CHIEF COMPLAINT: SAH/pancytopenia
REASON FOR MICU ADMISSION: intubated, elevated ICP s/p drain
placement

PRESENT ILLNESS: 33 yo female with no significant [**Hospital **] transferred from OSH to
[**Hospital1 18**] for MS changes, seizures, found to have large
intraparenchymal hemorrhage and midline shift/impending
herniation now s/p intrcranial drain placement for elevated ICP.
Five days ago, patient fell at home, and was evaluted at an OSH
with head CT without any acute bleed noted. She then presented
again to an OSH, with repeat HCT due to persistent HA, but still
no bleed seen. Patient then presented today to an OSH with HA,
weakness on her left, and possible seizure activity, and while
at OSH found to have large intraparenchymal bleed. She was
intubated at OSH, given dilantin prior to transfer to [**Hospital1 18**] for
NSGY eval. She reportedly had reactive pupils prior to transfer,
but on arrival, she had fixed/dilated pupils.

MEDICAL HISTORY: NONE

MEDICATION ON ADMISSION: occasional flexiril

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: BP: 110/73 HR: 72 R 17 O2Sats 100% intubated; intracranial
pressure 27
Gen: intubated; unresponsive to verbal stimuli
HEENT: 4 mm nonreactive pupils; intubated
CV: RRR
Lungs: CTA bilaterally
Abd: soft, normal BS
Ext: no edema
Neuro: no response to verbal stimuli.  withdraws on right to
deep painful stimuli. no response on left.  toes upgoing
bilaterally; clonus bilaterally.  EVD in place for intracranial
pressure monitoring

FAMILY HISTORY: unknown

SOCIAL HISTORY: married; works as postal worker. denies tobacco/etoh/drugs
Subarachnoid hemorrhage following injury without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level,Cerebral edema,Obstructive hydrocephalus,Acute myeloid leukemia, without mention of having achieved remission,Fall from other slipping, tripping, or stumbling,Civilian activity done for income or pay,Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level
Subarach hem-deep coma,Cerebral edema,Obstructiv hydrocephalus,Ac myl leuk wo achv rmsn,Fall from slipping NEC,Civilian activity-income,Brain hem NEC-deep coma
Admission Date:  [**2143-2-2**]              Discharge Date:   [**2143-2-3**]

Date of Birth:  [**2109-11-7**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
SAH/pancytopenia
REASON FOR MICU ADMISSION: intubated, elevated ICP s/p drain
placement


Major Surgical or Invasive Procedure:
extraventricular drain placement
central line placement
arterial line placement
intubation

History of Present Illness:
33 yo female with no significant [**Hospital **] transferred from OSH to
[**Hospital1 18**] for MS changes, seizures, found to have large
intraparenchymal hemorrhage and midline shift/impending
herniation now s/p intrcranial drain placement for elevated ICP.
Five days ago, patient fell at home, and was evaluted at an OSH
with head CT without any acute bleed noted. She then presented
again to an OSH, with repeat HCT due to persistent HA, but still
no bleed seen. Patient then presented today to an OSH with HA,
weakness on her left, and possible seizure activity, and while
at OSH found to have large intraparenchymal bleed. She was
intubated at OSH, given dilantin prior to transfer to [**Hospital1 18**] for
NSGY eval. She reportedly had reactive pupils prior to transfer,
but on arrival, she had fixed/dilated pupils.

In the ED, initial VS: 97.6, 78, 127/55, 100% AC/480/16/5/100%.
She had a CT head which showed a 3 cm IPH above thalamus with
extension into third ventricle, and evidence of likely impending
herniation. She was evaluted by NSGY, and had an emergent
external ventricular drain placed for elevated ICP (initially 45
in ED, on repeat prior to transfer 32). Her labs revealed
pancytopenia, decreased fibrinogen, and concern for DIC.
Heme/onc was called in the ED, and Dr. [**First Name (STitle) **] [**Name (NI) 653**] me
regarding starting her on ATRA for likely APML. She was given 2
units pRBC, 2 units of plts prior to transfer to the MICU for
further management. Dr. [**First Name (STitle) **] from neurosurgery held family
meeting and explained grave prognosis to the family.

Currently, she is intubated, sedated. She is not responsive to
voice.

ROS: unable to obtain


Past Medical History:
NONE

Social History:
married; works as postal worker. denies tobacco/etoh/drugs

Family History:
unknown

Physical Exam:
BP: 110/73 HR: 72 R 17 O2Sats 100% intubated; intracranial
pressure 27
Gen: intubated; unresponsive to verbal stimuli
HEENT: 4 mm nonreactive pupils; intubated
CV: RRR
Lungs: CTA bilaterally
Abd: soft, normal BS
Ext: no edema
Neuro: no response to verbal stimuli.  withdraws on right to
deep painful stimuli. no response on left.  toes upgoing
bilaterally; clonus bilaterally.  EVD in place for intracranial
pressure monitoring

Pertinent Results:
[**2143-2-3**] 07:27AM BLOOD WBC-12.8*# RBC-2.94* Hgb-8.6* Hct-23.2*
MCV-79* MCH-29.1 MCHC-36.9* RDW-18.7* Plt Ct-56*
[**2143-2-2**] 09:05PM BLOOD WBC-2.4* RBC-1.36* Hgb-4.2* Hct-11.6*
MCV-85 MCH-30.8 MCHC-36.1* RDW-19.9* Plt Ct-10*
[**2143-2-2**] 09:55PM BLOOD Neuts-5* Bands-0 Lymphs-25 Monos-1* Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1* Promyel-4* NRBC-1* Other-64*
[**2143-2-2**] 09:05PM BLOOD Neuts-3* Bands-1 Lymphs-14* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 Promyel-1* NRBC-3*
Other-79*
[**2143-2-3**] 07:27AM BLOOD PT-15.3* PTT-23.5 INR(PT)-1.3*
[**2143-2-2**] 09:05PM BLOOD PT-14.7* PTT-20.7* INR(PT)-1.3*
[**2143-2-3**] 07:27AM BLOOD FDP->1280*
[**2143-2-3**] 04:08AM BLOOD FDP-320-640*
[**2143-2-3**] 01:09AM BLOOD FDP-80-160*
[**2143-2-2**] 10:30PM BLOOD FDP-80-160*
[**2143-2-3**] 07:27AM BLOOD Fibrino-124*
[**2143-2-3**] 04:08AM BLOOD Fibrino-155
[**2143-2-3**] 01:04AM BLOOD Fibrino-147*
[**2143-2-2**] 09:05PM BLOOD Fibrino-115*
[**2143-2-3**] 07:27AM BLOOD Glucose-122* UreaN-16 Creat-1.0 Na-159*
K-3.5 Cl-122* HCO3-27 AnGap-14
[**2143-2-2**] 09:05PM BLOOD Glucose-138* UreaN-22* Creat-0.9 Na-137
K-4.0 Cl-104 HCO3-21* AnGap-16
[**2143-2-3**] 07:27AM BLOOD ALT-22 AST-42* LD(LDH)-529* AlkPhos-51
TotBili-2.9* DirBili-0.7* IndBili-2.2
[**2143-2-2**] 09:05PM BLOOD ALT-19 AST-36 LD(LDH)-392* AlkPhos-30*
TotBili-0.4
[**2143-2-3**] 07:27AM BLOOD Calcium-10.0 Phos-1.7* Mg-2.3 UricAcd-4.4
[**2143-2-2**] 09:05PM BLOOD TotProt-6.4 Calcium-8.8 Phos-4.0 Mg-1.8
UricAcd-3.6
[**2143-2-3**] 07:27AM BLOOD D-Dimer-GREATER TH
[**2143-2-3**] 01:09AM BLOOD D-Dimer-7895*
[**2143-2-3**] 07:27AM BLOOD Osmolal-334*
[**2143-2-3**] 04:08AM BLOOD Osmolal-332*
[**2143-2-3**] 01:04AM BLOOD Osmolal-328*
[**2143-2-2**] 09:05PM BLOOD PEP-NO SPECIFI IgG-567* IgA-70 IgM-50
[**2143-2-3**] 08:45AM BLOOD Type-ART Temp-40.0 Rates-/16 Tidal V-500
PEEP-5 FiO2-50 pO2-250* pCO2-33* pH-7.50* calTCO2-27 Base XS-3
Intubat-INTUBATED
[**2143-2-3**] 01:10AM BLOOD Type-ART Temp-35.8 pO2-499* pCO2-29*
pH-7.51* calTCO2-24 Base XS-1 Intubat-INTUBATED
[**2143-2-2**] 10:05PM BLOOD Hgb-4.6* calcHCT-14
[**2143-2-3**] 09:31AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.038*
[**2143-2-3**] 09:31AM URINE Blood-LG Nitrite-NEG Protein-150
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-8.0 Leuks-NEG
[**2143-2-3**] 09:31AM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-<1
[**2143-2-3**] 04:08AM URINE Hours-RANDOM Creat-12 Na-< 10
[**2143-2-3**] 04:08AM URINE Osmolal-224

[**2143-2-3**] 9:30 am SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2143-2-6**]**

   GRAM STAIN (Final [**2143-2-3**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS, CHAINS, AND
CLUSTERS.
      3+  (5-10 per 1000X FIELD):   GRAM NEGATIVE DIPLOCOCCI.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2143-2-6**]):
      HEAVY GROWTH Commensal Respiratory Flora.
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------   0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S

[**2143-2-3**] Blood cultures: no growth
[**2143-2-3**] Urine Cultures: no growth

[**2143-2-2**] ECG:
Sinus rhythm. Tracing is within normal limits. No previous
tracing available for comparison

[**2143-2-2**] CXR:
IMPRESSION:
1. Endotracheal tube tip is slightly low lying, approximately
2.6 cm from the carina. Nasogastric tube in standard position.
2. No acute cardiopulmonary abnormality.

[**2143-2-2**] CT HEAD:
IMPRESSION:
1. Intraparenchymal hemorrhage, largely centered over the right
thalamus,
with intraventricular extension and associated hydrocephalus.
2. Small extra-axial hematoma overlying the left cerebral
convexity, likely subdural in location.
3. Diffuse cerebral edema.
4. Effacement of the basal cisterns, suggestive of early or
impending central herniation.

[**2143-2-3**] CTA HEAD:
IMPRESSION:
1. Increased intraventricular and midbrain hemorrhage when
compared to the
most recent examination. Small low-attenuation subdural
collection overlying the left frontal lobe is not significantly
changed.
2. Abnormal contrast enhancement within the midbrain at the
inferior margin of the hematoma could represent small foci of
active extravasation, though the unusual curvilinear structure,
more dorsally, may represent abnormal intravascular enhancement,
either in a congested and distorted normal vein, or related to
an underlying vascular abnormality such as an AVM.
3. Interval insertion of a right frontal ventriculostomy
catheter tip
terminating near the third ventricle with slight interval
decrease in size of the frontal horns, though slight expansion
in size of the temporal and
occipital horns.
4. Persistent moderate cerebral edema with effacement of the
basal cisterns, indicative of central and downward
transtentorial herniation.
5. While the major intracranial arteries are patent, the mild
irregularity of the basilar artery suggests mild vasospasm.

[**2143-2-3**] CT HEAD:
IMPRESSION: Large right thalamic hemorrhage with
intraventricular extension, and the overall volume of hemorrhage
appears increased from the previous studies. There is also
moderate associated vasogenic edema.
NOTE ADDED IN ATTENDING REVIEW: In addition to the persistent
large amount of hemorrhage and unchanged ventricular dilatation,
despite the recently-inserted ventriculostomy, there is also
persistent effacement of all basal cisterns, suggestive of
central uncal and downward transtentorial herniation. There is
no evidence of tonsillar herniation, either on this study or the
sagittal reformations of the preceding CTA.

[**2143-2-3**] PERIPHERAL BLOOD FLOW CYTOMETRY:
INTERPRETATION:
Ommunophenotypic findings consistent with involvement by acute
promyelocytic leukemia.


Brief Hospital Course:
ASSESSMENT & PLAN:
33 yo female s/p fall presenting with HA, left sided weakness,
seizure activity now with 3 cm IPH with likely herniation s/p
EVD placement by NSGY with elevated ICP (45 initially), also
found to have pancytopenia and DIC labs consistent with likely
early DIC

# IPH/Elevated ICP: Patient was initially transferred to [**Hospital1 18**]
once noted to have 3 cm IPH on OSH head CT.  Dr. [**First Name (STitle) **]
(neurosurgery) evaluated patient in the ED, and and EVD was
placed with marked elevated pressures (45 initially). Patient
was at high risk for bleed given markedly low platelets, but
without this procedure, she would have continued to herniate
given the bleeding. She was transfused cryo, FFP, and platelets,
and once the drain was secured, she was transferred to the MICU.
 On arrival, her ICP was 23.  She had a central line placed, and
arterial line placed, and was closely monitored for ICP
elevation as well as sodium and osmolarity.  She was given
further products to maintain her plts greater than 50K.  She had
Q1H neurochecks, and mannitol was given to maintain Na and
osmolarity.  She was also started on dilantin for seizure
prophylaxis, and given cefazolin for EVD/skin prophylaxis.
Neurosurgery continued to monitor her progress.  Despite these
attempts, a few hours after admission to the MICU, the patient's
ICP drastically elevated again (>50).  Neurosurgery was at the
bedside to evaluate the patient, and it seemed the drain was
likely clotting off, most likely due to further bleeding.  She
was sent for a stat repeat head CT which showed worsening of the
bleeding within the ventricles.  Her neurologic status continued
to deteriorate.  After meetings with both Dr. [**First Name (STitle) **], Dr. [**First Name (STitle) **]
(hematology attending), the ICU team, and the patient's family,
it was determined that no further intervention can be performed
which would reverse the patient's condition.  The patient was
made CMO, and she expired later that afternoon.  An autopsy was
not wanted by the family.

# Pancytopenia: Patient initially presented with all depressed
cell lines. Given atypical cells, hematology was consulted.  The
intitial smear reviewed by hematology was felt to be most
consistent with AML, most likely APML given the clinical
scenario.  The patient was started on all trans retinoic acid
shortly after arrival to the MICU .  She was monitored for DIC
labs (which she did develop), and was given further blood
products (FFP, plateletes, cryoprecipitate).  Flow cytometry was
performed and was consistent with AML.  Given her poor prognosis
with the intracranial hemorrhage, as above, the patient was made
CMO.

The patient's family was present and updated frequently by the
primary ICU team, neurosurgical team, and hematology service.
Social work was also involved with this patient's care and her
family.  Autopsy was declined.


Medications on Admission:
occasional flexiril

Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
Acute promyelocytic Leukemia
Intracranial Hemorrhage
Thrombocytopenia
Anemia

-EXPIRED

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level,Cerebral edema,Obstructive hydrocephalus,Acute myeloid leukemia, without mention of having achieved remission,Fall from other slipping, tripping, or stumbling,Civilian activity done for income or pay,Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level'}


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/pancytopenia
REASON FOR MICU ADMISSION: intubated, elevated ICP s/p drain
placement

PRESENT ILLNESS: 33 yo female with no significant [**Hospital **] transferred from OSH to
[**Hospital1 18**] for MS changes, seizures, found to have large
intraparenchymal hemorrhage and midline shift/impending
herniation now s/p intrcranial drain placement for elevated ICP.
Five days ago, patient fell at home, and was evaluted at an OSH
with head CT without any acute bleed noted. She then presented
again to an OSH, with repeat HCT due to persistent HA, but still
no bleed seen. Patient then presented today to an OSH with HA,
weakness on her left, and possible seizure activity, and while
at OSH found to have large intraparenchymal bleed. She was
intubated at OSH, given dilantin prior to transfer to [**Hospital1 18**] for
NSGY eval. She reportedly had reactive pupils prior to transfer,
but on arrival, she had fixed/dilated pupils.

MEDICAL HISTORY: NONE

MEDICATION ON ADMISSION: occasional flexiril

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: BP: 110/73 HR: 72 R 17 O2Sats 100% intubated; intracranial
pressure 27
Gen: intubated; unresponsive to verbal stimuli
HEENT: 4 mm nonreactive pupils; intubated
CV: RRR
Lungs: CTA bilaterally
Abd: soft, normal BS
Ext: no edema
Neuro: no response to verbal stimuli.  withdraws on right to
deep painful stimuli. no response on left.  toes upgoing
bilaterally; clonus bilaterally.  EVD in place for intracranial
pressure monitoring

FAMILY HISTORY: unknown

SOCIAL HISTORY: married; works as postal worker. denies tobacco/etoh/drugs 

### Response:
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level,Cerebral edema,Obstructive hydrocephalus,Acute myeloid leukemia, without mention of having achieved remission,Fall from other slipping, tripping, or stumbling,Civilian activity done for income or pay,Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level'}
