CHIEF COMPLAINT: confusion, vomiting

PRESENT ILLNESS: 52 y old man who presented following acute onset of confusion
while driving. Apparently was able to talk with relative but
relative noted he was confused. Pulled off the road. Developed
acute onset headache with nausea and vomiting.
.
The patient was reviewed at [**Hospital6 10353**] where CT scan
showed L thalamic bleed with extension of blood to lateral and
thrid ventricles. Mr [**Known lastname **] was intubated there and tranferred to
[**Hospital1 18**] for further treatment.
.
Assessed by neurosurgery. CT here showed findings as above. CTA
negative for arteriovenous malformation or subarachnoid
hemorrhage. Preoperatively weak on R side. The patient was taken
to the OR for bilateral burr holes, and ventriculostomy drains.
Increased ICP. Transferred to ICU for monitoring.
.
Systems:
Recent endocrine review note states had been experiencing
bilateral hand numbness for 6 months with occassional LE
numbness

MEDICAL HISTORY: Diabetes diagnosed in [**Location (un) 6847**] 17y ago-poorly treated
-HbA1c 15.[**2145-9-10**]
-diabetic retinopathy with hemorrhages seen [**2144-8-3**] ([**Hospital1 336**]) s/p
laser treatments
-probable diabetic neuropathy (paraesthesias)
Hypertension diagnosed in [**2145-11-3**]
Hyperlipidaemia
Appendectomy [**2134**]

MEDICATION ON ADMISSION: MEDS: (From Quinsy note [**2145-12-14**])
Metformin 1700mg qam 850mg qpm
Actos (pioglitizone) 45mg qd
Glipizide 10mg [**Hospital1 **]
Atorvastatin 40mg po qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
T-97.3 BP-107/57 (once up to 139/-, mostly 100s-110 systolic)
HR-92 RR-14 O2Sat-100% 40%FiO2 FS 170
.
Gen: Lying in bed, intubated and ventilated
HEENT: Moist oral mucosa
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: 5cm PEEP Rate 12 Clear to auscultation bilaterally
aBd: +BS soft, nontender, old appendectomy scar RLQ
ext: no edema, cool
.
Neurologic examination (Propofol running):
.
Bilat external ventricular drains at 10cm,draining
serosanguinous fluid.
.
Mental status: Withdrawing to nailbed pressure L side. Not
opening eyes. No vocalisations.
.
Cranial Nerves:
Pupils equally round and sluggisly reactive to light, 2 to 1.5
mm bilaterally. Facial movement symmetric.
.
Motor:
Normal bulk bilaterally. Intermittent fine tremor bilat upper
limbs. Tone increased bilat LE. Fixed contracture at R elbow
unable to extend beyond about 120 deg and resistance to flexion
associated with previous injury.
.
NO response of RUE RLE to nail bed P. LUE withdraws and LLE
dorsiflexion at ankle to nailbed pressure.
.
Reflexes:
+2 L biceps, 1+ brachio and triceps on L; 1+ biceps on R and
absent brachio/triceps on R. Symmetric patella 2+, absent
ankles.
Toes mute bilaterally
.
Coordination/Gait/Romberg: Not tested

FAMILY HISTORY: Mother-diabetes [**Name2 (NI) **] insulin from 35-40y, with retinopathy; HTN,
hypercholesterolaemia
Father-colon CA

SOCIAL HISTORY: Married, 4 children. Immigrated from [**Location (un) 6847**] in [**2131**]. Speaks
Cantonese.
Truck driver, produce. Tob: 60 pack year +. EtOH: 1-2 beers per
week.
Intracerebral hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Mechanical complication of nervous system device, implant, and graft,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Acute respiratory failure,Communicating hydrocephalus,Polyneuropathy in diabetes,Background diabetic retinopathy,Long-term (current) use of insulin,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side
Intracerebral hemorrhage,Crbl art ocl NOS w infrc,Malfun neuro device/graf,DMII neuro uncntrld,Acute respiratry failure,Communicat hydrocephalus,Neuropathy in diabetes,Diabetic retinopathy NOS,Long-term use of insulin,Hypertension NOS,Hyperlipidemia NEC/NOS,Tobacco use disorder,Late ef-hemplga side NOS
Admission Date:  [**2145-12-17**]              Discharge Date:   [**2146-1-1**]

Date of Birth:  [**2093-1-21**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
confusion, vomiting

Major Surgical or Invasive Procedure:
Cerebral Angiogram
Intubation
Extraventricular drain placement
VP shunt placement


History of Present Illness:
52 y old man who presented following acute onset of confusion
while driving. Apparently was able to talk with relative but
relative noted he was confused. Pulled off the road. Developed
acute onset headache with nausea and vomiting.
.
The patient was reviewed at [**Hospital6 10353**] where CT scan
showed L thalamic bleed with extension of blood to lateral and
thrid ventricles. Mr [**Known lastname **] was intubated there and tranferred to
[**Hospital1 18**] for further treatment.
.
Assessed by neurosurgery. CT here showed findings as above. CTA
negative for arteriovenous malformation or subarachnoid
hemorrhage. Preoperatively weak on R side. The patient was taken
to the OR for bilateral burr holes, and ventriculostomy drains.
Increased ICP. Transferred to ICU for monitoring.
.
Systems:
Recent endocrine review note states had been experiencing
bilateral hand numbness for 6 months with occassional LE
numbness

Past Medical History:
Diabetes diagnosed in [**Location (un) 6847**] 17y ago-poorly treated
-HbA1c 15.[**2145-9-10**]
-diabetic retinopathy with hemorrhages seen [**2144-8-3**] ([**Hospital1 336**]) s/p
laser treatments
-probable diabetic neuropathy (paraesthesias)
Hypertension diagnosed in [**2145-11-3**]
Hyperlipidaemia
Appendectomy [**2134**]

Social History:
Married, 4 children. Immigrated from [**Location (un) 6847**] in [**2131**]. Speaks
Cantonese.
Truck driver, produce. Tob: 60 pack year +. EtOH: 1-2 beers per
week.

Family History:
Mother-diabetes [**Name2 (NI) **] insulin from 35-40y, with retinopathy; HTN,
hypercholesterolaemia
Father-colon CA

Physical Exam:
On admission:
T-97.3 BP-107/57 (once up to 139/-, mostly 100s-110 systolic)
HR-92 RR-14 O2Sat-100% 40%FiO2 FS 170
.
Gen: Lying in bed, intubated and ventilated
HEENT: Moist oral mucosa
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: 5cm PEEP Rate 12 Clear to auscultation bilaterally
aBd: +BS soft, nontender, old appendectomy scar RLQ
ext: no edema, cool
.
Neurologic examination (Propofol running):
.
Bilat external ventricular drains at 10cm,draining
serosanguinous fluid.
.
Mental status: Withdrawing to nailbed pressure L side. Not
opening eyes. No vocalisations.
.
Cranial Nerves:
Pupils equally round and sluggisly reactive to light, 2 to 1.5
mm bilaterally. Facial movement symmetric.
.
Motor:
Normal bulk bilaterally. Intermittent fine tremor bilat upper
limbs. Tone increased bilat LE. Fixed contracture at R elbow
unable to extend beyond about 120 deg and resistance to flexion
associated with previous injury.
.
NO response of RUE RLE to nail bed P. LUE withdraws and LLE
dorsiflexion at ankle to nailbed pressure.
.
Reflexes:
+2 L biceps, 1+ brachio and triceps on L; 1+ biceps on R and
absent brachio/triceps on R. Symmetric patella 2+, absent
ankles.
Toes mute bilaterally
.
Coordination/Gait/Romberg: Not tested

Pertinent Results:
CT brain [**2145-12-17**]
Acute hemorrhage in the left thalamus with surrounding vasogenic
edema, mass effect, and mild shift of normally midline
structures, and dissemination of the hemorrhage into bilateral
anterior horns, third ventricle, aqueduct, and fourth ventricle.
Multiple air fluid levels in paranasal sinuses as described
above, representing sinus disease.
.
CTA [**2145-12-17**] Left thalamic and intraventricular hemorrhage.
Prominent veins in the left hippocampus, could represent a
developmental venous anomaly. If this patient is not felt to
have a hypertensive hemorrhage, an angiogram should be performed
to evaluate for arteriovenous shunting, in which case, an
arteriovenous malformation could be considered.
.
Admission Labs [**2145-12-17**]
Urine: RBC->50 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0
BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-250 KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG
COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
.
WBC-13.8* RBC-4.43* HGB-13.1* HCT-37.8* MCV-85 MCH-29.6
MCHC-34.7 RDW-14.2 PLT COUNT-240
NEUTS-86.0* LYMPHS-10.0* MONOS-2.3 EOS-1.3 BASOS-0.3
PT-11.6 PTT-29.9 INR(PT)-1.0
ALT(SGPT)-21 AST(SGOT)-25 ALK PHOS-70 AMYLASE-85 TOT BILI-1.0
GLUCOSE-219* UREA N-22* CREAT-1.1 SODIUM-140 POTASSIUM-4.4
CHLORIDE-101 TOTAL CO2-27 ANION GAP-16
HGB-10.4* calcHCT-31
GLUCOSE-198* LACTATE-1.2 NA+-139 K+-3.5 CL--110
.
Angiogram [**2145-12-23**]:
FINDINGS:  No intraparenchymal arteriovenous malformations were
seen.  There are no aneurysms, stenoses, or occlusions. Right
external carotid artery injection demonstrates an arteriovenous
fistula from the distal branches of the  right internal
maxillary artery / ethmoidal arteries are seen to the ophthalmic
veins and the cavernous sinuses bilaterally.
.
IMPRESSION:  No intraparenchymal arteriovenous malformations.

Relatively small arteriovenous fistula is noted  from the distal
branches of the right internal maxillary artery / ethmoidal
arteries with drainage into the  ophthalmic vein and cavernous
sinus.
.
Head CT post op [**12-30**]:
FINDINGS:  An intraventricular drain enters the brain via a
right frontal burr hole, traversing the septum pellucidum and
terminating at the level of the left cerebellar peduncle.  The
ventricles appear smaller than on prior CT scan.  The amount of
blood layering in bilateral occipital horns is unchanged. The
appearance of the brain and paranasal sinuses is otherwise
unchanged.
.
IMPRESSION:  Interval replacement of the right intraventricular
drain as
described above with resultant decrease in ventricular
prominence


Brief Hospital Course:
52year old gentleman with background of diabetes, and
hypercholesterolaemia, with HTN diagnosed in [**Month (only) **], admitted
with a L thalamic bleed with extension to ventricular system.
.
Neuro:
Pt was initially admitted to Neurosurgery service. L thalamic
hemorrhage was about 10cc with extension to lateral and 3rd
ventricles on imaging (see results above). Bilateral EVDs were
placed on [**2145-12-17**] and revised [**2145-12-18**].  Cefazolin prophylaxis
was continued while EVDs in place.  Mental status improved and
pt was extubated without incident on [**2145-12-19**], and transferred
to Neurology step down unit on [**2145-12-22**].  EVD was clamped and
pt. developed increased ICPs to 30s, so VP shunt was placed with
no complications on [**12-29**].  Post-op Head CT showed decrease in
ventricle size after shunt placement  (see results above).  He
had no seizures in house.  He was initially given phenytoin for
seizure prophylaxis, which was titrated down prior to discharge.
 He should continue to be titrated off over the next 2 weeks
(100 mg [**Hospital1 **] through [**1-6**], then 100 QD through [**1-13**], then off).
BP was cotrolled with Metoprolol IV -> PO and Hydralazine IV PRN
to maintain MAPs < 110.  Angiogram was performed and showed no
evidence of aneurysm, but did show a small arteriovenous fistula
from the distal branches of the right internal maxillary artery
/ ethmoidal arteries with drainage into the ophthalmic vein and
cavernous sinus.  ENT was consulted about this and felt that it
needed no acute intervention.  This should be revisited by
Neurology in follow up.  The location of the hemorrhage was most
consistent with a hypertensive bleed and as angiogram showed no
other lesion this was felt to be the most likely cause of the
hemorrhage.
.
On the floor pt. was evaluated by PT and OT, who recommended
rehab, and speech, who felt that pt. was safe for advancement
from tube feeds to a soft solid diet with thin liquids, which he
tolerated well.  Pt. should be reassessed by speech at rehab and
advanced to a full diet if appropriate.
.
On day of discharge pt. had [**5-7**] grip strength on the right,
increased tone in his right arm, and some flexion of his right
arm with pain, although he was unable to lift the R arm off the
bed.  He had decreased tone and UMN pattern weakness in his
right leg but was able to lift it against gravity.  He had R
facial droop.  He was awake and alert and conversing with his
family in Cantonese.


Medications on Admission:
MEDS: (From Quinsy note [**2145-12-14**])
Metformin 1700mg qam 850mg qpm
Actos (pioglitizone) 45mg qd
Glipizide 10mg [**Hospital1 **]
Atorvastatin 40mg po qd


Discharge Medications:
1. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Fourteen
(14) units Subcutaneous QAM.
3. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Ten (10)
units Subcutaneous QPM.
4. Regular Insulin Sliding Scale
Please check FS QIDACHS and administer insulin per sliding scale
attached
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO BID (2 times a day) for 6 days: through [**2145-1-6**].
9. Dilantin 100 mg Capsule Sig: One (1) Capsule PO once a day
for 7 days: [**Date range (3) 54909**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
Left thalamic cerebral hemorrhage with infarction (stroke)
Hypertension


Discharge Condition:
Stable, left arm and leg weakness


Discharge Instructions:
Please call your doctor or go to the ER if you develop any
headache, blurry vision, double vision, fever, chills, nausea,
vomiting, worsening weakness or numbness in your arms or legs,
or any other symptoms that concern you.

Followup Instructions:
Neurology: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], Tuesday [**2145-2-15**] at 3:00,
[**Telephone/Fax (1) 657**], [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] 8.  Please call prior
to the appointment to update your information.

Neurosurgery: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], [**Telephone/Fax (1) 1669**].  Dr.[**Name (NI) 9034**]
office will call you with an appointment, please call his office
if you don't hear from them in the next week.

Primary Care: please call Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 8236**] to set up a
follow up in the next 2-4 weeks


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

Completed by:[**2146-1-1**]
{'Intracerebral hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Mechanical complication of nervous system device, implant, and graft,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Acute respiratory failure,Communicating hydrocephalus,Polyneuropathy in diabetes,Background diabetic retinopathy,Long-term (current) use of insulin,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side'}


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: confusion, vomiting

PRESENT ILLNESS: 52 y old man who presented following acute onset of confusion
while driving. Apparently was able to talk with relative but
relative noted he was confused. Pulled off the road. Developed
acute onset headache with nausea and vomiting.
.
The patient was reviewed at [**Hospital6 10353**] where CT scan
showed L thalamic bleed with extension of blood to lateral and
thrid ventricles. Mr [**Known lastname **] was intubated there and tranferred to
[**Hospital1 18**] for further treatment.
.
Assessed by neurosurgery. CT here showed findings as above. CTA
negative for arteriovenous malformation or subarachnoid
hemorrhage. Preoperatively weak on R side. The patient was taken
to the OR for bilateral burr holes, and ventriculostomy drains.
Increased ICP. Transferred to ICU for monitoring.
.
Systems:
Recent endocrine review note states had been experiencing
bilateral hand numbness for 6 months with occassional LE
numbness

MEDICAL HISTORY: Diabetes diagnosed in [**Location (un) 6847**] 17y ago-poorly treated
-HbA1c 15.[**2145-9-10**]
-diabetic retinopathy with hemorrhages seen [**2144-8-3**] ([**Hospital1 336**]) s/p
laser treatments
-probable diabetic neuropathy (paraesthesias)
Hypertension diagnosed in [**2145-11-3**]
Hyperlipidaemia
Appendectomy [**2134**]

MEDICATION ON ADMISSION: MEDS: (From Quinsy note [**2145-12-14**])
Metformin 1700mg qam 850mg qpm
Actos (pioglitizone) 45mg qd
Glipizide 10mg [**Hospital1 **]
Atorvastatin 40mg po qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
T-97.3 BP-107/57 (once up to 139/-, mostly 100s-110 systolic)
HR-92 RR-14 O2Sat-100% 40%FiO2 FS 170
.
Gen: Lying in bed, intubated and ventilated
HEENT: Moist oral mucosa
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: 5cm PEEP Rate 12 Clear to auscultation bilaterally
aBd: +BS soft, nontender, old appendectomy scar RLQ
ext: no edema, cool
.
Neurologic examination (Propofol running):
.
Bilat external ventricular drains at 10cm,draining
serosanguinous fluid.
.
Mental status: Withdrawing to nailbed pressure L side. Not
opening eyes. No vocalisations.
.
Cranial Nerves:
Pupils equally round and sluggisly reactive to light, 2 to 1.5
mm bilaterally. Facial movement symmetric.
.
Motor:
Normal bulk bilaterally. Intermittent fine tremor bilat upper
limbs. Tone increased bilat LE. Fixed contracture at R elbow
unable to extend beyond about 120 deg and resistance to flexion
associated with previous injury.
.
NO response of RUE RLE to nail bed P. LUE withdraws and LLE
dorsiflexion at ankle to nailbed pressure.
.
Reflexes:
+2 L biceps, 1+ brachio and triceps on L; 1+ biceps on R and
absent brachio/triceps on R. Symmetric patella 2+, absent
ankles.
Toes mute bilaterally
.
Coordination/Gait/Romberg: Not tested

FAMILY HISTORY: Mother-diabetes [**Name2 (NI) **] insulin from 35-40y, with retinopathy; HTN,
hypercholesterolaemia
Father-colon CA

SOCIAL HISTORY: Married, 4 children. Immigrated from [**Location (un) 6847**] in [**2131**]. Speaks
Cantonese.
Truck driver, produce. Tob: 60 pack year +. EtOH: 1-2 beers per
week. 

### Response:
{'Intracerebral hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Mechanical complication of nervous system device, implant, and graft,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Acute respiratory failure,Communicating hydrocephalus,Polyneuropathy in diabetes,Background diabetic retinopathy,Long-term (current) use of insulin,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side'}
