DATE OF ADMISSION : 12/18/2011 DATE OF DISCHARGE : 12/25/2011. ATTENDING PHYSICIAN: Samer Elbabaa, M.D.

CHIEF COMPLAINT: Headache and seizure. HISTORY OF PRESENT ILLNESS: Patient is a 59-year-old white male on Coumadin, who presented to an outside hospital with complaint of several days of headache and an episode of facial twitching that lasted for 4 to 5 minutes at home. Patient reports no loss of consciousness, none and no head trauma a. At this time., Patient was taken to Belleville Memorial Hospital where he was a a GCS of 15. CT obtained at that time showed acute on chronic subdural hemorrhage after subdural hematoma, and transversely transferred to SLU was initiated. During this process, he had another seizure at this time losing consciousness. Patient was then intubated for low GCS score and transferred Stalevo to SLU for further management. of Vitamin K and Keppra were administered at the outside hospital prior to transport. PAST MEDICAL HISTORY: Cardiomyopathy, aortic insufficiency, status post bileaflet mechanical aortic valve placed in 1995, ejection fraction of 35% on echo conducted in 08/2011, AFib, hypertension, diabetes mellitus, nonocclusive coronary artery disease, obstructive sleep apnea, and internal cardiac defibrillator placed in 07/2011 by Boston Scientific. PAST SURGICAL HISTORY: Mechanical bowel valve pacemaker defibrillator. ALLERGIES: No known drug allergies. MEDICATIONS: Include Amiodarone, Imdur, Coreg, Aldactone, glimepiride, Excedrin. SOCIAL HISTORY: No tobacco or drugs. Patient is a social drinker and married. FAMILY HISTORY: Positive for cardiomyopathy. PHYSICAL EXAMINATION: GENERAL: VITAL SIGNS: Patient is afebrile. . Vital signs are stable. Review of respiratory, cardiac and abdominal exams notable only for a clicking murmur on cardiac exam.. NEUROLOGIC: Patient is intubated, off sedation. Eyes open weekly to of the pain. EYES Eyes are bilaterally 1 mm dilated and reactive, purposeful on the right, localizes, the right greater than the left. Sensation intact throughout to pain. No Hoffmann or Babinski signs. Patient is your review OF IMAGING euareflexic. : REVIEW OF IMAGING: CT scan shows an acute on chronic right frontotemporal subdural hemorrhage 2.4 cm in greatest thickness. The g reatest thickness at greatest

thickness of the chronic component is 4 mm. There is 3 mm of midline shift, and significant mass effect on the right, sulci and gyri and there is an old basal ganglia infarct present. ASSESSMENT AND PLAN: Patient is a 59-year-old white male with acute on chronic right subdural hematoma and coagulopathy. Plan is to admit to the ICU for close neuro monitoring. Patient will be reexamined. Patient's coagulopathy will be reversed. HOSPITAL COURSE: Patient will be transfused 2 units of FFP and 1 unit of single donor platelets. Anesthesia and Critical Care will be consulted. Patient will undergo burr hole evacuation. Patient was discussed with Dr. Summers _____ and Dr. AElbannabaa. HOSPITAL COURSE: Patient presented on 12/18/2011, underwent operation for a right-sided burr holes for evacuation of the subdural hematoma. For full details of this operation, please see dictated operative note on 12/18/2011. Patient tolerated the procedure well, would returned to the unit, intubated. , Postoperative check showed the patient to open eyes spontaneously, eyes bilaterally were 2 mm and reactive, following commands in all 4 extremities., Patient with was moving his right greater than the left upper extremity. Postoperative labs showed INR corrected to 1.3 from a previous level of 2.8. and the Patient was otherwise with normal labs. Patient's previous cardiologist until were contacted, namely previous cardiologist, is Dr. Aparna Cherla Carp upon sure Lila, phone number 417-875-25-2500. Patient remained in the ICU overnight. The following day, a repeat CT showed a decreasing subdural hematoma. Postoperative drains were still in place, midline shift had reduced. and Ppatient is stable eand on ncephalomalacia. cephalomedullary Shah. On physical exam, patient was moving all 4 extremities with good strength; however, there were still some left-sided trace weakness. Patient was successfully extubated on this day. Head of bed was kept above 45 degrees and subdural drains were clamped. Post-extubation, patient had an episode of respiratory distress where were or patient complained of dyspnea, was transiently hypoxic with symptoms improved with breathing treatment and Lasix. There were no other events. O on 12/20/2011., Patient's physical exam improved. Patient was A&O x2, opening eyes spontaneously, moving all extremities, still trace left-sided weakness. Repeat CT showed resolving subdural hemorrhage and mal Malibu _____ a splint of placement of the the subdural drain for which the drain was pulled. On 12/21/2011, patient's diet was advanced to mechanical soft with thickened fluids. Patient was made out of bed to chair. Physical exam was unchanged. Patient remained afebrile, vital signs stable. Patient was then transferred to the floor on 12/22/2011., Patient had a repeat CT, which showed no increase in the subdural hemorrhage with stability of the head of the intracranial bleeding over 36 hours after the removal of the last drain. It was felt safe to begin anticoagulation for the patient's cardiac history. A, a heparin drip was started. PT/OT evaluated the patient and and recommended for rehab. On 12/23/2011, patient was accepted to rehab facility; however, it was required that . The Ppatient undergo a lower extremity duplex scans prior to being being accepted. the Patient underwent bilateral duplex, which was negative and was then accepted and discharged

out of the hospital on 12/25/2011, two to his rehab History facility. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: 1. Acute on chronic subdural hemorrhage, symptomatic with seizure, status post evacuation with right-sided burr hole drains stable. DISCHARGE INSTRUCTIONS: Patient is to follow up with Dr. Bucholz ____ Vu holes in 4 weeks in clinic. Patient is to obtain a noncontrast head CT prior to that appointment. Patient is to continue convalescence at rehab facility. Patient is to continue Keppra postoperatively until his followup appointment. cc: Samer Elbabaa cc: ______