CHIEF COMPLAINT: Decreased responsiveness

PRESENT ILLNESS: Patient is a 83 yo woman (born L handed but trained to use R
hand in school) with paroxysmal atrial fibrillation on Coumadin,
CAD, hx of TIA, HTN and hyperlipidemia here from [**Hospital **]
Hospital
after presenting with unresponsiveness.  Per husband, she awoke
around 5:30 and went to the bathroom.  She then called out for
her husband who found her sitting in the bathroom leaning
against
a wall (bathroom too small for her to be laying down flat).  She
was able to speak to him and answer his questions but she seemed
to fade hence 911 was called.  She was still answering EMT's
questions per husband.

MEDICAL HISTORY: 1. Paroxysmal AF - on Coumadin
2. CAD s/p MI in [**2147**] and PCI in [**2169**]
3. HTN
4. Hyperlipidemia
5. Stroke in [**5-1**] - presented with speech difficulty, continued
to have some word-finding difficulty.
6. Osteoporosis
7. R CEA in [**2168**]
8. s/p Tonsillectomy
9. ?L cataract repair

MEDICATION ON ADMISSION: 1. Coumadin (2.5 on MF and 5mg other days)
2. ASA 81mg daily
3. Lipitor 80mg daily
4. Sotalol 40mg [**Hospital1 **]
5. Lasix 20 daily
6. KCl 10mEq
7. Lisinopril 2.5mg daily
8. Fosamax 70 weekly

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: T 97 BP 120 - irregular HR 119/87 RR 16 O2Sat 100% intubated
Gen: Intubated - received paralytics and sedation prior to
transfer around 3 hrs previous to exam.
HEENT: Hard cervical collar.
CV: Irregularly irregular and rapid.
Lung: Clear anteriorly.
Abd: +BS, soft, nontender
Ext: No edema

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives with husband - DNR/[**Name2 (NI) 835**] per husband and son who is also
the HCP, [**Name (NI) **] [**Name (NI) 59454**] [**Name (NI) **] [**Telephone/Fax (1) 86112**]).  Remote (> 40 yrs ago)
smoking hx and no EtOH.  Walks without assistance at baseline -
independent in all ADLs.
Intracerebral hemorrhage,Compression of brain,Subarachnoid hemorrhage,Coma,Atrial fibrillation,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Other late effects of cerebrovascular disease,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Personal history of tobacco use,Encounter for palliative care
Intracerebral hemorrhage,Compression of brain,Subarachnoid hemorrhage,Coma,Atrial fibrillation,Long-term use anticoagul,Crnry athrscl natve vssl,Late effect CV dis NEC,Hypertension NOS,Hyperlipidemia NEC/NOS,Osteoporosis NOS,History of tobacco use,Encountr palliative care
Admission Date:  [**2171-3-27**]              Discharge Date:   [**2171-3-28**]

Date of Birth:  [**2087-5-24**]             Sex:   F

Service: NEUROLOGY

Allergies:
No Drug Allergy Information on File

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Decreased responsiveness

Major Surgical or Invasive Procedure:
extubation

History of Present Illness:
Patient is a 83 yo woman (born L handed but trained to use R
hand in school) with paroxysmal atrial fibrillation on Coumadin,
CAD, hx of TIA, HTN and hyperlipidemia here from [**Hospital **]
Hospital
after presenting with unresponsiveness.  Per husband, she awoke
around 5:30 and went to the bathroom.  She then called out for
her husband who found her sitting in the bathroom leaning
against
a wall (bathroom too small for her to be laying down flat).  She
was able to speak to him and answer his questions but she seemed
to fade hence 911 was called.  She was still answering EMT's
questions per husband.

At the OSH, head CT revealed large L IPH (per report measures
7X5cm with midline shift).  Hence patient paralyzed then
intubated.  Patient also received FFP for INR of 2.06 and loaded
with fosphenytoin 1g.  Additionally, 2mg of IV Ativan given
prior
to transfer but no report of any seizure activity.

Given the large hemorrhage, NSURG initially consulted but felt
that intervention would be futile.

Head CT repeated here showing again large L IPH measuring about
8x5cm seen in 13 slices with midline shift and sub falcine
herniation.  INR was 1.7 upon arrival and patient received 10mg
of Vitamin K in our ED.  No further sedatives given.



Past Medical History:
1. Paroxysmal AF - on Coumadin
2. CAD s/p MI in [**2147**] and PCI in [**2169**]
3. HTN
4. Hyperlipidemia
5. Stroke in [**5-1**] - presented with speech difficulty, continued
to have some word-finding difficulty.
6. Osteoporosis
7. R CEA in [**2168**]
8. s/p Tonsillectomy
9. ?L cataract repair

Social History:
Lives with husband - DNR/[**Name2 (NI) 835**] per husband and son who is also
the HCP, [**Name (NI) **] [**Name (NI) 59454**] [**Name (NI) **] [**Telephone/Fax (1) 86112**]).  Remote (> 40 yrs ago)
smoking hx and no EtOH.  Walks without assistance at baseline -
independent in all ADLs.



Family History:
NC


Physical Exam:
T 97 BP 120 - irregular HR 119/87 RR 16 O2Sat 100% intubated
Gen: Intubated - received paralytics and sedation prior to
transfer around 3 hrs previous to exam.
HEENT: Hard cervical collar.
CV: Irregularly irregular and rapid.
Lung: Clear anteriorly.
Abd: +BS, soft, nontender
Ext: No edema

Neurologic examination:
Mental status: Intubated and s/p sedation about 3 hrs prior.  No
response to verbal or noxious stimuli but some spontaneous
movements including L hand and both feet but not anti-gravity.

Cranial Nerves:
L pupil appears post-surgical - both pupils about same size
(2.5mm).  R pupil reactive but sluggish.  No blinking to visual
threat and no Doll's eyes.  No corneal's but some body movements
to nasal tickle.  +gag.  Face appears symmetric.

Motor:
Possibly increased tone in both LEs but no lateralization with
the tone.  Some spontaneous movements on L hand and both feet
but
not anti-gravity.  Does not appear to be myoclonic jerks.
Withdraws L arm to noxious stim and triple flexion to noxious
stim on both legs. No response on RUE.

Sensation: Intact to noxious stim - L arm appears to localize
when nail bed pressure applied on R fingers.

Reflexes:
2s for biceps, [**Last Name (un) **] and patellar.  Toes are upgoing
bilaterally.


Pertinent Results:
[**2171-3-27**] 08:45AM BLOOD WBC-15.7* RBC-4.26 Hgb-12.7 Hct-38.4
MCV-90 MCH-29.8 MCHC-33.1 RDW-13.0 Plt Ct-199
[**2171-3-27**] 08:45AM BLOOD Neuts-81.2* Lymphs-13.6* Monos-4.4
Eos-0.5 Baso-0.3
[**2171-3-27**] 08:45AM BLOOD UreaN-25* Creat-0.8
[**2171-3-27**] 08:45AM BLOOD PT-18.8* PTT-27.6 INR(PT)-1.7*
[**2171-3-27**] 08:45AM BLOOD cTropnT-0.08*
[**2171-3-27**] 08:45AM BLOOD Phenyto-22.9*

CT head:

IMPRESSION: Large left frontoparietal intraparenchymal
hemorrhage with
surrounding edema with sulcal effacement and rightward midline
shift, as
above. Areas of bifrontal subarachnoid hemorrhage. Findings may
relate to
patient's anticoagulation, although consider MRI once/if patient
is stable to evaluate for underlying mass or vascular
malformation.


Brief Hospital Course:
In summary, patient is a 83 yo born left-handed but trained
right handed woman with PAF, HTN, hyperlipidemia and prior
stroke
on Coumadin and ASA (INR 2.06 on presentation) who fell this
morning in the bathroom and found to have large L IPH measuring
8X5cm with midline shift and sub falcine herniation.  Unclear if
spontaneous or traumatic but likely exacerbated by
anticoagulation.  No indication or record of elevated BP.

On initial exam, patient was intubated and she did receive
paralytics and
sedation about 3 hrs prior to the exam.  R pupil is reactive but
sluggish.  She has gag and some spontaneous movements in L hand
and both feet.  She withdraws to nox stim on LUE and triple
flexion in both LEs.  Nothing on RUE but she appears to localize
with the RUE when noxious stim applied to RUE.  Reflexes present
and both toes going upward.

Given the hx and imaging, most likely either spontaneous or
traumatic hemorrhage exacerbated by anticoagulation.

Discussed with the family of the grim prognosis given ICH score
of 4 - expected 30
day mortality nears 90%.  At this time family chose to focus on
comfort care.  Patient was extubated and admitted to TSICU for
CMO care.  She passed away on [**3-28**] due to herniation.


Medications on Admission:
1. Coumadin (2.5 on MF and 5mg other days)
2. ASA 81mg daily
3. Lipitor 80mg daily
4. Sotalol 40mg [**Hospital1 **]
5. Lasix 20 daily
6. KCl 10mEq
7. Lisinopril 2.5mg daily
8. Fosamax 70 weekly


Discharge Medications:
na

Discharge Disposition:
Expired

Discharge Diagnosis:
na

Discharge Condition:
na

Discharge Instructions:
na

Followup Instructions:
na

                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

Completed by:[**2171-3-28**]
{'Intracerebral hemorrhage,Compression of brain,Subarachnoid hemorrhage,Coma,Atrial fibrillation,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Other late effects of cerebrovascular disease,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Personal history of tobacco use,Encounter for palliative care'}


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: Decreased responsiveness

PRESENT ILLNESS: Patient is a 83 yo woman (born L handed but trained to use R
hand in school) with paroxysmal atrial fibrillation on Coumadin,
CAD, hx of TIA, HTN and hyperlipidemia here from [**Hospital **]
Hospital
after presenting with unresponsiveness.  Per husband, she awoke
around 5:30 and went to the bathroom.  She then called out for
her husband who found her sitting in the bathroom leaning
against
a wall (bathroom too small for her to be laying down flat).  She
was able to speak to him and answer his questions but she seemed
to fade hence 911 was called.  She was still answering EMT's
questions per husband.

MEDICAL HISTORY: 1. Paroxysmal AF - on Coumadin
2. CAD s/p MI in [**2147**] and PCI in [**2169**]
3. HTN
4. Hyperlipidemia
5. Stroke in [**5-1**] - presented with speech difficulty, continued
to have some word-finding difficulty.
6. Osteoporosis
7. R CEA in [**2168**]
8. s/p Tonsillectomy
9. ?L cataract repair

MEDICATION ON ADMISSION: 1. Coumadin (2.5 on MF and 5mg other days)
2. ASA 81mg daily
3. Lipitor 80mg daily
4. Sotalol 40mg [**Hospital1 **]
5. Lasix 20 daily
6. KCl 10mEq
7. Lisinopril 2.5mg daily
8. Fosamax 70 weekly

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: T 97 BP 120 - irregular HR 119/87 RR 16 O2Sat 100% intubated
Gen: Intubated - received paralytics and sedation prior to
transfer around 3 hrs previous to exam.
HEENT: Hard cervical collar.
CV: Irregularly irregular and rapid.
Lung: Clear anteriorly.
Abd: +BS, soft, nontender
Ext: No edema

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives with husband - DNR/[**Name2 (NI) 835**] per husband and son who is also
the HCP, [**Name (NI) **] [**Name (NI) 59454**] [**Name (NI) **] [**Telephone/Fax (1) 86112**]).  Remote (> 40 yrs ago)
smoking hx and no EtOH.  Walks without assistance at baseline -
independent in all ADLs. 

### Response:
{'Intracerebral hemorrhage,Compression of brain,Subarachnoid hemorrhage,Coma,Atrial fibrillation,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Other late effects of cerebrovascular disease,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Personal history of tobacco use,Encounter for palliative care'}
