CHIEF COMPLAINT: Headache

PRESENT ILLNESS: 66 year old female with HTN, DLP, atrial fibrillation/flutter on
coumadin, coronary artery disease s/p DES to LAD [**2153**], h/o CVA
in [**2140**] with mild aphasia, rheumatic mitral stenosis s/p
vavuloplasty, history of colon cancer s/p resection, anxiety who
initially presented on [**2-25**] with a severe headache and
dizziness, found to have a large left subdural hemorrhage.  The
patient is currently POD 11 s/p emergent left craniotomy on
[**2-25**].  The patient had stable repeat head CT's on [**2-26**] and [**2-27**],
but developed episodes of somnolence and verbal unresponsiveness
followed by behavioral outbursts with violence.  There was
concern for speech difficulties due to edema at the operative
site.  She was transfused 2 units PRBC on [**2-27**].  An EEG showed
evidence of non-convulsive seizures, and she was loaded with
Levetiracetam 1 gm and continued on 500 mg [**Hospital1 **].  Lorazepam was
started at 1 mg po q6h standing and ASA 325 mg was started.
Neurology was consulted on [**3-1**].  Phenytoin was increased to 150
mg tid, Lorazepam was discontinued.  The last noted seizure on
EEG was [**2-28**], and subsequent EEG on [**3-2**] showed evidence of
encephalopathy and discharges but no further seizures.  LENI's
on [**3-2**] were negative, and Neurology suggested considering an
MRI head to r/o stroke, but the Neurosurgical team felt that the
patient's waxing and [**Doctor Last Name 688**] delirium was not consistent with a
stroke and an MRI was not ordered.  Keppra was increased on [**3-4**]
and she was called out to the Neuro step-down unit.  Most recent
Head CT on [**3-6**] was stable.

MEDICAL HISTORY: 1. Atrial fibrillation.
2. Atrial flutter.
3. Atrial tachycardia.
4. Rheumatic mitral stenosis status post commissurotomy in [**2124**]
and subsequent balloon valvuloplasties x2 with resultant mitral
valve area of approximately 1.4 cm2. Ejection fraction is normal
at 60%.
5. Hypercholesterolemia.
6. Hypertension.
7. Anxiety disorder.
8. History of CVA in [**2140**] with mild aphasia.
9. History of colon cancer in [**2153**] status post resection.
10. 40-pack-year history of tobacco use.
11. Coronary artery disease status post LAD Cypher stent in
[**2154-8-15**].

MEDICATION ON ADMISSION: Alendronate 70 mg weekly
Astelin 137 mcg Nasal Spray Aerosol 2 Sprays [**Hospital1 **]
Aspirin 81 mg daily
Coumadin 5 mg TTSS 1.5 tabs MWF
Cyclobenzaprine 10 mg at bedtime as needed for spasm/pain
Losartan-Fluocinolone 0.01 % Topical Soln apply to posterior
neck twice a day
Gabapentin 100 mg TID
Lisinopril 40mg QD
Losartan-HCTZ 50mg/12.5mg QD
Lovastatin 20 mg daily
Metoprolol succinate ER 50 mg [**Hospital1 **]
Omeprazole 20 mg daily
Zolpidem 5g QHS

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admisson:
O: T: 99.6 81 193/99 16 100% ra
Gen: WD/WN, comfortable, sitting in a stretcher
HEENT: atraumatic, full hair, eyes clear, ears: hearing intact,
nose patent Pupils:PERRL         EOMs - full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused no c/c/e

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: - Tobacco:  She has a 40-pack-year history of tobacco use and no
longer uses.
- EtOH:  She drinks alcohol occasionally.
- Illicit Drugs:  She denies any illicits. (from chart)
She emigrated from [**Country 532**] roughly 20 years ago and is married
and lives with her husband. Recently stopped working at bank and
is on disability.
Subdural hemorrhage,Other encephalopathy,Acute edema of lung, unspecified,Atrial flutter,Urinary tract infection, site not specified,Unspecified essential hypertension,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Late effects of cerebrovascular disease, aphasia,Personal history of malignant neoplasm of large intestine,Pure hypercholesterolemia,Anxiety state, unspecified,Personal history of tobacco use,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Hypopotassemia,Essential thrombocythemia,Epilepsy, unspecified, without mention of intractable epilepsy
Subdural hemorrhage,Encephalopathy NEC,Acute lung edema NOS,Atrial flutter,Urin tract infection NOS,Hypertension NOS,Long-term use anticoagul,Crnry athrscl natve vssl,Status-post ptca,Late eff CV dis-aphasia,Hx of colonic malignancy,Pure hypercholesterolem,Anxiety state NOS,History of tobacco use,Enterococcus group d,Hypopotassemia,Essntial thrombocythemia,Epilep NOS w/o intr epil
Name:  [**Known lastname **],[**Known firstname 8547**]                    Unit No:   [**Numeric Identifier 15245**]

Admission Date:  [**2161-2-25**]              Discharge Date:   [**2161-3-13**]

Date of Birth:  [**2094-7-4**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 11732**]
Addendum:
The patient has a long-standing, known history of atrial flutter
and has been up-titrated on Metoprolol as an inpatient with good
heart rate control.  The day of discharge, the patient developed
episodes of atrial flutter (1:2 conduction) with rates in the
140's, which was non-sustained, asymptomatic, and without
hemodynamic instability.  The patient's potassium level was
noted to be low and was repleted.  The Electrophysiology
consulting service was notified, and re-evaluated the patient.
It was noted that due to the nature of her structural and
valvular atrial flutter, a procedure such as an atrial flutter
ablation would not likely benefit the patient.  It was
recommended that her electrolytes be repleted aggressively, and
her Metoprolol dose was slightly increased to Metoprolol
Tartarate 125 mg TID.  She will be discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
hearts monitor in anticipation of her upcoming appointment with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Month (only) 412**].

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 41**] TCU - [**Location (un) 42**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11733**] MD [**MD Number(2) 11734**]

Completed by:[**2161-3-13**]

Admission Date:  [**2161-2-25**]              Discharge Date:   [**2161-3-13**]

Date of Birth:  [**2094-7-4**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Headache

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


History of Present Illness:
66 year old female with HTN, DLP, atrial fibrillation/flutter on
coumadin, coronary artery disease s/p DES to LAD [**2153**], h/o CVA
in [**2140**] with mild aphasia, rheumatic mitral stenosis s/p
vavuloplasty, history of colon cancer s/p resection, anxiety who
initially presented on [**2-25**] with a severe headache and
dizziness, found to have a large left subdural hemorrhage.  The
patient is currently POD 11 s/p emergent left craniotomy on
[**2-25**].  The patient had stable repeat head CT's on [**2-26**] and [**2-27**],
but developed episodes of somnolence and verbal unresponsiveness
followed by behavioral outbursts with violence.  There was
concern for speech difficulties due to edema at the operative
site.  She was transfused 2 units PRBC on [**2-27**].  An EEG showed
evidence of non-convulsive seizures, and she was loaded with
Levetiracetam 1 gm and continued on 500 mg [**Hospital1 **].  Lorazepam was
started at 1 mg po q6h standing and ASA 325 mg was started.
Neurology was consulted on [**3-1**].  Phenytoin was increased to 150
mg tid, Lorazepam was discontinued.  The last noted seizure on
EEG was [**2-28**], and subsequent EEG on [**3-2**] showed evidence of
encephalopathy and discharges but no further seizures.  LENI's
on [**3-2**] were negative, and Neurology suggested considering an
MRI head to r/o stroke, but the Neurosurgical team felt that the
patient's waxing and [**Doctor Last Name 688**] delirium was not consistent with a
stroke and an MRI was not ordered.  Keppra was increased on [**3-4**]
and she was called out to the Neuro step-down unit.  Most recent
Head CT on [**3-6**] was stable.

The patient had been having low grade fevers of 100-100.1 on
[**3-3**] and [**3-4**], but spiked to 102 on [**3-5**].  An infectious workup
was initiated with CXR, UA, and blood cultures.  The UA on [**3-5**]
returned positive, and the foley was discontinued and a repeat
UA/UCx were sent.  CXR was negative, blood cultures are negative
to date.  Urine culture from [**3-6**] returned positive for >100,000
Enterococcus, but did not receive antibiotics.  The patient
continued to have fevers and developed a leukocytosis of 12.6 on
[**3-7**].

While on the neurosurgical service, there was a concern for
aspiration and an NGT was placed on [**3-3**].  On [**3-6**], the
patient's NGT was pulled and diet was advanced after the patient
had a speech and swallow evaluation that recommended pureed
solids and thin liquid.  However, the patient's nurse felt that
the patient had a potential aspiration event and she was placed
back on NPO and NGT was re-placed.  Tube feeds were re-started
pending a repeat speech and swallow evaluation.

Additionally, the patient was also noted to have tachycardia
secondary to her known afib/flutter/a-tach.  She was loaded with
Amiodarone post-op, but this was subsequently discontinued due
to bradycardia, and she has been in atrial fibrillation/flutter
since.  Her home Metoprolol was re-started on [**2-28**].  She had
persistent episodes of tachycardia and EP was consulted on [**3-3**].
 Her Metoprolol was increased to 100 mg [**Hospital1 **] for rate control and
she was started on a Heparin bridge on [**3-6**] per EP recs, but the
primary team did not re-start Coumadin at that time.  She was
given Lasix 20 mg IV on [**3-2**] for pulmonary edema with good urine
output.

Currently, the patient is intermittently oriented, minimally
verbal, and able to follow simple commands.  At other times, she
is verbally unresponsive and responds only to noxious stimuli.
The current limited history is provided by her husband who is at
the bedside.

Past Medical History:
1. Atrial fibrillation.
2. Atrial flutter.
3. Atrial tachycardia.
4. Rheumatic mitral stenosis status post commissurotomy in [**2124**]
and subsequent balloon valvuloplasties x2 with resultant mitral
valve area of approximately 1.4 cm2. Ejection fraction is normal
at 60%.
5. Hypercholesterolemia.
6. Hypertension.
7. Anxiety disorder.
8. History of CVA in [**2140**] with mild aphasia.
9. History of colon cancer in [**2153**] status post resection.
10. 40-pack-year history of tobacco use.
11. Coronary artery disease status post LAD Cypher stent in
[**2154-8-15**].

Social History:
- Tobacco:  She has a 40-pack-year history of tobacco use and no
longer uses.
- EtOH:  She drinks alcohol occasionally.
- Illicit Drugs:  She denies any illicits. (from chart)
She emigrated from [**Country 532**] roughly 20 years ago and is married
and lives with her husband. Recently stopped working at bank and
is on disability.


Family History:
Noncontributory

Physical Exam:
On Admisson:
O: T: 99.6 81 193/99 16 100% ra
Gen: WD/WN, comfortable, sitting in a stretcher
HEENT: atraumatic, full hair, eyes clear, ears: hearing intact,
nose patent Pupils:PERRL         EOMs - full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused no c/c/e

Neuro:
Mental status: Awake but sleepy, cooperative with exam,
Oriented x2, dysphasic, slightly expressive

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 1
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-18**] throughout. right pronator
drift

Sensation: Intact to light touch
Toes extensor bilaterally
No clonus

Handedness Right

On Transfer to Medicine:
VS - 99.1 140/86 86 22 98%RA
GENERAL - Alert, somnolent, not oriented and not responding to
commands.
HEENT - large amounts of secretions, dry mucous membranes,
PERRLA, EOMI, sclerae anicteric. Left craniotomy inscision.
NECK - no thyromegaly, no JVD, no LAD
HEART - RRR no m/r/g
LUNGS - hard to assess given upper airway secretions
ABDOMEN - non-tender, soft, non-distened, no masses, no HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - waxing and [**Doctor Last Name 688**] between awake alert and oriented to
being somnolent and not simple following commands. Opens her
eyes easily with voice. Is able to shift attention to see who is
talking to her.  Has been noted to use the left hand greater
then the right
in terms of reaching for her NG tube and head which seems to be
bothering her and having a headache. She is otherwise moving all
four extremities well, she has her right leg crossed over her
left.


Pertinent Results:
Labs:
[**2161-2-25**] 06:50PM   GLUCOSE-128* UREA N-8 CREAT-0.9 SODIUM-132*
POTASSIUM-3.2* CHLORIDE-94* TOTAL CO2-24 ANION GAP-17
[**2161-2-25**] 06:50PM   CALCIUM-9.5 PHOSPHATE-3.4 MAGNESIUM-1.6
[**2161-2-25**] 06:50PM   WBC-14.3* RBC-3.62* HGB-11.9* HCT-33.4*
MCV-92 MCH-32.8* MCHC-35.6* RDW-13.5
[**2161-2-25**] 06:50PM   PLT COUNT-230
[**2161-2-25**] 06:50PM   NEUTS-93.2* LYMPHS-5.4* MONOS-1.2* EOS-0.1
BASOS-0.1
[**2161-2-25**] 06:50PM   PT-29.7* PTT-38.4* INR(PT)-2.9*
[**2161-2-25**] 09:15PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
[**2161-2-25**] 09:15PM URINE  RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0

Micro:
BCx [**3-5**] negative
BCx [**3-7**], [**3-8**] pending

UCx [**2-25**], [**3-1**] negative

URINE CULTURE (Final [**2161-3-8**]): ENTEROCOCCUS SP >100,000
ORGANISMS/ML..
    SENSITIVITIES: MIC expressed in MCG/ML
    AMPICILLIN------------   <=2 S
    NITROFURANTOIN--------  <=16 S
    TETRACYCLINE----------  =>16 R
    VANCOMYCIN------------     1 S

IMAGING:
[**2161-2-26**] CTA head and neck:
1. Acute subdural hematoma along left frontal and temporal
convexities and
along the falx causing mass effect and shift of midline
structures to the
right.
2. Unremarkable CTA head.
3. Mild narrowing (25%) of the origin of the right internal
carotid artery.

[**2161-2-26**] CT head postop:
Status post right frontotemporal craniotomy with evacuation of
subdural
hematoma. Significant decrease in subdural hematoma, mass
effect, and
midline shift. Some residual subdural hematoma remains overlying
the left
frontal and temporal convexities and falx. No evidence of new
hemorrhage. No evidence of infarction.

[**2161-2-27**] CT head: Stable, no new blood.

[**2161-3-1**] CT head:
Mild decrease in the subdural hemorrhage in the left middle
cranial fossa
and in the left inferior frontal region.

[**2161-3-2**] CT head:
No acute intracranial changes. Expected evolution of subdural
hematoma overlying left frontal and temporal convexities and
falx. No new hemorrhage or infarction.

[**2161-3-2**] Chest Xray: As compared to the previous radiograph, the
patient has been extubated and the nasogastric tube has been
removed. The right subclavian catheter is in unchanged position.
There is unchanged cardiomegaly. However, there is a substantial
increase in severity of the pulmonary edema, and mild bilateral
pleural effusions are now visible. Unchanged retrocardiac
atelectasis. Unchanged enlargement of the left atrium.

[**3-3**] CXR: Compared to the previous radiograph, the patient has
received a
nasogastric tube. Course of the tube is unremarkable, the tip of
the tube is located in the distal parts of the stomach. There is
no evidence of
complication, notably no pneumothorax.

Renal Ultrasound [**3-9**]:
The kidneys are normal in size with the right kidney measuring
11.3
cm and the left kidney measuring 10.8 cm. There are scattered
bilateral simple renal cysts, measuring up to 2.0 x 2.2 x 2.0 cm
on the right and 4.7 x 3.9 x 5.0 cm on the left, increased in
size compared to prior CT from [**2155-5-8**]. There is no
evidence of hydronephrosis, renal calculi, or a perinephric
collection. The renal parenchymal echotexture is normal. The
bladder is unremarkable. There is a small left pleural effusion.

IMPRESSION:
1. Bilateral simple renal cysts. Otherwise, unremarkable
kidneys.
2. Small left pleural effusion.

LLE Ultrasound [**3-9**]:  No evidence of DVT.

CT Head [**3-9**]:  Stable appearance of left subdural hematoma and
mild effacement of left frontal sulci. No new hemorrhage, edema,
or mass effect.

Video Swallow [**3-10**]:
Slight penetration but no gross aspiration was observed. For
details, please refer to speech and swallow notes in OMR.

Brief Hospital Course:
This is a 66 year old female with HTN, DLP, atrial
fibrillation/flutter on coumadin, coronary artery disease s/p
DES to LAD [**2153**], h/o CVA in [**2140**] with mild aphasia, rheumatic
mitral stenosis s/p vavuloplasty, history of colon cancer s/p
resection, anxiety who initially presented on [**2-25**] with a severe
headache and dizziness, found to have a large left subdural
hemorrhage, s/p emergent left craniotomy.  Now transferred to
medicine with tachycardia in the setting of known
afib/flutter/a-tach.  Also with fever and white count secondary
to enterococcus UTI.

# Subdural Hemorrhage:  The patient presented with a headache
and dizziness for one day in the setting of anticoagulation on
Coumadin.  Head CT in the ED showed a left subdural hemorrhage.
She was given profiline 9 and vitamin K and taken emergently to
the OR on [**2-25**] for a left craniotomy for evacutaion of L SDH.
The OR course was uncomplicated, and a subgaleal JP drain was
placed, which was later discontinued.  She was started on
Dilantin.  Post-op CT head showed a small, stable residual
temporal subdural hematoma.  She was transfused 2 units PRBC for
a post-op hematocrit of 21 in the setting of her cardiac
history.  On POD2, the patient was noted to be verbally
unresponsive in the setting of a stable CT head.  The patient
was then noted to be oriented x2 but was perseverating with non
fluent speech, delayed response, and inattention.  Strength was
full, there was no pronator drift, and pupils were reactive.
Speech difficulties were attributed to expected postoperative
edema but an EEG was ordered.  On POD3 ([**2-28**]), EEG showed
frequent seziure activity in the left spreading to the right,
and Dilantin was increased, Keppra load was given, and Keppra
and Ativan were started.  Neurology was consulted for management
of seizures, Dilantin, and Keppra.  Repeat head CT remained
stable. On [**3-4**], the Epilepsy team reviewed her EEGs which were
negative for seizure activity.  She was continued on Keppra and
Dilantin, and has been having daily Dilantin levels which were
corrected for her low albumin.  On [**3-5**], staples and sutures
were removed, and on [**3-6**], EEG leads were removed.  Since
transfer to the medical service on [**3-7**], the patient has
remained stable per Neurosurgery evaluation and repeat CT head
on [**3-9**] in the setting of full anti-coagulation (on Heparin gtt
for afib/flutter).  The patient will have follow-up with Dr.
[**First Name (STitle) **] in Neurosurgery in 2 weeks with noncontrast head CT at
that time.  Of note, the patient's Dilantin levels were low, and
her Dilantin level was increased on [**3-11**].  She is being
discharged on Keppra and Dilantin with follow-up with Neurology
and Neurosurgery.

# Fever/UTI: The patient began having low grade fevers to 100.1
while in SICU on [**3-3**].  On [**3-5**] she spiked a fever to 102 F.
Chest X-Ray [**3-6**] and [**3-7**] were negative. Blood cultures from
[**3-5**] and [**3-7**] are pending. Urine analysis was positive on [**3-6**]
with few bacteria, 62 WBC, <1 epi.  Repeat urine analysis on
[**3-6**] had a negative dipstick but as not sent for microscopic
exam.  However, the culture from the urine sample on [**3-6**]
returned positive for >100,000 Enterococcus, sensitive to
Ampicillin, which she has been on since the evening of [**3-7**].
Her fevers are most likely due to her enterococcus UTI, and her
fever curve and white count have been down-trending on
Ampicillin.  However, given she was still having low grade
fevers of 100.6 this morning with a white count of 12, a renal
ultrasound was obtained to rule out perinephric abscess or renal
calculi causing hydronephrosis, which was negative.  Also, given
mild LLE fullness compared to the RLE in the setting of low
grade fevers, LLE US was obtained to rule out DVT, which was
negative.  The patient's fevers resolved and she has been
afebrile without a white count or signs and symptoms of an
infection.  She will be continued on Ampicillin 500 mg PO
crushed in apple sauce for a 14 day course (d1=[**3-7**], last day on
[**3-21**]).  Her blood cultures have thus far returned negative, but
she does have two blood cultures from [**3-7**] and [**3-8**] that remain
pending on discharge.

# Thrombocytosis:  The patient has had a progressively
increasing platelet count, and has thrombocytosis today, [**3-12**],
with platelets of 692.  Although thrombocytosis in the setting
of her urinary tract infection and post-operative state is
expected, the reason for the trend of her increasing platelets
is unclear.  There is no evidence of acute infection or
inflammation, as the patient's fevers and leukocytosis have
resolved.  There is also no evidence of active bleeding.  The
patient may be having thrombocytosis secondary to medications
(new medications include Ampicillin).  It is also possible the
patient is having rebound thrombocytosis following her episode
of thrombocytopenia at the time of her craniotomy for the
subdural hemorrhage.  This should resolve within 10 days, and
her platelets should be trended as an outpatient to ensure
resolution.

# Delirium:  The patient was noted to have waxing and [**Doctor Last Name 688**]
delirium, likely secondary to her UTI infection.  She also had
post-operative seizures and was started on Keppra and Dilantin
with Neurology following (see above under Subdral Hemorrhage).
It was initially felt that her delirium may have been secondary
to non-convulsive seizures, but EEG showed no evidence of
continued seizures and she was discovered to have an
Enterococcus UTI.  She was started on Ampicillin on [**3-7**], and
sensitivities to the Enterococcus showed it was sensitive to
Ampicillin.  Her mental status improved significantly since
initiation of antibiotics for her UTI and her delirium cleared.
Her mental status is very close to baseline, and she is alert,
oriented, and appropriate.  Also, the patient had a large
subdural and is s/p left craniotomy, so may take some time to
return completely back to baseline.

# Atrial flutter: Known history of atrial fibrillation/flutter
and atrial tachycardia, which the patient was noted to have
in-house.  She had episodes of tachycardia requiring additional
doses of Metoprolol, and her standing dose was progressively
increased with improved heart rate control.  She is being
discharged on Metoprolol Tartrate 100 mg TID with good heart
rate (and blood pressure) control.  Of note, the patient has
intermittent episodes of variable block with atrial flutter
which is asymptomatic and non-sustained.  This is not
bradycardia, but atrial flutter with occasional variable
conduction.  Likewise, she also has brief, intermittent episodes
of 2:1 conduction where she becomes transiently tachycardic
without symptoms, and which sponatenaously resolves without
intervention.  She will have outpatient follow-up with her
cardiologist within several days of discharge, who will follow
up with management of her chronic atrial flutter.  However, in
the absence of symptoms of hemodynamic instability or symptoms,
this is not an acute or active medical issue at this time.  The
patient remains asymptomatic and hemodynamically stable during
these episodes, and no intervention is required at this time.
She will have outpatient follow-up with her cardiologist, and
Metoprolol was increased to Metoprolol Tartrate 100 mg TID.  The
patient was also started on a Heparin bridge on the
Neurosurgical service on [**3-6**], and Coumadin was started on [**3-7**].
 The patient's Coumadin dose was increased from 3 mg daily to 5
mg daily on [**3-9**] for persistent sub-therapeutic INR's.  She will
be discharged on a Lovenox bridge until her INR becomes
therapeutic, with goal INR of 2.5-3.0.

# ?Aspiration:  Post operatively, the patient had been on tube
feeds througn an NG tube.  She subsequently passed her speech
and swallow evaluation while on the Neurosurgical service, but
when she was started on a PO diet, nursing had concerns
regarding aspiration given coughing episodes with drinking
water.  Speech and swallow was reconsulted and the patient
underwent a repeat video swallow study after transfer to the
medical service.  The patient had also pulled out her NGT, but
failed her repeat video swallow study, which showed slight
penetration with no aspiration but significant abnormalities
with swallow putting her at risk for aspiration.  She was able
to take pills PO crushed with applesauce.  Attempts to place a
Dobhoff for nutrition failed, as the patient had a broken nose
in the past.  She subsequently was felt to have significantly
improved swallow with pills and her delirium had resolved, so
speech and swallow was reconsulted for re-evaluation on [**3-12**].
She was cleared for a diet of nectar thickened liquids and
pureed solids, with plan for re-evaluation in the future when
she is further out from her craniotomy.

#Hypertension:  On home Losartan and Hydrochlorothiazide, as
well as increased dose of Metoprolol as detailed above for
tachycardia with blood pressures within goal.  Home Lisinopril
was held in-house and the patient remained normotensive with the
increased Metoprolol off the Lisinopril.

#Coronary artery disease:  Patient status post LAD Cypher stent
in [**2154-8-15**].  She was continued on Aspirin and Metoprolol.

#Hypercholesterolemia:  Continued home Lovastatin 20 mg daily.

#Anxiety Disorder:  Patient on Gabapentin as an outpatient,
presumably for anxiety vs chronic pain.

# CODE: Full confirmed
# CONTACT: [**Name (NI) 4906**] [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 95948**]

Transitions of Care:
- f/u INR, with goal INR 2.5-3.0
- Lovenox bridge until INR therapeutic
- Ampicillin 500 mg PO crushed for a 14 day course (d1=[**3-7**],
last day on [**3-21**])
- Trend platelets on discharge to ensure resolution of
thrombocytosis
- f/u blood cultures 3/24, [**3-8**]
- f/u daily dilantin level for albumin
- Re-evaluation of speech and swallow when further out from her
craniotomy, to potentially advance diet from nectar thickened
liquids and pureed solids- Holding Lisinopril and HCTZ; may
re-start on discharge if blood pressure requires

Medications on Admission:
Alendronate 70 mg weekly
Astelin 137 mcg Nasal Spray Aerosol 2 Sprays [**Hospital1 **]
Aspirin 81 mg daily
Coumadin 5 mg TTSS 1.5 tabs MWF
Cyclobenzaprine 10 mg at bedtime as needed for spasm/pain
Losartan-Fluocinolone 0.01 % Topical Soln apply to posterior
neck twice a day
Gabapentin 100 mg TID
Lisinopril 40mg QD
Losartan-HCTZ 50mg/12.5mg QD
Lovastatin 20 mg daily
Metoprolol succinate ER 50 mg [**Hospital1 **]
Omeprazole 20 mg daily
Zolpidem 5g QHS

Discharge Medications:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.

2. Astelin 137 mcg Aerosol, Spray Sig: Two (2) sprays Nasal
twice a day.
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO at
bedtime as needed for back spasm.
5. fluocinolone 0.01 % Solution Sig: One (1) application Topical
twice a day: Apply to the back of the neck.
6. losartan-hydrochlorothiazide 50-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
7. lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. docusate sodium 50 mg/5 mL Liquid Sig: [**12-15**]  PO BID (2 times a
day).
9. Miralax 17 gram Powder in Packet Sig: One (1)  PO once a day.

10. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
11. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia: Please try to avoid giving if possible.
12. gabapentin 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
14. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6
hours) as needed for pain for 2 weeks: Post-operatively until
follow-up.
15. levetiracetam 100 mg/mL Solution Sig: 1500 (1500) mg PO BID
(2 times a day): Please take until follow-up with Neurology and
Neurosurgery.
16. phenytoin 125 mg/5 mL Suspension Sig: One [**Age over 90 1230**]y
(150) mg PO Q8H (every 8 hours): Please take until follow-up
with Neurology and Neurosurgery.  You will need to have
phenytoin and albumin levels drawn every week, as instructed.
17. insulin regular human 100 unit/mL Solution Sig: per sliding
scale  Injection ASDIR (AS DIRECTED): Please follow up with
primary care physician to determine whether you should continue
insulin on discharge from rehab.
18. enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) units
Subcutaneous Q12H (every 12 hours): To be used until INR >2.4.
19. ampicillin 500 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 9 days: Last dose on [**3-21**].
20. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal 2.5-3.0.
21. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] TCU - [**Location (un) 86**]

Discharge Diagnosis:
Left Subdural Hemorrhage
Urinary Tract Infection
Post-operative seizures


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital for headaches and dizzines,
and you were found to have bleeding around your brain called a
sub-dural hemorrhage.  You underwent an emergent surgery called
a craniotomy to drain the blood from your brain.  You were noted
to have seizures following your surgery, which sometimes occurs
after bleeding in the brain, and you were started on two
medications to prevent further seizures.  One of these
medications, called Dilantin, will need to be monitored weekly
with blood draws of your dilantin level and albumin level to
determine whether the dose needs to be adjusted.

While in the hospital, you were found to be confused with a
fever, and you were found to have a urinary tract infection.
You were treated with antibiotics with dramantic improvement of
your confusion.  You will remain on the antibiotics for a 14 day
course.

Because of the bleeding around your brain and the surgery to
drain the blood, your swallowing ability is abnormal.  You are
therefore at risk of aspiration, which occurs when food that you
swallow goes into your lungs instead of your stomach.  After
several evaluations by the speech and swallow therapists, you
were started on a modified diet with nectar thickened liquids
and pureed solids to decrease your risk of aspiration.  You will
follow up with the swallow therapists after discharge to rehab
to determine whether you will be able to eat a regular diet in
the future as you continue to recover from your brain surgery.
Please take care to remain well hydrated with plenty of
thickened fluid intake during this time period.

In the setting of the bleeding around your brain, your Coumadin,
which you take for your atrial fibrillation and atrial flutter,
was held.  It was restarted when the Neurosurgeons determined it
was safe to resume anticoagulation.  You should have your INR
checked on the Coumadin.  You will be on Lovenox shots
temporarily until your INR becomes 2.5-3.0, at which point you
will continue Coumadin and stop Lovenox.

You continued to have known atrial flutter and atrial
fibrillation, with very transient, brief episodes of slow and
fast heart rhythms that lasted only seconds.  Your blood
pressure remained stable and you did not have any symptoms
during these episodes.  Please eat foods containing potassium
(e.g. bananas) to keep your electrolyte normal which will help
your heart rhythm.  You may follow up with your cardiologist as
an outpatient.

The following changes have been made to your home medications:
- Ampicillin was STARTED, to be taken until [**2161-3-21**]
- Keppra was STARTED
- Dilantin was STARTED; please adjust dose as instructed based
on your weekly dilantin and albumin levels
- Oxycodone was STARTED, to be used as needed for post-operative
pain
- Docusate and Miralax were STARTED to help regulate bowel
movements
- Metoprolol was INCREASED to 100 mg TID until follow up with
your cardiologist
- Coumadin was INCREASED; please adjust as directed based on
your INR
- Lovenox was STARTED, to be used until your INR is above 2.4
- Insulin sliding scale was STARTED, to be used at rehab; please
discuss with your primary care physician whether you should
continue to be on insulin when discharged from rehab
- Omeprazole was SWITCHED to Ranitidine until you are able to
swallow pills whole without needing them crushed
- Gabapentin was stopped initially in the hospital but RESTARTED
on discharge
- Lisinopril was STOPPED; please follow up with your primary
care physician prior to [**Name9 (PRE) 18290**] this medication
For your post-surgical care, please following the instructions
below:
??????	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 after sutures and/or staples have been
removed.
??????	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, Advil, and Ibuprofen
etc.
??????	Because you are taking 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**].
??????	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

Department: BIDHC [**Location (un) **]
When: THURSDAY [**2161-3-19**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8471**], MD [**0-0-**]
Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) 861**]
Campus: OFF CAMPUS     Best Parking: On Street Parking

Department: SLEEP UNIT NEUROLOGY
When: MONDAY [**2161-4-6**] at 4:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. [**Telephone/Fax (1) 6856**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: RADIOLOGY
When: THURSDAY [**2161-4-9**] at 10:15 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: NEUROSURGERY
When: THURSDAY [**2161-4-9**] at 11:15 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Name: [**Location (un) **],[**Last Name (un) **] K.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Location (un) **], [**Apartment Address(1) 6850**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 3329**]
**Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.**
{'Subdural hemorrhage,Other encephalopathy,Acute edema of lung, unspecified,Atrial flutter,Urinary tract infection, site not specified,Unspecified essential hypertension,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Late effects of cerebrovascular disease, aphasia,Personal history of malignant neoplasm of large intestine,Pure hypercholesterolemia,Anxiety state, unspecified,Personal history of tobacco use,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Hypopotassemia,Essential thrombocythemia,Epilepsy, unspecified, without mention of intractable epilepsy'}


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: Headache

PRESENT ILLNESS: 66 year old female with HTN, DLP, atrial fibrillation/flutter on
coumadin, coronary artery disease s/p DES to LAD [**2153**], h/o CVA
in [**2140**] with mild aphasia, rheumatic mitral stenosis s/p
vavuloplasty, history of colon cancer s/p resection, anxiety who
initially presented on [**2-25**] with a severe headache and
dizziness, found to have a large left subdural hemorrhage.  The
patient is currently POD 11 s/p emergent left craniotomy on
[**2-25**].  The patient had stable repeat head CT's on [**2-26**] and [**2-27**],
but developed episodes of somnolence and verbal unresponsiveness
followed by behavioral outbursts with violence.  There was
concern for speech difficulties due to edema at the operative
site.  She was transfused 2 units PRBC on [**2-27**].  An EEG showed
evidence of non-convulsive seizures, and she was loaded with
Levetiracetam 1 gm and continued on 500 mg [**Hospital1 **].  Lorazepam was
started at 1 mg po q6h standing and ASA 325 mg was started.
Neurology was consulted on [**3-1**].  Phenytoin was increased to 150
mg tid, Lorazepam was discontinued.  The last noted seizure on
EEG was [**2-28**], and subsequent EEG on [**3-2**] showed evidence of
encephalopathy and discharges but no further seizures.  LENI's
on [**3-2**] were negative, and Neurology suggested considering an
MRI head to r/o stroke, but the Neurosurgical team felt that the
patient's waxing and [**Doctor Last Name 688**] delirium was not consistent with a
stroke and an MRI was not ordered.  Keppra was increased on [**3-4**]
and she was called out to the Neuro step-down unit.  Most recent
Head CT on [**3-6**] was stable.

MEDICAL HISTORY: 1. Atrial fibrillation.
2. Atrial flutter.
3. Atrial tachycardia.
4. Rheumatic mitral stenosis status post commissurotomy in [**2124**]
and subsequent balloon valvuloplasties x2 with resultant mitral
valve area of approximately 1.4 cm2. Ejection fraction is normal
at 60%.
5. Hypercholesterolemia.
6. Hypertension.
7. Anxiety disorder.
8. History of CVA in [**2140**] with mild aphasia.
9. History of colon cancer in [**2153**] status post resection.
10. 40-pack-year history of tobacco use.
11. Coronary artery disease status post LAD Cypher stent in
[**2154-8-15**].

MEDICATION ON ADMISSION: Alendronate 70 mg weekly
Astelin 137 mcg Nasal Spray Aerosol 2 Sprays [**Hospital1 **]
Aspirin 81 mg daily
Coumadin 5 mg TTSS 1.5 tabs MWF
Cyclobenzaprine 10 mg at bedtime as needed for spasm/pain
Losartan-Fluocinolone 0.01 % Topical Soln apply to posterior
neck twice a day
Gabapentin 100 mg TID
Lisinopril 40mg QD
Losartan-HCTZ 50mg/12.5mg QD
Lovastatin 20 mg daily
Metoprolol succinate ER 50 mg [**Hospital1 **]
Omeprazole 20 mg daily
Zolpidem 5g QHS

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admisson:
O: T: 99.6 81 193/99 16 100% ra
Gen: WD/WN, comfortable, sitting in a stretcher
HEENT: atraumatic, full hair, eyes clear, ears: hearing intact,
nose patent Pupils:PERRL         EOMs - full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused no c/c/e

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: - Tobacco:  She has a 40-pack-year history of tobacco use and no
longer uses.
- EtOH:  She drinks alcohol occasionally.
- Illicit Drugs:  She denies any illicits. (from chart)
She emigrated from [**Country 532**] roughly 20 years ago and is married
and lives with her husband. Recently stopped working at bank and
is on disability. 

### Response:
{'Subdural hemorrhage,Other encephalopathy,Acute edema of lung, unspecified,Atrial flutter,Urinary tract infection, site not specified,Unspecified essential hypertension,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Late effects of cerebrovascular disease, aphasia,Personal history of malignant neoplasm of large intestine,Pure hypercholesterolemia,Anxiety state, unspecified,Personal history of tobacco use,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Hypopotassemia,Essential thrombocythemia,Epilepsy, unspecified, without mention of intractable epilepsy'}
