CHIEF COMPLAINT: fall

PRESENT ILLNESS: HPI: 64y/o female on Coumadin was brought to [**Hospital1 18**] s/p fall at
[**Last Name (un) **] range today. Family members report that the patient
tripped while outside of the [**Last Name (un) **] range and fell hitting the
back of her head. She was able to stand, but then fell to the
floor as if she was having a seizure and lost consciousness. EMS
on scene states that she had a GCS of 4 and was intubated,
sedated and brought to [**Hospital1 18**]. CT scan shows L SDH and she taken
to the OR for an emergent evacuation of L SDH.

MEDICAL HISTORY: PMHx:seizure, HTN, bypass

MEDICATION ON ADMISSION: Medications prior to admission: fosamax, dilantin, amoxicillin,
lisinopril, Coumadin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
ON ARRIVAL
Gen: Patient is intubated s/p craniotomy for evacuation of L
SDH.
HEENT: Pupils: 3-2mm bilaterally    EOMs:unable to access
Neuro:
Mental status: patient is intubated,
Orientation: unable to access
Recall: Unable to access
Language: unable to access
Naming intact. unable to access

FAMILY HISTORY: unknown

SOCIAL HISTORY: unknown
Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Compression of brain,Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy,Fall from other slipping, tripping, or stumbling,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Heart valve replaced by other means,Old myocardial infarction,Other late effects of cerebrovascular disease,Other disorders of muscle, ligament, and fascia
Subdural hemorr-coma NOS,Compression of brain,Part epil w/o intr epil,Fall from slipping NEC,Long-term use anticoagul,Hypertension NOS,Heart valve replac NEC,Old myocardial infarct,Late effect CV dis NEC,Muscle/ligament dis NEC
Admission Date:  [**2112-7-16**]              Discharge Date:   [**2112-7-21**]

Date of Birth:  [**2048-4-2**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
fall

Major Surgical or Invasive Procedure:
Craniotomy


History of Present Illness:
HPI: 64y/o female on Coumadin was brought to [**Hospital1 18**] s/p fall at
[**Last Name (un) **] range today. Family members report that the patient
tripped while outside of the [**Last Name (un) **] range and fell hitting the
back of her head. She was able to stand, but then fell to the
floor as if she was having a seizure and lost consciousness. EMS
on scene states that she had a GCS of 4 and was intubated,
sedated and brought to [**Hospital1 18**]. CT scan shows L SDH and she taken
to the OR for an emergent evacuation of L SDH.


Past Medical History:
PMHx:seizure, HTN, bypass

Social History:
unknown

Family History:
unknown

Physical Exam:
PHYSICAL EXAM:
ON ARRIVAL
Gen: Patient is intubated s/p craniotomy for evacuation of L
SDH.
HEENT: Pupils: 3-2mm bilaterally    EOMs:unable to access
Neuro:
Mental status: patient is intubated,
Orientation: unable to access
Recall: Unable to access
Language: unable to access
Naming intact. unable to access

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: unable to access
V, VII: unable to access
VIII: unable to access
IX, X: unable to access
[**Doctor First Name 81**]: unable to access
XII: unable to access

Motor: RUE- attempts to localize to noxious stimuli, LUE-
extensor posturing, LE- triple flexion bilaterally

Positive corneal reflex bilaterally
Positive cough

ON DISCHARGE:
pt awake alert oriented x 3 - CN II - XII intact, slight right
drift, speech clear. Motor 4+ throughout.

Pertinent Results:
Pathology Examination

Name Birthdate    Age     Sex Pathology #     [**Hospital1 18**] [**Known lastname 83004**],[**Known firstname **]       [**2048-4-2**]    64 Female      [**-9/2721**]
[**Numeric Identifier 83005**]
Report to:   DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] GOODELL/dif

SPECIMEN SUBMITTED: SUBDURAL HEMATOMA (1 JAR).

Procedure date     Tissue received     Report Date    Diagnosed
by
[**2112-7-16**] [**2112-7-18**] [**2112-7-19**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **]/mtd


DIAGNOSIS:

"Subdural hematoma" (A):

Erythrocytes and fibrin consistent with hematoma.
Rare and minute fragments of bone.

Clinical:  64 year old woman, cranial bleed. Specimen submitted:
Subdural hematoma.
Gross:

The specimen is received fresh labeled with the patient's name,
"Eu, Critical / [**Known lastname **], [**Known firstname **]," her medical record number and
"subdural hematoma." It consists of multiple fragments of blood
clot measuring 6.9 x 5.5 x 0.6 cm in aggregate.  On sectioning
the clots are grossly unremarkable. The specimen is serially
sectioned and represented in cassette A.

Pathology Examination

Name Birthdate    Age     Sex Pathology #     [**Hospital1 18**] [**Known lastname 83004**],[**Known firstname **]       [**2048-4-2**]    64 Female      [**-9/2721**]
[**Numeric Identifier 83005**]
Report to:   DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] GOODELL/dif



SPECIMEN SUBMITTED: SUBDURAL HEMATOMA (1 JAR).

Procedure date     Tissue received     Report Date    Diagnosed
by
[**2112-7-16**] [**2112-7-18**] [**2112-7-19**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **]/mtd


DIAGNOSIS:

"Subdural hematoma" (A):

Erythrocytes and fibrin consistent with hematoma.
Rare and minute fragments of bone.

Clinical:  64 year old woman, cranial bleed. Specimen submitted:
Subdural hematoma.
Gross:

The specimen is received fresh labeled with the patient's name,
"Eu, Critical / [**Known lastname **], [**Known firstname **]," her medical record number and
"subdural hematoma." It consists of multiple fragments of blood
clot measuring 6.9 x 5.5 x 0.6 cm in aggregate.  On sectioning
the clots are grossly unremarkable. The specimen is serially
sectioned and represented in cassette A.

[**Known lastname **],[**Known firstname **] [**Medical Record Number 83006**] F  64  [**2048-4-2**]

Radiology Report CT HEAD W/O CONTRAST Study Date of [**2112-7-16**]
9:59 AM


[**Last Name (LF) **],[**First Name3 (LF) **] EU   [**2112-7-16**] 9:59 AM
CT HEAD W/O CONTRAST   Clip # [**Clip Number (Radiology) 83007**]
Reason: S/P FALL, ? BLEED



[**Hospital 93**] MEDICAL CONDITION:
   66 year old woman with s/p fall
REASON FOR THIS EXAMINATION:
   ? bleed
CONTRAINDICATIONS FOR IV CONTRAST:
   None.



Wet Read: SPfc SAT [**2112-7-16**] 10:32 AM
Large left, primarily subdural, extra-axial hemorrhage with
associate right
sub-falcine herniation of ~10mm. D/w Trauma surgery service.


Final Report
HISTORY: Fall.

COMPARISON: No prior studies available for comparison.

TECHNIQUE: Axial CT images were acquired through the head in the
absence of intravenous contrast. Coronal and sagittal
reformatted images were also
reviewed.

FINDINGS:
A large area of subdural blood extends over the entire left
cerebral
hemisphere, including parafalcine extension. At maximal depth,
this subdural collection appears to measure approximately 21 mm
(2:23). There is associated effacement of the ipsilateral sulci
and lateral ventricle as well as subfalcine herniation measuring
approximately 10 mm at greatest deviation (2:18). Small areas of
hyperdensity extending along the gyral surface overlying the
right parietal lobe (2:23) may represent foci of parenchymal
contusion or small amount of subarachnoid blood. There is no
evidence of entrapment of the contralateral lateral ventricle.
The third ventricle appears partially effaced as well as
displaced secondary to the subdural blood. The posterior fossa
appears unremarkable. There are no other foci of hemorrhage.
Extracranial soft tissue structures reveal a mild amount of soft
tissue prominence overlying a surgical defect in the left
parietal bone, possibly related to the recent fall or remote
surgery. Visualized osseous structures reveal the surgical
defect, overlying the subdural blood as previously depicted.
There is no other evidence of fracture. The included paranasal
sinuses reveal a hypoplastic left frontal sinus as well as
circumferential mucosal thickening in the ethmoidal air cells,
bilaterally, as well as in the maxillary sinuses bilaterally. A
large amount of fluid and secretions is seen in the included
portion of the nasopharynx and should be clinically correlated
for possibility of aspiration.

IMPRESSION:
1. Large primarily subdural extra-axial hemorrhage, with
associated right
deviation of normal midline anatomy of approximately 10 mm.
2. Hypodensity left frontoparietal lobe indicating
encephalomalacia.
3. S,all hyperdensity adjacent to left anterior [**Doctor Last Name 534**] due to
axonal injury or contusion.
4. Large amount of retained secretions in the nasopharynx which
should be
correlated for concern of possible aspiration. These findings
were discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] from the trauma surgery
service at 10:30 a.m. on [**2112-7-16**].


[**Known lastname **],[**Known firstname **] [**Medical Record Number 83006**] F  64  [**2048-4-2**]

Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2112-7-16**]
10:00 AM


[**Last Name (LF) **],[**First Name3 (LF) **] EU   [**2112-7-16**] 10:00 AM
CT C-SPINE W/O CONTRAST   Clip # [**Clip Number (Radiology) 83008**]
Reason: S/P FALL, ? C SPINE FX



[**Hospital 93**] MEDICAL CONDITION:
   66 year old woman with s/p fall
REASON FOR THIS EXAMINATION:
   ? fx
CONTRAINDICATIONS FOR IV CONTRAST:
   None.



Wet Read: SPfc SAT [**2112-7-16**] 10:50 AM
no fracture or traumatic malalignment.


Final Report
HISTORY: Fall.

COMPARISON: Comparison is made to concurrent CT of the head as
well as torso.

TECHNIQUE: Axial CT images were acquired through the cervical
spine in the
absence of intravenous contrast. Coronal and sagittal
reformatted images were also reviewed.

FINDINGS: There is no fracture or traumatic malalignment. There
is no
prevertebral soft tissue swelling. Intracranial contents are
better
characterized on a concurrent CT head dictated separately.
Vertebral body
heights are well preserved. The regional soft tissue and
vascular structures appear unremarkable. The portions of the
lung apices included are better characterized on the concurrent
CT of the torso.

Moderate amount of retained secretions in the hypo- and
[**Last Name (un) **]-pharynx are
redemonstrated.

IMPRESSION: No fracture or traumatic malalignment. Findings were
discussed
in person by Dr. [**Last Name (STitle) 14804**] with Dr. [**Last Name (STitle) 1132**] from the trauma surgery
service at
approximately 10:50 a.m. on [**2112-7-16**].



[**Known lastname **],[**Known firstname **] [**Medical Record Number 83006**] F  64  [**2048-4-2**]

Radiology Report CHEST (PORTABLE AP) Study Date of [**2112-7-16**] 9:59
AM


[**Last Name (LF) **],[**First Name3 (LF) **] EU   [**2112-7-16**] 9:59 AM
CHEST (PORTABLE AP)   Clip # [**Clip Number (Radiology) 83009**]
Reason: ? cp process



[**Hospital 93**] MEDICAL CONDITION:
   66 year old woman with s/p fall
REASON FOR THIS EXAMINATION:
   ? cp process



Final Report
HISTORY: 66-year-old woman status post fall.

PORTABLE CHEST RADIOGRAPH.

COMPARISON: None.

FINDINGS: Evaluation is limited by presence of trauma backboard
underlying
the patient. There are sternal wires as well as surgical clips
in the upper mediastinum. There is an endotracheal tube whose
tip abuts the carina and should be withdrawn approximately 3 to
4 cm. A nasogastric tube courses through the esophagus and into
the stomach. The cardiomediastinal silhouette appears abnormal
with abnormal widening of the upper mediastinum and an
indistinct aortic knob. There is opacification which obscures
the retrocardiac silhouette as well as the left heart border.
Additional opacity noted in right upper hemithorax. There is no
pneumothorax. There are no obvious rib fractures.

IMPRESSION:
1. Endotracheal tube abutting the carina and should be
re-positioned.
2. Abnormal widening of the mediastinum, in the setting of
trauma cannot
exclude possible aortic injury and recommend chest CT for
further evaluation.
3. Increased density in the retrocardiac region as well as
abutting the left heart border and in right upper lung.
Aspiration and/or contusion are
principal diagnostic considerations.
4. No displaced rib fracture or pneumothorax.

Findings were communicated via telephone to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3827**] at 10:15
a.m. [**2112-7-16**].



[**Known lastname **],[**Known firstname **] [**Medical Record Number 83006**] F  64  [**2048-4-2**]

Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2112-7-16**]
10:02 AM


[**Last Name (LF) **],[**First Name3 (LF) **] EU   [**2112-7-16**] 10:02 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
  Clip # [**Clip Number (Radiology) 83010**]
Reason: S/P FALL, ? INJURY
Contrast: OPTIRAY



[**Hospital 93**] MEDICAL CONDITION:
   66 year old woman with s/p fall
REASON FOR THIS EXAMINATION:
   ? thoracic injury
CONTRAINDICATIONS FOR IV CONTRAST:
   None.



Wet Read: SPfc SAT [**2112-7-16**] 10:59 AM
ETT is only 12-15mm above the carina and should be retracted.
Bilateral
pulmonary opacities are some combination of atelectasis and
aspiration. Note
is made of cholelithiasis.


Final Report
HISTORY: Fall.

COMPARISON: Comparison is made to concurrent CT of the cervical
spine.

TECHNIQUE: Axial CT images were acquired through the torso
following
administration of 130 cc of intravenous Optiray contrast.
Coronal and
sagittal reformatted images were also reviewed.

CT CHEST WITH CONTRAST: The patient is intubated with the tip of
the
endotracheal tube terminating approximately 12 mm above the
carina (301B:41). This tip could be retracted slightly.
Otherwise, airways are patent to segmental levels bilaterally.
Consolidative opacities are noted in the upper lobes bilaterally
as well as dependently in the lower lobes, likely reflecting
some combination of atelectasis and aspiration. The heart and
great vessels are notable for postoperative change, following an
apparent mitral valve replacement. Atherosclerotic calcification
is visualized along the aortic annulus as well as at the aortic
arch. There is no axillary or mediastinal lymphadenopathy.

CT ABDOMEN WITH CONTRAST: An orogastric tube terminates in the
stomach which is otherwise unremarkable. The duodenum, spleen,
fatty pancreas, adrenal glands, liver, kidneys are unremarkable.
The gallbladder contains numerous hyperattenuating foci
consistent with layering gallstones. There is no free gas or
fluid in the abdomen. There is no retroperitoneal or mesenteric
lymphadenopathy.

CT PELVIS WITH CONTRAST: The rectum, colon, uterus, adnexa are
unremarkable. The urinary bladder contains a Foley catheter.
There is no free gas or fluid in the abdomen. There is no pelvic
sidewall or inguinal lymphadenopathy.

OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic
osseous lesion. Note is made of multiple sternotomy wires. There
is a mild anterior wedge compression deformity of the T8
vertebral body of unknown chronicity.

IMPRESSION:
1. Bilateral pulmonary opacities are consistent with some
combination of
atelectasis and aspiration.
2. Endotracheal tube is approximately 12 mm above the carina and
could be
retracted slightly.
3. Cholelithiasis.

These findings were discussed in person by Dr. [**Last Name (STitle) 14804**] with Dr.
[**Last Name (STitle) 1132**] from
trauma surgery at approximately 10:50 a.m. on [**7-16**],


[**Known lastname **],[**Known firstname **] [**Medical Record Number 83006**] F  64  [**2048-4-2**]

Neurophysiology Report EEG Study Date of [**2112-7-18**]



OBJECT: History of epilepsy status post evacuation of subdural
hemorrhage with recurrent seizures on dilantin.


REFERRING DOCTOR: DR. [**First Name (STitle) 7495**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]


FINDINGS:
ABNORMALITY #1: In the awake state, there was voltage reduction
in the
right parasagittal region and occasional slowing on the right
accompanying drowsiness. There was earlier onset of drowsiness
on the
right versus the left.
ABNORMALITY #2: Later in the study, there were runs of
polymorphic theta
with rare sharps over the left central region during drowsiness.

BACKGROUND: Throughout the recording the background rhythm
remained slow
typically reaching a 7.5 Hz maximum.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Revealed a generally regular rhythm with
average rate
of 96 bpm.
IMPRESSION: This is an abnormal routine EEG due to persistent
decreased
voltage in the right parasaggital and frontal region.
Additionally, the
slow background suggests a mild encephalopathy affecting both
cortical
and subcortical structures. Medications, metabolic disturbances,
and
infection are among the most common causes. There were no
clearly
epileptiform feature.


[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname **], [**Known firstname **]       [**Hospital1 18**] [**Numeric Identifier 83011**]Portable TTE
(Complete) Done [**2112-7-18**] at 1:34:40 PM      FINAL
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 742**]
[**Hospital1 18**]-Division of Neurosurgery
[**Hospital Unit Name 18400**]
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2048-4-2**]
Age (years): 64 F  Hgt (in):
BP (mm Hg): 121/55  Wgt (lb): 182
HR (bpm): 95  BSA (m2):
Indication: Aortic valve replacement. Mitral valve replacement.

ICD-9 Codes: 424.1, 424.0, 424.2
Test Information
Date/Time: [**2112-7-18**] at 13:34    Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2009W055-0:00 Machine: Vivid [**7-11**]
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Ventricle - Septal Wall Thickness:  0.8 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  0.9 cm  0.6 - 1.1 cm

Left Ventricle - Diastolic Dimension:  4.1 cm  <= 5.6 cm
Left Ventricle - Systolic Dimension:  1.8 cm
Left Ventricle - Fractional Shortening:  0.56  >= 0.29
Left Ventricle - Ejection Fraction:  >= 60%  >= 55%
Aorta - Descending Thoracic:  2.1 cm  <= 2.5 cm
Aortic Valve - Peak Velocity:  *4.0 m/sec  <= 2.0 m/sec
Aortic Valve - Peak Gradient:  *64 mm Hg  < 20 mm Hg
Aortic Valve - Mean Gradient:  36 mm Hg
Mitral Valve - Peak Velocity:  1.9 m/sec
Mitral Valve - Mean Gradient:  7 mm Hg
Mitral Valve - Pressure Half Time:  70 ms
Mitral Valve - E Wave:  1.7 m/sec
Mitral Valve - A Wave:  1.6 m/sec
Mitral Valve - E/A ratio:  1.06
Mitral Valve - E Wave deceleration time:  182 ms  140-250 ms
TR Gradient (+ RA = PASP):  *38 to 48 mm Hg  <= 25 mm Hg

Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm)
with >55% decrease during respiration (estimated RA pressure
(0-5mmHg).

LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTIC VALVE: Mechanical aortic valve prosthesis (AVR).
Increased AVR gradient. No AR.

MITRAL VALVE: Bileaflet mitral valve prosthesis (MVR). Normal
MVR leaflet motion. Increased MVR gradient. No MR. [Due to
acoustic shadowing, the severity of MR may be significantly
UNDERestimated.]

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Moderate PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.

PERICARDIUM: No pericardial effusion.
Conclusions
The estimated right atrial pressure is 0-5 mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
cavity size and systolic function are normal. A mechanical
aortic valve prosthesis is present. The transaortic gradient is
higher than expected for this type of prosthesis. No aortic
regurgitation is seen. A bileaflet mitral valve prosthesis is
present. The motion of the mitral valve prosthetic discs appeas
normal. The gradients are higher than expected for this type of
prosthesis. No mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.

IMPRESSION: Suboptimal image quality. Mechanical aortic valve
prosthesis with increased gradient. Bileaflet mitral valve
prosthesis with good disc motion, but increased gradient.
Moderate pulmonary artery systolic hypertension. Preserved
global biventricular systolic function.

CLINICAL IMPLICATIONS:
Based on [**2110**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

[**Known lastname **],[**Known firstname **] [**Medical Record Number 83006**] F  64  [**2048-4-2**]

Radiology Report CT HEAD W/O CONTRAST Study Date of [**2112-7-19**]
6:56 PM


[**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG FA11 [**2112-7-19**] 6:56 PM
CT HEAD W/O CONTRAST   Clip # [**Clip Number (Radiology) 83012**]
Reason: ? change in bleed



[**Hospital 93**] MEDICAL CONDITION:
   64 year old woman s/p SDH w evacuation, seizure
REASON FOR THIS EXAMINATION:
   ? change in bleed
CONTRAINDICATIONS FOR IV CONTRAST:
   None.



Provisional Findings Impression: JMGw TUE [**2112-7-19**] 8:05 PM
IMPRESSION:
1. Unchanged appearance to left temporoparietal intraparenchymal
hemorrhage with hypodensity and small left subdural hematoma. No
new areas of hemorrhage. No midline shift.
2. Stable hyperdense foci anterior to the left lateral
ventricular [**Doctor Last Name 534**] may represent area of contusion injury or [**Doctor First Name **].


Final Report
HISTORY: 64-year-old woman status post subdural hematoma with
evacuation and seizure. Evaluate for change in bleed

HEAD CT: Axial imaging was performed through the brain without
IV contrast.

COMPARISON: CT head [**2112-7-17**]. There is unchanged appearance
to small
left frontoparietal subdural hematoma measuring approximately 4
mm in
thickness.

FINDINGS: There is no shift of normally midline structures.
There is
unchanged appearance to intraparenchymal hemorrhage and
hypodensity in the
right temporoparietal lobe (2A:17). The ventricles appear stable
in size
without evidence for hydrocephalus. There are no new areas of
hemorrhage.
[**Doctor Last Name **]-white matter differentiation appears well preserved. There
are
persistent hyperdense foci anterior to the anterior [**Doctor Last Name 534**] of the
left lateral ventricle (2A:16). There is no evidence for
herniation, ambient and basilar cisterns are widely patent.
Patient is status post left craniotomy. There is mucosal
thickening of ethmoid air cells and maxillary sinuses. There is
decreased hematoma with decreased subcutaneous gas along the
left frontal scalp. There is minimal pneumocephalus adjacent to
the left subdural
hematoma.

IMPRESSION:
1. Unchanged appearance to left temporoparietal intraparenchymal
hemorrhage with internal hypodensity, now with small layering
blood/flood levels, and small extra-axial hematoma over the left
convexity.
2. No new foci of hemorrhage or shift of midline structures.
3. Stable more punctate hyperdense focus anterior to the left
lateral
ventricular frontal [**Doctor Last Name 534**] may represent additional contusion, or
[**Doctor First Name **].

The study and the report were reviewed by the staff radiologist.



[**Known lastname **],[**Known firstname **] [**Medical Record Number 83006**] F  64  [**2048-4-2**]

Neurophysiology Report EEG Study Date of [**2112-7-20**]



OBJECT: Bedside LTM w/video ekg [**Date range (1) 23533**]. THERE WERE NO
PUSHBUTTON
ACTIVATIONS. ROUTINE SAMPLING AND SPIKE AND SEIZURE DETECTION
PROGRAMS
WERE UTILIZED.


REFERRING DOCTOR: DR. [**First Name (STitle) 7495**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]


FINDINGS:
ABNORMALITY #1: There was prominent fast activity in the left
temporal
region.
ABNORMALITY #2: Intermittent and isolated slow sharp waves were
noted in
the left posterior temporal region.
ABNORMALITY #3: Throughout the recording the background rhythm
remained
slow typically reaching a 7 Hz maximum.
ABNORMALITY #4: There was decreased voltage noted in the right
parasagittal and frontal regions.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This is an abnormal EEG telemetry study due to a
slow
background in the theta range which suggests a widespread
encephalopathy
affecting both cortical and subcortical structures. There was
breech
artifact as well as isolated slow sharp wave activity in the
left
temporal region. Finally, the decreased voltage in the right
parasagittal and frontal regions may present diffuse cortical
injury or
possible residual subdural hematoma. There were no epilpetiform
features.


INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) **] L.


Brief Hospital Course:
This pt was admitted through the emergency department for acute
left sdh / on coumadin.  INR was reversed on admission - She was
taken to the OR emergently for evacuation of the collection.
Post operative day # 1 she had focal sz activity that was
described as twitching movements of angle of mouth on the right
side. This was
followed by twitching movement of her Right upper limb upto hand
after few seconds. The entire episode lasted for less than 1
minute.  She was seen by the neurology service and their
recommendations were followed.  Cardiology consult was obtained
for guidance in anticoagulation for her mechanical heart valves.
 She started on ASA on [**Doctor Last Name **] day #2.   On [**Doctor Last Name **] day # 4 a heparin
drip was started / wt based, for her mechanical heart valves.
Surface echo was performed.  She is due to start coumadin on
monday the [**3-25**] while in rehab.  Her goal PTT is 50 at
which time she should have a CT scan of the brain. Her diet and
sctivity were advanced and she was seen by PT.  She did have a
24 hour EEG which did not show any sz activity.  Her home med of
dilantin was discontinued and only keppra remains.

Her exam steadily improved and she was transferred to the step
down unit.

PT/OT/ST evals deem pt a rehab candidtate.  She is to be d/c's
to rehab and agrees with plan.

Medications on Admission:
Medications prior to admission: fosamax, dilantin, amoxicillin,
lisinopril, Coumadin

Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheezing .
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Lorazepam 0.5 mg IV PRN seizure > 3 minutes
PLEASE CALL HOUSE OFFICE PRIOR TO USING. [**Month (only) **] REPEAT X 1 IF
NEEDED.
10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
11. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
12. heparin drip sliding scale
Heparin solution: 25,000 in 250cc of D5W

Goal PTT = 50

PTT (sec)                     RATE CHANGE (UNITS/HR)
PTT <30                          INCREASE INFUSION RATE BY 200
//
PTT 31-45                        INCREASE INFUSION RATE BY 100
//
PTT 46-55                        DO NOT CHANGE THE RATE  //

PTT 56-70                        DECREASE INFUSION RATE BY 200
//
PTT >71                          DECREASE INFUSION RATE BY 400
//

WHEN PTT IS AT GOAL OF 50 - PLEASE OBTAIN NON CONTRAST BRAIN CAT
SCAN

DO NOT RESTART COUMADIN DOSING UNTIL MONDAY [**2112-7-25**] PER DR.
[**Last Name (STitle) **] / NEUROSURGERY


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1970**] - [**Hospital1 1559**]

Discharge Diagnosis:
left SDH


Discharge Condition:
neurologically stable


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY

??????	Have a 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,
excessive bending
??????	You may wash your hair only after sutures and/or staples have
been removed
??????	You may shower before this time with assistance and use of a
shower cap
??????	Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
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, drainage
??????	Fever greater than or equal to 101?????? F

PLEASE HAVE YOUR STAPLES REMOVED ON [**2112-7-26**] AT THE REHAB
FACILITY OR RETURN TO THE OFFICE ON THAT DAY [**Telephone/Fax (1) **]


Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) 739**] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITH OR WITHOUT CONTRAST


                             [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]

Completed by:[**2112-7-21**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Compression of brain,Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy,Fall from other slipping, tripping, or stumbling,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Heart valve replaced by other means,Old myocardial infarction,Other late effects of cerebrovascular disease,Other disorders of muscle, ligament, and fascia'}


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: fall

PRESENT ILLNESS: HPI: 64y/o female on Coumadin was brought to [**Hospital1 18**] s/p fall at
[**Last Name (un) **] range today. Family members report that the patient
tripped while outside of the [**Last Name (un) **] range and fell hitting the
back of her head. She was able to stand, but then fell to the
floor as if she was having a seizure and lost consciousness. EMS
on scene states that she had a GCS of 4 and was intubated,
sedated and brought to [**Hospital1 18**]. CT scan shows L SDH and she taken
to the OR for an emergent evacuation of L SDH.

MEDICAL HISTORY: PMHx:seizure, HTN, bypass

MEDICATION ON ADMISSION: Medications prior to admission: fosamax, dilantin, amoxicillin,
lisinopril, Coumadin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
ON ARRIVAL
Gen: Patient is intubated s/p craniotomy for evacuation of L
SDH.
HEENT: Pupils: 3-2mm bilaterally    EOMs:unable to access
Neuro:
Mental status: patient is intubated,
Orientation: unable to access
Recall: Unable to access
Language: unable to access
Naming intact. unable to access

FAMILY HISTORY: unknown

SOCIAL HISTORY: unknown 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Compression of brain,Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy,Fall from other slipping, tripping, or stumbling,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Heart valve replaced by other means,Old myocardial infarction,Other late effects of cerebrovascular disease,Other disorders of muscle, ligament, and fascia'}
