CHIEF COMPLAINT: Intraventricular hemorrhage

PRESENT ILLNESS: 88 yo f with history of CVA x 3 (most recent last month) on
coumadin was found down and brought to OSH where she was found
to have a INR of 3.8 and an intraventricular hemorrhage on CT
scan.  Patient was then transferred to [**Hospital1 18**] SICU.

MEDICAL HISTORY: CVA x 3 with residual right sided weakness
Thyroid disease

MEDICATION ON ADMISSION: Coumadin 1.25mg/2.5mg alternating days
Atenolol 25mg daily
Levothyroxine 75mcg daily

ALLERGIES: Amoxicillin

PHYSICAL EXAM: VS: T 97.6, BP 146/89, HR 75, RR 20, O2sat 98%4L
Gen: Elderly female in NAD, sleeping but arousable. Not very
cooperative but responds to questions appropriately. Mood,
affect appropriate.
HEENT: NCAT. Conjunctiva pink. No xanthalesma.
Neck: Supple with JVD to angle of jaw, no carotid bruit.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diffuse crackles b/l on
auscultation of anterior lungs.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e.
Neuro: Oriented to name, "hospital" and "[**Month (only) 956**]." Not
cooperative with most of exam but able to follow 1-step
commands. PERRL, EOMI. Face appears symmmetric. Moves all
extremities independently.

FAMILY HISTORY: Unable to attain secondary to mental status.

SOCIAL HISTORY: Unable to attain secondary to mental status.
Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Acute myocardial infarction of other inferior wall, initial episode of care,Paroxysmal ventricular tachycardia,Other late effects of cerebrovascular disease,Muscle weakness (generalized),Coronary atherosclerosis of native coronary artery,Unspecified acquired hypothyroidism,Anemia, unspecified,Long-term (current) use of anticoagulants,Unspecified fall
Traumatic brain hem NEC,AMI inferior wall, init,Parox ventric tachycard,Late effect CV dis NEC,Muscle weakness-general,Crnry athrscl natve vssl,Hypothyroidism NOS,Anemia NOS,Long-term use anticoagul,Fall NOS
Admission Date:  [**2107-2-24**]              Discharge Date:   [**2107-3-1**]


Service: MEDICINE

Allergies:
Amoxicillin

Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Intraventricular hemorrhage

Major Surgical or Invasive Procedure:
None


History of Present Illness:
88 yo f with history of CVA x 3 (most recent last month) on
coumadin was found down and brought to OSH where she was found
to have a INR of 3.8 and an intraventricular hemorrhage on CT
scan.  Patient was then transferred to [**Hospital1 18**] SICU.

Past Medical History:
CVA x 3 with residual right sided weakness
Thyroid disease


Social History:
Unable to attain secondary to mental status.

Family History:
Unable to attain secondary to mental status.

Physical Exam:
VS: T 97.6, BP 146/89, HR 75, RR 20, O2sat 98%4L
Gen: Elderly female in NAD, sleeping but arousable. Not very
cooperative but responds to questions appropriately. Mood,
affect appropriate.
HEENT: NCAT. Conjunctiva pink. No xanthalesma.
Neck: Supple with JVD to angle of jaw, no carotid bruit.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diffuse crackles b/l on
auscultation of anterior lungs.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e.
Neuro: Oriented to name, "hospital" and "[**Month (only) 956**]." Not
cooperative with most of exam but able to follow 1-step
commands. PERRL, EOMI. Face appears symmmetric. Moves all
extremities independently.

Pertinent Results:
[**2-24**]: Head CT: - intraventricular hemorrhage fills and expands
3rd ventricle, extends into right lateral ventricle, small
amount of blood dependently within left occipital [**Doctor Last Name 534**].
ventricular enlargment concerning for hydrocephalus. 2.5cm left
frontal calcified mass - ? meningioma. no surrounding edema
prior CT from OSH not currently available
.
[**2-24**]: Neck CT: no fracture, malalignment or prevertebral
swelling identified
.
[**2-25**] Head CT: No change in intraventricular hemorrhage or
ventricular size. Unchanged calcified left frontal meningioma.
.
[**2-25**] Head MRI: Unchanged left frontal meningioma. Unchanged
right intraventricular hemorrhage. Unchanged ventricular size.
.
[**2-26**] CT Head/Abd/Pelvis: Expected evolution of blood products
within the ventricular system with no new regions of hemorrhage
identified.
no RP bleed. patchy RML, RLL, LLL opacities concerning for pna
or pneumonitis
.
EKG demonstrated TWI in inferior leads and precordial leads with
TWI in V5-V6 new since prior done 12 hours earlier.
.
TELEMETRY demonstrated:NSR
.
2D-ECHOCARDIOGRAM performed on [**2107-2-26**] demonstrated:  The left
atrium is mildly dilated. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with inferior akinesis and inferolateral
hypokinesis. The remaining segments contract normally (LVEF =
40-45%). Right ventricular chamber size is normal with mild
global free wall hypokinesis. The ascending aorta is mildly
dilated. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. An eccentric, posteriorly-directed jet of mild to
moderate ([**12-31**]+) mitral regurgitation is seen. There is mild
pulmonary artery systolic HTN. There is no pericardial effusion.
There is an anterior space which most likely represents a fat
pad. IMPRESSION: Mild regional biventricular systolic
dysfunction, c/w CAD (inferoposterior and ?right ventricular
infarction). Mild aortic regurgitation. Mild to moderate mitral
regurgitation. Mild pulmonary hypertension.


Brief Hospital Course:
Imaging at the OSH revealed right intraventricular hemorrhage
into the 3rd ventricle and expanding into the 4th ventricle. She
also has a left superior frontal calcified meningioma. She was
transferred to the SICU where she was managed conservatively in
the SICU with serial neurologic exams and head CT which remained
stable.
.
On [**2107-2-25**] she was noted to be hypotensive and bradycardic. EKG
showed ST elevations in the inferior leads and a peak CK of
1063. Given her hemorrhage, patient was managed conservatively
with aspirin 325mg, simvastatin 80 mg daily and low dose beta
blocker (lopressor 2.5mg IV Q6H). TTE performed showed
biventricular hypokinesis. On the day of transfer to the
cardiology floor [**2107-2-27**] she had two bradycardic episodes
associated with nausea and hypertension.
.
On the floor, patient remained somnolent but arousable, able to
answer simple questions and would follow commands.  She denied
any chest pain or shortness of breath.  Patient was monitored
closely on telemetry.  Asymptomatic pauses of 3 seconds were
noted and beta blockers were discontinued.  Patient remained
hemodynamically stable without symptoms of chest pain,
hypotension, shortness of breath, or further neurologic
deterioration during the rest of her admission. Cardiology
recommendation was to continue full strength aspirin and high
dose statin with baseline LFTs obtained near normal (ast 74, alt
21).  Risk of bradyarrhythmia outweighed the benefit of
beta-blockade, and decision was made to hold this medication
indefinitely. She will follow up with a cardiologist at [**Hospital1 18**]
after she is discharged from rehab to further discuss medical
managament of her coronary artery disease. At the time of
discharge, there was no indication for a coronary intervention
in the future, but this will continue to be discussed on follow
up.
.
Her home thyroid regimen was confirmed prior to discharge. It is
recommended that she continue on ....
.
Patient should continue current medical therapy with aspirin and
simvastatin.  Per neurology recommendations patient may restart
her coumadin on [**2107-3-12**].  Coumadin should be started at a low
dose (2.5 mg daily) given patient's supratherapeutic INR on
presentation.  Her INR should be closely monitored after
restarting coumadin and her hematocrit should be monitored at
the time of coumadin initation and 1 week later. She should have
a repeat MRI performed to evaluate the status of her bleed and a
follow up appointment with Neurology to review the imaging.
These have been scheduled. Patient should also schedule a follow
up appointment with Dr. [**Last Name (STitle) **] in Cardiology clinic after her
discharge from rehab.



Medications on Admission:
Coumadin 1.25mg/2.5mg alternating days
Atenolol 25mg daily
Levothyroxine 75mcg daily

Discharge Medications:


1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a
day.
9. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Please do not start this medication until [**2107-3-12**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Right Intraventricular Hemorrhage
ST Elevation Myocardial Infarction
Atrial Fibrillation

Secondary:
CVA x 3 with residual right sided weakness
Hypothyroidism


Discharge Condition:
Stable


Discharge Instructions:
You were transferred to [**Hospital1 18**] after you were found to have had
bleeding in your brain after a recent fall.  You were admitted
to the ICU where you were closely monitored.  During this
admission you had a heart attack.  You were started on new
medications for your heart and transferred to the cardiology
floor.  You tolerated the medication well without any further
events.
.
The following changes were made to your medications:
1) STOP coumadin can restart [**2107-3-12**] at 2 mg daily
2) START aspirin 325 mg daily
3) START atorvastatin 80 mg daily
4) START pantoprazole 40 mg daily
5) START senna 8.6 mg by mouth twice a day as needed for
constipation
6) START bisocodyl by mouth daily as needed for constipation
7) START docusate 100 mg by mouth twice a day
8) Continue levothyroxine 75mcg daily
.
Please continue all other home medications as previously
directed.
.
Please notify your physician or return to the hospital if you
experience fever, chills, chest pain, shortness of breath, new
neurologic problems or any other symptom that is concerning to
you.

Followup Instructions:
Please call the [**Hospital1 18**] Cardiology Clinic ([**Telephone/Fax (1) 62**]) after
discharge from rehabilitation to arrange a follow up appointment
with Dr. [**Last Name (STitle) **].
.
Please have a repeat MRI of your brain performed on [**4-8**]
at 2:35pm on the fourth floor of the [**Hospital Ward Name 23**] building on the
[**Hospital1 18**] [**Hospital Ward Name 516**]. Please call [**Telephone/Fax (1) 327**] if you need to
reschedule.
.
Please call the [**Hospital 18**] [**Hospital 878**] Clinic ([**Telephone/Fax (1) 2574**]) to confirm
your appointment with Dr. [**Last Name (STitle) **] currently scheduled for [**4-12**].
.
Please have your INR closely monitored after restarting your
coumadin on [**2107-3-12**].
{'Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Acute myocardial infarction of other inferior wall, initial episode of care,Paroxysmal ventricular tachycardia,Other late effects of cerebrovascular disease,Muscle weakness (generalized),Coronary atherosclerosis of native coronary artery,Unspecified acquired hypothyroidism,Anemia, unspecified,Long-term (current) use of anticoagulants,Unspecified fall'}


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: Intraventricular hemorrhage

PRESENT ILLNESS: 88 yo f with history of CVA x 3 (most recent last month) on
coumadin was found down and brought to OSH where she was found
to have a INR of 3.8 and an intraventricular hemorrhage on CT
scan.  Patient was then transferred to [**Hospital1 18**] SICU.

MEDICAL HISTORY: CVA x 3 with residual right sided weakness
Thyroid disease

MEDICATION ON ADMISSION: Coumadin 1.25mg/2.5mg alternating days
Atenolol 25mg daily
Levothyroxine 75mcg daily

ALLERGIES: Amoxicillin

PHYSICAL EXAM: VS: T 97.6, BP 146/89, HR 75, RR 20, O2sat 98%4L
Gen: Elderly female in NAD, sleeping but arousable. Not very
cooperative but responds to questions appropriately. Mood,
affect appropriate.
HEENT: NCAT. Conjunctiva pink. No xanthalesma.
Neck: Supple with JVD to angle of jaw, no carotid bruit.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diffuse crackles b/l on
auscultation of anterior lungs.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e.
Neuro: Oriented to name, "hospital" and "[**Month (only) 956**]." Not
cooperative with most of exam but able to follow 1-step
commands. PERRL, EOMI. Face appears symmmetric. Moves all
extremities independently.

FAMILY HISTORY: Unable to attain secondary to mental status.

SOCIAL HISTORY: Unable to attain secondary to mental status. 

### Response:
{'Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Acute myocardial infarction of other inferior wall, initial episode of care,Paroxysmal ventricular tachycardia,Other late effects of cerebrovascular disease,Muscle weakness (generalized),Coronary atherosclerosis of native coronary artery,Unspecified acquired hypothyroidism,Anemia, unspecified,Long-term (current) use of anticoagulants,Unspecified fall'}
