CHIEF COMPLAINT: Unresponsiveness

PRESENT ILLNESS: This is a [**Age over 90 **] year old female, who lives alone at home with
complete independence, was found down on the floor and
unresponsive by EMS on [**5-25**]. Per patient's grandson, the last
contact anyone had with her was last week some time.  The
patient was laying in urine with several pressure ulcers, but it
is
unknown how long she had been down.

MEDICAL HISTORY: Depression, Dementia

MEDICATION ON ADMISSION: Unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
O: T:95.4  BP: 118/80    HR:86    R: 20       O2Sats:100%
Gen: Cool to touch, in no acute distress. Skin breakdown to
numerous bony prominences. Snoring respirations.
HEENT:NC/AT Pupils: PEERLS, 2-1.5        EOMs N/A
Extrem: Slightly Cool, and well-perfused.
Neuro:
Mental status: Unresponsive. No commands, non-verbal.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Resides at home alone
Intracerebral hemorrhage,Obstructive hydrocephalus,Hyperosmolality and/or hypernatremia,Depressive disorder, not elsewhere classified,Other persistent mental disorders due to conditions classified elsewhere,Pressure ulcer, lower back
Intracerebral hemorrhage,Obstructiv hydrocephalus,Hyperosmolality,Depressive disorder NEC,Mental disor NEC oth dis,Pressure ulcer, low back
Admission Date:  [**2149-5-25**]              Discharge Date:   [**2149-6-2**]


Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Unresponsiveness

Major Surgical or Invasive Procedure:
[**2149-5-25**]: Emergent placement of External Ventricular Drain.


History of Present Illness:
This is a [**Age over 90 **] year old female, who lives alone at home with
complete independence, was found down on the floor and
unresponsive by EMS on [**5-25**]. Per patient's grandson, the last
contact anyone had with her was last week some time.  The
patient was laying in urine with several pressure ulcers, but it
is
unknown how long she had been down.

Upon arrival to the ED, she opened her eyes to noxious
stimulation only and could not provide any history. She has
pressure ulcers to her coccyx and other bony prominences, but
otherwise no other obvious injuries.

Past Medical History:
Depression, Dementia

Social History:
Resides at home alone

Family History:
non-contributory

Physical Exam:
On Admission:
O: T:95.4  BP: 118/80    HR:86    R: 20       O2Sats:100%
Gen: Cool to touch, in no acute distress. Skin breakdown to
numerous bony prominences. Snoring respirations.
HEENT:NC/AT Pupils: PEERLS, 2-1.5        EOMs N/A
Extrem: Slightly Cool, and well-perfused.
Neuro:
Mental status: Unresponsive. No commands, non-verbal.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1.5
mm bilaterally. Not Tested
III, IV, VI: Not Tested
V, VII: Not Tested
VIII: Not Tested
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Not Tested
XII: Not Tested

Motor: Decreased bulk and tone throughout. No abnormal
movements, tremors. Moves all 4 extremities spontaneously.

Sensation: Unknown

Reflexes: B T Br Pa
Right     1 1 1  2
Left      1 1 1  2

Toes downgoing bilaterally

Exam on Discharge:
Oriented x [**3-12**] depending on time of day. She waxes and wanes.
Pupils are asymmetric in shape but 2 mm and reactive to light
bilaterally.
EOMs intact.
Face symmetric, tongue midline.
No drift.
Strength is 5- in the upper extremities and [**5-12**] in the lower
extremities.
Incisions are clean, dry, and intact.

Pertinent Results:
Labs on Admission:
[**2149-5-25**] 12:00PM BLOOD WBC-12.8* RBC-5.18 Hgb-16.2* Hct-48.3*
MCV-93 MCH-31.3 MCHC-33.6 RDW-13.0 Plt Ct-350
[**2149-5-25**] 12:00PM BLOOD Neuts-81.5* Lymphs-10.4* Monos-6.7
Eos-0.3 Baso-1.0
[**2149-5-25**] 12:00PM BLOOD PT-14.0* PTT-23.4 INR(PT)-1.2*
[**2149-5-25**] 12:00PM BLOOD Glucose-140* UreaN-42* Creat-0.8 Na-138
K-7.2* Cl-102 HCO3-18* AnGap-25*
[**2149-5-25**] 12:00PM BLOOD ALT-56* AST-151* CK(CPK)-3040* AlkPhos-90
TotBili-1.2
[**2149-5-25**] 12:00PM BLOOD Lipase-25
[**2149-5-25**] 12:00PM BLOOD cTropnT-<0.01
[**2149-5-25**] 12:00PM BLOOD Calcium-8.8 Phos-4.4 Mg-2.4
IMAGING:
---------------
HEAD CT [**5-25**]:
Hemorrhage within the periaqueductal [**Doctor Last Name 352**] in the
medial-posterior mid brain extending into the cerebral aqueduct
as well as the dependent portion of the bilateral lateral
ventricles with moderate amount of proximal hydrocephalus and
transependymal flow of CSF.
NOTE ADDED AT ATTENDING REVIEW: It is not clear whether there is

intraparenchymal hemorrhage, or only intraventricular bleeding.
There is
hydrocephalus and transependymal resorption of CSF.

CTA HEAD [**5-25**]:
Normal CTA, no evidence of aneurysm or arteriovenous
malformation. Ventricular decompression status post placement of
a ventricular drain. Small amount of intracranial air compatible
with recent surgery. A preliminary report was issued that read
"status post right transfrontal ventricular drainage catheter
placement with tip in body of right lateral ventricle. Mild
improvement of hydrocephalus. Stable mid brain and
intraventricular hemorrhage. No arteriovenous malformation,
aneurysm greater than 3 mm, or flow-limiting stenosis. Mild
asymmetric narrowing of right M1 atherosclerotic disease. [**Doctor Last Name **]
[**Numeric Identifier 96691**]."

MRI HEAD [**5-26**]:
Stable intraventricular blood products compared to the most
recent prior study without evidence of progressive bleeding.
Ventriculostomy catheter in stable position.

Pelvis X-ray [**5-26**]:
There is a left total hip arthroplasty. There are no signs for
hardware-related complications. Distal portion of the femoral
stem is not
included on the field of view. There are severe degenerative
changes of the right hip with complete loss of joint space,
large osteophytes, and
subchondral sclerosis. No displaced fractures are seen. There
are severe
degenerative change of the lower lumbar spine as well.


Brief Hospital Course:
Patient is a [**Age over 90 **]F admitted to the NSURG service following being
found down at home, unresponsive. Per EMS reports, she was found
in a puddle of urine and with pressure sores. Upon arrival to
[**Hospital1 18**], her mental status was very poor, and head CT obtained.
This was revealing for an aqueductal hemorrhage and significant
hydrocephalus. The patient's grandson was [**Name (NI) 653**] over the
telephone, and verbal consent given to emergently place an
external ventricular drain. This was done in the Emergency
Department. Once the procedure was completed, CT of the head was
again performed to evaluate drain placement. CTA of the head was
also done, and did not show any finite cause of her bleeding.
She was then transferred to the ICU for close monitoring. On
[**5-26**], her examination was with minimal improvement, so
palliative care consult was obtained to discuss goals of care.
After discussion with family, it was decided to give her 72hrs
to see if she improves in the setting of the drain. On [**5-27**], she
was markedly improved, verbalizing, following commands and
requesting to eat. Her EVD continued to be open at 0cm.

She was transferred to the step down unit on [**5-28**]. She was
neurologically unchanged. Dr. [**First Name (STitle) **] had a meeting with her
granddaughter who is her HCP. After several hours of discussion
with regards to the possibility of a third ventriculostomy, the
granddaughter decided that the patient would not want to have
more surgical intervention.  She opted to have the EVD removed
The SQH was discontinued and plan was for the drain to be
removed in the morning of [**5-30**] so as to avoid an ICH from drain
removal while on SQH.

Palliative care visited the patient again on [**5-29**]. There was a
brief meeting with the granddaughter, palliative care and the
neurosurgery team the morning of [**5-30**]. The EVD was then removed.
The patient continued to be oriented and was able to participate
in therapy. She was eating on her own. She was waxing and [**Doctor Last Name 688**]
however in terms of how awake she was. Sometimes she was more
somnolent and required stimulation in order to participate in
the exam. After further discussion with her granddaughter it was
determined that she would go to a skilled nursing facility. She
will then pursue Hospice care at a later date.

Medications on Admission:
Unknown

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. K Phos Di & Mono-Sod Phos Mono 250 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for severe pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 4103**] on the [**Doctor Last Name **]

Discharge Diagnosis:
Aqueductal Hemorrhage
Hydrocephalus

Discharge Condition:
Neurologically stable
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.

Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE
??????	You or a family member should inspect your wound every day and
report any of the following problems to your physician.
??????	Keep your incision clean and dry.
??????	You may wash your hair with a mild shampoo 24 hours after your
[**Doctor Last Name 2729**] are removed.
??????	Do NOT apply any lotions, ointments or other products to your
incision.
??????	DO NOT DRIVE until you are seen at the first follow up
appointment.
??????	Do not lift objects over 10 pounds until approved by your
physician.
[**Name10 (NameIs) **]
Usually no special [**Name10 (NameIs) **] is prescribed after a craniotomy. A
normal well balanced [**Name10 (NameIs) **] is recommended for recovery, and you
should resume any specially prescribed [**Name10 (NameIs) **] you were eating
before your surgery.
MEDICATIONS:
??????	Take all of your medications as ordered.  You do not have to
take pain medication unless it is needed.  It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
??????	Do not use alcohol while taking pain medication.
??????	Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
	-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
??????	Follow the activity instructions given to you by your doctor
and therapist.
??????	Increase your activity slowly; do not do too much because you
are feeling good.
??????	You may resume sexual activity as your tolerance allows.
??????	If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
??????	DO NOT DRIVE until you speak with your physician.
??????	Do not lift objects over 10 pounds until approved by your
physician.
??????	Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
??????	   Do your breathing exercises every two hours.
??????	   Use your incentive spirometer 10 times every hour that you
are awake.

WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:

??????	Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
??????	Double, or blurred vision. Loss of vision, either partial or
total.
??????	Hallucinations
??????	Numbness, tingling, or weakness in your extremities or face.
??????	Stiff neck, and/or a fever of 101.5F or more.
??????	Severe sensitivity to light. (Photophobia)
??????	Severe headache or change in headache.
??????	Seizure
??????	Problems controlling your bowels or bladder.
??????	Productive cough with yellow or green sputum.
??????	Swelling, redness, or tenderness in your calf or thigh.

Call 911 or go to the Nearest Emergency Room if you Experience:
??????	Sudden difficulty in breathing.
??????	New onset of seizure or change in seizure, or seizure from
which you wake up confused.
??????	A seizure that lasts more than 5 minutes.

Important Instructions Regarding Emergencies and After-Hour
Calls
??????	If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
??????	Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.


Followup Instructions:
?????? Please return to the office in [**11-20**] days (from your date of
surgery) for removal of your [**Date Range 2729**] and 1 staple. Although we
try to be thorough, we may miss [**First Name (Titles) 2730**] [**Last Name (Titles) 2729**] or staples. Be
sure to point out any incisions, which may be covered by
clothing at the time of suture/staple removal. This appointment
can be made with the Nurse Practitioner.  Please make this
appointment by calling [**Telephone/Fax (1) 1669**].
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.



Completed by:[**2149-6-2**]
{'Intracerebral hemorrhage,Obstructive hydrocephalus,Hyperosmolality and/or hypernatremia,Depressive disorder, not elsewhere classified,Other persistent mental disorders due to conditions classified elsewhere,Pressure ulcer, lower back'}


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: Unresponsiveness

PRESENT ILLNESS: This is a [**Age over 90 **] year old female, who lives alone at home with
complete independence, was found down on the floor and
unresponsive by EMS on [**5-25**]. Per patient's grandson, the last
contact anyone had with her was last week some time.  The
patient was laying in urine with several pressure ulcers, but it
is
unknown how long she had been down.

MEDICAL HISTORY: Depression, Dementia

MEDICATION ON ADMISSION: Unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
O: T:95.4  BP: 118/80    HR:86    R: 20       O2Sats:100%
Gen: Cool to touch, in no acute distress. Skin breakdown to
numerous bony prominences. Snoring respirations.
HEENT:NC/AT Pupils: PEERLS, 2-1.5        EOMs N/A
Extrem: Slightly Cool, and well-perfused.
Neuro:
Mental status: Unresponsive. No commands, non-verbal.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Resides at home alone 

### Response:
{'Intracerebral hemorrhage,Obstructive hydrocephalus,Hyperosmolality and/or hypernatremia,Depressive disorder, not elsewhere classified,Other persistent mental disorders due to conditions classified elsewhere,Pressure ulcer, lower back'}
