CHIEF COMPLAINT: headache, nausea, vomiting, lethargy

PRESENT ILLNESS: 49 y/o with a hx of diverticulitis who is transferred from an
OSH with a L sided intraparenchymal hemorrhage.

MEDICAL HISTORY: Diverticulitis
No Hx of HTN

MEDICATION ON ADMISSION: Multivitamin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T- 97.5 BP- 126/70 HR- 72 RR- 18 O2Sat- 98% on RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema

FAMILY HISTORY: no family hx of stroke or HTN

SOCIAL HISTORY: lives with fiance, has 3 kids, works as a computer programmer,
occ social EtOH, no tobacco
Intracerebral hemorrhage,Meningitis, unspecified,Obstructive hydrocephalus,Other disorders of neurohypophysis,Unspecified essential hypertension,Pain in joint, shoulder region
Intracerebral hemorrhage,Meningitis NOS,Obstructiv hydrocephalus,Neurohypophysis dis NEC,Hypertension NOS,Joint pain-shlder
Admission Date:  [**2137-3-25**]              Discharge Date:   [**2137-4-19**]

Date of Birth:  [**2088-2-11**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
headache, nausea, vomiting, lethargy

Major Surgical or Invasive Procedure:
Extraventricular drain
Intubation and mechanical ventilation

History of Present Illness:
49 y/o with a hx of diverticulitis who is transferred from an
OSH with a L sided intraparenchymal hemorrhage.

Fiance reports that pt. was in his USOH, skiing with his family
the weekend of presentation.  On Saturday he skiied a whole day
and socialized with friends in the evening and had no
complaints.  On Sunday morning he woke up at 8AM and went
skiing.  He came back at 10 AM and complained of a severe,
bifrontal, pounding headache.  He seemed tired, and took 2
ibuprofen and layed down for 2 hours. He woke up at lunchtime
and seemed his normal self, although he still had a headache
(improved  but still present).  He went back out onto the
slopes.  His fiance was called to the first aid room at 2:30.
She reports that he looked very fatigued and pale as a ghost,
and had vomited once.  She is not sure if he fell on the slopes.
 She was advised by the staff there to take him to the doctor
when they got home.  They got in the car to drive back to [**Location (un) 86**]
around 3-3:30.  He sat in the front seat slumped forward, in an
"unnatural position" per his fiance, and slept for about 2
hours.  She did not try to arouse him or talk to him because she
thought that he was under the weather and needed to rest.  She
did not notice any facial droop or any obvious weakness.  At
around 4:30-5 he woke up somewhat, but seemed very confused, and
was saying things that didn't make sense, and talking like he
was "in a dream."  She decided to take him to the closest
hospital.  He was seen there and Head CT was performed (~7P),
and showed a large L intraparenchymal hemorrhage with
intraventricular extension and mild hydrocephalus.  He was
transported to [**Hospital1 18**]
for further evaluation.

When he arrived here Head CT was repeated (~9:30) and appeared
stable.  He was evaluated by Neurosurgery who did not feel that
he needed acute drainage of [**Last Name (LF) 71966**], [**First Name3 (LF) **] Neurology was consulted.

Pt. is very unclear on the events of the day.  He is unable to
tell me where he is or why he is here.  He does remember having
a headache earlier today, but feels it is not present now.  Has
no complaints at present, denies weakness, numbness, dysarthria,
dysphagia.

Past Medical History:
Diverticulitis
No Hx of HTN

Social History:
lives with fiance, has 3 kids, works as a computer programmer,
occ social EtOH, no tobacco

Family History:
no family hx of stroke or HTN

Physical Exam:
T- 97.5 BP- 126/70 HR- 72 RR- 18 O2Sat- 98% on RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema

Neurologic examination:
Mental status:  Awake, alert. Fully oriented. Digit span forward
7. Intermittently slightly confused. Speech normal. Slightly
apathetic.

Cranial Nerves: Pupils equally round and reactive to light, 4 to
2 mm bilaterally. Visual fields are full to confrontation.
Extraocular movements intact bilaterally, no nystagmus.
Sensation intact V1-V3.  Facial movement symmetric.  Hearing
intact to finger rub bilaterally.  Palate elevation symmetrical.
 Sternocleidomastoid and trapezius normal bilaterally. Tongue
midline, movements intact.

Motor: Normal bulk bilaterally. Tone normal. No observed
myoclonus or tremor
No pronator drift
  [**Doctor First Name **] Tri [**Hospital1 **]  WF WE FE FF  IP  H  Q DF PF TE TF
R  5   5   5  5  5  5  5   5   5  5  5  5  5  5
L  5   5   5  5  5  5  5   5   5  5  5  5  5  5

Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout. No extinction to DSS

Reflexes: +2 and symmetric throughout. Toes downgoing
bilaterally

Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.

Gait: not assessed

Pertinent Results:
Admission Labs:
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative

Color Yellow Appear Clr SpecGr 1.016 pH 7.0 Urobil Neg Bili Neg

Leuk Neg  Bld Neg  Nitr Neg  Prot Neg  Glu Neg  Ket Tr

Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative

138  104  16
------------< 123
4.6  25  1.0

Ca: 9.4 Mg: 2.5 P: 3.7

WBC 8.7 Hgb 12.8 Plt 228 Hct 37.5 MCV 93
 N:89.9 Band:0 L:8.5 M:1.1 E:0.1 Bas:0.4
Plt-Est: Normal

PT: 12.1  PTT: 20.5  INR: 1.0


Imaging:

Head CT [**3-24**]: 1.  Large intraparenchymal hematoma centered in
the left basal ganglia with associated intraventricular
hemorrhage resulting in mild-to-moderate hydrocephalus.  Mild
mass effect on the frontal [**Doctor Last Name 534**] of the left lateral ventricle.
The location is typical for hypertensive hemorrhage.  An MRI/MRA
can be performed to exclude other processes such as underlying
AVM or neoplasm. 2.  Mild mucosal thickening of the frontal
sinus.

CTA [**3-25**]: Again seen is a large area of intraparenchymal
hemorrhage in the left caudate and putamen, with extension to
the ventricles. No new areas of intracranial hemorrhage
identified. Normal CTA of the Circle of [**Location (un) 431**].

HEAD MRI [**3-25**]: Again seen is an area of large intraparenchymal
hemorrhage centered within the left caudate and putamen, with
extension to the lateral ventricles, third ventricle, and fourth
ventricle, without significant shift of normally midline
structures. There are no findings within this region to suggest
an underlying intraparenchymal mass at this location. The major
vascular flow voids are normal. Soft tissue and osseous
structures are normal.
MRA OF THE CIRCLE OF [**Location (un) **]: The major tributaries of the circle
of [**Location (un) 431**] are patent. There is no evidence of an aneurysm or
underlying AV malformation.
IMPRESSION: Again seen is intraparenchymal hemorrhage within the
left caudate and putamen extending to the ventricles. Findings
are most consistent with hypertensive-related hemorrhage. No
underlying mass lesion is identified.

HCT [**3-26**]: 1. Evolving left intraparenchymal hematoma centered in
the left basal ganglia not significantly change in size.
Interventricular hemorrhage results in mild-to-moderate
hydrocephalus, which has slightly decreased. There is mild mass
effect on the frontal [**Doctor Last Name 534**] of the left lateral ventricle. The
findings are consistent with hypertension hemorrhage.

Angio [**3-28**]: 1. No aneurysm or AVM identified.
2. Hypoplastic right A1 segment as well as distal right
vertebral artery.
3. Broad-based 2-mm infundibulum at the origin of the left
posterior communicating artery from the left internal carotid
artery.

HCT [**3-28**]: Evolving left intraparenchymal hemorrhage centered in
the left basal ganglia, not significantly changed in size.
Ventricular hemorrhage results in moderate-to-severe
hydrocephalus, notably worse in comparison with the prior study.
No new areas of hemorrhage are identified.

HCT [**3-29**]: Interval placement of right-sided ventricular drain
with improvement to hydrocephalus, now mild to moderate.
Unchanged appearance to left basal ganglia hemorrhage and edema
with slightly increased blood noted within the occiptal horns.

HCT [**4-3**]: Improvement to intraparenchymal and intraventricular
hemmorhagic component with stable surrounding edema and local
mass effect. No CT findings to explain increased somnolence.

HCT [**4-5**]: 1. Slight decrease to hyperdense left basal ganglia
hemorrhagic component with stable appearance to surrounding
edema and local mass effect. 2. Increased hyperdense material
along the choroid plexuses bilaterally within the lateral
ventricles likely represents adherent clot. The size of the
lateral ventricles themselves appears stable to slightly
improved.

HCT [**4-7**]: No evidence of hydrocephalus. No significant change in
the appearance of the brain since [**2137-4-5**].

Brief Hospital Course:
49 year old right handed man with history of diverticulitis and
without history of hypertension with a left caudate hemorrhage
with intraventricular spread to lateral, third and fourth
ventricles after skiing day of presentation.  He had been
normotensive since arrival.  His exam was initially significant
for decreased attention, subtle language deficit with some
paraphasias and decreased fluency, but normal naming and
repetition.  His strength was intact, his pupils were equal and
symmetric, extraocular movements were intact with no nystagmus,
and his toes were downgoing bilaterally.

Hospital course is detailed below by problem:

1. Intracerebral/intraventricular hemorrhage: Patient was
admitted to the Neurology ICU with serial neurochecks and ICU
telemetry.  Neurosurgery followed in case of clinical
deterioriation and development of hydrocephalus.  Repeat imaging
including MRI/MRA head and CTA head were negative for an
underlying mass, aneurysm or ateriovenous malformation and also
showed that bleed was stable 4-6 hours after initial head CT.
An additional head CT at 36 hours after presentation showed
evolving hemorrhage not signficantly changed in size with slight
decrease of mild-moderate hydrocephalus.

The etiology of his hemorrhage was not entirely clear; he had no
history of hypertension and had been normotensive on admission.
Amyloid angiopathy was unlikely given his age and no lesions
were seen on susceptibility to suggest microbleeds.  There has
been evidence in the literature of cold-induced hypertension
usually within 4 days of exposure but often related to chronic
cold exposure.  It is possible that cold and/or stress induced a
hypertensive bleed.  An underlying AVM was ruled out by
angiogram (see results section).

On [**3-28**] in the evening, the patien became disoriented (said he
was looking for apartments earlier in the day, and currently in
[**Location (un) **] in an executive suite). Then over the course of
approximately one hour, he became increasingly somnolent. He had
a stat head CT, showing significantly increased ventricle size
consistent with hydrocephalus. He was transferred to the SICU,
where he was intubated and Neurosurgery placed an EVD with
improvement in hydrocephalus.

Over the course of several days, the EVD was raised and finally
clamped. A repeat HCT after clamping showed no significant
change in hydrocephalus from after EVD placement. The EVD was
pulled [**4-5**], several minutes after which he had a 1 minute
seizure with L eye and head deviation and unresponsiveness,
which resolved spontaneously. A CT showed increased blood in the
ventricles and along the tract. Given that this occurred in the
setting of the EVD being pulled, it was thought to be secondary
to local irritation.

Repeat CT scans failed to show significant hydrocephalus.

The patient continued to be febrile and underwent lumbar
puncture, which was significant for meningitis and he was
started on a 14-day course of vanco/ceftaz for meningitis.

He is scheduled for follow-up with a repeat CT scan. For
intermittent confusion, he was placed empirically on keppra
500mg [**Hospital1 **], though EEG was negative - this may be discontinued on
a trial basis in the future.

2. Fever: He had a temperature >102 on [**4-3**]. He was pancultured
and started on ceftriaxone and vancomycin for empiric coverage
of meningitis given the EVD was in place. He defervesced [**4-5**].
Antibiotics were discontinued when all cultures were negative x
>48 hours. They were restarted as above. He continued to spike
fevers, though less high, until 48hrs prior to discharge. These
were thought to be central in origin. MRI brain/c-spine ruled
out abscess.

3. Hyponatremia: His sodium dropped as low as 124. Initially he
has a FeNa of 0.1%, so he was thought to be dry and was
rehydrated. His sodium continued to drop with IVF, so urine
lytes were resent and his urine Na had increased to the 90s. He
was thus thought to have SIADH and was put on fluid restriction.
Renal service was consulted. HCTZ was discontinued and his
sodium eventually recovered. If sodium remains above 135
consistently, fluid restriction may be discontinued.

4. Hypertension: He was noted to be slightly hypertensive while
in the hospital. This was first treated with prn hydralazine,
then he was started on HCTZ. However, soon after his sodium
began to drop, which was thought to be related to the HCTZ. He
was changed to metoprolol.

5. Stroke: the patient had an MRI brain, which incidentally
showed a subacute stroke in the midbrain/pons that had no
clinical correlate. We will start him on aspirin 81mg daily.
Lipids are at goal. HbA1c is pending. He will be seen as an
outpatient in stroke clinic.

Medications on Admission:
Multivitamin

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 3 days.
10. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: One
(1)  Intravenous Q8H (every 8 hours) for 3 days.
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Intracerebral and intraventricular hemorrhage, likely due to
cold-induced hypertension
Hypertension
Meningitis


Discharge Condition:
Awake, alert. Intermittently slightly confused. Nuchal rigidity.



Discharge Instructions:
You were admitted to the neurology service after an
intracerebral hemorrhage. Your course was complicated by high
pressure in your brain, which was relieved with an external
ventricular drain. This procedure was complicated by meningitis,
which is being treated with antibiotics. You were started on
keppra to prevent seizures; it should be continued until a
future date, at which point a trial off of it should be
considered.

Followup Instructions:
1. Primary Care Doctor:
[**Location (un) **]: [**Telephone/Fax (1) 11568**]

2. Ophthalmology:
VISUAL FIELD SCREENING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2137-5-9**]
11:00
[**Name6 (MD) 6131**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2137-5-9**] 11:30

3. [**Hospital 4038**] Clinic:
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2137-5-24**] 9:00
You are also scheduled for a repeat head CT on [**5-24**], in the
[**Hospital Ward Name 23**] building floor 4, at 11am.



Completed by:[**2137-4-19**]

Name:  [**Known lastname 12040**],[**Known firstname 801**]            Unit No:   [**Numeric Identifier 12041**]

Admission Date:  [**2137-3-25**]              Discharge Date:   [**2137-4-19**]

Date of Birth:  [**2088-2-11**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 11296**]
Addendum:
Keppra to be increased gradually to 1000mg [**Hospital1 **] as prescribed.

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): Take one tablet in the morning and two at night
for one week. Then increase to two tablets in the morning and
two in the night and continue.
9. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 3 days.
10. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: One
(1)  Intravenous Q8H (every 8 hours) for 3 days.
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 41**] - [**Location (un) 42**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11297**] MD [**MD Number(2) 11298**]

Completed by:[**2137-4-19**]
{'Intracerebral hemorrhage,Meningitis, unspecified,Obstructive hydrocephalus,Other disorders of neurohypophysis,Unspecified essential hypertension,Pain in joint, shoulder region'}


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: headache, nausea, vomiting, lethargy

PRESENT ILLNESS: 49 y/o with a hx of diverticulitis who is transferred from an
OSH with a L sided intraparenchymal hemorrhage.

MEDICAL HISTORY: Diverticulitis
No Hx of HTN

MEDICATION ON ADMISSION: Multivitamin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T- 97.5 BP- 126/70 HR- 72 RR- 18 O2Sat- 98% on RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema

FAMILY HISTORY: no family hx of stroke or HTN

SOCIAL HISTORY: lives with fiance, has 3 kids, works as a computer programmer,
occ social EtOH, no tobacco 

### Response:
{'Intracerebral hemorrhage,Meningitis, unspecified,Obstructive hydrocephalus,Other disorders of neurohypophysis,Unspecified essential hypertension,Pain in joint, shoulder region'}
