CHIEF COMPLAINT: SAH

PRESENT ILLNESS: HPI:69F was home watching TV with husband when c/o not feeling
well followed by witnessed collapse. EMT arrived, found her in
pulseless Vtach that converted with CPR. Went to OSH, intubated,
CT shows large SAH bilat Sylvian fissures with blood into 3rd
and
4th ventricles. Pt transferred here for further treatment.

MEDICAL HISTORY: HTN
Hyperlipidemia

MEDICATION ON ADMISSION: - lopressor XL 50 mg tab daily
- pravastatin 20 mg at bedtimes

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: On admission:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 4    [**Doctor Last Name **]:2      GCS 5T  E:1  V:1T  Motor:3

FAMILY HISTORY: unknown

SOCIAL HISTORY: Married, lives with husband. [**Name (NI) **] family at bedside.
Subarachnoid hemorrhage,Shock, unspecified,Cerebral artery occlusion, unspecified with cerebral infarction,Cerebral aneurysm, nonruptured,Hemoperitoneum (nontraumatic),Acidosis,Pulmonary congestion and hypostasis,Ventilator associated pneumonia,Precipitous drop in hematocrit,Other specified transient cerebral ischemias,Unspecified essential hypertension,Examination of participant in clinical trial,Other and unspecified hyperlipidemia,Acute respiratory failure
Subarachnoid hemorrhage,Shock NOS,Crbl art ocl NOS w infrc,Nonrupt cerebral aneurym,Hemoperitoneum,Acidosis,Pulm congest/hypostasis,Ventltr assoc pneumonia,Drop, hematocrit, precip,Trans cereb ischemia NEC,Hypertension NOS,Exam-clincal trial,Hyperlipidemia NEC/NOS,Acute respiratry failure
Admission Date:  [**2139-2-3**]              Discharge Date:   [**2139-2-25**]

Date of Birth:  [**2069-6-25**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
SAH

Major Surgical or Invasive Procedure:
[**2139-2-3**]: R EVD placement
[**2139-2-5**]: Cerebral Angiogram with coiling
[**2139-2-8**]: Left chest tube placement
[**2139-2-8**]: Tracheostomy
[**2139-2-10**]: Cerebral angiogram with verapamil
[**2139-2-10**]: Bronch
[**2139-2-11**]: Cerebral angiogram with verapamil
[**2139-2-16**]: VP shunt
[**2139-2-17**]: Cerebral angiogram with verapamil
[**2139-2-24**]: PEG placment


History of Present Illness:
HPI:69F was home watching TV with husband when c/o not feeling
well followed by witnessed collapse. EMT arrived, found her in
pulseless Vtach that converted with CPR. Went to OSH, intubated,
CT shows large SAH bilat Sylvian fissures with blood into 3rd
and
4th ventricles. Pt transferred here for further treatment.


Past Medical History:
HTN
Hyperlipidemia

Social History:
Married, lives with husband. [**Name (NI) **] family at bedside.

Family History:
unknown

Physical Exam:
On admission:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 4    [**Doctor Last Name **]:2      GCS 5T  E:1  V:1T  Motor:3

O:  BP: 137/80         HR: 95    R 16      O2Sats95

Gen: intubated, sedated, examined in ED.
Pupils:2mm NR

Neuro:intubated, no eye opening to oxious, minimal movement all
4
to noxious

On discharge:
Awake, Alert, interactive with family, mouthing words. Follows
commands on left side. LUE localizes. RUE minimal movement-
flexion at times. BLE withdraw, L more briskly. PERRL. Head
incision C/D/I, staples out.


Pertinent Results:
CT Head [**2139-2-3**]:
Large SAH bilateral into Sylvian fissures and extension into the
3rd and 4th ventricles.

CTA Head [**2139-2-3**]: IMPRESSION: 1. Diffuse bilateral subarachnoid
hemorrhage with intraventricular extension without significant
change compared with the CT head. 2. Left posterior
communicating artery aneurysm (neck: 4mm, widest point: 5mm,
height 8mm). A 4 mm daughter aneurysm is present at the
posterior base of the aneurysm.
3. The right A1 segment of the ACA is small and this may
represent spasm vs congenital variation. No other findings to
suggest vasospasm.

[**2-4**] Echo:IMPRESSION: Preserved [**Hospital1 **]-ventricular systolic function.
Mild tricuspid regurgitation.

[**2-5**] Head CT:IMPRESSION: 1. Persistent diffuse subarachnoid
hemorrhage as described above. Increased intraventricular
hemorrhagic extension.
2. Right frontal ventriculostomy catheter ends in the prepontine
near the
Basilar artery; the relationship between the catheter tip and
artery cannot be accurately determined on this non-contrast
study. Recommend reivew of these images by the clinician to
assess if the position of the tip is appropriate/desired.
3. Some degree of superimposed diffuse cerebral edema.

[**2-5**] Cerebral Angio: ****

[**2-6**]- EEG:
FINDINGS:
ROUTINE SAMPLING: An unreactive [**4-3**] Hz theta frequency
background is
seen throughout the tracing. There are frequent periods of
superimposed
0.5-1 Hz diffuse delta slowing, which occasionally becomes
semi-rhythmic. There are occasional bifrontal sharp waves seen
during
the periods of delta slowing, although less frequent and of
lower
amplitude than the previous tracing. In addition, on [**2-7**] at 6
pm and
on [**2-8**] at 9 am, there was a generalized suppression of the
record
corresponding to increased propofol administration.
SPIKE DETECTION PROGRAMS: There were numerous spike detections,
which
did not include any epileptiform discharges.
SEIZURE DETECTION PROGRAMS: There were 25 seizure detection
programs,
which did not include any epileptiform discharges.
PUSHBUTTON EVENTS: There were no pushbutton events.
SLEEP: The patient did not exhibit any normal features of sleep
architecture.
CARDIAC MONITOR: Showed a generally regular rhythm between 80-90
bpm.
IMPRESSION: This is an abnormal continuous EEG, due to the
presence of a
[**4-3**] Hz theta frequency background seen throughout most of the
tracing,
with frequent periods of superimposed 0.5-1 Hz diffuse delta
slowing,
which occasionally becomes semi-rhythmic. This pattern is
consistent
with a moderate diffuse encephalopathy, commonly caused by
medication
effect, metabolic disturbance, or infection. In addition, on
[**2-7**] at 6
pm and on [**2-8**] at 9 am, there was a generalized suppression of
the
record, which corresponded to increased propofol administration.
There
are occasional bifrontal sharp discharges, although less
frequent and of
lower amplitude than in the previous tracing, suggestive of a
cortical
irritability. There were no focal abnormalities or
electrographic
seizures noted.


[**2-8**] CTP FINDINGS:

There is still extensive residual subarachnoid hemorrhage with
extension into the occipital horns of the lateral ventricles
bilaterally. There is a right frontal ventriculostomy catheter
which ends in the prepontine cistern. The patient is status post
left PCOM coiling with streak artifact limiting local
assessment. There is a new hypodensity in the right cingulate
gyrus concerning for ischemia. The midline structures are
central. The ventricular configuration remains stable.

CT PERFUSION: The perfusion maps do not demonstrate evidence of
delayed
transit or reduced blood flow or blood volume.

CTA HEAD: Regions of focal narrowing in the ACA and MCA branches
are
suggestive of vasospasm. The left PCOM has a fetal
configuration. The
remaining branches of the vertebrobasilar system are patent
without evidence of significant stenosis, aneurysm or vascular
malformation.

IMPRESSION:

1. Extensive subarachnoid hemorrhage with intraventricular
extension.
2. Hypodensity in the cingulate gyri bilaterally concerning for
acute/subacute ischemia.
3. Regions of focal narrowing in the ACA and MCA branches
suggestive of
vasospasm, although not changed since CTA of [**2139-2-3**].
4. No abnormality seen on the perfusion maps.



[**2-10**] CXR / FINDINGS: There is a miniscule left apical
pneumothorax. Left chest tube is seen in unchanged position with
tip near the left apex. Left basilar atelectasis is unchanged.
No new consolidation or pleural effusion is seen.  Heart size is
normal. Tracheostomy is in unchanged position. Right-sided
central line is seen with tip at the cavoatrial junction.
Intestinal tube traverses below the diaphragm with tip out of
view.

IMPRESSION: Minuscule left apical pneumothorax.

CT Head [**2139-2-13**]:
IMPRESSION:
1. Interval decrease in the degree of subarachnoid hemorrhage
overlying the cerebral hemispheric convexities bilaterally.

2. Stable degree of intraventricular hemorrhage layering in the
occipital
horns of the lateral ventricles bilaterally and decreased degree
of hemorrhage within the fourth ventricle. No change in
ventricular size compared to [**2139-2-8**].

3. Decreased confluent hypodensities within the bilateral
cingulate gyri
compared to [**2139-2-8**], may represent improving vasospasm.

CT Head [**2139-2-14**]:
IMPRESSION:
1. CT head is unchanged from previous CT examination of
[**2139-2-13**] and
demonstrates subarachnoid and intraventricular blood and mild
ventriculomegaly. No new hypodensities to suggest evolving
infarcts.
2. CT angiography of the head demonstrates no evidence of
vasospasm. Subtle narrowing of the left middle cerebral artery
unchanged from previous CTA examination.

CT Head [**2139-2-16**]:
IMPRESSION:
1. New left MCA branch infarction.
2. Stable appearance of subarachnoid bleed.

CTA Head [**2139-2-16**]:
IMPRESSION:
1. There is a new large region of left hemisphere hypodensity
and sulcal
effacement involving left MCA distribution (please see series 2,
image 23), likely representing a large new infarction which was
not definitely present on the prior study at 2:31 hours the same
day.
2. The early subacute left MCA infarction within the left MCA
distribution, which was present on the prior study, is slightly
larger than on the prior study and shows evolution.
3. The diffuse subarachnoid hemorrhage and intraventricular
hemorrhage are
unchanged. No new hemorrhages are identified. The ventricles are
prominent
and stable. The ventricular catheter is unchanged in position.
4. CTA of the head demonstrates a small right M1 segment which
is similar to that seen on the prior study, [**2-14**], although
smaller compared with the study on [**2-3**], likely representing
continued vasospasm of this vessel. No new foci of vascular
stenosis are identified. No focus of left MCA occlusion is
identified to explain the possible new left acute large
infarction as described above.

CT Head [**2139-2-18**]:
IMPRESSION:
5 x 3 cm left parietal intraparenchymal hemorrhage. Unchanged
bilateral
subarachnoid hemorrhage and right occipital [**Doctor Last Name 534**]
intraventricular hemorrhage.

NOTE ADDED IN ATTENDING REVIEW: The left parietal process
represents
hemorrhagic conversion of the pre-existent evolving infarct in
the left MCA, superior division territory, demonstrated on the
most recent cranial CTA (on [**2139-2-16**]).

CT Abd/Pelvis [**2139-2-18**]:
IMPRESSION:
1. No evidence of retroperitoneal bleeding.
2. Colonic diverticulosis.
3. Bibasilar opacities at the lung bases could be atelectasis;
however,
cannot exclude aspiration or superinfection.
4. Hypodensity in the left renal pelvis, presumably a left
parapelvic cyst, suboptimal evaluation due to lack of IV
contrast.
5. VP shunt and post-pyloric tube in place.

[**2-19**] CTA/ CTP
CT ANGIOGRAM: The vertebral and carotid arteries and all major
branches are patent. Narrowing of the left MCA M1 segment is
similar to that seen on prior studies on [**2-16**] and [**2-14**]
consistent with stable vasospasm. There is no evidence of
arterial occlusion, aneurysm or AV malformation. Remaining MCA
and ACA branches are normal in caliber. The PCA branches are
normal with the exception of a fetal-type anatomy.

PERFUSION: Increased mean transit time and decreased cerebral
blood flow are seen in the left occipital lobe corresponding to
the area of hemorrhagic infarction. Mean transit time is
increased and blood volume is decreased in the left insular
cortex.

IMPRESSION:
1. Persistent left occipital lobe hemorrhagic infarction with
corresponding perfusion defects consistent with infarction.
2. Persistently narrowed left MCA M1 segment, consistent with
persistent mild vasospasm.


[**2-22**] lower extremtiy dopplers
FINDINGS: Grayscale and color Doppler images of bilateral common
femoral,
superficial femoral and popliteal veins were performed. There is
normal
compressibility, flow and augmentation. Flow is seen in the
veins of the
calf.

IMPRESSION: No evidence of deep venous thrombosis in bilateral
lower
extremities.

[**2-23**] CXR for line placement:
IMPRESSION:
1. New left PICC, tip at cavoatrial junction. No pneumothorax.
2. Standard position of a right paramedian catheter, left
subclavian line,
nasointestinal tube and tracheostomy.
3. Low lung volumes with possible minimal pulmonary edema.


Brief Hospital Course:
69F who was admitted to the Neuro ICU for SAH, L PCOMM aneurysm.
She had a EVD and a A-line was placed at bedside on admission.
Neo was started for BP control. She was placed on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
monitor, a Bicarb drip was initiated after a bolus for metabolic
acidosis, and she was medically paralyzed to stabilize her
respiratory status. A bedside echo was done and showed a EF >
50%, and neo was weaned off while uptitrating levophed. On [**2-4**]
morning she was on CMV 100% with a PEEP of 16, PO2 was 62, she
was started on Dopamine and Levophed. Patient appeared to be in
respiratory acidosis. In the afternoon, she remained on CMV 100%
with a PEEP of 14, PO2 86 with a lactate of 4.9. We started IV
Amicar for vasospasm.

on [**2-5**] Amicar was discontinued and the patient traveled to
Angio. Left Pcomm artery aneurysm was coiled and secured but not
completey. Vasospasm was not detected on the study.
On [**2-6**] dilantin level was corrected to 21 therefore standing
dose was decreased. EEG was initiated.

On [**2-7**] Pt remained neurologically stable but was becoming more
agitated and biting the ET tube. Propofol was started and neuro
checks were changed to Q2h. Overnight, patient spike a
temperature to 101.5 and was pancultured.

On [**2-8**], patient continued to bite on ET tube when propofol is
off. A pneumothorax in the LUL was seen on CXR after
reintubation and chest tube was placed at bedside. On
examination she briskly localized with her RUE and LUE
localized, but was slower than R to noxious stimuli, BLE
withdrew. CTA/P was done which showed

She remained stable, underwent a cerebral angiogram on [**2139-2-10**]
which showed moderate vasopsasm in the left ICA. She recieved
intraarterial verapamil injections.  She remained pressed
180-200 for sys bp.  Her chest tube was removed later that same
day.

On [**2-11**], she went to angio and received Verapamil 10mg total
(5mg to each ICA). Her exam remained stabled and her EVD was
raised to 25cm. On [**2-12**], her exam remained stable and her EVD
output was low and ICPs remained stable. Her EVD was clamped. On
[**2-13**], it was reported that there was CSF leaking from the EVD
site, a Head CT was stable, exam and ICPs remained stable. Her
EVD was re-opened to 25 and she continued to re-leak so the EVD
was dropped to 20. On [**2-13**] she also recieved 1 unit of PRBC's
and as she continued to leak following her EVD beign dropped to
20 it was again lowered this time to 15cm H2O.

On [**2-14**] she underwent a CTA of the head which was stable and
showed no vasospasm and subsequently her BP was liberalized to
100-200 systolic. Her neuro checks were also liberalized to
every 4 hours, CSF was sent for culture, and general surgery was
contact[**Name (NI) **] in preparation of VP shunt placement which was planned
for [**2-16**].  On [**2-15**] she remained stable in the ICU and on [**2-16**]
she was taken to the OR for VP shunt placement. Her post-op CT
showed a subacute left MCA infarct that was not noted in her
[**2-14**] CTA. A CTA was obtained that showed moderate to severe
spasm on the L MCA. Her SBP was kept at 180-200 and started on a
Neo drip. On [**2-17**], she was given Albumin, she was maxed on her
Neo and Levophed was started. On exam her right side was more
sluggish. She was taken to angiogram which appeared improved,
but did receive Verapamil. EEG was ordered. Later in the
evening, she appeared more lethargic, a Head CT was done which
showed a L IPH that appeared to be a hemorrhagic conversion from
the L MCA infarct. She was taken off pressors. She also had a
HCT drop and on [**2-18**] was given 2 units of PRBC and had a CT
abd/pelvis which did not show any bleed. A repeat head CT was
done which showed minimal spasm of the left MCA.  Patient was
observed to have a diffuse rash on her torso which was thought
to be a drug rash due to Vancomycin. This antibiotic was
discontinued and the patient will be followed closely for
developing fevers.

On [**2-24**], she remained stable. Her venting settings were weaned
down from the day prior and the patient is now tolerating CPAP
with a FIO2 of 41%. Her PEG was placed without difficulty.

On [**2-25**] her exam remained stable.


Medications on Admission:
- lopressor XL 50 mg tab daily
- pravastatin 20 mg at bedtimes


Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution Sig: [**11-30**]  PO Q6H (every
6 hours) as needed for fever,pain.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed for puritis.
6. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
7. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. bromocriptine 2.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. docusate sodium 50 mg/5 mL Liquid Sig: [**11-30**]  PO BID (2 times
a day).
12. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
13. HydrALAzine 10 mg IV Q6H:PRN sbp > 160
14. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once
a day: Hold if K > 5.0.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
SAH
Left PCOMM aneurysm
IVH
Respiratory Acidosis
Neurogenic Pulmonary Edema
Respiratory failure
Left pneumothorax
Post operative Fever
Obstructive hydrocephalus
Dysphagia
Left MCA Stroke
Left Intraparenchymal hemorrhage
Post-operative Anemia
Urinary tract infection / complicated
hyponatremia
Cerebral artery vasopsasm
Allergic reaction/drug/vancomycin/rash


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
??????	You do not need ASA or Plavix at this time.
??????       Please continue Keppra until follow-up.

What activities you can and cannot do:
??????	There is no activity restrictions at this time.

What to report to office:
??????	Changes in vision (loss of vision, blurring, double vision,
half vision)
??????	Slurring of speech or difficulty finding correct words to use
??????	Severe headache or worsening headache not controlled by pain
medication
??????	A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
??????	Trouble swallowing, breathing, or talking
??????	Numbness, coldness or pain in lower extremities
??????	Temperature greater than 101.5F for 24 hours
??????	New or increased drainage from incision or white, yellow or
green drainage from incisions
??????	Bleeding from groin puncture site

*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!


Followup Instructions:
You will need to return for completion of  your coiling in one
month's time. The tentative date is [**2139-3-18**]. Our office will
send further information to your home and her rehab facility.
Please call [**Telephone/Fax (1) 4296**] with any questions or concerns.



Completed by:[**2139-2-25**]
{'Subarachnoid hemorrhage,Shock, unspecified,Cerebral artery occlusion, unspecified with cerebral infarction,Cerebral aneurysm, nonruptured,Hemoperitoneum (nontraumatic),Acidosis,Pulmonary congestion and hypostasis,Ventilator associated pneumonia,Precipitous drop in hematocrit,Other specified transient cerebral ischemias,Unspecified essential hypertension,Examination of participant in clinical trial,Other and unspecified hyperlipidemia,Acute respiratory failure'}


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: SAH

PRESENT ILLNESS: HPI:69F was home watching TV with husband when c/o not feeling
well followed by witnessed collapse. EMT arrived, found her in
pulseless Vtach that converted with CPR. Went to OSH, intubated,
CT shows large SAH bilat Sylvian fissures with blood into 3rd
and
4th ventricles. Pt transferred here for further treatment.

MEDICAL HISTORY: HTN
Hyperlipidemia

MEDICATION ON ADMISSION: - lopressor XL 50 mg tab daily
- pravastatin 20 mg at bedtimes

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: On admission:
PHYSICAL EXAM:
Hunt and [**Doctor Last Name 9381**]: 4    [**Doctor Last Name **]:2      GCS 5T  E:1  V:1T  Motor:3

FAMILY HISTORY: unknown

SOCIAL HISTORY: Married, lives with husband. [**Name (NI) **] family at bedside. 

### Response:
{'Subarachnoid hemorrhage,Shock, unspecified,Cerebral artery occlusion, unspecified with cerebral infarction,Cerebral aneurysm, nonruptured,Hemoperitoneum (nontraumatic),Acidosis,Pulmonary congestion and hypostasis,Ventilator associated pneumonia,Precipitous drop in hematocrit,Other specified transient cerebral ischemias,Unspecified essential hypertension,Examination of participant in clinical trial,Other and unspecified hyperlipidemia,Acute respiratory failure'}
