CHIEF COMPLAINT: Syncope

PRESENT ILLNESS: 64 yo right-handed female with hx MVR, hx hemorrhagic stroke and
subsequent seizures, and HTN, with recent hospitalization at
[**Hospital1 18**] after a fall with acute left subdural hematoma, s/p
emergent evacuation and craniotomy, discharged [**7-21**]
on heparin (for mechanical heart valve) to [**Hospital3 **] and
noted to be awake, alert, and oriented at that time.  At
appromately 10 PM on [**2112-7-22**], she was noted to be unresponsive
with no clear description of preceeding events available.
However, it was thought she may have had a seizure and was
transferred to [**Hospital1 498**] ED where she was given 8 mg valium, 1500 mg
fosphenytoin IV.  She was transferred to [**Hospital1 18**] on [**2112-7-23**] for
further management and work-up.

MEDICAL HISTORY: Subdural hemorrhage, s/p evacuation and craniotomy [**2112-7-16**]
MVR s/p rheumatic heart disease
On coumadin for mechanical valve
H/o hemorrhagic stroke
History of seizure disorder (prior to SDH)
Hypertension
Hyperlipidemia
EF 60% on [**2112-7-18**] TTE

MEDICATION ON ADMISSION: Per [**2112-7-21**] DISCHARGE SUMMARY:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheezing .
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Lorazepam 0.5 mg IV PRN seizure > 3 minutes
PLEASE CALL HOUSE OFFICE PRIOR TO USING. [**Month (only) **] REPEAT X 1 IF
NEEDED.
10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
11. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: 99.9 (T max 100.3), P 75, BP 140/51, RR 16, 100% on
ventilator
Gen: intubated, sedated
Cardio: RR, II/VI SEM with ? click
Pulm: CTA anteriorly
Abd; soft, NT, ND
Neuro; intubated, sedated, does not awake to painful stimuli.
pupils 2 mm and minimally responsive.  Does not withdraw to
painful stimuli.  Flaccid tone throughout.  2+ reflexes biceps,
triceps, brachioradialis, patellar, b/l, upgoing toe on right.

FAMILY HISTORY: History of rheumatic heart disease in sisters

SOCIAL HISTORY: Lives with husband (but currently transferred from rehab); has a
lovely large family that frequently visits and is actively
involved in her care.
Other late effects of cerebrovascular disease,Pneumonitis due to inhalation of food or vomitus,Encephalopathy, unspecified,Acute posthemorrhagic anemia,Acute diastolic heart failure,Generalized convulsive epilepsy, without mention of intractable epilepsy,Nontraumatic hematoma of soft tissue,Dysphagia, unspecified,Pain in joint, ankle and foot,Unspecified essential hypertension,Heart valve replaced by other means,Long-term (current) use of anticoagulants,Other and unspecified hyperlipidemia,Anticoagulants causing adverse effects in therapeutic use
Late effect CV dis NEC,Food/vomit pneumonitis,Encephalopathy NOS,Ac posthemorrhag anemia,Ac diastolic hrt failure,Gen cnv epil w/o intr ep,Nontrauma hema soft tiss,Dysphagia NOS,Joint pain-ankle,Hypertension NOS,Heart valve replac NEC,Long-term use anticoagul,Hyperlipidemia NEC/NOS,Adv eff anticoagulants
Admission Date:  [**2112-7-23**]              Discharge Date:   [**2112-8-3**]

Date of Birth:  [**2048-4-2**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Syncope

Major Surgical or Invasive Procedure:
Right inferior epigastric artery embolization by interventional
radiology, [**2112-7-30**]


History of Present Illness:
64 yo right-handed female with hx MVR, hx hemorrhagic stroke and
subsequent seizures, and HTN, with recent hospitalization at
[**Hospital1 18**] after a fall with acute left subdural hematoma, s/p
emergent evacuation and craniotomy, discharged [**7-21**]
on heparin (for mechanical heart valve) to [**Hospital3 **] and
noted to be awake, alert, and oriented at that time.  At
appromately 10 PM on [**2112-7-22**], she was noted to be unresponsive
with no clear description of preceeding events available.
However, it was thought she may have had a seizure and was
transferred to [**Hospital1 498**] ED where she was given 8 mg valium, 1500 mg
fosphenytoin IV.  She was transferred to [**Hospital1 18**] on [**2112-7-23**] for
further management and work-up.



Past Medical History:
Subdural hemorrhage, s/p evacuation and craniotomy [**2112-7-16**]
MVR s/p rheumatic heart disease
On coumadin for mechanical valve
H/o hemorrhagic stroke
History of seizure disorder (prior to SDH)
Hypertension
Hyperlipidemia
EF 60% on [**2112-7-18**] TTE


Social History:
Lives with husband (but currently transferred from rehab); has a
lovely large family that frequently visits and is actively
involved in her care.

She is an ex-smoker, [**1-8**] ppd x 10 years, no EtOH or drugs


Family History:
History of rheumatic heart disease in sisters


Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.9 (T max 100.3), P 75, BP 140/51, RR 16, 100% on
ventilator
Gen: intubated, sedated
Cardio: RR, II/VI SEM with ? click
Pulm: CTA anteriorly
Abd; soft, NT, ND
Neuro; intubated, sedated, does not awake to painful stimuli.
pupils 2 mm and minimally responsive.  Does not withdraw to
painful stimuli.  Flaccid tone throughout.  2+ reflexes biceps,
triceps, brachioradialis, patellar, b/l, upgoing toe on right.

DISCHARGE PHYSICAL EXAM:
VS: afebrile, on RA
General: appears comfortable, conversant with somewhat slowed
speech
HEENT: CNII - XII in tact, left side of head shaved from prior
NS, incision on left side of head CDI, stables removed on
[**2112-8-3**] prior ot discharge
Lungs: CTA b/l, scant crackles at bases
Cardio: RR, II/VI SEM with ? click
Abd: binder on, quarter-sized ecchymosis on RLQ, minimally TTP
diffusely, + BS
Skin: no rashes, WWP
Extremities: slight RLE edema (R>L), right lateral malleolus
minimally TTP with full ROM of ankle though pt reporting some
pain with movement

Pertinent Results:
ADMISSION LABS:
[**2112-7-23**] 05:05AM BLOOD WBC-7.0 RBC-1.96*# Hgb-6.5*# Hct-19.9*#
MCV-101* MCH-33.4* MCHC-33.0 RDW-14.3 Plt Ct-264
[**2112-7-23**] 05:05AM BLOOD Neuts-73.3* Lymphs-16.1* Monos-7.9
Eos-2.0 Baso-0.6
[**2112-7-23**] 05:05AM BLOOD PT-12.5 PTT-25.6 INR(PT)-1.1
[**2112-7-23**] 05:05AM BLOOD Glucose-91 UreaN-5* Creat-0.2* Na-141
K-2.9* Cl-114* HCO3-20* AnGap-10
[**2112-7-23**] 03:46PM BLOOD Calcium-8.3* Phos-2.5* Mg-1.4*

CARDIAC ENZYMES:
[**2112-8-1**] 05:36AM BLOOD CK(CPK)-284*
[**2112-8-1**] 11:49AM BLOOD CK(CPK)-257*
[**2112-8-2**] 05:57AM BLOOD CK(CPK)-172*
[**2112-8-1**] 05:36AM BLOOD CK-MB-3 cTropnT-0.18*
[**2112-8-1**] 11:49AM BLOOD CK-MB-2 cTropnT-0.13*
[**2112-8-2**] 05:57AM BLOOD CK-MB-2 cTropnT-0.11*

HEMATOCRIT ON DISCHARGE:
[**2112-8-3**] Hct-28.7
[**2112-8-2**] Hct-27.3
[**2112-8-1**] Hct-28.7

OTHER LABS ON DISCHARGE:
[**2112-8-3**] 05:33AM BLOOD WBC-12.8* RBC-3.01* Hgb-9.2* Hct-28.7*
MCV-96 MCH-30.5 MCHC-32.0 RDW-15.7* Plt Ct-563*
[**2112-8-3**] 05:33AM BLOOD Glucose-216* UreaN-7 Creat-0.4 Na-137
K-3.5 Cl-99 HCO3-27 AnGap-15

URINE STUDIES:
[**2112-7-30**] 07:00PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2112-7-30**] 07:00PM URINE RBC-79* WBC-8* Bacteri-NONE Yeast-NONE
Epi-0

MICROBIOLOGY:
[**2112-8-2**] C diff: negative
[**7-23**], 24, 25/09 BCx: negative
[**7-27**], 25/09 UCx: negative

IMAGING:
[**2112-7-23**] HEAD CT W/O CONTRAST:
1. Unchanged and evolved appearance to left temporoparietal
intraparenchymal hemorrhage and small left subdural hematoma.
2. No new focus of hemorrhage or shift of midline structures.
3. Punctate hypodense focus anterior to the left lateral
ventricle has
persisted over 7 days.

[**2112-7-25**] EEG:
This is an abnormal video-EEG study due to slow theta frequency
background with left posterior sharp transients. Breech artifact
was noted in the left temporal and centroparietal regions. The
slow background suggests a encephalopathy affecting both
cortical and subcortical structures. Medications, metabolic
disturbances, and infection are among the most common causes.
There were no electrographic seizures or electrographic
correlate to push-button activations.

[**2112-7-29**] CT ABDOMEN/PELVIS W/ CONTRAST:
1. Large right rectus sheath hematoma extending into the
extraperitoneal
pelvis as well as the retroperitoneum.
2. Mild right renal collecting system dilatation related to mass
effect on
the right ureter from the hemorrhage.
3. Cholelithiasis.
4. Cardiomegaly.

[**2112-7-30**] CTA ABD/PELVIS:
1. Extensive right rectus sheath hematoma extending into the
extraperitoneal pelvis and also the retroperitoneum, not
significantly changed since examination one day prior performed
[**2112-7-29**]. No increase in size, and no evidence of active
extravasation in arterial, venous or delayed phases.
2. Persistent mild renal collecting system dilation secondary to
mass effect of the hemorrhage on the right distal ureter.
3. Cholelithiasis without secondary signs of cholecystitis.
4. Small amount of intra-abdominal ascites.
5. Bibasilar atelectasis and cardiomegaly.
6. Small hiatal hernia.

[**2112-7-23**] CXR:
1. Probably standard position of endotracheal tube. Could
consider PA and
lateral for better definition.
2. Perihilar predominant, ill-defined airspace opacification
suggests
pulmonary edema. Underlying infection cannot be excluded. Could
consider
another film after diuresis.

[**2112-7-31**] CXR:
There is a new left lower lobe infiltrate which given history
likely represents pneumonia. There continues to be bibasilar
subsegmental
atelectasis. There is also pulmonary vascular redistribution
consistent with fluid overload.
IMPRESSION: New left lower lobe infiltrate.

[**2112-8-1**] RIGHT LE US:
No evidence of DVT

[**2112-8-2**] RIGHT ANKLE/FOOT X-RAY:
No previous images. Three views of the foot and three of the
ankle show some generalized soft-tissue prominence without
evidence of acute bone or
joint space abnormality.

[**2112-8-3**] VIDEO SWALLOW:
Ms. [**Known lastname **] presents with mild oropharyngeal dysphagia
characterized by mildy reduced bolus formation, swallow delay
and incomplete epiglottic deflection. Patient was noted with one
episode of flash penetration before the swallow with consecutive
straw sips of thin liquids which cleared spontaneously. No deep
penetration or aspiration was observed. Recommend a PO diet of
thin liquids and small bites of soft solid consistencies. Please
continue 1:1 supervision to assist with feeding and monitor
swallow safety. Pills may be given whole or crushed with puree.
Please continue to monitor at rehab. This swallowing pattern
correlates to a Dysphagia Outcome Severity Scale (DOSS) rating
of level 5, mild dysphagia.
RECOMMENDATIONS:
1. PO diet of thin liquids and SMALL bites of soft solids.
2. Pills whole or crushed with puree.
3. Continue 1:1 supervision to assist with feeding and monitor
swallow safety.
4. Q8 oral care.
5. Patient seated upright for all meals.
6. Monitor for adequate caloric intake as indicated.
7. Please continue to monitor at rehab and recommend repeat
speech and swallow evaluation prior to upgrading diet. Patient
would also benefit from speech and language services at rehab.


Brief Hospital Course:
SEIZURE DISORDER:
Ms. [**Known lastname **] was admitted to the neurosurgery service after
transfer from [**Hospital1 498**] for possible new head bleed.  She was on a
heparin drip while at rehab with plans to start warfarin on
[**2112-7-25**].  She was monitored initially in the SICU and required
intubation for airway protection with GCS [**7-13**] (extubated
successfully on [**2112-7-25**]).  Repeat head CT upon admission showed
no evidence of acute bleed.  She was monitored with contiuous
EEG initially.  She was transferred to the neurology service,
and her seizure medications were adjusted.  She is being
discharged on Levetiracetam [**2103**] mg PO BID and zonisamide 100 mg
PO QD.

RECTUS SHEATH HEMATOMA:
Ms. [**Known lastname **] had a Hct of 19 and was transfused 2 units RBC on
admission.  On the fifth hospital day, Ms. [**Known lastname **] complained of
abdominal pain prompting abdominal CT on [**2112-7-29**] that showed a
large rectus sheath hematoma on the right side.  Hct dropped
from ~30 to 26 and she was subsequently transfused 2 units
RBC's, though she remained hemodynamically stable.
Interventional radiology performed more imaging on [**2112-7-30**]
looking for a source of the bleed.  There was no active bleeding
at the time of the study, making it difficult to identify the
source.  A prophylactic embolization of the right inferior
epigastric artery was performed as it was felt this could have
been the source.  There apeared to be partial compression of the
right ureter on imaging, though no further intervention was
performed on the ureter since her renal function remained
relatively stable.  Overnight from [**7-30**] to [**7-31**], she required
another transfusion for decreasing blood counts, though, again,
she remained hemodynamically stable.  An abdominal binder had
been placed on [**2112-7-30**] to help control the bleed.  Her
hematocrit stabilized at ~29 by [**2112-7-31**] and was 28.7 upon
discharge on [**2112-8-3**].  It is unclear what caused the hemorrhage
and at what point it developed.  She was noted to be on SQ
insulin sliding scale upon admission, though she has no prior
diagnosis of DM (confirmed with patient and PCP).

ANTICOAGULATION, MECHANICAL MITRAL VALVE:
Heparin was restarted on [**2112-7-31**] since the bleed appeared to be
stable by that time and she was considered to be high risk due
to a mechanical mitral valve.  A lower PTT goal of 60-70 was
recommended by cardiology due to the recent bleed.  Coumadin was
not restarted in the hospital, though it is recommended to be
started at 4 mg QHS beginning on [**2112-8-3**] upon discharge.  Goal
INR is 2.5 - 3.5 for mechanical valve.  It is noted that she was
on aspirin 325 mg on admission.  This was discontinued and
should be held until PCP [**Last Name (NamePattern4) 702**].

VOLUME OVERLOAD:
Patient was noted to be short of breath at rest and volume
overloaded on exam in the setting of multiple blood transfusions
and IVF for CT contrast exposure.  CXR was consistent with
volume overload.  She had a slight troponin leak in this
setting, though she had no chest pain and no EKG changes
concerning for AMI (i.e., no T wave or ST segment changes).
Recent TTE from [**2112-7-18**] showed EF 60%; echo was not repeated
this admission.  She was treated with several doses of lasix 10
mg IV with great improvement in her volume status.  She was
weaned from 2LNC to room air and appeared euvolemic on exam
prior to discharge.

PNEUMONIA, LEUKOCYTOSIS:
Throughout most of her stay, Ms. [**Known lastname **] had a persistent
leukocytosis of 15-20 and a 2L NC oxygen requirement that was
thought to be due to a pneumonia, though no clear infiltrate was
identified on CXR.  She was started empirically on vancomycin +
ceftriaxone on [**2112-7-27**] for HAP and then switched empirically to
vancomycin + zosyn on [**2112-7-28**] since her leukocytosis persisted.
Upon transfer to the medicine service on [**2112-7-30**], her WBS was
still elevated at 17 and her O2 requirement remained at 2L,
though she had been afebrile.  Blood and urine cultures as well
as CXR were repeated for an infection work-up.  All cultures
were negative, including a stool C diff from [**2112-8-2**] (when she
finally had a BM).  CXR from [**2112-7-31**] showed a LLL infiltrate c/f
pneumonia.  She was continued on vancomycin + zosyn, and her
leukocystosis slowly improved to 12.8 on discharge.  Antibiotics
are to continue through [**2112-8-5**] for treatment of HAP.

RIGHT ANKLE PAIN:
Ms. [**Known lastname **] was noted to have some right lower leg and ankle
pain beginning [**2112-8-1**].  She had slight asymmetric swellin of
the right leg.  RLE ultrasound was performed since she was
considered to be at risk for DVT with her immoblization and
being off anticoagulation for several days; the ultrasound was
negative for DVT.  She also had difficulty bearing weight on the
right foot and focal tenderness at her right lateral malleolus.
X-ray of the foot and ankle were nagtive for fracture and showed
generalized soft tissue swelling.  She reported that she has
worn a brace for stability on that foot ever since her stroke
though she did not have it at the hospital.  It was recommended
that her husband bring this to the rehab facility, and it is
suspected that she may have some foot/ankle pain secondary to
not wearing this brace in recent days.

DYSPHAGIA:
The patient was followed by speech and swallow for mild
dysphagia.  Please see results of video swallow study and
recommendations in the pertinent results section of this
summary.

PICC:
Ms. [**Known lastname **] has a PICC in her left arm from [**2112-7-18**] during her
prior hospitalization.  The need for this should be readdressed
once heparin is discontinued and IV antibiotics are completed.

Medications on Admission:
Per [**2112-7-21**] DISCHARGE SUMMARY:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheezing .
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Lorazepam 0.5 mg IV PRN seizure > 3 minutes
PLEASE CALL HOUSE OFFICE PRIOR TO USING. [**Month (only) **] REPEAT X 1 IF
NEEDED.
10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
11. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and

PRN.
12. heparin drip sliding scale
Heparin solution: 25,000 in 250cc of D5W


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for SOB, wheeze.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for SOB, wheeze.
7. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 3 days: Please
continue through [**2112-8-5**].
8. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
4.5 grams Intravenous Q6H (every 6 hours): Please continue
through [**2112-8-5**].
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
10. Keppra 1,000 mg Tablet Sig: Two (2) Tablet PO every twelve
(12) hours: Take [**2103**] mg twice a day.
11. Zonisamide 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: See dosing sheet  Intravenous ASDIR (AS DIRECTED)
for 2 days: Please see attached dosing sheet.
13. Med Administration
Meds can be given whole in puree due to mild dysphagia.
14. Q8 oral care
15. Coumadin 4 mg Tablet Sig: One (1) Tablet PO at bedtime: Goal
INR 2.5 - 3.5.
16. Labs
Please monitor CBC and INR daily beginning on [**2112-8-4**] until
stable.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1970**] - [**Hospital1 1559**]

Discharge Diagnosis:
Primary Diagnoses:
(1) Rectus sheath hematoma
(2) Pneumonia
(3) Seizure disorder

Secondary Diagnoses:
(1) Subdural hematoma
(2) Mechanical mitral valve requiring anticoagulation


Discharge Condition:
Stable.  SBP in the 120's, breathing comfortably on room air.
With minimal swelling of right lower leg compared to the left.


Discharge Instructions:
You were admitted ot the hospital for seizures, and your
medication has been adjusted to control these.

You had a bleed in your abdomen called a rectus sheath hematoma,
which was treated by a procedure called "embolization" that
helps block bleeding in the artery.  Your blood counts were a
little low, so you were given a blood transfusion.  Your
anticoagulation was initially held while you were bleeding,
though it was restarted once your bleeding stabilized.

You were also treated for a pneumonia and for extra fluid on
your lungs.

You are being discharged to a rehab facility for further
physical therapy and treatment.

Please call the doctor or return to the emergency department if
you feel short of breath, develop fevers, or feel lightheaded or
dizzy.

Followup Instructions:
(1) Please call your primary care doctor to be seen for
follow-up 1-2 weeks after you are discharged from the rehab
facility.  Doctors at the rehab facility will follow you while
you are there.

(2) You need an appointment for a four week follow-up with Dr.
[**Last Name (STitle) 739**] in neurosurgery.  His office is working on
scheduling something for the week of [**8-15**].  They will call
your home phone number to give you an appointment time (they
will leave a message for your husband).  You will need a
non-contrast head CT that day prior to talking to the doctor,
and they are also scheduling this for you.

(3) You also need an appointment to be seen by Dr. [**Last Name (STitle) 851**]
in neurology for follow-up related to your seizures. The phone
number is [**Telephone/Fax (1) 44**].  The office is scheduling you something
for the week of [**8-15**] or the next available appointment.
They will also be calling your home phone to leave an
appointment time.

If you do not hear from these doctor's offices by Friday
[**2112-8-5**], please call these offices to ask about the status of
those appointments.
{'Other late effects of cerebrovascular disease,Pneumonitis due to inhalation of food or vomitus,Encephalopathy, unspecified,Acute posthemorrhagic anemia,Acute diastolic heart failure,Generalized convulsive epilepsy, without mention of intractable epilepsy,Nontraumatic hematoma of soft tissue,Dysphagia, unspecified,Pain in joint, ankle and foot,Unspecified essential hypertension,Heart valve replaced by other means,Long-term (current) use of anticoagulants,Other and unspecified hyperlipidemia,Anticoagulants causing adverse effects in therapeutic use'}


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: Syncope

PRESENT ILLNESS: 64 yo right-handed female with hx MVR, hx hemorrhagic stroke and
subsequent seizures, and HTN, with recent hospitalization at
[**Hospital1 18**] after a fall with acute left subdural hematoma, s/p
emergent evacuation and craniotomy, discharged [**7-21**]
on heparin (for mechanical heart valve) to [**Hospital3 **] and
noted to be awake, alert, and oriented at that time.  At
appromately 10 PM on [**2112-7-22**], she was noted to be unresponsive
with no clear description of preceeding events available.
However, it was thought she may have had a seizure and was
transferred to [**Hospital1 498**] ED where she was given 8 mg valium, 1500 mg
fosphenytoin IV.  She was transferred to [**Hospital1 18**] on [**2112-7-23**] for
further management and work-up.

MEDICAL HISTORY: Subdural hemorrhage, s/p evacuation and craniotomy [**2112-7-16**]
MVR s/p rheumatic heart disease
On coumadin for mechanical valve
H/o hemorrhagic stroke
History of seizure disorder (prior to SDH)
Hypertension
Hyperlipidemia
EF 60% on [**2112-7-18**] TTE

MEDICATION ON ADMISSION: Per [**2112-7-21**] DISCHARGE SUMMARY:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheezing .
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Lorazepam 0.5 mg IV PRN seizure > 3 minutes
PLEASE CALL HOUSE OFFICE PRIOR TO USING. [**Month (only) **] REPEAT X 1 IF
NEEDED.
10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
11. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: 99.9 (T max 100.3), P 75, BP 140/51, RR 16, 100% on
ventilator
Gen: intubated, sedated
Cardio: RR, II/VI SEM with ? click
Pulm: CTA anteriorly
Abd; soft, NT, ND
Neuro; intubated, sedated, does not awake to painful stimuli.
pupils 2 mm and minimally responsive.  Does not withdraw to
painful stimuli.  Flaccid tone throughout.  2+ reflexes biceps,
triceps, brachioradialis, patellar, b/l, upgoing toe on right.

FAMILY HISTORY: History of rheumatic heart disease in sisters

SOCIAL HISTORY: Lives with husband (but currently transferred from rehab); has a
lovely large family that frequently visits and is actively
involved in her care. 

### Response:
{'Other late effects of cerebrovascular disease,Pneumonitis due to inhalation of food or vomitus,Encephalopathy, unspecified,Acute posthemorrhagic anemia,Acute diastolic heart failure,Generalized convulsive epilepsy, without mention of intractable epilepsy,Nontraumatic hematoma of soft tissue,Dysphagia, unspecified,Pain in joint, ankle and foot,Unspecified essential hypertension,Heart valve replaced by other means,Long-term (current) use of anticoagulants,Other and unspecified hyperlipidemia,Anticoagulants causing adverse effects in therapeutic use'}
