CHIEF COMPLAINT: Transferred from OSH, intubated

PRESENT ILLNESS: This is an 82 (not 72) yo M with
a history of CAD s/p MI [**17**] years prior, HLD, likely HTN and s/p
recent retinal surgery on the left who is transferred from
[**Hospital **] Hospital intubated and sedated for a higher level of
care. His wife provides the history, and she reports that he was
in his USOH until this afternoon around noon. At baseline he is
completely "healthy" and independent for all ADLs. He had been
nauseous for a few days. He was loading some dishes into the
dishwasher and suddenly fell backwards at around 12:30PM. Then
he
walked out to take the trash out and couldn't climb the two
steps
to come back into the house. Later, his wife sat him down
because
his speech became garbled and he couldn't really understand what
his wife was saying. EMS was called because his wife was
concerned for a TIA. He was taken to an OSH, and was noted to be
nauseous and vomiting en route in the ambulance. While at this
OSH, he was noted to be hypertensive. He was given labetalol IV,
fosphenytoin 1g load and zofran and intubated for airway
protection. He had a NCHCT which revealed a left sided basal
ganglia bleed, and was thus transferred to the [**Hospital1 18**] for a
higher
level of care. The wife denies that the patient is being
anticoagulated or ever having been treated for atrial
fibrillation.

MEDICAL HISTORY: - HLD
- HTN: wife reports that patient has had a history of having
relatively high blood pressures
- Recent eye surgery on left: Ripple retina procedure? Wife
reports that the patient may be on atropine eye drops
- CAD: s/p MI at age 50
- Tobacco abuse: smoked for 20 years, quit following his MI

MEDICATION ON ADMISSION: Medications per family (although they are very unsure)
Niacin
Cholesterol medication
aspirin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam on Admission:
Vitals: AF, 149/76, HR 80s, 96% on ETT FiO2 40%
General: Intubated, sedated
HEENT: Eyes open at baseline, no obvious oropharyngeal lesions
noted externally
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Negative for heavy alcoholism, current smoking or
illicit drug use.
Intracerebral hemorrhage,Cerebral edema,Ventilator associated pneumonia,Hemiplegia, unspecified, affecting unspecified side,Old myocardial infarction,Unspecified protein-calorie malnutrition,Acute respiratory failure,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Iron deficiency anemia, unspecified,Personal history of tobacco use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution
Intracerebral hemorrhage,Cerebral edema,Ventltr assoc pneumonia,Unsp hemiplga unspf side,Old myocardial infarct,Protein-cal malnutr NOS,Acute respiratry failure,Hypertension NOS,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Iron defic anemia NOS,History of tobacco use,Abn react-procedure NEC,Accid in resident instit
Admission Date:  [**2197-9-3**]              Discharge Date:   [**2197-9-13**]

Date of Birth:  [**2115-6-23**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 11784**]
Chief Complaint:
Transferred from OSH, intubated

Major Surgical or Invasive Procedure:
Tracheostomy/Gastrostomy

History of Present Illness:
This is an 82 (not 72) yo M with
a history of CAD s/p MI [**17**] years prior, HLD, likely HTN and s/p
recent retinal surgery on the left who is transferred from
[**Hospital **] Hospital intubated and sedated for a higher level of
care. His wife provides the history, and she reports that he was
in his USOH until this afternoon around noon. At baseline he is
completely "healthy" and independent for all ADLs. He had been
nauseous for a few days. He was loading some dishes into the
dishwasher and suddenly fell backwards at around 12:30PM. Then
he
walked out to take the trash out and couldn't climb the two
steps
to come back into the house. Later, his wife sat him down
because
his speech became garbled and he couldn't really understand what
his wife was saying. EMS was called because his wife was
concerned for a TIA. He was taken to an OSH, and was noted to be
nauseous and vomiting en route in the ambulance. While at this
OSH, he was noted to be hypertensive. He was given labetalol IV,
fosphenytoin 1g load and zofran and intubated for airway
protection. He had a NCHCT which revealed a left sided basal
ganglia bleed, and was thus transferred to the [**Hospital1 18**] for a
higher
level of care. The wife denies that the patient is being
anticoagulated or ever having been treated for atrial
fibrillation.


Past Medical History:
- HLD
- HTN: wife reports that patient has had a history of having
relatively high blood pressures
- Recent eye surgery on left: Ripple retina procedure? Wife
reports that the patient may be on atropine eye drops
- CAD: s/p MI at age 50
- Tobacco abuse: smoked for 20 years, quit following his MI


Social History:
Negative for heavy alcoholism, current smoking or
illicit drug use.


Family History:
Noncontributory

Physical Exam:
Physical Exam on Admission:
Vitals: AF, 149/76, HR 80s, 96% on ETT FiO2 40%
General: Intubated, sedated
HEENT: Eyes open at baseline, no obvious oropharyngeal lesions
noted externally
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.

Neurologic Examination (patient is currently receiving small
boluses of propofol/fentanyl for sedation and intubation):
- Eyes closed at baseline. Making some nonpurposeful movements
of
the left extremities, right arm and leg are visibly less active
- Left pupil is 5mm and nonreactive, right is 3-2mm reactive
briskly
- No roving eye movements or gaze deviation or nystagmus noted
- Breathing over the vent
- Positive VORs and corneals bilaterally
- RUE extensor postures to pain, LUE localizes to sternal rub
- RLE extends to painful stimulus, LLE withdraws nicely
- Right toe is upgoing

Physical Exam on Discharge:
vital signs: Tmax 100.7, Tc 99.3, BP 142/70 (114-165/55-86), HR
89 (72-112), RR 21 (17-34), 99% on trach with 40% FiO2
GEN: elderly male lying in bed asleep, NAD
HEENT: trach in place, OP clear
CV: RRR
PULM: central congestion, mild crackles at L base
ABD: soft, NT, ND
EXT: trace, non-pitting edema at ankles bilaterally.

Neuro Exam:
- opens eyes spontaneously
- L pupil large (5mm) and minimally reactive, R pupil reactive
3->2mm
- looks to the left, but not to the R past midline
- tracks to the left, but not to the right
- moves LUE and LLE spontaneously and sometimes purposefully
- very minimally and only occasionally withdraws RUE and RLE to
noxious stim
- toes upgoing bilaterally

Pertinent Results:
Labs on Admission:

[**2197-9-3**] 03:34PM BLOOD WBC-9.6 RBC-3.88* Hgb-13.7* Hct-39.2*
MCV-101* MCH-35.3* MCHC-34.9 RDW-13.5 Plt Ct-220
[**2197-9-3**] 03:34PM BLOOD Neuts-75.1* Lymphs-20.2 Monos-3.6 Eos-0.8
Baso-0.2
[**2197-9-3**] 03:34PM BLOOD PT-11.3 PTT-19.8* INR(PT)-0.9
[**2197-9-3**] 03:34PM BLOOD Glucose-169* UreaN-16 Creat-1.1 Na-138
K-3.9 Cl-99 HCO3-24 AnGap-19
[**2197-9-4**] 03:35AM BLOOD ALT-21 AST-25 LD(LDH)-211 CK(CPK)-75
AlkPhos-53 TotBili-0.5
[**2197-9-3**] 06:31PM BLOOD CK-MB-2 cTropnT-<0.01
[**2197-9-4**] 03:35AM BLOOD CK-MB-1 cTropnT-<0.01
[**2197-9-3**] 06:31PM BLOOD Calcium-9.1 Phos-3.2 Mg-1.9
[**2197-9-6**] 02:52AM BLOOD calTIBC-195* VitB12-265 Folate-14.7
Ferritn-432* TRF-150*
[**2197-9-4**] 03:35AM BLOOD %HbA1c-6.2* eAG-131*
[**2197-9-4**] 03:35AM BLOOD Triglyc-132 HDL-56 CHOL/HD-2.8 LDLcalc-77
[**2197-9-3**] 04:09PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-150 Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2197-9-3**] 04:09PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2197-9-3**] 04:09PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG

Labs on Discharge:

[**2197-9-13**] 04:02AM BLOOD WBC-10.2 RBC-2.64* Hgb-9.2* Hct-26.6*
MCV-101* MCH-34.7* MCHC-34.4 RDW-13.8 Plt Ct-368
[**2197-9-13**] 04:02AM BLOOD Glucose-136* UreaN-25* Creat-0.7 Na-140
K-4.0 Cl-103 HCO3-27 AnGap-14
[**2197-9-13**] 04:02AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.4

Microbiology:
[**2197-9-5**] 2:32 pm SPUTUM      Source: Endotracheal.
      MODERATE GROWTH Commensal Respiratory Flora.
      GRAM NEGATIVE ROD(S).    SPARSE GROWTH.
[**2197-9-6**] 3:00 pm BRONCHOALVEOLAR LAVAGE      LLL BAL.
      >100,000 ORGANISMS/ML. Commensal Respiratory Flora.
      GRAM NEGATIVE ROD(S).    ~1000/ML.  FURTHER WORKUP ON
REQUEST ONLY.
[**2197-9-6**] 3:00 pm SPUTUM
   GRAM STAIN (Final [**2197-9-6**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.
   RESPIRATORY CULTURE (Final [**2197-9-8**]):
      MODERATE GROWTH Commensal Respiratory Flora.
      GRAM NEGATIVE ROD(S).    RARE GROWTH.

URINE CULTURE (Final [**2197-9-12**]):    NO GROWTH.
   GRAM STAIN (Final [**2197-9-11**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2197-9-13**]):
      SPARSE GROWTH Commensal Respiratory Flora.

EEG [**2197-9-5**]: This telemetry captured no pushbutton
activations. The EEG
record showed a slow and encephalopathic background throughout.
There
were no prominent focal abnormalities, but encephalopathies may
obscure
focal findings. There were no epileptiform features or
electrographic
seizures.

Neuroimaging:
NCHCT ([**2197-9-3**]): 3.5-cm acute left basal ganglia hemorrhage,
with intraventricular extension. Interval increase in size since
the prior study. Mild increase in the edema and rightward shift
of midline structures.

CT C spine ([**2197-9-3**]): No acute cervical spine fracture.
Multilevel degenerative changes of the cervical spine, without
evidence of significant spinal canal stenosis.

NCHCT ([**2197-9-4**]): Unchanged acute left basal ganglia
intraparenchymal hemorrhage with redistribution of blood into
the bilateral occipital horns. No new areas of hemorrhage.

EEG [**2197-9-4**]: IMPRESSION: This telemetry captured no pushbutton
activations. It showed a slow encephalopathic background
throughout. Medications, metabolic disturbances, and infection
are among the most common causes. There were no areas of
prominent focal slowing, but encephalopathies may obscure focal
findings. There were no epileptiform features or electrographic
seizurs.

CT HEAD [**2197-9-12**]: IMPRESSION:
1. The left basal ganglia hematoma is slightly decreased in
size, though the associated mass effect is unchanged. No new
hemorrhage.
2. Decreased intraventricular blood. Stable ventricular size.


Brief Hospital Course:
Mr. [**Known lastname **] arrived to the [**Hospital1 18**] intubated and sedated for a higher
level of care for an intraparenchymal bleed into what was
initially reported as the left basal ganglia, later confirmed to
be largely thalamic in nature. On examination in the ED, he was
found to have an atropine-related fixed and dilated left pupil,
a dense right hemiparesis, spontaneous nonpurposeful movements
of the left arm and would not follow commands or open his eyes.

He was admitted to the neuro-ICU for close monitoring and q1hr
neuro checks. His blood pressures have since been controlled
under SBP<160 with PRN hydralazine/labetalol. A repeat NCHCT
performed the following day showed no difference in bleed
volume.

He remained intubated for the next several days. The concern was
that he would not be able to tolerate his secretions and that he
was not following commands, both signs that extubation would be
unsafe. His wife confirmed that he was a full code, but did
communicate his wishes that he would not want to continue life
"if he were a vegetable". In the days following, he started to
develop low grade fevers, an elevated WBC and thick secretions
from his ETT suction. Out of concern for a community acquired
pneumonia ([**1-18**] possible aspiration) he was initiated on IV
Ceftriaxone. His sputum and BAL cultures only grew out GNRs and
respiratory commensal flora. Initiating antibiotic therapy did
reduce his WBC and improve his fevers. His blood pressures
remained under control, especially after the addition of a low
dose of ACE inhibitor.

We had a family meeting on [**2197-9-7**] where we discussed (with
his extended family and wife) that he has a long road to
recovery, and that should be able to survive the various
complications that may occur (e.g., DVTs, infections, etc.), he
may be able to regain a greater degree of consciousness and
appreciate his surroundings. We discussed how his weakness could
improve and he may not be aphasic. We emphasized the long road
to recovery. On [**9-8**], the decision was finally made to
pursue tracheostomy and PEG tube placement in an attempt
expedite his transition out of the ICU and to rehabilitation.

He was continued on ceftriaxone for presumed CAP, but he
continued to spike fevers through this.  His sputum Cx initially
grew GNRs, but these cleared.  However, his CXR continued to
show a consolidation that was worsening at the LLL base.  He was
started on vancomycin and cefepime on [**9-12**] and his WBC and fever
curve trended down.  He will need to complete a 14 day course
for presumed VAP, which will stop on [**9-26**].  In addition, on
[**9-12**] he had a head CT done that showed that his bleed was
stable, and so he was started on ASA 81mg QD.

PENDING LABS:
Blood culture [**2197-9-10**]
Sputum culture [**2197-9-13**]

TRANSITIONAL CARE ISSUES:
We have been unable to ascertain who did patient's recent ripple
retina procedure.  This will need to be determined, and they
will need to be contact[**Name (NI) **] to determine if patient requires
specific eye drops for his post-surgical recovery.  His wife
thought he may have been on atropine, but wasn't sure, and
therefore this wasn't given here.  His wife had the medications
at home and should be able to bring them to the rehab facility
on request.


Medications on Admission:
Medications per family (although they are very unsure)
Niacin
Cholesterol medication
aspirin

Discharge Medications:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
3. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
4. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
5. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day).
6. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain/fever .
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
11. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1,000 mg
Intravenous Q 12H (Every 12 Hours): Day 1 = [**9-12**].
12. cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q8H
(every 8 hours): Day 1 = [**9-12**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)

Discharge Diagnosis:
Primary: Cerebral hemorrhage
Secondary: HTN, hyperlipidemia, CAD s/p MI


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

NEURO EXAM: L pupil 5mm and minimally reactive ([**1-18**] surgery), R
pupil reacts 3->2mm, opens eyes spont, moves LLE and LUE
spontaneously, and very occ. withdrawas RUE and RLE to noxious
stim.


Discharge Instructions:
Dear Mr. [**Known lastname **],
You were seen in the hospital for a bleed in your brain.  While
you were here, you were stabilized medically.  Your course was
complicated by a pneumonia, for which you were started on
antibiotics.  We were not completely sure of what medications
you were on as an outpatient, and your family and friends were
unable to tell us.

We made the following changes to your medications:
1) We STOPPED your NIACIN.  Your family was not sure you were on
this, so we did not start it here.
2) We STARTED you on LISINOPRUL 20mg once a day.
3) We STARTED you on SUBCUTANEOUS HEPARIN 5,000 units three
times a day to prevent DVTs
4) We STARTED you on ARTIFICIAL TEARS as needed for dry eyes
5) We STARTED you on CLORHEXIDINE GLUCONATE 15mL twice a day
6) We STARTED you on SENNA twice a day.
7) We STARTED you on DOCUSATE 100mg twice a day.
8) We STARTED you on BISACODYL 10mg once a day.
9) We STARTED you on TYLENOL 650mg every 6 hours as needed for
pain/fever.
10) We STARTED you on ASPIRIN 81mg once a day.
11) We STARTED you on a HEPARIN FLUSH for your PICC.  Once you
no longer need your PICC you won't need this medication.
12) We STARTED you on VANCOMYCIN 1,000mg twice a day for a total
of 14 days, to finish on [**9-26**].
13) We STARTED you on CEFEPIME 2 grams every 8 hours for a total
of 14 days to finish on [**9-26**].

If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room, or have
your rehab facility transport you to an emergency room.

It was a pleasure taking care of you on this hospitalization.

Followup Instructions:
Department: NEUROLOGY
When: MONDAY [**2197-11-13**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Intracerebral hemorrhage,Cerebral edema,Ventilator associated pneumonia,Hemiplegia, unspecified, affecting unspecified side,Old myocardial infarction,Unspecified protein-calorie malnutrition,Acute respiratory failure,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Iron deficiency anemia, unspecified,Personal history of tobacco use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution'}


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: Transferred from OSH, intubated

PRESENT ILLNESS: This is an 82 (not 72) yo M with
a history of CAD s/p MI [**17**] years prior, HLD, likely HTN and s/p
recent retinal surgery on the left who is transferred from
[**Hospital **] Hospital intubated and sedated for a higher level of
care. His wife provides the history, and she reports that he was
in his USOH until this afternoon around noon. At baseline he is
completely "healthy" and independent for all ADLs. He had been
nauseous for a few days. He was loading some dishes into the
dishwasher and suddenly fell backwards at around 12:30PM. Then
he
walked out to take the trash out and couldn't climb the two
steps
to come back into the house. Later, his wife sat him down
because
his speech became garbled and he couldn't really understand what
his wife was saying. EMS was called because his wife was
concerned for a TIA. He was taken to an OSH, and was noted to be
nauseous and vomiting en route in the ambulance. While at this
OSH, he was noted to be hypertensive. He was given labetalol IV,
fosphenytoin 1g load and zofran and intubated for airway
protection. He had a NCHCT which revealed a left sided basal
ganglia bleed, and was thus transferred to the [**Hospital1 18**] for a
higher
level of care. The wife denies that the patient is being
anticoagulated or ever having been treated for atrial
fibrillation.

MEDICAL HISTORY: - HLD
- HTN: wife reports that patient has had a history of having
relatively high blood pressures
- Recent eye surgery on left: Ripple retina procedure? Wife
reports that the patient may be on atropine eye drops
- CAD: s/p MI at age 50
- Tobacco abuse: smoked for 20 years, quit following his MI

MEDICATION ON ADMISSION: Medications per family (although they are very unsure)
Niacin
Cholesterol medication
aspirin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam on Admission:
Vitals: AF, 149/76, HR 80s, 96% on ETT FiO2 40%
General: Intubated, sedated
HEENT: Eyes open at baseline, no obvious oropharyngeal lesions
noted externally
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Negative for heavy alcoholism, current smoking or
illicit drug use. 

### Response:
{'Intracerebral hemorrhage,Cerebral edema,Ventilator associated pneumonia,Hemiplegia, unspecified, affecting unspecified side,Old myocardial infarction,Unspecified protein-calorie malnutrition,Acute respiratory failure,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Iron deficiency anemia, unspecified,Personal history of tobacco use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution'}
