CHIEF COMPLAINT: ICH

PRESENT ILLNESS: This is a 62 year old man with a history of hypertension and
smoking who presented to an outside hospital this morning
complaining of severe headache and left sided weakness.  He is
currently intubated and sedated and the notes from the OH ER are
scant.  I spoke with the staff at his homeless shelter
([**Telephone/Fax (1) 67746**]) who say that he was well until this morning
around
6AM, when he was suddenly unable to move his left arm. They
immediately called EMS.  He was brought to the OH ED:  vitals
were HR 68 BP230/119 RR 18 O2Sat 100%.  Initial NIHSS=8 (left
limb weakness, ataxia, dysarthria).  Head CT at 6:15AM revealed
a
2.2x2.1 cm hyperdensity within the right basal ganglia.  Per the
ED notes, he was complaining of headache at 7:50AM and given 2mg
of dilaudid for pain.  Shortly thereafter, he became obtunded
and
was intubated for "neurologic deterioration".  During
intubation,
he received fentanyl, versed and succ.  Over his course, he
received an additional 10mg IV labetalol for elevated blood
pressure.  He was also given ativan 2mg x 7 (14mg total), versed
2mg x1 and dilantin 1g IV x1.  Prior to transfer, he was given a
dose of vecuronium (about 40minutes ago) and versed.

MEDICAL HISTORY: HTN
Hepatitis C, untreated
EtOH abuse
h/o cocaine use

MEDICATION ON ADMISSION: Cardizem(not taking)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: BP-138/83 HR-60 RR-16 O2Sat-98
Gen: Lying in bed, intubated, sedated
HEENT: NC/AT, ETT and OGT in place
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: RRR, distant S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Intubated and sedated, eyes closed. Unresponsive
to verbal or tactile stimulation.  +grimace with vigorous
sternal
rub (no eye opening).

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Living in a homeless shelter since [**2196-1-10**]. He has some family
in the area and a girlfriend who is very close to him. EtOH use.
h/o cocaine, unsure if he has been using lately.
Intracerebral hemorrhage,Other emphysema,Meningitis due to unspecified bacterium,Chronic hepatitis C without mention of hepatic coma,Unspecified essential hypertension,Tobacco use disorder
Intracerebral hemorrhage,Emphysema NEC,Bacterial meningitis NOS,Chrnc hpt C wo hpat coma,Hypertension NOS,Tobacco use disorder
Admission Date:  [**2196-6-30**]              Discharge Date:   [**2196-7-15**]

Date of Birth:  [**2133-9-15**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
ICH

Major Surgical or Invasive Procedure:
LP
Ventricular Drain Placement
Intubation
CVL placement
Arterial line placement

History of Present Illness:
This is a 62 year old man with a history of hypertension and
smoking who presented to an outside hospital this morning
complaining of severe headache and left sided weakness.  He is
currently intubated and sedated and the notes from the OH ER are
scant.  I spoke with the staff at his homeless shelter
([**Telephone/Fax (1) 67746**]) who say that he was well until this morning
around
6AM, when he was suddenly unable to move his left arm. They
immediately called EMS.  He was brought to the OH ED:  vitals
were HR 68 BP230/119 RR 18 O2Sat 100%.  Initial NIHSS=8 (left
limb weakness, ataxia, dysarthria).  Head CT at 6:15AM revealed
a
2.2x2.1 cm hyperdensity within the right basal ganglia.  Per the
ED notes, he was complaining of headache at 7:50AM and given 2mg
of dilaudid for pain.  Shortly thereafter, he became obtunded
and
was intubated for "neurologic deterioration".  During
intubation,
he received fentanyl, versed and succ.  Over his course, he
received an additional 10mg IV labetalol for elevated blood
pressure.  He was also given ativan 2mg x 7 (14mg total), versed
2mg x1 and dilantin 1g IV x1.  Prior to transfer, he was given a
dose of vecuronium (about 40minutes ago) and versed.

In our ED, he received another 4mg of Versed (trying to pull out
ETT with right hand).


Past Medical History:
HTN
Hepatitis C, untreated
EtOH abuse
h/o cocaine use

Social History:
Living in a homeless shelter since [**2196-1-10**]. He has some family
in the area and a girlfriend who is very close to him. EtOH use.
h/o cocaine, unsure if he has been using lately.

Family History:
Unknown

Physical Exam:
BP-138/83 HR-60 RR-16 O2Sat-98
Gen: Lying in bed, intubated, sedated
HEENT: NC/AT, ETT and OGT in place
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: RRR, distant S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Intubated and sedated, eyes closed. Unresponsive
to verbal or tactile stimulation.  +grimace with vigorous
sternal
rub (no eye opening).

Cranial Nerves:
Pupils pinpoint bilaterally. No blink to threat. Absent VOR.
Absent corneals, no response to nasal tickle. +gag

Motor:
Normal bulk bilaterally. increased in the left leg.  Withdraws
right arm and leg to noxious stim.  triple flexion of left leg
and internal rotation of left arm to noxious stimulation.

Sensation: withdrawal as above

Reflexes:
More brisk on left, +2 on right
Toes upgoing bilaterally

Coordination/Gait: unable to assess


Pertinent Results:
[**2196-6-30**] 11:08AM BLOOD WBC-5.4 RBC-4.58* Hgb-14.4 Hct-41.8
MCV-91 MCH-31.4 MCHC-34.3 RDW-14.3 Plt Ct-184
[**2196-6-30**] 11:42AM BLOOD PT-12.9 INR(PT)-1.1
[**2196-6-30**] 11:08AM BLOOD Glucose-140* UreaN-13 Creat-0.9 Na-141
K-4.3 Cl-105 HCO3-25 AnGap-15
[**2196-6-30**] 11:08AM BLOOD ALT-28 AST-37 CK(CPK)-295* AlkPhos-72
Amylase-37 TotBili-0.3
[**2196-6-30**] 02:22PM BLOOD CK(CPK)-256*
[**2196-7-4**] 10:13AM BLOOD CK(CPK)-158
[**2196-6-30**] 11:08AM BLOOD CK-MB-5 cTropnT-<0.01
[**2196-6-30**] 02:22PM BLOOD cTropnT-<0.01
[**2196-7-4**] 10:13AM BLOOD CK-MB-2 cTropnT-<0.01
[**2196-6-30**] 11:08AM BLOOD Albumin-3.8 Calcium-8.3* Phos-2.6* Mg-1.8
[**2196-6-30**] 11:08AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2196-7-1**] 05:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025
[**2196-7-1**] 05:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG
[**2196-7-2**] 03:51PM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-<1
[**2196-6-30**] 11:08AM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2196-7-4**] 11:38PM CEREBROSPINAL FLUID (CSF) WBC-311 RBC-[**Numeric Identifier 67747**]*
Polys-88 Lymphs-8 Monos-4
[**2196-7-4**] 11:38PM CEREBROSPINAL FLUID (CSF) TotProt-79*
Glucose-57
----
Sputum Cx [**7-1**]:
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.    MODERATE
GROWTH.
         Beta-lactamse negative: presumptively sensitive to
ampicillin.
         Confirmation should be requested in cases of treatment
failure in
         life-threatening infections..
      STREPTOCOCCUS PNEUMONIAE.    RARE GROWTH.
         PRESUMPTIVE RESISTANCE NOT CONFIRMED BY MIC. REFER TO
MIC RESULTS.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STREPTOCOCCUS PNEUMONIAE
                             |
CEFTRIAXONE-----------<=0.06 S
ERYTHROMYCIN----------<=0.06 S
LEVOFLOXACIN----------     1 S
PENICILLIN------------<=0.06 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S


Brief Hospital Course:
62 year old with hx of HTN and smoking who presented to OSH with
left sided weakness and headache, found to have a large,
right-sided ICH centered in the thalamus.  His exam was limited
by sedation for much of his early stay, but he consistently had
little to no movement on his left side, but would follow
commands on the right.     The etiology of the bleed, given the
location, is likely to be poorly controlled hypertension.

1.Neuro:  The pt was admitted to the ICU and kept on close
neurochecks given the spread of his hemorrhage into all
ventricles and the concern that he may develop hydrocephalus.  A
CT scan here showed progression from the outside scan, and
despite normal coags, he was given Factor 7 as it was not known
whether his bleeding continued.  His BP was controlled
aggressively to keep his SBP<150.  He had serial CT scans which
showed stability.  Out of concern that he may develop
hydrocephalus given clotted blood in the 4th ventricle, an EVD
was placed and tpa was introduced into the ventricles.  This
resulted in clearance of blood from the 3rd and 4th ventricles.
His ICP remained in the 7-10 range with the drain and when
clamped, it stabilized out at ~14.  The drain was removed.  The
patient was kept sedated as he became very agitated when off
sedation and his BP would rise above goal ranges. When weaned,
he consistently followed commands on the right side but not the
left. His pupils were pinpoint and difficult to assess
throughout.

On transfer to the floor, the patient's alertness improved, as
did his attention to the left side of space and awareness of his
weakness. The patient requires further titration of his
captopril up - current dose is 37.5mg TID, for goal sbp<140.

2.ID: The patient was spiking fevers since admission and this
seemed to worsen over time, with spikes to the 103 range at
times.  His WBC ct went to 14, but then resolved over several
days on antibiotics.  Multiple sets of blood cultures were
negative.  Multiple UAs and urine cultures were also negative.
He had a sputum sent which grew haemophilus and strep
pneumoniae.  He also had a CXR which showed LLL hazy opacity.
He was put on vancomycin, levofloxacin, and flagyl.  This was
narrowed to levofloxacin when the sensitivities returned.  He
continued to be intermittently febrile.  CSF was sent from his
ventricular drain which had a negative GS and 300 WBCs(but with
200K RBCs, so the ratio is appropriate for normal blood).
However, as the fevers continued, he was expanded back to
vancomycin and ceftazidime.  He has evidence of sinus disease on
multiple CTs.  ENT looked at the scan and did not feel that this
could account for his fevers.  ID was consulted and suggested
repeating the CSF analysis.  This was done and showed
meningitis; fevers resolved on antibiotics and the external
ventricular drain was removed. He requires further antibiotic
treatment until [**7-20**].

3.CV: As above, he had significant hypertension with agitation.
He was started on metoprolol and lisinopril, with prn
hydralazine being used.  Hydralazine will be titrated down,
since lisinopril was switched to captopril. When sufficient bp
control is achieved, hydralazine should be d/c'd, with further
increase in captopril if necessary.

4.Pulm:  He was stable from a respiratory standpoint throughout.
On [**7-13**], an incidental R pulmonary nodule was found. On [**7-14**],
however, chest ct showed no R nodule, but did show severe
emphysema, chronic LLL inflammatory changes and a LLL nodule.
These lung changes were clinically silent and repeat CT was
recommended in 3mo's for follow up.

5.He was put on tube feeds and tolerated these well throughout.
On transfer from the ICU, he tolerated ground food well.

Medications on Admission:
Cardizem(not taking)

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Therapeutic Multivitamin     Liquid Sig: One (1) Cap PO DAILY
(Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
6. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for hyponatremia.
7. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
10. Captopril 12.5 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
11. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: One
(1)  Intravenous  Q8H (every 8 hours).
12. Thiamine HCl 100 mg/mL Solution Sig: One (1)  Injection
DAILY (Daily).
13. Hydralazine 20 mg/mL Solution Sig: One (1) 5mg Injection Q8H
(every 8 hours).
14. Vancomycin 500 mg Recon Soln Sig: [**1-11**] Recon Solns
Intravenous  Q 12H (Every 12 Hours): 750mg IV q12. End after
[**7-20**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] rehab

Discharge Diagnosis:
HTN
EtOH
HCV
Smoking
Cocaine use
Intracerebral hemorrhage in right basal ganglia/caudate
Bacterial meningitis


Discharge Condition:
Improved


Discharge Instructions:
Please continue to take all meds.

Followup Instructions:
- Repeat Chest CT with IV contrast in 3mo to follow LLL
pulmonary noduleProvider:

Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2196-8-11**] 4:30


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

Completed by:[**2196-7-15**]
{'Intracerebral hemorrhage,Other emphysema,Meningitis due to unspecified bacterium,Chronic hepatitis C without mention of hepatic coma,Unspecified essential hypertension,Tobacco use disorder'}


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: ICH

PRESENT ILLNESS: This is a 62 year old man with a history of hypertension and
smoking who presented to an outside hospital this morning
complaining of severe headache and left sided weakness.  He is
currently intubated and sedated and the notes from the OH ER are
scant.  I spoke with the staff at his homeless shelter
([**Telephone/Fax (1) 67746**]) who say that he was well until this morning
around
6AM, when he was suddenly unable to move his left arm. They
immediately called EMS.  He was brought to the OH ED:  vitals
were HR 68 BP230/119 RR 18 O2Sat 100%.  Initial NIHSS=8 (left
limb weakness, ataxia, dysarthria).  Head CT at 6:15AM revealed
a
2.2x2.1 cm hyperdensity within the right basal ganglia.  Per the
ED notes, he was complaining of headache at 7:50AM and given 2mg
of dilaudid for pain.  Shortly thereafter, he became obtunded
and
was intubated for "neurologic deterioration".  During
intubation,
he received fentanyl, versed and succ.  Over his course, he
received an additional 10mg IV labetalol for elevated blood
pressure.  He was also given ativan 2mg x 7 (14mg total), versed
2mg x1 and dilantin 1g IV x1.  Prior to transfer, he was given a
dose of vecuronium (about 40minutes ago) and versed.

MEDICAL HISTORY: HTN
Hepatitis C, untreated
EtOH abuse
h/o cocaine use

MEDICATION ON ADMISSION: Cardizem(not taking)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: BP-138/83 HR-60 RR-16 O2Sat-98
Gen: Lying in bed, intubated, sedated
HEENT: NC/AT, ETT and OGT in place
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: RRR, distant S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Intubated and sedated, eyes closed. Unresponsive
to verbal or tactile stimulation.  +grimace with vigorous
sternal
rub (no eye opening).

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Living in a homeless shelter since [**2196-1-10**]. He has some family
in the area and a girlfriend who is very close to him. EtOH use.
h/o cocaine, unsure if he has been using lately. 

### Response:
{'Intracerebral hemorrhage,Other emphysema,Meningitis due to unspecified bacterium,Chronic hepatitis C without mention of hepatic coma,Unspecified essential hypertension,Tobacco use disorder'}
