CHIEF COMPLAINT: Fall

PRESENT ILLNESS: HPI:  63 yo man who denies PMHx (also says he does not see PMD
regularly) who presents after being found down this am (~3am).
He reports getting up to go to BR when his "R knee give
way."  He fell and was unable to get up because "my knees kept
sliding out from under me" (both knees per patient).  He stayed
down and was unable to get up to a sitting position or to stand.

MEDICAL HISTORY: Social History:
no tob.  7 beers in one sitting Qweek. no illicits.

MEDICATION ON ADMISSION: asa 325 Qday x 1 week
nyquil

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS:  T 99.4  HR 99   BP 170/114 -> 136/94  RR 41   Sat93->96% on
RA
PE:  General 	NAD
HEENT 	AT/NC, MMM no lesions
Neck 	Supple, no bruits
Chest 	CTA B
CVS 	RRR, no m/r/g
ABD 	soft, NTND, + BS
EXT 	no C/C/E, multiple abrasions over L side.

FAMILY HISTORY: father with CAD - passed away from heart disease in late 40s.
GF
with CA, DM

SOCIAL HISTORY: no tob.  7 beers in one sitting Qweek. no illicits.
Intracerebral hemorrhage,Unspecified essential hypertension,Alcohol abuse, continuous,Conductive hearing loss, middle ear
Intracerebral hemorrhage,Hypertension NOS,Alcohol abuse-continuous,Conduc hear loss mid ear
Admission Date:  [**2112-3-8**]              Discharge Date:   [**2112-3-11**]

Date of Birth:  [**2048-10-3**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Fall

Major Surgical or Invasive Procedure:
CT/CTA
ECHO


History of Present Illness:
HPI:  63 yo man who denies PMHx (also says he does not see PMD
regularly) who presents after being found down this am (~3am).
He reports getting up to go to BR when his "R knee give
way."  He fell and was unable to get up because "my knees kept
sliding out from under me" (both knees per patient).  He stayed
down and was unable to get up to a sitting position or to stand.

His neighbor found him on the floor and contact[**Name (NI) **] paramedics.

He denies LOC, substance use.  Presently, he feels he is just as
strong as ever, however.  Denies sensory or visual symptoms,
feeling weak.

He does report 1 week of URI sx and cough for which he has been
taking nyquil and ASA 325.

ROS:
Gen:  No fevers/chills/sweats, CP, SOB, palpitations, N/V, abd
pain, dysuria, melena, BRBPR, rash, travel

Neurological:  No deficits noted in:  memory, personality,
vision, hearing, language/speech, swallowing, coordination,
writing, walking, bowel/bladder function.
No history of stroke, HA, seizures.  No weakness, no sensory
loss, no neck pain.


Past Medical History:

Social History:
no tob.  7 beers in one sitting Qweek. no illicits.


Family History:
father with CAD - passed away from heart disease in late 40s.
GF
with CA, DM


Physical Exam:
VS:  T 99.4  HR 99   BP 170/114 -> 136/94  RR 41   Sat93->96% on
RA
PE:  General 	NAD
HEENT 	AT/NC, MMM no lesions
Neck 	Supple, no bruits
Chest 	CTA B
CVS 	RRR, no m/r/g
ABD 	soft, NTND, + BS
EXT 	no C/C/E, multiple abrasions over L side.

NEUROLOGICAL
MS: 	
General: 	alert, appropriately interactive, normal affect
Orientation: 	oriented to person, place, date, situation. able
to
related coherent hx
Attention:	full??????days if week backwards
Speech/[**Doctor Last Name **]: 	fluent w/o paraphasic errors; simple and complex
command-following w/o L/R confusion.  Repetition impaired for
abstraction, naming intact. + dysarthria
Memory:	[**3-22**] after 5 minutes
Praxis:	Able to mimic brushing teeth with either hand.
Calculations: 7 quarters = $1.75

CN:
II,III: 	VFFTC, pupils 2.5-1 mm bilaterally to light
III,IV,V:	EOMI, no ptosis. Normal saccades/pursuits. R gaze
preference
V: 	sensation intact to LT/temp
VII: 	decreased NLF on L
VIII: 	hears finger rub bilaterally
IX,X: 	voice normal, palate elevates symmetrically
[**Doctor First Name 81**]: 	SCM/trapezeii [**5-24**] bilaterally
XII: 	tongue protrudes midline without atrophy or fasciculation

Motor:	Normal bulk and tone; no tremor, rigidity, or
bradykinesia.  No pronator drift.

Delt	[**Hospital1 **]	Tri	WE     FE     Grip	
C5	C6	C7	C6     C7     C8/T1	
L 3	5	5-	4      4-      5
R 5	5	5	5      5       5

IP	Quad	Hamst	DF      [**Last Name (un) 938**]    PF
L2	L3	L4-S1	L4	L5     S1/S2
5-	5	4+	5-	5      5
5	5	5	5	5      5

Reflex:		
  	[**Hospital1 **]	Tri	Bra	Pat	An	Plantar
	C5	C7	C6	L4	S1	CST
L	3	2	3	1	0	Extensor
R	2	2	2	1	0	Flexor

Sensation:  	LT intact. no extintction to DSS.

Coordination:	FTN intact on R. unable on L.  HTS intact on R,
decreased on L but consistent with weakness. [**Doctor First Name **] decreased on L
consistent with weakness.


Pertinent Results:
[**2112-3-10**] 06:00AM BLOOD WBC-14.5* RBC-3.76* Hgb-13.2* Hct-38.4*
MCV-102* MCH-35.1* MCHC-34.3 RDW-14.2 Plt Ct-215
[**2112-3-9**] 04:01AM BLOOD WBC-10.2 RBC-3.87* Hgb-13.5* Hct-39.0*
MCV-101* MCH-35.0* MCHC-34.8 RDW-14.3 Plt Ct-218
[**2112-3-8**] 08:54AM BLOOD WBC-17.3* RBC-4.28* Hgb-15.2 Hct-42.3
MCV-99* MCH-35.5* MCHC-36.0* RDW-13.5 Plt Ct-253
[**2112-3-9**] 04:01AM BLOOD Neuts-76.3* Lymphs-15.4* Monos-6.1
Eos-1.7 Baso-0.5
[**2112-3-10**] 06:00AM BLOOD Plt Ct-215
[**2112-3-10**] 06:00AM BLOOD PT-12.1 PTT-26.5 INR(PT)-1.0
[**2112-3-10**] 06:00AM BLOOD Glucose-51* UreaN-18 Creat-0.8 Na-142
K-4.0 Cl-106 HCO3-18* AnGap-22*
[**2112-3-9**] 04:01AM BLOOD Glucose-82 UreaN-12 Creat-0.7 Na-139
K-3.5 Cl-107 HCO3-24 AnGap-12
[**2112-3-8**] 08:54AM BLOOD Glucose-142* UreaN-13 Creat-0.9 Na-143
K-3.7 Cl-108 HCO3-23 AnGap-16
[**2112-3-9**] 03:18PM BLOOD CK(CPK)-169
[**2112-3-9**] 10:21AM BLOOD CK(CPK)-308*
[**2112-3-8**] 08:54AM BLOOD ALT-24 AST-43* CK(CPK)-191* AlkPhos-64
TotBili-0.6
[**2112-3-9**] 10:21AM BLOOD CK-MB-5
[**2112-3-8**] 08:54AM BLOOD Lipase-22
[**2112-3-8**] 10:08PM BLOOD CK-MB-7 cTropnT-<0.01
[**2112-3-10**] 06:00AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.1
[**2112-3-9**] 04:01AM BLOOD Calcium-8.4 Phos-2.5* Mg-1.5* Cholest-147
[**2112-3-8**] 08:54AM BLOOD Albumin-4.1 Calcium-9.1 Phos-1.4* Mg-1.5*
[**2112-3-9**] 04:01AM BLOOD %HbA1c-5.2
[**2112-3-9**] 04:01AM BLOOD Triglyc-108 HDL-53 CHOL/HD-2.8 LDLcalc-72
[**2112-3-8**] 08:54AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2112-3-8**] 08:57AM BLOOD Glucose-125* Lactate-2.1* Na-144 K-3.7
Cl-105 calHCO3-23
[**2112-3-8**] 08:57AM BLOOD Hgb-16.2 calcHCT-49

CT 2.17: 4.3 cm right basal ganglia hemorrhage with
approximately 2 to 3 mm of right to left midline shift. Given
the location of the hemorrhage, these findings likely represent
a hypertensive hemorrhage.
CT C-Spine: 1. No evidence of acute fracture of the cervical
spine.
2. Minimal grade 1 retrolisthesis of C3 on C4 which is likely
degenerative in nature. 3. 4-mm right apical pulmonary nodule in
a region of apical scarring. If indicated, a chest CT is
recommended for further evaluation on a nonemergent basis.
CT Sinus: Probable inflammatory bilateral mastoid and middle ear
opacification. No evidence of fracture is seen.


Brief Hospital Course:
Pt was admitted to the neuro-ICU for further management and
work-up of his basal ganglia bleed.  He was monitored with
cardiac telemetry and frequent neuro-checks.  Risk factor
work-up was done and was unremarkable.  His BP was closely
monitored.  ENT was consulted for prior issue of recent hearing
difficulty.  He was noted to have bilateral middle ear
effusions.  CT sinus revealed no significant pathology.  An
audoigram was ordered but was unable to be done during this
hospitalization.  It will be scheduled as an outpt.  ENT feels
this is likely conductive loss from his effusions and will
resolve over time.  His discharge exam is significant for minor
left facial droop, weakness of the left hand distal>proximal.
He also has some slight dysmetria of that hand as well.  He is
able to ambulate with assistance. He will have a follow-up MRI
in 6 weeks and then follow-up in stroke clinic as arranged.  He
should have his BP regularly checked and likely will need to go
on an anti-hypertensive therapy.

Medications on Admission:
asa 325 Qday x 1 week
nyquil


Discharge Medications:
1. FoLIC Acid 1 mg IV Q24H
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Pepcid AC 20 mg Tablet Sig: One (1) Tablet PO twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Right basal ganglia bleed


Discharge Condition:
Improved


Discharge Instructions:
You were admitted because of a bleed in your brain.  It was
likely caused by high blood pressure. If you have any new
weakness, numbness or dizziness you should immediately return to
the ER.  You will return next week for your hearing test as an
outpt.  You are also scheduled to get an MRI of your [**Doctor Last Name **] in 6
weeks

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2112-5-11**] 4:30

Audiogram [**2112-3-17**] at 2:30PM with Dr. [**Last Name (STitle) **] [**Name (STitle) 6752**] 6
floorProvider: RADIOLOGY MRI Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2112-4-29**] 11:55


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
{'Intracerebral hemorrhage,Unspecified essential hypertension,Alcohol abuse, continuous,Conductive hearing loss, middle ear'}


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:  63 yo man who denies PMHx (also says he does not see PMD
regularly) who presents after being found down this am (~3am).
He reports getting up to go to BR when his "R knee give
way."  He fell and was unable to get up because "my knees kept
sliding out from under me" (both knees per patient).  He stayed
down and was unable to get up to a sitting position or to stand.

MEDICAL HISTORY: Social History:
no tob.  7 beers in one sitting Qweek. no illicits.

MEDICATION ON ADMISSION: asa 325 Qday x 1 week
nyquil

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS:  T 99.4  HR 99   BP 170/114 -> 136/94  RR 41   Sat93->96% on
RA
PE:  General 	NAD
HEENT 	AT/NC, MMM no lesions
Neck 	Supple, no bruits
Chest 	CTA B
CVS 	RRR, no m/r/g
ABD 	soft, NTND, + BS
EXT 	no C/C/E, multiple abrasions over L side.

FAMILY HISTORY: father with CAD - passed away from heart disease in late 40s.
GF
with CA, DM

SOCIAL HISTORY: no tob.  7 beers in one sitting Qweek. no illicits. 

### Response:
{'Intracerebral hemorrhage,Unspecified essential hypertension,Alcohol abuse, continuous,Conductive hearing loss, middle ear'}
