CHIEF COMPLAINT: Trouble walking

PRESENT ILLNESS: 49-year-old man with static encephalopathy and
intractable epilepsy, now admitted after a cluster of seizures
in
the setting of probable infection.

MEDICAL HISTORY: Past medical history is notable for static encephalopathy after
prolonged status epilepticus, possible anoxic injury at age 7 or
8 years. Intractable epilepsy.

MEDICATION ON ADMISSION: oxcarbazepine 600 mgTID
zonisamide 300/400
gabapentin 2400/400/800
clonazepam 5 mg QHS
multivitamin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: T:95.6  P: 56 R: 15  BP: 105/63 SaO2: 98% RA
Gen: Lying in bed, awake, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: CTAB
ext: no C/C/E

FAMILY HISTORY: Father is well, mother died in car accident

SOCIAL HISTORY: lives in group home; non-smoker, no alcohol, no recreational
drugs.
Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Other encephalopathy,Epilepsy, unspecified, with intractable epilepsy,Unspecified pleural effusion,Sepsis,Unspecified intellectual disabilities,Hypothermia not associated with low environmental temperature
Septicemia NOS,Food/vomit pneumonitis,Encephalopathy NEC,Epilepsy NOS w intr epil,Pleural effusion NOS,Sepsis,Intellect disability NOS,Hypothrm-wo low env tmp
Admission Date:  [**2187-1-17**]              Discharge Date:   [**2187-1-23**]

Date of Birth:  [**2137-10-23**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 7567**]
Chief Complaint:
Trouble walking

Major Surgical or Invasive Procedure:
None

History of Present Illness:
49-year-old man with static encephalopathy and
intractable epilepsy, now admitted after a cluster of seizures
in
the setting of probable infection.

He had mild developmental delay as a child, and then at age 7 or
8 years had prolonged (greater than 24 hours) status epilepticus
with probable anoxic brain injury in the setting of a febrile
illness. Subsequently, he had severe static encephalopathy and
intractable epilepsy. He currently resides in a group home. He
is
nonverbal, but does understand some language. He requires
assistance with most activities of daily living. He has some
obstinate behavior, but no aggression or agitated behavior
recently.

His typical seizures are of 2 types: #1) episodes of rapid eye
blinking, staring, and urinary incontinence, unclear frequency,
and #2) episodes of facial grimacing, stiffening of his limbs,
some lip smacking, and incontinence of urine and stool,
occurring
3-4 times per year.

For the past week or so, his group home staff have noticed that
he has had more difficulty with balance. This is somewhat
similar
to symptoms he had in [**2186-10-30**], when he presented with
ataxia and increased seizures in the setting of pneumonia. His
balance problems became more severe yesterday, and Dr. [**Last Name (STitle) **]
recommended getting labs and AED levels. The staff was unable to
get him to walk to come to the clinic. They called EMS and he
was
transported to [**Hospital1 18**] ER. There he was found to be hypothermic to
92, hypoglycemic 61, with borderline blood pressure SBP 80s. He
subsequently had 3 seizures of type #2 lasting several minutes.
He received a total of 2 mg of Ativan and was loaded with IV
Dilantin. He had oxygen desaturation and was therefore
transferred to the ICU. There, his blood pressure remained
borderline and he required 6 L of IV fluids.

Today, he has had a total of 11 seizures so far, with one to 2
per hour. These consisted of stiffening of his body, neck
extension, grimacing, and tremors/twitching of the jaw and
eyelids, each lasting 10-15 seconds. Between the seizures, he is
lethargic. He has received a total of 4 mg of Ativan today.


Past Medical History:
Past medical history is notable for static encephalopathy after
prolonged status epilepticus, possible anoxic injury at age 7 or
8 years. Intractable epilepsy.

Social History:
lives in group home; non-smoker, no alcohol, no recreational
drugs.

Family History:
Father is well, mother died in car accident


Physical Exam:
Vitals: T:95.6  P: 56 R: 15  BP: 105/63 SaO2: 98% RA
Gen: Lying in bed, awake, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: CTAB
ext: no C/C/E

Neurologic examination:
Mental status: Awake,  looks at examiner, non-verbal and does
not follow commands (baseline)

Cranial Nerves:
PERRL (3 to 2 mm) Tracks light source in all directions. No
nystagmus.  Blinks to threat. Face symmetric. Patient refuses to
open mouth

Motor:
Patient does not participate in detailed motor exam. Normal
bulk. He is antigravity throughout and moves his arms and legs
away from light touch.

Reflexes:
His reflexes are brisk throughout, with downgoing toes
bilaterally.

Coordination: unable to test

Gait: unable to test

Pertinent Results:
[**2187-1-17**] 12:21PM BLOOD WBC-4.4 RBC-4.13* Hgb-13.1* Hct-38.5*
MCV-93 MCH-31.8 MCHC-34.1 RDW-15.5 Plt Ct-77*#
[**2187-1-22**] 06:15AM BLOOD Glucose-84 UreaN-12 Creat-0.8 Na-136
K-3.7 Cl-105 HCO3-23 AnGap-12
[**2187-1-17**] 12:21PM BLOOD ALT-62* AST-53* LD(LDH)-209 AlkPhos-141*
TotBili-0.1
[**2187-1-18**] 01:28AM BLOOD Phenyto-14.1
[**2187-1-17**] 04:11PM BLOOD GABAPENTIN-Test
[**2187-1-17**] 04:11PM BLOOD TRILEPTAL-Test
[**2187-1-17**] 04:11PM BLOOD ZONISAMIDE(ZONEGRAN)-Test

CT CHEST:
1. Small peribronchial consoldiations noted in right upper lobe.
Diagnostic
considerations include early bronchopneumonia versus aspiration.
Recommend
followup to resolution after therapy.
2. Non-specific thickened bladder wall.
3. Subacute rib fracture of the posterior left 5th rib.
4. Otherwise no source for hypotension localized.

CXR:  New large areas of consolidation in both lungs suggest
severe aspiration pneumonia. There may also be a moderate left
pleural effusion. Borderline cardiomegaly is unchanged. No
pneumothorax.


Brief Hospital Course:
Patient is [**Initials (NamePattern4) **] [**Known firstname **] [**Last Name (NamePattern1) **] is a 49-year-old man with static
encephalopathy and
intractable epilepsy admitted after a cluster of seizures in the
setting of bilateral pneumonia.

He was noted to have more trouble with walking hence he was
brought to the hospital where he was found to be hypothermic to
92, hypoglycemic 61, with borderline blood pressure SBP 80s. He
subsequently had 3 seizures lasting several minutes hence he was
received 2mg of IV ativan then loaded with Dilantin.  He
initially was admitted to the ICU where he needed IV fluids.

He was transferred out to the floor and was monitored on
video/EEG monitoring.  In addition to his home AED's, Keppra was
added but with treatment of pneumonia, his seizures stopped.

He was initially treated with cefepime and vancomycin then
switched to moxifloxacin.  He will need 3 days of moxifloxacin
for total 10 days of antiobiotics to treat his pneumonia.
Keppra was discontinued the day before his discharge and he
remained seizure-free.

Clinically, he appears baseline and he is discharged home with
no changes to his anti-seizure regimen.  His last day of
antibiotics will be [**2187-1-26**] and he has follow-up appt
scheduled with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].


Medications on Admission:
oxcarbazepine 600 mgTID
zonisamide 300/400
gabapentin 2400/400/800
clonazepam 5 mg QHS
multivitamin

Discharge Medications:
1. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
2. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO QAM (once
a day (in the morning)).
3. zonisamide 100 mg Capsule Sig: Four (4) Capsule PO QPM (once
a day (in the evening)).
4. gabapentin 400 mg Capsule Sig: Six (6) Capsule PO QAM (once a
day (in the morning)).
5. gabapentin 400 mg Capsule Sig: One (1) Capsule PO QAFTERNOON
().
6. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
7. clonazepam 1 mg Tablet Sig: Five (5) Tablet PO QHS (once a
day (at bedtime)).
8. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: 1/26~[**1-26**].


Discharge Disposition:
Home

Discharge Diagnosis:
Bilateral pneumonia
Epilepsy
Mental retardation

Discharge Condition:
Nonverbal.
Moves all extremities and ambulatory with assistance.

Discharge Instructions:
You came to the hospital with walking trouble and found to have
pneumonia.  Due to the infection, you were having increased
seizure frequency.  Initially, you were started on a new
anti-seizure medication but it was able to be discontinued with
treatment of your infection.

You are discharged with antibiotics for pneumonia.  You last day
of antibiotics will be [**2187-1-26**] to complete total 10 days of
antibiotics.

Followup Instructions:
You have follow-up appointment with your primary neurologist:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5285**]
Date/Time:[**2187-2-7**] 1:00


Completed by:[**2187-1-23**]
{'Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Other encephalopathy,Epilepsy, unspecified, with intractable epilepsy,Unspecified pleural effusion,Sepsis,Unspecified intellectual disabilities,Hypothermia not associated with low environmental temperature'}


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: Trouble walking

PRESENT ILLNESS: 49-year-old man with static encephalopathy and
intractable epilepsy, now admitted after a cluster of seizures
in
the setting of probable infection.

MEDICAL HISTORY: Past medical history is notable for static encephalopathy after
prolonged status epilepticus, possible anoxic injury at age 7 or
8 years. Intractable epilepsy.

MEDICATION ON ADMISSION: oxcarbazepine 600 mgTID
zonisamide 300/400
gabapentin 2400/400/800
clonazepam 5 mg QHS
multivitamin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: T:95.6  P: 56 R: 15  BP: 105/63 SaO2: 98% RA
Gen: Lying in bed, awake, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: CTAB
ext: no C/C/E

FAMILY HISTORY: Father is well, mother died in car accident

SOCIAL HISTORY: lives in group home; non-smoker, no alcohol, no recreational
drugs. 

### Response:
{'Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Other encephalopathy,Epilepsy, unspecified, with intractable epilepsy,Unspecified pleural effusion,Sepsis,Unspecified intellectual disabilities,Hypothermia not associated with low environmental temperature'}
