CHIEF COMPLAINT: Altered Mental Status

PRESENT ILLNESS: History of Present Illness: [**Age over 90 **] yo M with CAD s/p MI x2, CABG in
[**2161**], HTN, AF on anticoag, recent admission for CP, depression,
now admitted for a change in mental status, found to have acute
on chronic subdural hematoma. Pt was sent to ED by nurse [**First Name (Titles) **] [**Hospital3 **] because of worsening MS over last few days.
Refused POs or ambulation. Became more withdrawn and confused,
eventually minimally responsive. Said he felt like he didn't
want to live.  No history of trauma.  Psych meds were recently
changed.
.
In the ED, his VS were 97.3, HR 87 in AF, BP 207/137, RR 30,
100%RA. FS was 156. He received labetolol 10 IV x2, nitro paste.
Labs without acute findings. UA unremarkable. EKG with ST
depressions in V5/6. Trop 0.03. Pt had gag reflex and was not
intubated. Head CT with acute on chronic SDH. Neurosurgery was
consulted and felt that MS change was not likely related to SDH
as no mass effect or midline shift.  However, nipride gtt was
started to keep SBP less than 140. Anticoagulation was reversed
with ?proplex and Vit K 10mg IV x1. FFP was ordered but not
given. Pt was also started on Dilantin 1g IV and received 10mg
Lasix IV x1 as well as Narcan 0.2 IV with no response.

MEDICAL HISTORY: Past Medical History:
1. Coronary artery disease
- AMI ([**2139**])
- AMI ([**2161**])
- Status post CABG in [**2161**]
--> SVG-LAD, SVG-OM, SVG-RPDA and LIMA to D1
- PCI ([**7-16**])
--> SVG->LAD with drug-eluting stent
--> SVG->OM1 with drug-eluting stent
- Stress ([**4-16**]): MIBI showed normal myocardial perfusion with a

MEDICATION ON ADMISSION: MEDICATIONS:
1. Amlodipine 5 mg daily
2. Aspirin 81 mg daily
3. Calcium plus vitamin D 600 mg-200 units t.i.d.
4. Vitamin B12 200 mcg daily
5. Colace 100 mg b.i.d. p.r.n.
6. Lorazepam 0.5 mg one to two tablets q.h.s. p.r.n.
7. Milk of magnesia of uncertain dosage daily p.r.n.
8. Metoprolol tartrate 25 mg b.i.d.
9. Nitroglycerin SL 0.3 mg t.i.d. p.r.n.
10. Metamucil of uncertain dosage
11. Coumadin 2 mg q.h.s.
12. Duloxetine 30 mg PO daily
Note: Zyprexa was stopped prior to admission, as he was
developing hallucinations.
.
ALLERGIES:
1. Procardia
2. Verapamil

ALLERGIES: Procardia / Verapamil

PHYSICAL EXAM: Physical Exam on Admission:
.
VS: T96.8  122/79 HR 64 in AF RR 14 97% 2L
Gen: NAD, seems comfortable but not responding to questions
HEENT: head atraumatic, PERRL, dry MM, clear OP
Neck: supple, no JVD elevation
CV: irregularly irregular, S1 S2, II/VI systolic murmur at USB
(old)
Lungs: CTAB anteriorly
Abd: soft, nontender, nondistended BS +
Ext: no LE edema, DP's 2+ b/l
Neuro: responds to voice once but not thereafter, moves
extremities occasionally, no response to sternal rub. ?Slightly
catatonic (when lifting arm up, keeps it elevated briefly prior
to bringing it down again)

FAMILY HISTORY: Family History:
N/C; lost his wife and son in the Holocaust.

SOCIAL HISTORY: SOCIAL HISTORY:
He lives [**Street Address(1) 83359**] [**Hospital3 400**].  He is retired from
working as a  stitcher. He has a niece [**Name (NI) **] [**Name (NI) **] who lives
in the area who is involved in some of his day-to-day care. Her
home phone number is [**Telephone/Fax (1) 98712**]. Her cellular phone number is
[**Telephone/Fax (1) 98713**]. The patient also has a nephew Dr. [**First Name4 (NamePattern1) 6339**]
[**Known lastname 98584**] in [**State **] who is his healthcare proxy. The patient
has a social worker and a visiting nurse.  He uses a walker or a
cane to ambulate. No alcohol or tobacco. He does have a
lifeline.
The patient is a Holocaust survivor, and lost both his wife and
son in the Holocaust.  He survived by making shoes for the
Nazis.  He was in 5 different concentration camps in [**Country 2784**] and
Poland.  He is listed on the Shoah website.
Drug-induced delirium,Subdural hemorrhage,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Antidepressants causing adverse effects in therapeutic use,Atrial fibrillation,Old myocardial infarction,Aortocoronary bypass status,Personal history of malignant neoplasm of prostate,Depressive disorder, not elsewhere classified,Other abnormal blood chemistry,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified
Drug-induced delirium,Subdural hemorrhage,Urin tract infection NOS,Hyperosmolality,Adv eff antidepressants,Atrial fibrillation,Old myocardial infarct,Aortocoronary bypass,Hx-prostatic malignancy,Depressive disorder NEC,Abn blood chemistry NEC,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV
Admission Date:  [**2175-11-10**]              Discharge Date:   [**2175-11-20**]


Service: MEDICINE

Allergies:
Procardia / Verapamil

Attending:[**First Name3 (LF) 1620**]
Chief Complaint:
Altered Mental Status

Major Surgical or Invasive Procedure:
None


History of Present Illness:
History of Present Illness: [**Age over 90 **] yo M with CAD s/p MI x2, CABG in
[**2161**], HTN, AF on anticoag, recent admission for CP, depression,
now admitted for a change in mental status, found to have acute
on chronic subdural hematoma. Pt was sent to ED by nurse [**First Name (Titles) **] [**Hospital3 **] because of worsening MS over last few days.
Refused POs or ambulation. Became more withdrawn and confused,
eventually minimally responsive. Said he felt like he didn't
want to live.  No history of trauma.  Psych meds were recently
changed.
.
In the ED, his VS were 97.3, HR 87 in AF, BP 207/137, RR 30,
100%RA. FS was 156. He received labetolol 10 IV x2, nitro paste.
Labs without acute findings. UA unremarkable. EKG with ST
depressions in V5/6. Trop 0.03. Pt had gag reflex and was not
intubated. Head CT with acute on chronic SDH. Neurosurgery was
consulted and felt that MS change was not likely related to SDH
as no mass effect or midline shift.  However, nipride gtt was
started to keep SBP less than 140. Anticoagulation was reversed
with ?proplex and Vit K 10mg IV x1. FFP was ordered but not
given. Pt was also started on Dilantin 1g IV and received 10mg
Lasix IV x1 as well as Narcan 0.2 IV with no response.

Past Medical History:
Past Medical History:
1. Coronary artery disease
- AMI ([**2139**])
- AMI ([**2161**])
- Status post CABG in [**2161**]
--> SVG-LAD, SVG-OM, SVG-RPDA and LIMA to D1
- PCI ([**7-16**])
--> SVG->LAD with drug-eluting stent
--> SVG->OM1 with drug-eluting stent
- Stress ([**4-16**]): MIBI showed normal myocardial perfusion with a

normal left ventricular cavity size and systolic function (EF
62%)
2. Atrial fibrillation, on coumadin
3. Pulmonary artery systolic [**Month/Year (2) **], moderate (noted on
echo in [**11-15**])
3. Vestibular schwannoma treated with chemotherapy at [**Hospital 98711**]
4. Prostate cancer s/p Total radical resection of the prostate
5. Irritable bowel syndrome
6. s/p Bilateral inguinal hernia repairs
7. [**Hospital **]
8. Depression
9. Anxiety


Social History:
SOCIAL HISTORY:
He lives [**Street Address(1) 83359**] [**Hospital3 400**].  He is retired from
working as a  stitcher. He has a niece [**Name (NI) **] [**Name (NI) **] who lives
in the area who is involved in some of his day-to-day care. Her
home phone number is [**Telephone/Fax (1) 98712**]. Her cellular phone number is
[**Telephone/Fax (1) 98713**]. The patient also has a nephew Dr. [**First Name4 (NamePattern1) 6339**]
[**Known lastname 98584**] in [**State **] who is his healthcare proxy. The patient
has a social worker and a visiting nurse.  He uses a walker or a
cane to ambulate. No alcohol or tobacco. He does have a
lifeline.
The patient is a Holocaust survivor, and lost both his wife and
son in the Holocaust.  He survived by making shoes for the
Nazis.  He was in 5 different concentration camps in [**Country 2784**] and
Poland.  He is listed on the Shoah website.

Family History:
Family History:
N/C; lost his wife and son in the Holocaust.

Physical Exam:
Physical Exam on Admission:
.
VS: T96.8  122/79 HR 64 in AF RR 14 97% 2L
Gen: NAD, seems comfortable but not responding to questions
HEENT: head atraumatic, PERRL, dry MM, clear OP
Neck: supple, no JVD elevation
CV: irregularly irregular, S1 S2, II/VI systolic murmur at USB
(old)
Lungs: CTAB anteriorly
Abd: soft, nontender, nondistended BS +
Ext: no LE edema, DP's 2+ b/l
Neuro: responds to voice once but not thereafter, moves
extremities occasionally, no response to sternal rub. ?Slightly
catatonic (when lifting arm up, keeps it elevated briefly prior
to bringing it down again)

Pertinent Results:
Labs:
[**2175-11-10**] 05:50PM BLOOD WBC-5.7 RBC-5.40# Hgb-16.9# Hct-47.3#
MCV-88 MCH-31.2 MCHC-35.6* RDW-14.3 Plt Ct-229
[**2175-11-20**] 06:15AM BLOOD WBC-3.1* RBC-4.16* Hgb-13.3* Hct-37.5*
MCV-90 MCH-32.0 MCHC-35.5* RDW-13.6 Plt Ct-212
[**2175-11-10**] 05:50PM BLOOD Neuts-77.8* Lymphs-14.2* Monos-6.2
Eos-1.6 Baso-0.1
[**2175-11-11**] 04:08AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-3+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Target-OCCASIONAL
Schisto-OCCASIONAL Burr-2+
[**2175-11-10**] 05:50PM BLOOD PT-18.8* PTT-31.6 INR(PT)-1.8*
[**2175-11-20**] 06:15AM BLOOD PT-27.1* PTT-35.6* INR(PT)-2.7*
[**2175-11-11**] 04:08AM BLOOD Ret Aut-3.6*
[**2175-11-10**] 05:50PM BLOOD Glucose-107* UreaN-13 Creat-1.0 Na-136
K-4.0 Cl-94* HCO3-28 AnGap-18
[**2175-11-20**] 06:15AM BLOOD Glucose-98 UreaN-27* Creat-0.9 Na-131*
K-3.7 Cl-97 HCO3-24 AnGap-14
[**2175-11-10**] 05:50PM BLOOD ALT-26 AST-27 CK(CPK)-93 AlkPhos-117
Amylase-85 TotBili-2.1*
[**2175-11-17**] 06:15PM BLOOD CK(CPK)-34*
[**2175-11-18**] 08:50AM BLOOD CK(CPK)-36*
[**2175-11-10**] 05:50PM BLOOD Lipase-45
[**2175-11-10**] 05:50PM BLOOD cTropnT-0.03*
[**2175-11-11**] 04:08AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2175-11-11**] 02:24PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2175-11-17**] 06:15PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2175-11-18**] 08:50AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2175-11-11**] 04:08AM BLOOD Calcium-9.6 Phos-3.9 Mg-2.4
[**2175-11-20**] 06:15AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.1
[**2175-11-11**] 04:08AM BLOOD VitB12-675 Folate-18.3 Hapto-29*
[**2175-11-12**] 04:13AM BLOOD Osmolal-275
[**2175-11-11**] 04:08AM BLOOD TSH-0.44
[**2175-11-15**] 06:25AM BLOOD Phenyto-12.7
[**2175-11-10**] 05:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2175-11-17**] 10:28AM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.019
[**2175-11-11**] 08:53AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
[**2175-11-10**] 08:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2175-11-17**] 10:28AM URINE Blood-LG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-MOD
[**2175-11-11**] 08:53AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2175-11-10**] 08:00PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2175-11-17**] 10:28AM URINE RBC-10* WBC-36* Bacteri-RARE Yeast-NONE
Epi-<1
[**2175-11-11**] 08:53AM URINE RBC-[**2-13**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-<1
[**2175-11-10**] 08:00PM URINE RBC-[**5-21**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0
[**2175-11-18**] 02:54PM URINE Hours-RANDOM UreaN-912 Creat-75 Na-52
[**2175-11-12**] 02:40PM URINE Hours-RANDOM Creat-43 Na-96
[**2175-11-18**] 02:54PM URINE Osmolal-599
[**2175-11-12**] 02:40PM URINE Osmolal-467
[**2175-11-10**] 08:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
Micro:
.
Blood Cx ([**11-10**]): No growth
Urine Cx ([**11-10**]): No growth
[**11-11**]: RPR nonreactive
.
Imaging:
.
EKG: AFib at 93, new ST depressions in V5 and V6
.
Head CT: There is a mixed-attenuation extra-axial fluid
collection layering over the left frontal and parietal cerebral
convexities with relative [**Name (NI) 13215**] seen posteriorly,
consistent with an acute/subacute on chronic subdural hematoma.
This measures 11 mm in greatest transverse dimension. There is
no shift of the normally midline structures or hydrocephalus.
There are age-appropriate involutional changes and a chronic
right basal ganglial infarct.  Soft tissue thickening in the
posterior cervical region is stable.
The right frontal sinus is hypoplastic.  No fracture is
identified. The paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION:  Left frontal/parietal acute/subacute on chronic
subdural hematoma without evidence of herniation.
.
CXR ([**11-12**]): FINDINGS:
Since the prior study, there is mild interval increase in patchy
atelectasis at the left lung base.  There is also mild patchy
atelectasis at the right lung base.  Heart is mildly enlarged.
Mediastinum is within normal limits. There is mild tortuosity of
the aorta.  There is mild prominence of the central pulmonary
vasculature suggestive of mild congestive failure.
There is mild blunting of the left costophrenic angle consistent
with a small pleural effusion.
IMPRESSION:
1.  Patchy atelectasis at both lung bases.  Mild congestive
failure.  Mild cardiomegaly.
.
EEG ([**11-12**]): IMPRESSION: This is a mildly abnormal EEG in the
waking and drowsy states due to the mildly slow background
rhythm of 7 Hz. This may
be normal for age or may suggest an excessively drowsy state or
may
suggest a mild encephalopathy, which may be seen with medication
effect,
toxic metabolic abnormalities or infections. No epileptiform
discharges
and no electrographic seizures were noted.
.
CXR ([**11-18**]): IMPRESSION: Unchanged radiographic appearance in
comparison to [**2175-11-12**].

Brief Hospital Course:
# Acute on Chronic Subdural Hematoma: Head CT showed acute on
chronic SDH. However, SDH was not felt to contribute to the
patient's mental status changes per neurosurgery as there was no
mass effect of midline shift. No neurosurgical interventions
were required during the hospitalization.  In the MICU, he was
started on Dilantin for seizure prophylaxis, a nipride drip to
keep systolic bp <140, and his anticoagulation was reversed with
proplex and vitamin K.  The nipride drip was quickly weaned and
he was re-started on his home antihypertensive regimen in
addition to captopril (which was eventually changed to
Lisinopril).  Dilantin was discontinued per neurology
recommendations as it was thought to be possibly contributing to
his delerium.   Anticoagulation with heparin SC, Coumadin, and
Aspirin was restarted on hospital day 5 ([**11-14**]).  The patient as
instructed to follow-up with Dr. [**Last Name (STitle) **] in neurosurgery in 4
weeks with a non-contrast head CT.
.
# Altered Mental Status: The patient had decreased
responsiveness, increased depressive symptoms and no PO intake
for 24-48 hours prior to admission.  He initially appeared
slightly catatonic on exam.  Acute on chronic subdural hematoma
without mass effect was not thought to account for his mental
status change.  The patient has a history of depression
refractory to multiple medications and is followed by an
outpatient psychiatrist.  Per nursing home report, he was
recently started on Zyprexa which was discontinued on [**11-7**]
because of hallucinations.  He was also receiving Cymbalta prior
to admission which was held during this admission.  A
toxic-metabolic work-up demonstrated no urine or blood
infection, CXR with no opacification. TSH, B12 and folate were
normal.  RPR was nonreactive, Urine/Serum tox screens negative.
An EEG was also performed to evaluate for seizure as a cause of
mental status change, which showed no epileptiform discharges
and mild encephalopathy, which may be seen with medication
effect, toxic metabolic abnormalities or infections.  His
altered mental status was thought to be due to psychiatric
medication effect.  His mental status improved during the
hospitalization, and upon discharge he was alert and oriented X
3 with no focal neurologic findings.  He did have episodes of
delirium agitation during his stay in the MICU which were
controlled with low-dose haldol (0.5-1.0mg IV as needed).
Neurology was consulted for his paucity of speech, and did not
find evidence of stroke on exam and did not believe any further
neuroimaging was needed.  They recommended discontinuing
Dilantin as that may be contributing to his delerium and
bilateral horizontal nystagmus.  The patient may have [**Last Name (un) 309**] body
dementia, as he had adverse response to neuroleptics.  It is
recommeded to avoid neuroleptics and dopamine antagonists in
this patient. The patient's outpatient gerontologist Dr. [**Last Name (STitle) **]
was contact[**Name (NI) **] while he was in house, and will follow up with him
as an outpatient to decide if and when his psych meds should be
restarted.  He will also follow up with his psychiatrist and a
behavioral neurologist.  It should be noted that he and his
family had a very undesirable admission at the inpatient
geriatric psychiatry unit at [**Hospital3 2568**] in the recent past and
will not entertain any future stays at the facility.
.
# Coronary Artery Disease: The patient has a history of CAD s/p
myocardial infarction x2 and s/p CABG. EKG on admission
demonstrated ST depressions in V5/6.  Trop T 0.03->0.03->0.02
with CK flat (93->61->55), so he ruled-out for MI. He was
monitored on telemetry in the MICU.  His ASA was initially held
in the setting of SDH, but was restarted on hospital day 5.  He
was continued on metoprolol for blood pressure control.  Repeat
EKGs showed no evolving changes.  He was kept on a cardiac diet.
 Patient again complained of chest pain on [**11-17**], EKG unchanged,
tropT 0.07 -> 0.06 with CK flat 34 -> 36. Symptoms improved with
Nitro SL.  The patient's family informed us that the patient
would not want a catheterization or any other heroic measures if
this chest pain was cardiac in nature.  The patient was
discharged with a prescription for nitropaste prn.
.
# [**Month/Day (4) **]: In the ED, the patient's SBP was up to 207, and
he was given Labetolol IV and started on a Nipride drip to keep
SBP <140.  The nipride drip was quickly weaned in the MICU on
hospital day 2.  He was restarted on metoprolol and amlodipine
per his home regimen.  He was also started on captopril, which
was changed to Lisinopril on the medicine floor.  He was noted
to have bradycardia to 40s with metoprolol administration and
his dose was subsequently decreased to 12.5mg PO BID.
.
# Atrial Fibrillation: In the ED, his INR was therapeutic at 1.8
on Coumadin 2 mg daily.  Anticoagulation was reversed with
proplex and Vit K 10mg IV x1, and FFP was ordered but not given.
 Initially held anticoagulation given SDH, but Coumadin was
restarted on hospital day 5 ([**11-14**]).  The patient was continued
on Metoprolol 12.5 [**Hospital1 **] for rate control.
.
# Chronic Kidney Disease: Baseline creatinine 1-1.3 and has
ranged 0.9-1.0 this admission.  UrNa 96, UrCr 43, UrOsm 467.
FeNa 1.58 %.  Repeat urine lytes: UNa 52, UCr 75, Uurea 912,
Uosm 599.  FeNa 0.58, FeUrea 39.3%.  Patient given IVF NS x 500
cc x2, and was encouraged to take PO fluids.
.
# Hyponatremia: Sodium was decreased to nadir of 127 on hospital
day 3. Lab values initially thought to be consistent with SIADH,
and he was subsequently fluid restricted.  However, his urine
output increased on HD5, and SIADH was thought to be less
likely.  His Na decreased to 131, and he was given NS 500 cc at
100 cc/hr x2.  Na should be monitored closely as an outpatient.
.
# UTI: UA showed mod leuk, pos nitr, 36 WBC, rare bacteria.
Urine Cx with >100,000 GNRs, Proteus vulgaris sensitive to
Cipro.  Patient was started on Cipro 250 mg PO bid on [**11-18**].
Continue to monitor coags while on a quinolone.  Continue to
monitor Is/Os, and if retaining urine check a post-void
residual.
.
# Depression: The patient's outpatient psychiatrist is Dr. [**Last Name (STitle) 10166**].
He had a recent admission at [**Hospital3 **], and has a history of
refractory depression with multiple medication trials. He was
started on Zyprexa "recently" with development of hallucinations
3-4 days prior to presentation. Zyprexa was discontinued on
[**11-7**]. He was also on Cymbalta as outpatient.  All of his
psychiatric medications were held during this admission, as they
were thought to be contributing to his altered mental status.
The patient will follow up with his outpatient psychiatrist.
.
# Hyperbilirubinemia: The patient was found to have T bili 2.1
and D bili slightly up at 0.4.  Hemolysis labs: retic 3.6, LDH
210, hapto 29.  Repeat labs showed T bili 0.5 and direct bili
0.2, so no further work up was indicated.
.
# FEN: Patient placed on Regular Cardiac Kosher diet.  Given
Vitamin B12 200 mcg daily and Calcium plus vitamin D 600 mg-200
units t.i.d.
.
# Code Status: DNR/DNI confirmed with HCP
.
# Contact: nephew [**Name (NI) **] is his HCP [**Telephone/Fax (1) 98710**], niece [**Name (NI) **]
[**Name (NI) **] (cell [**Telephone/Fax (1) 98713**], home [**Telephone/Fax (1) 98712**])

Medications on Admission:
MEDICATIONS:
1. Amlodipine 5 mg daily
2. Aspirin 81 mg daily
3. Calcium plus vitamin D 600 mg-200 units t.i.d.
4. Vitamin B12 200 mcg daily
5. Colace 100 mg b.i.d. p.r.n.
6. Lorazepam 0.5 mg one to two tablets q.h.s. p.r.n.
7. Milk of magnesia of uncertain dosage daily p.r.n.
8. Metoprolol tartrate 25 mg b.i.d.
9. Nitroglycerin SL 0.3 mg t.i.d. p.r.n.
10. Metamucil of uncertain dosage
11. Coumadin 2 mg q.h.s.
12. Duloxetine 30 mg PO daily
Note: Zyprexa was stopped prior to admission, as he was
developing hallucinations.
.
ALLERGIES:
1. Procardia
2. Verapamil


Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Calcium + Vitamin D 600 (1,500)-200 mg-unit Tablet Sig: One
(1) Tablet PO three times a day.
4. Cyanocobalamin 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Nitroglycerin 2 % Ointment Sig: 0.5-2 inch Transdermal every
4-6 hours as needed for chest pain.
Disp:*1 bottle* Refills:*0*
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 9 doses.
Disp:*9 Tablet(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 599**] of [**Location (un) 55**]

Discharge Diagnosis:
PRIMARY:
Altered Mental Status
Subdural Hematoma-Acute on Chronic
Hyponatremia
[**Location (un) **]
Hyperbilirubinemia
.
SECONDARY:
Atrial Fibrillation
Coronary Artery Disease
Chronic Kidney Disease
Depression


Discharge Condition:
Stable


Discharge Instructions:
1.  You were admitted to the hospital for changes in mental
status.  You had a CT of your head which showed an old area of
bleeding (subdural hematoma) with a small area of new with
improvement in your medical status.
2.  Call your doctor or return to the hospital if you develop
- Changes in mental status
- New headache
- Seizure
- Fever, chills
- Nausea, vomiting
- Any other new or concerning symptoms
3. Please take all your medications as prescribe
4. Please attend all follow up appointments.

Followup Instructions:
You will need to make a follow-up appointment with Dr. [**Last Name (STitle) **] in
neurosurgery in 4 weeks.  You will also need a repeat
non-contrast Head CT before the appointment.  Call
([**Telephone/Fax (1) 1669**]) to make an appointment once you are discharged.
.
You have an appointment Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 77126**] in psychiatry
([**Telephone/Fax (1) 98714**]) on [**2175-11-23**] at 3:30 pm.
.
You have an appointment with Dr. [**First Name (STitle) 161**] DAS in urology
([**Telephone/Fax (1) 921**]) on [**2175-12-18**] at 10:30 in the [**Hospital Ward Name **] CENTER, [**Location (un) **] UROLOGY CC3.
.
You have an appointment with Dr. [**First Name (STitle) **] [**Doctor Last Name **] ([**Telephone/Fax (1) 719**]) on
[**2175-12-19**] at 10:00 in the [**Hospital Unit Name **], [**Location (un) **] GERONTOLOGY.
.
You have an appointment scheduled with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
behavioral neurology ([**Telephone/Fax (1) 1690**]) on [**2175-12-26**] at 10:00 in the
[**Hospital Ward Name 516**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Location (un) 551**], [**Apartment Address(1) 16806**].
{'Drug-induced delirium,Subdural hemorrhage,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Antidepressants causing adverse effects in therapeutic use,Atrial fibrillation,Old myocardial infarction,Aortocoronary bypass status,Personal history of malignant neoplasm of prostate,Depressive disorder, not elsewhere classified,Other abnormal blood chemistry,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}


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: Altered Mental Status

PRESENT ILLNESS: History of Present Illness: [**Age over 90 **] yo M with CAD s/p MI x2, CABG in
[**2161**], HTN, AF on anticoag, recent admission for CP, depression,
now admitted for a change in mental status, found to have acute
on chronic subdural hematoma. Pt was sent to ED by nurse [**First Name (Titles) **] [**Hospital3 **] because of worsening MS over last few days.
Refused POs or ambulation. Became more withdrawn and confused,
eventually minimally responsive. Said he felt like he didn't
want to live.  No history of trauma.  Psych meds were recently
changed.
.
In the ED, his VS were 97.3, HR 87 in AF, BP 207/137, RR 30,
100%RA. FS was 156. He received labetolol 10 IV x2, nitro paste.
Labs without acute findings. UA unremarkable. EKG with ST
depressions in V5/6. Trop 0.03. Pt had gag reflex and was not
intubated. Head CT with acute on chronic SDH. Neurosurgery was
consulted and felt that MS change was not likely related to SDH
as no mass effect or midline shift.  However, nipride gtt was
started to keep SBP less than 140. Anticoagulation was reversed
with ?proplex and Vit K 10mg IV x1. FFP was ordered but not
given. Pt was also started on Dilantin 1g IV and received 10mg
Lasix IV x1 as well as Narcan 0.2 IV with no response.

MEDICAL HISTORY: Past Medical History:
1. Coronary artery disease
- AMI ([**2139**])
- AMI ([**2161**])
- Status post CABG in [**2161**]
--> SVG-LAD, SVG-OM, SVG-RPDA and LIMA to D1
- PCI ([**7-16**])
--> SVG->LAD with drug-eluting stent
--> SVG->OM1 with drug-eluting stent
- Stress ([**4-16**]): MIBI showed normal myocardial perfusion with a

MEDICATION ON ADMISSION: MEDICATIONS:
1. Amlodipine 5 mg daily
2. Aspirin 81 mg daily
3. Calcium plus vitamin D 600 mg-200 units t.i.d.
4. Vitamin B12 200 mcg daily
5. Colace 100 mg b.i.d. p.r.n.
6. Lorazepam 0.5 mg one to two tablets q.h.s. p.r.n.
7. Milk of magnesia of uncertain dosage daily p.r.n.
8. Metoprolol tartrate 25 mg b.i.d.
9. Nitroglycerin SL 0.3 mg t.i.d. p.r.n.
10. Metamucil of uncertain dosage
11. Coumadin 2 mg q.h.s.
12. Duloxetine 30 mg PO daily
Note: Zyprexa was stopped prior to admission, as he was
developing hallucinations.
.
ALLERGIES:
1. Procardia
2. Verapamil

ALLERGIES: Procardia / Verapamil

PHYSICAL EXAM: Physical Exam on Admission:
.
VS: T96.8  122/79 HR 64 in AF RR 14 97% 2L
Gen: NAD, seems comfortable but not responding to questions
HEENT: head atraumatic, PERRL, dry MM, clear OP
Neck: supple, no JVD elevation
CV: irregularly irregular, S1 S2, II/VI systolic murmur at USB
(old)
Lungs: CTAB anteriorly
Abd: soft, nontender, nondistended BS +
Ext: no LE edema, DP's 2+ b/l
Neuro: responds to voice once but not thereafter, moves
extremities occasionally, no response to sternal rub. ?Slightly
catatonic (when lifting arm up, keeps it elevated briefly prior
to bringing it down again)

FAMILY HISTORY: Family History:
N/C; lost his wife and son in the Holocaust.

SOCIAL HISTORY: SOCIAL HISTORY:
He lives [**Street Address(1) 83359**] [**Hospital3 400**].  He is retired from
working as a  stitcher. He has a niece [**Name (NI) **] [**Name (NI) **] who lives
in the area who is involved in some of his day-to-day care. Her
home phone number is [**Telephone/Fax (1) 98712**]. Her cellular phone number is
[**Telephone/Fax (1) 98713**]. The patient also has a nephew Dr. [**First Name4 (NamePattern1) 6339**]
[**Known lastname 98584**] in [**State **] who is his healthcare proxy. The patient
has a social worker and a visiting nurse.  He uses a walker or a
cane to ambulate. No alcohol or tobacco. He does have a
lifeline.
The patient is a Holocaust survivor, and lost both his wife and
son in the Holocaust.  He survived by making shoes for the
Nazis.  He was in 5 different concentration camps in [**Country 2784**] and
Poland.  He is listed on the Shoah website. 

### Response:
{'Drug-induced delirium,Subdural hemorrhage,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Antidepressants causing adverse effects in therapeutic use,Atrial fibrillation,Old myocardial infarction,Aortocoronary bypass status,Personal history of malignant neoplasm of prostate,Depressive disorder, not elsewhere classified,Other abnormal blood chemistry,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}
