [**2143-11-12**],
after a night of heavy alcohol consumption while playing pool in
[**Location (un) 9101**].  The patient only recalls seizing on the way home and
apparently had 6 before arrival to the hospital.  She could not
offer further details.  She was apparently sedated, paralyzed,
and intubated for frequent, recurrent seizures.  Of particular
note, blood alcohol level there was elevated at 138 but a tox
screen was negative.  The patient was loaded with fosphenytoin,
and sent to the ICU, where she was continued on 200 mg [**Hospital1 **].  She
was extubated in the ICU at ~10 am on [**2143-11-12**], about 10 hours
after she had been intubated.  The patient reports that she
seized 8 times while at [**Hospital1 1562**].  She received valium 5 mg prn
for some of seizure episodes as well as agitation last evening.

Seizures were non-stereotyped.  One, by neurologist's report,
consisted of clonic movement of arms and legs in phase, eyes
closed (not in forced nature), left gaze deviation with passive
eye opening.  She was non-verbal and blinking afterwards, then
suddenly awoke and conversed on appropriate treatment.  Another,
seen by a nurse, began with choking, then diffuse tremulousness,
"like a panic attack."  Her eyes were open, gaze down and to the
left.  This episode lasted 13 minutes.  On transport into the
unit here, she was having an episode described by nursing as
unusual oral movements with the production of saliva, with
associated writhing and rolling on her side.  The paramedics
gave
her 5 mg valium as she came into out trauma SICU.  Vitals were
completely stable and the episode resolved after minutes.

Review of Systems:
Reports recurrent head trauma in past, falling from a hose "more
times than I can count."  Eating and sleeping well.  Recently
stopped valium after her physician stopped prescribing it.
Denies assocoaition of events with menstruation or stress.  No
history meningitis.  Over past few months, left frontal
throbbing
headache, associated with photo- and phonophobia, relieved with
rest in a dark room and Excedrin migraine.  This headache
awakens
her from sleep, but no postural component or worsening with
Valsalva.  Two weeks ago, had "sore throat" with low grade fewer
to [**Age over 90 **] F.  Received "ZPac."  Patient reports frequent urination,
10-15 times per day.  Bowel habits regular.  A thorough review
of
neurological systems, including weakness, numbness, tingling,
dysarthria, dysphagia is negative.  She states she occasionally
stutters.  Denies suicidal or homicidal ideation.

Past Medical History:
Seizures as above
Drug and alcohol abuse (see below)
Has prior suicide attempt in 10th grade, overdose on Ibuprofen.

Pneumomediastinum [**2140**]
Depression
HPV, s/p scrapings/biopsy
Recurrent bladder infections

Social History:
History of drug abuse including ecstasy, cocaine, acid, and
marijuana since [**2137**], but has reportedly abstained for 1.5
years.
No IVDU.  Alcohol consumption has continued, generally on
weekends "will have a few drinks."  Has been in rehab in both
10th grade and again in [**2142**].  Denies history of tobacco use.
Begins working full ime at animal hospital on Tuesday.


Family History:
Family History: Years ago, her mother had several seizures as a
young adult, requiring hospitalization.  Little else known.

Physical Exam:
Afebrile
General: well nourished and in no acute distress
Neck: supple
Lungs: clear to auscultation
CV: regular rate and rhythm
Abdomen:  non-tender, non-distended, bowel sounds present
Ext: warm, no edema

Neurologic Examination:
Mental Status:
Awake and alert, cooperative with exam, restricted affect
Oriented to person, place, time and president
Attention: can say days of week backward and forward
Language: fluent, no dysarthria, no paraphasic errors, naming
intact
Fund of knowledge normal, can perform crossed body commands
Registration: [**3-23**] items, recall [**3-23**] items at 3 minutes
No apraxia, No neglect
Calculations intact

Cranial Nerves:
Optic disc margins sharp; Visual fields are full to
confrontation. Pupils equally round and reactive to light, 5 to
3
mm bilaterally.  Extraocular movements intact, no nystagmus.
Facial sensation and facial movement normal bilaterally. Hearing
intact to finger rub bilaterally. Tongue midline, no
fasciculations.  Trapezius normal bilaterally.


Motor:
Normal bulk and tone throughout
No adventitious movements

      D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 5 * * 5  5  5   5   5  5  5 5  5  5  5  5
Left  5 5 5 5  5  5   5   5  5  5 5  5  5  5  5
* not tested due to uncomfortable line in place

Sensation was intact to light touch, pin prick, temperature
(cold), vibration, and proprioception

Reflexes: B T Br Pa Pl
Right     3 2 3  2  1
Left      3 2 3  2  1
Toes were downgoing on left, mute on right

Coordination is normal on finger-nose-finger (left only tested
give discomfort with line in right arm), FFMs normal, heel to
shin also normal

Pertinent Results:
Outside Hospital studies:
WBC on admission was 11.7 (abs lymps high, 4.7) then 9.8, H/H
12.6 and 36.  BAL 138, tox screen was negative.  Review of
chemistries, LFTs, serum HCG, UA on admission was unremarkable.
Dilantin levels 17.8, then 21 on repeat.  Prolactin level 11.
Normal head CT, except partial opacification of ethmoid air
cells.  EKG, CXR essentially unremarkable.


[**2143-11-16**] 08:15AM BLOOD WBC-9.1 RBC-4.02* Hgb-12.7 Hct-37.1
MCV-92 MCH-31.6 MCHC-34.2 RDW-13.1 Plt Ct-456*
[**2143-11-16**] 08:15AM BLOOD Plt Ct-456*
[**2143-11-16**] 08:15AM BLOOD Glucose-80 UreaN-10 Creat-0.7 Na-138
K-4.5 Cl-102 HCO3-29 AnGap-12
[**2143-11-16**] 08:15AM BLOOD ALT-16 AST-16 Amylase-54
[**2143-11-14**] 03:04AM BLOOD ALT-20 AST-25 LD(LDH)-154 AlkPhos-44
TotBili-0.4
[**2143-11-16**] 08:15AM BLOOD Albumin-3.5 Calcium-9.5 Phos-4.0 Mg-2.2
[**2143-11-15**] 03:38AM BLOOD Phenyto-15.1

EEG [**11-15**] This telemetry captured a single pushbutton
activation.
This showed an episode of writhing in bed, without clinical
features
suggestive of a seizure. The EEG showed normal wakefulness at
the time.
Routine sampling and automated detection showed no epileptiform
features
or electrographic seizures

EEG [**11-16**] Report to follow. Please refer to brief hospital
course for preliminary results (of importance).

Brief Hospital Course:
The patient was admitted, as outlined in detail in the history
of present illness, to qualify the nature of the recurrent
episodes concerning for seizures.

On [**11-15**], a single pushbutton event was analyzed, but it was not
a classical spell.

On [**11-16**] however, the patient had more than 7 episodes that,
also upon review of the video, were slight different each time,
but had a common pattern as follows: The patient would become
restless first, with non-specific semi-purposeful movements,
writhing in bed, rocking left to right, whimpering somewhat at
times. Her vital signs would remain stable. These behaviors
could last up to several minutes, and did not have any
stereotyped or rhytmic component to it. She would then arch her
back lightly, and would have non-synchronous random movements of
arms and legs, with intermittent bicycling movements. Then, the
behaviors would become more violent, with rhymthmic shakinng of
all 4 limbs, however still with limited synchrony, and pelvic
thrusting. Frothing at the mouth was seen, and the patient would
desaturate on occasion, but no tongue bite or urinary
incontince. Duration of this motor phase was again in the realm
of 2 minutes, and she could desturate (but with poor quality
signal on pulse-oximetry). Afterwards, she would have a normal
facial color, breath rapidly but regularly and not hypotonic.
She would not make eye contact until her name was called
repeatedly.

On EEG, there were no epileptiform abnormalities, prior, during
or after these events. Just prior, during the writhing phase, a
normal posterior dominant rhythm was identified. During the more
pronounced motoric phase, there was prominent muscle artifact as
well as large deflections [**Last Name (un) **] atypical morphology were seen,
representing movement artifact. At times, a normal background
EEG could be seen through this artifact. Post-ictally, there was
an immediate return of normal background, with a well-formed
reactive alpha-rhythm and a nice anterior-posterior frequency
amplitude gradient.

The family visited on Saturday the 27th and the Epilepsy Fellow
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] spoke to them and the patient at lenght,
explaining the nature of these non-epileptic events. The patient
was very understanding, and indicated that Dr [**Last Name (STitle) 75770**] had also
suggested such a thing. She expressed relief in the fact that we
were finally able to clarify the nature and that they are not
life-threatening. She felt like this good news would probably
already decrease the severity of the spells and she may be able
to fight them off better. The father was content and relieved,
but did say he had some worries about being discharged without
follow-up. We ensured him we could function as a backup and are
available by phone. We prescribed a small dose of Klonopin to
bridge [**Known firstname **] [**Last Name (NamePattern1) **] until follow-up.

We will contact Dr [**Name (NI) 75770**] at the B&W hospital, and will
provide the EEG data as well as our official read. There's a
followup scheduled already on [**11-27**] at 3PM.

Medications on Admission:
Only on ortho-evra as outpatient


Discharge Medications:
1. Klonopin 0.5 mg Tablet, Rapid Dissolve Sig: [**1-22**] Tablet, Rapid
Dissolves PO PRN maximum 3 times per day as needed for anxiety
leading to non-epileptic seizures.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*1*


Discharge Disposition:
Home

Discharge Diagnosis:
Non-epileptic seizures.


Discharge Condition:
Stable, afebrile, normal neurological exam.


Discharge Instructions:
You have been admitted for seizures that have been shown to be
of non-epileptic origin, as we have discussed. We have started
you on a medication called Klonopin (clonazepam) to decrease
anxiety related to these episodes. If there is insufficient
control of the episodes with Klonopin, the knowledge that these
are not life-threatening, the education we provied and the
follow-up plans that are coming in place, please contact us at
[**Telephone/Fax (1) 22727**] (ask for Epilepsy person on call). The same applies
with questions or concerns.

As we have discussed, the approach to managing these events will
be multimodal. You should probably be referred to a behavioral
neurologist and/or a psychiatrist, to help you address these
episodes and develop coping strategies for current stressors.

Followup Instructions:
Please follow-up with your epileptologist, Dr. [**First Name4 (NamePattern1) 2048**]
[**Last Name (NamePattern1) 75771**], at the [**Hospital6 1708**] at 3pm on
[**2143-11-27**]. Call [**Telephone/Fax (1) 68966**] with questions.



Completed by:[**2143-11-16**]
{'Other convulsions,Depressive disorder, not elsewhere classified,Other, mixed, or unspecified drug abuse, unspecified'}


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: Work-up of possible seizure disorder

PRESENT ILLNESS: 25 yo left-handed woman with seizures of unclear etiology since
[**2141**] in the setting of a history of drug and alcohol abuse and a
prior suicide attempt, and transferred here as a transfer from
[**Hospital 1562**] Hospital for evaluation and management of increasing
seizure frequency.  The history is obtained from the patient and
a review of records.  According to the patient, she had her
first
seizure at the end of [**2141**], in the context of drug abuse
("acid,"
cocaine, and marijuana).  However, she does not know any further
details regarding this event.  Records suggest that she may have
been seen in the ED in [**Location (un) 9101**] for seizures dating back to [**2141-7-21**].

MEDICAL HISTORY: Seizures as above
Drug and alcohol abuse (see below)
Has prior suicide attempt in 10th grade, overdose on Ibuprofen.

MEDICATION ON ADMISSION: Only on ortho-evra as outpatient

ALLERGIES: Sulfa (Sulfonamides) / Compazine / Keflex / Ativan

PHYSICAL EXAM: Afebrile
General: well nourished and in no acute distress
Neck: supple
Lungs: clear to auscultation
CV: regular rate and rhythm
Abdomen:  non-tender, non-distended, bowel sounds present
Ext: warm, no edema

FAMILY HISTORY: Family History: Years ago, her mother had several seizures as a
young adult, requiring hospitalization.  Little else known.

SOCIAL HISTORY: History of drug abuse including ecstasy, cocaine, acid, and
marijuana since [**2137**], but has reportedly abstained for 1.5
years.
No IVDU.  Alcohol consumption has continued, generally on
weekends "will have a few drinks."  Has been in rehab in both
10th grade and again in [**2142**].  Denies history of tobacco use.
Begins working full ime at animal hospital on Tuesday. 

### Response:
{'Other convulsions,Depressive disorder, not elsewhere classified,Other, mixed, or unspecified drug abuse, unspecified'}
