CHIEF COMPLAINT: Mental Status Change
Right frontal SDH/IPH

PRESENT ILLNESS: 73F who reported feeling more tired than usual last night,
husband also noted slurred speech. Patient went to bed early and
in the AM, husband felt she was more lethargic and speech
remained slurred. She was taken to [**Hospital6 2561**] where a
Head CT showed a R IPH/SDH. Patient was on Coumadin and received
profilnine IX then transferred to [**Hospital1 18**]. At the [**Hospital1 18**] ER, her
INR
was 2.0 and she received 2 units of FFP.

MEDICAL HISTORY: -Hypertension
-Diabetes mellitus, type 2 (insulin-dependent)
-Paroxysmal atrial flutter on warfarin
-Hx GI bleed s/p coil embolization of sigmoid branch of [**Female First Name (un) 899**]
-Hx left breast invasive lobular carcinoma w/ [**12-6**] +LN s/p
breast-conserving surgery ([**2168**]) w/ adjuvant chemotherapy
-Hypercholesterolemia
-Thyroid nodule s/p FNA revealing benign path ([**1-/2172**])
PSH:
-Left breast biopsy ([**2163**])
-Left breast needle-localized wide excision w/ SLNB ([**2168**])
-Microcoil embolization of simgoid arteriolar branch of [**Female First Name (un) 899**]
([**5-/2172**])

MEDICATION ON ADMISSION: Lopressor 75mg daily, Arimidex 1mg daily, Lipitor 40mg daily,
Lisinopril 5mg, Paxil 50mg, Metformin 1000mg [**Hospital1 **], Cardizem 60mg
[**Hospital1 **], Insulin Novolog 70/30 45u [**Hospital1 **], Insulin Humulin 70/30 SS,
Vitamin D, Caclium carbonate 600mg [**Hospital1 **]

ALLERGIES: Penicillins

PHYSICAL EXAM: On admission:
PHYSICAL EXAM:
O: T: 98.8  BP: 153/69   HR: 67    R 14    O2Sats 98%

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives with husband, 2 children nearby, retired, no tobacco
Intracerebral hemorrhage,Cerebral edema,Atrial flutter,Subdural hemorrhage,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of breast,Other fluid overload,Other respiratory abnormalities
Intracerebral hemorrhage,Cerebral edema,Atrial flutter,Subdural hemorrhage,Hypertension NOS,DMI wo cmp nt st uncntrl,Long-term use anticoagul,Hx of breast malignancy,Fluid overload NEC,Respiratory abnorm NEC
Admission Date:  [**2173-4-24**]              Discharge Date:   [**2173-5-2**]

Date of Birth:  [**2099-6-6**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 14802**]
Chief Complaint:
Mental Status Change
Right frontal SDH/IPH

Major Surgical or Invasive Procedure:
[**2173-4-24**]: Right frontal craniotomy for evacuation


History of Present Illness:
73F who reported feeling more tired than usual last night,
husband also noted slurred speech. Patient went to bed early and
in the AM, husband felt she was more lethargic and speech
remained slurred. She was taken to [**Hospital6 2561**] where a
Head CT showed a R IPH/SDH. Patient was on Coumadin and received
profilnine IX then transferred to [**Hospital1 18**]. At the [**Hospital1 18**] ER, her
INR
was 2.0 and she received 2 units of FFP.


Past Medical History:
-Hypertension
-Diabetes mellitus, type 2 (insulin-dependent)
-Paroxysmal atrial flutter on warfarin
-Hx GI bleed s/p coil embolization of sigmoid branch of [**Female First Name (un) 899**]
-Hx left breast invasive lobular carcinoma w/ [**12-6**] +LN s/p
breast-conserving surgery ([**2168**]) w/ adjuvant chemotherapy
-Hypercholesterolemia
-Thyroid nodule s/p FNA revealing benign path ([**1-/2172**])
PSH:
-Left breast biopsy ([**2163**])
-Left breast needle-localized wide excision w/ SLNB ([**2168**])
-Microcoil embolization of simgoid arteriolar branch of [**Female First Name (un) 899**]
([**5-/2172**])


Social History:
Lives with husband, 2 children nearby, retired, no tobacco


Family History:
non-contributory

Physical Exam:
On admission:
PHYSICAL EXAM:
O: T: 98.8  BP: 153/69   HR: 67    R 14    O2Sats 98%

Gen: Lethargic but arouseable to voice.
HEENT: No signs of trauma.

Neuro:
Mental status: Lethargic, needs continued prompting to stay
awake
for exam.
Orientation: Oriented to person, place, and date.
Language: Speech slurred. Naming intact.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields unable to assess given lethargy.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and mild L
asymmetry.
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 [**4-3**] throughout.

PHYSICAL EXAM UPON DISCHARGE:
non-focal
incision c/d/i, staples removed before discharge.

Pertinent Results:
Head CT [**2173-4-24**]:
Right frontal SDH/IPH with midline shift. Small R SAH.

Head CTA [**2173-4-24**]:
IMPRESSION:
1.  Moderate-sized acute subdural hematoma along the convexity
on the right side, with a more focal rounded component medially.
 Hypodense areas and fluid level representing ongoing
hemorrhage.  Correlate clinically for coagulopathy. No obvious
vascular abnormality in the vicinity allowing for the technical
limitations and delayed acquisition.  However, given the rounded
appearance medially, MRI if not CI, can be considered to exclude
a neoplastic lesion although less likely.
2.  Mass effect on the right lateral ventricle and leftward
shift of midline structures as described above.
3.  Patent major intracranial arteries without focal
flow-limiting stenosis, occlusion or aneurysm more than 3 mm
within the resolution of MR angiogram.

Head CT [**2173-4-24**]:
IMPRESSION:
1.  Post-evacuation of a large right subdural hematoma,
resulting in near
resolution of previously seen leftward midline shift.A small
amount of
residual blood products remains at the evacuation site.
Attention on f/u.
2.  There is re-definition of the right insula. Slight loss of
the [**Doctor Last Name 352**]-white matter differentiation here may reflect mild
ischemia  from prior compression.

Head CT [**2173-4-25**]:
IMPRESSION:
Essentially unchanged right postsurgical changes with residual
hyperdense
subdural collection also unchanged. Slightly dense appearance of
right
transverse sinus is unchanged.

CHEST (PA & LAT) Study Date of [**2173-4-25**] 1:06 PM
There is cardiomegaly.  There is moderate-to-severe pulmonary
edema with
prominence of the pulmonary interstitial markings.  There are
small bilateral pleural effusions.  No focal confluent area of
consolidation is seen.

CHEST (PORTABLE AP) Study Date of [**2173-4-26**] 4:28 AM
There is unchanged cardiomegaly.  There is mild improvement of
the pulmonary edema since the prior study.  Small bilateral
pleural effusions are present and stable.  There are no
pneumothoraces or focal areas of consolidation.

Cardiovascular Report ECG Study Date of [**2173-4-26**]  11:30:46 AM
Sinus rhythm. Right bundle-branch block. Compared to the
previous tracing
of [**2173-4-24**] there is ST segment depression in leads II, III and
aVF,
leads V3-V6 consistent with anterolateral and apical ischemic
process.
Followup and clinical correlation are suggested. No previous
tracing available for comparison. TRACING #1

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
78 124 148 388/419 83 43 -66

Cardiovascular Report ECG Study Date of [**2173-4-26**]  10:36:04 PM
Atrial fibrillation with rapid ventricular response and right
bundle-branch block. The ST segment changes previously recorded
on [**2173-4-26**] are more prominent. Rule out active ischemic process.
Followup and clinical
correlation are suggested.
TRACING #2

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
133 0 136 322/449 0 58 -86


 Radiology Report CT HEAD W/O CONTRAST Study Date of [**2173-4-26**]
2:24 PM

IMPRESSION:  Slightly decreased pneumocephalus from [**2173-4-25**].
Otherwise,
little change from [**2173-4-25**] in postsurgical changes with
residual hyperdense subdural collection and 4 mm leftward shift
of normally midline structures.

Radiology Report CHEST (PORTABLE AP) Study Date of [**2173-4-27**] 4:09
AM

IMPRESSION:  AP chest compared to [**4-25**] and 28:

Previous pulmonary edema has resolved.  Moderate to severe
cardiomegaly and central vascular engorgement persist.  There is
no appreciable pleural
effusion.  Rightward deviation of the mid portion of the
cervical trachea is a consistent finding on the only three chest
radiographs currently available and suggests mass effect by
either a nodule in the region of the left thyroid lobe, or
alternatively a Zenker's diverticulum.  Clinical correlation is
advised.

Radiology Report CHEST (PORTABLE AP) Study Date of [**2173-4-28**] 4:02
AM
FINDINGS:  Single portable semi-erect chest radiograph was
obtained.  Since yesterday, central pulmonary vascular
congestion has progressed to mild pulmonary edema which is not
as severe as that seen on the 28.  Cardiomegaly is unchanged.  A
small left effusion may be present.  No new consolidation or
pneumothorax is present.

IMPRESSION:  Progression of central pulmonary vascular
congestion to mild
pulmonary edema.


Brief Hospital Course:
This is a 73 year old Female admitted to neurosurgery, neuro ICU
for close monitoring for a right frontal Sub Dural Hemorhage and
IPH. Her INR in the Emergency Room was 2.0 and she received 2
units of Fresh Frozen Plasma. She became more lethargic but
maintained her airway. Surgical intervention was planned for.
There was concern there was an underlying mass. Her repeat INR
was 1.7 and she received two additional units of Fresh Frozen
Plasma which resulted a INR of 1.6. She was taken to the OR by
Dr [**Last Name (STitle) **] for a right craniotomy for evacuation and possible
tumor resection. She was given two additional units of Fresh
Frozen Plasma intraoperatively. Open opening of the dura and
evacuation of the clot- there was no abnormal tissue noted to
suggest underlying mass. The clot was sent to pathology for
testing. A subgaleal drain was in place. Post-operatively, she
was extubated and transferred back to the ICU. Her post-op head
CT showed interval evacuation of blood with near resolution of
midline shift. Her exam remained unchanged.

On [**4-25**] AM, she remained lethargic but followed commands and
MAE. Her subgaleal drain was removed without difficulty and a
stitch was placed. Her mental status continued without
improvement and repeat Head CT was performed which showed no
acute bleed and improved midline shift. A blood gas was sent
which showed a high PCO2 and a chest xray was done which showed
fluid overload. She was given Lasix 20mg without change. A
repeat ABG showed a lower PCO2 but worsening PO2. A bedside ECHO
showed filled ventricles and an additional 40mg of Lasix was
given. She was started on Bipap. A repeat ABG ART 108* 48* 7.47*
36* 9

On [**4-26**], The repeat CXR consistent with unchanged cardiomegaly.
There is mild improvement of the pulmonary edema since the prior
study.  Small bilateral pleural effusions are present and
stable.  There are no pneumothoraces or focal areas of
consolidation. The patinet O2 sat on Bypap is in the mid 90s off
Bypap the patient sesats to 90% quickly.  On exam, the patient
opens eyes to voice, pupils are reactive 3->2mm.  The patient
follows simple commands and moves all 4 extremities antigravity.
 The incision was well aproximated.

On [**4-27**], patient was alert and oriented with full stength.
Overnight, she was in SVT and was placed her on a diltiazem gtt.
She was started on SQH and encouraged to be OOB to chair.
Throughout the day, diltiazen gtt was weaned off and she was
placed on a PO regimen.

On [**4-28**], she remained neurologically stable. She was still seen
to be in SVT despite PO diltiazem 30mg. Overnight, she remained
in a-fib and was placed back on diltiazem gtt.

On [**4-29**], patient was nonfocal on exam. She remains in ICU for
her a-fib. The Diltiazem intravenous gtt was weaned and
transitioned to oral Diltiazem.

On [**4-30**], the patient was off the diltiazem for greater than 24
hrs. In the early morning the heart rate was 130.  The Heart
rate normalized and was stable at less than < 100.  The patient
was transferred to floor with telemetry when a bed is available.

On [**5-1**] she was again tachy to the 140's which was treated with
lopressor and diltiazem. Cardiology was consulted for assistance
and her medications were adjusted. She remained rate controlled
for the remainder of the day and through [**5-2**]. She was seen and
cleared by cardiology for home on [**5-2**]. It is being recommended
that she follow up with her cardiologist to discuss the need for
restarting coumadin in the setting of a previous GI bleed and
recent subdural hematoma. Her medications were changed to once
daily dosing and her staples were removed.



Medications on Admission:
Lopressor 75mg daily, Arimidex 1mg daily, Lipitor 40mg daily,
Lisinopril 5mg, Paxil 50mg, Metformin 1000mg [**Hospital1 **], Cardizem 60mg
[**Hospital1 **], Insulin Novolog 70/30 45u [**Hospital1 **], Insulin Humulin 70/30 SS,
Vitamin D, Caclium carbonate 600mg [**Hospital1 **]


Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. paroxetine HCl 20 mg Tablet Sig: 2.5 Tablets PO DAILY
(Daily).
6. anastrozole 1 mg Tablet Sig: One (1) Tablet PO qd ().
7. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Diltia XT 180 mg Capsule,Ext Release Degradable Sig: Two (2)
Capsule,Ext Release Degradable PO once a day.
Disp:*60 Capsule,Ext Release Degradable(s)* Refills:*2*
11. Toprol XL 200 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Right frontal SDH and IPH
Cerebral edema and midline shift
Altered mental status
Respiratory distress
Fluid overload
Atrial Fibrillation, tachycardia


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


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 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 were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this after clearance from your
Neurosurgeon.
??????	You have been prescribed 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:
*      Please follow-up with Dr [**Last Name (STitle) **] in 4 weeks with a
non-contrast Head CT. This appt can be made by calling
[**Telephone/Fax (1) 1669**].

*     You had problems with your heart rhythm and rate while in
the hospital and many medications were changed. Please call to
make an appt with your cardiologist for a followup visit. It is
also being recommended that you speak to her about the need to
restart Coumadin.



Completed by:[**2173-5-2**]
{'Intracerebral hemorrhage,Cerebral edema,Atrial flutter,Subdural hemorrhage,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of breast,Other fluid overload,Other respiratory abnormalities'}


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: Mental Status Change
Right frontal SDH/IPH

PRESENT ILLNESS: 73F who reported feeling more tired than usual last night,
husband also noted slurred speech. Patient went to bed early and
in the AM, husband felt she was more lethargic and speech
remained slurred. She was taken to [**Hospital6 2561**] where a
Head CT showed a R IPH/SDH. Patient was on Coumadin and received
profilnine IX then transferred to [**Hospital1 18**]. At the [**Hospital1 18**] ER, her
INR
was 2.0 and she received 2 units of FFP.

MEDICAL HISTORY: -Hypertension
-Diabetes mellitus, type 2 (insulin-dependent)
-Paroxysmal atrial flutter on warfarin
-Hx GI bleed s/p coil embolization of sigmoid branch of [**Female First Name (un) 899**]
-Hx left breast invasive lobular carcinoma w/ [**12-6**] +LN s/p
breast-conserving surgery ([**2168**]) w/ adjuvant chemotherapy
-Hypercholesterolemia
-Thyroid nodule s/p FNA revealing benign path ([**1-/2172**])
PSH:
-Left breast biopsy ([**2163**])
-Left breast needle-localized wide excision w/ SLNB ([**2168**])
-Microcoil embolization of simgoid arteriolar branch of [**Female First Name (un) 899**]
([**5-/2172**])

MEDICATION ON ADMISSION: Lopressor 75mg daily, Arimidex 1mg daily, Lipitor 40mg daily,
Lisinopril 5mg, Paxil 50mg, Metformin 1000mg [**Hospital1 **], Cardizem 60mg
[**Hospital1 **], Insulin Novolog 70/30 45u [**Hospital1 **], Insulin Humulin 70/30 SS,
Vitamin D, Caclium carbonate 600mg [**Hospital1 **]

ALLERGIES: Penicillins

PHYSICAL EXAM: On admission:
PHYSICAL EXAM:
O: T: 98.8  BP: 153/69   HR: 67    R 14    O2Sats 98%

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives with husband, 2 children nearby, retired, no tobacco 

### Response:
{'Intracerebral hemorrhage,Cerebral edema,Atrial flutter,Subdural hemorrhage,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of breast,Other fluid overload,Other respiratory abnormalities'}
