CHIEF COMPLAINT: Gait imbalance, vertigo

PRESENT ILLNESS: The patient is a 53-year-old right handed previously healthy
male transferred from OSH with acute right cerebellar infarct on
brain MRI.  He had been in his usual state of good health until
11:30 pm on [**2135-11-13**] when he had an episode of dizziness,
sweating, and nausea and vomiting.  He described the dizziness
as
both lightheadedness and not being able to tell up from down; he
never has experienced anything like this before.  He also had a
feeling of being too weak to walk.   He felt very tired.  His
symptoms of dizziness and sweating resolved after being brought
to the OSH via EMS.  However, he did continue to have nausea and
vomiting and was unable to keep down soup.  He has no appetite.
During the  day, he developed a posterior headache which he
rates
a 7 out of 10.  The work-up at OSH included MRI/MRA showing
right
PICA territory infarct with question of  possible R vertebral
artery dissection which could not be ruled out.  He was
transferred to [**Hospital1 18**] ICU for further management.

MEDICAL HISTORY: - History of vertigo 5 years ago
-s/p right knee surgery for torn meniscus

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.2 P: 96 R: 16  BP:169/90
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

FAMILY HISTORY: His father had a heart attack in his mid 50's and died
of brain cancer in his 80's.  His mother had hypertension.  No
history of stroke.

SOCIAL HISTORY: lives with wife and 3 children. works as a software
engineer.  Denies smoking, alcohol, or drugs.
Cerebral artery occlusion, unspecified with cerebral infarction,Ostium secundum type atrial septal defect,Family history of ischemic heart disease
Crbl art ocl NOS w infrc,Secundum atrial sept def,Fam hx-ischem heart dis
Admission Date:  [**2135-11-14**]              Discharge Date:   [**2135-11-17**]

Date of Birth:  [**2082-5-4**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

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

Major Surgical or Invasive Procedure:
none

History of Present Illness:
The patient is a 53-year-old right handed previously healthy
male transferred from OSH with acute right cerebellar infarct on
brain MRI.  He had been in his usual state of good health until
11:30 pm on [**2135-11-13**] when he had an episode of dizziness,
sweating, and nausea and vomiting.  He described the dizziness
as
both lightheadedness and not being able to tell up from down; he
never has experienced anything like this before.  He also had a
feeling of being too weak to walk.   He felt very tired.  His
symptoms of dizziness and sweating resolved after being brought
to the OSH via EMS.  However, he did continue to have nausea and
vomiting and was unable to keep down soup.  He has no appetite.
During the  day, he developed a posterior headache which he
rates
a 7 out of 10.  The work-up at OSH included MRI/MRA showing
right
PICA territory infarct with question of  possible R vertebral
artery dissection which could not be ruled out.  He was
transferred to [**Hospital1 18**] ICU for further management.

 NIHStroke Scale score was 0:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0

On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech.  Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.

On general review of systems, the pt denies recent fever or
chills.  No night sweats or recent weight loss or gain. Denies
cough, shortness of breath.  Denies chest pain or tightness,
palpitations.  Denies diarrhea, constipation or abdominal pain.
No recent change in bowel or bladder habits.  No dysuria.
Denies
arthralgias or myalgias. Denies rash. No history of heavy
lifting. Has never seen a chiropractor.


Past Medical History:
- History of vertigo 5 years ago
-s/p right knee surgery for torn meniscus


Social History:
lives with wife and 3 children. works as a software
engineer.  Denies smoking, alcohol, or drugs.


Family History:
His father had a heart attack in his mid 50's and died
of brain cancer in his 80's.  His mother had hypertension.  No
history of stroke.


Physical Exam:
Vitals: T: 98.2 P: 96 R: 16  BP:169/90
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: Alert, oriented x 3.  Able to relate history
without difficulty.  Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty.  Language is fluent with intact repetition and
comprehension.  Normal prosody.  There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects.  Able
to read without difficulty.  Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**1-18**] at 5 minutes.  The pt. had
good
knowledge of current events.  There was no evidence of apraxia
or
neglect.

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.  VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus.  Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.

-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L  5    5   5   5   5  5  5  5   5    5  5     5     5   5
R  5    5   5   5   5  5  5  5   5    5  5     5     5   5

-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2  2    2    2   1
R  2  2    2    2   1
Plantar response was flexor bilaterally.

-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.

-Gait: not tested

On exam next morning: patient had very subtle dysmteria on FNF

Pertinent Results:
[**2135-11-15**] 11:52PM BLOOD WBC-8.8 RBC-4.43* Hgb-13.5* Hct-39.4*
MCV-89 MCH-30.6 MCHC-34.4 RDW-13.1 Plt Ct-210
[**2135-11-15**] 06:01PM BLOOD Fibrino-269
[**2135-11-15**] 11:52PM BLOOD Glucose-111* UreaN-13 Creat-0.9 Na-142
K-3.8 Cl-104 HCO3-27 AnGap-15
[**2135-11-15**] 01:47AM BLOOD ALT-19 AST-18 CK(CPK)-58 AlkPhos-65
TotBili-0.8
[**2135-11-15**] 11:52PM BLOOD Calcium-8.6 Phos-2.7 Mg-2.0
[**2135-11-15**] 01:47AM BLOOD %HbA1c-5.6
[**2135-11-17**] 03:45AM BLOOD WBC-7.9 RBC-4.81 Hgb-14.7 Hct-42.7 MCV-89
MCH-30.5 MCHC-34.4 RDW-13.0 Plt Ct-238
[**2135-11-15**] 11:52PM BLOOD WBC-8.8 RBC-4.43* Hgb-13.5* Hct-39.4*
MCV-89 MCH-30.6 MCHC-34.4 RDW-13.1 Plt Ct-210
[**2135-11-15**] 06:01PM BLOOD WBC-9.0 RBC-4.63 Hgb-13.9* Hct-40.8
MCV-88 MCH-30.0 MCHC-34.1 RDW-13.1 Plt Ct-250
[**2135-11-17**] 09:25AM BLOOD PTT-61.1*
[**2135-11-17**] 03:45AM BLOOD Plt Ct-238
[**2135-11-17**] 03:45AM BLOOD PT-14.0* PTT-68.8* INR(PT)-1.2*
[**2135-11-16**] 08:55PM BLOOD PT-13.9* PTT-59.9* INR(PT)-1.2*
[**2135-11-16**] 12:00PM BLOOD PT-13.7* PTT-74.4* INR(PT)-1.2*
[**2135-11-16**] 05:55AM BLOOD PT-13.2 PTT-65.8* INR(PT)-1.1
[**2135-11-15**] 11:52PM BLOOD Plt Ct-210
[**2135-11-15**] 06:01PM BLOOD Fibrino-269
[**2135-11-15**] 06:01PM BLOOD AT III-88 ProtCFn-118 ProtSFn-100
[**2135-11-15**] 06:01PM BLOOD Lupus-NEG
[**2135-11-15**] 01:47AM BLOOD %HbA1c-5.6
[**2135-11-15**] 01:47AM BLOOD Triglyc-85 HDL-45 CHOL/HD-4.3
LDLcalc-130*
[**2135-11-15**] 01:47AM BLOOD TSH-0.64

Imaging:

MRI/A head/neck: [**2135-11-15**]
IMPRESSION:

1. Subacute medial right cerebellar hemisphere infarct in the
distribution of the posterior inferior cerebellar artery.

2. Probable thrombus within the V3 and V4 segments of the right
vertebral
artery; however, dissection cannot be definitively excluded.
Recommend CTA of the neck for further evaluation.

3. Sinus disease as decribed above, the activity of which is to
be determined
clinically.

Echo [**2135-11-15**]:
The left atrium and right atrium are normal in cavity size. The
interatrial septum is aneurysmal. A left-to-right shunt across
the superior portion of the interatrial septum is seen at rest
c/w a secundum type atrial septal defect. Multiple fenestrations
are suggested (clip [**Clip Number (Radiology) **]) There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Transmitral and tissue Doppler imaging
suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion.

IMPRESSION: Atrial septal defect with prominent left-to-right
flow and dilated right ventricle suggesting a signicant
intracardiac shunt. Mild mitral regurgitation. Mild symmetric
left ventricular hypertrophy with preserved global and regional
biventricular systolic function. Dilated ascending aorta.
If clinically indicated, a TEE would be best able to better
define the interatrial septum. A cardiac MRI would be best able
to quantify the intracardiac shunt.

Lower extremity dopplers ([**2135-11-15**]):
IMPRESSION: No evidence of bilateral lower extremity DVT.

CTA head/neck [**11-16**]

IMPRESSION:

1. Hyperdense distal right vertebral artery on pre-contrast
images which does
not opacify, likely secondary to thrombus as seen on prior MRA.
Lack of
appropriate opacification secondary to previously described
technical failure
limits the ability of the current examination to determine
whether a right
vertebral artery dissection is present. Repeat examination with
contrast
injection into the right upper extremity may be helpful for
further
evaluation.

2. Right cerebellar infarct as seen on prior MRI.

Findings discussed with Dr. [**Last Name (STitle) **] at 04:45 p.m. on [**2135-11-16**].

The study and the report were reviewed by the staff radiologist.




Brief Hospital Course:
The patient is a 53-year-old right handed previously healthy
male transferred from OSH with acute right cerebellar infarct in
territory of right PICA.  He presented to OSH after having an
episode of dizziness, sweating, and nausea and vomiting.  He
also had a feeling of being too weak to walk.   His neurologic
exam is normal with the exception of very subtle dysmetria on
the R side.  While at the OSH, after the administration of a
nitro patch the patient developed an occiptal headache that was
constant, with some relief with NSAIDs and tylenol.

He was transferred to the [**Hospital1 18**] ICU, for concern about
verterbral artery dissection and concern for possible edema in
the posterior fossa.  A MRI/MRA was obtain that confirmed the
location of a cerebellar infarct.  The MRA showed an occluded
right vertebral artery.  It could not be determined from the fat
suppression images if there was just an occlusion of the
vertebral artery or a dissection.  An echo was also obtained
which showed a moderate ASD with left to right shunting, with
some dilation of the right ventricle.  Given this finding and
the concern for a possible dissection, the decision was made to
start the patient on a heparin drip with a bridge to coumadin.
The patient did not have evidence on lower extremity doppler of
any DVT.  A hyper coagulable workup was initiated.  He had
negative dopplers of his lower extremities.  A follow up CTA was
performed but the contrast was injected on the left side, and
there was not significant enough flow to get a good image of the
right vertebral artery.

Cardiology was consulted and determined that the ASD would meet
criteria for repair.  However they wanted to delay this repair
until the patient has had his full course of coumadin.

The patient was transferred out of the unit to the floor on
[**2135-11-16**]. He was closely monitored on floor. He was started on
lovenox injections for anticoagulation and put on coumadin, with
goal INR of [**12-21**]. He was advised to stop lovenox once the INR
becomes therapeutic and follow with primary care doctor for dose
adustemnt of couamdin. LDL was high 130 and he was started on
simvastatin for that. He was advised to follow with cardiology
for further management of ASD.

He was seen by physical therapy who suggested outpatient PT for
gait and functional stability for few days. His exam at
discharge was significant for very mild cerebellar signs on
right side.


Medications on Admission:
none

Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90)  Subcutaneous
[**Hospital1 **] (2 times a day) for 7 days: stop taking Lovenox, once your
INR becomes therapeutic [**12-21**]. .
Disp:*14 14* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Q4PM ().
Disp:*30 Tablet(s)* Refills:*2*
5. Outpatient [**Name (NI) **] Work
PT/INR on [**11-19**] and on [**11-21**] and fax results to Dr.[**Last Name (STitle) 84371**], MD
at [**Telephone/Fax (1) 84372**]
6. Outpatient Physical Therapy


Discharge Disposition:
Home

Discharge Diagnosis:
-Right cerebellar stroke, possible dissection of the right
verterbral artery
- Atrial septal defect with septal aneurysm


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


Discharge Instructions:
You were admitted to an outside hospital with an episode of
vertigo, nausea, vomiting and ataxia.  At the outside hospital
you were found to have a stroke on the right side of your
cerebellum.  You also developed a mild headache.  You were
transferred to the [**Hospital1 18**] intensive care unit for further workup.
 Here you had imiaging that confirmed you stroke.  Imaging of
your blood vessels showed that there was a blockage of your
right vertebral artery (on of the arteries that supplies your
brain).  We could not determine if it was just blocked or there
was a tear in the vessel

By the time you arrived in our ICU, your symptoms had largely
resolved.  You were left with a very subtle problem with
coordination on your right side. You were transfered to floor
and started on Lovenox injections and coumadin , a blood
thinner. You will be stopping lovenox injections once your INR
becomes [**12-21**].

Followup Instructions:
Please follow up with
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2135-12-21**] 1:30

PMD f/u- Dr.[**Name (NI) 84373**] office will call you for appintment as
discussed on phone with her ( Covering MD [**First Name (Titles) **] [**Last Name (Titles) 3390**])


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
{'Cerebral artery occlusion, unspecified with cerebral infarction,Ostium secundum type atrial septal defect,Family history of ischemic heart disease'}


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, vertigo

PRESENT ILLNESS: The patient is a 53-year-old right handed previously healthy
male transferred from OSH with acute right cerebellar infarct on
brain MRI.  He had been in his usual state of good health until
11:30 pm on [**2135-11-13**] when he had an episode of dizziness,
sweating, and nausea and vomiting.  He described the dizziness
as
both lightheadedness and not being able to tell up from down; he
never has experienced anything like this before.  He also had a
feeling of being too weak to walk.   He felt very tired.  His
symptoms of dizziness and sweating resolved after being brought
to the OSH via EMS.  However, he did continue to have nausea and
vomiting and was unable to keep down soup.  He has no appetite.
During the  day, he developed a posterior headache which he
rates
a 7 out of 10.  The work-up at OSH included MRI/MRA showing
right
PICA territory infarct with question of  possible R vertebral
artery dissection which could not be ruled out.  He was
transferred to [**Hospital1 18**] ICU for further management.

MEDICAL HISTORY: - History of vertigo 5 years ago
-s/p right knee surgery for torn meniscus

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.2 P: 96 R: 16  BP:169/90
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

FAMILY HISTORY: His father had a heart attack in his mid 50's and died
of brain cancer in his 80's.  His mother had hypertension.  No
history of stroke.

SOCIAL HISTORY: lives with wife and 3 children. works as a software
engineer.  Denies smoking, alcohol, or drugs. 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Ostium secundum type atrial septal defect,Family history of ischemic heart disease'}
