CHIEF COMPLAINT: Gait imbalance

PRESENT ILLNESS: Ms. [**Name14 (STitle) 83615**] is a 75 yo RH woman with a PMH remarkable for HTN
and migraines who is transferred from another hospital
with a RIGHT cerebellar bleed.

MEDICAL HISTORY: HTN, migraines.
CNS bleeds ( ), brain aneurisms ( ), avm ( )
Strokes (-)
Procoagulant conditions (-)
CAD (-) , AF (-)
DM (-), HLD (-), OSA (-)
Seizures (-), migraine (-), CNS tumors (-)

MEDICATION ON ADMISSION: ASA (Fioricet)

ALLERGIES: Codeine

PHYSICAL EXAM: Per Admitting Resident-

FAMILY HISTORY: CNS bleeds ( ), brain aneurisms ( ), avm ( )
Hx of early strokes (-)
Seizures (-)
CNS tumors (-)
Demyelinating conditions (-)
Autoimmune conditions (-)
Procoagulant conditions (-)
CAD (-)

SOCIAL HISTORY: Does not really exercise, Tobacco (-), ETOH (-), Drugs (-)
Intracerebral hemorrhage,Unspecified essential hypertension,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Swelling of limb,Other nonspecific findings on examination of urine
Intracerebral hemorrhage,Hypertension NOS,Migrne unsp wo ntrc mgrn,Swelling of limb,Abn urine findings NEC
Admission Date:  [**2166-11-27**]              Discharge Date:   [**2166-12-2**]

Date of Birth:  [**2091-5-6**]             Sex:   F

Service: NEUROLOGY

Allergies:
Codeine

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Gait imbalance

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Ms. [**Name14 (STitle) 83615**] is a 75 yo RH woman with a PMH remarkable for HTN
and migraines who is transferred from another hospital
with a RIGHT cerebellar bleed.

This information is collected through the patient and the prior
conversation the ED team had with her sister. [**Name (NI) **] sister is the
only next of [**Doctor First Name **].

She was in her USOH at 3:00 am as per her sister. She then woke
up early in the am (unknown time) and felt fine till she got up
to go to the restroom. She then felt unsteady and her vision was
impaired ("things were out of place, upside-down"). She
initially
told me that things were spinning around, and then she told Dr.
[**First Name (STitle) **] that was not the case. There was no double vision, no
trouble speaking (not slurred or unable to produce proper
speech)
or understanding her sister as per the patient. She had no
weakness or numbness. She did not vomit. She reports she sat
down
in the floor at the restroom. Her sister apparently reported
that
she had fallen. There was no LOC, though. No seizure-like
activity. No Cp or SOB.

She was transferred to [**Hospital 19672**] Med Center were she was running
SBNPs
210-180 and received labetalol 10 mg iv when her CT CNS showed a
Right cerebellar stroke. At the time exam was normal as per ED
report.

No events while transferred by EMS. Once at [**Hospital1 18**], her SBPs were
still 200s and she received 10 mg labetalol and then
subsequently
was started on a labetalol drip. She received platelets also as
far as she was on daily ASA.

Seen by neurosuregery (Dr. [**First Name (STitle) **] who felt the pt was not
surgical now.

Rest of ROS is negative otherwise.

Baseline: IADLS. Lives on her own.


Past Medical History:
HTN, migraines.
CNS bleeds ( ), brain aneurisms ( ), avm ( )
Strokes (-)
Procoagulant conditions (-)
CAD (-) , AF (-)
DM (-), HLD (-), OSA (-)
Seizures (-), migraine (-), CNS tumors (-)



Social History:
Does not really exercise, Tobacco (-), ETOH (-), Drugs (-)



Family History:
CNS bleeds ( ), brain aneurisms ( ), avm ( )
Hx of early strokes (-)
Seizures (-)
CNS tumors (-)
Demyelinating conditions (-)
Autoimmune conditions (-)
Procoagulant conditions (-)
CAD (-)


Physical Exam:
Per Admitting Resident-

BP 150-140/ 80.   HR 80 bpm.   Off ventilator: RR 12. SO2 100%
RA.

GSC: 15/ 15

Gen: Lying in bed, responsive to verbal commands.
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit. LEFT sided-lipoma.
Back: No point tenderness or erythema
CV: Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: Soft, nontender, non-distended.  No masses or megalies.
Percussion within normal limits. +BS.
Ext: no edema, no DVT data. Pulses ++ and symmetric.

Neurologic examination:
No meningismus. No photophobia.
GSC: 15/ 15

Neurologic examination:
Follows simple/complex commands. No meningismus. No photophobia.
.
MS:
General:  alert, awake, normal affect
Orientation:  oriented to person, place, date, situation
.
Attention: DOWBWS +.
Speech/Language: fluent w/o paraphasic errors; comprehension,
repetition, naming: normal. Prosody: normal. Mildly dysarthric.


.
Memory: Registers [**1-28**] and Recalls [**1-28**] when given choices at 5
min
Praxis/ agnosia: Able to brush teeth. No field cuts.
.
No extinction. No neglect. No prosopagnosia, no anosognosia, no
asomatognosia.

CN:
I: not tested
II,III:  VFF to confrontation, PERRL 2mm to 1.5mm,  fundus w/o
papilledema.
III,IV,VI: EOM: there is a RIGHT sided lateral gaze limitation
and a bl upgaze limitation (symm), no ptosis. No nystagmus
V:  sensation intact V1-V3 to LT
VII:  Mil dleft facial droop.
VIII:  hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]:  SCM/trapezeii [**4-1**] bilaterally
XII:  tongue protrudes midline.
.

.
Motor:
Normal bulk.
Tone: normal.
No tremor, no asterixis or myoclonus. No pronator drift:
Antigravity with 4 limbs for > 10 secs.
.
Deep tendon Reflexes:
.
       Bicip: Tric: Brachial: Patellar:  Achilles   Toes:
Right   2     2         2          2        1   DOWNGOING
Left    2     2         2          2        1   DOWNGOING
.
Sensation: Intact to light touch, and temperature.

.
Coordination:
*Finger-nose-finger normal.
*Rapid Arm Movements normal.
*Fine finger tapping: normal.
*Heal to shin: normal.
*When sitting up: truncal ataxia (leaning toward the right)



Pertinent Results:
[**2166-12-1**] 05:35AM BLOOD WBC-9.7 RBC-3.98* Hgb-11.5* Hct-34.7*
MCV-87 MCH-28.9 MCHC-33.1 RDW-14.9 Plt Ct-449*
[**2166-11-30**] 06:40AM BLOOD WBC-9.6 RBC-3.55* Hgb-10.5* Hct-31.7*
MCV-89 MCH-29.5 MCHC-33.1 RDW-15.0 Plt Ct-344
[**2166-11-28**] 04:13AM BLOOD WBC-11.6* RBC-3.60* Hgb-10.8* Hct-31.5*
MCV-87 MCH-30.0 MCHC-34.3 RDW-14.7 Plt Ct-347
[**2166-11-27**] 07:39PM BLOOD WBC-14.9* RBC-3.75* Hgb-11.2* Hct-33.0*
MCV-88 MCH-29.8 MCHC-33.9 RDW-14.6 Plt Ct-335
[**2166-11-27**] 10:32AM BLOOD WBC-14.6* RBC-4.12* Hgb-12.1 Hct-36.0
MCV-88 MCH-29.4 MCHC-33.6 RDW-14.6 Plt Ct-376
[**2166-11-27**] 10:32AM BLOOD Neuts-92.5* Lymphs-4.7* Monos-2.4 Eos-0.1
Baso-0.2
[**2166-12-1**] 05:35AM BLOOD Plt Ct-449*
[**2166-12-1**] 05:35AM BLOOD PT-12.9 PTT-25.9 INR(PT)-1.1
[**2166-11-30**] 06:40AM BLOOD PT-12.6 PTT-26.0 INR(PT)-1.1
[**2166-11-28**] 04:13AM BLOOD PT-12.3 PTT-24.4 INR(PT)-1.0
[**2166-11-27**] 07:39PM BLOOD PT-12.3 PTT-23.2 INR(PT)-1.0
[**2166-11-27**] 10:32AM BLOOD PT-11.9 PTT-23.1 INR(PT)-1.0
[**2166-12-1**] 05:35AM BLOOD Glucose-104* UreaN-10 Creat-0.7 Na-140
K-3.3 Cl-108 HCO3-20* AnGap-15
[**2166-11-30**] 06:40AM BLOOD Glucose-106* UreaN-12 Creat-0.6 Na-139
K-5.3* Cl-114* HCO3-19* AnGap-11
[**2166-11-29**] 03:33AM BLOOD Glucose-118* UreaN-19 Creat-0.8 Na-140
K-3.8 Cl-108 HCO3-24 AnGap-12
[**2166-11-28**] 04:13AM BLOOD Glucose-127* UreaN-15 Creat-0.7 Na-138
K-3.4 Cl-100 HCO3-27 AnGap-14
[**2166-11-27**] 07:39PM BLOOD Glucose-145* UreaN-14 Creat-0.8 Na-137
K-3.4 Cl-99 HCO3-27 AnGap-14
[**2166-11-27**] 10:32AM BLOOD Glucose-134* UreaN-10 Creat-0.7 Na-138
K-3.0* Cl-99 HCO3-26 AnGap-16
[**2166-12-1**] 05:35AM BLOOD ALT-49* AST-35 LD(LDH)-208 AlkPhos-100
TotBili-0.4
[**2166-11-27**] 10:32AM BLOOD ALT-21 AST-26 CK(CPK)-76 AlkPhos-108
TotBili-0.3
[**2166-11-27**] 10:32AM BLOOD cTropnT-<0.01
[**2166-12-1**] 05:35AM BLOOD Albumin-3.9 Calcium-9.7 Phos-3.6 Mg-1.8
[**2166-11-30**] 06:40AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.7
[**2166-11-28**] 04:13AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.4
[**2166-11-28**] 04:13AM BLOOD %HbA1c-5.9
[**2166-11-27**] 10:32AM BLOOD Triglyc-108 HDL-79 CHOL/HD-3.1
LDLcalc-141*
[**2166-11-30**] 11:47AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017
[**2166-11-27**] 10:32AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2166-11-30**] 11:47AM URINE Blood-SM Nitrite-POS Protein-25
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD

CT head [**11-27**]
1. Right intracerebellar hemorrhage with surrounding edema, but
without
inferior tonsillar displacement.

2. Right opacified sphenoidal sinus.

CT C spine [**11-27**]
Anterior displacement of the C4 and C6 vertebral bodies along
with lateral
displacement of the inferior articular surface of the C6
vertebra.
Discontinuity of the anterior arch of the atlas is of unknown
chronicity. MR
is recommended for further evaluation of these findings.

CTA head/ neck [**11-27**]
FINDINGS: Again seen is a right cerebellar hemispheric hematoma.
This exerts
mass effect upon the fourth ventricle, but there is no evidence
of
hydrocephalus. There is no evidence of further bleeding since
the previous
study of [**2166-11-27**]. The CTA demonstrates a normal appearance of
the cervical
common and internal carotid arteries. The vertebral arteries
appear patent
throughout their courses. No intracranial vascular abnormalities
are
detected.

Again seen is bilateral periventricular white matter hypodensity
along with
left caudate and right putaminal lacunes. These findings
indicate chronic
small vessel ischemia.

CONCLUSION: Right cerebellar hemisphere hematoma with fourth
ventricular mass
effect, but no hydrocephalus. These findings have not changed
since the
earlier CT of [**2166-11-27**]. No vascular abnormalities are detected.

CT head [**2166-11-28**]
1. Stable appearance of 2.5 cm right cerebellar hemorrhage
without new mass
effect or ventricular obstruction.
2. No new intracranial hemorrhage.

Xray Humerus AP and L, Right side, [**2166-11-28**]
No fracture or dislocation is present.

USG doppler R arm [**2166-11-29**]
1. No DVT in the right upper extremity.
2. Incidental note of a partially visualized left
supraclavicular lipoma.
Although no concerning features are noted on this study. A low
grade
liopsarcoma can not be excluded and evaluation with further
imaging such as
MRI or close clinical/imaging follow-up should be considered.

ECHO [**2166-12-1**]
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function. Trace aortic
regurgitation with mild aortic valve sclerosis. No definite
structural cardiac source of embolism identified


Brief Hospital Course:
Ms. [**Known lastname 83616**] was admitted to neurology stroke service for
evaluation. She was initially admitted to Neuro ICU for close
monitoring. She was ruled out for myocardial infarction by EKG
and cardiac enzymes.

Neuro
She was closely monitored in ICU and monitored on telemetry.
Aspirin was held given intracranial bleed. Signs of raised ICP
were closely monitored as there was concern for edema and raised
ICP. She did not exhibit signs of raised ICP. Her neurological
examination was monitored closely and she had significant
improvement in truncal ataxia, facial weakness on right side,
and limitation of abduction towards right side. Antiplatelet and
anticoagulants including SQ heparin was avoided owing to risk of
bleeding and pneumoboots were used for prevention of DVT. She
was transferred out of ICU after initial observation to neuro
floor. Blood pressure was controlled by addition of captopril
and metoprolol to achieve goal SBP less than 140. CT scan was
repeated on [**2166-11-28**] to look for signs of cerebellar edema and/ or
new bleed.

Cards
Blood pressure was well controlled with captopril and
metoprolol. EKG was s/o possible left atrial abnormality. TTE
was done which showed no evdience of thrombus and EF more than
55 percent. Simvastatin was started for abnormal lipid profile
LDL of 141.

ID
UA showed pyuria but she did not have fever or clinical signs of
UTI. Foley was discontinued and was started on 3 day course of
ciprofloxacin.

General care
she complained of right arm pain  and swelling, USG Doppler did
not show evidence of DVT and X ray did not show evidence of
fracture. She was started on sc heparin after 72 hours to
prevent any bleed.

Rehab
she was seen by OT/PT and speech/ swallowing therapist, diet was
advanced as per recs. She was transferred to acute rehab for
further care.

Pending issues at discharge
Her blood pressure needs to be monitored closely with adjustment
of antihypertensive meds to keep goal of SBP less than 140 mm
Hg.


Medications on Admission:
ASA (Fioricet)





Discharge Medications:
1. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 doses.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain .
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Right cerebellar bleed


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)


Discharge Instructions:
You were admitted for evaluation of vertigo and unsteadniess.You
had CT scan of your brain whcih showed cerebellar bleed on right
side. You were monitored in ICU and then on stroke floor and
were seen by OT/PT for assessment.
You rblood pressure was found to be high and you were started on
medicines for that for better control of blood pressure.
Please take your medicines as prescribed. Please call 911 or
your doctor if you have any concerning symptoms.

Followup Instructions:
1. Please get MRI brain after 4-6 weeks and follow up with

2. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2167-1-13**] 11:30


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
{'Intracerebral hemorrhage,Unspecified essential hypertension,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Swelling of limb,Other nonspecific findings on examination of urine'}


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: Gait imbalance

PRESENT ILLNESS: Ms. [**Name14 (STitle) 83615**] is a 75 yo RH woman with a PMH remarkable for HTN
and migraines who is transferred from another hospital
with a RIGHT cerebellar bleed.

MEDICAL HISTORY: HTN, migraines.
CNS bleeds ( ), brain aneurisms ( ), avm ( )
Strokes (-)
Procoagulant conditions (-)
CAD (-) , AF (-)
DM (-), HLD (-), OSA (-)
Seizures (-), migraine (-), CNS tumors (-)

MEDICATION ON ADMISSION: ASA (Fioricet)

ALLERGIES: Codeine

PHYSICAL EXAM: Per Admitting Resident-

FAMILY HISTORY: CNS bleeds ( ), brain aneurisms ( ), avm ( )
Hx of early strokes (-)
Seizures (-)
CNS tumors (-)
Demyelinating conditions (-)
Autoimmune conditions (-)
Procoagulant conditions (-)
CAD (-)

SOCIAL HISTORY: Does not really exercise, Tobacco (-), ETOH (-), Drugs (-) 

### Response:
{'Intracerebral hemorrhage,Unspecified essential hypertension,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Swelling of limb,Other nonspecific findings on examination of urine'}
