CHIEF COMPLAINT: headache, vertigo

PRESENT ILLNESS: 69 year-old man with a history of hypertension, dyslipidemia,
atrial fibrillation (on baby aspirin), CAD, and s/p mitral valve
repair presents with sudden onset of headache and vertigo since
1:30 pm, and transferred here from an OSH for the finding of a
right cerebellar  and left occipital hypodensity on CT head.
The
patient was in his usual state of health until 1:30 pm
yesterday,
when he developed sudden onset of headache and vertigo.  The
headache was located frontally and occipitally and maximal [**10-12**]
at onset.  He states that it was alternatingly sharp and dull,
but constant over the past 30 hours.  It generally improved with
lying down and worsened with standing and coughing.  The pain
kept him awake overnight.  He vomited yesterday in association
with the headache and vertigo, but has had little appetite to
eat
since that time.

MEDICAL HISTORY: -Atrial fibrillation (Has not had this in quite some time, per
patient.  Cardiologist is Dr. [**Last Name (STitle) 27117**] of [**Location (un) 47**].)
-Hypertension
-Dyslipidemia
-Coronary artery disease
-s/p mitral valve replacement
-Chronic lumbar spine problems, s/p disc repair (fusion)
-GERD
-Kidney disease, unspecified
-s/p TURP
-s/p left ear surgery
-Left knee fracture with associated sensory disturbances below
the left knee

MEDICATION ON ADMISSION: -Aspirin 81 mg daily
-Simvastatin 20 mg qhs
-Tricor 145 mg daily
-Sotalol 80 mg [**Hospital1 **]
-Lisinopril 40 mg daily
-Amlodipine 10 mg daily
-Metoprolol 100 mg [**Hospital1 **]
-Omeprazole 40 mg daily
-Trazodone 100 mg qhs
-Ultram 50 mg TID prn pain
-Mirtazapine 30 mg qhs
-Nortriptyline 45 mg qhs
-Stool softener
-Calcium and Vitamin D supplement

ALLERGIES: Penicillins / Oxycontin

PHYSICAL EXAM: Vitals: T 98.0 F    BP 160/92   P 48    RR 16    SaO2 98 RA
General: NAD, disheveled elderly gentleman
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx,
edentulous
Neck: supple, no nuchal rigidity, no bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, no MMRG
Abdomen:  soft, non-tender, non-distended, bowel sounds present
Ext: warm, no edema, pedal pulses appreciated, toenails
overgrown
Skin: no rashes

FAMILY HISTORY: No stroke, denies family history of illness

SOCIAL HISTORY: Lives with son in [**Name (NI) 47**].  Has 10 pack year history of
tobacco use, but quit 40 years ago.  Has a history of alcohol
and
drug abuse, but has been sober for 15 years.  Denies history of
IVDU.
Cerebral artery occlusion, unspecified with cerebral infarction,Atrial fibrillation,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Heart valve replaced by other means,Esophageal reflux,Cerebral atherosclerosis
Crbl art ocl NOS w infrc,Atrial fibrillation,Hypertension NOS,Crnry athrscl natve vssl,Heart valve replac NEC,Esophageal reflux,Cerebral atherosclerosis
Admission Date:  [**2170-7-15**]              Discharge Date:   [**2170-7-20**]

Date of Birth:  [**2101-6-24**]             Sex:   M

Service: NEUROLOGY

Allergies:
Penicillins / Oxycontin

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
headache, vertigo

Major Surgical or Invasive Procedure:
none


History of Present Illness:
69 year-old man with a history of hypertension, dyslipidemia,
atrial fibrillation (on baby aspirin), CAD, and s/p mitral valve
repair presents with sudden onset of headache and vertigo since
1:30 pm, and transferred here from an OSH for the finding of a
right cerebellar  and left occipital hypodensity on CT head.
The
patient was in his usual state of health until 1:30 pm
yesterday,
when he developed sudden onset of headache and vertigo.  The
headache was located frontally and occipitally and maximal [**10-12**]
at onset.  He states that it was alternatingly sharp and dull,
but constant over the past 30 hours.  It generally improved with
lying down and worsened with standing and coughing.  The pain
kept him awake overnight.  He vomited yesterday in association
with the headache and vertigo, but has had little appetite to
eat
since that time.

With regard to the vertigo, he states that its onset arrived
with
the headache.  He noted the "room spinning" and it stopped after
a few minutes of lying down.  Like the headache, it seemed to
worsen with standing.  In fact, he states that the vertigo would
persist for as long as he assumed the standing position.

As his symptoms persisted, he went to [**Hospital **] Hospital for
further evaluation.  He reportedly had a normal CBC, CMP, and
EKG.  However, head CT showed a reported 4 cm right cerebellar
hypodensity with mass effect on the 4th ventricle and a smaller
possible left occipital hypodensity as well.  He was
subsequently
transferred to [**Hospital1 18**] for further evaluation and management.
Here
he has received Tylenol and compazine with improvement of his
headache to [**8-12**].  He has no vertigo while lying down still.

Review of Systems:
Son reports chronic problems with balance that have worsened
dramatically over the past day or so.  His speech is slurred at
baseline is now perhaps slightly more so, though his son is not
entirely sure.  Has chronic dry cough.  Otherwise, no vision or
auditory difficulties/abnormalities, difficulties with
comprehension, facial droop, dysphagia, numbness, tingling, or
weakness.


Past Medical History:
-Atrial fibrillation (Has not had this in quite some time, per
patient.  Cardiologist is Dr. [**Last Name (STitle) 27117**] of [**Location (un) 47**].)
-Hypertension
-Dyslipidemia
-Coronary artery disease
-s/p mitral valve replacement
-Chronic lumbar spine problems, s/p disc repair (fusion)
-GERD
-Kidney disease, unspecified
-s/p TURP
-s/p left ear surgery
-Left knee fracture with associated sensory disturbances below
the left knee


Social History:
Lives with son in [**Name (NI) 47**].  Has 10 pack year history of
tobacco use, but quit 40 years ago.  Has a history of alcohol
and
drug abuse, but has been sober for 15 years.  Denies history of
IVDU.


Family History:
No stroke, denies family history of illness


Physical Exam:
Vitals: T 98.0 F    BP 160/92   P 48    RR 16    SaO2 98 RA
General: NAD, disheveled elderly gentleman
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx,
edentulous
Neck: supple, no nuchal rigidity, no bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, no MMRG
Abdomen:  soft, non-tender, non-distended, bowel sounds present
Ext: warm, no edema, pedal pulses appreciated, toenails
overgrown
Skin: no rashes

Neurologic Examination:
Mental Status:
Awake and alert, able to relay coherent history, cooperative
with
exam, normal affect
Oriented to person, place, but thinks it is "[**2154-7-13**]"
Attention: can say months of year backward with one error (skips
[**Month (only) 958**])
Language: fluent, dysarthric speech, no paraphasic errors,
naming, comprehension, repetition intact
Calculation: can determine 7 quarters in $1.75
No evidence of apraxia or neglect

Cranial Nerves:
Fundoscopic exam difficult; Visual fields are full to
confrontation. Pupils equally round and reactive to light, 4 to
3
mm bilaterally.
Extraocular movements intact with exception of restricted
upgaze,
no nystagmus. Facial sensation intact bilaterally.  Facial
movement normal and symmetric.  Hearing intact to finger rub
bilaterally. Palate elevates midline.  Tongue protrudes midline,
no fasciculations.  Trapezii full strength bilaterally.

Motor:
Normal bulk throughout.  Increased tone versus poor relaxation
in
all four extremities.  Slight left pronator drift.  No tremor.
      D T B WE FiF [**Last Name (un) **] IP  Q  H  TA  [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] EDB
Right 5 5 5 5  5    5   5  5  5  5   5  4   4
Left  5 5 5 5  5    5   5  5  5  5   5  4   4

Sensation: Reduced PP below left knee.  Reduced vibration below
left ankle.  Reduced JPS to toes bilaterally.  Light touch and
cold sensation intact throughout.


Reflexes: B T Br Pa Pl
Right     3 3 3  3  0
Left      3 3 3  3  0
Toes were withdrawal bilaterally.

Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally. Normal cerebellar check reflex.  Has prominent
truncal ataxia upon sitting up.  Head thrust test negative.

Gait:  Slow initiation, wide-based requiring assistance,
extremely ataxic after just two steps.


Pertinent Results:
[**2170-7-18**] 10:50AM BLOOD WBC-9.6 RBC-4.07* Hgb-12.1* Hct-36.3*
MCV-89 MCH-29.7 MCHC-33.3 RDW-14.2 Plt Ct-296
[**2170-7-17**] 06:40AM BLOOD WBC-10.0 RBC-4.09* Hgb-12.3* Hct-36.0*
MCV-88 MCH-30.0 MCHC-34.2 RDW-14.2 Plt Ct-300
[**2170-7-16**] 03:24AM BLOOD WBC-9.1 RBC-4.24* Hgb-13.0* Hct-37.3*
MCV-88 MCH-30.7 MCHC-34.9 RDW-14.2 Plt Ct-324
[**2170-7-15**] 03:30PM BLOOD WBC-9.3 RBC-4.19* Hgb-12.6* Hct-37.2*
MCV-89 MCH-30.0 MCHC-33.8 RDW-14.2 Plt Ct-338
[**2170-7-15**] 03:30PM BLOOD Neuts-80.4* Lymphs-15.6* Monos-3.8
Eos-0.1 Baso-0.1
[**2170-7-18**] 10:50AM BLOOD Plt Ct-296
[**2170-7-17**] 06:40AM BLOOD Plt Ct-300
[**2170-7-17**] 06:40AM BLOOD PT-12.9 PTT-27.0 INR(PT)-1.1
[**2170-7-16**] 03:24AM BLOOD Plt Ct-324
[**2170-7-16**] 03:24AM BLOOD PT-12.8 PTT-24.6 INR(PT)-1.1
[**2170-7-15**] 04:15PM BLOOD PT-13.1 PTT-24.0 INR(PT)-1.1
[**2170-7-15**] 03:30PM BLOOD Plt Ct-338
[**2170-7-18**] 10:50AM BLOOD Glucose-117* UreaN-10 Creat-1.0 Na-143
K-4.2 Cl-110* HCO3-25 AnGap-12
[**2170-7-17**] 06:40AM BLOOD Glucose-105 UreaN-12 Creat-1.0 Na-142
K-3.3 Cl-107 HCO3-27 AnGap-11
[**2170-7-16**] 03:24AM BLOOD Glucose-98 UreaN-10 Creat-1.2 Na-145
K-4.8 Cl-111* HCO3-23 AnGap-16
[**2170-7-15**] 03:30PM BLOOD Glucose-128* UreaN-10 Creat-1.0 Na-143
K-4.0 Cl-107 HCO3-24 AnGap-16
[**2170-7-16**] 03:24AM BLOOD CK(CPK)-484*
[**2170-7-15**] 03:30PM BLOOD ALT-10 AST-18 LD(LDH)-171 CK(CPK)-154
AlkPhos-38* TotBili-0.5
[**2170-7-16**] 03:24AM BLOOD CK-MB-5 cTropnT-<0.01
[**2170-7-15**] 05:31PM BLOOD cTropnT-<0.01
[**2170-7-18**] 10:50AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.9
[**2170-7-17**] 06:40AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.8
[**2170-7-16**] 03:24AM BLOOD Calcium-9.5 Phos-2.8 Mg-2.0 Cholest-165
[**2170-7-15**] 03:30PM BLOOD Albumin-4.3
[**2170-7-16**] 03:24AM BLOOD %HbA1c-5.7
[**2170-7-16**] 03:24AM BLOOD Triglyc-151* HDL-44 CHOL/HD-3.8
LDLcalc-91
[**2170-7-15**] 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Brief Hospital Course:
This 69 yo M was transferred from OSH for monitoring of his new
right cerebellar infarct, which was substantial in size. He was
monitored in the ICU for 48 hours and where serial CT and MR
studies of the brain showed stable infarct and edema. He was
then transferred to the general stroke floor. There, pt's
vertigo had resolved with no evidence of nystagmus on physical
exam, however headache persisted intermittently. Pt's speech
remained dysarthric and quite difficult to understand, however,
per pt's son, this is his baseline.  Coumadin was held for 72
hours for concern of cerebellar hemorhage risk, and was then
resumed at 72 hours.  He is still subtherapeutic and will need
serial PT/INR to titrate for goal of [**2-4**].

    Pt had had a questionable hx of Afib in the past, and this
was confirmed when pt had a limited episode of AF over the night
of [**7-17**]. Over this same night, pt had an episode of transient
desaturation to ~90%, and there was concern for aspiration, so
he was made NPO with a subsequent bedside swallow eval which was
equivocal for aspiration. video swallow eval was ordered.
    Pt continued to work with PT/OT during his inpatient
admission and was referred to subacute rehab for further mgmt.

Medications on Admission:
-Aspirin 81 mg daily
-Simvastatin 20 mg qhs
-Tricor 145 mg daily
-Sotalol 80 mg [**Hospital1 **]
-Lisinopril 40 mg daily
-Amlodipine 10 mg daily
-Metoprolol 100 mg [**Hospital1 **]
-Omeprazole 40 mg daily
-Trazodone 100 mg qhs
-Ultram 50 mg TID prn pain
-Mirtazapine 30 mg qhs
-Nortriptyline 45 mg qhs
-Stool softener
-Calcium and Vitamin D supplement


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H prn as
needed for pain or fever.
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
to be stopped when INR therapeutic on coumadin.
4. Aspirin
Please stop patient's Aspirin when INR becomes therapeutic to
[**2-4**] on coumadin.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day):
hold for SBP < 100 or HR < 50.
13. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)): titrate for goal INR of [**2-4**].
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea: PRN N/V.
16. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1)
Injection Q6 hrs prn as needed: HA or N/V.


Discharge Disposition:
Extended Care

Facility:
-

Discharge Diagnosis:
right cerebellar stroke


Discharge Condition:
stable


Discharge Instructions:
You have had a stroke. In order to prevent recurrance of stroke,
it is important to modify your risk factors. You have been
placed on coumadin, an antithrombotic [**Doctor Last Name 360**], in order to thin
your blood.  Please return to the ER if you experience any
sudden weakness, change in sensation, visual change, headache,
change in speech, or anything else that concerns you seriously.

Followup Instructions:
follow up with PMD: [**Last Name (LF) 162**],[**First Name3 (LF) **] [**Telephone/Fax (1) 24107**]

neurological follow up with Dr. [**Last Name (STitle) **]: [**Telephone/Fax (1) 1694**].


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



Name:  [**Known lastname 12794**],[**Known firstname 126**]                 Unit No:   [**Numeric Identifier 12795**]

Admission Date:  [**2170-7-15**]              Discharge Date:   [**2170-7-20**]

Date of Birth:  [**2101-6-24**]             Sex:   M

Service: NEUROLOGY

Allergies:
Penicillins / Oxycontin

Attending:[**First Name3 (LF) 608**]
Addendum:
[**Hospital **] transfer to rehabilitation delayed for hypertension.
Appeared that some degree of hypertension was anxiety related,
but also had had some antihypertensives held for acute stroke.
Increased Sotalol to baseline dose of 80 [**Hospital1 **] and resumed
Lisinopril 40mg daily.  Patient's blood pressure responded
appropriately and had SBP 150s prior to discharge.  No other
events during his additional 24 hr stay.

Past Medical History:
-Atrial fibrillation (Has not had this in quite some time, per
patient.  Cardiologist is Dr. [**Last Name (STitle) 12796**] of [**Location (un) 4887**].)
-Hypertension
-Dyslipidemia
-Coronary artery disease
-s/p mitral valve replacement
-Chronic lumbar spine problems, s/p disc repair (fusion)
-GERD
-Kidney disease, unspecified
-s/p TURP
-s/p left ear surgery
-Left knee fracture with associated sensory disturbances below
the left knee


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H prn as
needed for pain or fever.
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
to be stopped when INR therapeutic on coumadin.
4. Aspirin
Please stop patient's Aspirin when INR becomes therapeutic to
[**2-4**] on coumadin.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)): titrate for goal INR of [**2-4**].
13. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea: PRN N/V.
14. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1)
Injection Q6 hrs prn as needed: HA or N/V.
15. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. Medications
Patient will need to be gradually restarted on Lopressor 100
[**Hospital1 **], and Norvasc 10 daily.  These were held briefly for his
stroke, but can now be resumed should his pressures tolerate.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) **] hills

                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**]

Completed by:[**2170-7-20**]
{'Cerebral artery occlusion, unspecified with cerebral infarction,Atrial fibrillation,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Heart valve replaced by other means,Esophageal reflux,Cerebral atherosclerosis'}


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: headache, vertigo

PRESENT ILLNESS: 69 year-old man with a history of hypertension, dyslipidemia,
atrial fibrillation (on baby aspirin), CAD, and s/p mitral valve
repair presents with sudden onset of headache and vertigo since
1:30 pm, and transferred here from an OSH for the finding of a
right cerebellar  and left occipital hypodensity on CT head.
The
patient was in his usual state of health until 1:30 pm
yesterday,
when he developed sudden onset of headache and vertigo.  The
headache was located frontally and occipitally and maximal [**10-12**]
at onset.  He states that it was alternatingly sharp and dull,
but constant over the past 30 hours.  It generally improved with
lying down and worsened with standing and coughing.  The pain
kept him awake overnight.  He vomited yesterday in association
with the headache and vertigo, but has had little appetite to
eat
since that time.

MEDICAL HISTORY: -Atrial fibrillation (Has not had this in quite some time, per
patient.  Cardiologist is Dr. [**Last Name (STitle) 27117**] of [**Location (un) 47**].)
-Hypertension
-Dyslipidemia
-Coronary artery disease
-s/p mitral valve replacement
-Chronic lumbar spine problems, s/p disc repair (fusion)
-GERD
-Kidney disease, unspecified
-s/p TURP
-s/p left ear surgery
-Left knee fracture with associated sensory disturbances below
the left knee

MEDICATION ON ADMISSION: -Aspirin 81 mg daily
-Simvastatin 20 mg qhs
-Tricor 145 mg daily
-Sotalol 80 mg [**Hospital1 **]
-Lisinopril 40 mg daily
-Amlodipine 10 mg daily
-Metoprolol 100 mg [**Hospital1 **]
-Omeprazole 40 mg daily
-Trazodone 100 mg qhs
-Ultram 50 mg TID prn pain
-Mirtazapine 30 mg qhs
-Nortriptyline 45 mg qhs
-Stool softener
-Calcium and Vitamin D supplement

ALLERGIES: Penicillins / Oxycontin

PHYSICAL EXAM: Vitals: T 98.0 F    BP 160/92   P 48    RR 16    SaO2 98 RA
General: NAD, disheveled elderly gentleman
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx,
edentulous
Neck: supple, no nuchal rigidity, no bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, no MMRG
Abdomen:  soft, non-tender, non-distended, bowel sounds present
Ext: warm, no edema, pedal pulses appreciated, toenails
overgrown
Skin: no rashes

FAMILY HISTORY: No stroke, denies family history of illness

SOCIAL HISTORY: Lives with son in [**Name (NI) 47**].  Has 10 pack year history of
tobacco use, but quit 40 years ago.  Has a history of alcohol
and
drug abuse, but has been sober for 15 years.  Denies history of
IVDU. 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Atrial fibrillation,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Heart valve replaced by other means,Esophageal reflux,Cerebral atherosclerosis'}
