CHIEF COMPLAINT: SAH/SDH

PRESENT ILLNESS: HPI: Mr. [**Known lastname **] is a R handed 88yM with a history of early
stage
dementia and ETOH abuse who presented to OSH [**6-13**] s/p fall at
~445pm. It is unclear if it was a mechanical fall down stairs or
fall from standing near stairs. He was initially responsive and
coherent but had worsening mental status changes/confusion. He
was vomiting and incontinent of urine after the fall. His son
found him ~5 minutes after the fall. He was BIBA to [**Hospital 1121**]
Hospital. There, his imaging demonstrated SAH L>R in the frontal
and temporal regions and SDH small frontal. He was transferred
to
[**Hospital1 18**] for further management. He had ETOH in the afternoon ETOH
at OSH 52.

MEDICAL HISTORY: [**Name (NI) **] pt suffered MI [**85**] years ago; had arrythmias from that time
until underwent ablation in [**2169**] (?)
CHF - per pt's family, pt's EF: 30-35%. No known
hospitalizations for CHF exacerbation.
ICD - has had pacemaker+defibrillator for approximately 5 years.
Per family, defibrillator activated several times, prompting
ablation procedures. Previously, the pt had pacemaker only.
Sub-arachnoid hemorrhages - pt has a history of multiple bleeds
[**2-6**] falls. Pt underwent surgical repair at [**Hospital1 112**] in [**2170**].
EtOH Abuse- per son/caretaker, pt drinks 1.5oz QOD.
Left Meningioma
Double vision - pt has experienced diplopia since [**70**]/[**2172**]. As a
result, he keeps his left eye shut.
Hip replacement
Asthma

MEDICATION ON ADMISSION: ASA 81
Amiodarone 200
Torsemide 10
Zoloft 112.5
Metoprolol 25
Zetia 10
Pravastatin 40
Flomax 0.4
Advair 100/50"
Proventil inh
Remeron 15
Abmien 5
Aricept ?5
MVI
Melatonin 5
Senna 8.5
Docusate 100

ALLERGIES: atenolol / atorvastatin / Medrol / Nefazodone / Phenylbutazone /
trazodone

PHYSICAL EXAM: EXAM ON ADMISSION TO NEUROSURGERY
GCS 11  E:4      V:2  Motor: 5
O: BP: 151 / 74        HR:69    R  18     O2Sats 99%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2 bilaterally  Conjunctival hemorrhage on
Right
      EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+ Umbo hernia reducible
Extrem: Warm and well-perfused. No C/C/E.

FAMILY HISTORY: NC
younger brothers died of heart disease

SOCIAL HISTORY: Pt was born and raised in [**Country 22965**]. Was member of underground
military resistance during WWII. Worked as food scientist for
Necco and then as VP of Product Development for [**Location (un) 112210**]
Chocolates.
Per family, pt has history of EtOH abuse. Former smoker (quit 25
years ago). Lives with son (caretaker) [**Name (NI) **] ([**Telephone/Fax (1) 112211**]) and
wife.
Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Metabolic encephalopathy,Delirium due to conditions classified elsewhere,Other closed fractures of distal end of radius (alone),Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Chronic systolic heart failure,Unspecified fall,Coronary atherosclerosis of native coronary artery,Alcohol abuse, continuous,Dementia, unspecified, without behavioral disturbance,Diplopia,Thrombocytopenia, unspecified,Other dysphagia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Nephritis and nephropathy, not specified as acute or chronic, with other specified pathological lesion in kidney,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Asthma, unspecified type, unspecified,Other and unspecified hyperlipidemia,Leukocytosis, unspecified,Atrial fibrillation,Constipation, unspecified,Benign neoplasm of cerebral meninges,Unspecified deficiency anemia,Other specified forms of hearing loss,Old myocardial infarction,Automatic implantable cardiac defibrillator in situ,Hip joint replacement,Do not resuscitate status
Subarachnoid hem-no coma,Metabolic encephalopathy,Delirium d/t other cond,Fx distal radius NEC-cl,Acute kidney failure NOS,Hyperosmolality,Chr systolic hrt failure,Fall NOS,Crnry athrscl natve vssl,Alcohol abuse-continuous,Demen NOS w/o behv dstrb,Diplopia,Thrombocytopenia NOS,Dysphagia NEC,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,Nephritis NEC,BPH w/o urinary obs/LUTS,Asthma NOS,Hyperlipidemia NEC/NOS,Leukocytosis NOS,Atrial fibrillation,Constipation NOS,Ben neo cerebr meninges,Deficiency anemia NOS,Hearing loss NEC,Old myocardial infarct,Status autm crd dfbrltr,Joint replaced hip,Do not resusctate status
Admission Date:  [**2172-6-13**]              Discharge Date:   [**2172-6-24**]


Service: MEDICINE

Allergies:
atenolol / atorvastatin / Medrol / Nefazodone / Phenylbutazone /
trazodone

Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
SAH/SDH


Major Surgical or Invasive Procedure:
none


History of Present Illness:
HPI: Mr. [**Known lastname **] is a R handed 88yM with a history of early
stage
dementia and ETOH abuse who presented to OSH [**6-13**] s/p fall at
~445pm. It is unclear if it was a mechanical fall down stairs or
fall from standing near stairs. He was initially responsive and
coherent but had worsening mental status changes/confusion. He
was vomiting and incontinent of urine after the fall. His son
found him ~5 minutes after the fall. He was BIBA to [**Hospital 1121**]
Hospital. There, his imaging demonstrated SAH L>R in the frontal
and temporal regions and SDH small frontal. He was transferred
to
[**Hospital1 18**] for further management. He had ETOH in the afternoon ETOH
at OSH 52.


Past Medical History:
[**Name (NI) **] pt suffered MI [**85**] years ago; had arrythmias from that time
until underwent ablation in [**2169**] (?)
CHF - per pt's family, pt's EF: 30-35%. No known
hospitalizations for CHF exacerbation.
ICD - has had pacemaker+defibrillator for approximately 5 years.
Per family, defibrillator activated several times, prompting
ablation procedures. Previously, the pt had pacemaker only.
Sub-arachnoid hemorrhages - pt has a history of multiple bleeds
[**2-6**] falls. Pt underwent surgical repair at [**Hospital1 112**] in [**2170**].
EtOH Abuse- per son/caretaker, pt drinks 1.5oz QOD.
Left Meningioma
Double vision - pt has experienced diplopia since [**70**]/[**2172**]. As a
result, he keeps his left eye shut.
Hip replacement
Asthma

PSH:
Craniotomy at [**Hospital6 **] 1.5 years ago Dr. [**Last Name (STitle) **] [**Last Name (STitle) 112209**]
hematoma
L hip replacement


Social History:
Pt was born and raised in [**Country 22965**]. Was member of underground
military resistance during WWII. Worked as food scientist for
Necco and then as VP of Product Development for [**Location (un) 112210**]
Chocolates.
Per family, pt has history of EtOH abuse. Former smoker (quit 25
years ago). Lives with son (caretaker) [**Name (NI) **] ([**Telephone/Fax (1) 112211**]) and
wife.


Family History:
NC
younger brothers died of heart disease


Physical Exam:
EXAM ON ADMISSION TO NEUROSURGERY
GCS 11  E:4      V:2  Motor: 5
O: BP: 151 / 74        HR:69    R  18     O2Sats 99%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2 bilaterally  Conjunctival hemorrhage on
Right
      EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+ Umbo hernia reducible
Extrem: Warm and well-perfused. No C/C/E.

Neuro:
Mental status: Awake non-cooperative
Orientation: not responding to any questions
Recall: unable to assess
Language: not answering questions. Per son since the fall he has
been speaking Norweigan only. (Native from [**Country 22965**], speaks
English
fluently)
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields unable to assess
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial symmetric.
VIII: Hearing: Pt deaf on Left
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-9**] throughout. No pronator drift

Sensation: Intact to light touch bilaterally

Reflexes: B Br Pa Ac
Right     + +  +  +
Left      + +  +  +

Toes upgoing bilaterally

Coordination: unable to assess

Handedness Right

Physical Exam on Discharge from Medicine Service
Vitals: 97.2 156/88 82 18 96%RA
General: Alert and Oriented x 0. NAD. Denies pain.
Skin: erythematous macules on back; large ecchymoses on upper
extremities and hands bilaterally.
HEENT: L pupil 3mm, R pupil 2mm. Subconjunctival hemorrhage in R
eye (lateral and medial to [**Doctor First Name 2281**]). Copious oral secretions. No
lymphadenopathy. Dop-off tube in place, and bridled. Neck
supple.
CV: RRR, no RMG; laterally displaced PMI.
Pulm: exam notable for upper airway sounds diffusely
transmitted. No wheezes, rhonchi, crackles. Pt breathing
comfortably. Occasional non-productive upper respiratory cough.
Abd: soft, non-tender, non-distended. Small umbilical hernia.
Ext: Cast on R wrist/forearm. 2+ upper and lower extremity
pulses. No lower extremity edema.
Neuro: A&Ox0. Able to follow some commands. Able to answer
questions, though comprehension very limited. No short-term
memory. Pupils stably asymmetric (L>R); both reactive.

Pertinent Results:
[**6-14**] Chest Xray: There is a left-sided AICD with lead tips in
the right atrium and right ventricle.  There is a feeding tube
whose tip and side port are below the gastroesophageal junction.
 Cardiomegaly which is stable.  There is atelectasis at the left
base.  There are no pneumothoraces.  There is mild prominence of
the pulmonary vascular markings without overt pulmonary edema.

[**6-14**] CT head
1.  Redemonstration of subarachnoid, subdural, and now
intraventricular
hematoma without significant interval change, or mass effect.
2.  Left CP angle mass extending into the middle cranial fossa,
most
consistent with meningioma.  This could be better evaluated with
MRI when
clinically appropriate.

[**6-14**] Abdominal xray:
NG within the stomach

[**6-16**] CT Head
1.  No change in the subarachnoid, subdural, and
intraventricular hemorrhage.  No new hemorrhage is appreciated.
2.  Enlargement of the bilateral frontal extra-axial spaces is
most consistent with developing hygromas.  There is no
significant mass effect from this change.
3.  Stable hypodensity in the right cerebellum is consistent
with an
infarction of indeterminate age.
4.  Stable left cerebellopontine angle meningioma

[**2172-6-16**] 10:57 PM
IMPRESSION: infrahilar atelectasis.  There is no pulmonary
edema or appreciable pleural effusion.  Severe cardiomegaly
including an apical ventricular aneurysm has not changed over
the past two days.

[**2172-6-18**] CXR
IMPRESSION:  Stable left infrahilar atelectasis without new
airspace opacity concerning for pneumonia.

[**2172-6-19**]: WRIST 3 VIEWS BILATERALLY
LEFT WRIST:  There are no signs for acute fractures or
dislocations.  There are some mild degenerative changes of the
first CMC joint.
RIGHT WRIST:  Subtle lucency involving the ulnar aspect of the
right distal radius which may represent a subtle non-displaced
fracture.  Please correlate with direct pain at this site.
There are mild degenerative changes of the first CMC and
triscaphe joints.

[**2172-6-21**]: CT ABDOMEN W/O CONTRAST
Reason: Pre-PEG placement
IMPRESSION:
1.  Isodense 1.6-cm renal lesion.  This finding can be better
evaluated with ultrasound.
2.  Small/trace bilateral pleural effusions, slightly greater on
the right.

[**2172-6-24**] 11:35 AM  [**Last Name (un) **]-INTESTINAL TUBE PLACEMENT
IMPRESSION:  Successful repositioning of Dobbhoff tube into the
post-pyloric position.  The tube is ready to use.

CBC
[**2172-6-24**] 05:30AM BLOOD WBC-8.4 RBC-3.46* Hgb-11.1* Hct-35.4*
MCV-102* MCH-32.0 MCHC-31.3 RDW-15.1 Plt Ct-244
[**2172-6-23**] 05:34AM BLOOD WBC-8.8 RBC-3.26* Hgb-10.7* Hct-32.7*
MCV-101* MCH-32.8* MCHC-32.7 RDW-15.3 Plt Ct-230
[**2172-6-22**] 05:45AM BLOOD WBC-10.0 RBC-3.22* Hgb-10.8* Hct-32.5*
MCV-101* MCH-33.4* MCHC-33.1 RDW-15.2 Plt Ct-204
[**2172-6-21**] 05:55AM BLOOD WBC-9.8 RBC-3.16* Hgb-10.3* Hct-31.8*
MCV-101* MCH-32.7* MCHC-32.4 RDW-15.5 Plt Ct-174
[**2172-6-20**] 05:00AM BLOOD WBC-11.0 RBC-3.20* Hgb-10.3* Hct-32.9*
MCV-103* MCH-32.0 MCHC-31.1 RDW-15.3 Plt Ct-182
[**2172-6-19**] 05:00AM BLOOD WBC-12.0* RBC-3.14* Hgb-10.3* Hct-32.0*
MCV-102* MCH-32.8* MCHC-32.2 RDW-15.6* Plt Ct-143*
[**2172-6-18**] 07:14AM BLOOD WBC-11.9* RBC-3.43* Hgb-11.2* Hct-35.5*
MCV-104* MCH-32.6* MCHC-31.5 RDW-15.8* Plt Ct-142*
[**2172-6-17**] 07:30AM BLOOD WBC-10.2 RBC-3.37* Hgb-10.8* Hct-34.5*
MCV-103* MCH-32.2* MCHC-31.3 RDW-15.5 Plt Ct-159
[**2172-6-16**] 11:56AM BLOOD WBC-10.5 RBC-3.68* Hgb-11.8* Hct-38.0*
MCV-103* MCH-31.9 MCHC-31.0 RDW-15.3 Plt Ct-158
[**2172-6-14**] 04:43AM BLOOD WBC-12.4* RBC-3.56* Hgb-11.8* Hct-35.1*
MCV-99* MCH-33.1* MCHC-33.6 RDW-15.5 Plt Ct-152
[**2172-6-13**] 10:30PM BLOOD WBC-13.3* RBC-3.62* Hgb-11.8* Hct-35.8*
MCV-99* MCH-32.7* MCHC-33.0 RDW-15.5 Plt Ct-140*
[**2172-6-19**] 05:00AM BLOOD Neuts-87.8* Lymphs-7.6* Monos-3.4 Eos-0.9
Baso-0.2
[**2172-6-13**] 10:30PM BLOOD Neuts-93.2* Lymphs-3.3* Monos-3.2 Eos-0.1
Baso-0.1

CHEMISTRIES
[**2172-6-24**] 05:30AM BLOOD Glucose-93 UreaN-32* Creat-1.4* Na-144
K-5.0 Cl-110* HCO3-20* AnGap-19
[**2172-6-23**] 05:34AM BLOOD Glucose-101* UreaN-32* Creat-1.5* Na-145
K-3.8 Cl-107 HCO3-27 AnGap-15
[**2172-6-22**] 05:45AM BLOOD Glucose-113* UreaN-31* Creat-1.3* Na-141
K-3.9 Cl-103 HCO3-28 AnGap-14
[**2172-6-21**] 05:55AM BLOOD Glucose-130* UreaN-31* Creat-1.3* Na-143
K-4.0 Cl-105 HCO3-30 AnGap-12
[**2172-6-20**] 05:00AM BLOOD Glucose-153* UreaN-28* Creat-1.2 Na-144
K-3.7 Cl-106 HCO3-30 AnGap-12
[**2172-6-18**] 07:14AM BLOOD Glucose-155* UreaN-26* Creat-1.3* Na-147*
K-4.3 Cl-110* HCO3-26 AnGap-15
[**2172-6-17**] 07:30AM BLOOD Glucose-160* UreaN-27* Creat-1.5* Na-145
K-3.2* Cl-108 HCO3-26 AnGap-14
[**2172-6-16**] 11:56AM BLOOD Glucose-94 UreaN-20 Creat-1.2 Na-149*
K-2.9* Cl-108 HCO3-28 AnGap-16
[**2172-6-14**] 04:43AM BLOOD Glucose-141* UreaN-20 Creat-1.5* Na-142
K-4.1 Cl-102 HCO3-26 AnGap-18
[**2172-6-13**] 10:30PM BLOOD Glucose-147* UreaN-21* Creat-1.5* Na-144
K-3.1* Cl-104 HCO3-26 AnGap-17

LYTES
[**2172-6-24**] 05:30AM BLOOD Phos-3.7 Mg-3.0*
[**2172-6-19**] 05:00AM BLOOD Phos-2.5* Mg-2.1
[**2172-6-18**] 07:14AM BLOOD Calcium-8.6 Phos-2.1* Mg-2.1
[**2172-6-17**] 05:40PM BLOOD Calcium-8.7 Phos-1.6* Mg-2.1
[**2172-6-18**] 07:14AM BLOOD VitB12-668

ENZYMES
[**2172-6-19**] 05:00AM BLOOD ALT-28 AST-29 AlkPhos-79 Amylase-153*
TotBili-0.9
[**2172-6-19**] 05:00AM BLOOD TSH-2.4

TOX SCREEN
[**2172-6-13**] 10:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

MICROBIOLOGY - URINE
[**2172-6-19**] 12:00PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG
[**2172-6-15**] 10:56AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM

URINE ELECTROLYTES
[**2172-6-19**] 12:00PM UreaN-490 Creat-42 Na-91 K-37 Cl-94

Brief Hospital Course:
88 M with history of prior subdural hemorrhages is admitted for
recurrent subdural and subarachnoid hemorrhage in setting of
mechanical fall.

#HEAD TRAUMA/INTRACRANIAL HEMORRHAGES
Mr. [**Known lastname **] was admitted to the Neurosurgical ICU for Q1 hour
neurochecks after having subdural and subarachnoid hemorrhages
in his brain after mechanial fall.  Aspirin was held due to his
head injury.  He was started on Keppra 500mg [**Hospital1 **] for seizure
prophylaxis given his extensive head injury.  His neuroligical
exam fluctuated likely due to his head injury with underlying
cognitive slowing.
On the morning of [**6-14**] repeat head CT demonstrated stable
bilateral SAH and contusions and he was transfered to the
regular floor.  He was unable to tolerate PO foods or pills so
an NG tube was placed. Speech and Swallow consult was obtained
and he was not able to control his secretions. On [**6-16**], a repeat
head CT was stable. At time of discharge, patient was still not
able to control oral secretions (failed speech and swallow the
day of discharge) and thus needed continued feeds through [**Last Name (un) 1372**]
gastric tube, a new [**Last Name (un) **]-gastric tube was placed post-pyloric
per IR on [**2172-6-24**].

# UPPER RESPIRATORY SECRETIONS/COUGH: Pt had some upper airway
crackles on exam. Serial CXRs were negative for pneumonia. Upper
airway crackles likely secondary to patient's poor ability to
control oral secretions. He was satting in high 90s on RA.

# ALTERED MENTAL STATUS: The patient had a persistently altered
mental status and was frequently A&Ox0. He was inattentive, and
clutched at gown and lines, and required soft restraints (mitts)
for several days to prevent injury to self. Mental status waxed
and waned daily; pt was occasionally able to engage in simple
conversation answering with 1 word. These deficits were likely
due primarily to recent head trauma, baseline deficits, and
delirium. [**2172-6-14**] EEG indicated mild diffuse encephalopathy. The
patient was maintained on his home regimen of Aricept, Zoloft,
and mirtazapine.

# Right upper extremity FRACTURE: The pt had marked bruising of
his upper extremities bilaterally, which prompted bilateral
upper extremity radiographs. Pt was found to have a right radial
fracture. Cast was placed, per orthopedics.

# THROMBOCYTOPENIA  On admission, pt had a mild
thrombocytopenia, which resolved spontaneously during his
hospital course.

# RENAL INCIDENTALOMA: On abdominal CT (preparation for ?PEG
placement), the pt was noted to have an isodense 1.6-cm renal
lesion. According to readiology, this finding can be better
evaluated with ultrasound. We did not pursue this finding
further, given the patient's age, active medical issues and
comorbidities, and absence of renal/urologic symptoms. Can be
further addressed outpatient.

# ELEVATED CREATININE/Chronic Kidney Disease: During his
admission, the pt's serum creatine ranged from 1.3 to 1.5.
Baseline Cr unknown. Cr stable the last week of his
hospitalization. Pt likely has some degree of CKD.

# GOALS OF CARE: Family very actively involved in patient's
care. Decision was made to make him DNR/DNI, although
immediately prior to transport to the rehab facility the family
changed him to DNI but okay to rescucitate. Family is interested
in pursuing treatments at this time to see if his father's
mental status can be optimized (ex: physical therapy, [**Last Name (un) **]
gastric feeding). If he does not clinically improve over the
next 1-2 weeks, family has expressed interest in discussing
changing goals of care to focusing on comfort. These wishes are
consistent with patient's living will.

Transitional issues:
-adrenal incidentaloma
-right wrist non displaced fracture


Medications on Admission:
ASA 81
Amiodarone 200
Torsemide 10
Zoloft 112.5
Metoprolol 25
Zetia 10
Pravastatin 40
Flomax 0.4
Advair 100/50"
Proventil inh
Remeron 15
Abmien 5
Aricept ?5
MVI
Melatonin 5
Senna 8.5
Docusate 100


Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Amiodarone 200 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC TID
5. LeVETiracetam 500 mg PO BID
6. Torsemide 10 mg PO DAILY
hold BP<100
7. Sertraline 75 mg PO DAILY
8. Pravastatin 40 mg PO DAILY
9. Senna 1 TAB PO HS
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Donepezil 5 mg PO HS
12. Ezetimibe 10 mg PO DAILY
13. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
14. Multivitamins 1 TAB PO DAILY
15. FoLIC Acid 1 mg PO DAILY
16. Mirtazapine 15 mg PO HS
17. Metoprolol Succinate XL 25 mg PO DAILY


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)

Discharge Diagnosis:
Bilateral traumatic Subarachnoid hemorrhage
Brain contusions
Subdural hematoma
Delirium


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


Discharge Instructions:
Dear Mr. [**Known lastname **],

It was a privilege to participate in your care.

You were admitted to the [**Hospital1 69**]
becaus you had fallen and hit your head, and were found to have
bleeding in your brain. You were admitted to the Neurosurgery
Service, where you were observed for several days. A tube was
put through your nose, into your stomach, so that you could
receive nutrients and medicines.
After several days, you were transferred to the General Medicine
Service, because of concerns about your breathing.

You were observed on the Medicine service for several days. You
did not have a lung infection (pneumonia), but you did have a
cough related to mucus and extra saliva in your throat. Because
you were unable to control your swallowing muscles, you
continued to be fed by a tube in your nose.

The Medicine Service discovered a fracture ("broken bone") in
your right wrist. This fracture probably occurred during your
recent fall. The Orthopedic Surgery service recommended that
your right arm be put in a cast.

Finally, you were often confused during your time on our
service. Often, you did not know your name or where you were. We
hope that this will improve, along with your physical health, in
the [**Hospital **] Hospital.

Neurosurgery provided the following recommendations:

-  You must stop drinking alcohol
??????	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.

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:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in _4_weeks (from [**2172-6-18**]).
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Metabolic encephalopathy,Delirium due to conditions classified elsewhere,Other closed fractures of distal end of radius (alone),Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Chronic systolic heart failure,Unspecified fall,Coronary atherosclerosis of native coronary artery,Alcohol abuse, continuous,Dementia, unspecified, without behavioral disturbance,Diplopia,Thrombocytopenia, unspecified,Other dysphagia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Nephritis and nephropathy, not specified as acute or chronic, with other specified pathological lesion in kidney,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Asthma, unspecified type, unspecified,Other and unspecified hyperlipidemia,Leukocytosis, unspecified,Atrial fibrillation,Constipation, unspecified,Benign neoplasm of cerebral meninges,Unspecified deficiency anemia,Other specified forms of hearing loss,Old myocardial infarction,Automatic implantable cardiac defibrillator in situ,Hip joint replacement,Do not resuscitate status'}


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: SAH/SDH

PRESENT ILLNESS: HPI: Mr. [**Known lastname **] is a R handed 88yM with a history of early
stage
dementia and ETOH abuse who presented to OSH [**6-13**] s/p fall at
~445pm. It is unclear if it was a mechanical fall down stairs or
fall from standing near stairs. He was initially responsive and
coherent but had worsening mental status changes/confusion. He
was vomiting and incontinent of urine after the fall. His son
found him ~5 minutes after the fall. He was BIBA to [**Hospital 1121**]
Hospital. There, his imaging demonstrated SAH L>R in the frontal
and temporal regions and SDH small frontal. He was transferred
to
[**Hospital1 18**] for further management. He had ETOH in the afternoon ETOH
at OSH 52.

MEDICAL HISTORY: [**Name (NI) **] pt suffered MI [**85**] years ago; had arrythmias from that time
until underwent ablation in [**2169**] (?)
CHF - per pt's family, pt's EF: 30-35%. No known
hospitalizations for CHF exacerbation.
ICD - has had pacemaker+defibrillator for approximately 5 years.
Per family, defibrillator activated several times, prompting
ablation procedures. Previously, the pt had pacemaker only.
Sub-arachnoid hemorrhages - pt has a history of multiple bleeds
[**2-6**] falls. Pt underwent surgical repair at [**Hospital1 112**] in [**2170**].
EtOH Abuse- per son/caretaker, pt drinks 1.5oz QOD.
Left Meningioma
Double vision - pt has experienced diplopia since [**70**]/[**2172**]. As a
result, he keeps his left eye shut.
Hip replacement
Asthma

MEDICATION ON ADMISSION: ASA 81
Amiodarone 200
Torsemide 10
Zoloft 112.5
Metoprolol 25
Zetia 10
Pravastatin 40
Flomax 0.4
Advair 100/50"
Proventil inh
Remeron 15
Abmien 5
Aricept ?5
MVI
Melatonin 5
Senna 8.5
Docusate 100

ALLERGIES: atenolol / atorvastatin / Medrol / Nefazodone / Phenylbutazone /
trazodone

PHYSICAL EXAM: EXAM ON ADMISSION TO NEUROSURGERY
GCS 11  E:4      V:2  Motor: 5
O: BP: 151 / 74        HR:69    R  18     O2Sats 99%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2 bilaterally  Conjunctival hemorrhage on
Right
      EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+ Umbo hernia reducible
Extrem: Warm and well-perfused. No C/C/E.

FAMILY HISTORY: NC
younger brothers died of heart disease

SOCIAL HISTORY: Pt was born and raised in [**Country 22965**]. Was member of underground
military resistance during WWII. Worked as food scientist for
Necco and then as VP of Product Development for [**Location (un) 112210**]
Chocolates.
Per family, pt has history of EtOH abuse. Former smoker (quit 25
years ago). Lives with son (caretaker) [**Name (NI) **] ([**Telephone/Fax (1) 112211**]) and
wife. 

### Response:
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Metabolic encephalopathy,Delirium due to conditions classified elsewhere,Other closed fractures of distal end of radius (alone),Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Chronic systolic heart failure,Unspecified fall,Coronary atherosclerosis of native coronary artery,Alcohol abuse, continuous,Dementia, unspecified, without behavioral disturbance,Diplopia,Thrombocytopenia, unspecified,Other dysphagia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Nephritis and nephropathy, not specified as acute or chronic, with other specified pathological lesion in kidney,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Asthma, unspecified type, unspecified,Other and unspecified hyperlipidemia,Leukocytosis, unspecified,Atrial fibrillation,Constipation, unspecified,Benign neoplasm of cerebral meninges,Unspecified deficiency anemia,Other specified forms of hearing loss,Old myocardial infarction,Automatic implantable cardiac defibrillator in situ,Hip joint replacement,Do not resuscitate status'}
