CHIEF COMPLAINT: fall with MS change

PRESENT ILLNESS: This is a 65 year old man with schizophrenia who was recently
transferred to rehab from the Neurosurgery service s/p
suboccipital craniotomy and clot evacuation following cerebellar
bleed after TPA for presumed stroke. He also had VPS placement
during that admission for hydrocephalus. He had fall on [**11-28**]
with significant chnage when compared to older imaging. He was
started on warfarin for bilateral DVTs and had a fall at rehab.
CT head demonstrated left acute subdural hematoma. with midline
shift and neurosurgery was consulted.

MEDICAL HISTORY: Recent hospitalisation under neurosurgery at [**Hospital1 18**] and
discharged
[**11-30**] with initial presentation with speeh arrest and developed
large cerebellar bleed sp TPA [**2141-11-7**]
s/p suboccipital craniotomy for clot evacuation [**11-9**]
s/p VPS insertion for hydrocephalus and CSF leak [**11-17**]
* HTN
* DM2
* Diabetic retinopathy OU
* Cystoid macular edema OS
* back injury
* hx of exposure to asbestos
* hx of excision of a Lipoma on posterior neck [**2126**]
* MRI [**2126**] of head and neck showed mild generalized atrophy
inconsistent with his age,nonspecific white matter densities
* Paranoid psychosis (recently untreated, but with multiple
prior hospitalizations)

MEDICATION ON ADMISSION: acetaminophen 650 mg Q6hrs PRN pain
insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day: At dinner.
insulin regular human 100 unit/mL Solution Sig: per sliding
scale per sliding scale Injection four times a day.
bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
amlodipine 10mg PO DAILY
lisinopril 10 mg PO DAILY
metoprolol tartrate 50 mg PO BID
docusate sodium 100MG PO BID
pantoprazole 40 mg daily
chlorhexidine gluconate 0.12 % Mouthwash Sig: 15 ML Mucous
membrane [**Hospital1 **]
warfarin 7.5mg - had not been getting at rehab due to high INR
olanzapine 5 mg Tablet, Rapid Dissolve PO QHS

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
BP: 157/80 HR: 85 R 18 O2Sats 100% RA
BP spiked acutely from 155/80 at 1700 up to 200/89 at 1756
Gen: Initially eyes closed and moving arms tehn developed
fidgety
movements predominantly in the hands and then latterly extensor
posturing. Eyes closed throughout. Left anterior frontal
hematoma
4x4cm.
HEENT: Pupils: Initialy 2.5mm bilateral and reactive and then
2mm
and sluggish prior to intubation
EOMs roving eye movements
Neck: Supple.
Lungs: CTA bilaterally anteriorly
Cardiac: RRR. Normal S1/S2 without murmurs.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. Calves soft - known DVTs

FAMILY HISTORY: Brother w/ h/o admission to a psychiatric hospital.

SOCIAL HISTORY: Born and raised in [**Location (un) 669**], [**Location (un) 686**] and [**Location (un) 2268**] and as of
[**2126**] he had been homelesss for 9 years. He reports that he now
lives in [**Location 669**] in his own apt alone. He is single has never
married and does not have any children. Hx of heavy use of ETOH
but stopped drinking many years ago. H/o past use of marijuana
and cocaine; none recently. Previous tobacco history.
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Encephalopathy, unspecified,Acute respiratory failure,Ventilator associated pneumonia,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Unspecified protein-calorie malnutrition,Paranoid type schizophrenia, unspecified,Mixed acid-base balance disorder,Subdural hemorrhage,Other convulsions,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Background diabetic retinopathy,Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Hematuria, unspecified,Leukocytosis, unspecified,Pressure ulcer, lower back,Apnea,Personal history of contact with and (suspected) exposure to asbestos,Other postprocedural status,Long-term (current) use of insulin,Accidents occurring in residential institution,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Fall from other slipping, tripping, or stumbling
Subdural hem w/o coma,Encephalopathy NOS,Acute respiratry failure,Ventltr assoc pneumonia,Ac DVT/emb distl low ext,Protein-cal malnutr NOS,Paranoid schizo-unspec,Mixed acid-base bal dis,Subdural hemorrhage,Convulsions NEC,DMII ophth nt st uncntrl,Mth sus Stph aur els/NOS,Diabetic retinopathy NOS,Hypertension NOS,Depressive disorder NEC,Anxiety state NOS,Hematuria NOS,Leukocytosis NOS,Pressure ulcer, low back,Apnea,Hx-contct/expos asbestos,Post-proc states NEC,Long-term use of insulin,Accid in resident instit,Abn react-procedure NEC,Fall from slipping NEC
Admission Date:  [**2141-12-2**]              Discharge Date:   [**2142-1-11**]

Date of Birth:  [**2076-9-25**]             Sex:   M

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
fall with MS change

Major Surgical or Invasive Procedure:
[**2141-12-2**]: left craniotomy for evacuation of acute SDH
[**2141-12-4**]: IVC filter placement
[**2141-12-29**]: Tracheostomy
[**2141-12-29**]: PEG
[**2142-1-5**]: Bronchoscopy with washing


History of Present Illness:
This is a 65 year old man with schizophrenia who was recently
transferred to rehab from the Neurosurgery service s/p
suboccipital craniotomy and clot evacuation following cerebellar
bleed after TPA for presumed stroke. He also had VPS placement
during that admission for hydrocephalus. He had fall on [**11-28**]
with significant chnage when compared to older imaging. He was
started on warfarin for bilateral DVTs and had a fall at rehab.
CT head demonstrated left acute subdural hematoma. with midline
shift and neurosurgery was consulted.

Patient was stable at rehab until he was found down at roughly
15:00 after last being seen well about 40 minutes prior. Patient
had apparently fallen after trying to stand up and sustained a
head injury. At the rehab facility he had complained of right
head pain but per them seemed to be at his usual neurological
baseline. He had not been receiving warfarin at rehab due to
supratherapeutic INR last 2.3. Vitals at that time were 140/81
94
98% RA.

He was transferred to teh [**Hospital1 18**] ED and initially he was able to
follow commands but did not open his eyes with initial vitals 85
157/80 18 100% RA. CT showed a left sided acute SDH with midline
shift and edema. INR was 2.1 and he was reversed. He
progresively
declined such that he would initially groan and intermittently
follow commands and latterly at the time of my assessment became
unresponsive to sternal rub preceded by fidgety movements of the
hands and latterluy extensor posturing in the UE with GCS 4 E1
V1
M2. HE also had a hypertensive spiek with HR stable/borderlien
bradycardic and SBP 190s -200s. He was intubated in the ED and
repeat scan showed a possible bleeding vessel with considerable
enlargememnt in the ASDH and worse midline shift. BP improved
with sedation. Given worsening in scan and clinical status, he
was tarnsferred directly to teh OR for an emergent left
craniotomy and clot evacuation.

Past Medical History:
Recent hospitalisation under neurosurgery at [**Hospital1 18**] and
discharged
[**11-30**] with initial presentation with speeh arrest and developed
large cerebellar bleed sp TPA [**2141-11-7**]
s/p suboccipital craniotomy for clot evacuation [**11-9**]
s/p VPS insertion for hydrocephalus and CSF leak [**11-17**]
* HTN
* DM2
* Diabetic retinopathy OU
* Cystoid macular edema OS
* back injury
* hx of exposure to asbestos
* hx of excision of a Lipoma on posterior neck [**2126**]
* MRI [**2126**] of head and neck showed mild generalized atrophy
inconsistent with his age,nonspecific white matter densities
* Paranoid psychosis (recently untreated, but with multiple
prior hospitalizations)


Social History:
Born and raised in [**Location (un) 669**], [**Location (un) 686**] and [**Location (un) 2268**] and as of
[**2126**] he had been homelesss for 9 years. He reports that he now
lives in [**Location 669**] in his own apt alone. He is single has never
married and does not have any children. Hx of heavy use of ETOH
but stopped drinking many years ago. H/o past use of marijuana
and cocaine; none recently. Previous tobacco history.


Family History:
Brother w/ h/o admission to a psychiatric hospital.


Physical Exam:
On Admission:
BP: 157/80 HR: 85 R 18 O2Sats 100% RA
BP spiked acutely from 155/80 at 1700 up to 200/89 at 1756
Gen: Initially eyes closed and moving arms tehn developed
fidgety
movements predominantly in the hands and then latterly extensor
posturing. Eyes closed throughout. Left anterior frontal
hematoma
4x4cm.
HEENT: Pupils: Initialy 2.5mm bilateral and reactive and then
2mm
and sluggish prior to intubation
EOMs roving eye movements
Neck: Supple.
Lungs: CTA bilaterally anteriorly
Cardiac: RRR. Normal S1/S2 without murmurs.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. Calves soft - known DVTs

Neuro:
Mental status: Drowsy and obeying commands initially and then
rapidly only intermittently following commands and finally
unresponsive to sternal rub

Cranial Nerves:
I: Not tested
II: Pupils equally round and weakly reactive to light, 2 to
1.5mm bilaterally prior to intubation. Eyes closed and no fields
done.
III, IV, VI: Roving eye movements
V, VII: Face symmetric
VIII: Unable to assess
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Likely normal
XII: Unable to assess given inability to followi commands.

Limb exam:

Grossly normal tone when GCS was suficinetly high and having
spontaneous movements.
Motor:
Wsa able to resist in UE and LE at initial assessment by me
Sensation: Latterly no movement to noxious.
Reflexes: Hyporeflexic throughout.
Plantar reflexes mute bilaterally
Cerebellar: Unable to assess

Discharge exam:


Pertinent Results:
[**2141-12-2**] 05:00PM   PT-22.3* PTT-31.2 INR(PT)-2.1*
[**2141-12-2**] 05:00PM   PLT COUNT-391
[**2141-12-2**] 05:00PM   NEUTS-64.6 LYMPHS-27.7 MONOS-5.3 EOS-2.0
BASOS-0.4
[**2141-12-2**] 05:00PM   WBC-9.3 RBC-4.21* HGB-12.2* HCT-37.5* MCV-89
MCH-29.0 MCHC-32.5 RDW-13.2
[**2141-12-2**] 05:00PM   estGFR-Using this
[**2141-12-2**] 05:00PM   UREA N-13 CREAT-0.9 SODIUM-138 POTASSIUM-4.4
CHLORIDE-97 TOTAL CO2-30 ANION GAP-15
[**2141-12-2**] 05:20PM   LACTATE-1.4
[**2141-12-2**] 10:12PM   PT-16.1* PTT-26.9 INR(PT)-1.4*
[**2141-12-2**] 10:12PM   PLT COUNT-333
[**2141-12-2**] 10:12PM   NEUTS-73.3* LYMPHS-21.0 MONOS-5.2 EOS-0.3
BASOS-0.2
[**2141-12-2**] 10:12PM   WBC-8.6 RBC-3.35* HGB-9.7* HCT-29.6* MCV-88
MCH-28.9 MCHC-32.7 RDW-13.4
[**2141-12-2**] 10:12PM   ALBUMIN-3.2* CALCIUM-8.6 PHOSPHATE-3.2
MAGNESIUM-1.9
[**2141-12-2**] 10:12PM   ALT(SGPT)-19 AST(SGOT)-14 ALK PHOS-96 TOT
BILI-0.7
[**2141-12-2**] 10:12PM   GLUCOSE-215* UREA N-13 CREAT-0.8 SODIUM-136
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-29 ANION GAP-12

[**2141-12-2**] UPRIGHT AP VIEW OF THE CHEST: The heart size is mildly
enlarged with a left ventricular predominance, but unchanged.
The mediastinal and hilar contours are stable. Pulmonary
vascularity is not engorged. There is minimal patchy opacity in
the retrocardiac region, most likely reflective of atelectasis.
No pleural effusion or pneumothorax is present. A catheter is
seen coursing over the right hemithorax.

[**2141-12-2**] 16:30  CT Head  IMPRESSION:
1. Large, new, acute subdural hematoma overlying left cerebral
hemisphere
with mass effect and 7-mm rightward shift of normally midline
structures.
Basal cisterns are patent with no evidence of transtentorial
herniation.
2. Slightly improved areas of subarachnoid hemorrhage.
3. Small amount of intracranial hemorrhage, with blood layering
in the
occipital [**Doctor Last Name 534**] of the left lateral ventricle.
4. Stable appearance of post-surgical changes related to
hematoma evacuation and suboccipital craniectomy. Stable fluid
collection within the post-surgical bed.

[**2141-12-2**] CHEST, SINGLE AP PORTABLE SEMI-UPRIGHT VIEW.
An ET tube is present, tip in satisfactory position
approximately 5.7 cm above the carina. No pneumothorax is
detected.  A linear density overlying the right lung likely
reflects a VP shunt catheter unchanged.

[**2141-12-2**] 18:49  CT Head: IMPRESSION: Worsening SDH
1. Increased hyperdense material anteriorly within in the left
hemispheric
extra-axial collection is likely redistribution of blood
products or
additional new blood. Hypodense foci within are concerning for
on-going
hemorrhage and unclotted blodd related to coagulopathy.
2. Increased rightward shift of midline structures, now 17 mm,
previously 7 mm.
3. Stable subarachnoid and left intraventricular hemorrhage.

[**2141-12-2**] CT cervical spine: No fracture or malalignment

[**2141-12-2**] 21:48  CT Head: IMPRESSION:
1. Status post evacuation of a left subdural hematoma via left
frontal
craniotomy, with no evidence of new acute hemorrhage or large
vascular
territorial infarction. Pneumocephalus as described above.
Attention on
close followup if no intervention is contemplated.
2. Interval improvement of mild rightward shift of midline
structures
persitent to some degree .
3. Unchanged subarachnoid hemorrhage within the right frontal
and vertex.

[**2141-12-3**] MRI Brain: IMPRESSION:
1. Infarcts in the brainstem. Areas of decreased diffusion in
the left cerebellar hemisphere, corresponding to the previously
noted hypodense area on CT studies. These likely represent
evolving blood products.  There is mild mass effect on the
fourth ventricle on the left side with distortion.
2. Persistent left subdural fluid collection, with
pneumocephalus causing
mass effect on the cerebral hemispheres, along with
post-surgical changes and fluid collection in the soft tissues,
not significantly changed compared to the recent CT head study.
Improvement in the mass effect on the left lateral ventricle
compared to the prior CT head study.

[**2141-12-3**] MRI Cervical Spine: IMPRESSION:
1. Multilevel multifactorial degenerative changes with
moderate-to-severe
canal stenosis at C3-4 level with some degree of deformity on
the cervical
spinal cord. Multilevel moderate-to-severe neural foraminal
narrowing as
described above. Assessment for subtle cord signal intensity
changes is
limited; no gross focal lesions in cord.
2. C7-T1: Increased signal intensity in the disc and adjacent
endplates.
3. No ligamentous injury apparent.

[**12-4**] CT Head- IMPRESSION: Status post evacuation of subdural
hematoma with small amount of residual or procedure related
hemorrhage and fluid. Post-procedure pneumocephalus. Small
amount of hemorrhage with left lateral ventricle posteriorly. No
shift of midline structures. Stable appearance of known
subarachnoid hemorrhage.

[**12-10**] MRI Brain: unchanged from previous MRI brain.  Old
infarcts in the brainstem are stable.

[**12-10**] Chest Xray portable: FINDINGS: The ET tube is 3 cm above
the carina. Left PICC line tip is in the SVC. Lung volumes are
slightly low. There is pulmonary vascular redistribution and
volume loss at both bases. There is no effusion and no definite
infiltrate.

[**12-11**] Chest xray: Since [**2141-12-10**] pulmonary vascular
congestion has improved and there is no pulmonary edema

[**12-12**]: Chest xray stable

[**12-17**]: CT Head: IMPRESSION:
1. Status post evacuation of left frontal subdural hematoma with
increased
left frontal collection beneath the craniotomy site up to 15 mm.

2. No new bleeding with continued evolution of right-sided
subarachnoid
hemorrhage.
3. Unchanged appearance of the left occipital craniectomy and
left cerebellar hypodensities from prior hemorrhage.
4. Right frontal approach ventriculostomy catheter unchanged
appearance
within the frontal [**Doctor Last Name 534**] of the right lateral ventricle without
hydrocephalus.
5. No shift of midline structures.
6. Subgaleal fluid in the left frontal and temporal regions
adjacent to the craniotomy site, likely post-surgical in
etiology.

CHEST (PORTABLE AP) Study Date of [**2141-12-20**] 3:18 AM
FINDINGS: Endotracheal tube ends approximately 5.5 cm above the
carina and is adequately placed. Orogastric tube is seen to
course below the diaphragm into the stomach and is appropriate.
Left PICC line ends at mid SVC. Bilteral lung volumes are
better. Since [**2141-12-17**], there are no new interval lung
changes. Bibasal atelectasis is similar. Since the patient is
rotated, assessment of the cardiomediastinal silhouette was
limited, however, no gross changes.

Radiology Report BILAT LOWER EXT VEINS Study Date of [**2141-12-21**]
8:58 AM IMPRESSION: Deep vein thrombosis again seen in one of
the two posterior
tibial veins in the left calf. The remainder of the deep veins
of both legs are normal.

CXR [**2141-12-22**]
Endotracheal tube terminates approximately 5.8 cm above the
carina, left PICC line ends at lower SVC, and orogastric tube is
seen to course below the diaphragm into the stomach, though
distal end is beyond the radiograph, all are appropriate. Since
[**2141-12-20**], bibasal atelectases, left more than right,
have improved. No new lung opacities of concern. Mild pulmonary
vascular and mediastinal congestion hasresolved. Heart size
normal.  Mediastinal and hilar contours are unremarkable.

[**2141-12-23**] MRI brain with and without contrast
IMPRESSION:
1. No evidence of an acute infarct seen.
2. Evolution of blood products in the left cerebellum and
presence of blood products in the ventricles, in the right
occipital [**Doctor Last Name 534**].
3. Subdural hematoma left greater than right side unchanged.
Changed but
with evolution of blood products.
4. No evidence of change in the ventricular system which remains
slightly
prominent.

[**2141-12-25**] CXR: no changes

[**2141-12-26**] CXR: IMPRESSION: Little interval change from one day
prior. Persistent left basilar opacities, likely atelectasis. No
convincing evidence of pneumonia or pulmonary edema.

[**2141-12-28**] CXR: no changes

[**2141-12-29**]: no changes

[**2141-12-31**]: The patient has been extubated and a tracheostomy tube
was placed.  The tube is in correct position. No evidence of
complications, notably no pneumothorax. In the interval, the
nasogastric tube has also been removed, the left-sided PICC line
is in unchanged position. Unchanged ventriculoperitoneal shunt.

Unchanged mild-to-moderate atelectasis at the left lung base.
The presence of a small left pleural effusion cannot be
excluded.

[**2141-12-31**] CT head noncontrast IMPRESSION:
1. No interval increase in thickness or extent of the left
frontoparietal
subdural fluid collection, without acute component or increased
mass effect.
2. Right transfrontal ventriculostomy terminates in the frontal
[**Doctor Last Name 534**] of the right lateral ventricle, as before, without change
in ventricular size or shape.
3. Fluid collection at the site of the suboccipital craniectomy
stable in
appearance, with no rim-enhancement to suggest infection.
4. Bilateral mastoid effusions with fluid-opacification of the
left middle
ear cavity, as on the MR study of [**2141-12-23**].

[**2142-1-1**] CXR:
In comparison with study of [**12-31**], there is no change in the
appearance of the tracheostomy, though it is difficult to
evaluate given the obliquity of the patient. The PEG device is
not appreciated. The overall appearance of the heart and lungs
is essentially unchanged

[**2142-1-2**] CXR
As compared to the previous radiograph, there is no relevant
change. No
evidence of pneumonia. No pulmonary edema. Borderline size of
the cardiac
silhouette with mild fluid overload. No pleural effusions.
Unchanged
tracheostomy tube, unchanged left central venous access line,
unchanged
ventriculoperitoneal shunt.

[**2142-1-3**] CXR
1. Persistent mild pulmonary vascular congestion.
2. Possible new left small pleural effusion or consolidation for
which an
upright radiograph is necessary for further evaluation

[**2142-1-4**] CXR
Previously reported questionable left pleural effusion or
consolidation is no longer evident. No new areas of
consolidation to suggest a source of infection.

[**2142-1-5**] CXR
In comparison with the study of [**1-4**], the tracheostomy tube
remains in place and there is pneumomediastinum or pneumothorax.
Central
catheter remains in place. There is the suggestion of some vague

opacification in the retrocardiac region that could represent
some atelectatic changes. Mild fullness of pulmonary central
vessels raises the possibility of elevated pulmonary venous
pressure.

 [**2142-1-5**] LENS
DVT involving bilateral CFV, left proximal SFV, and one of the
left PTV's.


Brief Hospital Course:
Mr. [**Known lastname **] was taken emergently from the ER to the Operating
Room for evacuation of enlarging acute SDH.  His coagulopathy
was reversed with FFP, initial INR 2.1 and subsequent post
transfusion INR of 1.4.  He was also given 3 days of Vitamin K.
 Postoperatively he remained intubated for periods of apnea.
His exam slowly improved to withdrawal of all 4 extremities and
purposeful left arm movement.

On POD2 the patient underwent placement of IVC filter as he
cannot be anticoagulated given his acute SDH evacuation and
multiple falls.  Post-procedure the patient had multiple
episodes of seizure activity involving right arm rhythmic
jerking and right facial twitching that resolved with Dilantin
300mg IV and ativan 2mg IV.  His dilantin dose was increased to
200mg IV BID.

On POD3 [**12-5**] the patient was placed on continuous EEG
monitering which showed frequent seizures in the setting of
corrected dilantin level > 10, that did not resolve with
dilantin boluses.  Epilepsy team was consulted for
recommendations and cessation of seizures occured after Ativan
IV and IV Keppra bolus.  His dilantin dose was increased and he
was placed on standing Keppra 1500mg [**Hospital1 **].  He remained on
Continuous EEG monitoring.

On [**12-6**] the patient's neurological exam was stable but poor.
His EEG monitoring continued and was negative for active
seizures. Corrected dilantin level was 16.6.
On [**12-7**] vent settings were being weaned and neurological exam
was stable. EEG was again negative for seizures on current
regimen.  As a result, on [**12-8**], neurology discontinued EEG
monitoring.

Patient continued to require respiratory and nutritional support
via tube feeding. It was plan to have PEG/Trach, however family
have not been available for consent as of [**12-12**].  Social work
involved and is trying to schedule a famly meeting to discuss
goals of care.

On [**12-10**] the patient's mental status continued to be depressed
with a minimal exam and so he underwent an MRI of the brain to
assess for the possibility of new strokes.  MRI was stable and
did not show new strokes.

As the patient was not able to follow commands and had a
difficult airway, the ICU team did not feel that he was a
candidate for extubation, compounded by an increase in
secretions due to VAP, the decision was made to proceed to trach
and PEG.  His sister and guardian was consulted for consent
however she expressed an unwillingness to make medical decisions
for him.  Social work and ethics teams were consulted on how
best to proceed.

On [**12-13**] staples/suture were removed. His dilantin level was
corrected at 9 therefore his standing dose was increased. He
remained neurologically stable awaiting guardianship/plan per
social work and ethics. On [**12-14**] his dilantin level was 8.3
corrected so he was bolused 500mg of fosphenytoin.  On [**12-15**]
dilantin was corrected to 13. Neurologically he seems more awake
and opened eyes to voice. His BAL from [**12-13**] grew coag + staph
aureus and enterobacter so ancef was d/c'd and changed to
vanc/cefepime/cipro. Cipro was later d/c'd given it's properties
of lowering the seizure threshold. Hi secretions continued to be
prominent on [**12-16**], therefore extubation was not attempted. On
[**12-17**] he was noted to have some ? seizure activity with twitching
of the LUE and left eye/face. This self resolved and a
neuromedicine consult was called and EEG was continued. On the
morning of 11.7 he was noted to have probable seizure activity
evidenced by twitching of the right eye and mouth. He was given
ativan and per neuromed consult recs was bolused with vimpat.
later on he developed LUE and left facial twitching and was
given ativan.

On [**12-19**] a court hearing was held regarding his guardianship. His
exam was stable and he had no seizures overnight into [**12-19**].
During the court hearing he was appointed a guardian and plan
was set to begin the process of obtaining consent for trach and
PEG.

On [**12-21**] his dilantin level was corrected to 10 so he was
bolused and given an increased dose. Also LENI's were performed
for routine monitoring and was consistent with deep vein
thrombosis again seen in one of the two posterior
tibial veins in the left calf. The remainder of the deep veins
of both legs
are normal.


On [**12-22**], The patient was on a continuous EEG which was read per
the neurology service with frequent worseing spikes and the
lacasomide was increased to 300 [**Hospital1 **]. Neurology recommended an
MRI to evaluate the patient for possible worsening infarct which
might be a source of the EEG findings. The VP shunt was verified
to be at a setting of 2.5 prior to MRI. The patient continued on
lacasomide 300 mg IV BID, ativan(standing)1 mg IV QID,keppra 2g
[**Hospital1 **],Fosphenytoin 300 mgIV Q8H(on hold [**12-22**]) per Neurology's
recommendations.  Dilantin level was sent which was 9.8. The
patient was awaiting formal appointed guardianship for decision
regarding trach and peg placement. On Exam, the patient was
intubated, there was no eye opening, pupils were equal and
reactive, the patient localized to noxious in the left upper
extremity.  The patient exhibits minimal withdrawal in the right
upper and left upper extremity.  He continues to not follow
commands. (on standing ativan 1mg QID per neurology). A chest
xray was performed which showed improvement in atelectasis and
consolidation.

He remained on EEG on  [**12-23**] and [**12-24**] which neurology said
showed unchanged seizure activity. His dilantin was increased to
350mg TID as well. On [**12-26**] his guardian was officially
appointed and consent was obtained for trach and PEG, also he
was placed on versed for supression x 24 hours and on [**12-27**] it
was weaned off. On [**12-28**] he was more awake on exam and was
awaiting trach and PEG planned for [**12-29**]. On [**12-29**] he underwent
Trach and PEG placement by general surgery and toelrated it
well. Also his EEG's for [**12-26**], [**12-27**], and [**12-28**] were reviewed
and all showed moderate to severe encephalopathy but there were
no electrographic seizures.

On [**12-29**] the patient underwent Trach and PEG and tube feeds were
restarted and titrated to goal on [**12-30**].  On [**12-31**] he was noted
to have developed hematuria in the evening and urology was
consulted to assist in management. there was a question of
traumatic foley palcement versus urethral erosion. He had
continuous bladder irrigation and his urine cleared. On [**1-1**]
the patient was febrile to 102.3 and a fever workup was
inititated.  He was started on empiric antibiotics for pneumonia
as the patient continued to have copious secretions. He
continued to have epsiodes of fevers on [**1-2**] while on triple
antibiotics. He is awaiting rehab palcement.

On [**1-5**] he exhibited twitching in his face and left side.
Dilantin was again recommended by Neurology. This behavior
continued in to [**1-6**] and Ativan was given. ID was consulted as
well and they left recommendations for treatment which were not
followed. Neuromedicine was again called and the felt that he
should not be treated for this. Formal recommendations recieved
on [**1-7**] were to give standing Ativan 2mg q4hours x 24 hours
while attempting to attain goal Dilantin level of 20. His dosing
was increased to 250mg TID. On [**1-8**] his Dilantin level 18.4
corrected and he had continued drainage fro his trach site.
cultures were sent and his antibiotics were changed to nafcillin
only. On [**1-9**] his Dilantin level was 16.8 corrected he and
recieved a 500g Dilantin Bolus.

On [**1-10**], patient's VP shunt was dialed down to 1.0.  Now DOD,
he is afebrile VSS, he is neurologically stable.  He is set for
d/c to [**Hospital1 1501**] in stable condition and will follow-up accordingly.

Issues by system:
Neurologic:
- neuro checks Q4 hrs
- Keppra [**2130**] [**Hospital1 **]; Vimpat 300 [**Hospital1 **], fosphenytoin 250 TID, ativan
2mg q4h until dilantin levels are at 17-20; monitor renal
function since may have to adjust AED
- Taper ativan to off within the next week as long as he is
seizure free

Cardiovascular:
- goal SBP 100-160
- amlodipine 10 qday, metoprolol 25 daily, stopped lisinopril,
spironolactone and hydralazine on [**1-11**]
- Ok to stop amlodipine if still hypotensive

Pulmonary:
- episodes of apnea on CPAP, back on MMV. Wean vent as tolerated

- per radiology, small nodule RUL, needs follow up eventually
- purulent secretions from trach, improving on current
antibiotics

Gastrointestinal / Abdomen:
- continue bowel regimen
- PEG site has improved
- famotidine ppx

Nutrition:
- TF Glucerna 90ml/hr
Renal:
- foley restarted due to poor output s/p lasix. Put out 1100cc
when foley inserted
- ~17L positive- lasix gtt, monitor K and HCO to avoid worsening
met alkalosis
- primary metabolic alkalosis w/ inappropriate respiratory
compensation, on aldactone 50 and is tolerating well
- diuresis was held due to rising Crea (1.6 on [**1-11**])
- Hematuria: f/u with urology for outpt cystoscopy


Hematology:
- continue ASA 81mg/SQ heparin
- s/p IVC filter [**12-4**] (has DVT)
- Hct stable
- LENI: DVT involving bilateral CFV, left proximal SFV, and one
of the left PTV's are thought to be superficial.  Vascular
surgery recommend repeat LENIS prior to [**2142-1-15**]

Endocrine:
- NPH 50/50
- monitor FS

Infectious disease:
- completed course for PNA
- having purulent secretions around trach site (Culture as of
[**1-10**] respiraory flora and  STAPH AUREUS COAG +.
- purulent discharge from PEG insertion site, monitor
- nafcillin([**1-2**]- ): complete 14 day course until [**2142-1-16**]
- d/c'ed cefepime ([**Date range (1) 99653**], [**Date range (1) 99654**]) and gentamicin
([**Date range (1) 24439**] )

Tubes/Lines/Drains: L PICC, trach, PEG
- d/c'ed T/L/D's: a-line ([**12-15**]), foley

Dispo:
- Guardian [**Name (NI) 402**] [**Name (NI) 36653**], [**Telephone/Fax (1) 99655**], [**Telephone/Fax (1) 99656**]

Wounds: L craniotomy


Medications on Admission:
acetaminophen 650 mg Q6hrs PRN pain
insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day: At dinner.
insulin regular human 100 unit/mL Solution Sig: per sliding
scale per sliding scale Injection four times a day.
bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
amlodipine 10mg PO DAILY
lisinopril 10 mg PO DAILY
metoprolol tartrate 50 mg PO BID
docusate sodium 100MG PO BID
pantoprazole 40 mg daily
chlorhexidine gluconate 0.12 % Mouthwash Sig: 15 ML Mucous
membrane [**Hospital1 **]
warfarin 7.5mg - had not been getting at rehab due to high INR
olanzapine 5 mg Tablet, Rapid Dissolve PO QHS

Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

6. acetaminophen 325 mg Suppository Sig: 1-2 tabs Rectal Q6H
(every 6 hours) as needed for fever, pain.
7. levetiracetam 100 mg/mL Solution Sig: [**2130**] ([**2130**]) mg PO BID
(2 times a day).
8. lacosamide 150 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. lorazepam 2 mg/mL Syringe Sig: Two (2) mg Injection Q6H
(every 6 hours).
12. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2)
grams Intravenous Q4H (every 4 hours): discontinue on [**2142-1-16**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 86**]

Discharge Diagnosis:
Left acute subdural hematoma
Brain stem infarct
Seizures
left tibilal Deep Vein Thrombosis
malnutrition
respiratory failure
pneumonia
Hematuria
leukocytosis
post-op pyrexia
metabolic alkalosis
Hypervolemia
Tachypnea
hyperglycemia


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.


Discharge Instructions:
******* YOU HAVE A PROGRAMMABLE VP SHUNT THAT IS SET AT 1.0
*******
  Your shunt settings can be changed with a magnet, please avoid
magnets. If you have a MRI, you will need your shunt to be
re-programmed.
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	Keep incision clean and dry
??????	You may shower before this time using a shower cap to cover
your head.
??????	If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week.  This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
You have been discharged on Keppra (Levetiracetam), you will not
require blood work monitoring.

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:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast.

Epilepsy/Stroke Follow-up: Please follow-up neurology.  Please
call [**Telephone/Fax (1) 99657**] week with a Head CT scan.

Urology follow-up:  Please call ([**Telephone/Fax (1) 99658**] to schedule an
outpatient cystocopy when appropriate.



Completed by:[**2142-1-11**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Encephalopathy, unspecified,Acute respiratory failure,Ventilator associated pneumonia,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Unspecified protein-calorie malnutrition,Paranoid type schizophrenia, unspecified,Mixed acid-base balance disorder,Subdural hemorrhage,Other convulsions,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Background diabetic retinopathy,Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Hematuria, unspecified,Leukocytosis, unspecified,Pressure ulcer, lower back,Apnea,Personal history of contact with and (suspected) exposure to asbestos,Other postprocedural status,Long-term (current) use of insulin,Accidents occurring in residential institution,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Fall from other slipping, tripping, or stumbling'}


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: fall with MS change

PRESENT ILLNESS: This is a 65 year old man with schizophrenia who was recently
transferred to rehab from the Neurosurgery service s/p
suboccipital craniotomy and clot evacuation following cerebellar
bleed after TPA for presumed stroke. He also had VPS placement
during that admission for hydrocephalus. He had fall on [**11-28**]
with significant chnage when compared to older imaging. He was
started on warfarin for bilateral DVTs and had a fall at rehab.
CT head demonstrated left acute subdural hematoma. with midline
shift and neurosurgery was consulted.

MEDICAL HISTORY: Recent hospitalisation under neurosurgery at [**Hospital1 18**] and
discharged
[**11-30**] with initial presentation with speeh arrest and developed
large cerebellar bleed sp TPA [**2141-11-7**]
s/p suboccipital craniotomy for clot evacuation [**11-9**]
s/p VPS insertion for hydrocephalus and CSF leak [**11-17**]
* HTN
* DM2
* Diabetic retinopathy OU
* Cystoid macular edema OS
* back injury
* hx of exposure to asbestos
* hx of excision of a Lipoma on posterior neck [**2126**]
* MRI [**2126**] of head and neck showed mild generalized atrophy
inconsistent with his age,nonspecific white matter densities
* Paranoid psychosis (recently untreated, but with multiple
prior hospitalizations)

MEDICATION ON ADMISSION: acetaminophen 650 mg Q6hrs PRN pain
insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day: At dinner.
insulin regular human 100 unit/mL Solution Sig: per sliding
scale per sliding scale Injection four times a day.
bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
amlodipine 10mg PO DAILY
lisinopril 10 mg PO DAILY
metoprolol tartrate 50 mg PO BID
docusate sodium 100MG PO BID
pantoprazole 40 mg daily
chlorhexidine gluconate 0.12 % Mouthwash Sig: 15 ML Mucous
membrane [**Hospital1 **]
warfarin 7.5mg - had not been getting at rehab due to high INR
olanzapine 5 mg Tablet, Rapid Dissolve PO QHS

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
BP: 157/80 HR: 85 R 18 O2Sats 100% RA
BP spiked acutely from 155/80 at 1700 up to 200/89 at 1756
Gen: Initially eyes closed and moving arms tehn developed
fidgety
movements predominantly in the hands and then latterly extensor
posturing. Eyes closed throughout. Left anterior frontal
hematoma
4x4cm.
HEENT: Pupils: Initialy 2.5mm bilateral and reactive and then
2mm
and sluggish prior to intubation
EOMs roving eye movements
Neck: Supple.
Lungs: CTA bilaterally anteriorly
Cardiac: RRR. Normal S1/S2 without murmurs.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. Calves soft - known DVTs

FAMILY HISTORY: Brother w/ h/o admission to a psychiatric hospital.

SOCIAL HISTORY: Born and raised in [**Location (un) 669**], [**Location (un) 686**] and [**Location (un) 2268**] and as of
[**2126**] he had been homelesss for 9 years. He reports that he now
lives in [**Location 669**] in his own apt alone. He is single has never
married and does not have any children. Hx of heavy use of ETOH
but stopped drinking many years ago. H/o past use of marijuana
and cocaine; none recently. Previous tobacco history. 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Encephalopathy, unspecified,Acute respiratory failure,Ventilator associated pneumonia,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Unspecified protein-calorie malnutrition,Paranoid type schizophrenia, unspecified,Mixed acid-base balance disorder,Subdural hemorrhage,Other convulsions,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Background diabetic retinopathy,Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Hematuria, unspecified,Leukocytosis, unspecified,Pressure ulcer, lower back,Apnea,Personal history of contact with and (suspected) exposure to asbestos,Other postprocedural status,Long-term (current) use of insulin,Accidents occurring in residential institution,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Fall from other slipping, tripping, or stumbling'}
