CHIEF COMPLAINT: Feeling "lousy"

PRESENT ILLNESS: Pt is a 86 yo M with PMHx sig. for afib on coumadin, CAD, DM2
who presented to the ED on [**4-12**] with weakness. He was recently
admitted here from [**Date range (1) 20495**] with pneumonia and was treated with 5
day course of levofloxacin. He was feeling pretty good for [**3-7**]
days. He still had a residual cough with clear phelgm. Then, he
started to feel lousy again. His cough got slightly worse, no
worsening SOB. He has become weaker, generalized, with poorer po
intake. He states he just wasn't thirsty. No chest pain. He has
occ. palpitations, which are not new. No N/V/abdominal
pain/diarrhea/constipation. No fevers, chills, night sweats.
.
In the ED, initial VS were: 97 49 151/94 16 100. Exam is sig.
for bibasilar crackles. CXR is stable. Labs were sig. for
elevated Cr to 1.3. He received 2L IVFs.
.
On the floor, he just feels tired.
.
Further history in the morning revealed that he has some trouble
describing his symptoms, but does say that he feels like he has
been having trouble using his right hand to eat, pick up
objects, etc for ~24 hours. He does say that he had a PCP
[**Name Initial (PRE) 648**] [**4-13**] but does note that he did not call his PCP last
night when feeling poorly, and is not able to say why.
Yesterday, he started to feel lousy again. He told night float
that his cough got slightly worse, but this morning he says that
he thinks his cough is overall better. He denies worsening SOB.
He has become weaker, generalized to everywhere, with poorer PO
intake. When asked why, he states he just wasn't thirsty. Denies
chest pain. He has occasional palpitations, which are not new
(known afib). No N/V/abdominal pain/diarrhea/constipation. No
fevers, chills, night sweats. He does note that he feels more
down lately, particularly with respect to an ongoing
disagreement with his son whom he has not seen in 3 weeks
.

MEDICAL HISTORY: 1. Atrial fibrillation, on coumadin
2. Coronary artery disease, s/p MI [**00**] years ago
3. Cerebral vascular accident
4. Diabetes mellitus, type II
5. Hypertension
6. Hypercholesterolemia
7. Gastroesophageal reflux disease
8. Osteoarthtritis
9. Anemia
10. Bilateral cataract surgeries
11. History of microscopic hematuria
12. Erythrodermic CTCL (mycosis fungoides, MF)
13. Prostate Adenocarcinoma [**2191**] s/p XRT and lupron

MEDICATION ON ADMISSION: Atorvastatin 80 mg PO HS
Fexofenadine 60 mg PO BID as needed for rhinorrhea.
Folic Acid 1 mg PO DAILY
Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
Aspirin 81 mg PO DAILY
Hydrochlorothiazide 12.5 mg PO DAILY
Benzonatate 100 mg PO TID
Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr PO
DAILY
Methotrexate
Docusate Sodium 100 mg PO BID
Zolpidem 5 mg PO at bedtime.
Miralax 17 gram/dose Powder Sig: One (1) packet PO once a day.
Tamsulosin 0.4 mg PO at bedtime.
Hydroxyzine HCl 25 mg PO four times a day as needed for itching.

ALLERGIES: Codeine / Valsartan

PHYSICAL EXAM: Vitals: T: 96.2, BP: 133/74, P: 51 (51-76), R: 18, O2: 99 on RA

FAMILY HISTORY: Mother died in her 30s and father at 89, but doesn't know what
the cause was. No strokes or MI.

SOCIAL HISTORY: Pt lives in [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) 731**], [**Hospital3 **] housing. He has VNA
service that sets up his medications. He states that his
children recently have "turned their backs" on the patient whent
he (pt) refused to move to [**Location (un) 47**]. He has a son in
[**Name (NI) 47**] who he has not spoken to in 3 weeks. He does speak
with his daughter in CA, who he thinks updates his
daughter-in-law of his situation. He quit smoking and ETOH 30
yrs ago, previously was a 1 pack Q3 days.
Subdural hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Compression of brain,Acute kidney failure, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Esophageal reflux,Anemia, unspecified,Atrial fibrillation,Coronary atherosclerosis of unspecified type of vessel, native or graft,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of prostate
Subdural hemorrhage,Crbl art ocl NOS w infrc,Compression of brain,Acute kidney failure NOS,Hypertension NOS,Pure hypercholesterolem,Esophageal reflux,Anemia NOS,Atrial fibrillation,Cor ath unsp vsl ntv/gft,DMII wo cmp nt st uncntr,Long-term use anticoagul,Hx-prostatic malignancy
Admission Date:  [**2198-4-12**]              Discharge Date:   [**2198-4-19**]


Service: NEUROSURGERY

Allergies:
Codeine / Valsartan

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Feeling "lousy"

Major Surgical or Invasive Procedure:
Craniotomy for evacuation of L SDH


History of Present Illness:
Pt is a 86 yo M with PMHx sig. for afib on coumadin, CAD, DM2
who presented to the ED on [**4-12**] with weakness. He was recently
admitted here from [**Date range (1) 20495**] with pneumonia and was treated with 5
day course of levofloxacin. He was feeling pretty good for [**3-7**]
days. He still had a residual cough with clear phelgm. Then, he
started to feel lousy again. His cough got slightly worse, no
worsening SOB. He has become weaker, generalized, with poorer po
intake. He states he just wasn't thirsty. No chest pain. He has
occ. palpitations, which are not new. No N/V/abdominal
pain/diarrhea/constipation. No fevers, chills, night sweats.
.
In the ED, initial VS were: 97 49 151/94 16 100. Exam is sig.
for bibasilar crackles. CXR is stable. Labs were sig. for
elevated Cr to 1.3. He received 2L IVFs.
.
On the floor, he just feels tired.
.
Further history in the morning revealed that he has some trouble
describing his symptoms, but does say that he feels like he has
been having trouble using his right hand to eat, pick up
objects, etc for ~24 hours. He does say that he had a PCP
[**Name Initial (PRE) 648**] [**4-13**] but does note that he did not call his PCP last
night when feeling poorly, and is not able to say why.
Yesterday, he started to feel lousy again. He told night float
that his cough got slightly worse, but this morning he says that
he thinks his cough is overall better. He denies worsening SOB.
He has become weaker, generalized to everywhere, with poorer PO
intake. When asked why, he states he just wasn't thirsty. Denies
chest pain. He has occasional palpitations, which are not new
(known afib). No N/V/abdominal pain/diarrhea/constipation. No
fevers, chills, night sweats. He does note that he feels more
down lately, particularly with respect to an ongoing
disagreement with his son whom he has not seen in 3 weeks
.

Past Medical History:
1. Atrial fibrillation, on coumadin
2. Coronary artery disease, s/p MI [**00**] years ago
3. Cerebral vascular accident
4. Diabetes mellitus, type II
5. Hypertension
6. Hypercholesterolemia
7. Gastroesophageal reflux disease
8. Osteoarthtritis
9. Anemia
10. Bilateral cataract surgeries
11. History of microscopic hematuria
12. Erythrodermic CTCL (mycosis fungoides, MF)
13. Prostate Adenocarcinoma [**2191**] s/p XRT and lupron

Social History:
Pt lives in [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) 731**], [**Hospital3 **] housing. He has VNA
service that sets up his medications. He states that his
children recently have "turned their backs" on the patient whent
he (pt) refused to move to [**Location (un) 47**]. He has a son in
[**Name (NI) 47**] who he has not spoken to in 3 weeks. He does speak
with his daughter in CA, who he thinks updates his
daughter-in-law of his situation. He quit smoking and ETOH 30
yrs ago, previously was a 1 pack Q3 days.


Family History:
Mother died in her 30s and father at 89, but doesn't know what
the cause was. No strokes or MI.

Physical Exam:
Vitals: T: 96.2, BP: 133/74, P: 51 (51-76), R: 18, O2: 99 on RA

General: No acute distress, alert, oriented
HEENT: Sclera anicteric, MM slightly dry, oropharynx clear
Neck: supple, JVP normal, no LAD
Lungs: Overall clear throughout, no wheezes. Occasional coughing
productive of white/clear sputum.
CV: Irregularly irregular, no murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused, 1+ pulses, no edema
Neuro: MS [**6-6**] in BUEs and BLEs. CN II-XII intact. Does have
intact sensation in both upper and lower extremities. Intact
finger to nose on L, impaired on R. Impaired pincer grasp on R,
but [**6-6**] hand strength bilaterally. Rapid alternating movements
intact bilaterally. Speech fluent but with frequent word-finding
difficulties/substitutions (once/sentence).

Pertinent Results:
CBCs:
[**2198-4-12**] 07:19PM BLOOD WBC-6.4 RBC-3.93* Hgb-10.3* Hct-31.6*
MCV-80* MCH-26.3* MCHC-32.7 RDW-19.6* Plt Ct-331
[**2198-4-13**] 07:00AM BLOOD WBC-5.5 RBC-3.94* Hgb-9.8* Hct-31.3*
MCV-79* MCH-24.9* MCHC-31.4 RDW-19.3* Plt Ct-281
[**2198-4-14**] 07:30AM BLOOD WBC-6.1 RBC-4.10* Hgb-10.2* Hct-32.4*
MCV-79* MCH-25.0* MCHC-31.6 RDW-18.9* Plt Ct-289
[**2198-4-15**] 07:30AM BLOOD WBC-5.4 RBC-4.03* Hgb-10.3* Hct-32.4*
MCV-81* MCH-25.6* MCHC-31.8 RDW-19.5* Plt Ct-321
Coags:
[**2198-4-12**] 08:28PM BLOOD PT-31.3* PTT-36.5* INR(PT)-3.1*
[**2198-4-14**] 07:30AM BLOOD PT-32.2* PTT-32.7 INR(PT)-3.2*
[**2198-4-15**] 07:30AM BLOOD PT-29.3* PTT-31.3 INR(PT)-2.9*
[**2198-4-15**] 02:55PM BLOOD PT-21.4* PTT-28.0 INR(PT)-2.0*
Lytes:
[**2198-4-12**] 07:19PM BLOOD Glucose-65* UreaN-23* Creat-1.3* Na-141
K-3.4 Cl-105 HCO3-26 AnGap-13
[**2198-4-13**] 07:00AM BLOOD Glucose-65* UreaN-17 Creat-1.1 Na-138
K-3.9 Cl-105 HCO3-28 AnGap-9
[**2198-4-14**] 07:30AM BLOOD Glucose-105* UreaN-15 Creat-1.0 Na-139
K-3.8 Cl-104 HCO3-29 AnGap-10
[**2198-4-15**] 07:30AM BLOOD Glucose-129* UreaN-13 Creat-0.9 Na-140
K-3.5 Cl-104 HCO3-29 AnGap-11
LFTs:
[**2198-4-13**] 07:00AM BLOOD ALT-12 AST-20 LD(LDH)-214 AlkPhos-58
Amylase-74 TotBili-0.9
Card Enzymes:
[**2198-4-12**] 07:19PM BLOOD CK(CPK)-122
[**2198-4-15**] 02:55PM BLOOD CK(CPK)-81
[**2198-4-12**] 07:19PM BLOOD cTropnT-0.01
[**2198-4-15**] 02:55PM BLOOD CK-MB-NotDone cTropnT-<0.01
TSh/B12:
[**2198-4-13**] 07:00AM BLOOD TSH-0.83
[**2198-4-13**] 07:00AM BLOOD VitB12-593
.
EKG:
[**4-12**]: Sinus rhythm with ventricular and supraventricular
premature depolarizations. Left axis deviation. Possible left
ventricular hypertrophy. Possible left anterior fascicular
block. Diffuse non-diagnostic repolarization abnormalities.
Compared to the previous tracing of [**2198-4-8**] there is no
diagnostic change.
.
Imaging:
CXR [**4-12**]:
AP ERECT AND LATERAL VIEWS OF THE CHEST: Little change in right
basilar
opacity at the cardiophrenic angle and left base is consistent
with
atelectasis. There is no pleural effusion or pneumothorax. The
heart size is normal. Aorta is slightly unfolded, but the
mediastinal silhouette is
otherwise unremarkable. Hilar contours and pulmonary vasculature
are
unremarkable.
IMPRESSION: No acute intrathoracic abnormality.
.
MRI Head [**4-15**]:
FINDINGS: There is a very large left cerebral hemispheric mixed
T1 and T2
signal intensity subdural hemorrhage effacing the left cerebral
hemispheric sulci, but causing, at most only a mm of rightward
subfalcine herniation. The signal pattern of the subdural
hemorrhage suggests a prominent area of acute bleeding, located
posterior to the coronal suture. On the axial FLAIR images,
there may be a very thin right frontal subdural hemorrhage,
without overt mass effect.

There are a few small areas of restricted diffusion within the
left parietal lobe subcortical region, subjacent to the acute
hemorrhagic component of the subdural hemorrhage. This finding
could indicate acute brain ischemia. There are very extensive
areas of high T2 signal within the white matter of both cerebral
hemispheres, consistent with chronic small vessel infarction.

The principal vascular flow patterns are identified. There is
moderate
bilateral maxillary and prominent bilateral ethmoid sinus, as
well as mild
frontal sinus and sphenoid sinus mucosal thickening, all
consistent with an ongoing inflammatory process.

CONCLUSION: Large left cerebral convexity subdural hemorrhage,
which has
developed since the prior head CT scan. Dr. [**Last Name (STitle) 20059**] has
already contact[**Name (NI) **] the requesting physician, [**Name10 (NameIs) 29418**] her of
these findings, as well as other is noted in the above report.
Dr. [**Last Name (STitle) 20059**] indicated that emergency neurosurgical
consultation is mandated. Please see above report for additional
findings.
.
CT Head [**4-15**]: FINDINGS: There is confirmation of the presence of
a large left cerebral convexity subdural hemorrhage, with
verification of the acute components of this hemorrhage
positioned posterior to the left coronal suture. There is
negligible subfalcine herniation, but likely mild effacement of
the left lateral ventricle. Low-density zones within the left
basal ganglia, and to a lesser extent the periventricular white
matter of the cerebral hemispheres again reflect chronic
small-vessel infarction. There is prominent atherosclerotic
calcification of the cavernous internal carotid arteries, and to
a lesser extent the distal left vertebral artery at the level of
the foramen magnum.

CONCLUSION: Large left cerebral convexity subdural hemorrhage,
including some acute components. Once again, emergency
neurosurgical consultation is
mandated.
.
CT head [**4-15**] pm: prelim: No evidence of tonsillar (or any other)
herniation
.

CT HEAD W/O CONTRAST [**2198-4-17**]
Status post left frontoparietal craniotomy and subdural hematoma

evacuation, expected frontal pneumocephalus is visualized with a
draining tube in place, persistent effacement of the sulci with
no evidence of shifting or deviation of the midline structures.
Mild residual subdural blood is identified at the left parietal
convexity, contiguous followup is recommended.


Brief Hospital Course:
Mr. [**Known lastname 29419**] is an 86 yo M with past medical history significant
for afib on coumadin, CAD, DM2, HTN, h/o of CVA and recent
pneumonia who presents with feeling "lousy" and right-handed
weakness.
.
#. Generalized weakness: The onset of symptoms was initially
unclear at patient's initial presentation. He appeared slightly
volume-depleted, and was noted to have been taking in poor pos
due to poor appetite. He was given IV fluids overnight after
admission, and his Cr improved. Per information from caretakers
at his [**Hospital3 **] facility, the right hand weakness was new
but of uncertain onset. They stated that he had generally looked
unwell since returning from the hospital on [**4-8**] and had mostly
stayed in his room. On exam, he had actually good strength, but
difficulty with specific motor movements in the hand. PT and OT
were consulted and saw the patient on [**4-13**]. There was concern of
delirium versus subacute stroke for the cause. TSH and B12 were
normal. His blood sugars were controlled with an insulin sliding
scale. The decision was made to do an MRI of his head. This was
completed by early morning of [**4-15**], and was significant for
large L subdural hematoma (see below).
.
# Subdural Hematoma: Found on MRI [**4-15**]. Patient without history
of falls or head trauma; had been on coumadin for some time
given atrial fibrillation. INR on admission was elevated, so
coumadin was initially held. It was re-started on [**4-13**], and held
again on [**4-14**]. After the finding of SDH, a stat CT head was
performed which demonstrated both old and new areas of bleeding.
A neurosurgery consult was called. He was given 10 mg vitamin K
and 2 units of FFP. Q 4 neuro checks and telemetry monitoring
were initiated. He was started on Keppra 500 [**Hospital1 **] and prednisone
40 mg daily. A final read of the MRI was also notable for acute
to subacute strokes in the L parietal lobe. A neurology consult
was called as well, and their recommendations were similar. The
patient was noted to have periodic bradycardic events to the 30s
as well as BPs to 130-140/90s, and given concern for worsened
bleeding, a stat head CT was performed. This demonstrated no
evidence of herniation. At this point the decision was made to
transfer the patient to the neurosurgery service and the
step-down unit on [**Hospital Ward Name 121**] 11. . .. .
.
#. Community-acquired Pneumonia: The patient had completed a 5
day course of levofloxacin. His symptoms and CXR seemed to be
improving, so he was not given any further antibiotics. He was
given a cough suppressant as needed.
.
#. Acute renal failure: On admission, the patient had a
creatinine of 1.3 from a baseline creatinine of around 1.0. This
was felt to be likely secondary to pre-renal causes. He was
given IV fluids, and his creatinine gradually came back down to
1.0. His HCTZ was held and the decision to re-start can be
re-considered as an outpatient.
.
#. Atrial fibrillation: CHADS2 score 5. On admission, the
patient was being treated with warfarin with an INR goal of
[**3-6**].5 per records. Warfarin was held, then restarted, then held
again for supratherapeutic INRs. Following the discovery of the
subdural, it was stopped and his anticoagulation was reversed.
Aspirin was also stopped.
.
#. Coronary artery disease: The patient is s/p MI in past. He
did not have any ischemic signs or symptoms on admission or
throughout his hospitalization. He was initially continued on
aspirin, imdur, atorvastatin and HCTZ was stopped. Later aspirin
stopped. He had negative troponins and CKs upon presentation.
His EKG was at baseline.
.
#. Diabetes mellitus type II: Given the concern that the patient
had low blood sugars on his electrolyte panels in the ED, and
may have been taking his home medications incorrectly, these
were held on admission, and he was placed on an insulin sliding
scale.
.
#. Erythrodermic CTCL (mycosis fungoides): The patient is
followed by hematology. As an outpatient, he is on methotrexate
therapy. Following discussion with the nurse practitioner
working with his heme/onc doctor, his methotrexate was held
during this admission given his other medical concerns. He
should follow up with this provider as an outpatient.

Patient was readmitted s/p presenting feeling "lousy". He was
found to have a L acute on chronic SDH. He has a history of
a-fib and was on coumadin at presentation. Patient was taken to
the OR for evacuation of L SDH on [**4-17**]. Post operatively patient
appeared to have a R droop presumed to be from weakness and R
side weakness. He was also observed to have episodes of
bradycardia where cardiology was consulted. There recs were to
continue care currently, restart coumadin when able, and follow
up with cardiology as an out patient.

On [**4-18**], patient was alert and oriented x2 and RUE [**4-6**] deltoid,
[**6-6**] biceps/triceps and full strength on L side. His subdural
drain was removed and he was transferred to the floor.

on [**4-19**], patient was accessed by PT was it was determined that
he was safe to go to rehab. Patient continues to be alert and
oriented x 3 with prompting, moving all extremities, some R
deltoid weakness 3/5. Incision is clean, dry and intact with
staples in place.

Medications on Admission:
Atorvastatin 80 mg PO HS
Fexofenadine 60 mg PO BID as needed for rhinorrhea.
Folic Acid 1 mg PO DAILY
Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
Aspirin 81 mg PO DAILY
Hydrochlorothiazide 12.5 mg PO DAILY
Benzonatate 100 mg PO TID
Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr PO
DAILY
Methotrexate
Docusate Sodium 100 mg PO BID
Zolpidem 5 mg PO at bedtime.
Miralax 17 gram/dose Powder Sig: One (1) packet PO once a day.
Tamsulosin 0.4 mg PO at bedtime.
Hydroxyzine HCl 25 mg PO four times a day as needed for itching.

Metformin 500 mg PO twice a day.
Glipizide 10 mg PO twice a day.
Fluticasone Nasal spray twice a day.
Coumadin 7.5 mg Tue-Sun, 5 mg Mon

Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)  PO
DAILY (Daily) as needed for constipation.
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheezes.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for wheezes.
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
13. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**2-3**]
Tablets PO Q6H (every 6 hours) as needed for headache.
14. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for
5 days.
18. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 5
days.


Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] at [**Location (un) 1821**] for Nursing & Rehab

Discharge Diagnosis:
L SDH


Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent


Discharge Instructions:
??????	Have a friend/family member check your incision daily for
signs of infection.
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	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.
??????	You may shower before this time using a shower cap to cover
your head.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????	If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this after it has been discussed with Dr.
[**First Name (STitle) **] at your follow up visit.
??????	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**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit.
??????	Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.

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:
Follow-Up Appointment Instructions

??????Please return to the office in [**8-11**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check.  Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If
you live quite a distance from our office, please make
arrangements for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.



Completed by:[**2198-4-19**]
{'Subdural hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Compression of brain,Acute kidney failure, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Esophageal reflux,Anemia, unspecified,Atrial fibrillation,Coronary atherosclerosis of unspecified type of vessel, native or graft,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of prostate'}


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: Feeling "lousy"

PRESENT ILLNESS: Pt is a 86 yo M with PMHx sig. for afib on coumadin, CAD, DM2
who presented to the ED on [**4-12**] with weakness. He was recently
admitted here from [**Date range (1) 20495**] with pneumonia and was treated with 5
day course of levofloxacin. He was feeling pretty good for [**3-7**]
days. He still had a residual cough with clear phelgm. Then, he
started to feel lousy again. His cough got slightly worse, no
worsening SOB. He has become weaker, generalized, with poorer po
intake. He states he just wasn't thirsty. No chest pain. He has
occ. palpitations, which are not new. No N/V/abdominal
pain/diarrhea/constipation. No fevers, chills, night sweats.
.
In the ED, initial VS were: 97 49 151/94 16 100. Exam is sig.
for bibasilar crackles. CXR is stable. Labs were sig. for
elevated Cr to 1.3. He received 2L IVFs.
.
On the floor, he just feels tired.
.
Further history in the morning revealed that he has some trouble
describing his symptoms, but does say that he feels like he has
been having trouble using his right hand to eat, pick up
objects, etc for ~24 hours. He does say that he had a PCP
[**Name Initial (PRE) 648**] [**4-13**] but does note that he did not call his PCP last
night when feeling poorly, and is not able to say why.
Yesterday, he started to feel lousy again. He told night float
that his cough got slightly worse, but this morning he says that
he thinks his cough is overall better. He denies worsening SOB.
He has become weaker, generalized to everywhere, with poorer PO
intake. When asked why, he states he just wasn't thirsty. Denies
chest pain. He has occasional palpitations, which are not new
(known afib). No N/V/abdominal pain/diarrhea/constipation. No
fevers, chills, night sweats. He does note that he feels more
down lately, particularly with respect to an ongoing
disagreement with his son whom he has not seen in 3 weeks
.

MEDICAL HISTORY: 1. Atrial fibrillation, on coumadin
2. Coronary artery disease, s/p MI [**00**] years ago
3. Cerebral vascular accident
4. Diabetes mellitus, type II
5. Hypertension
6. Hypercholesterolemia
7. Gastroesophageal reflux disease
8. Osteoarthtritis
9. Anemia
10. Bilateral cataract surgeries
11. History of microscopic hematuria
12. Erythrodermic CTCL (mycosis fungoides, MF)
13. Prostate Adenocarcinoma [**2191**] s/p XRT and lupron

MEDICATION ON ADMISSION: Atorvastatin 80 mg PO HS
Fexofenadine 60 mg PO BID as needed for rhinorrhea.
Folic Acid 1 mg PO DAILY
Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
Aspirin 81 mg PO DAILY
Hydrochlorothiazide 12.5 mg PO DAILY
Benzonatate 100 mg PO TID
Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr PO
DAILY
Methotrexate
Docusate Sodium 100 mg PO BID
Zolpidem 5 mg PO at bedtime.
Miralax 17 gram/dose Powder Sig: One (1) packet PO once a day.
Tamsulosin 0.4 mg PO at bedtime.
Hydroxyzine HCl 25 mg PO four times a day as needed for itching.

ALLERGIES: Codeine / Valsartan

PHYSICAL EXAM: Vitals: T: 96.2, BP: 133/74, P: 51 (51-76), R: 18, O2: 99 on RA

FAMILY HISTORY: Mother died in her 30s and father at 89, but doesn't know what
the cause was. No strokes or MI.

SOCIAL HISTORY: Pt lives in [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) 731**], [**Hospital3 **] housing. He has VNA
service that sets up his medications. He states that his
children recently have "turned their backs" on the patient whent
he (pt) refused to move to [**Location (un) 47**]. He has a son in
[**Name (NI) 47**] who he has not spoken to in 3 weeks. He does speak
with his daughter in CA, who he thinks updates his
daughter-in-law of his situation. He quit smoking and ETOH 30
yrs ago, previously was a 1 pack Q3 days. 

### Response:
{'Subdural hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Compression of brain,Acute kidney failure, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Esophageal reflux,Anemia, unspecified,Atrial fibrillation,Coronary atherosclerosis of unspecified type of vessel, native or graft,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of prostate'}
