CHIEF COMPLAINT: Headache

PRESENT ILLNESS: 64 y/o M with CAD s/p CABG x 2 and ruptured chordae tendinae s/p
mechanical mitral valve placement in [**1-11**] admitted to the
neurosurgical service on [**2-25**] for emergent evacuation of left
subdural hematoma (surgery on [**2-25**]) after falling and hitting
his head on the ice two days prior. Anticoagulation was reversed
with FFP and vitamin K. He did well postoperatively and a
heparin bridge was begun on [**3-2**], followed by the addition of
coumadin on [**3-5**]. His INR (1.7) has yet to become therapeutic
(2.5-3.5).

MEDICAL HISTORY: [**1-11**] Cardiac Surgery
-mechanical MV placement [**3-9**] chordae rupture following IE
-CABG x 2 (LIMA to LAD, SVG to Diag)
-PFO closure
-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation
CAD
Permanent AFib s/p MAZE
DMII
COPD
Gout
Anxiety/Depression
s/p cataract surgery

MEDICATION ON ADMISSION: ASA 81 mg
Albuterol INR
Advair 500/50 [**Hospital1 **]
Symbicort 160/4.5 [**Hospital1 **]
Lasix 40 mg daily
Singulair 10 mg daily
Simvastatin 20 mg daily
Spiriva 18 mcg daily
Warfarin 15 mg daily
Ranitidine 150 mg [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
Ambien 10 mg QHS/PRN insomnia
Colchicine daily/PRN gout flare

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
O: Afebrile, stable
Gen: WD/WN, appears in pain.
HEENT: normocephalic, atraumatic.
Pupils: PERRL         EOMs: intact, with lateral nystagmus
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.

FAMILY HISTORY: Mother had CAD and colon CA in her mid 70's. Father had COPD.

SOCIAL HISTORY: Retired electrical engineer. Lives at home alone. Has a
girlfriend in the area. Friend, [**Name (NI) 553**] [**Name (NI) 174**], is legal HCP
([**Telephone/Fax (1) 9082**]). Quit smoking [**10-12**] after 100 pack-years.
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Systolic heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Fall from other slipping, tripping, or stumbling,Atrial fibrillation,Abnormal coagulation profile,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Gout, unspecified,Iron deficiency anemia, unspecified,Unspecified essential hypertension,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Heart valve replaced by other means,Long-term (current) use of anticoagulants
Subdural hem w/o coma,Systolic hrt failure NOS,Chr airway obstruct NEC,Fall from slipping NEC,Atrial fibrillation,Abnrml coagultion prfile,DMII wo cmp nt st uncntr,Gout NOS,Iron defic anemia NOS,Hypertension NOS,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Heart valve replac NEC,Long-term use anticoagul
Admission Date:  [**2150-2-25**]              Discharge Date:   [**2150-3-14**]

Date of Birth:  [**2085-5-14**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
Headache

Major Surgical or Invasive Procedure:
[**2150-2-25**]: Left sided craniotomy for subdural evacuation


History of Present Illness:
64 y/o M with CAD s/p CABG x 2 and ruptured chordae tendinae s/p
mechanical mitral valve placement in [**1-11**] admitted to the
neurosurgical service on [**2-25**] for emergent evacuation of left
subdural hematoma (surgery on [**2-25**]) after falling and hitting
his head on the ice two days prior. Anticoagulation was reversed
with FFP and vitamin K. He did well postoperatively and a
heparin bridge was begun on [**3-2**], followed by the addition of
coumadin on [**3-5**]. His INR (1.7) has yet to become therapeutic
(2.5-3.5).

Past Medical History:
[**1-11**] Cardiac Surgery
-mechanical MV placement [**3-9**] chordae rupture following IE
-CABG x 2 (LIMA to LAD, SVG to Diag)
-PFO closure
-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation
CAD
Permanent AFib s/p MAZE
DMII
COPD
Gout
Anxiety/Depression
s/p cataract surgery


Social History:
Retired electrical engineer. Lives at home alone. Has a
girlfriend in the area. Friend, [**Name (NI) 553**] [**Name (NI) 174**], is legal HCP
([**Telephone/Fax (1) 9082**]). Quit smoking [**10-12**] after 100 pack-years.


Family History:
Mother had CAD and colon CA in her mid 70's. Father had COPD.

Physical Exam:
ADMISSION PHYSICAL EXAM
O: Afebrile, stable
Gen: WD/WN, appears in pain.
HEENT: normocephalic, atraumatic.
Pupils: PERRL         EOMs: intact, with lateral nystagmus
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,with lens
implant; 3mm to
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally with
nystagmus in the lateral gaze.
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 [**6-9**] throughout. No pronator drift

Sensation: Intact to light touch

On Discharge:
AOx3, bilateral surgical pupils, full strength and power
throughout upper and lower extremities.

Pertinent Results:
[**2150-2-25**] 08:30AM BLOOD WBC-14.2* RBC-3.70* Hgb-11.8*# Hct-32.7*#
MCV-88 MCH-31.9 MCHC-36.1* RDW-13.8 Plt Ct-217
[**2150-2-25**] 11:47AM BLOOD WBC-12.7* RBC-3.27* Hgb-10.5* Hct-28.5*
MCV-87 MCH-32.2* MCHC-36.9* RDW-14.5 Plt Ct-229
[**2150-2-26**] 01:43AM BLOOD WBC-21.2*# RBC-3.16* Hgb-10.1* Hct-28.0*
MCV-89 MCH-32.0 MCHC-36.1* RDW-14.4 Plt Ct-248
[**2150-2-27**] 05:33AM BLOOD WBC-16.9* RBC-2.79* Hgb-8.7* Hct-24.8*
MCV-89 MCH-31.3 MCHC-35.1* RDW-14.5 Plt Ct-183
[**2150-2-28**] 07:30PM BLOOD WBC-11.5* RBC-2.78* Hgb-9.0* Hct-25.2*
MCV-91 MCH-32.2* MCHC-35.5* RDW-14.5 Plt Ct-252
[**2150-3-1**] 06:50AM BLOOD WBC-12.0* RBC-2.84* Hgb-9.2* Hct-25.6*
MCV-90 MCH-32.4* MCHC-35.8* RDW-14.5 Plt Ct-263
[**2150-3-2**] 05:45AM BLOOD WBC-13.2* RBC-2.95* Hgb-9.4* Hct-26.4*
MCV-89 MCH-31.9 MCHC-35.7* RDW-14.5 Plt Ct-307
[**2150-3-3**] 05:33AM BLOOD WBC-10.9 RBC-3.15* Hgb-9.9* Hct-28.0*
MCV-89 MCH-31.4 MCHC-35.3* RDW-14.8 Plt Ct-328
[**2150-3-5**] 05:40AM BLOOD WBC-12.4* RBC-3.04* Hgb-9.7* Hct-27.5*
MCV-91 MCH-31.9 MCHC-35.2* RDW-14.7 Plt Ct-382
[**2150-3-7**] 07:45AM BLOOD WBC-11.6* RBC-3.21* Hgb-9.7* Hct-29.3*
MCV-91 MCH-30.3 MCHC-33.3 RDW-14.6 Plt Ct-426
[**2150-3-8**] 07:56AM BLOOD WBC-12.5* RBC-3.33* Hgb-10.4* Hct-30.2*
MCV-91 MCH-31.2 MCHC-34.4 RDW-14.4 Plt Ct-473*
[**2150-3-10**] 05:55AM BLOOD WBC-10.9 RBC-3.22* Hgb-9.9* Hct-29.0*
MCV-90 MCH-30.9 MCHC-34.2 RDW-14.4 Plt Ct-461*
[**2150-3-12**] 07:50AM BLOOD WBC-9.9 RBC-3.42* Hgb-10.7* Hct-31.0*
MCV-91 MCH-31.4 MCHC-34.6 RDW-14.2 Plt Ct-505*
[**2150-3-13**] 09:05AM BLOOD WBC-9.2 RBC-3.55* Hgb-10.8* Hct-32.0*
MCV-90 MCH-30.4 MCHC-33.7 RDW-14.2 Plt Ct-508*
[**2150-3-14**] 08:00AM BLOOD WBC-9.8 RBC-3.59* Hgb-10.7* Hct-32.6*
MCV-91 MCH-29.8 MCHC-32.9 RDW-14.3 Plt Ct-494*
[**2150-2-25**] 06:42AM BLOOD PT-23.8* PTT-30.2 INR(PT)-2.3*
[**2150-2-25**] 08:30AM BLOOD PT-21.1* PTT-28.1 INR(PT)-2.0*
[**2150-2-25**] 11:47AM BLOOD PT-18.6* PTT-24.1 INR(PT)-1.7*
[**2150-2-26**] 01:43AM BLOOD PT-14.2* PTT-21.2* INR(PT)-1.2*
[**2150-3-5**] 05:40AM BLOOD PT-13.3 PTT-38.4* INR(PT)-1.1
[**2150-3-5**] 07:35PM BLOOD PT-14.6* PTT-60.6* INR(PT)-1.3*
[**2150-3-8**] 10:10PM BLOOD PT-15.9* PTT-96.4* INR(PT)-1.4*
[**2150-3-10**] 03:15PM BLOOD PT-16.7* PTT-56.2* INR(PT)-1.5*
[**2150-3-11**] 09:13PM BLOOD PT-19.0* PTT-72.0* INR(PT)-1.8*
[**2150-3-12**] 07:50AM BLOOD PT-21.4* PTT-95.8* INR(PT)-2.0*
[**2150-3-13**] 12:55AM BLOOD PT-22.9* PTT-120.6* INR(PT)-2.2*
[**2150-3-13**] 09:05AM BLOOD PT-23.3* PTT-75.0* INR(PT)-2.3*
[**2150-3-13**] 04:56PM BLOOD PT-22.0* PTT-53.2* INR(PT)-2.1*
[**2150-3-14**] 02:43AM BLOOD PT-22.9* PTT-69.7* INR(PT)-2.2*
[**2150-3-14**] 08:00AM BLOOD PT-24.9* PTT-97.4* INR(PT)-2.4*
[**2150-3-14**] 10:00AM BLOOD PT-25.1* PTT-92.9* INR(PT)-2.5*

[**2150-2-25**] 08:30AM BLOOD Glucose-170* UreaN-14 Creat-0.8 Na-138
K-4.8 Cl-103 HCO3-27 AnGap-13
[**2150-2-25**] 11:47AM BLOOD Glucose-195* UreaN-14 Creat-0.8 Na-138
K-5.2* Cl-105 HCO3-27 AnGap-11
[**2150-3-12**] 07:50AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.3 Iron-38*

IMAGING:
Head CT [**2-25**]:
IMPRESSION:
1. Large mixed but predominantly hyperdense left extra-axial
collection
consistent with acute subdural hematoma with gyral and lateral
ventricular
effacement, 9- mm rightward shift of midline structures and left
uncal
herniation.
2. Internal relatively low-attenuation foci may represent
non-clotted blood
from hyperacute hemorrhage, related to active bleeding.
3. Small right frontal extra-axial, likely subdural hematoma.
4. No fracture.

Head CT [**2150-2-25**] (post-evacuation):
IMPRESSION:
1. Status post virtual-complete evacution of left convexity
subdural hematoma with expected post-surgical changes including
bifrontal subdural
pneumocephalus.
2. Unchanged subdural blood layering along the tentorial
margins, as
described.

Head CT [**2150-3-4**]
IMPRESSION: Status post evacuation of subdural hematoma layering
over the
left cerebral convexity, without evidence of new intracranial
hemorrhage,
mass effect or herniation.  The CSF-atttenuation fluid,
occupying the more anterior portion of the left frontal extra-
axial space, was present on the initial scan of [**2150-2-25**], and may
reflect decompression and re-expansion of pre-existent
compartmentalized subdural space, or true hygroma.

Head CT [**2150-3-13**]
FINDINGS: The patient is status post left frontoparietal
craniotomy with
expected amount of pneumocephalus, which has decreased compared
to the prior study. There is a small amount of remaining blood
products in the left frontal convexity consistent with expected
evolution of left subdural
hematoma. There is no evidence of new hemorrhage, mass effect,
or major
vascular territory infarction. There is no hydrocephalus or
herniation. There has been an interval decrease in left
frontoparietal subgaleal soft tissue edema. Visualized paranasal
sinuses and mastoid air cells remain well aerated. As before, no
lens is identified within the right globe.

IMPRESSION:
1. No evidence of acute intracranial hemorrhage or major
vascular territory infarction.
2. Status post craniotomy with expected evolution in remaining
blood products and decrease in pneumocephalus.


Brief Hospital Course:
#Bifrontal subdural hematoma evacuation - The patient did well
postoperatively following left craniotomy and evacuation of SDH
on [**2150-2-25**]. Neurological exam remained normal. Blood pressure
was closely monitored. Primary seizure prophylaxis was achieved
initially with dilantin and then with keppra, to be continued
after discharge. Heparin gtt was started on POD#5 followed by
coumadin on POD#8. Therapeutic INR was achieved without any
evidence of progression of SDH by CT. Physical therapy did not
recommended any post-discharge services. He will have his INR
checked 5 days after discharge. The patient will follow up with
neurosurgery 4 weeks after discharge.
.
#Mechanical mitral valve - TTE on [**3-2**] showed a well-seated
prosthesis with normal disc motion and transvalvular gradients,
without MR. Heparin bridge to therapeutic anticoagulation with
warfarin was achieved, as above, with a goal INR 2.5-3.5. The
patient was instructed to abstain from alcohol or starting new
medications until a stable coumadin level is established. He
will continue to be managed by the [**Company 191**] ACMS. It was recommended
that he follow up with his cardiologist [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 9083**] of [**Location (un) 9084**], MA.
.
#DMII - Serial elevated fasting glucose confirmed the diagnosis
of DMII. Metformin was started and well-tolerated prior to
discharge.
.
#CAD - Restarted aspirin prior to discharge. [**Month (only) 116**] benefit from
initiating beta-blockade as an outpatient if reactive airway
disease permits.
.
#Iron-deficiency anemia - Hematocrit remained stable, obviating
the need for blood transfusion. [**Month (only) 116**] benefit from iron
supplementation as outpatient. Outpatient colonoscopy
recommended.
.
#COPD - Continued the outpatient regimen.


Medications on Admission:
ASA 81 mg
Albuterol INR
Advair 500/50 [**Hospital1 **]
Symbicort 160/4.5 [**Hospital1 **]
Lasix 40 mg daily
Singulair 10 mg daily
Simvastatin 20 mg daily
Spiriva 18 mcg daily
Warfarin 15 mg daily
Ranitidine 150 mg [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
Ambien 10 mg QHS/PRN insomnia
Colchicine daily/PRN gout flare


Discharge Medications:
1. Warfarin 5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*90 Tablet(s)* Refills:*2*
2. Metformin 500 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
3. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
4. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: Two
(2) Tablet PO every twelve (12) hours.
Disp:*28 Tablet(s)* Refills:*0*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
6. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation twice a day.
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain: as needed for gout flare.
9. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.

11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).


Discharge Disposition:
Home

Discharge Diagnosis:
Primary
1) Acute bilateral subdural hematoma
2) Mechanical mitral valve replacement
3) Type II Diabetes
4) Iron deficiency anemia

Secondary
1) Coronary artery disease
2) Chronic obstructive pulmonary disease
3) Hyperlipidemia
4) Gout


Discharge Condition:
Asymptomatic with stable vital signs and normal neurological
exam.


Discharge Instructions:
You were admitted to the hospital after a fall with bleeding
outside of the brain, also known as subdural hematoma.  Surgery
to remove the blood was performed on [**2150-2-25**] without
complications.

Please follow these recommendations for dosing your coumadin:
If your INR upon discharge is 2.5-3.5, take the following doses
of coumadin:
  -10 mg Saturday and Sunday nights
  -12.5 mg Monday night
  -10 mg Tuesday night
  -12.5 mg Wednesday night
  -Have your coumadin level (INR) checked at [**Hospital3 **] on
Thursday, [**3-19**] and sent to the [**Hospital3 **]
on Thursday for further coumadin dosing.

Please continue to take Fiorecet for headaches until your INR
has stabilized.  Fiorecet can affect the INR and your dose of
Fiorecet should be the same until you see Dr. [**Last Name (STitle) **] who will
decrease it.

Please do not take aspirin when you are discharged.  You can
resume taking this 1 week after discharge.

**Please notify the [**Hospital3 **] Anticoagulation
[**Hospital 9085**] Clinic of any new medications.
**Please avoid alcohol until a stable dose of coumadin is
established.
You were also diagnosed with type II diabetes and started on a
medication called metformin (glucophage) to treat this
condition.

The following medication changes were made:
1) Keppra (Levetiracetam) was started to prevent a seizure.
2) Metformin (Glucophage) was started to treat diabetes.
3) Fiorecet 2 tablets every 12 hours for headaches.

The following are recommendations from your neurosurgery team:

??????	Have a friend/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,
or excessive bending.
??????	Your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
??????	You may shower before this time using a shower cap to cover
your head.
??????	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, and
Ibuprofen etc.
??????	You have been discharged on Keppra (Levetiracetam) but you
will not require blood work monitoring.
??????	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, or drainage.
??????	Fever greater than or equal to 101?????? F.


Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of Neurosurgery within 4 weeks' time.
??????Inform the person who books your appointment that you will need
a CT scan of the brain without contrast prior to the
appointment.

Please follow-up with Dr. [**Last Name (STitle) **] in [**2-6**] weeks.  Please follow-up
with the [**Hospital3 **] for your coumadin dosing.

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2150-5-15**] 2:40
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2150-5-29**] 9:40
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2150-5-29**] 10:00



Completed by:[**2150-3-15**]

Admission Date:  [**2150-3-19**]              Discharge Date:   [**2150-3-22**]

Date of Birth:  [**2085-5-14**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
subtherapeutic INR

Major Surgical or Invasive Procedure:
none

History of Present Illness:
64M PMH mechanical MVR, recent admission for SDH s/p evacuation
p/w subtherapeutic INR. The patient was discharged [**2150-3-14**]
after a two-week hospitalization for SDH. His INR was noted to
be 1.7 the day of admission and he was sent to the ED for
heparin gtt. He had taken his prescribed coumadin 15 mg PO
today. He believes he has been complaint with his coumadin, but
admits to some confusion regarding his medications as he was
recently discharged with several new medications. Per notes he
complained of somnulence earlier, but currently denies.
.
In the ED, VS 98.4 112/67 54 20 99%RA. CT head negative for
acute change. He was given coumadin 2.5 mg PO after discussion
with the patient's PCP and was started on heparin gtt.
.
On arrival to the floor, the patient has no specific complaints.

.
ROS: Denies fever, chills, night sweats, headache, vision
changes, cough, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, melena, hematochezia,
dysuria, hematuria.


Past Medical History:
[**1-11**] Cardiac Surgery
-mechanical MV placement [**3-9**] chordae rupture following IE
-CABG x 2 (LIMA to LAD, SVG to Diag)
-PFO closure
-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation
CAD
Permanent AFib s/p MAZE
DMII
COPD
Gout
Anxiety/Depression
s/p cataract surgery


Social History:
Retired electrical engineer. Lives at home alone. Has a
girlfriend in the area. Friend, [**Name (NI) 553**] [**Name (NI) 174**], is legal HCP
([**Telephone/Fax (1) 9082**]). Quit smoking [**10-12**] after 100 pack-years.


Family History:
Mother had CAD and colon CA in her mid 70's. Father had COPD.

Physical Exam:
VS: 110/65, HR 50, RR 20, O2 Sat 95% on RA
Gen: appears comfortable
Neuro: A&O x 3, coherent, no neuro deficits noted
HEENT: head scar healing well, no hematoma, moist MM, oropharynx
clear
Heart: regular, bradycardic, no murmurs
Lungs: clear bilaterally
Abdomen: soft, nontender, nondistended
Extremities: warm, no edema


Pertinent Results:
Admission labs:

[**2150-3-19**] 05:35PM   WBC-8.5 RBC-3.69* HGB-11.0* HCT-32.6* MCV-88
MCH-29.8 MCHC-33.7 RDW-14.4
[**2150-3-19**] 05:35PM   NEUTS-65.4 LYMPHS-26.6 MONOS-5.0 EOS-2.2
BASOS-0.8
[**2150-3-19**] 05:35PM   GLUCOSE-101 UREA N-17 CREAT-0.9 SODIUM-143
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-29 ANION GAP-14

Coagulation parameters:

[**2150-3-19**] 05:35PM BLOOD PT-19.8* PTT-27.9 INR(PT)-1.8*
[**2150-3-20**] 01:15AM BLOOD PT-19.9* PTT-38.6* INR(PT)-1.9*
[**2150-3-21**] 04:25AM BLOOD PT-23.0* PTT-86.9* INR(PT)-2.2*
[**2150-3-22**] 07:55AM BLOOD PT-26.6* PTT-112.6* INR(PT)-2.6*

Brief Hospital Course:
A 63 year-old man with a history of mechanical mitral valve
presents with subtherapeutic INR.
.
# Subtherapeutic INR: Goal 2.5-3.5, admitted for heparin bridge
given high risk nature of a mechanical mitral valve.  He was
started on heparin with goal PTT 60-100, and coumadin was dosed
daily.  In consultation with [**Company 191**] anticoagulation team, he
received 17.5 mg coumadin for two days then 15 mg for one day.
INR rose to 2.6 and he was discharged with plans for repeat INR
[**3-24**].

Given the patient's confusion around his medications, home VNA
was arranged prior to discharge for medication reconciliation.
.
# Bradycardia: Asymptomatic. No evidence of cause of increased
ICP on head imaging, and not hypertensive. During last
hospitalization HR mostly 60s.
.
# Anemia: At recent baseline.
.
# Status post SDH evacuation: CT head on admission negative for
acute change.  Keppra was continued for seizure prophylaxis.
.
# COPD/emphysema: Patient was asymptomatic, with normal O2 Sats,
advair (instead of symbicort), spiriva, albuterol  were
continued.
.
# Type 2 diabetes:  Metformin was continued; he was given
insulin SS.
.
# History of atrial fibrillation: Status post MAZE procedure. In
sinus bradycardia. Anticoagulation as above.
.
# Hypercholesterolemia:  Atorvastatin was continued.
.
.

Medications on Admission:
1. Warfarin 15 mg PO DAILY
2. Metformin 500 mg PO DAILY
3. Keppra 1,000 mg PO BID
4. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Two Tablets
PO Q12H - no longer taking
5. Albuterol Sulfate Inhaler 1-2 Puffs Inhalation every [**5-11**]
hours as needed for shortness of breath or wheezing.
6. Fluticasone-Salmeterol 500-50 mcg/Dose 1 Puff Inhalation [**Hospital1 **]

7. Montelukast 10 mg PO DAILY
8. Colchicine 0.6 mg PO DAILY:PRN gout flare
9. Symbicort 160-4.5 mcg Inhaler 2 puffs [**Hospital1 **]
10. Simvastatin 20 mg PO DAILY
11. Tiotropium Bromide 18 mcg 1 Cap Inhalation DAILY
12. Furosemide 40 mg PO DAILY
13. Zolpidem 10 mg PO HS:PRN insomnia
14. Ranitidine HCl 150 mg PO BID


Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
12. Coumadin 2.5 mg Tablet Sig: Five (5) Tablet PO once a day.
Disp:*150 Tablet(s)* Refills:*0*
13. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day:
prn gout flare.
14. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. Outpatient Lab Work
coagulation profile. INR
[**2150-3-24**]
Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 9190**]


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
primary:  mechanical mitral valve, subtherapeutic INR
secondary:  atrial fibrillation, type 2 diabetes mellitus,
hyperlipidemia, anxiety, chronic obstructive pulmonary disease,
coronary artery disease


Discharge Condition:
stable, INR 2.6


Discharge Instructions:
You were admitted to the hospital because your INR (marker of
warfarin level) was too low.  You were given IV heparin until
your INR was correct.

Your fioricet was stopped.  Please do not take this medication,
as it may affect your INR.  Your warfarin dose was changed to
12.5mg daily. You must have your INR checked on tuesday.

Please call your doctor or return to the hospital if you have
chest pain, shortness of breath, high fevers and chills, or
other symptoms that are concerning to you.
.
Please take all of your medications as prescribed and follow up
with the appointments below.

Followup Instructions:
Please follow up with your primary care provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**],
MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2150-3-26**] 10:40

Also please follow up as previously scheduled:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2150-4-9**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2150-4-9**] 3:30
.
Please be sure to have your INR checked tuesday at [**Hospital1 9191**].



Completed by:[**2150-3-23**]

Name:  [**Known lastname **],[**Known firstname **] G                 Unit No:   [**Numeric Identifier 1214**]

Admission Date:  [**2150-3-19**]              Discharge Date:   [**2150-3-22**]

Date of Birth:  [**2085-5-14**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1215**]
Addendum:
The patient received a dose of 12.5 mg of warfarin prior to
leaving the hospital on the day of discharge, [**2150-3-22**].

Discharge Disposition:
Home With Service

Facility:
[**Hospital1 328**] VNA

                             [**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 1216**] MD [**MD Number(2) 1217**]

Completed by:[**2150-3-24**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Systolic heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Fall from other slipping, tripping, or stumbling,Atrial fibrillation,Abnormal coagulation profile,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Gout, unspecified,Iron deficiency anemia, unspecified,Unspecified essential hypertension,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Heart valve replaced by other means,Long-term (current) use of anticoagulants'}


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: Headache

PRESENT ILLNESS: 64 y/o M with CAD s/p CABG x 2 and ruptured chordae tendinae s/p
mechanical mitral valve placement in [**1-11**] admitted to the
neurosurgical service on [**2-25**] for emergent evacuation of left
subdural hematoma (surgery on [**2-25**]) after falling and hitting
his head on the ice two days prior. Anticoagulation was reversed
with FFP and vitamin K. He did well postoperatively and a
heparin bridge was begun on [**3-2**], followed by the addition of
coumadin on [**3-5**]. His INR (1.7) has yet to become therapeutic
(2.5-3.5).

MEDICAL HISTORY: [**1-11**] Cardiac Surgery
-mechanical MV placement [**3-9**] chordae rupture following IE
-CABG x 2 (LIMA to LAD, SVG to Diag)
-PFO closure
-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation
CAD
Permanent AFib s/p MAZE
DMII
COPD
Gout
Anxiety/Depression
s/p cataract surgery

MEDICATION ON ADMISSION: ASA 81 mg
Albuterol INR
Advair 500/50 [**Hospital1 **]
Symbicort 160/4.5 [**Hospital1 **]
Lasix 40 mg daily
Singulair 10 mg daily
Simvastatin 20 mg daily
Spiriva 18 mcg daily
Warfarin 15 mg daily
Ranitidine 150 mg [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
Ambien 10 mg QHS/PRN insomnia
Colchicine daily/PRN gout flare

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
O: Afebrile, stable
Gen: WD/WN, appears in pain.
HEENT: normocephalic, atraumatic.
Pupils: PERRL         EOMs: intact, with lateral nystagmus
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.

FAMILY HISTORY: Mother had CAD and colon CA in her mid 70's. Father had COPD.

SOCIAL HISTORY: Retired electrical engineer. Lives at home alone. Has a
girlfriend in the area. Friend, [**Name (NI) 553**] [**Name (NI) 174**], is legal HCP
([**Telephone/Fax (1) 9082**]). Quit smoking [**10-12**] after 100 pack-years. 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Systolic heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Fall from other slipping, tripping, or stumbling,Atrial fibrillation,Abnormal coagulation profile,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Gout, unspecified,Iron deficiency anemia, unspecified,Unspecified essential hypertension,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Heart valve replaced by other means,Long-term (current) use of anticoagulants'}
