CHIEF COMPLAINT: Difficulty focusing vision, frontal headache, disorientation

PRESENT ILLNESS: 78 yo RHM on Coumadin for porcine AVR in [**2114**], also pacemaker
for sick sinus syndrome. Quite functionally independent at
baseline and cognitively intact, living with wife. Was in his
USOH until 9 am today when he was driving back home and couldn't
seem to focus visually on the road. When he got home he
developed a R frontal headache. He normally has intact vision,
s/p cataract surgery. He noted that when he tried to read the
newspaper he "couldn't focus". He also felt "dizzy" by which he
means imbalanced when walking but did not fall. When his wife
came home she thought he seemed a little disoriented because he
couldn't see the chair she was pointing out to him, but it may
have been due to neglect. His INR had been 1.8-1.9 two weeks ago
so his Coumadin dose was increased at that time, and INR last
Friday was 2.5. He was brought to [**Location (un) 620**] ED where a NCHCT at
18h00 showed a large R parietal IPH with edema and mass effect
but no midline shift. Possible LUE numbness reported at OSH,
denies this currently. At [**Location (un) 620**] tx Profiline 2 vials and Vit K
5 mg at 19h00. INR decreased from 2.6 to 1.8. Currently
receiving 4 U FFP. ROS notable for baseline decreased auditory
acuity. No dysarthria or aphasia.

MEDICAL HISTORY: -porcine AVR [**2114**], at that time found to have arch
atherosclerosis but no coronary artery disease
-cardiac pacemaker ([**Company 1543**] Adapta), dominantly
ventricular-paced, for sick sinus syndrome
-ingunial hernia

MEDICATION ON ADMISSION: -Coumadin 5 mg po Mon-Wed-Fri, 2.5 mg poQday the other days
-HCTZ 25 mg Qday
-Simvastatin
-Cosopt and Xalatan eye gtts

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS: T 99.4 HR 62 paced BP 142/66 RR 18 sO2 100%on 4L nc O2
GEN: NAD
HEENT: mmm
NECK: no LAD; no carotid bruits; full range neck movements
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema

FAMILY HISTORY: No brain tumor, ICH, or vascular malformations

SOCIAL HISTORY: Lives with wife, no tobacco, 3 children, 1 son and daughter
present today
Intracerebral hemorrhage,Cerebral edema,Amyloidosis, unspecified,Sinoatrial node dysfunction,Long-term (current) use of anticoagulants,Heart valve replaced by transplant,Giant cell arteritis,Cardiac pacemaker in situ
Intracerebral hemorrhage,Cerebral edema,Amyloidosis NOS,Sinoatrial node dysfunct,Long-term use anticoagul,Heart valve transplant,Giant cell arteritis,Status cardiac pacemaker
Admission Date:  [**2116-10-26**]              Discharge Date:   [**2116-11-2**]

Date of Birth:  [**2037-11-4**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Difficulty focusing vision, frontal headache, disorientation


Major Surgical or Invasive Procedure:
None


History of Present Illness:
78 yo RHM on Coumadin for porcine AVR in [**2114**], also pacemaker
for sick sinus syndrome. Quite functionally independent at
baseline and cognitively intact, living with wife. Was in his
USOH until 9 am today when he was driving back home and couldn't
seem to focus visually on the road. When he got home he
developed a R frontal headache. He normally has intact vision,
s/p cataract surgery. He noted that when he tried to read the
newspaper he "couldn't focus". He also felt "dizzy" by which he
means imbalanced when walking but did not fall. When his wife
came home she thought he seemed a little disoriented because he
couldn't see the chair she was pointing out to him, but it may
have been due to neglect. His INR had been 1.8-1.9 two weeks ago
so his Coumadin dose was increased at that time, and INR last
Friday was 2.5. He was brought to [**Location (un) 620**] ED where a NCHCT at
18h00 showed a large R parietal IPH with edema and mass effect
but no midline shift. Possible LUE numbness reported at OSH,
denies this currently. At [**Location (un) 620**] tx Profiline 2 vials and Vit K
5 mg at 19h00. INR decreased from 2.6 to 1.8. Currently
receiving 4 U FFP. ROS notable for baseline decreased auditory
acuity. No dysarthria or aphasia.

ROS: denies any fever, chills, weight loss, neckpain, nausea,
vomiting, dysphagia, weakness, tingling, numbness, bowel-bladder
dysfunction, chest pain, shortness of breath, abdominal pain,
dysuria, hematuria, or bright red blood per rectum, rash, muscle
aches, joint pains.

Past Medical History:
-porcine AVR [**2114**], at that time found to have arch
atherosclerosis but no coronary artery disease
-cardiac pacemaker ([**Company 1543**] Adapta), dominantly
ventricular-paced, for sick sinus syndrome
-ingunial hernia


Social History:
Lives with wife, no tobacco, 3 children, 1 son and daughter
present today


Family History:
No brain tumor, ICH, or vascular malformations


Physical Exam:
VITALS: T 99.4 HR 62 paced BP 142/66 RR 18 sO2 100%on 4L nc O2
GEN: NAD
HEENT: mmm
NECK: no LAD; no carotid bruits; full range neck movements
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema

MENTAL STATUS:
Awake and alert, cooperative with exam, normal affect.
Oriented to place, month, day, and date, person.
Attention: mildly inattentive on DOWbw.
Memory: Registration: [**2-24**] items; Recall [**2-24**] at 5 min.
Language: fluent; Naming difficulties to low frequency objects;
Comprehension intact; no dysarthria, no paraphasic errors.
Prosody: normal. No Apraxia.
Dense L hemi-neglect: would not attend to any stimuli presented
to his L, did not even note his wife when she was standing to
that side, when shown his own L thumb stated it was mine.

CRANIAL NERVES:
II: L hemianopia. Pupils equally round and reactive to light
both directly and consensually, 3-->2 mm bilaterally.
III, IV, VI: Extraocular movements intact without nystagmus.
Mild L ptosis.
V: Facial sensation intact to light touch.
VII: Facial movement symmetrical; no facial droop.
VIII: Decreased auditory acuity bilat.
IX: Palate elevates in midline.
XII: Tongue protrudes in midline, no fasciculations.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.

MOTOR SYSTEM: Normal bulk and tone bilaterally. No adventitious
movements, no tremor, no asterixis. Strength full throughout. No
pronator drift.

REFLEXES: DTRs brisk [**Name2 (NI) 65749**] but symmetric, nml in UEs. L
plantar response extensor, R flexor.

SENSORY SYSTEM: Sensation intact to light touch and
proprioception in all extremities. Extinction to DSS.

COORDINATION: Nml FNF on R, some pastpointing with L hand, [**Doctor First Name **]
nml. No dysmetria.

GAIT: not evaluated

Pertinent Results:
LABS:

[**2116-10-26**] 08:15PM BLOOD WBC-7.5 RBC-3.80*# Hgb-12.5*# Hct-35.7*#
MCV-94 MCH-32.9* MCHC-35.0 RDW-13.6 Plt Ct-165
[**2116-11-2**] 06:40AM BLOOD WBC-7.3 RBC-3.69* Hgb-12.1* Hct-33.6*
MCV-91 MCH-32.9* MCHC-36.1* RDW-13.7 Plt Ct-175
[**2116-10-26**] 08:15PM BLOOD Neuts-69.6 Lymphs-19.9 Monos-8.3 Eos-1.9
Baso-0.2
[**2116-10-26**] 08:15PM BLOOD PT-19.0* PTT-22.8 INR(PT)-1.8*
[**2116-10-30**] 06:50AM BLOOD PT-13.4 PTT-21.3* INR(PT)-1.1
[**2116-10-31**] 11:10AM BLOOD ESR-60*
[**2116-10-26**] 08:15PM BLOOD Glucose-89 UreaN-16 Creat-1.0 Na-140
K-3.6 Cl-103 HCO3-30 AnGap-11
[**2116-11-2**] 06:40AM BLOOD Glucose-115* UreaN-26* Creat-1.2 Na-133
K-3.8 Cl-95* HCO3-28 AnGap-14
[**2116-10-26**] 11:46PM BLOOD CK(CPK)-120
[**2116-10-27**] 03:49AM BLOOD ALT-18 AST-26
[**2116-10-27**] 10:14AM BLOOD CK(CPK)-104
[**2116-10-27**] 05:02PM BLOOD CK(CPK)-96
[**2116-10-26**] 11:46PM BLOOD CK-MB-3
[**2116-10-27**] 10:14AM BLOOD CK-MB-2 cTropnT-<0.01
[**2116-10-28**] 03:19AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.0
[**2116-10-27**] 03:49AM BLOOD Cholest-162
[**2116-10-27**] 03:49AM BLOOD Triglyc-49 HDL-73 CHOL/HD-2.2 LDLcalc-79
[**2116-10-27**] 03:49AM BLOOD %HbA1c-6.1*
[**2116-10-27**] 03:49AM BLOOD TSH-0.92
[**2116-10-27**] 03:49AM BLOOD CRP-7.1*
[**2116-10-31**] 11:10AM BLOOD CRP-46.2*
[**2116-10-26**] 08:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2116-10-26**] 08:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2116-10-26**] 08:15PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0

MICRO:
Blood Cx ([**10-28**]): Pending
Urine Cx ([**10-28**]): No growth

IMAGING:
ECG ([**10-26**]): Sinus rhythm at a rate of 68. A-V conduction delay.
Compared to the previous tracing of [**2115-2-25**] the inferolateral
ST-T wave changes have improved.

CTA Head ([**10-26**]): IMPRESSION:
1 Stable in appearance 5 x 4 cm intraparenchymal hemorrhage of
the right
parietal lobe with mass effect and vasogenic edema and midline
shift of 1.5 mm that is unchanged from previous examination. No
evidence of arterial venous malformation or an underlying
lesion.
However, this hemorrhage may mask an underlying lesion, and
repeat imaging is recommended to follow up resolution and to
assess for an underlying mass or malformation.

CXR ([**10-27**]): FINDINGS: In comparison with the study of [**2115-3-27**],
there has been placement of a dual-channel pacemaker device,
with the leads in the region of the apex of the right ventricle
and the right atrium. Mild enlargement of the cardiac silhouette
without vascular congestion, pleural effusion, or acute
pneumonia.

CT Head ([**10-27**]): IMPRESSION:
1. Intraparenchymal hemorrhage within the right parietal lobe
that is largely unchanged in size and appearance from previous
examination from [**2116-10-26**]. No worsening mass effect. The
differential diagnosis for this lesion includes a hypertensive
hemorrhage, underlying lesion or arteriovenous malformation.
This intraparenchymal hemorrhage may mask an underlying lesion,
recommend repeat followup imaging to ensure resolution.

CT Head ([**10-28**]): IMPRESSION:
1. Right intraparenchymal hemorrhage within the right parietal
lobe that is largely unchanged in size and appearance from
previous examination from [**2116-10-27**]. No new hemorrhage, no
worsening mass effect, and no associated hydrocephalus. The
differential diagnosis for this hemorrhage includes amyloid
angiopathy, hypertensive hemorrhage, an underlying lesion, or
arteriovenous malformation.

Carotid Ultrasound ([**11-2**]): (prelim) 0% stenosis bilaterally

Brief Hospital Course:
The patient is a 78 year old man with a history of porcine AVR
in [**2114**] on Coumadin (for paroxysmal atrial fibrillation around
the time of the procedure) and sick sinus syndrome s/p PPM, who
presented to an OSH with difficulty focusing his vision, frontal
headache, and disorientation, who was found to have a large 5x4
cm intraparenchymal hemorrhage within the right parietal lobe
with surrounding vasogenic edema and local mass effect with
slight midline shift and compression of the right lateral
ventricle. His bp was 156/88 on admission to the OSH, and his
INR was 2.6. He received Profilnine IV x2 and Vitamin K 5 IV at
[**Location (un) 620**], and was transferred to [**Hospital1 18**] where he received 4 U FFP.
Neurosurgery was consulted on admission to [**Hospital1 18**], and
recommended keeping INR <1.3 and no neurosurgical intervention.
CTA Head showed stable in appearance 5 x 4 cm intraparenchymal
hemorrhage of the right parietal lobe with mass effect and
vasogenic edema and midline shift of 1.5 mm that is unchanged
from previous examination, no evidence of arterial venous
malformation or an underlying lesion.
It was thought that the most likely cause of his IPH was amyloid
angiopathy, but he could not get an MRI to confirm this
diagnosis because of his history of PPM. His Coumadin was
discontinued during this admission. The neurology team spoke
with his cardiologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 4105**]) who
agrees not starting ASA or restarting Coumadin given he is at
high risk to re-bleed. CEs: CK 120-104-96, TropT <0.01; FLP Chol
162, TG 49, HDL 73, LDL 79; HgA1c 6.1%; TSH 0.92, LFTs WNL. He
was continued on HCTZ 25 mg daily and Simvastatin 20 daily. His
blood pressure should remain SBP <160. His urine culture showed
no growth, and his blood culture was pending at the time of
discharge.
His CRP was 7.1 on admission, but the patient then started
complaining of headache and had tenderness to palpation of his
left temporal lobe. Repeat CRP was 46.2 and ESR 60. He was
determined to have temporal arteritis clinically, and was
started on Prednisone 60 daily for the next 3 months. Carotid
ultrasound showed 0% carotid stenosis bilaterally on preliminary
report. While in rehab, he should have FSBGs checked at least
daily while on Prednisone, and given an HISS as needed.
Contact: Daughter ([**First Name8 (NamePattern2) 2110**] [**Name (NI) 805**]) [**Telephone/Fax (1) 4105**] (w),
[**Telephone/Fax (1) 65750**] (c)

Medications on Admission:
-Coumadin 5 mg po Mon-Wed-Fri, 2.5 mg poQday the other days
-HCTZ 25 mg Qday
-Simvastatin
-Cosopt and Xalatan eye gtts

Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 months.
9. Medication
Humalog Insulin Sliding Scale


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]

Discharge Diagnosis:
Right parietal IPH, likely due to amyloid angiopathy
Temporal arteritis


Discharge Condition:
Left sided neglect, no dysarthria, tender to palpation of right
temporal region, extinction to DSS (tactile and visual)


Discharge Instructions:
You were admitted to the hospital with difficulty focusing
vision, frontal headache, and disorientation, and were found to
have a large right parietal hemorrhage. This is most likely due
to amyloid angiopathy. Your Coumadin was discontinued, as you
are at high risk to re-bleed.

The following changes were made to your medications: Your
Coumadin was discontinued. You were started on Prednisone 60 mg
daily for the next 3 months, given that you were found to have
temporal arteritis on exam.

If you develop weakness or numbness, difficulty speaking or
swallowing, decreased vision or blurry vision, or any other
symptoms that concern you, call your PCP or return to the ED.

Followup Instructions:
You have a follow up appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **]
([**Telephone/Fax (1) 2574**]) on [**2116-12-29**] at 1:30p in the [**Hospital Ward Name 23**] Center, [**Location (un) 6749**].


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
{'Intracerebral hemorrhage,Cerebral edema,Amyloidosis, unspecified,Sinoatrial node dysfunction,Long-term (current) use of anticoagulants,Heart valve replaced by transplant,Giant cell arteritis,Cardiac pacemaker in situ'}


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: Difficulty focusing vision, frontal headache, disorientation

PRESENT ILLNESS: 78 yo RHM on Coumadin for porcine AVR in [**2114**], also pacemaker
for sick sinus syndrome. Quite functionally independent at
baseline and cognitively intact, living with wife. Was in his
USOH until 9 am today when he was driving back home and couldn't
seem to focus visually on the road. When he got home he
developed a R frontal headache. He normally has intact vision,
s/p cataract surgery. He noted that when he tried to read the
newspaper he "couldn't focus". He also felt "dizzy" by which he
means imbalanced when walking but did not fall. When his wife
came home she thought he seemed a little disoriented because he
couldn't see the chair she was pointing out to him, but it may
have been due to neglect. His INR had been 1.8-1.9 two weeks ago
so his Coumadin dose was increased at that time, and INR last
Friday was 2.5. He was brought to [**Location (un) 620**] ED where a NCHCT at
18h00 showed a large R parietal IPH with edema and mass effect
but no midline shift. Possible LUE numbness reported at OSH,
denies this currently. At [**Location (un) 620**] tx Profiline 2 vials and Vit K
5 mg at 19h00. INR decreased from 2.6 to 1.8. Currently
receiving 4 U FFP. ROS notable for baseline decreased auditory
acuity. No dysarthria or aphasia.

MEDICAL HISTORY: -porcine AVR [**2114**], at that time found to have arch
atherosclerosis but no coronary artery disease
-cardiac pacemaker ([**Company 1543**] Adapta), dominantly
ventricular-paced, for sick sinus syndrome
-ingunial hernia

MEDICATION ON ADMISSION: -Coumadin 5 mg po Mon-Wed-Fri, 2.5 mg poQday the other days
-HCTZ 25 mg Qday
-Simvastatin
-Cosopt and Xalatan eye gtts

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS: T 99.4 HR 62 paced BP 142/66 RR 18 sO2 100%on 4L nc O2
GEN: NAD
HEENT: mmm
NECK: no LAD; no carotid bruits; full range neck movements
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema

FAMILY HISTORY: No brain tumor, ICH, or vascular malformations

SOCIAL HISTORY: Lives with wife, no tobacco, 3 children, 1 son and daughter
present today 

### Response:
{'Intracerebral hemorrhage,Cerebral edema,Amyloidosis, unspecified,Sinoatrial node dysfunction,Long-term (current) use of anticoagulants,Heart valve replaced by transplant,Giant cell arteritis,Cardiac pacemaker in situ'}
