CHIEF COMPLAINT: Transfer with subdural hematoma

PRESENT ILLNESS: 73 yo woman with PMH sig. for HTN and hyperlipidemia
who presents from an OSH intubated after discovery of left SDH
with 1 cm of shift. She was apparently reporting a HA and
malaise this morning. Over the day, she was more confused and
lethargic. She was unsteady when her family got her up to walk
and became more lethargic and confused. She had no reported or
observed trauma. At the OSH, she was intermittently answering
yes/no questions and following some commands. She was reportedly

MEDICAL HISTORY: HTN and hyperlipidemia
Hypoglycemia

MEDICATION ON ADMISSION: 1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Penicillins

PHYSICAL EXAM: On admission
CN:
Pupils:1.5 to 1 bilat.
Nasal Tickle:Mild grimace bilaterally ? right >left
Gag/Cough:Gags and coughs on ETT
Corneal Reflex:Slight bilaterally
OCRs:Eyes with some motion bilaterally, but not full.

FAMILY HISTORY: Non contributory

SOCIAL HISTORY: No smoking or drinking. Her son and husband are here with her
Subdural hemorrhage,Acute respiratory failure,Urinary tract infection, site not specified,Blood in stool,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Anemia, unspecified,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Subdural hemorrhage,Acute respiratry failure,Urin tract infection NOS,Blood in stool,Klebsiella pneumoniae,Hypertension NOS,Hyperlipidemia NEC/NOS,Anemia NOS,Abn react-urinary cath
Admission Date:  [**2145-6-1**]              Discharge Date:   [**2145-6-16**]

Date of Birth:  [**2071-10-3**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Transfer with subdural hematoma

Major Surgical or Invasive Procedure:
Left craniotomy
Tracheostomy


History of Present Illness:
73 yo woman with PMH sig. for HTN and hyperlipidemia
who presents from an OSH intubated after discovery of left SDH
with 1 cm of shift. She was apparently reporting a HA and
malaise this morning. Over the day, she was more confused and
lethargic. She was unsteady when her family got her up to walk
and became more lethargic and confused. She had no reported or
observed trauma. At the OSH, she was intermittently answering
yes/no questions and following some commands. She was reportedly

moving all extremities per her son. [**Name (NI) 15110**] to confusion and
transport, she was intubated there after head CT showed 8mm SDH
with 1 cm midline shift and subfalcine herniation.


Past Medical History:
HTN and hyperlipidemia
Hypoglycemia


Social History:
No smoking or drinking. Her son and husband are here with her

Family History:
Non contributory

Physical Exam:
On admission
CN:
Pupils:1.5 to 1 bilat.
Nasal Tickle:Mild grimace bilaterally ? right >left
Gag/Cough:Gags and coughs on ETT
Corneal Reflex:Slight bilaterally
OCRs:Eyes with some motion bilaterally, but not full.

Motor:No spontaneous movement. Minimal movement of LUE to
painful
stimulus(nailbed pressure), and more significant(but still
slight) movement of RUE. Mild withdrawal of LEs to painful
stimulus(nailbed).

Toes:Mute on right, up on left.

DTRs: [**Name2 (NI) **] Tri Br Pa [**Doctor First Name **]
R 2 2 x 1 0
L 2 2 x 1 0

Respiration:Pt is on ventilator.


Pertinent Results:
[**2145-6-16**] 06:30AM BLOOD Hct-22.1*
[**2145-6-15**] 09:30PM BLOOD WBC-10.0 RBC-2.54* Hgb-7.4* Hct-22.3*
MCV-88 MCH-29.2 MCHC-33.2 RDW-14.4 Plt Ct-586*
[**2145-6-14**] 03:45AM BLOOD WBC-11.0 RBC-2.86* Hgb-8.3* Hct-25.3*
MCV-89 MCH-29.1 MCHC-32.8 RDW-14.4 Plt Ct-537*
[**2145-6-15**] 09:30PM BLOOD Plt Ct-586*
[**2145-6-14**] 03:45AM BLOOD PT-11.8 PTT-24.4 INR(PT)-1.0
[**2145-6-15**] 06:30AM BLOOD Glucose-196* UreaN-11 Creat-0.4 Na-138
K-4.4 Cl-104 HCO3-27 AnGap-11
[**2145-6-8**] 01:43AM BLOOD CK(CPK)-20*
[**2145-6-2**] 01:50AM BLOOD Lipase-25
[**2145-6-8**] 01:43AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2145-6-15**] 06:30AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1 Iron-32
[**2145-6-15**] 06:30AM BLOOD calTIBC-194* Ferritn-1043* TRF-149*

Brief Hospital Course:
73-year-old woman who presented with significant obtundation
from a large subdural
hematoma on the left side. She had significant midline
shift,therefore we decided to do a left frontoparietal
craniotomy and evacuation of subdural hematoma. Post operatively
she was monitored in the ICU and awoke without any neurological
difficulites she was receiving Mannitol and her BP was kept
below 140 for the first 24 hours. Follow up CTs showed less
midline shift.  While in the ICU she was extubated on [**6-5**]
and needed to be reintubated because she became fatigued. A
second attempt was tried on [**6-7**] and again needed
re-intubation. On [**6-11**] she received a tracheostomy.
On [**6-14**] she was noted to have hematuria and guiac positive
stool, her HCT 23.1 medicine was consulted they felt she had
anemia of inflammation/chronic disease. She had no further
hematuria or GI blood. They recommended only transfusing if
HCT<21.
She is currently being treated for a UTI until [**6-18**] which we
feel has contributed to some low grade temps. Neurologically she
had no deficits.

On discharge she a video swallow which showed she was not
aspirating. Speech and swallow recommends a ground solid diet
with thin liquids and crushed pill. Her trach can be downsized
to size smaller at the rehab facility.

Medications on Admission:
1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).


Discharge Medications:
1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1)  PO DAILY
(Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1)  Inhalation Q6H (every 6 hours) as needed.
13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
14. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
respiratory failure
left subdural hematoma
post operative hematuria
post operative anemia
urinary tract infection
hematochezia


Discharge Condition:
Neurologically stable


Discharge Instructions:
General 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.
??????	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 have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.

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 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 for that
visit.
??????You should follow up with your primary care physician and
notify him/her of your hospital stay and new diagnosis'.



Completed by:[**2145-6-16**]
{"Subdural hemorrhage,Acute respiratory failure,Urinary tract infection, site not specified,Blood in stool,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Anemia, unspecified,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure"}


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: Transfer with subdural hematoma

PRESENT ILLNESS: 73 yo woman with PMH sig. for HTN and hyperlipidemia
who presents from an OSH intubated after discovery of left SDH
with 1 cm of shift. She was apparently reporting a HA and
malaise this morning. Over the day, she was more confused and
lethargic. She was unsteady when her family got her up to walk
and became more lethargic and confused. She had no reported or
observed trauma. At the OSH, she was intermittently answering
yes/no questions and following some commands. She was reportedly

MEDICAL HISTORY: HTN and hyperlipidemia
Hypoglycemia

MEDICATION ON ADMISSION: 1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Penicillins

PHYSICAL EXAM: On admission
CN:
Pupils:1.5 to 1 bilat.
Nasal Tickle:Mild grimace bilaterally ? right >left
Gag/Cough:Gags and coughs on ETT
Corneal Reflex:Slight bilaterally
OCRs:Eyes with some motion bilaterally, but not full.

FAMILY HISTORY: Non contributory

SOCIAL HISTORY: No smoking or drinking. Her son and husband are here with her 

### Response:
{"Subdural hemorrhage,Acute respiratory failure,Urinary tract infection, site not specified,Blood in stool,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Anemia, unspecified,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure"}
