CHIEF COMPLAINT: code stroke

PRESENT ILLNESS: Ms. [**Known lastname **] is a 86 yo W with h/o AF not on coumadin, MVR and
recent hip fracture s/p ORIF [**2147-12-20**] who presents with acute
onset L sided weakness and facial droop at rehab.
The patient was noticed by rehab staff to acutely develop left
facial droop and left arm and leg weakness at 13:45 today. There
is no other collateral history available.
Per patient's daugther, she has been declining since [**2147-9-13**] with more confusion, falls and finally the hip fracture for
which she remained hospitalized for 3 weeks with complications
including delirium. She is intermitently confused, but usually
oriented x 2, she is able to feed herself. She has not walked
since the surgery, but was previously using a walker. Before
[**Month (only) **], she was living alone and independent.

MEDICAL HISTORY: - MVR for prolapse
- chronic Afib
- HTN
- hyperlipidemia
- hypothyroidism
- UTIs

MEDICATION ON ADMISSION: 1. docusate sodium 100 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO BID (2

ALLERGIES: Penicillins / Amoxicillin / Banana

PHYSICAL EXAM: <<on admission>>

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Had been @Rehab Facility. Had been living alone until [**9-/2147**],
then went to rehab due to falls, then [**Hospital3 **] ([**Hospital **]), and then fell again prompting recent hospitalization and
discharge to rehab.
Cerebral embolism with cerebral infarction,Other primary cardiomyopathies,Atrial flutter,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Nontraumatic compartment syndrome of lower extremity,Hematoma complicating a procedure,Cachexia,Fibrinolysis-affecting drugs causing adverse effects in therapeutic use,Hip joint replacement,Do not resuscitate status,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Heart valve replaced by other means
Crbl emblsm w infrct,Prim cardiomyopathy NEC,Atrial flutter,Late ef-hemplga side NOS,Nontraum comp syn-low ex,Hematoma complic proc,Cachexia,Adv eff fibrinolysis agt,Joint replaced hip,Do not resusctate status,Hypothyroidism NOS,Hypertension NOS,Hyperlipidemia NEC/NOS,Heart valve replac NEC
Admission Date:  [**2148-1-11**]              Discharge Date:   [**2148-1-16**]


Service: NEUROLOGY

Allergies:
Penicillins / Amoxicillin / Banana

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
code stroke

Major Surgical or Invasive Procedure:
- IV-tPA given for stroke, with minimal improvement
- Right thigh fasciotomy for hematoma / compartment syndrome
- Made CMO
- Deceased


History of Present Illness:
Ms. [**Known lastname **] is a 86 yo W with h/o AF not on coumadin, MVR and
recent hip fracture s/p ORIF [**2147-12-20**] who presents with acute
onset L sided weakness and facial droop at rehab.
The patient was noticed by rehab staff to acutely develop left
facial droop and left arm and leg weakness at 13:45 today. There
is no other collateral history available.
Per patient's daugther, she has been declining since [**2147-9-13**] with more confusion, falls and finally the hip fracture for
which she remained hospitalized for 3 weeks with complications
including delirium. She is intermitently confused, but usually
oriented x 2, she is able to feed herself. She has not walked
since the surgery, but was previously using a walker. Before
[**Month (only) **], she was living alone and independent.

On arrival in [**Hospital1 18**] ED, NIHSS 8 for L facial droop, L
hemiparesis, answers name but not age correctly, dysarthria.
Head CT showed hypodensity of the R MCA territory, no cut-off
seen, no ICH. Patient was deemed candidate for t-PA with no
absolute contraindications (surgery was >14 days ago). She was
given t-PA with no immediate improvement. After 30 minutes, L
arm
was antigravity, she was opening eyes more and answering yes/no
questions with nodding head. Denies pain or headache.

Upon completion of t-PA (1 hour), patient was lifting L hand
antigravity to command, proximal strength better than distal
strength (still not squeezing hand). She was indicating she had
pain in the right lower back and right thigh. Inspection of the
right thigh revealed swollen, hard area c/w hematoma. Ortho was
consulted for possible compartment syndrome. CT scan of the
thigh
was ordered.

Past Medical History:
- MVR for prolapse
- chronic Afib
- HTN
- hyperlipidemia
- hypothyroidism
- UTIs


Social History:
Had been @Rehab Facility. Had been living alone until [**9-/2147**],
then went to rehab due to falls, then [**Hospital3 **] ([**Hospital **]), and then fell again prompting recent hospitalization and
discharge to rehab.

Family History:
Non-contributory

Physical Exam:
<<on admission>>

VS: T AF   HR 84   BP 123/65  RR 19   02 100/face mask
GEN: cachectic elderly woman, moderate distress
HEENT: sclera anicteric
CV: irregular
PULM: CTAB
AB: ND/NT
EXT: no edema

NEURO:
MS: Eyes closed, do not open to command, open slightly to
noxious
stimuli. Answers name, says age is 61. Speech dysarthria, also
moaning, difficult to assess language further.
CN: PERRL 2.5 to 2mm. EOMI. Blinks to threat bilaterally. L
facial droop at rest. Tongue midline
MOTOR: moving R side spontaneously and to command (cannot lift
RLE to command s/p hip surgery), moving LLE to command
antigravity for 8 seconds, no movement of LUE to command.
Withdraws and localizes pain in all 4 extremities.
SENSATION: withdraws to pain in all 4 extremities.
COORDINATION: intact finger to nose on RUE

Pertinent Results:
[**2148-1-12**] 04:52AM BLOOD WBC-10.9 RBC-2.95* Hgb-9.2* Hct-26.9*
MCV-91 MCH-31.2 MCHC-34.3 RDW-19.9* Plt Ct-243
[**2148-1-11**] 09:34PM BLOOD WBC-15.1* RBC-2.44* Hgb-7.8* Hct-23.6*
MCV-96 MCH-32.1* MCHC-33.3 RDW-19.5* Plt Ct-285
[**2148-1-11**] 02:44PM BLOOD WBC-10.1 RBC-2.60* Hgb-8.8* Hct-26.3*
MCV-101* MCH-33.9* MCHC-33.5 RDW-16.9* Plt Ct-359
[**2148-1-11**] 09:34PM BLOOD PT-14.4* PTT-27.3 INR(PT)-1.3*
[**2148-1-11**] 02:44PM BLOOD PT-13.2 PTT-24.9 INR(PT)-1.1
[**2148-1-12**] 04:52AM BLOOD Glucose-99 UreaN-28* Creat-0.6 Na-138
K-4.8 Cl-105 HCO3-26 AnGap-12
[**2148-1-11**] 09:34PM BLOOD Glucose-101* UreaN-28* Creat-0.6 Na-135
K-5.0 Cl-106 HCO3-24 AnGap-10
[**2148-1-11**] 02:44PM BLOOD Glucose-91 UreaN-29* Creat-0.7 Na-138
K-4.7 Cl-104 HCO3-27 AnGap-12
[**2148-1-11**] 09:34PM BLOOD CK(CPK)-42
[**2148-1-11**] 09:34PM BLOOD CK-MB-4 cTropnT-0.04*
[**2148-1-11**] 02:44PM BLOOD CK-MB-5
[**2148-1-11**] 02:44PM BLOOD cTropnT-0.04*
[**2148-1-12**] 04:52AM BLOOD Calcium-7.9* Phos-4.1 Mg-2.4
[**2148-1-11**] 09:34PM BLOOD Calcium-7.9* Phos-4.3# Mg-1.8

[**2148-1-11**] ECG:
<<a.flutter>>
Cardiology Report ECG Study Date of [**2148-1-11**]  2:35:06 PM
Possible atrial flutter with multiple premature ventricular
complexes. Right axis deviation. Left ventricular hypertrophy
with secondary repolarization abnormalities. Inferolateral ST
segment changes secondary to left ventricular hypertrophy versus
myocardial ischemia. Clinical correlation is suggested.
Extensive baseline artifact. Compared to the previous tracing of
[**2148-1-3**] the rhythm now appears to be more consistent with
atrial flutter versus atrial fibrillation and multiple premature
ventricular complexes are now seen.
TRACING #1
Read by: FISH,[**Doctor First Name **] E.
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
87 0 122 364/411 0 69 35

[**2148-1-11**] HCT/CTA/CT-perfusion (@presentation to our ED):
FINDINGS:
HEAD CT: An extensive region of the right MCA distribution
demonstrates loss of the [**Doctor Last Name 352**]-white matter differentiation and
is diffusely hypodense. There is minimal sulcal effacement.
There is no associated intracranial hemorrhage.  Elsewhere in
the brain, there is no edema, hemorrhage, mass effect, or
evidence of infarction. Ventricles and sulci are otherwise
normal in size and configuration for the patient's age. No
fractures are identified. The right maxillary sinus is again
atelectatic and completely opacified. Remaining paranasal
sinuses and mastoid air cells are well aerated. The
configuration of the calvarium is again unusual, with thinning
of the posterior calvarium bilaterally, with a congenital
appearance.
CT PERFUSION: The perfusion maps demonstrate an extensive region
of prolonged transit time and reduced blood flow and blood
volume throughout the right MCA distribution, compatible with
infarct. There is no mismatch to indicate a penumbra.
HEAD AND NECK CTA: There is an abrupt cutoff of the superior
division of the right M2 segment of the right middle cerebral
artery. The inferior division arises early from the M1 segment
on the right. There is a relative paucity of distal
opacification within the MCA territory on the right. However, a
few opacified vessels are present, the result of collateral
flow. The remainder of the circle of [**Location (un) 431**] is patent without
other area of occlusion. The anterior communicating artery has a
slightly bulbous appearance. The cervical carotid and vertebral
arteries and major branches are patent with no high-grade
stenoses. However, the entire right cervical ICA is slightly
diminutive in caliber relative to the left, and slightly
irregular suggesting a long segment of atherosclerosis. Both
carotid bulbs demonstrate atheromatous irregularity without
high-grade stenosis. There is atherosclerotic calcification of
the cavernous carotids bilaterally as well.
Lung apices demonstrate scarring and high-density material
bilaterally, with bronchiectasis at the right lung apex. The
aortic arch and origin of the major vessels demonstrate dense
atherosclerotic calcification.
The right internal carotid artery measures 8.3 mm at the bulb, 3
mm just above the bulb, and 3 mm at its upper portion. The left
internal carotid artery measures 9 mm at the bulb, 5 mm just
above the bulb, and 3.3 mm along the upper segment.
IMPRESSIONS:
1. Large acute infarct in the right MCA distribution, with no
perfusion
mismatch.
2. Abrupt occlusion of the superior division of the right M2
segment of the right middle cerebral artery, with decreased
filling of distal branches. Otherwise, patent circle of [**Location (un) 431**].
3. Atheromatous irregularity at the carotid bulb bilaterally,
with slightly diminutive right cervical ICA along its entire
length, suggesting long segment atherosclerosis versus
vasculitis. However, no high-grade stenosis of either side.
4. Slightly bulbous appearance of the anterior communicating
artery. Please correlate with angiography.
5. Complete opacification and atelectasis of the right maxillary
sinus as seen previously.

[**2148-1-11**] NCHCT:
FINDINGS: Again noted is loss of the [**Doctor Last Name 352**]-white matter
differentiation in the right insula. Sulcal effacement and loss
of [**Doctor Last Name 352**]-white differentiation extends to the right frontal and
parietal lobes in a right MCA distribution. No evidence of acute
hemorrhage is seen. There is some compression of the right
lateral ventricle, not significantly changed from the prior
examination. General prominence of the ventricles and sulci is
compatible with generalized atrophy, age related. Areas of
periventricular and subcortical white matter hypodensity likely
reflect sequela of chronic small vessel ischemic disease.
No concerning osseous lesion is seen. There are vascular
calcifications of the bilateral carotid siphons. Complete
opacification of the right maxillary sinus is unchanged.
IMPRESSION:
1. No evidence of acute hemorrhage.
2. Infarction in right MCA distribution as previously seen. No
shift of
midline structures.

[**2148-1-12**] NCHCT:
FINDINGS: Again seen is a large right MCA territory infarct with
expected
evolution. There is no evidence of hemorrhage within the
infarct. No
significant mass effect or shift of midline structures is seen.
The
ventricles and sulci are mildly dilated, consistent with
age-related
involutional changes. The basal cisterns are normal.
Calcification of the
cavernous portion of bilateral carotid arteries is present.
The mastoid air cells and imaged paranasal sinuses are clear.
  IMPRESSION:
1. Expected evolution of the large right MCA territory infarct.
No
significant mass effect or shift of midline structures is seen.
2. No evidence of hemorrhage within the infarct.


Brief Hospital Course:
86y F with atrial flutter and recently worsening dementia
(undiagnosed), who was not taking anti-coagulation for her afib,
recently s/p right Femur repair [**2147-12-20**]. Returned from Rehab
to our ED as a code stroke due to Left-sided weakness, and was
found to have a Right-M2 (superior division) occlusion,
presumably due to cardioembolic clot given her aflutter without
A/C. Given IV-tPA in the ED, with some improvement in her LUE
(anti-gravity strength), but this was c/b a large and painful
hematoma in the region of her recent surgery, which required
that she go to OR urgently with Orthopedics for fasciotomy to
relieve pressure from compartment syndrome (70mmHg pressure
measured by Ortho). Her H&H dropped, but improved appopriately
after transfusion of 2U PRBCs. Her family decided to stop
pursuing aggressive care measures; fasciotomy and transfusion
were performed due to their palliative value (pt. in severe pain
from pressure/compartment syndrome). Pt was made CMO by family
and transferred to the floor, with removal of tubes, lines, and
invasive interventions and testing measures. She remained
comfortable, but minimally responsive, with PRN sublingual
morphine and with scopolamine patch. She died [**2147-1-16**].

Medications on Admission:
1. docusate sodium 100 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO BID (2

times a day).
2. senna 8.6 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO HS (at bedtime).
3. aspirin 81 mg Tablet, Chewable [**Year (4 digits) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. levothyroxine 100 mcg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY
5. lisinopril 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).

6. [**Year (4 digits) **] 0.03 % Drops [**Year (4 digits) **]: One (1) drop Ophthalmic at bedtime.

7. megestrol 400 mg/10 mL (40 mg/mL) Suspension [**Year (4 digits) **]: One (1)
pill PO DAILY (Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet [**Year (4 digits) **]: Two (2)
Tablet PO DAILY (Daily).
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Year (4 digits) **]: One
(1) Tablet, Chewable PO TID (3 times a day).
10. sertraline 50 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO DAILY
(Daily).
11. digoxin 125 mcg Tablet [**Year (4 digits) **]: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
12. polyethylene glycol 3350 17 gram/dose Powder [**Year (4 digits) **]: One (1)
packet PO DAILY (Daily) as needed for constipation.
13. bisacodyl 10 mg Suppository [**Year (4 digits) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. olanzapine 5 mg Tablet, Rapid Dissolve [**Year (4 digits) **]: 0.5 Tablet,
Rapid Dissolve PO BID (2 times a day).
15. cyanocobalamin (vitamin B-12) 250 mcg Tablet [**Year (4 digits) **]: One (1)
Tablet PO DAILY (Daily).
16. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain fever.
18. enoxaparin 30 mg/0.3 mL Syringe [**Last Name (STitle) **]: One (1) syringe
Subcutaneous QHS (once a day (at bedtime)) for 10 days: Last day

= [**1-20**].
19. mirtazapine 15 mg Tablet [**Month (only) **]: One (1) Tablet PO at bedtime.

20. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
[**Month (only) **]: 1.5 Tablet Sustained Release 24 hrs PO once a day.

Discharge Medications:
deceased

Discharge Disposition:
Expired

Discharge Diagnosis:
deceased


Discharge Condition:
deceased


Discharge Instructions:
deceased

Followup Instructions:
deceased


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

Completed by:[**2148-1-23**]
{'Cerebral embolism with cerebral infarction,Other primary cardiomyopathies,Atrial flutter,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Nontraumatic compartment syndrome of lower extremity,Hematoma complicating a procedure,Cachexia,Fibrinolysis-affecting drugs causing adverse effects in therapeutic use,Hip joint replacement,Do not resuscitate status,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Heart valve replaced by other means'}


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: code stroke

PRESENT ILLNESS: Ms. [**Known lastname **] is a 86 yo W with h/o AF not on coumadin, MVR and
recent hip fracture s/p ORIF [**2147-12-20**] who presents with acute
onset L sided weakness and facial droop at rehab.
The patient was noticed by rehab staff to acutely develop left
facial droop and left arm and leg weakness at 13:45 today. There
is no other collateral history available.
Per patient's daugther, she has been declining since [**2147-9-13**] with more confusion, falls and finally the hip fracture for
which she remained hospitalized for 3 weeks with complications
including delirium. She is intermitently confused, but usually
oriented x 2, she is able to feed herself. She has not walked
since the surgery, but was previously using a walker. Before
[**Month (only) **], she was living alone and independent.

MEDICAL HISTORY: - MVR for prolapse
- chronic Afib
- HTN
- hyperlipidemia
- hypothyroidism
- UTIs

MEDICATION ON ADMISSION: 1. docusate sodium 100 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO BID (2

ALLERGIES: Penicillins / Amoxicillin / Banana

PHYSICAL EXAM: <<on admission>>

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Had been @Rehab Facility. Had been living alone until [**9-/2147**],
then went to rehab due to falls, then [**Hospital3 **] ([**Hospital **]), and then fell again prompting recent hospitalization and
discharge to rehab. 

### Response:
{'Cerebral embolism with cerebral infarction,Other primary cardiomyopathies,Atrial flutter,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Nontraumatic compartment syndrome of lower extremity,Hematoma complicating a procedure,Cachexia,Fibrinolysis-affecting drugs causing adverse effects in therapeutic use,Hip joint replacement,Do not resuscitate status,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Heart valve replaced by other means'}
