CHIEF COMPLAINT: IPH

PRESENT ILLNESS: Ms. [**Known lastname 110862**] is a 77 yo W with h/o RA, AF on coumadin, who presents
with L frontal IPH s/p fall.
The patient was at her baseline until 8pm last night, when she
stood up from eating dinner, took [**4-15**] steps then suddenly
blacked
out and fell. She struck her L eye/forehead and landed
face-down.
Her husband could not awaken her at first, though she was
breathing, but in [**3-16**] minutes she moved her mouth and tried to
speak. Within 5-10 minutes, she was speaking normally, was not
confused or disoriented, but could not sit or stand despite
help.
Her husband brought her a blanket and pillow and let her rest on
the floor. After about 30 minutes, she was able to ambulate with
assistance to her bedroom, where she sat in a chair watching TV
then went to bed. Her husband sleeps in a different bedroom, and
typically hears her get up a few times per night to use the
bathroom. He did not hear her get up, so around 4am, went to
check on her. It appeared that she had attempted to get up but
could not, in that she was slumped sideways across the bed. She
awakens to his voice, opened her eyes, and was able to speak
normally. He did not think she was disoriented or confused, but
because she was sleepy and could not get up, he called 911.
The patient was brought to [**Hospital6 **]. Per ED notes, GCS
14, AOx3, nonfocal neuro exam. Head CT revealed L frontal IPH
with minimal intraventricular and subarachnoid spread. She was
also found to have L orbital and L wrist fractures. INR was 2.0.
She was given Keppra 500 mg IV, Vitamin K and bebulin (Factor IX
complex) and transferred to [**Hospital1 18**] for neurosurgery evaluation.
In [**Hospital1 18**], patient was somnolent, but able to follow commands,
oriented to hospital and month. She was intubated due to her
lethargy, and did have brief hypotension requiring pressor
post-sedation. She received FFP completed at 11:10am. Repeat
head
CT was stable.
Neurosurgery consult determined since head CT stable, no midline
shift, there was no acute indication for surgery. They agreed
with continued reversal of INR, BP control and repeat head CT
this evening.

MEDICAL HISTORY: - atrial fibrillation, on coumadin
- HTN
- GERD
- depression
- RA, had been on Humira until 2 years ago when she developed
Legionella, on prednisone since, rheumatologist is Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
- no h/o stroke or TIA

MEDICATION ON ADMISSION: ASA 81
coumadin
omeprazole 20 mg daily
prednisone 10 mg daily
Lopressor 50 mg [**Hospital1 **]
Cartia XL 240 mg daily
Lexapro 10 mg daily
Detrol LA 4 mg daily
Lasix 60 mg daily
fosamax 70 mg qSUN
MVI
iron
calcium

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At admission:
VS: afebrile BP 119/82  HP 90-100s  intubated
GEN: large hematoma involving L orbit, L eye is completely
bloodshot, L wrist hematoma.
HEENT: sclera anicteric
CV: irregular, no murmurs
PULM: crackles at bases
AB: ND/NT
EXT: no edema
SKIN: no rash

FAMILY HISTORY: negative for ICH

SOCIAL HISTORY: lives with husband. Retired special ed teacher. Has 1 son
(lives in [**Name (NI) **]) and 1 daughter (lives in [**Name (NI) 36413**]).
Independent in ADLs, drives. Smoked for a few years, quit in
[**2118**]. Drinks 2-4 whiskey sours/glasses of wine per day. Most
recent EtOH was last night at dinner. No illicits.
Subarachnoid hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Acute on chronic systolic heart failure,Encephalopathy, unspecified,Ventilator associated pneumonia,Aphasia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Closed fracture of other facial bones,Other iatrogenic hypotension,Unspecified sinusitis (chronic),Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Esophageal reflux,Rheumatoid arthritis,Depressive disorder, not elsewhere classified,Osteoporosis, unspecified,Physical restraints status,Long-term (current) use of anticoagulants,Fall from other slipping, tripping, or stumbling,Other opiates and related narcotics causing adverse effects in therapeutic use,Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use,Adrenal cortical steroids causing adverse effects in therapeutic use,Anticoagulants causing adverse effects in therapeutic use,History of fall,Other specified disorders of breast
Subarach hem-brief coma,Ac on chr syst hrt fail,Encephalopathy NOS,Ventltr assoc pneumonia,Aphasia,Mth sus Stph aur els/NOS,Atrial fibrillation,Fx facial bone NEC-close,Iatrogenc hypotnsion NEC,Chronic sinusitis NOS,Gstr/ddnts NOS w/o hmrhg,Crnry athrscl natve vssl,Hypertension NOS,Esophageal reflux,Rheumatoid arthritis,Depressive disorder NEC,Osteoporosis NOS,Physical restrain status,Long-term use anticoagul,Fall from slipping NEC,Adv eff opiates,Adv eff benzodiaz tranq,Adv eff corticosteroids,Adv eff anticoagulants,Personal history of fall,Disorders breast NEC
Admission Date: [**2170-5-21**]        Discharge Date: [**2170-6-11**]

Date of Birth:  [**2092-6-9**]        Sex:  F

Service:  NME


ADDENDUM:

BRIEF HOSPITAL COURSE:
1. She did have encephalopathy during the admission.
2. She had acute systolic congestive heart failure
    superimposed on chronic systolic congestive heart
    failure.



                        [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 80146**]

Dictated By:[**Last Name (NamePattern4) 86982**]
MEDQUIST36
D:  [**2170-7-10**] 17:08:43
T:  [**2170-7-11**] 01:09:14
Job#:  [**Job Number 110866**]


Admission Date:  [**2170-5-21**]              Discharge Date:   [**2170-6-11**]

Date of Birth:  [**2092-6-9**]             Sex:   F

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
IPH

Major Surgical or Invasive Procedure:
intubation and extubation
[**Last Name (NamePattern1) 282**] tube placement


History of Present Illness:
Ms. [**Known lastname 110862**] is a 77 yo W with h/o RA, AF on coumadin, who presents
with L frontal IPH s/p fall.
The patient was at her baseline until 8pm last night, when she
stood up from eating dinner, took [**4-15**] steps then suddenly
blacked
out and fell. She struck her L eye/forehead and landed
face-down.
Her husband could not awaken her at first, though she was
breathing, but in [**3-16**] minutes she moved her mouth and tried to
speak. Within 5-10 minutes, she was speaking normally, was not
confused or disoriented, but could not sit or stand despite
help.
Her husband brought her a blanket and pillow and let her rest on
the floor. After about 30 minutes, she was able to ambulate with
assistance to her bedroom, where she sat in a chair watching TV
then went to bed. Her husband sleeps in a different bedroom, and
typically hears her get up a few times per night to use the
bathroom. He did not hear her get up, so around 4am, went to
check on her. It appeared that she had attempted to get up but
could not, in that she was slumped sideways across the bed. She
awakens to his voice, opened her eyes, and was able to speak
normally. He did not think she was disoriented or confused, but
because she was sleepy and could not get up, he called 911.
The patient was brought to [**Hospital6 **]. Per ED notes, GCS
14, AOx3, nonfocal neuro exam. Head CT revealed L frontal IPH
with minimal intraventricular and subarachnoid spread. She was
also found to have L orbital and L wrist fractures. INR was 2.0.
She was given Keppra 500 mg IV, Vitamin K and bebulin (Factor IX
complex) and transferred to [**Hospital1 18**] for neurosurgery evaluation.
In [**Hospital1 18**], patient was somnolent, but able to follow commands,
oriented to hospital and month. She was intubated due to her
lethargy, and did have brief hypotension requiring pressor
post-sedation. She received FFP completed at 11:10am. Repeat
head
CT was stable.
Neurosurgery consult determined since head CT stable, no midline
shift, there was no acute indication for surgery. They agreed
with continued reversal of INR, BP control and repeat head CT
this evening.

Of note, the patient did fall 3 weeks ago upon going to bathroom
in middle of night. She fractured her shoulder. She has felt
"weak" since then but able to continue most of her usual
activities.


Past Medical History:
- atrial fibrillation, on coumadin
- HTN
- GERD
- depression
- RA, had been on Humira until 2 years ago when she developed
Legionella, on prednisone since, rheumatologist is Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
- no h/o stroke or TIA


Social History:
lives with husband. Retired special ed teacher. Has 1 son
(lives in [**Name (NI) **]) and 1 daughter (lives in [**Name (NI) 36413**]).
Independent in ADLs, drives. Smoked for a few years, quit in
[**2118**]. Drinks 2-4 whiskey sours/glasses of wine per day. Most
recent EtOH was last night at dinner. No illicits.


Family History:
negative for ICH


Physical Exam:
At admission:
VS: afebrile BP 119/82  HP 90-100s  intubated
GEN: large hematoma involving L orbit, L eye is completely
bloodshot, L wrist hematoma.
HEENT: sclera anicteric
CV: irregular, no murmurs
PULM: crackles at bases
AB: ND/NT
EXT: no edema
SKIN: no rash

NEURO: off sedation 5 minutes
MSE: opens eyes to loud voice, does not consistently track
examiner. Follows midline and appendicular commands (L arm
limited by fracture/bandage)- including showing 2 fingers on R.

CN: PERRL 6 to 4mm but re-dilate quickly. Eyes midline, looks
toward left more easily than looks toward right. No facial
droop.
Tongue midline.

MOTOR: normal tone in upper extremities, increased tone in L
compared to R lower extremity. No tremor or myoclonus.
Able to squeeze hands and wiggles toes bilaterally. Cannot hold
limbs antigravity, but withdraws well antigravity with noxious
stimulation, this is symmetrical.

[**Last Name (un) **]: intact to noxious throughout

DTR: 2+ b/l biceps, triceps, 1+ brachiorad, trace patellar and
Achilles. Toes upgoing b/l.

At discharge:
Neurologic: Lethargic, arouses to voice, able to answer a few
simple questions with 1-2 word responses, oriented to [**Hospital 61**], does not know date. Does not consistently follow
commands. Pupils equal and reactive, extraocular movements
intact. Face is symmetric. Moves all extremities anti-gravity,
somewhat less in R lower extremity. Withdraws to noxious
stimulation throughout. L toe upgoing, R mute.

Pertinent Results:
[**2170-5-21**] 08:45AM BLOOD WBC-11.3* RBC-4.43 Hgb-12.7 Hct-39.2
MCV-89 MCH-28.7 MCHC-32.4 RDW-15.2 Plt Ct-202
[**2170-5-21**] 08:45AM BLOOD Neuts-76.1* Lymphs-18.6 Monos-4.6 Eos-0.3
Baso-0.5
[**2170-5-21**] 08:45AM BLOOD PT-16.5* PTT-26.3 INR(PT)-1.6*
[**2170-5-21**] 02:31PM BLOOD PT-13.5* PTT-24.0* INR(PT)-1.3*
[**2170-5-22**] 02:42AM BLOOD PT-12.0 PTT-24.5* INR(PT)-1.1
[**2170-5-21**] 08:45AM BLOOD Glucose-166* UreaN-15 Creat-0.5 Na-138
K-3.2* Cl-100 HCO3-28 AnGap-13
[**2170-5-22**] 02:42AM BLOOD Glucose-138* UreaN-10 Creat-0.5 Na-136
K-4.2 Cl-104 HCO3-26 AnGap-10
[**2170-5-25**] 12:58AM BLOOD ALT-31 AST-50* AlkPhos-78 TotBili-1.1
[**2170-5-22**] 02:42AM BLOOD Calcium-7.3* Phos-2.6* Mg-1.6
[**2170-5-22**] 06:33PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2170-5-22**] 06:33PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2170-5-22**] 06:33PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0

Blood Cx on [**5-22**] x 2 and [**5-25**] x 2: No growth.
Urine Cx on [**5-22**] and [**5-25**]: No growth.

[**2170-5-23**] 5:26 am SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2170-5-28**]**

   GRAM STAIN (Final [**2170-5-23**]):
      <10 PMNs and <10 epithelial cells/100X field.
      1+    (<1 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.
      QUALITY OF SPECIMEN CANNOT BE ASSESSED.

   RESPIRATORY CULTURE (Final [**2170-5-28**]):
      THIS IS A CORRECTED REPORT [**2170-5-28**].
      PREVIOUSLY REPORTED INCORECTLY WITH  ERYTHROMYCIN MIC ON
[**2170-5-26**].
      Reported to and read back by [**Last Name (un) **] [**Doctor Last Name 110863**] [**2170-5-28**] 1:24PM.
      MODERATE GROWTH Commensal Respiratory Flora.
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         OF TWO COLONIAL MORPHOLOGIES.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------       R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S

[**2170-5-25**] 11:17 am BRONCHOALVEOLAR LAVAGE

                            **FINAL REPORT [**2170-5-27**]**

   GRAM STAIN (Final [**2170-5-25**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS, CHAINS, AND
CLUSTERS.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2170-5-27**]):
      >100,000 ORGANISMS/ML. Commensal Respiratory Flora.

C diff [**5-25**] negative

ECG:
Baseline artifact. Atrial fibrillation with rapid ventricular
response.
Vertical axis for age. Prominent precordial voltage. Consider
left
ventricular hypertrophy. ST-T wave abnormalities of
strain/ischemia.
No previous tracing available for comparison. Clinical
correlation is
suggested.
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
112 0 88 354/445 0 81 -98

[**2170-5-21**] NCHCT:
Final Report
CLINICAL INFORMATION: 77-year-old female with intracranial
hemorrhage and
hypoxia.

COMPARISON: Images performed at [**Hospital6 2561**] at 0652
hours on
today's date.

TECHNIQUE: Axial CT images were acquired of the head without
contrast and
reformatted into coronal and sagittal planes.

FINDINGS: There is a left frontal intraparenchymal hemorrhage,
which is
unchanged in size compared with prior, measuring 3.1 x 1.8 cm.
Blood is seen
layering within the left sylvian fissure, and within the left
lateral
ventricle adherent to the septum. Minimal mass effect is seen
around the left
frontal hemorrhage, though the generalized enlargement of the
extra-axial
spaces allows for this, without shift of midline structures, or
evidence of
herniation. The ventricles are not enlarged, though there is ex
vacuo
dilatation of the right lateral ventricle adjacent to the
frontal [**Doctor Last Name 534**],
perhaps from prior ischemic insult. The periventricular white
matter is
generally hypodense, likely the result of chronic small vessel
ischemic
change. [**Doctor Last Name **] matter/white matter differentiation is preserved
throughout,
without evidence of acute infarction.

The orbits are unremarkable, though bilateral lens implants are
noted. There
is left periorbital hematoma extending into the left temporal
region. There
is no definite fracture. There is mucosal thickening within
multiple ethmoid
air cells. The maxillary and sphenoid sinuses are clear. The
mastoid air
cells are clear bilaterally.

IMPRESSION:
1. Stable appearance of intraparenchymal, intraventricular, and
subarachnoid
hemorrhage.
2. Left periorbital hematoma.


CTA chest/abd/pelvis:
Final Report
CLINICAL INFORMATION: 77-year-old female status post fall with
intracranial
hemorrhage, evaluate for traumatic injury to the chest, abdomen,
and pelvis.

COMPARISON: None.

TECHNIQUE: Helical MDCT images were acquired of the chest,
abdomen and pelvis
following the uneventful administration of 130 cc of Omnipaque.
Images were
reformatted into coronal and sagittal planes.

FINDINGS:
CHEST: There is left lower lobe collapse, with a small left
pleural effusion.
Subsegmental atelectasis is noted in the left upper lobe. There
is right
lower lobe subsegmental atelectasis, with a small right pleural
effusion.
Hypodense material in the left lower lobe airways suggests
aspiration. The
lungs are otherwise clear. The central airways appear patent.
The patient is
intubated, the tip of the endotracheal tube approaches the level
of the
carina. There is cardiac enlargement, with significant
enlargement of the
bilateral atria. There is calcification noted of the coronary
arteries, of
the mitral valve annulus, and of the aortic valve annulus and
leaflets. There
is no pericardial effusion. The aortic root is prominent,
measuring 3.4 cm.
The great vessels are unremarkable with some calcification noted
at their
origins. The central pulmonary arteries appear patent.
Nonspecific
calcifications are noted in the left breast, there is asymmetric
breast
tissue, with a 3.7 x 2.7 cm left breast mass resulting in nipple
retraction
(2; 38). There is no mediastinal, hilar, or axillary
lymphadenopathy.

ABDOMEN: The fatty liver, spleen, and pancreas are unremarkable.
There is a
left adrenal nodule which measures 1.3 cm. The right adrenal is
unremarkable.
The kidneys demonstrate brisk bilateral contrast enhancement,
and excretion.

The stomach contains an NG tube, the tip of which is in the
region of the
stomach body, and is collapsed. There is submucosal edema at the
gastric
antrum. Loops of small bowel are normal in caliber, and are
normally
opacified by ingested oral contrast. The small bowel mesentery
is normal in
appearance. The aorta is normal in caliber along its abdominal
course. There
is marked calcification at the origins of the celiac, and SMA,
which remain
patent. The [**Female First Name (un) 899**] is not well seen. There is no retroperitoneal,
or pelvic
side wall lymphadenopathy.

PELVIS: There is a Foley catheter seen within the bladder, which
is
collapsed. The uterus is retroverted, and enlarged. The rectum
is
unremarkable. There are innumerable diverticula seen throughout
the colon.
There is no evidence for acute diverticulitis. There is no
intraperitoneal
free air, or free fluid.

BONE WINDOWS: There are chronic right-sided rib fractures, some
of which have
not healed well including the right second, third, fourth,
fifth, sixth,
seventh, eighth, and ninth ribs. Likewise, there are fractures
of the left
seventh, eighth, ninth, and tenth ribs which are in stages of
healing. There
is a thoracic kyphosis. Vertebral body height and alignment are
maintained.
There is multilevel facet degenerative change, and Baastrup's
disease.

IMPRESSION:
1. Left lower lobe collapse, aspiration, and bilateral
subsegmental
atelectasis. The patient is intubated with the tip of the
endotracheal tube
approaching the level of the carina.

2. Biatrial enlargement, without pulmonary edema.

3. Multiple bilateral healing rib fractures, none of which
appear acute.

3. Left breast mass with nipple retraction, recommend
correlation with
mammography when clinically appropriate.

4. Bulky uterus, recommend further evaluation with pelvic
son[**Name (NI) 867**] when
clinically appropriate.

5. Severe diverticulosis, without evidence of acute
diverticulitis.

6. Gastric thickening of the gastric antrum, nonspecific,
suggests gastritis.

Left wrist/hand Xray:
WRIST(3 + VIEWS) LEFT; HAND (AP, LAT & OBLIQUE) LEFT   Clip #
[**Clip Number (Radiology) 110864**]
Reason: please eval for fracture
Final Report
INDICATION: 77-year-old female with left hand and wrist
deformity of the
distal radius , evaluate for fracture.

COMPARISON: None available.

FINDINGS: Three views of the wrist and three views of the hand.
Diffuse
osteopenia slightly limits the examination. There are vascular
calcifications. There is sclerosis and joint space narrowing at
the first CMC
joint likely representing osteoarthritis. No fracture or
dislocation seen.
Possible subluxation of the second MCP joint.

IMPRESSION: No acute fracture or dislocation. Degenerative
changes most
prominent at the first CMC joint and osteopenia.


MRI brain with and without contrast:
FINDINGS: There is an acute intraparenchymal hematoma seen in
the left
frontal lobe measuring 3.2 x 2.1 x 3.4 cm with surrounding
edema, causing mass
effect on left lateral ventricle. There is no definite
enhancement seen. As
seen on the prior CT, there are blood products in the left
sylvian fissure and
within the lateral ventricles. There is no hydrocephalus or
midline shift.
There is ex vacuo dilatation of the right lateral ventricle
adjacent to the
frontal [**Doctor Last Name 534**], likely from prior ischemic insult. There are
extensive
confluent T2, FLAIR hyperintensities in bilateral
periventricular white matter
likely represent sequelae of small vessel ischemic disease.
There is no acute
intracranial infarction. Major intracranial flow voids are
preserved.
Visualized orbits and mastoid air cells appear unremarkable.
There is minimal
mucosal thickening along the inferior aspect of bilateral
maxillary and
bilateral ethmoid sinuses. There is no abnormal leptomeningeal
or parenchymal
enhancement seen.

IMPRESSION:
1. Intraparenchymal hematoma in the left frontal lobe with
surrounding edema, subarachnoid and intraventricular hemorrhage,
similar to that seen on the prior CT. There is no definite
underlying lesion seen. However, followup MRI should be obtained
once the hemorrhage resolves.
2. Small vessel ischemic disease.

[**2170-5-22**] NCHCT:
IMPRESSION:
1. Little change in comparison to prior study from [**2170-5-21**], roughly 32 hours earlier, with stable appearance of left
frontal parenchymal hemorrhage, as well as small
intraventricular and left-sided subarachnoid hemorrhage.
2. Stable appearance of left periorbital soft tissue hematoma.

[**5-25**] CXR:
FINDINGS:
Increased retrocardiac density reflecting left lower lung
consolidation and/or
atelectasis is unchanged, whereas right lower lung opacity,
which has
improved, is atelectasis. The orogastric tube has been
repositioned, and end
into the stomach.

[**2170-5-22**]- [**2170-5-27**] EEG - LTM:
FINDINGS:
CONTINUOUS EEG RECORDING: Began at 14:23 on the afternoon of [**5-22**].
It showed a low voltage and mildly slow background with 6 Hz
frequencies
dominating posteriorly. There was also minimal additional focal
slowing
in the left hemisphere and occasional sharp waves in the same
region.
After 14:50, the background was of much lower voltage in all
areas.
They became even lower by 21:00 that evening but resumed a
moderate
voltage activity after 4 the next morning. Sharp waves were not
prominent after the afternoon of the 10th. There were no
electrographic
seizures.
SPIKE DETECTION PROGRAMS: Showed some of the same sharp waves,
most
with a generalized distribution, but all seen in isolation
rather than
repetitively.
SEIZURE DETECTION PROGRAMS: Showed no electrographic seizures.
PUSHBUTTON ACTIVATIONS: There was a single activation at 15:36
on the
afternoon of [**5-22**]. There was no electrographic seizure on
EEG. The
patient was obscured on video.
SLEEP: No normal waking or sleeping patterns were evident.
CARDIAC MONITOR: Showed an irregularly irregular tachycardia
with a
rate of about 110.
IMPRESSION: This telemetry captured a single pushbutton
activation.
This showed no evidence of seizure. The background was a bit
slow and
of very low voltage throughout, especially in some periods,
likely
correlating with medication usage. There was minimal additional
slowing
on the left side but no area of persistent and prominent focal
slowing.
There were several isolated sharp waves, most with a generalized

distribution but some with a leftsided emphasis. These were all
seen in
isolation, and there were no electrographic seizures.
[**5-23**]:
IMPRESSION: This telemetry captured no pushbutton activations.
It
showed a slow background throughout, indicative of an
encephalopathy.
There were frequent bursts of slowing, some with sharp features,
and
there were some generalized blunted sharp waves, but there were
no
definitely epileptiform abnormalities. There were no
electrographic
seizures
[**5-24**]:
IMPRESSION: This telemetry captured no pushbutton activations.
It
showed a slow background throughout, indicative of a continuing
encephalopathy. There were no prominent focal features. There
were
very frequent generalized sharp wave discharges, especially at
the
beginning of the recording. They were not so rhythmic or
prolonged as
to suggest ongoing seizures, but they indicate some increased
potential for seizures.
[**5-25**]:
IMPRESSION: This telemetry captured no pushbutton activations.
The
background remained slow throughout. There were very frequent
generalized blunt and sharp wave discharges, but they were never
rapid
or rhythmic enough to be considered electrographic seizure
activity.
While they were most likely part of the encephalopathy, they
suggest an
increased risk for seizures. There were no prominent focal
abnormalities. The sharp waves were a bit less frequent than on
the
previous day's recording.
[**5-26**]:
IMPRESSION: This telemetry captured no pushbutton activations.
It
showed a slow background throughout, indicative of a widespread
encephalopathy. In addition, there were generalized and left
hemisphere
blunted sharp wave discharges, almost always seen in isolation
rather
than repetitively. They diminished over the course of the
recording as
the background became slower, likely a medication effect. There
were no
rapid or rhythmic discharges to suggest an ongoing
electrographic
seizure.
[**5-27**]:
IMPRESSION: This telemetry captured one pushbutton activation.
It did
not show a seizure. The rest of the recording showed a
moderately slow
posterior background, indicative of an encephalopathy.
Nevertheless,
sharp waves evident on earlier recordings were no longer
present. The
recording suggests an improvement in the encephalopathy.

Routine EEG [**6-9**]:
Prelim read shows disorganized theta background, generalized
slow waves but no sharp waves or epileptiform activity. Final
read pending at time of discharge.


Brief Hospital Course:
77 yo W with h/o RA, AF on coumadin, who presents with L frontal
IPH and small SAH s/p fall. The mechanism of fall is unclear but
presumed to be mechanical with resultant traumatic IPH/SAH. The
patient was initially intubated in the ED for airway protection
and admitted to the neuroICU. Her admission exam initially
showed her to follow commands, moving all extremities. However
within a few hours she became obtunded and was no longer not
following commands with minimal movements of all extremities,
but otherwise nonfocal. Exam was intermittently concerning for
seizure activity given no responsiveness to voice, hippus, right
beating nystagmus, mouth movements and right hand tremors, for
which Keppra was increased. EEG [**2073-5-20**] showed occasional spikes
(left hemispheric and generalized) but no seizures. MRI brain
with and without contrast shows stable size of bleed with no
underlying mass or evidence for amyloid. The patient's alertness
gradually increased over the next week and she was extubated
[**2170-5-30**]. She remained somewhat lethargic for unclear reasons,
thought to be related to bleed, possible post-ictal state, drug
effects, and pneumonia. She was transferred to the neurology
floor on [**6-1**].

NEURO:
Upon transfer to the floor she continued to be largely nonverbal
but was following limited commands (wiggle toes). She was able
to move all extremities spontaneously although somewhat less in
the R leg. Keppra was decreased to 750mg IV BID and she was
started on amantadine 100mg daily on [**6-1**] with some improvement
in her level of alertness. Keppra was further decreased to 500mg
[**Hospital1 **] on [**6-8**]. A repeat EEG was performed on [**6-9**] which showed
disorganized theta background, generalized slow waves but no
sharp waves or epileptiform activity. She will need to remain on
Keppra until she follows up with Dr. [**Last Name (STitle) **]; it may be able to
be slowly weaned down at that point.

Due to persistent lethargy at toxic/metabolic work-up was
pursued, which was unremarkable except for TSH of 9.4. Free T4
was normal at 1.3.

She was restarted on subQ heparin for DVT prophylaxis on [**5-24**].
Aspirin 81mg was restarted on [**5-28**]. Coumadin was held during her
admission in light of her recent hemorrhage. The timing of
restarting her coumadin will be further discussed at her
follow-up visit with Dr. [**Last Name (STitle) **].

She will need a repeat MRI in 3 months to better assess for any
underlying lesions after resolution of her hemorrhage. She has a
follow up appointment scheduled with Dr. [**Last Name (STitle) **] on [**2170-7-23**].

A CT torso on [**5-21**] showed a left breast mass with nipple
retraction as well as a bulky uterus. This was discussed with
her PCP. [**Name10 (NameIs) **] is possible that the breast abnormality may have
been related to a hematoma in the setting of her fall but should
be followed up with a mammogram once medically stable. Pelvic
son[**Name (NI) 867**] was recommended for further evaluation of her uterus.

CV:
She was maintained on telemetry monitoring for her a fib. Her
home metoprolol 50mg [**Hospital1 **] and diltiazem 60mg QID were restarted.
Aspirin 81mg was restarted on [**5-28**].

ID:
Fevers and mental status improved while completing VAP protocol
[**Date range (1) 110865**] with Cefepime/Cipro/Vanc. Sputum cx grew coag positive
staph aureus. UA was negative. UCx and Blood Cx showed no
growth. She completed antibiotics on [**6-1**] and remained afebrile.
After her transfer to the floor she was noted to have persistent
leukocytosis to 14-15 although she remained afebrile with no
clinical signs of infection. This was thought to be related to
sinusitis / inflammation from her NGT. NGT was removed after [**Month/Year (2) 282**]
placement on [**6-8**]. WBC subsequently trended down and normalized.

PULM:
She was continued on lasix 20mg IV BID with improvement in her
volume overload.

HEME:
INR was reversed. Coumadin was held throughout her admission.
The timing of restarting coumadin will be further discussed at
her follow-up visit with Dr. [**Last Name (STitle) **].

GI:
After her transfer to the floor her BUN was noted to be
persistently high in the 40's. Stool guiac was positive. She had
no clinical signs of bleeding and Hct remained stable. Aspirin
was held. She was maintained on famotidine. This was thought to
be related to mild gastritis related to chronic prednisone use
and possibly irritation from NGT as well. BUN was monitored and
trended down. Hct remained stable. Aspirin was restarted on
[**2170-6-10**].

Due to her obtundation she was kept NPO and a NGT was placed for
tube feeds. She remained unable to swallow safely despite
multiple repeat swallow evaluations. After discussion with her
husband a [**Name2 (NI) 282**] tube was placed on [**6-7**]. She will need continued
monitoring by speech and swallow and nutrition.

ENDO:
She was maintained on ISS for blood glucose control during her
admission.

Musculoskeletal:
She was continued on her home prednisone 10mg daily for RA.

Ophtho:
She was found to have a L lateral non-displaced orbit fracture
and hematoma on admission. She was seen by ophthalmology who did
not recommend any acute intervention. She has a follow-up
appointment for a repeat exam scheduled on [**2170-6-27**] with Dr.
[**Last Name (STitle) **].

Code status: Full (discussed with husband [**Doctor First Name 3788**]

Dispo:
She was discharged to [**Hospital 100**] Rehab in good condition on [**2170-6-11**].

Transitional care issues:
She will need continued PT, OT, and speech therapy. Nutrition
should also be involved for management of her tube feeds.
She has a follow-up appointment scheduled with Dr. [**Last Name (STitle) **] in
ophthalmology clinic on [**2170-6-27**], and with Dr. [**Last Name (STitle) **] in
neurology clinic on [**2170-7-23**].

Medications on Admission:
ASA 81
coumadin
omeprazole 20 mg daily
prednisone 10 mg daily
Lopressor 50 mg [**Hospital1 **]
Cartia XL 240 mg daily
Lexapro 10 mg daily
Detrol LA 4 mg daily
Lasix 60 mg daily
fosamax 70 mg qSUN
MVI
iron
calcium


Discharge Medications:
1. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
4. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash in genital area.
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
7. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): As per insulin sliding scale.
11. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
12. amantadine 50 mg/5 mL Syrup Sig: Ten (10) ml PO QAM (once a
day (in the morning)): 100mg QAM.
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
14. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
15. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - LTC

Discharge Diagnosis:
Left frontal intraparenchymal hemorrhage
Pneumonia


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.

Neurologic: Lethargic, arouses to voice, able to answer a few
simple questions with 1-2 word responses, oriented to [**Hospital 61**], does not know date. Does not consistently follow
commands. Pupils equal and reactive, extraocular movements
intact. Face is symmetric. Moves all extremities anti-gravity,
somewhat less in R lower extremity. Withdraws to noxious
stimulation throughout. L toe upgoing, R mute.


Discharge Instructions:
Dear Ms. [**Known lastname 110862**],
You were admitted to [**Hospital1 69**] on
[**2170-5-21**] after experiencing a fall at home. You were found to have
bleeding in the left front part of your brain. Your bleeding was
likely due to your fall in the setting of taking coumadin. An
MRI showed no evidence of any underlying abnormalities that
could have contributed to your bleeding. You should have a
repeat MRI in about 3 months once your bleeding has resolved to
take a better look. You had some activity concerning for
seizures when you were first admitted and were started on a
medication called Keppra to prevent further seizures. You will
need to remain on this medication until you follow up with Dr.
[**Last Name (STitle) **]; you may be able to be slowly weaned off it at that
point. You were also treated for pneumonia with IV antibiotics.
You continued to be quite lethargic during your admission and
had persistent difficulty swallowing. Because of this, a [**Last Name (STitle) 282**]
(percutaneous endoscopic gastrostomy) tube was placed to help
give you nutrition and medications. This can hopefully be
removed in the future once you are able to swallow on your own.
You will need physical and occupational therapy to help you
regain your strength.

During your fall you sustained a fracture of your left orbit
(the bone that encases your eye). You were seen by ophthalmology
during your hospitalization who did not feel that you needed any
surgical intervention. They would like you to be seen in their
clinic for a follow-up eye exam - your appointment is listed
below.

We made the following changes to your medications:
Started Keppra 500mg twice a day to prevent seizures
Started amantadine 100mg daily to help increase your alertness
Stopped coumadin
Increased metoprolol to 75mg three times a day to help control
your heart rate
Changed Diltiazem XL 240mg daily to Diltiazem 60mg four times a
day
Increased lasix to 40mg twice a day

If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.

It was a pleasure taking care of you during your hospital stay.

Followup Instructions:
You have the following appointment scheduled with Dr. [**Last Name (STitle) **] in
our stroke clinic:
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2170-7-23**] 3:30
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
  NEUROLOGY UNIT CC8 (SB)

You also have the following appointment with Dr. [**Last Name (STitle) **] in
ophthalmology clinic regarding your left orbital fracture:
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2170-6-27**]
3:00
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Acute on chronic systolic heart failure,Encephalopathy, unspecified,Ventilator associated pneumonia,Aphasia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Closed fracture of other facial bones,Other iatrogenic hypotension,Unspecified sinusitis (chronic),Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Esophageal reflux,Rheumatoid arthritis,Depressive disorder, not elsewhere classified,Osteoporosis, unspecified,Physical restraints status,Long-term (current) use of anticoagulants,Fall from other slipping, tripping, or stumbling,Other opiates and related narcotics causing adverse effects in therapeutic use,Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use,Adrenal cortical steroids causing adverse effects in therapeutic use,Anticoagulants causing adverse effects in therapeutic use,History of fall,Other specified disorders of breast'}


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: IPH

PRESENT ILLNESS: Ms. [**Known lastname 110862**] is a 77 yo W with h/o RA, AF on coumadin, who presents
with L frontal IPH s/p fall.
The patient was at her baseline until 8pm last night, when she
stood up from eating dinner, took [**4-15**] steps then suddenly
blacked
out and fell. She struck her L eye/forehead and landed
face-down.
Her husband could not awaken her at first, though she was
breathing, but in [**3-16**] minutes she moved her mouth and tried to
speak. Within 5-10 minutes, she was speaking normally, was not
confused or disoriented, but could not sit or stand despite
help.
Her husband brought her a blanket and pillow and let her rest on
the floor. After about 30 minutes, she was able to ambulate with
assistance to her bedroom, where she sat in a chair watching TV
then went to bed. Her husband sleeps in a different bedroom, and
typically hears her get up a few times per night to use the
bathroom. He did not hear her get up, so around 4am, went to
check on her. It appeared that she had attempted to get up but
could not, in that she was slumped sideways across the bed. She
awakens to his voice, opened her eyes, and was able to speak
normally. He did not think she was disoriented or confused, but
because she was sleepy and could not get up, he called 911.
The patient was brought to [**Hospital6 **]. Per ED notes, GCS
14, AOx3, nonfocal neuro exam. Head CT revealed L frontal IPH
with minimal intraventricular and subarachnoid spread. She was
also found to have L orbital and L wrist fractures. INR was 2.0.
She was given Keppra 500 mg IV, Vitamin K and bebulin (Factor IX
complex) and transferred to [**Hospital1 18**] for neurosurgery evaluation.
In [**Hospital1 18**], patient was somnolent, but able to follow commands,
oriented to hospital and month. She was intubated due to her
lethargy, and did have brief hypotension requiring pressor
post-sedation. She received FFP completed at 11:10am. Repeat
head
CT was stable.
Neurosurgery consult determined since head CT stable, no midline
shift, there was no acute indication for surgery. They agreed
with continued reversal of INR, BP control and repeat head CT
this evening.

MEDICAL HISTORY: - atrial fibrillation, on coumadin
- HTN
- GERD
- depression
- RA, had been on Humira until 2 years ago when she developed
Legionella, on prednisone since, rheumatologist is Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
- no h/o stroke or TIA

MEDICATION ON ADMISSION: ASA 81
coumadin
omeprazole 20 mg daily
prednisone 10 mg daily
Lopressor 50 mg [**Hospital1 **]
Cartia XL 240 mg daily
Lexapro 10 mg daily
Detrol LA 4 mg daily
Lasix 60 mg daily
fosamax 70 mg qSUN
MVI
iron
calcium

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At admission:
VS: afebrile BP 119/82  HP 90-100s  intubated
GEN: large hematoma involving L orbit, L eye is completely
bloodshot, L wrist hematoma.
HEENT: sclera anicteric
CV: irregular, no murmurs
PULM: crackles at bases
AB: ND/NT
EXT: no edema
SKIN: no rash

FAMILY HISTORY: negative for ICH

SOCIAL HISTORY: lives with husband. Retired special ed teacher. Has 1 son
(lives in [**Name (NI) **]) and 1 daughter (lives in [**Name (NI) 36413**]).
Independent in ADLs, drives. Smoked for a few years, quit in
[**2118**]. Drinks 2-4 whiskey sours/glasses of wine per day. Most
recent EtOH was last night at dinner. No illicits. 

### Response:
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Acute on chronic systolic heart failure,Encephalopathy, unspecified,Ventilator associated pneumonia,Aphasia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Closed fracture of other facial bones,Other iatrogenic hypotension,Unspecified sinusitis (chronic),Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Esophageal reflux,Rheumatoid arthritis,Depressive disorder, not elsewhere classified,Osteoporosis, unspecified,Physical restraints status,Long-term (current) use of anticoagulants,Fall from other slipping, tripping, or stumbling,Other opiates and related narcotics causing adverse effects in therapeutic use,Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use,Adrenal cortical steroids causing adverse effects in therapeutic use,Anticoagulants causing adverse effects in therapeutic use,History of fall,Other specified disorders of breast'}
