CHIEF COMPLAINT: transferred from OSH for IPH

PRESENT ILLNESS: Mr. [**Known lastname 90430**] is a 74 year-old left-handed man
with a history of hypertension, hyperlipidemia, and emphysema
(on
3L suppl O2 at baseline)initially evaluated at [**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 85061**]
after being found unresponsive and was transferred to the [**Hospital1 18**]
when imaging revealed several foci of hemorrhage in the left
forntoparietal regions.
.
According to the patient's fiance, Mr. [**Known lastname 90430**] has not been
feeling well for several days (although the details of the
malaise are unclear).  She does recall that he fell down in the
few days prior to presentation.  He presented to his PCP two
days
prior to presentation and was referred for a head CT.  The
study,
performed on the day prior to evaluation, was apparently normal.
.
The patient went to bed (without dinner) at about 4 pm on the
day
prior to evaluation.  On the morning of evaluation, he appeared
to be sleeping comfortably.  At around 11 am, his fiance went to
wake him up for some breakfast.  At that time she found him
lying
on the ground (rather than in bed) bleeding from the ear and
nose.  He was not responsive to voice or tactile stimulation.
She called an ambulance.
.
Reports from EMS suggest the patient appeared to be seizing at
the time of their arrival (no further details available).  The
patient was intubated for airway protection.  He was
subsequently
transported to [**Hospital3 **].  There, vitals were recorded as T
101.7, BP 214/117, HR 121, RR 19.  A non-contrast CT of the head
was done, and showed hemorrhage in the left frontaoparietal
regions.  He was given fospheytoin 1.5 grams and transferred to
the [**Hospital1 18**] for further evaluation and care.

MEDICAL HISTORY: - CHF (EF unknown)
- SBO
- gallstones
- HTN
- HLD
- GERD
- emphysema - on 3.5 L suppl O2 at baseline

MEDICATION ON ADMISSION: - atenolol 100 mg po daily
- protonix 40 mg po daily
- asa 325 mg po daily
- lisinopril 10 mg po daily
- albuteral 2 puffs inh [**Hospital1 **] prn SOB
- simvastatin 40 mg po daily
- spiriva 1 inh daily
- prilosec 20 mg po daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Exam on Admission:

FAMILY HISTORY: - negative for known neurological conditions

SOCIAL HISTORY: - lives with fiance
- retired police officer
Intracerebral hemorrhage,Other amyloidosis,Ventilator associated pneumonia,Urinary tract infection, site not specified,Hemiplegia, unspecified, affecting nondominant side,Hyperosmolality and/or hypernatremia,Closed fracture of phalanx or phalanges of hand, unspecified,Accidental fall from bed,Other convulsions,Unspecified essential hypertension,Other emphysema,Other dependence on machines, supplemental oxygen,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Abdominal aneurysm without mention of rupture,Diarrhea,Other and unspecified hyperlipidemia,Esophageal reflux,Tobacco use disorder,Personal history of contact with and (suspected) exposure to asbestos
Intracerebral hemorrhage,Amyloidosis NEC,Ventltr assoc pneumonia,Urin tract infection NOS,Unsp hmiplga nondmnt sde,Hyperosmolality,Fx phalanx, hand NOS-cl,Fall from bed,Convulsions NEC,Hypertension NOS,Emphysema NEC,Depend-supplement oxygen,Oth gram negatv bacteria,Abdom aortic aneurysm,Diarrhea,Hyperlipidemia NEC/NOS,Esophageal reflux,Tobacco use disorder,Hx-contct/expos asbestos
Admission Date:  [**2173-3-5**]              Discharge Date:   [**2173-3-22**]

Date of Birth:  [**2098-12-21**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
transferred from OSH for IPH

Major Surgical or Invasive Procedure:
intubation
tracheostomy
PEG tube placement

History of Present Illness:
Mr. [**Known lastname 90430**] is a 74 year-old left-handed man
with a history of hypertension, hyperlipidemia, and emphysema
(on
3L suppl O2 at baseline)initially evaluated at [**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 85061**]
after being found unresponsive and was transferred to the [**Hospital1 18**]
when imaging revealed several foci of hemorrhage in the left
forntoparietal regions.
.
According to the patient's fiance, Mr. [**Known lastname 90430**] has not been
feeling well for several days (although the details of the
malaise are unclear).  She does recall that he fell down in the
few days prior to presentation.  He presented to his PCP two
days
prior to presentation and was referred for a head CT.  The
study,
performed on the day prior to evaluation, was apparently normal.
.
The patient went to bed (without dinner) at about 4 pm on the
day
prior to evaluation.  On the morning of evaluation, he appeared
to be sleeping comfortably.  At around 11 am, his fiance went to
wake him up for some breakfast.  At that time she found him
lying
on the ground (rather than in bed) bleeding from the ear and
nose.  He was not responsive to voice or tactile stimulation.
She called an ambulance.
.
Reports from EMS suggest the patient appeared to be seizing at
the time of their arrival (no further details available).  The
patient was intubated for airway protection.  He was
subsequently
transported to [**Hospital3 **].  There, vitals were recorded as T
101.7, BP 214/117, HR 121, RR 19.  A non-contrast CT of the head
was done, and showed hemorrhage in the left frontaoparietal
regions.  He was given fospheytoin 1.5 grams and transferred to
the [**Hospital1 18**] for further evaluation and care.

NEUROLOGICAL REVIEW OF SYSTEMS
- unobtainable

GENERAL REVIEW OF SYSTEMS:
- unobtainable


Past Medical History:
- CHF (EF unknown)
- SBO
- gallstones
- HTN
- HLD
- GERD
- emphysema - on 3.5 L suppl O2 at baseline


Social History:
- lives with fiance
- retired police officer


Family History:
- negative for known neurological conditions


Physical Exam:
Exam on Admission:

Vitals: T: nr P: 83 R: 16  BP: 135/61 SaO2: 100%
propofol suspended for 10 minutes
General: intubated
HEENT: Normocepahlic, truamatic with dried blood in region of
left ear, right nare
Neck: c-collar
Cardiac: Regular rate, normal S1 and S2.  No murmurs appreciated
Pulmonary: Lungs clear to auscultation bilaterally.
Abdomen: Obese. Normoactive bowel sounds.  Soft.  Non-tender,
non-distended.
Extremities: Warm, well-perfused.  DP intact bilat.
Skin: scattered ecchymoses mostly on right aspect of body; no
appreciable splinter hemorrhages.  Right great toe
purple/ecchymotic.

NEUROLOGIC EXAMINATION:

Mental Status:
* Degree of Alertness: does not open eyes to loud voice, sternal
rub

Cranial Nerves:
* I: Olfaction not evaluated.
* II: PERRL 1.5 to 1 mm and brisk.
* III, IV, VI: gaze conjugate; eyes stay midline with doll's
maneuver
* V, VI: corneals intact bilat
* VII: No obvious facial droop.
* IX, X: cough reported to be intact

Motor:
* Tone: Normal.

Strength:
* Left Upper Extremity:  withdraws purposefully
* Right Upper Extremity: plegic
* Left Lower Extremity:  withdraws purposefully
* Right Lower Extremity: withdraws purposefully

Reflexes:
* Left:  2+ throughout Biceps, Patellar, 1+ Achilles
* Right: 2+ thoughout Biceps, Patellar, 1+ Achilles
* Babinski: flexor left, mute right

Sensation:
* intact to noxious

Neuro Exam on Discharge:

He opens eyes to voice. He can follow simple commands on left
such as squeezing fingers, showing thumb, and wiggling toes. On
cranial nerve exam, his pupils are reactive. He does not track
but seems to be able to look around room appropriately. He has a
right facial droop. On motor exam, he moves his left side
spontaneously- LUE [**3-27**] and LLE [**2-27**]. He has dense right
hemiplegia.


Pertinent Results:
Initial Labs:

wbc 19.1, hct 44, plt 177
bun 24, cre 1.2
trop 0.07, ck 1228, MB 17, MBI 1.4
INR 1.5, PTT 23.3

UA neg

Utox: pos barbs, opiates

Recent Labs:
  CBC ([**3-22**]): WBC 13.8 Hb 10.5 HCT 34.4 Plt 302
  BMP ([**3-22**]): Na 156 K 4.6 Cl 116 CO2 36 BUN 56 Cr 1.3 Glu 131

Micro Data:
  urine cx ([**3-8**]): >100,000 Proteus
  urine cx ([**3-19**]): no growth
  BAL ([**3-9**]): >100,000 commensal resp. flora
  mini BAL ([**3-19**]): ~3000/ML Commensal Respiratory Flora
  Blood cx have remained sterile
  RPR nonreactive
  C.diff negative x1

IMAGES:

CT chest/abd ([**3-5**]): . No evidence of acute intrathoracic or
intra-abdominal injury; Cholelithiasis; Calcifications along the
pleura on the left, likely due to prior asbestos exposure; Focal
aneurysmal dilation of the infrarenal abdominal aorta measuring
up to 3.1 cm.

CT C-spine: No fracture. Alignment maintained. Degenerative
changes noted throughout the cervical spine with moderate
anterior osteophytes and calcification of the anterior
longitudinal ligament. Small posterior osteophytes are noted at
C4-5 and cause mild canal narrowing

CTA ([**3-5**]): Left frontal hemorrhage with mild surrounding edema;
CT angiography demonstrates no evidence of abnormal vascular
structures,
early draining veins to indicate arteriovenous malformation or
enhancing
lesion in the region of hemorrhage; A tiny 1.5-mm infundibulum
versus aneurysm at the right posterior communicating artery is
likely incidental, unrelated to the hemorrhage.

TTE ([**3-6**]): The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The right ventricular cavity is mildly dilated with
focal basal free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.

MR head with and w/out contrast ([**3-6**]): Left frontal intra-axial
hematoma with mild surrounding edema without evidence of
associated abnormal vascular structures or abnormal enhancement;
Chronic microhemorrhage is seen in the right posterior temporal
region; No evidence of acute infarct, midline shift or
hydrocephalus; Small vessel disease; Soft tissue swelling in the
parietal skull.

EEG ([**3-9**]): continuous EEG on [**3-9**] showed a low voltage
slow encephalopathic background throughout. There were no areas
of
prominent focal slowing, but encephalopathies may obscure focal
findings. There were no epileptiform features or electrographic
seizures.

TEE ([**3-9**]): No evidence for ASD/PFO. No atrial thrombus
identified. Simple atherosclerotic plaque in descending aorta
and aortic arch.

MRI/V head ([**3-10**]): Evolving left frontal intra-axial hematoma
with surrounding edema. No evidence of a mass lesion. No
evidence of major dural venous sinus thrombosis. Punctate foci
of slow diffusion is demonstrated in the left posterior frontal
lobe and right parasagittal frontal lobe likely suggesting
hemorrhage. Stable shallow subdural collection overlying the
right cerebral convexity

CXR ([**2173-3-20**]):   The cardiac silhouette and mediastinum are
within normal limits. The lungs are grossly clear.


Brief Hospital Course:
74 yo LHM w pmh including htn, hld, emphysema (3.5 L suppl O2 at
baseline) who presented to [**Hospital1 189**] Gen after found unresponsive
to tactile/verbal stim + bleeding from ear + nose and was
transferred to [**Hospital1 **] when found to have several foci of L
frontoparietal hemorrhages in a watershed distribution.  He also
has some microbleeds and punctate infarcts in bilateral
hemispheres.

Neurologic: He was admitted to the Neurology ICU for his left
frontoparital hemorrhages. His goal BP was <160. HOB kept
greater than 30 degrees. Was initially in C-collar but this was
cleared by CT C-spine. Initially found seizing by EMS so was
started on Keppra 1000mg [**Hospital1 **]. EEG was performed and did not show
any epileptiform discharges or electrographic seizures. Given
that he was found seizing initially, the Keppra was continued.
Given that he initially had fevers, there was concern that he
may have had septic embolic with hemorrhagic conversion; however
TTE and TEE performed with no evidence vegetations. There was
also no evidence of ASD or atrial clot. MRI performed to further
evaluate etiology of bleed; MRI showed presence of hemorrhage
without acute infarct, shift or hydrocephalus. Possible
etiologies for the hemorrhage include hemorrhagic conversion vs.
amyloid vs. HTN. For the remote possibility of vasculitis [**First Name8 (NamePattern2) **] [**Doctor First Name **]
and RPR were checked, both were negative. His neurologic exam at
disharge is: He opens eyes to voice. He can follow simple
commands on left such as squeezing fingers, showing thumb, and
wiggling toes. On cranial nerve exam, his pupils are reactive.
He does not track but seems to be able to look around room
appropriately. He has a right facial droop. On motor exam, he
moves his left side spontaneously- LUE [**3-27**] and LLE [**2-27**]. He has
dense right hemiplegia.

Cardiovascular:  Given the IPH, goal SBP was less than 160. He
was started on Amlodipine for BP conteol as well as continued on
his home Atenolol. He also received Hydral prn for SBP >160.
Troponins were cycled and trended down.  He initially had an
elevated CK, however this trended down following IVF support. He
was continued on his home Simvastatin.  His CT showed 3cm
infrarenal aortic aneurysm; no acute intervention was determined
to be necessary. During hospitilization, he was started on an IV
lasix drip to help with fluid overload; however this was
discontinued.

Pulmonary: Intubated in the field for airway protection and was
unable to be weaned off vent so tracheostomy performed. He is
now on trach collar during the day and CPAP at night.

GI: was started on tube feeds. Had PEG placed. Currently
receiving feeds via PEG. Has been receiving bowel prep, but
currently having diarrhea (first C. diff negative) so bowel prep
can be held when having diarrhea.

ID: Completed 8 day course of antibiotics (Cefepime/[**Month/Day (1) **]/Vanco)
for suspected VAP (gram stain from BAL indicative infection but
only commensal respiratory grew out on cultures). Urine cx
during this time grew out Proteus, which was sensitive to both
Cefempime and [**Last Name (LF) **], [**First Name3 (LF) **] this was covered on his antibiotic
regimen. Repeat urine cx negative. Blood cx have remained
sterile. About 2 days after completing course of abx, he was
spiking fevers again and WBC trending up. Cultures resent and
mini BAL performed. On the mini BAL culture, ~3000/ML Commensal
Respiratory Flora grew. Given the elevated white count and
fevers, he was started on Vanco and Zosyn empirically. WBC count
has since trended down and he is currently afebrile. He has
currently received 3 days of the new course of antibiotics.

Renal: Was briefly on IV Lasix drip for fluid overload.
Currently not on any drip. Condom cathether for urination.

Musculoskeletal: Found to have R great toe fracture; ortho
recommended no treatment at this time, but can follow-up in
ortho clinic.

FEN: Hypernatremic. Free water flushes down PEG have been
increased to correct this.
PEG feeds for nutrition.


Medications on Admission:
- atenolol 100 mg po daily
- protonix 40 mg po daily
- asa 325 mg po daily
- lisinopril 10 mg po daily
- albuteral 2 puffs inh [**Hospital1 **] prn SOB
- simvastatin 40 mg po daily
- spiriva 1 inh daily
- prilosec 20 mg po daily


Discharge Medications:
1. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO bid prn as needed
for constipation.
2. simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. atenolol 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).

4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).

6. erythromycin 5 mg/gram (0.5 %) Ointment [**Last Name (STitle) **]: One (1)
Ophthalmic QID (4 times a day).
7. nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
8. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed for rash.
9. Keppra 1,000 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
10. docusate sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO bid
prn as needed for constipation.
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
Six (6) Puff Inhalation QID (4 times a day) as needed for SOB.
12. vancomycin in D5W 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous Q 12H (Every 12 Hours) for 5 days.
13. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
[**Last Name (STitle) **]: One (1)  Intravenous Q8H (every 8 hours) for 5 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
L intraparnechymal hemorrhage
Ventilator Associated Pneumonia (treated, though culture
negative)

Discharge Condition:
Mental Status: Opens eyes to voice
Level of Consciousness: lethargic, arousable can follow simple
commands
Activity Status: Out of Bed with assistance to chair or
wheelchair.

Discharge Instructions:
You came to the hospital after being unresponsive at home. Per
EMS reports, you were found seizing upon their arrival and was
intubated for airway protection. You were found to have bleeding
on the left side of your brain; this is resulting in your right
sided weakness. For the seizure, you were started on a
medication called Keppra. To help with BP control given the
bleeding in your brain, you were started on a medication called
Amlodipine and were continued on your home Atenolol.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2173-5-5**] 1:00


Completed by:[**2173-3-22**]

Name:  [**Known lastname 14291**],[**Known firstname 448**]                 Unit No:   [**Numeric Identifier 14292**]

Admission Date:  [**2173-3-5**]              Discharge Date:   [**2173-3-22**]

Date of Birth:  [**2098-12-21**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 4697**]
Addendum:
For DVT proph, was initially on pneumoboots for DVT proph and
then Hep SQ. On day of discharge, he was receiving Hep SQ for
DVT proph.

ASA was held on admission due to the bleed. It is not restarted
at time of d/c given that there does not seem to be a clear
indication for him to currently be on ASA. While it is possible
that the bleed was due to hemorrhagic transformation of an
ischemic stroke, this is not clear at this time as it may also
have been due to amyloid. Thus, the risks of restarting ASA at
this time outweigh the benefits.

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 609**] for the Aged - MACU

                             [**First Name8 (NamePattern2) 77**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern4) 4698**] MD [**MD Number(2) 4699**]

Completed by:[**2173-3-22**]
{'Intracerebral hemorrhage,Other amyloidosis,Ventilator associated pneumonia,Urinary tract infection, site not specified,Hemiplegia, unspecified, affecting nondominant side,Hyperosmolality and/or hypernatremia,Closed fracture of phalanx or phalanges of hand, unspecified,Accidental fall from bed,Other convulsions,Unspecified essential hypertension,Other emphysema,Other dependence on machines, supplemental oxygen,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Abdominal aneurysm without mention of rupture,Diarrhea,Other and unspecified hyperlipidemia,Esophageal reflux,Tobacco use disorder,Personal history of contact with and (suspected) exposure to asbestos'}


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 for IPH

PRESENT ILLNESS: Mr. [**Known lastname 90430**] is a 74 year-old left-handed man
with a history of hypertension, hyperlipidemia, and emphysema
(on
3L suppl O2 at baseline)initially evaluated at [**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 85061**]
after being found unresponsive and was transferred to the [**Hospital1 18**]
when imaging revealed several foci of hemorrhage in the left
forntoparietal regions.
.
According to the patient's fiance, Mr. [**Known lastname 90430**] has not been
feeling well for several days (although the details of the
malaise are unclear).  She does recall that he fell down in the
few days prior to presentation.  He presented to his PCP two
days
prior to presentation and was referred for a head CT.  The
study,
performed on the day prior to evaluation, was apparently normal.
.
The patient went to bed (without dinner) at about 4 pm on the
day
prior to evaluation.  On the morning of evaluation, he appeared
to be sleeping comfortably.  At around 11 am, his fiance went to
wake him up for some breakfast.  At that time she found him
lying
on the ground (rather than in bed) bleeding from the ear and
nose.  He was not responsive to voice or tactile stimulation.
She called an ambulance.
.
Reports from EMS suggest the patient appeared to be seizing at
the time of their arrival (no further details available).  The
patient was intubated for airway protection.  He was
subsequently
transported to [**Hospital3 **].  There, vitals were recorded as T
101.7, BP 214/117, HR 121, RR 19.  A non-contrast CT of the head
was done, and showed hemorrhage in the left frontaoparietal
regions.  He was given fospheytoin 1.5 grams and transferred to
the [**Hospital1 18**] for further evaluation and care.

MEDICAL HISTORY: - CHF (EF unknown)
- SBO
- gallstones
- HTN
- HLD
- GERD
- emphysema - on 3.5 L suppl O2 at baseline

MEDICATION ON ADMISSION: - atenolol 100 mg po daily
- protonix 40 mg po daily
- asa 325 mg po daily
- lisinopril 10 mg po daily
- albuteral 2 puffs inh [**Hospital1 **] prn SOB
- simvastatin 40 mg po daily
- spiriva 1 inh daily
- prilosec 20 mg po daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Exam on Admission:

FAMILY HISTORY: - negative for known neurological conditions

SOCIAL HISTORY: - lives with fiance
- retired police officer 

### Response:
{'Intracerebral hemorrhage,Other amyloidosis,Ventilator associated pneumonia,Urinary tract infection, site not specified,Hemiplegia, unspecified, affecting nondominant side,Hyperosmolality and/or hypernatremia,Closed fracture of phalanx or phalanges of hand, unspecified,Accidental fall from bed,Other convulsions,Unspecified essential hypertension,Other emphysema,Other dependence on machines, supplemental oxygen,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Abdominal aneurysm without mention of rupture,Diarrhea,Other and unspecified hyperlipidemia,Esophageal reflux,Tobacco use disorder,Personal history of contact with and (suspected) exposure to asbestos'}
