CHIEF COMPLAINT: Headache

PRESENT ILLNESS: 42 yo M with history of hypertension transferred from OSH
with IVH.  He is a challenging historian but as per records he
devloped nausea, vomiting, and mild headache earlier today and
appeared slow to respond to questions and was taken to [**Hospital1 **]
[**Location (un) 47**].  There he was found to have BP 213/133 P 72 RR 18 T
97.5 100% RA and was noted to be "slow to respond" but otherwise
nonfocal exam.  He received multiple doses of lopressor and
labetalol for his continued hypertension and underwent CT head
which revealed intraventricular hemorrhage in lateral, 3rd, and
4th ventricles, greater on right than left and transferred to
[**Hospital1 18**] for further management.  Upon arrival BP 213/121 P 79 and
was started on a nicardipine drip.  He was seen by neurosurgery
who recommended neurology admission.

MEDICAL HISTORY: - Hypertension (says PCP recently took him off meds)
-15-inch titanium rod placed in left femur

MEDICATION ON ADMISSION: None.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS; BP 213/121 (current 157/90 on nicardipine drip) P 100 RR 19
98% on 2L

FAMILY HISTORY: Father with stroke at unknown age.  No history of aneurysms.

SOCIAL HISTORY: Lives with parents, works at [**Company 12670**] Drug pharmacy, says he is
a "[**Doctor Last Name **] of all trades."  Denies tobacco or drugs.  Occasional
alcohol use.
Intracerebral hemorrhage,Obstructive hydrocephalus,Malignant essential hypertension,Meningismus,Other constipation,Family history of stroke (cerebrovascular)
Intracerebral hemorrhage,Obstructiv hydrocephalus,Malignant hypertension,Meningismus,Constipation NEC,Family hx-stroke
Admission Date:  [**2162-9-10**]              Discharge Date:   [**2162-9-22**]

Date of Birth:  [**2120-4-12**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Headache

Major Surgical or Invasive Procedure:
Formal angiogram of the brain


History of Present Illness:
42 yo M with history of hypertension transferred from OSH
with IVH.  He is a challenging historian but as per records he
devloped nausea, vomiting, and mild headache earlier today and
appeared slow to respond to questions and was taken to [**Hospital1 **]
[**Location (un) 47**].  There he was found to have BP 213/133 P 72 RR 18 T
97.5 100% RA and was noted to be "slow to respond" but otherwise
nonfocal exam.  He received multiple doses of lopressor and
labetalol for his continued hypertension and underwent CT head
which revealed intraventricular hemorrhage in lateral, 3rd, and
4th ventricles, greater on right than left and transferred to
[**Hospital1 18**] for further management.  Upon arrival BP 213/121 P 79 and
was started on a nicardipine drip.  He was seen by neurosurgery
who recommended neurology admission.

Patient denies any recent fevers, chills, cough, chest pain,
shortness of breath, dizziness, visual changes, focal weakness,
sensory changes, bowel or bladder changes.   He reports
generalized fatigue.

Past Medical History:
- Hypertension (says PCP recently took him off meds)
-15-inch titanium rod placed in left femur


Social History:
Lives with parents, works at [**Company 12670**] Drug pharmacy, says he is
a "[**Doctor Last Name **] of all trades."  Denies tobacco or drugs.  Occasional
alcohol use.


Family History:
Father with stroke at unknown age.  No history of aneurysms.

Physical Exam:
VS; BP 213/121 (current 157/90 on nicardipine drip) P 100 RR 19
98% on 2L

Gen; lying in bed, NAD
HEENT; NC/AT, mucous membranes moist, oropharynx clear
CV; RRR, no murmurs
Pulm; CTA b/l
Abd; soft, nt, nd
Extr; no edema
Neuro
MS; Drowsy but arousable to voice.  Somewhat tangential,
requiring redirection to obtain history.  A&Ox3.  Speech mildly
slurred.  Naming repetition and comprehension intact.  Follows
basic commands.  No apraxia or neglect.

CN; PERRL 6mm-->5mm, EOMI, no nystagmus.  Visual fields full.
Face sensation intact V1-V3.  Mild NLF flattening on right.
Palate symmetric.  Tongue midline.
Motor; normal bulk, mild increased tone in legs.  No pronator
drift. 5/5 strength in R and L delt, bicep, tricep, WrE, FF, IP,
ham, quad, TA, gastrocs.
Sensory; intact to light touch and pinprick throughout
Reflexes; 2+ and symmetric at biceps, brachioradialis, patellars
and achilles.  Plantar response is withdrawl b/l.
Coordination; no dysmetria on FNF
Gait; deferred

Pertinent Results:
[**2162-9-21**] 06:40AM BLOOD WBC-9.2 RBC-5.42 Hgb-16.4 Hct-49.0 MCV-90
MCH-30.3 MCHC-33.5 RDW-12.8 Plt Ct-246
[**2162-9-10**] 05:47PM BLOOD Neuts-89.6* Lymphs-6.7* Monos-2.6 Eos-0.4
Baso-0.8
[**2162-9-19**] 10:40AM BLOOD PT-13.8* PTT-29.6 INR(PT)-1.2*
[**2162-9-21**] 06:40AM BLOOD Glucose-87 UreaN-22* Creat-1.2 Na-133
K-4.0 Cl-95* HCO3-26 AnGap-16
[**2162-9-21**] 06:40AM BLOOD ALT-46* AST-20 LD(LDH)-270* AlkPhos-95
TotBili-0.6
[**2162-9-17**] 02:48AM BLOOD ALT-103* AST-50* AlkPhos-81 TotBili-0.9
[**2162-9-15**] 06:40AM BLOOD ALT-64* AST-55* LD(LDH)-265* AlkPhos-91
TotBili-1.0
[**2162-9-12**] 04:08AM BLOOD CK-MB-3 cTropnT-<0.01
[**2162-9-21**] 06:40AM BLOOD Albumin-4.6 Calcium-9.4 Phos-3.9 Mg-2.3
[**2162-9-11**] 11:45AM BLOOD Triglyc-42 HDL-61 CHOL/HD-2.7 LDLcalc-97
[**2162-9-11**] 08:25PM BLOOD TSH-1.3
[**2162-9-10**] 05:47PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2162-9-17**] 02:48AM BLOOD RENIN-2.78
[**2162-9-17**] 07:20AM BLOOD ALDOSTERONE- 1 ng/dl (normal < 26)
[**2162-9-11**] 04:30PM BLOOD INSULIN-LIKE GROWTH FACTOR-1- normal


NCHCT [**2162-9-10**]
TECHNIQUE: Noncontrast Head CT.
COMPARISON: Outside hospital CT from earlier same date.
FINDINGS: Compared to prior study from 15:46 p.m. about three
hours prior,
there has been no change. Otherwise, intraventricular blood
extending from
bilateral lateral ventricles continuously to the foramina of
Luschka at the
fourth ventricle is stable. Calcified structure in the left
sylvian fissure
can represent an aneurysm. There is no large territorial
infarct. There is
no evidence of uncal herniation or transtentorial herniation.
There is no
bony lesion to suggest malignancy or infection. Left small
[**Doctor Last Name 13856**] bullosa is
seen. Mild mucosal thickening in the right maxillary sinus and
sphenoid
sinuses is noted.
IMPRESSION:
1. Stable distribution of extensive intraventricular hemorrhage.
2. Calcified structure in the left sylvian fissure can represent
an aneurysm.

CTA Head and Neck [**2162-9-10**]
TECHNIQUE: CT of the head was acquired without contrast.
Following this,
using departmental protocol, CT angiography of the head
acquired. The
examination is limited due to delays in acquisition and optimum
bolus was not
obtained.
FINDINGS:
CT HEAD: There is intraventricular hemorrhage identified
involving right
lateral ventricle, third ventricle, with some extension to the
left lateral
ventricle. A small area of hyperdensity is also identified in
the left
sylvian fissure region.
CT ANGIOGRAPHY HEAD: CT angiography of the head demonstrates a
vascular
prominence adjacent to the left middle cerebral artery. However,
due to
incomplete vascular opacification, it is unclear whether this is
due to an
aneurysm or due to a prominent venous structure. A repeat CT
angiography or a
conventional angiography of the head would be helpful for
further assessment.
The remaining vascular structures appear patent.
IMPRESSION:
1. Intraventricular hemorrhage is identified on CT of the head
along with a
small area of hypodensity in the left middle cranial fossa.
2. CT angiography is limited due to delay in acquisition, but
demonstrates a
small area of contrast enhancement in the left middle cranial
fossa adjacent
to the sphenoid margin and adjacent to the left middle cerebral
artery. It is
unclear whether this is due to an MCA aneurysm or due to venous
filling.
Repeat CT angiography of the head or conventional angiography
would be helpful
for further assessment.

RENAL ULTRASOUND [**2162-9-11**]
COMPARISON: None.
FINDINGS: The right kidney measures 12.3 cm and the left kidney
measures 11.8
cm. No masses, stones or hydronephrosis were present. Within the
right
kidney, renal resistive indices measure within cortical vessels
range between
0.58 and 0.65. Within the main renal artery, resistive indices
was measured
at 0.6. In the left kidney, resistive indices in the cortical
vessels range
between 0.58 and 0.65. Resistive index in the main renal artery
was 0.59.
There is normal flow and waveform within bilateral main renal
veins.
IMPRESSION: Normal renal ultrasound. No secondary evidence for
renal artery
stenosis.

MRI and MRA Head, Brain and Neck [**2162-9-14**]
TECHNIQUE: MRI of the brain was performed -sagittal T1, axial
T1, axial
FLAIR, axial T2, and diffusion with ADC map sequences without
intravenous
contrast. After the administration of intravenous contrast,
axial T1 and
sagittal MPRAGE sequences were performed. Coronal and axial
MPRAGE sequences
were reformatted from the sagittal post-contrast MPRAGE
sequence.
Three-dimensional time-of-flight MR angiography of the head was
performed with
3D reformations.
COMPARISON: No prior MR for comparison. CT and CTA of the head
performed on
[**2162-9-10**] was reviewed. CT of the head from [**9-11**]
and [**2162-9-12**] were also reviewed.
FINDINGS:
MR HEAD WITHOUT AND WITH CONTRAST
The intraventricular hemorrhage, predominantly in the right
lateral ventricle
and fourth ventricle with a smaller volume of hemorrhage within
the left
lateral ventricle and third ventricle, is not significantly
changed compared
with the prior CT examination. No new foci of hemorrhage are
identified. The
ventricles are unchanged in size and not enlarged.
There are a few prominent extra-axial T2 flow voids in the
anterior aspect of
the left middle cranial fossa in the region of the previously
described
enhancing abnormality with punctate focus of calcficiation noted
on the prior
CT examinations. A more focal area measures up to 5-8mm in
greatest dimension
with a lobulated appearance. This structure is adjacent to the
MCA M1-M2
branches without definite arterial component noted on
time-of-flight sequence.
No significant mass effect upon the surrounding structures. On
the
post-contrast MPRAGE sequence (sequence 106, images 46 through
51), this
region has the appearance of prominent venous tributaries
without associated
prominent arteries.
No evidence of parenchymal hemorrhage or restricted diffusion is
noted. There
is minimal mucosal thickening of the sphenoid sinuses and
ethmoid sinuses.
MRA HEAD: Patent visualized major intracrnaial arteries without
focal flow
limiting stenosis or occlusion or obvious arterial aneurysm. The
distal
vertebral arteries are not completely included. The right distal
vertebral
artery is diminutive in caliber.
IMPRESSION:
1. Stable intraventricular hemorrhage. No evidence of
ventricular
enlargement.
2. The previously described left anterior middle cranial fossa
enhancing
abnormality noted on prior CTA does demonstrate prominent T2
flow void
without flow signal on time-of-flight MRA imaging. It is
adjacent to the
M1-M2 branches, but does not definitely have dilated arteries
within the
resolution of noncontrast MRA. The appearance suggests possible
venous
abnormality such as a malformation with a focal venous
varix/aneurysm. Given
the close proximity to the MCA branches, an arterio-venous
communication
cannot be excluded based on this study alone even though there
are no dilated
arteries of the MRA. Neurology and Interventional neuroradiology
consult are
recommended for possible conventional angiography to exclude an
AVM/AVF and
any additional lesions.
The above findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at 10:40
a.m., [**2162-9-14**].

CT Chest, Abdomen and Pelvis [**2162-9-17**]
TECHNIQUE: Contiguous axial images were obtained through the
chest, abdomen
and pelvis with the administration of IV contrast. Multiplanar
reformats were
generated and reviewed.
CT OF THE CHEST: Pleural plaque is noted at the right lung base.
Left
axillary nodes measure up to 6 mm and do not meet CT size
criteria for
pathologic enlargement. Mediastinal and hilar lymph nodes do not
meet CT size
criteria for pathologic enlargement. There is mild left
ventricular
hypertrophy. There is no evidence of pericardial effusion.
Otherwise, the
visualized lungs appear unremarkable.
CT OF THE ABDOMEN: The liver shows hypodensity in the right lobe
(3, 70)
which is too small to characterize. There is evidence of intra-
and
extra-hepatic biliary dilation with the common bile duct
measuring up to 9 mm
(3, 73). The gallbladder shows no evidence of gallstones. The
spleen,
pancreas and bilateral adrenal glands are unremarkable. Both
kidneys enhance
and excrete contrast symmetrically without evidence of
hydronephrosis or
stones. A hypodensity in the interpolar region of the right
kidney measures
30 x 21 mm and likely represents renal cyst. Bilateral
subcentimeter
hyperdensities in both kidneys are too small to characterize but
likely
represent simple cysts.
The intra-abdominal loops of large and small bowel are
unremarkable. There is
no free air or free fluid within the abdomen. Retroperitoneal
and mesenteric
lymph nodes do not meet CT size criteria for pathologic
enlargement.
CT OF THE PELVIS: The bladder, distal ureters, rectum and
sigmoid colon
appear unremarkable.
OSSEOUS STRUCTURES: The visualized osseous structures appear
unremarkable.
IMPRESSION:
1. No evidence of bilateral adrenal disease. No evidence of
pheochromocytoma
is noted along the course of the abdominal aorta.
2. Pleural plaque at the right lung base.
3. Left ventricular hypertrophy.
4. Hypodensity in the liver which is too small to characterize
and likely
represents a hepatic cyst.
5. Mild intra- and extra-hepatic biliary dilation.
6. Hypodensity in the interpolar region of the right kidney
measures 30 x 21
mm and likely represents renal cyst. Bilateral subcentimeter
hyperdensities
in both kidneys are too small to characterize but likely
represent simple
cysts.

Formal Angiogram [**2162-9-20**]
[**Known firstname 87783**] [**Known lastname 87784**] underwent cerebral angiography which showed
significant
tortuosity of the aortic arch and the origins of the common
carotid artery and
the vertebral artery. The right vertebral artery was seen to be
significantly
stenosed with significant supply through the left vertebral as
seen on the
MRI/MRA. He had also area of stenosis in the left middle
cerebral artery
followed by a dilatation in the distal M1 segment. No definite
evidence of
aneurysm or AVM.

Echocardiogram [**2162-9-13**]
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is moderate symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is normal (LVEF>55%). There is no left ventricular
outflow obstruction at rest or with Valsalva. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
No valvular pathology or pathologic flow identified.

Brief Hospital Course:
Hypertension, intraventricular hemorrhage, headache and
constipation were significant issues for this admission:

Headache
Presenting complaint and attributed to intraventricular
hemorrhage. Headache continued through the admission, abating
toward the end. There was some correlation between blood
pressure and headache. Headache was improved at discharge and
medications Fioricet and Tramadol were given for control after
discharge.

Intraventricular Hemorrhage
No underlying aneurysm was found. This was felt to be most
likely secondary to small-vessel lenticulostriate bleed
originating in right medial head of the caudate, although it was
also possible that this represented a primary intraventricular
bleed. Formal angiogram revealed tortuous vessels that were felt
to represent vascular disease of high poorly controlled blood
pressure and possible atherosclerosis.

Hypertension
BP control was poor, and PO meds were introduced gradually.
Nicardipine gtt was d/c'd by ICU team on HD2 and pt managed with
IV Hydralazine boluses. As of [**9-14**], PO regimen was amlodipine
10mg (started [**9-12**], d/c'd by ICU, then re-started [**9-13**]),
lisinopril 40mg (started at 20 on [**9-12**] and increased to 40 on
[**9-13**]), labetalol 200mg tid (started on [**9-12**] at 100, increased
to 200 on [**9-14**] am). ICU team gave one dose of clonidine 0.2.
Oral regimen was up-titrated until adequate control was gained
and he was discharged on this regimen (see below) with follow-up
arranged for both Renal and Neurology. Renin, TSH, IGF1,
aldoterone were normal. No pheochromocytoma was seen on CT.
Renal arteries were patent. Left ventricular hypertrophy and
vascular effects are present suggesting that this has been
long-standing, but specific etiology was not identified. Blood
pressure was in the 140s-150s systolic on discharge.

Constipation
Resolved with appropriate bowel regimen.

Medications on Admission:
None.

Discharge Medications:
Two-week scripts were given along with 90 days so that he could
get free supply of the first and sort out veteran coverage for
the latter:

1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*14 Tablet(s)* Refills:*0*
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
3. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*14 Tablet(s)* Refills:*0*
4. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*90 Tablet(s)* Refills:*2*
5. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours) as needed for headache for 14
days.
Disp:*84 Tablet(s)* Refills:*0*
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for headache for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
7. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*14 Tablet(s)* Refills:*0*
8. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
9. labetalol 200 mg Tablet Sig: Two (2) Tablet PO every eight
(8) hours.
Disp:*84 Tablet(s)* Refills:*0*
10. labetalol 200 mg Tablet Sig: Two (2) Tablet PO every eight
(8) hours.
Disp:*540 Tablet(s)* Refills:*2*
11. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1)
Transdermal once a week for 1 doses: Remove present patch and
place on [**2162-9-29**].
Disp:*1 patch* Refills:*0*
12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*14 Tablet(s)* Refills:*0*
13. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary intraventricular hemorrhage
Hypertension

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

Discharge Instructions:
You came to the hospital after having an intraventricular
hemorrhage (bleed into the fluid filled lateral ventricle of
your brain). You were also markedly hypertensive. We controlled
your blood pressure with medications. You underwent angiography
which showed that your blood vessels have been affected by high
blood pressure, but did not show any other underlying
abnormality that would result in your bleed.

It is very important that you take you antihypertensive
medications - if you do not, you may have a further hemorrhage.
Please follow-up with the hypertension clinic for continuing
medication adjustment.

We have given you a script for one more clonidine patch, so that
you can take the old one off and put this on next Wednesday
[**2162-9-29**]. This way you will have this on until you are seen by
the kidney doctors (Renal/Nephrology) for your hypertension.

Followup Instructions:
*** Before you come to any appointments, please complete your
registration (providing details of your insurance and doctor)
with the hospital. Please call [**Telephone/Fax (1) 10676**] when you get home.

We have ordered a follow-up MRI to be done prior to your
appointment with neurology, for follow-up of your
intraventricular hemorrhage:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2162-11-10**] 4:30
Your MRI will likely be on [**2162-11-2**]. They will call with a time.

You are also scheduled to follow-up with Dr. [**Last Name (STitle) 4090**], renal
specialist for your hypertension/BP control.  His office is
located on [**Hospital Ward Name 517**], [**Hospital Ward Name 121**] building [**Location (un) 453**]:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2162-10-7**]
1:00

                             [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
{'Intracerebral hemorrhage,Obstructive hydrocephalus,Malignant essential hypertension,Meningismus,Other constipation,Family history of stroke (cerebrovascular)'}


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: Headache

PRESENT ILLNESS: 42 yo M with history of hypertension transferred from OSH
with IVH.  He is a challenging historian but as per records he
devloped nausea, vomiting, and mild headache earlier today and
appeared slow to respond to questions and was taken to [**Hospital1 **]
[**Location (un) 47**].  There he was found to have BP 213/133 P 72 RR 18 T
97.5 100% RA and was noted to be "slow to respond" but otherwise
nonfocal exam.  He received multiple doses of lopressor and
labetalol for his continued hypertension and underwent CT head
which revealed intraventricular hemorrhage in lateral, 3rd, and
4th ventricles, greater on right than left and transferred to
[**Hospital1 18**] for further management.  Upon arrival BP 213/121 P 79 and
was started on a nicardipine drip.  He was seen by neurosurgery
who recommended neurology admission.

MEDICAL HISTORY: - Hypertension (says PCP recently took him off meds)
-15-inch titanium rod placed in left femur

MEDICATION ON ADMISSION: None.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS; BP 213/121 (current 157/90 on nicardipine drip) P 100 RR 19
98% on 2L

FAMILY HISTORY: Father with stroke at unknown age.  No history of aneurysms.

SOCIAL HISTORY: Lives with parents, works at [**Company 12670**] Drug pharmacy, says he is
a "[**Doctor Last Name **] of all trades."  Denies tobacco or drugs.  Occasional
alcohol use. 

### Response:
{'Intracerebral hemorrhage,Obstructive hydrocephalus,Malignant essential hypertension,Meningismus,Other constipation,Family history of stroke (cerebrovascular)'}
