CHIEF COMPLAINT: Epilepsy

PRESENT ILLNESS: 46 yo right handed man with intractable epilepsy secondary to
traumatic brain injury. Multiple failed medication trials. On
[**2175-8-30**] he had depth electrodes and grid placement for seizure
foci mapping.

MEDICAL HISTORY: Epilepsy secondary to trauma

MEDICATION ON ADMISSION: Dilantin 200 mg every morning
Dilantin 300 mg every evening
(Brand Name Only)

ALLERGIES: Bee Pollens

PHYSICAL EXAM: Physical Exam:
On Admission:
AOx3, neurologically intact.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Married, lives with wife.
Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy,Late effect of intracranial injury without mention of skull fracture,Late effects of other accidents,Other acute postoperative pain,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Psymotr epil w intr epil,Lt eff intracranial inj,Late eff accident NEC,Acute postop pain NEC,Abn reac-organ rem NEC
Name:  [**Known lastname 1937**],[**Known firstname 126**]                 Unit No:   [**Numeric Identifier 12892**]

Admission Date:  [**2175-10-25**]              Discharge Date:   [**2175-10-30**]

Date of Birth:  [**2129-5-3**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Bee Pollens

Attending:[**First Name3 (LF) 3656**]
Addendum:
Patient was to be discharged on [**10-29**], but pain management was an
issue and he was kept inpatient for pain management.

Chief Complaint:
Epilepsy

Major Surgical or Invasive Procedure:
[**2175-10-25**]: s/p left temporal lobectomy with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1703**]


History of Present Illness:
46 yo right handed man with intractable epilepsy secondary to
traumatic brain injury. Multiple failed medication trials. On
[**2175-8-30**] he had depth electrodes and grid placement for seizure
foci mapping.


Past Medical History:
Epilepsy secondary to trauma

Social History:
Married, lives with wife.


Family History:
Non-contributory

Physical Exam:
Physical Exam:
On Admission:
AOx3, neurologically intact.

At Discharge:
The patient had swelling at the craniotomy site with some
subgaleal swelling.  Visual field deficits were hard to confirm
due to the associated eyelid swelling post-operatively.  There
were no focal neurological deficits upon discharge.


Pertinent Results:
[**2175-10-26**] 01:31AM BLOOD WBC-11.3*# RBC-4.09* Hgb-13.0* Hct-38.4*
MCV-94 MCH-31.9 MCHC-33.9 RDW-14.6 Plt Ct-227
[**2175-10-26**] 01:31AM BLOOD Glucose-134* UreaN-14 Creat-0.9 Na-145
K-4.5 Cl-107 HCO3-29 AnGap-14
[**2175-10-26**] 01:31AM BLOOD Calcium-9.2 Phos-5.4*# Mg-1.7
[**2175-10-26**] 01:31AM BLOOD Phenyto-13.3

MRI Brain [**2175-10-25**]:
IMPRESSION:
1. Redemonstration of the post-surgical changes in the left
frontal region
and left frontal lobe and increased FLAIR hyperintense signal in
the left
temporal lobe anteriorly and medially for surgical planning.
2. Increased signal related to mucosal thickening in the right
maxillary in the bilateral mastoid air cells.


Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 46 yo male electively admitted for left
temporal lobectomy with Dr. [**Last Name (STitle) 1703**] for intractable Epilepsy.
Post-operatively, he remained in the ICU for close monitoring.
He had post op CT that showed some blood in operative bed, but
this was stable on repeat CT 12 hrs later.  His exam remained
intact.  He complained of incisional pain/headache.  He was
transferred to the floor POD#1.  His diet and activity were
advanced. He was on steroids that were tapered.  His dilanatin
(name brand only) was continued. On POD#2 he was not taking a
full diet and was somewhat uncomfortable there was a question of
a seizure versus dizziness from ambulating. On [**10-29**], discharge
home was planned but pain management was an issue and he was
kept inpatient for pain management. On [**10-30**] Oxycontin 30mg [**Hospital1 **]
was initiated with Dilaudid 2-4mg PO Q3 for break through pain.
Pain was well managed and on [**10-30**] was discharged home.

Medications on Admission:
Dilantin 200 mg every morning
Dilantin 300 mg every evening
(Brand Name Only)

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain.
2. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO QPM (once a day (in the evening)).
3. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO QAM (once a day (in the morning)).
4. Oxycodone 30 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) for 7
days.
Disp:*14 Tablet Sustained Release 12 hr(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for Breakthrough Pain.
Disp:*80 Tablet(s)* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day.
8. Dulcolax 10 mg Suppository Sig: One (1)  Rectal once a day as
needed for constipation.


Discharge Disposition:
Home

Discharge Diagnosis:
Epilepsy


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent


Discharge Instructions:
General Instructions

??????Have a friend/family member check your incision daily for signs
of infection.
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????You may wash your hair only after sutures and/or staples have
been removed.
??????You may shower before this time using a shower cap to cover
your head.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your surgery, please
refrain from taking until your follow-up appointment.
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
??????Make sure to continue to use your incentive spirometer while at
home, unless you have been instructed not to.

Please continue your seizure medications per your Neurologist.

Please call Dr.[**Name (NI) 4957**] office with any questions or concerns
at [**Telephone/Fax (1) 4958**]

Followup Instructions:
Your sutures will need to be discontinued on [**2175-11-6**] with the
nurse practitioner, please call [**Location (un) 4956**] at [**Telephone/Fax (1) 4958**] to make
this appointment.

You will need to follow-up with your neurosurgeon 4 weeks
post-operatively with a Head CT w/o contrast. Please call for an
appointment [**Telephone/Fax (1) 4958**].


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3657**] MD [**MD Number(2) 3658**]

Completed by:[**2175-10-30**]

Admission Date:  [**2175-10-25**]              Discharge Date:   [**2175-10-30**]

Date of Birth:  [**2129-5-3**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Bee Pollens

Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Epilepsy

Major Surgical or Invasive Procedure:
[**2175-10-25**]: s/p left temporal lobectomy with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]


History of Present Illness:
46 yo right handed man with intractable epilepsy secondary to
traumatic brain injury. Multiple failed medication trials. On
[**2175-8-30**] he had depth electrodes and grid placement for seizure
foci mapping.


Past Medical History:
Epilepsy

Social History:
Married, lives with wife.

Family History:
Non-contributory

Physical Exam:
On Admission:
AOx3, neurologically intact.

At Discharge:
The patient had swelling at the craniotomy site with some
subgaleal swelling.  Visual field deficits were hard to confirm
due to the associated eyelid swelling post-operatively.  There
were no focal neurological deficits upon discharge.


Pertinent Results:
[**2175-10-26**] 01:31AM BLOOD WBC-11.3*# RBC-4.09* Hgb-13.0* Hct-38.4*
MCV-94 MCH-31.9 MCHC-33.9 RDW-14.6 Plt Ct-227
[**2175-10-26**] 01:31AM BLOOD Glucose-134* UreaN-14 Creat-0.9 Na-145
K-4.5 Cl-107 HCO3-29 AnGap-14
[**2175-10-26**] 01:31AM BLOOD Calcium-9.2 Phos-5.4*# Mg-1.7
[**2175-10-26**] 01:31AM BLOOD Phenyto-13.3

Brief Hospital Course:
[**Known firstname **] [**Known lastname 1169**] is a 46 yo male electively admitted for left
temporal lobectomy with Dr. [**Last Name (STitle) **] for intractable Epilepsy.
Post-operatively, he remained in the ICU for close monitoring.
He had post op CT that showed some blood in operative bed, but
this was stable on repeat CT 12 hrs later.  His exam remained
intact.  He complained of incisional pain/headache.  He was
transferred to the floor POD#1.  His diet and activity were
advanced. He was on steroids that were tapered.  His dilanatin
(name brand only) was continued. On POD#2 he was not taking a
full diet and was somewhat uncomfortable there was a question of
a seizure versus dizziness from ambulating. On day of discharge
he was tolerating a regular diet and voiding without difficulty

Medications on Admission:
Dilanin 200mg Qam, 300mg Qpm

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain.
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*40 Capsule(s)* Refills:*0*
4. Dexamethasone 2 mg Tablet Sig: 1.5 tabs [**Hospital1 **] X3 days, 1 tab
[**Hospital1 **] x2 days 1 tab qdX2 days then stop Tablets PO see does.
Disp:*20 Tablet(s)* Refills:*0*
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO QPM (once a day (in the evening)).
6. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO QAM (once a day (in the morning)).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
6 days.
Disp:*6 Tablet, Delayed Release (E.C.)(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Epilepsy


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent


Discharge Instructions:
General Instructions

??????Have a friend/family member check your incision daily for signs
of infection.
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????You may wash your hair only after sutures and/or staples have
been removed.
??????You may shower before this time using a shower cap to cover
your head.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your surgery, please
refrain from taking until your follow-up appointment.
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
??????Make sure to continue to use your incentive spirometer while at
home, unless you have been instructed not to.

Please continue your seizure medications per your Neurologist.

Please call Dr.[**Name (NI) 12757**] office with any questions or concerns
at [**Telephone/Fax (1) 3231**]

Followup Instructions:
You will need you sutures to be removed on [**11-3**] please call for
an appointment to [**Telephone/Fax (1) 3231**]

You will need to follow-up with Dr [**Last Name (STitle) 11294**] 4 weeks
post-operatively with a Head CT w/o contrast. Please call for an
appointment appointment.
{'Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy,Late effect of intracranial injury without mention of skull fracture,Late effects of other accidents,Other acute postoperative pain,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: Epilepsy

PRESENT ILLNESS: 46 yo right handed man with intractable epilepsy secondary to
traumatic brain injury. Multiple failed medication trials. On
[**2175-8-30**] he had depth electrodes and grid placement for seizure
foci mapping.

MEDICAL HISTORY: Epilepsy secondary to trauma

MEDICATION ON ADMISSION: Dilantin 200 mg every morning
Dilantin 300 mg every evening
(Brand Name Only)

ALLERGIES: Bee Pollens

PHYSICAL EXAM: Physical Exam:
On Admission:
AOx3, neurologically intact.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Married, lives with wife. 

### Response:
{'Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy,Late effect of intracranial injury without mention of skull fracture,Late effects of other accidents,Other acute postoperative pain,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
