CHIEF COMPLAINT: Rule out vasculitis

PRESENT ILLNESS: 48 yo LH woman with a history of MS x 2 years, migraine
headaches, HTN, cervical and lumbar spondylosis, and depression
was in her USOH until [**12-27**], when she experienced an atypical
headache.  Her typical headaches in the past have typically been
left temporoparietal in distribution, occasional with radiation
to the front of the head and the neck.  They are severe [**10-16**],
stabbing in quality, and have lasted anywhere from 2 hrs. to 3
days in duration.  They often have associated photo- and
phonophobia.  She frequently has associated double vision in all
directions of gaze, even with each eye closed.  These headaches
improve while laying down in a dark room, and worsen with
Valsalva.

MEDICAL HISTORY: -Multiple sclerosis: Diagnosed 2 years ago in [**State 108**], was
started on Rebif at time of diagnosis, but stopped after 6 mos.
due to flu-like symptoms.  She reports that she has not seen her
neurologist since discontinuing this medication.
-Migraine
-Cervical/lumbar spondylosis
-HTN
-Depression
-Childhood asthma
-s/p hysterectomy
-s/p bronchoscopy for mass on CXR- results "indeterminate"

MEDICATION ON ADMISSION: Outpatient:
-Cymbalta 20 (Depression)
-Fentora 600 mg PRN (Pain)
-Verapamil 20 QD (HTN)
-Opana 40 [**Hospital1 **] (Pain)
-Baclofen 10 PRN (MS)
-Lyrica 40 QD (MS/Pain)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: V T 99.4 BP 146/89 HR 86 RR 13 SaO2 96% RA
General: well nourished, tired, but in no acute distress
HEENT: NC/AT, sclerae anicteric, MMM
Lungs: clear to auscultation
CV: regular rate and rhythm
Abdomen:  soft, non-tender, non-distended, bowel sounds present
Ext: cool bilaterally, non-palpable pedal pulses, but capillary
refill present, no edema
Skin: No rashes; brown nevus type lesion over posterior right
hip, ~1 cm in diameter

FAMILY HISTORY: Non-contributory per patient

SOCIAL HISTORY: Visiting family in [**State 350**] for holidays. [**State 108**] resident.
Other specified disorders of arteries and arterioles,Subarachnoid hemorrhage,Malignant essential hypertension,Multiple sclerosis
Arterial disease NEC,Subarachnoid hemorrhage,Malignant hypertension,Multiple sclerosis
Admission Date:  [**2189-1-3**]              Discharge Date:   [**2189-1-12**]

Date of Birth:  [**2140-9-9**]             Sex:   F

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Rule out vasculitis


Major Surgical or Invasive Procedure:
None (Transcranial doppler)


History of Present Illness:
48 yo LH woman with a history of MS x 2 years, migraine
headaches, HTN, cervical and lumbar spondylosis, and depression
was in her USOH until [**12-27**], when she experienced an atypical
headache.  Her typical headaches in the past have typically been
left temporoparietal in distribution, occasional with radiation
to the front of the head and the neck.  They are severe [**10-16**],
stabbing in quality, and have lasted anywhere from 2 hrs. to 3
days in duration.  They often have associated photo- and
phonophobia.  She frequently has associated double vision in all
directions of gaze, even with each eye closed.  These headaches
improve while laying down in a dark room, and worsen with
Valsalva.

On [**12-27**], the patient reports the onset of a different kind of
headache while riding in the car.  This headache was diffuse,
bilateral, through the head and neck.  She describes it as
pounding, sudden in onset, and her "worst ever."  She
experienced the same double vision as with other headaches.  She
was
diaphoretic and "dizzy" (vertiginous and pre-syncopal).  She
went to an OSH at that time, where a CT head was reportedly
negative and the patient discharged home.  The headache
gradually improved somewhat, but never entirely subsided over
the ensuing week.  It did improve with lying down, although she
did has been awoken by it at night.  She had some mild nausea
and "awkward on [my] feet"
over the following week.  At 4 pm yesterday ([**2189-1-2**]), the same
headache worsened to its previous intensity and she returned to
an OSH ED. CT head there demonstrated showed a small amount of
bilateral SAH, for which she was transferred to [**Hospital1 18**] for
further evaluation and management.  Here, a NCHCT showed
scattered foci of SAH in frontal lobes bilaterally, without mass
effect; no aneurysm seen on CT.  The patient was admitted by
neurosurgery,
who performed cerebral angiogram that reported foci of stenosis
in both posterior cerebral arteries and their branches. There
was concern for vasculitis or focal spasm.  While
atherosclerosis was also considered, there was no evidence of
atherosclerosis elsewhere in the interrogated vasculature.


Review of Systems:
+ F/C, nausea, short- and long- term memory loss, chronic
left-sided weakness with MS, right hand tingling x 2 months
(from
last two digits through entire palm, chronic LLE numbness and
tingling in the front of both the foot and calf; recent plane
trip from [**State 108**] to visit family here in [**State 350**]
-vomiting, loss of vision, changes in taste, smell, dysphagia,
seizures, incontinence (urinary or bowel), weight loss; no
reported head or neck manipulation


Past Medical History:
-Multiple sclerosis: Diagnosed 2 years ago in [**State 108**], was
started on Rebif at time of diagnosis, but stopped after 6 mos.
due to flu-like symptoms.  She reports that she has not seen her
neurologist since discontinuing this medication.
-Migraine
-Cervical/lumbar spondylosis
-HTN
-Depression
-Childhood asthma
-s/p hysterectomy
-s/p bronchoscopy for mass on CXR- results "indeterminate"


Social History:
Visiting family in [**State 350**] for holidays. [**State 108**] resident.

Smoked 1 ppd for 35 yrs; denies EtOH and IVDA abuse.


Family History:
Non-contributory per patient


Physical Exam:
V T 99.4 BP 146/89 HR 86 RR 13 SaO2 96% RA
General: well nourished, tired, but in no acute distress
HEENT: NC/AT, sclerae anicteric, MMM
Lungs: clear to auscultation
CV: regular rate and rhythm
Abdomen:  soft, non-tender, non-distended, bowel sounds present
Ext: cool bilaterally, non-palpable pedal pulses, but capillary
refill present, no edema
Skin: No rashes; brown nevus type lesion over posterior right
hip, ~1 cm in diameter

Neurologic Examination:
Mental Status:
Awake and alert, cooperative with exam, normal affect
Oriented to person, place, month
Attention: can say months of year backward and forward
Language: fluent, no dysarthria, no paraphasic errors, naming,
comprehension intact, [**Location (un) 1131**] and writing intact
Registration: [**3-9**]  registry of items, recall 0/3 items at 3
minutes
No apraxia, no neglect
Calculations: 7 qtrs in $1.75 intact


Cranial Nerves:
Fundoscopic: no papilledema appreciated, left disc pallor noted;
visual fields are full to confrontation, no red desaturation.
Pupils equally round and reactive to light, 5 to 3 mm
bilaterally, no APD seen.  Extraocular movements intact, no
nystagmus.  Reports diplopia in all directions of gaze, even
with
each eye shut.  Facial sensation to soft and PP symmetric and
normal, facial movement normal bilaterally. Hearing intact to
finger rub bilaterally. Tongue midline, no fasciculations.
Sternocleidomastoid and trapezius normal bilaterally.


Motor:
Normal bulk. Difficulty relaxing upper extremities, normal tone
throughout lower extremities.
No tremor or adventitious movements.

      D  T B  WE FiF [**Last Name (un) **] IP  Q H AF AE  TE
Right 5  5 5  5  5   5   5   5 5 5  5    4
Left  5  5 5  5  5   5   5   5 5 5  5    4+
No pronator drift

Sensation was intact to light touch, pin prick, temperature
(cold), vibration.  Reduced proprioception toes.

Reflexes: B T Br Pa Pl
Right     2 1 2  2  2
Left      2 1 2  2  2
Toes were downgoing bilaterally

Coordination is normal on finger-nose-finger (although slowed),
FFM, heel to shin also normal

Gait: Deferred due to restrictions post-angio


Pertinent Results:
[**2189-1-2**] 11:34PM   GLUCOSE-233* UREA N-8 CREAT-0.7 SODIUM-137
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-25 ANION GAP-17
[**2189-1-2**] 11:34PM   CALCIUM-9.7 PHOSPHATE-4.2 MAGNESIUM-2.1
[**2189-1-2**] 11:34PM   WBC-14.8* RBC-4.39 HGB-14.6 HCT-41.7 MCV-95
MCH-33.3* MCHC-35.1* RDW-13.4
[**2189-1-2**] 11:34PM   PLT COUNT-441*
[**2189-1-3**] 07:05PM   [**Doctor First Name **]-POSITIVE TITER-1:80  [**Last Name (un) **]
[**2189-1-3**] 07:05PM   RHEU FACT-9 CRP-8.3*
[**2189-1-3**] 07:05PM   C3-145 C4-22
[**2189-1-3**] 07:05PM   SED RATE-12

<br>
CTA head and neck [**2189-1-3**]:   The non-contrast CT scan
demonstrates diffuse subarachnoid hemorrhage over the
convexities with normal appearance of the basal cisterns.

The CTA examination demonstrates mild atheromatous disease at
the right common carotid bifurcation, and otherwise appears
normal.

<br>
Cerebral angiogram [**2189-1-3**]:
IMPRESSION:
1.  No evidence of an aneurysm or a vascular malformation.
2.  Foci of stenosis in both posterior cerebral arteries and
their branches.  This may be related to vasculitis or focal
spasm.  While atherosclerosis may also be considered, there is
no
evidence of atherosclerosis elsewhere in the interrogated
vasculature.
3.  Anterior communicating artery is not visualized, likely
representing aplasia or hypoplasia.

<br>
MRI HEAD [**2189-1-4**]:
1. Diffuse subarachnoid hemorrhage, consistent with 12/29 CTA
head.

2. Scattered subcortical acute infarcts located bilaterally in
the cerebral and cerebellar hemispheres, of unclear etiology.

3. No findings of demyelinating disease.

<br>
CT HEAD [**2188-1-9**]:
Unchanged mild subarachnoid hemorrhage with no new bleeding or
fracture.


Brief Hospital Course:
Ms. [**Known lastname **] is a 48-year-old woman with a history of migraine
headaches, hypertension, cervical and lumbar spondylosis, and
depression who presented with headache. Prior to admission, she
had had a CT that showed small foci of subarachnoid hemorrhage.
A cerebral angiogram revealed no aneurysm, but concern for  foci
of stenosis in both posterior cerebral arteries and their
branches that could
be related to vasculitis or focal spasm. Vasculitis was ruled
out with a normal ESR (12). The presentation was consistent with
Call-[**Doctor Last Name 8271**] Syndrome, or reversible cerebral artery
vasoconstriction. This was confirmed with serial transcranial
dopplers demonstrating increased velocities. She was started on
high doses of Verapamil. Although doses as high as 720 mg per
day have been used, she did well with only 600 mg, and tolerated
this dose without side effect. Her TCD on the day of discharge
showed markedly improved velocities, suggesting improvement of
her vasospasm.

Her headache persisted, although improved to the point that she
was able to perform banking and other routine online chores from
her hospital bed. Her pain regimen was unchanged; see discharge
medications. Her gait initially appeared somewhat unsteady, but
she was able to walk with a narrow base. PT was eventually able
to clear her for discharge home.


Medications on Admission:
Outpatient:
-Cymbalta 20 (Depression)
-Fentora 600 mg PRN (Pain)
-Verapamil 20 QD (HTN)
-Opana 40 [**Hospital1 **] (Pain)
-Baclofen 10 PRN (MS)
-Lyrica 40 QD (MS/Pain)


Discharge Medications:
1. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Baclofen 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*15 Adhesive Patch, Medicated(s)* Refills:*0*
9. Lyrica 200 mg Capsule Sig: One (1) Capsule PO qhs ().
Disp:*30 Capsule(s)* Refills:*0*
10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
Disp:*16 Tablet(s)* Refills:*0*
11. Verapamil 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QHS (once a day (at bedtime)).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
12. Verapamil 180 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
13. Outpatient Physical Therapy
Please provide physical therapy for stability and gait training.


Discharge Disposition:
Home With Service

Facility:
Mederi

Discharge Diagnosis:
Primary:
1. Call-[**Doctor Last Name 8271**] Syndrome (Reversible segmental vasoconstriction
of cerebral arteries)


Discharge Condition:
Good condition, slight headache, gait stable.


Discharge Instructions:
You have been evaluated for headache. You were found to have
Call-[**Doctor Last Name 8271**] Syndrome that caused small bleeding in your head.
Please take all medications as directed and keep all follow-up
appointments.

If you would like additional copies of your images and/or
discharge summary, you can call [**Hospital 18**] Medical Records at ([**Telephone/Fax (1) 76938**].

If you have any new symptoms such as vertigo, facial droop,
difficulty speaking, difficulty swallowing, one-sided weakness,
sensory loss, or any other symptom that is concerning to you,
please call your PCP or go to the nearest hospital emergency
department.

Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-7**] weeks after returning
home.

Please also call your neurologist, Dr. [**Last Name (STitle) 76939**], to be seen in
[**4-12**] weeks.

Finally, please call your Pain Specialist to be seen in [**2-9**]
weeks.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

Completed by:[**2189-1-12**]
{'Other specified disorders of arteries and arterioles,Subarachnoid hemorrhage,Malignant essential hypertension,Multiple sclerosis'}


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: Rule out vasculitis

PRESENT ILLNESS: 48 yo LH woman with a history of MS x 2 years, migraine
headaches, HTN, cervical and lumbar spondylosis, and depression
was in her USOH until [**12-27**], when she experienced an atypical
headache.  Her typical headaches in the past have typically been
left temporoparietal in distribution, occasional with radiation
to the front of the head and the neck.  They are severe [**10-16**],
stabbing in quality, and have lasted anywhere from 2 hrs. to 3
days in duration.  They often have associated photo- and
phonophobia.  She frequently has associated double vision in all
directions of gaze, even with each eye closed.  These headaches
improve while laying down in a dark room, and worsen with
Valsalva.

MEDICAL HISTORY: -Multiple sclerosis: Diagnosed 2 years ago in [**State 108**], was
started on Rebif at time of diagnosis, but stopped after 6 mos.
due to flu-like symptoms.  She reports that she has not seen her
neurologist since discontinuing this medication.
-Migraine
-Cervical/lumbar spondylosis
-HTN
-Depression
-Childhood asthma
-s/p hysterectomy
-s/p bronchoscopy for mass on CXR- results "indeterminate"

MEDICATION ON ADMISSION: Outpatient:
-Cymbalta 20 (Depression)
-Fentora 600 mg PRN (Pain)
-Verapamil 20 QD (HTN)
-Opana 40 [**Hospital1 **] (Pain)
-Baclofen 10 PRN (MS)
-Lyrica 40 QD (MS/Pain)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: V T 99.4 BP 146/89 HR 86 RR 13 SaO2 96% RA
General: well nourished, tired, but in no acute distress
HEENT: NC/AT, sclerae anicteric, MMM
Lungs: clear to auscultation
CV: regular rate and rhythm
Abdomen:  soft, non-tender, non-distended, bowel sounds present
Ext: cool bilaterally, non-palpable pedal pulses, but capillary
refill present, no edema
Skin: No rashes; brown nevus type lesion over posterior right
hip, ~1 cm in diameter

FAMILY HISTORY: Non-contributory per patient

SOCIAL HISTORY: Visiting family in [**State 350**] for holidays. [**State 108**] resident. 

### Response:
{'Other specified disorders of arteries and arterioles,Subarachnoid hemorrhage,Malignant essential hypertension,Multiple sclerosis'}
