CHIEF COMPLAINT: Hydrocephlus

PRESENT ILLNESS: The patient is a 51 year old man with a history of traumatic
brain injury s/p ventriculoperitoneal shunt who suffered a fall
ten days ago and has had subacute on chronic worsening of his
gait. He has a poor baseline level of neurologic functioning, in
particular his mental status (disoriented, poor attention). He
had an episode of stiffening last night and initially was found
to have a mild right facial weakness and right arm drift,
possibly secondary to [**Doctor Last Name 555**] Paralysis from a seizure. However,
on imaging, he has been found to have an interval increase in
ventricular size suggestive of hydrocephalus.

MEDICAL HISTORY: 1. TBI (left temporal skull fracture) w/ resultant seizure d/o
2. History of status epilepticus
3. Anemia
4. former EtOH abuse
5. chronic cholecystitis

MEDICATION ON ADMISSION: Lacosamide, Lamotrigine, Lorazepam, Clonazepam,
Ibuprofen, Diphenhydramine, Phenytoin, Quetiapine, Zonisamide,
Docusate, Sennosides, Acetaminophen

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Awake, NAD, lying in bed comfortably.
Head: NC/AT, no scleral icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilateraly, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulse
Psych: Inattentive, occasionally laughs inappropriately and says
"true but false"

FAMILY HISTORY: Father had Pick's Disease and Mother died of a glioma

SOCIAL HISTORY: The patient is divorced. He currently resided at [**Location (un) **] Neuro
Rehab Center/Chip's House. He is a former computer programmer
and has 2 teenage children (Son and daughter)
EtoH: former significant abuse per wife
[**Name (NI) 1139**]: 1ppd since a teenager; stopped after injury
Mechanical complication of nervous system device, implant, and graft,Obstructive hydrocephalus,Hemiplegia, unspecified, affecting unspecified side,Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,History of fall,Abnormality of gait,Personal history of traumatic brain injury
Malfun neuro device/graf,Obstructiv hydrocephalus,Unsp hemiplga unspf side,Psymotr epil w/o int epi,Abn react-artif implant,Personal history of fall,Abnormality of gait,Hx traumatc brain injury
Admission Date:  [**2113-6-14**]              Discharge Date:   [**2113-6-16**]

Date of Birth:  [**2061-10-24**]             Sex:   M

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Hydrocephlus

Major Surgical or Invasive Procedure:
[**6-14**] Proxima revision of VP Shunt

History of Present Illness:
The patient is a 51 year old man with a history of traumatic
brain injury s/p ventriculoperitoneal shunt who suffered a fall
ten days ago and has had subacute on chronic worsening of his
gait. He has a poor baseline level of neurologic functioning, in
particular his mental status (disoriented, poor attention). He
had an episode of stiffening last night and initially was found
to have a mild right facial weakness and right arm drift,
possibly secondary to [**Doctor Last Name 555**] Paralysis from a seizure. However,
on imaging, he has been found to have an interval increase in
ventricular size suggestive of hydrocephalus.


Past Medical History:
1. TBI (left temporal skull fracture) w/ resultant seizure d/o
2. History of status epilepticus
3. Anemia
4. former EtOH abuse
5. chronic cholecystitis


Social History:
The patient is divorced. He currently resided at [**Location (un) **] Neuro
Rehab Center/Chip's House. He is a former computer programmer
and has 2 teenage children (Son and daughter)
EtoH: former significant abuse per wife
[**Name (NI) 1139**]: 1ppd since a teenager; stopped after injury


Family History:
Father had Pick's Disease and Mother died of a glioma


Physical Exam:
General: Awake, NAD, lying in bed comfortably.
Head: NC/AT, no scleral icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilateraly, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulse
Psych: Inattentive, occasionally laughs inappropriately and says
"true but false"

Neurologic Examination:

- Mental Status - Awake, alert, oriented x name but not month,
year, place or situation (near baseline, per wife). Cannot
recall
a coherent story. Recall 0/3. Attention moderately difficult to
attain and maintain. Follows simple one step commands, midline
and appendicular, but does so sporadically. Language volume
decreased, repetition intact. No dysarthria. No neglect.
Perseverative with words and actions.

- Cranial Nerves - [II] PERRL 4->2 brisk. VF full to number
counting. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without
deficits to light touch bilaterally. [VII] No facial asymmetry.
[VIII] Hearing intact to finger rub bilaterally. [IX, X] Palate
elevation symmetric. [[**Doctor First Name 81**]] SCM/Trapezius strength 5/5
bilaterally.
[XII] Tongue midline.

- Motor - Normal bulk and tone. No pronation, no drift. No
tremor
or asterixis.
=[Delt] [Bic] [Tri] [ExD] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[[**Last Name (un) 938**]]
L  5      5     5     5     5    5    5      5     5    5     5
R  5      5     5     5     5    5    5      5     5    5     5

- Sensory - No deficits to light touch bilaterally.

- Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2      2      2      2        2
R 2      2      2      2        2
Plantar response flexor bilaterally.

- Coordination - No dysmetria with finger/foot mirrored
movements.

- Gait - Slow initiation. Wide base. Short stride length.
Present
Romberg.


Pertinent Results:
[**2113-6-15**] 06:05AM BLOOD WBC-10.1 RBC-3.90* Hgb-12.5* Hct-37.3*
MCV-96 MCH-32.1* MCHC-33.5 RDW-13.5 Plt Ct-284
[**2113-6-14**] 01:45PM BLOOD Neuts-71.3* Lymphs-19.6 Monos-5.6 Eos-2.9
Baso-0.6
[**2113-6-15**] 06:05AM BLOOD Plt Ct-284
[**2113-6-15**] 06:05AM BLOOD Glucose-108* UreaN-8 Creat-0.5 Na-139
K-3.6 Cl-109* HCO3-22 AnGap-12
[**2113-6-15**] 06:05AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.7
[**2113-6-14**] 01:45PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG

CT brain [**6-14**] - Mild ventricular enlargement in a stable and
symmetric fashion compared to the prior exam. Findings suggest a
communicating hydrocephalus, possibly due to shunt failure.
Slightly more conspicuous hypoattenuation in a confluent nature
throughout the periventricular white matter may simply reflect a
progression of small vessel ischemic disease, although given the
periventricular distribution, an element of transependymal CSF
flow cannot be entirely excluded.

Ct brain [**6-15**] - 1. Right ventriculostomy catheter terminating in
the frontal [**Doctor Last Name 534**] of the right lateral ventricle at the septum
pellucidum, stable in position from prior study. Clinician to
review images to see if positioning is desired.
2. Minimally decreased ventricular size by 1-2 mm.
3. Encephalomalacia involving primarily the right temporal lobe
and left
frontal lobe, stable from prior study. Prominent extra-axial CSF
space in the  left middle cranial fossa, compatible with a
preexisting arachnoid cyst.


Brief Hospital Course:
Mr [**Known lastname 20663**] was admitted to the neurosurgery service and
emergently was taken to the OR and changed the proximal valve as
the old one was fractured right before the valve. Post
operatively he was neurologically at his baseline, orientated
X2, he was perseverative with poor comprehension. Neurology was
consulted given his seizure history and recent seizures. They
recommended an EEG, and UA and tox screen. On post op day one
his CT scan showed stable placement of RVP shunt catheter with
slight improvement of dilated ventricles.

On [**6-16**] patient had an EEG for which full report was pending.
Pt was consulted and they recommend rehab vs. home.  Now DOD,
patient is afebrile, VSS, and neurologically stable.  Patient's
pain is well-controlled and the patient is tolerating a good
oral diet.  Pt's incision is clean, dry and inctact without
evidence of infection.  He is set for discharge back to his
group home in stable condition and will follow-up accordingly
with neurology and neurosurgery.

Medications on Admission:
Lacosamide, Lamotrigine, Lorazepam, Clonazepam,
Ibuprofen, Diphenhydramine, Phenytoin, Quetiapine, Zonisamide,
Docusate, Sennosides, Acetaminophen


Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. lacosamide 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. lamotrigine 100 mg Tablet Sig: Five (5) Tablet PO BID (2
times a day).
5. phenytoin sodium extended 100 mg Capsule Sig: Two (2) Capsule
PO QHS (once a day (at bedtime)).
6. phenytoin sodium extended 30 mg Capsule Sig: One (1) Capsule
PO BREAKFAST (Breakfast).
7. quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for severe agitation.
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
9. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO NOON (At
Noon).
10. clonazepam 0.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
11. zonisamide 100 mg Capsule Sig: One (1) Capsule PO BREAKFAST
(Breakfast).
12. zonisamide 100 mg Capsule Sig: Six (6) Capsule PO HS (at
bedtime).


Discharge Disposition:
Extended Care

Facility:
Group home

Discharge Diagnosis:
Hydrocephlus
S/P Traumatic brain injury,
Status epilepticus
Anemia
Chronic cholecystitis


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


Discharge Instructions:
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
??????	If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week.  This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**] to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.

-  Neurology f/u
[**2113-8-21**]  10:30a   [**Last Name (LF) **],[**First Name3 (LF) **] L.
  SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
  NEUROLOGY UNIT CC8 (SB)


                             [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]

Completed by:[**2113-6-16**]
{'Mechanical complication of nervous system device, implant, and graft,Obstructive hydrocephalus,Hemiplegia, unspecified, affecting unspecified side,Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,History of fall,Abnormality of gait,Personal history of traumatic brain injury'}


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: Hydrocephlus

PRESENT ILLNESS: The patient is a 51 year old man with a history of traumatic
brain injury s/p ventriculoperitoneal shunt who suffered a fall
ten days ago and has had subacute on chronic worsening of his
gait. He has a poor baseline level of neurologic functioning, in
particular his mental status (disoriented, poor attention). He
had an episode of stiffening last night and initially was found
to have a mild right facial weakness and right arm drift,
possibly secondary to [**Doctor Last Name 555**] Paralysis from a seizure. However,
on imaging, he has been found to have an interval increase in
ventricular size suggestive of hydrocephalus.

MEDICAL HISTORY: 1. TBI (left temporal skull fracture) w/ resultant seizure d/o
2. History of status epilepticus
3. Anemia
4. former EtOH abuse
5. chronic cholecystitis

MEDICATION ON ADMISSION: Lacosamide, Lamotrigine, Lorazepam, Clonazepam,
Ibuprofen, Diphenhydramine, Phenytoin, Quetiapine, Zonisamide,
Docusate, Sennosides, Acetaminophen

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Awake, NAD, lying in bed comfortably.
Head: NC/AT, no scleral icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilateraly, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulse
Psych: Inattentive, occasionally laughs inappropriately and says
"true but false"

FAMILY HISTORY: Father had Pick's Disease and Mother died of a glioma

SOCIAL HISTORY: The patient is divorced. He currently resided at [**Location (un) **] Neuro
Rehab Center/Chip's House. He is a former computer programmer
and has 2 teenage children (Son and daughter)
EtoH: former significant abuse per wife
[**Name (NI) 1139**]: 1ppd since a teenager; stopped after injury 

### Response:
{'Mechanical complication of nervous system device, implant, and graft,Obstructive hydrocephalus,Hemiplegia, unspecified, affecting unspecified side,Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,History of fall,Abnormality of gait,Personal history of traumatic brain injury'}
