CHIEF COMPLAINT: Increasing seizures

PRESENT ILLNESS: The pt is a 50 year-old right-handed man with a history of
intractable complex partial epilepsy who presents with increased
seizure frequency.  The patient reports that he was first
diagnosed with seizures in ~[**2163**].  The semiology has varied to
some degree over the years, with his current seizures consisting
of a prodrome of nausea.  Occasionally this will be all that he
experiences, however this will often progress to include right
arm and foot shaking, accompanied by a headache.  These will
generally last ~5-10 minutes.  He retains consciousness
throughout the episode, but does note that he is quite tired
afterwards, and will nap for 1-2 hours.  At his worst his
seizures occurred at a frequency of 15-20/day, however recently
since starting Lamictal, he reports he has actually had several
month to 1 year where he only gets them 2-3 times/week.
However, starting ~2 weeks ago, he began to have an increase in
seizure frequency and duration.  He notes he had increased to
having up to 15-20/day.  2 days ago he mentioned to his wife
that he may need to consider going into the hospital to try to
break this cluster, however held off at that time.  Yesterday
evening he was at home, and his wife came home from work and
found him having one of his typical seizures, so she gave him
1mg of Ativan.  Later that evening he was complaining of a
severe headache, which often accompanies his seizures, so she
gave him another 1mg.  Then, when trying to go to sleep he had a
third episode, again consisting of right sided shaking, but with
maintained consciousness and ability to follow commands on the
left.  She gave him a 3rd mg of Ativan at that time, but the
seizure did not stop, so she called EMS.  On arrival they gave
him 10mg of Diastat.  It is unclear how long this final episode
lasted - reports range from 25-40 minutes.  He was taken to a
local hospital in VT, where upon discussion with his outpatient
Epileptologist, it was decided to give him an extra 1000mg of
Keppra.  He was admitted to the hospital overnight for
observation, and today was transferred to [**Hospital1 18**].  He is not
clear how many seizures he had in total yesterday, but today
believes he had 1 prior to transfer, 2 in the ambulance (for
which he received 0.5mg and 1mg of Midazolam) and 1 upon arrival
to the ED.  He reports no recent illness and no recent
medication changes.

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: Lipitor 40 mg Qday
- Lamictal 225mg [**Hospital1 **]
- Keppra 2500mg [**Hospital1 **]
- Felbatol 1800mg/1800mg/1200mg
- Clarinex 5mg qday
- Zetia 10mg Qday
- Celexa 20mg [**Hospital1 **]
- Omeprazole 20mg Qam
- ASA 81mg
- Metoprolol ER 50mg Qday
- Zantac 300mg QHS
- Ativan 1mg tid

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

PHYSICAL EXAM: Physical Exam:
Vitals: T: afebrile P: 60  R: 16  BP: 120/80  SaO2: 99% on RA
General: Awake, cooperative, NAD.
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, 2+ radial, DP pulses
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.  Due to
adoption, the remainder of family history is unclear.

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.
Mechanical complication of nervous system device, implant, and graft,Grand mal status,Esophageal reflux,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Personal history of urinary calculi,Vasectomy status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Personal history of venous thrombosis and embolism
Malfun neuro device/graf,Grand mal status,Esophageal reflux,Hyperlipidemia NEC/NOS,Depressive disorder NEC,Obstructive sleep apnea,Prsnl hst urnr dsrd calc,Vasectomy status,Abn react-artif implant,Hx-ven thrombosis/embols
Admission Date:  [**2182-8-6**]              Discharge Date:   [**2182-8-16**]

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

Service: NEUROLOGY

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

Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
Increasing seizures

Major Surgical or Invasive Procedure:
VNS interrogation
VNS generator replacement
intubation


History of Present Illness:
The pt is a 50 year-old right-handed man with a history of
intractable complex partial epilepsy who presents with increased
seizure frequency.  The patient reports that he was first
diagnosed with seizures in ~[**2163**].  The semiology has varied to
some degree over the years, with his current seizures consisting
of a prodrome of nausea.  Occasionally this will be all that he
experiences, however this will often progress to include right
arm and foot shaking, accompanied by a headache.  These will
generally last ~5-10 minutes.  He retains consciousness
throughout the episode, but does note that he is quite tired
afterwards, and will nap for 1-2 hours.  At his worst his
seizures occurred at a frequency of 15-20/day, however recently
since starting Lamictal, he reports he has actually had several
month to 1 year where he only gets them 2-3 times/week.
However, starting ~2 weeks ago, he began to have an increase in
seizure frequency and duration.  He notes he had increased to
having up to 15-20/day.  2 days ago he mentioned to his wife
that he may need to consider going into the hospital to try to
break this cluster, however held off at that time.  Yesterday
evening he was at home, and his wife came home from work and
found him having one of his typical seizures, so she gave him
1mg of Ativan.  Later that evening he was complaining of a
severe headache, which often accompanies his seizures, so she
gave him another 1mg.  Then, when trying to go to sleep he had a
third episode, again consisting of right sided shaking, but with
maintained consciousness and ability to follow commands on the
left.  She gave him a 3rd mg of Ativan at that time, but the
seizure did not stop, so she called EMS.  On arrival they gave
him 10mg of Diastat.  It is unclear how long this final episode
lasted - reports range from 25-40 minutes.  He was taken to a
local hospital in VT, where upon discussion with his outpatient
Epileptologist, it was decided to give him an extra 1000mg of
Keppra.  He was admitted to the hospital overnight for
observation, and today was transferred to [**Hospital1 18**].  He is not
clear how many seizures he had in total yesterday, but today
believes he had 1 prior to transfer, 2 in the ambulance (for
which he received 0.5mg and 1mg of Midazolam) and 1 upon arrival
to the ED.  He reports no recent illness and no recent
medication changes.

Over the years he has tried multiple medications, including
Tranxene, Phenobarbitol, Carbamazepine, Depakote, Neurontin,
Dilantin and Tegretol.  He is currently maintained on Felbamate,
Lamictal and Keppra, with no recent dose changes.  He also has a
VNS that is 8-9 years old, last interrogated [**4-27**], and plans
were being made to change the battery this summer.  He also had
left temporal grids placed in [**2165**], and underwent cortical
sectioning at that time.  He reports that his only GTCs occurred
in the context of the grid placement, during which time he had a
total of 2.

The patient reports a normal birth and developmental history,
and denies any history of head trauma.  He does note that at age
13 he had viral meningitis.

On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech.  Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.

On general review of systems, the pt denies recent fever or
chills.  No night sweats or recent weight loss or gain. Denies
cough, shortness of breath.  Denies chest pain or tightness,
palpitations.  Denies nausea, vomiting, diarrhea, constipation
or abdominal pain.  No recent change in bowel or bladder habits.
 No dysuria.  Denies arthralgias or myalgias. Denies rash.


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.  Due to
adoption, the remainder of family history is unclear.


Physical Exam:
Physical Exam:
Vitals: T: afebrile P: 60  R: 16  BP: 120/80  SaO2: 99% on RA
General: Awake, cooperative, NAD.
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, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: Alert, oriented to [**Hospital1 18**], [**2182-7-18**], however
states it is Monday the 18th.  Able to relate history without
difficulty.  Attentive, able to name [**Doctor Last Name 1841**] backward, but skips
[**Month (only) 958**].  Language is fluent with intact repetition and
comprehension.  Normal prosody.  There were no paraphasic
errors.  Pt. was able to name both high and low frequency
objects.  Able to read without difficulty.  Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall [**3-20**] at 5
minutes.  The pt. had good knowledge of current events.  There
was no evidence of apraxia or neglect.

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.  VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
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**] EDB
L  5    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   5

-Sensory: No deficits to light touch, pinprick, 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 flexor bilaterally.

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

-Gait: Good initiation. Narrow-based, normal stride and arm
swing.  Able to walk in tandem without difficulty. Romberg
absent.



Pertinent Results:
[**2182-8-6**] 03:50PM   PLT COUNT-322
[**2182-8-6**] 03:50PM   NEUTS-65.5 LYMPHS-27.9 MONOS-4.0 EOS-1.7
BASOS-0.8
[**2182-8-6**] 03:50PM   WBC-8.4 RBC-4.57* HGB-14.7 HCT-43.2 MCV-95
MCH-32.3* MCHC-34.1 RDW-13.9
[**2182-8-6**] 03:50PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2182-8-6**] 03:50PM   CALCIUM-9.4 PHOSPHATE-3.9 MAGNESIUM-1.9
[**2182-8-6**] 03:50PM   estGFR-Using this
[**2182-8-6**] 03:50PM   GLUCOSE-91 UREA N-13 CREAT-0.8 SODIUM-139
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-32 ANION GAP-12
[**2182-8-6**] 05:00PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2182-8-6**] 05:00PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2182-8-6**] 05:00PM URINE  bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2182-8-6**] 05:00PM URINE  HOURS-RANDOM

AED LEVELS:

LAMOTRIGINE                   5.3

LEVETIRACETAM (KEPPRA)        28.3

IMAGING:
C-SPINE TRAUMA SERIES:
VNS wires are seen on the left lateral aspect of the cervical
spine extending from C5 through C7. No significant abnormality
of the
cervical spine identified.


Brief Hospital Course:
The pt is a 50 year-old right-handed man with a history of
intractable complex partial epilepsy who presents with increased
seizure frequency.  The patient reports that he was first
diagnosed with seizures in ~[**2163**].  The semiology has varied to
some degree over the years, with his current seizures consisting
of a prodrome of nausea.  Occasionally this will be all that he
experiences, however this will often progress to include right
arm and foot shaking, accompanied by a headache.  These will
generally last ~5-10 minutes.  He retains consciousness
throughout the episode, but does note that he is quite tired
afterwards, and will nap for 1-2 hours.  At his worst his
seizures occurred at a frequency of 15-20/day, however recently
since starting Lamictal, he reports he has actually had several
month to 1 year where he only gets them 2-3 times/week.
However, starting ~2 weeks ago, he began to have an increase in
seizure frequency and duration.  He notes he had increased to
having up to 15-20/day.  2 days ago he mentioned to his wife
that he may need to consider going into the hospital to try to
break this cluster, however held off at that time.  Yesterday
evening he was at home, and his wife came home from work and
found him having one of his typical seizures, so she gave him
1mg of Ativan.  Later that evening he was complaining of a
severe headache, which often accompanies his seizures, so she
gave him another 1mg.  Then, when trying to go to sleep he had a
third episode, again consisting of right sided shaking, but with
maintained consciousness and ability to follow commands on the
left.  She gave him a 3rd mg of Ativan at that time, but the
seizure did not stop, so she called EMS.  On arrival they gave
him 10mg of Diastat.  It is unclear how long this final episode
lasted - reports range from 25-40 minutes.  He was taken to a
local hospital in VT, where upon discussion with his outpatient
Epileptologist, it was decided to give him an extra 1000mg of
Keppra.  He was admitted to the hospital overnight for
observation, and today was transferred to [**Hospital1 18**].  He is not
clear how many seizures he had in total yesterday, but today
believes he had 1 prior to transfer, 2 in the ambulance (for
which he received 0.5mg and 1mg of Midazolam) and 1 upon arrival
to the ED.  He reports no recent illness and no recent
medication changes.

Over the years he has tried multiple medications, including
Tranxene, Phenobarbitol, Carbamazepine, Depakote, Neurontin,
Dilantin and Tegretol.  He is currently maintained on Felbamate,
Lamictal and Keppra, with no recent dose changes.  He also has a
VNS that is 8-9 years old, last interrogated [**4-27**], and plans
were being made to change the battery this summer.  He also had
left temporal grids placed in [**2165**], and underwent cortical
sectioning at that time.  He reports that his only GTCs occurred
in the context of the grid placement, during which time he had a
total of 2.

The patient reports a normal birth and developmental history,
and denies any history of head trauma.  He does note that at age
13 he had viral meningitis.

On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech.  Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.

On general review of systems, the pt denies recent fever or
chills.  No night sweats or recent weight loss or gain. Denies
cough, shortness of breath.  Denies chest pain or tightness,
palpitations.  Denies nausea, vomiting, diarrhea, constipation
or abdominal pain.  No recent change in bowel or bladder habits.
 No dysuria.  Denies arthralgias or myalgias. Denies rash.

  Since coming to the hospital the patient continued to have
seizures.  VNS was interogated. At first it read 0, but then
appeared to maintain.
  ENT evaluetd patient due to hoarse voice/muffled voice. Did
not think the hoarseness was due to VNS issues. The dose of
Ativan was increased to 2 mg TID.
  Neurosurgery was consulted to assess need for replacement or
battery change.  They reccomended VNS generator replacement,
which was done [**8-13**].
Unfortunately, over the weekend while awaiting this procedure,
the patient went into status epilepticus and was transferred to
the neuro ICU. He had multiple extended seizures that were
difficult to break and required high doses of Ativan. In order
to acheive better seizure control, the patient was intubated
pre-op. He was extubated 48 hours later and then re-intubated
for operation. Given the airway trauma of multiple intubations,
the patient remained intubated overnight post-op. He had one
seizure post-op in the evening of [**8-13**].
He was then extubated on [**8-14**] and remained seizure free for the
duration of his admission.
He was tapered down on his Ativan dose to 1 mg QID. He will
taper down to 1 mg TID 1 week after discharge. He was discharged
on an increased dose of Keppra, his home doses of Lamictal and
felbamate.
The patient will need gradual increase of his VNS generator
settings as an outpatient. This will be arranged by [**First Name8 (NamePattern2) 16883**]
[**Last Name (NamePattern1) 85740**].
The patient will follow up with the Epilepsy Center (Dr.
[**Last Name (STitle) **] and will neurosurgery.



Medications on Admission:
 Lipitor 40 mg Qday
- Lamictal 225mg [**Hospital1 **]
- Keppra 2500mg [**Hospital1 **]
- Felbatol 1800mg/1800mg/1200mg
- Clarinex 5mg qday
- Zetia 10mg Qday
- Celexa 20mg [**Hospital1 **]
- Omeprazole 20mg Qam
- ASA 81mg
- Metoprolol ER 50mg Qday
- Zantac 300mg QHS
- Ativan 1mg tid


Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Felbamate 400 mg Tablet Sig: 4.5 Tablets PO Qam ().
3. Felbamate 400 mg Tablet Sig: Three (3) Tablet PO Qpm ().
4. Levetiracetam 500 mg Tablet Sig: Five (5) Tablet PO BID (2
times a day).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Felbamate 400 mg Tablet Sig: 4.5 Tablets PO NOON (At Noon).
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Ativan 2 mg PO TID


Discharge Disposition:
Home

Discharge Diagnosis:
Increasing seizure activity
VNS malfunction

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic exam: mild right sided weakness, otherwise normal


Discharge Instructions:
It was a pleasure taking care of you. You were admitted for
increased seizures. You underwent replacement of your VNS
generator. This will be adjusted gradually as an outpatient. You
were continued on your home anti-epileptic medications. You will
decrease your dose of Ativan from 4 to 3 times a day after 1
week.

Followup Instructions:

Please call [**First Name8 (NamePattern2) 16883**] [**Last Name (NamePattern1) 85740**] on Monday to schedule an appointment
for check-in and VNS adjustment in the next 2 weeks.

You have an appointment in the neurosurgery clinic for suture
removal
[**2183-8-21**]:30 AM
[**Last Name (NamePattern1) **]. [**Location (un) 470**] [**Hospital Unit Name **]
Phone: [**Telephone/Fax (1) 1669**]

You have an appointment tentatively with Dr. [**Last Name (STitle) **]
Wednesday [**1-8**] 2:30 pm
This will likely be moved up and you will be called by the
office.
{'Mechanical complication of nervous system device, implant, and graft,Grand mal status,Esophageal reflux,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Personal history of urinary calculi,Vasectomy status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Personal history of venous thrombosis and embolism'}


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: Increasing seizures

PRESENT ILLNESS: The pt is a 50 year-old right-handed man with a history of
intractable complex partial epilepsy who presents with increased
seizure frequency.  The patient reports that he was first
diagnosed with seizures in ~[**2163**].  The semiology has varied to
some degree over the years, with his current seizures consisting
of a prodrome of nausea.  Occasionally this will be all that he
experiences, however this will often progress to include right
arm and foot shaking, accompanied by a headache.  These will
generally last ~5-10 minutes.  He retains consciousness
throughout the episode, but does note that he is quite tired
afterwards, and will nap for 1-2 hours.  At his worst his
seizures occurred at a frequency of 15-20/day, however recently
since starting Lamictal, he reports he has actually had several
month to 1 year where he only gets them 2-3 times/week.
However, starting ~2 weeks ago, he began to have an increase in
seizure frequency and duration.  He notes he had increased to
having up to 15-20/day.  2 days ago he mentioned to his wife
that he may need to consider going into the hospital to try to
break this cluster, however held off at that time.  Yesterday
evening he was at home, and his wife came home from work and
found him having one of his typical seizures, so she gave him
1mg of Ativan.  Later that evening he was complaining of a
severe headache, which often accompanies his seizures, so she
gave him another 1mg.  Then, when trying to go to sleep he had a
third episode, again consisting of right sided shaking, but with
maintained consciousness and ability to follow commands on the
left.  She gave him a 3rd mg of Ativan at that time, but the
seizure did not stop, so she called EMS.  On arrival they gave
him 10mg of Diastat.  It is unclear how long this final episode
lasted - reports range from 25-40 minutes.  He was taken to a
local hospital in VT, where upon discussion with his outpatient
Epileptologist, it was decided to give him an extra 1000mg of
Keppra.  He was admitted to the hospital overnight for
observation, and today was transferred to [**Hospital1 18**].  He is not
clear how many seizures he had in total yesterday, but today
believes he had 1 prior to transfer, 2 in the ambulance (for
which he received 0.5mg and 1mg of Midazolam) and 1 upon arrival
to the ED.  He reports no recent illness and no recent
medication changes.

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: Lipitor 40 mg Qday
- Lamictal 225mg [**Hospital1 **]
- Keppra 2500mg [**Hospital1 **]
- Felbatol 1800mg/1800mg/1200mg
- Clarinex 5mg qday
- Zetia 10mg Qday
- Celexa 20mg [**Hospital1 **]
- Omeprazole 20mg Qam
- ASA 81mg
- Metoprolol ER 50mg Qday
- Zantac 300mg QHS
- Ativan 1mg tid

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

PHYSICAL EXAM: Physical Exam:
Vitals: T: afebrile P: 60  R: 16  BP: 120/80  SaO2: 99% on RA
General: Awake, cooperative, NAD.
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, 2+ radial, DP pulses
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.  Due to
adoption, the remainder of family history is unclear.

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:
{'Mechanical complication of nervous system device, implant, and graft,Grand mal status,Esophageal reflux,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Personal history of urinary calculi,Vasectomy status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Personal history of venous thrombosis and embolism'}
