CHIEF COMPLAINT: Known aneurysm, now enlarged in size

PRESENT ILLNESS: The patient is a 50-year-old  female that was found to have an
incidentally discovered  right-sided ICA bifurcation aneurysm.
This aneurysm has been known for several years. It is followed
up by sequential scans. The  patient has now undergone a formal
angiogram by Dr.[**Name (NI) 10136**]  service on [**2159-4-5**]. The
catheter angiogram with  gadolinium has confirmed a 9 x 5.5mm
bilobed aneurysm at the bifurcation of the right anterior and
middle cerebral arteries. It appears to have a wide neck
measuring approximately 4.5 to 5mm. Overall, the patient has
done well and remains clinically  intact and stable. She has
done [**Location (un) 1131**] on the issue and decided that she does not want to
undergo coiling which is technically difficult with wide neck
aneurysms anyway. The patient opted to have an open surgery and
wants to have definite occlusion by clipping. She is seen for
surgical counseling in neurosurgery office.

MEDICAL HISTORY: - DM type I x 29 years - last A1c 11.3 [**5-10**], followed at the
[**Last Name (un) **]. CHecks FS QID, vary widely from 40's to 400's.
- cardiomyopathy, EF 15-20% from TTE yesterday, on Coumadin
- CKD s/p transplant in [**2152**], Cr 1.9 to 2.9 range since [**1-9**]
- Intracranial right ICA aneurysm, diagnosed "several years
ago,"
gets yearly imaging. 5mm [**2154**], 8mm on [**2159-2-7**] MRA.
- History of C4-5 and C5-6 anterior decompression and fusion
after MVA [**2157**], Dr. [**Last Name (STitle) 363**]
- ulnar nerve impingement bilaterally
- Hypertension
- Hepatitis C acquired via transfusion for menses that were
hemorrhagic, now menopausal.
- Rotator cuff repair
- CMV [**2155**]
- E.coli UTI in [**12-11**]
- right carpal tunnel surgically released

MEDICATION ON ADMISSION: tacrolimus 3", sirolimus 5', toprol XL 100', lipitor 20',
losartan 25', Zantac 75', Lantus/Novalog, tramadol 50',
?coumadin

ALLERGIES: Percocet

PHYSICAL EXAM: VITALS: 97.8, 144/88, 98, 18, 98% RA, FS 99-210
GEN: no acute distress, pleasant woman that appears younger than

FAMILY HISTORY: Sister died of [**Name (NI) 101497**], many other family members with type 1 and 2
DM

SOCIAL HISTORY: Pt Lives at home with son and his wife and their 4 children. Pt
works at [**Location (un) 686**] District Court
EtOH - used to drink, none in 9 years
Tob - 1ppd for 27 years, quit about 8 years ago
Cerebral aneurysm, nonruptured,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Complications of transplanted kidney,Acute kidney failure, unspecified,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Acidosis,Unspecified viral hepatitis C without hepatic coma,Unspecified pleural effusion,Hemorrhage complicating a procedure,Delirium due to conditions classified elsewhere,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Long-term (current) use of insulin
Nonrupt cerebral aneurym,Pneumonia, organism NOS,CHF NOS,Compl kidney transplant,Acute kidney failure NOS,DMI wo cmp nt st uncntrl,Acidosis,Hpt C w/o hepat coma NOS,Pleural effusion NOS,Hemorrhage complic proc,Delirium d/t other cond,Obstructive sleep apnea,Hypertension NOS,Long-term use of insulin
Admission Date:  [**2159-5-16**]              Discharge Date:   [**2159-6-1**]

Date of Birth:  [**2108-12-6**]             Sex:   F

Service: MEDICINE

Allergies:
Percocet

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Known aneurysm, now enlarged in size

Major Surgical or Invasive Procedure:
1.Right sided pterional craniotomy for right-sided ICA
bifurcation aneurysm clipping.
2.  Microsurgical dissection.
3.  Duroplasty.


History of Present Illness:
The patient is a 50-year-old  female that was found to have an
incidentally discovered  right-sided ICA bifurcation aneurysm.
This aneurysm has been known for several years. It is followed
up by sequential scans. The  patient has now undergone a formal
angiogram by Dr.[**Name (NI) 10136**]  service on [**2159-4-5**]. The
catheter angiogram with  gadolinium has confirmed a 9 x 5.5mm
bilobed aneurysm at the bifurcation of the right anterior and
middle cerebral arteries. It appears to have a wide neck
measuring approximately 4.5 to 5mm. Overall, the patient has
done well and remains clinically  intact and stable. She has
done [**Location (un) 1131**] on the issue and decided that she does not want to
undergo coiling which is technically difficult with wide neck
aneurysms anyway. The patient opted to have an open surgery and
wants to have definite occlusion by clipping. She is seen for
surgical counseling in neurosurgery office.

Currently, she denies any new symptoms such as headaches,
nausea, vomiting, or dizziness. The patient has no seizures or
focal neurological deficits. She had persistent balance problems
secondary to spinal and cervical stenosis.


Past Medical History:
- DM type I x 29 years - last A1c 11.3 [**5-10**], followed at the
[**Last Name (un) **]. CHecks FS QID, vary widely from 40's to 400's.
- cardiomyopathy, EF 15-20% from TTE yesterday, on Coumadin
- CKD s/p transplant in [**2152**], Cr 1.9 to 2.9 range since [**1-9**]
- Intracranial right ICA aneurysm, diagnosed "several years
ago,"
gets yearly imaging. 5mm [**2154**], 8mm on [**2159-2-7**] MRA.
- History of C4-5 and C5-6 anterior decompression and fusion
after MVA [**2157**], Dr. [**Last Name (STitle) 363**]
- ulnar nerve impingement bilaterally
- Hypertension
- Hepatitis C acquired via transfusion for menses that were
hemorrhagic, now menopausal.
- Rotator cuff repair
- CMV [**2155**]
- E.coli UTI in [**12-11**]
- right carpal tunnel surgically released



Social History:
Pt Lives at home with son and his wife and their 4 children. Pt
works at [**Location (un) 686**] District Court
EtOH - used to drink, none in 9 years
Tob - 1ppd for 27 years, quit about 8 years ago


Family History:
Sister died of [**Name (NI) 101497**], many other family members with type 1 and 2
DM

Physical Exam:
VITALS: 97.8, 144/88, 98, 18, 98% RA, FS 99-210
GEN: no acute distress, pleasant woman that appears younger than

stated age
NECK: limited ROM

NEURO:
Mental status:
Patient is alert, awake, pleasant affect. Oriented to person,
place, time. Good attention - tells a coherant story.
Language is fluent with good comprehension, repitition, naming,
no dysarthria. No apraxia, agnosias, no neglect. Able to
calculate, no left/right mismatch. Registration [**4-10**] objects.
Recalls [**4-10**] objects after 3 minutes.

Cranial Nerves:
I: deferred
II: Visual fields: full to left/right/upper/lower fields.
Fundoscopic exam: discs flat, fundi clear, no hemorrhages or
exudates. Pupils: 3->2 mm, consensual constriction to light.
III, IV, VI: EOMS full, gaze conjugate. No nystagmus or ptosis.
- UPON DISCHARGE PERSISTANT R SIDED UPPER LID PTOSIS.  NO OTHER
FACIAL ASSYMETRY
V: facial sensation intact over V1/2/3 to light touch and pin
prick.
VII: symmetric face
VIII: hearing intact to finger rubs
IX, X: Symmetric elevation of palate.
[**Doctor First Name 81**]: SCM and trapezius [**5-11**] bilaterally
XII: tongue midline without atrophy or fasciculations.

Sensory:
Normal touch, proprioception, pinprick. Decreased cold in a
stocking/glove distribution. No extinction to double
simultaneous stimulation.

Motor:
Wasting bilateral APB, FDI, EDB bulk, mildly increased tone
legs.
No fasciculations or drift. + postural tremor low amplitude
worse with motion. No asterixis.

      D   T  B  WE  WF   FE  FF  IP  QD  Ham DF PF [**Last Name (un) 938**]
RT:   5   4  5  5   5    5   5   4   5   4-  5   5  4+
LEFT: 5   4  4+ 5   5    5   5   4   5   4-  5   5  4+

Reflexes: + [**Doctor Last Name **] bilaterally. No Jaw jerk. Crossed
adductors.  SLIGHTLY MORE HYPERREFLEXIC ON L PATELLAR.

      [**Hospital1 **] BR Tri Pat Ach Toes
RT:   3  3  tr  3   tr  up
LEFT: 3  3  2   3   tr  up

Coordination:
Normal finger-to-nose (tremor constant throughout testing, worse
with posture and action), heel-to-shin, RAMs.

Gait:
Gait is antalgic, favors the left leg.

Pertinent Results:
CXR [**5-17**]:
IMPRESSION: NG tube in left lower lobe segmental bronchus. This
has been communicated immediately to Dr. [**Last Name (STitle) **] at the time of
the review of the study at approximately 10 p.m. on [**2159-5-16**].
.
Angeography:
IMPRESSION: No evidence of perfusion to the clipped right ICA
bifurcation aneurysm. No evidence of residual aneurysm. The
right ICA, MCA, ACA and the major branches are patent.
.
CT [**5-18**]:
IMPRESSION: Again noted is intraparenchymal hemorrhage within
the right temporal lobe with surrounding edema that measures
slightly larger compared to prior study. Increase in
high-density material seen within the right frontal extra-axial
space with slight increase in leftward shift of midline
structures. Discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13013**] at 6:45 a.m. on [**5-18**], [**2159**].
.
NOTE ADDED AT ATTENDING REVIEW: The increase in extra axial
fluid is expected as fluid replaces air at the surgical site.
The slight change in the appearance of the post operative
hemorrhage in the temporal lobe does not necessarily reflect
increased bleeding.
.
[**5-19**] CT:
IMPRESSION: Stable appearance of right inferior frontotemporal
intraparenchymal hemorrhage with surrounding edema.
Post-surgical changes from right frontal craniotomy. No new
hemorrhage, hydrocephalus or increased shift of normally midline
structures is identified.
.
[**5-22**] CT:
FINDINGS: Examination is essentially unchanged from the previous
study. Again is noted increased density in middle cranial fossa
consistent with hemorrhage within the temporal lobe and/or
subjacent to it. There is some gas still seen in the right
frontal extra-axial compartment. Artifact to the aneurysm
clipping is again noted. There is low density in the head of the
caudate consistent with infarction. There are some malacic
changes in the right frontal lobe.
.
IMPRESSION: Stable appearance when compared to previous
examination.
.
[**5-24**] CXR:
The previously identified opacities in both lower lobes have
been markedly improving. The lungs are clear otherwise. The
heart and mediastinum are within normal limits. The right
jugular IV catheter remains in place. No pneumothorax is
identified.
.
[**5-24**] Renal US:
FINDINGS:
The right lower quadrant renal transplant measures 13.8 cm in
length, which is unchanged from the prior study. Cortical
echogenicity is likely within normal limits but may be mildly
increased. Cortical-medullary differentiation persists. There
are no renal masses, hydronephrosis, or calculi. Arterial flow
is identified within the upper, mid and lower pole wrist with
resistive indices up to 0.90 which are increased from the prior
study. Renal vein is patent. No perinephric fluid collections.

IMPRESSION:
Right lower quadrant renal transplant without hydronephrosis.
All vessels patent though resistive indices are slightly
increased from the prior study, which is nonspecific.
.
[**5-25**] EKG:
Sinus rhythm. Left atrial abnormality. First degree A-V block.
Left
bundle-branch block. Compared to the previous tracing of [**2159-5-19**]
no significant diagnostic change.
.
[**5-28**] US:
FINDINGS: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the left internal
jugular, subclavian, axillary, brachial, and basilic veins were
performed. There is a small amount of non-occlusive thrombus
within the left internal jugular vein. The left subclavian,
axillary, and brachial veins are patent with normal flow,
augmentation, compressibility, and waveforms. The basilic vein
is patent.
.
IMPRESSION: Small amount of non-occlusive thrombus within the
left internal jugular vein. No evidence of left upper extremity
DVT.
Cx negative - BCx, UCx negative
.
[**5-31**] US:
LEFT UPPER EXTREMITY DVT STUDY: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**]
of the left IJ, left subclavian, left axillary, and left
brachial veins were performed. There is again noted a small
nonocclusive thrombus in the left internal jugular vein in the
neck, which is probably slightly decreased when compared to the
prior study. No new thrombus is identified. The other visualized
veins are unremarkable.

IMPRESSION: Persistent tiny nonocclusive thrombus in the left
internal jugular vein in the neck. It appears to be slightly
decreased when compared to the prior study.
.
CT [**5-29**]:
COMPARISON: Compared to the CT of [**2159-5-22**], there is
decreased density within the right temporal lobe hematoma,
indicating maturing hemorrhage. Low densities within the head of
the caudate and temporal lobes secondary to infarction are
stable. Mild edema and mass effect slightly reduced. The
ventricles are not dilated. The small extra-axial fluid
collection at the craniotomy site is stable with no evidence for
new intracranial hemorrhage. Post- surgical soft tissue swelling
is unchanged. Aneurysm clip related artifact again present.

IMPRESSION: Slight improvement from [**2159-5-22**] with no
evidence for new hemorrhage.
.
VRE/MRSA SCREENS NEGATIVE
.
Labs upon d/c:
Hematology
  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2159-6-1**] 04:50AM    6.9 3.26* 8.8* 26.9* 82 26.9* 32.6 18.9*
611*
  DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2159-5-28**] 05:57AM    68.7   22.7 5.5 2.8 0.4
  RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Microcy
[**2159-5-28**] 05:57AM      1+ 1+ 1+
  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2159-6-1**] 04:50AM        611*
HEMOLYTIC WORKUP Ret Aut
[**2159-5-28**] 05:57AM    1.7

Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2159-6-1**] 04:50AM    137* 14 1.9* 146* 3.8 111* 26 13
  ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2159-5-29**] 06:09AM        354*       0.1
  OTHER ENZYMES & BILIRUBINS Lipase
[**2159-5-25**] 06:25AM    20
CPK ISOENZYMES CK-MB cTropnT
[**2159-5-19**] 12:10AM    4 0.01
  CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron

[**2159-6-1**] 04:50AM          8.8 3.1 1.6
  HEMATOLOGIC calTIBC Hapto Ferritn TRF
[**2159-5-29**] 06:09AM      87
  LIPID/CHOLESTEROL Cholest Triglyc
[**2159-5-20**] 03:22AM      89
  OTHER CHEMISTRY Osmolal
[**2159-5-22**] 03:17AM    314*
THYROID PTH
[**2159-5-23**] 01:43PM    54
  NEUROPSYCHIATRIC Phenyto
[**2159-5-20**] 07:30AM    15.5
[**2159-5-20**] 03:22AM    17.1
  TOXICOLOGY, SERUM AND OTHER DRUGS FK506 rapmycn
[**2159-6-1**] 04:50AM    4.9*
[**2159-6-1**] 04:50AM      5.8



Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is 50 y.o. F with DM 1, s/p cadaveric renal
transplant '[**52**], admitted for clipping of right sided bilobed
middle cerebral artery bifurcation aneurysm on [**2159-5-16**],
complicated by left temporal contusion. Patient was observed
Neuro ICU for hemodynamic and close neurologic monitoring.
Failed 3 attempt of placement of NGT/OG for immunosuppressive
drug as well as for nutrition immediate postoperative period
with LLL PNA as complication. Post operative head CT revealed
right temporal contusion which has bees stable in appearance in
serial cat scans of the head.  The course was complicated by
persistent somnolence attributed to Keppra and anemia and
improving ARF with resolving CHF.
..............................................................
.
Neuro:  Her initial postoperative neurologic exam off sedation
showed normal extremity response to pain but right eye ptosis,
IIIrd nerve palsy. Pupils are sluggishly reactive 3-2mm
bilaterally. She had a cerebral arteriogram on [**2159-5-17**].  There
were no immediate complications during arteriogram.  Arteriogram
revealed a surgical clip is seen in the region of the previously
seen ICA bifurcation aneurysm on the right.  There is no
evidence of residual perfusion of this aneurysm. The superior
sagittal sinus, right transverse sinus, right sigmoid sinus and
upstream portion of the right internal jugular vein are widely
patent as well as the right ICA, MCA, ACA and the major branches
are patent.  Patient remained with R eye ptosis, and improvement
in III nerve palsy that was presumed to be due to operation and
neurosurgery did not feel certain whether it was going to be
reversed.  Patient with increased somnolence during the day and
several episodes of [**Last Name (un) 6055**]-stoke breathing suggesting central
apnea.  She was evaluated by pulmonary service who also noted an
element for apnea and she was referred for outpatient sleep
study.  R temporal contusion remained stable on CT, last one
[**5-29**] showed maturing hematoma without any evidence of new
hemorrhage.  Patient with persistent somnolence although quickly
arrousable.  The etiology of somnolence remained unclear and may
have been due to sleep apnea as described above.  Patient was
also taken off Keppra after discussion with Dr. [**Last Name (STitle) **] and
somnolence improved slightly.  She is to f/u with Dr. [**Last Name (STitle) **] in
6 months, CTA in 1 yr.  There was no evidence of seizures while
in house.
.
# LLL PNA - Patient was found to have a LLL PNA on [**5-17**] CXR that
was obtained after
patient had a desaturation episode where her oxygen saturation
dropped to 86%. This may have been a complication of multiple
failed NGT placement attempts.  Patient was initially placed on
Levo/Flagyl.  Flagyl was subsequently discontinued.  Her
saturation remained excellent on room air.  Cultures were not
done as patient denied any sputum or fever.  Repeat chest
radiograph on [**5-24**] showed marked improvement pneumonia and
pleural effusion. She completed 7 day course of Levaquin -last
dose 5/22.
.
Patient with DM nephropathy s/p renal transplant.  Patient was
being followed by nephrology transplant service while in house.
Her creatinine at baseline is 2.0-3.0 with large fluctuations.
Patient's her creatinine was 2.9 on [**5-16**] preop, post arteriogram
peaked to 4.1, and was attributed likely due to peri-operative
hypotension and worsening renal failure.  There was no evidence
of hydronephrosis on Renal ultrasound preformed on [**5-24**].  The
contrast during angiogram was unlikely to be a contributor since
Cr started rising 3 days after exposure.   US evaluation of the
right lower quadrant renal transplant showed all vessels patent
though resistive indices are slightly increased from the prior
study, which is nonspecific. Microscopic urine sediment
confirmed ATN with FeNa 2.4 % on [**5-24**] with pr/cr of 1.7 .
Patient's Cr slowly improved to low 2.0s and she was restarted
on her regular CHF regiment included Losartan.  Patient
tolerating small doses of Lasix prn as her renal function also
improved with diuresis.  Patient was also continued on
sacrolimus/tacrolimus and the dosages were adjusted based on
daily values.  Patient will f/u with Dr. [**First Name (STitle) 805**] as outpatient.
.
# Anemia - Patient with microcytic anemia.  Work up revealed
guiac negative stool on [**5-29**].  FeStudies c/w nl Fe, low TIBC,
suggesting anemia of chronic diseases. nl B12/Folate [**2-12**].
Patient also noted to have low reticulocyte index, no
schistocytes on smear, LDH/hapto nl.  She was continued on
Epogen and it was increased to compensate her anemia.  Patient
was given 1 unit PRBC on [**5-26**] and her Hct remained stable for
the rest of her hospitalization.  There was no evidence of
increasing hematoma on head CT and no other source of bleeding
was suspected.
.
# HTN - patient was managed on Metoprolol XL, Hydralazine and
Imdur were titrated off while she was restarted on Losartan and
subsequently Nifedipine CR was added to her regiment.  Goal BP
was 140-150 to assure adequate renal perfusion.
.
# Pyuria - on [**2159-5-31**], although UCx was negative she was
empirically treated with cipro 250 [**Hospital1 **] x 7 days.  Patient denied
any fever or urinary symptoms.  She urinated well after removal
of the foley.
.
# LUE DVT - Patient was noted to have L arm swelling on [**5-28**].
Subsequent US showed non-occlusive thrombus in Left internal
jugular vein probably due to prior line placement.  Patient's
was a high risk for anticoagulation due to guiac negative stools
but steadily decline hematocrit as described above.  The risk
and benefits were discussed with the patient multiple times and
she agreed that the anticoagulation would be too risky not
knowing the source of her blood loss.  Repeat US o [**5-31**] showed
tiny improved nonocclusive L IJ clot and it was decided to forgo
anticoagulation upon discharge with a knowledge of organizing
hematoma seen upon repeat CT.
.
# CHF - Patient with known nonischemic cardiomyopathy, and
initial volume overloaded likely due to worsening renal
function.  Patient's trace edema improved with mild diuresis due
to prn lasix and while she was started on hydralazine and Imdur.
 Patient's respiratory status was never compromised and slowly
her renal function improved.  Patient subsequently was switched
from Hydral/Imdur to Losartan for afterload reduction.  No Lasix
were Rx for home therapy.  Patient will follow up with
Cardiologist @ [**Hospital1 2177**] or [**Hospital 1902**] clinic here.  She may require
subsequent ICD eval and risk stratification.
.
# IDDM - patient Type I DM and was followed by [**Last Name (un) **] service
during her stay.  She was maintained on insulin gtt while in the
ICU and subsequently switched to sliding scale with Lantus.  Her
tight scale was maintained < 150 with at least 13 u Lantus even
when NPO.
.
# Full code
.
Follow up - patient will follow up with her renal doctor, her
PCP, [**Name10 (NameIs) **] and pulmonary clinic and also Dr.[**Last Name (STitle) **] in 6 months.


Medications on Admission:
tacrolimus 3", sirolimus 5', toprol XL 100', lipitor 20',
losartan 25', Zantac 75', Lantus/Novalog, tramadol 50',
?coumadin

Discharge Medications:
1. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for headache.
4. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*3*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
6. Tramadol 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day for 1 weeks.
Disp:*7 Tablet Sustained Release 24HR(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours.
Disp:*30 Tablet(s)* Refills:*0*
8. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous at bedtime.
Disp:*1 cartridge* Refills:*3*
9. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*3*
10. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*3*
11. Metoprolol Succinate 200 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO at bedtime.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*3*
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
13. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
14. Epogen 4,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR.
Disp:*30 injection* Refills:*3*
15. Outpatient Physical Therapy
Please continue physical therapy 3x/week at home for as long as
needed
16. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO at
bedtime.
Disp:*90 Capsule(s)* Refills:*3*
17. Sirolimus 1 mg Tablet Sig: Seven (7) Tablet PO DAILY
(Daily).
Disp:*210 Tablet(s)* Refills:*3*
18. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO qAM.
Disp:*120 Capsule(s)* Refills:*3*
19. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: 1-10 units
Subcutaneous qACHS: as per your sliding scale.
Disp:*2 bottle* Refills:*3*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 2255**] [**Name (NI) 2256**]

Discharge Diagnosis:
R MCA aneurysm
R temporal lobe contusion
Acute Renal Failure
Chronic Renal Insufficiency - s/p renal transplant
Obstructive Sleep Apnea
Anemia
Acidosis
Congestive Heart Failure
Pneumonia
IDDM
Hypertension
Hepatitis C


Discharge Condition:
Stable. Pt afebrile. Ambulating with cane. Oxygenating well.
Tolerating PO.


Discharge Instructions:
Please take all your medicatios as instructed.
.
It is important to keep all your appointment and follow up with
them as scheduled.
.
Please seek immediate medical attention if you experiences a
worsening headache, nausea/vomiting, increasing
numbness/weakness in any of your extremities, or if you noticed
slurred speech or worsening swallowing.

Followup Instructions:
Follow up with PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] - [**6-12**], @ 11:30 am.
[**Telephone/Fax (1) 1260**]
.
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**], renal clinic, on [**2159-6-7**] @ 12
pm.
.
Follow up in sleep clinic once your symtpoms improved and call
[**Telephone/Fax (1) 16716**] to make an appointment.  You will also need to make
a subsequent appointment with a pulmonary doctor - call ([**Telephone/Fax (1) 35871**] to make an appointment.
.
Follow up with Dr. [**Last Name (STitle) **] in 6 months.  Call ([**Telephone/Fax (1) 88**] to
make an appointment.
.
Follow up with [**Hospital **] clinic ([**Telephone/Fax (1) 17240**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**] -
[**6-8**] @ 11 am
.
Follow up with Dr. [**Last Name (STitle) 363**] re: your spine procedure.  Call him to
make an appointment @ ([**Telephone/Fax (1) 11061**]



Completed by:[**2159-6-18**]
{'Cerebral aneurysm, nonruptured,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Complications of transplanted kidney,Acute kidney failure, unspecified,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Acidosis,Unspecified viral hepatitis C without hepatic coma,Unspecified pleural effusion,Hemorrhage complicating a procedure,Delirium due to conditions classified elsewhere,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Long-term (current) use of insulin'}


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: Known aneurysm, now enlarged in size

PRESENT ILLNESS: The patient is a 50-year-old  female that was found to have an
incidentally discovered  right-sided ICA bifurcation aneurysm.
This aneurysm has been known for several years. It is followed
up by sequential scans. The  patient has now undergone a formal
angiogram by Dr.[**Name (NI) 10136**]  service on [**2159-4-5**]. The
catheter angiogram with  gadolinium has confirmed a 9 x 5.5mm
bilobed aneurysm at the bifurcation of the right anterior and
middle cerebral arteries. It appears to have a wide neck
measuring approximately 4.5 to 5mm. Overall, the patient has
done well and remains clinically  intact and stable. She has
done [**Location (un) 1131**] on the issue and decided that she does not want to
undergo coiling which is technically difficult with wide neck
aneurysms anyway. The patient opted to have an open surgery and
wants to have definite occlusion by clipping. She is seen for
surgical counseling in neurosurgery office.

MEDICAL HISTORY: - DM type I x 29 years - last A1c 11.3 [**5-10**], followed at the
[**Last Name (un) **]. CHecks FS QID, vary widely from 40's to 400's.
- cardiomyopathy, EF 15-20% from TTE yesterday, on Coumadin
- CKD s/p transplant in [**2152**], Cr 1.9 to 2.9 range since [**1-9**]
- Intracranial right ICA aneurysm, diagnosed "several years
ago,"
gets yearly imaging. 5mm [**2154**], 8mm on [**2159-2-7**] MRA.
- History of C4-5 and C5-6 anterior decompression and fusion
after MVA [**2157**], Dr. [**Last Name (STitle) 363**]
- ulnar nerve impingement bilaterally
- Hypertension
- Hepatitis C acquired via transfusion for menses that were
hemorrhagic, now menopausal.
- Rotator cuff repair
- CMV [**2155**]
- E.coli UTI in [**12-11**]
- right carpal tunnel surgically released

MEDICATION ON ADMISSION: tacrolimus 3", sirolimus 5', toprol XL 100', lipitor 20',
losartan 25', Zantac 75', Lantus/Novalog, tramadol 50',
?coumadin

ALLERGIES: Percocet

PHYSICAL EXAM: VITALS: 97.8, 144/88, 98, 18, 98% RA, FS 99-210
GEN: no acute distress, pleasant woman that appears younger than

FAMILY HISTORY: Sister died of [**Name (NI) 101497**], many other family members with type 1 and 2
DM

SOCIAL HISTORY: Pt Lives at home with son and his wife and their 4 children. Pt
works at [**Location (un) 686**] District Court
EtOH - used to drink, none in 9 years
Tob - 1ppd for 27 years, quit about 8 years ago 

### Response:
{'Cerebral aneurysm, nonruptured,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Complications of transplanted kidney,Acute kidney failure, unspecified,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Acidosis,Unspecified viral hepatitis C without hepatic coma,Unspecified pleural effusion,Hemorrhage complicating a procedure,Delirium due to conditions classified elsewhere,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Long-term (current) use of insulin'}
