CHIEF COMPLAINT: Worst headache of life

PRESENT ILLNESS: Mr. [**Known lastname 91567**] is a 47 yo Right handed man who has no
substantial medical history who developed WHOL shortly after
coitus at about 10:30pm. He states that this came on very
abruptly and became excruciating.

MEDICAL HISTORY: GERD

MEDICATION ON ADMISSION: PPI

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Hunt and [**Doctor Last Name 9381**]: 1  [**Doctor Last Name **]: 2   GCS  E: 5 V: 5 Motor: 5
O: T: Afebrile BP: /   HR:    R:
Gen: WD/WN, comfortable, NAD.
HEENT: MMM, O/P clear
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.

FAMILY HISTORY: NC

SOCIAL HISTORY: Works as a pipe fitter. Smokes 1.5 PPD for several
years. Drinks 2-3 beers a day.
Subarachnoid hemorrhage,Unspecified transient cerebral ischemia,Unspecified disorder of kidney and ureter,Constipation, unspecified,Tobacco use disorder,Esophageal reflux
Subarachnoid hemorrhage,Trans cereb ischemia NOS,Renal & ureteral dis NOS,Constipation NOS,Tobacco use disorder,Esophageal reflux
Admission Date:  [**2166-8-10**]              Discharge Date:   [**2166-8-20**]

Date of Birth:  [**2119-7-9**]             Sex:   M

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Worst headache of life

Major Surgical or Invasive Procedure:
Diagnostic cerebral angiogram x 2


History of Present Illness:
Mr. [**Known lastname 91567**] is a 47 yo Right handed man who has no
substantial medical history who developed WHOL shortly after
coitus at about 10:30pm. He states that this came on very
abruptly and became excruciating.

He presented to [**Hospital6 **] where he received
morphine with some relief of his headache. He also reports some
nuchal rigidity.

He never lost consciousness. He denies any diplopia, ptosis,
dysarthria, unilateral weakness or numbness, vertigo.


Past Medical History:
GERD

Social History:
Works as a pipe fitter. Smokes 1.5 PPD for several
years. Drinks 2-3 beers a day.

Family History:
NC

Physical Exam:
Hunt and [**Doctor Last Name 9381**]: 1  [**Doctor Last Name **]: 2   GCS  E: 5 V: 5 Motor: 5
O: T: Afebrile BP: /   HR:    R:
Gen: WD/WN, comfortable, NAD.
HEENT: MMM, O/P clear
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.

Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Orientation: Oriented to person, place, and date.
Recall: [**2-20**] objects at 5 minutes. Language: Speech fluent with
good comprehension and repetition. Naming intact. No dysarthria
or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-24**] throughout. No pronator drift

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Reflexes: B T Br Pa Ac
Right     2 2 2  2  1
Left      2 2 2  2  1

Toes downgoing bilaterally

Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin.

On discharge - He is awake alert and oriented with a non focal
neuro exam except for mild headache.  He is afebrile, tolerating
good oral intact and voicing without difficulty.  He is
independent in ADL's and ambulatory.

Pertinent Results:
CTA Head and neck [**2166-8-10**]
1.Non-contrast CT head: Small amount of SAH pools just above the
sella
tursica at the bifurcation of the internal carotid arteris,
unchanged from the priror OSH study. Tiny hemorrhage pools in
the bioccipital horns. No
midline shift.
2. CTA head/neck. Pending 3-D rendering. Major cervical and
intra-cranial
vessels patents. No evidence of aneurysm > 3 mm.

[**2166-8-10**] INTERVENTIONAL PROCEDURE PERFORMED: Diagnostic cerebral
angiogram.

ANESTHESIA: The patient was sedated with Versed and fentanyl. 1
mg of
Versed, and 50 mcg of fentanyl iv was administered for a total
intra-service time of 70 minutes.

PHYSICIANS: [**First Name8 (NamePattern2) **] [**Doctor Last Name **] (attending), K.C. Tan (fellow).

DETAILS OF THE PROCEDURE:

The patient was brought to the angiography suite. IV anesthesia
was induced in the supine position. A safety timeout was
obtained.

Following this, access was gained into the right common femoral
artery using a micropuncture needle, and a Seldinger technique.
The right brachiocephalic artery was catheterized with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
2 5 French catheter. Under roadmap guidance, a right internal
carotid artery, and a right external carotid artery arteriograms
were obtained. Following this, the left common carotid artery
was catheterized. A left common carotid artery arteriogram was
obtained. Under roadmap guidance, the left ICA, and left ECA
were subsequently selected. Selective arteriograms were then
obtained. The catheter was then withdrawn into the aortic arch,
and the right vertebral artery was catheterized using roadmap
guidance, and the [**Doctor Last Name **] 2 catheter. A selective right
vertebral artery arteriogram was obtained.

The left subclavian artery was then selected, and the left
vertebral artery was catheterized. A left vertebral artery
arteriogram was obtained. Following this, a right common femoral
arteriogram was performed, and a 6 French Angio- seal Evolution
closure device was used to secure hemostasis at the right common
femoral artery arteriotomy site.

FINDINGS: The right external carotid artery was patent, and
showed no
significant stenosis. In particular, there was no evidence of a
dural AV
fistula.

The right common carotid artery showed no significant stenosis
at the
bifurcation.

The right internal carotid artery angiogram demonstrated the
presence of two MCA branches. This is reminiscent of an
accessory MCA variant. One branch arises directly from the
internal carotid artery, and the other arises from the
bifurcation. The MCA is otherwise unremarkable, and patent.

Right vertebral arteriogram demonstrates reflux into the left
vertebral
artery. Both the superior cerebellar artery, and PICA were well
visualized, and appeared unremarkable. There is no aneurysm at
the basilar apex.

Left external carotid arteriogram demonstrated no dural AV
fistula. The left external carotid artery was unremarkable, and
patent.

The left common carotid artery demonstrated no significant
stenosis at the
bifurcation.

A left internal carotid artery angiogram appeared unremarkable.
The left
internal carotid artery showed a normal cervical, petrous, and
supraclinoid segment. The anterior and middle cerebral artery
did not show any evidence of aneurysms.

The left vertebral artery is patent. The PICA origin was noted
to be normal. There is a muscular branch arising from the left
vertebral artery anastomosing with the occipital branch artery
of the left external carotid artery.

Right common femoral arteriogram showed a patent common femoral
artery with no significant stenosis.

IMPRESSION:

Unremarkable diagnostic cerebral angiogram. In particular, no
aneurysm, AVM or dural AV fistula was noted.

[**2166-8-18**] CTA OF HEAD

There is near resolution of the previously seen subarachnoid
hemorrhage in the basal cisterns bilaterally. Note in this study
is fenestration of the right ACA. There is a focal narrowing
found in the A2 segment of the left ACA also seen in the
previous study and is unchanged. This finding is most likely
related to atherosclerotic narrowing of the vessels and does not
represent vasospasm.

There is no evidence of new hemorrhage. No edema, masses, mass
effect or
infarction. The ventricles are normal in size and configuration
and are now free of hemorrhage previously seen.

No fractures are identified.

The carotid and vertebral arteries and the major branches are
patent with no evidence of stenosis. The distal cervical
internal carotid arteries measure 3 mm in diameter bilaterally.
There is no evidence of aneurysm formation.

IMPRESSION:
1. No evidence of vasospasm. Near resolution of previously seen
subarachnoid hemorrhage. Focal narrowing of the left ACA segment
A2, not likely representing vasospasm.
2. No edema, masses, mass effect or infarction. The ventricles
are normal in size and configuration with no evidence of
hydrocephalus. Previously seen blood in the dependent portions
of the ventricles are now resolved.

[**2166-8-18**] LENIE
FINDINGS: Grayscale, color and pulse Doppler images of the right
and left
common femoral, superficial femoral, and popliteal veins were
obtained.
Normal flow, compressibility, augmentation, and waveforms
demonstrated. No
intraluminal thrombus is identified. Normal compressibility is
demonstrated in the posterior tibial and peroneal veins
bilaterally.

IMPRESSION: No deep venous thrombosis in right or left lower
extremity.

[**2166-8-18**] CXR
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:

Normal heart, lungs, hila, mediastinum and pleural surfaces.



Brief Hospital Course:
Pt was admitted to the neurosurgery service and the ICU for
further workup and care of his SAH. A CTA was negative for
aneurysm and he was taken for cerebral angiogram on the morning
of [**8-10**]. His angiogram was negative and plan was for a repeat
procedure in 1 week. On [**8-14**], patient reported headache that was
not relieved with pain medication, he was started on the a
prednisone taper. He remained intact throughout the day.

Mr. [**Known lastname 91567**] remained neurologically stable and was transferred
out of the ICU to the Step down unit on [**8-15**] with plans to
undergo and CTA on Monday [**8-18**]. On TCD, patient seen to
have bilateral MCA spasm and was trasferred back to ICU. His
exam remained nonfocal. On [**8-17**], patient complained of headache
and his pain medication was adjusted accordingly. On [**8-18**],
patient underwent CTA of the head, bilateral lower extremity
vein doppler scan, and was transferred to the Neurosurgery
inpatient unit's step-down bed.

He underwent cerbral angiography on [**2166-8-20**] which revealed mild
vasospasm to the ICA but clinically the patient remained
nonfocal. No aneurysm or other vascular malformation was noted
on the angiogram. Post-angio he was monitored and on bedrest for
two hours. He was then able to ambulate and tolerate a regular
diet. He was discharged with a rx for Nimodipine and a two day
hospital supply.


Medications on Admission:
PPI

Discharge Medications:
1. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 11 days.
Disp:*132 Capsule(s)* Refills:*0*
2. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO every four
(4) hours for 2 days.
Disp:*24 Capsule(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**12-22**]
Tablets PO Q6H (every 6 hours) as needed for headache.
Disp:*90 Tablet(s)* Refills:*1*
6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for Pain.
Disp:*40 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Perimesencephalic subarachnoid hemorrhage
Headache
GERD


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
??????	You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.

What activities you can and cannot do:
??????	When you go home, you may walk and go up and down stairs.
??????	You may shower (let the soapy water run over groin incision,
rinse and pat dry)
??????	Your groin puncture site may be left uncovered, unless you
have small amounts of drainage from the wound, then place a dry
dressing or band aid over the area that is draining, as needed
??????	No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
??????	After 4 weeks, you may resume sexual activity.
??????	After 4 weeks, gradually increase your activities and distance
walked as you can tolerate.
??????	No driving until you are no longer taking pain medications

What to report to office:
??????	Changes in vision (loss of vision, blurring, double vision,
half vision)
??????	Slurring of speech or difficulty finding correct words to use
??????	Severe headache or worsening headache not controlled by pain
medication
??????	A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
??????	Trouble swallowing, breathing, or talking
??????	Numbness, coldness or pain in lower extremities
??????	Temperature greater than 101.5F for 24 hours
??????	New or increased drainage from incision or white, yellow or
green drainage from incisions
??????	Bleeding from groin puncture site

*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest E


Followup Instructions:
Please call the office to schedule an appointment with Dr.
[**First Name (STitle) **] to be seen in 1 month for follow up. You will need a Head
CT w/o contrast for this appointment. Please call [**Telephone/Fax (1) 4296**]
to make this appointment.



Completed by:[**2166-8-20**]
{'Subarachnoid hemorrhage,Unspecified transient cerebral ischemia,Unspecified disorder of kidney and ureter,Constipation, unspecified,Tobacco use disorder,Esophageal reflux'}


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: Worst headache of life

PRESENT ILLNESS: Mr. [**Known lastname 91567**] is a 47 yo Right handed man who has no
substantial medical history who developed WHOL shortly after
coitus at about 10:30pm. He states that this came on very
abruptly and became excruciating.

MEDICAL HISTORY: GERD

MEDICATION ON ADMISSION: PPI

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Hunt and [**Doctor Last Name 9381**]: 1  [**Doctor Last Name **]: 2   GCS  E: 5 V: 5 Motor: 5
O: T: Afebrile BP: /   HR:    R:
Gen: WD/WN, comfortable, NAD.
HEENT: MMM, O/P clear
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.

FAMILY HISTORY: NC

SOCIAL HISTORY: Works as a pipe fitter. Smokes 1.5 PPD for several
years. Drinks 2-3 beers a day. 

### Response:
{'Subarachnoid hemorrhage,Unspecified transient cerebral ischemia,Unspecified disorder of kidney and ureter,Constipation, unspecified,Tobacco use disorder,Esophageal reflux'}
