CHIEF COMPLAINT: ICH

PRESENT ILLNESS: The patient is a 87 yo R-handed man, on Coumadin for his heart
but not sure exactly why, no priro cardiac surgeries, who at 6
pm suddenly felt like his R leg was "asleep"/heavy such that he
couldn't walk. He denies headache, neck pain, paresthesias,
bowel/bladder dysfunction, change in mentation or speech, no
visual changes. He was brought to [**Hospital 27217**] Hospital. He said on
his way there he had some mild chest pain and SOB, which he
attributed to being anxious about coming to the hospital.
Remainder of ROS negative including fever, hearing changes,
nausea, vomiting, abdominal pain.

MEDICAL HISTORY: -HTN
-prosthetic R eye
-CAD
-[**2182-9-6**]  Multiple bilateral PE
-95% stenosis of the right carotid artery
-Prostate cancer
  Most recent PSA 19
  Patient has not had chemotherapy, radiation
  or surgery (per Dr. [**Last Name (STitle) 30106**]
-Chronic renal insufficiency
  Cr 1.8 in [**2185-7-6**]
  Cr 1.7 in [**2180-1-7**]
-[**2181**] Cardiac catheterization
  Diffuse CAD

MEDICATION ON ADMISSION: -Coumadin
-Lisinopril
-Isosorbide
-Ranexa
-ASA
-Ferrous sulfate
-?Zetia
-NTG PRN
-Atenolol

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 97.7 po HR 73 BP 192/78 (117) RR 21 sO2 98% 2L
GEN:
HEENT: mmm
NECK: no LAD; no carotid bruits; full range neck movements
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema
SKULL AND SPINE: no bruits.

FAMILY HISTORY: NA

SOCIAL HISTORY: lives with his wife, no tobacco/EtOH/recreational drugs
Subendocardial infarction, initial episode of care,Intracerebral hemorrhage,Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction,Malignant neoplasm of prostate,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Pure hypercholesterolemia,Esophageal reflux,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Acquired absence of organ, eye,Anticoagulants causing adverse effects in therapeutic use
Subendo infarct, initial,Intracerebral hemorrhage,Ocl mlt bi art w infrct,Malign neopl prostate,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,Crnry athrscl natve vssl,Pure hypercholesterolem,Esophageal reflux,Long-term use anticoagul,Hx-ven thrombosis/embols,Acquired absence of eye,Adv eff anticoagulants
Admission Date:  [**2185-12-31**]              Discharge Date:   [**2186-1-5**]


Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
ICH

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is a 87 yo R-handed man, on Coumadin for his heart
but not sure exactly why, no priro cardiac surgeries, who at 6
pm suddenly felt like his R leg was "asleep"/heavy such that he
couldn't walk. He denies headache, neck pain, paresthesias,
bowel/bladder dysfunction, change in mentation or speech, no
visual changes. He was brought to [**Hospital 27217**] Hospital. He said on
his way there he had some mild chest pain and SOB, which he
attributed to being anxious about coming to the hospital.
Remainder of ROS negative including fever, hearing changes,
nausea, vomiting, abdominal pain.


Past Medical History:
-HTN
-prosthetic R eye
-CAD
-[**2182-9-6**]  Multiple bilateral PE
-95% stenosis of the right carotid artery
-Prostate cancer
  Most recent PSA 19
  Patient has not had chemotherapy, radiation
  or surgery (per Dr. [**Last Name (STitle) 30106**]
-Chronic renal insufficiency
  Cr 1.8 in [**2185-7-6**]
  Cr 1.7 in [**2180-1-7**]
-[**2181**] Cardiac catheterization
  Diffuse CAD


Social History:
lives with his wife, no tobacco/EtOH/recreational drugs


Family History:
NA

Physical Exam:
T 97.7 po HR 73 BP 192/78 (117) RR 21 sO2 98% 2L
GEN:
HEENT: mmm
NECK: no LAD; no carotid bruits; full range neck movements
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema
SKULL AND SPINE: no bruits.

MENTAL STATUS:
Awake and alert, cooperative with exam, normal affect.
Oriented to place, month, but said [**2184**].
Attention: DOWbw.
Language: fluent; Naming intact to high and low-frequency
objects; Comprehension intact; no dysarthria, no paraphasic
errors. Prosody: normal. No Neglect.

CRANIAL NERVES:
II: pupils equally round and reactive to light both directly and
consensually, 3-->2 mm bilaterally.
III, IV, VI: Extraocular movements intact without nystagmus. No
ptosis.
V: Facial sensation intact to light touch and pinprick.
VII: Facial movement symmetrical; no facial droop.
VIII: Hearing intact to finger rub bilaterally.
IX: Palate elevates in midline.
XII: Tongue protrudes in midline, no fasciculations.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.

MOTOR SYSTEM: Normal bulk and tone bilaterally. No adventitious
movements, no tremor, no asterixis.
      D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 5 5 5 5  5   5   5   5-  5- 5- 5 5 5 5 5  5
Left  5 5 5 5  5   5   5   5  5 5 5 5 5 5 5  5
No pronator drift. No rebound.

REFLEXES: 2+ and symmetric, R plantar upgoing, L downgoing
SENSORY SYSTEM: Sensation intact to light touch
COORDINATION: Normal FNF
GAIT: not tested




Pertinent Results:
[**2185-12-31**] 12:50AM BLOOD WBC-6.0 RBC-3.46* Hgb-10.9* Hct-31.5*
MCV-91 MCH-31.5 MCHC-34.7 RDW-15.0 Plt Ct-170
[**2186-1-2**] 04:37AM BLOOD WBC-6.3 RBC-3.46* Hgb-11.1* Hct-31.7*
MCV-92 MCH-32.1* MCHC-35.0 RDW-15.5 Plt Ct-136*
[**2185-12-31**] 12:50AM BLOOD PT-33.2* PTT-31.2 INR(PT)-3.5*
[**2186-1-2**] 04:37AM BLOOD PT-14.6* PTT-24.1 INR(PT)-1.3*
[**2185-12-31**] 12:50AM BLOOD CK-MB-10 MB Indx-5.2 cTropnT-0.05*
[**2185-12-31**] 06:10AM BLOOD cTropnT-0.27*
[**2185-12-31**] 01:30PM BLOOD CK-MB-15* MB Indx-5.7 cTropnT-0.26*
[**2185-12-31**] 08:58PM BLOOD CK-MB-12* MB Indx-4.7 cTropnT-0.27*
[**2186-1-1**] 03:30AM BLOOD CK-MB-10 MB Indx-4.0 cTropnT-0.31*
[**2186-1-1**] 04:19PM BLOOD CK-MB-10 MB Indx-3.4 cTropnT-0.25*

MRI/MRA:
Demonstration of known left posterior frontal hemorrhage, and
possible second small hemorrhagic residuum adjacent to it. Given
the patient's advanced age and peripheral location of the
hemorrhages, amyloid angiopathy would be the most reasonable
diagnostic consideration. The location is most unlikely to be
associated with an aneurysmal hemorrhage. Please note that the
MR angiogram did not encompass the entire area of the
hemorrhage, nor was gadolinium enhancement employed at this
time. Perhaps when the hemorrhage regresses, the gadolinium
study would be of greater benefit in excluding an underlying
mass lesion.


Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the ICU for closer monitoring. His
hospital course by problem is as follows:

1) Left parietal hemorrhage-
This was likely in the setting of supratherapeutic coumadin
level. There was some concern for possible underlying amyloid
angiopathy, but MRI evaluation was not strongly supportive of
this diagnosis. There was no AVM visualized by MRA. An MRI with
contrast was deffered given his renal insufficiency.

He was admitted to the neuro ICU for close neurologic and
hemodynamic monitoring. He was given proplex to reverse his
anticoagulation, followed by 2 units of FFP. His INR normalized
to 1.4. His neurologic exam remained stable with slight right
pronator drift. Right facial droop. He was transferred to the
neurology floor for further care. He developed an acute episode
of chest pain treated with nitrates, morphine and beta blocked.
Cardiac troponins peaked at 0.85. (further description of NSTEMI
below). His neurologic exam was stable. Serial CT scans revealed
stable size of hemorrhage. He was restarted on full dose aspirin
therapy for coronary and stroke prevention. There is a risk of
recurrent hemorrhage with the use of anticoagulation in the
future especially if this is amyloid, but this needs to be
weighted against his risk of thrombotic complication. He should
not be anticoagulated for now but there will need to be a
discussion regarding the risks and benefits in the future.

2) NSTEMI:
In the ICU, After receiving the proplex, he developed a bump in
his troponins which peaked at .31. He was started on metoprolol
but aspirin was not given as he had a large ICH. He was started
on a statin and his FLP was checked. His BP was maintained
between 120 and 140 with a MAP of less than 130. Second episode
of chest pain on the floors managed medically with full dose
atorvastatin, metoprolol, nitrates, and aspirin. Cardiology was
consulted on admission and followed the patient during his
hospital stay. He likely has unstable coronary plaque with need
for PCI, but cannot undergo intervention given his cerebral
hemorrhage. Maximum medical management, with narrow BP goals SBP
110-120 should be achieved. The patient should follow up with
either his primary cardiologist while at rehab or return for a
follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] and Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**]
at [**Hospital1 18**] for further evaluation in four weeks.

3) HEME:
Given his recent history if PE's, he was slowly restared on SQ
heparin. He should not re-start anticoagulation at this time.

4) Bilateral Carotid Artery Stnnosis-
Carotid US revealed 70-70% stenosis bilaterally. This was not
thought to be related to his presenting condition. He should
remain on aspirin therapy. He was not symptomatic from this but
should be followed for any symptoms and with carotid U/S
q6months-1 year.


Medications on Admission:
-Coumadin
-Lisinopril
-Isosorbide
-Ranexa
-ASA
-Ferrous sulfate
-?Zetia
-NTG PRN
-Atenolol

Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale  Injection every six (6) hours.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.

6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection three times a day.
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Isosorbide Mononitrate 10 mg Tablet Sig: 1.5 Tablets PO BID
(2 times a day).
12. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
Fifteen (15) ML PO QID (4 times a day) as needed for
indigestion.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
Left parietal intracranial hemorrhage
Non ST elevation myocardial infarction
Hypertension
Hypercholesterolemia
Systolic heart dysfunction


Discharge Condition:
Slight right facial droop. Right eye prosthesis. Slight right
arm pronator drift.


Discharge Instructions:
You were admitted for hemorrage around your brain that was
likely related to a high coumadin level. You also had a heart
attack while in the hospital.

You should avoid further coumadin use and take all medications
only as prescribed.

Please call your doctor or 911 if you experience any new onset
of chest pain, shortness of breath, new headache, tingling,
numbness, weakness, difficulty speaking or any other concerning
symptoms.

Followup Instructions:
Close monitoring of your blood pressure and heart rate at rehab
will be essential to prevent another heart attack.

Please see Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] for follow up in the Stroke
[**Hospital 878**] Clinic in [**3-12**] weeks. Call [**Telephone/Fax (1) 2574**] to make an
appointment.

Please see your cardiologist Dr. [**Last Name (STitle) 31101**] or Call ([**Telephone/Fax (1) 2037**]
to make an appointment at the [**Hospital1 18**] department of cardiology
with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] and Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] (they saw you here in
the hospital and can consider performing a heart catheterization
once they see you in clinic). The appointment should be made
within the next 4 weeks if possible.

Follow up with your primary care doctor within 1 week of
discharge from rehab.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
{'Subendocardial infarction, initial episode of care,Intracerebral hemorrhage,Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction,Malignant neoplasm of prostate,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Pure hypercholesterolemia,Esophageal reflux,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Acquired absence of organ, eye,Anticoagulants causing adverse effects in therapeutic use'}


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: ICH

PRESENT ILLNESS: The patient is a 87 yo R-handed man, on Coumadin for his heart
but not sure exactly why, no priro cardiac surgeries, who at 6
pm suddenly felt like his R leg was "asleep"/heavy such that he
couldn't walk. He denies headache, neck pain, paresthesias,
bowel/bladder dysfunction, change in mentation or speech, no
visual changes. He was brought to [**Hospital 27217**] Hospital. He said on
his way there he had some mild chest pain and SOB, which he
attributed to being anxious about coming to the hospital.
Remainder of ROS negative including fever, hearing changes,
nausea, vomiting, abdominal pain.

MEDICAL HISTORY: -HTN
-prosthetic R eye
-CAD
-[**2182-9-6**]  Multiple bilateral PE
-95% stenosis of the right carotid artery
-Prostate cancer
  Most recent PSA 19
  Patient has not had chemotherapy, radiation
  or surgery (per Dr. [**Last Name (STitle) 30106**]
-Chronic renal insufficiency
  Cr 1.8 in [**2185-7-6**]
  Cr 1.7 in [**2180-1-7**]
-[**2181**] Cardiac catheterization
  Diffuse CAD

MEDICATION ON ADMISSION: -Coumadin
-Lisinopril
-Isosorbide
-Ranexa
-ASA
-Ferrous sulfate
-?Zetia
-NTG PRN
-Atenolol

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 97.7 po HR 73 BP 192/78 (117) RR 21 sO2 98% 2L
GEN:
HEENT: mmm
NECK: no LAD; no carotid bruits; full range neck movements
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema
SKULL AND SPINE: no bruits.

FAMILY HISTORY: NA

SOCIAL HISTORY: lives with his wife, no tobacco/EtOH/recreational drugs 

### Response:
{'Subendocardial infarction, initial episode of care,Intracerebral hemorrhage,Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction,Malignant neoplasm of prostate,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Pure hypercholesterolemia,Esophageal reflux,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Acquired absence of organ, eye,Anticoagulants causing adverse effects in therapeutic use'}
