CHIEF COMPLAINT: Subdural Hematoma

PRESENT ILLNESS: Mr. [**Known lastname 73819**] is an 82 y/o M with PMH of CAD admitted following
a fall at home on [**7-11**]. Per admit notes, the patient was
reaching for something in the cabinet when he fell from standing
to the ground; his wife was at home at the time and found him on
the floor within seconds, complaining of head pain. He was
brought to [**Hospital3 **] where he was intubated (airway
protection) and then transferred to [**Hospital1 18**] for further
management; CT scan demonstrated L acute SDH with 10 mm shift.
GCS prior to intubation was [**1-3**].  In [**Hospital1 18**] ED, he received
mannitol, dilantin, and fentanyl for sedation; he was
transferred to the TSICU.

MEDICAL HISTORY: * Coronary artery disease - cath in [**7-26**] showing significant
left main and 3 vessel coronary disease (specifically 70% distal
left main, 70% osteo, 60% proximal and 70% mid LAD stenosis, 90%
proximal circumflex disease and a totally occluded right
coronary artery with moderately impaired left ventricular
function, with anterior and inferior hypokinetic zones and mild
to moderate mitral regurgitation)
* Hypertension
* osteoporosis
* Alzheimer's (reported baseline A&O to self only)
* s/p R total hip replacement 4 years ago
* BPH
* trigeminal neuralgia

MEDICATION ON ADMISSION: plavix, metoprolol 25, Isosorbide 90, Donepezil 10, ASA 325,
calcium 600, crestor 20, finasteride 5, fosamax, nitro

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: O: T: BP: 135/69 HR:78 R 18 O2Sats 100% intubated
Gen: intubated. withdraws from painful stimuli. Does not open
eyes to voice of examiner or to sternal rub
HEENT: Pupils: +corneal reflex EOMs no movement
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated
Orientation: Intubated.
Language: Intubated.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Married for nearly 50 years. No children. No tobacco.
Rare alcohol use. The patient is Armenian but speaks fluent
English.
Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Unspecified fall,Subendocardial infarction, initial episode of care,Mitral valve disorders,Coronary atherosclerosis of native coronary artery,Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction,Congestive heart failure, unspecified,Pressure ulcer, other site,Encounter for palliative care,Other and unspecified complications of medical care, not elsewhere classified,Pneumonia, organism unspecified,Acidosis,Paralysis agitans,Alzheimer's disease,Unspecified essential hypertension,Hemiplegia, unspecified, affecting unspecified side,Other abnormal glucose,Diarrhea,Leukocytosis, unspecified
Traumatic subdural hem,Fall NOS,Subendo infarct, initial,Mitral valve disorder,Crnry athrscl natve vssl,Ocl mlt bi art w infrct,CHF NOS,Pressure ulcer, site NEC,Encountr palliative care,Complic med care NEC/NOS,Pneumonia, organism NOS,Acidosis,Paralysis agitans,Alzheimer's disease,Hypertension NOS,Unsp hemiplga unspf side,Abnormal glucose NEC,Diarrhea,Leukocytosis NOS
Admission Date:  [**2159-7-11**]              Discharge Date:   [**2159-7-27**]

Date of Birth:  [**2077-4-16**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Subdural Hematoma

Major Surgical or Invasive Procedure:
right subclavian central line [**2159-7-13**]
s/p intubation and extubation
s/p craniotomy

History of Present Illness:
Mr. [**Known lastname 73819**] is an 82 y/o M with PMH of CAD admitted following
a fall at home on [**7-11**]. Per admit notes, the patient was
reaching for something in the cabinet when he fell from standing
to the ground; his wife was at home at the time and found him on
the floor within seconds, complaining of head pain. He was
brought to [**Hospital3 **] where he was intubated (airway
protection) and then transferred to [**Hospital1 18**] for further
management; CT scan demonstrated L acute SDH with 10 mm shift.
GCS prior to intubation was [**1-3**].  In [**Hospital1 18**] ED, he received
mannitol, dilantin, and fentanyl for sedation; he was
transferred to the TSICU.


Past Medical History:
* Coronary artery disease - cath in [**7-26**] showing significant
left main and 3 vessel coronary disease (specifically 70% distal
left main, 70% osteo, 60% proximal and 70% mid LAD stenosis, 90%
proximal circumflex disease and a totally occluded right
coronary artery with moderately impaired left ventricular
function, with anterior and inferior hypokinetic zones and mild
to moderate mitral regurgitation)
* Hypertension
* osteoporosis
* Alzheimer's (reported baseline A&O to self only)
* s/p R total hip replacement 4 years ago
* BPH
* trigeminal neuralgia

Social History:
Married for nearly 50 years. No children. No tobacco.
Rare alcohol use. The patient is Armenian but speaks fluent
English.

Family History:
Unknown

Physical Exam:
O: T: BP: 135/69 HR:78 R 18 O2Sats 100% intubated
Gen: intubated. withdraws from painful stimuli. Does not open
eyes to voice of examiner or to sternal rub
HEENT: Pupils: +corneal reflex EOMs no movement
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated
Orientation: Intubated.
Language: Intubated.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5 to
1.5 mm bilaterally. Corneal reflex intact
III, IV, VI: no movement. Pt intubated and not obeying commands
V, VII: Facial strength and sensation intact and symmetric.
VIII: Intubated and no response to voice.
IX, X: + gag reflex
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. Withdraws from pain
along all extremities

Sensation: Intubated.

Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2


Toes downgoing bilaterally

Coordination: intubated


Pertinent Results:
[**2159-7-11**] WBC-19.0* RBC-4.67 Hgb-15.1 Hct-40.6 MCV-87 MCH-32.3*
MCHC-37.1* RDW-13.5 Plt Ct-211 Neuts-90.9* Bands-0 Lymphs-6.5*
Monos-1.9* Eos-0.5 Baso-0.2
[**2159-7-13**]  WBC-13.4* RBC-4.17* Hgb-13.0* Hct-35.9* MCV-86
MCH-31.1 MCHC-36.1* RDW-13.5 Plt Ct-165
[**2159-7-15**]  WBC-12.4* RBC-3.80* Hgb-11.9* Hct-33.2* MCV-88
MCH-31.4 MCHC-35.9* RDW-13.9 Plt Ct-234
[**2159-7-17**]  WBC-8.7 RBC-3.70* Hgb-11.6* Hct-32.4* MCV-88 MCH-31.2
MCHC-35.7* RDW-13.8 Plt Ct-279 Neuts-75.6* Lymphs-13.1*
Monos-6.6 Eos-4.5* Baso-0.3
[**2159-7-19**]  WBC-10.3 RBC-3.79* Hgb-11.6* Hct-33.4* MCV-88 MCH-30.6
MCHC-34.7 RDW-13.5 Plt Ct-382
[**2159-7-21**]  WBC-13.5* RBC-3.38* Hgb-10.5* Hct-30.6* MCV-91
MCH-31.0 MCHC-34.2 RDW-13.7 Plt Ct-424
[**2159-7-23**]  WBC-11.1* RBC-3.28* Hgb-9.9* Hct-29.7* MCV-91 MCH-30.2
MCHC-33.4 RDW-13.8 Plt Ct-588*
[**2159-7-24**] WBC-26.2*# RBC-3.42* Hgb-10.4* Hct-30.3* MCV-89
MCH-30.4 MCHC-34.3 RDW-14.0 Plt Ct-697* Neuts-94* Bands-4
Lymphs-0 Monos-1* Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0

[**2159-7-11**] 07:56PM BLOOD PT-11.7 PTT-28.7 INR(PT)-1.0
[**2159-7-24**] 02:28AM BLOOD PT-14.6* PTT-38.2* INR(PT)-1.3*

[**2159-7-11**]  Glucose-169* UreaN-15 Creat-0.9 Na-137 K-4.3 Cl-100
HCO3-25
[**2159-7-13**]  Glucose-128* UreaN-9 Creat-0.6 Na-139 K-2.9* Cl-107
HCO3-20*
[**2159-7-15**]  Glucose-196* UreaN-25* Creat-0.8 Na-139 K-3.3 Cl-103
HCO3-27
[**2159-7-17**]  Glucose-171* UreaN-29* Creat-0.7 Na-138 K-3.8 Cl-101
HCO3-29
[**2159-7-19**]  Glucose-162* UreaN-27* Creat-0.8 Na-134 K-4.9 Cl-98
HCO3-27
[**2159-7-21**]  Glucose-236* UreaN-30* Creat-0.8 Na-134 K-3.9 Cl-100
HCO3-23
[**2159-7-23**]  Glucose-162* UreaN-31* Creat-1.0 Na-134 K-3.5 Cl-102
HCO3-22
[**2159-7-24**]  Glucose-133* UreaN-31* Creat-1.3* Na-138 K-4.2 Cl-108
HCO3-16*
[**2159-7-20**] 02:18AM BLOOD freeCa-1.11*

[**2159-7-11**] 07:56PM BLOOD CK(CPK)-67 CK-MB-NotDone cTropnT-<0.01
[**2159-7-13**] 02:20AM BLOOD CK(CPK)-139 CK-MB-9 cTropnT-0.13*
[**2159-7-13**] 04:27PM BLOOD CK(CPK)-292* CK-MB-27* MB Indx-9.2*
cTropnT-0.50*
[**2159-7-14**] 11:01AM BLOOD CK(CPK)-133 CK-MB-10 MB Indx-7.5*
cTropnT-0.41*
[**2159-7-24**] 02:28AM BLOOD LD(LDH)-441* CK(CPK)-98 CK-MB-NotDone
cTropnT-0.37*
[**2159-7-24**] 06:35AM BLOOD CK(CPK)-104 CK-MB-5 cTropnT-0.32*

[**2159-7-24**] 01:23AM BLOOD Type-ART FiO2-40 pO2-191* pCO2-29*
pH-7.38 calTCO2-18* Base XS--6 -ASSIST/CON Intubat-INTUBATED
[**2159-7-12**] 03:46AM BLOOD Type-ART pO2-142* pCO2-33* pH-7.44
calTCO2-23 Base XS-0

[**2159-7-20**] 02:18AM BLOOD Lactate-2.1*
[**2159-7-24**] 01:23AM BLOOD Lactate-3.1*

[**2159-7-11**] CT C-SPINE: 1. No fracture or acute alignment
abnormality.
2. Intralobular septal thickening most consistent with volume
overload.

[**2159-7-11**] NON-contrast HEAD CT: 1) Extensive subdural blood with
subfalcine and possible uncal herniation as described.
2) Limited evaluation without priors, though dilatation of the
right lateral ventricle is suggested and continued monitoring is
recommended to exclude worsening hydrocephalus.
3) Equivocal small interpeduncular fossa blood may represent a
subarachnoid component to the hemorrhage though no other
subarachnoid blood is seen.

[**2159-7-13**]  NON-CONTRAST HEAD CT: Compared to prior CT there is no
significant change.  Again identified is a large subdural
hematoma along left convexity with a maximum thickness of
approximately 1.1 cm. There is also blood seen along the left
side of the falx as well as above the tentorium cerebelli.
Extent of sulcal effacement along the hemispheric subdural
hematoma is not significantly changed. Small amount of subdural
blood along the right frontal region is also unchanged. The
remainder of the exam is unchanged.
IMPRESSION: Compared to prior CT from [**2159-7-12**], there is no
significant change.

[**2159-7-20**] NON CONTRAST HEAD CT: 1. Status post craniotomy and
evacuation of a left subdural hematoma. Persistent subdural
blood along the falx and tentorium. Approximately 6 mm of
subfalcine herniation.
2. New left parietotemporal extensive hypodensity may represent
postoperative edema however infarct, likely subacute cannot be
excluded.
NOTE ADDED AT ATTENDING REVIEW: This is a subacute infarction in
the territory of the inferior division of the left MCA. There is
a tiny amount of hemorrahge in the occipital hornof the left
lateral ventricle. There is
left hemispheric mass effect due to swelling of the infarction.

[**2159-7-21**] CTA HEAD: Status post evacuation of left subdural
hematoma. Evolution of the left middle cerebral artery
infarction with increasing local mass effect. Dense
calcifications of the vertebral arteries and cavernous carotid
arteries. Probable stenosis at the vertebral basilar injunction.
 Two millimeter anterior communicating artery aneurysm.

[**2159-7-11**] CXR: Nasogastric tube and endotracheal tubes in adequate
position. No acute cardiopulmonary process identified.

[**2159-7-16**] CXR portable: Mild pulmonary edema and moderate
bilateral pleural effusion have increased since [**7-15**]. Heart
size is top normal, unchanged. ET tube, nasogastric tube, and a
right central venous line in standard placements. No
pneumothorax.

[**2159-7-23**] CXR portable: Endotracheal tube terminates about 5.5 cm
above the carina. Central venous catheter and nasogastric tube
are unchanged in position. Cardiac and mediastinal contours are
stable. Bilateral pattern of pulmonary edema has worsened and is
accompanied by enlarging moderate bilateral pleural effusions.

[**2159-7-23**] KUB: No evidence of obstruction or ileus.

[**2159-7-18**] ECHOCARDIOGRAM: The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate to severe global left ventricular hypokinesis. No
masses or thrombi are seen in the left ventricle. [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] Right ventricular
chamber size is normal with moderate global free wall
hypokinesis. The aortic valve leaflets are mildly thickened.
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets and supporting
structures are mildly thickened. There is no mitral valve
prolapse. Moderate to severe (3+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Biventricular hypokinesis c/w diffuse process (toxin
metabolic, etc.) Moderate to severe mitral regurgitation. Mild
aortic regurgitation.


Brief Hospital Course:
82 y/o M with known CAD s/p fall resulting in SDH s/p evacuation
on [**7-19**]. Hospitalization complicated by large L MCA stroke and
demand ischemia.

#) SDH/new stroke: Mr [**Name13 (STitle) 73820**] was initially admitted to Trauma
SICU where he was kept intubated and neurologically followed
very closely.  His Plavix was held and it was decided to wait on
surgery for 4 days until the effects of the Plavix wore off.  He
underwent craniotomy and evacuation of SDH.  The patient had
repeat head imaging s/p SDH evacuation morning with new
left-sided stroke.  Given additional cardiac issues he was
transferred to the CCU team.  Plavix was restarted and aspirin
was continued.  The patient had known bilateral carotid disease
which could account for the new stroke. However, this could also
have been related to underlying SDH with resultant ischemia
secondary to edema.  Patient was not felt to be a candidate for
carotid intervention.  Repeat CT/CTA of the head on [**7-21**] showed
evolving L MCA infarction with increasing mass effect. An EEG
was performed.  Neurology was consulted for further input into
patient's overall prognosis given unresponsiveness and it was
felt that prognosis was poor.

#) CAD: The patient had severe left main disease with 3VD but
not a surgical candidate. He has been medically managed to this
point with ASA, plavix, statin, beta blocker, and nitrate.
While in the trauma SICU post-op, he developed CHF and demand
ischemia.  He was managed medically with ASA, statin,
beta-blocker and plavix (restarted).

#) Rhythm:  Patient remained in sinus rhythm with occasional
PVCs.

#) Pump:  EF depressed compared to prior. As above, the patient
has been evaluated several times at [**Hospital3 **] for CABG but
has been deemed a poor surgical candidate. Medical regimen was
optimized.  Pt was diuresed with lasix until he was euvolemic.

#) Vent-dependent respiratory failure: Pt was intubated for
airway protection and respiratory distress thought [**2-23**] pulmonary
edema. Also  possible LLL infiltrate, which was treated with
vanco/zosyn for presumed vent associated pneumonia (as below).
Also found to be in respiratory alkalosis (initially on ABG
prior to transfer from TSICU), which was thought likely
secondary to central hyperventilation and was treated with
acetazolamide until improved.

#) Fever: The patient continued to have fevers (which were felt
to be most likely szecondary to head bleed - central fever).
However, in setting of LLL infiltrate on CXR and ventilated, was
treated with zosyn and vancomyin for possible pna; vancomycin
was initiated on [**7-17**] (with levofloxacin) with reported
improvement in the patient's secretions. Zosyn was initiated on
[**7-20**]. Multiple sputum cultures only positive for oropharyngeal
flora. Blood and urine cultures no growth.

#) Leukocytosis: WBC increased on [**7-24**] from 11K to 26K in setting
of new diarrhea. Started empiric flagyl and WBC decreased the
following day.  Two CDiff toxin A samples were negative. Blood
cultures also sent to rule out line infection as etiology for
leukocytosis.  Possible line infection was considered, but given
negative blood cultures and discussion with family who did not
want a new central line placed (given invasive procedure), the
line was maintained for access.

#) Abd distention: Abdomen became increasingly distended
(positive bowel sounds).  KUB on [**7-23**] revealed no ileus. Tube
feeds were held and patient was treated with lactulose.  Pt put
out ~1L liquid stool on the morning of [**7-24**] which was sent for c.
diff.

#) Metabolic acidosis: Lactate was 3.1 on [**7-24**]. Concern for
sepsis/overwhelming infection. Acetazolamide which had been
started when metab alkalemia was stopped.

#) Hyperlipidemia: Continued crestor 20mg daily.

#) Hyperglycemia: long acting and insulin sliding scales

#) FEN:  On Tube feeds.

#) PPX:  On heparin SC BID, PPI, Bowel regimen until patient
developed diarrhea.

#) Access:  R subclavian.  Would have been hospital protocol to
change the line in the setting of fever, however line was left
in per family's wishes not to have pt undergo new central line
placement.
.
#) Dispo: Patient remained unresponsive off sedation in the CCU.
 After extensive discussions with patient's wife, Neurosurgery,
Neurology, about patient's poor prognosis and low likelihood of
meaningful recovery, the patient was made comfort measures only
on [**2159-7-27**].  He was started on a morphine drip and extubated.  He
expired on [**2159-7-28**] with his wife at his bedside.

DNR/DNI/Comfort Measures

Medications on Admission:
plavix, metoprolol 25, Isosorbide 90, Donepezil 10, ASA 325,
calcium 600, crestor 20, finasteride 5, fosamax, nitro


Discharge Medications:
N/A

Discharge Disposition:
Expired

Discharge Diagnosis:
subdural hematoma
Left MCA CVA
congestive heart failure
coronary artery disease
demand ischemia
possible ventilator associated pneumonia

Discharge Condition:
expired

Discharge Instructions:
N/A

Followup Instructions:
N/A


Completed by:[**2159-7-30**]
{"Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Unspecified fall,Subendocardial infarction, initial episode of care,Mitral valve disorders,Coronary atherosclerosis of native coronary artery,Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction,Congestive heart failure, unspecified,Pressure ulcer, other site,Encounter for palliative care,Other and unspecified complications of medical care, not elsewhere classified,Pneumonia, organism unspecified,Acidosis,Paralysis agitans,Alzheimer's disease,Unspecified essential hypertension,Hemiplegia, unspecified, affecting unspecified side,Other abnormal glucose,Diarrhea,Leukocytosis, unspecified"}


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: Subdural Hematoma

PRESENT ILLNESS: Mr. [**Known lastname 73819**] is an 82 y/o M with PMH of CAD admitted following
a fall at home on [**7-11**]. Per admit notes, the patient was
reaching for something in the cabinet when he fell from standing
to the ground; his wife was at home at the time and found him on
the floor within seconds, complaining of head pain. He was
brought to [**Hospital3 **] where he was intubated (airway
protection) and then transferred to [**Hospital1 18**] for further
management; CT scan demonstrated L acute SDH with 10 mm shift.
GCS prior to intubation was [**1-3**].  In [**Hospital1 18**] ED, he received
mannitol, dilantin, and fentanyl for sedation; he was
transferred to the TSICU.

MEDICAL HISTORY: * Coronary artery disease - cath in [**7-26**] showing significant
left main and 3 vessel coronary disease (specifically 70% distal
left main, 70% osteo, 60% proximal and 70% mid LAD stenosis, 90%
proximal circumflex disease and a totally occluded right
coronary artery with moderately impaired left ventricular
function, with anterior and inferior hypokinetic zones and mild
to moderate mitral regurgitation)
* Hypertension
* osteoporosis
* Alzheimer's (reported baseline A&O to self only)
* s/p R total hip replacement 4 years ago
* BPH
* trigeminal neuralgia

MEDICATION ON ADMISSION: plavix, metoprolol 25, Isosorbide 90, Donepezil 10, ASA 325,
calcium 600, crestor 20, finasteride 5, fosamax, nitro

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: O: T: BP: 135/69 HR:78 R 18 O2Sats 100% intubated
Gen: intubated. withdraws from painful stimuli. Does not open
eyes to voice of examiner or to sternal rub
HEENT: Pupils: +corneal reflex EOMs no movement
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated
Orientation: Intubated.
Language: Intubated.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Married for nearly 50 years. No children. No tobacco.
Rare alcohol use. The patient is Armenian but speaks fluent
English. 

### Response:
{"Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Unspecified fall,Subendocardial infarction, initial episode of care,Mitral valve disorders,Coronary atherosclerosis of native coronary artery,Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction,Congestive heart failure, unspecified,Pressure ulcer, other site,Encounter for palliative care,Other and unspecified complications of medical care, not elsewhere classified,Pneumonia, organism unspecified,Acidosis,Paralysis agitans,Alzheimer's disease,Unspecified essential hypertension,Hemiplegia, unspecified, affecting unspecified side,Other abnormal glucose,Diarrhea,Leukocytosis, unspecified"}
