CHIEF COMPLAINT: found down/unresponsive on the floor

PRESENT ILLNESS: Mrs. [**Known lastname **] is a 75 yo W with h/o HTN, HL, CAD who presents
with IVH.
The patient vomited once the night before admission, but was
otherwise normal. She
was last seen well at 8am before her husband left for work. He
came home at 6pm to find her slumped behind the bedroom door.
She
opened her eyes and knew who he was. EMS arrived. She was
reported to have agonal breathing. She was taken to [**Hospital **]
Hospital where NCHCT showed isolated IVH.
Initial GCS 8. BPs 150/80, 188/98, 184/86. Initial exam revealed
patient unresponsive, pupils pinpoint and nonreactive, withdraws
from pain on L side only. Toes upgoing bilaterally. She was
given
ceftriaxone and azithromycin for possible aspiration.
The family was given a poor prognosis so decided to make her
CMO.
She was admitted to the floor, but she soon began to open her
eyes and speak, she was AOx3, moving all extremities, with a
mild
R hemiparesis.
Because of this improvement, the family wanted to pursue more
aggressive treatment, and patient was transferred to [**Hospital1 18**].

MEDICAL HISTORY: [] Cardiovascular - HTN, HL, mild CAD
[] Hematologic - essential thrombocythemia (on ASA) by history,
however, this might have progressed over the last years and she
might have developed into a Polycythemia [**Doctor First Name **] (JAK 2 mutation
positive). Her Hematologist is [**First Name8 (NamePattern2) **] [**State 108**] and she has not
established any contact with an hematologist up here.
[] MSK - bilateral total hip replacements, s/p thigh/hip
abscess/infx requiring IV abx ~ 18 months ago

MEDICATION ON ADMISSION: Metoprolol succinate 25 daily
Omega 3 fatty acids (1 tablet daily)
Aspirin 81 daily (Ecotrin)

ALLERGIES: Zosyn

PHYSICAL EXAM: At admission:
GEN: NAD
HEENT: sclera anicteric, mmm
CV: RRR no m/r/g
PULM: CTAB
AB: ND/NT
EXT: no edema

FAMILY HISTORY: negative for stroke, ICH, aneurysm

SOCIAL HISTORY: lives with husband. Smokes 1 pack/day, no EtOH in several
years.
Subarachnoid hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Cerebral edema,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Other and unspecified coagulation defects,Obstructive hydrocephalus,Atrial fibrillation,Polycythemia vera,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Fever, unspecified,Long-term (current) use of aspirin
Subarachnoid hemorrhage,Crbl art ocl NOS w infrc,Cerebral edema,Acute respiratry failure,Hyperosmolality,Coagulat defect NEC/NOS,Obstructiv hydrocephalus,Atrial fibrillation,Polycythemia vera,Crnry athrscl natve vssl,Hypertension NOS,Fever NOS,Long-term use of aspirin
Admission Date:  [**2177-8-28**]              Discharge Date:   [**2177-9-5**]

Date of Birth:  [**2101-10-22**]             Sex:   F

Service: NEUROLOGY

Allergies:
Zosyn

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
found down/unresponsive on the floor

Major Surgical or Invasive Procedure:
Ventriculostomy placement

History of Present Illness:
Mrs. [**Known lastname **] is a 75 yo W with h/o HTN, HL, CAD who presents
with IVH.
The patient vomited once the night before admission, but was
otherwise normal. She
was last seen well at 8am before her husband left for work. He
came home at 6pm to find her slumped behind the bedroom door.
She
opened her eyes and knew who he was. EMS arrived. She was
reported to have agonal breathing. She was taken to [**Hospital **]
Hospital where NCHCT showed isolated IVH.
Initial GCS 8. BPs 150/80, 188/98, 184/86. Initial exam revealed
patient unresponsive, pupils pinpoint and nonreactive, withdraws
from pain on L side only. Toes upgoing bilaterally. She was
given
ceftriaxone and azithromycin for possible aspiration.
The family was given a poor prognosis so decided to make her
CMO.
She was admitted to the floor, but she soon began to open her
eyes and speak, she was AOx3, moving all extremities, with a
mild
R hemiparesis.
Because of this improvement, the family wanted to pursue more
aggressive treatment, and patient was transferred to [**Hospital1 18**].

ROS per patient's husband is negative for headaches, fevers,
weakness, speech difficulties, gait difficulties.

Past Medical History:
[] Cardiovascular - HTN, HL, mild CAD
[] Hematologic - essential thrombocythemia (on ASA) by history,
however, this might have progressed over the last years and she
might have developed into a Polycythemia [**Doctor First Name **] (JAK 2 mutation
positive). Her Hematologist is [**First Name8 (NamePattern2) **] [**State 108**] and she has not
established any contact with an hematologist up here.
[] MSK - bilateral total hip replacements, s/p thigh/hip
abscess/infx requiring IV abx ~ 18 months ago

Social History:
lives with husband. Smokes 1 pack/day, no EtOH in several
years.


Family History:
negative for stroke, ICH, aneurysm


Physical Exam:
At admission:
GEN: NAD
HEENT: sclera anicteric, mmm
CV: RRR no m/r/g
PULM: CTAB
AB: ND/NT
EXT: no edema

NEURO:
MSE: Eyes open to voice. Oriented to self, states she is in
rehabilitation hospital (had been told by nurse where she was 2
minutes earlier), doesnt know month or year. Cannot name pen or
glasses. Repetition intact. Comprehension intact. Follows
midline
and appendicular commands (shows 2 fingers on each hand). No
obvious neglect.

CN: PERRL 3 to 2mm and brisk. EOMI intact except for limited
upgaze (poorly following directions). No nystagmus. Face
symmetric. Tongue midline.

MOTOR: normal bulk and tone.
Limited cooperation with testing.
Bilateral delts at least 4.
R tricep 4, finger ext 5-, finger flex 5
L tri, finger ext/flex 5

Bilateral IPs, ham, TA, [**Last Name (un) 938**], gastroc at least 3. There is
asymmetry in withdrawal of RLE to noxious suggestive of
weakness.

DTR: brisk and 2+ in bilateral [**Hospital1 **], tri, brachiorad, patellar,
achilles. Toes upgoing.
___________________________________________________________
At Discharge:


Pertinent Results:
[**2177-8-27**] CT/CTA Head - CT Head: Little change in bihemispheric
subarachonoid hemorrhage and large amount of intraventricular
hemorrhage compared to 9 hours prior. CTA: No large aneurysm,
flow limiting stenosis or other major vasc abnl. Carotid artery
calcification b/l. Final read pending recons.

[**2177-8-28**] CT/CTA Head - IMPRESSION:
1. Unchanged intraventricular hemorrhage in all the ventricles,
predominantly in the frontal [**Doctor Last Name 534**] of left lateral ventricle.
There is associated dilatation of the lateral and third
ventricles. Subarachnoid hemorrhage is noted along cortical
sulci predominantly along the sylvian fissures. The subarachnoid
hemorrhage appears more prominent as compared to the prior CT.
2. No significant abnormality is noted on CTA head. No evidence
of aneurysm.

[**2177-8-28**] CXR - IMPRESSION: Emphysema with concomitant pulmonary
edema and two discrete basal opacities which are suspicious for
aspiration.

[**2177-8-29**] TTE - The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is severe
thickening of the mitral valve chordae. Mild (1+) 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: Mild symmetric left ventricular hypertrophy with
vigorous biventricular systolic function. Aortic valve sclerosis
without stenosis. Mild mitral regurgitation. Moderate pulmonary
hypertension.

[**2177-8-29**] NCHCT - 1. Expected short interval evolution in
intraventricular hemorrhage with persistent dilatation of the
lateral and third ventricles.
2. Slight expected interval evolution of bihemispheric
subarachnoid
hemorrhage.

[**2177-8-30**] NCHCT - IMPRESSION: Status post placement of right
frontal ventricular drain with the tip in the region of foramen
of [**Last Name (un) 2044**]. There remains ventriculomegaly with prominence of
temporal horns, not significantly changed from the prior CT.
Previously noted intraventricular and subarachnoid hemorrhage
again noted.

[**2177-8-31**] CTPA - IMPRESSION:
1. No evidence of pulmonary embolus.
2. Generalized volume overload with bilateral effusions and
pulmonary edema.  Areas of air space opacity may reflect
superimposed infection.

[**2177-9-3**] MRI/MRA Brain - IMPRESSION:
1. Multiple small acute infarcts as described above. There is no
associated
hemorrhage or mass effect.
2. No interval change regarding the subarachnoid and
intraventricular
hemorrhage.
3. Unchanged diameter of the intraventricular system with
unchanged position
of the right frontal ventriculostomy catheter.
4. No evidence of vessel occlusion or vasospasm.

[**2177-9-4**] EEG - (preliminary) no epileptiform activity, diffuse
theta-delta slowing, severe diffuse encephalopathic pattern


Brief Hospital Course:
75 yo W h/o CAD, HTN, HL, history of essential thrombocythemia
which may have evolved into a Polycythemia [**Doctor First Name **] (JAK2+), tobacco
use p/w up to 10 hours of depressed level of awareness and R
hemiparesis with spontaneous improvement and found to have IVH
and very mild SAH due to hemorrhage leaking out from the foramen
Lushkae into the [**Female First Name (un) **].

[] Intraventricular Hemorrhage - She was found on the ground on
the evening of [**8-27**] by her husband. When she arrived at an
outside hospital, her exam was very poor: she was nonresponsive,
her pupils were described as pinpoint, and she was only
minimally withdrawing on the left side. Based on her poor exam
and large amount of IVH on CT, the OSH physicians predicted a
poor prognosis and the husband decided to change her code status
from DNR to CMO, but her mental status spontaneously improved
without major intervention to the point of her arousing, being
partly oriented, and following commands. Her husband requested
that she be transferred to [**Hospital1 18**] for more aggressive care (if
needed). Her exam since arrival has fluctuated significantly: at
times she was minimally arousable and at other times she
remained awake and followed simple commands with only mild
right-sided upper extremity-predominant weakness, inattention,
and some memory deficits. Neurosurgery was consulted but decided
to hold off on placing a ventriculostomy while her mental status
remained relatively functional. Her exam worsened on [**2177-8-30**]
mainly due to respiratory problems and she was intubated. At
this time, Neurosurgery decided to place a ventriculostomy; the
EVD was placed without complication and with maintenance of
appropriate ICPs with minimal change in neurologic exam. During
her complicated medical course, her neurologic exam has
gradually deteriorated with worsening of her right sided arm and
leg weakness and decreased level of awareness (unable to obtain
attention, no longer following commands reliably). After several
days of delay due to multiple medical complications, she was
stable enough to receive an MRI of the Brain on [**2177-9-3**] which
shows multiple small right-sided ischemic infarcts (DWI bright,
ADC dark), extensive subcortical and periventricular white
matter disease, and persistence (but improvement) in the degree
of intraventricular hemorrhage. The strokes by themselves would
not explain her depressed level of consciousness, and thus an
EEG was performed due to concerns for potential status
epilepticus as she was having rhythmic eyelid contractions and
sporadic eye movements. The EEG was negative for seizure
activity. Given the patient's lack of neurologic improvement and
poor prognosis, the patient's husband opted for comfort care.
She was made CMO overnight on [**7-27**], placed on a morphine
infusion, and she passed away at 0745 on [**2177-9-5**].

[] Thrombocythemia, likely Polycythemia [**Doctor First Name **] - She is noted to
have a history of thrombocythemia per report, and per prior
records from her previous Hematologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 90792**] in
[**State 108**], she has the JAK2 mutation that is strongly suggestive
of Polycythemia [**Doctor First Name **]. We consulted Hematology-Oncology regarding
bleeding risk assessment in case the patient requires further
invasive procedures, for which it appears that her
thrombocytosis would place her at risk for both thrombosis and
hemorrhage (via acquired [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease). Heme-Onc
recommended starting Hydroxyurea to which the patient's cell
counts responded with decreases in all cell lines.

[] Pulmonary Edema, Hemodynamic Instability - On [**2177-8-28**], the
patient became progressively tachycardic, tachypneic, and
hypertensive and required more supplemental O2 to maintain her
SaO2 in the 90s in the setting of a 500cc fluid bolus given for
suspected hypovolemia in the setting of progressive tachycardia.
Her hemodynamic status normalized with metoprolol,
albuterol/ipratropium, oxygen and mild diuresis with furosemide
10 IV. This may have been related to mild volume overload in the
setting of likely COPD or beta blocker withdrawal from having
been off medications during the prehospital obtunded period.
However, her respiratory status continued to be tenuous and she
was intubated for persistent respiratory distress. She
intermittently had episodes of tachynea/tachycardia/hypoxia
without any evident cause (clear lungs to auscultation besides
upper airway sounds and secretions, no infiltrates on CXR, no
cardiac or metabolic causes) which resolved to some degree with
sedation with Propofol.

[] Fever of Unknown Origin - On [**2177-8-30**], the patient became
febrile and had blood, urine, and sputum cultures drawn, all of
which have had no growth to date. On [**9-1**], she had a CSF culture
drawn. She was started on empiric broad-spectrum antibiotics
with Cefepime and Vancomycin; these were stopped when all of her
cultures remained negative. It is possible that her fever was
central in origin and was the result of temperature regulation
dysfunction from the intraventricular hemorrhage.

[] Hypernatremia - The patient was mildly hypernatremic at
admission to the high 140s, thought to be secondary to
hypovolemic hypernatremia. In the setting of large amounts of
IVH and no ventriculostomy for decompression, she was permitted
to have mild hypernatremia to minimize cerebral edema. However,
this progressed during [**Date range (1) 10659**], and the patient was started on
NS, then 1/2NS and Furosemide to address her hypernatremia which
resolved with this treatment. She was kept normovolemic with
tube feeds at goal 100 cc/hr.

Medications on Admission:
Metoprolol succinate 25 daily
Omega 3 fatty acids (1 tablet daily)
Aspirin 81 daily (Ecotrin)

Discharge Medications:
N/A

Discharge Disposition:
Expired

Discharge Diagnosis:
Intraventricular hemorrhage, Subarachnoid hemorrhage, Acute
Ischemic Stroke, Polycythemia [**Doctor First Name **], Hypoxic Respiratory Failure

Discharge Condition:
Deceased

Discharge Instructions:
N/A

Followup Instructions:
N/A

                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
{'Subarachnoid hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Cerebral edema,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Other and unspecified coagulation defects,Obstructive hydrocephalus,Atrial fibrillation,Polycythemia vera,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Fever, unspecified,Long-term (current) use of aspirin'}


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: found down/unresponsive on the floor

PRESENT ILLNESS: Mrs. [**Known lastname **] is a 75 yo W with h/o HTN, HL, CAD who presents
with IVH.
The patient vomited once the night before admission, but was
otherwise normal. She
was last seen well at 8am before her husband left for work. He
came home at 6pm to find her slumped behind the bedroom door.
She
opened her eyes and knew who he was. EMS arrived. She was
reported to have agonal breathing. She was taken to [**Hospital **]
Hospital where NCHCT showed isolated IVH.
Initial GCS 8. BPs 150/80, 188/98, 184/86. Initial exam revealed
patient unresponsive, pupils pinpoint and nonreactive, withdraws
from pain on L side only. Toes upgoing bilaterally. She was
given
ceftriaxone and azithromycin for possible aspiration.
The family was given a poor prognosis so decided to make her
CMO.
She was admitted to the floor, but she soon began to open her
eyes and speak, she was AOx3, moving all extremities, with a
mild
R hemiparesis.
Because of this improvement, the family wanted to pursue more
aggressive treatment, and patient was transferred to [**Hospital1 18**].

MEDICAL HISTORY: [] Cardiovascular - HTN, HL, mild CAD
[] Hematologic - essential thrombocythemia (on ASA) by history,
however, this might have progressed over the last years and she
might have developed into a Polycythemia [**Doctor First Name **] (JAK 2 mutation
positive). Her Hematologist is [**First Name8 (NamePattern2) **] [**State 108**] and she has not
established any contact with an hematologist up here.
[] MSK - bilateral total hip replacements, s/p thigh/hip
abscess/infx requiring IV abx ~ 18 months ago

MEDICATION ON ADMISSION: Metoprolol succinate 25 daily
Omega 3 fatty acids (1 tablet daily)
Aspirin 81 daily (Ecotrin)

ALLERGIES: Zosyn

PHYSICAL EXAM: At admission:
GEN: NAD
HEENT: sclera anicteric, mmm
CV: RRR no m/r/g
PULM: CTAB
AB: ND/NT
EXT: no edema

FAMILY HISTORY: negative for stroke, ICH, aneurysm

SOCIAL HISTORY: lives with husband. Smokes 1 pack/day, no EtOH in several
years. 

### Response:
{'Subarachnoid hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Cerebral edema,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Other and unspecified coagulation defects,Obstructive hydrocephalus,Atrial fibrillation,Polycythemia vera,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Fever, unspecified,Long-term (current) use of aspirin'}
