CHIEF COMPLAINT: "I've been swimming to the left"

PRESENT ILLNESS: 82yo white,right handed male with significant cardiac hx of 6
vessel CABG, symptomatic Atrial Fibrillation, pacemaker
currently on coumadin/ASA reports that for past 2weeks feels he
is drifting to the left when he swims, gait instability with
leaning to the left, and R.sided h/a with increased extension to
R.temporal region. Pt swims every day and notes he recently
feels as though he is having difficulty with the strokes and
swimming straight in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Pt also reported he was showering
yesterday and suddenly felt off balance, falling to the left out
of the tub from a standing position to the ground landing on his
back. Denies striking his head, denies LOC. States the headaches
have been intermittent with some relief from Tylenol, but the
h/a extends further each day x1week. Pt denies any recent
illness, no hx of falls, no N/V, no change of vision, taste or
smell, denies sensory loss or subjective weakness. [**12-22**] pt
sought care from his cardiologist for the above mentioned
symptoms, labwork and head CT were ordered. Head CT showed lg
subacute R.frontal SDH. INR 2.9-pt given 1unit FFP, 5mg IV [**Name (NI) 75481**]
pt then transferred to [**Hospital1 18**].

MEDICAL HISTORY: '[**30**] 6 vessel bypass
'[**39**] symptomatic Atrial Fibrillation,
'[**42**] pacemaker
'[**50**] bilateral hernia repair
chronic constipation

MEDICATION ON ADMISSION: Prevacid 30mg QD
Coumadin 5mg M,W,Fri,Sat,Sun
Coumadin 2.5mg Tu, Thurs
Lipitor 20mg QPM
Atenolol 25mg QAM
Lisinopril 10mg QAM
ASA 81mg QAM
VitC/B6 QAM

ALLERGIES: Penicillins

PHYSICAL EXAM: 98.2 BP: 193/96 HR: 80 R: 18 O2Sats: 100%2L
Gen: WD/WN,youthful well appearing,comfortable, NAD.
HEENT: Normocephalic Pupils: PERRLA [**3-19**] EOMs intact with FFOV
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-20**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: Son: gout

SOCIAL HISTORY: Lives with his wife, denies smoking, ETOH, illegal drugs.
Subdural hemorrhage,Compression of brain,Cardiac complications, not elsewhere classified,Subendocardial infarction, initial episode of care,Acute systolic heart failure,Cardiogenic shock,Hyperosmolality and/or hypernatremia,Other pulmonary insufficiency, not elsewhere classified,Pneumonia, organism unspecified,Atrial fibrillation,Gout, unspecified,Other and unspecified complications of medical care, not elsewhere classified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Mitral valve disorders,Cardiac pacemaker in situ,Aortocoronary bypass status
Subdural hemorrhage,Compression of brain,Surg compl-heart,Subendo infarct, initial,Ac systolic hrt failure,Cardiogenic shock,Hyperosmolality,Other pulmonary insuff,Pneumonia, organism NOS,Atrial fibrillation,Gout NOS,Complic med care NEC/NOS,Hypertension NOS,Hyperlipidemia NEC/NOS,Mitral valve disorder,Status cardiac pacemaker,Aortocoronary bypass
Admission Date:  [**2151-12-22**]              Discharge Date:   [**2152-1-12**]

Date of Birth:  [**2069-7-20**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
"I've been swimming to the left"

Major Surgical or Invasive Procedure:
Left sided Burr Holes
Left sided craniotomy
tracheostomy [**1-2**] by trauma surgery
PEG tube placement [**1-2**]  by trauma surgery

History of Present Illness:
82yo white,right handed male with significant cardiac hx of 6
vessel CABG, symptomatic Atrial Fibrillation, pacemaker
currently on coumadin/ASA reports that for past 2weeks feels he
is drifting to the left when he swims, gait instability with
leaning to the left, and R.sided h/a with increased extension to
R.temporal region. Pt swims every day and notes he recently
feels as though he is having difficulty with the strokes and
swimming straight in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Pt also reported he was showering
yesterday and suddenly felt off balance, falling to the left out
of the tub from a standing position to the ground landing on his
back. Denies striking his head, denies LOC. States the headaches
have been intermittent with some relief from Tylenol, but the
h/a extends further each day x1week. Pt denies any recent
illness, no hx of falls, no N/V, no change of vision, taste or
smell, denies sensory loss or subjective weakness. [**12-22**] pt
sought care from his cardiologist for the above mentioned
symptoms, labwork and head CT were ordered. Head CT showed lg
subacute R.frontal SDH. INR 2.9-pt given 1unit FFP, 5mg IV [**Name (NI) 75481**]
pt then transferred to [**Hospital1 18**].


Past Medical History:
'[**30**] 6 vessel bypass
'[**39**] symptomatic Atrial Fibrillation,
'[**42**] pacemaker
'[**50**] bilateral hernia repair
chronic constipation

Social History:
Lives with his wife, denies smoking, ETOH, illegal drugs.


Family History:
Son: gout

Physical Exam:
98.2 BP: 193/96 HR: 80 R: 18 O2Sats: 100%2L
Gen: WD/WN,youthful well appearing,comfortable, NAD.
HEENT: Normocephalic Pupils: PERRLA [**3-19**] EOMs intact with FFOV
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-20**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,3to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally minimal
conjugated lateral nystagmus
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-22**] throughout. No pronator drift

Sensation: Intact to light touch, propioception.
Reflexes: B T Br Pa Ac
Right 2------------>
Left 2------------>

Toes mute.

Coordination: normal on finger-nose-finger, diminshed rapid
alternating movements

Exam On Discharge:


Pertinent Results:
LABS:
MICRO:
No growth to date in blood, urine, stool or sputum cx
.
PERTINENT LABS:
Peak troponin: 5.51
Peak CK: 2691
.
Hct ranged from 28-31.
WBC as high as 18, but on day of discharge was #####
.
On discharge:
Na 138
K 4.0
HCO3 104
CL 28
BUN/cre: 18/1.0
ALT 109 (peak 126)
AST 98 (peak 186)
.
STUDIES:
.
[**2151-12-22**] CT HEAD WITHOUT CONTRAST:
There is large right subdural hematoma, measuring up to 2.7 cm
in maximum thickness.  Intermediate density of the hematoma is
likely compatible with subacute chronicity.  There is adjacent
sulcal effacement.  There is leftward subfalcine herniation with
15-mm shift of the midline structures. There is no acute
intracranial hemorrhage or major vascular territorial
infarction.  There is an 8-mm hypodensity in the right basal
ganglia, likely representing lacunar infarction, of uncertain
chronicity.
There is air-fluid level in the left maxillary sinus.  There is
fluid in the right middle ear cavity, and clinical correlation
is advised.  Surrounding soft tissues and osseous structures are
unremarkable.
.
IMPRESSION:
1. Large right subdural hematoma with associated ipsilateral
sulcal effacement with left-[**Hospital1 **] subfalcine herniation.
Intermediate density of the hematoma likely compatible with
subacute chronicity.  No prior studies available for comparison
to assess interval change.
2. Fluid in the left maxillary sinus and right middle ear.
.
[**2151-12-26**] CT HEAD WITHOUT CONTRAST:
Patient is status post recent trans burr hole evacuation of a
right convexity subdural collection.  A moderate amount of mixed
density extraaxial collection remains overlying the right
cerebral
hemisphere, unchanged from prior exam.  The degree of leftward
shift of
normally midline structures (12 mm) and effacement of the
subjacent sulci is essentially unchanged.  Basal cisterns remain
open.  No new hemorrhage is identified.  Note is made of
equivocal loss of [**Doctor Last Name 352**]-white differentiation along the right
frontoparietal cortex,  which may be related to post-surgical
swelling.  An air-fluid level is identified within the left
maxillary sinus. The remainder of the visualized paranasal
sinuses and mastoid air cells remain normally aerated.
Cavernous carotid are heavily calcified.
.
IMPRESSION:  Stable appearance of mixed density extraaxial
collection along the right cerebral convexity status post burr
hole evacuation.  Note is made of subtle equivocal loss of
[**Doctor Last Name 352**]-white matter differentiation along the right frontoparietal
cortex, which may be related to post surgical swelling. If there
is concern of infarction an MR examination or a CTP may be
helpful.
.
[**2151-12-27**] HEAD CT WITHOUT CONTRAST:
FINDINGS:  There is now a drain in the right subdural
collection. The tip
of the catheter appears to extend beyond the subdural space into
the brain with a small amount of surrounding edema. The size of
the hematoma has decreased compared to the prior study. The
degree of leftward shift and subfalcine herniation remains
essentially stable. There is no new hemorrhage, and no change in
degree of sulcal effacement. Subtle area of hypodensity in the
right frontal lobe may relate to post- surgical edema.
.
IMPRESSION:  Interval decrease in size of mixed density along
the right
cerebral convexity status post evacuation and drain placement.
The drain
appears to extend beyond the subdural space into the brain.
Essentially
unchanged the rest of the examination.
.
[**2151-12-30**] Non-contrast head CT.
FINDINGS:  There is interval decrease in the degree of
pneumocephalus compared to previous exam.  Drainage catheter has
been removed in the interim.  The overall thickness of the
extraaxial collection has decreased compared to previous exam
with less underlying sulcal effacement and slightly less
midline shift (displacement of the septum pellucidum to the left
of 6 mm, previously approximately 9 mm). Dural thickening is
present in the right frontal region. No new foci of hemorrhage
are seen.  There is no new ventricular dilatation. Fluid is seen
in the left maxillary sinus and in the left middle ear.  There
is mucosal thickening of the ethmoid sinuses.
.
IMPRESSION:  Interval removal of drainage catheter with decrease
in extra
axial fluid/hematoma size and mass effect.
.
.
[**2152-1-10**] ECHO:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with focal hypokinesis of the basal half of
the inferolateral wall. The remaining segments contract normally
(LVEF = 50-55 %). The estimated cardiac index is borderline low
(2.0-2.5L/min/m2). 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 mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction
c/w CAD. Moderate mitral regurgitation. Mild pulmonary artery
systolic hypertension.
Compared with the prior study (images reviewed) of [**2151-12-28**],
left ventricular systolic function has improved and the severity
of mitral and tricuspid regurgitation and the estimated
pulmonary artery systolic pressure all are reduced.
.
[**2152-1-11**] CXR: FINDINGS: PA and lateral views of the chest
demonstrate some interval clearing of the right upper lobe
infiltrate; the infiltrate is still present but is less opaque.
There are small bilateral pleural effusions that are similar in
size compared to prior. The pacemaker and tracheostomy are
unchanged.


Brief Hospital Course:
TRAUMA ICU COURSE:
Mr [**Known lastname **] was admitted to the ICU for close neurological
observation. On admission to the ICU his INR was reversed with
Profiline, FFP and platelets due to his Aspirin use.  He was
taken to the OR and underwent a burr hole evacuation on [**12-23**].
Post operative CT showed. Post operative CT showed slightly
increase size of shift.  On [**12-25**] he suffered an MI and had and
developed left sided weakness a stat head ct showed stable
appearance.  On [**12-26**] his CT showed new hemorrhage after a
bedside aspiration.  The patient underwent a formal craniotomy.
On [**12-27**] the patient suffered another MI requiring pressors and
antiarrhythmics. He remained intubated for 8 days, although he
continued to progress neurologically. He continued to be
intubated for so long because the patient expressed wishes not
to be reintubated if he was ever extubated and failed the trial.
Mr. [**Known lastname **] agreed to a tracheostomy and a PEG placement, which
he received on [**1-2**]. A chest xray on [**1-2**] showed bilateral
patchy infiltrates and a left pleural effusion. He was started
on trach mask trials starting on [**1-3**]. Early on the morning of
[**1-4**], Mr. [**Known lastname **] decided that he wanted to be DNR/DNI status.
He stated that regardless of his good neurosurgical prognosis
that he did not wish to prolong his life any further and that he
felt that he lived a full life already for the past 82 years. A
social work consultation was requested later that day.
.
CCU COURSE:
82 M readmitted to CCU after SDH detailed above for mangement of
ongoing NSTEMI first noted on [**12-25**]. Active CCU issues include:
.
# Cardiac: On the morning of [**2151-12-25**], he told his son that he
felt like he'd been "sitting up too long", developed [**5-27**] chest
pain, squeezing, radiating to his upper arms bilaterally,
diaphoretic and nauseated at the time. He denies any LH,
dizziness, vision changes, palpitations, SOB, cough, or vomiting
associated with his pain.  He was given sublingual ntg as well
as a nitropatch with minimal improvement in his symptoms (his
pain went from a [**5-27**] to a [**3-27**]) but mild hypotension which
resolved after nitropatch stopped. He was also given 2mg
morphine IV and 2.5mg of lopressor IV. His EKG revealed deep T
wave inversions in V1-6, with ST depressions in V3-5, as well as
<1mm ST depressions in I. Given his hypotension, his EKG
changes, and the inability to use anticoagulation because of his
recent SDH, he was transferred to the CCU for further medical
management of a possible NSTEMI.
.
In the CCU, 3rd SL ntg completely resolved of his symptoms. He
did, however, complain of continued "nausea" in his chest,
unrelieved by zofran or nitroglycerin. Adequate HR and BP
response was able to be achieved by IV boluses and PO doses of
metoprolol. Repeat EKG when CP free continued to show the EKG
changes mentioned above.  From the cardiac stand point, post-op
his CI was initially low, dobutamine was started on [**2151-12-30**] and
was weaned off on [**1-3**] at 5 pm maintaining adequate CI. His
metoprolol was also been weaned down from 75 TID to 25 TID.
.
Given the inability to anticoagulate pt [**2-19**] SDH, pt was not a
candidate for catheterization/heparin and was therefore managed
conservatively. His ASA was initially held, then restarted
[**2151-12-26**]. CK peaked at 2691, pt was treated with low dose
metoprolol [**2-19**] hypotension which gradually resolved, as well as
atorvastatin and lisinopril. His atorvastatin dose was reduced
to 40 mg daily, as his liver function studies were elevated,
presumedly from hepatic congestion secondary to heart failure.
His EF per [**Month/Day (2) **] on [**12-28**] was 45% with with mild regional LV
systolic dysfunction with inferior and lateral hypokinesis.
Prior [**Month/Year (2) **] from [**1-23**] from OSH records showing EF of 60%, mild to
moderate concentric LVH.  He was aggressively diuresed (1-2L/day
x 3d) over the course of his CCU course with gradually improving
O2 sats. On [**1-6**], he was breathing comfortably on 50%
tracheostomy mask, and decision was made to downsize his cuff,
which was done [**1-6**], and removed on [**1-10**].
.
Regarding cardiac rhythm, pt has a pacemaker for apparent h/o
tachy/brady, and has a h/o paroxysmal afib, with RVR. He was
treated with an amiodarone load, and given total load of 8g
during his SICU course. His daily dose was decreased to 200mg po
qdaily upon transfer to the CCU. He is on metoprol, as above.
.
Pt is not currently a candidate for anticoagulation [**2-19**] subdural
hematoma, and should not be anticoagulated until he has
followed-up in the neurosurgical clinic and been cleared from
their standpoint. This will occur on [**2152-2-16**].
.
Regarding valves, by [**Name (NI) **] pt has no AS, 3+ TR, 3+ MR. In [**1-23**],
ECHO at OSH showing 1+ MR, trace TR.  Plan is for an outpt f/u
[**Date Range **] once volume status has improved to assess final degree of
regurgitation.
.
Pt will need to follow-up with cardiology within 4-6 weeks of
his discharge.  At that time he should have a follow-up
echocardiogram.
.
# Subdural hematoma: Pt is s/p evacuation of subdural hematoma
on [**2151-12-23**] and re-evacuation overnight on [**12-26**]. Postoperatively
doing well. Neurosurgery signed off pt's care at time of CCU
transfer [**1-4**].  Per their reccomendations, pt should  continue
200mg po bid of dilantin until he has f/u w/ neurosurgery as
outpatient in 4 weeks w/ head CT done at that time. Pt will need
to call to arrange this f/u appointment. He was cleared to
resume aspirin, but should not initiate any other
anticoagulation until he has been seen by neurosurgery. He
should have a weekly dilantin level checked while in rehab and
adjusted for his albumin level. His goal dilantin level is
[**11-6**].
.
# Trasaminase elevation - pt with transient rise in LFTs, likely
felt [**2-19**] passive congestion from CHF in setting of NSTEMI, this
resolved without intervention. Urine legionella was negative,
and medication side effect secondary to statin or amiodarone was
felt unlikely. On [**1-10**] LFTs were down to AST=98, ALT=109.
.
# Respiratory: Patient was initially intubated in SICU and
subsequently s/p tracheostomy. His respiratory status was
complicated by pneumonia as well as pulmonary edema. Pneumonia
course and treatment as below. He was diuresed with lasix with
resolution of pulmonary edema. His respiratory gradually
improved, and he will continue lasix 60mg po daily as an
outpatient. His trach cannula size was decreased from 8 french
to 6 french and capped. Patient tolerated this very well, was
sating well on room air for several days, and on [**2152-1-11**],
tracheostomy was removed by surgery.
.
# ID: During his hospital course, he had intermittent and
recurrent fevers and leukocytosis. He was started on abx on
[**12-26**] (including Vanc, levo, flagyl), which were broadened to
Vanc/Cefepime when he again developed leukocytosis on [**1-4**]. His
blood, urine, stool cultures remained negative; however, on CXR,
he developed a PNA in the RUL. A midline line was placed for
abx, and his coverage was narrowed to Cefepime only for
pneumonia. Cefepime was chosen given patient's PCN allergy and
per ID, this was least likely to interact. By discharge, he had
been afebrile for greater than 3 days and leukocytosis had
resolved.
.
# Gout: Following aggressive diuresis, pt developed painful
swelling and erythema of all of his PIP joints in both hands as
well as all joints in toes. He had a minor history of gout prior
to this, but had never experienced anything so severe.
Rheumatology was consulted and felt that despite its atypical
appearance, this was consistent with gout. Uric acid 5.1. He
received colchicine and indomethacin with improvement of
symptoms. He was discharged with plan to take colchicine for 2
weeks or shorter if symptoms resolve quicker.  His colchicine
dose was decreased to 0.6mg qdaily on [**1-11**] because of diarrhea
felt [**2-19**] colchicine and improvement of his symptoms.  If
symptoms persist, he should follow-up with rheumatology either
as referred by PCP or at [**Hospital1 18**] with Dr. [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 12434**]
(information for appt given to pt.)
.
# Hypernatremia: Patient developed mild hypernatremia likely
secondary to decreased free water before he was tolerating POs.
This normalized after patient started eating POs.
.
# FEN: A PEG was placed by trauma surgery on [**1-2**], and pt was
initated on tube feeds.  Upon transfer to the CCU, pt was seen
by Speech and swallow who recommended thin liquids, ground
solids.  Patient ate soft solids once his wife brought in his
dentures.  Supplement such as Ensure were added as albumin was
quite low. On [**1-10**] per nutrition recs, pt was felt to be eating
well, and may have his tube feeds discontinued completely once
he consume > half of his tray.  calorie counts were performed.
Per the trauma surgery service, the PEG should not be removed at
this time as no track formed yet and risk of stomach falling
away from bowel wall if removed too early.  He should follow-up
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the trauma surgery clinic 4 weeks after
discharge for outpatient removal of PEG tube.  He will need to
call to arrange for this follow-up appointment.
.
# PPX: pt treated with pneumoboots, PPI, and prn bowel regimen.
.
# ACCESS: a midline catheter was placed on [**1-9**] for the purpose
of antibiotic administration.
.
# CODE: pt initially expressed desire to be DNR/DNI while on the
surgical service during his acute decompensation.  This was
re-addressed with pt upon transfer to the CCU, and on [**1-5**], he
changed his code status to FULL CODE.

#######################################
APPOINTMENTS FOR FOLLOW-UP AFTER D/C FROM HOSPITAL:
1. Pt needs follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] 4-6 weeks
following d/c from hospital
2. Pt needs f/u with neurosurgery with repeat head CT on
[**2152-2-16**], as detailed above.
3. Pt needs f/u with urology regarding hematuria in 4 weeks
after d/c from hospital.
4. Pt may follow-up with rheumatology if his gout symptoms do
not resolve after discharge
5. Pt will need to see Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of truma surgery to have
PEG tube removed 4 weeks after discharge from hospital.

Medications on Admission:
Prevacid 30mg QD
Coumadin 5mg M,W,Fri,Sat,Sun
Coumadin 2.5mg Tu, Thurs
Lipitor 20mg QPM
Atenolol 25mg QAM
Lisinopril 10mg QAM
ASA 81mg QAM
VitC/B6 QAM


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache.
2. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day): Can stop if pt ambulating at
leats 3 times per day.
8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet
Sig: One (1) Powder in Packet PO TID (3 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
11. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

14. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
18. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks: Day 1= [**2152-1-9**]
Can also stop once resolution of symptoms.
19. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day.
20. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 2 days: last day [**2152-1-14**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
Primary:
Right frontal subdural hematoma
non-st-elevation myocardial infarction


Discharge Condition:
Neurologically stable, breathing well on room air, pain free


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY

??????	Have a family member check your incision daily for signs of
infection
??????	Take your pain medicine as prescribed
??????	Exercise should be limited to walking; no lifting, straining,
excessive bending
??????	You may wash your hair only after sutures and/or staples have
been removed
??????	You may shower before this time with assistance and use of a
shower cap
??????	Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
??????	If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:

??????	New onset of tremors or seizures
??????	Any confusion or change in mental status
??????	Any numbness, tingling, weakness in your extremities
??????	Pain or headache that is continually increasing or not
relieved by pain medication
??????	Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
??????	Fever greater than or equal to 101?????? F

ADDITIONAL DISCHARGE INSTRUCTIONS:
You had a heart attack after your craniotomy called a
Non-ST-segment elevation myocardial infarction. You were
medically treated for this, and certain medications have been
added an adjusted to your medication list. It is very important
that you take all medications as prescribed.

You also developed a pneumonia and received antibitoics for
this.

Please call 911 or go to the emergency room if you have any
chest pain, chest tightness/pressure, difficulty breathing,
severe back pain, abdominal pain, bloody stools, fever greater
than 101, weight gain greater than 3 pounds in one day or any
other concerning symptoms.

Followup Instructions:
1. An appointment has been made for you on [**2152-2-16**] @245 PM for a
repeat CT scan of your head to monitor your craniotomy and
subdural hematoma. The scan is at [**Hospital1 7768**], [**Location (un) **].
You have an appointment with Dr. [**Last Name (STitle) 739**] afterwards at
3:30PM @ [**Hospital Unit Name 18400**], [**Location (un) 86**], MA. You will need
to discuss whether it is safe for you to begin anticoagulant
medications at this appointment. If you have questions, or need
to reschedule, you can reach Dr.[**Name (NI) 4674**] office at
[**Telephone/Fax (1) 1669**].
.
2. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**4-23**] weeks after
you have seen [**Doctor Last Name 739**] in clinic. Her office should be
contacting you to make an appointment, but if you don't hear
from them in one week after discharge from hospital, please call
to schedule an appointment to see her. Her office number is
([**Telephone/Fax (1) 29517**].
.
3. Please follow-up with urology regarding the blood seen in
your urine. You can either have your primary care doctor refer
you so a urologist or you can call ([**Telephone/Fax (1) 772**] to see any
urologist at [**Hospital1 18**].
.
4. Please follow-up with rheumatology if you continue to have
gout or joint pains. You can follow-up in the [**Hospital 18**] [**Hospital 2225**]
clinic [**Telephone/Fax (1) 2226**] to see Dr. [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 12434**].
.
5. Please follow-up with the trauma surgery clinic with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] in 4 weeks after discharge from the hospital to have your
gastric feeding tube removed. Please call ([**Telephone/Fax (1) 22750**] to
schedule this appointment.
{'Subdural hemorrhage,Compression of brain,Cardiac complications, not elsewhere classified,Subendocardial infarction, initial episode of care,Acute systolic heart failure,Cardiogenic shock,Hyperosmolality and/or hypernatremia,Other pulmonary insufficiency, not elsewhere classified,Pneumonia, organism unspecified,Atrial fibrillation,Gout, unspecified,Other and unspecified complications of medical care, not elsewhere classified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Mitral valve disorders,Cardiac pacemaker in situ,Aortocoronary bypass 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: "I've been swimming to the left"

PRESENT ILLNESS: 82yo white,right handed male with significant cardiac hx of 6
vessel CABG, symptomatic Atrial Fibrillation, pacemaker
currently on coumadin/ASA reports that for past 2weeks feels he
is drifting to the left when he swims, gait instability with
leaning to the left, and R.sided h/a with increased extension to
R.temporal region. Pt swims every day and notes he recently
feels as though he is having difficulty with the strokes and
swimming straight in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Pt also reported he was showering
yesterday and suddenly felt off balance, falling to the left out
of the tub from a standing position to the ground landing on his
back. Denies striking his head, denies LOC. States the headaches
have been intermittent with some relief from Tylenol, but the
h/a extends further each day x1week. Pt denies any recent
illness, no hx of falls, no N/V, no change of vision, taste or
smell, denies sensory loss or subjective weakness. [**12-22**] pt
sought care from his cardiologist for the above mentioned
symptoms, labwork and head CT were ordered. Head CT showed lg
subacute R.frontal SDH. INR 2.9-pt given 1unit FFP, 5mg IV [**Name (NI) 75481**]
pt then transferred to [**Hospital1 18**].

MEDICAL HISTORY: '[**30**] 6 vessel bypass
'[**39**] symptomatic Atrial Fibrillation,
'[**42**] pacemaker
'[**50**] bilateral hernia repair
chronic constipation

MEDICATION ON ADMISSION: Prevacid 30mg QD
Coumadin 5mg M,W,Fri,Sat,Sun
Coumadin 2.5mg Tu, Thurs
Lipitor 20mg QPM
Atenolol 25mg QAM
Lisinopril 10mg QAM
ASA 81mg QAM
VitC/B6 QAM

ALLERGIES: Penicillins

PHYSICAL EXAM: 98.2 BP: 193/96 HR: 80 R: 18 O2Sats: 100%2L
Gen: WD/WN,youthful well appearing,comfortable, NAD.
HEENT: Normocephalic Pupils: PERRLA [**3-19**] EOMs intact with FFOV
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-20**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: Son: gout

SOCIAL HISTORY: Lives with his wife, denies smoking, ETOH, illegal drugs. 

### Response:
{'Subdural hemorrhage,Compression of brain,Cardiac complications, not elsewhere classified,Subendocardial infarction, initial episode of care,Acute systolic heart failure,Cardiogenic shock,Hyperosmolality and/or hypernatremia,Other pulmonary insufficiency, not elsewhere classified,Pneumonia, organism unspecified,Atrial fibrillation,Gout, unspecified,Other and unspecified complications of medical care, not elsewhere classified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Mitral valve disorders,Cardiac pacemaker in situ,Aortocoronary bypass status'}
