CHIEF COMPLAINT: intracranial hemorrhage

PRESENT ILLNESS: The pt is a 58  year-old L-handed male who presents with new
onset IPH.  History taken over the phone from wife and daughter.

MEDICAL HISTORY: Renal Failure
DM2- non insulin dependent, had been on glucophage/metformin
HTN
anemia
Hep C

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T:97.8  P:74  R:19 BP:130/89  SaO2:98%

FAMILY HISTORY: unknown

SOCIAL HISTORY: has past EtOH, tobacco, and drug history including
cocaine prior to prison.  Formerly worked in construction, no
longer working.
Intracerebral hemorrhage,Cerebral edema,Acute kidney failure with lesion of tubular necrosis,Intermediate coronary syndrome,Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I through stage IV, or unspecified,Other specified hemiplegia and hemiparesis affecting dominant side,Cocaine abuse, unspecified,Chronic kidney disease, unspecified,Hypocalcemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of other infectious and parasitic diseases,Personal history of noncompliance with medical treatment, presenting hazards to health
Intracerebral hemorrhage,Cerebral edema,Ac kidny fail, tubr necr,Intermed coronary synd,Mal hy kid w cr kid I-IV,Ot sp hmiplga domnt side,Cocaine abuse-unspec,Chronic kidney dis NOS,Hypocalcemia,DMII wo cmp nt st uncntr,Prsnl hst oth nfct parst,Hx of past noncompliance
Admission Date:  [**2140-8-28**]              Discharge Date:   [**2140-9-2**]

Date of Birth:  [**2082-5-9**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
intracranial hemorrhage

Major Surgical or Invasive Procedure:
none


History of Present Illness:
The pt is a 58  year-old L-handed male who presents with new
onset IPH.  History taken over the phone from wife and daughter.

Around 7 pm yesterday evening the patient some weakness in his
left arm, however, he did not think much of it and went to
sleep.
He then awoke around 11 pm having to use the restroom.  At that
time he was unable to walk with profound weakness in his left
lower and upper extremities.  At that time his wife called an
ambulance.

Patient was then taken to an OSH.  Per report patient had a
Seizure in transit, however no discription of the event is
available.  Patient was then intubated for unresponsiveness and
was found to have an initial SBP of 290.  Initial NCHCT
demonstrated a large intraparenchymal hemorrhage and patient was
transferred to [**Hospital1 18**] for further management.  Patient was
reportedly given the following medications at the OSH:
Vec 10 IVP
Atomidate 10
Ativan 2 mg
Protonix 40 mg
Hydralazine 10
Lopressor
Clindamycin 600 mg IVPB
Fosphenytoin 1 gram
Propofol gtt

Patient has a PMH of renal disease (no dialysis), DM, HTN,
anemia, hep C. Patient was recently released from prison 4 weeks
ago after 5 years of incarceration.  Patient has not taken any
of
his medications since being released from prison.

Past Medical History:
Renal Failure
DM2- non insulin dependent, had been on glucophage/metformin
HTN
anemia
Hep C


Social History:
has past EtOH, tobacco, and drug history including
cocaine prior to prison.  Formerly worked in construction, no
longer working.


Family History:
unknown

Physical Exam:
Vitals: T:97.8  P:74  R:19 BP:130/89  SaO2:98%

General: Awake, cooperative, NAD.
HEENT: NC/AT,
Neck: Supple, No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: warm well perfused
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: patient unable to open eyes to noxious stimuli
-Cranial Nerves:
Brain stem reflexes

II: PERRL 3 to 2mm and brisk. BL
Dolls was not performed at this time until neck injury ruled out
V/VII: + corneal reflex bilateral.
IX, X: + gag

[**Last Name (un) **]/ Motor: R upper and lower extremity spontaneous movement
and
withdrawl from noxious.  Left upper and lower extremity with
minimal withdrawal to noxious.

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2  2    2    2   1
R  2  2    2    2   1
crossed adductor reflex on left patellar
Plantar response was flexor bilaterally.

-Coordination:unable to assess

-Gait: unable to assess


Pertinent Results:
LABORATORY STUDIES:

[**2140-8-28**] 08:15AM BLOOD WBC-12.6* RBC-4.17* Hgb-12.4* Hct-36.7*
MCV-88 MCH-29.8 MCHC-33.9 RDW-15.8* Plt Ct-234
[**2140-8-28**] 08:15AM BLOOD Neuts-89.9* Lymphs-6.6* Monos-2.1 Eos-0.7
Baso-0.6

[**2140-8-28**] 08:15AM BLOOD PT-13.6* PTT-25.4 INR(PT)-1.2*

[**2140-8-28**] 03:50PM BLOOD Glucose-154* UreaN-57* Creat-4.2* Na-140
K-5.0 Cl-106 HCO3-22 AnGap-17

[**2140-8-28**] 08:15AM BLOOD ALT-15 AST-25 CK(CPK)-649* AlkPhos-124
TotBili-0.3

CARDIAC ENZYMES:
[**2140-8-28**] 03:50PM BLOOD CK(CPK)-485*
[**2140-8-28**] 11:57PM BLOOD CK(CPK)-429*
[**2140-8-31**] 05:10AM BLOOD CK(CPK)-458*
[**2140-8-28**] 03:50PM BLOOD CK-MB-5 cTropnT-0.12*
[**2140-8-28**] 11:57PM BLOOD CK-MB-4 cTropnT-0.12*
[**2140-8-29**] 09:37AM BLOOD cTropnT-0.10*

[**2140-8-29**] 09:37AM BLOOD Albumin-3.4*

[**2140-8-29**] 09:37AM BLOOD Triglyc-208* HDL-35 CHOL/HD-4.1
LDLcalc-66  Cholest-143

[**2140-8-29**] 03:53AM BLOOD %HbA1c-6.5* eAG-140*

[**2140-8-29**] 09:37AM BLOOD PTH-340*

[**2140-8-28**] 09:00AM URINE Color-Yellow Appear-SlHazy Sp [**Last Name (un) **]-1.021
[**2140-8-28**] 09:00AM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2140-8-28**] 09:00AM URINE RBC-[**1-29**]* WBC-[**5-5**]* Bacteri-MOD Yeast-NONE
Epi-0
[**2140-8-28**] 09:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS amphetm-NEG mthdone-NEG

MICRO:
URINE CX NEGATIVE

DISCHARGE LABORATORIES:
[**2140-8-30**] 03:53AM BLOOD WBC-9.8 RBC-3.27* Hgb-9.7* Hct-29.1*
MCV-89 MCH-29.7 MCHC-33.3 RDW-15.7* Plt Ct-187

IMAGING:

HEAD CT [**8-28**]: Unchanged right parietal lobar hemorrhage.

MRI/A HEAD AND NECK
1. Stable appearance of the right frontal and parietal
intraparenchymal
hemorrhage with surrounding vasogenic edema. Stable ventricular
size. No
evidence of underlying vascular malformation on this
non-contrast study.
However, when the patient is able, additional post-contrast
imaging as well as CTA can be considered to further evaluate for
underlying lesion/vascular malformation.
2. Foci of susceptibility artifact in the right cerebellum, left
subcortical white matter, right temporal cortex/subcortical
white matter, could represent areas of microhemorrhage,
cavernomas, or amyloid angiopathy. No calcifications were noted
on prior CT in these areas.
3. Unremarkable non-contrast MRA of the head and neck. Of note,
the MRA of
the head did not entirely cover the area of hemorrhage.

TTE
Mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function. Mild mitral
regurgitation with normal valve morphology. Mild pulmonary
artery systolic hypertension. Dilated thoracic aorta.

Brief Hospital Course:
NEURO:
Mr [**Known lastname **] was transferred from an outside hospital for a right
parietal intracranial hemorrhage. He was intubated before being
transferred. He also had a witnessed GTC seizure at OSH, and was
started on phenytoin. He was admitted into the ICU and was
placed on a nicardipine gtt for blood pressure control. In the
ICU was extubated the next day without problems. [**Name (NI) **] had a CT
scan of the head which demonstrated a stable hemorrhage. He was
placed on PO medications for blood pressure management
amlodipine and labetalol. He was also seen by nephrology for his
acute on chronic renal failure. The etiology of his hemorrhage
as well as his acute kidney injury was due to hypertensive
emergency as a result of primary HTN with medication
non-compliance and cocaine abuse. Troponin were also measured
and were stable. He had an uncomplicated course in the ICU and
was transferred to the floor for further care.

For seizure secondary ppx, patient was initially continued on
phenytoin, and then switched to Keppra for easier compliance and
fewer side effects. No further seizure activity.

On the floor, blood pressure medications were titrated for goal
SBP<160 and DBP<110. He may restart ASA 81 mg on [**2140-9-10**]. He
will follow up in stroke clinic, he will need a PCP [**Name Initial (PRE) 28085**].

Patient was treated with insulin sliding scale rather than oral
hypoglycemics given renal failure. He will follow up with renal
outpatient.

Medications on Admission:
none

Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: per sliding
scale  Injection ASDIR (AS DIRECTED).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stool.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or Temp > 100.0.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two
(2) Tablet, Chewable PO TID (3 times a day).
10. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. labetalol 300 mg Tablet Sig: One (1) Tablet PO three times a
day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
right parietal intraparenchymal hemorrhage
hypertension
diabetes mellitus
acute on chronic renal insufficiency


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Neuro status: left hemiparesis and hemisensory deficit, tactile
extinction, no visual field cut.


Discharge Instructions:
You were admitted with a brain hemorrhage caused by cocaine and
high blood pressure. You were monitored carefully in the
intensive care unit, and remained stable. You were treated for
high blood pressure, and you need to take your medications every
day to prevent more strokes.
Do not use cocaine or other drugs, these can cause more strokes
and hemorrhages which are often life threatening.
You should start taking a baby aspirin in 10 days.

You also had kidney injury, and you will need to follow up with
a kidney specialist.

Followup Instructions:
** You will need to establish a primary care physician and
obtain referrals for these appointments.

Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2140-10-18**] 2:00

Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2140-10-3**] 2:30
[**Hospital Ward Name 23**] Clinical Center
[**Telephone/Fax (1) 1694**]
{'Intracerebral hemorrhage,Cerebral edema,Acute kidney failure with lesion of tubular necrosis,Intermediate coronary syndrome,Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I through stage IV, or unspecified,Other specified hemiplegia and hemiparesis affecting dominant side,Cocaine abuse, unspecified,Chronic kidney disease, unspecified,Hypocalcemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of other infectious and parasitic diseases,Personal history of noncompliance with medical treatment, presenting hazards to health'}


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: intracranial hemorrhage

PRESENT ILLNESS: The pt is a 58  year-old L-handed male who presents with new
onset IPH.  History taken over the phone from wife and daughter.

MEDICAL HISTORY: Renal Failure
DM2- non insulin dependent, had been on glucophage/metformin
HTN
anemia
Hep C

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T:97.8  P:74  R:19 BP:130/89  SaO2:98%

FAMILY HISTORY: unknown

SOCIAL HISTORY: has past EtOH, tobacco, and drug history including
cocaine prior to prison.  Formerly worked in construction, no
longer working. 

### Response:
{'Intracerebral hemorrhage,Cerebral edema,Acute kidney failure with lesion of tubular necrosis,Intermediate coronary syndrome,Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I through stage IV, or unspecified,Other specified hemiplegia and hemiparesis affecting dominant side,Cocaine abuse, unspecified,Chronic kidney disease, unspecified,Hypocalcemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of other infectious and parasitic diseases,Personal history of noncompliance with medical treatment, presenting hazards to health'}
