CHIEF COMPLAINT: near falling

PRESENT ILLNESS: Per admitting resident:

MEDICAL HISTORY: HTN

MEDICATION ON ADMISSION: Occasionally ASA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam on admission:

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Lives with girlfriend (home [**Telephone/Fax (1) 83593**], cell [**Telephone/Fax (1) 83594**])
[**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) **] who is also HCP/POA.  Retired VP of a tech company.
Very remote smoking hx - quit over 35 yrs ago and drinks 1 glass
of wine nightly.  Walks about 3~4 miles daily.  Full code but
would not want prolonged care if in persistent
Intracerebral hemorrhage,Acute kidney failure, unspecified,Other pulmonary embolism and infarction,Compression of brain,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Hemiplegia, unspecified, affecting nondominant side,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension,Open wound of toe(s), without mention of complication,Unspecified accident,Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use,Accidents occurring in residential institution
Intracerebral hemorrhage,Acute kidney failure NOS,Pulm embol/infarct NEC,Compression of brain,Food/vomit pneumonitis,Acute respiratry failure,Unsp hmiplga nondmnt sde,Hyperosmolality,Hypertension NOS,Open wound of toe,Accident NOS,Drug dermatitis NOS,Adv eff penicillins,Accid in resident instit
Admission Date:  [**2198-11-28**]              Discharge Date:   [**2198-12-11**]

Date of Birth:  [**2137-11-10**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
near falling

Major Surgical or Invasive Procedure:
Endotracheal intubation, tracheostomy, PEG tube


History of Present Illness:
Per admitting resident:

Patient is a 61 yo man with hx of occasionally elevated BP
but not on any anti-hypertensive who presented to [**Hospital3 **] around midnight after a near-fall at home.  Per
patient's girlfriend/HCP, she came home late after school and
found him watching television.  While she went to wash up
upstairs, he reportedly went to the bathroom to urinate then she
heard a "thud, thud" and found him leaning next to a fall but
awake and conversant although appeared confused.  She laid him
down on the floor and put a pillow under his head then proceeded
to call 911.  Then she came back with 2 ASA with water, he
coughed a bit but was able to swallow the pills.  She called 911
again and the EMS arrived and took him to [**Hospital3 **].

Per report, he was quite hypertensive initially (213/133) with L
sided weakness and slurring of speech but answering questions
appropriately.  Head CT revealed large R BG hemorrhage (3X7cm)
with some midline shift to the left.  Patient developed
nausea/vomiting hence was intubated for airway protection prior
to being med-flighted here for further care.

NSURG reviewed the films and given no signs of hydrocephalus,
did
not intervene.  Patient remains intubated and sedated with
Propofol.


Past Medical History:
HTN


Social History:
Lives with girlfriend (home [**Telephone/Fax (1) 83593**], cell [**Telephone/Fax (1) 83594**])
[**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) **] who is also HCP/POA.  Retired VP of a tech company.
Very remote smoking hx - quit over 35 yrs ago and drinks 1 glass
of wine nightly.  Walks about 3~4 miles daily.  Full code but
would not want prolonged care if in persistent

Family History:
Unknown


Physical Exam:
Exam on admission:

T  BP 140/95 HR 57 RR 18 O2Sat 100% vented.
Gen: Lying in bed, sedated and intubated.
HEENT: hard-cervical collar in place.
CV: RRR, no murmurs/gallops/rubs
Lung: Clear anteriorly.
Abd: +BS, soft.
Ext: No edema - some cuts/blood in toes.

Neurologic examination:
MSE: Sedated and intubated but examined off Propofol for 5
minutes.  Keeps eyes closed and not responsive to verbal or
noxious stimuli but has some spontaneous, anti-gravity movements
in RUE and both legs.

Cranial Nerves:
Pupils small but reactive (1.5 ->1mm) and midline.  No Doll's
eyes and no blinking to visual threats.  Positive corneal's on R
only.  +Cough when suctioning.  Face appears symmetric.

Motor:
Normal bulk and tone bilaterally. Spontaneous, anti-gravity
movements in both legs and RUE.  Withdraws to noxious stim in
both legs and RUE but extensor posturing for LUE.

Sensation: Intact to noxious stim in all extremities.

Reflexes:
2s for biceps and 2 for R patellar but none for L.  Toes upgoing
bilaterally.

Exam at time of discharge:


Pertinent Results:
[**2198-11-28**] 01:30AM BLOOD WBC-6.1 RBC-4.22* Hgb-13.9* Hct-41.6
MCV-99* MCH-33.0* MCHC-33.5 RDW-13.7 Plt Ct-202
[**2198-11-29**] 02:01AM BLOOD WBC-15.3*# RBC-4.80 Hgb-15.5 Hct-47.2
MCV-99* MCH-32.4* MCHC-32.9 RDW-13.9 Plt Ct-236
[**2198-12-2**] 02:18AM BLOOD WBC-11.3* RBC-3.70* Hgb-12.2* Hct-36.3*
MCV-98 MCH-33.0* MCHC-33.7 RDW-13.4 Plt Ct-272
[**2198-11-28**] 01:30AM BLOOD Neuts-80.7* Lymphs-12.7* Monos-5.0
Eos-1.2 Baso-0.4
[**2198-11-28**] 01:30AM BLOOD Glucose-156* UreaN-20 Creat-0.8 Na-142
K-3.3 Cl-104 HCO3-28 AnGap-13
[**2198-12-2**] 02:18AM BLOOD Glucose-142* UreaN-36* Creat-1.0 Na-144
K-3.9 Cl-115* HCO3-22 AnGap-11
[**2198-11-28**] 01:30AM BLOOD cTropnT-<0.01
[**2198-11-28**] 01:30AM BLOOD CK(CPK)-122
[**2198-11-28**] 03:53AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2 Cholest-196
[**2198-11-28**] 03:53AM BLOOD %HbA1c-5.8
[**2198-11-28**] 03:53AM BLOOD Triglyc-138 HDL-47 CHOL/HD-4.2
LDLcalc-121
[**2198-11-28**] 01:30AM URINE RBC-[**2-22**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0
[**2198-11-28**] 01:30AM URINE Blood-MOD Nitrite-NEG Protein-75
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2198-11-28**] 01:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007

Hematology
  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2198-12-11**] 05:45AM    10.3 3.54* 11.1* 33.7* 95 31.3 32.9 12.9
506*
  DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2198-12-11**] 05:45AM    83.9*   9.8* 4.8 1.2 0.3
  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2198-12-11**] 05:45AM        506*
[**2198-12-11**] 05:45AM    13.7* 34.5   1.2*

Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2198-12-11**] 05:45AM    135* 25* 0.8 141 4.1 104 27 14


  ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2198-12-10**] 06:40AM    56* 35
  CPK ISOENZYMES CK-MB cTropnT
[**2198-11-28**] 01:30AM      <0.011
[**2198-11-28**] 01:30AM    4


  CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
[**2198-12-11**] 05:45AM          8.6 3.7 2.3
DIABETES MONITORING %HbA1c
[**2198-11-28**] 03:53AM    5.81


LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
[**2198-11-28**] 03:53AM    196 138 47 4.2 121


  PITUITARY TSH
[**2198-12-10**] 06:40AM    1.3
THYROID Free T4
[**2198-12-10**] 06:40AM    1.0

Blood Gas
  BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS AADO2 REQ O2   Intubat
[**2198-12-8**] 04:20AM    ART             127* 36 7.48* 28 4

WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
[**2198-12-1**] 09:59AM    127* 1.1 143 3.8 110
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT O2 Sat
[**2198-12-1**] 09:59AM    13.9* 42 99
  CALCIUM freeCa
[**2198-12-4**] 01:45AM    1.14


Microbiology:

[**2198-11-30**] 8:56 am SPUTUM      Source: Endotracheal.

   GRAM STAIN (Final [**2198-11-30**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN CLUSTERS.
      1+    (<1 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.

   RESPIRATORY CULTURE (Preliminary):
      Further incubation required to determine the presence or
absence of
      commensal respiratory flora.
      STAPH AUREUS COAG +.    MODERATE GROWTH.
      GRAM NEGATIVE ROD(S).    SPARSE GROWTH.

[**2198-12-5**] 12:37 am SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2198-12-8**]**

   GRAM STAIN (Final [**2198-12-5**]):
      >25 PMNs and <10 epithelial cells/100X field.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2198-12-8**]):
      Commensal Respiratory Flora Absent.
      KLEBSIELLA OXYTOCA.    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             KLEBSIELLA OXYTOCA
                             |
AMPICILLIN/SULBACTAM--     8 S
CEFAZOLIN-------------     8 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

[**2198-12-10**] 9:30 am SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2198-12-10**]**

   GRAM STAIN (Final [**2198-12-10**]):
      >25 PMNs and >10 epithelial cells/100X field.
      Gram stain indicates extensive contamination with upper
respiratory
      secretions. Bacterial culture results are invalid.
      PLEASE SUBMIT ANOTHER SPECIMEN.

   RESPIRATORY CULTURE (Final [**2198-12-10**]):
      TEST CANCELLED, PATIENT CREDITED.

BCx [**11-30**] - No Growth, [**12-5**]- No growth
UCx [**11-30**] - no growth

Imaging:

CT C-spine - IMPRESSION:
1. No fracture or malalignment of the cervical spine.
2. Degenerative changes result in mild-moderate canal narrowing
at C6-7,
deforming the ventral thecal sac. If there are neurologic
symptoms referable
to this level (e.g. new myelopathy), MRI can be obtained to
evaluate the
thecal sac and its contents.
3. Multilevel neural foraminal narrowing, most severe at C6-7.

CT head:

[**11-28**] -
IMPRESSION:
1. Interval increase in size of right basal ganglia hemorrhage,
now measuring
approximately 7.5 x 3.2 cm, with new intraventricular extension
and new
leftward subfalcine herniation.
2. Stable asymmetry of the ambient cisterns, concerning for
impending
downward transtentorial herniation.
3. No new foci of bleeding.
4. No fracture.

[**11-20**] pm:

IMPRESSION:

1. Large right basal ganglia hemorrhage with intraventricular
extension,
subfalcine herniation, sulcal effacement, and effacement of the
ambient
cisterns concerning for impending transtentorial herniation.

2. No new site of hemorrhage, and no interval development of
hydrocephalus.

[**11-30**]

IMPRESSION:
1. Large right basal ganglia hemorrhage with intraventricular
extension,
shift of midline structures towards the left, sulcal effacement,
which appears
unchanged in size and appearance from [**2198-11-28**].
2. No new site of hemorrhage.

[**12-2**]
IMPRESSION: 1. No significant change in large right basal
ganglia hemorrhage
with intraventricular extension. Persistent shift of normally
midline
structures towards the left, not significantly changed.

[**11-30**] CTA chest

IMPRESSION:
1. Right middle lobe segmental and bilateral lower lobe
subsegmental
pulmonary artery filling defects compatible with acute pulmonary
embolism.

2. Right hilar prominent 7-mm lymph node and a few subcentimeter
mediastinal
lymph nodes.

3. 4-mm lingular nodule. Followup CT in 12 months is
recommended.

4. Distended esophagus containing fluid-secretions; NG tube at
the GE
junction. Repositioning is recommended.

5. Right lower lobe pneumonia

[**11-30**] LENIs - no DVT b/l

CXR [**11-28**]:

IMPRESSION:
1. Nasogastric tube terminating within the stomach, with the tip
oriented
cephalad.
2. Interval removal of the endotracheal tube.
3. Small left pleural effusion and adjacent atalectasis.

CXR [**12-10**]
FINDINGS: As compared to the previous examination, there is no
relevant
change. Tracheostomy tube is in unchanged position. The
retrocardiac lung
areas have increased in transparency, no evidence of newly
occurred focal
parenchymal opacity suggesting pneumonia. No pleural effusions.
Unchanged
size of the cardiac silhouette.

USG  kidneys [**12-10**]
IMPRESSION:
1. No son[**Name (NI) 493**] evidence for renal artery stenosis.
2. Normal grayscale appearance of the kidneys bilaterally.




Brief Hospital Course:
61 yo man with likely HTN not on medications who had a near fall
at home and found to have L sided weakness by EMS, was
hypertensive (213/133) with a head CT revealing a large R
Putamenal/IPH, at which time was transferred to [**Hospital1 18**]. He was
admitted to NeuroICU for further treatment and monitoring.

NEURO.  On initial examination he was unable to open eyes, but
grunted to verbal stimuli.  He had roving eye movements with
rightward gaze deviation as well as spontaneous R sided
movements and L sided hemiplegia.  Initial repeat CT showed some
progression of ICH (likely putamenal w/ extension along white
matter tracts), with new IVH, worsening midline shift and
subfalcine herniation, however the following CT in PM on day of
admission was unchanged.  Patients' BP was maintained at < 160,
HOB > 30 and a negative fluid balance was achieved.  By HD2, he
was able to follow appendicular commands, was able to answer
yes/no questions and his gaze deviation improved.  He had full
strength on R side and began to move L side.  He was extubated
and transferred to floor.

However developed tachypnea and fever and respiratory distress,
along with decreased responsiveness and inability to move L
sides w/ R withdrawal to noxious as flexor while on the floor.
He was transferred back to ICU on HD#3.  Repeat CT head was
unchanged. He was diagnosed with a PNA (likely VAP) and a
Pulmonary embolism (see below)

An IVC filter was placed on [**2198-12-1**].  He continued to have mild
improvement in awareness but was not able to be wened of the
ventilator.  After a long discussion with his girlfreind and
health care proxy the decision was made to go ahead with a
tracheostomy and PEG feeding tube.  These were both placed on
[**2198-12-6**].  The patient continued to do well and was transferred
to the floor on [**2198-12-8**].  He was able to come of the ventilator
but is trach dependant. After coming back to floor, he was
maintaing a good saturation on tracheostomy. His physical exam
at the time of discharge is significant for left sided
hemiparesis and inattention towards left, minimal response to
verbal commands. He has hypotonia on left side and his plantar
is upgoing on the left side.

CV.  Hypertensive to SBP max of 180 intermittently, however
maintained < 160 for majority of HD 1 - 3.  He was treated with
nicardipine gtt for one day and transition to PO medications
including hydralazine, captopril and amlodipine, also on
clonidine patch and HCTZ. he had renal doppler for evaluation of
renal artery stenosis which did not show evidence of renal
artery stenosis. His blood pressure medicines need to be
adjusted at rehab hospital depending upon his blood pressure.
His blood pressures at the time of discharge were
110-120/70-80s.

PULM/ID. Extubated on [**11-28**] as above but reintubated on [**11-30**].
Diagnosed with VAP on HD#2 and treated with Vancomycin and Zosyn
(day 1 = [**11-30**]).  Also found to have right segmental and
subsegmental PE. He is on tracheostromy and needs usual
trachostormy care.

HEME.  Pt. was on pneumoboots x 48 hrs after admission due to
ICH.  On HD#2, was noted to have tachypnea to 50s.  CTA revealed
R segmental and subsegmental PEs.  He underwent IVC filter
placement on [**2198-12-1**] as anticoagulation was contraindicated in
setting of a large intracranial hemorrhage.  LENIs were negative
b/l on [**2198-11-30**]., given his intracranial bleed, long term
anticoagulation was not favoured.

ID- He was started on zosyn in ICU based on tracheal asp which
showed Klebsiella (scanty) , after coming to floor he did not
spike fever, his chest Xray, UA was repeated and which did not
show evidence of infection. His antibiotics (zosyn and
vancomycin) were stopped at the time of discharge.


Medications on Admission:
Occasionally ASA


Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: 1-2 MLs Mucous
membrane [**Hospital1 **] (2 times a day).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly
Transdermal every twenty-four(24) hours.
9. Captopril 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

11. Metoprolol Tartrate 25 mg Tablet Sig: Five (5) Tablet PO TID
(3 times a day).
12. Hydralazine 50 mg Tablet Sig: 1.5 Tablets PO Q4H (every 4
hours): hold if sbp less than 100.
13. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily): hold if sbp less than 100.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Right basal ganglia /intraparenchymal bleed


Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Lethargic but arousable
Activity Status:Bedbound


Discharge Instructions:
You were admitted for evaluation and management of stroke.
Please take your medicines as prescribed and call 911 or your
doctor if you have any concerns.

Followup Instructions:
Please follow up with neurology clinic as
Scheduled Appointments :
Provider [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2199-1-9**] 4:00


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
{'Intracerebral hemorrhage,Acute kidney failure, unspecified,Other pulmonary embolism and infarction,Compression of brain,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Hemiplegia, unspecified, affecting nondominant side,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension,Open wound of toe(s), without mention of complication,Unspecified accident,Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use,Accidents occurring in residential institution'}


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: near falling

PRESENT ILLNESS: Per admitting resident:

MEDICAL HISTORY: HTN

MEDICATION ON ADMISSION: Occasionally ASA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam on admission:

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Lives with girlfriend (home [**Telephone/Fax (1) 83593**], cell [**Telephone/Fax (1) 83594**])
[**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) **] who is also HCP/POA.  Retired VP of a tech company.
Very remote smoking hx - quit over 35 yrs ago and drinks 1 glass
of wine nightly.  Walks about 3~4 miles daily.  Full code but
would not want prolonged care if in persistent 

### Response:
{'Intracerebral hemorrhage,Acute kidney failure, unspecified,Other pulmonary embolism and infarction,Compression of brain,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Hemiplegia, unspecified, affecting nondominant side,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension,Open wound of toe(s), without mention of complication,Unspecified accident,Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use,Accidents occurring in residential institution'}
