CHIEF COMPLAINT: L medullary bleed

PRESENT ILLNESS: The patient is a 66 year old right handed woman with a history
of mechanical MVR on Coumadin, atrial fibrillation s/p PPM, DM
on insulin pump, hypertension, hyperlipidemia, CHF, and COPD who
presents with left upper and middle back pain and SOB s/p fall
Saturday morning with head CT showing hemorrhage in the left
medulla and small focus of SAH.

MEDICAL HISTORY: s/p mechanical MVR in [**2101**] for MR [**First Name (Titles) **] [**Last Name (Titles) 2177**], on Coumadin since the
surgery
Atrial fibrillation s/p PPM and defibrillator
Diabetes mellitus since [**2098**], on insulin pump
Hypertension
Hyperlipidemia
CHF
COPD, not on home O2
Hypothyroidism
Ulcers
Anemia and "chronic bleeding", 2 months ago Hct dropped from 34
to 18, s/p endoscopy, colonoscopy, and capsule endoscopy wihtout
source of bleed, Hct been back up to 35 over past 5-6 weeks
Osteoporosis

MEDICATION ON ADMISSION: Lasix 40 mg daily
Coumadin 3 mg daily
Lisionpril 5 mg daily
Lipitor 40 mg daily
Celexa 40 mg daily
Metoprolol 25 mg [**Hospital1 **]
Protonix 40 mg [**Hospital1 **]
Levothyroxine 150 mcg daily
Albuterol 90 tid prn
Humalog Insulin pump
Iron 150-160 U tid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: HR 60, bp 135/45, RR 19, SaO2 96% on 2L
Genl: Awake, alert, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear, slight contusion palpated in left posterior occiput
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: Bilateral crackles to the apices, no wheezes or rhonchi
Abd: Quiet BS, soft, NTND abdomen
Spine: No tenderness to palpation of the spinous processes
Back: 2 large ecchymoses in the left upper and middle lateral
back, tender to palpation

FAMILY HISTORY: Both of her parents died of an MI. She denies a family history
of stroke and DM.

SOCIAL HISTORY: She moved in with her daughter in [**Name (NI) 205**]. She has had recent falls
at home, and 4 months ago broke her wrist when falling over an
open dishwasher door. She is retired from customer service in
AAA. She smoked 2 ppd for 40 years, but quit
10 years ago. She denies EtOH or illicit drug use.
Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Fall from other slipping, tripping, or stumbling,Long-term (current) use of anticoagulants,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Insulin pump status,Heart valve replaced by other means,Congestive heart failure, unspecified,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Anemia, unspecified,Osteoporosis, unspecified,Nausea alone,Lack of coordination,Automatic implantable cardiac defibrillator in situ
Brain hem NEC w/o coma,Acute kidney failure NOS,Urin tract infection NOS,Fall from slipping NEC,Long-term use anticoagul,Atrial fibrillation,Chr airway obstruct NEC,DMII wo cmp nt st uncntr,Insulin pump status,Heart valve replac NEC,CHF NOS,Hyperlipidemia NEC/NOS,Hypothyroidism NOS,Anemia NOS,Osteoporosis NOS,Nausea alone,Lack of coordination,Status autm crd dfbrltr
Admission Date:  [**2108-2-19**]              Discharge Date:   [**2108-2-25**]

Date of Birth:  [**2042-1-22**]             Sex:   F

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
L medullary bleed

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is a 66 year old right handed woman with a history
of mechanical MVR on Coumadin, atrial fibrillation s/p PPM, DM
on insulin pump, hypertension, hyperlipidemia, CHF, and COPD who
presents with left upper and middle back pain and SOB s/p fall
Saturday morning with head CT showing hemorrhage in the left
medulla and small focus of SAH.

The patient reports that on Saturday [**2-18**] at 3:00 am, she woke
up to use the restroom which she often needs to do since she is
on Lasix. While walking back to bed, she tripped over a metal
garbage can and fell on top of the trash can. She landed on her
left side and back, and did not initially think she hit her head
and denied LOC. She got back in to bed to sleep. She woke up
Saturday morning, and had left sided mid back pain which was
[**3-9**] in intensity and worse with movement. She did not take any
medications for this because she was concerned it would interact
with her other medications. She woke up Sunday morning with
worsened back pain which was up to [**7-9**] in intensity. She also
noticed a contusion in her left posterior head, which she had
not seen before. She complained of being more short of breath
than usual, so her daughter called urgent care and took her to
the ED.

On ROS, she denied headache, lightheadness, dizziness,
nausea/vomitting, weakness/numbness, diplopia/blurry vision,
dysarthria, or dysphagia.

She initially presented to [**Hospital1 **], where vitals on admission
were bp 126/77, HR 60, RR 20, temp 98.9, SaO2 95% on RA. Her
exam was "speaking in full sentences, contusion in left
occipital region, tenderness to palpation of left posterior
chest wall, no vertebral point tenderness or step-offs, cranial
II-XII wnl, motor, sensory and cerebellar functions normal."
Labs showed Hct
35.2, WBC 6.6, plt 198, Na 135, Cr 0.92, INR 2.6. Per report,
head CT showed an 8 mm bleed in the left medulla. CT
abdomen/pelvis was ordered to rule out retroperitoneal bleed
which was preliminarily negative. Dr. [**First Name (STitle) **] in cardiology
recommended 2 U FFP, which was given. She also received Percocet
2 tabs PO x1. She was transferred to [**Hospital1 18**].

At [**Hospital1 18**], Head CT wet read showed similar appearing hemmorhagic
posterior medulla focus, possible slightly increased anterior
medulla hemmorhagic focus. no evidence of herniation, and small
focus of subarachnoid hemmorhge likely unchanged. Neurosurgery
was consulted who thought that the bleed was due to a cavernous
malformation in medulla with acute blood. She did complain of
nausea after laying down for the head CT. She currently denies
back pain. She received Zofran 4 mg IV x1, and since her repeat
INR was 2.2 she was scheduled to receive another 2 U FFP.

Past Medical History:
s/p mechanical MVR in [**2101**] for MR [**First Name (Titles) **] [**Last Name (Titles) 2177**], on Coumadin since the
surgery
Atrial fibrillation s/p PPM and defibrillator
Diabetes mellitus since [**2098**], on insulin pump
Hypertension
Hyperlipidemia
CHF
COPD, not on home O2
Hypothyroidism
Ulcers
Anemia and "chronic bleeding", 2 months ago Hct dropped from 34
to 18, s/p endoscopy, colonoscopy, and capsule endoscopy wihtout
source of bleed, Hct been back up to 35 over past 5-6 weeks
Osteoporosis

Social History:
She moved in with her daughter in [**Name (NI) 205**]. She has had recent falls
at home, and 4 months ago broke her wrist when falling over an
open dishwasher door. She is retired from customer service in
AAA. She smoked 2 ppd for 40 years, but quit
10 years ago. She denies EtOH or illicit drug use.


Family History:
Both of her parents died of an MI. She denies a family history
of stroke and DM.


Physical Exam:
VS: HR 60, bp 135/45, RR 19, SaO2 96% on 2L
Genl: Awake, alert, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear, slight contusion palpated in left posterior occiput
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: Bilateral crackles to the apices, no wheezes or rhonchi
Abd: Quiet BS, soft, NTND abdomen
Spine: No tenderness to palpation of the spinous processes
Back: 2 large ecchymoses in the left upper and middle lateral
back, tender to palpation

Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says [**Doctor Last Name 1841**]
backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. [**Location (un) **] intact.
Registers [**1-31**], recalls [**12-3**] in 5 minutes even with prompting. No
right-left confusion. No evidence of apraxia or neglect.

Cranial Nerves: Fundoscopic examination reveals sharp disc
margins. Pupils equally round and reactive to light, 5 to 3 mm
bilaterally. Visual fields are full in all 4 quadrants.
Extraocular movements intact bilaterally with 2-3 beats of
nystagmus at left end-gaze. Sensation intact V1-V3. Facial
movement symmetric. Hearing intact to finger rub bilaterally.
Palate elevation symmetric. Sternocleidomastoid and trapezius
full strength bilaterally. Tongue midline, movements intact.

Motor: Normal bulk bilaterally. No observed myoclonus,
asterixis, or tremor. No pronator drift.
  [**Doctor First Name **] Tri [**Hospital1 **]  WE FE FF  IP  H  Q DF PF TE
R  5   5   5  5  5  5   5   5  5  5  5  5
L  5   5   5  5  5  5   5   5  5  5  5  5

Sensation: Intact to pinprick, position sense, and cold
sensation throughout. Patient unable to feel vibration sense at
the left great toe, but intact at the left ankle. Decreased
vibration sense of the right great toe (8 seconds). No
extinction to DSS.

Reflexes: 2+ and symmetric in biceps, brachioradialis. 3+ and
symmetric in knees. 1+ and symmetric in triceps. 0 and symmetric
in ankles. Toes upgoing bilaterally.

Coordination: Mild dysmetria on L with FTF and HTS.

Gait: Took a few steps (limited by oxygen/telemetry/IV). Romberg
negative.

Pertinent Results:
[**2108-2-20**] 03:26AM BLOOD WBC-4.3 RBC-3.38* Hgb-8.7* Hct-27.2*
MCV-81* MCH-25.7* MCHC-31.9 RDW-14.8 Plt Ct-154
[**2108-2-20**] 03:26AM BLOOD PT-18.3* PTT-30.7 INR(PT)-1.7*
[**2108-2-19**] 08:05PM BLOOD PT-22.8* PTT-32.1 INR(PT)-2.2*
[**2108-2-20**] 03:26AM BLOOD TSH-0.18*
[**2108-2-19**] 08:05PM BLOOD Calcium-9.4 Phos-3.4 Mg-1.8
[**2108-2-19**] 08:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

CT HEAD [**2-19**]: Similar-appearing medullary hemorrhagic foci and
possible tiny left frontal subarachnoid hemmorhage.


Brief Hospital Course:
The patient is a 66 year old right handed woman with a history
of mechanical MVR on Coumadin, atrial fibrillation s/p PPM, DM
on insulin pump, hypertension, hyperlipidemia, CHF, and COPD who
presents with left upper and middle back pain and
SOB s/p fall Saturday morning with head CT showing hemorrhage in
the left medulla and possible small focus of SAH.

She reports a mechanical fall over a garbage can 2 days ago, and
then developed left sided back pain, and presented to an OSH
with SOB. Head CT there showed an 6 mm
medullary hemorrhage, and she received 2 U FFP for INR 2.6.  Her
INR on arrival to [**Hospital1 18**] was 2.2 hence received 2 more units of
FFP and repeat head CT showed no change.

She had no lateral medullary finding including vertigo,
hemisensory findings (ipsilateral face and contralateral
hemibody for pain and temperature) or ataxia.  She does have
slight L sided dysmetria with FTF and HTS.  She also had no
nausea or headache but did have significant left sided back
pain.  She was initially admitted to ICU where she remained
stable with no further deterioration and CTA (MRI unable to be
obtained due to pacemaker) showed no obivous vascular
malformation.

Her hemorrhage most likely cavernoma with bled due to trauma and
the fact that she is anticoagulated hence more prone to bleed.
Since she does have significant risk factor for stroke without
anticoagulation with her mechanical valve, she had repeat head
CT on HD#2 ([**2-21**]) as well as on [**2-23**], both of which showed
stability of her bleed. She had been off of her coumadin and her
INR drifted down to 1.6. At this point she was started on a
heparin gtt and re-started on coumadin. The heparin gtt was
later DC'd and she was started on full dose lovenox in
anticipation of her discharge.

Patient also had significant hematocrit drop from admission (35
at [**Hospital1 **] then 27 here on [**2-20**]).  Given risk factor for
possible hematoma since she had a fall and was anticoagulated,
CT torso was obtained which showed no evidence of hematoma. Her
Hct subsequently stabilized around 30.

Her course was also complicated by a one-time fever to 102 F.
Her urine was mildly dirty and she was started on Bactrim for 10
days given her prior indwelling foley. There was no other
identifiable source of infection, though some atelectasis was
noted on her CXR which may have also been contributing to her
fever.

Her course was also complicated by mild ARF (Cre 1.4) which we
felt was the product of over-diuresis in the setting of decresed
PO intake. Her lasix was held for one day and she received a
half-dose (20 mg) the following day. She also received 500 mL
NS. Her Cre subsequently improved and her usual dose of lasix
was resumed (40 mg).


Medications on Admission:
Lasix 40 mg daily
Coumadin 3 mg daily
Lisionpril 5 mg daily
Lipitor 40 mg daily
Celexa 40 mg daily
Metoprolol 25 mg [**Hospital1 **]
Protonix 40 mg [**Hospital1 **]
Levothyroxine 150 mcg daily
Albuterol 90 tid prn
Humalog Insulin pump
Iron 150-160 U tid

She stopped taking ASA 81 mg daily 2 months ago with recent Hct
drop.

Discharge Disposition:
Home With Service

Facility:
[**Hospital **] Hospice and VNA

Discharge Diagnosis:
left medullary bleed


Discharge Condition:
stable


Discharge Instructions:
You were admitted with a small medullary bleed in the context of
being on coumadin after a fall. Fortunately you have had little
deficit on your neurological exam. You were off coumadin for
several days, but it has beenr restarted now. You will need a
CAT scan of your head in one week to ensure stability of the
bleed.
Please return to the ER if you experience any focal weakness,
change in sensation, vision, language, or cognition, develop any
severe headaches, vertigo, limb clumsiness, or anything else
that concerns you seriously.

Followup Instructions:
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27772**] Phone:
Date/Time: [**2108-3-6**] 12:00pm

Provider (neurology): [**Name6 (MD) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2108-4-3**] 3:30

Head CT in about one week after discharge. Call [**Telephone/Fax (1) 327**] to
schedule.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

Completed by:[**2108-4-5**]
{'Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Fall from other slipping, tripping, or stumbling,Long-term (current) use of anticoagulants,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Insulin pump status,Heart valve replaced by other means,Congestive heart failure, unspecified,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Anemia, unspecified,Osteoporosis, unspecified,Nausea alone,Lack of coordination,Automatic implantable cardiac defibrillator in situ'}


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: L medullary bleed

PRESENT ILLNESS: The patient is a 66 year old right handed woman with a history
of mechanical MVR on Coumadin, atrial fibrillation s/p PPM, DM
on insulin pump, hypertension, hyperlipidemia, CHF, and COPD who
presents with left upper and middle back pain and SOB s/p fall
Saturday morning with head CT showing hemorrhage in the left
medulla and small focus of SAH.

MEDICAL HISTORY: s/p mechanical MVR in [**2101**] for MR [**First Name (Titles) **] [**Last Name (Titles) 2177**], on Coumadin since the
surgery
Atrial fibrillation s/p PPM and defibrillator
Diabetes mellitus since [**2098**], on insulin pump
Hypertension
Hyperlipidemia
CHF
COPD, not on home O2
Hypothyroidism
Ulcers
Anemia and "chronic bleeding", 2 months ago Hct dropped from 34
to 18, s/p endoscopy, colonoscopy, and capsule endoscopy wihtout
source of bleed, Hct been back up to 35 over past 5-6 weeks
Osteoporosis

MEDICATION ON ADMISSION: Lasix 40 mg daily
Coumadin 3 mg daily
Lisionpril 5 mg daily
Lipitor 40 mg daily
Celexa 40 mg daily
Metoprolol 25 mg [**Hospital1 **]
Protonix 40 mg [**Hospital1 **]
Levothyroxine 150 mcg daily
Albuterol 90 tid prn
Humalog Insulin pump
Iron 150-160 U tid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: HR 60, bp 135/45, RR 19, SaO2 96% on 2L
Genl: Awake, alert, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear, slight contusion palpated in left posterior occiput
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: Bilateral crackles to the apices, no wheezes or rhonchi
Abd: Quiet BS, soft, NTND abdomen
Spine: No tenderness to palpation of the spinous processes
Back: 2 large ecchymoses in the left upper and middle lateral
back, tender to palpation

FAMILY HISTORY: Both of her parents died of an MI. She denies a family history
of stroke and DM.

SOCIAL HISTORY: She moved in with her daughter in [**Name (NI) 205**]. She has had recent falls
at home, and 4 months ago broke her wrist when falling over an
open dishwasher door. She is retired from customer service in
AAA. She smoked 2 ppd for 40 years, but quit
10 years ago. She denies EtOH or illicit drug use. 

### Response:
{'Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Fall from other slipping, tripping, or stumbling,Long-term (current) use of anticoagulants,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Insulin pump status,Heart valve replaced by other means,Congestive heart failure, unspecified,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Anemia, unspecified,Osteoporosis, unspecified,Nausea alone,Lack of coordination,Automatic implantable cardiac defibrillator in situ'}
