CHIEF COMPLAINT: headache, lethargy

PRESENT ILLNESS: 66yo left-handed man with recent R MCA stroke and multiple
vascular risk factors presents with difficulty seeing, change in
personality, and lethargy. On Saturday prior to admission he did
not seem himself to his wife; she felt he was quieter than usual
and more lethargic. She asked him what was wrong and he
complained of a headache on the right side of his head behind
his
ear. Throughout the next 5 days, he continued to complain of
headache and did not seem his usual self. He was quiet, sleeping
more than usual. He was not eating as much. He was having
difficulty "seeing" - for example, he would have to feel around
on the table for his fork. He dropped a spoon and potato and had
difficulty finding them. His wife thought this was mostly a
problem with things that were white or silver, but she was not
sure. He had difficulty telling time, difficulty with the big
and
little hand - thought 20 of 5 was 20 past 8. She also felt he
was
emotionally labile, acting silly more than normal, acting angry,
when usually he is eventempered. For example, he was walking up
the ambulance ramp to the ED when she heard a car behind them,
told him to move out of the way, and he stopped, shouted "leave
me alone!" He has not had any change in his speech, gait, or
weakness.

MEDICAL HISTORY: R M1 segment MCA stroke [**7-/2111**] with residual left facial droop,
left hand weakness/stiffness, mild dysarthria
hyperlipidemia
hypertension
diabetes, diagnosed [**8-/2111**], initially diet controlled w/ FS
100s,
last A1C 6.8, started on metformin
h/o tobacco use, quit after stroke [**7-/2111**]
s/p tonsillectomy

MEDICATION ON ADMISSION: AGGRENOX 25 mg-200 mg [**Hospital1 **]
Labetalol 300 mg tid
SIMVASTATIN 80 mg daily
Metformin 500mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97.8, HR 51, Bp 116/64, RR 16, SaO2 99%/RA
Genl: NAD
HEENT: NCAT, MMM, OP clear, left [**Doctor First Name 2281**] with brown in left upper
quadrant, eyes otherwise blue
Neck: supple, no bruits
CV: RRR, nl S1, S2, no m/r/g
Chest: CTAB
Abd: soft, NTND, BS+
Ext: warm and dry

FAMILY HISTORY: mother died age 66, had HTN, stroke; father died age 87

SOCIAL HISTORY: tob 2.5ppd x 50yrs, h/o heavy EtOH use, "in recovery" 21yrs,
no drug use, married
Cerebral embolism with cerebral infarction,Acute posthemorrhagic anemia,Hematoma complicating a procedure,Ostium secundum type atrial septal defect,Peripheral vascular complications, not elsewhere classified,Atrial flutter,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Late effects of cerebrovascular disease, other speech and language deficits,Other ill-defined heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Aneurysm of artery of lower extremity,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Hypovolemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other disorders of muscle, ligament, and fascia
Crbl emblsm w infrct,Ac posthemorrhag anemia,Hematoma complic proc,Secundum atrial sept def,Surg comp-peri vasc syst,Atrial flutter,Ocl crtd art wo infrct,Late ef-spch/lang df NEC,Ill-defined hrt dis NEC,DMII wo cmp nt st uncntr,Hyperlipidemia NEC/NOS,Hypertension NOS,Lower extremity aneurysm,Abn react-surg proc NEC,Hypovolemia,Abn react-procedure NEC,Muscle/ligament dis NEC
Admission Date:  [**2111-12-3**]              Discharge Date:   [**2111-12-16**]

Date of Birth:  [**2045-6-26**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
headache, lethargy


Major Surgical or Invasive Procedure:
 Right femoral pseudoaneurysm rupture with thigh hematoma.


History of Present Illness:
66yo left-handed man with recent R MCA stroke and multiple
vascular risk factors presents with difficulty seeing, change in
personality, and lethargy. On Saturday prior to admission he did
not seem himself to his wife; she felt he was quieter than usual
and more lethargic. She asked him what was wrong and he
complained of a headache on the right side of his head behind
his
ear. Throughout the next 5 days, he continued to complain of
headache and did not seem his usual self. He was quiet, sleeping
more than usual. He was not eating as much. He was having
difficulty "seeing" - for example, he would have to feel around
on the table for his fork. He dropped a spoon and potato and had
difficulty finding them. His wife thought this was mostly a
problem with things that were white or silver, but she was not
sure. He had difficulty telling time, difficulty with the big
and
little hand - thought 20 of 5 was 20 past 8. She also felt he
was
emotionally labile, acting silly more than normal, acting angry,
when usually he is eventempered. For example, he was walking up
the ambulance ramp to the ED when she heard a car behind them,
told him to move out of the way, and he stopped, shouted "leave
me alone!" He has not had any change in his speech, gait, or
weakness.

He has had a recent stroke for which he presented to [**Hospital1 **] [**Location (un) 620**]
with acute onset dysarthria and left facial droop, left hand
weakness. He was diagnosed with a right MCA infarct. MRI/MRA and
ECHO were performed (see reports below). He was newly diagnosed
with diabetes. He was started on medications for hypertension,
hyperlipidemia, and more recently for hyperglycemia. He was put
on aggrenox, which he has been taking regularly. He has modified
his diet, but BS continue to be 129-173, mostly in the 160s
(fasting am). He has quit smoking.


Past Medical History:
R M1 segment MCA stroke [**7-/2111**] with residual left facial droop,
left hand weakness/stiffness, mild dysarthria
hyperlipidemia
hypertension
diabetes, diagnosed [**8-/2111**], initially diet controlled w/ FS
100s,
last A1C 6.8, started on metformin
h/o tobacco use, quit after stroke [**7-/2111**]
s/p tonsillectomy


Social History:
tob 2.5ppd x 50yrs, h/o heavy EtOH use, "in recovery" 21yrs,
no drug use, married


Family History:
mother died age 66, had HTN, stroke; father died age 87


Physical Exam:
VS: T 97.8, HR 51, Bp 116/64, RR 16, SaO2 99%/RA
Genl: NAD
HEENT: NCAT, MMM, OP clear, left [**Doctor First Name 2281**] with brown in left upper
quadrant, eyes otherwise blue
Neck: supple, no bruits
CV: RRR, nl S1, S2, no m/r/g
Chest: CTAB
Abd: soft, NTND, BS+
Ext: warm and dry

Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place (hospital, ED, middle of
[**Location (un) 86**]), and date. Mildly inattentive, says [**Doctor Last Name 1841**] backwards to
[**Month (only) 958**], slowly. Speech is fluent with normal comprehension and
repetition; naming intact. Mild dysarthria. Reads "speak on the
radio last night" but can read full sentence when visually
prompted to the beginning; reads "near the table the dining
room." Writing intact (messy, but at baseline per wife).
Registers [**2-1**], recalls [**1-3**] +1 from list in 5 minutes. No
right-left confusion. No evidence of apraxia. Left visual
neglect. Describes pictures on stroke cards initially correctly
on right, but says "heart shape in circle" for key, and does not
initially mention hammock, just tree. With additional time
given,
then names skeleton key and hammock. Describes cookie thief
picture in parts, first notes the pitcher and plate, then the
small cabinet, then sink, then "young fellow climbing on
stepstool"; when asked how many people names the girl much later
than the others. Can identify it as kitchen. Difficulty with
drawing a house (draws roof, window on it, chimney with smoke,
but nothing else). Cannot copy complex picture (draws left side
of leftmost shape, with extensive spiral coming from it as
squiggle, but nothing else to the right.

Cranial Nerves: Fundoscopic examination reveals sharp disc
margins. Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. No RAPD. Left inferior quadrantonopia. Extraocular
movements intact bilaterally without nystagmus. Sensation intact
V1-V3. Mild L facial droop. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. Sternocleidomastoid and
trapezius full strength bilaterally. Tongue midline, movements
intact.

Motor: Normal bulk and increased tone bilaterally. No observed
myoclonus, asterixis, or tremor. Left pronator drift.
  [**Doctor First Name **] Tri [**Hospital1 **]  WE FE FF  IP  H  Q DF PF TE
R  5   5   5  5  5  5   5   5  5  5  5  5
L  5   5   5  5  5  5   5   5  5  5  5  5-

Sensation: Intact to light touch, pinprick, vibration and cold
sensation throughout. Extinction on L to DSS in face,
inconsistent in hands.

Reflexes: 1 in R [**Hospital1 **], tri, br, 2 in L [**Hospital1 **], tri, br, 2 in R pat,
ach, 2+ in L pat, ach, R toe down, L toe upgoing

Coordination: finger-nose-finger, finger-to-nose slightly
inaccurate b/l, fine finger movements and [**Doctor First Name **] slowed on left.

Gait: Narrow based, steady. Some difficuly with tandem, ?if in
proportion to age.

Romberg negative.


Pertinent Results:
Labs:
139  103  14
------------< 152
4.2  28  0.9
Comments: K: Hemolysis Falsely Elevates K
7.7 > 40.1 < 225
 N:72.9 L:18.9 M:5.4 E:2.4 Bas:0.4
PT: 13.5  PTT: 28.7  INR: 1.2
TOX screens (urine and serum) negative ASA-NEG ETHANOL-NEG
ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
[**2111-12-4**] 02:15AM
LIPID/CHOLESTEROL Cholest 177  Triglyc 149  HDL 38  CHOL/HD 4.7
LDLcalc 109
a1c 6.3
.
[**2111-12-10**]
TSH 1.8

<br>
Imaging:
ECHO [**7-7**] from d/c summary: "This reveals normal EF of 65%.
There is left ventricular hypertrophy.  The echo is consistent
with the presence of a patent foramen ovale."
<br>

HCT [**2111-12-3**] shows subacute infarct of right parieto-temporal
region, as well as more chronic infarct. Multiple chronic
lacunes.
<br>
CTA HEAD/NECK [**2111-12-3**]
1.  Findings consistent with embolus completely occluding the
proximal right
MCA.
  2.  Substantial focal narrowing of the basilar artery,
presumably due to
atheromatous disease.
  3.  Substantial calcification of the internal carotid arteries
bilaterally
in the cavernous sinus, and at the bifurcation of the common
carotid arteries
bilaterally.
  4.  60 percent stenosis of the right common carotid artery at
the
bifurcation.  No stenosis seen on the left.
<br>
.
MRI/A BRAIN [**2111-12-4**]:
MRI Head:
Right middle cerebral artery inferior division infarction
similar
to the appearance on the recent CT examinations.  No evidence of
hemorrhage.

Small bilateral occipital lobe infarctions suggesting basilar
artery disease, likely embolic to the top of the basilar.

MRA appears similar to the CTA with a severe stenosis of the M1
segment of the right middle cerebral artery as well as severe
narrowing and irregularity of the basilar artery.
<br>

CAROTID ANGIOGRAM [**2111-12-5**]:
PROCEDURE: The patient was brought to the operating room.
Anesthesia was induced in the supine position. Following this,
both groins were prepped and draped in a sterile fashion. The
right common femoral artery was accessed using a Seldinger
technique and a 6 French vascular sheath was placed in the right
groin. This was connected to a continuous saline flush. Through
the sheath, we now advanced [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 2 catheter into the aortic
arch from where the left vertebral artery, the right internal
carotid artery and the right common carotid artery was
catheterized and AP lateral filming done. Three- dimensional
imaging was done where indicated.

Following this, the patient was found to have a completely
occluded right middle cerebral artery in the M1 region with very
minimal stenosis of his right internal carotid artery.
Therefore, we decided not to pursue any aggressive
interventional strategies. The left common carotid artery was
not catheterized as we felt that this was not necessary as the
CT angiogram had supplied us with enough information.

The vascular sheath was left in place since the patient was
heparinized and removed later in the recovery room after the
heparin was stopped for 2 hours.

FINDINGS
The left vertebral artery arteriogram demonstrates filling of
the left vertebral artery with minimal stenosis at the origin.
There is good reflux into the right vertebral artery. Both PICAs
are seen. The AICA is seen on both sides as well as the superior
cerebellar artery. There is a very significant basilar stenosis
which is about 80% just distal to the vert confluence. This
segment approximately measures about 0.7 cm in length. The right
PCA is not well visualized as it is mainly fetal.

The right common carotid artery arteriogram demonstrates 20%
stenosis of the left internal carotid artery just distal to the
bifurcation. The right external carotid artery has about 80%
stenosis at the origin.

Right internal carotid artery arteriogram demonstrates normal
filling of the right internal carotid artery along the cervical,
petrous, cavernous and supraclinoid portion. The right M1 seems
to end abruptly. There is no antegrade flow. The distal M2
vessels seem to fill retrograde through pial collaterals. There
is a large area of hypoperfusing area in the superior division
of the middle cerebral artery. There is significant pial
collateralization through the divisions of the anterior cerebral
artery. There is also significant disease in the anterior
cerebral artery with the proximal anterior cerebral arteries
rather dilated, leading one to conclude that the MCA occlusion
may be longstanding.

The common femoral artery arteriogram demonstrates diffuse
atherosclerotic disease with no significant stenosis seen.

IMPRESSION: Mr. [**Known firstname **] [**Known lastname 23203**] underwent cerebral arteriography
for possible right ICA and right middle cerebral artery
stenting, however the right MCA was seen to be chronically
occluded and the right ICA did not have significant stenosis.
.

<br>
Transthoracic ECHO: The left atrium is elongated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 70%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The ascending aorta is moderately dilated. There are
focal calcifications in the aortic arch. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.

There is diffuse thickening of the left atrial anterior wall,
abutting the posterior aortic root, and extending to the basal
portion of the interatrial septum (? lipomatous hypertrophy);
adherent thrombus cannot be excluded.

If clinically indicated, a transesophageal echocardiographic
examination is recommended.

..
[**2111-12-7**]:

CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: The lung bases
show mild dependent hypoventilatory change. There is an area of
equivocal differential attenuation in the region of the origin
of the right inferior pulomnary vein in the left atrium, for
which adherent thrombus cannot be excluded.

Within the limitations of a non- contrast exam, the liver,
spleen, adrenal glands, pancreas, and kidneys are within normal
limits. The intra- abdominal loops of large and small bowel
maintain a normal caliber without evidence of obstruction.
Scattered colonic diverticuli are present without evidence of
diverticulitis. No free fluid, free air or lymphadenopathy is
appreciated. Atherosclerotic calcification is seen involving the
abdominal aorta and branch vessels. HIgh attenuation material is
seen within the gallbladder likely representing vicarious
excretion of contrast.

CT PELVIS WITHOUT INTRAVENOUS CONTRAST: The rectum, sigmoid
colon, bladder, prostate, and seminal vesicles are unremarkable.
No free fluid or lymphadenopathy is appreciated. There is a
large right groin intramuscular hematoma extending down to the
mid thigh and involving various compartments of the anterior
thigh. No evidence of retroperitoneal extension of the hematoma.

BONE WINDOWS: No suspicious lytic or sclerotic lesion is
identified.

IMPRESSION:

1. Massive intramuscular hematoma extending from the right groin
into the mid thigh and involving various compartments of the
anterior thigh.

2. An equivocal area of differential attenuation is seen in the
region of the origin of the right inferior pulmonary vein in the
left atrium for which adherent thrombus cannot be excluded.
Given history of CVA, does patient have recent echocardiography?

The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: WED [**2111-12-9**] 4:59 PM
.
GROIN ULTRASOUND [**12-8**]:
FINDINGS: Duplex evaluation was performed only of the right
groin vessels. The common femoral artery is patent with a
triphasic waveform.

IMPRESSION: Right groin pseudoaneurysm measuring 2.9 cm.
.
EKG [**12-10**]:
Baseline artifact. Probable irregular supraventricular rhythm
with fairly
organized atrial activity, probably atrial fibrillation with a
single
ventricular premature beat. There is borderline voltage for left
ventricular
hypertrophy in lead aVL. Precordial voltage is also increased
but probably
does not meet criteria for left ventricular hypertrophy. ST-T
wave
abnormalities. Compared to the previous tracing of [**2111-12-4**] sinus
bradycardia is
no longer present and QRS voltage is more prominent. Clinical
correlation is
suggested.


Brief Hospital Course:
This 66 year old gentleman with h/o HTN, hyperlipidemia, DM2 and
recent right MCA stroke, was readmitted for right MCA stroke on
[**12-3**].  During this admission, he was found on MRI/MRA to have
severe stenosis of the M1 segment of the right middle cerebral
artery with recurrent MCA stroke. He underwent angiography which
showed total occlusion of right MCA with some collateral
circulation and with stenosis of the basilar artery. He was
started on a heparin gtt and coumadin post angio for stroke
prevention, after which he developed a right groin hematoma. His
hematoma has been progressively enlarging and heparin gtt was
discontinued; he received 5mg PO vitamin K. Vascular surgery was
consulted and right groin U/S revealed pseudoaneurysm. Since
[**2111-12-9**], his hct has fallen from 40-->26.6 and he has received 2U
prbcs on [**2111-12-8**]. He received only approximately 150cc prbcs on
[**2111-12-9**] after which time transfusion was stopped due to fever (no
rash, hives, etc).
.
On the evening of [**2111-12-9**], his HR was noted to be 150s and EKG
revealed a.fib vs. a. flutter w/ 2:1 conduction. He received
10mg IV diltiazem x2, then 60mg PO diltiazem. His HR briefly
responded to each IV diltiazem with rates improving to the low
100s, however HR then rose to 130s. He was written for 2units
prbcs. His SBPs remained stable in the 130s range. He then
received 5mg IV lopressor to which his HR responded-->80s-90s.
He was then transferred to the ICU for 20 point hct drop from
[**12-6**]-->[**12-9**] now with new a. fib with RVR initially difficult to
control on the floor.  He received 10 IV lopressor and started
on oral diltiazem.  He was given 3 units pRBC and the following
morning underwent repair of R femoral pseudoaneurysm by vascular
surgery.  He received an additional 2 units of pRBC
post-operatively.  He had no further signs of bleeding and his
blood pressure and hypertension remained under good control.
He remained in the MICU for two more days, at one time requiring
IV diltiazem to control an episode of AF with RVR.   This, along
with his hypertension, was further controlled with PO diltiazem
and metoprolol
.
ROS: Endorses right groin and leg pain. Denies CP, SOB,
palpitations. Denies dysuria/hematuria. No rashes.
He underwent, now found to have expanding right groin hematoma
and hct drop after initiating heparin gtt; also with new a. fib
w/ RVR on the floor.
.
# New atrial fibrillation/flutter with RVR: Etiology not
entirely clear, but differential broad. Despite continued hct
drop/volume status, appears slightly hypovolemic->euvolemic;
currently getting prbcs. Does not appear to have infection to
suggest as underlying cause. Although less frequently ischemic
arrhythmia, may be in his case given his anemia (last hct prior
to tx 26.6). In review of imaging there is some ? of left atrial
thrombus on CT which may be a reflection of prev. undocumented
h/o a.fib vs. etiology of current a. fib if has know atrial
dilatation and now w/ ? atrial thrombus. Echo suggested that
atrial clot was less likely than lipomatous hypertrophy.  His
wife declined a [**Month/Day (4) **] to confirm.  EKG with rate related ST
depressions which improved with decreased rate. If a. fib
persists beyond acute illness, CHADS2 score 4 w/ HTN, DM2,
stroke and would warrant anticoagulation.

He was monitored in the MICU and continued on oral diltiazem,
using IV lopressor PRN.  Rate stabilized and rapid a-fib did not
recur except briefly on [**2110-12-15**] for several minutes on the floor
(responded to IV lopressor 5mg).  He was given PRBCs x 2 units
and hematocrit increased.  Transfusion reaction was explored and
determined that he did have a mild reaction to the blood he
received.  This did not recur with further transfusion.  TSH was
checked and was normal.  Echo [**12-10**] again showed "There is
diffuse thickening of the left atrial anterior wall, abutting
the posterior aortic root, and extending to the basal portion of
the interatrial septum (? lipomatous hypertrophy); adherent
thrombus cannot be excluded."  Coumadin was felt to be
indicated, and despite thigh hematoma, was restarted on [**12-16**],
the day of discharge at a very low dose of 2.5mg/day after
deemed safe by vascular.  He needs to have his INR checked daily
to aim for a level of [**1-3**]. The risks and benefits were discussed
with his wife, who agreed to use of coumadin. He will need to be
monitored for bleeding closely.

.
# Hct drop: No other clear source of bleed beyond known right
groin pseudoaneurysm and marked hematoma extending from groin to
distal anterior thigh. Vascular is on board. Had previously only
received 2Units prbc prior to today, now s/p addtional 2units
(total 4Units prbcs thus far).  Once again, after several days
in the ICU and 2 PRBC packs, hematocrit rose to a tolerable
level and remained stable.  Aspirin was restarted after several
days.
.
# Right groin hematoma: Management as above (pseudoaneurysm
repaired by vascular surgery).  Hematocrit remained stable, and
vascular surgery felt it was resafe to start low-dose coumadin
with NO heparin on [**12-16**].
.
# S/P recurrent Right MCA stroke: MRI/MRA to have severe
stenosis of the M1 segment of the right middle cerebral artery
as well as severe narrowing and irregularity of the basilar
artery, right middle cerebral artery inferior division without
evidence of hemorrhage, small bilateral occipital lobe
infarctions suggesting basilar artery disease, likely embolic to
the top of the basilar.  As above, his infarcts were felt to be
embolic, and considering the new diagnosis of afib, coumadin was
felt to be strongly indicated.  After several days of aspirin
following repair of the pseudoaneurysm, coumadin was resumed at
discharge - this should be followed closely considering his
bleeding risk.
.
# ?Left atrial thrombus: Commented on in [**2111-12-7**] CT abd/pelvis;
reportedly possible adherent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**]. Patient does not have
previous echo in our system. Does not appear to have been
further investigated with echo here. Reportedly has patent PFO
from echo at during [**7-/2111**] admission.  Echo was repeated [**12-10**]
and as above, confirmed possible thrombus.  This should be
repeated after several months of coumadin therapy. Wife refused
[**Name2 (NI) **].
.
# Hyperlipidemia: Statin was continued.
.
# HTN: Home dose labetalol has been held in the setting of his
significant hct drop. Blood pressure was stabilized and he was
discharged on alternate antihypertensives that were
short-acting, and had some rate control properties.
.
# DM: HgbA1c 6.3% on this admission.  He should be continued on
insulin SS  at discharge.
.
# F/E/N: Receiving prbcs currently. Replete lytes PRN. NPO.
.
# PPx: Bowel regimen, famotidine given CVA, pneumoboots.
.
# Access: 2 20G PIVs, 1 18G PIV.
.
# Dispo: after a stay in the MICU, he was transferred back to
the neuro service on [**12-15**], and remained stable in the stepdown
unit for over 24 hours.  He was transferred to floor status and
worked with PT, and OT.  Swallowing was evaluated and he was
felt not to be aspirating.  He was discharged on [**12-16**] to
[**Hospital 38**] rehab.
.
# Code Status: DNI, chest compressions okay, wife thinking about
whether shocks okay. Discussed with patient's wife that in code
situations oftentimes these go together; will need to continue
further discussion.
.
# Communication: Wife [**Telephone/Fax (1) 52032**] (h), [**Telephone/Fax (1) 52033**] (c)


Medications on Admission:
AGGRENOX 25 mg-200 mg [**Hospital1 **]
Labetalol 300 mg tid
SIMVASTATIN 80 mg daily
Metformin 500mg daily

All: NKDA


Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed.
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-2**]
Puffs Inhalation Q4H (every 4 hours) as needed.
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
12. Cefazolin 10 gram Recon Soln Sig: Two (2) grams Injection
Q8H (every 8 hours) for 7 days: 2 grams q8h IV - first day is
[**2111-12-15**].
13. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
14. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Acute stroke - RMCA
Chronic occlusion of the right MCA
Atrial fibrillation
Thigh hematoma and associated anemia
Pseudoaneurysm of femoral artery s/p repair [**2111-12-10**]
Transfusion reaction


Discharge Condition:
Fair - some thigh pain remains on R; nearly full strength in the
left lower extremity, 4+/5 upper motor neuron pattern strength
on left lower extremity, subtle neglect both visual and tactile
on the left, very mild dysarthria, mild inattention but normal
speech and language


Discharge Instructions:
Please return to ER if you have any new signs of bleeding, as
coumadin is being started today, and he has had bleeding
complications during the acute hospitalization.

Please return to ER if you have any signs of new stroke,
including new visual problems, problems speaking or swallowing,
numbness, tingling, clumsiness, or new gait problems.  Please
[**Name8 (MD) 138**] MD immediately if you have a severe headache.

You are being discharged with a foley catheter in place - this
should be discontinued at [**Hospital 38**] Rehab, with a voiding trial
to follow.

You must have your INR checked DAILY until it is within
therapeutic range ([**1-3**]).  We are starting coumadin at a low
dose, but this dose will be adjusted by the inpatient facility
based on the INR.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23183**], MD Phone:[**Telephone/Fax (1) 9347**]
Date/Time:[**2112-1-12**] 8:30
.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2112-2-9**] 4:00
.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]

Completed by:[**2111-12-16**]
{'Cerebral embolism with cerebral infarction,Acute posthemorrhagic anemia,Hematoma complicating a procedure,Ostium secundum type atrial septal defect,Peripheral vascular complications, not elsewhere classified,Atrial flutter,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Late effects of cerebrovascular disease, other speech and language deficits,Other ill-defined heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Aneurysm of artery of lower extremity,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Hypovolemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other disorders of muscle, ligament, and fascia'}


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, lethargy

PRESENT ILLNESS: 66yo left-handed man with recent R MCA stroke and multiple
vascular risk factors presents with difficulty seeing, change in
personality, and lethargy. On Saturday prior to admission he did
not seem himself to his wife; she felt he was quieter than usual
and more lethargic. She asked him what was wrong and he
complained of a headache on the right side of his head behind
his
ear. Throughout the next 5 days, he continued to complain of
headache and did not seem his usual self. He was quiet, sleeping
more than usual. He was not eating as much. He was having
difficulty "seeing" - for example, he would have to feel around
on the table for his fork. He dropped a spoon and potato and had
difficulty finding them. His wife thought this was mostly a
problem with things that were white or silver, but she was not
sure. He had difficulty telling time, difficulty with the big
and
little hand - thought 20 of 5 was 20 past 8. She also felt he
was
emotionally labile, acting silly more than normal, acting angry,
when usually he is eventempered. For example, he was walking up
the ambulance ramp to the ED when she heard a car behind them,
told him to move out of the way, and he stopped, shouted "leave
me alone!" He has not had any change in his speech, gait, or
weakness.

MEDICAL HISTORY: R M1 segment MCA stroke [**7-/2111**] with residual left facial droop,
left hand weakness/stiffness, mild dysarthria
hyperlipidemia
hypertension
diabetes, diagnosed [**8-/2111**], initially diet controlled w/ FS
100s,
last A1C 6.8, started on metformin
h/o tobacco use, quit after stroke [**7-/2111**]
s/p tonsillectomy

MEDICATION ON ADMISSION: AGGRENOX 25 mg-200 mg [**Hospital1 **]
Labetalol 300 mg tid
SIMVASTATIN 80 mg daily
Metformin 500mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97.8, HR 51, Bp 116/64, RR 16, SaO2 99%/RA
Genl: NAD
HEENT: NCAT, MMM, OP clear, left [**Doctor First Name 2281**] with brown in left upper
quadrant, eyes otherwise blue
Neck: supple, no bruits
CV: RRR, nl S1, S2, no m/r/g
Chest: CTAB
Abd: soft, NTND, BS+
Ext: warm and dry

FAMILY HISTORY: mother died age 66, had HTN, stroke; father died age 87

SOCIAL HISTORY: tob 2.5ppd x 50yrs, h/o heavy EtOH use, "in recovery" 21yrs,
no drug use, married 

### Response:
{'Cerebral embolism with cerebral infarction,Acute posthemorrhagic anemia,Hematoma complicating a procedure,Ostium secundum type atrial septal defect,Peripheral vascular complications, not elsewhere classified,Atrial flutter,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Late effects of cerebrovascular disease, other speech and language deficits,Other ill-defined heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Aneurysm of artery of lower extremity,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Hypovolemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other disorders of muscle, ligament, and fascia'}
