CHIEF COMPLAINT: severe headache

PRESENT ILLNESS: Mr. [**Known lastname 111912**] is a 34 yo RHM with a history of GERD and vitiligo
who presented to [**Hospital1 18**] as a transfer from OSH for headache with
SAH on NCHCT.  Patient was in his usual state of health until
Friday evening when he developed a sudden rapidly progressive
b/l R sided frontal headache with 10/10 intensity followed by
nausea and several episodes of vomiting (at the end of which he
noted some coffee ground emesis). Of note, headache came on at a
time when he was having an intense argument with his girlfriend.
 [**Name (NI) **] notes that after 2-3 hours, that his headache quickly
dissipated (he also had taken 2 naproxen at that time)and
continued to decrease in severity since that time. On Saturday
morning, he woke up with a hint of a headache which he thought
worsened only with valsalva, coughing and rapid shaking of his
head from side-to-side.
.
He had a very similar episode 1 month prior with sudden onset
[**11-13**] headache. That episode lasted only 10 seconds and
dissipated on its own without intervention. He had never
experienced anything prior to that beforehand.
.
His headache history is otherwise unremarkable. He does not have
headaches very often.  He does notice that sometimes when he
drinks beer, he has a mild b/l posterior headache.  He has never
been so inebriated that he would have been unaware of a severe
headache.

MEDICAL HISTORY: GERD
vitiligo

MEDICATION ON ADMISSION: Naproxen 500 mg PO Q8H:PRN pain
Zantac prn

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAM ON ADMISSION:
Hunt and [**Doctor Last Name 9381**]: 1        [**Doctor Last Name **]: 2       GCS 15
O: T:97.8  BP:134/86         HR:106    R14     O2Sats 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT
Neck: Supple.no nuchal rigidity
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.

FAMILY HISTORY: No aneurysm, strokes, intracerebral bleeds in family

SOCIAL HISTORY: Quit smoking 1 year ago, drinks 1 drink per day, no illicits.
Subarachnoid hemorrhage,Unspecified transient cerebral ischemia,Esophageal reflux,Personal history of tobacco use,Vitiligo
Subarachnoid hemorrhage,Trans cereb ischemia NOS,Esophageal reflux,History of tobacco use,Vitiligo
Admission Date:  [**2126-9-14**]              Discharge Date:   [**2126-9-18**]

Date of Birth:  [**2092-7-19**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
severe headache

Major Surgical or Invasive Procedure:
[**2126-9-15**] Cerebral angiogram with verapamil injection to bil ICAs


History of Present Illness:
Mr. [**Known lastname 111912**] is a 34 yo RHM with a history of GERD and vitiligo
who presented to [**Hospital1 18**] as a transfer from OSH for headache with
SAH on NCHCT.  Patient was in his usual state of health until
Friday evening when he developed a sudden rapidly progressive
b/l R sided frontal headache with 10/10 intensity followed by
nausea and several episodes of vomiting (at the end of which he
noted some coffee ground emesis). Of note, headache came on at a
time when he was having an intense argument with his girlfriend.
 [**Name (NI) **] notes that after 2-3 hours, that his headache quickly
dissipated (he also had taken 2 naproxen at that time)and
continued to decrease in severity since that time. On Saturday
morning, he woke up with a hint of a headache which he thought
worsened only with valsalva, coughing and rapid shaking of his
head from side-to-side.
.
He had a very similar episode 1 month prior with sudden onset
[**11-13**] headache. That episode lasted only 10 seconds and
dissipated on its own without intervention. He had never
experienced anything prior to that beforehand.
.
His headache history is otherwise unremarkable. He does not have
headaches very often.  He does notice that sometimes when he
drinks beer, he has a mild b/l posterior headache.  He has never
been so inebriated that he would have been unaware of a severe
headache.

Upon arrival to the ER, a CTA head was performed which showed
vasospasm in the distal ICA/proximal MCA as well as L ACA,
raising concern for Reversible Cerebral Vasoconstriction
Syndrome. He was admitted to the ICU for monitoring.
.
He otherwise denies neurological symptoms on ROS. He has no
significant family history of neurological disease. He denies
cocaine use or other stimulants.

Past Medical History:
GERD
vitiligo

Social History:
Quit smoking 1 year ago, drinks 1 drink per day, no illicits.


Family History:
No aneurysm, strokes, intracerebral bleeds in family


Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Hunt and [**Doctor Last Name 9381**]: 1        [**Doctor Last Name **]: 2       GCS 15
O: T:97.8  BP:134/86         HR:106    R14     O2Sats 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT
Neck: Supple.no nuchal rigidity
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.

Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4to3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally with
extinquishing nystagmus on leftward gaze.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-8**] throughout. No pronator drift

Sensation: Intact to light touch, propioception bilaterally.

Reflexes: B T Br Pa Ac
Right     2  2  2  2 1
Left      2  2  2  2  1

Toes downgoing bilaterally

Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
.
PHYSICAL EXAM ON DISCHARGE:
-Vitals: 98.1 110/68 [110-135/68-99] 81-90 20 100% RA
-Neuro: completely intact

Pertinent Results:
Labs on Admission:

[**2126-9-14**] 05:59PM   estGFR-Using this
[**2126-9-14**] 05:59PM   NEUTS-69.2 LYMPHS-22.5 MONOS-6.4 EOS-1.6
BASOS-0.3
[**2126-9-14**] 05:59PM   PT-10.8 PTT-29.6 INR(PT)-1.0
[**2126-9-14**] 05:58PM   LACTATE-1.7
[**2126-9-14**] 05:59PM   GLUCOSE-105* UREA N-12 CREAT-1.0 SODIUM-140
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
[**2126-9-14**] 10:50PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG

Relevant Labs:

[**2126-9-15**] 04:34AM BLOOD ANCA-NEGATIVE B
[**2126-9-15**] 04:34AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2126-9-15**] 04:03AM BLOOD RheuFac-8 CRP-0.7
[**2126-9-15**] 04:03AM BLOOD ESR-4

Imaging:

NCHCT: hyperdensity in the quadrigeminal cistern

CTA head/neck:

1.  Diffuse subarachnoid hemorrhage identified in the
non-contrast head CT, more conspicuous at the right ambient
cistern.  There is no evidence of hydrocephalus or
intraventricular hemorrhage.

2.  The 3D rendering reconstructions of the intracranial
vessels, demonstrate vasospasm at the M1 and A1 segments with no
definite aneurysm identified or vascular malformation.

MRI OF THE HEAD:

Trace of subarachnoid hemorrhage is redemonstrated with high
signal intensity in the sulci evident on the FLAIR sequence
(image #9, series #14, image #15, #16, series #14).  There is no
evidence of hydrocephalus or shifting of the normally midline
structures.  The diffusion-weighted sequences demonstrate a
questionable cortical area with high signal intensity on the DWI
sequence with no definite restricted diffusion, possibly related
with T2 shining-through
effect from diffuse subarachnoid hemorrhage.  The major vascular
flow voids are patent.  The orbits are unremarkable, the
paranasal sinuses and the mastoid air cells are clear.

IMPRESSION:  Evidence of subarachnoid hemorrhage, previously
demonstrated by CT of the head, there is no evidence of
intraventricular hemorrhage or hydrocephalus.

No definite areas with restricted diffusion are identified,
there is possible T2 shining-through effect along the left
parietooccipital region, possibly related with subarachnoid
hemorrhage.

MRV OF THE HEAD.

The major dural venous sinuses are patent, the superior
longitudinal sinus, straight sinus and transverse sinuses are
patent with no evidence of venous sinus thrombosis.

IMPRESSION:  Essentially normal MRV of the head.

MRA BRAIN WITHOUT CONTRAST ([**9-16**]): There is evidence of vascular
flow in both internal carotid arteries as well as the
vertebrobasilar system, the supraclinoid carotid arteries are
notable for bilateral vasospasm involving the A1 and M1
segments, no aneurysms larger than 3 mm in size are seen.  The
basilar artery and the posterior cerebral arteries are grossly
unremarkable, the anterior cerebral arteries are patent and
appear grossly normal.

IMPRESSION:  Bilateral vasospasm involving the supraclinoid
carotid arteries, extending at the level of M1 and A1 segments
as described above, no aneurysms larger than 3 mm in size are
seen, the visualized vascular structures of the posterior
circulation are unremarkable.

Brief Hospital Course:
34yo M without significant pmh, presents with sudden intense
headache and found to have SAH in the basal cistern on NCHCT.

# Neuro:

Patient was initially admitted to Neurosurgical service who took
care of him during first two days in ICU. He was started on
Dilantin for seizure prophylaxis and Nimodipine for prevention
of vasospasm. His SBP goal was 100-160. He remained stable
overnight. On HD#2, patient underwent angiogram with Dr. [**Last Name (STitle) **],
revealing moderate narrowing of both ICAs. Prednisone 100mg x3
doses was ordered as precaution given concern for vasculitis.
MRI head did not show any evidence of acute or prior infarcts
and MRV head showed patent sinuses.

Patient was transferred to neurology service on HD #3.
Nimodipine was d/c'ed and started Verapamil 80mg PO tid instead
presumptively for vasospasm. Dilantin was discontinued, as SAH
was quite small and not in location typically associated with
seizures. Imaging revealed vasospasm of the distal ICA/proximal
MCA as well as L ACA, raising concern for Reversible Cerebral
Vasoconstriction Syndrome. Neuro exam did not demonstrate any
abnormality. CTA with no evidence of aneurysm. MRA head with no
acute infarct. MRV brain with patent sinuses.  Angiogram showed
b/l moderate narrowing of ICAs. TCD was normal. The etiology of
his bleed was likely small vessel extravasation secondary to
vasospasm as no aneurysms were visualized on multiple imaging
modalities.  Differential also included vasculitic process;
however, ESR/CRP, ANCA and RF, [**Doctor First Name **] are all normal.
.
On HD #4 patient was transferred to the neurology floor, where
his neurologic exam remained normal and nonfocal. On discharge
he was switched to Verapamil LA 180mg PO daily. His neuro exam
on discharge remained completely nonfocal. He declined
outpatient angiogram, so will instead have outpatient CT in one
month to follow up on his vasospasm and see whether it has
resolved.
.
====================
TRANSITIONS OF CARE:
-Needs outpatient CT angiogram in 4 weeks
-Will follow up with Dr. [**First Name (STitle) **] and Dr. [**First Name (STitle) **]

Medications on Admission:
Naproxen 500 mg PO Q8H:PRN pain
Zantac prn


Discharge Medications:
1. Verapamil SR 180 mg PO Q24H
RX *verapamil 180 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1


Discharge Disposition:
Home

Discharge Diagnosis:
Subarachnoid hemorrhage
Vasospasm


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


Discharge Instructions:
You were admitted to the hospital with a severe headache
followed by nausea and vomiting. You were found to have a
subarachnoid hemorrhage (bleeding on the surface of the brain),
and cerebral artery vasospasm (constriction/spasm of the
arteries supplying your brain). We believe that you may have a
condition called Reversible Cerebral Vasoconstriction Syndrome,
which is a temporary narrowing of the cerebral arteries that
results in bleeding. However, you will need further brain
imaging as an outpatient to confirm this diagnosis.
.
Please attend the outpatient follow-up appointments with
neurologist Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] (see below). You will need a CT
angiogram (CTA) in FOUR WEEKS, prior to your appointment with
Dr. [**First Name (STitle) **] (see below for information on how to schedule this).
.
We made the following changes to your medications:
1. STARTED verapamil 180mg by mouth daily
2. STOPPED naproxen (increases risk for bleeding) -- for
headache in the future, you should take Tylenol if needed.

Followup Instructions:
-You will be called by the radiology department to schedule an
outpatient CT angiogram (CTA) in FOUR WEEKS. If you do not hear
from them within one week, please call ([**Telephone/Fax (1) 111884**] to schedule
the appointment.

Department: NEUROLOGY
When: MONDAY [**2126-11-18**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
{'Subarachnoid hemorrhage,Unspecified transient cerebral ischemia,Esophageal reflux,Personal history of tobacco use,Vitiligo'}


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: severe headache

PRESENT ILLNESS: Mr. [**Known lastname 111912**] is a 34 yo RHM with a history of GERD and vitiligo
who presented to [**Hospital1 18**] as a transfer from OSH for headache with
SAH on NCHCT.  Patient was in his usual state of health until
Friday evening when he developed a sudden rapidly progressive
b/l R sided frontal headache with 10/10 intensity followed by
nausea and several episodes of vomiting (at the end of which he
noted some coffee ground emesis). Of note, headache came on at a
time when he was having an intense argument with his girlfriend.
 [**Name (NI) **] notes that after 2-3 hours, that his headache quickly
dissipated (he also had taken 2 naproxen at that time)and
continued to decrease in severity since that time. On Saturday
morning, he woke up with a hint of a headache which he thought
worsened only with valsalva, coughing and rapid shaking of his
head from side-to-side.
.
He had a very similar episode 1 month prior with sudden onset
[**11-13**] headache. That episode lasted only 10 seconds and
dissipated on its own without intervention. He had never
experienced anything prior to that beforehand.
.
His headache history is otherwise unremarkable. He does not have
headaches very often.  He does notice that sometimes when he
drinks beer, he has a mild b/l posterior headache.  He has never
been so inebriated that he would have been unaware of a severe
headache.

MEDICAL HISTORY: GERD
vitiligo

MEDICATION ON ADMISSION: Naproxen 500 mg PO Q8H:PRN pain
Zantac prn

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAM ON ADMISSION:
Hunt and [**Doctor Last Name 9381**]: 1        [**Doctor Last Name **]: 2       GCS 15
O: T:97.8  BP:134/86         HR:106    R14     O2Sats 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT
Neck: Supple.no nuchal rigidity
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.

FAMILY HISTORY: No aneurysm, strokes, intracerebral bleeds in family

SOCIAL HISTORY: Quit smoking 1 year ago, drinks 1 drink per day, no illicits. 

### Response:
{'Subarachnoid hemorrhage,Unspecified transient cerebral ischemia,Esophageal reflux,Personal history of tobacco use,Vitiligo'}
