CHIEF COMPLAINT: worst headache of life with right sided numbness and weakness.
nausea, vomiting, slurred speech

PRESENT ILLNESS: This is a 78 year old male who at 9pm this evening was
ambulating to the bathroom when he "reeled" to the right side
and
then leaned to his right side.  At the same moment he
experienced
right lateral neck pain and headache associated with numbness on
the right side of his body, slurred speech, and nausea and
vomiting.  The pt denies any visual disturbance, bowel and
bladder incontinence, or hearing deficit at the time of the
event.  The patient was brought to an outside hospital where he
had a Head Ct which was consistent with a posterior fossa
hemorrhage with hemorrhage in the ventricles as well.  The
patient was transferred here for further management. The patient
denies taking aspirin, Coumadin, Plavix heparin or Lovenox

MEDICAL HISTORY: HTN, asthma, low back surgery, enlarged prostate

MEDICATION ON ADMISSION: HCTZ 25mg Po daily, Monopril 40mg Po daily, Mevacor 10mg PO
daily, Hytrin 5mg Po Daily, Claritin 10mg PO prn, Relafen 750mg
PO prn, Ultracet 50mg PO prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
O: T:97  BP: 136 / 66  HR:54    R: 18    O2Sats: 97% r/a
Gen: pt is lying on stretcher with eyes closed in no apparent
distress.
HEENT: Pupils:1mm  EOMs: lateral bilateral nystagmus
Neck: supple
Extrem: Warm and well-perfused.
Neuro:
Mental status: pt lethargic, eyes open to voice, cooperative
with
exam with much prompting.
Orientation: Oriented to person, place, and date.
Recall:grossly intact
Language: Speech slow with good comprehension and repetition.
Naming intact.

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: lives at home with his wife.  The patient has three
daughters who are at the bedside and one son who is flying in to
see the patient overnight.
Intracerebral hemorrhage,Anomalies of cerebrovascular system,Acute respiratory failure,Meningitis due to gram-negative bacteria, not elsewhere classified,Cerebral edema,Obstructive hydrocephalus,Alkalosis,Intestinal infection due to Clostridium difficile,Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Subarachnoid hemorrhage,Other facial nerve disorders,Hematuria, unspecified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Obstructive sleep apnea (adult)(pediatric),Asthma, unspecified type, unspecified,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Dysphagia, unspecified,First degree atrioventricular block,Pure hypercholesterolemia,Other postprocedural status
Intracerebral hemorrhage,Cerebrovascular anomaly,Acute respiratry failure,Mningts gram-neg bct NEC,Cerebral edema,Obstructiv hydrocephalus,Alkalosis,Int inf clstrdium dfcile,SIRS-noninf w/o ac or ds,Subarachnoid hemorrhage,Facial nerve dis NEC,Hematuria NOS,Klebsiella pneumoniae,Obstructive sleep apnea,Asthma NOS,Hypertension NOS,BPH w/o urinary obs/LUTS,Dysphagia NOS,Atriovent block-1st degr,Pure hypercholesterolem,Post-proc states NEC
Admission Date:  [**2168-2-1**]              Discharge Date:   [**2168-2-17**]

Date of Birth:  [**2089-4-21**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
worst headache of life with right sided numbness and weakness.
nausea, vomiting, slurred speech

Major Surgical or Invasive Procedure:
Right Frontal EVD
Diagnostic cerebral angiogram
Tracheostomy
PEG placement


History of Present Illness:
This is a 78 year old male who at 9pm this evening was
ambulating to the bathroom when he "reeled" to the right side
and
then leaned to his right side.  At the same moment he
experienced
right lateral neck pain and headache associated with numbness on
the right side of his body, slurred speech, and nausea and
vomiting.  The pt denies any visual disturbance, bowel and
bladder incontinence, or hearing deficit at the time of the
event.  The patient was brought to an outside hospital where he
had a Head Ct which was consistent with a posterior fossa
hemorrhage with hemorrhage in the ventricles as well.  The
patient was transferred here for further management. The patient
denies taking aspirin, Coumadin, Plavix heparin or Lovenox

Past Medical History:
HTN, asthma, low back surgery, enlarged prostate


Social History:
lives at home with his wife.  The patient has three
daughters who are at the bedside and one son who is flying in to
see the patient overnight.


Family History:
noncontributory

Physical Exam:
PHYSICAL EXAM:
O: T:97  BP: 136 / 66  HR:54    R: 18    O2Sats: 97% r/a
Gen: pt is lying on stretcher with eyes closed in no apparent
distress.
HEENT: Pupils:1mm  EOMs: lateral bilateral nystagmus
Neck: supple
Extrem: Warm and well-perfused.
Neuro:
Mental status: pt lethargic, eyes open to voice, cooperative
with
exam with much prompting.
Orientation: Oriented to person, place, and date.
Recall:grossly intact
Language: Speech slow with good comprehension and repetition.
Naming intact.

Cranial Nerves:
I: Not tested
II: Pupils are 1 mm bilaterally. Visual fields are full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally with
nystagmus.
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 on right 4- biceps/triceps/delts.left foot
drop
is reported as patients baseline.  dorsiflexors/plantar flexors
[**1-21**].

Sensation: Intact to light touch.

Toes downgoing bilaterally

Coordination: normal on finger-nose-finger, rapid alternating
movements.

ON DISCHARGE
Exam fluctuates ; at best he will eye open to voice with tactile
stim.  No tracking, + simple commands (sticks out tongue /
wiggle toes), Nods yest to name only (appropirate to challenge
of name), + right facial weakness, pupils 1.5mm to pinpoint/
reactive, attempts to localize to sternal rub/ + grimace, triple
flexion on lower ext.

Pertinent Results:
CT Head with and without contrast [**2168-1-31**]
1.Intracranial hemorrhage, centered in the superior vermis of
the
cerebellum, with extension to involve the subarachnoid and
intraventricular spaces. The extent of hemorrhage has increased
over the short-interval since the prior examination, with an
increase in the size of the ventricles, which is likely related
to the hemorrhage within the ventricular system resulting in
outflow obstruction.
Consideration may be given to external ventricular drainage.

2.Multiple small arterial feeding vessels extending towards the
cerebellar
vermian hemorrhage, with single prominent collecting vein,
draining directly into the vein of [**Male First Name (un) 2096**], concerning for a
vascular malformation. Given that there is no principal arterial
feeder or typical vascular nidus identified, and that there is a
close relationship of these multiple arteries to the tentorial
dura, these findings suggest an underlying dural arteriovenous
fistula, rather than a true arteriovenous malformation (which
would, in any case, be unusual in a patient of this age).

CT Head without contrast [**2168-2-2**]
1)New or increased bitemporal subarachnoid hemorrhage,
concerning for new or
continued bleeding from the cerebellar hemorrhagic focus.
2) Otherwise, stable appearance of cerebellar vermian hemorrhage
with unchanged vasogenic edema causing mild supratentorial
herniation. No midline shift. No increased mass effect.
3) Interval placement of a right frontal approach
ventriculostomy catheter terminating into the third ventricle.
No significant change in the degree of ventricular dilatation.
Stable appearance of blood products within third, fourth and
lateral ventricles, with some redistribution.

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________________________________________________________________
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2168-2-3**] 12:36 AM

Final Report
HISTORY: 78-year-old man, with altered mental status, and large
cerebellar
intraparenchymal hemorrhage, with intraventricular extension to
the lateral, third and fourth ventricles. Now status post stent
placement. De-saturating in the 70% FIO2 and febrile. Assess for
pulmonary source.

COMPARISON: Limited comparison from prior chest radiographs with
the latest on [**2168-2-2**].

TECHNIQUE: MDCT images were acquired from the thoracic inlet to
the lung
bases before and after administration of IV contrast.
Multiplanar reformatted images were obtained for evaluation.

CTA CHEST: The study is moderately limited by suboptimal IV
bolus timing as the segmental and subsegmental branches of the
pulmonary arterial vasculature are insufficiently opacified.
There is no central pulmonary embolism. The study is further
limited by patient's inadvertent expiration during the
supposedly end-inspiratory phase, evident by posterior tracheal
wall bowing (2:16). The tracheobronchial tree remains patent.

Respiratory motions limits evaluation of the lower lobes, but no
suspicious lung masses or nodules are detected. There is
bibasilar dependent atelectasis. Bilateral simple pleural
effusions are small on the right and trace on the left. There is
no pneumothorax. There are scattered calcified lymph nodes, with
representative ones seen in the subcarinal station (2:26) and
the right hilum (2:27). None of the central lymph nodes are not
pathologically enlarged, ranging up to 6 mm in the right lower
paratracheal station (3:52). There is no hilar or axillary
lymphadenopathy.

The visualized thyroid is normal. Heart size is top normal, with
trace
physiologic pericardial effusion. The left main coronary artery
and the left anterior descending artery are partially calcified.
Calcified atherosclerotic plaques scatter along the aortic arch.
The aorta is otherwise normal in caliber and course, without
acute aortic pathology. The remaining great mediastinal vessels
are normal.

The study is not designed for subdiaphragmatic diagnosis. A 24 x
21 mm
hypodense left hepatic lesion (2:24) is compatible with a liver
cyst. The
right kidney is not imaged, but in the expected location of the
right upper pole, there is a hypodense lesion, likely represents
a exophytic renal cyst (2:56). The visualized spleen, adrenal
glands and pancreas are grossly unremarkable. There is a small
hiatal hernia.

BONE WINDOW: No suspicious osteolytic or blastic lesion is
noted. There are mild-to-moderate multilevel degenerative
changes.

IMPRESSION:
1. Suboptimal IV bolus timing limits assessment of subsegmental
and segmental pulmonary artery vasculature. No central pulmonary
embolism. No acute aortic pathology.
2. Bilateral small pleural effusions, right larger than left.
3. Partially calcified mediastinal and hilar lymph nodes. No
lymphadenopathy.


The study and the report were reviewed by the staff radiologist.



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________________________________________________________________

[**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M  78  [**2089-4-21**]

Radiology Report CT HEAD W/O CONTRAST Study Date of [**2168-2-3**]
12:36 AM


FINDINGS: The size of the cerebellar hemorrhage is similar to
the previous
study, measuring approximately 2.6 x 2 cm (AP x TRV). In
comparison to [**2168-2-2**], there is new/increased bifrontal
subarachnoid hemorrhage (2:24, 2:23). The amount and
distribution of subarachnoid hemorrhage in the temporal lobe is
similar to the most recent prior study. Blood again layers in
the occipital horns. The amount of vasogenic edema surrounding
the cerebellar hemorrhage is similar to the previous study, with
partial effacement of the right ambient cistern. The ventricles
have decreased in size. The right frontal approach
ventriculostomy catheter is unchanged, terminating at the level
of the foramen of [**Last Name (un) 2044**]. There is no shift of normally midline
structures. No new parenchymal hemorrhage is identified.

The visualized paranasal sinuses demonstrate minimal mucosal
thickening of the posterior ethmoid air cells on the right. The
paranasal sinuses and mastoid air cells are otherwise normally
pneumatized and aerated. A small focus of pneumocephalus
overlies the right frontal lobe, unchanged.

IMPRESSION:
1. New or increased bifrontal subarachnoid hemorrhage in
comparison to the
study of roughly 16 hours earlier, concerning for new or
continued bleeding, with extension of existing hemorrhage into
the subarachnoid spaces.
2. Otherwise unchanged appearance of the cerebellar hemorrhage
with
surrounding vasogenic edema resulting in mild upward
transtentorial
herniation.
3. Interval decrease in the size of the lateral and third
ventricles in
comparison to [**2168-2-2**], s/p EVD. Unchanged blood layering
in the
occipital horns.

COMMENT: Discussed by Dr. [**Last Name (STitle) 20059**] with [**Doctor First Name **] [**Doctor Last Name **] of
neurosurgery 5:00am, [**2168-2-3**].

The study and the report were reviewed by the staff radiologist.


_____________________________________________________________


[**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M  78  [**2089-4-21**]

Radiology Report CT HEAD W/O CONTRAST Study Date of [**2168-2-8**]
3:54 PM


Final Report
INDICATION: 78-year-old man with cerebellar bleed.

Please evaluate.

COMPARISON:
Angiogram from [**2168-2-8**]. CT of the head from [**2168-2-6**], [**2-3**] and [**2168-2-5**]. Outside hospital CT from
[**2168-1-31**].

TECHNIQUE: Contiguous axial images were obtained through the
brain without IV contrast.

FINDINGS:

CT OF THE HEAD: Again seen is an intraventricular shunt
traversing the right frontal lobe and ending in the frontal [**Doctor Last Name 534**]
of the right lateral ventricle. In the interval, multiple
hyperdense streak artifacts are visualized at the level of the
superior vermis consistent with AVM embolization meterial. There
is unchanged, predominantly right-sided hemorrhage in the
superior vermis and superior cerebellar cistern. There is
unchanged trace subarachnoid hemorrhage, predominantly seen in
the right parietal lobe. There is significant decrease of the
previously described intraventricular hemorrhage of the lateral
ventricles and fourth ventricle. Unchanged periventricular and
subcortical bilateral white matter hypodensities likely
represent mixed small vessel ischemic disease. Unchanged mild
mucosal thickening of the ethmoid sinuses.

IMPRESSION:
1. Unchanged superior vermis, intraparenchymal and superior
cerebellar
cistern hemorrhage secondary to AVM.
2. In the interval, multiple hyperdense streak artifacts are
visualized at
the level of the superior vermis consistent with AVM
embolization.
3. Unchanged position of the right lateral ventricle drain.
4. Significant decrease of the intraventricular hemorrhage.
Unchanged right parietal lobe subarachnoid hemorrhage.

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________________________________________________________________

 [**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M  78  [**2089-4-21**]

Radiology Report UNILAT UP EXT VEINS US RIGHT PORT Study Date of
[**2168-2-7**] 10:16 AM
 Final Report
INDICATION: 78-year-old man with new right arm swelling. Rule
out DVT.

COMPARISON: None.

FINDINGS: Grayscale, color, and Doppler evaluation of the right
internal
jugular vein, subclavian vein, brachial, cephalic, and basilic
veins were
performed. There is normal compressibility, flow, and
augmentation. There is no evidence of DVT.

IMPRESSION: No evidence of DVT in the right upper extremity.

The study and the report were reviewed by the staff radiologist.


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________________________________________________________________


[**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M  78  [**2089-4-21**]

Radiology Report CT CHEST W/O CONTRAST Study Date of [**2168-2-9**]
10:52 AM

Final Report
HISTORY: 78-year-old man, with pulmonary edema and possible
infiltrate in the left lower lobe. Assess for changes.

COMPARISON: CTA chest on [**2168-4-4**] and multiple chest
radiographs with the latest on [**2168-2-9**].

TECHNIQUE: Non-contrast MDCT images were acquired from the
thoracic inlet to the lung bases. Multiplanar reformatted images
were obtained in 5 mm and 1.25 mm slice thickness for
evaluation.

CT CHEST WITHOUT CONTRAST: Compared to the prior study six days
ago, there is interval increase to now small bilateral pleural
effusions. There are
relaxation atelectasis in the lower lobes, but superimposed
infection cannot be excluded. Evaluation of the underlying lung
lesions is limited in the setting of atelectasis and pleural
effusions but no gross mass or nodule are noted. A calcified
granuloma is noted in the right lower lobe (2:21). There is no
pneumothorax. The patient is intubated with the endotracheal
tube terminating 2.4 cm above the carina. A nasogastric tube
traversing the esophagus with the tip terminating in the
first/second portion of the duodenum.

The heart is mild-to-moderately enlarged but without significant
pericardial effusion. The unopacified great mediastinal vessels
are grossly within normal limits. Mild coronary artery
calcifications are most evident along the LAD.  Scattered
mediastinal lymph nodes are not pathologically enlarged, and
likely reactive. There is no gross hilar or axillary
lymphadenopathy. Several partially calcified mediastinal and
hilar lymph nodes are indicative of old granulomatous disease.

The study is not designed for subdiaphragmatic diagnosis. The
2.7 cm
hypodense left hepatic lesion again seen, unchanged, likely
represents hepatic cyst (2:38). Bilateral multiple hypodense
renal lesions, incompletely evaluated but are likely to be renal
cysts. The remaining visualized abdomen is grossly normal.

BONE WINDOW: There is no osteolytic or blastic lesions
concerning for
malignancy. Lumbar spinal fusion hardware is noted in the scout
image (1:2).

IMPRESSION:
1. Interval increase of now small bilateral pleural effusions.
Bibasilar
relaxation atelectasis. Superimposed infection cannot be
excluded.
2. Stable mild-to-moderate cardiomegaly, without significant
pericardial
effusion.

The study and the report were reviewed by the staff radiologist.


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[**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M  78  [**2089-4-21**]

Neurophysiology Report EEG Study Date of [**2168-2-13**]


FINDINGS:
BACKGROUND: Is diffusely slow and disorganized consisting mostly
of
delta frequency slowing with occasional theta frequencies. There
are
fairly frequent generalized and multifocal (R>L) spikes and
sharps
occurring both in isolation as well as in brief semi-periodic
runs with
a frequency of around 1 Hz. There were no electrographic
seizures
noted.
HYPERVENTILATION: Could not be performed secondary to patient
being
intubated.
INTERMITTENT PHOTIC STIMULATION: Could not be performed
secondary to
the portable nature of this study.
SLEEP: No normal sleep architecture was seen on this recording.
CARDIAC MONITOR: A generally regular rhythm was noted; however,
there
were two distinct rhythms noted, one with a prolonged QRS
complex and
another with a narrow QRS complex.
IMPRESSION: This is an abnormal extended routine EEG due to a
diffusely
slow and disorganized background marked by fairly frequent
generalized
and multifocal R>L spikes and sharps. At times, these occurred
in brief
semi-periodic runs with a frequency of about 1 Hz. There were no

electrographic seizures noted. Overall, this background is
suggestive
of a sever encephalopathy. Amongst the most common causes of
encephalopathy are metabolic derangements, medications,
infection, and
anoxia.


[**Known lastname 109375**],[**Known firstname **] W. [**Medical Record Number 109376**] M  78  [**2089-4-21**]

Radiology Report BILAT LOWER EXT VEINS Study Date of [**2168-2-16**]
7:25 AM


[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-A [**2168-2-16**] 7:25 AM
BILAT LOWER EXT VEINS   Clip # [**Clip Number (Radiology) 109377**]
Reason: eval for dvt



[**Hospital 93**] MEDICAL CONDITION:
   78 year old man with cerebellar hemorrhage. prolonged bedrest
/ low frade temps
   as of [**2168-2-15**]
REASON FOR THIS EXAMINATION:
   eval for dvt



Provisional Findings Impression: DLrc TUE [**2168-2-16**] 11:31 AM
PFI: No evidence of bilateral lower extremity DVT.


Final Report
INDICATION: Patient is a 78-year-old male. With prolonged
immobilization.
Evaluate for deep venous thrombus.

EXAMINATION: Bilateral lower extremity DVT study.

COMPARISONS: None available.

FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the bilateral
common femoral,
superficial femoral, and popliteal veins were performed. There
is normal
flow, compressibility and augmentation. In addition, normal flow
is
demonstrated within the post-bilateral posterior tibial and
peroneal veins.
Symmetric respiratory variability is demonstrated in the common
femoral veins.

IMPRESSION: No evidence of bilateral lower extremity DVT.

The study and the report were reviewed by the staff radiologist.


DR. [**First Name (STitle) **] LI
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2168-2-16**] 1:25 PM

  Imaging Lab


CT scan +/- contrast this am - reviewed by Dr. [**First Name (STitle) **] as stable
without abcess.  Final read pending.


Brief Hospital Course:
Patient presented to OSH after experiencing the worst headache
of his life.   on the evening of [**2-1**].  he complained of right
sided head and neck pain as well as associated right sided
numbness and weakness, nausea, vomiting, and slurred speech.  On
ehad Ct he was found to have a cerebellar hemorrhage most likely
secondary to an AVM.  He was transferred to [**Hospital1 18**] for further
management and was placed in the ICU. Given his cerebellar
bleeding as well as his Head CT which showed that his hemmorhage
included both lateral ventricles as well as the third and fourth
ventricles, he was taken to the OR semi-urgently on the
afternoon of [**2-1**] for palcement of an EVD under anesthesia.
This procedure was uneventful and he came out of the OR with the
EVD at 20cm and clamped.  He was stable overnight into the 16th
with the EVD clamped and ICP's ranging from [**3-6**]. His mental
status seemed to be slightly better on exam on [**2-2**] and he
underwent cerebral angiography for diagnostic purposes.

He later had ICP's that were slightly elevated with a headache
as well.  His EVD was opened at 20cm.  He spiked a temp and was
hypoxic as well.  A fever workup ensued as well as a CTA of the
chest. PE workup was negative.  Ultimiately CSF grew out gram
negative rods.  It was re-sent and the gram stain was confirmed.


On the 18th the distal collection system was changed out and csf
was again sent off of the new system, the results were gram
negative rods once again. Patient's EVD was then clamped in
attemps to determine if EVD can be removed. ID is involved and
recommended that we continue current antibiotic regimen. An
echocardiogram was ordered.

On the morning of [**2-5**] he was quite lethargic on exam with
increased weakness right greater than left.  This may be
secondary to his fevers.  Hhe was mentating appropriately and
his EVD, which had been clamped overnight was working
effectively when opened to assess.  He had minimal ICP issues
over night which did not require unclamping of his drain.  A
Head CT with contrast was obtained as well which was planned.
CSF was obtained via the EVD in order to assess for any
progression of infection.  He was switched to meropenem.

He had mental status changes and his EVD stopped working on
[**2168-2-6**].  A new catheter was placed by Dr. [**Last Name (STitle) **].  His exam
remained stable with the drain open at 20.  The patient was
brought to the angio suite for emobolization on Monday [**2168-2-8**].
he underwent the procedure without issue.  His BP was tightly
controlled 90-110 sys for approx. the first 24 hours.  He was
due to be extubated the am of [**2168-2-9**] but he had upper extremity
twitching that was non suppressable, somewhat rhythmic and non
responsive to ativan.

An EEG was performed and the preliminary results were the he was
not having seizures
Stroke neurology was also consulted to assist in the assessment
of the possible seizure activity.  They recommended starting
Keppra.

He remained intubated in the ICU with no eye opeing or ability
to follow commands and was subsequently trach and peged on
[**2168-2-13**].

on [**2-14**] the EVD had remained clamped for 48 hours and
subsequently removed.  He was later weaned off of the ventilator
to trach collar.  His transfer to step down was hindered x 24
hours only by increased secreations requiring frequent
suctioning.

He had lower extremity dopplers which were negative.  His CT +/-
contrast was negative this am.  He was deemed safe for d/c to
rehab.

Medications on Admission:
HCTZ 25mg Po daily, Monopril 40mg Po daily, Mevacor 10mg PO
daily, Hytrin 5mg Po Daily, Claritin 10mg PO prn, Relafen 750mg
PO prn, Ultracet 50mg PO prn

Discharge Medications:
1. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day).
2. Metoclopramide 10 mg IV Q6H:PRN TF residual > 200
Hold for elevated QTc
3. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
4. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours) for stop after last dose on [**2168-2-24**]
weeks.
5. HydrALAzine 15-25 mg IV Q3H:PRN SBP > 160
do not exceed the dose of 200mg/24hrs
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
9. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
10. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
13. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Four (4) Puff Inhalation Q4H (every 4 hours).
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation Q4H (every 4 hours) as needed for Wheezing.

15. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTHUR (every Thursday).
16. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
17. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
20. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q 24H (Every 24 Hours)
as needed for back pain.
21. Lovastatin 20 mg Tablet Sig: 0.5 Tablet PO Daily ().
22. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
23. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day) as needed for constipation.
24. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
25. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]

Discharge Diagnosis:
CEREBELLAR AVM
respiratory failure
dysphagia
altered mental status
CNS venrticulitis with Gram negative rod CNS infection


Discharge Condition:
Neuroligically improving.


Discharge Instructions:
Angiogram with embolization
Medications:
??????	Continue all medications you were taking before surgery,
unless otherwise directed
??????	You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.

What activities you can and cannot do:
??????	When you go home, you may walk and go up and down stairs.
??????	You may shower (let the soapy water run over groin incision,
rinse and pat dry)
??????	Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
??????	No driving until you are no longer taking pain medications

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:
Please call the office at [**Telephone/Fax (1) **] to be seen by Dr. [**First Name (STitle) **]
/ Neurosurgery in  4 weeks - you will need a CT scan of the
brain with contrast at that time.



Completed by:[**2168-2-17**]
{"Intracerebral hemorrhage,Anomalies of cerebrovascular system,Acute respiratory failure,Meningitis due to gram-negative bacteria, not elsewhere classified,Cerebral edema,Obstructive hydrocephalus,Alkalosis,Intestinal infection due to Clostridium difficile,Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Subarachnoid hemorrhage,Other facial nerve disorders,Hematuria, unspecified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Obstructive sleep apnea (adult)(pediatric),Asthma, unspecified type, unspecified,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Dysphagia, unspecified,First degree atrioventricular block,Pure hypercholesterolemia,Other postprocedural status"}


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: worst headache of life with right sided numbness and weakness.
nausea, vomiting, slurred speech

PRESENT ILLNESS: This is a 78 year old male who at 9pm this evening was
ambulating to the bathroom when he "reeled" to the right side
and
then leaned to his right side.  At the same moment he
experienced
right lateral neck pain and headache associated with numbness on
the right side of his body, slurred speech, and nausea and
vomiting.  The pt denies any visual disturbance, bowel and
bladder incontinence, or hearing deficit at the time of the
event.  The patient was brought to an outside hospital where he
had a Head Ct which was consistent with a posterior fossa
hemorrhage with hemorrhage in the ventricles as well.  The
patient was transferred here for further management. The patient
denies taking aspirin, Coumadin, Plavix heparin or Lovenox

MEDICAL HISTORY: HTN, asthma, low back surgery, enlarged prostate

MEDICATION ON ADMISSION: HCTZ 25mg Po daily, Monopril 40mg Po daily, Mevacor 10mg PO
daily, Hytrin 5mg Po Daily, Claritin 10mg PO prn, Relafen 750mg
PO prn, Ultracet 50mg PO prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
O: T:97  BP: 136 / 66  HR:54    R: 18    O2Sats: 97% r/a
Gen: pt is lying on stretcher with eyes closed in no apparent
distress.
HEENT: Pupils:1mm  EOMs: lateral bilateral nystagmus
Neck: supple
Extrem: Warm and well-perfused.
Neuro:
Mental status: pt lethargic, eyes open to voice, cooperative
with
exam with much prompting.
Orientation: Oriented to person, place, and date.
Recall:grossly intact
Language: Speech slow with good comprehension and repetition.
Naming intact.

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: lives at home with his wife.  The patient has three
daughters who are at the bedside and one son who is flying in to
see the patient overnight. 

### Response:
{"Intracerebral hemorrhage,Anomalies of cerebrovascular system,Acute respiratory failure,Meningitis due to gram-negative bacteria, not elsewhere classified,Cerebral edema,Obstructive hydrocephalus,Alkalosis,Intestinal infection due to Clostridium difficile,Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Subarachnoid hemorrhage,Other facial nerve disorders,Hematuria, unspecified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Obstructive sleep apnea (adult)(pediatric),Asthma, unspecified type, unspecified,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Dysphagia, unspecified,First degree atrioventricular block,Pure hypercholesterolemia,Other postprocedural status"}
