CHIEF COMPLAINT: Status post fall from standing position

PRESENT ILLNESS: 25 yo female history of seizures and depresison found at bottom
of stairs with positive blood bilateral tympanic membrane. Ct
with basilar skull fx with / extension into the right carotid
canal and possible facial nerve injury. Pt intubated in ED for
worsened MS [**First Name (Titles) **] [**Last Name (Titles) **]. + emesis of blood.

MEDICAL HISTORY: Seizure disorder
Depression
Anxiety
ADHD

MEDICATION ON ADMISSION: 1. Adderall 10 qpm
2. Adderral XR 30 mg q am
3. Cymbalta 30 q am/ 60 q am
4. Klonipin 1 mg [**Hospital1 **]
5. Topamax 25 mg qam
6. Trazadoe 100 qhs
7. Zonegam 300 mg [**Hospital1 **]
8. Ativan 1 mg Po for oncoming seizure and post seizure.
9. Benadryl 25 mg q4
9. Dulcolax 100 qd
10.Ibuprofen 600mg q 6
11.Melatonin 5mg qhs
12.Tyelenol 100 q4h prn.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Initial Exam:
Gen: Patient intubated, sedated.  NAD
Periorbital ecchymosis with multiple scattered abrasions
Ear: Two lacerations of antihelix, one of helix, 3 cm laceration
on the posterior auricular region.  Patient with hematoma above
poas[**Name (NI) **] auricular laceration.
Maxilla stable.
Nose: Stable nasal bone, no active bleeding
CTA bilateral lung fields
Cardiac RRR's
Abdomen: Soft, no tender, no distended.
EXT: no edema, bilateral pulses positive

FAMILY HISTORY: cousin with seizures

SOCIAL HISTORY: Per mother, pt has a hx of polysubstance abuse, unclear when
first started using or what recent use has been like. Per
mother, has abused alcohol, stimulants, benzos, ecstacy, MJ in
the past. Has also noted pt has had "drug-seeking" in the past
with different providers.  Unknown if pt has had any hx of
withdrawal phenomena.
Recently started smoking. In group home for the past
100 days secondary to depression. Was initially in the Babcock
home and recently advanced to the Gateway area where she can
function more independently. Per father when living at home
would
drink [**4-10**] glasses of wine 1x/month. Occasional marijuana use per
father. Graduated from Catholic [**Location (un) **] in DC. Was working at
[**Company 86694**] in [**Location (un) 7349**] until 1 yar ago.
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness,Encephalopathy, unspecified,Delirium due to conditions classified elsewhere,Generalized convulsive epilepsy, without mention of intractable epilepsy,Bell's palsy,Open wound of auricle, ear, without mention of complication,Accidental fall on or from other stairs or steps,Fever presenting with conditions classified elsewhere,Dermatitis due to drugs and medicines taken internally,Other abnormal blood chemistry,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Antidepressants causing adverse effects in therapeutic use,Barbiturates causing adverse effects in therapeutic use,Abrasion or friction burn of hip, thigh, leg, and ankle, without mention of infection,Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection,Contusion of orbital tissues,Acute sinusitis, unspecified,Tear film insufficiency, unspecified,Other disorders of middle ear and mastoid,Conjunctival hemorrhage,Attention deficit disorder with hyperactivity,Dysthymic disorder,Degeneration of cervical intervertebral disc
Cl skl base fx/menin hem,Encephalopathy NOS,Delirium d/t other cond,Gen cnv epil w/o intr ep,Bell's palsy,Open wound of auricle,Fall on stair/step NEC,Fever in other diseases,Drug dermatitis NOS,Abn blood chemistry NEC,Adv eff antconvl NEC/NOS,Adv eff antidepressants,Adv eff barbiturates,Abrasion hip & leg,Abrasion head,Contusion orbital tissue,Acute sinusitis NOS,Tear film insuffic NOS,Dis mid ear/mastoid NEC,Conjunctival hemorrhage,Attn deficit w hyperact,Dysthymic disorder,Cervical disc degen
Admission Date:  [**2183-7-19**]              Discharge Date:   [**2183-8-26**]

Date of Birth:  [**2157-10-31**]             Sex:   F

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
Status post fall from standing position

Major Surgical or Invasive Procedure:
EEG


History of Present Illness:
25 yo female history of seizures and depresison found at bottom
of stairs with positive blood bilateral tympanic membrane. Ct
with basilar skull fx with / extension into the right carotid
canal and possible facial nerve injury. Pt intubated in ED for
worsened MS [**First Name (Titles) **] [**Last Name (Titles) **]. + emesis of blood.

25 year old right handed female with a history of
generalized epilepsy (since age 8 currently on zonegran and
topamax with increasing seizures over the past year),
depression,
anxiety, ADD, who was admitted 1 day [**7-19**] ago following a fall 4
feet
down stairs onto her face and a 2 minute generalized seizure.

Per [**Last Name (LF) **], [**Known firstname **] was an ex FT girl with generalized epilepsy
since age 8 treated with depakote form age 8 until 24 with less
than  1 seizure per year until the past year. She has had about
10 seizures in the past year. She follows with Dr. [**First Name4 (NamePattern1) 714**]
[**Last Name (NamePattern1) **] in [**Hospital1 1559**], MA and in [**4-15**] started to wean off of
depakote. Keppra was tried but stopped because it worsened her
depression. Lamictal was tried with depakote but caused more
seizures. She did not have adequate control with lamictal alone
either.  In [**2183-3-10**] was hospitalized with a reportedly
normal EEG and changed medications rapidly. She has been on
zonegran and topamax since [**2183-3-10**]. Dose of topamax
decreased because of weight loss and she comes in with only 25
mg
PO QD. She is on zonegran 300mg PO BID. Seizures have always
been
worsened by sleep deprivation and alcohol use. Typical seizures
per mother are always characterized by starting with stuttering
speech, falls, loss of consciousness with extremity shaking
without incontinance. She is confused afterwards and tired and
sleeps for 15 minutes to an hour.

On [**2183-7-9**] [**Known firstname **] had a generalized tonic clonic seizure at
her group home while she was smoking outside. She was taken to
the [**Hospital1 18**] ED and found to be postictal and later discharged home
to follow up with her Neurologist.

On [**2183-7-19**] around 6 pm her friend [**Name (NI) **] (who is present
today) witnessed her walking normally and then fell down stairs
outside about 4 feet onto her face. She was then noted to have
stiffening of her arms and legs and convulse for two minutes.
She
was covered with blood and EMS was called and arrived after 6
minutes. No alcohol recently per friend and father. Reported to
be taking her medications.

She was brought to the ED, had a CT head revealing IPH, SAH,
basilar skull fractures. She was loaded with dilantin,
intubated,
seen by Neurosurgery, and admitted to the ICU. CTA imaging
completed.  She was extubated this [**7-20**] am and as not had
further
seizures.


Past Medical History:
Seizure disorder
Depression
Anxiety
ADHD

Social History:
Per mother, pt has a hx of polysubstance abuse, unclear when
first started using or what recent use has been like. Per
mother, has abused alcohol, stimulants, benzos, ecstacy, MJ in
the past. Has also noted pt has had "drug-seeking" in the past
with different providers.  Unknown if pt has had any hx of
withdrawal phenomena.
Recently started smoking. In group home for the past
100 days secondary to depression. Was initially in the Babcock
home and recently advanced to the Gateway area where she can
function more independently. Per father when living at home
would
drink [**4-10**] glasses of wine 1x/month. Occasional marijuana use per
father. Graduated from Catholic [**Location (un) **] in DC. Was working at
[**Company 86694**] in [**Location (un) 7349**] until 1 yar ago.

Family History:
cousin with seizures

Physical Exam:
Initial Exam:
Gen: Patient intubated, sedated.  NAD
Periorbital ecchymosis with multiple scattered abrasions
Ear: Two lacerations of antihelix, one of helix, 3 cm laceration
on the posterior auricular region.  Patient with hematoma above
poas[**Name (NI) **] auricular laceration.
Maxilla stable.
Nose: Stable nasal bone, no active bleeding
CTA bilateral lung fields
Cardiac RRR's
Abdomen: Soft, no tender, no distended.
EXT: no edema, bilateral pulses positive

Pertinent Results:
[**2183-7-19**] 05:55PM BLOOD WBC-8.4 RBC-4.78 Hgb-14.5 Hct-42.6 MCV-89
MCH-30.4 MCHC-34.1 RDW-12.9 Plt Ct-298
[**2183-7-19**] 09:22PM BLOOD Glucose-103* UreaN-12 Creat-0.9 Na-136
K-3.7 Cl-102 HCO3-21* AnGap-17
[**2183-7-20**] 05:02PM BLOOD Glucose-106* UreaN-8 Creat-0.6 Na-142
K-3.5 Cl-111* HCO3-21* AnGap-14
[**2183-7-22**] 07:05AM BLOOD Glucose-93 UreaN-4* Creat-0.5 Na-140
K-3.7 Cl-106 HCO3-23 AnGap-15
[**2183-7-26**] 06:00AM BLOOD Glucose-101* UreaN-13 Creat-0.6 Na-136
K-3.9 Cl-103 HCO3-21* AnGap-16
[**2183-7-19**] 09:22PM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0
[**2183-7-20**] 05:02PM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9
[**2183-7-22**] 07:05AM BLOOD Calcium-8.5 Phos-2.1* Mg-1.9
[**2183-7-19**] 08:05PM BLOOD Type-ART Rates-12/ Tidal V-400 PEEP-5
FiO2-50 pO2-235* pCO2-44 pH-7.32* calTCO2-24 Base XS--3
-ASSIST/CON Intubat-INTUBATED
[**2183-7-20**] 02:38AM BLOOD Type-ART pO2-268* pCO2-42 pH-7.34*
calTCO2-24 Base XS--2

[**2183-7-29**] 04:20AM BLOOD WBC-6.8 RBC-4.42 Hgb-13.0 Hct-38.4 MCV-87
MCH-29.5 MCHC-33.9 RDW-13.4 Plt Ct-334
[**2183-7-27**] 05:25AM BLOOD WBC-8.9 RBC-4.06* Hgb-11.8* Hct-35.2*
MCV-87 MCH-29.1 MCHC-33.6 RDW-13.4 Plt Ct-329
[**2183-7-26**] 06:00AM BLOOD WBC-9.9 RBC-4.40 Hgb-12.7 Hct-37.6 MCV-85
MCH-28.8 MCHC-33.8 RDW-13.3 Plt Ct-338
[**2183-7-24**] 06:55AM BLOOD WBC-11.5* RBC-4.63 Hgb-13.6 Hct-40.6
MCV-88 MCH-29.5 MCHC-33.6 RDW-13.0 Plt Ct-299
[**2183-7-22**] 07:05AM BLOOD WBC-14.1* RBC-3.74* Hgb-11.1* Hct-33.5*
MCV-90 MCH-29.7 MCHC-33.2 RDW-12.8 Plt Ct-216
[**2183-7-21**] 02:18AM BLOOD WBC-18.8* RBC-3.68* Hgb-10.6* Hct-32.2*
MCV-87 MCH-28.9 MCHC-33.1 RDW-13.0 Plt Ct-228
[**2183-7-20**] 02:25AM BLOOD WBC-21.0* RBC-4.12* Hgb-12.5 Hct-36.7
MCV-89 MCH-30.3 MCHC-34.1 RDW-13.0 Plt Ct-250
[**2183-7-19**] 09:22PM BLOOD WBC-24.7*# RBC-4.52 Hgb-13.2 Hct-39.2
MCV-87 MCH-29.3 MCHC-33.7 RDW-12.8 Plt Ct-319
[**2183-7-19**] 05:55PM BLOOD WBC-8.4 RBC-4.78 Hgb-14.5 Hct-42.6 MCV-89
MCH-30.4 MCHC-34.1 RDW-12.9 Plt Ct-298
[**2183-7-27**] 05:25AM BLOOD Neuts-81.4* Lymphs-13.8* Monos-3.7
Eos-0.9 Baso-0.3
[**2183-7-19**] 09:22PM BLOOD Neuts-92.7* Lymphs-5.4* Monos-1.6*
Eos-0.1 Baso-0.2
[**2183-7-29**] 04:20AM BLOOD Plt Ct-334
[**2183-7-27**] 05:25AM BLOOD Plt Ct-329
[**2183-7-27**] 05:25AM BLOOD PT-12.0 PTT-26.3 INR(PT)-1.0
[**2183-7-26**] 06:00AM BLOOD Plt Ct-338
[**2183-7-24**] 06:55AM BLOOD Plt Ct-299
[**2183-7-22**] 07:05AM BLOOD Plt Ct-216
[**2183-7-21**] 02:18AM BLOOD Plt Ct-228
[**2183-7-20**] 02:25AM BLOOD Plt Ct-250
[**2183-7-19**] 05:55PM BLOOD Fibrino-288
[**2183-7-29**] 04:20AM BLOOD
[**2183-7-26**] 06:00AM BLOOD
[**2183-7-24**] 06:55AM BLOOD
[**2183-7-22**] 07:05AM BLOOD
[**2183-7-29**] 04:20AM BLOOD Glucose-89 UreaN-10 Creat-0.5 Na-133
K-3.9 Cl-97 HCO3-24 AnGap-16
[**2183-7-27**] 05:25AM BLOOD Glucose-96 UreaN-11 Creat-0.5 Na-134
K-3.9 Cl-101 HCO3-22 AnGap-15
[**2183-7-26**] 06:00AM BLOOD Glucose-101* UreaN-13 Creat-0.6 Na-136
K-3.9 Cl-103 HCO3-21* AnGap-16
[**2183-7-24**] 06:55AM BLOOD Glucose-105* UreaN-7 Creat-0.5 Na-137
K-3.8 Cl-101 HCO3-22 AnGap-18
[**2183-7-22**] 07:05AM BLOOD Glucose-93 UreaN-4* Creat-0.5 Na-140
K-3.7 Cl-106 HCO3-23 AnGap-15
[**2183-7-21**] 02:18AM BLOOD Glucose-101* UreaN-6 Creat-0.6 Na-139
K-3.6 Cl-109* HCO3-20* AnGap-14
[**2183-7-20**] 05:02PM BLOOD Glucose-106* UreaN-8 Creat-0.6 Na-142
K-3.5 Cl-111* HCO3-21* AnGap-14
[**2183-7-20**] 02:25AM BLOOD Glucose-101* UreaN-11 Creat-0.8 Na-136
K-3.8 Cl-102 HCO3-21* AnGap-17
[**2183-7-19**] 09:22PM BLOOD Glucose-103* UreaN-12 Creat-0.9 Na-136
K-3.7 Cl-102 HCO3-21* AnGap-17
[**2183-7-29**] 04:20AM BLOOD ALT-21 AST-13 LD(LDH)-169 AlkPhos-75
TotBili-0.2
[**2183-7-20**] 02:25AM BLOOD CK(CPK)-318*
[**2183-7-19**] 05:55PM BLOOD Lipase-29
[**2183-7-29**] 04:20AM BLOOD Calcium-9.4 Phos-3.9 Mg-1.9
[**2183-7-27**] 05:25AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.7
[**2183-7-26**] 06:00AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.9
[**2183-7-24**] 06:55AM BLOOD Calcium-9.2 Phos-4.0# Mg-1.8
[**2183-7-20**] 05:02PM BLOOD Osmolal-290
[**2183-7-30**] 04:20AM BLOOD Phenoba-32.3
[**2183-7-29**] 04:20AM BLOOD Phenoba-28.9
[**2183-7-27**] 05:25AM BLOOD Phenoba-17.3
[**2183-7-26**] 04:25PM BLOOD Phenoba-9.3*
[**2183-7-26**] 06:00AM BLOOD Valproa-52
[**2183-7-25**] 12:50PM BLOOD Valproa-55
[**2183-7-25**] 01:13AM BLOOD Valproa-37*
[**2183-7-22**] 07:05AM BLOOD Phenyto-10.7
[**2183-7-19**] 09:22PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2183-7-19**] 05:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2183-7-20**] 02:38AM BLOOD Type-ART pO2-268* pCO2-42 pH-7.34*
calTCO2-24 Base XS--2
[**2183-7-19**] 08:05PM BLOOD Type-ART Rates-12/ Tidal V-400 PEEP-5
FiO2-50 pO2-235* pCO2-44 pH-7.32* calTCO2-24 Base XS--3
-ASSIST/CON Intubat-INTUBATED
[**2183-7-20**] 02:38AM BLOOD Glucose-113* Lactate-0.8
[**2183-7-19**] 06:14PM BLOOD Glucose-100 Lactate-1.7 Na-140 K-3.3*
Cl-102 calHCO3-20*
[**2183-7-20**] 02:38AM BLOOD freeCa-1.19
[**2183-8-1**] 04:15AM BLOOD WBC-7.0 RBC-4.19* Hgb-12.6 Hct-36.9
MCV-88 MCH-30.1 MCHC-34.2 RDW-13.4 Plt Ct-332
[**2183-7-31**] 04:20AM BLOOD WBC-9.7 RBC-4.32 Hgb-13.1 Hct-38.3 MCV-89
MCH-30.3 MCHC-34.2 RDW-13.1 Plt Ct-433
[**2183-8-1**] 04:15AM BLOOD Plt Ct-332
[**2183-7-31**] 04:20AM BLOOD Plt Ct-433
[**2183-7-31**] 04:20AM BLOOD Neuts-82.5* Lymphs-13.8* Monos-3.0
Eos-0.4 Baso-0.3
[**2183-8-1**] 04:15AM BLOOD Glucose-88 UreaN-7 Creat-0.7 Na-138 K-3.9
Cl-103 HCO3-25 AnGap-14
[**2183-7-31**] 04:20AM BLOOD Glucose-90 UreaN-9 Creat-0.7 Na-138 K-3.8
Cl-102 HCO3-28 AnGap-12
[**2183-7-19**] 05:55PM BLOOD Fibrino-288
[**2183-8-1**] 04:15AM BLOOD
[**2183-8-1**] 04:15AM BLOOD Glucose-88 UreaN-7 Creat-0.7 Na-138 K-3.9
Cl-103 HCO3-25 AnGap-14
[**2183-7-31**] 04:20AM BLOOD Glucose-90 UreaN-9 Creat-0.7 Na-138 K-3.8
Cl-102 HCO3-28 AnGap-12
[**2183-8-1**] 04:15AM BLOOD ALT-24 AST-21
[**2183-8-4**] 05:25AM BLOOD Phenoba-32.6 Valproa-62
[**2183-8-2**] 06:00AM BLOOD Phenoba-29.0 Valproa-59
[**2183-8-1**] 04:15AM BLOOD Phenoba-32.7
[**2183-7-31**] 04:20AM BLOOD Phenoba-35.0 Valproa-40*
[**2183-7-30**] 04:20AM BLOOD Phenoba-32.3
[**2183-7-29**] 04:20AM BLOOD Phenoba-28.9
[**2183-7-27**] 05:25AM BLOOD Phenoba-17.3
[**2183-7-26**] 04:25PM BLOOD Phenoba-9.3*
[**2183-7-26**] 06:00AM BLOOD Valproa-52
[**2183-7-25**] 12:50PM BLOOD Valproa-55
[**2183-7-25**] 01:13AM BLOOD Valproa-37*
[**2183-7-22**] 07:05AM BLOOD Phenyto-10.7
[**2183-7-20**] 02:38AM BLOOD Glucose-113* Lactate-0.8

[**2183-7-19**] CT HEAD: HISTORY: Patient with seizure and trauma.

TECHNIQUE: Contiguous axial images were obtained through the
brain. No
intravenous contrast was administered.

COMPARISON: No prior.

FINDINGS: There are bilateral basal temporal lobe contusions,
(2:9). There
are linear foci of hyperdensity, (2:14), along the left
convexity in the
frontoparietal region, concerning for focal area of a
subarachnoid hemorrhage.
There is preserved [**Doctor Last Name 352**]-white matter differentiation. There is
no extension
of the hemorrhage within the ventricles. There is no shift of
midline
structures. There is no subfalcine or uncal herniation.

There is hyperdense material within the right maxillary sinus,
and sphenoid
sinus, concerning for blood, with fluid in the ethmoid air
cells.

There is an extensive fracture at the base of the skull.
Primarily, there is
a longitudinal right temporal bone fracture extending in the
middle ear cavity
with resultant ossicular disruption. There is fluid within the
mastoid air
cells on the right, and fluid in the external auditory canal on
the right,
presumed hemorrhage. A component of the fracture extends as a
small depressed
fracture fragment of the right squamous temporal bone, (3:15),
with foci of
pneumocephalus in the area. The fracture is extending further in
the right
carotid canal, and posterior aspect of the right pterygopalatine
fossa, (3:5),
likely into the right orbital apex. Fracture is involving the
sphenoid
sinuses, extending through sella turcica, (3:15), involving the
anterior left
anterior clinoid process. There is a locule of air in the
retroorbital,
extraconal fat lateral to the left lateral rectus muscle,
(3:12). Although no
definite fracture line is seen, there is a presumed fracture of
the left
orbit. A separate component of the right temporal bone fracture
extends
through the right basiocciput extending through the occipital
protuberance
into the left occipital bone. Foci of air seen in the transverse
sinuses.
Additionally, there is a longitudinal fracture through the left
temporal bone,
with no apparent left ossicular disruption. There is fluid
within left mastoid
air cells. There is a possible fracture of the left lateral
pterygoid plate.

IMPRESSION:
1. Bilateral foci of basal temporal lobe contusions.
2. Focal subarachnoid hemorrhage at the left temporoparietal
region.
3. No subfalcine or uncal herniation. Preserved [**Doctor Last Name 352**]-white
matter
differentiation.
4. Foci of pneumocephalus and foci of air in the transverse
sinus.
5. Fluid in the mastoid air cells and fluid in the external
auditory canals
bilaterally, presumed hemotympanum.
6. Blood in the right maxillary sinus and sphenoid sinus.
7. Extensive basal skull fractures, as described in detail in
the body of the
report.

[**7-19**]: CXRAY/PELVIS: IMPRESSION: Within limitations, no traumatic
injury of the chest or pelvis noted.

[**7-19**]: CT sinus:
IMPRESSION:

1. Hyperdense fluid in the right maxillary sinus, ethmoid air
cells and
sphenoid sinus, in keeping with hemorrhage.

2. Focus of air lateral to the lateral rectus muscle on the left
in the
extraconal fat and even though no underlying fracture is seen,
concern for
fracture due to underlying findings.

3. Extensive basal skull fracture better detailed on
accompanying head CT
report. CTA of the head and neck was recommended to evaluate for
vessel
injury given involvement of right carotid canal. Findings were
discussed with the trauma team.


CT C/A/P: FINDINGS:

CT CHEST: Airways are patent up to subsegmental level. There are

predominantly left lower lobe foci of ground-glass opacity, for
example (2:20,
2:28, 2:33), concerning for foci of aspiration. A separate
isolated focus is
seen in the right upper lobe. There is no pleural effusion.
There is no
pneumothorax. Patient has a residual thymus tissue. There is no
evidence of
lymphadenopathy according to size criteria in the mediastinum,
hilum, or
axilla. Vessels are of normal caliber. Heart size is normal.
There is no
pericardial effusion.

CT ABDOMEN: The liver enhances homogeneously with no evidence of
focal liver lesion, or injury. The gallbladder is normal. There
is no extra- or intra- hepatic biliary duct dilatation. The
spleen is unremarkable. The pancreas, loops of large and small
bowel, and adrenal glands appear unremarkable. There is no bowel
obstruction. There is no free fluid or free air. The kidneys
enhance symmetrically and excrete contrast symmetrically with no
evidence of hydronephrosis. Focal area of hypodensity in the
interpolar region of the right kidney, (2:57), too small to
characterize, could be small cysts. No retroperitoneal or
mesenteric lymphadenopathy.

CT PELVIS: The urinary bladder, uterus, loops of large and small
bowel appear unremarkable. There is no free fluid in the pelvis.
Patient has IUD in place.

OSSEOUS STRUCTURES: No evidence of fracture.

IMPRESSION: Subtle bilateral focal ground-glass opacities
concerning for
aspiration.

TECHNIQUE: CT C-spine without contrast. Coronal and sagittal
reformats.
COMPARISON: No prior.
FINDINGS: There is preserved alignment of the cervical spine.
The vertebral body height is preserved. There is no evidence of
fracture in the C-spine. There is isolated degenerative disc
disease at level C6-C7, with posterior disc osteophyte complex,
impinging anteriorly on the thecal sac with no significant canal
stenosis. Anterior osteophytes are incidentally noted at this
level as well, (501B:25). There is no prevertebral soft tissue
hematoma. Extensive basal skull fracture better detailed on
accompanying head CT report.

IMPRESSION:
  1. No fracture in the cervical spine.
  2. Isolated degenerative disc disease at C6-C7.
  3. Extensive basal skull fracture better detailed on
accompanying head CT from the same day, [**2183-7-19**].


CTA HEAD [**7-19**]
CLINICAL INDICATION: 26-year-old woman with possible carotid
impingement,
skull base fractures.

COMPARISON: Prior CT of the head and cervical spine dated [**7-19**], [**2183**], and also prior CT of the maxillofacial structures
performed concurrently.

TECHNIQUE: Initial non-contrast images through the brain were
obtained
followed by angiographic phase images through the head after
administration of intravenous contrast material, multiplanar
reconstructions through the head and neck were acquired.

FINDINGS: The initial non-contrast images through the brain
again
demonstrates right temporal intraparenchymal hemorrhage, stable
in size and configuration. A small 4-mm hyperdensity medially
appears more apparent in this examination. The left temporal
lobe extra-axial collection has increased in size from 9 to 13
mm. Persistent extra-axial lentiform collection overlying the
left convexity appear slightly larger, measuring approximately
10 mm. No significant midline shifting is identified; however,
there is diffuse effacement of the sulci, possibly reflecting
brain edema. The perimesencephalic cisterns are patent. Complex
skull fractures remain unchanged, please see prior report of
[**2183-7-19**] for further details, opacities of the ethmoid and
maxillary sinuses remain stable.

The angiographic phase images demonstrate vascular enhancement
in the major arterial vascular structures with no flow, stenotic
lesions or aneurysms larger than 2 mm in size, no dissection or
filling defects are demonstrated. The patient is intubated. ET
and NG tubes are in place. Unchanged opacity of the right
maxillary and sphenoid sinuses, there is patchy ethmoidal
mucosal thickening. Small amount of pneumocephalus is identified
adjacent to the right temporal lobe, related with the previously
described skull base fractures.

IMPRESSION: Enlargement of the previously described subarachnoid
hemorrhage with stable right temporal intraparenchymal
hemorrhage, unchanged complex skull base fractures, see prior
report of [**2183-7-19**] for further details. Persistent
opacities of the ethmoid and maxillary sinuses and also sphenoid
sinus. The vascular structures appear patent with no flow
stenotic lesions, aneurysms, or evidence of dissection.

EEG [**7-21**]: IMPRESSION: This video EEG telemetry captured no
pushbutton
activations. No electrographic seizures were seen. Interictally,
some
broad-based bifrontal sharp waves were seen, suggesting the
possibility of underlying epileptogenesis in those regions. The
background did reach a normal alpha rhythm during wakefulness
but had
bursts of generalized slowing quite frequently and multifocal
regions of
intermittent slowing were also seen. These findings together
suggest
the presence of multiple regions of subcortical dysfunction
including
deep midline brain dysfunction.

EEG [**7-22**]: IMPRESSION: This video EEG telemetry captured no
pushbutton
activations. No electrographic seizures or interictal
epileptiform
discharges were seen. The background was disorganized and
frequently
slow during the day's recording with both generalized bursts of
slowing,
runs of bifrontal monomorphic slowing, and multiple regions of
intermittent focal slowing. These findings together suggest the
presence of a mild encephalopathy with deep midline brain
dysfunction
and multiple areas of subcortical dysfunction.

EEG [**7-23**]: IMPRESSION: This telemetry captured no clear ongoing
seizure activity; however, the background activity alternated
between relatively normal slightly slow background with focal
slowing in the right fronto-central area and markedly abnormal
background of more rhythmic delta and theta activity sometimes
with accompanying sharp waves. Although, at times, this activity
was rhythmic, it did not have a clear onset, offset, or
progression to suggest an equivocal electrographic seizure.
Interictally, there were spike and polyspike and wave activity
in a
generalized distribution with right frontal predominance.

EEG [**7-24**]: IMPRESSION: This telemetry captured a clear clinical
electrographic seizure which seemed to start bifrontally with a
right predominance and had an asymmetric offset with continuous
rhythmic activity only in the left hemisphere. There were
additional electrographic seizures seen in a generalized
distribution lasting for several seconds with no clear clinical
correlate. Interictally, there was abundant epileptic activity
of spike and wave in a generalized distribution with right
predominance and sometimes in runs of discharges. The background
activity was slow suggestive of encephalopathy.

EEG [**7-25**]:IMPRESSION: This telemetry captured no pushbutton
activations; however, the EEG activity showed frequent
interictal epileptic activity and electrographic seizures in a
generalized distribution. The background
activity was slow suggestive of encephalopathy.

EEG [**7-26**]: IMPRESSION: This telemetry captured no clear clinical
seizures;
however, it did capture rhythmic delta activity with intermixed
sharp
waves which may suggest electrographic seizure activity as well
as
interictal generalized sharp waves. The background activity was
slow
suggestive of encephalopathy.

EEG [**7-27**]: IMPRESSION: This telemetry captured no clear ongoing
seizure activity; however, it did capture numerous periods of
rhythmic generalized delta activity especially when the patient
was aroused from sleep. It also
captured many generalized sharp discharges. The background
activity was
slow suggestive of encephalopathy.

SKULL AND FACIAL BONE RADIOGRAPHS OF [**2183-7-27**].
INDICATION: Seizures.

Exam is technically limited by the presence of a multitude of
electrodes
overlying the skull and obscuring bone detail. Questionable
partial
opacification of the left frontal sinus on one of two views
could be
projectional as it is not confirmed on both projections.
However, given the limitations of the current study, a CT should
be considered if there is strong clinical suspicion for acute
facial bone or skull injury. If CT is performed, emoval of the
electrodes prior to the procedure would be helpful to avoid
artifacts, if feasible clinically.


EEG [**7-28**]: IMPRESSION: This telemetry captured no pushbutton
activations and no clear ictal epileptiform activity.
Interictally, there were generalized sharp waves with bifrontal
predominance. The background activity alternated between
semi-rhythmic delta waves and a more lower voltage intermixed
beta and theta activity.

MR [**Name13 (STitle) **]:
INDICATION: 25-year-old woman with facial nerve palsy and
temporal bone
fracture. Please assess facial nerve.

COMPARISON: CT of the head from [**2183-7-19**].

TECHNIQUE: CISS sequences through the internal auditory canal
and temporal
bones were obtained axially, sagittally on the right and left,
and axial T1 fat saturated images through the temporal bones
were also obtained. The
patient was disoriented and the entire study could not be
completed.

FINDINGS: The study is limited by motion artifacts.

The T1 fat saturated images demonstrate the previously noted
left and right temporal intraparenchymal contusions, the
left-sided subdural hematoma, and patchy areas of subarachnoid
hemorrhage in the imaged portion of the cranium.  There is high
signal along the anterior right middle cranial fossa, which
appears to be another area of subdural hematoma. Please refer to
earlier dedicated head studies for a complete description of
intracranial findings.

There is also high signal on the T1W fat-saturated images in the
right
transverse sinus. This sinus demonstrated air on a prior head
CT, indicating disruption in the setting of the known skull base
fractures. Focal thrombosis cannot be excluded.

In addition, there is high T1 signal within the mastoid air
cells bilaterally, and extending anteromedially on the right to
the sphenoid sinus, which is completely opacified. This
corresponds to blood related to known temporal bone and skull
base fractures. The cisternal and canalicular segments of the
facial nerve appear normal. Due to the mastoid opacification,
the temporal segments including the tympanic, mastoid, and
labyrinthine segments as well as the geniculate ganglion cannot
be adequately evaluated.

The inner ear structures are normal in signal.

IMPRESSION:

1. Limited evaluation of the facial nerves due to blood in the
mastoids. No evidence of cisternal or canalicular abnormalities
of the seventh cranial nerves bilaterally. A CT of the temporal
bones would be beneficial to determine if the known fractures
through the facial nerve canals.

2. Extensive intracranial hemorrhage, as seen on prior head CTs.


3. High T1 signal along the right transverse sinus in an area of
known
fracture raises the possibility of focal thrombosis. An MRV or
CTV may be
valuable for further evaluation.

[**7-30**]: EEG IMPRESSION: This telemetry captured five pushbutton
activations for agitation with no electrographic correlate.
There was no ongoing
seizure activity seen in this recording. There were some
generalized
sharp waves with bifrontal predominance. The background activity
was
slow suggestive of a mild to moderate encephalopathy.

[**7-30**]: EKG Sinus tachycardia. Otherwise, normal tracing. Since
the previous tracing  of [**2183-7-22**] sinus tachycardia is now
present.

[**7-31**]: EEG IMPRESSION: This telemetry captured no pushbutton
activations and no ictal epileptiform activity. Interictally,
there were generalized sharp waves with bifrontal predominance.
The background activity was slow
suggestive of a moderate encephalopathy.

[**8-1**]: IMPRESSION: This telemetry captured three pushbutton
activations for no clear clinical seizures and with no EEG
correlate. Interictally, there
were sharp waves seen bifrontally, sometimes with a right
predominance.
There was no clear ongoing seizure activity seen in this
recording.
There was right central slowing suggestive of subcortical
dysfunction in
this region. The background activity was slow suggestive of a
mild to
moderate encephalopathy.

[**8-2**]: EEG IMPRESSION: This telemetry captured one pushbutton
activation for unclear reasons with no change in the background
activity. There were
numerous entries in the seizure files for generalized as well as
more
localized rhythmic theta and delta activity in the right central
area
with no clinical correlate. There were sharp waves seen
bifrontally
with a right predominance and the background activity was slow
suggestive of a moderate encephalopathy.


[**8-3**]:IMPRESSION: This telemetry captured no pushbutton
activations and no
ongoing seizure activity or clinical seizures; however,
interictally,
there were sharp waves seen bifrontally sometimes with a right
predominance and there were times when the background activity
became
more rhythmic in the theta and delta range of frequencies with
no
clinical correlate. The background activity was slow suggestive
of a
moderate encephalopathy with additional focal slowing in the
right
central area suggestive of subcortical dysfunction in that
region

CXRAY [**8-4**]:
REASON FOR EXAM: Fever.
Cardiomediastinal contours are normal. The lungs are clear.
There is no
pneumothorax or pleural effusion.
IMPRESSION: No evidence of acute cardiopulmonary abnormality.



Brief Hospital Course:
EVENTS while on the Trauma service:

[**7-19**]: patient was admitted to TSICU, facial nerve at least
partially functioning, plastics sutured the left pinna.
CT head showed increase intraparenchymal hematoma, CTA negative,
carotids intact .
Transiently asymmetric pupils

CXR: ETT 3 cm above carina, NGT in stomach.
CT C-SPINE:extensive basal skull fx better; cspine neg for fx or
malalignment; isolated degenerative disk disease at C6-7
CT TORSO: no evidence of trauma on CT torso
CT SINUS:extensive skull base fracture, right max and sphenoid
sinus hyperdense material, blood
CT HEAD: Bilateral contusions in the brain,and foci of SAH along
left convexity. No hydrocephalus. Blood in right maxillary
sinus.

[**7-20**]: Patient was extubated
CT head: Stable Rbtem IPH, with more apparent small 4-mm focus
medially. Left temporal extra-axial collection has increased in
size from 9 to 13 mm.
[**7-21**]: S/S eval. Psych called. HSQ. EEG ordered. Patient was
transfer to floor.

[**7-22**]: Decrease mental status, patient had CT scan head, it
showed slight interval increase in right temporal parenchymal
blood products, without increased mass effect. Stable size of
extra-axial blood products along the left convexity.

[**7-24**]: Three generalized tonic clonic seizures.
Epilepsy Service Course:

# Neuro: Course noted on the trauma team as above. On [**2183-7-24**]
she had three generalized tonic clonic seizures. She was given
ativan x 1, loaded with depakote 650 mg IV, and started on
depakote 500 mg [**Hospital1 **]. She was transferred to the Epilepsy service
on [**2183-7-25**] and placed on LTM. EEG showed nonconvulsive status
epilepticus and she was started on phenobarbital and the EEG
quieted down. Levels are as listed above. We decided to wean the
depakote [**7-28**] and as we weaned the medication she developed an
encephalopathy/acute delirium on [**7-29**]. Delirium was likely
multifactorial in that she had received ativan for an MRI, sleep
wake cycle broken, and depakote weaned.  The depakote was
restarted for mood stabilization. She remained encephalopathic
for two days [**Date range (1) 86695**] and then cleared. During that time we
used trazadone 25 mg at night to sleep. She did not repspond
well to seroquil and this should be avoided. We also used
zyprexa 2.5 mg one time. Psychiatry was following closely and we
avoided benzos. Regarding her AEDS, home low dose of topamax was
discontinued and she was continued on zonisamide 300 mg PO BID
(home medication). Dilantin was used for two days post injury
but then stopped. She was on on phenobarbital 60mg PO BID,
trough level was 32.6 on [**2183-8-4**] and when she became febrile
with a rash it was stopped on [**2183-8-5**]. She is on depakote 500
mg PO BID for mood stabilization and the level on [**8-4**] was 62.
She was felt to be ready for discharge on [**8-6**], however,
developed cyclic fevers, skin rash, sore throat, transammonitis,
and eosinophilia. A broad infectious workup, including formal ID
consult, was pursued, however, in the end, it was felt that the
constellation of symptoms and lab findings were consistent with
an adverse response to zonisimide. Zonisamide was stopped, and
the symptoms and lab findings resolved over about a week.
Gabapentin was added to her regimen for added seizure control.
This was chosen due to its kidney clearance and the team's
reluctance to start a new anticonvulsant cleared by the liver
while her LFT's were elevated. Keppra was reported to have side
effects in the past for her. Though she was also covered with
some standing Ativan, patient had a seizure 6 days after
stopping zonisamide. At that point, the standing Ativan was
increased in dose, and both Depakote and Gabapentin were
increased. About 5 days after this, a new diffuse skin rash
developed, which was felt to be due to either the Gabapentin or
Cymbalta that had been started for her depression in the last
few days. Thus both Cymbalta and Gabapentin were discontinued.
Dermatology was consulted and the plan was to treat the rash
symptomatically with benadryl, atarax, and Sarna lotion. The
rash has continued to reslove and on [**8-22**] the patient was able
to be discharged with close follow up with an epileptologist,
psychiatrist, Physical therapist, and neuro cognitive.   The
plan is to reintroduce seizure and psychiatric medications after
30 days following most recent drug reaction.
Also to note [**Known firstname 86696**] facial droop has been improving daily.  On
[**2183-8-26**] [**Known firstname **] was medically stable and able to go home.

# CV: She had periods of tachycardia with agitation and also
with walking. Orthostatics were normal. Tachycardia responded to
IVF. EKG only showed sinus tach.

# ID: Was febrile to 101 on [**8-4**]. Overnight on [**8-5**] was febrile
to 103.4.  U/A and CXRAY negative. No WBC count. Blood culture
was NGTD.  Developed erythematous rash thought to be possibly be
drug fever and phenobarbital was stopped. She defervesced with
tylenol and motrine. Was on ciprofloxacin ear drops for her
hospital course. EBV titers were negative for an acute
infection.

#F/E/N: Tolerating Regular diet. LFTS elevated on [**8-5**] and
trazadone stopped. LFT's have continued to trend down after
stopping Zonisamide.

# Psych: Period of delirium improved with resuming depakokte,
resuming sleep-wake cycle with trazadone at night and lowering
phenobarbital dose which is now stopped.  Pscyh closely followed
inpatient given history of ADD, anxiety, and depression. They
also followed for acute delirium. Case discussed with
psychiatrist at rehab by our inpatient psychiatrist. Many of her
psych meds from home have not been resumed yet given
encephalopathy. The Duloxetine was restarted and then stopped
after rash developed.

#  Plastics: Saw the patient for suturing of her ear and
posteriorly. Sutures removed on [**2183-7-25**] and also on [**2183-8-6**].

# ENT:She had MRI imaging to further evaluate her facial nerve
injury but it was a  limited evaluation of the facial nerves due
to blood in the mastoids. No
evidence of cisternal or canalicular abnormalities of the
seventh cranial
nerves bilaterally. A CT of the temporal bones would help us
visualize the nerve
and this is being arranged for [**2183-9-4**] when she will also
follow up with Neurosurgery for a CT head.   There was a High T1
signal along the right transverse sinus in an area of known
fracture raising the possibility of focal thrombosis, but when
CTV from admission reviewed this corresponds to an area of
decreased flow and she is not thought to have a thrombosos. A
CTV will be repeated with above imaging on [**2183-9-4**] to
better view this area. An audiology exam noted bilaterall
hearing loss. ENT was made aware and will repeat as out patient.



Follow up in Epilepsy, Neurosurgery, ENT, Neurology, Psychiatry,
Neurocognitive, PT, and therapy has been arranged.

Follow up in the [**Hospital 4695**] Clinic with Dr. [**First Name (STitle) **] as scheduled
with a Non Contrast Head CT; Patient should also have a CTV and
CT temporal bone at that time.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2183-9-4**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2183-9-4**] 3:00

Follow up in [**Hospital **] clinic with Dr. [**Last Name (STitle) 3878**] in [**4-10**] weeks for
audiogram; ( Appt: [**2183-9-1**] at 9:00am.

Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**], Epilepsy
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2183-10-20**] 8:30 Location [**Hospital Ward Name 23**] 5.

Outpt Epileptologist:[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] requesting DC summ sent to
her: fax [**Telephone/Fax (1) 86697**]

[**Hospital1 **] Neuro-psych: [**2183-9-30**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].

OT/PT: [**Name (NI) 620**]: [**2183-8-29**], 12pm, call [**Telephone/Fax (1) 86698**]





Medications on Admission:
1. Adderall 10 qpm
2. Adderral XR 30 mg q am
3. Cymbalta 30 q am/ 60 q am
4. Klonipin 1 mg [**Hospital1 **]
5. Topamax 25 mg qam
6. Trazadoe 100 qhs
7. Zonegam 300 mg [**Hospital1 **]
8. Ativan 1 mg Po for oncoming seizure and post seizure.
9. Benadryl 25 mg q4
9. Dulcolax 100 qd
10.Ibuprofen 600mg q 6
11.Melatonin 5mg qhs
12.Tyelenol 100 q4h prn.


Discharge Medications:
 White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed) as needed for dry eyes.
 Divalproex 500 mg Tablet Sustained Release 24 hr Sig: 1 [**2-8**]
Tablet Sustained Release 24 hr PO BID (2 times a day).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 1-2 Drops
Ophthalmic PRN (as needed) as needed for dry eyes.
Ciprofloxacin 0.3 % Drops Sig: Five (5) Drop Ophthalmic TID (3
times a day) for 7 days.
Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for itching.
Disp:*50 Tablet(s)* Refills:*0*
8. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itch, insomnia.
9. Petrolatum     Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for pruritis.


Discharge Disposition:
Home

Discharge Diagnosis:
Seizure
Left subarachnoid hemorrhage
Right intraparenchymal hemorrhage
Bilateral temporal lobe contusions
Basilar skull fracture

Secondary diagnosis:
Seizure disorder
Resolved delirium
Facial nerve palsy


Discharge Condition:
Mental Status: Clear and coherent. Oriented and Somewhat
perseverative.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were hospitalized following being found down and having a
seizure; as a result you sustained bleeding injury to your brain
and fractures of your skull bone. Your injuries did not require
any surgeries but there was concern given your seizure history.
Neurology was closely involved in your care and several
adjustments of your medications were made.
You were transferred to the Epilepsy service during your
admission. You are now on Zonisamide 300 mg twice daily. You are
also on depakote 500 mg twice a day.

Please take all medications and go to all follow up
appointments. You are being discharged to rehab and follow up
studies will need to be done.

Followup Instructions:
Follow up in the [**Hospital 4695**] Clinic with Dr. [**First Name (STitle) **] as scheduled
with a Non Contrast Head CT; Patient should also have a CTV and
CT temporal bone at that time.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2183-9-4**] 2:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2183-9-4**] 2:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2183-9-4**] 3:00

Follow up in [**Hospital **] clinic with Dr. [**Last Name (STitle) 3878**] in [**4-10**] weeks for
audiogram; ([**Telephone/Fax (1) 7767**] for an appointment. Appt: [**2183-9-1**] at 9:00am.

Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**], Epilepsy
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2183-10-20**] 8:30 Location [**Hospital Ward Name 23**] 5.

After discharge from rehab, please follow up with Dr. [**Last Name (STitle) **]
as well. Please call the office for an appointment.



Completed by:[**2183-9-4**]
{"Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness,Encephalopathy, unspecified,Delirium due to conditions classified elsewhere,Generalized convulsive epilepsy, without mention of intractable epilepsy,Bell's palsy,Open wound of auricle, ear, without mention of complication,Accidental fall on or from other stairs or steps,Fever presenting with conditions classified elsewhere,Dermatitis due to drugs and medicines taken internally,Other abnormal blood chemistry,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Antidepressants causing adverse effects in therapeutic use,Barbiturates causing adverse effects in therapeutic use,Abrasion or friction burn of hip, thigh, leg, and ankle, without mention of infection,Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection,Contusion of orbital tissues,Acute sinusitis, unspecified,Tear film insufficiency, unspecified,Other disorders of middle ear and mastoid,Conjunctival hemorrhage,Attention deficit disorder with hyperactivity,Dysthymic disorder,Degeneration of cervical intervertebral disc"}


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 post fall from standing position

PRESENT ILLNESS: 25 yo female history of seizures and depresison found at bottom
of stairs with positive blood bilateral tympanic membrane. Ct
with basilar skull fx with / extension into the right carotid
canal and possible facial nerve injury. Pt intubated in ED for
worsened MS [**First Name (Titles) **] [**Last Name (Titles) **]. + emesis of blood.

MEDICAL HISTORY: Seizure disorder
Depression
Anxiety
ADHD

MEDICATION ON ADMISSION: 1. Adderall 10 qpm
2. Adderral XR 30 mg q am
3. Cymbalta 30 q am/ 60 q am
4. Klonipin 1 mg [**Hospital1 **]
5. Topamax 25 mg qam
6. Trazadoe 100 qhs
7. Zonegam 300 mg [**Hospital1 **]
8. Ativan 1 mg Po for oncoming seizure and post seizure.
9. Benadryl 25 mg q4
9. Dulcolax 100 qd
10.Ibuprofen 600mg q 6
11.Melatonin 5mg qhs
12.Tyelenol 100 q4h prn.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Initial Exam:
Gen: Patient intubated, sedated.  NAD
Periorbital ecchymosis with multiple scattered abrasions
Ear: Two lacerations of antihelix, one of helix, 3 cm laceration
on the posterior auricular region.  Patient with hematoma above
poas[**Name (NI) **] auricular laceration.
Maxilla stable.
Nose: Stable nasal bone, no active bleeding
CTA bilateral lung fields
Cardiac RRR's
Abdomen: Soft, no tender, no distended.
EXT: no edema, bilateral pulses positive

FAMILY HISTORY: cousin with seizures

SOCIAL HISTORY: Per mother, pt has a hx of polysubstance abuse, unclear when
first started using or what recent use has been like. Per
mother, has abused alcohol, stimulants, benzos, ecstacy, MJ in
the past. Has also noted pt has had "drug-seeking" in the past
with different providers.  Unknown if pt has had any hx of
withdrawal phenomena.
Recently started smoking. In group home for the past
100 days secondary to depression. Was initially in the Babcock
home and recently advanced to the Gateway area where she can
function more independently. Per father when living at home
would
drink [**4-10**] glasses of wine 1x/month. Occasional marijuana use per
father. Graduated from Catholic [**Location (un) **] in DC. Was working at
[**Company 86694**] in [**Location (un) 7349**] until 1 yar ago. 

### Response:
{"Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness,Encephalopathy, unspecified,Delirium due to conditions classified elsewhere,Generalized convulsive epilepsy, without mention of intractable epilepsy,Bell's palsy,Open wound of auricle, ear, without mention of complication,Accidental fall on or from other stairs or steps,Fever presenting with conditions classified elsewhere,Dermatitis due to drugs and medicines taken internally,Other abnormal blood chemistry,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Antidepressants causing adverse effects in therapeutic use,Barbiturates causing adverse effects in therapeutic use,Abrasion or friction burn of hip, thigh, leg, and ankle, without mention of infection,Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection,Contusion of orbital tissues,Acute sinusitis, unspecified,Tear film insufficiency, unspecified,Other disorders of middle ear and mastoid,Conjunctival hemorrhage,Attention deficit disorder with hyperactivity,Dysthymic disorder,Degeneration of cervical intervertebral disc"}
