CHIEF COMPLAINT: subdural hematoma/falls

PRESENT ILLNESS: Pt is a [**Age over 90 **] y.o male with h.o CAD s/p CABG, AS, afib on asa, CHF
EF 50%, DM2, PAD, HTN, CRI, DM2, GERD, "urinary problems",who
presented from OSH for evaluation of SDH.
Per pt's son, pt with multiple falls recently. Had a fall in the
driveway 4 months ago where he apparently "broke his nose" and
coumadin was stopped. Pt went to rehab, but per pt's son, has
remained weak since that time. [**Name (NI) 1094**] son reports "at least" [**3-5**]
falls since then. [**Name (NI) 1094**] son reports that pt never complains of
anything and often just toughs things out. [**Name (NI) 1094**] son also
reported that pt has been complaining of "feeling lousy" and
having a "bad headache" for some time. [**Name (NI) 1094**] son reports that
complaints of headache likely preceded the last fall "a few
weeks ago". [**Name (NI) 1094**] son does not recall an other complaints and
reports that his father is usually "sharp as a tack". Complaints
of feeling lousy and headache prompted the admission to OSH.
.
At OSH, CT reportedly showed 6mm R.sided SDH without shift. Pt
was transferred to [**Hospital1 18**]. Neurosurg eval in ED stated no acute
issues. Follow up in 4 weeks, start keppra. Per neurosurgery and
ED notes, pt had an intact neuro exam without any facial
assymetry noted.
.
In the ED:
US of RLE at OSH negative for DVT
.
Time Pain Temp HR BP RR Pox
- 19:06 10 96.5 80 140/70 20 100% 4L
Most Recent Vitals: 96.9, 76, 113/67, 22, 95% 2L NC
Pt underwent a neurosurg evaluation. He was given lasix 40mg IV,
lorazepam 1mg, lasix 80mg PO, metoprolol 25mg daily, aspirin
325mg, lisinpril 10mg, keppra 500mg, Imdur 60mg, glyburide
1.25mg
.
Currently, pt denies any complaints. He is confused. Denies any
headache, blurred vision, ST, URI, cp, sob, palpitations, abd
pain, nausea, vomiting, diarrhea, constipation, melena, brbpr,
dysuria, hematuria, joint pain, skin rash, weight loss, change
in appetite, weakness, paresthesias.

MEDICAL HISTORY: Per report, pt and family unable to verify
PMH - CAD (3 vessel CABG '[**91**]), cardiomyopathy EF 50%, aortic
stenosis, CHF, PAD, HTN, CEA, CRI, Afib, anemia, Type 2 DM,
GERD, gout
.
PSH: pt reports s/p appy, gallbladder, hernia, CABG surgery.

MEDICATION ON ADMISSION: Not confirmed with patient.
[**Doctor Last Name 1819**] Aspirin 325 mg Tab Oral
1 Tablet(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:16)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: GEN: confused. Sitting upright in bed. NAD, appears slightly
tachypneic
Vitals: Tafeb BP 150
HEENT: +facial assymetry with R.sided facial droop. [**Name (NI) 22031**],
[**Name (NI) 39436**] pt does not look to left side well. +Dry MM
neck: no LAD, +scars c/w prior carotid surgery. NO bruits,
difficult to assess for JVP
chest: b/l ae +decreased BS at the bases, no audible crackles
heart: s1s2 irregular rate, +[**5-6**] murmur c/w AS with radiation
throughout precordium
abd: +bs, soft, ND, NT, no guarding or rebound. +well healed
surgical scars
ext: no c/c 1+RLE erythema warmth and edema
neuro: Awake, alert, inattentive at times, AAOx2 (but did know
year), [**Month/Day (4) 22031**], R.sided facial droop noted. But otherwise CN2-12
intact, except during extraocular movement testing, pt did not
look to the left. Motor [**6-4**] UE and LE, sensation intact and
equal to LT, no tremor noted. Able to slowly perform heel/shin
testing. Very slow and did have difficulty with finger/nose
testing
psych: calm, occasionally agitated, cooperative
L.hip-with ??stage pressure ulcer ~2cm noted.

FAMILY HISTORY: Pt denies states his children are "healthy". Denies history of
CAD in the family

SOCIAL HISTORY: Pt reports he lives at home with his grandson [**Name (NI) **]. Supposed
to use a walker but does not. Reports multiple falls. Denies any
history smoking, ETOH, drug use
Subdural hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Acute on chronic systolic heart failure,Metabolic encephalopathy,Pressure ulcer, hip,Acidosis,Cellulitis and abscess of leg, except foot,Other primary cardiomyopathies,Other generalized ischemic cerebrovascular disease,Aortocoronary bypass status,Aortic valve disorders,Atrial fibrillation,Long-term (current) use of aspirin,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Esophageal reflux,Gout, unspecified,Do not resuscitate status,Other specified disorders of male genital organs,History of fall
Subdural hemorrhage,Crbl art ocl NOS w infrc,Food/vomit pneumonitis,Acute respiratry failure,Ac on chr syst hrt fail,Metabolic encephalopathy,Pressure ulcer, hip,Acidosis,Cellulitis of leg,Prim cardiomyopathy NEC,Ac cerebrovasc insuf NOS,Aortocoronary bypass,Aortic valve disorder,Atrial fibrillation,Long-term use of aspirin,DMII wo cmp nt st uncntr,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Esophageal reflux,Gout NOS,Do not resusctate status,Male genital dis NEC,Personal history of fall
Admission Date:  [**2111-10-28**]              Discharge Date:   [**2111-11-21**]


Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 633**]
Chief Complaint:
subdural hematoma/falls

Major Surgical or Invasive Procedure:
intubation

History of Present Illness:
Pt is a [**Age over 90 **] y.o male with h.o CAD s/p CABG, AS, afib on asa, CHF
EF 50%, DM2, PAD, HTN, CRI, DM2, GERD, "urinary problems",who
presented from OSH for evaluation of SDH.
Per pt's son, pt with multiple falls recently. Had a fall in the
driveway 4 months ago where he apparently "broke his nose" and
coumadin was stopped. Pt went to rehab, but per pt's son, has
remained weak since that time. [**Name (NI) 1094**] son reports "at least" [**3-5**]
falls since then. [**Name (NI) 1094**] son reports that pt never complains of
anything and often just toughs things out. [**Name (NI) 1094**] son also
reported that pt has been complaining of "feeling lousy" and
having a "bad headache" for some time. [**Name (NI) 1094**] son reports that
complaints of headache likely preceded the last fall "a few
weeks ago". [**Name (NI) 1094**] son does not recall an other complaints and
reports that his father is usually "sharp as a tack". Complaints
of feeling lousy and headache prompted the admission to OSH.
.
At OSH, CT reportedly showed 6mm R.sided SDH without shift. Pt
was transferred to [**Hospital1 18**]. Neurosurg eval in ED stated no acute
issues. Follow up in 4 weeks, start keppra. Per neurosurgery and
ED notes, pt had an intact neuro exam without any facial
assymetry noted.
.
In the ED:
US of RLE at OSH negative for DVT
.
Time Pain Temp HR BP RR Pox
- 19:06 10 96.5 80 140/70 20 100% 4L
Most Recent Vitals: 96.9, 76, 113/67, 22, 95% 2L NC
Pt underwent a neurosurg evaluation. He was given lasix 40mg IV,
lorazepam 1mg, lasix 80mg PO, metoprolol 25mg daily, aspirin
325mg, lisinpril 10mg, keppra 500mg, Imdur 60mg, glyburide
1.25mg
.
Currently, pt denies any complaints. He is confused. Denies any
headache, blurred vision, ST, URI, cp, sob, palpitations, abd
pain, nausea, vomiting, diarrhea, constipation, melena, brbpr,
dysuria, hematuria, joint pain, skin rash, weight loss, change
in appetite, weakness, paresthesias.




Past Medical History:
Per report, pt and family unable to verify
PMH - CAD (3 vessel CABG '[**91**]), cardiomyopathy EF 50%, aortic
stenosis, CHF, PAD, HTN, CEA, CRI, Afib, anemia, Type 2 DM,
GERD, gout
.
PSH: pt reports s/p appy, gallbladder, hernia, CABG surgery.

Social History:
Pt reports he lives at home with his grandson [**Name (NI) **]. Supposed
to use a walker but does not. Reports multiple falls. Denies any
history smoking, ETOH, drug use

Family History:
Pt denies states his children are "healthy". Denies history of
CAD in the family

Physical Exam:
GEN: confused. Sitting upright in bed. NAD, appears slightly
tachypneic
Vitals: Tafeb BP 150
HEENT: +facial assymetry with R.sided facial droop. [**Name (NI) 22031**],
[**Name (NI) 39436**] pt does not look to left side well. +Dry MM
neck: no LAD, +scars c/w prior carotid surgery. NO bruits,
difficult to assess for JVP
chest: b/l ae +decreased BS at the bases, no audible crackles
heart: s1s2 irregular rate, +[**5-6**] murmur c/w AS with radiation
throughout precordium
abd: +bs, soft, ND, NT, no guarding or rebound. +well healed
surgical scars
ext: no c/c 1+RLE erythema warmth and edema
neuro: Awake, alert, inattentive at times, AAOx2 (but did know
year), [**Month/Day (4) 22031**], R.sided facial droop noted. But otherwise CN2-12
intact, except during extraocular movement testing, pt did not
look to the left. Motor [**6-4**] UE and LE, sensation intact and
equal to LT, no tremor noted. Able to slowly perform heel/shin
testing. Very slow and did have difficulty with finger/nose
testing
psych: calm, occasionally agitated, cooperative
L.hip-with ??stage pressure ulcer ~2cm noted.

Pertinent Results:
[**2111-10-28**] 09:30PM URINE  HOURS-RANDOM
[**2111-10-28**] 09:30PM URINE  UHOLD-HOLD
[**2111-10-28**] 09:30PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2111-10-28**] 09:30PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2111-10-28**] 08:00PM   GLUCOSE-131* UREA N-18 CREAT-1.0 SODIUM-132*
POTASSIUM-3.9 CHLORIDE-92* TOTAL CO2-26 ANION GAP-18
[**2111-10-28**] 08:00PM   estGFR-Using this
[**2111-10-28**] 08:00PM   WBC-6.3 RBC-4.81# HGB-13.2*# HCT-41.0# MCV-85
MCH-27.5 MCHC-32.2 RDW-15.8*
[**2111-10-28**] 08:00PM   NEUTS-50.2 LYMPHS-41.7 MONOS-6.3 EOS-1.2
BASOS-0.7
[**2111-10-28**] 08:00PM   PT-14.4* PTT-28.1 INR(PT)-1.2*
[**2111-10-28**] 08:00PM   PLT COUNT-228
.
Radiology:
CXR [**10-28**]-
IMPRESSION: Moderate congestive heart failure.

Head CT: IMPRESSION:
1. No significant change in size of the subdural hematoma
overlying the right cerebral hemisphere. Associated right
hemispheric sulcal effacement and compression of the right
lateral ventricle are also unchanged. No significant midline
shift or central herniation.
2. Unchanged minimal left parafalcine subdural hematoma.
3. No new intracranial hemorrhage.
4. No evidence of acute large vascular territorial infarction.

CXR [**10-29**]: Mild pulmonary edema persists in the left lung. There
is greater
consolidation in the perihilar right lung than there was before,
which could
be due to asymmetric pulmonary edema, but raises concern for
pneumonia, could
be due to large scale aspiration. Moderate-to-severe
cardiomegaly stable.
Pleural effusions are small if any.

Echocardiogram: Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is severely depressed (LVEF=
25%) with regional akinesis of the septum, anterior and apical
walls. The remaining segments are hypokinetic. No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. The right ventricular cavity is dilated with
severe global free wall hypokinesis. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets are moderately thickened. There is at least
moderate (low gradient/low output) aortic valve stenosis (valve
area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. There is no pericardial effusion.

[**10-31**] Head CT: IMPRESSION: Stable appearance of 7-mm right
convexity subdural hematoma and
small left parafalcine subdural hematoma. No new focal
hemorrhage or
increased mass effect.

[**11-1**] EEG: IMPRESSION: This EEG in the awake and drowsy states
demonstrated a
waking background that was slightly slower than the normal alpha
frequency range. This is a common finding at an advanced age but
is
non-specific in etiology. No focal or epileptiform features were
seen.
Note is made of an irregular cardiac rhythm.

[**11-2**] video swallowing study:
IMPRESSION: Gross aspiration and penetration of nectar thick and
thin barium
with significant amount of residue in the vallecula. Other
consistencies of
barium were not administered due to safety concerns.

[**11-3**] CXR: Cardiomegaly is severe. Mediastinum is stable. There
is slight interval
improvement in pulmonary edema and substantial improvement in
the right lung
opacities consistent with resolution of infectious process.
Small amount of
pleural effusion cannot be excluded in conjunction with
currently mild
interstitial edema. No pneumothorax is seen.

[**11-4**] CXR: Moderate-to-severe cardiomegaly and widened
mediastinum are stable. The main
pulmonary arteries are enlarged. Diffuse opacities in the right
lung and
opacities in the left lower lobe have worsened in the right
lung, consistent
with worsening pneumonic aspiration. There is no evident
pneumothorax. If
any, there is a small right pleural effusion. The sternal wires
are aligned.
Patient is status post CABG. No other interval changes from
prior studies.
.
[**11-9**] CT abd/pelvis-
IMPRESSION:
1. No evidence of biliary obstruction.
2. Volume overload with cardiomegaly, bilateral pleural
effusions, ascites,
and anasarca.
3. BPH
.
[**11-10**] CT head-
IMPRESSION: Stable subdural collection and stable mass effect
since the
[**2111-11-7**] study
.
Ct [**11-17**]-IMPRESSION:
1. Similar right subdural hemorrhage with stable mass effect.
2. Bihemispheric subcortical and periventricular white matter
hypodensities,
more marked on the left; similar to CTs dating to the [**Hospital 39437**] Hospital
study of [**2111-10-28**], likely subcortical infarcts
superimposed on the
sequelae of chronic small vessel ischemic disease.

If there is clinical concern for acute ischemia, MRI would be
more sensitive.
3. Stable size of the ventricles
.
CXR [**11-18**]-IMPRESSION: AP chest compared to [**11-17**]:

ET tube in standard placement, 4 cm above the carina. Moderate
right pleural
effusion decreasing. No pulmonary edema. No pneumothorax. Right
subclavian
or PIC line ends in the mid SVC as before. Moderate-to-severe
cardiomegaly is
chronic


Brief Hospital Course:
[**Age over 90 **] yo M with a PMHx of DM-2, CAD s/p CABG, AF on coumadin (now
on hold due to SDH), acute systolic HF with EF 20%, PVD,
moderate AS ([**Location (un) 109**] 1.0-1.2) admitted with frequent falls and h/a
found to have SDH, conservatively managed by Neurosurgery.
Hospital course has been c/b hypoxia and suspicion for a stroke
(HCT unchanged) which he was briefly in the [**Hospital Unit Name 153**] and was
diuresed.  Patient's deterioration was about 1.5 weeks ago when
he had aspiration PNA and is s/p 8 days of vanco/zosyn.  Failed
speech and swallow evaluation due to UES relaxation impairment;
could not eat anything without aspirating.  Had been maintained
as NPO and GI saw patient and rec'd 2 weeks follow up prior to
PEG insertion for speech and swallow evaluation.  Team spoke
with family and they wanted PEG placed and patient to remain
full code.  The patient then decompensated from hypoxia and was
sent to the ICU on [**2111-11-17**] for Cheynes breathing.  He was
intubated and a emergent Head CT was done. He was placed on
broad spectrum antibiotics to cover for pneumonia.
CT head showed Similar right subdural hemorrhage with stable
mass effect and Bihemispheric subcortical and periventricular
white matter hypodensities,
more marked on the left; similar to CTs dating to the [**Hospital 39437**] Hospital
study of [**2111-10-28**], likely subcortical infarcts
superimposed on the
sequelae of chronic small vessel ischemic disease.
Goals of care discussion was carried out with the family, who
decided to change code status to DNR/DNI and extubate patient
with no plans to reintubate.
Patient was successfully extubated. He remained in the ICU and
was intermittently hypotensive, but responsive to IVF boluses
and pressors did not need to be started. He continued to spike
temperatures to 101 while on broad spectrum antibiotics. Given
the concern that IVF and early goal directed therapy for sepsis
could potentially lead to respiratory failure in the setting of
his severe systolic heart failure, further goals of care
discussions were had with the family. During this entire time,
patient remained responsive only to pain and noncommunicative.
Family decided to make patient comfort measures only and patient
was transferred out of the ICU onto the medical floor. Upon
assuming care of the patient on [**11-21**], he was found to be
non-responsive and exhibiting [**Last Name (un) **]-[**Doctor Last Name 6056**], end of life style
of breathing. Both of patient's sons were present and they were
informed that pt had approximately hours to live. Social work
was available and present for this conversation. Initially their
hopes were to transfer the patient to a hospice facility on the
[**Location (un) **]. However, pt's sons were informed that pt had
limited time left. Pt was continued on IV morphine for
pain/dyspnea/tachypnea. Around 5pm, pt passed away with his
son's present at the bedside. PCP's office was called and
notified.
.
Other hospital course as below:
#Acute on subacute SDH:
Patient was found to have acute on subacute SDH at OSH and
transferred for neurosurgical evaluation. Pt was seen by
Neurosurgery who recommended conservative management and repeat
head CT in 4 months. He was started on keppra for seizure
prophylaxis. His course was notable for new facial droop and
upper extremity weakness on the left side. Neurology evaluated
for stroke, but it was felt that the patient's symptoms were
more likely related to his subdural hematomas. He is at risk for
stroke given his atrial fibrillation, but he was not a TPA
candidate. His symptoms remained stable and repeat head CT did
not show progression of his bleed or infarction. The patient was
kept on low dose ASA as this was felt to be safe from a
Neurology and Neurosurgery standpoint.  Subsequent head CT
revealed small increase in hemorrhage that remained stable on
repeat CT so conservative management was continued.  Mental
status deteriorated and he was transfered to the ICU on [**2111-11-17**]
were he was intubated for a repeat H-CT which showed some
subcortical white matter changes.

#Acute systolic heart failure:
Upon admission to the hospital [**Hospital1 **] the patient had acute
hypoxia and exam and CXR were consistent with acute pulmonary
edema and CHF. He had an echocardiogram which showed a new
reduced EF of 25% down from 50% a few months earlier. The
patient was diuresed, maintained on aspirin, BB, and ACEI with
improvement in oxygen requirement and BNP down from [**Numeric Identifier 39438**] to
[**Numeric Identifier 7206**]. During his stay he was intermittently on 2LNC and
requiring Lasix for diuresis.  Hypoxia continued to be a issue
throughout his course and he was only maintained on IV heart
failure medications

#CAD s/p CABG/Aortic stenosis:
Patient was found to have new reduced EF from prior and it is
unclear whether this was a result of aortic stenosis or ischemic
disease. Increase in antiplatelet therapy was not possible due
to new head bleeds and that patient remained hemodynamically
stable and was able to tolerate betablockade, ACE-Inhibitor
therapy, and long acting nitrate without deleterious hemodynamic
effect. Patient not a surgical candidate for valve replacement.

#Encephalopathy: Patient had intermittent encephalopathy during
hospitalization which in retrospect was most probably related to
recurrence aspiration and transient hypoxia. One episode was
also associated with hypoglycemia with improvement in mental
status with glucose administration.  This continued to be a
problem for the patient which lead to recurrent aspiration and
and hypoxia

#DM2: As above patient had hypoglycemic episode and his insulin
sliding scale was reduced and his oral hypoglycemic agents were
held.
.
#Aspiration: Patient was found to have gross aspiration on video
swallow eval. This has probably been a chronic problem but may
have been exacerbated by his subdural hemorrhages. He also had a
documented aspiration pneumonia with persistent fever and mental
status change that improved over 48-72 hours with antibiotics.
His initial hypoxia most probably also had a component of
aspiration. Therefore GI was consulted re: PEG tube and
suggested re-evaluation in 2 weeks.  Repeat evaluation in one
week when mental status had improved, showed persistent impaired
relaxation of the upper esophageal sphincter which was felt to
be able to recover without dilatation.  Yet, this procedure has
a low chance of success per GI evaluation. Discussion was had
with patient and his son [**Name (NI) 3075**] and decision was made to trial
on TPN and NPO.  Unfortunately the patient had a repeat event of
aspiration around [**11-17**] and went to the ICU. See above.
.
#Aspiration pneumonia: Patient was started on Vancomycin and
Zosyn and treated for an 8 day course through [**2111-11-12**].  Repeat
events of aspiration lead to his hypoxia and delerium
.
#Falls: Patient was seen by PT and felt to require 24 hour
supervision but capable of rehab
.
#R.leg cellulitis: Patient was treated with one week of Keflex
with resolution.
.
#L.hip pressure ulcer-wound care.
.
Goals of care:
-multiple disussion were had with the family-most recently in
the ICU about the patients poor prognosis
-it was decided to make the patient CMO on [**2111-11-19**]
-the patient was evaluated by palliative care for inpatient vs.
outpatient hospice. However, pt continued to rapidly decline and
exhibit end stage cheynes [**Doctor Last Name 6056**] breathing and died on [**2111-11-21**].
.


Medications on Admission:
Not confirmed with patient.
[**Doctor Last Name 1819**] Aspirin 325 mg Tab Oral
1 Tablet(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:16)

Calcium 500 With D 500 mg (1,250 mg)-400 unit Tab Oral
1 Tablet(s) , as needed
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:16)

chromium 1,000 mcg Tab Oral
1 Tablet(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:17)

ferrous sulfate 325 mg (65 mg iron) Tab Oral
1 Tablet(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:17)

glyburide 1.25 mg Tab Oral
1 Tablet(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:17)

Imdur 60 mg 24 hr Tab Oral
1 Tablet Extended Release 24 hr(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:18)

potassium chloride ER 10 mEq Tab Oral
1 Tablet Extended Release(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:18)

Lasix 80 mg Tab Oral
1 Tablet(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:18)

lisinopril 10 mg Tab Oral
1 Tablet(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:18)

magnesium oxide 400 mg Tab Oral
1 Tablet(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:24)

metoprolol tartrate 25 mg Tab Oral
0.5 Tablet(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:24)

omeprazole 20 mg Tab, Delayed Release Oral
1 Tablet, Delayed Release (E.C.)(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:25)

ranitidine 150 mg Tab Oral
1 Tablet(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:25)

cyanocobalamin (vitamin B-12) -- Unknown Strength
1 Solution(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:25)


Discharge Medications:
pt expired

Discharge Disposition:
Expired

Discharge Diagnosis:
Subdural hemorrhage
Acute systolic heart failure
Atrial fibrillation
expired


Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired
{'Subdural hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Acute on chronic systolic heart failure,Metabolic encephalopathy,Pressure ulcer, hip,Acidosis,Cellulitis and abscess of leg, except foot,Other primary cardiomyopathies,Other generalized ischemic cerebrovascular disease,Aortocoronary bypass status,Aortic valve disorders,Atrial fibrillation,Long-term (current) use of aspirin,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Esophageal reflux,Gout, unspecified,Do not resuscitate status,Other specified disorders of male genital organs,History of fall'}


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: subdural hematoma/falls

PRESENT ILLNESS: Pt is a [**Age over 90 **] y.o male with h.o CAD s/p CABG, AS, afib on asa, CHF
EF 50%, DM2, PAD, HTN, CRI, DM2, GERD, "urinary problems",who
presented from OSH for evaluation of SDH.
Per pt's son, pt with multiple falls recently. Had a fall in the
driveway 4 months ago where he apparently "broke his nose" and
coumadin was stopped. Pt went to rehab, but per pt's son, has
remained weak since that time. [**Name (NI) 1094**] son reports "at least" [**3-5**]
falls since then. [**Name (NI) 1094**] son reports that pt never complains of
anything and often just toughs things out. [**Name (NI) 1094**] son also
reported that pt has been complaining of "feeling lousy" and
having a "bad headache" for some time. [**Name (NI) 1094**] son reports that
complaints of headache likely preceded the last fall "a few
weeks ago". [**Name (NI) 1094**] son does not recall an other complaints and
reports that his father is usually "sharp as a tack". Complaints
of feeling lousy and headache prompted the admission to OSH.
.
At OSH, CT reportedly showed 6mm R.sided SDH without shift. Pt
was transferred to [**Hospital1 18**]. Neurosurg eval in ED stated no acute
issues. Follow up in 4 weeks, start keppra. Per neurosurgery and
ED notes, pt had an intact neuro exam without any facial
assymetry noted.
.
In the ED:
US of RLE at OSH negative for DVT
.
Time Pain Temp HR BP RR Pox
- 19:06 10 96.5 80 140/70 20 100% 4L
Most Recent Vitals: 96.9, 76, 113/67, 22, 95% 2L NC
Pt underwent a neurosurg evaluation. He was given lasix 40mg IV,
lorazepam 1mg, lasix 80mg PO, metoprolol 25mg daily, aspirin
325mg, lisinpril 10mg, keppra 500mg, Imdur 60mg, glyburide
1.25mg
.
Currently, pt denies any complaints. He is confused. Denies any
headache, blurred vision, ST, URI, cp, sob, palpitations, abd
pain, nausea, vomiting, diarrhea, constipation, melena, brbpr,
dysuria, hematuria, joint pain, skin rash, weight loss, change
in appetite, weakness, paresthesias.

MEDICAL HISTORY: Per report, pt and family unable to verify
PMH - CAD (3 vessel CABG '[**91**]), cardiomyopathy EF 50%, aortic
stenosis, CHF, PAD, HTN, CEA, CRI, Afib, anemia, Type 2 DM,
GERD, gout
.
PSH: pt reports s/p appy, gallbladder, hernia, CABG surgery.

MEDICATION ON ADMISSION: Not confirmed with patient.
[**Doctor Last Name 1819**] Aspirin 325 mg Tab Oral
1 Tablet(s) Once Daily
([**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39439**] [**2111-10-28**] 20:16)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: GEN: confused. Sitting upright in bed. NAD, appears slightly
tachypneic
Vitals: Tafeb BP 150
HEENT: +facial assymetry with R.sided facial droop. [**Name (NI) 22031**],
[**Name (NI) 39436**] pt does not look to left side well. +Dry MM
neck: no LAD, +scars c/w prior carotid surgery. NO bruits,
difficult to assess for JVP
chest: b/l ae +decreased BS at the bases, no audible crackles
heart: s1s2 irregular rate, +[**5-6**] murmur c/w AS with radiation
throughout precordium
abd: +bs, soft, ND, NT, no guarding or rebound. +well healed
surgical scars
ext: no c/c 1+RLE erythema warmth and edema
neuro: Awake, alert, inattentive at times, AAOx2 (but did know
year), [**Month/Day (4) 22031**], R.sided facial droop noted. But otherwise CN2-12
intact, except during extraocular movement testing, pt did not
look to the left. Motor [**6-4**] UE and LE, sensation intact and
equal to LT, no tremor noted. Able to slowly perform heel/shin
testing. Very slow and did have difficulty with finger/nose
testing
psych: calm, occasionally agitated, cooperative
L.hip-with ??stage pressure ulcer ~2cm noted.

FAMILY HISTORY: Pt denies states his children are "healthy". Denies history of
CAD in the family

SOCIAL HISTORY: Pt reports he lives at home with his grandson [**Name (NI) **]. Supposed
to use a walker but does not. Reports multiple falls. Denies any
history smoking, ETOH, drug use 

### Response:
{'Subdural hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Acute on chronic systolic heart failure,Metabolic encephalopathy,Pressure ulcer, hip,Acidosis,Cellulitis and abscess of leg, except foot,Other primary cardiomyopathies,Other generalized ischemic cerebrovascular disease,Aortocoronary bypass status,Aortic valve disorders,Atrial fibrillation,Long-term (current) use of aspirin,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Esophageal reflux,Gout, unspecified,Do not resuscitate status,Other specified disorders of male genital organs,History of fall'}
