CHIEF COMPLAINT: Large Left cerebellar hemorrhage

PRESENT ILLNESS: 84F who presented to OSH after a two day history of nausea
and vomiting.  She went to the ED earlier this evening for
ongoing nausea and vomiting and increased drowsiness, with an
"inability" to get OOB. Of note patient takes Coumadin 2.5mg
daily for an unknown condition.

MEDICAL HISTORY: 1. Unknown cardiac condition requiring anticoaguation
2. Insomnia
3. Hypertension
4. s/p CVA
5. s/p THR

MEDICATION ON ADMISSION: 1. Prednisone 5mg daily
2. Warfarin 2.5mg daily
3. Lunesta 2mg QHS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
O: T: afebrile  BP:207/122   HR: 85   RR:18     O2Sats: 97%
ventilated
Gen: intubated.
HEENT: normocephalic, atraumatic
Pupils: equal bilaterally, minimally reactive to light.
EOMs: unable to assess
Extrem: Warm and well-perfused.
Neuro:
Mental status: Spontaneously moving all four extremities,
briskly
withdrawing LE to noxious>upper extremities.  Brisk corneals,
+gag to deep suction with associated facial grimacing.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: non-contributory
Dysphagia, oropharyngeal phase,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Abdominal aneurysm without mention of rupture,Hip joint replacement,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Intracerebral hemorrhage,Aphasia,Other specified conduction disorders,Obstructive hydrocephalus,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere
Dysphagia, oropharyngeal,Hypertension NOS,Chr airway obstruct NEC,Abdom aortic aneurysm,Joint replaced hip,Hx TIA/stroke w/o resid,Intracerebral hemorrhage,Aphasia,Conduction disorder NEC,Obstructiv hydrocephalus,Urin tract infection NOS,Delirium d/t other cond
Admission Date:  [**2183-6-9**]              Discharge Date:   [**2183-6-27**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Large Left cerebellar hemorrhage

Major Surgical or Invasive Procedure:
[**6-9**]: Suboccipital craniotomy for hematoma evacuation and
placement of EVD


History of Present Illness:
84F who presented to OSH after a two day history of nausea
and vomiting.  She went to the ED earlier this evening for
ongoing nausea and vomiting and increased drowsiness, with an
"inability" to get OOB. Of note patient takes Coumadin 2.5mg
daily for an unknown condition.

Past Medical History:
1. Unknown cardiac condition requiring anticoaguation
2. Insomnia
3. Hypertension
4. s/p CVA
5. s/p THR

Social History:
non-contributory

Family History:
non-contributory

Physical Exam:
On Admission:
O: T: afebrile  BP:207/122   HR: 85   RR:18     O2Sats: 97%
ventilated
Gen: intubated.
HEENT: normocephalic, atraumatic
Pupils: equal bilaterally, minimally reactive to light.
EOMs: unable to assess
Extrem: Warm and well-perfused.
Neuro:
Mental status: Spontaneously moving all four extremities,
briskly
withdrawing LE to noxious>upper extremities.  Brisk corneals,
+gag to deep suction with associated facial grimacing.

Cranial Nerves:
I: Not tested
II: Pupils equally round and minimally reactive to light,2mm
bilaterally.
III, IV, VI-XII: unable to assess

Toes downgoing bilaterally


Pertinent Results:
CT Scan([**6-8**]) Pre-operative:
IMPRESSION:
1. Large intraparenchymal hemorrhage centered within the left
cerebellar hemisphere with associated effacement of the fourth
ventricle and quadrigeminal plate cistern.
2. Hydrocephalus.
3. Encephalomalacia within the left frontal lobe.

   RADIOLOGY  Final Report
MR HEAD W/O CONTRAST  [**2183-6-25**] 3:29 PM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: ? evidence for embolic stroke.
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with possible history of PFO/embolic stroke,
previously on coumadin admitted with left cerebellar hemorrhage,
s/p evacuation. Now with new AMS, aphasia.
REASON FOR THIS EXAMINATION:
? evidence for embolic stroke.
CONTRAINDICATIONS for IV CONTRAST: None.
MRI OF THE BRAIN WITHOUT GADOLINIUM. MRA OF THE BRAIN USING 3D
TIME-OF-FLIGHT TECHNIQUE.
HISTORY: History of embolic stroke on Coumadin, left cerebellar
hemorrhage status post evacuation and change in mental status.
Comparison is made with CT from the same day.
There are encephalomalacic and gliotic changes in the left
cerebellum with blood products relating to a hematoma
evacuation. There is no significant mass effect on the fourth
ventricle. Old infarction in the left frontal lobe is again
noted. There is a focus of restricted diffusion in the right
thalamus, which is probably related to old hemorrhage in this
site. There is an apparent focus of restricted diffusion in the
right frontal lobe, which is quite small. This could represent a
focus of subacute ischemia. There is no significant associated
mass effect. There is no midline shift. There is evidence for
prior hemorrhage or blood products in the right putamen, caudate
and to a lesser extent, the left basal ganglia.
Intracranial flow voids are maintained.
Ventricles and sulci are unchanged in size and configuration.
There is bilateral mastoid opacification.
MRA of the circle of [**Location (un) 431**] demonstrates there is irregularity
of the right distal MCA extending to M2 branches. There is also
narrowing in the left interior M2 branch. These are likely
related to atherosclerotic disease. Bilateral distal PCA
irregularity and narrowing is also noted.

IMPRESSION:
Moderate small vessel ischemic sequela.
Small focus of restricted diffusion in the right frontal white
matter, which could represent a subacute infarction. There is no
associated mass effect or midline shift.
Atherosclerotic narrowing in the circle of [**Location (un) 431**], which does
not appear to be hemodynamically significant.

   RADIOLOGY   Preliminary Report

VIDEO OROPHARYNGEAL SWALLOW  [**2183-6-26**] 1:54 PM
VIDEO OROPHARYNGEAL SWALLOW
Reason: ? aspiration, ? can advance diet.
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with ICH, AVNRT, AMS with histor of dysphagia,
silent aspiration.
REASON FOR THIS EXAMINATION:
? aspiration, ? can advance diet.
VIDEO OROPHARYNGEAL SWALLOW
INDICATION: 84-year-old woman with intracranial hemorrhage,
presenting with aspiration.
COMPARISON: [**2183-6-20**].
FINDINGS: Oral and pharyngeal swallowing videofluoroscopy was
performed today in collaboration with speech and language
pathology. Various consistencies of barium were administered.
ORAL PHASE: There is moderate impairment of bolus formation and
prolongation of the mastication. The remainder of the oral phase
was within functional limits. There is mild coating of residue
after the _____ solids.
PHARYNGEAL PHASE: There is mild delay in swallow initiation and
mild reduction in laryngeal valve closure. The remainder of the
pharyngeal phase was within functional limits. Mild coating
remains in the valleculae after solid food and purees.
ASPIRATION/PENETRATION: There is intermittent penetration before
the swallow with thin liquids, no aspiration was seen today.
IMPRESSION: Mild-to-moderate oropharyngeal dysphagia but
improved from previous video swallow, resulting in intermittent
penetration with thin liquids, no aspiration was seen today.

EEG:
FINDINGS:
ABNORMALITY #1: Throughout the recording there were frequent
bursts of
mixed frequency generalized slowing.
ABNORMALITY #2: There were also bursts of mixed frequency
slowing seen
bilaterally and independently in temporal areas or a bit more
broadly,
with a mild rightsided emphasis.
BACKGROUND: Was somewhat disorganized but reached an 8 Hz alpha
frequency at times.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Produced symmetric driving.
SLEEP: The patient progressed from wakefulness to drowsiness but
did
not appear to enter stage II of sleep during this recording.
CARDIAC MONITOR: Showed a generally regular rhythm with frequent
PVCs.
IMPRESSION: Abnormal EEG due to the multifocal slowing described
above.
This suggests multifocal subcortical dysfunction. Vascular
disease is
the most common cause at this age. Nevertheless, there were no
areas of
very prominent and fixed focal slowing. There were no
epileptiform
features.

[**6-10**] TTE:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
The estimated cardiac index is high (>4.0L/min/m2). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is markedly dilated The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-15**]+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is moderate pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
normal systolic function. Mild aortic regurgitation, mild to
moderate mitral regurgitation. Moderate pulmonary hypertension.
Markedly dilated ascending aorta.


Brief Hospital Course:
84F with h/o stroke and temporal arteritis admitted with
cerebellar hemorrhage, s/p evacuation, transferred to MICU after
code blue in setting of AVNRT, required intubation for airway
protection, rapidly extubated.  After transfer to general
medical floor she had a recurrent episode of AVNRT prompting
transfer to the cardiology service.

# S/p cerebellar hemorrhage: s/p evacuation on [**6-9**].  Has been
stable, on head CT [**6-25**], no evidence of recurrent bleed or
hydrocephalus.  No contraindication to future anticoagulation
per neurosurgical team.  Pt will need a repeat MRI in one month
and should follow up with neurosurgery after as an outpatient.

# SVT: likely common AVNRT. Breaks with adenosine. She had three
episodes on [**6-22**] which were responsive to adenosine.  Amiodarone
was started, but discontinued after 3 days due to concerns for
mental status changes.  Her nodal agents were also titrated up
for improved rate control.  There have been no further episodes
of AVNRT this hospitalization.  The patient should follow up
with her cardiologist as an outpatient.

# AMS. Geriatrics consulted [**6-24**] for altered MS. Concerned that
she seemed less responsive that she had been on medical floor.
Recommended d/c amiodarone, dilaudid, famotidine and trazodone,
check TSH, B12, folate, UA, CXR. CXR unremarkable, UA negative.
Nl B12/folate.
-Head CT negative for bleed or hydrocephalus. Per son pt had an
embolic stroke ~ 10 years ago and was on coumadin for a possible
"hole in her heart." No PFO seen on in house TTE although no
bubble study was performed.  Per neurosurgery coumadin not
contraindicated if deemed necessary.  Pt should follow up with
her outpatient cardiologist to discuss whether coumadin is
indicated.
-Neurology consult appreciated. Acute infarct unlikely giving
lack of focality of symptoms and waxing/[**Doctor Last Name 688**] of MS, MRI shows
no evidence of acute infarct. No seizure seen on EEG, findings
more consistent with multifocal cortical dysfunction likely
attributable to vascular disease.  Pt to follow up with Dr.
[**Last Name (STitle) **].
-off amiodarone, dilaudid, trazodone, famotidine.
- TSH slightly elevated, FT4 WNL, c/w subclinical
hypothyroidism, to follow up as outpatient and consider possible
initiation of replacement therapy
-no evidence of ongoing infection on CXR or repeat UA.

# HTN: Blood pressure well controlled on new regimen of
lisinopril at 40 mg qday, toprol, verapamil SR

# UTI: Completed 7 day course of cefpodixime for cipro resistant
catheter associated e.coli UTI.

# Respiratory failure: resolved, now extubated. Originally
intubated for treatement of SVT and airway protection.  . Chest
CT was negative for PE. Concerning for COPD/reactive airway
disease.  Sputum gram stain c/w oropharyngeal flora
- Pt on high dose steroids for presumed COPD exacerbation, has
completed taper and is  back to home dose of 5mg maintenance.
- Nebs prn
- has completed 5 days of azithromycin for possible COPD
exacerbation.

# FEN/Lytes: cleared on video swallow for purees softs. NGT
removed [**6-23**]. Was refusing diet and crushed meds as she did not
like taste/texture. Doboff placed for meds/TF. Had repeat video
swallow on [**6-26**], diet advanced to thin liquids/ground solids.
Pt taking more [**Last Name (LF) **], [**First Name3 (LF) **] leave doboff in place for supplemental
feeds, would remove after calorie counts if taking adequate PO,
otherwise may need G-tube.

# Communication: HCP [**Name (NI) 14492**] [**Telephone/Fax (3) 78428**], daughter.


# Prophylaxis: Heparin SC 5000 TID

# Code status: FULL CODE

The patient will be discharged to rehab with outpatient follow
up with neurology, cardiology, neurosurgery and her primary care
physician.


Medications on Admission:
1. Prednisone 5mg daily
2. Warfarin 2.5mg daily
3. Lunesta 2mg QHS

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Verapamil 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary:
- Cerebellar intracerebral hemorrhage
- Atrioventricular nodal reentrant tachycardia (AVNRT)
- E. coli UTI
- Dysphagia
- Delirium

Secondary:
- Left frontal CVA [**2163**] (? Paradoxical embolism)
- Temporal arteritis
- Chronic obstructive pulmonary disease
- Hypertension
- Right total hip replacement
- Osteoporosis

Procedures:
- Endotracheal intubation
- Insertion of right frontal ventricular catheter, left
  suboccipital craniectomy and evacuation of a cerebellar
  intracerebral hemorrhage.


Discharge Condition:
Hemodynamically stable bradycardia, oxygenating well.  Pain
free.  Oriented to 'hospital', name and date.


Discharge Instructions:
General Neurosurgical Instructions
??????	Have a friend/family member check your incision daily for
signs of infection.
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	You may wash your hair only after sutures and/or staples have
been removed.
??????	You may shower before this time using a shower cap to cover
your head.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????	If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.
??????	Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
??????	Fever greater than or equal to 101?????? F.
Patient discharge instructionsL\:
You were admitted with an intracranial hemorrage and underwent
an evacuation operation to treat this. Please see above
instructions and follow up for MRI and neurosurgical follow up 1
month after discharge

Your hospital course was complicated by a rapid heart rate
treated with two medications, Toprol and Verapamil.  Please
follow up with your cardiologist after discharge.

Please take all medications as prescribed, please attend all
scheduled follow up appointments.

Some of your medications have been changed:
Your warfarin has been stopped, please discuss whether to
restart this with your cardiologist
You have been started on the following medications
-Toprol XL 200mg daily
-Aspirin 81mg daily
-Verapamil 240mg daily
-Lisinopril 40mg daily
-Vitamin D
-Multivitamin

Please call your doctor or return to the emergency room if you
develop any change in your sensation, strength, speech or
vision, or if you have palpitations, shortness of breath,
lightheadedness, loss of consiousness or fever or for any other
concerning symptom.

Followup Instructions:
Please contact your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11907**] for a
follow up appointment [**Telephone/Fax (1) 56152**].

Please contact Dr. [**Last Name (STitle) **] for a follow up cardiology
appointment ([**Telephone/Fax (1) 5862**]

Neurosurgery Follow-Up Appointment Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast in one
month, please call radiology to schedule: ([**Telephone/Fax (1) 6713**].
{'Dysphagia, oropharyngeal phase,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Abdominal aneurysm without mention of rupture,Hip joint replacement,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Intracerebral hemorrhage,Aphasia,Other specified conduction disorders,Obstructive hydrocephalus,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere'}


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: Large Left cerebellar hemorrhage

PRESENT ILLNESS: 84F who presented to OSH after a two day history of nausea
and vomiting.  She went to the ED earlier this evening for
ongoing nausea and vomiting and increased drowsiness, with an
"inability" to get OOB. Of note patient takes Coumadin 2.5mg
daily for an unknown condition.

MEDICAL HISTORY: 1. Unknown cardiac condition requiring anticoaguation
2. Insomnia
3. Hypertension
4. s/p CVA
5. s/p THR

MEDICATION ON ADMISSION: 1. Prednisone 5mg daily
2. Warfarin 2.5mg daily
3. Lunesta 2mg QHS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
O: T: afebrile  BP:207/122   HR: 85   RR:18     O2Sats: 97%
ventilated
Gen: intubated.
HEENT: normocephalic, atraumatic
Pupils: equal bilaterally, minimally reactive to light.
EOMs: unable to assess
Extrem: Warm and well-perfused.
Neuro:
Mental status: Spontaneously moving all four extremities,
briskly
withdrawing LE to noxious>upper extremities.  Brisk corneals,
+gag to deep suction with associated facial grimacing.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: non-contributory 

### Response:
{'Dysphagia, oropharyngeal phase,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Abdominal aneurysm without mention of rupture,Hip joint replacement,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Intracerebral hemorrhage,Aphasia,Other specified conduction disorders,Obstructive hydrocephalus,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere'}
