CHIEF COMPLAINT: Seizures s/p R hip replacement

PRESENT ILLNESS: 86 y/o man with CAD, MVR, admitted from OSH with continuous
seizure-like activity following hip fracture repair.
.
Had repair of hip fracture @ OSH and post op was noted to have
several tonic-clonic like movements.  They are described in an
unsedated neurologist exam as "intermittent spells with hooting
or grunting associated with eyes driven to the left, and a
flexion jerk to the left. There is no sustained motor activity.
He has diminished responsivity...come out a few seconds later,
answer [**2-18**] questions but not reliably, and go back and do it
again"
.
He was loaded with dilantin, phosphenytoin, and transfered to
the ICU. 0.5mg IV lorazepam dropped his blood pressure to high
80s  systolic and did not relieve the abnormal motor activity.
.
Post-op labs prior to transfer @ OSH also notable for anemia and
mild acute renal failure.

MEDICAL HISTORY: CAD - s/p CABG unclear dates
MVR - unclear dates
CHF - no documented baseline cardiac function
h/o Afib with cardioversion
MGUS
h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] bare in reaction to Influenza Vaccine
Prostate CA s/p XRT c/b hematuria
Hematuria - s/p multiple cystoscopies, felt to be radiation
related
Cataract repair
hernia repair x 3

MEDICATION ON ADMISSION: HOME MEDICATIONS:
Digoxin 0.25mg po qday
Norvasc 5mg po Qday
citalopram 40mg po qday
Lasix 40mg po qday
Lisinopril 20mg po BID
Coumadin 5mg po qday
detrol 4mg po qday
actonel 35mg po qday
lorazepam prn 0.5mg
Oxipam for sleep
Multivitamin
Iron
.
MEDICATIONS ON TRANSFER:
Dilantin 100mg IV TI
Lovenox 70mg SQ q12h
Protonix 40mg IV daily
Digoxin 0.25mg IV slow push daily
Ativan 0,5mg IV q2hours prn

ALLERGIES: Influenza Virus Vaccine / Sulfa (Sulfonamides) / Iodine /
Penicillins / Toprol Xl / Clopidogrel / Succinylcholine

PHYSICAL EXAM: 99.6   69   102/47   100% AC 50%fiO2 600/10 5 PEEP
GEN: non responsive, lying in bed
HEENT: prominent V wave noted in jugular venous pulse
CV: irregular rhythym, s1, s2, dialstolic rumble heard @ apex,
no promiment MR murmur noted
RESP: CTA anteriorly
ABD: distended, soft, decreased bowel sounds
EXT: decreased pulses, no edema
NEURO: PERRL - constricted but equal and reactive, corneal
reflexes present. Does not open eyes to command, does not move
extremities. Does not withdraw to noxious stimuli.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Patient is retired, lives in [**Location **], family is aware of
transfer per notes
Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Hematoma complicating a procedure,Acute cholecystitis,Chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Other convulsions,Other and unspecified complications of medical care, not elsewhere classified,Infection with microorganisms resistant to penicillins,Anemia, unspecified,Diseases of tricuspid valve,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension
Acute respiratry failure,Meth sus pneum d/t Staph,Hematoma complic proc,Acute cholecystitis,Chr diastolic hrt fail,Hyperosmolality,Convulsions NEC,Complic med care NEC/NOS,Inf mcrg rstn pncllins,Anemia NOS,Tricuspid valve disease,Crnry athrscl natve vssl,Atrial fibrillation,DMII wo cmp nt st uncntr,Hypertension NOS
Admission Date:  [**2121-12-6**]              Discharge Date:   [**2121-12-30**]


Service: MEDICINE

Allergies:
Influenza Virus Vaccine / Sulfa (Sulfonamides) / Iodine /
Penicillins / Toprol Xl / Clopidogrel / Succinylcholine

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Seizures s/p R hip replacement

Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy tube placement by IR on [**2121-12-9**]
Bronchoscopy
Lumbar Puncture
Tracheostomy
PEG tube placement


History of Present Illness:
86 y/o man with CAD, MVR, admitted from OSH with continuous
seizure-like activity following hip fracture repair.
.
Had repair of hip fracture @ OSH and post op was noted to have
several tonic-clonic like movements.  They are described in an
unsedated neurologist exam as "intermittent spells with hooting
or grunting associated with eyes driven to the left, and a
flexion jerk to the left. There is no sustained motor activity.
He has diminished responsivity...come out a few seconds later,
answer [**2-18**] questions but not reliably, and go back and do it
again"
.
He was loaded with dilantin, phosphenytoin, and transfered to
the ICU. 0.5mg IV lorazepam dropped his blood pressure to high
80s  systolic and did not relieve the abnormal motor activity.
.
Post-op labs prior to transfer @ OSH also notable for anemia and
mild acute renal failure.

Past Medical History:
CAD - s/p CABG unclear dates
MVR - unclear dates
CHF - no documented baseline cardiac function
h/o Afib with cardioversion
MGUS
h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] bare in reaction to Influenza Vaccine
Prostate CA s/p XRT c/b hematuria
Hematuria - s/p multiple cystoscopies, felt to be radiation
related
Cataract repair
hernia repair x 3

Social History:
Patient is retired, lives in [**Location **], family is aware of
transfer per notes

Family History:
Non-contributory.

Physical Exam:
99.6   69   102/47   100% AC 50%fiO2 600/10 5 PEEP
GEN: non responsive, lying in bed
HEENT: prominent V wave noted in jugular venous pulse
CV: irregular rhythym, s1, s2, dialstolic rumble heard @ apex,
no promiment MR murmur noted
RESP: CTA anteriorly
ABD: distended, soft, decreased bowel sounds
EXT: decreased pulses, no edema
NEURO: PERRL - constricted but equal and reactive, corneal
reflexes present. Does not open eyes to command, does not move
extremities. Does not withdraw to noxious stimuli.

Pertinent Results:
LABORATORIES:
[**2121-12-6**] 05:02AM BLOOD WBC-7.5 RBC-3.03* Hgb-9.6* Hct-28.0*
MCV-92 MCH-31.8 MCHC-34.4 RDW-15.7* Plt Ct-145*
[**2121-12-30**] 03:21AM BLOOD WBC-6.3 RBC-2.74* Hgb-8.5* Hct-25.6*
MCV-93 MCH-30.9 MCHC-33.1 RDW-16.7* Plt Ct-262
[**2121-12-6**] 05:02AM BLOOD Neuts-82.3* Bands-0 Lymphs-12.4*
Monos-4.9 Eos-0.5 Baso-0.1
[**2121-12-26**] 02:53AM BLOOD Neuts-88.8* Bands-0 Lymphs-5.7* Monos-2.6
Eos-3.0 Baso-0
[**2121-12-6**] 05:02AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
[**2121-12-26**] 02:53AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2121-12-6**] 05:02AM BLOOD PT-21.1* PTT-53.8* INR(PT)-2.1*
[**2121-12-30**] 03:21AM BLOOD PT-13.2* PTT-23.5 INR(PT)-1.2*
[**2121-12-22**] 03:54AM BLOOD ESR-38*
[**2121-12-9**] 08:05PM BLOOD ACA IgG-5.4 ACA IgM-11.2
[**2121-12-9**] 08:05PM BLOOD Lupus-NEG
[**2121-12-6**] 05:02AM BLOOD Glucose-156* UreaN-24* Creat-1.4* Na-141
K-4.2 Cl-109* HCO3-26 AnGap-10
[**2121-12-30**] 01:59PM BLOOD Glucose-145* UreaN-17 Creat-1.0 Na-137
K-4.0 Cl-102 HCO3-27 AnGap-12
[**2121-12-6**] 05:02AM BLOOD ALT-31 AST-55* LD(LDH)-217 CK(CPK)-1226*
AlkPhos-40 Amylase-17 TotBili-2.1* DirBili-0.4* IndBili-1.7
[**2121-12-30**] 03:21AM BLOOD ALT-23 AST-23 LD(LDH)-407* AlkPhos-129*
TotBili-0.8
[**2121-12-6**] 05:02AM BLOOD Lipase-9
[**2121-12-8**] 03:22AM BLOOD Lipase-8
[**2121-12-6**] 05:02AM BLOOD CK-MB-7 cTropnT-0.02*
[**2121-12-6**] 04:06PM BLOOD CK-MB-7 cTropnT-0.01
[**2121-12-6**] 05:02AM BLOOD Albumin-3.0* Calcium-7.4* Phos-2.4*
Mg-2.9*
[**2121-12-27**] 04:18AM BLOOD Albumin-2.5* Calcium-7.6* Phos-2.5*
Mg-2.7*
[**2121-12-30**] 01:59PM BLOOD Calcium-8.1* Phos-2.7 Mg-2.5
[**2121-12-16**] 03:42AM BLOOD calTIBC-127* VitB12-907* Folate-13.2
Ferritn-409* TRF-98*
[**2121-12-6**] 07:44AM BLOOD Ammonia-11*
[**2121-12-9**] 09:23AM BLOOD Ammonia-59*
[**2121-12-6**] 05:02AM BLOOD TSH-5.5*
[**2121-12-22**] 03:54AM BLOOD CRP-76.3*
[**2121-12-22**] 03:54AM BLOOD PEP-AWAITING F IgG-1395 IgA-205 IgM-87
IFE-MONOCLONAL
[**2121-12-6**] 05:02AM BLOOD Digoxin-1.6
[**2121-12-30**] 03:21AM BLOOD Digoxin-0.8*
[**2121-12-6**] 05:02AM BLOOD Phenyto-8.5* Valproa-67
[**2121-12-28**] 04:04AM BLOOD Phenyto-9.5*
.
LP: Normal (WBC 0, RBC 0, Poly 0, TotProt 32, Glucose 79 LD(LDH)
18)
.
MICROBIOLOGY:
Sputum: Multiple positive for MRSA (first [**12-11**], last was a BAL
on [**12-25**])
Blood: [**12-27**]: 1/4 bottles Coag Negative Staph
R Hip Hematoma: [**12-17**]: Coag negative Staph rare growth
R Hip Synovial Fluid: [**12-23**]: No growth
Bile Culture: [**12-25**]: mixed bacterial types ( >= 3 colony types)
CSF: [**12-18**]:  No Growth
.
RADIOLOGY:
CT HEAD [**12-6**]: IMPRESSION: No evidence of intracranial
hemorrhage, mass effect, or infarct.
.
MRI Brain [**12-6**]:
IMPRESSION: No evidence of acute infarct or abnormal
enhancement. Mild-to- moderate brain atrophy.
.
EEG [**12-6**]: IMPRESSION: This is a likely normal portable EEG in
the briefly waking as well as sleeping states. No clearly focal,
lateralized, or
epileptiform features were evident.
.
CT Chest/Abdomen/Pelvis [**12-8**]: IMPRESSION:

1. Extensive right thigh/hip hematoma as above.

2. Cholelithiasis and gallbladder wall thickening. Clinical
correlation with respect to possible cholecystitis is
recommended.

3. Cardiomegaly, bilateral pleural effusions, and interstitial
septal thickening suggestive of pulmonary edema.

4. Mild aneurysmal dilatation of the ascending thoracic aorta.

5. Mild-to-moderate dilatation of the main as well as right and
left pulmonary arteries.

6. Multiple hypodense liver lesions, likely representing cysts.

7. Pancreatic atrophy with numerous pancreatic calcifications
suggestive of chronic pancreatitis.
.
R Lower Extremity U/S: [**12-8**]: RIGHT EXTREMITY NON-VASCULAR
ULTRASOUND: There is a small amount of fluid anterior to the
proximal femur. The largest dimension measures 2.8 x 1.3 x 3.2
cm.
.
CT Abdomen/Pelvis [**12-17**]: IMPRESSION:
1. New bilateral retroperitoneal hematoma involving the psoas
and iliacus muscles.
2. Interval placement of cholecystostomy tube, with decompressed
gallbladder. No abnormal intra-abdominal collections identified.
3. Interval increase in bilateral subsegmental atelectasis with
persistent left pleural effusion. Superimposed infection cannot
be entirely excluded.
4. Multiple hypodense lesions are again seen within the liver,
the smallest of which also too small to characterize by CT.
.


Brief Hospital Course:
Patient is an 86 year old man with CAD, CHF, MVR, s/p recent
elective hip repair, who was transfered from OSH for question of
continued seizure-like activity post-operatively.
.
# Seizure like activity and Mental Status:
Patient did not have any further seizure like activity during
his stay at [**Hospital1 18**]. He was initailly on valproate, and was then
loaded with phenytoin, per neurology recommendations. Neurology
consulted and assisted with management during his stay.
An EEG was completed on [**2121-12-7**] which was interpreted as likely
normal, without any evidence of seizure activity.
- Phenytoin was continued and eventually tapered down per
neurology recommendations.
- A lumbar puncture was completed to ensure patient did not have
an infection or any other abnormalities, which was within normal
limits.
- Patient's mental status continued to improve, at time of
discharge he was following commands and moving all extremities.
It was felt his mental status was altered after his hip repair
and during his stay due to delerium from his prolonged stay and
infections.
- Patient will receive Phenytoin 100 mg daily for 3 more days,
then can be stopped per neurology recommendations
.
# Fever: Patient had fevers during his stay, for which extensive
work up for sources was undertaken.
- He completed a course of treatment with vancomycin and
aztreonam for MRSA pneumonia, and is currently being treated
with linezolid again for MRSA pneumonia.
- [**2-20**] Blood Cx from [**12-27**] grew Coag Negative Staph, repeat Blood
Cx were negative.
- His hip hematoma was also felt likely contributing to his
fevers. A sample taken from that revealed coag negative Staph.
As a result, his replaced right hip was aspirated to assess for
any infection--results from this aspiration were not consistent
with infection, and cultures demonstrated no growth.
- Patient had numerous urine cultures, which only demonstrated
yeast, for which his folely catheter was changed.
- Patient had percutaneous gall bladder drainage, and was
treated with antibiotics for cholecystitis, covered initially by
flagyl and levofloxacin. Repeat cultures did not demonstrate any
growth.
- PICC line was removed [**12-30**], after concern of line infection,
need to f/u line cultures.
- Tylenol was given as needed.
- Patient remained afebrile for over 48 hours prior to
discharge.
- He should continue linezolid 600 PO bid for 14 days after last
positive culture (last day as of now [**1-10**]).
.
# Abdominal Distension/Acalculous Cholecystitis:
Patient developed abdominal distension and discomfort during his
stay. An abdominal US and CT scan show a distended gallbladder
with wall thickening and pericholecystitc fluid. Surgery was
consulted, and a percutaneous drain was placed via
interventional radiology, to help manage his presumed
cholecystitis. He completed empiric treatment with Levofloxacin
and Flagyl and Vancomycin.
- The drain should remain in place for 6 weeks time, and the
patient should follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the department
of surgery at ([**Telephone/Fax (1) 22750**] to have the drain evaluated and
removed.
.
# Anemia: Patient was noted to have anemia during his hospital
stay, which was thought at one point to be secondary to an
expanding hematoma at the site of his hip surgery. He was also
noted to have a retroperitoneal bleed. Both the hematoma and
retroperitoneal bleed remained stable after their initial
discovery, and the patient's hematocrit remained stable around
25. He received several packed red blood cell transfusions
during his stay. It was also felt that he likely had anemia of
chronic disease.
.
# Right hip replacement with subsequent hematoma:
Patient underwent right hip replacement at outside hospital, and
was followed by orthopaedics during his stay at [**Hospital1 18**]. He was
noted to have an expanding hematoma at the site of his right hip
replacement, which remained stable for the majority of his stay
and prior to discharge it appeared to be resolving. Surgery and
IR attempted bedside and ultrasound guided evaccuation of the
hematoma, however this could not be completed. Cultures from the
hip hematoma demonstrated rare growth of gram positive cocci,
which may have been a contaminate, or could represent a true
infection, and he was continued on vancomycin for possible
infected hematoma. In light of possible infected hematoma,
patient underwent IR guided aspiration of right hip joint, which
did not reveal any organisms on gram stain, and rare coag neg
staph on culture, so it was not felt that his hip was infected.
Due to risk of possibly causing infection in his newly replaced
hip joint, it was decided by orthopaedics that any debridement
or cleaning out of the hematoma was not desired.
- Orthopedics removed hip staples on [**12-30**]
- f/u with outside hospital orthopedic surgeon
- Cont. Heparin SC tid for DVT prophylaxis
.
# Respiratory Distress: Patient was intubated initially for
hypoxemia and airway protection for procedure. He was extubated
for several days, but then re-intubated for hypoxia and
respiratory fatigue. He was treated for ventilator associated
pneumonia twice, and he was diuresed as much as possible.
Several weaning attempts were made, however the patient failed
multiple spontaneous breathing trials. Attempts were made to
maximize the patient's respiratory status, however he did not
appear to tolerate weaning from the ventilator. After discussion
with the family and patient, decision was made to have
trachestomy and PEG placed, which were completed on [**2121-12-24**].
Prior to discharge he was tolerating his tracheostomy well
without any ventilator support. He was maintained on trach mask
with FiO2 of 35%.
- The speech pathology team evaluated patient for assistance
with PMV, and PMV valve was given
- Patient is tachypneic at baseline, with respiratory rate of
20s-40s, with stable oxygenation and arterial blood gas results.
He frequently attempts to clear his throat.
- Albuterol and ipratropium nebulizer treatments were continued.
- Patient responds to Lasix 20-40 mg IV to help decrease fluid
in his lungs and to improve his respiratory status.
.
# Triscuspid regurgitation: Patient has JVP noted to earlobe. A
transthoracic echo completed demonstrated right atrial and right
ventriclar dilatation, along with moderate to severe [3+]
tricuspid regurgitaiton, and pulmonary hypertension. No further
interventions were made during this stay.
.
# Hypotension / Hypertension: Patient was initially hypotensive
on transfer, which was felt to be likely multifactorial,
specifically from medication effects, such as anesthesia and
anti-epilpetics including: dilantin, ativan, valproic acid, and
propofol on intubation and transfer. Throughout his stay he had
labile blood pressure, which finally stabalized. Blood pressure
medications were slowly re-introduced.
- Currently on Lisinopril 20 daily, can titrate up as SBP allows
.
# Atrial fibrillation: Patient remained in atrial fibrillation
during his stay. Patient was previously anticoagulated on
Coumadin, however this was discontinued in light of his hip
hematoma and retroperitoneal bleed. His rate was controlled with
diltiazem and digoxin, which was initiated and levels were
followed. A beta blocker may be added if his rate control is not
adequate. His heart rate remained mainly in the low 100s, which
was hemodynamically stable and tolerable for him.
- Patient will need to be re-evaluated for initiation of
anticoagulation after his hip hematoma and RP bleed resolve.
Can be restarted on Lovenox with bridge to Coumadin at [**Hospital1 1501**] with
close watch on Hct and clinical status.
- Currently on diltizem 90 mg PO q6 hour and digoxin 0.25 mg
daily.
.
# Agitation: Patient was noted to have agitation at times,
especially at night. This improved during his stay, and was felt
to be multifactorial in nature, specifically related to stress
of acute illness and ICU setting.
- He was started on Zyprexa 2.5 mg [**Hospital1 **], which he tolerated well.
He may also benefit from seroquel at night if needed to help
re-establish his circadian rhythm.
- He was started on ropinirole 0.25 mg daily for restless leg
syndrome.
.
# CAD: s/p 1V CABG and mitral valve repair (not replacement).
- LVEF 50-55%,  On some views the inferior and infero-lateral
walls appear hypokinetic.
- Patient was diuresed during his stay with lasix as needed.
- Patient may benefit from re-starting his aspirin in future
after hematoma resolves and hematocrit stable, after discussion
with cardiology.
.
# Chronic Diastolic Heart Failure
.
# Abnormal Chest CT findings:
CTA completed on [**2121-12-11**] demonstrated several scattered
mediastinal lymph nodes with the largest measuring 15 x 13 mm in
a precarinal location.
-  Ill defined pulmonary nodules along with enlarged mediastinal
lymph node
are likely infectious or inflamatory and a followup Chest CT in
3 months would
be useful to assess resolution/change. This will need to be
re-assessed as an outpatient.
.
# Hyperglycemia: Patient was kept on NPH along with sliding
scale of insulin. He was on NPH 8 units [**Hospital1 **] at time of discharge
with adequate control of his blood sugars.
- He followed a diabetic diet.
.
# Urinary retention: Patient had urinary retention and had
failed voiding trials. His foley was changed prior to discharge.
He may benefit from repeat voiding trial as an outpatient, and
follow up with urology if this fails.
.
# FEN:
- Nutrition assisted with patient's tube feedings, and at time
of discharge he was on:
Probalance Full strength;
Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 70
ml/hr
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 50 ml water q8h
- Speech and Swallow evaluated for PMV valve fitting, and gave a
PMV valve
- Protonix PO


Medications on Admission:
HOME MEDICATIONS:
Digoxin 0.25mg po qday
Norvasc 5mg po Qday
citalopram 40mg po qday
Lasix 40mg po qday
Lisinopril 20mg po BID
Coumadin 5mg po qday
detrol 4mg po qday
actonel 35mg po qday
lorazepam prn 0.5mg
Oxipam for sleep
Multivitamin
Iron
.
MEDICATIONS ON TRANSFER:
Dilantin 100mg IV TI
Lovenox 70mg SQ q12h
Protonix 40mg IV daily
Digoxin 0.25mg IV slow push daily
Ativan 0,5mg IV q2hours prn

Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day): Hold for diarrhea.
2. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for fever, pain.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation: Hold for diarrhea.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Phenytoin 100 mg/4 mL Suspension Sig: One Hundred (100) mg
PO Q24H (every 24 hours) for 3 days: 3 more days, then can
titrate off per neurology recs.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U
Injection TID (3 times a day).
12. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
13. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Puff Inhalation QID (4 times a day) as needed for shortness of
breath or wheezing.
15. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
16. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
18. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 11 days: Day 1 was [**12-26**], treat for 14 days after
last positive culture.
19. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4
hours) as needed for agitation.
20. Morphine 10 mg/mL Solution Sig: 2-5 mg Intravenous Q2H
(every 2 hours) as needed for pain.
21. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Eight
(8) U Subcutaneous twice a day.
22. Medication
Regular Insulin Sliding Scale


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]

Discharge Diagnosis:
PRIMARY:
Seizures/Mental Status Changes
MRSA Ventilator Associated Pneumonia
Respiratory Distress
s/p R Hip Replacement
R Hip Hematoma
RP Hematoma
Acalculous Cholecystitis
Abdominal Distension
.
SECONDARY:
Anemia
Thrombocytosis
Tricuspid Regurgitation
CAD
Atrial Fibrillation
DM
Hypernatremia
Hypertension
Chronic Diastolic Heart Failure


Discharge Condition:
Stable, afebrile, VSS, able to talk with PMV


Discharge Instructions:
1. If you develop fever >101.5, cough, shortness of breath,
abdominal pain, jaundice, increased swelling around R hip
hematoma site, or any other symptoms that concern you, call your
PCP or return to the ED.
2. Take all of your medications as prescribed.
3. Attend all follow up appointments.
4. The surgical staples from your hip surgery were removed on
[**12-30**].
5. The biliary drainage tube needs to remain in place for 6
weeks per IR recommendations.
6. You will need to stay on Linezolid for a 14 day course from
the last positive culture (which will be at least until [**1-10**]).
7. Your Foley catheter was most recently changed on [**12-30**].
8. Your arterial line and PICC line were removed on [**12-30**],
follow up the cultures from the PICC line.
9. You will receive 3 more doses of Phenytoin daily, then it can
be stopped per neurology recs.
10. Anticoagulation (Coumadin) was held during hospitalization
for the R hip hematoma and RP bleed.  At rehab, Lovenox should
be restarted as a bridge to Coumadin per ortho recommendations,
with a close watch on Hct and coags.
11.  You received occasional Lasix 20-40 mg IV x1 doses to help
with volume overload and your respiratory status.  The physician
at the rehab facility can determine if more Lasix is needed.

Followup Instructions:
The cholecystostomy tube should remain in place for 6 weeks
time, and you should follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the
department of surgery at ([**Telephone/Fax (1) 22750**] to have the drain
evaluated and removed.
.
You will need to follow up with the outpatient surgeons who did
your hip replacement.
.
Follow up with your primary care physician [**Last Name (NamePattern4) **] [**2-18**] weeks.
{'Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Hematoma complicating a procedure,Acute cholecystitis,Chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Other convulsions,Other and unspecified complications of medical care, not elsewhere classified,Infection with microorganisms resistant to penicillins,Anemia, unspecified,Diseases of tricuspid valve,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}


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: Seizures s/p R hip replacement

PRESENT ILLNESS: 86 y/o man with CAD, MVR, admitted from OSH with continuous
seizure-like activity following hip fracture repair.
.
Had repair of hip fracture @ OSH and post op was noted to have
several tonic-clonic like movements.  They are described in an
unsedated neurologist exam as "intermittent spells with hooting
or grunting associated with eyes driven to the left, and a
flexion jerk to the left. There is no sustained motor activity.
He has diminished responsivity...come out a few seconds later,
answer [**2-18**] questions but not reliably, and go back and do it
again"
.
He was loaded with dilantin, phosphenytoin, and transfered to
the ICU. 0.5mg IV lorazepam dropped his blood pressure to high
80s  systolic and did not relieve the abnormal motor activity.
.
Post-op labs prior to transfer @ OSH also notable for anemia and
mild acute renal failure.

MEDICAL HISTORY: CAD - s/p CABG unclear dates
MVR - unclear dates
CHF - no documented baseline cardiac function
h/o Afib with cardioversion
MGUS
h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] bare in reaction to Influenza Vaccine
Prostate CA s/p XRT c/b hematuria
Hematuria - s/p multiple cystoscopies, felt to be radiation
related
Cataract repair
hernia repair x 3

MEDICATION ON ADMISSION: HOME MEDICATIONS:
Digoxin 0.25mg po qday
Norvasc 5mg po Qday
citalopram 40mg po qday
Lasix 40mg po qday
Lisinopril 20mg po BID
Coumadin 5mg po qday
detrol 4mg po qday
actonel 35mg po qday
lorazepam prn 0.5mg
Oxipam for sleep
Multivitamin
Iron
.
MEDICATIONS ON TRANSFER:
Dilantin 100mg IV TI
Lovenox 70mg SQ q12h
Protonix 40mg IV daily
Digoxin 0.25mg IV slow push daily
Ativan 0,5mg IV q2hours prn

ALLERGIES: Influenza Virus Vaccine / Sulfa (Sulfonamides) / Iodine /
Penicillins / Toprol Xl / Clopidogrel / Succinylcholine

PHYSICAL EXAM: 99.6   69   102/47   100% AC 50%fiO2 600/10 5 PEEP
GEN: non responsive, lying in bed
HEENT: prominent V wave noted in jugular venous pulse
CV: irregular rhythym, s1, s2, dialstolic rumble heard @ apex,
no promiment MR murmur noted
RESP: CTA anteriorly
ABD: distended, soft, decreased bowel sounds
EXT: decreased pulses, no edema
NEURO: PERRL - constricted but equal and reactive, corneal
reflexes present. Does not open eyes to command, does not move
extremities. Does not withdraw to noxious stimuli.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Patient is retired, lives in [**Location **], family is aware of
transfer per notes 

### Response:
{'Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Hematoma complicating a procedure,Acute cholecystitis,Chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Other convulsions,Other and unspecified complications of medical care, not elsewhere classified,Infection with microorganisms resistant to penicillins,Anemia, unspecified,Diseases of tricuspid valve,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}
