CHIEF COMPLAINT: right arm shaking, numbness

PRESENT ILLNESS: The pt is a 51 year-old right-handed man with a history of
intractable complex partial epilepsy who presents with increased
seizure frequency. The patient had a long recent hospitalization
at [**Hospital1 18**] last month after having increased seizure frequency and
a prolonged seizure in the epilepsy clinic. At that time, he
required ICU disposition because he would seize for 30-60
minutes, requiring high doses of ativan (>10 mg) total to break
the seizures. He was started on Vimpat, and his dose of
felbamate
and standing Ativan was increased. After discharge, he reports
doing very well for a few weeks. Then he began to have longer
events again, and was seen at a local hospital in [**State 3914**]. After
that, he continued to have frequent and prolonged events. He has
a very poor recollection of the past few weeks, but thinks he
seizes for hours a day. His wife will give him up to 5 doses of
Ativan, but the events have still been lasting over an hour. He
recalls on one ocassion he was very disoriented and walked into
a
wall. He has also been very sleepy, taking many naps during the
daytime. He denies any particular triggers including time of
day,
sleep deprivation.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
-intractable complex partial epilepsy and likely secondary
generalized seizures since [**2163**]
* s/p cortical sectioning of epileptogenic focus: lower sensory
motor strip [**11/2165**],
* s/p left VNS [**6-/2170**], with VNS replacement [**8-18**]
- L4-5 disc herniation
* s/p left L4-5 hemilaminectomy, median facetectomy and L4-5
disketctomy [**10/2164**]
-chronic headaches
-sinusitis
-viral meningitis at age 13
-GERD
-HLD
-possible sleep apnea
-depression
-benign hematuria, kidney stones (thought to be [**2-19**] topamax)
- traumatic right third digit amputation, s/p re-attachment
PAST SURGICAL HISTORY
- cortical sectioning of epileptogenic focus: lower sensory
motor strip [**11/2165**],
- left VNS placement [**6-/2170**], with VNS replacement [**8-18**]
- left L4-5 hemilaminectomy, median facetectomy and L4-5
disketctomy [**10/2164**]
- tonsillectomy
- vasectomy
- attachment of right third digit s/p traumatic amputation

MEDICATION ON ADMISSION: - Ativan 2 mg q4h
- Lamictal 200mg am and 300 mg at night
- Keppra [**2172**] QID
- Felbatol 1800mg/1800mg/1500mg
- Vimpat 250 mg daily
- Clarinex 5mg qday
- Zetia 10mg Qday
- Celexa 40 daily
- Omeprazole 20mg Qam
- ASA 81mg
- Metoprolol ER 50mg Qday
- Lipitor 40 mg Qday

ALLERGIES: Dilantin Kapseal / Depakote / Tegretol / Codeine / Phenobarbital
/ Penicillins

PHYSICAL EXAM: At admission:
General: drowsy
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.

FAMILY HISTORY: The patient reports that two of his children developed seizures
as infants, which resolved by six months of age.  Mother living,
age 76 with a history of MI and uterine cancer.  Father died at
age 64 of a stroke and MI

SOCIAL HISTORY: The patient lives with his wife.  Had worked as truck driver and
mechanic.  Reportedly, he has used cigarettes and pipes in the
past.  He enjoys alcohol occasionally. There is no history of
recreational drug use.
Epilepsia partialis continua, with intractable epilepsy,Body Mass Index 40.0-44.9, adult,Major depressive affective disorder, single episode, unspecified,Obesity, unspecified,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Anemia, unspecified,Unspecified essential hypertension,Headache,Vasectomy status,Personal history of tobacco use,Personal history of urinary calculi,Personal history of venous thrombosis and embolism,Long-term (current) use of other medications,Encounter for therapeutic drug monitoring
Epil par cont w intr epi,BMI 40.0-44.9, adult,Depress psychosis-unspec,Obesity NOS,Esophageal reflux,Obstructive sleep apnea,Hyperlipidemia NEC/NOS,Anemia NOS,Hypertension NOS,Headache,Vasectomy status,History of tobacco use,Prsnl hst urnr dsrd calc,Hx-ven thrombosis/embols,Long-term use meds NEC,Therapeutic drug monitor
Admission Date:  [**2183-9-8**]              Discharge Date:   [**2183-10-3**]

Date of Birth:  [**2131-11-1**]             Sex:   M

Service: NEUROLOGY

Allergies:
Dilantin Kapseal / Depakote / Tegretol / Codeine / Phenobarbital
/ Penicillins

Attending:[**First Name3 (LF) 17813**]
Chief Complaint:
right arm shaking, numbness

Major Surgical or Invasive Procedure:
none

History of Present Illness:
The pt is a 51 year-old right-handed man with a history of
intractable complex partial epilepsy who presents with increased
seizure frequency. The patient had a long recent hospitalization
at [**Hospital1 18**] last month after having increased seizure frequency and
a prolonged seizure in the epilepsy clinic. At that time, he
required ICU disposition because he would seize for 30-60
minutes, requiring high doses of ativan (>10 mg) total to break
the seizures. He was started on Vimpat, and his dose of
felbamate
and standing Ativan was increased. After discharge, he reports
doing very well for a few weeks. Then he began to have longer
events again, and was seen at a local hospital in [**State 3914**]. After
that, he continued to have frequent and prolonged events. He has
a very poor recollection of the past few weeks, but thinks he
seizes for hours a day. His wife will give him up to 5 doses of
Ativan, but the events have still been lasting over an hour. He
recalls on one ocassion he was very disoriented and walked into
a
wall. He has also been very sleepy, taking many naps during the
daytime. He denies any particular triggers including time of
day,
sleep deprivation.

Today, the patient had R sided shaking for over an hour, and
wife
gave him 5 doses of 1.5 mg of Ativan solution, and then he
received 10 mg IV Valium in the ambulance. He arrived at OSH ED
somnolent, arousable, with continued shaking of right upper and
occassionally lower extremities. Given his complex history, he
was accepted to be transferred to [**Hospital1 18**] ICU.

Past Medical History:
PAST MEDICAL HISTORY:
-intractable complex partial epilepsy and likely secondary
generalized seizures since [**2163**]
* s/p cortical sectioning of epileptogenic focus: lower sensory
motor strip [**11/2165**],
* s/p left VNS [**6-/2170**], with VNS replacement [**8-18**]
- L4-5 disc herniation
* s/p left L4-5 hemilaminectomy, median facetectomy and L4-5
disketctomy [**10/2164**]
-chronic headaches
-sinusitis
-viral meningitis at age 13
-GERD
-HLD
-possible sleep apnea
-depression
-benign hematuria, kidney stones (thought to be [**2-19**] topamax)
- traumatic right third digit amputation, s/p re-attachment
PAST SURGICAL HISTORY
- cortical sectioning of epileptogenic focus: lower sensory
motor strip [**11/2165**],
- left VNS placement [**6-/2170**], with VNS replacement [**8-18**]
- left L4-5 hemilaminectomy, median facetectomy and L4-5
disketctomy [**10/2164**]
- tonsillectomy
- vasectomy
- attachment of right third digit s/p traumatic amputation

Social History:
The patient lives with his wife.  Had worked as truck driver and
mechanic.  Reportedly, he has used cigarettes and pipes in the
past.  He enjoys alcohol occasionally. There is no history of
recreational drug use.


Family History:
The patient reports that two of his children developed seizures
as infants, which resolved by six months of age.  Mother living,
age 76 with a history of MI and uterine cancer.  Father died at
age 64 of a stroke and MI


Physical Exam:
At admission:
General: drowsy
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: drowsy but arousable. Oriented to self, [**Hospital3 **], [**2183-8-18**] (but thinks its the 10th). Unable to
complete
[**Doctor Last Name 1841**] backwards past [**Month (only) 205**]. Naming, repetition and comprehension
intact. No neglect.

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.  VFF to confrontation.
III, IV, VI: EOMI without nystagmus.  Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.

-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
  Delt Bic Tri WrE FFl FE  IO IP   Quad  Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L  5    5   5     5   5  5  5  5    5    5   5     5     5
R  5    5   5     5   5  5  5  5    5    5   5     5     5

-Sensory: No deficits to light touch, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.


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

-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.

-Gait: Defd

Pertinent Results:
Admission labs:
[**2183-9-8**] 02:51AM BLOOD WBC-8.4 RBC-3.83* Hgb-12.6* Hct-34.8*
MCV-91 MCH-32.7* MCHC-36.1* RDW-13.5 Plt Ct-316
[**2183-9-8**] 02:51AM BLOOD Glucose-105* UreaN-13 Creat-0.8 Na-140
K-3.7 Cl-102 HCO3-29 AnGap-13
[**2183-9-8**] 02:51AM BLOOD Albumin-4.2 Calcium-9.2 Phos-3.9 Mg-1.8
.
Other pertinent labs:
[**2183-9-12**] 03:40PM BLOOD Cholest-232*
[**2183-9-12**] 03:40PM BLOOD Triglyc-178* HDL-62 CHOL/HD-3.7
LDLcalc-134*
[**2183-9-8**] 02:51AM BLOOD ALT-27 AST-22 LD(LDH)-162 AlkPhos-93
TotBili-0.2
[**2183-9-12**] 03:40PM BLOOD %HbA1c-5.5 eAG-111
[**2183-9-12**] 03:40PM BLOOD Acetone-NEG
[**2183-9-12**] 06:53AM BLOOD Ammonia-56
[**2183-9-12**] 03:51PM BLOOD Type-[**Last Name (un) **] pH-7.40 Comment-GREEN TOP
[**2183-9-12**] 08:29PM BLOOD Type-ART pO2-184* pCO2-48* pH-7.42
calTCO2-32* Base XS-6
[**2183-9-12**] 03:51PM BLOOD Lactate-1.0
[**2183-9-12**] 03:40PM BLOOD BETA-HYDROXYBUTYRATE-PND
.
AED levels:
[**2183-9-8**] 12:46 LAMOTRIGINE  6.6 mcg/mL
[**2183-9-8**] 12:46 LEVETIRACETAM (KEPPRA) 60.1 mcg/mL
[**2183-9-9**] 05:50 LAMOTRIGINE 7.4 mcg/mL
.

.
.
Urine:
[**2183-9-8**] 12:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2183-9-8**] 12:45PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2183-9-8**] 12:45PM URINE RBC-<1 WBC-6* Bacteri-NONE Yeast-NONE
Epi-0
[**2183-9-8**] 12:45PM URINE Mucous-RARE
.
.
Microbiology:
[**2183-9-8**]	MRSA SCREEN	MRSA SCREEN-FINAL
.
.
Radiology:
CHEST (PORTABLE AP)	Study Date of [**2183-9-8**] 5:56 AM
IMPRESSION: Due to overlying monitoring and supporting devices
assessment of
right lung base was limited. Otherwise lungs are clear without
any evidence
of consolidation, pleural effusion or pneumothorax. Heart size
is top normal.
Mediastinal and hilar contours are unchanged.
.
SPECT BRAIN SCAN	Study Date of [**2183-9-9**]
IMPRESSION:
Interictal study demonstrating generalized decreased perfusion
of left
supratentorial region, most pronounced in left mesial temporal
lobe. Recommend
ictal study for further evaluation.
.
SPECT BRAIN SCAN	Study Date of [**2183-9-12**]
IMPRESSION:
Ictal study demonstrating asymmetric activity in left insular
region not present
on interictal study, suggesting this site as a possible
epileptogenic focus.
.
MR HEAD W & W/O CONTRAST	Study Date of [**2183-9-11**] 3:35 PM
IMPRESSION: Unchanged cortical thinning and FLAIR hyperintensity
in the left
primary somatosensory cortex. Without further history on the
patient and given
the status post left sided craniectomy the differential
considerations include sequela of
trauma, embolic infarct, infection or hemorrhage.
.
.
Neurophysiology:
EEG	Study Date of [**2183-9-8**]
IMPRESSION: This is an abnormal video telemetry recording
because of
focal slowing and isolated epileptiform discharges over the left
frontal
temporal region. This is suggestive of an area of focal
epileptogenic
activity in the left frontotemporal region. There is higher
amplitude
on the left consistent with breach rhythm. There is excess
diffuse beta
activity consistent with benzodiazepine use.
.
EEG	Study Date of [**2183-9-9**]
IMPRESSION: This is an abnormal extended routine study because
of
focal slowing and isolated epileptiform discharges over the left
frontal
temporal region. This is suggestive of an area of focal
epileptogenic
activity in the left frontotemporal region. There is higher
amplitude
on the left consistent with breach rhythm. There is excess
diffuse beta
activity consistent with benzodiazepine use.
.
.
Cardiology:
ECG	Study Date of [**2183-9-10**]  1:00:02 PM

Sinus rhythm with premature atrial contractions. Compared to the
previous
tracing of [**2183-8-12**] there is no significant change.

Read by:	[**Last Name (LF) **],[**Known firstname **] J.
 	Intervals	Axes
Rate	PR	QRS	QT/QTc	P	QRS	T
67	150	100	408/420	35	-23	21

Brief Hospital Course:
51 yo M with intractable complex partial epilepsy s/p cortical
sectioning of epileptogenic focus in the lower sensory motor
strip [**11/2165**], s/p left VNS presents with increased seizure
frequency and duration with no clear trigger. Patient has long
focal seizures and requires large doses of lorazepam.

# Neuro:
Patient presented with increased seizure frequency and duration
with no clear trigger. Had a long admission in [**Month (only) 205**] due to
increased seizure frequency. During this hospitalisation, he
required ICU care due to very prolonged seizures often for 30-60
minutes, requiring high doses of lorazepam (>10 mg) total to
break the seizures. He was started on Lacosamide, and his dose
of felbamate and standing lorazepam was increased. It seems that
while he had reached a dose of 250mg [**Hospital1 **] in house, per previous
d/c instructions was D/C'd on daily dosing.

After discharge, he reported doing very well for a few weeks.
Then he began to have longer events again, and was seen at a
local hospital in [**State 3914**]. After that, he continued to have
frequent and prolonged events. His wife will give him up to 5
doses of lorazepam (in liquid form), but the seizures have still
been lasting often for over an hour. He has had medication side
effects and recalls on one ocassion he was very disoriented and
walked into a wall. He also had problems with sedation due to
benzodiazepine therapt often taking many naps during the
daytime. Due to these medication side effects, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
RN had distributed Felbamate dose on [**2183-9-3**]. Patient
presented to OSH after a prolonged seizure refractory to
benzodiazepine therapy. He was then transferred to [**Hospital1 18**]. The
reason for this worsening is unclear, toxic/metabolic and
infectious workups at OSH were negative.

By the time of his arrival in the ED he had returned to his
neurologic baseline besides drowsiness. He was admitted to the
ICU for close monitoring and was restarted on his home
antiseizure medications. He had two further seiizures in the ICU
and these did not generalize with right limb shaking.

He was somnolent on transfer to the floor on [**9-8**] and was
initially difficult to rouse during a further episode just on
arrival to the floor. His keppra was decreased to 1500mg qid and
lacosamide was increased to 150mg [**Hospital1 **] initially and latterly to
250mg [**Hospital1 **]. His seizure semiology has been shaking of the right
arm and leg and has been unresponsive at times during these. Due
to poor seizure control his keppra was increased back to 1500mg
qid and latterly back to 2000mg qid.

He had an interictal SPECT which showed generalized decreased
perfusion of left supratentorial region, most pronounced in left
mesial temporal lobe. Ictal SPECT on [**9-12**] showed asymmetric
activity in left insular region not present on interictal study,
suggesting this site as a possible epileptogenic focus. MRI
showed unchanged cortical thinning and FLAIR hyperintensity in
the left primary somatosensory cortex in the area of previous
surgery. His case will be discussed at the epilepsy surgery
conference on [**2183-9-16**].

Due to increased seizure frequency (5 in 24 hours) large
requirement for benzodiazepines (had 16mg IV in addition to
standing po 2mg Q4) he was transferred for close monitoring to
the neuro-ICU. The goal is to limit benzo use and consideration
for surgery for definitive seizure control.

The following was noted in the ICU:
[**9-12**]- transferred to ICU for desaturations while seizing as
well as increasing frequency and length of seizures; patient
seized at [**2102**], magneted at [**2103**], ativan 2mg @ [**2104**], repeat
ativan 2mg @ [**2112**], desaturated to mid 80s @ [**2117**], neuro by
bedside at [**2122**], repeat ativan at [**2182**], repeat magnet @ [**2197**],
seizure stopped st 2040.
[**9-13**]: refractory seizure ~6am lasting approx 90 minutes; rec'd
8mg ativan and mult magnet swipes; desaturation to 70s at onset
of seizure in PM; responsive to supplemental O2; rec'd 8mg
ativan and mult magnet swipes; neuro team notified; early AM
seizure [**9-14**]; protocol followed;
[**9-14**]: No seizure activity over last 24 hours
[**9-15**]: seizure activity starting at 1750, neuro at bedside, VNS
stimulation multiple times, also given ativan 8 mg, seizure
resolved in 75 min. oxygen saturation was >95% throughout the
seizure
[**9-16**]: seizure activity starting at 0230, total duration 75 min,
total ativan dose 10mg, number of VNS swipes 6, maintained >97%
oxygen throughout seizure with CPAP, radiology for PICC
placement, lamotrigine and ativan standing doses increased per
neuro
Seizure Protocol
- Give 2mg of ativan only after ten minutes
- Give the next 2mg only after thirty minutes
- If continues to seize at 45 minutes, give 100mg IV lacosamide

- Then call attending on call ([**Doctor Last Name 2442**])
- At the same time, please swipe VNS device (q15 mins) and try
antagonistic maneuvers\
[**9-17**]: 90 min seizure in AM, ceased with IV lacosamide. No
further seizure activity over the day. Continued on ativan gtt.
Went to IR for advancement of PICC line.
[**9-18**]: No seizure activity over daytime. Continue current
management per neuro service.
[**9-19**]: Started seizing this morning. Given 12mg IV ativan and 3
doses of lacosamine (300mg) without resolution. Neuro at
bedside, epilepsy attending notified. EKG done. Hct 32-- 25,
rechecked as well as electrolytes. Repeat Hct 33. Neuro service
revised seizure protocol
[**9-20**]: 40 min seizure at 1030. Ativan 6mg x2. VNS swipe x 2.
Antagonistic movements. Neuro at bedside. 15 min seizure at
1120. Aitvan 5mg x1. VNS swipe x 1. No desats w/ both seizures.

[**9-21**]: started on methylpred, new seizure protocol initiated,
desat to mid 80's while sleeping with CPAP. Given concern for
aspiraton, CXR obtained, no evidence of consolidation. Last
seizure at 10:30 am on [**9-21**].
[**9-22**]: Seizure activity @ 0330 and lasted for 90 minutes, keppra
1000, lacosamide 100, felbatam 1200, ativan 6; a-line started to
evaluate for possible hypercarbic cause of seizure
[**9-23**]: EKG - QTc stable. D/c a-line. D/c ISS. UA w/out evidence of
UTI.
[**9-24**]: QTc stable. discussed dispo with primary team. PT consult
placed. no seizures.
[**9-25**]: seizure at 1030 lasted for 30 minutes and stopped after
only receiving lacosamide, switched from ativan gtt, to ativan 2
mg q2 IV,

While in the Neuro-ICU he was started on a ketogenic diet and
his AED regimen was modified to Keppra 2000mg qid, Lacosamide
250mg [**Hospital1 **], lamotrigine 200mg QAM and 300mg QPM and Felbamate
1800/1800/1500.

He was then transfered to the floor.

Given overall sedation, his AED regimen was changed again to
keppra 1000mg QID, Vimpat 200mg TID, Lamictal 150/150/300,
lorazepam 6mg QID, felbamate 1500/1500/1800mg.

His diet was modified and urine ketones/serum glucose were
checked serially.

He did remarkably well for the next week with only a few
seizures reported. He was discharged home with the AED regimen
outlined in this discharge with instructions on maintaining the
diet.

# PULM: Patient has known hx of OSA. Has been desatting to high
80s on sleeping with O2. We continued CPAP at autoset per
respiratory.
.
# CARDS: Patient was monitored on cardiac telemetry. We
continued atorvastatin, exetemibe and metoprolol succinate.
.
# GI: pt w/ known GERD. We continued omeprazole.

=================================================

Follow up:

He will follow up with Dr. [**Last Name (STitle) **] on [**11-19**] in outpatient
epilepsy clinic.

Medications on Admission:
- Ativan 2 mg q4h
- Lamictal 200mg am and 300 mg at night
- Keppra [**2172**] QID
- Felbatol 1800mg/1800mg/1500mg
- Vimpat 250 mg daily
- Clarinex 5mg qday
- Zetia 10mg Qday
- Celexa 40 daily
- Omeprazole 20mg Qam
- ASA 81mg
- Metoprolol ER 50mg Qday
- Lipitor 40 mg Qday

Discharge Medications:
1. lacosamide 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): please take at breakfast, lunch, dinner
.
Disp:*90 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): Please take at breakfast, lunch, dinner and at bedtime
.
Disp:*240 Tablet(s)* Refills:*2*
8. lamotrigine 100 mg Tablet Sig: as directed Tablet PO three
times a day: please take 1.5 tablets with breakfast, 1.5 tablets
with lunch and 3 tablets with dinner.
Disp:*180 Tablet(s)* Refills:*2*
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. lorazepam 1 mg Tablet Sig: Six (6) Tablet PO Q6H (every 6
hours): please take at breakfast, lunch, dinner and at bedtime
.
Disp:*720 Tablet(s)* Refills:*2*
12. psyllium 1.7 g Wafer Sig: One (1) Wafer PO TID (3 times a
day).
Disp:*90 Wafer(s)* Refills:*2*
13. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
14. felbamate 600 mg Tablet Sig: as directed Tablet PO three
times a day: Please take 2.5 tabs (1500mg) at breakfast, 2.5
tabs (1500mg) at lunch and 3 tabs (1800mg) at dinner.
Disp:*240 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Refer to Care Centrix. They will generate refferal

Discharge Diagnosis:
Seizures,


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


Discharge Instructions:
You were admitted to the [**Hospital3 **] Medical center for
increased seizures. You were treated with a variety of
anti-epileptic medications and were placed on a ketogenic diet
(low sugar). This helped limit your seizures.

You should continue to take the following medications as
prescribed. You should also continue your ketogenic diet.

- Lamictal 150mg in the morning, 150mg at lunch and 300mg at
dinner
- Keppra 1000mg at breakfast, lunch, dinner and at bedtime
- Lorazepam 6mg at breakfast, lunch, dinner and at bedtime
- Vimpat 200mg at breakfast, lunch, dinner
- Felbamate 1500mg at breakfast, 1500mg at lunch and 1800mg at
dinner

For breakthrough seizures, please wait 30 minutes at which time
you can take an extra dose of 6mg ativan(lorazepam) sublingual.
You may repeat this 6mg dose once. You should not take more than
2 extra doses of ativan over a 24hr period. If you continue to
have seizures despite this regimen, you should call your
neurologist.

Please note that you should continue your low sugar, ketogenic
diet at all times.


Followup Instructions:
Department: NEUROLOGY
When: WEDNESDAY [**2183-10-22**] at 1:30 PM
With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 6531**] RN [**Telephone/Fax (1) 876**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: NEUROLOGY/[**Hospital Ward Name **] 503
When: WEDNESDAY [**2183-11-19**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 5285**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage
{'Epilepsia partialis continua, with intractable epilepsy,Body Mass Index 40.0-44.9, adult,Major depressive affective disorder, single episode, unspecified,Obesity, unspecified,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Anemia, unspecified,Unspecified essential hypertension,Headache,Vasectomy status,Personal history of tobacco use,Personal history of urinary calculi,Personal history of venous thrombosis and embolism,Long-term (current) use of other medications,Encounter for therapeutic drug monitoring'}


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: right arm shaking, numbness

PRESENT ILLNESS: The pt is a 51 year-old right-handed man with a history of
intractable complex partial epilepsy who presents with increased
seizure frequency. The patient had a long recent hospitalization
at [**Hospital1 18**] last month after having increased seizure frequency and
a prolonged seizure in the epilepsy clinic. At that time, he
required ICU disposition because he would seize for 30-60
minutes, requiring high doses of ativan (>10 mg) total to break
the seizures. He was started on Vimpat, and his dose of
felbamate
and standing Ativan was increased. After discharge, he reports
doing very well for a few weeks. Then he began to have longer
events again, and was seen at a local hospital in [**State 3914**]. After
that, he continued to have frequent and prolonged events. He has
a very poor recollection of the past few weeks, but thinks he
seizes for hours a day. His wife will give him up to 5 doses of
Ativan, but the events have still been lasting over an hour. He
recalls on one ocassion he was very disoriented and walked into
a
wall. He has also been very sleepy, taking many naps during the
daytime. He denies any particular triggers including time of
day,
sleep deprivation.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
-intractable complex partial epilepsy and likely secondary
generalized seizures since [**2163**]
* s/p cortical sectioning of epileptogenic focus: lower sensory
motor strip [**11/2165**],
* s/p left VNS [**6-/2170**], with VNS replacement [**8-18**]
- L4-5 disc herniation
* s/p left L4-5 hemilaminectomy, median facetectomy and L4-5
disketctomy [**10/2164**]
-chronic headaches
-sinusitis
-viral meningitis at age 13
-GERD
-HLD
-possible sleep apnea
-depression
-benign hematuria, kidney stones (thought to be [**2-19**] topamax)
- traumatic right third digit amputation, s/p re-attachment
PAST SURGICAL HISTORY
- cortical sectioning of epileptogenic focus: lower sensory
motor strip [**11/2165**],
- left VNS placement [**6-/2170**], with VNS replacement [**8-18**]
- left L4-5 hemilaminectomy, median facetectomy and L4-5
disketctomy [**10/2164**]
- tonsillectomy
- vasectomy
- attachment of right third digit s/p traumatic amputation

MEDICATION ON ADMISSION: - Ativan 2 mg q4h
- Lamictal 200mg am and 300 mg at night
- Keppra [**2172**] QID
- Felbatol 1800mg/1800mg/1500mg
- Vimpat 250 mg daily
- Clarinex 5mg qday
- Zetia 10mg Qday
- Celexa 40 daily
- Omeprazole 20mg Qam
- ASA 81mg
- Metoprolol ER 50mg Qday
- Lipitor 40 mg Qday

ALLERGIES: Dilantin Kapseal / Depakote / Tegretol / Codeine / Phenobarbital
/ Penicillins

PHYSICAL EXAM: At admission:
General: drowsy
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.

FAMILY HISTORY: The patient reports that two of his children developed seizures
as infants, which resolved by six months of age.  Mother living,
age 76 with a history of MI and uterine cancer.  Father died at
age 64 of a stroke and MI

SOCIAL HISTORY: The patient lives with his wife.  Had worked as truck driver and
mechanic.  Reportedly, he has used cigarettes and pipes in the
past.  He enjoys alcohol occasionally. There is no history of
recreational drug use. 

### Response:
{'Epilepsia partialis continua, with intractable epilepsy,Body Mass Index 40.0-44.9, adult,Major depressive affective disorder, single episode, unspecified,Obesity, unspecified,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Anemia, unspecified,Unspecified essential hypertension,Headache,Vasectomy status,Personal history of tobacco use,Personal history of urinary calculi,Personal history of venous thrombosis and embolism,Long-term (current) use of other medications,Encounter for therapeutic drug monitoring'}
