CHIEF COMPLAINT: Reason for consult: intracranial bleeding

PRESENT ILLNESS: [**Known firstname 5969**] is an 89 year-old right-handed woman with complex
past medical history which includes end stage renal disease
recently started on dialysis, HTN, AFib s/p pacemaker and in
coumadin, hyperlipidemia amoung other conditions who presented
with with left sided weakness secondary to right thalamic
hemorrhage. Patient had her dialysis session yesterday and she
was reportedly more tired than usual. This morning around 9am
her
daughter woke her up and was helping her to go to the bathroom,
when she noted that [**Known firstname 5969**] was leaning to the left side. Patient
was returning from the bathroom in her walker when she
continuing
to lean to the left and ended up falling. Her daughter picked
her
up and noticed a overall weakness described as "dead weight".
There was no LOC, and patient was speaking through the episode.
She continue at home waiting for the nurse home to evaluated
her.
After her evaluation around 11am, 911 was called and patient was
transferred to the [**Hospital 85279**] hospital. There she was evaluated and
underwent a CT which revealed right basal ganglia hemorrhage.
Patient had INR of 2.67 and she received FFP and vit K, doses
uncertain and transfer to [**Hospital1 18**] for further care. In the ED
[**Hospital1 18**]
patient has been stable, if anything she is slightly better
according to her daughter report.

MEDICAL HISTORY: PMH:
1. End stage renal disease as above
2. HTN
3. pacemaker for AFib, sick sinus syndrome, presyncope with
pauses in [**2108**]
4. History of palpitations
5. Hyperlipidemia
6. Hiatal hernia with GERD
7. Right knee total replacement in [**2096**]
8. Right carotid endarterectomy in [**2108-4-1**]
9. Appendicectomy
10. Uterine suspension
11. Hemorrhoidectomy
12. ex-smoker
13. Remote history of pancreatitis
14. Hearing impairment bilaterally

MEDICATION ON ADMISSION: Medications:
Amlodipine 5mg daily
Hydralazine 50mg [**Hospital1 **]
Metoprolol 75mg [**Hospital1 **]
Warfarin 2mg daily and yesterday her daughter received a
communication to hold coumadin for three days.
AREDS (?)
Nephrocaps

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: Physical Exam:
Vitals: T: afebrile P: 87bpm RR R: 16 BP: 157/75 SaO2:
General: Awake, cooperative, NAD. Falling asleep easily. During
the evaluation two episodes of respiratory pause were observed
without desaturation.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity

FAMILY HISTORY: Family Hx: non-contributory

SOCIAL HISTORY: Social Hx: Lives with her daugther and receives visit from nurse
at home.
Intracerebral hemorrhage,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hemiplegia, unspecified, affecting unspecified side,Renal dialysis status,Atrial fibrillation,Cardiac pacemaker in situ,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants
Intracerebral hemorrhage,End stage renal disease,Hyp kid NOS w cr kid V,Unsp hemiplga unspf side,Renal dialysis status,Atrial fibrillation,Status cardiac pacemaker,Hyperlipidemia NEC/NOS,Long-term use anticoagul
Admission Date:  [**2113-5-5**]              Discharge Date:   [**2113-5-6**]


Service: NEUROLOGY

Allergies:
No Drug Allergy Information on File

Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Reason for consult: intracranial bleeding


Major Surgical or Invasive Procedure:
CT HEAD
DIALYSIS [**2113-5-6**]

History of Present Illness:
[**Known firstname 5969**] is an 89 year-old right-handed woman with complex
past medical history which includes end stage renal disease
recently started on dialysis, HTN, AFib s/p pacemaker and in
coumadin, hyperlipidemia amoung other conditions who presented
with with left sided weakness secondary to right thalamic
hemorrhage. Patient had her dialysis session yesterday and she
was reportedly more tired than usual. This morning around 9am
her
daughter woke her up and was helping her to go to the bathroom,
when she noted that [**Known firstname 5969**] was leaning to the left side. Patient
was returning from the bathroom in her walker when she
continuing
to lean to the left and ended up falling. Her daughter picked
her
up and noticed a overall weakness described as "dead weight".
There was no LOC, and patient was speaking through the episode.
She continue at home waiting for the nurse home to evaluated
her.
After her evaluation around 11am, 911 was called and patient was
transferred to the [**Hospital 85279**] hospital. There she was evaluated and
underwent a CT which revealed right basal ganglia hemorrhage.
Patient had INR of 2.67 and she received FFP and vit K, doses
uncertain and transfer to [**Hospital1 18**] for further care. In the ED
[**Hospital1 18**]
patient has been stable, if anything she is slightly better
according to her daughter report.

Of Note: Patient has been in coumadin for the past 3 weeks,
after
one medical visit that she was noted to have abnormal cardiac
rhythm. No details were given. Regarding to her renal disease,
[**Known firstname 5969**] started dialysis last month. Dr [**Last Name (STitle) **] is Dr [**Last Name (STitle) **].
The dyalisis sessions happen on: Tuesday, Thursday and Saturday
[**Street Address(1) 85280**]. She has a subclavian dialysis catheter.

ROS:
The pt denied headache, loss of vision, blurred vision, vertigo.
Denied difficulties producing or comprehending speech. The pt
denied recent fever or chills.Denied cough, shortness of breath.
Denied chest pain or tightness, palpitations. Denied nausea,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias. Denied rash.



Past Medical History:
PMH:
1. End stage renal disease as above
2. HTN
3. pacemaker for AFib, sick sinus syndrome, presyncope with
pauses in [**2108**]
4. History of palpitations
5. Hyperlipidemia
6. Hiatal hernia with GERD
7. Right knee total replacement in [**2096**]
8. Right carotid endarterectomy in [**2108-4-1**]
9. Appendicectomy
10. Uterine suspension
11. Hemorrhoidectomy
12. ex-smoker
13. Remote history of pancreatitis
14. Hearing impairment bilaterally


Social History:
Social Hx: Lives with her daugther and receives visit from nurse
at home.

Family History:
Family Hx: non-contributory


Physical Exam:
Physical Exam:
Vitals: T: afebrile P: 87bpm RR R: 16 BP: 157/75 SaO2:
General: Awake, cooperative, NAD. Falling asleep easily. During
the evaluation two episodes of respiratory pause were observed
without desaturation.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity

Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.

Neurologic:
-Mental Status: awake, easily falling asleep, but also easily
arousable.. Able to relate history without difficulty.
Attentive.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt. was able to
name both high and low frequency objects. Speech was dysarthric.
Able to follow both midline and appendicular commands. CN
I: not tested
II,III: VFF to confrontation, surgical pupils bilaterally, fundi
normal
III,IV,VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: left facial weakness
VIII: hearing impairment bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**4-5**] bilaterally
XII: tongue protrudes midline,
Motor: Left leg xternally rotated. Overall thin patient, mildly
decreased tone in the left side. Significant asterixis L>R.
Evident Left pronator drift.
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 4 4 4 4 4 4 4
R 5 5 5 5 5 5 5

IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 4 4 4 4 4 4
R 5 5 5 5 5 5
Reflex:
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 3 3 3 3 3 babinski
R 2 2 2 2 2 Flexor
-Sensory: No deficits to light touch. Left sided extinction to
DSS.

-Coordination: No intention tremor.

-Gait: not tested.


Pertinent Results:
[**2113-5-5**] 05:30PM   GLUCOSE-82 UREA N-12 CREAT-3.4* SODIUM-139
POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-32 ANION GAP-15
[**2113-5-5**] 05:30PM   estGFR-Using this
[**2113-5-5**] 05:30PM   CK(CPK)-40
[**2113-5-5**] 05:30PM   cTropnT-0.06*
[**2113-5-5**] 05:30PM   CK-MB-2
[**2113-5-5**] 05:30PM   WBC-7.6 RBC-4.02* HGB-11.8* HCT-36.9 MCV-92
MCH-29.2 MCHC-31.8 RDW-16.4*
[**2113-5-5**] 05:30PM   PLT COUNT-184
[**2113-5-5**] 05:30PM   PT-18.6* PTT-31.0 INR(PT)-1.7*
[**2113-5-6**] 01:52AM BLOOD WBC-7.8 RBC-3.88* Hgb-11.2* Hct-36.2
MCV-93 MCH-29.0 MCHC-31.1 RDW-16.6* Plt Ct-184
[**2113-5-6**] 01:52AM BLOOD Neuts-70.7* Lymphs-22.7 Monos-6.0 Eos-0.5
Baso-0.2
[**2113-5-6**] 01:52AM BLOOD PT-14.8* PTT-27.8 INR(PT)-1.3*
[**2113-5-6**] 01:52AM BLOOD Glucose-97 UreaN-15 Creat-4.0* Na-139
K-3.8 Cl-97 HCO3-32 AnGap-14
[**2113-5-6**] 10:28AM BLOOD CK(CPK)-31
[**2113-5-6**] 10:28AM BLOOD CK(CPK)-31
[**2113-5-6**] 01:52AM BLOOD ALT-11 AST-17 LD(LDH)-205 CK(CPK)-28*
AlkPhos-66 Amylase-104* TotBili-0.5
[**2113-5-6**] 01:52AM BLOOD Lipase-29
[**2113-5-6**] 10:28AM BLOOD CK-MB-3
[**2113-5-6**] 01:52AM BLOOD CK-MB-2 cTropnT-0.07*
[**2113-5-5**] 05:30PM BLOOD cTropnT-0.06*
[**2113-5-5**] 05:30PM BLOOD CK-MB-2
[**2113-5-6**] 10:28AM BLOOD Cholest-208*
[**2113-5-6**] 01:52AM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.3 Mg-1.9
UricAcd-4.5 Cholest-192
[**2113-5-6**] 10:28AM BLOOD %HbA1c-5.2 eAG-103
[**2113-5-6**] 01:52AM BLOOD %HbA1c-5.1 eAG-100
[**2113-5-6**] 10:28AM BLOOD Triglyc-87 HDL-54 CHOL/HD-3.9
LDLcalc-137*
[**2113-5-6**] 01:52AM BLOOD Triglyc-97 HDL-51 CHOL/HD-3.8 LDLcalc-122
[**2113-5-6**] 10:28AM BLOOD TSH-0.91
[**2113-5-6**] 01:52AM BLOOD TSH-1.0
[**2113-5-6**] 01:52AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2113-5-5**] 05:30PM BLOOD LtGrnHD-HOLD

CT HEAD [**2113-5-5**] 6:46

FINDINGS: There is a 21 x 15 mm hyperdensity consistent with
intraparenchymal hemorrhage, within the right basal ganglia with
evidence of surrounding vasogenic edema which is relatively
unchanged in size and appearance since the CT scan obtained
earlier today, previously 20 x 15 mm. There is 5-mm leftward
shift of normally midline structures which is relatively
unchanged from the CT scan obtained earlier today. There is no
evidence of acute major vascular territorial infarction.
Bilateral dystrophic calcifications are noted within the
cerbellar hemispheres.

There is no evidence of acute fracture. The bilateral mastoid
air cells
appear well aerated on the left side but appear relatively less
aerated on the right side with no evidence of underlying
fracture or air cell opacification.

IMPRESSION: No interval change since the CT scan obtained
earlier today with stable size and appearance of the right basal
ganglia hemorrhage and adjacent hemorrhage and stable shift of
normally midline structures.

CT HEAD 9:17am
REASON FOR EXAM: Intracranial hemorrhage.
COMPARISON: Head CT from [**2113-5-5**].

NON-CONTRAST HEAD CT: Right thalamic and basal ganglia hematoma
with
surrounding vasogenic edema and 8 mm of midline shift is only
minimally
increased in size and mass effect as compared to prior study,
may be secondary to slice selection. There is small amount of
intraventricular hemorrhage within the right lateral ventricle,
unchanged since [**2113-5-5**]. There is no new area of
intracranial hemorrhage. Cerebellar calcifications and basal
ganglia calcifications are also noted. Prominence of the lateral
ventricles and cerebral sulci is compatible with age-appropriate
atrophy.  Periventricular and subcortical white matter
hypodensities are compatible with chronic small vessel ischemic
disease. Osseous structures appear stable since prior exam. This
exam is severely limited due to motion artifact.

IMPRESSION:

Limited study due to motion artifact. No change in the right
basal ganglia
and thalamic hemorrhage with 8 mm of midline shift as well as
extension into the right lateral ventricle. Consider close
follow up if no intervention is contemplated; further work up
for underlying vascular/mass lesion, even though this is more
likely to be related to HTN.

CT HEAD WITHOUT CONTRAST. 5:55 pm
COMPARISON: [**2113-5-6**] at 9:20 a.m.

TECHNIQUE: MDCT axially acquired images through the brain were
obtained. No IV contrast was administered.

HISTORY: Altered mental status change with intracranial
hemorrhage, evaluate for interval change.

FINDINGS: The previously identified right thalamic and basal
ganglial
hemorrhage has markedly increased in size and currently measures
approximately 3.9 x 4.3 cm (2A, 15). In addition, there has been
intraventricular extension of hemorrhage with blood within the
entire ventricular system including the fourth ventricle. There
is obstructive hydrocephalus with dilation of the temporal
horns. There is shift of normally midline structures towards the
left by approximately 10 mm. This has increased when compared to
prior exam.
In addition, there is effacement of the suprasellar cistern
consistent with uncal herniation. Extensive motion somewhat
limits evaluation of exam.  Mucosal retention cyst in the right
maxillary sinus is noted.
Underpneumatized right mastoid air cells are also identified.

IMPRESSION: Marked interval increase in right thalamic and basal
ganglial
hemorrhage with new intraventricular extension, hydrocephalus.
Worsening left subfalcine herniation and uncal herniation.
Underlyign vascular lesion/ mass cannot be excluded.



Brief Hospital Course:
This is an 89 year-old right-handed woman with a complex past
medical history which included end stage renal disease recently
started on dialysis three times a week, HTN, AFib s/p pacemaker,
and recently started on coumadin (INR 2.67 at OSH),
hyperlipidemia amoung other conditions who presented with with
left sided weakness secondary to right thalamic hemorrhage.
Patient had been stable, but more sleepy. Patient had two
episodes of respiratory pauses without desaturation during the
clinical evaluation in the ED.

She was admitted to the Neuro ICU with the plan to monitor INR
(1.7, 1.6 as to she was reversed at the OSH) and to check CT
scan in the am. On [**2113-5-6**], she was examined on rounds and was
awake with left sided weakness and transfer to the Neuro step
down unit was ordered. Home antihypertensives were restarted.
Labs showed Na 139, Cr 3.4, troponin 0.07 from 0.06. CT head
repeated at 9:15 am and showed No change in the right basal
ganglia and thalamic hemorrhage with 8 mm of midline shift as
well as extension into the right lateral ventricle. Dialysis was
arranged that afternoon since she typically receives it on
(Saturday, tuesday, thursday) and this was started but not
completed since the line was clotted. She did not receive
heparin or tpa products during dialysis. BP and other vitals
were stable during dialysis but developed right arm tremors and
nausea at that time. She was transferred to the step down unit
and evaluated. SBP was in the 140s, but she was not arousing to
voice, not following commands, and pupils sluggishly reactive.
STAT CT head ordered and showed marked interval increase in
right basal ganglia hemorrhage with new intraventricular
extension, hydrocephalus, and worsening left subfalcine
herniation and uncal herniation. She had respiratory arrest en
route from the scanner back to the floor. She arrived on the
floor bradycardic and passed away several minutes later.

Family discussions with two of her daughters were ongoing during
her hospital course and they were considering CMO status which
is what they felt their mother would have wanted. They had
declined NG tube placement for medications.  She was DNR/DNI for
her hospital course although the intial admission note and
orders were listed as full code. This was corrected prior to her
passing. Daughters understood the grave situation and after she
stopped breathing requested over the phone that no aggressive
measures be taken. Daughters returned to the hospital after her
passing and we requested the chaplain to help with grieving.
Daughters declined autopsy and case discussed with the medical
examiner since she passed within 24 hours of admission and he
declined the case.


Medications on Admission:
Medications:
Amlodipine 5mg daily
Hydralazine 50mg [**Hospital1 **]
Metoprolol 75mg [**Hospital1 **]
Warfarin 2mg daily and yesterday her daughter received a
communication to hold coumadin for three days.
AREDS (?)
Nephrocaps


Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
Intracerebral hemorrhage (non traumatic)
Atrial fibrillation
ESRD

Discharge Condition:
Deceased

                             [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

Completed by:[**2113-5-13**]
{'Intracerebral hemorrhage,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hemiplegia, unspecified, affecting unspecified side,Renal dialysis status,Atrial fibrillation,Cardiac pacemaker in situ,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants'}


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: Reason for consult: intracranial bleeding

PRESENT ILLNESS: [**Known firstname 5969**] is an 89 year-old right-handed woman with complex
past medical history which includes end stage renal disease
recently started on dialysis, HTN, AFib s/p pacemaker and in
coumadin, hyperlipidemia amoung other conditions who presented
with with left sided weakness secondary to right thalamic
hemorrhage. Patient had her dialysis session yesterday and she
was reportedly more tired than usual. This morning around 9am
her
daughter woke her up and was helping her to go to the bathroom,
when she noted that [**Known firstname 5969**] was leaning to the left side. Patient
was returning from the bathroom in her walker when she
continuing
to lean to the left and ended up falling. Her daughter picked
her
up and noticed a overall weakness described as "dead weight".
There was no LOC, and patient was speaking through the episode.
She continue at home waiting for the nurse home to evaluated
her.
After her evaluation around 11am, 911 was called and patient was
transferred to the [**Hospital 85279**] hospital. There she was evaluated and
underwent a CT which revealed right basal ganglia hemorrhage.
Patient had INR of 2.67 and she received FFP and vit K, doses
uncertain and transfer to [**Hospital1 18**] for further care. In the ED
[**Hospital1 18**]
patient has been stable, if anything she is slightly better
according to her daughter report.

MEDICAL HISTORY: PMH:
1. End stage renal disease as above
2. HTN
3. pacemaker for AFib, sick sinus syndrome, presyncope with
pauses in [**2108**]
4. History of palpitations
5. Hyperlipidemia
6. Hiatal hernia with GERD
7. Right knee total replacement in [**2096**]
8. Right carotid endarterectomy in [**2108-4-1**]
9. Appendicectomy
10. Uterine suspension
11. Hemorrhoidectomy
12. ex-smoker
13. Remote history of pancreatitis
14. Hearing impairment bilaterally

MEDICATION ON ADMISSION: Medications:
Amlodipine 5mg daily
Hydralazine 50mg [**Hospital1 **]
Metoprolol 75mg [**Hospital1 **]
Warfarin 2mg daily and yesterday her daughter received a
communication to hold coumadin for three days.
AREDS (?)
Nephrocaps

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: Physical Exam:
Vitals: T: afebrile P: 87bpm RR R: 16 BP: 157/75 SaO2:
General: Awake, cooperative, NAD. Falling asleep easily. During
the evaluation two episodes of respiratory pause were observed
without desaturation.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity

FAMILY HISTORY: Family Hx: non-contributory

SOCIAL HISTORY: Social Hx: Lives with her daugther and receives visit from nurse
at home. 

### Response:
{'Intracerebral hemorrhage,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hemiplegia, unspecified, affecting unspecified side,Renal dialysis status,Atrial fibrillation,Cardiac pacemaker in situ,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants'}
