CHIEF COMPLAINT: Non-verbal, right hemiparesis

PRESENT ILLNESS: Pt is a 63 year old man with a hx of HTN, DM, and COPD who went
to work as usual today and was last seen normal around 7:00AM.
At 10:30, a customer found him "confused" and "staggaring
around" his trophy shop.  EMS was called.  They found him
sitting on the ground outside the store. Vitals in the field
were: 168/90 58 16 100%.  He was noted to be non verbal and had
a right HP.  Per their notes, he appeared to understand what was
being said to him.  On Arrival to the ER, vitals were: T 97.4,
BP 162/98, HR 58 RR18 and O2Sat 100%.  He was initially examined
by the ER resident and the stroke fellow who found him awake,
but with a fluctuating level of arousal, non-verbal, not
following commands, and with a dense right hemiplegia. He was
intubated for airway protection and is now sedated in the ER.
CT scan showed large left putamenal hemorrhage with
intraventricular extension. Neurosurgery evaluated the patient
and felt that no surgical intervention was indicated at this
point. He will be admitted to the neuro ICU for continued care.

MEDICAL HISTORY: COPD, HTN, DM

MEDICATION ON ADMISSION: beta blocker
insulin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T afebrile BP158/80 HR50's  RR14-18 O2 Sat 100%
Gen: Intubated, +spontaneous movement of the left arm and leg
HEENT:  NC/AT, no icterus or injection, ET and OG tubes in
place.
Neck: Difficult to rotate or flex neck, no Kernigs, no bruit
CV: RRR, Nl S1 and S2,
Lung: +course BS bilaterally anteriorly
Abd: +BS soft, non-distended
Ext: no edema

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Divorced, has one son [**Male First Name (un) **]. Lives with son, daughter-in-law
and grandson.  Owns and works in a trophy shop in [**Location (un) 1411**].
Former Tob, no EtOH or drugs.
Intracerebral hemorrhage,Chronic airway obstruction, not elsewhere classified,Pneumonitis due to inhalation of food or vomitus,Paroxysmal ventricular tachycardia,Meningitis due to unspecified bacterium,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Intracerebral hemorrhage,Chr airway obstruct NEC,Food/vomit pneumonitis,Parox ventric tachycard,Bacterial meningitis NOS,Hypertension NOS,DMII wo cmp nt st uncntr
Admission Date:  [**2120-6-14**]              Discharge Date:   [**2120-7-9**]

Date of Birth:  [**2057-5-22**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Non-verbal, right hemiparesis

Major Surgical or Invasive Procedure:
s/p Intubation, mechanical ventilation
s/p Ventricular drain placement
Arterial line, central venous catheter, PICC placement

History of Present Illness:
Pt is a 63 year old man with a hx of HTN, DM, and COPD who went
to work as usual today and was last seen normal around 7:00AM.
At 10:30, a customer found him "confused" and "staggaring
around" his trophy shop.  EMS was called.  They found him
sitting on the ground outside the store. Vitals in the field
were: 168/90 58 16 100%.  He was noted to be non verbal and had
a right HP.  Per their notes, he appeared to understand what was
being said to him.  On Arrival to the ER, vitals were: T 97.4,
BP 162/98, HR 58 RR18 and O2Sat 100%.  He was initially examined
by the ER resident and the stroke fellow who found him awake,
but with a fluctuating level of arousal, non-verbal, not
following commands, and with a dense right hemiplegia. He was
intubated for airway protection and is now sedated in the ER.
CT scan showed large left putamenal hemorrhage with
intraventricular extension. Neurosurgery evaluated the patient
and felt that no surgical intervention was indicated at this
point. He will be admitted to the neuro ICU for continued care.

Past Medical History:
COPD, HTN, DM


Social History:
Divorced, has one son [**Male First Name (un) **]. Lives with son, daughter-in-law
and grandson.  Owns and works in a trophy shop in [**Location (un) 1411**].
Former Tob, no EtOH or drugs.


Family History:
Unknown

Physical Exam:
T afebrile BP158/80 HR50's  RR14-18 O2 Sat 100%
Gen: Intubated, +spontaneous movement of the left arm and leg
HEENT:  NC/AT, no icterus or injection, ET and OG tubes in
place.
Neck: Difficult to rotate or flex neck, no Kernigs, no bruit
CV: RRR, Nl S1 and S2,
Lung: +course BS bilaterally anteriorly
Abd: +BS soft, non-distended
Ext: no edema

Neurologic examination:
Mental status: Unresponsive, does not open eyes to verbal or
tactile stimulation. Grimaces to noxious stim and moves the left
arm and leg spontaneously.  Doesn't follow commands.

Cranial Nerves: No blink to threat bilaterally.  Pupils 3mm and
sluggish bilaterally, fundi could not be visualised. Eyes
disconjugate with the left eye slightly laterally deviated.
+dolls bilaterally. +corneal reflex bilaterally,. +gag movement
of ETT.

Motor: Normal bulk bilaterally. Tone increased in the right LE.
Right UE flaccid.  Does not move or withdraw right side
spontaneously or to noxious stim.  Left arm and leg with
vigorous spontaneous movement (at least [**5-7**])

Sensation: Winces to pain in all 4 extremities

Reflexes: DTRs normal but slightly more brisk on the right. Toes
upgoing bilaterally

Coordination and gait: unable to assess due to mental status


Pertinent Results:
WBC-10.1 HGB-13.1* HCT-37.3* PLT-184
PT-12.7 PTT-26.1 INR(PT)-1.1
Na-141 K-4.5 Cl-106 HCO3-26  BUN-22  CREAT-1.1  GLUC 150
CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-1.4*
Cardiac enzymes negative    %HgbA1C 6.5
TRIGLYCER-144 CHOL-186  LDL-113 HDL CHOL-44

Head CT: Roughly 3.6 cm hemorrhage in the left basal ganglia,
involving putamen and globus pallidus. Blood has dissected into
the ventricular system, and there is blood in all of the
ventricles. There is some expansion of the left temporal [**Doctor Last Name 534**],
and there is edema in the adjacent periventricular white matter.
Otherwise, the ventricles are not dilated. The hematoma
impresses the left lateral ventricle, but there is minimal shift
of midline structures to the right. Patchy areas of decreased
attenuation are present in the cerebral white matter, likely
reflecting microvascular infarction.


Brief Hospital Course:
Assessment: 63 year old man with hypertension, diabetes who was
found confused with right sided weakness on morning of
admission. On arrival to the ER, he was non-verbal with
fluctuating level of arousal and flaccid right hemiparesis. He
was intubated due to declining mental status. CT scan showed
large hemorrhage in the left basal ganglia with intraventricular
extension. The location of the bleed is typical for hypertensive
hemorrhage.

1. Hemorrhagic cerebral infarction: Mr [**Known lastname 61470**] was admitted to
the neuro ICU service. Blood pressure was controlled with
labetalol to try and minimize further hemorrhage. Repeat head CT
showed slight interval increase in left midbrain compression and
loss of the paramesencephalic space, with extension of blood
into the fourth ventricle. He was started on mannitol and a
ventricular drain was placed by neurosurgery on [**2120-6-15**] given
high likelihood of developing hydrocephalus. Drain was removed
on [**2120-6-21**], mannitol discontinued a few days prior. After
several days in the ICU, he became intermittently agitated and
was restarted on propofol. This was successfully discontinued,
and several days later he became more alert and responsive,
starting ~[**6-22**]. Additionally, he began to recover some movement
of his right leg, and some minimal movement of his right arm.
Multipodus boots were started, as was range of motion exercises
of his right hand to prevent flexion contractures once tone
began ot increase. He was very dysarthric, but did follow simple
commands and could repeat simple words. With assistance of
[**Last Name (un) **] consult, blood sugars were also controlled to help
neurological recovery.

Though bleed was likely due to hypertension, MRI was done to
evaluate for any other etiology. It showed unusual enhancement
of basal cisterns and area just lateral to bleed, which per
neuroradiology could represent effect of blood vs infection-
advised sending CSF. Initial CSF showed elevated RBCs from the
intraventricular blood but no evidence of infection.

2. Pulmonary: Pt was intubated in ED due to fluctuating mental
status and concern for airway protection. Once he became more
alert and started following simple commands he was extubated on
[**6-23**]. Post-extubation he had difficulty managing secretions and
was not oxygenating well. However, with aggressive pulmonary
toilet, this improved and he was weaned to nasal cannula. There
was initially concern for possible aspiration, as pt did vomit
prior to arrival in ED. However, chest x-ray remained clear,
without evidence of infiltrates.

3. Cardiovascular: Pt was ruled out for a myocardial infarction
with serial EKGs and enzymes. He was weaned form labetalol to
captopril and metoprolol for blood pressure control.

4. ID: Shortly after admission he began to spike fevers and had
elevated white count. Sputum, blood and urine cultures remained
negative. LFTs, pancreatic enzymes were also normal, and head CT
without evidence of sinusitis. He was on ancef prophylactically
while drain was in place. CSF sampled from the ventricular drain
on [**6-17**] still had significant RBCs and a proportional number of
WBCs, so still without evidence of infection. On [**6-23**], patient
was less alert than in the several days prior, lungs had
increased crackles, and sputum had Gram-positive cocci on Gram
stain so he was started empirically on levofloxacin and
vancomycin as fevers to 102 persisted, WBC count remained at 14,
and it was felt his decreased alertness was likely due to fever
and infection. Fever slightly better on [**6-24**], but then on [**6-25**]
spiked again to 102 and WBC count up to 16. Lumbar puncture was
done, and CSF was xanthochromic with 300 WBC (69%N, 4%L, 27%M),
166 RBC, protein 150, glucose 53. Therefore, levofloxacin was
discontinued, he was started on ceftraixone 2gm, and vancomycin
was continued as CSF was consistent with partially treated
bacterial meningitis, especially as he was s/p ventricular
drain. His mental status improved and he became more alert as
treatment continued.

5. FEN: While intubated pt was given tube feeds to maintain
adequate nutrition. After extubation, he was sleepy and
inattentive, most likely due to infection, so tube feeds were
continued.

Course on floor:
Patient was transferred to the floor on [**6-26**]. His exam remained
unchanged and he was felt to be too sleepy for swallow
evaluation. An extensive family meeting was held on both [**6-27**]
and [**6-28**] and the decision was made to make the patient CMO. All
medications were stopped and morphine and ativan given for
comfort as needed. However, over the course of the next week the
patient became much more alert and responsive and seemed to
start gaining some receptive language function. Based on this
marked improvement another family meeting was held and the CMO
was reversed, he was made DNR/DNI. Antihypertensives and insulin
sliding scale were restarted. SC heparin was restarted for DVT
prophylaxis. Speech and swallow evaluation was performed and
patient was started on nectar thick liquids and ground solids.
Over the remainder of his stay he coninued to make improvements
with some antigravity movement of his RUE and productive
language (said "baseball," grandson's name) and was able to
follow one step axial and appendicular commands. He was
discharged to an acute rehab facility.


Medications on Admission:
beta blocker
insulin

Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection TID (3 times a day). ml
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) tab PO BID
(2 times a day).
5. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose
Injection ASDIR (AS DIRECTED).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
L putamenal hemorrhage with intraventricular extension, likely
hypertensive

Discharge Condition:
improved, patient is following simple commands and speaks
multiple single words appropriately, has some antigravity
movement of his right upper and lower extremity.

Discharge Instructions:
patient can be restarted on his home insulin regimen once he is
taking full PO's

Followup Instructions:
please call Dr.[**Name (NI) 5255**] office at [**Telephone/Fax (1) 1694**] to give
registration information and schedule him for a follow up
appointment.
{'Intracerebral hemorrhage,Chronic airway obstruction, not elsewhere classified,Pneumonitis due to inhalation of food or vomitus,Paroxysmal ventricular tachycardia,Meningitis due to unspecified bacterium,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: Non-verbal, right hemiparesis

PRESENT ILLNESS: Pt is a 63 year old man with a hx of HTN, DM, and COPD who went
to work as usual today and was last seen normal around 7:00AM.
At 10:30, a customer found him "confused" and "staggaring
around" his trophy shop.  EMS was called.  They found him
sitting on the ground outside the store. Vitals in the field
were: 168/90 58 16 100%.  He was noted to be non verbal and had
a right HP.  Per their notes, he appeared to understand what was
being said to him.  On Arrival to the ER, vitals were: T 97.4,
BP 162/98, HR 58 RR18 and O2Sat 100%.  He was initially examined
by the ER resident and the stroke fellow who found him awake,
but with a fluctuating level of arousal, non-verbal, not
following commands, and with a dense right hemiplegia. He was
intubated for airway protection and is now sedated in the ER.
CT scan showed large left putamenal hemorrhage with
intraventricular extension. Neurosurgery evaluated the patient
and felt that no surgical intervention was indicated at this
point. He will be admitted to the neuro ICU for continued care.

MEDICAL HISTORY: COPD, HTN, DM

MEDICATION ON ADMISSION: beta blocker
insulin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T afebrile BP158/80 HR50's  RR14-18 O2 Sat 100%
Gen: Intubated, +spontaneous movement of the left arm and leg
HEENT:  NC/AT, no icterus or injection, ET and OG tubes in
place.
Neck: Difficult to rotate or flex neck, no Kernigs, no bruit
CV: RRR, Nl S1 and S2,
Lung: +course BS bilaterally anteriorly
Abd: +BS soft, non-distended
Ext: no edema

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Divorced, has one son [**Male First Name (un) **]. Lives with son, daughter-in-law
and grandson.  Owns and works in a trophy shop in [**Location (un) 1411**].
Former Tob, no EtOH or drugs. 

### Response:
{'Intracerebral hemorrhage,Chronic airway obstruction, not elsewhere classified,Pneumonitis due to inhalation of food or vomitus,Paroxysmal ventricular tachycardia,Meningitis due to unspecified bacterium,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
