CHIEF COMPLAINT: ataxia

PRESENT ILLNESS: The pt is a 86 year-old right-handed man with a history of
CHF, COPD, dementia and 2 prior strokes resulting in residual R
sided weakness and vision loss who presents with a new
cerebellar
hemorrhage.  His family reports that he has been slightly more
congested over the past few days, for which they gave him an
extra dose of Lasix this weekend, but he was still able to walk
with only slight assistance.  However, this morning when they
sat
him up he consistently kept falling over to the left, both with
sitting and with walking.  Because of this he was taken to
[**Hospital **] Hospital, where he was given Lasix, Solumedrol and
Levaquin for presumed bronchitis vs. COPD exacerbation, and had
a
NCHCT which showed an 8mm L cerebellar hemorrhage, for which he
was transferred to [**Hospital1 18**] for further evaluation.  BPs on arrival
at [**Hospital1 **] were 199/87, for which he was given 10mg of
labetalol,
and nitropaste.

MEDICAL HISTORY: - CHF
- COPD
- 2 prior strokes - in [**2104**] presented with R sided weakness, and
in [**2106**] presented with right sided vision loss (large L sided
PCA
infarct on CT scan)
- HTN - per daughter they have been having difficulties with
orthostasis when working with PT, so decreased his BP meds
recently - systolics at home run 150-170s when lying down, but
apparently drop further when standing.

MEDICATION ON ADMISSION: - Plavix 75mg daily
- Lasix 20mg daily
- Potassium 10mEq
- Namenda 10mg [**Hospital1 **]
- Carvedilol 12.5mg [**Hospital1 **]
- Ranitidine 300mg daily
- Aricept 5mg QHS

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: T: 96.6 P: 59 R: 16  BP: 196/74 SaO2: 100% on RA
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: Expiratory wheezes throughout
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: multiple echymoses throughout

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives in [**Location 1456**] with his daughter who takes care of
most of his ADLs.  Previously lived in [**State 108**] and is a retired
printer.  Prior smoker, but quit in the 80s.  No EtOH or
illicits.
Cerebral artery occlusion, unspecified with cerebral infarction,Chronic diastolic heart failure,Other conditions of brain,Chronic airway obstruction, not elsewhere classified,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Coronary atherosclerosis of native coronary artery,Cardiac pacemaker in situ,Hyperpotassemia,Other late effects of cerebrovascular disease,Homonymous bilateral field defects,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Profound impairment, both eyes, impairment level not further specified
Crbl art ocl NOS w infrc,Chr diastolic hrt fail,Brain conditions NEC,Chr airway obstruct NEC,Alzheimer's disease,Dementia w/o behav dist,Crnry athrscl natve vssl,Status cardiac pacemaker,Hyperpotassemia,Late effect CV dis NEC,Homonymous hemianopsia,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,Both eyes blind-who def
Name:  [**Known lastname 14063**],[**Known firstname 133**]                     Unit No:   [**Numeric Identifier 14064**]

Admission Date:  [**2109-5-6**]              Discharge Date:   [**2109-5-10**]

Date of Birth:  [**2023-3-5**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 4697**]
Addendum:
It is possible that there was an infarct in the posterior
circulation (specifically the cerebellum) that could not be
visualized using a CT.  Given his pacemaker and MRI could not be
preformed.  He was restarted on his Plavix for continued
antiplatelet control and will get repeat imaging in 1 month time
and stroke follow up.

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 3465**] - [**Location (un) 824**]

                             [**First Name8 (NamePattern2) 77**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern4) 4698**] MD [**MD Number(2) 4699**]

Completed by:[**2109-5-10**]

Admission Date:  [**2109-5-6**]              Discharge Date:   [**2109-5-10**]

Date of Birth:  [**2023-3-5**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
ataxia

Major Surgical or Invasive Procedure:
none


History of Present Illness:
The pt is a 86 year-old right-handed man with a history of
CHF, COPD, dementia and 2 prior strokes resulting in residual R
sided weakness and vision loss who presents with a new
cerebellar
hemorrhage.  His family reports that he has been slightly more
congested over the past few days, for which they gave him an
extra dose of Lasix this weekend, but he was still able to walk
with only slight assistance.  However, this morning when they
sat
him up he consistently kept falling over to the left, both with
sitting and with walking.  Because of this he was taken to
[**Hospital **] Hospital, where he was given Lasix, Solumedrol and
Levaquin for presumed bronchitis vs. COPD exacerbation, and had
a
NCHCT which showed an 8mm L cerebellar hemorrhage, for which he
was transferred to [**Hospital1 18**] for further evaluation.  BPs on arrival
at [**Hospital1 **] were 199/87, for which he was given 10mg of
labetalol,
and nitropaste.

On ROS he reports feeling slightly more congested over the last
few days, and that he has worsening gait instability.  He
complains of feeling dizzy for days, though family reports he
always says he is dizzy, so they did not necessarily consider
this new.


Past Medical History:
- CHF
- COPD
- 2 prior strokes - in [**2104**] presented with R sided weakness, and
in [**2106**] presented with right sided vision loss (large L sided
PCA
infarct on CT scan)
- HTN - per daughter they have been having difficulties with
orthostasis when working with PT, so decreased his BP meds
recently - systolics at home run 150-170s when lying down, but
apparently drop further when standing.


Social History:
Lives in [**Location 1456**] with his daughter who takes care of
most of his ADLs.  Previously lived in [**State 108**] and is a retired
printer.  Prior smoker, but quit in the 80s.  No EtOH or
illicits.


Family History:
NC


Physical Exam:
Vitals: T: 96.6 P: 59 R: 16  BP: 196/74 SaO2: 100% on RA
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: Expiratory wheezes throughout
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: multiple echymoses throughout

Neurologic:
-Mental Status: Alert, oriented to self, [**Hospital1 18**] and eventually
gets [**Month (only) 116**], but states it is [**2069**].  Can count backwards from 20
without difficulty.  Has difficulty seeing objects to name them,
but can eventually make out the key.  When [**Location (un) 1131**], can see the
first 2 letters, than fills in a word (not usually correctly).
Poor cooperation with single or multi-step commands.

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.  Right hemianopsia as well as
partial left superior quadrantanopsia when mapped with a red pin
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: Slight right facial droop
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. Slight right pronator
drift.  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. Poor cooperation with proprioception, stating
'I'm moving it up and down' while volitionally moving his own
toes.

-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 extensor bilaterally.

-Coordination: Unable to complete FNF as he has difficulty
seeing
the target, and can not understand commands for other tasks of
[**Doctor First Name **].

-Gait: Requires 2 person assist just to sit up, at which point
he
tilts slightly to the left.  Deferred further gait testing due
to
significant instability just while sitting.

**********
Laboratory Data:

141 | 100 | 41
----------------< 118
5.2 |  28 | 2.4

      13.8
14.0 >-----< 247
      40.4

PT: 13.9 PTT: 26.5 INR: 1.2

U/A (OSH): Neg

NCHCT:
New 8mm focus of high density within the left cerebellar
hemisphere concerning for intra-axial hemorrhage.  Evidence of
remote prior infarcts within the left cerebral and cerebellar
hemisphere and brainstem.


Pertinent Results:
Labs on admission:
[**2109-5-6**] 07:35PM   GLUCOSE-118* UREA N-41* CREAT-2.4* SODIUM-141
POTASSIUM-5.2* CHLORIDE-100 TOTAL CO2-28 ANION GAP-18
[**2109-5-6**] 07:35PM   estGFR-Using this
[**2109-5-6**] 07:35PM   cTropnT-0.03*
[**2109-5-6**] 07:35PM   WBC-14.0* RBC-4.67 HGB-13.8* HCT-40.4 MCV-86
MCH-29.6 MCHC-34.3 RDW-14.9
[**2109-5-6**] 07:35PM   NEUTS-91.6* LYMPHS-6.6* MONOS-0.6* EOS-1.0
BASOS-0.2
[**2109-5-6**] 07:35PM   PLT COUNT-247
[**2109-5-6**] 07:35PM   PT-13.9* PTT-26.5 INR(PT)-1.2*
.
Labs on discharge:
[**2109-5-9**] 05:30AM BLOOD WBC-10.6 RBC-3.64* Hgb-10.7* Hct-32.3*
MCV-89 MCH-29.3 MCHC-33.1 RDW-15.0 Plt Ct-196
[**2109-5-9**] 05:30AM BLOOD Glucose-97 UreaN-50* Creat-2.0* Na-143
K-4.0 Cl-106 HCO3-27 AnGap-14
[**2109-5-9**] 05:30AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1
[**2109-5-7**] 01:15AM BLOOD %HbA1c-5.3 eAG-105
[**2109-5-7**] 01:15AM BLOOD Triglyc-68 HDL-44 CHOL/HD-4.5
LDLcalc-138*
.
Imaging:
[**2109-5-7**]   CT HEAD W/O CONTRAST: 1. Multiple calcifications
along the cerebellar folia and tentorium. No evidence of acute
intracranial hemorrhage.
2. Large chronic infarction in the left posterior cerebral
artery territory.  Numerous small chronic infarctions in the
cerebellar hemispheres, left pons, left putamen, and bilateral
supratentorial white matter.
3. Fluid in the right middle and posterior ethmoid air cells.

[**2109-5-7**]   CAROTID SERIES COMPLETE: Although velocities indicate
a less than 40% carotid stenosis bilaterally, there is
significant calcification, which can underestimate the actual
degree. Clinical correlation and potentially CTA followup is
warranted. There is evidence of distal right vertebral artery
disease.

[**2109-5-7**]   ECHO: The left atrium is moderately dilated. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is no
pericardial effusion.

IMPRESSION: Grossly preserved biventricular systolic function.
Minimal aortic stenosis. Very limited study.
[**2109-5-6**]   CHEST (PA & LAT): Mild cardiomegaly and atelectasis.

[**2109-5-6**]   ECG: Ventricular pacing. Atrial rhythm uncertain may
be atrial paced. No previous tracing available for comparison.

Brief Hospital Course:
Mr. [**Known lastname **] is an 86 year-old right-handed man with a history of
COPD, chronic dCHF (LVEF > 55%), dementia, and multiple prior
strokes presenting after tilting to the left this morning, found
to have evidence for a new left cerebellar lesion (8mm) as well
as multiple old infarcts.  While pt had elevated blood pressure
on arrival to the OSH (199/87) and reports of poor blood
pressure control at home, the lesion does not appear to
hemorrhagic upon review of imaging.  Pt initially required
nicardipine drip for blood pressure control and was admitted to
the ICU.  He was transferred to the neuromedicine floor without
complications on hospital day 2.

Neuro: **Pt legally blind, at high fall risk.** Patient with
baseline Alzheimer's dementia.  Baseline neurologic exam reveals
patient awake, alert and oriented x2.  Has R eye blindness and L
visual field cuts. CT head revealed "multiple calcifications
along the cerebellar folia and tentorium. No evidence of acute
intracranial hemorrhage.  Large chronic infarction in the left
posterior cerebral artery territory.  Numerous small chronic
infarctions in the cerebellar hemispheres, left pons, left
putamen, and bilateral supratentorial white matter." Initial
preliminary read included differential of intracranial
hemorrhage; Plavix held until day of discharge. Simvastation
20mg started due to suboptimal stroke risk factors, as listed
below.
.
Stroke Risk Factors
A1c:5.3
Lipids:LDL 138
Echo: LVEF>55%
.
Cardiovascular:  Goal of SBP <160; pt was initially on
nicardipine gtt upon arrival due to elevated SBP, off as of [**5-7**]
AM. We kept patient on home carvedilol 12.5mg [**Hospital1 **]. Cardiac
enzymes negative x 2. TTE negative without thrombi, PFO.
We restarted home Plavix [**5-9**], not on ASA at home. Pt has a [**First Name8 (NamePattern2) **]
[**Male First Name (un) 923**] pacemaker (model 5386, serial # [**Serial Number 88573**])
.
Pulm: Pt with history COPD. He was given levaquin at OSH for
PNA, discontinued upon during admission as no evidence of
infiltrate on imaging or fevers. Expiratory wheezes noted on
exam while in ICU, given nebs with good response.
.
GI: Cardiac diet, passed bedside S+S for regular solids, thin
liquids.

Renal: BUN and Cr elevated at time of admission. Baseline Cr
1.7-2.5 at OSH, however per discussion with daughter he has a
history of renal failure and they have been declining dialysis.
Pt was given gentle IV hydration. Creatinine peaked at 2.5, 2.0
at time of discharge. Lasix 20mg daily initially held, restarted
[**5-7**].  Pt on potassium supplementation at home prior to
admission. Potassium level was elevated at time of admission,
trended within normal limits and remained there without
repletion throughout admission. We will hold potassium
supplementation at time of discharge.
.
FEN: Mildly hyperkalemic at time of admission, though improved
from OSH.  Will hold home potassium as stated above. No EKG
changes.
.
Endocrine: RISS
.
Infectious Disease: Urine culture negative, blood culture
pending at time of discharge.
.
CODE: FULL (though does have documentation to withdraw care if
there is 'no chance for recovery or he is in a persistent
vegetative state')

Medications on Admission:
- Plavix 75mg daily
- Lasix 20mg daily
- Potassium 10mEq
- Namenda 10mg [**Hospital1 **]
- Carvedilol 12.5mg [**Hospital1 **]
- Ranitidine 300mg daily
- Aricept 5mg QHS

Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day.
4. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a day.

5. ranitidine HCl 300 mg Capsule Sig: One (1) Capsule PO once a
day.
6. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
Intracranial lesion of unclear etiology


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mr [**Known lastname **],

You were admitted for a lesion in your cerebellum.  As we were
unable to perform an MRI, this lesion could not be better
visualized, but it does not appear to be blood.  Your home
Lovenox was held briefly, but restarted at time of discharge.
You had a cardiac echocardiogram which demonstrated no definite
cardioembolic source.  We will reimage your brain in 1 months
time to look for any changes.

Your stroke risk factors were checked.  You should not smoke.
Your cholesterol was high with an LDL of 131.  You were started
on simvastatin 20mg daily to lower your cholesterol.  You were
checked for blood glucose control with a HgB A1c.  The level was
5.3.  You need to continue your blood pressure control.

You should continue to eat a low fat healthy diet, and follow up
with your primary care physician and stroke Neurology as noted
below.

It was a pleasure taking care of you.

Followup Instructions:
Please call your primary care provider [**Name9 (PRE) **],[**First Name4 (NamePattern1) 5557**]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 88574**] within 7 days upon discharge from
rehabilitation center.

Department: RADIOLOGY
When: FRIDAY [**2109-6-7**] at 8:15 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: NEUROLOGY
When: FRIDAY [**2109-6-7**] at 12:00 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
{"Cerebral artery occlusion, unspecified with cerebral infarction,Chronic diastolic heart failure,Other conditions of brain,Chronic airway obstruction, not elsewhere classified,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Coronary atherosclerosis of native coronary artery,Cardiac pacemaker in situ,Hyperpotassemia,Other late effects of cerebrovascular disease,Homonymous bilateral field defects,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Profound impairment, both eyes, impairment level not further specified"}


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: ataxia

PRESENT ILLNESS: The pt is a 86 year-old right-handed man with a history of
CHF, COPD, dementia and 2 prior strokes resulting in residual R
sided weakness and vision loss who presents with a new
cerebellar
hemorrhage.  His family reports that he has been slightly more
congested over the past few days, for which they gave him an
extra dose of Lasix this weekend, but he was still able to walk
with only slight assistance.  However, this morning when they
sat
him up he consistently kept falling over to the left, both with
sitting and with walking.  Because of this he was taken to
[**Hospital **] Hospital, where he was given Lasix, Solumedrol and
Levaquin for presumed bronchitis vs. COPD exacerbation, and had
a
NCHCT which showed an 8mm L cerebellar hemorrhage, for which he
was transferred to [**Hospital1 18**] for further evaluation.  BPs on arrival
at [**Hospital1 **] were 199/87, for which he was given 10mg of
labetalol,
and nitropaste.

MEDICAL HISTORY: - CHF
- COPD
- 2 prior strokes - in [**2104**] presented with R sided weakness, and
in [**2106**] presented with right sided vision loss (large L sided
PCA
infarct on CT scan)
- HTN - per daughter they have been having difficulties with
orthostasis when working with PT, so decreased his BP meds
recently - systolics at home run 150-170s when lying down, but
apparently drop further when standing.

MEDICATION ON ADMISSION: - Plavix 75mg daily
- Lasix 20mg daily
- Potassium 10mEq
- Namenda 10mg [**Hospital1 **]
- Carvedilol 12.5mg [**Hospital1 **]
- Ranitidine 300mg daily
- Aricept 5mg QHS

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: T: 96.6 P: 59 R: 16  BP: 196/74 SaO2: 100% on RA
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: Expiratory wheezes throughout
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: multiple echymoses throughout

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives in [**Location 1456**] with his daughter who takes care of
most of his ADLs.  Previously lived in [**State 108**] and is a retired
printer.  Prior smoker, but quit in the 80s.  No EtOH or
illicits. 

### Response:
{"Cerebral artery occlusion, unspecified with cerebral infarction,Chronic diastolic heart failure,Other conditions of brain,Chronic airway obstruction, not elsewhere classified,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Coronary atherosclerosis of native coronary artery,Cardiac pacemaker in situ,Hyperpotassemia,Other late effects of cerebrovascular disease,Homonymous bilateral field defects,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Profound impairment, both eyes, impairment level not further specified"}
