CHIEF COMPLAINT: Dizziness, unsteadiness

PRESENT ILLNESS: 80yo right handed woman without known prior medical history
(rarely seeks medical care), now presenting with sudden onset
dizziness, found to have posterior pontine hemorrhage on head
CT. She awoke feeling well. Descended the steps in her home and
had the sudden onset of dizziness, which she describes as
feeling "unsteady." No vertigo. She was able to guide herself to
the floor, but was unable to get up for several hours until her
husband found her. He was able to transfer her to a lounge chair
with wheels. They waited things out most of the day and got a
neighbor for help, who then called EMS ~6:30pm. Head CT at
[**Hospital **] Hospital reveals 1cm right posterior pontine/inferior
colliculus hemorrhage.

MEDICAL HISTORY: Left tongue keratosis- s/p excision x 2, most recent ~1month ago
told it was "benign."

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
T: 98.2, HR 68, BP 175/82, R 16, Sat 98%
Gen: well appearing, thin elderly woman, hyperpigmented patches,
prefers to have eyes closed, alert, very pleasant, NAD
HEENT- NCAT, MMM, OP clear
Neck- no carotid bruits bilaterally
CV- RRR, no MRG
Pulm- CTA B
Abd- soft, ND, NT, BS+
Extrem- no CCE
Skin- multiple hyperpigmented patches

FAMILY HISTORY: no known FH of stroke or CAD

SOCIAL HISTORY: lives with her husband on the [**Location (un) 1121**], never smoker, no
ETOH, no illicits. She is a retired telephone operator.
Intracerebral hemorrhage,Unspecified essential hypertension,Pure hypercholesterolemia
Intracerebral hemorrhage,Hypertension NOS,Pure hypercholesterolem
Admission Date:  [**2103-6-14**]              Discharge Date:   [**2103-6-18**]

Date of Birth:  [**2022-7-16**]             Sex:   F

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Dizziness, unsteadiness

Major Surgical or Invasive Procedure:
None

History of Present Illness:
80yo right handed woman without known prior medical history
(rarely seeks medical care), now presenting with sudden onset
dizziness, found to have posterior pontine hemorrhage on head
CT. She awoke feeling well. Descended the steps in her home and
had the sudden onset of dizziness, which she describes as
feeling "unsteady." No vertigo. She was able to guide herself to
the floor, but was unable to get up for several hours until her
husband found her. He was able to transfer her to a lounge chair
with wheels. They waited things out most of the day and got a
neighbor for help, who then called EMS ~6:30pm. Head CT at
[**Hospital **] Hospital reveals 1cm right posterior pontine/inferior
colliculus hemorrhage.

She has never been hospitalized until now.

Her only complaint at the moment is slurred speech. She denies
any headache. No diplopia. no loss of vision. She noted "jumping
of her vision" when trying to track objects. She does not have
any lightheadedness when not moving. no hearing difficulty. She
denies any weakness, numbness or paresthesias.

On general review of systems, the pt denied recent fever or
chills.  No night sweats or recent weight loss or gain. Denied
cough, shortness of breath.  Denied chest pain or tightness,
palpitations.  Denied nausea, vomiting, diarrhea, constipation
or abdominal pain.  No recent change in bowel or bladder habits.
 No dysuria.  Denied arthralgias or myalgias. Denied rash.

Past Medical History:
Left tongue keratosis- s/p excision x 2, most recent ~1month ago
told it was "benign."

Social History:
lives with her husband on the [**Location (un) 1121**], never smoker, no
ETOH, no illicits. She is a retired telephone operator.


Family History:
no known FH of stroke or CAD


Physical Exam:
PHYSICAL EXAM:
T: 98.2, HR 68, BP 175/82, R 16, Sat 98%
Gen: well appearing, thin elderly woman, hyperpigmented patches,
prefers to have eyes closed, alert, very pleasant, NAD
HEENT- NCAT, MMM, OP clear
Neck- no carotid bruits bilaterally
CV- RRR, no MRG
Pulm- CTA B
Abd- soft, ND, NT, BS+
Extrem- no CCE
Skin- multiple hyperpigmented patches

NEUROLOGIC EXAM:
MS- 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.  Pt had trouble [**Location (un) 1131**] due to ocular bobbing, but was
able to read.  Speech was dysarthric. Able to follow both
midline and appendicular commands. There was no apraxia or
neglect.

CN- her pupils are equal 3mm-2mm bilaterally, reactive to light,
VFF to confrontation, no papilledema, there is right upper and
lower facial droop, R > L ptosis. There is complete
ophthalmoplegia in all directions except for downgaze with L
downgaze impaired greater than right. She exhibits vertical
ocular bobbing when trying to read text. hearing intact to FR.
unable to fully visualize palate. tongue at midline.

Motor: increased tone throughout. No adventitious movements
noted. No asterixis noted. ? left pronator drift.

  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  4   5   5  5    5     5    5
R  5-   5    5  5    5  5  5  4   5   5  5    5     5    5

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

Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF although has trouble tracking with visual
pursuits.

Deep Tendon Reflexes:
  [**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L  3   3   3    3   1
R  3   3   3    3   1

Plantar response was upgoing bilaterally

Pertinent Results:
LABS:
[**2103-6-14**] 08:15PM BLOOD WBC-11.8* RBC-4.70 Hgb-13.3 Hct-39.4
MCV-84 MCH-28.2 MCHC-33.7 RDW-13.8 Plt Ct-285
[**2103-6-18**] 05:15AM BLOOD WBC-9.5 RBC-4.56 Hgb-13.2 Hct-38.4 MCV-84
MCH-28.9 MCHC-34.3 RDW-14.2 Plt Ct-311
[**2103-6-14**] 08:15PM BLOOD Neuts-88.3* Lymphs-8.5* Monos-2.5 Eos-0.6
Baso-0.1
[**2103-6-14**] 08:15PM BLOOD PT-12.4 PTT-25.4 INR(PT)-1.0
[**2103-6-14**] 08:15PM BLOOD Glucose-121* UreaN-16 Creat-0.7 Na-137
K-3.9 Cl-101 HCO3-24 AnGap-16
[**2103-6-18**] 05:15AM BLOOD Glucose-108* UreaN-17 Creat-0.7 Na-139
K-3.7 Cl-102 HCO3-28 AnGap-13
[**2103-6-15**] 02:32AM BLOOD CK(CPK)-104
[**2103-6-15**] 08:48AM BLOOD CK(CPK)-142*
[**2103-6-16**] 06:35AM BLOOD CK(CPK)-146*
[**2103-6-17**] 06:50AM BLOOD CK(CPK)-151*
[**2103-6-15**] 02:32AM BLOOD CK-MB-4 cTropnT-<0.01
[**2103-6-15**] 08:48AM BLOOD CK-MB-6 cTropnT-<0.01
[**2103-6-18**] 05:15AM BLOOD ALT-11 AST-20 CK(CPK)-107 AlkPhos-71
[**2103-6-15**] 02:32AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.1 Cholest-186
[**2103-6-15**] 02:32AM BLOOD Triglyc-113 HDL-47 CHOL/HD-4.0
LDLcalc-116
[**2103-6-15**] 02:32AM BLOOD %HbA1c-5.8
[**2103-6-14**] 08:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.014
[**2103-6-14**] 08:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG

IMAGING:
ECG ([**6-14**]): Artifact is present. Sinus rhythm at a rate of 65.
The P-R interval is prolonged. Right bundle-branch block. There
are non-diagnostic Q waves in the inferior leads. No previous
tracing available for comparison.

CXR ([**6-14**]): IMPRESSION: No acute pulmonary process.

CT Head ([**6-14**]): NON-CONTRAST HEAD CT: There is acute
high-attenuation hemorrhage within the dorsal pons. This
measures 10 x 14 mm in the axial plane and is unchanged from
prior study. There is no other focus of hemorrhage identified.
Ventricles are mildly prominent, as are the sulci, suggesting
underlying parenchymal atrophy. There is periventricular white
matter hypodensity, which likely reflects sequelae of small
vessel ischemic disease. There is no shift of normally midline
structures, no mass effect, no acute large vascular territory
ischemic infarction. Basilar cisterns are preserved. There is no
shift of normally midline structures.
There are vascular calcifications in the cavernous carotids. The
osseous structures demonstrate no suspicious lytic or sclerotic
lesions. The visualized paranasal sinuses and mastoid air cells
are clear.
IMPRESSION:
1. Acute hemorrhage in the dorsal pons/tectum. Most likely
etiology is hypertensive, although underlying vascular
malformation such as a cavernoma cannot be excluded.
2. Periventricular white matter hypodensity suggests small
vessel ischemic disease.

CT Head ([**6-15**]): IMPRESSION:
1. Stable appearance of the acute pontine hemorrhage. Recommend
MR to define underlying etiology (hypertensive versus cavernoma
versus AVM)
2. Stable appearance of sequelae of small vessel ischemic
disease.

Brief Hospital Course:
The patient is an 80 year old right handed woman with no known
past medical history who presented with sudden onset dizzines
described as feeling unsteady. Physical exam on [**6-16**] was notable
for dyarthria, vertical occular bobbing, PERRL, and inability to
abduct with either eye. She had impaired downgaze and upgaze of
both eyes but this was more prominent with the left eye. When
looking downward, this elicited ocular bobbing. She had right
upper and lower facial droop, impaired pinprick in the left V3
area, left pronator drift, decreased pinprick of the left arm
and leg, mild ataxia of left finger-nose-finger, and upgoing
toes bilaterally. Head CT on admission showed acute
high-attenuation hemorrhage within the dorsal pons/tectum
measuring 10 x 14 mm in the axial plane. The etiology of this
hemorrhage was thought to be hypertension. Underlying vascular
malformation could not be excluded; however, the patient did not
want to have an MRI/MRA or CTA head during this admission as she
did not think she would want any intervention if an AVM or
aneurysm was found. Neurosurgery was consulted on admission
because of the hemorrhage, but no intervention was indicated.
She was initially admitted to the NeuroICU for close
observation, and then called out to the Neurology floor.
Lipid panel showed: Chol 186, TG 113, HDL 47, LDL 116, and she
was started on Simvastatin 20 daily. HgA1c 5.8%, CK
104-142-146-151 but TropT negative. Her goal SBP is 120-140, and
she was started on HCTZ 12.5 mg daily. Speech and swallow
cleared her for soft solids/nectar prethickened liquids. At the
time of discharge, she began to have slight abduction of her
right eye. She will follow up with Dr. [**Last Name (STitle) **] in Neurology as an
outpatient.


Medications on Admission:
None

Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 **] hosp

Discharge Diagnosis:
PRIMARY:
Acute hemorrhage in the dorsal pons/tectum, likely hypertensive
Hypertension
Hypercholesterolemia


Discharge Condition:
Oriented to place and date, has slight abduction with right eye,
has upgaze with ocular bobbing, slight weakness in the left
triceps and finger extensors and in the bilateral IPs


Discharge Instructions:
You were admitted with a feeling of unsteadiness and left sided
weakness, and were found to have an acute hemorrhage in your
pons. This was thought to be due to high blood pressure;
however, we cannot rule out a vascular malformation as you did
not want to further pursue an MRI or CTA. You were initially in
the NeuroICU. You were found to have elevated LDL cholesterol,
and were started on Simvastatin 20 mg daily. Your blood pressure
was found to be elevated, and you were started on
Hydrochlorothiazide 12.5 mg daily which can be titrated up in
rehab.

If you develop headache, weakness/numbness, dizziness or gait
imbalance, double vision, difficulty speaking or swallowing, or
any other symptoms that concern you, call your PCP or return to
the ED.

Followup Instructions:
You should make a follow up appointment with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 13553**]), within 1 week of discharge from rehab.

You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
Neurology ([**Telephone/Fax (1) 2574**]) on [**2103-7-20**] at 1:30 in the [**Hospital Ward Name 23**]
Center, [**Location (un) 858**].
{'Intracerebral hemorrhage,Unspecified essential hypertension,Pure hypercholesterolemia'}


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: Dizziness, unsteadiness

PRESENT ILLNESS: 80yo right handed woman without known prior medical history
(rarely seeks medical care), now presenting with sudden onset
dizziness, found to have posterior pontine hemorrhage on head
CT. She awoke feeling well. Descended the steps in her home and
had the sudden onset of dizziness, which she describes as
feeling "unsteady." No vertigo. She was able to guide herself to
the floor, but was unable to get up for several hours until her
husband found her. He was able to transfer her to a lounge chair
with wheels. They waited things out most of the day and got a
neighbor for help, who then called EMS ~6:30pm. Head CT at
[**Hospital **] Hospital reveals 1cm right posterior pontine/inferior
colliculus hemorrhage.

MEDICAL HISTORY: Left tongue keratosis- s/p excision x 2, most recent ~1month ago
told it was "benign."

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
T: 98.2, HR 68, BP 175/82, R 16, Sat 98%
Gen: well appearing, thin elderly woman, hyperpigmented patches,
prefers to have eyes closed, alert, very pleasant, NAD
HEENT- NCAT, MMM, OP clear
Neck- no carotid bruits bilaterally
CV- RRR, no MRG
Pulm- CTA B
Abd- soft, ND, NT, BS+
Extrem- no CCE
Skin- multiple hyperpigmented patches

FAMILY HISTORY: no known FH of stroke or CAD

SOCIAL HISTORY: lives with her husband on the [**Location (un) 1121**], never smoker, no
ETOH, no illicits. She is a retired telephone operator. 

### Response:
{'Intracerebral hemorrhage,Unspecified essential hypertension,Pure hypercholesterolemia'}
