CHIEF COMPLAINT: S/p Fall

PRESENT ILLNESS: 82f who is quite active at home and lives with her sister.
Tonight she was taking care of the garbage when she felt
somewhat
dizzy and fell, striking her head. This was witnessed by her
sister. She did not have LOC and was awake and answering
questions when EMS arrived. She was taken to OSH where CT showed
R SDH and R temporal hemorrhagic contusion. At the OSH she
became
more lethargic and was intubated as a result. She was
transferred
to [**Hospital1 18**] for further evaluation. Her sister states she is on ASA
81mg daily but not on plavix or coumadin.

MEDICAL HISTORY: Hypertension
Hyperthyroidism
asthma
bronchiectasia
Chronic MAC- that was treated with multiple agents in [**2117**]-[**2118**].
She is folled by pulm

MEDICATION ON ADMISSION: propranolol
HCTZ
PTU
ASA 81mg
Steroids (uncertain about dose up to 2-3 weeks ago)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAM:
 BP: 198/101  HR: 69   R   16    O2Sats 100
HEENT: Pupils: 2mm and reactive, unable to assess visual fields.

FAMILY HISTORY: . Per records, no history of stroke.

SOCIAL HISTORY: lived with sister at home and did all ADLs. As per sister she
was very independent, she was driving and doing choirs around
the house. Per records there is no significant history of EtOh,
tobacco, or other drug use
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Cerebral edema,Chronic diastolic heart failure,Urinary tract infection, site not specified,Body Mass Index less than 19, adult,Pulmonary diseases due to other mycobacteria,Closed fracture of one rib,Unspecified protein-calorie malnutrition,Delirium due to conditions classified elsewhere,Cachexia,Closed fracture of acromial end of clavicle,Atrial fibrillation,Unspecified essential hypertension,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Asthma, unspecified type, unspecified,Bronchiectasis without acute exacerbation,Hypotension, unspecified,Dysphagia, unspecified,Anemia of other chronic disease,Leukocytosis, unspecified,Retention of urine, unspecified,Other chronic pulmonary heart diseases,Accidental fall on or from other stairs or steps
Brain lacer NEC w/o coma,Cerebral edema,Chr diastolic hrt fail,Urin tract infection NOS,BMI less than 19,adult,Pulmonary mycobacteria,Fracture one rib-closed,Protein-cal malnutr NOS,Delirium d/t other cond,Cachexia,Fx clavicl, acrom end-cl,Atrial fibrillation,Hypertension NOS,Thyrotox NOS no crisis,Asthma NOS,Bronchiectas w/o ac exac,Hypotension NOS,Dysphagia NOS,Anemia-other chronic dis,Leukocytosis NOS,Retention urine NOS,Chr pulmon heart dis NEC,Fall on stair/step NEC
Admission Date:  [**2121-12-24**]              Discharge Date:   [**2122-1-2**]

Date of Birth:  [**2039-7-24**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
S/p Fall

Major Surgical or Invasive Procedure:
Peg tube placement on [**2122-1-1**]


History of Present Illness:
82f who is quite active at home and lives with her sister.
Tonight she was taking care of the garbage when she felt
somewhat
dizzy and fell, striking her head. This was witnessed by her
sister. She did not have LOC and was awake and answering
questions when EMS arrived. She was taken to OSH where CT showed
R SDH and R temporal hemorrhagic contusion. At the OSH she
became
more lethargic and was intubated as a result. She was
transferred
to [**Hospital1 18**] for further evaluation. Her sister states she is on ASA
81mg daily but not on plavix or coumadin.

Past Medical History:
Hypertension
Hyperthyroidism
asthma
bronchiectasia
Chronic MAC- that was treated with multiple agents in [**2117**]-[**2118**].
She is folled by pulm

Social History:
lived with sister at home and did all ADLs. As per sister she
was very independent, she was driving and doing choirs around
the house. Per records there is no significant history of EtOh,
tobacco, or other drug use

Family History:
. Per records, no history of stroke.

Physical Exam:
PHYSICAL EXAM:
 BP: 198/101  HR: 69   R   16    O2Sats 100
HEENT: Pupils: 2mm and reactive, unable to assess visual fields.

Neck: Supple. C Collar in place.
Extrem: Warm and well-perfused.

Neuro:
Intubated. Gag reflex present. Face appears symetric. Not
following commands. No movement in upper extremities to noxious
stimuli but will grimmace to pain. Withdraws both lower
extremities briskly to noxious.

PE ON TRANSFER TO MEDICINE ON [**2121-12-27**]
VS: HR 80s-90s (in and out of a-fib on tele), 151/84, RR 25, sat
95% on RA
Gen: thin female, sleeping comfortably in bed, arousable to
voice. Following commands and answering questions
HEENT: Pupil on the right is mildly dilated compare to the left,
reactive to light. Intact EOM, Bruising over eyes, anisocoric
Neck: no JVD, no LAD
CV: irregular rhythm, tachycardic, hyperdynamic
Resp: LCTA bil ant, sl diminished at bases with bronchial breath
sounds, no crackles.
GI: soft NTND no HSM, +BS
Ext: no c/c/eNeuro: sleeping but easily arousable, Oriented x
place and person. Responding to calling her name. She was able
to answer simpled questions and is following simple commands.
Moving all 4 extremities.

DISCHARGE PE:
VS: 97.7, (tmax 98.2), 75 (NSR on tele), BP 155/81, 18, 97% on
RA
Gen: thin female, A+ Ox person and place and at times to time in
NAD
HEENT: Pupil on the right 2-3mm minimally reactive compare to L
(unchanged since admission). Intact EOM, Bruising over eyes
resolving
Neck: no JVD, no LAD
CV: RRR, hyperdynamic, no murmurs, normal S1-S2
Resp: LCTA bil, sl diminished at bases with bronchial breath
sounds, no crackles/W/R
GI: soft, NT/ND, no HSM, +BS (small BM today)
Ext: CNII-XII intact except for different pupil size (R>L) and
dysphagia.   Oriented x place and person and time at times.
Decrease in short term memory.  She answers questions
appropriately. Symmetrical strength bil [**4-21**] bil UE and [**4-21**] on
Bil LE.  OOB w/ assist
Skin: Inc on left upper scalp with staples that is C/D/I (needs
to be removed on [**1-4**])


Pertinent Results:
ADMISSION LABS:

[**2121-12-24**] 01:05AM   PT-12.6 PTT-24.2 INR(PT)-1.1
[**2121-12-24**] 01:05AM   WBC-13.9* RBC-3.73* HGB-11.1* HCT-31.5*
MCV-84 MCH-29.7 MCHC-35.1* RDW-13.3
[**2121-12-24**] 01:05AM   GLUCOSE-123* UREA N-21* CREAT-0.9 SODIUM-139
POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-28 ANION GAP-15

DISCHARGE LABS:
Hematology
COMPLETE BLOOD COUNT WBC RBC   Hgb   Hct   MCV MCH  MCHC RDW
Plt Ct
[**2122-1-2**] 06:25    7.4  3.60* 10.6* 30.5* 85  29.5 34.8 14.1
227
[**2122-1-1**] 11:20    5.8  3.61* 10.7* 31.9* 88  29.7 33.7 13.9
266

Chemistry
RENAL & GLUCOSE Glucose  UreaN Creat Na   K   Cl  HCO3 AnGap
[**2122-1-2**] 06:25    91.1  15    0.4  138 3.9 106  24   12
[**2122-1-1**] 11:10    100.1 19    0.5  139 4.2 108  25   10


ENZYMES & BILIRUBIN ALT  AST   LD(LDH) CK(CPK) AlkPhos Amylase
TotBili [**2122-1-1**] 11:10    57*  68*                    71
        0.3

CHEMISTRY TotProt Albumin Globuln  Calcium  Phos    Mg
[**2122-1-2**] 06:25                    8.0*    3.7    1.7
[**2122-1-1**] 11:10      3.1*          8.2*    2.6*   1.9

PITUITARY TSH
[**2121-12-27**] 18:41    0.73

  NEUROPSYCHIATRIC  Phenyto
[**2122-1-2**] 06:25     11.4
[**2121-12-30**] 07:30     11.0

MICRO:
[**2121-12-27**] 6:35 am URINE      Source: Catheter.

                            **FINAL REPORT [**2121-12-31**]**

   URINE CULTURE (Final [**2121-12-31**]):
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.
         Piperacillin/tazobactam sensitivity testing available
on request.
      PRESUMPTIVE STREPTOCOCCUS BOVIS.    >100,000
ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------     8 S
AMPICILLIN/SULBACTAM--     4 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

IMAGING:

ECHO ON [**2121-12-24**]:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no systolic
anterior motion of the mitral valve leaflets. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.

Head CT [**12-24**]:
1. A moderate-sized right temporal intraparenchymal hemorrhage,
slightly more organized and mildly larger than the prior study
two hours ago.
2. Right-sided subdural hematoma tracking along the hemispheric
convexity and tentorium.
3. A 4 mm leftward midline shift.
4. Left frontoparietal subgaleal hematoma.
5. Questionable trace intraventricular hemorrhagic extension. No

hydrocephalus.

FINDINGS:
Redemonstrated centered within the right temporal lobe, there is
an area of intraparenchymal hemorrhage that is now slightly
decreased in size measuring 3.9 x 1.9 cm, where on similar
measurements on the most recent prior examination it measured
4.6 x 2.2 cm. Surrounding adjacent edema is similar as compared
to the prior examination. There is a subdural component of
hemorrhage seen immediately adjacent to the right cerebral
convexity and along the right tentorium, that overall, appears
similar in extent since the prior examination. There is a tiny
amount of likely subarachnoid hemorrhage (series 2A: image 21
and series 2A:19) that is also similar in extent since the prior
examination. Layering intraventricular hemorrhage seen within
the occipital horns appears to be slightly improved since the
prior examination. Hemorrhage seen extending to involve the
fourth ventricle on the prior examination, is less conspicuous
on today's examination. The ventricular system, however,
demonstrates interval enlargement since the prior examination,
now the lateral ventricles measuring up to 10 mm where
previously measured up to 7 mm and where the third ventricle
measures 7 mm where previously it measured 6 mm.

There is stable minimal leftward shift of normally midline
structures by
approximately 4 mm. There is some degree of edema in the right
cerebral
hemispshere as before with decreased conspicuity of the CSF
spaces. There has been no interval development of transtentorial
or uncal herniation. There are no new areas of hemorrhage.
Surgical staples are redemonstrated over the left frontoparietal
convexity. The visualized portions of the paranasal sinuses are
stable demonstrating mild mucosal thickening of the ethmoid air
cells and the sphenoid sinuses with the remainder being well
aerated. The mastoid air cells are well aerated.

IMPRESSION:
1. Mild increase in ventricular system size since prior
examination. Close
interval follow-up is recommended.
2. Slight interval decrease in known multicompartmental
hemorrhage with the largest focus, an area of right temporal
intraparenchymal hemorrhage. A few hypodense areas within may
relate to evolution/ less liekly more acute component if there
is h/o anemia/coagulopathy- follow up closely.  Some degree of
edema of the right cerebral hemisphere.
3. Slight interval decrease in known intraventricular
hemorrhage.


Brief Hospital Course:
ICU Course:
82 year-old female with HTN, asthma, bronchiectasia,
hyperthyroidism who was admitted to the neurosurgery service on
[**12-24**] with a subdural hematoma after feeling dizzy then falling
while climbing the stairs (witnessed by her sister).  She was
taken to OSH where CT showed R SDH and R temporal hemorrhagic
contusion. At the OSH she became more lethargic and was
intubated as a result. She was transferred to
[**Hospital1 18**] for further evaluation. The patient was admitted to the
TSICU for Q1 neuro checks.  She was loaded with dilantin, and
transfused with platelets for her history of ASA use.  She
remained intubated.  Her repeat Head CT in the morning showed a
slight worsening of her IPH.  Her exam also slightly worsened,
as she no longer followed commands or moved her LE with
commands.  Neurology was consulted, and ordered a Stat CTA
Head/Neck. Neurology recommended that 3% saline be started and
to continue with dilantin.  On [**12-25**] She was extubated. She did
well from a respiratory standpoint but her mental status
remained poor. She was transferred to the step down unit on
[**12-26**]. Overnight she was noted on telemetry to be in atrial fib
with a rate in the 120s which spontaneously resolved. Then, on
AM rounds, her HR was as high as 160 and the patient's SBP was
67. She was bolused 250cc and her SBP increased into the 90s but
her HR remained 120-140. Per nursing, her mental status has not
changed during this time. She denies chest pain, shortness of
breath or dizziness. As per her sister she had no prior history
of [**Name (NI) 17584**] or heart problems that she knows of.
.
Of note, the patient had a CT chest which was read as
'Multifocal calcified and noncalcified nodules with associated
fibrosis,  bronchiectasis, and patchy opacification most
consistent with chronic  mycobacterium avium-intracellulare
infection. Patient is thin, but unable to say (due to confusion)
whether she has had recent cough, sputum production, fever,
nightsweats. As per her sister, she had lung problems with
increase in secreation for the last 3-4 years. She sees a
pulmonologist, Dr. [**Last Name (STitle) 88352**] in [**Hospital6 **] who follows
her. She had recent CT of chest prior to her hospilalization and
had PFTs she was scheduled to f/u with pulm this week. She often
has increase in secreations which is attributed to
bronchiectasis. She was on steroids which were stopped 2-3 weeks
ago, she is uncertain why. Her sister also states that she has a
chronic infection of her lungs.
.
Hospital course on medicine service:
..
#. Atrial Fibrillation with RVR: She has now converted back to
sinus with HR in 70s on Metoprolol 25mg TID. She does not have
prior hx of A-fib and this is likely new onset. She had episode
of Afib with RVR with rates 120s-160s leading to hypotension
that responded to fluids. She also had ST depressions that
normalized with rate control. Her CE were elevated and have
trended down, indicating demand ischemia. She was started on
metoprolol 12.5mg TID and then increased to 25mg TID with
improvement of her HR. Patient has multiple reasons to have
afib; she is predisposed with longstanding hypertension, she is
acutely ill and has a head injury, she also had a high WBC count
and positive U/A and she had electrolyte abnormalities. As well
she is known to have hyperthyroidism and is on PTU. ECHO done on
[**12-24**] showed no structural heart disease and no focal WMA but did
show diastolic dysfunction. Her CHADS score is [**2-19**].  She just
had head bleed so not candidate for anticoagulation at this time
as per neurosurgery. She will be reacess by Dr. [**Last Name (STitle) **] and have
repeat CT in [**Last Name (LF) **], [**First Name3 (LF) **] he will give further recs for ASA or other
types of anticoagulation.
- Cont on Metoprolol tartrate  25mg TID
- d/ced all other anti-hypertensives (HCTZ and hydralazine)
- Repeat lytes and replete as needed
- Currently treating UTI w/ antibiotics
.
# Parenchymal and subdural hematoma: Pt appears to be stable.
Repeat head CT on [**12-27**] showed mild increase in ventricular
size, but sl. decrease in size of bleed. As per neurosurg, she
had repeat head CT that showed overall stable appearance of
multicompartmental hemorrhage without increase in ventricular
caliber. In regards her MS, she is more alert and oriented x 2
(person and place). She remember her home phone # and asked that
I called her sister.  She was also asking appropriate questions.
Decrease in short term memory. She failed her swallow eval x 2
which may be r/t brain injury. Her right pupil size 2-3mm,
minimally reactive (unchanged). Moving all ext in bed. Pt has
been on dilantin and level today was 11 within therapeutic range
(goal >10). So will continue at current dose. She will need to
have weekly levels drawn and results sent to Dr. [**Last Name (STitle) **] as per
D/c instructions. Neuro-surgery will continue to follow and she
has appointment on [**2121-2-3**] with neuro surge and for repeat CT.
- Cont dilantin 100mg TID with weekly levels
- Will need to have continue  PT, OT and re-eval of her
swallowing
- F/u w/ neurosurgery in [**Month (only) **]
- No anticoagulation for now (including ASA) until re-evaluated
by neurosurg in [**Name (NI) **]
- Pt has staples on left side of skull from laceration and
should be removed on Sunday [**1-4**]
.
# UTI: Uculture now showing >100,000 E.coli pan sensitive. She
had increase in WBC from 11.8->16.7 on [**12-27**], pt was hypothermic
on that AM with temp of 95F. No fevers, noted. WBC now WNL. Pt
had previously Negative UA on admission and she had a foley
placed during this admssion. Her foley was removed on [**12-28**] but
she failed voiding trial and had foley replaced on [**12-29**]. She
was started on ceftriaxone 1gm Q24hours on [**12-27**] and then
switched to cipro once sensitivities were available (today is
day 6 of antibiotics), she will only need two more doses of
antibiotics. Treating for total of 7 days, as complicated UTI
given that pt has foley. Plan is to D/c foley next week on Wed
[**1-8**] given that she fail voiding trial twice and once more
alert and mobile.
- D/ced Ceftriaxone 1 gm Q24hours  and chanded to cipro toatl of
7 days ( currently on day 6)
- D/c foley on [**1-8**] if patient fails trial. Replace foley and
follow-up with MD
- If febrile or has any signs of infection repeat UA
.
# CT Lung findings: Ms. [**Known lastname 88353**] has history of MAC with
bronchiectasis. She does have hx of asthama, but no COPD. She
was diagnosed in [**2117**] and at the time she had wt loss and
hemoptsis. She was treated with multi-agents with  azithromycin,
rifabutin, and ethambutol from [**2117**]-[**2118**]. Her current symptom is
increase in mucous secreation and has recurrent sinusitis and
she was recommended to have NS rinses and to use flonase. She
also had recent PFTs that showed severe restrictive disease. She
has increase amounts of mucous on the back of her throat at
times. Breathing without difficulty, sats in mid 90s%.
- Humidified O2 to help with secreations since pt is NPO
- Will start on flonase as recommended
- Mouth care Q4hours
- She will need close f/u with pulmonologist as outpatient
.
# L Clavicular fx: This is due to fall. Pt was found to have a
distal clavicular fracture, with the distal fragment slightly
superiorly displaced w/ intact AC joint. She also has a 1st rib
fx seen on CT. Pt has area of ecchymosis on L shoulder and has
no limitation of movement. She states that shoulder hurts, seems
to be more aware of shoulder pain.
- Place sling while she is out of bed for comfort
- Started on oxycodone 2.5mg for severe pain
- tylenol to Q 6hours PRN (LFTs sl. elevated, so would cont to
monitor and limit tylenol to <4Gm per 24hours)
- Cont to monitor LUE for perfusion
.
# HYPOTENSION: Now normotensive. She has hx of hypertension and
was on propanolol and HCTZ as outpatient. She had one episode on
[**12-27**] w/ SBP in 60s on the setting of A-fib with RVR and
receiving HCTZ and possibly due hypovolemia given that she
quickly responded to fluids. She also had recent ECHO w/ dCHF
and may be more preloaded depended. Her HCTZ was d/ced and she
was started on metoprolol for her HR control.
- D/ced HCTZ and propanolol for now
- Cont on Metoprolol as BP tolerates

# Hyperthyroidism: Pt has been on PTU 50mg Qday (held for the
last  day since NPO and pnd PEG tube placement). Her TSH is WNL
at 0.73. Will cont PTU at 50mg Qday once PEG is placed.
.
#Dysphagia: As per sister, pt had difficulty swallowing prior to
the accident and had to have small bites and take solids with
liquids to help with swallowing. She has dobhoff tube in place
with tube feeds as recommended by nutrition, due to decrease in
gag reflex. Speech and swallow eval x 2 and failed. she had no
gag reflex and is at high risk for aspiration. She had PEG tube
placed on [**1-1**] and can be used after 3PM on [**1-2**]. Tube feed
recs for per d/c orders an instructions with Fibrosource HN [**Doctor First Name **]
40cc/hr. Uncertain if this will be temporary measure given pt's
brain injury. She will need to continue to be re-evaluated by
speech and swallow in the hopes that her swallow will improve.
.
# Anemia: pt has hx of anemia likely due to chronic disease. Her
Hct has been stable on the low 30s.
-Cont to monitor HCT
.
#Transaminitis: Pt has sl increase in LFTs uncertain what is her
baseline (ALT 57/AST 68) with normal alk phos and tbili.
Possibly due to meds. She denies having any abd pain.
- Changed tylenol from standing to PRN
- Would repeat LFTs in [**2-19**] days
.
# Prophylaxis:  DVT: boots, stool softners
.
Communication:  Patient and sister ([**Doctor First Name **]) home [**Telephone/Fax (1) 88354**]
Cell phone: [**Telephone/Fax (1) 88355**]
.
#Code status: Full Code confirmed with sister who is HCP


Medications on Admission:
propranolol
HCTZ
PTU
ASA 81mg
Steroids (uncertain about dose up to 2-3 weeks ago)

Discharge Medications:
1. propylthiouracil 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. calcium carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension Sig:
Five Hundred (500) mg PO TID (3 times a day).
4. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
5. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO HS (at
bedtime).
6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
7. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6HRS: PRN as needed for pain.
8. famotidine 40 mg/5 mL Suspension Sig: Twenty (20) mg PO once
a day.
9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 doses: Last day on [**2122-1-3**]. Tablet(s)
10. phenytoin 100 mg/4 mL Suspension Sig: One Hundred (100) mg
PO every eight (8) hours: Please check dilantin level once per
week.
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours: Please hold for SBP<100 and HR <60.
12. oxycodone 5 mg/5 mL Solution Sig: 2.5 mg PO every 4-6 hours
as needed for pain: Please hold for sedation and RR<12.
13. insulin regular human 100 unit/mL Solution Sig: One (1)
injection  Injection ASDIR (AS DIRECTED): Please follow current
SS and check FSG while pt is on tube feeds.
14. Fibersource HN     Liquid Sig: Forty (40) cc/hr PO
continuous: Goal tube feeds at 40cc/hour. Please checkk for
residual Q 4hours and hold for >200cc residual. Water flushes
150cc Q 4 hours .
15. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol: glucose <60.
16. dextrose 50% in water (D50W)     Syringe Sig: One (1) amp
Intravenous PRN (as needed) as needed for hypoglycemia protocol:
for glucose <60 or as per hypoglycemia protocol.
17. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
18. Humidified O2
PRN: As needed for increase secretions while NPO
19. Mouth care
Q 4 hours while NPO with OP suction as needed
20. Right arm sling
Please place right arm sling while OOB for comfort


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
PRIMARY:
Right Subdural Hematoma
Temporal Contusion
A-fib with RVR
dysphagia
Urinary retention
UTI


Discharge Condition:
Mental Status: Confused - sometimes (oriented x person/place and
occ x time)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Ms. [**Known lastname 88353**],

Thank you for allowing us to participate in your care. You were
admitted to the hospital after you had a fall at home and hit
your head. You were found to have a head bleed and you were
closely observed. You have been doing well, but had trouble
swallowing. So you had a tube placed on your stomach for
feeding. You were also found to have an urinary tract infection
for which you are being treated for. We have also attempted to
remove your foley cathter twice and you were unable to void in
your own. So this will need to be removed once you get to
rehabilitation facility. You have also developed an abnormal
heart rythm called atrial fibrilation and you will need to take
medication for this.

We have made the following changes to your medications:
- Started on metoprolol 25mg via NG tube or orally once
tolerating three times per day
- STOP ASPIRIN until this is further discuss with Dr. [**Last Name (STitle) **]
neurologist
- Stop propanolol, hydrochlorothiazide
- Started on Dilantin 100mg three times per day
- Started on Cipro 500mg twice daily (last day today [**2122-1-3**])

This are the neurosurgery recs:
# Exercise should be limited to walking; no lifting, straining,
or excessive bending.
# Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
# You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week.  This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion, lethargy 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.
??????	New onset of the loss of function, or decrease of function on
one whole side of your body.


Followup Instructions:
# You have an appointment with Dr. [**Last Name (STitle) **], neurosurgeon, on [**2-3**] th. [**2122-2-3**]  09:00a
LM [**Hospital Unit Name **], [**Location (un) **]
NEUROSURGERY WEST

#You will also need to have to have a repeat Cat-scan of your
head on the same day at.
[**2122-2-3**]  08:15a   XCT [**Apartment Address(1) 9394**] [**Hospital Ward Name **]
CC CLINICAL CENTER, [**Location (un) **]
RADIOLOGY
.
# Please call your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 88356**],  as
soon as you leave the Rehabilitation facility and schedule an
appointment soon after discharge. He will need to help manage
your new diagnose of atrial fibrilation.
[**Telephone/Fax (1) 88357**]
.
# You will need to have blood work checked and you will need to
have the dilatin levels checked at least once per week and have
result faxed to Dr. [**Last Name (STitle) **] at faxed to [**Telephone/Fax (1) 87**].

# PULMONOLOGIST: It is also very important that you continue to
follow with your pulmonologist for management of your chronic
lung infection. Please call Dr. [**Last Name (STitle) 88352**] in [**Hospital3 **] after
your rehabiliation discharge or within 1 month.
Office Address
[**Hospital3 58713**]
[**Hospital1 8**], [**Numeric Identifier 4293**]
Phone Number: ([**Telephone/Fax (1) 88358**]
Fax Number: ([**Telephone/Fax (1) 88359**]
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Cerebral edema,Chronic diastolic heart failure,Urinary tract infection, site not specified,Body Mass Index less than 19, adult,Pulmonary diseases due to other mycobacteria,Closed fracture of one rib,Unspecified protein-calorie malnutrition,Delirium due to conditions classified elsewhere,Cachexia,Closed fracture of acromial end of clavicle,Atrial fibrillation,Unspecified essential hypertension,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Asthma, unspecified type, unspecified,Bronchiectasis without acute exacerbation,Hypotension, unspecified,Dysphagia, unspecified,Anemia of other chronic disease,Leukocytosis, unspecified,Retention of urine, unspecified,Other chronic pulmonary heart diseases,Accidental fall on or from other stairs or steps'}


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: S/p Fall

PRESENT ILLNESS: 82f who is quite active at home and lives with her sister.
Tonight she was taking care of the garbage when she felt
somewhat
dizzy and fell, striking her head. This was witnessed by her
sister. She did not have LOC and was awake and answering
questions when EMS arrived. She was taken to OSH where CT showed
R SDH and R temporal hemorrhagic contusion. At the OSH she
became
more lethargic and was intubated as a result. She was
transferred
to [**Hospital1 18**] for further evaluation. Her sister states she is on ASA
81mg daily but not on plavix or coumadin.

MEDICAL HISTORY: Hypertension
Hyperthyroidism
asthma
bronchiectasia
Chronic MAC- that was treated with multiple agents in [**2117**]-[**2118**].
She is folled by pulm

MEDICATION ON ADMISSION: propranolol
HCTZ
PTU
ASA 81mg
Steroids (uncertain about dose up to 2-3 weeks ago)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAM:
 BP: 198/101  HR: 69   R   16    O2Sats 100
HEENT: Pupils: 2mm and reactive, unable to assess visual fields.

FAMILY HISTORY: . Per records, no history of stroke.

SOCIAL HISTORY: lived with sister at home and did all ADLs. As per sister she
was very independent, she was driving and doing choirs around
the house. Per records there is no significant history of EtOh,
tobacco, or other drug use 

### Response:
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Cerebral edema,Chronic diastolic heart failure,Urinary tract infection, site not specified,Body Mass Index less than 19, adult,Pulmonary diseases due to other mycobacteria,Closed fracture of one rib,Unspecified protein-calorie malnutrition,Delirium due to conditions classified elsewhere,Cachexia,Closed fracture of acromial end of clavicle,Atrial fibrillation,Unspecified essential hypertension,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Asthma, unspecified type, unspecified,Bronchiectasis without acute exacerbation,Hypotension, unspecified,Dysphagia, unspecified,Anemia of other chronic disease,Leukocytosis, unspecified,Retention of urine, unspecified,Other chronic pulmonary heart diseases,Accidental fall on or from other stairs or steps'}
