CHIEF COMPLAINT: Status Epilepticus

PRESENT ILLNESS: PER THE ADMITTING RESIDENT:
49 yo RHM with history of intractible complex partial
epilepsy diagnosed in [**2163**], with cortical sectioning of
epileptic
area of lower central sensory motor strip in [**2165**], s/p left VNS
placement in [**2170**], and history of viral meningitis at age 13,
presenting in status epilepticus.  At 5 PM yesterday, the
patient's wife found him grunting and moving his right leg,
followed by choking and gagging.  Seizures were witnessed for
forty minutes before medical care arrived.  He was originally
taken to [**Hospital 3175**] Hospital where he had a witnessed seizure with
right leg flexion and extension, with hyperventilation and
unresponsiveness, lasting between one and five minutes and given
ativan 2 mg IV x1.  A subsequent seizure occurred and got a
repeat 2 mg ativan and took his PM AEDs including felbatol 1800
mg, keppra 2500 mg, and lamictal 125 mg.  Patient was arranged
for transfer to [**Hospital1 18**] for further evaluation and management.  En
route the patient had 3 seizures in the ambulance and had been
given another 8 mg ativan total.  The ambulance had run out of
ativan and patient was continuing to seize for another 12-13
minutes, and was given 2.5 mg valium.  The ambulance stopped at
[**Hospital 1514**] Hospital for further stabilization.  At this facility he
continued to actively seize, given an additional keppra 1g IV
and
ativan 8 mg total, and was subsequently intubated.
Transportation to [**Hospital1 18**] resumed and no further seizure activity
was witnessed.

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: -lamictal 125 mg [**Hospital1 **]
-felbatol 1800mg/1200mg/1800mg
-keppra 2500 mg [**Hospital1 **]
-ativan 1 mg q4h
-ativan 1 mg prn for seizure
-Aspirin 81 mg
-Toprol XL 50 mg daily
-Atorvastatin 40 mg qhs
-Zetia 10 mg qhs
-Omeprazole 20 mg daily
-Ranitidine 300 mg qhs
-Celexa 20 mg [**Hospital1 **]
-Clarinex 5 mg daily
-Magnesium (Mag 64) daily

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

PHYSICAL EXAM: The patient's neurological examination was notable for symmetric
hyporeflexia in all four limbs (baseline per patient).

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.
Epilepsia partialis continua, with intractable epilepsy,Other pulmonary embolism and infarction,Obstructive sleep apnea (adult)(pediatric),Esophageal reflux,Other and unspecified hyperlipidemia,Personal history of tobacco use,Other postprocedural status
Epil par cont w intr epi,Pulm embol/infarct NEC,Obstructive sleep apnea,Esophageal reflux,Hyperlipidemia NEC/NOS,History of tobacco use,Post-proc states NEC
Admission Date:  [**2181-8-31**]              Discharge Date:   [**2181-9-7**]

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

Service: NEUROLOGY

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

Attending:[**First Name3 (LF) 848**]
Chief Complaint:
Status Epilepticus

Major Surgical or Invasive Procedure:
Video EEG Monitoring


History of Present Illness:
PER THE ADMITTING RESIDENT:
49 yo RHM with history of intractible complex partial
epilepsy diagnosed in [**2163**], with cortical sectioning of
epileptic
area of lower central sensory motor strip in [**2165**], s/p left VNS
placement in [**2170**], and history of viral meningitis at age 13,
presenting in status epilepticus.  At 5 PM yesterday, the
patient's wife found him grunting and moving his right leg,
followed by choking and gagging.  Seizures were witnessed for
forty minutes before medical care arrived.  He was originally
taken to [**Hospital 3175**] Hospital where he had a witnessed seizure with
right leg flexion and extension, with hyperventilation and
unresponsiveness, lasting between one and five minutes and given
ativan 2 mg IV x1.  A subsequent seizure occurred and got a
repeat 2 mg ativan and took his PM AEDs including felbatol 1800
mg, keppra 2500 mg, and lamictal 125 mg.  Patient was arranged
for transfer to [**Hospital1 18**] for further evaluation and management.  En
route the patient had 3 seizures in the ambulance and had been
given another 8 mg ativan total.  The ambulance had run out of
ativan and patient was continuing to seize for another 12-13
minutes, and was given 2.5 mg valium.  The ambulance stopped at
[**Hospital 1514**] Hospital for further stabilization.  At this facility he
continued to actively seize, given an additional keppra 1g IV
and
ativan 8 mg total, and was subsequently intubated.
Transportation to [**Hospital1 18**] resumed and no further seizure activity
was witnessed.

Per the patient's wife, his typical seizures are characterized
by
right leg extension and flexion, with occasional spread to right
arm along with panting and no loss of consciousness.  He has
been
having more intense and more frequent seizures over the past
month, having up to 15-20 "minor seizures" daily.  He was
admitted to [**Hospital 3175**] Hospital two weeks ago after a 45-minute
seizure and was discharged on ativan 1 mg q4 and his lamictal
was
increased from 100 mg [**Hospital1 **] to 125 mg [**Hospital1 **].  Also, approximately
two
months ago the patient underwent a  partial amputation of his
right middle finger which was surgically reattached and he has
been on keflex since the procedure.

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:
The patient's neurological examination was notable for symmetric
hyporeflexia in all four limbs (baseline per patient).


Pertinent Results:
[**2181-8-31**] 03:00AM   WBC-9.5 RBC-4.08* HGB-13.2* HCT-38.6* MCV-95
MCH-32.4* MCHC-34.2 RDW-13.1
[**2181-8-31**] 10:31AM   WBC-12.5* RBC-3.79* HGB-12.9* HCT-35.9*
MCV-95 MCH-34.2* MCHC-36.1* RDW-13.3
[**2181-8-31**] 04:40AM CEREBROSPINAL FLUID (CSF)  PROTEIN-86*
GLUCOSE-74  Opening pressure 26.5.
[**2181-8-31**] 04:40AM CEREBROSPINAL FLUID (CSF)  WBC-2 RBC-235*
POLYS-67 LYMPHS-33 MONOS-0
[**2181-8-31**] 04:40AM CEREBROSPINAL FLUID (CSF)  WBC-33 RBC-5800*
POLYS-100 LYMPHS-0 MONOS-0
[**2181-8-31**] 03:00AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2181-8-31**] 03:00AM URINE  bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2181-8-31**]: felbamate 76 (h), keppra 23.6, lamotrigene 2.7 (l)
MICRO:
8/14-16/09 Blood culture: No growth
[**2181-8-31**] MRSA Screen: No MRSA isolated
[**2181-9-1**] Urine cx: No growth
[**2181-9-2**] Urine cx: No growth
[**2181-8-31**] CSF
CRYPTOCOCCAL Ag: Not detected
HSV PCR: Not detected
GRAM STAIN:  1+ PMNs  NO MICROORGANISMS SEEN
FLUID CULTURE (Preliminary):    NO GROWTH
FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED
IMAGING:
CT HEAD ([**2181-8-31**]):
A 3 mm extra-axial density in the left frontotemporal subdural
space adjacent
to an area of surgical change in the calvarium. Differential
diagnosis
includes a small acute-to-subacute subdural hematoma versus
post-surgical
dural thickening.
MRI HEAD ([**2181-8-31**]):
* No acute infarction.
* Small focus of FLAIR hyperintensity in the left inferolateral
frontal cortex,
is of uncertain nature. A followup complete study, per Seizure
protocol can
be considered including spinecho postcontrast sequences.
* Correlation with EEG is also recommended to assess the
significance of this
finding. No abnormal foci of enhancement. Evaluation of the
hippocampi is
limited due to the lack of coronal T2 and the FLAIR sequences.
However, no
gross abnormality noted on the sequences available.
NECK SOFT TISSUE ([**2181-8-31**]):
The study is markedly limited due to patient's large body
habitus as well as
technique. There is again seen a left vagal nerve stimulator to
the left of
the mid cervical spine. The tip is approximately to the level of
the mid-to-
lower cervical spine, unchanged since chest radiograph from
earlier today.
Endotracheal tube and nasogastric tube are again seen.
RIGHT THIRD DIGIT FILMS ([**2181-9-4**])
There is a fracture of the base of the third distal phalanx,
with slight
(cortical width) palmar displacement of the distal fragment, but
otherwise
overall anatomic alignment. There is faint callus adjacent to
the fracture
site, though the fracture line remains visible. The DIP joint is
congruent and
grossly unremarkable. There is surrounding soft tissue swelling.
No obvious
bone destruction to suggest osteomyelitis is identified, though
subtle
osteomyelitis at the fracture site or subtle soft tissue abcess
would be
difficult to exclude.
The remainder of the middle finger is within normal limits,
without evidence
of bone destruction.
CT TORSO WITH ANGIOGRAM ([**2181-9-4**]):
1. Embolic occlusion of the segmental artery supplying the
posterior segment
of the left upper lobe.
2. No evidence of central PE.
3. Pulsation artifacts in both the left and right lower lobe
segmental
arteries, small emboli in the left dorsal segmental arteries can
therefore not
be excluded.
4. No evidence of right cardiac abnormalities.
5. No evidence of substantial lung parenchymal damage.
LOWER EXTREMITY NON-INVASIVE IMAGING ([**2181-9-5**]):
There is no ultrasound evidence of deep venous thrombosis in
relation to either lower limb.
EEG RECORDINGS
EEG [**2181-9-1**]:
IMPRESSION: This telemetry captured two pushbutton activations,
one for
a presumed seizure with no change in the background activity.
There was
no clear epileptiform, ictal or interictal activity throughout
this
recording. The background activity was dominated by excessive
beta
range activity suggestive of medication effect. However, a
normal
background could occasionally be seen. In addition, there was
focal
slowing and high amplitude sharper activity seen in the left
temporal
area. These findings suggest dysfunction in that area and a
breach
rhythm which is usually seen in areas of skull defect.
EEG [**2181-9-2**]:
IMPRESSION: This telemetry captured five pushbutton activations
for
periods of unresponsiveness, two of them being correlated with
short 20
second runs of rhythmic delta activity seen with a T3 lead. This
finding could represent seizure activity; however, the fact that
it was
only seen in one lead makes it also suspicious for being
artifactual.
The background showed beta activity suggestive of a medication
effect
and there was focal slowing seen in the left temporal area as
well as
higher amplitude and sharper activity in that region. Those
findings
are suggestive of a dysfunction in this area as well as a breach
rhythm
which is seen with skull defects.
EEG [**2181-9-3**]:
MPRESSION: This telemetry captured two pushbutton activations
for
events of unresponsiveness accompanied by slow movements of the
right
leg and groaning. There was no clear epileptiform seizure
activity
during these events. In addition, there was no clearly ictal or
interictal epileptiform activity seen throughout this recording
and the
background activity was normal with excessive beta activity and
focal
slowing and breach rhythm in the left temporal area.
EEG [**2181-9-4**]:
IMPRESSION: This is an abnormal video EEG study due to increased
frequency and voltage in the mid-temporal region likely
secondary to
breach artifact. There were three pushbutton activations without
EEG
correlate. There were no epileptiform discharges or
electrographic
seizures.
EEG [**2181-9-5**]:
IMPRESSION: This is an abnormal video EEG study due to two
electrographic seizures in seizure detection programs.
Interictal
background activity was normal. There were no epileptiform
discharges.
Pushbutton activations showed no change in EEG from background
interictal activity.
EEG [**2181-9-6**]:
IMPRESSION: This is a normal video EEG study. Interictal
background
activity was normal. There were no epileptiform discharges or
electrographic seizures. This telemetry captured no pushbutton
activations. Compared to 24 hours prior, this EEG has fewer
seizures.



Brief Hospital Course:
Mr. [**Known lastname **] is a 49-year-old right-handed man with a remote history
of viral meningitis, 18-year history of intractable complex
partial epilepsy, s/p cortical sectioning and left VNS
placement, who presented [**2181-8-31**] intubated in status epilepticus
after a recent increase in seizure frequency and duration.

NEURO: Epilepsy
The patient was admitted to the NeuroICU, where continuous EEG
monitoring was initiated. The outpatient anti-epileptic drug
regimen, including keppra 2500 mg [**Hospital1 **], felbamate 1800 mg
qAM/1200 mg qPM/ 1800 mg qHS, and lamictal 125 mg [**Hospital1 **], was
continued.  Ativan 1 mg q4H was re-started. The lamictal level
was found to be slightly low.   The lamictal dose was gradually
increased in the course of the hospitalization to 225 mg po bid,
with a corresponding improvement in seizure control.   The
pre-admission increase in seizures could be related to the
slightly subtherapeutic lamictal level.

Several studies were performed to identify other causes for the
increased seizure frequency and duration preceding admission.
There was no evidence of toxic or metabolic disturbance. Imaging
was thought to  show no new structural substrate for seizure.
The Vagus Nerve Stimulator was interrogated and found to be
working properly.

ID: ? Sources of Infection
Although afebrile at admission, the patient developed
intermittent fevers early in the hospital course.  Because a
lumbar puncture showed a mild leukocytosis, ceftriaxone 2g q12,
vancomycin 1g q12, and acyclovir 1200mg q8 were administered for
empiric treatment of meningitis.  These antibiotics were
discontinued after 48 hours given the low suspicion for
bacterial meningitis. Instead, clindamycin was started to treat
potential aspiration pneumonitis in the setting of recent
intubation.

Blood, urine, and cerebrospinal fluid cultures have been
negative to date. Chest x-rays were negative. An x-ray of the
right middle finger demonstrated no signs of osteomyelitis. CT
scans of the chest and abdomen failed to suggest occult sources
of infection, including those related to the implanted device.
The patient received a total of six days of antibiotic
treatment; with the support of the Medicine Team, the
antibiotics were completely discontinued when no source of
infection could be identified.

PULM: Pulmonary Embolism
Because the patient developed fever and shortness of breath in
the context of immobility, a CT Angiogram was performed; the
study did show an embolic occlusion of the segmental artery
supplying the posterior segment of the left upper lobe. However,
there was no evidence of DVT on lower extremity duplex studies.
Weight-based lovenox (130 mg sc q 12H) was started with a plan
to transition to coumadin (started at 5 mg po daily). Within 24
hours of starting anticoagulation, the fevers resolved.  As the
PE is thought to have occurred in the context of a modifiable
risk factor, the Medicine Team recommended anticoagulation for
six months.  Of note, it was suggested the treatment duration
could be shortened to three months if the coumadin dosing were
to become difficult to calibrate due to interactions with other
medicines.

PULM: Obstructive Sleep Apnea
At the time of arrival, the patient was intubated.  He was
successfully extubated within 24 hours. In addition to episodes
of apnea and tachycardia, nocturnal oxygen saturations were
thereafter noted to decrease into the 70s.  Sleep Medicine study
findings were consistent with the presence of at least mild
sleep disordered breathing. CPAP therapy was initiated in the
hospital.  The patient tolerated the CPAP well, and continuous
monitoring demonstrated oxygen saturations consistently above
91% overnight.

CODE STATUS:
At the time of discharge, the patient was FULL CODE.


Medications on Admission:
-lamictal 125 mg [**Hospital1 **]
-felbatol 1800mg/1200mg/1800mg
-keppra 2500 mg [**Hospital1 **]
-ativan 1 mg q4h
-ativan 1 mg prn for seizure
-Aspirin 81 mg
-Toprol XL 50 mg daily
-Atorvastatin 40 mg qhs
-Zetia 10 mg qhs
-Omeprazole 20 mg daily
-Ranitidine 300 mg qhs
-Celexa 20 mg [**Hospital1 **]
-Clarinex 5 mg daily
-Magnesium (Mag 64) daily


Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day. Tablet Sustained
Release 24 hr(s)
3. Felbamate 400 mg Tablet Sig: 4.5 Tablets PO qam and qpm ().
Tablet(s)
4. Felbamate 400 mg Tablet Sig: Three (3) Tablet PO q 1200 ().
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Levetiracetam 500 mg Tablet Sig: Five (5) Tablet PO BID (2
times a day).
7. Enoxaparin 150 mg/mL Syringe Sig: One [**Age over 90 10973**]y (130)
mg/mL Subcutaneous every twelve (12) hours: Continue until the
INR is above 2 for over 48 hours.
Disp:*10 syringes* Refills:*2*
8. Lamotrigine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days: Take together with 25 mg tab for a total of
225 mg po bid x 7 days.
Disp:*60 Tablet(s)* Refills:*2*
9. Ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at
bedtime.
10. Clarinex 5 mg Tablet Sig: One (1) Tablet PO once a day.
11. Zetia 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Ativan 1 mg Tablet Sig: One (1) Tablet PO every four (4)
hours.
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: Take
together with 3-mg tab for a total of 5 mg po qhs unless
otherwise directed.
Disp:*30 Tablet(s)* Refills:*2*
14. Warfarin 3 mg Tablet Sig: One (1) Tablet PO at bedtime: Take
together with 2-mg tab for a total of 5 mg po qhs unless
otherwise directed.
Disp:*30 Tablet(s)* Refills:*2*
15. Ativan 1 mg Tablet Sig: One (1) Tablet PO x1 as needed for
seizure.
16. Magnesium-64  Sig: One (1)  PO once a day.
17. Lamotrigene - 25 mg  Sig: One (1)  PO twice a day: Take one
25-mg tab together with the 200 mg tab for a total of 225 mg po
qhs x 7 days.  Then take two 25-mg tabs together with the 200 mg
tab for a total of 250 mg po bid.
Disp:*120 Tablets* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Status Epilepticus
Pulmonary Embolism
Obstructive Sleep Apnea


Discharge Condition:
Stable.  At the time of discharge, the patient's neurological
examination was notable for symmetric hyporeflexia in all four
limbs.


Discharge Instructions:
You were admitted to the [**Hospital1 18**] after experiencing a prolonged
seizure.

You were monitored very closely in the intensive care unit, and
then on the [**Hospital1 **], with continuous epilepsy recording.  Your
seizures seemed to become better controlled with an increase in
the lamictal.

Several studies were performed to identify the cause for the
increased seizure frequency and duration preceding your
admission.  There was no evidence of toxic or metabolic
disturbances.  The lamictal level was found to be slightly low.
A magnetic resonance image of the brain showed no new structural
substrate for seizure.  The Vagus Nerve Stimulator was found to
be working properly.  Beacuse the lumbar puncture showed a
mildly increased number of white blood cells (which can indicate
infection and inflammation), you were given antibiotics to treat
meningitis; these antibiotics were changed after 48 hours to
treat potential aspiration pneumonia in the setting of recent
intubation.  You received a total of six days of antibiotic
treatment.  The antibiotics were discontinued when no source of
infection could be identified.  The etiology of the increase in
seizures remains unclear but could be related to the slightly
subtherapeutic lamictal level.

Despite empiric antibiotics, you developed intermittent fevers
early in the hospital course.  Blood and urine cultures have
been negative to date.  Chest x-rays were negative.  An x-ray of
the right middle finger demonstrated no signs of osteomyelitis.
CT scans of the chest and abdomen failed to suggest "hidden"
sources of infection, including those related to the implanted
devices.  Becuase you developed shortness of breath in the
context of fever and immobility, a CT Angiogram was also
performed; the study did show a small blood clot in one of the
vessels serving your lungs.  However, there were no blood clots
found in the deep veins of your legs.  "Blood thinners" lovenox
and coumadin were started to address the lung clot.  Within 24
hours of starting treatment your fevers resolved.  Our
colleagues on the medicine team suggested the anticoagulation
treatment be continued for as long as six months.  If the
coumadin dosing becomes difficult to modify due to interaction
with the anti-epileptic medicines, the treatment could be
shortnened to three months.  It will be important to work with
Dr. [**First Name (STitle) 15532**] to monitor the INR (goal range 2-3) and make
necessary adjustments.

At the time of your arrival, a breathing tube was in place to
protect your airway.  It was successfully removed within 24
hours.  Thereafter, your lung function was normal during the
day; however, changes in your oxygen saturation at night
suggested you could have sleep apnea.  The sleep medicine team
performed studies that confirmed the presence of the condition
and started CPAP therapy.  It will be important to participate
in the upcoming outpatient sleep study to further refine the
CPAP settings.

* Please take all of your medication as prescribed.  Please note
that the LAMICTAL has been INCREASED.  In one week,[**2181-9-14**],
please increase the dose of lamictal to 250 mg by mouth twice
daily.  Dr. [**Last Name (STitle) **] will make any necessary further adjustments.

* Please attend all follow-up appoitnments.

* It will be important to have the INR value checked anytime on
Saturday [**2181-9-8**] at the [**Hospital 3175**] Hospital Lab in [**Location (un) 94757**] (a
requisition has been faxed).  Please WAIT UNTIL YOU HEAR FROM
THE DOCTOR ON CALL BEFORE TAKING YOUR NEXT DOSE OF THE COUMADIN.
 If you do not hear from the on-call doctor, please call Dr. [**Name (NI) 94758**] office at [**Telephone/Fax (1) 94759**] and ask to have the doctor on
call paged.

* It will be important to have the INR checked again on Monday
[**2181-9-10**] at Dr.[**Name (NI) 49335**] office at 10 am.

The target INR range is [**2-20**].  The lovenox injections should be
continued until the INR value is above 2 for at least 48 hours.
Thereafter, the lovenox can be stopped.  The coumadin should be
continued for 3-6 months.

* Please wear the CPAP mask at night to treat Obstructive Sleep
Apnea.

* Please seek medical attention if you develop seizures of
increased number or length, confusion, chest discomfort,
shortness of breath, or any other symptom you find concerning.

* For safety reasons, please do not drive without checking with
Dr. [**Last Name (STitle) **] beforehand.  Please do not take a bath alone.

Followup Instructions:
* Please attend [**Hospital 3175**] Hospital Lab on Saturday [**2181-9-8**] for the
INR check and wait to hear from the on-call physician before
taking your next dose of coumadin.  If you do not hear from the
doctor, call Dr.[**Name (NI) 49335**] office at [**Telephone/Fax (1) 94760**] and ask for
the on-call physician to be paged.

* Please attend Dr.[**Name (NI) 49335**] office on Monday, [**2181-9-10**] at 10 am
for another INR check.

* Please an outpatient sleep study as directed.  The Sleep
Health Center should contact you to coordinate an appointment.
If you do not hear from the center, please call [**Telephone/Fax (1) **],
dial option one, and make an appointment.

* Please also attend a post-sleep study follow-up appointment
with a sleep medicine specialist.  The Sleep Health Center
should contact you to coordinate an appointment.  If you do not
hear from the center, please call [**Telephone/Fax (1) **], dial option one,
and make an appointment.
{'Epilepsia partialis continua, with intractable epilepsy,Other pulmonary embolism and infarction,Obstructive sleep apnea (adult)(pediatric),Esophageal reflux,Other and unspecified hyperlipidemia,Personal history of tobacco use,Other postprocedural status'}


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: Status Epilepticus

PRESENT ILLNESS: PER THE ADMITTING RESIDENT:
49 yo RHM with history of intractible complex partial
epilepsy diagnosed in [**2163**], with cortical sectioning of
epileptic
area of lower central sensory motor strip in [**2165**], s/p left VNS
placement in [**2170**], and history of viral meningitis at age 13,
presenting in status epilepticus.  At 5 PM yesterday, the
patient's wife found him grunting and moving his right leg,
followed by choking and gagging.  Seizures were witnessed for
forty minutes before medical care arrived.  He was originally
taken to [**Hospital 3175**] Hospital where he had a witnessed seizure with
right leg flexion and extension, with hyperventilation and
unresponsiveness, lasting between one and five minutes and given
ativan 2 mg IV x1.  A subsequent seizure occurred and got a
repeat 2 mg ativan and took his PM AEDs including felbatol 1800
mg, keppra 2500 mg, and lamictal 125 mg.  Patient was arranged
for transfer to [**Hospital1 18**] for further evaluation and management.  En
route the patient had 3 seizures in the ambulance and had been
given another 8 mg ativan total.  The ambulance had run out of
ativan and patient was continuing to seize for another 12-13
minutes, and was given 2.5 mg valium.  The ambulance stopped at
[**Hospital 1514**] Hospital for further stabilization.  At this facility he
continued to actively seize, given an additional keppra 1g IV
and
ativan 8 mg total, and was subsequently intubated.
Transportation to [**Hospital1 18**] resumed and no further seizure activity
was witnessed.

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: -lamictal 125 mg [**Hospital1 **]
-felbatol 1800mg/1200mg/1800mg
-keppra 2500 mg [**Hospital1 **]
-ativan 1 mg q4h
-ativan 1 mg prn for seizure
-Aspirin 81 mg
-Toprol XL 50 mg daily
-Atorvastatin 40 mg qhs
-Zetia 10 mg qhs
-Omeprazole 20 mg daily
-Ranitidine 300 mg qhs
-Celexa 20 mg [**Hospital1 **]
-Clarinex 5 mg daily
-Magnesium (Mag 64) daily

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

PHYSICAL EXAM: The patient's neurological examination was notable for symmetric
hyporeflexia in all four limbs (baseline per patient).

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:
{'Epilepsia partialis continua, with intractable epilepsy,Other pulmonary embolism and infarction,Obstructive sleep apnea (adult)(pediatric),Esophageal reflux,Other and unspecified hyperlipidemia,Personal history of tobacco use,Other postprocedural status'}
