CHIEF COMPLAINT: Vertigo, N/V

PRESENT ILLNESS: 53 year old male with h/o RCC s/p left partial nephrectomy, HTN,
and obesity who was transferred from [**Hospital3 4298**] for
evaluation of vertigo, nausea, and vomiting with abnormal OSH CT
head results.

MEDICAL HISTORY: HTN
Obesity
?OSA (reports heavy snoring and periods of apnea)
Renal cell carcinoma with left partial nephrectomy [**2111**]
Tobacco Use

MEDICATION ON ADMISSION: Avalide (irbesartan/HCTZ) 300mg/??mg po daily
Prostate medication (?doxazosin?)
ASA 81mg po daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission Physical:
VS: 96.3 176/90 72 20 96%2L
GEN: Awake, obese gentleman lying still in bed
HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout anteriorly
CV: RR, S1 and S2 wnl, no m/r/g
ABD: Soft, obese, +BS, NT, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: No rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.  Mild difficulty
with finger to nose but patient not cooperative with exam.
2+DTR's-patellar and biceps, downgoing toes.  3-4 beats
horizontal nystagmus, worse on leftward gaze.

FAMILY HISTORY: Mother still living and healthy, father died of lung cancer.

SOCIAL HISTORY: Works in an office in [**Location (un) 7349**].  Smokes 1ppd x 40 years.  Drinks
average of 0-1drink/week, last drink yesterday afternoon.
Denies other drug use.  Lives alone.  Has daughter.
Cerebral embolism with cerebral infarction,Acidosis,Obesity hypoventilation syndrome,Obstructive sleep apnea (adult)(pediatric),Nausea with vomiting,Personal history of malignant neoplasm of kidney,Acquired absence of kidney,Tobacco use disorder,Nystagmus, unspecified,Dizziness and giddiness,Lack of coordination,Need for prophylactic vaccination and inoculation against influenza
Crbl emblsm w infrct,Acidosis,Obesity hypovent synd,Obstructive sleep apnea,Nausea with vomiting,Hx of kidney malignancy,Acquired absence kidney,Tobacco use disorder,Nystagmus NOS,Dizziness and giddiness,Lack of coordination,Vaccin for influenza
Admission Date:  [**2115-9-25**]              Discharge Date:   [**2115-10-4**]

Date of Birth:  [**2062-8-13**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Vertigo, N/V

Major Surgical or Invasive Procedure:
none


History of Present Illness:
53 year old male with h/o RCC s/p left partial nephrectomy, HTN,
and obesity who was transferred from [**Hospital3 4298**] for
evaluation of vertigo, nausea, and vomiting with abnormal OSH CT
head results.

He reports going on vacation to [**Hospital3 4298**] this week
(lives in [**Location 7349**]) to play golf.  He woke up in the middle of the
night at 3am last night and when he got up, he noted loss of
balance and leaning to the left.  He experienced nausea and
vertigo and needed to hold onto the walls to get to the
restroom.  He then went back to sleep and had another episode of
nausea, vomiting vertigo and lightheadedness at 7am.  He then
went back to sleep and felt in his usual state of health at
11am.  He then went outside and had a third episode and called
911.  At the OSH, vitals were 181/90, 60, 18, 97.4, O2 Sat
92%RA.  CT head showed a possible left cerebellar infarct and he
was transferred to [**Hospital1 18**].  He was given 5mg IV valium, Antivert,
and Zofran and was transferred to [**Hospital1 18**].

In the [**Hospital1 18**] ED, he was seen by neurology and underwent CTA
head.  Neurology recommended MRI brain with and without contrast
and recommended admission to medicine for hypercarbia and workup
of his leukocytosis.  He was hypercarbic with a PCO2 65 with O2
sat 88%RA that corrected to 95% on 2L.  He was sleepy but
arousable and was tried on Bipap but he did not tolerate it.
Vitals on transfer T 97.9 HR 73 BP 154/77 RR 20 96%2L

Review of systems: Negative for fever, chills, night sweats,
chest pain, shortness of breath, abdominal pain, diarrhea,
constipation, urianry changes, rashes, headaches, weakness,
numbness, changes in vision, changes in speech, difficulty
swallowing.


Past Medical History:
HTN
Obesity
?OSA (reports heavy snoring and periods of apnea)
Renal cell carcinoma with left partial nephrectomy [**2111**]
Tobacco Use

Social History:
Works in an office in [**Location (un) 7349**].  Smokes 1ppd x 40 years.  Drinks
average of 0-1drink/week, last drink yesterday afternoon.
Denies other drug use.  Lives alone.  Has daughter.

Family History:
Mother still living and healthy, father died of lung cancer.


Physical Exam:
Admission Physical:
VS: 96.3 176/90 72 20 96%2L
GEN: Awake, obese gentleman lying still in bed
HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout anteriorly
CV: RR, S1 and S2 wnl, no m/r/g
ABD: Soft, obese, +BS, NT, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: No rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.  Mild difficulty
with finger to nose but patient not cooperative with exam.
2+DTR's-patellar and biceps, downgoing toes.  3-4 beats
horizontal nystagmus, worse on leftward gaze.

Discharge Physical:
General exam normal. Neuro exam, continues to vomit on sitting
upright, Subtle left rebound, no overshooting, no other
cerebellar signs.

Pertinent Results:
EKG: Normal sinus rhythm with rate 70, normal axis, normal
intervals

Telemetry: normal sinus, episodes of bradycardia overnight while
asleep, pauses 3-4 seconds.

CT Head at OSH: Subtle hypodensity in left PICA territory is
concerning for an acute infarction.  Additional, small bilateral
cerebellar hypodensities are liekly subacute to chronic
infarcts.

CTA Head/Neck [**9-25**]: (Wet Read): C- head: no acute findings. CTA:
limited evaluation of the proximal vertebral arteries due to
streak, but mid and distal verts appear normal. normal carotids.
normal COW without aneurysm, dissection or stenosis. Tracheal
secretions put pt at risk for aspiration.

MRI BRAIN:
Bilateral PICA territory infarcts, dominant on the left. Embolic
etiology is most likely.

CXR: Mild cardiomegaly. Otherwise, grossly unremarkable. No
overt CHF
or evidence of pneumonia.


TTE:
The left atrium is mildly dilated. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. The aortic
root is mildly dilated at the sinus level. The ascending aorta
is mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.

TEE:
Simple plaque in aortic arch and descending aorta. No
intracardiac thrombus seen. No ASD/PFO seen with 2D, color, or
maneuvers.

LABORATORY STUDIES:

[**2115-9-25**] 06:40PM BLOOD WBC-15.4* RBC-4.31* Hgb-13.2* Hct-38.4*
MCV-89 MCH-30.7 MCHC-34.5 RDW-14.3 Plt Ct-273
[**2115-9-28**] 05:15AM BLOOD WBC-11.1* RBC-4.62 Hgb-13.9* Hct-42.4
MCV-92 MCH-30.1 MCHC-32.8 RDW-14.3 Plt Ct-274
Neuts-90.2* Lymphs-7.5* Monos-1.9* Eos-0.2 Baso-0.2

PT-11.5 PTT-24.0 INR(PT)-1.0

Glucose-104* UreaN-9 Creat-0.7 Na-143 K-3.7 Cl-103 HCO3-32
AnGap-12

ALT-15 AST-17 AlkPhos-93 TotBili-0.3

cTropnT-<0.01

Calcium-8.3* Phos-2.8 Mg-2.0

Cholest-201*
Triglyc-160* HDL-42 CHOL/HD-4.8 LDLcalc-127

%HbA1c-5.9 eAG-123

SERUM TOX: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG

[**2115-9-27**] 03:11PM BLOOD Lactate-0.9

ABG
  Type-ART FiO2-21 pO2-62* pCO2-56* pH-7.40 calTCO2-36* Base
XS-7 Intubat-NOT INTUBA

UA
 Color-Yellow Appear-Clear Sp [**Last Name (un) **]-<=1.005
 Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR
Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
 RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0

MICRO:
BLOOD, URINE CX NEG
LYME TITERS NEG

Brief Hospital Course:
53 year old male with h/o RCC s/p left partial nephrectomy, HTN,
and obesity who was transferred from [**Hospital3 4298**] for
evaluation of vertigo, nausea, and vomiting with abnormal OSH CT
head results. Found to have acute cerebellar infarct.

NEURO:
Patient was transferred to [**Hospital1 18**] for what was thought to be
cerebellar infarct on OSH head CT. This was confirmed on repeat
head CT. On initial neuro evaluation, patient had nystagmus on
leftward gaze and severe N/V on positional changes. He then
developed facial numbness the following morning, and he was
hypertensive and bradycardic. Repeat head CT did show mild
worsening of mass effect. It was unlikely that he was developing
Cushings triad, but he was transferred to step up unit for
frequent neuro checks and BP control.
Extensive workup for stroke etiology was negative. CTA showed
normal vessels. TTE and then TEE showed no cardioembolic source
or PFO. There was likely a local plaque that caused emboli, but
was not seen on our investigation.
Patient was treated with aspirin and simvastatin for stroke
prevenetion. HbA1c showed no evidence of diabetes.
He will neurology follow up as an outpatient near his home.

CV:
Patient was hypertensive throughout course. HTN was worst at
night due to OSA. Patient was continued on home HCTZ, [**Last Name (un) **].
Amlodipine was added initially. However, pt had asymptomatic
bradycardia while sleeping likely due to OSA as well, and there
was concern about nodal blockers. He was therefore discharged on
lisinopril. He should follow up with PCP for HTN control.

PULM:
Patient has severe OSA and obesity hypoventilation sndrome. He
has a long smoking history, but no clear evidence of COPD. On
admission, he was hypercarbic with pCO2 60, and at this time his
mental status was lethargic. Pulmonary was consulted. ABG showed
adequate compensation. Patient was placed on BIPAP with good
results. He required BIPAP overnight due to OSA. He will need
outpatient sleep study, mask fitting clinic, and pulmonary
follow up. Since patient is from out of state, he will need to
arrange for this locally.

ID:
Had elevated WBC to 15.2 with left shift on admission with no
localizing symptoms and no lab/imaging evidence of infection.
Can see leukocytosis as stress response in setting of stroke. It
trended down and he remained afebrile.

# Code:  Full code, confirmed


Medications on Admission:
Avalide (irbesartan/HCTZ) 300mg/??mg po daily
Prostate medication (?doxazosin?)
ASA 81mg po daily

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Avalide 300-25 mg Tablet Sig: One (1) Tablet PO once a day.
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Extended Care

Facility:
[**Hospital 84680**] Hospital

Discharge Diagnosis:
cerebellar stroke
obstructive sleep apnea
hypertension


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurologic Status: positional vomiting, otherwise essentially
normal exam


Discharge Instructions:
You were admitted with a large left cerebellar stroke. You
underwent an extensive workup for the source of this stroke.
Imaging of the blood vessels to the brain, echocardiogram of the
heart, and transesophageal echocardiogram, were normal.
You were found to have severe obstructive sleep apnea. This is a
dangerous disease that causes decreased oxygen levels, high
blood pressure and increases your risk for stroke and death. You
need to set up a sleep study and be fitted for a CPAP mask.
Please call your primary care physician to set up an appointment
with a pulmonologist in your area.
You were treated with aspirin and simvastatin, which helps to
prevent strokes.
You should follow up with a neurologist in your area.

You were also found to have high blood pressure. You were stared
on lisinopril.

Followup Instructions:
You should follow up with your primary care for hypertension,
with a neurologist, and with a pulmonologist.
{'Cerebral embolism with cerebral infarction,Acidosis,Obesity hypoventilation syndrome,Obstructive sleep apnea (adult)(pediatric),Nausea with vomiting,Personal history of malignant neoplasm of kidney,Acquired absence of kidney,Tobacco use disorder,Nystagmus, unspecified,Dizziness and giddiness,Lack of coordination,Need for prophylactic vaccination and inoculation against influenza'}


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: Vertigo, N/V

PRESENT ILLNESS: 53 year old male with h/o RCC s/p left partial nephrectomy, HTN,
and obesity who was transferred from [**Hospital3 4298**] for
evaluation of vertigo, nausea, and vomiting with abnormal OSH CT
head results.

MEDICAL HISTORY: HTN
Obesity
?OSA (reports heavy snoring and periods of apnea)
Renal cell carcinoma with left partial nephrectomy [**2111**]
Tobacco Use

MEDICATION ON ADMISSION: Avalide (irbesartan/HCTZ) 300mg/??mg po daily
Prostate medication (?doxazosin?)
ASA 81mg po daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission Physical:
VS: 96.3 176/90 72 20 96%2L
GEN: Awake, obese gentleman lying still in bed
HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout anteriorly
CV: RR, S1 and S2 wnl, no m/r/g
ABD: Soft, obese, +BS, NT, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: No rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.  Mild difficulty
with finger to nose but patient not cooperative with exam.
2+DTR's-patellar and biceps, downgoing toes.  3-4 beats
horizontal nystagmus, worse on leftward gaze.

FAMILY HISTORY: Mother still living and healthy, father died of lung cancer.

SOCIAL HISTORY: Works in an office in [**Location (un) 7349**].  Smokes 1ppd x 40 years.  Drinks
average of 0-1drink/week, last drink yesterday afternoon.
Denies other drug use.  Lives alone.  Has daughter. 

### Response:
{'Cerebral embolism with cerebral infarction,Acidosis,Obesity hypoventilation syndrome,Obstructive sleep apnea (adult)(pediatric),Nausea with vomiting,Personal history of malignant neoplasm of kidney,Acquired absence of kidney,Tobacco use disorder,Nystagmus, unspecified,Dizziness and giddiness,Lack of coordination,Need for prophylactic vaccination and inoculation against influenza'}
