CHIEF COMPLAINT: increased lethargy and unsteadiness

PRESENT ILLNESS: 77 yo woman with a PMHx significant for DM2, HTN, and
hyperlipidemia presents with increasing weakness over past 2
weeks, lethargy and unsteadiness (per family). Pt is s/p Right
SDH evacuation via burr hole on [**2171-9-11**].She has had 2 episodes
of incontinence which she attributes to not ambulating fast
enough.
Pt presented to her PCP today who sent her to the emergency room
for CT scan. CT scan revealed re-accumulation of SDH (chronic)
and she was transferred to [**Hospital1 18**]. Pt denies h/a, vision
changes,N/V.

MEDICAL HISTORY: PMHx:
Type II Diabetes
HTN
HL

MEDICATION ON ADMISSION: Glyburide 5 mg
Amitriptylene 10 mg
Januvia 100 mg
Metformin 1000 mg
Lisinopril 5 mg
Simvistatin

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: PHYSICAL EXAM:
O: T:99.2  BP: 137/62   HR:78    R 16    O2Sats 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL   EOMs intact
Neck: Supple.
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place only.
Language: Speech with good comprehension of simple questions
(language barrier). Speaking with family appropriately.

FAMILY HISTORY: Mother and Father both were healthy into their late 80s. 4
children - 1 deceased (not medical cause) 3 other children
healthy

SOCIAL HISTORY: Patient lives in [**Location 8242**] w/ her husband who worked as a
mechanic. She is from [**Location (un) **] [**Country 2559**] and speaks only italian but has
been living in the country for the past 44 years. Non-smoker, no
EtOH
Subdural hemorrhage,Acute posthemorrhagic anemia,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other iatrogenic hypotension
Subdural hemorrhage,Ac posthemorrhag anemia,Hyperlipidemia NEC/NOS,DMII wo cmp nt st uncntr,Hypertension NOS,Iatrogenc hypotnsion NEC
Admission Date:  [**2171-9-24**]              Discharge Date:   [**2171-9-30**]

Date of Birth:  [**2093-12-14**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
increased lethargy and unsteadiness

Major Surgical or Invasive Procedure:
Right craniotomy with evacuation SDH


History of Present Illness:
77 yo woman with a PMHx significant for DM2, HTN, and
hyperlipidemia presents with increasing weakness over past 2
weeks, lethargy and unsteadiness (per family). Pt is s/p Right
SDH evacuation via burr hole on [**2171-9-11**].She has had 2 episodes
of incontinence which she attributes to not ambulating fast
enough.
Pt presented to her PCP today who sent her to the emergency room
for CT scan. CT scan revealed re-accumulation of SDH (chronic)
and she was transferred to [**Hospital1 18**]. Pt denies h/a, vision
changes,N/V.

Past Medical History:
PMHx:
Type II Diabetes
HTN
HL

Social History:
Patient lives in [**Location 8242**] w/ her husband who worked as a
mechanic. She is from [**Location (un) **] [**Country 2559**] and speaks only italian but has
been living in the country for the past 44 years. Non-smoker, no
EtOH


Family History:
Mother and Father both were healthy into their late 80s. 4
children - 1 deceased (not medical cause) 3 other children
healthy

Physical Exam:
PHYSICAL EXAM:
O: T:99.2  BP: 137/62   HR:78    R 16    O2Sats 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL   EOMs intact
Neck: Supple.
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place only.
Language: Speech with good comprehension of simple questions
(language barrier). Speaking with family appropriately.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3
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 [**4-17**] throughout. No pronator drift

Sensation: Intact to light touch

Exam upon discharge:
xxxxx

Pertinent Results:
CT (head) - reviewed from OSH. Chronic right SDH, increasing in
size and MLS compared to previous scan.



Brief Hospital Course:
Pt was admitted to the ICU for close monitoring.  She was
brought to the OR [**9-25**] where under general anesthesia she
underwent craniotomy with evacuation of SDH.  Post-op she was
extubated and returned to ICU for close monitoring.  She was
less lethargic and neurologically intact with the exception of
poor date identification though this is reportedly her baseline
by the family.  Post op CT showed good resolution of SDH
collection.  On POD#1 she had some hypotension to systolic of
80's and her hematocrit was 26.  She received fluid bolus and 2u
PRBC transfusion. Her HCT on repeat testing increased to 29.6
and she had no further episodes of hypotension.
 She was transfered to the floor in stable condition on POD#2. A
repeat CBC on this day showed stable HCT at 29.7. Upon exam she
was non focal and AOx3. She was seen by physical therapy and
occupational therapy and plan was for discharge to a rehab
facility vs home pending her progress. The physical therapy team
saw her again on [**9-29**] and cleared her for discharge home with
family support on [**9-30**].

Medications on Admission:
Glyburide 5 mg
Amitriptylene 10 mg
Januvia 100 mg
Metformin 1000 mg
Lisinopril 5 mg
Simvistatin

Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. lisinopril 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily).
5. sitagliptin 100 mg Tablet Sig: One (1) Tablet PO daily ().
6. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 2436**] Home Care

Discharge Diagnosis:
Right subdural hematoma
hypotension
acute blood loss anemia with transfusion


Discharge Condition:
AOx3. Activity as tolerated.


Discharge 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.

??????     You have been prescribed 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.

Followup Instructions:
Please have your staples removed the week of [**10-7**].  Call to
schedule this appt.  You will also need appt in 4 weeks with
Head CT. Please call [**Telephone/Fax (1) 2992**] to arrange.



Completed by:[**2171-9-30**]
{'Subdural hemorrhage,Acute posthemorrhagic anemia,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other iatrogenic hypotension'}


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: increased lethargy and unsteadiness

PRESENT ILLNESS: 77 yo woman with a PMHx significant for DM2, HTN, and
hyperlipidemia presents with increasing weakness over past 2
weeks, lethargy and unsteadiness (per family). Pt is s/p Right
SDH evacuation via burr hole on [**2171-9-11**].She has had 2 episodes
of incontinence which she attributes to not ambulating fast
enough.
Pt presented to her PCP today who sent her to the emergency room
for CT scan. CT scan revealed re-accumulation of SDH (chronic)
and she was transferred to [**Hospital1 18**]. Pt denies h/a, vision
changes,N/V.

MEDICAL HISTORY: PMHx:
Type II Diabetes
HTN
HL

MEDICATION ON ADMISSION: Glyburide 5 mg
Amitriptylene 10 mg
Januvia 100 mg
Metformin 1000 mg
Lisinopril 5 mg
Simvistatin

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: PHYSICAL EXAM:
O: T:99.2  BP: 137/62   HR:78    R 16    O2Sats 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL   EOMs intact
Neck: Supple.
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place only.
Language: Speech with good comprehension of simple questions
(language barrier). Speaking with family appropriately.

FAMILY HISTORY: Mother and Father both were healthy into their late 80s. 4
children - 1 deceased (not medical cause) 3 other children
healthy

SOCIAL HISTORY: Patient lives in [**Location 8242**] w/ her husband who worked as a
mechanic. She is from [**Location (un) **] [**Country 2559**] and speaks only italian but has
been living in the country for the past 44 years. Non-smoker, no
EtOH 

### Response:
{'Subdural hemorrhage,Acute posthemorrhagic anemia,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other iatrogenic hypotension'}
