CHIEF COMPLAINT: Worst headache of her life

PRESENT ILLNESS: 88 y/o female who developed a severe headache this morning
around 10am followed by malaise and sweating and episodes of dry
heaving. Taken to the hospital by her daughter. Transferred from
[**Hospital3 **] to [**Hospital1 18**] for further care.

MEDICAL HISTORY: HTN

MEDICATION ON ADMISSION: Enalapril 20mg daily, ASA 81 mg daily, Aledronate 70mg qweek

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Hunt and [**Doctor Last Name 9381**]: 2       [**Doctor Last Name **]: 3       GCS  E: 4     V: Motor 6
O: T:  BP: 160 /74         HR: 59    R       O2Sats
Gen: Uncomfortable with a headache
HEENT: NCNT
Neck: Nuchal rigidity
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives with her daughter, Daughter denies knowledge of
Tobacco use.
Subarachnoid hemorrhage,Acute respiratory failure,Obstructive hydrocephalus,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Unspecified protein-calorie malnutrition,Candidiasis of mouth,Blood in stool,Atrial fibrillation,Unspecified essential hypertension,Urinary incontinence, unspecified,Goiter, unspecified,Fever, unspecified,Anemia, unspecified,Other diseases of trachea and bronchus
Subarachnoid hemorrhage,Acute respiratry failure,Obstructiv hydrocephalus,Ac DVT/emb prox low ext,Protein-cal malnutr NOS,Thrush,Blood in stool,Atrial fibrillation,Hypertension NOS,Urinary incontinence NOS,Goiter NOS,Fever NOS,Anemia NOS,Trachea & bronch dis NEC
Admission Date:  [**2180-11-17**]              Discharge Date:   [**2180-12-14**]


Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Worst headache of her life

Major Surgical or Invasive Procedure:
[**2180-11-17**] Cerebral angiogram for coiling of R PCOMM aneurysm
[**2180-11-18**] R EVD placement
[**2180-12-3**] BRONCHIAL BALLOON DILITATION
[**2180-12-4**] IVCF
[**2180-12-4**] RIGHT VENTRICULOPERITONEAL SHUNT
[**2180-12-6**] TRACHEOSTOMY
[**2180-12-6**] BRONCHOSCOPY WITH TRACHEAL BIOPSY
[**2180-12-12**] UPPER ENDOSCOPY


History of Present Illness:
88 y/o female who developed a severe headache this morning
around 10am followed by malaise and sweating and episodes of dry
heaving. Taken to the hospital by her daughter. Transferred from
[**Hospital3 **] to [**Hospital1 18**] for further care.

Upon evaluation, patient is accompanied by her daughter who
helps
with the exam and translates for her. She is complaining of
posterior headache and nuchal pain and stiffness, denies chest
pain, SOB, visual changes.


Past Medical History:
HTN


Social History:
Lives with her daughter, Daughter denies knowledge of
Tobacco use.


Family History:
 NC


Physical Exam:
Hunt and [**Doctor Last Name 9381**]: 2       [**Doctor Last Name **]: 3       GCS  E: 4     V: Motor 6
O: T:  BP: 160 /74         HR: 59    R       O2Sats
Gen: Uncomfortable with a headache
HEENT: NCNT
Neck: Nuchal rigidity
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.

Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect, Spanish speaking
Orientation: Oriented to person, place, and date.

Language: Speech fluent Spanish

Cranial Nerves:
I: Not tested
II: Pupils righ 4mm, left 3mm and reactive. Visual fields are
full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-20**] throughout. No pronator drift

Sensation: Intact to light touch

On discharge -

she is afebrile / vss and has had a bm since peg placed
Neurologically she awakens easily and is attentive. Oriented to
herself, she follows commands. Her pupils are 4-2mm bilaterally/
EOMI/ face is symmetric and tongue is ML with some noted oral
thrush.  She has some difficulty following commands but is
antigravity x all four extremities without noted deficit.  There
is no obvious drift.  Her Incisions to her scalp as well as her
peg site are all benign.  Her trach is clean and dry without
acitive bleeding / oozing.  She is incontinent of urine.


Pertinent Results:
CTA HEAD W&W/O C & RECONS [**2180-11-17**]
1. Extensive subarachnoid hemorrhage, likely originating from 6
mm bilobed
right posterior communicating artery aneurysm.
2. Two tiny infundibula or aneurysms measuring 1-2 mm involving
the left PCom and possibly the left anterior choroidal artery.
3. Large superior mediastinal mass which may represent a
descending goiter, which should be further investigated once the
patient is clinically stable.

CT HEAD W/O CONTRAST [**2180-11-17**]
1. Interval placement of right-sided vascular coil.
2. Very minimal increase in ventricular size compared to most
recent prior
exam.
3. Extensive subarachnoid hemorrhage with blood layering in the
occipital
horns bilaterally.

ECHO:
EF 80%, Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.

CT HEAD W/O CONTRAST [**2180-11-19**]
Reduction in ventricular size. Somewhat caudal placement of
ventriculostomy catheter. Readjustment may be necessary.



CT Chest [**2180-11-20**]:
IMPRESSION:
1. Approximately 8-cm diameter heterogeneous mass arising from
the right lobe of thyroid gland and descending inferiorly into
the middle mediastinum with associated displacement and
narrowing of the trachea. The etiology of the mass is uncertain,
but could relate to a thyroid goiter. A neoplasm arising within
a goiter is also possible, particularly considering the presence
of right paratracheal lymph node enlargement below the level of
the mass.
2. Small right pleural effusion with adjacent right lower lobe
atelectasis.
3. Incompletely imaged 6.5-cm diameter left renal lesion is
probably a simple cyst but is incompletely imaged on this study
and cannot be fully
characterized.

CTA [**11-22**]:
IMPRESSION:

1. No infarct, extension of existing hemorrhage, or new
hemorrhage.
2. New left subdural hygroma overlying the frontoparietal
convexity.
3. The A1 branch of the right anterior cerebral artery exhibits
minimal
vasospasm, but remains widely patent.

CTA [**11-25**]:
IMPRESSION: Limited examination due to poor arterial
enhancement,
possible/equivocal vasospasm involving the right middle cerebral
artery in
segments M2 and M3, the left middle cerebral artery appears
patent, the
patient is status post coil embolization in the right internal
carotid artery.
Unchanged intraventricular hemorrhage and subarachnoid
hemorrhage with major
distribution of the blood on the right sylvian fissure. Slightly
more
prominent subdural hematoma and also midline shifting towards
the right as
described above.

[**2180-11-28**] Portable Head CT:
IMPRESSION:
1. New small hemorrhage into the pre-existing left subdural
hygroma, which is unchanged in size however.
2. Reduction in rightward shift of midline structures from 6 mm
to 2.5 mm.
3. Unchanged ventricular size with no evidence of hydrocephalus.
The amount of fluid being drained by the EVD catheter should be
monitored closely, as intracranial hypotension from overtly
aggressive CSF drainage is one possible cause of the spontaneous
left subdural hygroma.
4. Continued expected evolution of preexisting subarachnoid and
intraventricular blood collections.

[**2180-12-4**] Head CT:
IMPRESSION:
1. Stable left subdural fluid collection.
2. Minimal increase in ventricular size.
3. Continued redistribution and clearance of subarachnoid
hemorrhage.
4. Progressive fluid opacification of right mastoid air cells.

[**2180-12-4**] LENIS:
IMPRESSION:
1. Nonocclusive thrombus of the right common femoral vein. No
other
thrombosis identified within the deep venous system of the right
lower
extremity.
2. No DVT in left lower extremity.

[**2180-12-4**] Head CT:
IMPRESSION:
1. Interval EVD removal, and placement of VP shunt catheter with
tip in the right frontal [**Doctor Last Name 534**]. Mild improvement in ventricular
size.
2. Stable left subdural fluid collection, evolving subarachnoid
hemorrhage, and trace intraventricular hemorrhage with mild
rightward shift of left cerebral hemisphere and left lateral
ventricle.
3. Continued partial opacification of the right mastoid air
cells.

[**12-8**] Video Swallow: Swallowing videofluoroscopy was performed
in conjunction with the speech and swallow division. Attempt was
made to pass multiple consistencies of barium; however, the
patient was too lethargic to participate in the study. Upon the
administration of nectar thickened liquids, penetration was
seen. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric feeding tube was present.

[**12-11**] CXR
IMPRESSION: Right hemidiaphragmatic elevation with resultant
atelectasis,
perhaps a result of phrenic nerve paralysis secondary to the
large right
mediastinal mass.



Brief Hospital Course:
88 y/o F s/p WHOL presents to [**Hospital1 18**] for evaluation. A CT head
showed diffuse SAH. CTA was done which was suspicious for
aneurysm. Angiogram was done with coiling of R PCOM aneurysm.
Patient was transferred to ICU for close monitoring.

ICU Course:
On [**11-18**], an EVD was placed for developing hydrocephalus. She was
stable and was extubated on the morning of [**11-19**], but need to be
re-intubated that evening for hypoxemia.  A chest x-ray revealed
an enlarged mass at the thyroid level. A CT of the chest was
done for further workup.  CT confirmed a Thyroid mass, likely a
goiter causing tracheal compression and stenosis.

[**11-21**]: Thoracic surgery was consulted along with Intraventional
IP for possible tracheal stenting.  We started to wean the EVD
raising it to 15 and subsequently to 20.

[**11-22**]: Interventional IP recommended EBUS via ET tube on [**11-23**].
Her EVD was clamped in the morning with no issue. On exam, it
was noted she had RUE weakness compared to left. A CTA head was
done which showed no vasospasm. A family meeting was held and
current diagnosis and plan were discussed.

[**11-24**]: EVD remains clamped, a CT of the head was performed which
revealed a left sided expanding CSF collection likely secondary
to hydrocephalus.Patient also underwent a baloon dilation of her
trachea in the operating room with interventional pulmonary.

[**11-25**]: CTA was performed that was questionable for mild
vasospasm, there were no changes made to her management given
that she remained clinically stable and continued to follow
commands in her primary language.

[**11-26**]: EVD opened after review of the prior CTA which showed in
increase in the extra axial CSF collection, with the intention
to repeat the study in two days to determine whether the patient
will need a shunt.  The plan for extubation was postponed given
increased secretions.

On [**11-27**] & [**11-28**] the patient remained stable with her EVD at 15
and IVF at 100. CT head was done and this was stable.

On [**11-29**] a family meeting was held to discuss treatment plan.

On [**11-30**] patient was noted to be more awake. The plan was made
to place her VP shunt on Friday and ENT to resect the thyroid
mass on Monday. Her ceftaz was discontinued. She became febrile
overnight and was pancultured. Ceftaz was restarted.

On [**12-1**] the OR case was cancelled given she had been febrile.
CSF was sent, gram stain was negative. Her exam remained stable,
more awake, following commands x4, antigravity x4. Her foley was
changed out given her borderline UA.

Over the weekend, patient remained stable. She was pre-oped for
the OR on Monday for VP shunt placement.

On [**12-4**] a programmable VP shunt was placed without
complication. Resection of the thyroid mass was postponed.
Screening lower extremity ultrasound showed a DVT in the right
common femoral vein. Vascular surgery was consulted and an IVC
filter was placed by interventional radiology.

On [**12-5**] the surgical team reached a consensus that
thyroidectomy should be avoided if possible, and a trial of
extubation was indicated. Pt was given decadron for 24hrs, with
extubation planned for [**12-6**]. IP then saw patient [**12-5**] and felt
extubation was not indicated given the risk for airway
obstruction. On [**12-6**], it was decided she would go to the OR for
a flexible and rigid bronchoscopy with possible biopsy. At that
time if the airway appears too small, a trach would be done.

[**12-7**] Patient tolerated trach mask over night and was seen in
the morning by physicial therapy and was transferred to the
floor in stable neuro and pulmonary status. She was noted to
have a black tarry stool which was guaic positive so general
surgery was consulted. They recommended endoscopy at the time of
PEG placement.

[**12-8**] A video swallow was perfromed that indicated patient was
likely aspirating, general surgery was consulted for PEG
placement. Patient was found to have black tarry stools that
were guiac positive. A GI consult was obtained. Patient will
need an endoscopy and the plan is for the GI team to coordinate
the scope with the general surgery team to perform the study at
the same time as the PEG placement in the OR. Nimodipine was
discontinued as patient had completed 21 day course.

On [**12-9**] the patients trach site was noted to be bleeding so IP
was reconsulted for evaluation but no intervention was
necessary. The patient trach site & neurological status remained
stable for the next couple days. On [**12-12**] she went to the OR for
PEG tube placement and endoscopy. The PEG was placed without
complication and the endoscopy revealed no bleeding ulcers or
varicies.

On [**12-13**] she was again neurologically stable. Tube feedings were
initiated via the PEG tube. PT and OT recommended discharge to
acute rehab hospital.


Medications on Admission:
Enalapril 20mg daily, ASA 81 mg daily, Aledronate 70mg qweek

Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 50 mg/5 mL Liquid Sig: Two (2)  PO BID (2
times a day).
4. acetaminophen 650 mg/20.3 mL Solution Sig: One (1)  PO Q6H
(every 6 hours) as needed for fever.
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): [**Hospital1 **]
PER GASTRENTEROLOGY REQUEST FOR COVERAGE.
10. HydrALAzine 10 mg IV Q8H SBP > 200
If aneurysm secured, SBP can be liberalized post angio to less
than 200
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
12. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One
(1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
Subarachnoid hemorrhage
R PCOMM aneurysm
Respiratory failure
Hydrocephalus
Left sided hygroma
Thyroid mass
Fevers
Oral thrush
melanous stool
anemia requiring transfusion
Deep vein thrombosis


Discharge Condition:
Mental Status: Confused - sometimes.

Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted to the hospital for subarachnoid hemorrhage
from a posterior communicating artery aneurysm.  This was
treated with coiling. You also required an external ventricular
drain and subsequent ventriculoperitoneal shunt.  During your
stay a mass was noted in your neck.  It was biopsied but the
results were non diagnostic meaning we still don't know what it
is.  You had a tracheostomy to support your airway because of
this neck mass.  You also had a feeding tube placed for
nutritional support.  You had some blood in your stool during
your stay and received transfusions for this.  You were seen by
the gastroenterology doctors.  Their work up did not reveal a
source of your bleeding.
Medications:
??????	Take Aspirin 325mg (enteric coated) once daily.
??????	Continue all other medications you were taking before surgery,
unless otherwise directed
??????	You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.

What activities you can and cannot do:
??????	When you go home, you may walk and go up and down stairs.
??????	You may shower (let the soapy water run over groin incision,
rinse and pat dry)
??????	Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
??????	No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
??????	After 1 week, you may resume sexual activity.
??????	After 1 week, gradually increase your activities and distance
walked as you can tolerate.
??????	No driving until you are no longer taking pain medications

What to report to office:
??????	Changes in vision (loss of vision, blurring, double vision,
half vision)
??????	Slurring of speech or difficulty finding correct words to use
??????	Severe headache or worsening headache not controlled by pain
medication
??????	A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
??????	Trouble swallowing, breathing, or talking
??????	Numbness, coldness or pain in lower extremities
??????	Temperature greater than 101.5F for 24 hours
??????	New or increased drainage from incision or white, yellow or
green drainage from incisions
??????	Bleeding from groin puncture site

*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!


Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 4 weeks with a MRI/MRA
([**Doctor Last Name **] protocol). Please call [**Telephone/Fax (1) 4296**] to make this
appointment.

You will need to follow up with Dr. [**Last Name (STitle) **] of interventional
pulmonary for your trach, in 10 days to 2 weeks.  Their office
phone number is [**Telephone/Fax (1) **] / they will also discuss the non
diagnostic biopsy results of your neck mass.

Please follow up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks
of discharge.



Completed by:[**2180-12-14**]
{'Subarachnoid hemorrhage,Acute respiratory failure,Obstructive hydrocephalus,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Unspecified protein-calorie malnutrition,Candidiasis of mouth,Blood in stool,Atrial fibrillation,Unspecified essential hypertension,Urinary incontinence, unspecified,Goiter, unspecified,Fever, unspecified,Anemia, unspecified,Other diseases of trachea and bronchus'}


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: Worst headache of her life

PRESENT ILLNESS: 88 y/o female who developed a severe headache this morning
around 10am followed by malaise and sweating and episodes of dry
heaving. Taken to the hospital by her daughter. Transferred from
[**Hospital3 **] to [**Hospital1 18**] for further care.

MEDICAL HISTORY: HTN

MEDICATION ON ADMISSION: Enalapril 20mg daily, ASA 81 mg daily, Aledronate 70mg qweek

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Hunt and [**Doctor Last Name 9381**]: 2       [**Doctor Last Name **]: 3       GCS  E: 4     V: Motor 6
O: T:  BP: 160 /74         HR: 59    R       O2Sats
Gen: Uncomfortable with a headache
HEENT: NCNT
Neck: Nuchal rigidity
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives with her daughter, Daughter denies knowledge of
Tobacco use. 

### Response:
{'Subarachnoid hemorrhage,Acute respiratory failure,Obstructive hydrocephalus,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Unspecified protein-calorie malnutrition,Candidiasis of mouth,Blood in stool,Atrial fibrillation,Unspecified essential hypertension,Urinary incontinence, unspecified,Goiter, unspecified,Fever, unspecified,Anemia, unspecified,Other diseases of trachea and bronchus'}
