CHIEF COMPLAINT: multiple falls, acute on chronic SDH

PRESENT ILLNESS: This is a 63 year old Male who was switched from Cymbalta a few
months prior to Prozac and noted some dizziness and
lightheadedness episodes. The patient notes over the past 2.5
weeks he has experienced 2 falls without LOC, associated with
intermittent 6/10 intensity headaches, with gait instability,
but he did not seek medical care. His daughter lives with him.
She finally noticed he had multiple ecchymoses and chronic falls
and decided to bring him to [**Hospital1 18**] [**Location (un) **]. A CT head [**2207-12-13**]
showed a grossly stable acute on chronic Right hemispheric
subdural hematoma and scattered Right SAH; R cerebral sulcal
effacement and roughly 6 mm R-to-L MLS (was 5mm) with no
evidence of
herniation. No recent trauma or injury for at least 2 weeks. He
has a history of chronic anticoagulation for history of PE with
Coumadin (INR 17.5 on admission). Patient received oral/IV
vitamin K prior to transfer.
.
He notes chronic peripheral neuropathy with no sensation,
temperature or pain felt below the knees bilaterally, but
ongoing.

MEDICAL HISTORY: -Gout: diagnosed when patient was in his 20's. Experiences
flares regularly and is on chronic meds.
-Status post clamshell repair of PFO: presented with massive
bilateral pulmonary emboli and emboli in spleen
-Hypertension
-Hyperhomocysteinemia
-Alcohol abuse
-Cervical stenosis
-Neuropathy
-ETOH abuse

MEDICATION ON ADMISSION: Medications prior to admission: Coumadin 2.5 mg PO daily, Folic
Acid, Colchicine, Allopurinol, Lisinopril, Plavix, Estrilyrica,
Prozac

ALLERGIES: Heparin Agents

PHYSICAL EXAM: PHYSICAL EXAM: On Admission
O: T 97.2 BP 120/84 P 108 R 16 O2sat 94%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-2 mm bilateral pupils equally reactive to
light.
EOMs intact bilaterally.
Neck: Supple. No point tenderness.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, tender, BS+ Notable ecchymosis over LUQ/LLQ
diffusely.
Extrem: Warm and well-perfused. Right 4th digit tender to
palpation with ecchymosis.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-1**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: Father died from complication of abdominal surgery at 93. Mother
with brain tumor.

SOCIAL HISTORY: Works as a personal consultant. Lives with 27 year old daughter
and her son. [**Name (NI) **] used to smoke, but stopped 7 years ago.
Denies current alcohol abuse, but endorses previous alcohol
abuse.
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Toxic encephalopathy,Pneumonia due to other gram-negative bacteria,Acute on chronic combined systolic and diastolic heart failure,Critical illness polyneuropathy,Hyperosmolality and/or hypernatremia,Pulmonary collapse,Acute venous embolism and thrombosis of superficial veins of upper extremity,Delirium due to conditions classified elsewhere,Flaccid hemiplegia and hemiparesis affecting unspecified side,Unspecified protein-calorie malnutrition,Subdural hemorrhage,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Atrial fibrillation,Acute gouty arthropathy,Retention of urine, unspecified,Hypoxemia,Abdominal aneurysm without mention of rupture,Chronic ulcer of other specified sites,Chronic cholecystitis,Unspecified hemorrhoids without mention of complication,Anemia, unspecified,Other and unspecified alcohol dependence, unspecified,Personal history of venous thrombosis and embolism,Personal history of tobacco use,Long-term (current) use of anticoagulants
Subdural hem w/o coma,Toxic encephalopathy,Pneumo oth grm-neg bact,Ac/chr syst/dia hrt fail,Crit illness neuropathy,Hyperosmolality,Pulmonary collapse,Ac embl suprfcl up ext,Delirium d/t other cond,Flccd hmiplga unspf side,Protein-cal malnutr NOS,Subdural hemorrhage,Hyperlipidemia NEC/NOS,Hypertension NOS,Atrial fibrillation,Acute gouty arthropathy,Retention urine NOS,Hypoxemia,Abdom aortic aneurysm,Chronic skin ulcer NEC,Chronic cholecystitis,Hemorrhoids NOS,Anemia NOS,Alcoh dep NEC/NOS-unspec,Hx-ven thrombosis/embols,History of tobacco use,Long-term use anticoagul
Admission Date:  [**2207-12-13**]              Discharge Date:   [**2208-1-7**]

Date of Birth:  [**2143-12-24**]             Sex:   M

Service: MEDICINE

Allergies:
Heparin Agents

Attending:[**Doctor First Name 3290**]
Chief Complaint:
multiple falls, acute on chronic SDH

Major Surgical or Invasive Procedure:
[**12-15**] Right Craniotomy for SDH
[**12-21**] IVC filter
[**2207-12-31**] PEG
[**2208-1-4**] MRI spine with sedation

History of Present Illness:
This is a 63 year old Male who was switched from Cymbalta a few
months prior to Prozac and noted some dizziness and
lightheadedness episodes. The patient notes over the past 2.5
weeks he has experienced 2 falls without LOC, associated with
intermittent 6/10 intensity headaches, with gait instability,
but he did not seek medical care. His daughter lives with him.
She finally noticed he had multiple ecchymoses and chronic falls
and decided to bring him to [**Hospital1 18**] [**Location (un) **]. A CT head [**2207-12-13**]
showed a grossly stable acute on chronic Right hemispheric
subdural hematoma and scattered Right SAH; R cerebral sulcal
effacement and roughly 6 mm R-to-L MLS (was 5mm) with no
evidence of
herniation. No recent trauma or injury for at least 2 weeks. He
has a history of chronic anticoagulation for history of PE with
Coumadin (INR 17.5 on admission). Patient received oral/IV
vitamin K prior to transfer.
.
He notes chronic peripheral neuropathy with no sensation,
temperature or pain felt below the knees bilaterally, but
ongoing.

Past Medical History:
-Gout: diagnosed when patient was in his 20's. Experiences
flares regularly and is on chronic meds.
-Status post clamshell repair of PFO: presented with massive
bilateral pulmonary emboli and emboli in spleen
-Hypertension
-Hyperhomocysteinemia
-Alcohol abuse
-Cervical stenosis
-Neuropathy
-ETOH abuse

Social History:
Works as a personal consultant. Lives with 27 year old daughter
and her son. [**Name (NI) **] used to smoke, but stopped 7 years ago.
Denies current alcohol abuse, but endorses previous alcohol
abuse.



Family History:
Father died from complication of abdominal surgery at 93. Mother
with brain tumor.

Physical Exam:
PHYSICAL EXAM: On Admission
O: T 97.2 BP 120/84 P 108 R 16 O2sat 94%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-2 mm bilateral pupils equally reactive to
light.
EOMs intact bilaterally.
Neck: Supple. No point tenderness.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, tender, BS+ Notable ecchymosis over LUQ/LLQ
diffusely.
Extrem: Warm and well-perfused. Right 4th digit tender to
palpation with ecchymosis.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-1**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
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 [**5-4**] throughout bilateral LE, but
full strength 5/5 UE. No pronator drift.

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally in upper extremities; below the knee, no
vibration, temperature sensation bilaterally.

Reflexes: B T Br Pa Ac
Right     2+ --  1+ --
Left      2+ --  1+ --

Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin

DISCHARGE PHYSICAL EXAM
VS: Tm99. Tc96.1, BP 90s-120s/50s-80s, 80s-110s, 18, 94/RA
I/O: Y: 2.6/800 + (inc); MN: 1L/incontinent
GEN: responds intermittently (verbal today), appears
comfortable. Acknowleges questions but answers dysarthric.
Shaved right head after craniotomy with scar
Neck: JVP at 7 cm with possibly HJR
Cardiac: irregular, no murmurs appreciable
Pulm: lungs with some crackles in anterior lung fields
bilaterally
Abd: soft and nontender
Ext: 1+ edema in upper and lower extremities. LUE elbow with
erythema, effusion noted, and TTP in elbow as well as to passive
flexion/extension (improved from yesterday), decreased erythema.

Neuro: Pupils equal but sluggish in reaction, EOMI, visual
tracking intact intermittently. Withdraws to pain in upper
extremities but non localizing. This am moves both arms, but not
legs.
Skin: Pt noted to have erythema and skin breakdown by PEG tube.
On back side, violaceous macular skin changes on left gluteal
region along medial area area with no mass underneath, no fluid
collections in left gluteal region.


Pertinent Results:
CT HEAD W/O CONTRAST [**2207-12-13**]: Grossly stable acute on chronic R
hemispheric SDH and scattered R SAH; R cerebral sulcal
effacement and ~6mm R-to-L MLS (was 5mm) with no herniation
noted, final read pending, film reviewed with Neurorads.
.
CT head [**2207-12-14**]
Interval enlargement of previously visualized right subdural
hematoma with more of an acute component, more mass effect, and
a greater shift of the normally midline structures.
.
CT head [**2207-12-15**]
Interval decrease in thickness of the right convexity subdural
hematoma, which may, in part, reflect redistribution and stable
small left frontal subdural hematoma, with decreased leftward
shift of normally midline structures.
.
CT head [**2207-12-16**]
Stable overall appearance of bilateral subdural hematomas, with
stable leftward shift of the normally-midline structures.
.
GB US [**2207-12-16**]
1. Focused examination demonstrates an abnormal, sludge-filled,
distended
gallbladder with wall edema, concerning for acalculous
cholecystitis. A
hepatobiliary nuclear medicine scan with CCK may be of use if
further
assessment is desired.
2. Echogenic liver compatible with fatty infiltration. Other
forms of liver disease such as cirrhosis or fibrosis cannot be
excluded by imaging.
Evaluation for portal hypertension can be achieved with Doppler
ultrasound if desired.
.
EEG [**2207-12-16**]
This is an abnormal video EEG telemetry due to the presence of a
slow background which reached a maximum of 4 Hz frequency. This
is representative of a moderate to severe encephalopathy such as
can be seen in diffuse ischemia, infection, toxic/metabolic, or
other diffuse etiologies. Of note, there was significant
electrical artifact from 17:23 onward in the right hemisphere
leads. There were no clear epileptiform discharges or
electrographic seizures noted.
.
EEG [**2207-12-17**]
Showed an irregularly irregular rhythm.
IMPRESSION: This is an abnormal video EEG telemetry due to the
presence
of bursts of up to one minute each of periodic lateralized
epileptiform
discharges (PLEDs) over the right central region. PLEDs are
commonly
seen in the setting of acute structural brain lesions and can
indicate
epileptogenic cortex, although no frank electrographic seizures
were
seen. The slow background also indicates a moderate to severe
encephalopathy such as seen in toxic/metabolic, ischemic, or
infectious
etiologies.
.
CT head [**2207-12-17**]
No significant change in the size of the right-sided subdural
hemorrhage
with mild mass effect on the cerebral hemisphere, cerebral edema
and shift of the midline structures to the left side along with
mass effect on the right lateral ventricles; along with a few
foci of hemorrhage in the right frontal lobe at the vertex. Mild
improvement in the post-surgical changes noted before. No new
hemorrhage noted. Continued close followup as clinically
indicated.
.
EEG [**2207-12-18**]
This video EEG telemetry was abnormal due to the presence of a
slow, disorganized background that was usually in the delta
frequency range with superimposed bursts of generalized delta
slowing, often with a bifrontal predominance. These findings
suggest the presence of a severe encephalopathy which can be due
to diffuse ischemia, toxic/metabolic changes, infections,
medication effects, or other etiologies. No epileptiform
features or electrographic seizures were seen.
.
ECHO [**2207-12-18**]
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF 80%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). The right ventricular cavity is markedly
dilated with depressed free wall contractility. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. No mitral regurgitation is seen. The main
pulmonary artery is dilated. The branch pulmonary arteries are
dilated. There is no pericardial effusion. Compared with the
findings of the prior study (images reviewed) of [**2204-4-16**],
the right ventricle is now dilated and hypocontractile, and the
left ventricle is now hyperdynamic
.
EEG [**2207-12-19**]
This video EEG telemetry is abnormal due to the presence of a
slow, disorganized background, mostly in the delta frequency
range, with bursts of generalized slowing. These findings
suggest the presence of a severe encephalopathy such as can be
seen from diffuse ischemia, toxic/metabolic changes, medication
effects, infections, and other such etiologies. Bursts of more
prominent slowing were often seen in the right fronto-central
region, sometimes with sharp features, suggesting the presence
of more focal subcortical dysfunction in that area, but no frank
epileptiform discharges or electrographic seizures were seen.
.
EEG [**2207-12-20**]
This EEG gives evidence still for intermittent PLEDs-like
discharges in the right central temporal region. On occasion,
these become more organized and appear to have electrographic
seizure occurrence. There is no obvious clinical accompaniment.
Over time, these seem, if anything, to be increasing in
frequency of occurrence and in duration. There is also a severe
diffuse encephalopathy with some structural asymmetric features
suggesting more right hemisphere involvement.
.
CT head  [**2207-12-20**]
1. Overall stable appearance of bilateral subdural hematoma with
stable
leftward shift of normal midline structure.
2. Stable appearance of right parenchymal hemorrhage with
slightly increased zone of surrounding vasogenic edema.
3. Stable appearance of small foci of subarachnoid hemorrhage
within the
right hemisphere.
.
UE US
Nonocclusive thrombosis of the left cephalic vein. No evidence
of deep venous thrombosis.
.
CT head  [**2207-12-27**]
1. Stable size of right-sided subdural hematoma and small
left-sided subdural hematoma. Stable leftward shift of midline
structures of 5 mm.
2. Resolving right frontal intraparenchymal hemorrhage with
stable amount of surrounding edema. No new acute hemorrhage.
NOTE ON ATTENDING REVIEW:
There is 2.9x1.6cm mass lesion in the nasopharynx, similar the
prior MR of
[**2198-4-15**] with obstruction to the lumen; this was felt to
represent a
lipoma/cyst with dense contents, more likely the latter given
the density on CT. There is likely obstruction of the eustachian
tubes. There is diffuse mucosal thickening and fluid in the
mastoid air cells on both sides. Rec. ENT consult as suggested
earlier in [**2204**].
.
CTA chest [**2207-12-27**]
1. Breathing motion gives suboptimal evaluation of the vessels
at
subsegmental level. No pulmonary embolus in the main pulmonary
artery, right and left pulmonary artery and segmental branches.
2. Bilateral moderate pleural effusions with adjacent
atelectasis.
3. Emphysema.
4. Tip of left central line terminates at the left
brachiocephalic vein.
5. Right heart enlargement.
.
Abd X-ray [**2207-12-27**]
In comparison with the study of [**12-29**], the tip of the
nasogastric
tube is in the region of the esophagogastric junction with the
side hole in the lower esophagus. It should be pushed forward
approximately 20 cm. IVC filter is in place.
.
Chest X-ray [**2207-12-29**]
In comparison with earlier studies of this date, the side port
of
the nasogastric tube again lies above the diaphragm. Much of the
proximal
portion of the tube is coiled in the hypopharynx.
.
CT head  [**2207-12-30**]
IMPRESSION: Incomplete study with substantial artifact limiting
evaluation
for interval change. Apparent residual right subdural collection
with
leftward shift of normally midline structures.
COMMENT: Patient could return for completion of the study, with
appropriate pre-medication, when feasible.
.
CT HEAD [**2208-1-3**]
IMPRESSION: Limited study, demonstrating interval evolution of
right subdural
hematoma, without increase in size. There is no midline shift,
and mass
effect upon the right lateral ventricle is unchanged

Venous Duplex [**2208-1-4**]
IMPRESSION: No evidence of DVT of the left upper extremity.

MRI C/T/L SPINE [**2208-1-4**]
1. Compared with the prior study of the cervical spine performed
[**10-14**], [**2204**], the anterolisthesis of C4 on C5 unchanged. There is
new 2-3mm grade
1 retrolisthesis of C3 on C4 whcihc results in mild-to-moderate
spinal canal
narrowing without signal abnormality of the cervical cord. No
signal
abnormality is identified on the STIR sequences to suggest edema
suggesting
this retrolisthesis is of a degenerative etiology.

2. Incompletely imaged within the left gluteus maximus muscle,
there is a T1
hyperintense oval-shaped mass. Clinical correlation and
ultrasound are
recommended.

3. Mild cervical and lumbar spondylosis without severe spinal
canal or neural
foraminal narrowing.

4. Aneurysmal dilation of the infrarenal abdominal aorta- tr-
5cm,
incompletely assessed and likely increased from prior of [**2200**].
Consider
dedicated imaging with ultrasound/MR

ADMISSION LABS:
[**2207-12-13**] 05:00PM BLOOD WBC-6.1 RBC-3.93* Hgb-13.5* Hct-37.0*
MCV-94 MCH-34.3*# MCHC-36.4* RDW-14.8 Plt Ct-102*
[**2207-12-13**] 05:00PM BLOOD Neuts-77.3* Lymphs-14.7* Monos-6.3
Eos-0.4 Baso-1.3
[**2207-12-13**] 05:00PM BLOOD PT-133.2* PTT-60.0* INR(PT)-17.5*
[**2207-12-13**] 05:00PM BLOOD Glucose-126* UreaN-24* Creat-1.4* Na-134
K-2.4* Cl-85* HCO3-35* AnGap-16
[**2207-12-13**] 05:00PM BLOOD Lipase-26
[**2207-12-13**] 05:00PM BLOOD cTropnT-<0.01
[**2207-12-13**] 11:08PM BLOOD Calcium-7.8* Phos-1.9*# Mg-1.3*
[**2207-12-13**] 11:08PM BLOOD Phenyto-LESS THAN
[**2207-12-13**] 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2207-12-13**] 05:21PM BLOOD Glucose-120* Lactate-3.2* Na-135 K-2.4*
Cl-80* calHCO3-39*
[**2207-12-13**] 05:21PM BLOOD Hgb-14.0 calcHCT-42

PERTINENT LABS
[**2207-12-15**] 04:50PM BLOOD Fibrino-342
[**2207-12-16**] 05:08PM BLOOD Fibrino-390
[**2207-12-18**] 01:30AM BLOOD proBNP-[**Numeric Identifier 46533**]*
[**2207-12-28**] 09:08AM BLOOD CK-MB-2 cTropnT-<0.01
[**2207-12-28**] 04:26PM BLOOD cTropnT-0.02*
[**2207-12-16**] 02:51AM BLOOD VitB12-509 Folate-6.7
[**2207-12-31**] 07:00AM BLOOD Free T4-1.1
[**2207-12-31**] 07:00AM BLOOD TSH-2.4
[**2208-1-1**] 07:20AM BLOOD Digoxin-0.4*
[**2208-1-3**] 05:55AM BLOOD Digoxin-0.6*

DISCHARGE LABS
Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na K    Cl HCO3 AnGap
[**2208-1-6**] 07:45    97     27*   0.8 145 3.6 109* 27    13
Hct: 27.3


Brief Hospital Course:
# Subdural Hematoma / SAH -
Pt was admitted to the ICU and monitored closely. He remained
neurologically intact but repeat CT of head [**12-14**] showed
expanding SDH. He demonstrated a significant coagulopathy on
admission with an INR of 17.5 and a PTT of 133.2 which was
reversed with oral/IV vitamin K and 2U FFP in the ER at [**Hospital1 18**].
Repeat INR/PTT revealed improvement, but he required another 2U
FPP. On [**12-14**] the patient experienced a LUE seizure and received
6 mg of Ativan which resulted in cessation of seizure activity.
Patient's mental status was declining along with neurologic exam
and repeat imaging documented progression of his right sided
SDH. He was taken to the OR on [**2207-12-15**] for right craniotomy and
subdural hematoma evacuation. Intra-operatively, the patient
received 2 more units of FFP and 1 pack of platelets. His INR
was 1.8 pre-op and platelets 81 pre-op. He tolerated the
procedure well. Repeat imaging 4 hours post-op showed
improvement of his right SDH with post-surgical changes and no
complications. He remained intubated post-op given his inability
to awaken, but he was breathing spontaneoulsy. On [**12-16**], his
neurologic exam demonstrated continued difficulty with arousal
and the patient followed minimal commands with slight response
to noxious stimuli.  The patient was started on phenytoin, and
then was transitioned to Keppra, to be continued on discharge.
His Keppra will be readdressed by NSGY at f/u.
.
The patient was able to be transferred out of the ICU to the
step down unit on [**12-24**].  His neuro exam was followed by the
neurosurgery service, and NSG continued to follow the patient
after the pt was transferred to the Medical service for
management of his tachypnea and atrial fibrillation (see below).
.
# Respiratory Status/tachypnea/hypoxia: Directly after the
surgery, the pt was transferred to the ICU intubated.  He was
able to weaned and extubated, however was reintubated on [**12-17**].
After he was weaned from the vent, he was extubated on [**2207-12-23**].
 The medicine consult service was consulted for persistent
tachypnea and hypoxia.  Chest x-rays demonstrated pulmonary
edema, and the patient was aggressively diuresed.  An ECHO was
also done which showed an EF of 80% and right heart strain.  Out
of concern for PE causing the tachypnea, a CTA was performed,
which ruled out PE.  Prior to the CTA, an IVC filter was placed
(as suspicion was high and a CTA could not be done at the time
[**3-3**] high Cr).  Also, the patient had a Cx that was positive for
Moraxella, and so was treated with abx (broad spectrum, then
narrowed to cefepime for 8 days).  Upon transfer to the medical
floor, he was satting well on RA, but over time, required O2 and
further diuresis in the setting of volume overload.  daily
weights and strict Is/Os were done and he was diuresed with a
goal of negative 1.5-2L per day.  Also complicating the issue
was a-fib which developed in the setting of diuresis, then
contributing to volume backup into the lungs.  (See below for
management of A-fib)
.
# Atrial Fibrillation - The patient is not an anticoagulation
candidate given SDH.  For that reason, cardioversion wasn't an
option.  The medicine consult service saw the patient while he
was on the NSG service, and the patient was titrated up on
metoprolol.  After transfer to the medicine service, metoprolol
was further titrated up to 50 mg PO/NG QID, however could not be
continued given low BPs.  The patient was subsequently dig
loaded and was ultimately maintained on 0.250 mg of dig PO/NG
daily.  Out of concern for underlying reasons for the Afib/RVR,
the patient was treated for pain with
fentanyl/dilaudid/lidocaine patch, and labs were sent to r/o
other causes (pt has a normal TSH/Free T4).  Also, the pt had
fevers upon transfer, however this subsided after the pt's
subclavian line was pulled, and so fevers/infx were no longer
thought to be the reason for his Afib-RVR.  As the pt was volume
overloaded, it was thought that perhaps diuresis would help his
heart rate.  Also, to ensure all causes of the tachycardia were
r/o, we consulted the Cardiology service, which agreed with our
work up, and recommended adding verapamil.  This was done and
the patient's heart rate was controlled to the 80s-100s range.
EKGs were done over the course of his hospitalization which
verified Afib with RVR.  The pt has pAF, as he also was noted to
be in sinus rhythm at times.  When his PCP was [**Name (NI) 653**], it
seems he has been in pAF for 7 years now.
.
Of note, anticoagulation is definitely indicated in this
gentleman.  Unfortunately, we are unable to do so currently
given the recent NSG intervention.  It will be important that
this issue is followed up by Neurosurgery as well as his PCP so
that he can hopefully be restarted on coumadin after NSG deems
it safe to do so.
.
# LE weakness:  The patient's LEs were noted to be markedly
weak, which was not consistent with the SDH.  For that reason,
the pt underwent an MRI of the C, T, and L spine.  There was
concern for hematoma or other compressive physiology on the
spinal cord.  The MRI revealed no acute pathology or cord
compression to account for the weakness.  A Neurology c/s was
called who felt that this was c/w neuropathy of critical
illness.  Other recommendations were to send B12, folate, RPR,
TSH, which were done prior to his discharge.  However, this will
need to be followed up as an outpatient/at rehab.
.
# Hypernatremia: Secondary to the patient's inability to take in
water from thirst given AMS.  For that reason, free water
flushes were increased with tube feeds, and D5W was administered
prn hypernatremia.  Care was taken to evaluate his Chem7 to
ensure correction was both effective, and not too rapid.  Upon
discharge, his Na was 149, and per discussion with Nutrition,
would recommend increasing Free water flushes to 350 cc Q4h.
Recommends increasing further if hypernatremia persists.  Also,
can give D5W slowly (500cc at 75cc/hr) if necessary.
.
# Fevers - The patient developed a fever during his
hospitalization.  He had already been treated with 8 days of
cefepime for possible HAP.  It may also be due to the SDH, and
also the pt was noted to have a CVL (left subclavian) at the
time.  The subclavian was pulled on the floor, and the fevers
resolved.  The pt was pan-cx'ed after the fever, and all cxs
were negative.  He was given tylenol prn for symptomatic
treatment.  Of note, the pt did have an indwelling foley,
however the UCx was negative. We continued to monitor with VS.
He had been afebrile for >1 week at the time of discharge.  Of
note, the pt did have a short course of dicloxacillin as well
for possible cellulitis, however this was d/c'ed after we
concluded it was more likely gouty elbow vs bursitis instead of
cellulitis.
.
# Report of bloody stools/Anemia: The pt was guaiac'ed and was
negative, however was noted to have some blood on other
instances.  This is most likely [**3-3**] hemorrhoidal bleeding given
that it is not intermixed with the stool but rather overlying
it.  Prior to this, the pt had an active type and screen, and
his Hct was monitored daily to [**Hospital1 **].  Of note, earlier in the
hospitalization, the pt did receive transfusions for low Hct.
At time of d/c, his Hct was stable between 27 and 30.
.
# Hypertension - The pt's BP was normotensive to hypotensive
with the titration of nodal agents for his a-fib.  We stopped
the pt's atenolol that he was on as an outpatient as his BP is
normotensive on the new regimen for A-fib.
.
# [**Name (NI) 20973**] The pt had an NG-tube after the procedure for tube
feeds and PO medications.  He was actually advanced to a soft
diet with NSG, however with further altered mental status, he
was made NPO and all nutrition was done via NG tube.  The pt
self-d/c'ed his NGT, and after an unsuccessful attempt to
replace it, he underwent a PEG placement after a family meeting
was called and it was deemed in line with his healthcare goals.
The general surgery service assisted us in the placement of his
PEG tube.  His tube feeds were restarted after 24 hours without
incidence.  (See below for management of erythema at site of PEG
tube per Surgery team)
.
# Gout vs Bursitis: L elbow eryhema and MTP erythema and
swelling felt to be most consistent with gout. In addition,
supportive evidence was the fact that this occurred in the
setting of diuresis. Patient initially placed on dicloxacillin,
but discontinued when felt to be less likely cellulitis. Patient
improved with indomethicin treatment, with plan to continue Rx
for 2 more days.  If necessary, can use prednisone after
indomethacin if clinical improvement slows (eg 20 mg daily).
.
# Erythema and skin breakdown at PEG site: Evaluated by surgery,
feels no need to loosen stitches.  Recommends dry dressings,
changes daily, clean regularly, keep dry.
.
# Hyperlipidemia - On statin
.
# HIT history - Avoided heparin products, not anticoagulation
candidate. To maintain pneumoboots and compression stockings for
prevention of DVT.
.
# Incidental findings on MRI: Patient noted to have infrarenal
abdominal aneurysm on routine imaging. Size warrants follow-up
with ultrasound or MRI per PCP.  [**Name Initial (NameIs) **] T1 hyperintense image in
left gluteal muscle. On clinical exam no fluid filled area,
slight erythema along midline without inflammatory signs.  Would
recommend to continue to monitor, no indication to US at this
time.
.
# Communication: With [**Name (NI) **], [**First Name3 (LF) **] ([**Telephone/Fax (1) 46534**])
.
# On discharge, please continue PT, OT, PEG tube feeds, wound
care, and please consider repeat speech and swallow evaluation.
F/U with NSGY and neurology.

Medications on Admission:
Medications prior to admission: Coumadin 2.5 mg PO daily, Folic
Acid, Colchicine, Allopurinol, Lisinopril, Plavix, Estrilyrica,
Prozac


Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mls PO BID (2
times a day): can hold if diarrhea.
2. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day: please crush to administer via G-tube.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb treatment Inhalation Q6H (every 6 hours) as needed
for shortness of breath or wheezing.
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
6. verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): hold if sbp<100 or hr<55.
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to
right shoulder.
10. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. indomethacin 25 mg/5 mL Suspension Sig: Ten (10) mls PO TID
(3 times a day).
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold if sbp<100.
14. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours): hold if sbp<100 or hr<55.
16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever or pain.
18. Ondansetron 4 mg IV Q8H:PRN nausea
19. HYDROmorphone (Dilaudid) 0.125 mg IV Q4H:PRN pain
hold for sedation, RR < 10
20. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
21. ipratropium bromide 0.02 % Solution Sig: One (1) neb
treatment Inhalation Q6H (every 6 hours) as needed for wheezing.



Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Hospital for Continuing Medical Care-[**Hospital1 8**]

Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Subdural Hematoma

SECONDARY DIAGNOSES
- Subarachnoid hemorrhage
- Intraparenchyma hemorrhage
- Atrial Fibrillation
- Hospital Acquired Pneumonia
- Polyneuropathy of Critical illness
- Gout arthropathy vs. Bursitis

Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.

Discharge Instructions:
It was a pleasure taking care of you during your
hospitalization.  You were admitted to [**Hospital1 18**] with a Subdural
Hematoma (bleed around the brain), and you were on the
Neurosurgery service after your surgical procedure to relieve
the blood/pressure in the skull.  Afterward, you developed a
pneumonia which was treated with antibiotics, and you also had a
fast heart rate from "Atrial Fibrillation" which was treated
with medications to slow your heart down.  You also weren't
moving your legs too much after the procedure, and so an MRI was
done which showed nothing that could account for your weakness.
We asked our Neurology colleagues who felt you had weakness
because of your critical illness.  Also, you had a sore left
elbow which we feel is gout or bursitis, which we are treating
with medications (Indomethacin).

PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS
1) START taking KEPPRA 1000 mg G-tube twice daily
2) START taking VERAPAMIL 40 mg G-tube every 8 hours
3) START taking METOPROLOL 50 mg G tube every 6 hours
4) START taking INDOMETHACIN 50 mg G-tube three times a day for
2 more days
5) START using IPROTROPIUM NEBS every 6 hours as needed for
shortness of breath or wheezing
6) START using ALBUTEROL NEBS every 6 hours as needed for
shortness of breath or wheezing
7) CONTINUE taking THIAMINE 100 mg G-tube daily
8) CONTINUE taking FOLATE 1 mg G-tube daily
9) START taking DILAUDID 0.125 mg IV every 4 hrs as needed for
pain
10) START taking SENNA 1 tab G-tube twice daily as needed for
constipation
11) START taking DOCUSATE 100 mg G-tube twice daily (hold if
diarrhea)
12) CONTINUE taking LASIX 40 mg G-tube daily
13) CONTINUE taking MULTIVITAMIN 1 tab G-tube daily
14) START taking ZOFRAN 4 mg IV every 8 hours as needed for
nausea
15) START taking BISACODYL 10 mg daily as needed for
constipation
16) START using FENTANYL patch 12 mcg/hr every 72 hours
17) START using LIDODERM PATCH 5% daily to right shoulder (12
hrs on, 12 hrs off)
18) START using MICONAZOLE POWDER as needed for fungal rash
19) INCREASE the dose of DIGOXIN to 250 mcg G-tube daily
20) START taking POTASSIUM 20 Meq daily

DO NOT USE HEPARIN as you have a history of HIT. Please wear
compression stocking and/or pneumoboots to prevent blood clots.

STOP taking the following medications:
COUMADIN
COLCHICINE
ALLOPURINOL
LISINOPRIL
PLAVIX
ESTRILYRICA
PROZAC
ATENOLOL
PYRIDOXINE

General Instructions from the Neurosurgery Service:
??????	You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
??????	New onset of tremors or seizures.
??????	Any confusion 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.
??????	Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
??????	Fever greater than or equal to 101?????? F.

Followup Instructions:
Department: NEUROSURGERY
When: THURSDAY [**2208-1-28**] at 10:15 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: NEUROLOGY
When: THURSDAY [**2208-4-28**] at 10:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


Completed by:[**2208-1-7**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Toxic encephalopathy,Pneumonia due to other gram-negative bacteria,Acute on chronic combined systolic and diastolic heart failure,Critical illness polyneuropathy,Hyperosmolality and/or hypernatremia,Pulmonary collapse,Acute venous embolism and thrombosis of superficial veins of upper extremity,Delirium due to conditions classified elsewhere,Flaccid hemiplegia and hemiparesis affecting unspecified side,Unspecified protein-calorie malnutrition,Subdural hemorrhage,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Atrial fibrillation,Acute gouty arthropathy,Retention of urine, unspecified,Hypoxemia,Abdominal aneurysm without mention of rupture,Chronic ulcer of other specified sites,Chronic cholecystitis,Unspecified hemorrhoids without mention of complication,Anemia, unspecified,Other and unspecified alcohol dependence, unspecified,Personal history of venous thrombosis and embolism,Personal history of tobacco use,Long-term (current) use of anticoagulants'}


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: multiple falls, acute on chronic SDH

PRESENT ILLNESS: This is a 63 year old Male who was switched from Cymbalta a few
months prior to Prozac and noted some dizziness and
lightheadedness episodes. The patient notes over the past 2.5
weeks he has experienced 2 falls without LOC, associated with
intermittent 6/10 intensity headaches, with gait instability,
but he did not seek medical care. His daughter lives with him.
She finally noticed he had multiple ecchymoses and chronic falls
and decided to bring him to [**Hospital1 18**] [**Location (un) **]. A CT head [**2207-12-13**]
showed a grossly stable acute on chronic Right hemispheric
subdural hematoma and scattered Right SAH; R cerebral sulcal
effacement and roughly 6 mm R-to-L MLS (was 5mm) with no
evidence of
herniation. No recent trauma or injury for at least 2 weeks. He
has a history of chronic anticoagulation for history of PE with
Coumadin (INR 17.5 on admission). Patient received oral/IV
vitamin K prior to transfer.
.
He notes chronic peripheral neuropathy with no sensation,
temperature or pain felt below the knees bilaterally, but
ongoing.

MEDICAL HISTORY: -Gout: diagnosed when patient was in his 20's. Experiences
flares regularly and is on chronic meds.
-Status post clamshell repair of PFO: presented with massive
bilateral pulmonary emboli and emboli in spleen
-Hypertension
-Hyperhomocysteinemia
-Alcohol abuse
-Cervical stenosis
-Neuropathy
-ETOH abuse

MEDICATION ON ADMISSION: Medications prior to admission: Coumadin 2.5 mg PO daily, Folic
Acid, Colchicine, Allopurinol, Lisinopril, Plavix, Estrilyrica,
Prozac

ALLERGIES: Heparin Agents

PHYSICAL EXAM: PHYSICAL EXAM: On Admission
O: T 97.2 BP 120/84 P 108 R 16 O2sat 94%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-2 mm bilateral pupils equally reactive to
light.
EOMs intact bilaterally.
Neck: Supple. No point tenderness.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, tender, BS+ Notable ecchymosis over LUQ/LLQ
diffusely.
Extrem: Warm and well-perfused. Right 4th digit tender to
palpation with ecchymosis.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-1**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: Father died from complication of abdominal surgery at 93. Mother
with brain tumor.

SOCIAL HISTORY: Works as a personal consultant. Lives with 27 year old daughter
and her son. [**Name (NI) **] used to smoke, but stopped 7 years ago.
Denies current alcohol abuse, but endorses previous alcohol
abuse. 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Toxic encephalopathy,Pneumonia due to other gram-negative bacteria,Acute on chronic combined systolic and diastolic heart failure,Critical illness polyneuropathy,Hyperosmolality and/or hypernatremia,Pulmonary collapse,Acute venous embolism and thrombosis of superficial veins of upper extremity,Delirium due to conditions classified elsewhere,Flaccid hemiplegia and hemiparesis affecting unspecified side,Unspecified protein-calorie malnutrition,Subdural hemorrhage,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Atrial fibrillation,Acute gouty arthropathy,Retention of urine, unspecified,Hypoxemia,Abdominal aneurysm without mention of rupture,Chronic ulcer of other specified sites,Chronic cholecystitis,Unspecified hemorrhoids without mention of complication,Anemia, unspecified,Other and unspecified alcohol dependence, unspecified,Personal history of venous thrombosis and embolism,Personal history of tobacco use,Long-term (current) use of anticoagulants'}
