CHIEF COMPLAINT: Transfer from OSH with intravetricular bleed.

PRESENT ILLNESS: 77 year-old male with history of seizure and atrial fibrillation
on coumadin who presents with intraventricular bleed. He was
found yesterday sitting on the floor of his apartment and was
incontinent of urine and confused. He went to [**Hospital3 **] in Methuan where he was found to have fever 101.2 and
leukocytosis of 14. INR was 1.1 and hematocrit 58.6. Head CT was
obtained and showed an intraventricular bleed. Patient was
transferred to [**Hospital1 18**] for further work-up and management. The
patient was loaded with dilantin prior to transfer.
.
In the [**Hospital1 18**] ER, repeat CT head was obtained without change from
the OSH study. The patient was followed by neurosurgery and it
was decided not to proceed with surgical intervention at this
time. Incidental finding was made of a T2 compression fracture
and the patient was placed in a C-collar. The patient was given
one dose of levofloxacin in the ED.
.
MICU course: He was continued on Dilantin intially with stable
neurologic exam. Ortho Spine was consulted for the T2 fracture,
and they recommended continuing C-collar and bedrest as he was
felt unable to tolerate flex-ex films. He was also found to have
a large pulsatile abdominal mass and ultrasound showed a 6 cm
AAA. [**Hospital1 **] Surgery was consulted and recommended CTA and
deferred intervention for now as would require heparin for
repair. He was started on NTG gtt for BP, then changed to
labetalol gtt, ultimately transitioned to po. He developed
agitation and dyskinesia. Neurology was consulted with change of
dilantin changed to keppra for dyskinesia. The patient was
maintained on CIWA scale for possible alcohol withdrawal. EEG
showed encephalopathy but no seizure activity. MRI/A with no
aneurysm or infarct. He failed two swallow evaluations and tube
feeds were initiated. He completed a three-day course of
ciprofloxacin for presumed urinary tract infection. He continued
to spike fevers and was started on Vancomycin/Zosyn for empiric
treatment of aspiration pneumonia. The patient was afebrile
prior to transfer to the floor. PICC line placed [**1-10**]. Mental
status now improving, off 1:1 sitter.
.
On transfer to the floor, the patient complained of discomfort
at NG tube site. Denies headache, neck pain, chest pain,
shortness of breath, abdominal pain. Unable to provide further
history.

MEDICAL HISTORY: 1. Seizure disorder
2. Atrial fibrillation on coumadin
3. Hypertension
4. Status post cholecystectomy [**1-12**]

MEDICATION ON ADMISSION: Dilantin
Coumadin
Atenolol

ALLERGIES: Dilantin / Heparin Agents

PHYSICAL EXAM: On admission to the MICU:
VS: Temp 97.9 HR 117 BP 148/93 O2 sat 96% RA RR 21
Gen: thin, elderly male, confused
HEENT: dry MM, anicteric sclera
Neck: supple
Pulm: CTA b/l ant
Cardio: RRR, nl S1 S2, 2/6 systolic murmur loudes LUSB
Abd:soft, NT, pulsatile abd mass felt, though abd is thin
Ext: no peripheral edema, 2+ DP pulses
Neuro: A&0 x1, no oriented to place or time
Pupils pinpoint but reactive to light
CN 2-12 intact
Muscle strength 5/5 in bilateral upper and lower extremities
sensation to light touch intact
.
On transfer to the floor:
Vitals- 99.3, HR 84, BP 144/87, RR 25, O2sat 99%RA, Wt 52kg
General- elderly man lying in bed, awake, oriented to self only,
answering questions, follows simple commands, intermittently
picks at sheets
HEENT- NCAT, sclerae anicteric, tacky MM
Neck- soft collar in place
Pulm- CTAB with good effort, ?poor cough
CV- irregularly irregular, no murmur
Abd- large pulsatile mass, soft, nontender
Extrem- trace ankle edema, DP pulses 2+ b/l
Neuro- alert, oriented to self only, CN III-XII intact to
challenge, UE/LE strength 5/5 throughout, pt reports intact
sensation throughout, no pronator drift

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Retired from [**Company 2676**], lives alone, Non smoker, no alcohol, has
son and daughter-in-law.
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with no loss of consciousness,Atrial fibrillation,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Methicillin susceptible Staphylococcus aureus septicemia,Encephalopathy, unspecified,Unspecified fall,Pneumonitis due to inhalation of food or vomitus,Infection and inflammatory reaction due to other vascular device, implant, and graft,Chronic kidney disease, unspecified,Hematoma complicating a procedure,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pathologic fracture of vertebrae,Long-term (current) use of anticoagulants,Abdominal aneurysm without mention of rupture,Subacute dyskinesia due to drugs,Hydantoin derivatives causing adverse effects in therapeutic use,Anticoagulants causing adverse effects in therapeutic use,Neoplasm of uncertain behavior of skin,Epilepsy, unspecified, without mention of intractable epilepsy,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Infection with microorganisms resistant to penicillins
Cl skull vlt fx w/o coma,Atrial fibrillation,Urin tract infection NOS,Acute kidney failure NOS,Meth susc Staph aur sept,Encephalopathy NOS,Fall NOS,Food/vomit pneumonitis,React-oth vasc dev/graft,Chronic kidney dis NOS,Hematoma complic proc,Chr airway obstruct NEC,Hyp kid NOS w cr kid V,Path fx vertebrae,Long-term use anticoagul,Abdom aortic aneurysm,Subac dyskinesa d/t drug,Adv eff hydantoin deriv,Adv eff anticoagulants,Unc behav neo skin,Epilep NOS w/o intr epil,Phlbts sprfc vn up extrm,Inf mcrg rstn pncllins
Admission Date:  [**2199-1-6**]              Discharge Date:   [**2199-2-9**]

Date of Birth:  [**2121-4-19**]             Sex:   M

Service: MEDICINE

Allergies:
Dilantin / Heparin Agents

Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
Transfer from OSH with intravetricular bleed.

Major Surgical or Invasive Procedure:
PICC line placement.

History of Present Illness:
77 year-old male with history of seizure and atrial fibrillation
on coumadin who presents with intraventricular bleed. He was
found yesterday sitting on the floor of his apartment and was
incontinent of urine and confused. He went to [**Hospital3 **] in Methuan where he was found to have fever 101.2 and
leukocytosis of 14. INR was 1.1 and hematocrit 58.6. Head CT was
obtained and showed an intraventricular bleed. Patient was
transferred to [**Hospital1 18**] for further work-up and management. The
patient was loaded with dilantin prior to transfer.
.
In the [**Hospital1 18**] ER, repeat CT head was obtained without change from
the OSH study. The patient was followed by neurosurgery and it
was decided not to proceed with surgical intervention at this
time. Incidental finding was made of a T2 compression fracture
and the patient was placed in a C-collar. The patient was given
one dose of levofloxacin in the ED.
.
MICU course: He was continued on Dilantin intially with stable
neurologic exam. Ortho Spine was consulted for the T2 fracture,
and they recommended continuing C-collar and bedrest as he was
felt unable to tolerate flex-ex films. He was also found to have
a large pulsatile abdominal mass and ultrasound showed a 6 cm
AAA. [**Hospital1 **] Surgery was consulted and recommended CTA and
deferred intervention for now as would require heparin for
repair. He was started on NTG gtt for BP, then changed to
labetalol gtt, ultimately transitioned to po. He developed
agitation and dyskinesia. Neurology was consulted with change of
dilantin changed to keppra for dyskinesia. The patient was
maintained on CIWA scale for possible alcohol withdrawal. EEG
showed encephalopathy but no seizure activity. MRI/A with no
aneurysm or infarct. He failed two swallow evaluations and tube
feeds were initiated. He completed a three-day course of
ciprofloxacin for presumed urinary tract infection. He continued
to spike fevers and was started on Vancomycin/Zosyn for empiric
treatment of aspiration pneumonia. The patient was afebrile
prior to transfer to the floor. PICC line placed [**1-10**]. Mental
status now improving, off 1:1 sitter.
.
On transfer to the floor, the patient complained of discomfort
at NG tube site. Denies headache, neck pain, chest pain,
shortness of breath, abdominal pain. Unable to provide further
history.

Past Medical History:
1. Seizure disorder
2. Atrial fibrillation on coumadin
3. Hypertension
4. Status post cholecystectomy [**1-12**]


Social History:
Retired from [**Company 2676**], lives alone, Non smoker, no alcohol, has
son and daughter-in-law.

Family History:
Non-contributory.

Physical Exam:
On admission to the MICU:
VS: Temp 97.9 HR 117 BP 148/93 O2 sat 96% RA RR 21
Gen: thin, elderly male, confused
HEENT: dry MM, anicteric sclera
Neck: supple
Pulm: CTA b/l ant
Cardio: RRR, nl S1 S2, 2/6 systolic murmur loudes LUSB
Abd:soft, NT, pulsatile abd mass felt, though abd is thin
Ext: no peripheral edema, 2+ DP pulses
Neuro: A&0 x1, no oriented to place or time
Pupils pinpoint but reactive to light
CN 2-12 intact
Muscle strength 5/5 in bilateral upper and lower extremities
sensation to light touch intact
.
On transfer to the floor:
Vitals- 99.3, HR 84, BP 144/87, RR 25, O2sat 99%RA, Wt 52kg
General- elderly man lying in bed, awake, oriented to self only,
answering questions, follows simple commands, intermittently
picks at sheets
HEENT- NCAT, sclerae anicteric, tacky MM
Neck- soft collar in place
Pulm- CTAB with good effort, ?poor cough
CV- irregularly irregular, no murmur
Abd- large pulsatile mass, soft, nontender
Extrem- trace ankle edema, DP pulses 2+ b/l
Neuro- alert, oriented to self only, CN III-XII intact to
challenge, UE/LE strength 5/5 throughout, pt reports intact
sensation throughout, no pronator drift

Pertinent Results:
Labwork on admission:
[**2199-1-6**] 02:50AM   WBC-16.5* RBC-5.91 HGB-18.9* HCT-53.7* MCV-91
MCH-32.0 MCHC-35.2* RDW-14.2
[**2199-1-6**] 02:50AM   PLT COUNT-234
[**2199-1-6**] 02:50AM   NEUTS-81.5* LYMPHS-12.1* MONOS-6.3 EOS-0.1
BASOS-0.1
[**2199-1-6**] 02:50AM   PT-13.3* PTT-25.0 INR(PT)-1.2*
[**2199-1-6**] 02:50AM   GLUCOSE-179* UREA N-55* CREAT-1.7* SODIUM-140
POTASSIUM-6.3* CHLORIDE-100 TOTAL CO2-27 ANION GAP-19
[**2199-1-6**] 02:50AM   CK(CPK)-201*
[**2199-1-6**] 02:50AM   CK-MB-4 cTropnT-<0.01
.
CT HEAD W/O CONTRAST  [**2199-1-6**]
IMPRESSION:
1. Intraventricular hemorrhage within the right lateral
ventricle and layering both ventricles posteriorly.
2. Hypodensity with sulcal effacement within the right parietal
lobe, which may represent a subacute infarct. There is equivocal
hyperdensity within the right MCA.
3. Mild dilatation of the ventricles, particularly the third
ventricle.
4. Chronic lacunar infarcts in the left basal ganglia.
5. Mucosal thickening of the sphenoid sinuses.
NOTE ADDED AT ATTENDING REVIEW: The right parietal infarction
appears chronic.
There is a possible tiny, nondisplaced, fracture of the left
parietal bone, seen on images 43 and 44 of series 3. There is no
associated soft tissue swelling or hemorrhage, and this may
alternatively represent a venous channel.
There does not appear to be a nasal fracture on these images,
but the nose is not completely included in the study.
The periventricular hypodensity appears to be due to chronic
small vessel ischemia, there is not evidence of hydrocephalus at
this time.
The right internal carotid artery and MCA appear enlarged. These
may be due to hypertension. However, given the intraventricular
hemorrhage, it may be advisable at some point to obtain an MR, a
CTA, or both to evaluate the possibility of an arteriovenous
malformation.
.
CT C-SPINE W/O CONTRAST  [**2199-1-6**]
IMPRESSION:
1. T2 compression fracture.
2. Interventricular hemorrhage as described on head CT scan.
NOTE ADDED AT ATTENDING REVIEW: The T2 fracture involves the
posterior aspect of the vertebral body with buckling of the
cortex and retropulsion of bone into the canal.
.
RETROPERITONEAL US  [**2199-1-6**]
IMPRESSION: Large fusiform abdominal aneurysm, measuring up to
6cm in the mid abdomen. Findings d/w the covering medical
resident.
.
CHEST (SINGLE VIEW)  [**2199-1-6**]
IMPRESSION:
1. Emphysema.
2. No focal consolidations.
.
ECG Study Date of [**2199-1-6**]  2:43:56 AM
Technically difficult study
Atrial fibrillation
Early R wave progression
Extensive ST-T changes
Consider left or biventricular hypertrophy
.
CTA HEAD W&W/O C & RECONS  [**2199-1-7**]
IMPRESSION:
1) Stable right choroid plexus, intraventricular hemorrhage.
2) No focal aneurysm, however, there is diffuse broadening of
the anterior communicating artery and likely atherosclerotic
irregularity of the M1 segment of the right MCA.
3) Stable right posterior parietal encephalomalacia, likely from
chronic infarct.
4) Previously questioned left parietal fracture is not seen on
today's study and thought to most likely have represented a
small venous channel.
.
CHEST (PORTABLE AP) [**2199-1-9**]
IMPRESSION:
1.  Too proximal position of the NG tube should be advanced for
at least 10 cm.
2.  Pulmonary hypertension and lung hyperinflation suggests
chronic lung
disease.
3.  Worsening of pulmonary edema.  An underlying infectious
process or
aspiration in the right upper lobe cannot be excluded.  Please
correlate
clinically.
.
CTA CHEST/ABDOMEN/PELVIS [**2199-1-9**]
IMPRESSION:
1. Infrarenal abdominal aortic aneurysm measuring 6.6 cm in
transverse x 6.1 cm in AP x 7.8 cm in craniocaudal dimensions
with a dissection of fresh blood between two layers of old
thrombus.
2. Bilateral pleural effusions, emphysematous change and
calcified bronchiectasis in the upper lobes.
3. Pneumobilia in patient status post cholecystectomy.
4. Enlarged prostate and bladder diverticula.
.
MRI/A BRAIN W/O CONTRAST  [**2199-1-10**]
IMPRESSION: Findings consistent with interventricular
hemorrhage. No definite evidence of acute infarction. No
definite stigmata to suggest the presence of a [**Year/Month/Day 1106**]
malformation. Examination is limited due to patient motion.
IMPRESSION: Limited MRA of the Circle of [**Location (un) 431**] with no evidence
of major [**Location (un) 1106**] flow abnormality.
.
CT HEAD W/O CONTRAST  [**2199-1-16**]
IMPRESSION:
1. Since [**2199-1-6**], decrease in size of intraventricular
hemorrhage with stable appearance of enlarged ventricles.
2. New air-fluid level within the left sphenoid sinus, with a
nasogastric tube in place.
3. Old infarcts of the right frontal and parietal lobes with
extensive small vessel infarcts.
.
BONE SCAN  [**2199-1-18**]
IMPRESSION: No evidence of increased tracer activity in the
upper thoracic
spine suggesting that the known T2 compression fracture is
chronic.
.
PERC PLCMT GASTROMY TUBE  [**2199-1-23**]
IMPRESSION: Successful placement of 14 French 63 cm [**Doctor Last Name 9835**] GJ
tube with pigtail formed in the duodenum and tip present in the
jejunum. The tube is now ready for use.
.
ECHO Study Date of [**2199-1-25**]
Conclusions:
1. The left atrium is normal in size. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Regional left ventricular wall motion is normal.
Left
ventricular systolic function is hyperdynamic (EF>75%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. No aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
6.There is borderline pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
.
CTA ABD W&W/O C & RECONS  [**2199-1-29**]
IMPRESSION:
1. Unchanged appearance of infrarenal abdominal aortic aneurysm
measuring 6.6 TV x 6.1 AP x 7.8 CC cm. No evidence of
progression of abdominal aortic aneurysm. No evidence of
infection of the aneurysm. No fluid collections identified in
the abdomen or pelvis.
2. Pneumobilia.
3. Enlarged prostate.
4. Previously noted small bilateral pleural effusions are
predominantly resolved. Small amount of atelectasis is seen at
the right lung base.
.
UNILAT UP EXT VEINS US LEFT  [**2199-1-29**]
IMPRESSION: Thrombus identified within the left internal jugular
vein extending to the junction with the subclavian vein.
Occlusive thrombus also identified within the left basilic vein.


Brief Hospital Course:
77 year-old male with past medical history of seizure disorder,
atrial fibrillation on coumadin presenting with intraventricular
bleed and incidental findings of T2 compression fracture and 6
cm AAA. The patient developed MRSA bacteremia with PICC catheter
tip positive for MRSA and heparin-inducted thrombocytopenia.
.
1. Intraventricular bleed: Status post fall. The patient was not
coagulopathic on admission. No clear [**Month/Day/Year 1106**] abnormalities on
MRA. The patient was initially on Dilantin for seizure
prophylaxis, but was changed to Keppra for dyskinesia. The
patient's imaging and neurologic exam was stable during
hospitalization. Repeat CT head one week after admission showed
decrease in size of intraventricular hemorrhage with stable
appearance of enlarged ventricles. The patient was continued on
serial neurologic checks. The patient will follow-up with
neurosurgery in four weeks with repeat CT head at that time to
monitor.
.
2. Encephalopathy/agitation: Patient appears to have severe
inattention following a fall and right intraventricular
hemorrhage greater than left with some early hydrocephalus (and
pneumocephalus, bone fracture) on imaging; inattention could be
due to injury to right side, versus old right-deficits from
prior injury or stroke exacerbated in context of toxic-metabolic
derangement. The patient also had akasthesia/dyskinesias on
admission that resolved by changing dilantin to keppra. EEG
showed nonspecific encephalopathy. MRI/A without evidence of
infarction or [**Month/Day/Year 1106**] malformation. RPR negative, TSH normal.
B12 low, folate low normal. The patient was continued on
thiamine/folate/MVI/B12 daily. The patient's mental status is
not at baseline on discharge; baseline mental status is AAOx3
and independent per family. This may continue to improve as the
patient recovers from his acute insult. The patient will
follow-up with neurosurgery in four weeks.
.
3. Seizure disorder: The patient was on dilantin as an
outpatient and loaded with dilantin at OSH. The patient was
followed by Neurology during admission. There was no seizure
activity noted on EEG. The patient's dilantin was changed to
keppra for dyskinesia. The patient was started on keppra 500
twice daily and titrated per Neurology recommendations to
[**Telephone/Fax (1) 36883**] on [**2199-1-16**] and 1000 twice daily on [**2199-1-23**].
.
4. Renal insufficiency: Creatinine elevated on admission to 1.7
and BUN 55, thought pre-renal with response to fluids. Improved
to 0.9-1.3. Unclear baseline creatinine. The decreased
creatinine later in admission likely represented decreased
muscle mass and was not a true increase in glomerular filtration
rate.
.
5. Infectious disease: The patient is status post three-day
course of ciprofloxacin on admission for presumed urinary tract
infection [**1-8**] and eight-day course of Vancomycin/Zosyn [**1-16**] for
RUL infiltrate while in MICU. The patient spiked a fever to
101.8 overnight [**1-22**] with leukocytosis on laboratories. The
patient subsequently had multiple positive blood culture bottles
for MRSA from [**Date range (1) 71521**]. The patient was started on vancomycin
and trough were therapeutic. PICC tip removed [**1-24**] and positive
for MRSA. The persistently positive blood cultures were believed
secondary to an endovascular source; hematoma at site of PICC or
seeding of the AAA. Left upper extremity ultrasound was ordered
and showed a hematoma the site of previous PICC. CT abdomen
performed to evaluate AAA negative for change or signs of
infection. The patient was followed by Infectious Disease. The
patient should complete an eight-week course of antibiotics from
the first day of negative blood cultures, [**1-28**], to treat the
bacteremia complicated by hematoma and possible endocarditis or
bone spread. The patient will have weekly bloodwork drawn and
results sent to the Infectious Disease clinic. The patient will
follow-up in the Infectious Disease clinic. The patient may need
suppressive therapy after this time. There were no new murmurs
or peripheral stigmata of endocarditis during admission. TTE was
negative for signs of endocarditis and the patient did not
tolerated TEE. No soft tissue source. Unlikely secondary to
osteomyelitis with recent negative bone scan. Differential
includes dental as patient has poor dentition and attempts at
NGT placement prior and sinus disease although unlikely with
speciation. CXR negative. Urinalysis negative. No localizing
signs or symptoms.
.
6. Heparin-induced thrombocytopenia: The patient was positive
for HIT antibodies with optical density > 1.0. Platelet count on
admission 229 with drop in platelets [**1-24**] from 179 to 109. The
patient was first exposed to heparin [**1-11**] and heparin
discontinued [**1-25**]. The patient was started on argatroban and
transitioned to coumadin. The patient should continue coumadin
indefinitely. The patient was followed by hematology.
.
7. Abdominal aortic aneursym: Incidental finding was made of a 6
cm AAA. The patient was followed by [**Month/Year (2) 1106**] surgery during
admission. Repair was deferred secondary to the patient's acute
illness. The patient will follow-up with [**Month/Year (2) 1106**] sugery in four
weeks regarding elective AAA repair.
.
8. Hypertension: The patient was started on metoprolol and
enalopril with good effect.
.
9. T2 compression fracture: The patient was followed by ortho
spine during admission. The patient was initially on C-spine
protection but this was discontinued per orthopedic
recommendations when bone scan showed the fracture was chronic.
The patient does not need follow-up with orthopedics unless new
findings arise.
.
10. Atrial fibrillation: Rate controlled on metoprolol. Coumadin
was initally held for intraventriculat hemorrhage. Per
neurosurgery and [**Month/Year (2) 1106**] surgery, the patient was able to
restart anticoagulation seven days after initial diagnosis of
IVH, [**2199-1-6**]. Anticoagulation was initially held for placement
of PEG tube.
.
11. COPD: No current issues. The patient was given nebulizers as
needed.
.
12. Skin lesion: The patient was noted to have a 1 cm round
lesion under the right eye with central necrosis. The appearance
is concerning for basal versus squamous skin cancer. The patient
was scheduled for follow-up with dermatology as an outpatient.
.
13. Nutrition: The patient failed Speech and Swallow evaluations
on multiple occasions during admission. The decision was made
with the family to place a PEG tube for nutrition.   Patient had
speech and swallow videos while in-house.  Plan was to continue
NPO but trial with nectar fluids with nursing daily.  Please
evaluate at rehab.
.
Code status: DNR/DNI
.
Disposition: The patient was discharged to rehabilitation.

Medications on Admission:
Dilantin
Coumadin
Atenolol

Discharge Medications:
1. Outpatient Lab Work
Weekly CBC with differential, BUN and creatinine, liver function
tests, and vancomycin trough. Please fax to [**Telephone/Fax (1) 1419**].
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 650 mg Suppository Sig: [**1-8**] Suppositorys Rectal
Q4-6H (every 4 to 6 hours) as needed for fever or pain.
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
7. Enalapril Maleate 10 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day) as needed.
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
First dose PM of [**2-9**] with recheck of PT/INR daily, goal INR [**2-9**].

10. Vancomycin 1,000 mg Recon Soln Sig: One (1)  Intravenous
q24hours: TO STOP [**2199-3-26**].  THIS WILL COMPLETE 8-WEEK
COURSE FROM TIME OF NEGATIVE BLOOD CULTURE ON [**2199-1-28**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
Primary:
1. Intraventricular hemorrhage
2. Abdominal aortic aneursym 6 cm
3. Chronic T2 compression fracture
4. Urinary tract infection
5. Acute on chronic renal failure
6. Skin lesion, question basal cell versus squamous cell
carcinoma versus other lesion
7. MRSA bacteremia/septicemia
8. thrombocytopenia/HIT antibody positive
.
Secondary:
1. Atrial fibrillation
2. Seizure disorder
3. Hypertension
4. Status post cholecystectomy [**1-12**]


Discharge Condition:
Afebrile, vital signs stable.


Discharge Instructions:
You were hospitalized with head bleed after a fall. The bleed is
stable on imaging. You will follow-up with neurosurgery and have
a repeat head CT.
.
While hospitalized, you were noted to have an aortic aneursym.
You will follow-up with [**Month/Year (2) 1106**] surgery regarding elective
repair of this aneursym.
.
While hospitalized, you were noted to have an old spine
fracture. You do not need to follow-up with orthopedics unless
you have pain or develop new findings.
.
While hospitalized, you developed a bloodstream infection. You
will take vancomycin, an antibiotic, for 8 weeks for treatment.
You will have labwork drawn every week and faxed to the
Infectious Disease clinic. You will follow-up in the Infectious
Disease clnic.
.
While hospitalized, you developed a reaction to heparin. You
should take coumadin as you were taking previously to prevent
clots.
.
Please contact a physician if you experience fevers, chills,
headache, focal neurologic symptoms, back pain, or any other
concerning symptoms.
.
Please take your medications as prescribed.
- Take your medications as prescribed.  Vancomycin to be
administered until [**2199-3-26**], to complete 8-week course.
.
Please verify your follow-up appointments as below.
.
Patient needs PT/INR checks daily to assess for change in
coumadin dosing.  Argatroban and coumadin were bridged until
[**2-8**].

Followup Instructions:
1.  Follow-up CT head: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2199-2-19**] 11:45
.
2.  Follow-up appointment neurosurgery: Provider:
[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. NEUROSURGERY WEST Date/Time:[**2199-2-19**] 1:00
.
3.  Follow-up with [**Month/Day/Year 1106**] surgery regarding repair of AAA:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2199-2-21**] 10:30. Please call ([**Telephone/Fax (1) 9393**] if you have
any questions or concerns.
.
4.  Follow-up with Infectious Disease regarding your bloodstream
infection: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] ID WEST (SB) Date/Time:
[**2199-3-26**]  11:00a. Please call ([**Telephone/Fax (1) 4170**] if you have any
questions or concerns.
.
5.  Follow-up with dermatology regarding the lesion under your
right eye: [**Last Name (LF) **], [**First Name3 (LF) **]. Date/Time:[**2199-4-2**] 02:15 pm. Please
call ([**Telephone/Fax (1) 8132**] if you have any questions or concerns.
.
6.  Follow-up Urology - [**2202-3-1**]:00AM.  [**Hospital Ward Name 23**] Building,
[**Location (un) 470**], surgical specialities.
.
7.  Patient needs to be evaulated by speech and swallow at rehab
to assess for ability to swallow.  Had video swallow here, team
was about to implement NPO but trials of nectar feeds with
nursing tid:prn.  Please reassess.
{'Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with no loss of consciousness,Atrial fibrillation,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Methicillin susceptible Staphylococcus aureus septicemia,Encephalopathy, unspecified,Unspecified fall,Pneumonitis due to inhalation of food or vomitus,Infection and inflammatory reaction due to other vascular device, implant, and graft,Chronic kidney disease, unspecified,Hematoma complicating a procedure,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pathologic fracture of vertebrae,Long-term (current) use of anticoagulants,Abdominal aneurysm without mention of rupture,Subacute dyskinesia due to drugs,Hydantoin derivatives causing adverse effects in therapeutic use,Anticoagulants causing adverse effects in therapeutic use,Neoplasm of uncertain behavior of skin,Epilepsy, unspecified, without mention of intractable epilepsy,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Infection with microorganisms resistant to penicillins'}


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: Transfer from OSH with intravetricular bleed.

PRESENT ILLNESS: 77 year-old male with history of seizure and atrial fibrillation
on coumadin who presents with intraventricular bleed. He was
found yesterday sitting on the floor of his apartment and was
incontinent of urine and confused. He went to [**Hospital3 **] in Methuan where he was found to have fever 101.2 and
leukocytosis of 14. INR was 1.1 and hematocrit 58.6. Head CT was
obtained and showed an intraventricular bleed. Patient was
transferred to [**Hospital1 18**] for further work-up and management. The
patient was loaded with dilantin prior to transfer.
.
In the [**Hospital1 18**] ER, repeat CT head was obtained without change from
the OSH study. The patient was followed by neurosurgery and it
was decided not to proceed with surgical intervention at this
time. Incidental finding was made of a T2 compression fracture
and the patient was placed in a C-collar. The patient was given
one dose of levofloxacin in the ED.
.
MICU course: He was continued on Dilantin intially with stable
neurologic exam. Ortho Spine was consulted for the T2 fracture,
and they recommended continuing C-collar and bedrest as he was
felt unable to tolerate flex-ex films. He was also found to have
a large pulsatile abdominal mass and ultrasound showed a 6 cm
AAA. [**Hospital1 **] Surgery was consulted and recommended CTA and
deferred intervention for now as would require heparin for
repair. He was started on NTG gtt for BP, then changed to
labetalol gtt, ultimately transitioned to po. He developed
agitation and dyskinesia. Neurology was consulted with change of
dilantin changed to keppra for dyskinesia. The patient was
maintained on CIWA scale for possible alcohol withdrawal. EEG
showed encephalopathy but no seizure activity. MRI/A with no
aneurysm or infarct. He failed two swallow evaluations and tube
feeds were initiated. He completed a three-day course of
ciprofloxacin for presumed urinary tract infection. He continued
to spike fevers and was started on Vancomycin/Zosyn for empiric
treatment of aspiration pneumonia. The patient was afebrile
prior to transfer to the floor. PICC line placed [**1-10**]. Mental
status now improving, off 1:1 sitter.
.
On transfer to the floor, the patient complained of discomfort
at NG tube site. Denies headache, neck pain, chest pain,
shortness of breath, abdominal pain. Unable to provide further
history.

MEDICAL HISTORY: 1. Seizure disorder
2. Atrial fibrillation on coumadin
3. Hypertension
4. Status post cholecystectomy [**1-12**]

MEDICATION ON ADMISSION: Dilantin
Coumadin
Atenolol

ALLERGIES: Dilantin / Heparin Agents

PHYSICAL EXAM: On admission to the MICU:
VS: Temp 97.9 HR 117 BP 148/93 O2 sat 96% RA RR 21
Gen: thin, elderly male, confused
HEENT: dry MM, anicteric sclera
Neck: supple
Pulm: CTA b/l ant
Cardio: RRR, nl S1 S2, 2/6 systolic murmur loudes LUSB
Abd:soft, NT, pulsatile abd mass felt, though abd is thin
Ext: no peripheral edema, 2+ DP pulses
Neuro: A&0 x1, no oriented to place or time
Pupils pinpoint but reactive to light
CN 2-12 intact
Muscle strength 5/5 in bilateral upper and lower extremities
sensation to light touch intact
.
On transfer to the floor:
Vitals- 99.3, HR 84, BP 144/87, RR 25, O2sat 99%RA, Wt 52kg
General- elderly man lying in bed, awake, oriented to self only,
answering questions, follows simple commands, intermittently
picks at sheets
HEENT- NCAT, sclerae anicteric, tacky MM
Neck- soft collar in place
Pulm- CTAB with good effort, ?poor cough
CV- irregularly irregular, no murmur
Abd- large pulsatile mass, soft, nontender
Extrem- trace ankle edema, DP pulses 2+ b/l
Neuro- alert, oriented to self only, CN III-XII intact to
challenge, UE/LE strength 5/5 throughout, pt reports intact
sensation throughout, no pronator drift

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Retired from [**Company 2676**], lives alone, Non smoker, no alcohol, has
son and daughter-in-law. 

### Response:
{'Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with no loss of consciousness,Atrial fibrillation,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Methicillin susceptible Staphylococcus aureus septicemia,Encephalopathy, unspecified,Unspecified fall,Pneumonitis due to inhalation of food or vomitus,Infection and inflammatory reaction due to other vascular device, implant, and graft,Chronic kidney disease, unspecified,Hematoma complicating a procedure,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pathologic fracture of vertebrae,Long-term (current) use of anticoagulants,Abdominal aneurysm without mention of rupture,Subacute dyskinesia due to drugs,Hydantoin derivatives causing adverse effects in therapeutic use,Anticoagulants causing adverse effects in therapeutic use,Neoplasm of uncertain behavior of skin,Epilepsy, unspecified, without mention of intractable epilepsy,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Infection with microorganisms resistant to penicillins'}
