CHIEF COMPLAINT: Headache w/ spontaneous subarachnoid hemorrhage, fevers

PRESENT ILLNESS: 47yo male with history of diffuse large B cell lymphoma, Type 1
diabetes mellitus, and gastroparesis was transferred to medicine
from neurosurgery for evaluation of fevers in the setting of
spontaneous subarachnoid hemorrhage.
.
Patient initially presented on [**2195-12-31**] with the sudden onset of
headache, diplopia, and neck stiffness while watching
television. He presented to the ED where he was found to have a
subarachnoid hemorrhage with no evidence of aneurysm. He was
initially admitted to the Trauma ICU and was then transferred to
the neurosurgery floor. Surprisingly, his bleed was thought to
be spontaneous with no clear precipitant. His course has been
complicated by blood sugar abnormalities for which [**Last Name (un) **] is
following, nausea and vomiting for which he has been left NPO,
and fevers. His nausea and vomiting has markedly improved today
on the day of transfer due to his being allowed to eat.
.
Regarding his fevers, he initially developed fevers to 101 on
[**1-1**] and has had near daily fevers since then. His Tmax during
his hospitalization was 103.1 on [**2196-1-7**]. His WBC was initially
elevated to 24 and has remained between [**11-6**] during his
hospitalization. He has not received any antibiotics during this
hospitalization. He has felt malaise and occasional chills with
fevers.
.
He reports otherwise feeling generally feeling well,
particularly since starting eating today. His nausea, vomiting,
and diarrhea has now markedly improved since starting his diet.
Regarding recent antibiotic use, he took a 5 day course of
clindamycin after surgery on [**2195-12-18**] for trigger finger. His
antibiotic course was complicated by diarrhea which improved
with yogurt and probiotics. On review of systems specifically,
he denies neck stiffness, vision change, photophobia, chest
pain, shortness of breath, abdominal pain, diarrhea, dysuria,
joint pains.

MEDICAL HISTORY: 1. Type 1 Diabetes Mellitus
On insulin pump at home
2. Hypertension
3. Goiter
4. Diabetic Retinopathy
5. Gastroparesis
6. Hypercholesterolemia
7. H/o PTB, smear positive, in [**2170**] - had pneumomediastinum,
treated with Isoniazid and Rifampin for 9 1/2 months. Stopped
early b/c of pancreatitis.
8. Diffuse Large B Cell Lymphoma
- diagnosed in [**2190**] and followed with watchful waiting
9. Psoriasis

MEDICATION ON ADMISSION: 1. Centrum 1 tab daily
2. Lisinopril 5mg daily
3. Lomotil 2.5mg PO prn
4. Ativan 1mg PO qhs prn
5. Pravastatin 20mg PO daily
6. Pantoprazole 40mg PO daily
7. Reglan 10mg PO qid
8. Zofran 4mg PO bid
9. Insulin pump
10. Vitamin D 400 units daily
11. Magnesium 350mg daily

ALLERGIES: Penicillins / Zantac / Codeine

PHYSICAL EXAM: PHYSICAL EXAM (on admission):
O: T: 98.2 BP: 117/ 66        HR: 53   R   16     O2Sats  99 RA
Gen: WD/WN, comfortable, NAD.
HEENT: MMM and intact
Neck: stiff
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Left 6th N palsy, but otherwise intact
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-22**] throughout. No pronator drift
.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
.
Reflexes: B T Br Pa Ac
Right     2 2 2 2   2
Left      2 2 2 2   2
.
Toes downgoing bilaterally. Coordination: normal on
finger-nose-finger.
.
PHYSICAL EXAM (on transfer):
T 98.6 / BP 111/70 / HR 77 / RR 16 / Pulse ox 97% RA / FS 256
Gen: NAD, resting comfortably in bed
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. 2/6 systolic murmur heard best at
LUSB
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM. Insulin pump sites clean, dry,
and intact
EXT: No edema. 2+ DP pulses BL
SKIN: No rashes
NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation
throughout. 5/5 strength throughout. Normal coordination. Gait
assessment normal
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: - Father - [**Age over 90 **]yo - hypertension
- MOther - died at age 51 - breast cancer
- Sister - age 53 - TTP

SOCIAL HISTORY: Home: lives with partner [**Name (NI) **]; previously employed as an
investigator for the Supreme Court
Occupation: disabled; volunteers; previously ran a soup kitchen
Subarachnoid hemorrhage,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Subdural hemorrhage,Fever, unspecified,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Gastroparesis,Background diabetic retinopathy,Polyneuropathy in diabetes,Long-term (current) use of insulin,Goiter, unspecified,Pure hypercholesterolemia,Sixth or abducens nerve palsy
Subarachnoid hemorrhage,Oth lymp unsp xtrndl org,Subdural hemorrhage,Fever NOS,DMI neuro nt st uncntrld,Gastroparesis,Diabetic retinopathy NOS,Neuropathy in diabetes,Long-term use of insulin,Goiter NOS,Pure hypercholesterolem,Sixth nerve palsy
Admission Date:  [**2195-12-31**]              Discharge Date:   [**2196-1-11**]

Date of Birth:  [**2148-3-27**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Zantac / Codeine

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Headache w/ spontaneous subarachnoid hemorrhage, fevers

Major Surgical or Invasive Procedure:
Diagnostic Angiogram


History of Present Illness:
47yo male with history of diffuse large B cell lymphoma, Type 1
diabetes mellitus, and gastroparesis was transferred to medicine
from neurosurgery for evaluation of fevers in the setting of
spontaneous subarachnoid hemorrhage.
.
Patient initially presented on [**2195-12-31**] with the sudden onset of
headache, diplopia, and neck stiffness while watching
television. He presented to the ED where he was found to have a
subarachnoid hemorrhage with no evidence of aneurysm. He was
initially admitted to the Trauma ICU and was then transferred to
the neurosurgery floor. Surprisingly, his bleed was thought to
be spontaneous with no clear precipitant. His course has been
complicated by blood sugar abnormalities for which [**Last Name (un) **] is
following, nausea and vomiting for which he has been left NPO,
and fevers. His nausea and vomiting has markedly improved today
on the day of transfer due to his being allowed to eat.
.
Regarding his fevers, he initially developed fevers to 101 on
[**1-1**] and has had near daily fevers since then. His Tmax during
his hospitalization was 103.1 on [**2196-1-7**]. His WBC was initially
elevated to 24 and has remained between [**11-6**] during his
hospitalization. He has not received any antibiotics during this
hospitalization. He has felt malaise and occasional chills with
fevers.
.
He reports otherwise feeling generally feeling well,
particularly since starting eating today. His nausea, vomiting,
and diarrhea has now markedly improved since starting his diet.
Regarding recent antibiotic use, he took a 5 day course of
clindamycin after surgery on [**2195-12-18**] for trigger finger. His
antibiotic course was complicated by diarrhea which improved
with yogurt and probiotics. On review of systems specifically,
he denies neck stiffness, vision change, photophobia, chest
pain, shortness of breath, abdominal pain, diarrhea, dysuria,
joint pains.

Past Medical History:
1. Type 1 Diabetes Mellitus
On insulin pump at home
2. Hypertension
3. Goiter
4. Diabetic Retinopathy
5. Gastroparesis
6. Hypercholesterolemia
7. H/o PTB, smear positive, in [**2170**] - had pneumomediastinum,
treated with Isoniazid and Rifampin for 9 1/2 months. Stopped
early b/c of pancreatitis.
8. Diffuse Large B Cell Lymphoma
- diagnosed in [**2190**] and followed with watchful waiting
9. Psoriasis

Social History:
Home: lives with partner [**Name (NI) **]; previously employed as an
investigator for the Supreme Court
Occupation: disabled; volunteers; previously ran a soup kitchen

EtOH:  occasional
Drugs:  none
Tobacco:  none


Family History:
- Father - [**Age over 90 **]yo - hypertension
- MOther - died at age 51 - breast cancer
- Sister - age 53 - TTP


Physical Exam:
PHYSICAL EXAM (on admission):
O: T: 98.2 BP: 117/ 66        HR: 53   R   16     O2Sats  99 RA
Gen: WD/WN, comfortable, NAD.
HEENT: MMM and intact
Neck: stiff
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Left 6th N palsy, but otherwise intact
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-22**] throughout. No pronator drift
.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
.
Reflexes: B T Br Pa Ac
Right     2 2 2 2   2
Left      2 2 2 2   2
.
Toes downgoing bilaterally. Coordination: normal on
finger-nose-finger.
.
PHYSICAL EXAM (on transfer):
T 98.6 / BP 111/70 / HR 77 / RR 16 / Pulse ox 97% RA / FS 256
Gen: NAD, resting comfortably in bed
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. 2/6 systolic murmur heard best at
LUSB
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM. Insulin pump sites clean, dry,
and intact
EXT: No edema. 2+ DP pulses BL
SKIN: No rashes
NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation
throughout. 5/5 strength throughout. Normal coordination. Gait
assessment normal
PSYCH: Listens and responds to questions appropriately, pleasant

.
Upon dishcarge: Pt was neurologically intact without any
deficits. L 6th nerve palsy now resolved.

Pertinent Results:
LABS:
[**2196-1-10**] 07:20AM BLOOD WBC-17.3* RBC-3.86* Hgb-12.6* Hct-35.3*
MCV-91 MCH-32.6* MCHC-35.6* RDW-14.6 Plt Ct-337
[**2196-1-11**] 06:05AM BLOOD WBC-13.0* RBC-3.48* Hgb-11.1* Hct-32.0*
MCV-92 MCH-31.9 MCHC-34.7 RDW-14.7 Plt Ct-353
[**2196-1-10**] 07:20AM BLOOD Neuts-34* Bands-0 Lymphs-48* Monos-13*
Eos-1 Baso-0 Atyps-4* Metas-0 Myelos-0
[**2196-1-11**] 06:05AM BLOOD Neuts-40.6* Lymphs-50.9* Monos-7.1
Eos-1.0 Baso-0.4
[**2196-1-10**] 07:20AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-2+ Target-1+ Schisto-1+
Burr-1+
[**2196-1-9**] 07:45AM BLOOD PT-14.3* PTT-28.9 INR(PT)-1.2*
[**2196-1-10**] 07:20AM BLOOD PT-14.5* PTT-27.6 INR(PT)-1.3*
[**2196-1-10**] 07:20AM BLOOD Glucose-145* UreaN-6 Creat-0.8 Na-138
K-3.5 Cl-100 HCO3-26 AnGap-16
[**2196-1-11**] 06:05AM BLOOD Glucose-198* UreaN-10 Creat-0.8 Na-135
K-3.8 Cl-98 HCO3-27 AnGap-14
[**2195-12-31**] 01:30AM BLOOD ALT-67* AST-42* AlkPhos-72 TotBili-0.4
[**2196-1-7**] 01:47AM BLOOD ALT-54* AST-40 LD(LDH)-212 AlkPhos-90
TotBili-0.6
[**2196-1-10**] 07:20AM BLOOD LD(LDH)-272*
[**2196-1-11**] 06:05AM BLOOD LD(LDH)-215
[**2195-12-31**] 01:30AM BLOOD Lipase-16
[**2196-1-9**] 07:45AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9
[**2196-1-10**] 07:20AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1
.
MICROBIOLOGY:
- [**2195-12-31**] - MRSA screen - negative
- [**2196-1-4**] - Urine Cx - negative
- [**2196-1-4**] - MRSA Screen - negative
- [**2196-1-4**] - Blood Cx x 2 - negative
- [**2196-1-6**] - Blood Cx x 1 - negative
- [**2196-1-6**] - Urine Cx - negative
- [**2196-1-7**] - Blood Cx x 1 - negative
- [**2196-1-8**] - Blood Cx x 2 - no growth to date
- [**2196-1-8**] - Cdiff - negative
- [**2196-1-8**] - Urine Cx - Coag negative staph
- [**2196-1-8**] - Stool C diff - negative
- [**2196-1-8**] - EBV Serologies -- IgG positive and IgM negative
- [**2196-1-8**] - CMV Viral Load - pending
- [**2196-1-11**] - Toxoplasmosis serologies - negative
- [**2196-1-10**] - HIV Ab - pending
- [**2196-1-11**] - Cdiff negative
- [**2196-1-11**] - Stool O+P - pending
.
STUDIES:
- [**2195-12-31**] - Noncontrast Head CT - Subarachnoid hemorrhage
centered in the suprasellar cistern with extension along the
tentorium on the right. Subacute/chronic subdural also seen
along falx. CTA is recommended to evaluate for aneurysm.
- [**2195-12-31**] - CTA Head - Subarachnoid hemorrhage centered in the
suprasellar cistern with extension along the tentorium on the
right. Subacute/chronic subdural also seen along falx. CTA is
recommended to evaluate for aneurysm.
- [**2196-1-4**] - CT Brain Perfusion -
1. Expected evolution of subarachnoid and subdural hemorrhage,
without evidence of interim rebleeding.
2. Mild stenosis at the origin of the left vertebral artery.
3. No evidence of an intracranial aneurysm or vascular
malformation.
4. Unremarkable CT perfusion study in the middle cerebral
arterial
territories.
- [**2196-1-4**] - CXR Portable - The lungs are clear without
infiltrate or effusion. The cardiac and mediastinal silhouettes
are normal. There is no focal infiltrate. No significant change
compared to prior
- [**2196-1-6**] - Carotid / Cerebral Study - pending
- [**2196-1-7**] - LENIs - No lower extremity DVT bilaterally.
- [**2196-1-8**] - KUB Portable - No evidence for ileus or obstruction.
Unchanged vas deferens calcifications.
- [**2196-1-8**] - Portable CXR - No evidence of pneumonia.
- [**2196-1-8**] - CT Head - Marked improvement in subarachnoid and
subdural hemorrhage since [**2196-1-4**], without evidence of interim
bleeding or hydrocephalus.
- [**2196-1-11**] - Cardiac Echo - The left atrium and right atrium are
normal in cavity size. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). The estimated cardiac index is normal (>=2.5L/min/m2).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion. IMPRESSION: Trace aortic regurgitation
with normal valve morphology.Normal biventricular cavity sizes
with preserved global and regional biventricular systolic
function.

Brief Hospital Course:
1. Fevers - Had episodic fevers from 101 - 103 deg F with no
localizing signs/symptoms.  ID was consulted for evaluation and
infectious workup was pursued.  Multiple sets of blood cultures
were negative or no growth to date.  Urine culture showed
coag-negative staph, likely a contaminant.  Had no signs of CSF
infection, and CXR was negative for pneumonia.  Echo was
obtained due to question of new murmur on exam, which showed
trace AR, normal valves, and otherwise normal heart
structure/function.  Given his initial diarrhea and recent
exposure to clindamycin, stool for C. diff was sent, and was
negative.  HIV, Toxo, EBV, and CMV serologies were also sent.
HIV serologies were pending at time of discharge.  He was
monitored for signs of lymphoma, but no lymphadenopathy was
appreciated, WBC count/diff appeared to be within his baseline,
and LDH was normal.  Drug effect was thought to be the most
likely possibility, and he was transitioned from Dilantin to
Keppra on [**1-7**]. Fever secondary to his recent bleed were thought
to also be contributing.
.
2. Subdural and subarachnoid hemorrhage - Initially found to
have spontaneous hemorrhages, with no source by CTA and
diagnostic angiogram, but which were stable on repeat imaging.
Presented as headache pain, N/V, and diplopia.  His associated
headache pain was controlled with IV pain medication initially,
and he was then transitioned to a PO pain regimen, which was
well-tolerated prior to discharge.  In addition, he was started
on Keppra for seizure prophylaxis and nimodipine for vasospasm
protection.  Nimodipine was discontinued prior to discharge.  He
remained neurologically intact and stable through
hospitalization, with resolution of a 6th cranial nerve palsy
thought due to his hemorrhages.
.
3. Hypertension - Blood pressure was stable and wnl during
hospitalization, and he was transitioned from nimodipine to his
home antihypertensive, lisinopril, prior to discharge.
.
4. Type 1 Diabetes Mellitus - Self-managed by patient via his
insulin pump.  Was followed by [**Last Name (un) **] Diabetes team, where he
receives his diabetic care, and his blood sugars were wnl with
his self-management.
.
5. Gastroparesis - Had several days of nausea, vomiting,
diarrhea, which resolved fully when patient resumed a normal
diet.  After resolution of symptoms, he was restarted on his
home anti-emetic regimen of Zofran, Reglan, and Ativan.  His
lomotil was held during hospitalization and he was instructed to
resume use at home, as needed.  Stool was C. diff negative x1
with second set pending.
.
7. Hyperlipidemia - Stable, was continued on home pravastatin.
.
8. GERD - Stable, was continued on his home PPI.

Medications on Admission:
1. Centrum 1 tab daily
2. Lisinopril 5mg daily
3. Lomotil 2.5mg PO prn
4. Ativan 1mg PO qhs prn
5. Pravastatin 20mg PO daily
6. Pantoprazole 40mg PO daily
7. Reglan 10mg PO qid
8. Zofran 4mg PO bid
9. Insulin pump
10. Vitamin D 400 units daily
11. Magnesium 350mg daily

Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed for headache for 2 weeks: This medication may make you
drowsy or sedated. Do not drive or use heavy machinery until you
know how this affects you.
Disp:*60 Tablet(s)* Refills:*0*
2. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
for 2 weeks: This medication may make you drowsy or sedated. Do
not drive or use heavy machinery until you know this affects
you. .
Disp:*30 Tablet(s)* Refills:*0*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day for
30 days: Please take twice daily for 1 month.
Disp:*60 Tablet(s)* Refills:*0*
9. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
12. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
13. Ativan 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed.
14. Lomotil 2.5-0.025 mg Tablet Sig: One (1) Tablet PO once a
day as needed.
15. Magnesium 300 mg Capsule Sig: One (1) Capsule PO once a day.



Discharge Disposition:
Home

Discharge Diagnosis:
Atraumatic Subarachnoid Hemorrhage


Discharge Condition:
Stable with normal VS, able to ambulate unassisted.


Discharge Instructions:
You were admitted to the neurosurgery service for a spontaneous
bleed in your head, with no surgical intervention warranted.
You were given medication to control your headache pain, which
improved by the time of discharge.  Your fevers were evaluated
by the medical and infectious disease services, and no signs of
an infection in your blood, urine, heart, or lungs were found.
You are asked to record your temperature daily and when you feel
feverish, and use Tylenol when needed.  You were felt safe to go
home, with close outpatient follow-up.
.
You were started on Keppra, a medication to prevent seizures.
Please continue taking Keppra for 1 month and discuss with your
neurosurgeon when you see him.  You were also given a
prescription for pain medication, which you should take if your
headache returns.  Lastly, you may begin taking Lomotil again at
home, as you need it.
.
You are asked to follow-up with your primary care doctor, Dr.
[**Last Name (STitle) 4390**], for lab results that are pending.  Please schedule an
appointment with her in the next two weeks.
.
Please seek medical attention immediately if you develop a new
headache which does not respond to pain medication, increased
sensitivity to light, double vision, fever > 101.4 deg F,
chills, sweats, weight loss, chest pain, trouble breathing,
abdominal pain, or any other concerning symptoms.

Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] with a CT angiogram in 1 month.
If you have any questions please call [**Telephone/Fax (1) 1669**].

You have the following appointments scheduled:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (Prefixes) **], OTR Phone:[**Telephone/Fax (1) 2484**]
Date/Time:[**2196-1-12**] 1:00
Provider: [**Name10 (NameIs) **] GATES, RNC MSN Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2196-1-20**] 11:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2196-2-11**] 10:15


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
{'Subarachnoid hemorrhage,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Subdural hemorrhage,Fever, unspecified,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Gastroparesis,Background diabetic retinopathy,Polyneuropathy in diabetes,Long-term (current) use of insulin,Goiter, unspecified,Pure hypercholesterolemia,Sixth or abducens nerve palsy'}


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: Headache w/ spontaneous subarachnoid hemorrhage, fevers

PRESENT ILLNESS: 47yo male with history of diffuse large B cell lymphoma, Type 1
diabetes mellitus, and gastroparesis was transferred to medicine
from neurosurgery for evaluation of fevers in the setting of
spontaneous subarachnoid hemorrhage.
.
Patient initially presented on [**2195-12-31**] with the sudden onset of
headache, diplopia, and neck stiffness while watching
television. He presented to the ED where he was found to have a
subarachnoid hemorrhage with no evidence of aneurysm. He was
initially admitted to the Trauma ICU and was then transferred to
the neurosurgery floor. Surprisingly, his bleed was thought to
be spontaneous with no clear precipitant. His course has been
complicated by blood sugar abnormalities for which [**Last Name (un) **] is
following, nausea and vomiting for which he has been left NPO,
and fevers. His nausea and vomiting has markedly improved today
on the day of transfer due to his being allowed to eat.
.
Regarding his fevers, he initially developed fevers to 101 on
[**1-1**] and has had near daily fevers since then. His Tmax during
his hospitalization was 103.1 on [**2196-1-7**]. His WBC was initially
elevated to 24 and has remained between [**11-6**] during his
hospitalization. He has not received any antibiotics during this
hospitalization. He has felt malaise and occasional chills with
fevers.
.
He reports otherwise feeling generally feeling well,
particularly since starting eating today. His nausea, vomiting,
and diarrhea has now markedly improved since starting his diet.
Regarding recent antibiotic use, he took a 5 day course of
clindamycin after surgery on [**2195-12-18**] for trigger finger. His
antibiotic course was complicated by diarrhea which improved
with yogurt and probiotics. On review of systems specifically,
he denies neck stiffness, vision change, photophobia, chest
pain, shortness of breath, abdominal pain, diarrhea, dysuria,
joint pains.

MEDICAL HISTORY: 1. Type 1 Diabetes Mellitus
On insulin pump at home
2. Hypertension
3. Goiter
4. Diabetic Retinopathy
5. Gastroparesis
6. Hypercholesterolemia
7. H/o PTB, smear positive, in [**2170**] - had pneumomediastinum,
treated with Isoniazid and Rifampin for 9 1/2 months. Stopped
early b/c of pancreatitis.
8. Diffuse Large B Cell Lymphoma
- diagnosed in [**2190**] and followed with watchful waiting
9. Psoriasis

MEDICATION ON ADMISSION: 1. Centrum 1 tab daily
2. Lisinopril 5mg daily
3. Lomotil 2.5mg PO prn
4. Ativan 1mg PO qhs prn
5. Pravastatin 20mg PO daily
6. Pantoprazole 40mg PO daily
7. Reglan 10mg PO qid
8. Zofran 4mg PO bid
9. Insulin pump
10. Vitamin D 400 units daily
11. Magnesium 350mg daily

ALLERGIES: Penicillins / Zantac / Codeine

PHYSICAL EXAM: PHYSICAL EXAM (on admission):
O: T: 98.2 BP: 117/ 66        HR: 53   R   16     O2Sats  99 RA
Gen: WD/WN, comfortable, NAD.
HEENT: MMM and intact
Neck: stiff
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Left 6th N palsy, but otherwise intact
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-22**] throughout. No pronator drift
.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
.
Reflexes: B T Br Pa Ac
Right     2 2 2 2   2
Left      2 2 2 2   2
.
Toes downgoing bilaterally. Coordination: normal on
finger-nose-finger.
.
PHYSICAL EXAM (on transfer):
T 98.6 / BP 111/70 / HR 77 / RR 16 / Pulse ox 97% RA / FS 256
Gen: NAD, resting comfortably in bed
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. 2/6 systolic murmur heard best at
LUSB
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM. Insulin pump sites clean, dry,
and intact
EXT: No edema. 2+ DP pulses BL
SKIN: No rashes
NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation
throughout. 5/5 strength throughout. Normal coordination. Gait
assessment normal
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: - Father - [**Age over 90 **]yo - hypertension
- MOther - died at age 51 - breast cancer
- Sister - age 53 - TTP

SOCIAL HISTORY: Home: lives with partner [**Name (NI) **]; previously employed as an
investigator for the Supreme Court
Occupation: disabled; volunteers; previously ran a soup kitchen 

### Response:
{'Subarachnoid hemorrhage,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Subdural hemorrhage,Fever, unspecified,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Gastroparesis,Background diabetic retinopathy,Polyneuropathy in diabetes,Long-term (current) use of insulin,Goiter, unspecified,Pure hypercholesterolemia,Sixth or abducens nerve palsy'}
