CHIEF COMPLAINT: patient arrived intubated w/ a suspected R parietal hemorrhage

PRESENT ILLNESS: (per notes, [**Hospital1 18**] ED reports, [**Hospital3 6265**] records, and [**Location (un) 582**] Staff):
Ms. [**Known lastname 86119**] is an 88 [**Hospital **] nursing home resident of unknown
handedness with a past medical history including HTN, a fib for
which she is on coumadin, prior stroke, DVT/PE s/p IVC filter
placement, and HD-dependent ESRD who initially presented to
[**Hospital3 3583**] with language difficulties and was transferred
to
the [**Hospital1 18**] after she was thought to have evidence of traumatic
parietal intracranial hemorrhage.
.
There are discrepant accounts of the events preceding the
patient's presentation.  Reports sent from [**Hospital3 3583**]
suggest that the patient fell in the bathroom this evening and
struck her head.  However, according to members of the nursing
care team at [**Location (un) 582**], the patient was in her usual state of
health on [**2111-4-13**].  She attended her regularly scheduled dialysis
session and returned to [**Location 582**] at about 7:30 pm.  She was noted
to eat a full dinner and take all of her evening medicines.
Apparently the patient's roommate saw the patient stand up at
about 9:30 pm and slide down into a seated position next to her
bed.  There was no head trauma or loss of consciousness.  At
about 9:35 pm, the patient's nurse heard a call for help.  When
she entered the patient's room, the patient was apparently
resting on her side on top of a pillow.  At the time of
evaluation, the patient denied pain.  Vitals were recorded as t
98.1, bp 140/80, hr 116, rr 20, and o2 sat 95% on ra  She was
observed to pull herself up into an upright position
independently.  She appeared alert and was able to follow
commands appropriately in the course of an exam.   Although her
speech was grammatical English, it was characterized as
"disorganized" and the patient was noted to refer to herself in
the third person.  She was reported to be moving all four limbs,
but was thought to have decreased coordination.  She was
transferred to bed and a 1:1 observation was reportedly ordered;
the on-call physician and the patient's family were notified.
It
is unclear if she suffered further changes in mental status.
Regardless, she was tranferred by ambulance to [**Hospital3 3583**]
by
10:20 pm.
.
At [**Hospital1 46**], a non-contrast CT of the head was thought to show
evidence of hemorrhage.  Therefore, vitamin K (and possibly FFP
by some reports) was administered to reverse the INR.  For
reasons that are not completely clear based on the available
records, the patient was intubated (of note a vecuronium - total
20 mg - was administered in addition to etomidate, lidocaine,
ativan were given).  She was subsequently transferred to the
[**Hospital1 18**] for further evaluation and care with a presumed diagnosis
of traumatic intracranial hemorrhage.  Of note, no acute
hemorrhage was detected upon repeat imaging performed at the
[**Hospital1 18**].
.
Efforts to connect with the [**Hospital 228**] health care proxy were
unsuccessful.  According to the [**Location (un) 582**] care team, the patient
is
generally independent at baseline.
.
NEUROLOGICAL REVIEW OF SYSTEMS
- unable to obtain

MEDICAL HISTORY: - CAD s/p MI
- HTN
- A fib, on coumadin
- prior stroke (presumaby in right parietal +/- left occipital
based on imaging)
- HD-ESRD, receives dialysis M, W, F, right chest access
- DVT/PE, s/p IVC filter placement
- PMR
- anxiety
- vertigo
- upper GIB
- bilateral TKR
- OA
- probable right eye procedure

MEDICATION ON ADMISSION: - coumadin 7 mg po daily
- renal soft gel 1 cap po daily
- renagel 2400 mg po TID
- sensipar 30 mg po daily
- metoprolol xl 200 mg po daily
- nifedipine ER 30 mg po bid
- simvastatin 40 mg po daily
- pantoprazole 40 mg po daily
- prednisone 30 mg po daily
- albuterol neb prn
- tylenol prn
- bowel regimen prn

ALLERGIES: Codeine / Diltiazem Hcl / Nsaids / Sulfa (Sulfonamide
Antibiotics) / Methyldopa / Propoxyphene

PHYSICAL EXAM: PHYSICAL EXAMINATION on admission:

FAMILY HISTORY: - NC

SOCIAL HISTORY: lives at nursing home was recently hospitalized multiple times
and required initiation of HD.  Prior to arrival patient
ambulated with a walker, was oriented to place and year,
required assisst w/ some toileting, was able to fee herself most
of the time
Other encephalopathy,End stage renal disease,Urinary tract infection, site not specified,Unspecified pleural effusion,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Infection with microorganisms without mention of resistance to multiple drugs,Polymyalgia rheumatica,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Long-term (current) use of anticoagulants,Atrial fibrillation,Anxiety state, unspecified,Knee joint replacement,Renal dialysis status,Anemia in chronic kidney disease
Encephalopathy NEC,End stage renal disease,Urin tract infection NOS,Pleural effusion NOS,Hyp kid NOS w cr kid V,Enterococcus group d,Inf mcr rst ot drg nt ml,Polymyalgia rheumatica,Old myocardial infarct,Crnry athrscl natve vssl,Long-term use anticoagul,Atrial fibrillation,Anxiety state NOS,Joint replaced knee,Renal dialysis status,Anemia in chr kidney dis
Admission Date:  [**2111-4-14**]              Discharge Date:   [**2111-4-20**]


Service: NEUROLOGY

Allergies:
Codeine / Diltiazem Hcl / Nsaids / Sulfa (Sulfonamide
Antibiotics) / Methyldopa / Propoxyphene

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
patient arrived intubated w/ a suspected R parietal hemorrhage

Major Surgical or Invasive Procedure:
extubation, arterial line placement and removal

History of Present Illness:
(per notes, [**Hospital1 18**] ED reports, [**Hospital3 6265**] records, and [**Location (un) 582**] Staff):
Ms. [**Known lastname 86119**] is an 88 [**Hospital **] nursing home resident of unknown
handedness with a past medical history including HTN, a fib for
which she is on coumadin, prior stroke, DVT/PE s/p IVC filter
placement, and HD-dependent ESRD who initially presented to
[**Hospital3 3583**] with language difficulties and was transferred
to
the [**Hospital1 18**] after she was thought to have evidence of traumatic
parietal intracranial hemorrhage.
.
There are discrepant accounts of the events preceding the
patient's presentation.  Reports sent from [**Hospital3 3583**]
suggest that the patient fell in the bathroom this evening and
struck her head.  However, according to members of the nursing
care team at [**Location (un) 582**], the patient was in her usual state of
health on [**2111-4-13**].  She attended her regularly scheduled dialysis
session and returned to [**Location 582**] at about 7:30 pm.  She was noted
to eat a full dinner and take all of her evening medicines.
Apparently the patient's roommate saw the patient stand up at
about 9:30 pm and slide down into a seated position next to her
bed.  There was no head trauma or loss of consciousness.  At
about 9:35 pm, the patient's nurse heard a call for help.  When
she entered the patient's room, the patient was apparently
resting on her side on top of a pillow.  At the time of
evaluation, the patient denied pain.  Vitals were recorded as t
98.1, bp 140/80, hr 116, rr 20, and o2 sat 95% on ra  She was
observed to pull herself up into an upright position
independently.  She appeared alert and was able to follow
commands appropriately in the course of an exam.   Although her
speech was grammatical English, it was characterized as
"disorganized" and the patient was noted to refer to herself in
the third person.  She was reported to be moving all four limbs,
but was thought to have decreased coordination.  She was
transferred to bed and a 1:1 observation was reportedly ordered;
the on-call physician and the patient's family were notified.
It
is unclear if she suffered further changes in mental status.
Regardless, she was tranferred by ambulance to [**Hospital3 3583**]
by
10:20 pm.
.
At [**Hospital1 46**], a non-contrast CT of the head was thought to show
evidence of hemorrhage.  Therefore, vitamin K (and possibly FFP
by some reports) was administered to reverse the INR.  For
reasons that are not completely clear based on the available
records, the patient was intubated (of note a vecuronium - total
20 mg - was administered in addition to etomidate, lidocaine,
ativan were given).  She was subsequently transferred to the
[**Hospital1 18**] for further evaluation and care with a presumed diagnosis
of traumatic intracranial hemorrhage.  Of note, no acute
hemorrhage was detected upon repeat imaging performed at the
[**Hospital1 18**].
.
Efforts to connect with the [**Hospital 228**] health care proxy were
unsuccessful.  According to the [**Location (un) 582**] care team, the patient
is
generally independent at baseline.
.
NEUROLOGICAL REVIEW OF SYSTEMS
- unable to obtain

GENERAL REVIEW OF SYSTEMS:
- unable to obtain


Past Medical History:
- CAD s/p MI
- HTN
- A fib, on coumadin
- prior stroke (presumaby in right parietal +/- left occipital
based on imaging)
- HD-ESRD, receives dialysis M, W, F, right chest access
- DVT/PE, s/p IVC filter placement
- PMR
- anxiety
- vertigo
- upper GIB
- bilateral TKR
- OA
- probable right eye procedure

Social History:
lives at nursing home was recently hospitalized multiple times
and required initiation of HD.  Prior to arrival patient
ambulated with a walker, was oriented to place and year,
required assisst w/ some toileting, was able to fee herself most
of the time


Family History:
- NC

Physical Exam:
PHYSICAL EXAMINATION on admission:

Vitals: not recorded in triage - per report sbp dropped into 90s
with propofol, sbp as high as 200s/diastolic 100s following
eval,
hr in 1teens
General: Awake, cooperative, NAD.
HEENT: Normocepahlic, atruamatic, no scleral icterus noted.
C-collar in place.  Intubated.
Neck: C-collar.
Cardiac: tachycardic rate, normal S1 and S2.
Pulmonary: Lungs clear to auscultation bilaterally anteriorly.
Abdomen: Obese. Normoactive bowel sounds.  Soft.  Non-tender,
non-distended.
Extremities: cool.
Skin: no rashes or concerning lesions noted.

NEUROLOGIC EXAMINATION: performed about two hrs after propofol
was discontinued; vecuronium was probably still a factor.

Mental Status:
* Degree of Alertness: does not arouse to voice, gentle tactile,
or noxious stimulation

Cranial Nerves:
* I: Olfaction not evaluated.
* II, III: right pupil fixed at about 5 mm, left pupil 4 --> 2
* V, VII: Corneals absent bilaterally
.
Motor:
* Bulk: No evidence of atrophy.
* Tone: Flaccid.
.
Strength:
* Left Upper Extremity:  no spontaneous movement
* Right Upper Extremity: no spontaneous movement
* Left Lower Extremity:  no spontaneous movement
* Right Lower Extremity: no spontaneous movement
* Does not withdraw any extremity to noxious

Reflexes:
* Left:  1+ throughout Biceps, 0 Patellar, 0 Achilles
* Right: 1+ thoughout Biceps, 0 Patellar, 0 Achilles
* Babinski: mute
* Doll's Eye Maneuver: gaze remains midline
.
Sensation:
* Noxious: does not withdraw to noxious
.
Coordination
* unable to assess
.
Gait:
* unable to assess

Examination at time of discharge:

.


Pertinent Results:
[**2111-4-14**] 02:48AM BLOOD WBC-8.5 RBC-4.31 Hgb-12.0 Hct-38.7 MCV-90
MCH-27.9 MCHC-31.0 RDW-18.2* Plt Ct-225
[**2111-4-16**] 03:29AM BLOOD WBC-8.2 RBC-3.44* Hgb-10.0* Hct-31.6*
MCV-92 MCH-29.2 MCHC-31.7 RDW-18.1* Plt Ct-218
[**2111-4-14**] 02:48AM BLOOD Neuts-78.4* Lymphs-16.5* Monos-3.5
Eos-1.2 Baso-0.3
[**2111-4-14**] 02:48AM BLOOD PT-15.4* PTT-24.4 INR(PT)-1.4*
[**2111-4-16**] 09:57AM BLOOD PT-16.6* PTT-49.1* INR(PT)-1.5*
[**2111-4-14**] 02:48AM BLOOD Glucose-197* UreaN-21* Creat-4.0* Na-142
K-3.5 Cl-98 HCO3-30 AnGap-18
[**2111-4-16**] 03:29AM BLOOD Glucose-102* UreaN-33* Creat-6.4* Na-139
K-3.9 Cl-101 HCO3-27 AnGap-15
[**2111-4-14**] 02:48AM BLOOD CK(CPK)-28*
[**2111-4-15**] 08:23AM BLOOD CK(CPK)-32
[**2111-4-15**] 01:54PM BLOOD CK(CPK)-62
[**2111-4-15**] 08:23AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2111-4-15**] 01:54PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2111-4-14**] 02:48AM BLOOD Calcium-10.2 Phos-2.9 Mg-1.8
[**2111-4-15**] 08:23AM BLOOD TSH-2.7
[**2111-4-14**] 03:55AM URINE RBC-0-2 WBC->50 Bacteri-MOD Yeast-NONE
Epi-0
[**2111-4-14**] 03:55AM URINE Blood-SM Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-MOD
[**2111-4-14**] 03:55AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.010

URINE

   URINE CULTURE (Preliminary):
      ENTEROCOCCUS SP..    >100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------  =>16 R
LINEZOLID-------------     2 S
NITROFURANTOIN--------  <=16 S
TETRACYCLINE----------  =>16 R

Imaging;

CT head [**4-14**] -

IMPRESSION:

1. No evidence of acute intracranial hemorrhage.

2. Encephalomalacia and cortical laminar necrosis in the right
parietal lobe
consistent with old infarct. Hypodensity in the left occipital
lobe may
represent subacute or chronic infarct. If there is concern for
acute
ischemia, MRI is recommended for further evaluation, if there is
no
contra-indication.

3. Bilateral ethmoid mucosal thickening. Clinical correlation
recommended.

CT Cspine [**4-14**]:

IMPRESSION:

1. No acute fracture or malalignment.

2. Severe multilevel degenerative change with multilevel neural
foraminal
narrowing as above. If there is continued concern for cord,
ligamentous or
nerve injury, MR C spine can be considered if there is no
contra-indication.

The study and the report were reviewed by the staff radiologist.


CT torso (obtained at OSH):

IMPRESSION:

1. No acute intrathoracic, abdominal or pelvic injury.

2. Peribronchial thickening in the right lower lobe suggestive
of bronchitis.

3. Multiple 3-5 mm pulmonary nodules. Six-month followup is
recommended to
ensure stability.

4. Aneurysmal dilatation of the proximal descending aorta up to
4.5 cm,
incompletely evaluated on this study.

5. Colonic diverticulosis without evidence of acute
diverticulitis.

CXR [**4-15**];

FINDINGS: In comparison with study of [**4-14**], the endotracheal and
nasogastric
tubes have been removed. Persistent opacification at the left
base with some
degree of mediastinal shift is again consistent with volume loss
and possible
effusion. The right hemidiaphragm now is not seen, suggesting
atelectasis and
effusion on this side as well.

Central catheter remains in place.


Brief Hospital Course:
Ms. [**Known lastname 86119**] is an 88 year-old W from NH handedness with a past
medical history including HTN, a fib for which she is on
coumadin, prior stroke(s), DVT/PE s/p IVC filter placement, and
HD-dependent ESRD who initially presented to [**Hospital3 3583**]
with ? language difficulties and mild confusion, and was
transferred to the [**Hospital1 18**] after she was thought to have evidence
of traumatic parietal intracranial hemorrhage.  Studies in the
ED revealed urinary tract infection (which could
potentially account for the patient's presenting syndrome) as
well as a CT showing chronic to subacute strokes w/ suspected
hemorrhage being consistent w/ a calcification.  Given pt's
intubated state, she was admitted to NEURO ICU.

NEURO.

Underwent repeat CT w/o any changes.  Since patient received IV
Vit. K and FFP at OSH and has afib, she was started on heparin
gtt bridge to coumadin.  Examination remained severely
encephalopathic with a poor motor examination (withdrawal to
noxious that was sluggish) due to having had received over 7mg
of Ativan, etomidate, succinyl choline and vecuronium.

She was extubated on [**2111-4-15**].  At this time she was alert, awake,
however remarkably encephalopathic (inattentive, unable to
conduct a congruent conversation) however with intact
spontaneous language, albeit w/ markedly hoarse voice.  Motor
exam was notable for sign. increased RUE tone vs. LUE and
increase RLE vs. LLE tone.

She underwent HD on [**2111-4-18**] and [**2111-4-21**].

ID: Started on Nitrofurantoin for positive UA.  On [**2111-4-16**], urine
culture was positive for Vancomycin Resistant Enteroccus (VRE).
On [**2111-4-16**], nitrofurantoin was discontinued, and linezolid 600 mg
[**Hospital1 **] was started for 7 day course.  The last day of linezolid
will by on [**2111-4-24**].
.
CVS.  Patient was maintained on home dose of BB converted to IR
dosing, however developed Afib w/ RVR and subsequent hypotension
to mid 70s SBP while intubated.  Bedside echo revealed poor
filling. She was treated w/ IVF, and started on amiodarone gtt
(no response to esmolol and allergy to diltiazem).  HR control
improved to 80s, SBP improved to low 100s and she was
transitioned to PO amiodarone. Patient was initially continued
on coumadin.  After starting amiodarone, her INR elevated up to
a max 3.7. Coumadin was discontinued on [**4-19**]. Her INR on [**4-20**] was
3.7.  Her INR should be checked daily.  The plan regarding her
INR is that once INR is < or = to 3.2, coumadin can be
restarted.  Coumadin should be started at 2.5 mg daily.

RESP. Patient initially failed extubation attempt due to low
lung volumes on CPAP in setting of persistent paralytics.  She
was extubated on HD2.  There was evidence of b/l pleural
effusions on CXR attributed to vol. overload prior to HD.  CT
chest showed multiple pulmonary nodules (see Pertinent results)
that will require imaging follow up on [**4-18**] months with CT.

.
ENDO.
Treated with ISS.

RENAL.  Stage IV renal failure on HD, over the past few months
per family.  No cause identified, however, likely due to
longstanding HTN.  She was continued on renagel, sensipar and
underwent HD session on [**2-10**], and [**4-20**].


Medications on Admission:
- coumadin 7 mg po daily
- renal soft gel 1 cap po daily
- renagel 2400 mg po TID
- sensipar 30 mg po daily
- metoprolol xl 200 mg po daily
- nifedipine ER 30 mg po bid
- simvastatin 40 mg po daily
- pantoprazole 40 mg po daily
- prednisone 30 mg po daily
- albuterol neb prn
- tylenol prn
- bowel regimen prn


Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for SOB, wheezing.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 4 days: Last day of linezolid is [**2111-4-24**] to complete
7 day course.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 days: dosing to change on [**2111-4-23**] to 400 mg/day for
1 month, then change to 200 mg/day  .
10. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day:
Please start after treatment of UTI is complete.
12. Nifedipine 30 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO twice a day.
13. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
***NOTE: This should be started once INR is less than or equal
to 3.2. Please check INR daily.
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 months: Starting [**2111-4-23**]; give 400 mg daily for one month,
then change to 200 mg daily thereafter.


Discharge Disposition:
Extended Care

Facility:
Evanswood Center for Older Adults - [**Location (un) 8072**]

Discharge Diagnosis:
Primary Diagnosis:
Severe encephalopathy secondary to VRE UTI
Secondary Diagnoses:
Afib
HTN
CAD
prior stroke
ESRD


Discharge Condition:
Neuro exam:Mental Status: Awake,Confused, perseverates, can
follow simple commands; moves all extremities at least against
gravity
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair


Discharge Instructions:
Ms. [**Known lastname 86119**] is an 88 year-old W from NH handedness with a past
medical history including HTN, a fib for which she is on
coumadin, prior stroke(s), DVT/PE s/p IVC filter placement, and
HD-dependent ESRD who initially presented to [**Hospital3 3583**]
with ? language difficulties and mild confusion, and was
transferred to the [**Hospital1 18**] after she was thought to have evidence
of traumatic parietal intracranial hemorrhage.  Studies in the
ED revealed urinary tract infection (which could potentially
account for the patient's presenting syndrome) as well as a CT
showing chronic to subacute strokes w/ suspected hemorrhage
being consistent w/ a calcification.  Given pt's intubated
state, she was admitted to NEURO ICU.

1) Urine culture was positive for vancomyicn resistant
enterococcus.  Therefore, she was started on linezolid 600 mg
[**Hospital1 **] was for 7 day course.  The last day of linezolid will by on
[**2111-4-24**].

2)She has been on coumadin for her history of afib. However, her
INR has been elevated up to 3.7 on [**2111-4-20**].  Therefore, her
coumadin is on hold for now.  Her INR should be checked daily.
Once INR is less than or equal to 3.2, coumadin should be
resumed at 2.5 mg daily.

3)Please follow up with neurologist Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] as
outlined below.  Please call the registration line at
[**Telephone/Fax (1) 10676**] to register prior to your appointment.  Please
register as soon as possible.

4) Patient was started on new medication, amiodarone. Six day
course of amiodarone 400 mg [**Hospital1 **] will complete on [**2111-4-22**]. Then,
on [**2111-4-23**] start amiodarone 400 mg daily for 1 month, then
change to 200mg daily thereafter.


Followup Instructions:
Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **]. Tuesday [**2111-6-23**] at 11:30 am. [**Hospital1 18**].
[**Telephone/Fax (1) 1694**].
NOTE: Please call registration line at [**Telephone/Fax (1) 10676**] to register
prior to your appointment.  Please register as soon as possible.


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

Completed by:[**2111-4-20**]
{'Other encephalopathy,End stage renal disease,Urinary tract infection, site not specified,Unspecified pleural effusion,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Infection with microorganisms without mention of resistance to multiple drugs,Polymyalgia rheumatica,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Long-term (current) use of anticoagulants,Atrial fibrillation,Anxiety state, unspecified,Knee joint replacement,Renal dialysis status,Anemia in chronic kidney disease'}


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: patient arrived intubated w/ a suspected R parietal hemorrhage

PRESENT ILLNESS: (per notes, [**Hospital1 18**] ED reports, [**Hospital3 6265**] records, and [**Location (un) 582**] Staff):
Ms. [**Known lastname 86119**] is an 88 [**Hospital **] nursing home resident of unknown
handedness with a past medical history including HTN, a fib for
which she is on coumadin, prior stroke, DVT/PE s/p IVC filter
placement, and HD-dependent ESRD who initially presented to
[**Hospital3 3583**] with language difficulties and was transferred
to
the [**Hospital1 18**] after she was thought to have evidence of traumatic
parietal intracranial hemorrhage.
.
There are discrepant accounts of the events preceding the
patient's presentation.  Reports sent from [**Hospital3 3583**]
suggest that the patient fell in the bathroom this evening and
struck her head.  However, according to members of the nursing
care team at [**Location (un) 582**], the patient was in her usual state of
health on [**2111-4-13**].  She attended her regularly scheduled dialysis
session and returned to [**Location 582**] at about 7:30 pm.  She was noted
to eat a full dinner and take all of her evening medicines.
Apparently the patient's roommate saw the patient stand up at
about 9:30 pm and slide down into a seated position next to her
bed.  There was no head trauma or loss of consciousness.  At
about 9:35 pm, the patient's nurse heard a call for help.  When
she entered the patient's room, the patient was apparently
resting on her side on top of a pillow.  At the time of
evaluation, the patient denied pain.  Vitals were recorded as t
98.1, bp 140/80, hr 116, rr 20, and o2 sat 95% on ra  She was
observed to pull herself up into an upright position
independently.  She appeared alert and was able to follow
commands appropriately in the course of an exam.   Although her
speech was grammatical English, it was characterized as
"disorganized" and the patient was noted to refer to herself in
the third person.  She was reported to be moving all four limbs,
but was thought to have decreased coordination.  She was
transferred to bed and a 1:1 observation was reportedly ordered;
the on-call physician and the patient's family were notified.
It
is unclear if she suffered further changes in mental status.
Regardless, she was tranferred by ambulance to [**Hospital3 3583**]
by
10:20 pm.
.
At [**Hospital1 46**], a non-contrast CT of the head was thought to show
evidence of hemorrhage.  Therefore, vitamin K (and possibly FFP
by some reports) was administered to reverse the INR.  For
reasons that are not completely clear based on the available
records, the patient was intubated (of note a vecuronium - total
20 mg - was administered in addition to etomidate, lidocaine,
ativan were given).  She was subsequently transferred to the
[**Hospital1 18**] for further evaluation and care with a presumed diagnosis
of traumatic intracranial hemorrhage.  Of note, no acute
hemorrhage was detected upon repeat imaging performed at the
[**Hospital1 18**].
.
Efforts to connect with the [**Hospital 228**] health care proxy were
unsuccessful.  According to the [**Location (un) 582**] care team, the patient
is
generally independent at baseline.
.
NEUROLOGICAL REVIEW OF SYSTEMS
- unable to obtain

MEDICAL HISTORY: - CAD s/p MI
- HTN
- A fib, on coumadin
- prior stroke (presumaby in right parietal +/- left occipital
based on imaging)
- HD-ESRD, receives dialysis M, W, F, right chest access
- DVT/PE, s/p IVC filter placement
- PMR
- anxiety
- vertigo
- upper GIB
- bilateral TKR
- OA
- probable right eye procedure

MEDICATION ON ADMISSION: - coumadin 7 mg po daily
- renal soft gel 1 cap po daily
- renagel 2400 mg po TID
- sensipar 30 mg po daily
- metoprolol xl 200 mg po daily
- nifedipine ER 30 mg po bid
- simvastatin 40 mg po daily
- pantoprazole 40 mg po daily
- prednisone 30 mg po daily
- albuterol neb prn
- tylenol prn
- bowel regimen prn

ALLERGIES: Codeine / Diltiazem Hcl / Nsaids / Sulfa (Sulfonamide
Antibiotics) / Methyldopa / Propoxyphene

PHYSICAL EXAM: PHYSICAL EXAMINATION on admission:

FAMILY HISTORY: - NC

SOCIAL HISTORY: lives at nursing home was recently hospitalized multiple times
and required initiation of HD.  Prior to arrival patient
ambulated with a walker, was oriented to place and year,
required assisst w/ some toileting, was able to fee herself most
of the time 

### Response:
{'Other encephalopathy,End stage renal disease,Urinary tract infection, site not specified,Unspecified pleural effusion,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Infection with microorganisms without mention of resistance to multiple drugs,Polymyalgia rheumatica,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Long-term (current) use of anticoagulants,Atrial fibrillation,Anxiety state, unspecified,Knee joint replacement,Renal dialysis status,Anemia in chronic kidney disease'}
