CHIEF COMPLAINT: subarachnoid hemorrhage

PRESENT ILLNESS: Mr. [**Known lastname 724**] is a 55 y/o male with a PMH significant for
hypertension who was transported to the ED at [**Hospital1 18**] via
ambulance.  Around 12 pm today he told his housekeeper he was
not feeling well and requested she call 911.  He was met at the
ED by his wife and his father-in-law; they do not know what his
symptoms were which triggered the 911 call.  His father-in-law
states that the last time Mr. [**Known lastname 724**] was "normal" was at 3 a.m.

MEDICAL HISTORY: hypertension: on atenolol

MEDICATION ON ADMISSION: Atenolol 50 mg PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
==============
T: 98.8   BP: 169/100   HR: 46    R: 14   O2Sats 100%
Gen: WD/WN, lying in bed; lethargic.
HEENT: Pupils:  3mm-2mm bilaterally; sluggish.
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Drowsy opens eyes to voice and name; not
following
commands. Withdraws to pain in the upper extremities;  moves
upper extremities spontaneously and purposefully.  No
spontaneous
movement in the lower extremities.

FAMILY HISTORY: NC

SOCIAL HISTORY: Resides at home with his wife. [**Name (NI) 1403**] at a Vitamin shop. No
tobacco or alcohol use.
Subarachnoid hemorrhage,Acute duodenal ulcer with hemorrhage, without mention of obstruction,Staphylococcal meningitis,Cerebral edema,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure with lesion of tubular necrosis,Dissection of vertebral artery,Acute on chronic diastolic heart failure,Toxic encephalopathy,Infection and inflammatory reaction due to nervous system device, implant, and graft,Obstructive hydrocephalus,Bacteremia,Hyposmolality and/or hyponatremia,Unspecified protein-calorie malnutrition,Acute posthemorrhagic anemia,Intracerebral hemorrhage,Dysphagia, unspecified,Unspecified essential hypertension,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Hypotension, unspecified,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Other and unspecified special symptoms or syndromes, not elsewhere classified,Physical restraints status,Obstructive sleep apnea (adult)(pediatric),Adrenal cortical steroids causing adverse effects in therapeutic use
Subarachnoid hemorrhage,Ac duodenal ulcer w hem,Staphylococc meningitis,Cerebral edema,Food/vomit pneumonitis,Ac kidny fail, tubr necr,Dissect vertebral artery,Ac on chr diast hrt fail,Toxic encephalopathy,React-nerv sys dev/graft,Obstructiv hydrocephalus,Bacteremia,Hyposmolality,Protein-cal malnutr NOS,Ac posthemorrhag anemia,Intracerebral hemorrhage,Dysphagia NOS,Hypertension NOS,Abn react-procedure NEC,Hypotension NOS,Drug dermatitis NOS,Adv eff cephalosporin,Cardiac dysrhythmias NEC,Special symptom NEC/NOS,Physical restrain status,Obstructive sleep apnea,Adv eff corticosteroids
Admission Date:  [**2177-10-5**]              Discharge Date:   [**2177-11-13**]

Date of Birth:  [**2122-2-9**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
subarachnoid hemorrhage

Major Surgical or Invasive Procedure:
[**2177-10-5**] Cerebral angiogram with embolization of Right PICA
aneurysm
[**2177-10-5**] Right frontal EVD
[**2177-10-6**] replacement of right frontal EVD
[**2177-10-22**] replacement of right frontal EVD


History of Present Illness:
Mr. [**Known lastname 724**] is a 55 y/o male with a PMH significant for
hypertension who was transported to the ED at [**Hospital1 18**] via
ambulance.  Around 12 pm today he told his housekeeper he was
not feeling well and requested she call 911.  He was met at the
ED by his wife and his father-in-law; they do not know what his
symptoms were which triggered the 911 call.  His father-in-law
states that the last time Mr. [**Known lastname 724**] was "normal" was at 3 a.m.

Past Medical History:
hypertension: on atenolol

Social History:
Resides at home with his wife. [**Name (NI) 1403**] at a Vitamin shop. No
tobacco or alcohol use.


Family History:
NC

Physical Exam:
ADMISSION EXAM
==============
T: 98.8   BP: 169/100   HR: 46    R: 14   O2Sats 100%
Gen: WD/WN, lying in bed; lethargic.
HEENT: Pupils:  3mm-2mm bilaterally; sluggish.
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Drowsy opens eyes to voice and name; not
following
commands. Withdraws to pain in the upper extremities;  moves
upper extremities spontaneously and purposefully.  No
spontaneous
movement in the lower extremities.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors.

Toes downgoing bilaterally

Handedness: Right

DISCHARGE EXAM
==============
VS: Tc 98 (Tm 98.8) BP 113/79 (84-120/46-81) P 97 (95-107) RR 24
O2Sat 93% on RA (mid-90s on RA)
General: Lethargic/somnolent, but more arousable compared to
yesterday, lying in bed, breathing comfortably, NAD
Skin: Macular, erythematous rash most prominent on extremities
today. fine, blanching [**Doctor Last Name **] rash on chest.
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: Supple. No LAD.
Lungs: Exam limited to anterior lung fields. Good aeration,
CTAB. No wheezes, rales, rhonchi.
CV: Tachycardic, regular rhythm, normal S1 + S2, S4 present. No
murmurs, rubs, or gallops.
Abdomen: PEG tube in place. Normoactive bowel sounds, soft,
moderately distended, nontender, no rebound tenderness or
guarding,
Ext: Warm, no edema. 2+ distal pulses.
Neuro: CNII-XII intact. Moves all extremities.


Pertinent Results:
ADMISSION LABS
==============
[**2177-10-5**] 01:20PM BLOOD WBC-12.2* RBC-4.83 Hgb-14.8 Hct-43.6
MCV-90 MCH-30.7 MCHC-34.0 RDW-14.1 Plt Ct-286
[**2177-10-5**] 01:20PM BLOOD Neuts-39.4* Lymphs-55.7* Monos-2.8
Eos-1.3 Baso-0.9
[**2177-10-5**] 01:20PM BLOOD PT-10.5 PTT-27.3 INR(PT)-1.0
[**2177-10-5**] 01:20PM BLOOD Glucose-161* UreaN-17 Creat-1.0 Na-139
K-3.2* Cl-103 HCO3-23 AnGap-16
[**2177-10-5**] 01:20PM BLOOD ALT-39 AST-30 AlkPhos-68 TotBili-0.6
[**2177-10-5**] 01:20PM BLOOD Lipase-44
[**2177-10-5**] 10:00PM BLOOD Calcium-8.5 Phos-2.9 Mg-1.7

MICRO
=====
-GRAM STAIN ([**2177-10-20**]):  4+   (>10 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. 3+  (5-10 per 1000X FIELD):   GRAM
POSITIVE COCCI. IN PAIRS AND CLUSTERS.
-CSF FLUID CULTURE (Final [**2177-10-23**]): STAPHYLOCOCCUS, COAGULASE
NEGATIVE. SPARSE GROWTH.
-CSF FLUID CULTURE (Final [**2177-10-26**]): STAPHYLOCOCCUS EPIDERMIDIS.
RARE GROWTH.

IMAGING:
-CT HEAD ([**2177-10-30**]): IMPRESSION: 1. Right EVD drain has been
removed with tiny focus of hemorrhage and edema surrounding the
tract. 2. Stable size of ventricles.  No progression of
hydrocephalus.
-CT HEAD ([**2177-11-4**]): CONCLUSION: 1. Mild partial interval
improvement in the dilatation of the lateral and third
ventricular size compared to the prior study.  Unchanged size of
the fourth ventricle. 2. No acute hemorrhage.
-CXR (PORTABLE AP) ([**2177-11-7**]): Comparison is made with prior
study, [**11-5**]. Extensive bilateral lung opacities, worse
on the right lung, are unchanged consistent with multifocal
aspiration pneumonia.  Bilateral pleural effusions, Larger on
the right side, are grossly unchanged allowing the difference in
positioning of the patient.  Cardiomediastinal contours are
stable. Right PICC tube tip is in the lower SVC.
-VIDEO OROPHARYNGEAL SWALLOW ([**2177-11-11**]): IMPRESSION: Penetration
with thin liquids.  Otherwise, normal oropharyngeal swallowing
videofluoroscopy.
-CT HEAD ([**2177-11-12**]): CONCLUSION: Prominent but stable appearance
of the ventricles compared to most recent CT without evidence of
new hemorrhage.

DISCHARGE LABS
==============
[**2177-11-13**] 06:33AM BLOOD WBC-6.8 RBC-3.40* Hgb-9.7* Hct-29.0*
MCV-85 MCH-28.6 MCHC-33.5 RDW-14.1 Plt Ct-453*
[**2177-11-13**] 06:33AM BLOOD Glucose-149* UreaN-54* Creat-2.8* Na-138
K-5.5* Cl-96 HCO3-34* AnGap-14
[**2177-11-13**] 06:33AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.3


Brief Hospital Course:
Mr. [**Known lastname 724**] is a 55 year old male with a history of hypertension
who was treated for a subarachnoid hemorrhage with coiling of a
right PICA aneurysm and placement of an external ventricular
drain. He developed a Staph epidermidis infection of the drain,
for which he was treated with IV vancomycin and removal of the
drain. He had a precipitous drop in hematocrit due to a bleeding
duodenal ulcer that was treated with an ulcer clipping, blood
transfusions, pantoprazole, and sucralfate. Due to hypotension,
initiation of lisinopril, and supra-therapeutic levels of
vancomycin, he developed acute kidney injury/acute tubular
necrosis, which improved over the course of his stay. He then
developed hypoxemia, from a combination of fluid overload in the
setting of acute kidney injury and pneumonia. He was treated
with careful fluid management and vancomycin and cefepime with
resolution in his hypoxemia. His course was notable for a waxing
and [**Doctor Last Name 688**] level of consciousness, related to injury sustained
during his subarachnoid hemorrhage. He was discharged to a
skilled nursing facility for further rehabilitation.

# Subarachnoid hemorrhage: Head CT imaging revealed a diffuse,
extensive subarachnoid hemorrhage along with hydrocephalus.
Further imaging revealed a right posterior inferior cerebellar
artery aneurysm, that was treated with coiling. An external
ventricular drain was placed to decreased intraventricular
pressure. Repeat head CT imaging after drain removal did not
reveal progression of his hydrocephalus or significant continued
bleeding. While hospitalized, the patient's mental status waxed
and waned, with periods of increased alertness and orientation
and periods of somnolence, related to injuries sustained from
his subarachnoid hemorrhage. [**Hospital 92114**] medical complications
detailed below also contributed to his wavering mental status.

# Pneumonia: After the patient developed low grade fevers and
new hypoxemia, chest x-ray revealed right lung opacities
consistent with an aspiration pneumonia. The patient was treated
with vancomycin and cefepime for 8 days out of concern for a
hospital-acquired pneumonia. The patient was afebrile after
treatment and was weaned off of supplemental oxygen.

# Acute kidney injury with acute tubular necrosis: This was due
to hypotension, lisinopril, and supra-therapeutic levels of
vancomycin. The patient was treated with careful fluid
management, including Lasix diuresis, and discontinuation of
lisinopril and additional vancomycin. His creatinine peaked at
4.5 (baseline 0.5), before trending downwards to 2.8 at
discharge. Creatinine and electrolytes should be checked every 7
days to ensure continued improvment.

# Drug rash: The patient developed a macular, erythematous rash
on his trunk and bilateral lower extremities from cefepime while
hospitalized. There was no evidence of mucosal involvment, no
lesions on the palms or soles. He was treated with Sarna lotion
and Benadryl. The rash remained on the day of dishcarge.

# Gastrointestinal bleed: The patient experienced an acute drop
in hematocrit to 20.5 with black, tarry stools while
hospitalized. He was treated with blood transfusions. An upper
endoscopy revealed 2 duodenal ulcers, of which 1 bleeding ulcer
was clipped. He was further treated with pantoprazole and
sucralfate. His morning gastrin level, sent for further
evaluation of duodenal ulcers, was pending at discharge.

# EVD infection: The patient developed a Staph epidermidis
infection of his external ventricular drain. He was treated with
intravenous vancomycin and removal of his drain, with resolution
of his fevers.

# Dysphagia: After evaluation by the hospital speech and swallow
team, the patient was made NPO due to his aspiration risk. A PEG
tube was placed, through which the patient received nutrition. A
follow up evaluation later in the [**Hospital 228**] hospital course
placed him at lower aspiration risk, permitting the patient's
transition to ground solids and thin liquids by mouth with
cycled tube feeds through his PEG at discharge.

# Sinus tachycardia: The patient's heart rate ranged from the
90s to 110s. Electrocardiograms and echocardiography did not
reveal a cause. He was without pain or anxiety. Hematocrit had
trended down following gastrointestinal bleedinig and he was
again transfused 2 units PRBc however there was no change in
tachycardia. He did not appear hypovolemic. Bilateral lower
extremity ultrasound was negative for DVT and echocardiography
did not show evidence of right ventricular strain (suggesting
against a hemodynamically significant pulmonary embolism). Sinus
tachycardia was attributed to his recent brain injury. The
patient received metoprolol, which was later changed to
labetalol for additional treatment of hypertension. On the day
of discharge, heart rate remained in the range of 80-110.

# Hypertension: The patient's systolic blood pressures were
often above 160, while his diastolic blood pressure ranged from
the 80s to 110s. The patient was treated with metoprolol
initially, which was later changed to labetalol and amlodipine.
On the day of discharge, patient was hypotensive with physical
therapy and amoldipine downtitrated from 10mg daily to 5mg
daily. As renal failure resolves, he will require further
titration of amlodipine and labetalol to maintain SBP <160.

TRANSITIONAL ISSUES
===================
- Mr. [**Known lastname 724**] will need to follow up with his neurosurgeon, Dr.
[**First Name (STitle) **], in 4 weeks. He will require an MRI/MRA with the [**Doctor Last Name **]
protocol prior to his appointment. An appointment is currently
being made.
- The patient's creatinine has been downtrending since
developing acute renal failure. Please continue to trend his
serum creatinine and electrolytes with measurements
approximately every 7 days.
- The patient's goal systolic blood pressure is less than 160
mmHg. His amlodipine was decreased from 10 mg to 5 mg daily on
[**2177-11-13**]. Please monitor his blood pressure, as further
titration of his labetalol and amlodipine may be required.
- The patient has a morning serum gastrin ordered as part of an
evaluation of duodenal ulcers and recent bleeding, the results
were pending at the time of discharge
- The patient is currently receiving tube feeds. As his need for
supplemental nutrition decreases, please consider slowing or
stopping his tube feeds.

Medications on Admission:
Atenolol 50 mg PO DAILY


Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain/fever
2. Labetalol 300 mg PO BID
Hold for SBP<100 HR<60
3. Sarna Lotion 1 Appl TP TID:PRN pruritic rash
4. Amlodipine 5 mg PO DAILY
Hold for SBP<100
5. Aspirin 325 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H Hypoxemia, SOB
8. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN Hypoxemia, SOB


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Primary: Subarachnoid Hemorrhage, Intraventricular Hemorrhage,
Right posterior inferior cerebellar artery aneurysm,
Hydrocephalus
Secondary: Meningitis, Duodenal ulcers x 2, Gastrointestinal
bleed, Hyponatremia, Acute kidney injury, Tachycardia,
Pneumonia, Hypertension, Sinus tachycardia


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mr. [**Known lastname 724**],

You were admitted after experiencing bleeding in your brain due
to rupture of a blood vessel. You underwent a procedure to close
the blood vessel using a coil of wire, you will need to take
aspirin 325mg daily following this procedure.

We placed a tube in your brain to drain excess fluid that had
built up as a result of inflammation and bleeding. The tube
became infected and you were treated with antibiotics. You
suffered a gastrointestinal bleed related to an ulcer in the
small intestine. The ulcer was clipped to stop bleeding and you
were given blood to replace the losses.

Lastly, you were treated for injury to your kidneys, an excess
of fluid, and a lung infection that led to difficulty breathing.
You were discharged to a skilled nursing facility for further
rehabilitation after your recent injury.

Please follow up with your neurosurgeon, Dr. [**First Name (STitle) **], in 4 weeks
for further evaluation and management of your recent
subarachnoid hemorrhage. You will need to undergo an MRI/MRA
[**Doctor Last Name **] protocol prior to your visit.

MEDICATION CHANGES
START ACETAMINOPHEN 650 MG PO Q6H PRN PAIN/FEVER
START ASPIRIN 325 MG PO/NG DAILY
START LABETALOL 300 mg PO BID
START AMLODIPINE 5 MG PO BID
START SARNA LOTION 1 APPL TP TID PRN PRURITIC RASH
START PANTOPRAZOLE 40 MG PO DAILY
STOP ATENOLOL 50 MG PO DAILY

Angiogram with Embolization and/or Stent placement
Medications:
??????	**Take Aspirin 325mg (enteric coated) once daily.


Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with an MRI/MRA
[**Doctor Last Name **] protocol. Please call [**Telephone/Fax (1) 4296**] to make this
appointment.
We are working on a follow up appt in the Neurosurgery
department with Dr. [**First Name (STitle) **] in 4 weeks. You will be called at
rehab with the appointment. If you have not heard or have
questions, please call [**Telephone/Fax (1) 1669**].
{'Subarachnoid hemorrhage,Acute duodenal ulcer with hemorrhage, without mention of obstruction,Staphylococcal meningitis,Cerebral edema,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure with lesion of tubular necrosis,Dissection of vertebral artery,Acute on chronic diastolic heart failure,Toxic encephalopathy,Infection and inflammatory reaction due to nervous system device, implant, and graft,Obstructive hydrocephalus,Bacteremia,Hyposmolality and/or hyponatremia,Unspecified protein-calorie malnutrition,Acute posthemorrhagic anemia,Intracerebral hemorrhage,Dysphagia, unspecified,Unspecified essential hypertension,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Hypotension, unspecified,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Other and unspecified special symptoms or syndromes, not elsewhere classified,Physical restraints status,Obstructive sleep apnea (adult)(pediatric),Adrenal cortical steroids causing adverse effects in therapeutic 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: subarachnoid hemorrhage

PRESENT ILLNESS: Mr. [**Known lastname 724**] is a 55 y/o male with a PMH significant for
hypertension who was transported to the ED at [**Hospital1 18**] via
ambulance.  Around 12 pm today he told his housekeeper he was
not feeling well and requested she call 911.  He was met at the
ED by his wife and his father-in-law; they do not know what his
symptoms were which triggered the 911 call.  His father-in-law
states that the last time Mr. [**Known lastname 724**] was "normal" was at 3 a.m.

MEDICAL HISTORY: hypertension: on atenolol

MEDICATION ON ADMISSION: Atenolol 50 mg PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
==============
T: 98.8   BP: 169/100   HR: 46    R: 14   O2Sats 100%
Gen: WD/WN, lying in bed; lethargic.
HEENT: Pupils:  3mm-2mm bilaterally; sluggish.
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Drowsy opens eyes to voice and name; not
following
commands. Withdraws to pain in the upper extremities;  moves
upper extremities spontaneously and purposefully.  No
spontaneous
movement in the lower extremities.

FAMILY HISTORY: NC

SOCIAL HISTORY: Resides at home with his wife. [**Name (NI) 1403**] at a Vitamin shop. No
tobacco or alcohol use. 

### Response:
{'Subarachnoid hemorrhage,Acute duodenal ulcer with hemorrhage, without mention of obstruction,Staphylococcal meningitis,Cerebral edema,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure with lesion of tubular necrosis,Dissection of vertebral artery,Acute on chronic diastolic heart failure,Toxic encephalopathy,Infection and inflammatory reaction due to nervous system device, implant, and graft,Obstructive hydrocephalus,Bacteremia,Hyposmolality and/or hyponatremia,Unspecified protein-calorie malnutrition,Acute posthemorrhagic anemia,Intracerebral hemorrhage,Dysphagia, unspecified,Unspecified essential hypertension,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Hypotension, unspecified,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Other and unspecified special symptoms or syndromes, not elsewhere classified,Physical restraints status,Obstructive sleep apnea (adult)(pediatric),Adrenal cortical steroids causing adverse effects in therapeutic use'}
