CHIEF COMPLAINT: Seizures

PRESENT ILLNESS: The pt is a 67 year-old woman with a PMH of GSW, shunt and
subsequent seizures. She was reportedly in her USOH this morning
when she fell and was then witnessed to have "GTC" lasting 20-25
minutes as well as earlier briefer seizures the specifics of
which are not known. She is afebrile and her
exam reveals L sided weakness and spasticity consistent with her
PMH of brain injury. I am not able to access for nuchal rigidity
given her C collar but she does not have a Brudzinski sign.

MEDICAL HISTORY: PMH:
- GSW in [**2096**] years ago to the head, burr holes at the time and
a
shunt, unsure if metal residual brain
- one history of shunt failure and seizures 7 years ago
- L sided weakness at baseline from GSW and uses a cane and
"shuffling gait"; limited short term memory and minimal insight
- seizures per report generalized, has been associated with
shunt
failure
- ? HTN
- L mastectomy for breast CA, no hx of mets 3 years
- abm surgery ? PEG given the scars on her abm
- bilateral hip replacements

MEDICATION ON ADMISSION: - amlodipine 5mg PO QD
- gabapentin 600mg PO QD
- detrol LA 4mg PO QD
- Tegretol XR 40mg PO BID
- folic acid 1mg PO QD
- clindamycin 150mg PO QD ?
- spironolactone 25mg PO QD

ALLERGIES: Penicillins

PHYSICAL EXAM: Physical Exam upon admission
Vitals: T: 99.4 (PR) P: 90  R: [**11-29**]  BP:  141-187/85-87 SaO2:
100% on ET
General: intubated, off sedation
HEENT: NC/AT, no scleral icterus noted, ET in place, some blood
at nare; palpable burr holes which are easily depressable
Neck: in C collar; no Brudzinski
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, + BS but multiple scars, with mastectomy
of
the L breast and several well healed abm incisions
Extremities: LLE pitting edema
Skin: no rashes

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: -Ex husband her shot her
-lives with support
-EtOH: not her HCP
-tobacco: not per HCP
-drug use: not per HCP
Epilepsia partialis continua, without mention of intractable epilepsy,Late effect of intracranial injury without mention of skull fracture,Abnormality of gait,Memory loss,Other musculoskeletal symptoms referable to limbs,Presence of cerebrospinal fluid drainage device,History of fall,Personal history of malignant neoplasm of breast,Hip joint replacement,Late effects of injury purposely inflicted by other person
Epil par cont w/o int ep,Lt eff intracranial inj,Abnormality of gait,Memory loss,Muscskel sympt limb NEC,Ventricular shunt status,Personal history of fall,Hx of breast malignancy,Joint replaced hip,Late effect assault
Admission Date:  [**2116-12-31**]              Discharge Date:   [**2117-1-5**]

Date of Birth:  [**2049-11-16**]             Sex:   F

Service: NEUROLOGY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 17813**]
Chief Complaint:
Seizures

Major Surgical or Invasive Procedure:
none


History of Present Illness:
The pt is a 67 year-old woman with a PMH of GSW, shunt and
subsequent seizures. She was reportedly in her USOH this morning
when she fell and was then witnessed to have "GTC" lasting 20-25
minutes as well as earlier briefer seizures the specifics of
which are not known. She is afebrile and her
exam reveals L sided weakness and spasticity consistent with her
PMH of brain injury. I am not able to access for nuchal rigidity
given her C collar but she does not have a Brudzinski sign.

Her work-up to date has included a negative UA and CXR as well
as
normal electrolytes and liver fxn. Her WBC at the OSH was 8 and
here it is 14. This may be due to her seizures or intubation,
however underlying infection must be evaluated. She will
therefore need a tap of her shunt in the ED. She will also need
a
shunt series to evaluate for shunt malfunction given her prior
history of shunt failure causing seizures. She also has a mildly
elevated troponin which may be due to demand ischemia from her
prior tachycardia, however I will check her CE to evaluate for
an
NSTEMI.

Given her presentation and low Tegretol level of 6 at the OSH,
she may have seized merely from being subtherapeutic on her AED.
Infection or structural etiologies including meningitis, shunt
failure or other infections will need to be evaluated as well.
Will therefore admit to neuro ICU for further care.


Past Medical History:
PMH:
- GSW in [**2096**] years ago to the head, burr holes at the time and
a
shunt, unsure if metal residual brain
- one history of shunt failure and seizures 7 years ago
- L sided weakness at baseline from GSW and uses a cane and
"shuffling gait"; limited short term memory and minimal insight
- seizures per report generalized, has been associated with
shunt
failure
- ? HTN
- L mastectomy for breast CA, no hx of mets 3 years
- abm surgery ? PEG given the scars on her abm
- bilateral hip replacements


Social History:
-Ex husband her shot her
-lives with support
-EtOH: not her HCP
-tobacco: not per HCP
-drug use: not per HCP


Family History:
Non-contributory

Physical Exam:
Physical Exam upon admission
Vitals: T: 99.4 (PR) P: 90  R: [**11-29**]  BP:  141-187/85-87 SaO2:
100% on ET
General: intubated, off sedation
HEENT: NC/AT, no scleral icterus noted, ET in place, some blood
at nare; palpable burr holes which are easily depressable
Neck: in C collar; no Brudzinski
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, + BS but multiple scars, with mastectomy
of
the L breast and several well healed abm incisions
Extremities: LLE pitting edema
Skin: no rashes

Neurologic:  this exam is done 5 minutes off of propofol
-Mental Status: initially drowsy and difficult to arouse, moving
her R leg intermittently (non-rhythmically); 5 minutes later she
as able to follow basic commands (squeezes with R hand, opens
eyes, shows 1 finger) and nod Y to simple questions
inconsistently.

CN
I: not tested
II,III: no blink to threat bilaterally, pupils 1.5->1mm
bilaterally, unable to visualize fundi due to miosis
III,IV,V: no dolls, No nystagmus
V: + corneals and nasal tickle bilaterally
VII: no gross facial asymmetry but very difficult to assess as
pt
has ET in place
VIII: UA
IX,X: + gag
[**Doctor First Name 81**]: UA
XII: UA (ET in place)

Motor: Normal bulk and tone on the R arm and leg, L arm and leg
have increased tone and atrophy; moves R arm and leg
spontaneously but not the L side (even to nox stim)

Reflex: No clonus
  [**Hospital1 **] Tri Bra Pat An Plantar
  C5 C7  C6  L4  S1 CST
L 2+ ----------- 1 Up
R 1------------- 0 Flexor

-Sensory: withdraws to nox stim on the R arm and leg but not the
L side

-Coordination: NA

-Gait: NA


Pertinent Results:
[**2116-12-31**]
EEG IMPRESSION: A markedly abnormal portable EEG due to the
persistent and
frequent spike and sharp and slow wave bursts in the right
anterior
quadrant and due to the irregular slowing in the left central
region as
well as the mildly slow background. The right anterior quadrant
sharp
wave activity suggests an acute structural lesion in the right
anterior
quadrant, likely with epileptogenic potential. Nevertheless, the

discharges did not become rapid enough or evolve so as to
suggest an
ongoing seizure during the course of this recording. The
left-sided
slowing suggests an additional subcortical dysfunction there.
The
background reflected the use of the propofol early in the
recording and
a subsequent mild encephalopathy later.

EEG [**2117-1-3**]
IMPRESSION: Abnormal EEG due to the presence of persistent
frequent
spike and sharp slow waves bursts in the right temporal region
as well
as irregular slowing in the left central region and a mildly
slow
background. The right temporal activity suggests an area of
epileptogenesis. The left central slowing indicates an area of
subcortical dysfunction. The generalized background slowing is
indicative of mild encephalopathy. Medications, metabollic
disturbances
and infection are among the most causes. There is no area
ongoing
seizure during this recording.

Head CT [**2116-12-31**]
IMPRESSION:
1. No hemorrhage. 2. The distal tip of the shunt terminates in
the frontal [**Doctor Last Name 534**] of the right lateral ventricle with no signs of
hydrocephalus.
3. Diffuse encephalomalacic changes of the brain in a linear
pattern, bullet fragments inside the brain and bilateral skull
defects are most likely related to the bullet injury. 4.
Depressed fracture fragment of the left frontal area.

Shunt series [**2116-12-31**]
FINDINGS: At least two separate craniotomies are identified.
There is a
shunt catheter extending to the central cerebrum through a right
posterior
burr hole. Catheter tubing extends through the soft tissues of
the posterior scalp and occiput to the right neck where there is
a single loop. The catheter then traverses and projects over the
midline chest, coursing into the abdomen with the tip is located
in the left upper quadrant. There is a coiled presumably remnant
catheter in the right hemipelvis. Incidental note is made of
left base atelectasis and at least four lamellated calcified
gallstones. Total hip replacements are also incidentally noted.

IMPRESSION: Shunt catheter as described above. No discontinuity
is noted.
Incidental findings as above.

Echo cardiogram [**2117-1-1**]:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.

IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild mitral regurgitation. No pericardial effusion.
EKG [**2116-12-31**]
Sinus rhythm. Left axis deviation. Left anterior fascicular
block. No previous tracing available for comparison.

Sinus rhythm. Left axis deviation. Left anterior fascicular
block. There is a
late transition that is probably normal. Compared to the
previous tracing
of [**2116-12-31**] there is no significant change

[**2116-12-31**]
LEFT LOWER EXTREMITY ULTRASOUND: The left common femoral,
superficial femoral and popliteal veins demonstrate normal
waveforms, augmentation and flow and compressibility. There is
no intraluminal thrombus.

IMPRESSION: No evidence of DVT in the left lower extremity.

[**2116-12-31**] 08:54PM   CK(CPK)-477*
[**2116-12-31**] 08:54PM   CK-MB-14* MB INDX-2.9 cTropnT-0.17*
[**2116-12-31**] 04:15PM   TYPE-ART TIDAL VOL-550 O2-40 PO2-124*
PCO2-31* PH-7.49* TOTAL CO2-24 BASE XS-2 -ASSIST/CON
INTUBATED-INTUBATED
[**2116-12-31**] 03:44PM URINE  HOURS-RANDOM
[**2116-12-31**] 03:44PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2116-12-31**] 01:15PM   GLUCOSE-83 UREA N-18 CREAT-0.6 SODIUM-137
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
[**2116-12-31**] 01:15PM   estGFR-Using this
[**2116-12-31**] 01:15PM   ALT(SGPT)-22 AST(SGOT)-34 CK(CPK)-280* ALK
PHOS-69 TOT BILI-0.6
[**2116-12-31**] 01:15PM   LIPASE-23
[**2116-12-31**] 01:15PM   CK-MB-10 MB INDX-3.6
[**2116-12-31**] 01:15PM   cTropnT-0.25*
[**2116-12-31**] 01:15PM   ALBUMIN-3.8 PHOSPHATE-2.3* MAGNESIUM-1.9
[**2116-12-31**] 01:15PM   ASA-NEG ETHANOL-NEG CARBAMZPN-5.2
ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2116-12-31**] 01:15PM   WBC-14.5* RBC-4.26 HGB-13.6 HCT-37.9 MCV-89
MCH-31.8 MCHC-35.8* RDW-13.6
[**2116-12-31**] 01:15PM   NEUTS-87.1* LYMPHS-8.2* MONOS-4.5 EOS-0.1
BASOS-0.1
[**2116-12-31**] 01:15PM   PT-11.7 PTT-20.1* INR(PT)-1.0
[**2116-12-31**] 01:15PM   PLT COUNT-304
[**2116-12-31**] 12:55PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2116-12-31**] 12:55PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG

Brief Hospital Course:
Neurologically: The pt is a 67 year-old woman with a PMH of GSW,
shunt and subsequent seizures, who was admitted for convulsive
status epilepticus and her initial Tegretol level was low at
5.2. She was successfully extubated and transferred to the
neurology floor. The Tegretol was changed to XR formulation and
increased to 600mg [**Hospital1 **] and she did not have additional seizures.
Her initial EEG showed frequent epileptiform discharges in the R
anterior quadrant although no clear electrographic seizures were
seen. After the medication adjustment, a repeat EEG was done and
showed persistent discharges but signficantly improved and were
much less frequent. A shunt series demonstrated no obstruction
or evidence of dysfunction. Initially, on exam she was lethargic
and slow to answer and had profound left arm and leg weakness,
which were likely postictal phenomenon, as this improved with
time. The R arm and leg strength improved to baseline and she
was able to ambulate with a cane and assistance.  Her physical
exam upon discharge: slow to answer, but alert and responsive.
oriented to place and person, not to time. Moderate left
hemiparesis with strength of [**3-14**] in lower and upper extremities.
She stated that she has an outpatient neurologist who has been
following her and she will follow him after discharge.

2) CV:
-troponins elevated but trending downward
-TTE Mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function. Mild mitral
regurgitation. No pericardial effusion
-monitor on telemetry with variable elevated heart rate with no
identified cause. PCP was [**Name (NI) 653**] and no previous history of
tachicardia

3) RESP:
-extubation without complications
-monitor for aspiration PNA

4) RENAL:
-no active issues, replete lytes as needed

5) ENDO:
-normoglycemia

6) FEN/GI:
-patient had feeding by NGTube, passed on swallow test and diet
with restriction was initiated.

7) ID:
- CSF no signs of infection
-Negative blood & urine cx


Medications on Admission:
- amlodipine 5mg PO QD
- gabapentin 600mg PO QD
- detrol LA 4mg PO QD
- Tegretol XR 40mg PO BID
- folic acid 1mg PO QD
- clindamycin 150mg PO QD ?
- spironolactone 25mg PO QD


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 582**] - [**Location (un) 7658**]

Discharge Diagnosis:
Seizures
VP shunt


Discharge Condition:
stable. No further seizures


Discharge Instructions:
You were admitted to this hospital after having seizures. You
have history of epilepsy and VP shunt placement. During your
admission no signs of infection was noted. No evidence of shunt
mal-function was detected.

You will be transfered to rehabilitation facility to continue
your care.

Followup Instructions:
Please contact your PCP Dr [**Name (NI) **] [**Numeric Identifier 60301**] for a follow up
appointment and to referal for a neurologist.

Also, you need to follow up with a Neurologist.  Please call [**Location (un) 4368**] Neurological at [**Telephone/Fax (1) 60302**] to schedule a follow up.
{'Epilepsia partialis continua, without mention of intractable epilepsy,Late effect of intracranial injury without mention of skull fracture,Abnormality of gait,Memory loss,Other musculoskeletal symptoms referable to limbs,Presence of cerebrospinal fluid drainage device,History of fall,Personal history of malignant neoplasm of breast,Hip joint replacement,Late effects of injury purposely inflicted by other person'}


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: Seizures

PRESENT ILLNESS: The pt is a 67 year-old woman with a PMH of GSW, shunt and
subsequent seizures. She was reportedly in her USOH this morning
when she fell and was then witnessed to have "GTC" lasting 20-25
minutes as well as earlier briefer seizures the specifics of
which are not known. She is afebrile and her
exam reveals L sided weakness and spasticity consistent with her
PMH of brain injury. I am not able to access for nuchal rigidity
given her C collar but she does not have a Brudzinski sign.

MEDICAL HISTORY: PMH:
- GSW in [**2096**] years ago to the head, burr holes at the time and
a
shunt, unsure if metal residual brain
- one history of shunt failure and seizures 7 years ago
- L sided weakness at baseline from GSW and uses a cane and
"shuffling gait"; limited short term memory and minimal insight
- seizures per report generalized, has been associated with
shunt
failure
- ? HTN
- L mastectomy for breast CA, no hx of mets 3 years
- abm surgery ? PEG given the scars on her abm
- bilateral hip replacements

MEDICATION ON ADMISSION: - amlodipine 5mg PO QD
- gabapentin 600mg PO QD
- detrol LA 4mg PO QD
- Tegretol XR 40mg PO BID
- folic acid 1mg PO QD
- clindamycin 150mg PO QD ?
- spironolactone 25mg PO QD

ALLERGIES: Penicillins

PHYSICAL EXAM: Physical Exam upon admission
Vitals: T: 99.4 (PR) P: 90  R: [**11-29**]  BP:  141-187/85-87 SaO2:
100% on ET
General: intubated, off sedation
HEENT: NC/AT, no scleral icterus noted, ET in place, some blood
at nare; palpable burr holes which are easily depressable
Neck: in C collar; no Brudzinski
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, + BS but multiple scars, with mastectomy
of
the L breast and several well healed abm incisions
Extremities: LLE pitting edema
Skin: no rashes

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: -Ex husband her shot her
-lives with support
-EtOH: not her HCP
-tobacco: not per HCP
-drug use: not per HCP 

### Response:
{'Epilepsia partialis continua, without mention of intractable epilepsy,Late effect of intracranial injury without mention of skull fracture,Abnormality of gait,Memory loss,Other musculoskeletal symptoms referable to limbs,Presence of cerebrospinal fluid drainage device,History of fall,Personal history of malignant neoplasm of breast,Hip joint replacement,Late effects of injury purposely inflicted by other person'}
