CHIEF COMPLAINT: diplopia, HA

PRESENT ILLNESS: [**Known firstname **] [**Known lastname 805**] is a 54y F smoker with a h/o HTN who p/w p/w HA and
back-of-neck pain for the past [**2-3**] d as well as diplopia. Her HA
started suddenly Wednesday night with 1x episode of vomiting at
that time. HA has been relatively constant since then (2d), and
was worst one night PTA, on [**7-29**]. HA is bifrontal and
orbital, not occipital, not unilateral. Not throbbing. No
response to tylenol here or at home. +difficulty sleeping due to
the pain. She came to our ED on the advice of her sister with
whom she spoke on the phone. Sister says she not only had a
HA,but "sounds sick." HCT revealed blood in sylvian fissure and
over R-convexity, also hydrocephalus with enlarged temp horns
and compression of R-midbrain (obliterated R-sided quadrigeminal
cistern). Despite a normal MS exam, the patient is difficult and
a poor historian, and her sister has not been  round for a
couple weeks until today, and so cannot provide collateral
history. The patient does deny any recent head trauma or illness
or changes in her vision (other than the diplopia). No weakness,
numbness,paresthesias, auditory changes or changes in speech, no
slurred speech, no clumsiness or difficulty with gait. No h/o MI
or CVA. No known personal or FH of aneurysm. Pt would not relate
to me clearly whether or not she takes any medications at home
or whether she has any chronic medical condiitons. Exam
unrevealing other than her c/o diplopia, which resolves with
covering either eye. EOMI on exam with no dysconjugate eye
movements. VFF, PERRL 2.5-->2. Patient initially AAOx3 with
intact naming/repetition/attention, following commands, no
weakness, sensation intact.

MEDICAL HISTORY: unknown

MEDICATION ON ADMISSION: unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS:
Temp:97.4
HR: mostly in 60s, but frequent excursions to the 40s and 50s
BP: initially 147/89, but 180s-190s systolic during my exam
(before we started nicardipine gtt)
Resp:18
SaO2:100% RA

FAMILY HISTORY: nc

SOCIAL HISTORY: unknown
Subarachnoid hemorrhage,Bacteremia,Obstructive hydrocephalus,Other complications due to other vascular device, implant, and graft,Acute venous embolism and thrombosis of deep veins of upper extremity,Hyposmolality and/or hyponatremia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Unspecified essential hypertension,Other specified cardiac dysrhythmias,Other and unspecified hyperlipidemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Subarachnoid hemorrhage,Bacteremia,Obstructiv hydrocephalus,Comp-oth vasc dev/graft,Ac DVT/embl up ext,Hyposmolality,Mth sus Stph aur els/NOS,Hypertension NOS,Cardiac dysrhythmias NEC,Hyperlipidemia NEC/NOS,Abn react-procedure NEC
Name:  [**Known lastname 183**],[**Known firstname **]                    Unit No:   [**Numeric Identifier 13808**]

Admission Date:  [**2134-7-30**]              Discharge Date:   [**2134-8-20**]

Date of Birth:  [**2079-10-1**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1698**]
Addendum:
Please Note that as part of the infectious work up pt. had a
cardiac Echo which did not reveal any valvular vegitations.

Pertinent Results:
The left atrium is normal in size. Color-flow imaging of the
interatrial septum raises the suspicion of an atrial septal
defect, but this could not be confirmed on the basis of this
study. The estimated right atrial pressure is 0-5 mmHg. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.

IMPRESSION: Moderate symmetric left ventricular hypertrophy with
hyperdynamic function. No vegetation identified.

Discharge Disposition:
Home With Service

Facility:
[**Location (un) 42**] VNA

                             [**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**]

Completed by:[**2134-8-20**]

Admission Date:  [**2134-7-30**]              Discharge Date:   [**2134-8-20**]

Date of Birth:  [**2079-10-1**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
diplopia, HA

Major Surgical or Invasive Procedure:
Angiogram with coiling


History of Present Illness:
[**Known firstname **] [**Known lastname 805**] is a 54y F smoker with a h/o HTN who p/w p/w HA and
back-of-neck pain for the past [**2-3**] d as well as diplopia. Her HA
started suddenly Wednesday night with 1x episode of vomiting at
that time. HA has been relatively constant since then (2d), and
was worst one night PTA, on [**7-29**]. HA is bifrontal and
orbital, not occipital, not unilateral. Not throbbing. No
response to tylenol here or at home. +difficulty sleeping due to
the pain. She came to our ED on the advice of her sister with
whom she spoke on the phone. Sister says she not only had a
HA,but "sounds sick." HCT revealed blood in sylvian fissure and
over R-convexity, also hydrocephalus with enlarged temp horns
and compression of R-midbrain (obliterated R-sided quadrigeminal
cistern). Despite a normal MS exam, the patient is difficult and
a poor historian, and her sister has not been  round for a
couple weeks until today, and so cannot provide collateral
history. The patient does deny any recent head trauma or illness
or changes in her vision (other than the diplopia). No weakness,
numbness,paresthesias, auditory changes or changes in speech, no
slurred speech, no clumsiness or difficulty with gait. No h/o MI
or CVA. No known personal or FH of aneurysm. Pt would not relate
to me clearly whether or not she takes any medications at home
or whether she has any chronic medical condiitons. Exam
unrevealing other than her c/o diplopia, which resolves with
covering either eye. EOMI on exam with no dysconjugate eye
movements. VFF, PERRL 2.5-->2. Patient initially AAOx3 with
intact naming/repetition/attention, following commands, no
weakness, sensation intact.

Past Medical History:
unknown

Social History:
unknown

Family History:
nc

Physical Exam:
VS:
Temp:97.4
HR: mostly in 60s, but frequent excursions to the 40s and 50s
BP: initially 147/89, but 180s-190s systolic during my exam
(before we started nicardipine gtt)
Resp:18
SaO2:100% RA

Gen: Uncomfortable, shifting in bed. WN/WD woman, appears her
stated age.
HEENT: Pupils: 2.5--2 and equal. EOMs conjugate and full.
Neck: Supple. Mild exacerbation of her neck/head pain with
turning head to either side, but no paresthesias. No bruits.
Lungs: CTA bilaterally. Non-labored.
Cardiac: RRR. Normal S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.

Neuro:
Mental status: AAOx3, frustrated affect/mood. Poor cooperation
with exam despite normal attention on MS exam (DOW backwards
with
minimal pauses).
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming and [**Location (un) 1131**] intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5 to
2 mm bilaterally. VFF. +diplopia, which per pt is only present
with both eyes open.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus. +diplopia, which per pt is only present with both
eyes
open.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact and equal to finger rub bilaterally,
althout
the patient thinks it is louder on the right. [**Doctor Last Name 11586**] does not
lateralize.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Trapezius full strenght and equal.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-5**] throughout. No pronator drift

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Reflexes: B T Br Pa Ac
Right     2 2 2  2  2
Left      2 2 2  2  2
Toes downgoing bilaterally

Coordination: FNF and HKS normal with no dysmetria or tremor.
Gait not tested [**2-2**] pain, ?HDS instability with bradycardia and
hypertension during exam, bedrest with HOB elevated.

EXAM ON DISCHARGE:
Neurologically intact

Pertinent Results:
Labs:
CBC 7.9 / 13.7 / 458
BMP 139/3.7 / 98/29  18/0.6
INR 1.1  /  PTT 27.3
UA normal; UCx pending

CXR normal

NCHCT: prelim read -- Right Subarachnoid hemorrhage with
intraventricular extension. (also, to this writer, the vents
appear large, and the right quadrigeminal cistern is
obliterated)

CT-angio: prelim read -- SAH, Interventricular hemorrhage. AComm
aneurysm measuring 6mm, left M1 aneurysm measuring 2-3mm. Right
A2 aneurysm

Angio [**7-30**]:

RIGHT INTERNAL CAROTID ARTERY: Selective injection of the right
internal
carotid artery demonstrated a 6.8 x 2.3 mm anterior
communicating aneurysm, a 3.8 x 2.5 mm pericallosal artery
aneurysm and a 3 mm broadbased ophthalmic
artery aneurysm. Judging by the location of the subarachnoid
hemorrhage and the appearances of the aneurysms
angiographically, the most likely source of the subarachnoid
hemorrhage was the anterior communicating artery aneurysm. There
was also a small infundibulum of the right posterior
communicating
artery. After coil embolization, no residual filling in the
aneurysm necks
were seen. There were no filling defects, vasospasm, stenosis or
vessel wall irregularity suggestive of iatrogenic injury. The
capillary and venous phases
were unremarkable.

LEFT INTERNAL CAROTID ARTERY: There was minimal irregularity of
the proximal
left internal carotid artery. Otherwise, there was brisk filling
of ACA and
MCA branches. There was no aneurysm, AVM or fistula on the left.
3D images
were helpful in ruling out pathology within the left internal
carotid artery and its branches. The capillary and venous phases
were unremarkable.
LEFT VERTEBRAL ARTERY: Selective injection of the left vertebral
artery
demonstrated brisk filling of its branches. No aneurysm, AVM or
fistula was noted. The capillary and venous phases were
unremarkable.

IMPRESSION: Successful coil embolization of anterior
communicating artery and right pericallosal artery aneurysms.
Upper extremity Doppler
IMPRESSION: Deep vein thrombosis seen in the two right brachial
veins
extending upward becoming non-occlusive thrombus and the right
axillary vein and a small amount is seen in the right subclavian
vein. Occlusive thrombus is also seen within the right cephalic
vein.



Brief Hospital Course:
patient presented to the [**Hospital1 18**] ER with headache and back of neck
pain which began on [**7-28**] and became increasingly worse,
Initially she had a single episode of vomiting and her headache
was the worst on [**7-29**]. Her Head CT upon arrival at [**Hospital1 18**] on [**7-30**]
showed blood in the sylvian fissure and overlying the right
convexity.  Also noted was hydrocephalus with enlarged temp
horns and compression of the right midbrain. She was admitted to
the ICU with q1hour neuro checks. She had a cerebral angiogram
which showed 3 aneurysms. one in the acomm, Right A2, and Left
M1.  She had coiling of her acomm and pericolosol aneurysms. She
was placed on a heparin gtt. On [**7-31**] she had EEG leads placed
and her heparin gtt was discontinued. On [**8-1**] she was noted to
have a left pronator drift which was new and her arterial line
was displaced. There were multiple attempts to replace it with
no success.  On [**8-2**] she was foudn to ahve a change in mental
status and a CTA/P was done to rule out vasospasm. The imaging
showed possible mild vasospasm at the A1 segment which was most
likely artifact.  On [**8-3**] she had a PICC line placed and her
prednisione was discontinued by the ICU team against the
recommednations of the neurosurgery team.  She continued to be
lethargic on exam on [**8-4**] however ther was nochange in her
clinical exam.

On [**8-5**] during morning rounds she was noted to have a serum
sodium of 126. As a result 3% saline was started.  On exam she
continued with a left drift and weakness in her Left [**Last Name (un) 938**] and AT
of 5-/5.  Her up gaze was limited on the left and she was unable
to bury the sclera on the left as well. her sodium went to 122
and subsequently 119 overnight and her 3% sodium was titrated
and salt tabs were added. A axillary arterial line was placed by
the surgical ICU team for continuous blood pressure monitoring.
Resultant blood pressure monitoring after placement showed that
her pressures were consistently between the goal of 170-220. Her
sodium was again 122 on the morning of [**8-6**] and her exam was
improved as she had no pronator drift and her left lateral gaze
was improved as she was now burying the sclera on the left. her
upgaze was still mildly limited and appeared stable from the
exam on [**8-5**]. She was more alert and interactive and less
agitated. She continued to receive q6hour serum sodium and osm
checks. On the afternoon of [**8-6**] she underwent a cerebral
angiogram with Dr. [**Last Name (STitle) **] which showed moderate spasm in the
Right A1 and A2 as well as the Left A2, mild spasm in the Right
M2 and left A1, and that there was still filling of the right
pericolosal aneurysm.  She had 5mg of Verapamil instilled into
each carotid artery during the procedure. Later in teh afternoon
of [**8-6**] she was ntoed to have a sodium of 142 and the 3% saline
was down titrated.

On [**8-7**] She refused her morning exam and EEG was read as having
no epileptiform activity or asymmetric midline slowing.  HEr
sodium also remained stable at 140 and as a result her 3% saline
was dicontinued while the salt tabs remained.  on [**8-8**] she
remained stable in the ICU and on [**8-9**] she complained of RUE pain
where her PICC line was placed.  The line was discontinued and
as a result upper extremity dopplers were done to rule out DVT.
On the dopplers she was found to have a diffuse RUE DVT in two
right brachial veins and right axillary vein as well as a small
amount in the right subclavian. A heparin drip was not initiated
for treatment of the DVT's.

On [**8-10**] she underwent cerebral angiogram to evaluate for spasm
and coil placement. The angio showed that there was spasm in the
Right MCA and verapamil was instilled. Her blood pressure
parameters were changed so that her goal blood pressure was
greater then 150 systolic. She was also febrile to 103.4 and
cultures were done which showed gram positive cocci in her blood
and vancomycin was started for empiric coverage. On [**8-12**] her
antibiotic coverage was changed to nafcillin after the
sensitivites returned and her exam remained stable.  On [**8-13**] she
continued to be stable and her blood pressure goal was
liberalized again to greater than 140 systolic and a PICC line
was placed in her LUE.

She was able to be transferred out of the ICU with a stable exam
to the Neuro step down unit. After being observed there with no
clinical change she was moved to the floor.

The remainder of her stay was uneventful. Given her positive
blood cultures and the formation of a right upper extremity DVT
and Infectious disease consult was obtained. Serial blood
cultures were preformed and a treatment plan was decided upon.
Ms. [**Known firstname **] will be recieving IV Nafcillin thru a new picc line that
was placed on [**8-20**] ( after a day long line holiday) for a total
of 4 weeks. Antibiotics are to end on [**2134-9-15**]. During this time
she will be followed in [**Hospital **] clinic. She will have a repeat right
upper extremity Doppler in 3 weeks, and will follow up with Dr.
[**First Name (STitle) **] in one month with a CTA.

A repeat ultrasound of the right upper extremity showed no
evolution or extension of the right upper extremity Clot as read
by Radiology.


Medications on Admission:
unknown


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours): 2gm Q 4hrs X 4 weeks. End date
[**2134-9-15**].
Disp:*qs * Refills:*10*
6. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for Headaches.
Disp:*60 Tablet(s)* Refills:*0*
7. 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.


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
SAH ruptured aneurysm


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Angiogram with Embolization
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.

??????	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

Followup Instructions:
Follow up with Dr [**First Name (STitle) **] in one month with a CTA. This
appointment can be made by calling [**Telephone/Fax (1) 1669**]. We will arrange
for your CTA at that time.
You also will need to have a right upper extremity Ultrasound to
evaluate the clot in your arm 3 weeks from the date of
discharge. This can be arranged thru our office as well.
you will need to have weekly labs drawn while you are on
Antibiotics.Laboratory monitoring required:
Weekly CBC with differential,BUN, Cr, AST, ALT, Alk phos, Tbili.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions regarding outpatient
antibiotics should be directed to the infectious disease R.Ns.
at


                             [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]

Completed by:[**2134-8-20**]
{'Subarachnoid hemorrhage,Bacteremia,Obstructive hydrocephalus,Other complications due to other vascular device, implant, and graft,Acute venous embolism and thrombosis of deep veins of upper extremity,Hyposmolality and/or hyponatremia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Unspecified essential hypertension,Other specified cardiac dysrhythmias,Other and unspecified hyperlipidemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: diplopia, HA

PRESENT ILLNESS: [**Known firstname **] [**Known lastname 805**] is a 54y F smoker with a h/o HTN who p/w p/w HA and
back-of-neck pain for the past [**2-3**] d as well as diplopia. Her HA
started suddenly Wednesday night with 1x episode of vomiting at
that time. HA has been relatively constant since then (2d), and
was worst one night PTA, on [**7-29**]. HA is bifrontal and
orbital, not occipital, not unilateral. Not throbbing. No
response to tylenol here or at home. +difficulty sleeping due to
the pain. She came to our ED on the advice of her sister with
whom she spoke on the phone. Sister says she not only had a
HA,but "sounds sick." HCT revealed blood in sylvian fissure and
over R-convexity, also hydrocephalus with enlarged temp horns
and compression of R-midbrain (obliterated R-sided quadrigeminal
cistern). Despite a normal MS exam, the patient is difficult and
a poor historian, and her sister has not been  round for a
couple weeks until today, and so cannot provide collateral
history. The patient does deny any recent head trauma or illness
or changes in her vision (other than the diplopia). No weakness,
numbness,paresthesias, auditory changes or changes in speech, no
slurred speech, no clumsiness or difficulty with gait. No h/o MI
or CVA. No known personal or FH of aneurysm. Pt would not relate
to me clearly whether or not she takes any medications at home
or whether she has any chronic medical condiitons. Exam
unrevealing other than her c/o diplopia, which resolves with
covering either eye. EOMI on exam with no dysconjugate eye
movements. VFF, PERRL 2.5-->2. Patient initially AAOx3 with
intact naming/repetition/attention, following commands, no
weakness, sensation intact.

MEDICAL HISTORY: unknown

MEDICATION ON ADMISSION: unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS:
Temp:97.4
HR: mostly in 60s, but frequent excursions to the 40s and 50s
BP: initially 147/89, but 180s-190s systolic during my exam
(before we started nicardipine gtt)
Resp:18
SaO2:100% RA

FAMILY HISTORY: nc

SOCIAL HISTORY: unknown 

### Response:
{'Subarachnoid hemorrhage,Bacteremia,Obstructive hydrocephalus,Other complications due to other vascular device, implant, and graft,Acute venous embolism and thrombosis of deep veins of upper extremity,Hyposmolality and/or hyponatremia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Unspecified essential hypertension,Other specified cardiac dysrhythmias,Other and unspecified hyperlipidemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
