CHIEF COMPLAINT: Headache and confusion.

PRESENT ILLNESS: Mr. [**Name13 (STitle) 7518**] is a 78 yo right handed man who presents for
evaluation of confusion.  The history is given both by the
patient and his daughter.  Apparently, the patient lives
predominantly alone.  His daughter recalls speaking to him on
Saturday and he appeared to be his typical self.  This morning,
around 9am she received a phone call from her father- he was
asking for the phone number to his office, something he should
know very well.  She became concerned and he told her that he
was
not feeling well and was lying in bed (also unlike him).  They
hung up the phone and just minutes later, he called back, again
asking the same questions and without recalling that he had just
spoken to her.  This prompted his daughter to go to his home
where she found things in disarray- he had apparently soiled
himself as well as vomited on the floor as well as a nose bleed
and had no cleaned it up.  She is not sure how long things had
been like that.  The patient refused to go to the ED and
requested calling his PCP [**Name Initial (PRE) **].  Upon hearing this, the PCP
rightfully referred the pt to the ED.

MEDICAL HISTORY: - Sleep Apnea, on CPAP
- Emphysema (baseline O2 84% on RA.  Goal ~88 RA)
- "Leaky Valve", per most recent ECHO, multiple valve disease
with mild regurge from mitral, aortic and tricuspid valves.
- Nephrolithiasis
- Spinal Stenosis (lumbar)
- GI Bleed/BRBPR, no off ASA
- s/p Cataract [**Doctor First Name **] (bilaterally)
- s/p resection of skin lesion on his head.
- s/p B/L knee replacements
- s/p cholecystectomy
- s/p appendectomy
- s/p tonsillectomy

MEDICATION ON ADMISSION: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs inhaled every 6-8 hours as needed for shortness of breath
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inhaled twice a day rinse after use
OXYGEN -   - 4L via nasal cannula use 24/7 Please provide liquid
oxygen system. Saturation 83% on RA, 86-88% on 4LNC. Diagnosis
COPD. Please call patient when oxygen is available as he would
li
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaled once a day

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam changes during the admission:
Patient remained afebrile. Was hypertensive briefly,
particularly on exertion, until antihypertensives added to 170s
at maximum. His oxygen saturation was typically low, often in
80's - he appears to have habituated to this, with some
polycythemia and no symptoms. His neurologic examination is
essentially normal now, with some confusion in the evening on
two nights. His family judge that he is approaching his
cognitive baseline.

FAMILY HISTORY: Gm HYPERTENSION, LIVER DISORDER (SECONDARY TO DAILY
ACETAMINOPHEN
Father- diabetes type I, ? bone ca?

SOCIAL HISTORY: Semi retired- works in real estate part time.  Lives alone but
son comes and stays with him 3 days per week.  He spends a good
amount of time at [**Location (un) **].  He has 4 children, 2 of which are
in
the area.  Remote smoking history of 2ppx, quit 30 years ago.
No
alcohol in years, no drugs.
Intracerebral hemorrhage,Obstructive hydrocephalus,Polycythemia, secondary,Other chronic pulmonary heart diseases,Other emphysema,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Mitral valve insufficiency and aortic valve insufficiency,Diseases of tricuspid valve,Hypoxemia,Spinal stenosis, lumbar region, without neurogenic claudication,Personal history of urinary calculi,Knee joint replacement,Other acquired absence of organ,Personal history of tobacco use
Intracerebral hemorrhage,Obstructiv hydrocephalus,Secondary polycythemia,Chr pulmon heart dis NEC,Emphysema NEC,Obstructive sleep apnea,Hypertension NOS,Mitral/aortic val insuff,Tricuspid valve disease,Hypoxemia,Spin sten,lumbr wo claud,Prsnl hst urnr dsrd calc,Joint replaced knee,Acq absence of organ NEC,History of tobacco use
Admission Date:  [**2174-10-17**]              Discharge Date:   [**2174-10-22**]

Date of Birth:  [**2096-1-15**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Headache and confusion.

Major Surgical or Invasive Procedure:
None.


History of Present Illness:
Mr. [**Name13 (STitle) 7518**] is a 78 yo right handed man who presents for
evaluation of confusion.  The history is given both by the
patient and his daughter.  Apparently, the patient lives
predominantly alone.  His daughter recalls speaking to him on
Saturday and he appeared to be his typical self.  This morning,
around 9am she received a phone call from her father- he was
asking for the phone number to his office, something he should
know very well.  She became concerned and he told her that he
was
not feeling well and was lying in bed (also unlike him).  They
hung up the phone and just minutes later, he called back, again
asking the same questions and without recalling that he had just
spoken to her.  This prompted his daughter to go to his home
where she found things in disarray- he had apparently soiled
himself as well as vomited on the floor as well as a nose bleed
and had no cleaned it up.  She is not sure how long things had
been like that.  The patient refused to go to the ED and
requested calling his PCP [**Name Initial (PRE) **].  Upon hearing this, the PCP
rightfully referred the pt to the ED.

On arrival to the ED, the patient was noted to be extremely
hypoxic (O2 sat 65% off oxygen).  ABG at the time showed mild
bicarb retention and normal COhb. EKG was notable for PACs.  A
head CT was obtained which identifed a large intraventricular
bleed in the left caudate, extending into the ventricular
system.
Neurosurgery was consulted but felt there was no issued for an
acute intervention.  His sats quickly correctly and neurology
was
consulted.

Mr. [**First Name (Titles) 104720**] [**Last Name (Titles) 104721**] feeling "Plunky" that last few hours but
he cannot give a further description of his overall well being
other than feeling fatigued.  His daughter feels his fatigue
predates his presentation, stating he has been a bit more quiet
and down over the past few weeks than he typically is.  He
denies
any recent head injuries or falls.  He reports a mild headache
(0.5/10) which is a central pressure and which appears to be
resolving.   On further neurologic review of systems, the
patient
denied loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denied difficulties producing or comprehending
speech.  Denied focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention. Denied difficulty with
gait.

On general review of systems, the patient denied recent fever or
chills.  No night sweats or recent weight loss or gain. Denied
cough, shortness of breath.  Denied chest pain or tightness,
palpitations.  Denied nausea, vomiting, diarrhea, constipation
or
abdominal pain.  No recent change in bowel or bladder habits.
No
dysuria.  Denied arthralgias or myalgias. Denied rash.


Past Medical History:
- Sleep Apnea, on CPAP
- Emphysema (baseline O2 84% on RA.  Goal ~88 RA)
- "Leaky Valve", per most recent ECHO, multiple valve disease
with mild regurge from mitral, aortic and tricuspid valves.
- Nephrolithiasis
- Spinal Stenosis (lumbar)
- GI Bleed/BRBPR, no off ASA
- s/p Cataract [**Doctor First Name **] (bilaterally)
- s/p resection of skin lesion on his head.
- s/p B/L knee replacements
- s/p cholecystectomy
- s/p appendectomy
- s/p tonsillectomy


Social History:
Semi retired- works in real estate part time.  Lives alone but
son comes and stays with him 3 days per week.  He spends a good
amount of time at [**Location (un) **].  He has 4 children, 2 of which are
in
the area.  Remote smoking history of 2ppx, quit 30 years ago.
No
alcohol in years, no drugs.

Family History:
Gm HYPERTENSION, LIVER DISORDER (SECONDARY TO DAILY
ACETAMINOPHEN
Father- diabetes type I, ? bone ca?

Physical Exam:
Exam changes during the admission:
Patient remained afebrile. Was hypertensive briefly,
particularly on exertion, until antihypertensives added to 170s
at maximum. His oxygen saturation was typically low, often in
80's - he appears to have habituated to this, with some
polycythemia and no symptoms. His neurologic examination is
essentially normal now, with some confusion in the evening on
two nights. His family judge that he is approaching his
cognitive baseline.

T 99.3 BP 162/85 (prepeat 115/70) HR 94  RR 92 O2%  4L
General: Awake, cooperative, NAD.
Head and Neck: no cranial abnormalities, no scleral icterus
noted, mmm, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: irregular rate (PV/PAcs on tele).  [**1-29**] diffuse murmur.
Abdomen: soft, non-tender, normoactive bowel sounds, no masses
or
organomegaly noted.
Extremities: 1+ radial, DP pulses bilaterally.
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: Alert, oriented to hospital, "[**2174-10-27**])".
Able to relate history with some difficulty and amnestic
regarding some of the events of the last 2 days; confabulates.
Attentive (DOW backwards 23 seconds). 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.  Able to read without difficulty.  Speech was
not dysarthric.  There was no evidence of apraxia or neglect,
calculations intact. Registered [**2-23**] after 4 tries; and recalled
0/3 at 5 minutes.

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL irregularly shaped, 3 to 2mm and sluggish, b/l lens
replacements, + red reflex.  Visual fields full on bedside
testing with red pin. Unable to view fundus
III, IV, VI: EOMI without nystagmus.  Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: decreased hearing on right compared to left ear to finger
rub.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid
bilaterally.

XII: Tongue protrudes in midline.

-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No rigidity. No adventitious movements, such as
tremors, noted. No asterixis.

  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L  5    5   5   5   5  5  5  5   5    5  5    5     5    5
R  5    5   5   5   5  5  5  5   5    5  5    5     5    5

-Sensory: No deficits to light touch, decreased pinprick and
temperature sensation in bilateral feet to ankles.  Also
decreased  vibratory sense on right to shin and left to ankle.
Impaired proprioception to fine movements at the toes
bilaterally. No extinction to double simultaneous stimuli.

-Deep tendon reflexes:
    [**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L   2   1    1    1   1
R   2   1    1    1   1
Plantar response was flexor bilaterally.

-Coordination: Mild bilateral intention tremor, no
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.

-Gait: initially deferred

Pertinent Results:
[**2174-10-17**] 12:00PM BLOOD WBC-11.6* RBC-5.58 Hgb-18.6* Hct-58.1*
MCV-104* MCH-33.2* MCHC-32.0 RDW-14.1 Plt Ct-229
[**2174-10-21**] 05:45AM BLOOD WBC-15.2* RBC-5.75 Hgb-19.6* Hct-58.5*
MCV-102* MCH-34.1* MCHC-33.5 RDW-14.2 Plt Ct-223
[**2174-10-17**] 12:00PM BLOOD Neuts-80.3* Lymphs-12.0* Monos-5.2
Eos-0.8 Baso-1.7
[**2174-10-17**] 12:00PM BLOOD PT-14.0* PTT-28.8 INR(PT)-1.2*
[**2174-10-21**] 05:45AM BLOOD PT-16.1* PTT-29.4 INR(PT)-1.4*
[**2174-10-21**] 05:45AM BLOOD Ret Aut-2.0
[**2174-10-17**] 12:00PM BLOOD Glucose-135* UreaN-12 Creat-0.8 Na-139
K-4.1 Cl-102 HCO3-27 AnGap-14
[**2174-10-20**] 05:50AM BLOOD Glucose-117* UreaN-14 Creat-0.7 Na-140
K-4.3 Cl-102 HCO3-31 AnGap-11
[**2174-10-18**] 02:51AM BLOOD ALT-40 AST-31 LD(LDH)-196 CK(CPK)-97
AlkPhos-63 TotBili-1.4
[**2174-10-18**] 02:51AM BLOOD CK-MB-5 cTropnT-<0.01
[**2174-10-17**] 12:00PM BLOOD Calcium-9.4 Phos-2.3* Mg-1.9
[**2174-10-20**] 05:50AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.0
[**2174-10-21**] 05:45AM BLOOD UricAcd-4.1
[**2174-10-17**] 04:35PM BLOOD %HbA1c-6.0* eAG-126*
[**2174-10-18**] 02:51AM BLOOD Triglyc-101 HDL-37 CHOL/HD-3.7 LDLcalc-79
[**2174-10-17**] 12:11PM BLOOD Type-[**Last Name (un) **] O2 Flow-4 pO2-55* pCO2-45
pH-7.40 calTCO2-29 Base XS-1 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2174-10-17**] 12:11PM BLOOD Lactate-1.8
[**2174-10-21**] 12:40PM BLOOD JAK2 MUTATION (V617F) ANALYSIS, PLASMA
BASED-PND
[**2174-10-21**] 12:40PM BLOOD ERYTHROPOIETIN-PND

EKG
Sinus rhythm and frequent atrial ectopy. Left atrial
abnormality. Right ventricular conduction delay. Compared to the
previous tracing of [**2172-5-16**] the axis is indeterminate. There are
new repolarization abnormalities in leads V1-V4 and increase in
rate which may represent anterior myocardial ischemia. Followup
and clinical correlation are suggested.
Rate PR QRS QT/QTc P QRS T
85 148 96 350/393 51 0 4

CT Head [**2174-10-17**]
FINDINGS: There is a large intraventricular hemorrhage which
appears to be extending from a small focus of intraparenchymal
hemorrhage within the left caudate (2:12). There is no evidence
of obstructive hydrocephalus. There are no other foci of
hemorrhage, major vascular territorial infarction, edema or
shift of normally midline structures. There are no fractures or
soft tissue injuries. The visualized sinuses and mastoid air
cells are well pneumatized.
IMPRESSION: Intraventricular hemorrhage likely from ventricular
extension of left caudate hemorrhage. No obstructive
hydrocephalus.
Addendum: Upon further review, there is bihemispheric
subarachnoid hemorrhage manifested as subtle hyperdensity within
the sulci most conspicuous along the cerebral vertex on the
right.

CT Head [**2174-10-19**]
FINDINGS: Again identified is diffuse bilateral subarachnoid
hemorrhage, not significantly changed in size and distribution.
There is intraventricular hemorrhage with increased ventricular
size concerning for early obstructive hydrocephalus. In
particular, the third ventricle now measures 14 mm (2, 13),
previously measuring 11 mm. There is also increased dilatation
of the temporal horns bilaterally. There has been slight
redistribution of the intraventricular hemorrhage with blood now
identified in right occipital [**Doctor Last Name 534**] (2, 17) and resolved from the
right frontal [**Doctor Last Name 534**]. The previously identified hemorrhage within
the third ventricle has resolved. The hemorrhage within the left
ventricular system is stable in configuration. Small amount of
hemorrhage within the fourth ventricle is now present within the
bilateral foramen of Luschka.
There is no new hemorrhage identified. There is no shift of
normally midline structures or acute major vascular territorial
infarction. There is normal [**Doctor Last Name 352**]-white matter differentiation.
No evidence of acute fracture. The visualized paranasal sinuses
are unremarkable.
IMPRESSION:
1. Intraventricular hemorrhage with increased dilatation of the
ventricular system concerning for early obstructive
hydrocephalus.
2. Extensive subarachnoid hemorrhage, unchanged. No new
hemorrhage
identified.

CT Head [**2174-10-21**]
Ventricular size reduced by comparison on [**2174-10-19**]

MRA/MRI Head [**2174-10-17**]
TECHNIQUE: Sagittal T1-weighted and axial T1-weighted,
T2-weighted, FLAIR, gradient echo, and diffusion-weighted images
of the head were obtained.  Three-dimensional time-of-flight MRA
of the head and two-dimensional time-of-flight MRV of the head
were obtained, with a three-dimensional maximal intensity
projection images. Two-dimensional time-of-flight MRA of the
neck was obtained, with three-dimensional maximal intensity
projection reformatted images. During intravenous gadolinium
administration, dynamic coronal VIBE imaging of neck was
performed. Following intravenous gadolinium administration,
multiplanar T1-weighted images of the head were obtained.

FINDINGS:
HEAD MRI: There is a small focus of blood in the left
caudothalamic groove. There is a large amount of blood within
the left lateral ventricle, third ventricle and fourth
ventricle, as well as a small amount of blood in the frontal and
occipital horns of the right lateral ventricle. The septum
pellucidum is shifted to the right. These findings are
unchanged. There is high signal on FLAIR images and low signal
on gradient echo images in the hemispheric sulci bilaterally,
corresponding to the subarachnoid hemorrhage seen on the
preceding CT scan. There is no evidence of an enhancing mass or
abnormal blood vessels. Multiple small foci of high T2 signal in
the supratentorial white matter and pons, probably represent
chronic microvascular infarcts, given the patient's age.
HEAD MRV: Flow is visualized in the major dural sinuses without
evidence of thrombosis.
HEAD MRA: The study is limited by motion artifacts. The
intracranial right vertebral artery is hypoplastic, better
visualized on the concurrent neck MRA with gadolinium. There is
no evidence of a hemodynamically significant arterial stenosis
or intracranial aneurysm. This study does not cover the entire
head as it is targeted for evaluation of the circle of [**Location (un) 431**],
but no evidence of an arteriovenous malformation is seen within
the area of coverage.
NECK MRA: The gadolinium-enhanced dynamic neck MRA is slightly
limited due to suboptimal injection timing. However, no
hemodynamically significant stenosis is seen in the cervical
carotid or vertebral arteries.
IMPRESSION:
1. Extensive intraventricular hemorrhage, bilateral subarachnoid
hemorrhage, and a small parenchymal hemorrhage in the left
caudothalamic groove, as seen on the preceding CT scan.
2. No evidence of an intracranial mass.
3. No evidence of venous sinus thrombosis.
4. Slightly limited MRAs of the head and neck. No evidence of an

intracranial aneurysm. No evidence of an intracranial
malformation within the area of coverage, though the entire head
is not covered by the MRA.

Brief Hospital Course:
Intraventricular Hemorrhage
Typical causes of intraventricular hemorrhage include dissection
into the ventricle from periventricular strucutres, particulary
after hypertension hemorrhage into striatum. Other possibilities
include periventricular neoplasm with necrosis and bleeding,
aterovenous malformation, arising from choroid. In this case, a
small amount of disrupted tissue adjacent to the left lateral
ventricle, next to the head of the causeal is seen - we think
that blood likely dissected into the ventricle from this
possible hypertensive lesion. We will need to repeat MRI of the
head in about six weeks to reevaluate for an underlying lesion
at this site. Again the hypertensive hypothesis seem somewhat
odd given quite reasonable blood pressure values while here. We
started antihypertensive agents, as listed below. We will see
him in clinic for follow-up after repeat MRI.

Systemic Hypertension
Not very elevated. Response to exercise/exertion brought to 170s
while here, but was typically from 110s to 140s at rest. We
added agents as listed below.

Chronic Obstructive Pulmonary Disease
Patient has previously refused day-time oxygen therapy and
tolerates a very low oxygen saturation in the 80s. This
hypoxemia, perhaps along with sleep apnea, has resulted in
pulmonary hypertension, possibly worsening his respiratory
status. He has actually been symptom free, however. Hypoxemia is
also the likely cause of his polycythemia.

Pulmonary Hypertension
Likely secondary to COPD and hypoxia, perhaps with a
contribution from OSA.

Obstructive Sleep Apnea
The patient used BiPAP while an inpatient.

Polycythemia
Was seen by Hematology while here, who recommended no phlebotomy
at this time. JAK2 mutation and EPO level were pending at the
time of discharge, but it seems more likely attributable to
hypoxemia.

Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs inhaled every 6-8 hours as needed for shortness of breath
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inhaled twice a day rinse after use
OXYGEN -   - 4L via nasal cannula use 24/7 Please provide liquid
oxygen system. Saturation 83% on RA, 86-88% on 4LNC. Diagnosis
COPD. Please call patient when oxygen is available as he would
li
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaled once a day

Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) -  (Prescribed by Other Provider) -
1,000 unit Capsule - 1 Capsule(s) by mouth once daily
MULTIVITAMIN -  (OTC) -   Capsule - Capsule(s) by mouth once a
day
OMEGA-3 FATTY ACIDS [FISH OIL] -  (Prescribed by Other Provider)
- Dosage uncertain

Discharge Medications:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
8. multivitamin with minerals     Capsule Sig: One (1) Capsule
PO once a day.
9. Vitamin D-3 400 unit Capsule Sig: One (1) Capsule PO twice a
day.
10. Omega-3 Fish Oil 1,000 (120-180) mg Capsule Sig: One (1)
Capsule PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Primary
Intracerebral hemorrhage with intraventricular extension

Secondary
Chronic obstructive pulmonary disease/emphysema
Obstructive sleep apnea
Pulmonary hypertension
Systemic hypertension
Polycythemia, likely secondary to hypoxemia (from chronic
obstructive pulmonary disease and, to a lesser extent, pulmonary
hypertension)

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).

Discharge Instructions:
You came to the hospital after having a hemorrhage in your
brain, which erupted into the ventricles (fluid filled spaces
inside the brain). This blocked your ventricular system, leading
to the build-up of some fluid in your brain. Given this, you
needed close monitoring. You recovered quickly and well from
this event. Repeat imaging demonstrated that your ventricular
system was again draining, so we thought that you were safe to
go to rehabilitation. Please take your medications as written
below and as specified by rehabilitation at your discharge from
there. You will need to follow-up with our stroke team after
discharge, as detailed below.

Followup Instructions:
Please see our stroke team as follows:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2174-12-7**] 1:30

Prior to this appointment, you will need a repeat CT then MRI of
your brain (imaging). The CT will need to be in two weeks (about
[**2174-11-6**]), then the MRI in six weeks. Please call to schedule a
time - the order is in, but the exact time is not booked. You
can have this done in the week prior to the appointment, i.e. in
the week [**11-29**] to [**12-6**]. Please call [**Telephone/Fax (1) 327**].

Please make an appointment to see your primary care doctor -
make this appointment to see your doctor a few days after
discharge - please see your doctor within a week.

[**Last Name (LF) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 3329**]

We also note other appointments in our system:

Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2174-11-29**] 8:30

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2308**], MD Phone:[**Telephone/Fax (1) 3965**]
Date/Time:[**2175-3-30**] 7:30
{'Intracerebral hemorrhage,Obstructive hydrocephalus,Polycythemia, secondary,Other chronic pulmonary heart diseases,Other emphysema,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Mitral valve insufficiency and aortic valve insufficiency,Diseases of tricuspid valve,Hypoxemia,Spinal stenosis, lumbar region, without neurogenic claudication,Personal history of urinary calculi,Knee joint replacement,Other acquired absence of organ,Personal history of tobacco 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: Headache and confusion.

PRESENT ILLNESS: Mr. [**Name13 (STitle) 7518**] is a 78 yo right handed man who presents for
evaluation of confusion.  The history is given both by the
patient and his daughter.  Apparently, the patient lives
predominantly alone.  His daughter recalls speaking to him on
Saturday and he appeared to be his typical self.  This morning,
around 9am she received a phone call from her father- he was
asking for the phone number to his office, something he should
know very well.  She became concerned and he told her that he
was
not feeling well and was lying in bed (also unlike him).  They
hung up the phone and just minutes later, he called back, again
asking the same questions and without recalling that he had just
spoken to her.  This prompted his daughter to go to his home
where she found things in disarray- he had apparently soiled
himself as well as vomited on the floor as well as a nose bleed
and had no cleaned it up.  She is not sure how long things had
been like that.  The patient refused to go to the ED and
requested calling his PCP [**Name Initial (PRE) **].  Upon hearing this, the PCP
rightfully referred the pt to the ED.

MEDICAL HISTORY: - Sleep Apnea, on CPAP
- Emphysema (baseline O2 84% on RA.  Goal ~88 RA)
- "Leaky Valve", per most recent ECHO, multiple valve disease
with mild regurge from mitral, aortic and tricuspid valves.
- Nephrolithiasis
- Spinal Stenosis (lumbar)
- GI Bleed/BRBPR, no off ASA
- s/p Cataract [**Doctor First Name **] (bilaterally)
- s/p resection of skin lesion on his head.
- s/p B/L knee replacements
- s/p cholecystectomy
- s/p appendectomy
- s/p tonsillectomy

MEDICATION ON ADMISSION: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs inhaled every 6-8 hours as needed for shortness of breath
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inhaled twice a day rinse after use
OXYGEN -   - 4L via nasal cannula use 24/7 Please provide liquid
oxygen system. Saturation 83% on RA, 86-88% on 4LNC. Diagnosis
COPD. Please call patient when oxygen is available as he would
li
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaled once a day

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam changes during the admission:
Patient remained afebrile. Was hypertensive briefly,
particularly on exertion, until antihypertensives added to 170s
at maximum. His oxygen saturation was typically low, often in
80's - he appears to have habituated to this, with some
polycythemia and no symptoms. His neurologic examination is
essentially normal now, with some confusion in the evening on
two nights. His family judge that he is approaching his
cognitive baseline.

FAMILY HISTORY: Gm HYPERTENSION, LIVER DISORDER (SECONDARY TO DAILY
ACETAMINOPHEN
Father- diabetes type I, ? bone ca?

SOCIAL HISTORY: Semi retired- works in real estate part time.  Lives alone but
son comes and stays with him 3 days per week.  He spends a good
amount of time at [**Location (un) **].  He has 4 children, 2 of which are
in
the area.  Remote smoking history of 2ppx, quit 30 years ago.
No
alcohol in years, no drugs. 

### Response:
{'Intracerebral hemorrhage,Obstructive hydrocephalus,Polycythemia, secondary,Other chronic pulmonary heart diseases,Other emphysema,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Mitral valve insufficiency and aortic valve insufficiency,Diseases of tricuspid valve,Hypoxemia,Spinal stenosis, lumbar region, without neurogenic claudication,Personal history of urinary calculi,Knee joint replacement,Other acquired absence of organ,Personal history of tobacco use'}
