CHIEF COMPLAINT: found down

PRESENT ILLNESS: This ia an 80 year old man with history of DM, HTN, on [**Month/Day/Year **] 81,
found down by his wife at 2:30 am.  On arrival to ED, GCS was 5
and he was intubated in the ED. CT head revealed bilateral SAH
and Neurosurgery was consulted.

MEDICAL HISTORY: DM, HTN, HL

MEDICATION ON ADMISSION: allopurinol 100qD, [**Last Name (LF) 13426**], [**First Name3 (LF) **] 81, atenolol 50qD, lipitor 20 qD,
avandia, colchicine 0.6, losartan, NTG prn

ALLERGIES: Nifedipine / Lisinopril

PHYSICAL EXAM: At Admission:
V: intubated Motor: withdraws to pain, posturing
O: T:  BP: 163/91         HR:65    R       O2Sats: 100%
HEENT: Pupils: 2-1.5        EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Intubated
Orientation: Intubated
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
Motor/Sensory:  localizes to pain in B LE; withdraws in B UE
Toes downgoing bilaterally

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: He is married and lives with his wife. [**Name (NI) **] was tobacco free for
>12 months and he occasionally used ETOH.
Subarachnoid hemorrhage,Acute respiratory failure,Encephalopathy, unspecified,Acute kidney failure, unspecified,Obstructive hydrocephalus,Mechanical complication of nervous system device, implant, and graft,Intracerebral hemorrhage,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tachycardia, unspecified,Hyperpotassemia,Other and unspecified hyperlipidemia,Personal history of tobacco use
Subarachnoid hemorrhage,Acute respiratry failure,Encephalopathy NOS,Acute kidney failure NOS,Obstructiv hydrocephalus,Malfun neuro device/graf,Intracerebral hemorrhage,Abn react-artif implant,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,DMII wo cmp nt st uncntr,Tachycardia NOS,Hyperpotassemia,Hyperlipidemia NEC/NOS,History of tobacco use
Admission Date:  [**2164-5-31**]              Discharge Date:   [**2164-6-16**]

Date of Birth:  [**2081-5-21**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Nifedipine / Lisinopril

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
found down

Major Surgical or Invasive Procedure:
[**2164-5-31**]- Cerebral angiogram with coiling of ruptured Left
Pcomm artery aneurysm
[**2164-5-31**]- EVD placement
[**2164-6-8**] EVD replaced

History of Present Illness:
This ia an 80 year old man with history of DM, HTN, on [**Month/Day/Year **] 81,
found down by his wife at 2:30 am.  On arrival to ED, GCS was 5
and he was intubated in the ED. CT head revealed bilateral SAH
and Neurosurgery was consulted.


Past Medical History:
DM, HTN, HL


Social History:
He is married and lives with his wife. [**Name (NI) **] was tobacco free for
>12 months and he occasionally used ETOH.

Family History:
non-contributory

Physical Exam:
At Admission:
V: intubated Motor: withdraws to pain, posturing
O: T:  BP: 163/91         HR:65    R       O2Sats: 100%
HEENT: Pupils: 2-1.5        EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Intubated
Orientation: Intubated
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
Motor/Sensory:  localizes to pain in B LE; withdraws in B UE
Toes downgoing bilaterally

PHYSICAL EXAM UPON DISCHARGE:
expired

Pertinent Results:
CSF studies:
[**2164-6-14**] 09:47AM CEREBROSPINAL FLUID (CSF) WBC-5800 HCT,Fl-14*
Polys-77 Lymphs-8 Monos-0 Eos-3 Macroph-12
[**2164-6-14**] 09:47AM CEREBROSPINAL FLUID (CSF) TotProt-1150*

Microbiology: Positive Cultures
[**2164-6-6**] Sputum
GRAM STAIN (Final [**2164-6-6**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.

   RESPIRATORY CULTURE (Final [**2164-6-9**]):
      MODERATE GROWTH Commensal Respiratory Flora.
      ENTEROBACTER AEROGENES.    SPARSE GROWTH.
         This organism may develop resistance to third
generation
         cephalosporins during prolonged therapy. Therefore,
isolates that
         are initially susceptible may become resistant within
three to
         four days after initiation of therapy.  For serious
infections,
         repeat culture and sensitivity testing may therefore be
warranted
         if third generation cephalosporins were used.
         Piperacillin/Tazobactam sensitivity testing performed
by
         Microscan.

[**2164-6-13**] Sputum
GRAM STAIN (Final [**2164-6-11**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.
      SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2164-6-13**]):
      SPARSE GROWTH Commensal Respiratory Flora.
      ENTEROBACTER AEROGENES.    MODERATE GROWTH.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 13424**]
         ([**2164-6-6**]).

IMAGING:
[**2164-5-31**]: CTA Head/Neck: IMPRESSION:
1. Extensive subarachnoid hemorrhage with a large 1-cm sized
aneurysm arising at the junction of the left posterior cerebral
artery and posterior communicating artery as described above.
2. Intraventricular extension of hemorrhage with mild
hydrocephalus.
3. Duplicated origin of the left vertebral artery with one of
the left
vertebral arteries arising directly from the aortic arch and the
second left vertebral artery arising from the left subclavian
artery.

[**5-31**] CT Cspine- IMPRESSION:
1. No evidence of acute fracture or malalignment. Multilevel
degenerative
joint changes, as described above.MRI would be more sensitive
for ligamentous injury.
2. Nasogastric tube is coiled in the oropharynx.

[**5-31**] CT head- IMPRESSION:
1. Expected post-EVD changes.
2. Slightly increased size of lateral ventricles when compared
to the most
recent prior study performed six hours earlier with increased
subarachnoid
hemorrhage layering in the occipital horns of the lateral
ventricles.
3. Unchanged extensive bilateral subarachnoid hemorrhage with
intraventricular extension.
4. Stable small parafalcine and right temporal subdural
hematomas.
5. Generalized loss of [**Doctor Last Name 352**]-white matter differentiation
suggesting diffuse cerebral edema slightly increased from six
hours earlier.

[**5-31**] Cerebral Angio-

[**6-1**] ECHO- Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: Limited study. Normal global and regional
biventricular systolic function. No major valvular disease seen.

[**6-1**] Head CT-
1. New focus of hemorrhage measuring 27 x 25 mm along the
superior track of the EVD without mass effect or edema involving
the right frontal lobe.
2. Bilateral subdural hematomas extending along the posterior
convexity at
the cerebral hemispheres bilaterally has layering along the
tentorium,
increased significantly from 21 hours prior.
3. Decreased size of lateral ventricles compared to the most
recent prior
studies.
4. Unchanged extensive bilateral subarachnoid hemorrhage with
evidence of
redistribution from [**2164-5-31**].
5. Generalized loss of [**Doctor Last Name 352**]-white matter differentiation
consistent with
diffuse cerebral edema.

[**2164-6-1**] TCD
Abnormal TCD evaluation. Below normal velocities of the
bilateral middle cerebral arteries, anterior cerebral anteries,
posterior cerebral arteries, and internal carotid artery siphons
may have been due to poor temporal and ophthalmic windows.
Mildly increased P.I. indices have a differential of increased
intracranial pressure or possibly distal stenosis, including
from small vessel disease. There was no evidence of
vasospasm. Recommend repeat TCD on [**2164-6-4**].

[**6-2**] EEG
This is an abnormal continuous ICU monitoring study because
of the presence of a severe diffuse encephalopathy manifest by
diffuse
voltage suppression and loss of fast frequencies over all head
regions
but showing asymmetry in the right occipital pole. The
background
itself is dramatically abnormal with a frontal central rhythmic
theta
and virtually no posterior rhythms. No clear seizure discharges
were
identified.

CTA Head [**6-4**]
1. Expected evolution of subarachnoid blood products with no
evidence of new hemorrhage.
2. Stable parenchymal hemorrhage along the ventriculostomy tract
with stable position of catheter and decrease in size of
ventricles. This is associated with more prominent subdural
collections bilaterally, likely reative to
shunting.
3. No evidence of infarct following coiling of the left PCom
aneurysm.
4. Small caliber of left posterior cerebral artery as well as
the bilateral A1 segments which is unchanged from [**5-31**] and
thus unlikely to represent vasospasm.

TCD [**2164-6-5**]
Mildly abnormal TCD evaluation. Above normal
velocities of the proximal right middle cerebral artery and the
left posterior cerebral artery. There was no evidence of
vasospasm. Recommend repeat TCD on [**2164-6-6**].

TCD [**2164-6-6**]
Mildly abnormal TCD evaluation. Above normal
velocities of the proximal right middle cerebral artery and the
left posterior cerebral artery. There was no evidence of
vasospasm. Recommend repeat TCD on [**2164-6-7**].

CXR [**2164-6-6**]
ET tube and right subclavian line are in standard placements and
a nasogastric tube can be traced to the upper stomach but the
tip is indistinct. Upper lungs are clear. Heterogeneous
opacification in both lower lungs is either atelectasis or
pneumonia. The involvement at the right base is the greater of
the two, and it is essentially unchanged since [**6-1**]. Heart
size is normal. Mediastinal veins are mildly engorged. No
pneumothorax.

TCD [**2164-6-7**]
Mildly abnormal TCD evaluation. Above normal
velocities of the proximal right middle cerebral artery. There
was no evidence of vasospasm. Recommend repeat TCD on [**2164-6-8**].

CXR [**2164-6-7**]
Unchanged appearance. Probably left basal atelectasis and/or
effusion

CXR [**2164-6-8**]
Lines and tubes are in standard position. There are persistent
low lung
volumes. Mild cardiomegaly is accentuated by low lung volumes.
Bibasilar
opacities, larger on the left side, are unchanged, consistent
with
atelectasis. The upper lungs are grossly clear. There are no new
lung
abnormalities, pneumothorax or enlarging pleural effusions.

TCD [**2164-6-8**]
Abnormal TCD evaluation. Severe vasospasm of the
right proximal middle cerebral artery. This represents a marked
worsening compared to the TCD results from [**2164-6-7**]. Clinical
correlation is needed

CTA head [**2164-6-8**]
1. Moderate vasospasm of the intracranial vessels including the
basilar,
distal M1 segment of the right MCA and M2 and M3 segments of the
bilateral MCA increased from [**2164-6-4**] with persistent
narrowing/vasospasm of the bilateral A1 and A2 segments of the
ACAs, unchanged from [**2164-6-4**].
2. Status post coiling of large left PCOM aneurysm with expected

redistribution of subarachnoid hemorrhage and no evidence of new
hemorrhage.
3. Slightly resolved intraparenchymal hemorrhage within the
right frontal
lobe along the superior EVD tract with unchanged position of EVD
and stable size of ventricles from [**2164-6-4**].
4. Slightly increased bilateral hypodense subdural hematomas
along the
anterior cerebral convexities without significant change in mass
effect and no shift of normally midline structures.
5. Stable posterior hyperdense subdural hematoma.

CTA head [**2164-6-9**]
1. New hyperdense focus at the tip of the external ventricular
drain, which may represent a focus of acute hemorrhage or clot.
2. Minimal increase in ventricular size from 23 to 26 mm.
3. Otherwise, unchanged exam with subarachnoid hemorrhage and
bilateral
subdural collections

CXR [**2164-6-9**]
Compared to the exam from the prior day, there is no significant

interval change.

CT head [**2164-6-10**]
1. Interval evolution of a right frontal parenchymal hemorrhage
along the
shunt catheter. Interval decrease in the intraventricular
hemorrhage. No new change in the size of the ventricles.
2. Bihemispheric subdural hematomas and subarachnoid hemorrhage,
not
significantly changed since the prior study.
3. Pansinus opacification relates to the endotracheal
intubation.

EEG [**2164-6-11**]
This is an abnormal continuous ICU monitoring study because
of a severe diffuse encephalopathy. Superimposed upon this
encephalopathy are some subtle lateralizing features suggesting
greater
damage to the right hemisphere. There are multifocal paroxysmal
sharp
transient suggesting irritability. These tended also to have
right
hemisphere predominance.

TCD [**2164-6-11**]
Abnormal TCD evaluation. Moderate vasospasm of the
right proximal middle cerebral artery. This was not markedly
different from the TCD results of [**2164-6-8**]. The left MCA had
below
normal velocities but this was probably due to technical
factors.
Clinical correlation is needed. Recommend repeat TCD on [**2164-6-12**].

CXR [**2164-6-11**]
As compared to the previous radiograph, there is no relevant
change. The monitoring and support devices are in constant
position. The
lung volumes have minimally decreased. The diameter of the
vascular
structures is at the upper range of normal, potentially
indicative of mild
fluid overload, but no overt pulmonary edema is present.
Moderate
retrocardiac atelectasis. No new parenchymal opacities in the
ventilated
areas of the lung parenchyma.

CT head [**2164-6-11**]
1. Right transfrontal external ventricular drain with blood
products along
the EVD track and decreased post-operative right frontal
pneumocephalus from [**2164-6-10**].
2. Stable intraventricular hemorrhage with blood products in the
anterior
[**Doctor Last Name 534**] of the right lateral ventricle and layering posteriorly
within the
occipital horns of the lateral ventricles.
3. Evidence of redistributed subarachnoid hemorrhage, unchanged
in extent.
4. Stable frontal hypodense and posterior hyperdense subdural
hematomas.
5. No evidence of acute hemorrhage or large vascular territorial
infarct

EEG [**2164-6-12**]
This is an abnormal continuous ICU monitoring study because
of severe diffuse encephalopathy with subtle features suggesting
great
right hemisphere pathology. There are a number of paroxysmal
sharp
features to the record. No clear interictal epileptic discharges
were
noted. The right side tends to predominate in terms of the sharp

features. Compared to the prior day's recording, there were no
significant changes.

CXR [**2164-6-13**]
There are low lung volumes. Mild cardiomegaly is accentuated by
the low lung volumes. Bibasilar atelectases have minimally
improved. ET tube is in the standard poition. NG tube is out of
view below the diaphragm. A right PICC line catheter tip is in
the upper SVC.

CT head [**2164-6-13**]
Unchanged position of the right frontal approach internal
ventricular drain catheter with slightly increased adjacent
pneumocephalus.  Multicompartmental hemorrhage and some degree
of edema unchanged compared to recent study. Bil. subdural fluid
collections, increased since the initial study of [**2164-5-31**]-?
superimposed intracranial hypotension. Correlate clinically and
followup.

CXR [**2164-6-14**]
As compared to the previous radiograph, there is no relevant
change. The monitoring and support devices are constant. There
is unchanged appearance of the low lung volumes and the moderate
retrocardiac atelectasis as well as the mildly enlarged cardiac
silhouette. No larger pleural effusions. No newly appeared focal
parenchymal opacities.

[**6-14**] MRI brain: IMPRESSION:
1.  Multicompartmental hemorrhage and bil. subdural fluid
collections as
described above, better characterized on the prior CT head
studies.
2. Scattered small foci of increased DWI signal with decreased
ADC signal,
related to ischemic/infarction-related changes.  The etiology of
this is
unclear and it is also unclear if these explain the patient's
quadriplegia. Correlate clinically to decide on the need for
further workup.
3. Bil. mastoid fluid and mucosal thickening.

[**6-14**] MRI C-spine:
1.  Multilevel, multifactorial degenerative changes with [**Last Name (un) 13425**]
changes and
moderate canal stenosis at C3-4 from disc extrusion and bulge
and ligamentum flavum thickening and deformity on the cord at
this level.
2.  Evaluation for marrow edema from trauma or ligamentous
injury or cord
signal intensity changes is limited given the lack of sagittal
STIR and axial T2-weighted sequence.  These were not done due to
technical issue.  The patient will be brought back, for the
additional sequences, which will be performed as a separate
study.
3.  Multilevel moderate foraminal narrowing with deformity of
the nerves in these locations.

[**6-15**] CXR: The left lower lobe atelectasis is unchanged.
Vascular congestion is unchanged but no overt edema is seen.
Right central venous line tip is at the level of mid SVC.  ET
tube and the NG tube are in appropriate location, unchanged
since the prior study.

[**6-16**] CT Head- IMPRESSION:
1.  Right frontal approach shunt catheter has an
extraventricular course,
terminating at the septum pellucidum.
2.  Mild increase in the parenchymal hemorrhage surrounding the
shunt catheter in the right frontal lobe.
3.  Bihemispheric subarachnoid and intraventricular hemorrhage,
subdural
hematomas have not significantly changed since the prior study.

[**6-16**] CT Head- IMPRESSION:
1.  Status post ventriculostomy catheter placement from right
frontal approach without a definitive intraventricular course as
described on prior report.
2.  Similar appearance of bilateral subdural collections with
similar to
slightly increased subarachnoid hemorrhage and definite increase
in
intraventricular hemorrhage.  This finding was discovered at
9:39 a.m. and
discussed with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at 9:43 a.m. on [**2164-6-16**] by Dr.
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 11623**] over the phone.
3.  Similar appearance of air and blood products around the
course of the
ventriculostomy catheter within the right frontal parenchyma.


Brief Hospital Course:
The patient was admitted to the Neurosurgery ICU for Q1
Neurochecks and Vital Signs. She was started on Nimodipine 60mg
Q 4 hours and Seizure Prophylaxis. Strict SBP less < 130
parameters was initiated and she was kept NPO. An EVD was placed
at 15cm h20 and a CT was performed which confirmed good
placement. In the am of [**5-31**] she underwent a cerebral angiogram
and coiling of a left Pcomm artery aneurysm. She was transferred
back to the SICU post procedure. A portable Head CT was
performed in the AM [**6-1**] which revealed a new hemorrhage along
the EVD track and increased SDH.  Baseline TCD's were performed.
An Echo and EEG were also requested. The Echo showed LVEF>55%,
and the EEG showed diffuse encephalopathy with no evidence of
clinical seizures.  On [**6-2**] his collar was cleared, and on [**6-3**]
his IVF were decreased from 100cc/hr to 75cc/hr. On [**6-4**] his EVD
was raised to 20, he had a CTA that showed more porminent
hygromas and no vasospasm. Overnight, ICPs were stable [**9-16**] and
EVD draining adequately.

On [**6-6**], patient w/d BUE and triple flexes BLE. His drain remains
at 20 and TCDs are negative for vasospasm.

On [**6-7**], TCDs with no evidence of vasospasm. IVF were
discontinued and Lasix ws given for diuresis with goal of 2L
negative.

On [**6-8**], The External Ventricular Drain was at 20 H2O CM above
the tragus.  The patient had a low grade fever of 100. ICP were
[**11-17**].  Family meeting****. A CTA  was performed which was
consistent with spasm R MCA & basilar arteries.

On [**6-9**], The External Ventricular Drain stopped draining. A NCHCT
was performed which was stable and did not show any
hydrocephalas.  The patient was tachypneic and hypertensive.  On
exam the patient withdrew to noxious stimulous in all 4
extremities.

On [**6-10**], The external ventricular catheter was clamped 0800.  Teh
clamping trial failed at 1130 am  whe the patient ICP elevated
to 27-29.  The serum BUN was noted to be  40 which was elevated
from the mid 20s on [**6-4**].  Ancef 2 gm TID was added for empiric
EVD coverage as the EVD site was slightly edematous and warm on
palpation. WBC was slightly elevated at 13.4.

On [**6-11**]: The EVD site appearance was improved. There was no
erythema and improved edema.  The IVF 100 at cc/hr wa
sdiscontinued.  The EVD stopped draing at 0600, 1200, and 4pm
and each time TPA was instilled in the line for 20 mints to
obtain patency.A NCHCT was performed which was stable. On exam
the patient opened the left eye to noxous stimuli,minimal
withdrew to noxious in the Bilateral Upper Eextremities, and
triple flexion was exhibited in the bilateral lower extremities.
 The serum BUN was improved to 33. The WBC improved to 12.3  A
TCD was performed which showed right MCA spasm which was stable
when compared to [**6-8**]. The External Ventricular Drain was lowered
to 10 H2O mmhg above the tragus.  An EEG was ordered to evaluate
for seizure activity and to evaluate the further requirment of
keppra.  The EEG was consistent with no seizures. His ICP
waveform was dampened at 011 on [**6-12**] and it was flushed with
return of waveform. On [**6-12**] his exam remained poor overall, his
drain output began to slow and tPA was instilled at 1430,
clamped for 30 mins, and when re-opened there was brisk drainage
of CSF.

During the day of [**6-13**], his EVD was functioning well. In the
evening it was no longer draining and flushing did not help. The
tubing was pulled back a bit then began draining. Head CT to
confirm placement was performed. On [**6-14**] CSF was sent and MRI
head and C-SPINE imaging was done. MRI revealed multiple small
infarcts but nothing to explain mental status. The results were
discussed in a family meeting as well as goals of care. It was
decided to proceed with trach and peg planning. On [**6-15**] the EVD
continued to be tenuous with periods of non-drainage requiring
flushing and TPA. His neurological exam remained unchanged. On
[**6-16**] in the early AM the EVD required TPA infusion again for
non-drainage. This was infused after a Head CT was performed and
stable. At approx 8:30AM the patients blood pressure rose to
over 200, ICP increased to 70's with a wave form. It was also
noted to have new blood around the EVD dressing. Neurological
exam was stable but the patient was taken for a stat Head CT. CT
revealed new acute IVH. The findings were discussed with the
SICU staff and family. At this time it was recommended that care
be withdrawn and not proceeding with trach and peg. The family
was in agreement with this plan and asked for EVD and ET tube to
be removed as soon as possible. He was started on a morphine gtt
and these were both performed. The patient passed away of
respiratory failure with the family at the bedside in the
afternoon of [**2164-6-16**].


Medications on Admission:
allopurinol 100qD, [**Last Name (LF) 13426**], [**First Name3 (LF) **] 81, atenolol 50qD, lipitor 20 qD,
avandia, colchicine 0.6, losartan, NTG prn


Discharge Medications:
n/a

Discharge Disposition:
Expired

Discharge Diagnosis:
aneurysmal subarachnoid hemorrhage
intraventricular hemorrhage
hydrocephalus
encephalopathy
cerebral vasospasm


Discharge Condition:
n/a


Discharge Instructions:
n/a

Followup Instructions:
n/a



Completed by:[**2164-6-16**]
{'Subarachnoid hemorrhage,Acute respiratory failure,Encephalopathy, unspecified,Acute kidney failure, unspecified,Obstructive hydrocephalus,Mechanical complication of nervous system device, implant, and graft,Intracerebral hemorrhage,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tachycardia, unspecified,Hyperpotassemia,Other and unspecified hyperlipidemia,Personal history of tobacco use'}


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: found down

PRESENT ILLNESS: This ia an 80 year old man with history of DM, HTN, on [**Month/Day/Year **] 81,
found down by his wife at 2:30 am.  On arrival to ED, GCS was 5
and he was intubated in the ED. CT head revealed bilateral SAH
and Neurosurgery was consulted.

MEDICAL HISTORY: DM, HTN, HL

MEDICATION ON ADMISSION: allopurinol 100qD, [**Last Name (LF) 13426**], [**First Name3 (LF) **] 81, atenolol 50qD, lipitor 20 qD,
avandia, colchicine 0.6, losartan, NTG prn

ALLERGIES: Nifedipine / Lisinopril

PHYSICAL EXAM: At Admission:
V: intubated Motor: withdraws to pain, posturing
O: T:  BP: 163/91         HR:65    R       O2Sats: 100%
HEENT: Pupils: 2-1.5        EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Intubated
Orientation: Intubated
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
Motor/Sensory:  localizes to pain in B LE; withdraws in B UE
Toes downgoing bilaterally

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: He is married and lives with his wife. [**Name (NI) **] was tobacco free for
>12 months and he occasionally used ETOH. 

### Response:
{'Subarachnoid hemorrhage,Acute respiratory failure,Encephalopathy, unspecified,Acute kidney failure, unspecified,Obstructive hydrocephalus,Mechanical complication of nervous system device, implant, and graft,Intracerebral hemorrhage,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tachycardia, unspecified,Hyperpotassemia,Other and unspecified hyperlipidemia,Personal history of tobacco use'}
