history of present illness: is a 78 year old woman who is status post a fall out of bed today presenting with complaint of headache, status post a fall. she has a significant past medical history including a stroke three years ago secondary to an embolic stenting procedure currently on coumadin, diabetes, glaucoma, malignant breast cancer, neck mass. the patient hit the back of her head on the fall. there was no loss of consciousness according to her daughter. after the fall she did have some dizziness. the patient also became more lethargic. her usual inr is approximately 3.5 and she does have this checked weekly. past medical history: as above. past surgical history: the stenting procedure. medications at the time of admission: metformin 500 mg once per day, lipitor 10 mg once per day and coumadin. physical examination: heart rate was 67, blood pressure was 251/80, respiratory rate was 21, o2 saturation was 100 percent. she was in no apparent distress. she was alert and oriented times three, conversant. head, eyes, ears, nose and throat showed pupils were be equal, round and reactive to light. extraocular movements were intact. she is normocephalic, atraumatic, no erythema or ecchymoses. heart showed regular rate and rhythm, no murmurs, rubs or gallops. respiratory was clear to auscultation bilaterally. abdomen was soft, nontender without masses. sensation was intact, no known deficits. motor examination showed good muscle tone, mild right pronatal drift. she had 5/5 strength bilaterally in the upper and lower extremities. deep tendon reflexes were 2 plus bilaterally - achilles, patellar, biceps, brachial radialis. finger to nose was performed well. cranial nerves 2 through 12 were grossly intact. laboratory data: at time of admission where white count of 10, hematocrit of 32.0, platelets of 286, pt 23.6, ptt 43.6, inr 3.5. sodium 139, potassium 4.90, chloride 103, bicarb 28, bun 21, creatinine .9, glucose of 194. she had a urinalysis that showed small blood, few bacteria. protein less than 30, glucose was trace and red cells were 6 to 10. she had a ct that did show a right subdural hematoma with early falxian herniation. hospital course: she was admitted and started on fresh frozen plasma and vitamin k to reverse her inr. her systolic blood pressure was to be maintained at less than 140. the did discuss with family the possibility of surgery for evacuation of subdural hematoma versus conservative management. he recommended surgery but the family preferred to wait and see how she did. she was admitted to the surgical intensive care unit for close monitoring. she had a repeat head ct and did receive some mannitol. her hematocrit did drop from 34 to 32 and she received two units of packed red blood cells. her stools were guaiaced and surgery consult was recommended and they recommended and abdominal and pelvic ct did not show any evidence of bleeding. her inr did reverse to 1.2. she did have a chest x-ray which did show some fluid overload. she was diuresed and intravenous was hep-locked. her hematocrit became stable. on she did complain of difficulty with her vision and was unable to read. she had left homonymous hemianopsia and a repeat ct scan was obtained that did show a hypodensity in the right pca distribution. she was seen in consultation by neurology that was consistent with acute infarct. they recommended blood pressures maintained in the 150 to 160s, keep head of bed flat and to hold off on anticoagulation for two to four weeks. she did continue to improve slowly by steadily neurologically. she was transferred to the neurology step-down unit. she was seen in consultation by both occupational therapy and physical therapy who felt that she would benefit from a rehabilitation stay. she did have swallowing evaluation which recommended pureed foods with no liquids, crushed medications and tongue exercises. she did continue to improve. will screen for rehabilitation. , md Procedure: Arterial catheterization Transfusion of packed cells Transfusion of other serum Transfusion of platelets Diagnoses: Acute posthemorrhagic anemia Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Personal history of malignant neoplasm of breast Constipation, unspecified Personal history of other diseases of circulatory system Long-term (current) use of anticoagulants Accidental fall from bed Other and unspecified coagulation defects Cerebral artery occlusion, unspecified with cerebral infarction Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Homonymous bilateral field defects