CHIEF COMPLAINT: WHOL and neck pain at home / ems was called / pt intubated on
arrival

PRESENT ILLNESS: Asked to see this 81 year old white female who was transfered
from OSH for SAH.  By EMS reports, pt reported CP and SOB and
family called 911. On their arrival pt required CPR.  Family
reports pt in her usual state of health yesterday and this am
until she c/o of pain in her head and neck this am and they
called EMS.  They deny c/o CP or SOB.  No trauma in history. Pt
was intubated by report at OSH.

MEDICAL HISTORY: CABG x 2 / [**2103**], HTN, hysterectomy (remote), Cholecystectomy
(remote), no recent hospitalizatin or illness per family

MEDICATION ON ADMISSION: diovan, vytorin 10/40, metoprolol 12.5 [**Hospital1 **], asa 325 daily, MVI,
glucosoamine, calcium.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: on arrival

FAMILY HISTORY: Family Hx:has a twin sister/present

SOCIAL HISTORY: Social Hx: unknown at present
Subarachnoid hemorrhage,Subendocardial infarction, initial episode of care,Cerebral artery occlusion, unspecified with cerebral infarction,Acute respiratory failure,Unspecified protein-calorie malnutrition,Obstructive hydrocephalus,Unspecified essential hypertension,Aortocoronary bypass status
Subarachnoid hemorrhage,Subendo infarct, initial,Crbl art ocl NOS w infrc,Acute respiratry failure,Protein-cal malnutr NOS,Obstructiv hydrocephalus,Hypertension NOS,Aortocoronary bypass
Name:  [**Known lastname 13180**],[**Known firstname **]                  Unit No:   [**Numeric Identifier 13181**]

Admission Date:  [**2107-5-29**]              Discharge Date:   [**2107-6-24**]

Date of Birth:  [**2025-12-28**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 40**]
Addendum:
Correction to above, Follow up information:
Please follow up with Dr. [**First Name (STitle) **], please call ([**Telephone/Fax (1) 13182**] to
schedule your appointment in 4 weeks.

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] Health Network

                             [**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]

Completed by:[**2107-6-24**]

Admission Date:  [**2107-5-29**]              Discharge Date:   [**2107-6-24**]

Date of Birth:  [**2025-12-28**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
WHOL and neck pain at home / ems was called / pt intubated on
arrival

Major Surgical or Invasive Procedure:
Bilateral external ventricular drains [**2107-5-29**]
cerebral angiogram [**2107-5-31**]


History of Present Illness:
Asked to see this 81 year old white female who was transfered
from OSH for SAH.  By EMS reports, pt reported CP and SOB and
family called 911. On their arrival pt required CPR.  Family
reports pt in her usual state of health yesterday and this am
until she c/o of pain in her head and neck this am and they
called EMS.  They deny c/o CP or SOB.  No trauma in history. Pt
was intubated by report at OSH.


Past Medical History:
CABG x 2 / [**2103**], HTN, hysterectomy (remote), Cholecystectomy
(remote), no recent hospitalizatin or illness per family


Social History:
Social Hx: unknown at present


Family History:
Family Hx:has a twin sister/present


Physical Exam:
on arrival

PHYSICAL EXAM:
O: T:AF   BP:77/70  HR:74    R vented        O2Sats100%
Gen: WD/WN, intubated, no obvious trauma noted
HEENT: NC/AT Pupils: 2mm non reactive at present, +trace
corneals, conjugate gaze. No hemotympanum, battles sign or
raccoons sign, no csf rhinorrhea or otorrhea.
Neck: no cervical collar in place
Abd: Soft
Extrem: Warm.
Neuro:
Mental status: No eye opening to voice or noxious, currently off
sedation and gagging vs pre-emesis.  No commands,  +
localization
with RUE, w/d's LUE and LE's B/L.fect.

PR equivocal

ON DISCHARGE:
A&O x 3, mouthing words, following commands
Pupils: PERRL 4-3mm bilaterally
EOMs: intact
Face symmetrical
Motor:
UE: Right-grasp [**3-31**], biceps, triceps, and deltoids- 4-
Left- no movement
LE: Right- antigravity, bends knees, wiggles toes
Left-bends knees, wiggles toes


Pertinent Results:
Cardiology Report ECG Study Date of [**2107-5-29**]  10:51:26 AM
Sinus rhythm Nonspecific intraventricular conduction delay
Possible anterior infarct - age undetermined Nonspecific ST-T
wave changes
No previous tracing available for comparison
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 152 102 438/467 83 43 174

Imaging:
CT HEAD W/O CONTRAST [**2107-5-29**] 10:59 AM
Final Addendum
ADDENDUM: Findings of subarachnoid hemorrhage and
intraventricular hemorrhage discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from
neurosurgery at the time of subsequent CTA head examination.
TECHNIQUE: Contiguous axial images were obtained through the
brain. No
contrast was administered. Multiplanar reformatted images were
generated.
FINDINGS: There is an extensive amount of high-density material
tracking
around the cerebellum, as well as through the basilar cisterns.
Overall, this is consistent with subarachnoid hemorrhage. There
is no obvious area of greatest density to indicate a source for
the bleeding. Hyperdense material also layers dependently within
the occipital horns of the lateral ventricles, and collects in
the third and fourth ventricles. Lateral ventricles are not
enlarged, although comparison with the prior study is not
possible at the time of dictation. However, there is no large
ventricular outlet obstruction. High-density material also
layers along the tentorium cerebelli. There are no other foci of
intracranial hemorrhage. There is no edema, shift of normally
midline structures or evidence of major vascular territorial
infarct. There is no large mass effect associated with
intraventricular and subarachnoid bleeding. There is no other
evidence of herniation. There is no fracture. Mastoid air cells
are well aerated. There is fluid within scattered ethmoid air
cells, but the sphenoid, maxillary and frontal air cells are
well aerated.
IMPRESSIONS:
1. Diffuse subarachnoid hemorrhage along the base of the brain,
and
collecting within the ventricles, predominantly within the third
and fourth ventricles, but also layering dependently in the
lateral ventricles. No evidence of outlet obstruction at this
time, although a comparison with prior CT would be useful to
determine interval change. No mass effect or herniation at this
time.
2. No other foci of hemorrhage.
3. Opacification of scattered ethmoid air cells.

CTA HEAD W&W/O C & RECONS [**2107-5-29**] 2:36 PM
SCAN FINDINGS: Non-contrast CT of the head demonstrates diffuse
cerebral
subarachnoid hemorrhage including blood products within the
lateral
ventricles, third ventricles and filling the fourth ventricle
extending
through the foramen of Luschka with subarachnoid hemorrhage in
the right
perimesencephalic cistern. There is no significant shift of
midline
structures.
CTA OF THE HEAD: CTA of the head demonstrates a tiny 2.5-mm
outpouching at
the origin of the right posterior inferior cerebellar artery
suggestive of a tiny aneurysm. 2.5 mm indicates the patent
lumen. The location of this
aneurysm would be consistent with the pattern of subarachnoid
hemorrhage.
The right vertebral artery terminates in the PICA. The remaining
intracranial circulation demonstrates no evidence of
hemodynamically significant stenosis, aneurysm or occlusion. The
right vertebral artery, basilar artery as well as the anterior
circulation is intact. Note is made of bilateral ventriculostomy
catheters in the frontal lobes terminating within the lateral
ventricles.
IMPRESSION:
Diffuse subarachnoid hemorrhage including right
perimesencephalic cistern
and fourth intraventricular hemorrhage. 2.5 mm likely tiny
aneurysm at the origin of the right posterior inferior
cerebellar artery. Further evaluation with cerebral angiography
is recommended, as clinically relevant.

ECHOCARDIOGRAPHY REPORT [**2107-5-30**] at 9:45:40 AM
Conclusions:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is moderate global left
ventricular hypokinesis (LVEF = 35%). No masses or thrombi are
seen in the left ventricle. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no ventricular septal defect. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is borderline pulmonary artery systolic hypertension. There is
no pericardial effusion.

ECG Study [**2107-5-30**]  10:08:18 AM
Sinus rhythm
Nonspecific diffuse ST-T changes. Since previous tracing of
[**2107-5-29**], T wave inversion more prominent in lead V3, atrial
premature complex absent
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 158 90 [**Telephone/Fax (2) 82428**] -175

CTA HEAD W&W/O C & RECONS Study Date of [**2107-6-13**] 11:51 AM
1. Unchanged appearance of the right posterior inferior
cerebellar artery
territory infarction.

2. 2 mm aneurysm at the origin of the right posterior inferior
cerebellar
artery is again seen. The posterior inferior cerebellar artery
remains
patent.

3. Unchanged subarachnoid and intraventricular hemorrhage

TTE (Complete) Done [**2107-6-13**] at 2:03:19 PM
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is no pericardial
effusion.

Compared with the prior study (images reviewed) of [**2107-5-30**], the
estimated pulmonary artery systolic pressure is slightly higher
and the severity of mitral regurgitation and tricuspid
regurgitation is slightly higher. No cardiac source of embolism
identified.

CTA HEAD W&W/O C & RECONS Study Date of [**2107-6-13**] 11:51
1. Unchanged appearance of the right posterior inferior
cerebellar artery
territory infarction.

2. 2 mm aneurysm at the origin of the right posterior inferior
cerebellar
artery is again seen. The posterior inferior cerebellar artery
remains
patent.

3. Unchanged subarachnoid and intraventricular hemorrhage

CT HEAD W/O CONTRAST Study Date of [**2107-6-14**] 5:31
1. Interval removal of right frontal ventriculostomy catheter
with slight
interval increase in lateral ventricle size. Close follow-up
recommended.

2. Stable residual subarachnoid and intraventricular hemorrhage.


3. Expected evolution of right cerebellar infarction.

TRANSCATH THERAPY Study Date of [**2107-6-17**] 10:51 AM
Evaluation of the right vertebral artery showed moderate
stenosis
at the origin. The arteriogram demonstrated mild vasospasm. The
aneurysm
appeared well clipped. 5 mg of Verapamil were given IV via slow
infusion,
secondary to the vasospasm. No new aneurysms, regions of
flow-limiting
stenosis or occlusions were identified.

The left internal carotid artery arteriogram demonstrated
minimal vasospasm in the left lenticulostriate and MCA branches.
No new aneurysm is identified. 5mg of Verapamil were infused via
slow infusion.

The left vertebral artery arteriogram demonstrated minimal
vasospasm. No new aneurysms are identified. 5 mg of Verapamil
were infused via slow infusion.

A right common carotid artery arteriogram was performed
secondary to moderate plaque at the origin of the right internal
carotid artery. Mild vasospasm was noted. 5 mg of Verapamil were
infused IV via slow infusion.

Moderate sedation was provided by administering divided doses of
Fentanyl
throughout the total intraservice time of 1 hour and 15 minutes
during which the patient's hemodynamic parameters were
continuously monitored.

CHEST (PORTABLE AP) Study Date of [**2107-6-23**] 4:01 AM
Small bilateral pleural effusions and mild pulmonary edema have
improved since [**6-21**]. Heart size is top normal. Leftward
mediastinal shift and
opacification at the left lung base suggest left lower lobe
collapse, present since at least [**6-6**]. Tracheostomy tube in
standard placement. No
pneumothorax.



Brief Hospital Course:
Pt was received to the ED from OSH after c/o headache and neck
pain at home.  Accorrding to EMS records she required
resucitation.  IN the ED she was severly hypotensive and
required fluid resucitation.

CT scan reveled SAH with IVH and HCP.  She was taken emergently
to the OR for placment of bilateral EVD's.  After the OR she had
an emergent CTA of the brain which did not reveal a source of
the SAH.

She was transfered to the SICU and monitored closely. Nimodipine
and dilantin were started.  Cardilogy consult was initiated in
the ED for elevated troponins.  She underwent a TTE which the
results are in the results section of this summary.

A Cerebral angiogram was performed on [**2107-5-31**].  It revealed a
Right PICA aneurysm.
MRI did not show any infarcts.  Pt was medically managed as she
was not able to be coiled.  A decision was made monitor her exam
for a few more days to see if she improved before considering an
open craniotomy.

On [**6-5**] pt began opening eys and able to stick tongue out on
command. On [**6-7**] she began withdrawing her lower extremities to
stimulation and nodding head to simple questions. Her L EVD was
dc'd without difficulty.

Her neurological exam vastly improved to following commands by
nodding head appropriately to questions correctly and lifting
all extremeties off the bed to command. She received a trach
placed on [**6-7**]. She underwent an attempted coiling on [**6-10**] of
her right vertebral artery but it was unable to be accessed.

On [**6-12**], patient had a right cerbellar infact that was not
previously seen on CT. Neuro suspected that the infarct may have
occluded the PICA and the aneurysm. Patient mouthing words, A&O
x3, moves all extremites to command. [**6-13**], CTA showed patency of
PICA and planning for open coiling or clipping of PICA aneurysm
started. CTA will be repeated on [**6-15**] to recheck patency of
PICA. EVD "fell" out and stat CT showed stable SAH.

On [**6-15**], patient A&O x3 and following commands. Her repeat head
CT shows slight increase in lateral ventricle size, but stable.
Patient will be sent to OR for open clipping of PICA aneurysm.

On [**6-16**] patient was brought to the OR where she underwent a
clipping of her R pica aneurysm. She tolerated the procedure
well and her post-op head CT show no new hemorrhage however she
did have further evolution or R cerebellar infarct.

On [**6-17**], angiogram showed good clip placement with mild
vasospasm. She was able to still follow commands and open her
eyes spontaneoulsy. She was not moving her upper extremities.
She was also placed on nimodipine 60mg Q4H for vasospasm.

On the 23rd and 24th, patient's physical exam improved, she was
able to move both upper and lower extremities, but UE<LE. Her
nimodipine was discontinued.

Patient's physical exam showed she was following commands,
mouthing words, and moving lower extremities. She will be
discharged to a rehab facility with ventilator.

Medications on Admission:
diovan, vytorin 10/40, metoprolol 12.5 [**Hospital1 **], asa 325 daily, MVI,
glucosoamine, calcium.

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever pain .
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
5. Simvastatin 10 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. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
12. Calcium Gluconate in D5W 2 gram/100 mL Solution Sig: One (1)
 Intravenous ASDIR (AS DIRECTED).
13. Magnesium Sulfate 4 % Solution Sig: One (1)  Injection PRN
(as needed).
14. Fentanyl Citrate 25-50 mcg IV Q4H:PRN pain
15. Potassium Chloride  Intravenous
16. Labetalol 10 mg IV Q2H:PRN sbp>160mmHg
17. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] Health Network

Discharge Diagnosis:
Intraventricular Hemorrhage, subarachnoid hemorrhage, cerebral
aneurysm(Rt PICA)
NSTEMI; depressed cardiac function (EF 35%, global hypokinesis)


Discharge Condition:
Neurologically Stable


Discharge Instructions:
General Instructions

??????	Have a friend/family member check your incision daily for
signs of infection.
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	You may wash your hair only after sutures have been removed.
??????	You may shower before this time using a shower cap to cover
your head.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????	You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week.  This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit.
??????	Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.
??????	Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
??????	Fever greater than or equal to 101?????? F.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please return to the office in [**8-5**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
 Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.



Completed by:[**2107-6-24**]
{'Subarachnoid hemorrhage,Subendocardial infarction, initial episode of care,Cerebral artery occlusion, unspecified with cerebral infarction,Acute respiratory failure,Unspecified protein-calorie malnutrition,Obstructive hydrocephalus,Unspecified essential hypertension,Aortocoronary bypass status'}


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: WHOL and neck pain at home / ems was called / pt intubated on
arrival

PRESENT ILLNESS: Asked to see this 81 year old white female who was transfered
from OSH for SAH.  By EMS reports, pt reported CP and SOB and
family called 911. On their arrival pt required CPR.  Family
reports pt in her usual state of health yesterday and this am
until she c/o of pain in her head and neck this am and they
called EMS.  They deny c/o CP or SOB.  No trauma in history. Pt
was intubated by report at OSH.

MEDICAL HISTORY: CABG x 2 / [**2103**], HTN, hysterectomy (remote), Cholecystectomy
(remote), no recent hospitalizatin or illness per family

MEDICATION ON ADMISSION: diovan, vytorin 10/40, metoprolol 12.5 [**Hospital1 **], asa 325 daily, MVI,
glucosoamine, calcium.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: on arrival

FAMILY HISTORY: Family Hx:has a twin sister/present

SOCIAL HISTORY: Social Hx: unknown at present 

### Response:
{'Subarachnoid hemorrhage,Subendocardial infarction, initial episode of care,Cerebral artery occlusion, unspecified with cerebral infarction,Acute respiratory failure,Unspecified protein-calorie malnutrition,Obstructive hydrocephalus,Unspecified essential hypertension,Aortocoronary bypass status'}
