CHIEF COMPLAINT: Headache in the setting of dehydration (significant nausea and
vomiting)

PRESENT ILLNESS: PER ADMITTING RESIDENT:
The pt is a  47 y/o RHW with a history of UC (no current
flare) presented with HA x days.
She states that on Monday night she suffered from diarrhea and
vomiting x 24 hours, on Wed morning she awoke with a headache
worse on the right side associated with right eye pain. The pain
was getting gradually worse, aggravated by activity. Because of
the pain she showed up in the ED. Here her only complaints are
headache and right eye pain. She notes no other problems, no
weakness, no fever, chills, no current nasuea or vomiting, chest
pain, SOB, palpitations, pain in her extremities, diplopia, or
numbness. No neck pain

MEDICAL HISTORY: Ulcerative colitis (well controlled, not currently medicated)

MEDICATION ON ADMISSION: - None

ALLERGIES: Penicillins / Heparin Agents

PHYSICAL EXAM: On Admission:
Vitals: 98.8 62 116/72 16 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: No edema or deformities.
Skin: no rashes or lesions noted.

FAMILY HISTORY: father had DM and died of complications from such.

SOCIAL HISTORY: no drugs, etoh, smoking
Phlebitis and thrombophlebitis of intracranial venous sinuses,Subarachnoid hemorrhage,Cerebral edema,Third or oculomotor nerve palsy, partial,Ulcerative colitis, unspecified,Hemiplegia, unspecified, affecting unspecified side,Ostium secundum type atrial septal defect,Other facial nerve disorders,Muscle weakness (generalized),Iron deficiency anemia, unspecified,Diarrhea,Abnormal coagulation profile
Phlebitis intrcran sinus,Subarachnoid hemorrhage,Cerebral edema,Partial third nerv palsy,Ulceratve colitis unspcf,Unsp hemiplga unspf side,Secundum atrial sept def,Facial nerve dis NEC,Muscle weakness-general,Iron defic anemia NOS,Diarrhea,Abnrml coagultion prfile
Admission Date:  [**2115-2-1**]              Discharge Date:   [**2115-2-20**]

Date of Birth:  [**2067-10-31**]             Sex:   F

Service: NEUROLOGY

Allergies:
Penicillins / Heparin Agents

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Headache in the setting of dehydration (significant nausea and
vomiting)

Major Surgical or Invasive Procedure:
Decompressive right hemicraniectomy with partial right temporal
lobectomy


History of Present Illness:
PER ADMITTING RESIDENT:
The pt is a  47 y/o RHW with a history of UC (no current
flare) presented with HA x days.
She states that on Monday night she suffered from diarrhea and
vomiting x 24 hours, on Wed morning she awoke with a headache
worse on the right side associated with right eye pain. The pain
was getting gradually worse, aggravated by activity. Because of
the pain she showed up in the ED. Here her only complaints are
headache and right eye pain. She notes no other problems, no
weakness, no fever, chills, no current nasuea or vomiting, chest
pain, SOB, palpitations, pain in her extremities, diplopia, or
numbness. No neck pain


Past Medical History:
Ulcerative colitis (well controlled, not currently medicated)

Social History:
no drugs, etoh, smoking


Family History:
father had DM and died of complications from such.


Physical Exam:
On Admission:
Vitals: 98.8 62 116/72 16 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: No edema or deformities.
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: Alert, oriented x 3.  Able to relate history
without difficulty. Language is fluent with intact repetition
and
comprehension.  There were no paraphasic errors.   Speech was
not
dysarthric. Able to follow both midline and appendicular
commands.   There was no evidence of apraxia or neglect or
graphesthesia.

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.  VFF to confrontation.
III, IV, VI: EOMI without nystagmus.  Normal saccades.
V: Facial sensation intact to light touch.
VII: left NL fold flat at rest.
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. No pronator drift
bilaterally.
No  tremor, asterixis noted.
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L  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

-Sensory: No deficits to light touch, cold sensation,
proprioception throughout. No extinction to DSS (touch).

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  1  0    0    0   0
R  1  0    0    0   0
Plantar response was flexor bilaterally.

-Coordination:  No dysmetria on FNF bilaterally.

....
On DISCHARGE: ?

Pertinent Results:
Admission Labs:
[**2115-2-1**] 09:15PM BLOOD WBC-12.1* RBC-4.49 Hgb-9.6* Hct-32.2*
MCV-72* MCH-21.4* MCHC-29.9* RDW-18.5* Plt Ct-392
[**2115-2-1**] 09:15PM BLOOD PT-12.2 PTT-23.3* INR(PT)-1.1
[**2115-2-2**] 03:15AM BLOOD ESR-29*
[**2115-2-2**] 03:26PM BLOOD Sickle-NEG
[**2115-2-2**] 03:15AM BLOOD Fibrino-450*
[**2115-2-2**] 09:30AM BLOOD ACA IgG-2.5 ACA IgM-6.0
[**2115-2-2**] 03:26PM BLOOD Lupus-NEG
[**2115-2-2**] 03:26PM BLOOD AT-93 ProtCFn-100 ProtSFn-58
[**2115-2-2**] 03:26PM BLOOD ACA IgG-2.7 ACA IgM-6.0
[**2115-2-1**] 09:15PM BLOOD Glucose-85 UreaN-7 Creat-0.7 Na-139 K-3.7
Cl-102 HCO3-23 AnGap-18
[**2115-2-9**] 05:00AM BLOOD ALT-52* AST-26 LD(LDH)-198 AlkPhos-35
TotBili-0.2
[**2115-2-6**] 12:58AM BLOOD CK-MB-1 cTropnT-<0.01
[**2115-2-6**] 05:20AM BLOOD CK-MB-1 cTropnT-<0.01
[**2115-2-9**] 03:53PM BLOOD CK-MB-1 cTropnT-<0.01
[**2115-2-2**] 03:15AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.0 Cholest-165
[**2115-2-3**] 03:47AM BLOOD calTIBC-335 Ferritn-13 TRF-258
[**2115-2-2**] 03:26PM BLOOD D-Dimer-1100*
[**2115-2-2**] 03:15AM BLOOD %HbA1c-5.6 eAG-114
[**2115-2-2**] 03:15AM BLOOD Triglyc-85 HDL-50 CHOL/HD-3.3 LDLcalc-98
[**2115-2-2**] 09:30AM BLOOD Homocys-6.0
[**2115-2-2**] 03:15AM BLOOD CRP-78.6*
[**2115-2-2**] 03:15AM BLOOD HCG-<5
[**2115-2-5**] 05:45AM BLOOD ASA-NEG Acetmnp-13 Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2115-2-1**] 09:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2115-2-1**] 09:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.032

MICROBIOLOGY Reports:
[**2115-2-12**] 7:00 pm SWAB      RIGHT CRANIAL BONE FLAP.
   GRAM STAIN (Final [**2115-2-12**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.
   WOUND CULTURE (Final [**2115-2-14**]):    NO GROWTH.
   ANAEROBIC CULTURE (Preliminary):    NO GROWTH.

REPORTS
NCHCT [**2115-2-1**]: Large right temporal and occipital hypodense
region which is slightly expansile with effacement of [**Doctor Last Name 352**]-white
matter differentiation
worrisome for infarction with areas of subarachnoid and probable

intraparenchymal hemorrhage, overall worrisome for infarction
which could be seen with venous thrombosis. Less likely
considerations include a primary neoplasm with hemorrhagic
features. evaluation with MRI/MRV can is recommended to aid in
understanding the etiology.

CTA Head/neck [**2115-2-1**]: Although the major arteries are patent,
there appears to be a linear high-density area in the right
occipital lobe which could be due to a thrombosed vein or a
thrombosed branch of the posterior cerebral artery. In addition,
some prominent vascular structures in the right sylvian fissure
could be due to prominent cortical veins. The findings in
correlation with the MRI examination obtained subsequently are
suggestive of either a cortical venous thrombosis or in situ
arterial thrombosis secondary to vasospasm. Findings were
discussed with Dr. [**Last Name (STitle) **] at the time of interpretation of this
study.

MRI [**2115-2-2**]: Although no major vascular occlusion is seen
around the circle of [**Location (un) 431**], it appears that the linear
hyperintensity intensity area seen in the right occipital lobe
on T1 images could be connecting to the calcarine branch of the
right posterior cerebral artery. Alternatively this could also
be a venous structure as described. Mid basilar artery is not
well seen on the maximum intensity projections but is visualized
on T2-weighted images as flow void and on the CTA and is likely
artifactual.

Echo [**2115-2-5**]: The left atrium is elongated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion. Agitated saline contrast study
revealed trace borderline evidence of an intracardiac shunt (one
bubble seen within 3 beats of right atrial opacification with
Valsalva release).

LENIs [**2115-2-5**]: No evidence of DVT in bilateral lower extremity
veins.

CTA Head/neck: [**2115-2-5**]: 1. Interval increase in the large
region of, primarily, vasogenic edema, with worsening mass
effect. Decrease in size of hemorrhagic foci within this
process, as well as the subarachnoid blood. The prominent
peripherally-enhancing vessel in the right occipital lobe is
still present, which likely represents a thrombosed cortical
vein.  Of note, the appearance and evolution of this infarct,
and this finding, suggest a venous rather than an arterial
etiology. Technical difficulties limit the assessment of vessel
narrowing or vasospasm. However, allowing for these limitation,
the major arteries of the
anterior and posterior circulation enhance symmetrically and the
venous
sinuses are unremarkable.

EKG [**2115-2-3**]: Sinus bradycardia. Normal tracing. No previous
tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
55 142 76 [**Telephone/Fax (2) 88913**] 39

NCHCT [**2115-2-5**]: 1. Interval worsening of mass effect caused by
large infarct of the right MCA and PCA territories. Right uncal
herniation is again noted, although it is unclear whether it has
worsened compared to prior exam.

NCHCT [**2115-2-7**]: Decrease in the degree of leftward shift of the
normally midline structures compared to previous examination.

MRV [**2115-2-7**]: No pelvic venous clot. Fibroid uterus. Bilateral
simple ovarian cysts, likely follicular in a patient of this
age. Cholelithiasis.

Diagnostic 4 vessel angiogram [**2115-2-9**]: [**Known firstname **] [**Known lastname 15352**]
underwent cerebral angiography which showed a paucity of venous
structures in the right temporal area consistent with a right
vein of [**Last Name (un) 70890**] occlusion.

NCHCT [**2115-2-10**]: No significant interval change compared to
[**2115-2-9**]. Severe right hemispheric mass effect and uncal
herniation.

NCHCT [**2115-2-11**] AM: Minimal increase in leftward shift in
normally midline structures from 10 mm to 12 mm, likely due to
minimal increase in surrounding vasogenic edema. Severe right
hemispheric mass effect and uncal herniation persist.

NCHCT [**2115-2-11**] PM: Minimal increase in leftward shift in
normally midline structures from 10 mm to 12 mm, likely due to
minimal increase in surrounding vasogenic edema. Severe right
hemispheric mass effect and uncal herniation persist.

NCHCT [**2115-2-12**] PM: Stable appearance of right parietal,
temporal and occipital lobe infarction. Significant mass effect
on the right lateral ventricle, leftward shift of approximately
11 mm, and right uncal herniation is stable since the earlier
study of 9:06 a.m.

NCHCT [**2115-2-13**] AM: Stable large right hemispheric venous
infarction with surrounding vasogenic edema involving the
midbrain and basal ganglia. Increase in leftward midline shift
and the degree of cerebral herniation through the craniectomy
defect. Unchanged right uncal herniation.

NCHCT [**2115-2-16**]:
IMPRESSION: Persistent but decreased mass effect in the right
cerebral
hemisphere.

NCHCT [**2115-2-20**]:
Prelim read: Decreased mass effect.
.
Conventional Cerebral Angiography ([**2115-2-9**]):
IMPRESSION: [**Known firstname **] [**Known lastname 15352**] underwent cerebral angiography which
showed a
paucity of venous structures in the right temporal area
consistent with a
right vein of [**Last Name (un) 70890**] occlusion.





Brief Hospital Course:
Ms. [**Known lastname 15352**] is a 47 year-old woman with a history of ulcerative
colitis (untreated) who presented to the [**Hospital1 18**] emergency
department a few days following 'violent' nausea and vomiting
with severe right-sided headache.  A non-contrast CT showed
hypodensities in the right hemisphere (middle cerebral artery
and posterior cerebral artery territories) with a hemorrhagic
component and midline shift.  The etiology of the syndrome was
not immediately clear.  She was admitted to the stroke service
from [**2115-2-1**] until [**2115-2-20**] for further evaluation and care.
.
Further investigation included vessel imaging, which showed the
presence of a fetal posterior cerebral artery on the right (in
this anatomical variant the blood supply to the middle cerebral
artery and posterior cerebral artery comes from the same source
- the internal carotid artery). Accordingly, ischemic right MCA
and PCA strokes in the setting of cardioembolic disease (eg from
valsalva during recent vomiting) was considered a possible
explanation.  Given the severity of headache and evidence of
hemorrhage in the hypodensities, cerebral vasoconstriction (with
secondary arterial occlusion) was also thought to be a viable
cause.  As ulcerative colitis, dehydration, and the use of an
estrogen patch (for birth control) can predispose to
hypercoaguability, there was also concern for venous thrombosis.
 However, there was no clear evidence of venous sinus thrombosis
on initial imaging.  Although there was a suggestion of a
thrombosed vein, the distribution of venous drainage at the area
of this clot was not thought to be sufficient to explain the
degree of her cerebral edema.
.
To evaluate for arterial embolic sources, a transthoracic
echocardiogram was done.  The study identified a patent foramen
ovale.  Lower extremity dopplers were negative for DVT and an
MRV of her pelvis did not show any evidence of proximal thrombi
or thrombogenic sources. Telemetry monitoring showed no
contributory arrhythmias.  Aspirin was started as empiric
treatment.  A heparin drip was deferred in the context of
hemorrhage; however, subcutaneous heparin heparin was started.
.
To address the potential role of reversible cerebral
vasoconstriction, verapamil was started. Unfortunately, the
medication did not translate into clear relief.  Angiography and
transcranial doppler studies showed no obvious evidence of
arterial vasospasm.
.
In  the setting of persistent headache and cerebral edema (with
midline shift), arterial and venous vessel imaging was repeated
with the thought that progressive venous processes might be more
evident.  The tests were unrevealing.  She ultimately underwent
conventional cerebral angiography which revealed thrombus in the
right vein of [**Last Name (un) **].  Accordingly, a heparin drip was started
with a goal of transitioning to coumadin (INR goal [**2-22**]).
.
The patient's examination worsened slightly, with the
development of a right ptosis, partial right third nerve palsy,
and subtle left pronator drift.  As the headache was also
unremitting, she was given a mannitol challenge.  The mannitol
provided relief. In the setting of radiological shift,
examination change, and symptomatic relief, scheduled mannitol
was started. Hypertonic saline was subsequently added. Decadron
was implemented.
.
Despite aggressive osmotic management, the patient's examination
ultimately worsened.  A very mild and subtle left hemiparesis
progressed gradually to include a complete left hemiplegia,
slight right hemiparesis and a pupil sparing right third nerve
palsy. She became more lethargic.  Neurosurgery was consulted
and she ultimately underwent an emergent right hemicraniectomy
and partial temporal lobectomy.  Keppra was started for seizure
prophylaxis. She received two units of PRBCs in the OR.
.
Two days following her surgery, her exam was such that she was
awake, alert and oriented without speech or language deficits.
She had no visual or sensory extiction to stimuli on the left,
but did have a dense left homonymous hemianopia. Her pupils were
equal and briskly reactive to light with full extraocular
movements. She displayed full strength on the right and full
sensation throughout her body. She did have quite a dense
hemiparesis on the left arm and leg without face involvement.
There were perhaps a trace of movements in her left fingers and
toes. At this time, she was able to tolerate POs and she passed
her bedside swallow evaluation.
.
Given her stable clinical picture, she was transferred to the
neuro-step down unit. She was restarted on a heparin drip as a
bridge to coumadin, and per neurosurgery recs, she was quickly
tapered off of her decadron and remained on keppra seizure
prophylaxis. The dose was decreased to 500 mg po bid prior to
discharge.  Prior to discharge, the INR became therapeutic.  The
heparin was stopped.  A non-contrast head CT was repeated; there
was no evidence of new hemorrhage and the edema had markedly
decreased.  The initially visualized hypodensities are thought
to represent edema rather than infarct.  Accordingly, she is
expected to regain function in the left limbs.
.
** Patient will need to have prothrombin gene mutation and
Factor 5 Leiden drawn as an outpatient to complete
hypercoagulability work up.

Medications on Admission:
- None

Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. sodium phosphates 19-7 gram/118 mL Enema Sig: One (1)  Rectal
DAILY (Daily) as needed for constipation.
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
11. Ondansetron 4 mg IV Q8H:PRN nausea


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Venous sinus thrombosis
cerebral edema s/p craniectomy
Ulcerative colitis
Iron deficiency anemia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurological examination is notable for inattention (able to do
DOY backwards but not [**Doctor Last Name 1841**]), right ptosis, left visual field
deficit, and left hemiparesis. More specifically, on the left
there is 0/5 strength in the deltoid, biceps, ECR, and finger
extensors. 4/5 strength at the triceps and finger flexors. [**3-25**]
strength in the IP, Quad; [**2-24**] at the Ham and adductors. 0/5 in
the TA and [**Last Name (un) 938**]; and [**4-25**] in the [**Month/Day (1) 2339**] and abductors. There is
occasional extinction of left-sided stimuli to double
simultaneous stimulation.


Discharge Instructions:
Dear Ms. [**Known lastname 15352**],
   You were admitted to the Neurology wards and the
Neuro-Intensive Care unit of the [**Hospital1 1170**] for an evaluation of symptoms of headaches that you were
experiencing at home. Through a series of physical examinations,
laboratory studies, neuroimaging modalities and other medical
tests, we were able to determine that the cause for your
symptoms was an occlusion (or blockage) of one of the veins in
the right part of your brain. This blockage unfortunately lead
to a large amount of swelling (probably from increased backflow
and obstruction) which ultimately caused worsening weakness of
your left side of the body, problems with moving your right eye,
as well as difficulties staying awake. You received a number of
treatments including aspirin therapy, heparin  therapy and a
"decompressive hemicraniectomy", which is a procedure designed
to remove the skull over a part of the brain so that the
underlying brain can be allowed to swell.

- We were able to organize a rehabilitation facility for you,
where skilled therapists will continue to help you regain the
strength on your left side. You will be discharged to [**Hospital1 **] - [**Location (un) 86**].
- We have arranged a helmet for you to wear so that your brain
can be protected in the absence of the overlying skull (on the
right). Please keep this helmet on at all times.
- We have started you on a medication to thin your blood called
WARFARIN While on this medication, there is a higher risk of
bleeding problems such as lower intestinal bleeding or traumatic
bleeding in your head. Please be sure to seek medical attention
following a fall or after hurting yourself.
- As part of your work-up, we sent bloodwork to look for any
additional disorders that may make you more likely to develop
blood clots. Two tests, the prothrombin gene mutation and factor
5 Leiden will need to be drawn in our outpatient bloodwork lab
on the [**Hospital Ward Name **]. An order for this has been placed in our
computer system. Please have this done when you return for
follow up with the neurology or neurosurgery clinics.
.
MEDICATION CHANGES:
- Coumadin (warfarin) was started.


Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]
[**2115-2-25**] @ 1020AM
[**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Fax: [**Telephone/Fax (1) 6808**]

Please also follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of the Department of
Neurology, Vascular Division. The clinic is located on the [**Hospital1 18**]
[**Hospital Ward Name **], [**Hospital Ward Name 23**] Bldg, [**Location (un) **]. We have made an
appointment for you on [**4-3**] at  3:30pm.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2115-4-3**] 3:30

Please follow up with Dr. [**Last Name (STitle) **] in the [**Hospital 4695**] clinic in
regard to replacing the bone flap in your skull. You will have a
CAT scan done prior to your appointment as scheduled below.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2115-4-9**] 10:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 9151**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2115-4-9**] 10:45


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
{'Phlebitis and thrombophlebitis of intracranial venous sinuses,Subarachnoid hemorrhage,Cerebral edema,Third or oculomotor nerve palsy, partial,Ulcerative colitis, unspecified,Hemiplegia, unspecified, affecting unspecified side,Ostium secundum type atrial septal defect,Other facial nerve disorders,Muscle weakness (generalized),Iron deficiency anemia, unspecified,Diarrhea,Abnormal coagulation profile'}


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 in the setting of dehydration (significant nausea and
vomiting)

PRESENT ILLNESS: PER ADMITTING RESIDENT:
The pt is a  47 y/o RHW with a history of UC (no current
flare) presented with HA x days.
She states that on Monday night she suffered from diarrhea and
vomiting x 24 hours, on Wed morning she awoke with a headache
worse on the right side associated with right eye pain. The pain
was getting gradually worse, aggravated by activity. Because of
the pain she showed up in the ED. Here her only complaints are
headache and right eye pain. She notes no other problems, no
weakness, no fever, chills, no current nasuea or vomiting, chest
pain, SOB, palpitations, pain in her extremities, diplopia, or
numbness. No neck pain

MEDICAL HISTORY: Ulcerative colitis (well controlled, not currently medicated)

MEDICATION ON ADMISSION: - None

ALLERGIES: Penicillins / Heparin Agents

PHYSICAL EXAM: On Admission:
Vitals: 98.8 62 116/72 16 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: No edema or deformities.
Skin: no rashes or lesions noted.

FAMILY HISTORY: father had DM and died of complications from such.

SOCIAL HISTORY: no drugs, etoh, smoking 

### Response:
{'Phlebitis and thrombophlebitis of intracranial venous sinuses,Subarachnoid hemorrhage,Cerebral edema,Third or oculomotor nerve palsy, partial,Ulcerative colitis, unspecified,Hemiplegia, unspecified, affecting unspecified side,Ostium secundum type atrial septal defect,Other facial nerve disorders,Muscle weakness (generalized),Iron deficiency anemia, unspecified,Diarrhea,Abnormal coagulation profile'}
