CHIEF COMPLAINT: transferred for carotid stenting

PRESENT ILLNESS: Pt. is a 66 y/o Hindi-speaking female with a hx of HTN,
hyperlipidemia, DM2, recent TIA ([**3-18**]) with w/u that revealed RCA
stenosis, followed by an episode of chest pain ([**4-1**]), NSTEMI,
found to have 3VD on cardiac catheterization, who is transferred
here for carotid stenting.

MEDICAL HISTORY: 1.  Diabetes type 2.
2.  Hypertension.
3.  Hyperlipidemia.
4.  h/o TIAs in [**2131**] and [**3-/2137**] with known carotid stenosis
5.  Iron deficiency anemia.
6.  Hyperthyroidism with h/o multinodular goiter
7.  Sciatica
8.  Coronary artery disease

MEDICATION ON ADMISSION: Tylenol 650 Q4H PRN Headache
ASA 325 QD
Lipitor 80 mg QD
Plavix 75 mg QD
Colace 100 [**Hospital1 **]
Lovenox 30 mg SC QD
NPH 18 U QAM, 6 U QPM
RISS
Maalox PRN
MOM PRN
Methimazole 15 mg QAM
Metoprolol 12.5 mg TID
NTG PRN chest pain
Omeprazole 20 mg QD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T- 98.7 BP- 145/64 HR- 66 RR- 18 O2Sat- 100% on RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema

FAMILY HISTORY: No family history of stroke or cardiovascular disease.

SOCIAL HISTORY: The patient is from [**Country 11150**] and speaks Hindi, lives with her
daughter's family. Activities of daily living: She is able to
cook, clean, and ambulate without difficulty. She denies any
alcohol, tobacco, or occasional drug use.
Subendocardial infarction, initial episode of care,Occlusion and stenosis of carotid artery with cerebral infarction,Other nervous system complications,Coronary atherosclerosis of native coronary artery,Personal history of other diseases of circulatory system,Unspecified transient cerebral ischemia,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Iron deficiency anemia, unspecified
Subendo infarct, initial,Ocl crtd art w infrct,Surg comp nerv systm NEC,Crnry athrscl natve vssl,Hx-circulatory dis NEC,Trans cereb ischemia NOS,Hypertension NOS,Hyperlipidemia NEC/NOS,DMII wo cmp nt st uncntr,Iron defic anemia NOS
Admission Date:  [**2138-4-17**]              Discharge Date:   [**2138-5-5**]

Date of Birth:  [**2071-7-24**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
transferred for carotid stenting


Major Surgical or Invasive Procedure:
Right carotid extracranial angioplasty and intracranial stent
placement [**2138-4-19**]
s/p CABGx6(LIMA->LAD, SVG->Diag, OM1, OM2, RCA, PDA) [**2138-4-24**]


History of Present Illness:
Pt. is a 66 y/o Hindi-speaking female with a hx of HTN,
hyperlipidemia, DM2, recent TIA ([**3-18**]) with w/u that revealed RCA
stenosis, followed by an episode of chest pain ([**4-1**]), NSTEMI,
found to have 3VD on cardiac catheterization, who is transferred
here for carotid stenting.

Pt's history starts on [**3-18**], when she was admitted to [**Hospital 8**]
hospital for work up of a TIA.  Per Dr.[**Name (NI) 20920**] initial stroke
consult note, she had awoken to use the bathroom and felt like
she was falling to the right. She then stood up and her left leg
gave out. Her family had to pick her up from the floor, and
noticed that she had left sided weakness with facial droop and
dysarthria. The symptoms lasted approximately 6 hours.
Examination by neurology was reportedly normal. An MRA revealed
severe stenosis of the right ICA cavernous segment and
additional
proximal right common carotid artery stenosis of 67-75%. She was
noted to also have elevated troponins, LVH with ST depressions
in
V2-6 on EKG, and an ECHO showing diastolic dysfunction. She was
discharged on aggrenox and ASA. On follow up in interventional
neuroradiology, she was not taking the ASA, but had no further
symptoms. The plan was for an outpatient angiogram.

Before this could be performed she presented again to [**Hospital 8**]
Hospital on [**4-1**] with chest pain. She had elevated troponins
with
peak Tn-I of 0.7 and was diagnosed with a NSTEMI. She was
started
on heparin and loaded with plavix. Catheterization showed three
vessel disease (99% RCA, 70% pLAD, 75% Lcx) and was transferred
to [**Hospital1 18**] for possible CABG.

Per her [**4-11**] d/c summary, as part of the work up prior to CABG,
she underwent cerebral angiogram on [**4-8**] by Dr. [**Last Name (STitle) **] which
revealed 30 to 40% stenosis of the right internal carotid artery
at the bifurcation, 55% stenosis at the junction of the petrous
and cavernous portions of the right internal carotid artery, 40
to 45% stenosis of the petrous portion of the left internal
carotid artery. On the evening of [**4-9**], the patient was noted to
be orthostatic with SBP 90s and developed slurred speech and
left
leg weakness. She was bolused with IV fluids and her
anti-hypertensive held to maintain a goal SBP>120. Her symptoms
completely resolved with these measures, and were felt to
represent TIA.  It was felt that her peri-CABG stroke risk
outweighed the risk of carotid stenting and that the risk of the
stroke during CABG was greater than the risk of MI in the next
few days and based on the location of her lesions, they
recommended transfer to [**Hospital1 112**] for Wingspan stenting of her right
carotid lesion. She was re-loaded with 600mg plavix, followed by
75mg daily, and continued on aspirin 325mg daily. Her aggrenox
continued to be held. She was transferred to the Neurology
Service at [**Hospital1 112**] on [**4-11**], with a plan for Wingspan stenting by Dr.
[**Last Name (STitle) 73121**].  It was planned that she return to [**Hospital1 18**] for CABG
with
Dr. [**Last Name (STitle) 914**] from Cardiothoracic Surgery after carotid stenting.

At [**Hospital1 112**] MRI was performed and showed acute R frontal infarcts,
predominantly affecting the ACA territory, possibly minimally
affecting the right MCA territory, and hypertensive
microvascular
disease.  Cerebral angiogram was repeated and showed 60%
stenosis
of the left ICA at C3 and C4 vertebral body levels, diffuse
intracranial atherosclerosis, R ICA cavernous segment with 40%
stenosis at the posterior genu.  Angiographically the R A1
segment demonstrated no filling and the L A1 segment was
hypoplastic.  Dr. [**Last Name (STitle) 73120**] was consulted and felt that since the
ICA
lesions did not appear to be flow limiting she didn't meet
criteria for wingspan.  She was therefore transferred back to
[**Hospital1 18**] for traditional carotid stenting.

Her daughter (who translates for her) reports that she has not
had any further episodes of L sided weakness, facial droop, or
slurred speech, or any symptoms concerning for stroke.


Past Medical History:
1.  Diabetes type 2.
2.  Hypertension.
3.  Hyperlipidemia.
4.  h/o TIAs in [**2131**] and [**3-/2137**] with known carotid stenosis
5.  Iron deficiency anemia.
6.  Hyperthyroidism with h/o multinodular goiter
7.  Sciatica
8.  Coronary artery disease

Social History:
The patient is from [**Country 11150**] and speaks Hindi, lives with her
daughter's family. Activities of daily living: She is able to
cook, clean, and ambulate without difficulty. She denies any
alcohol, tobacco, or occasional drug use.

Family History:
No family history of stroke or cardiovascular disease.

Physical Exam:
T- 98.7 BP- 145/64 HR- 66 RR- 18 O2Sat- 100% on RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema

Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect.  Speech is fluent with normal comprehension per
daughter.
[**Name (NI) **] dysarthria per daughter. [**Name (NI) **] right left confusion. No evidence
of apraxia or neglect.

Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular
movements intact bilaterally, no nystagmus. Sensation intact V1-
V3.  Facial movement symmetric.  Hearing intact to finger rub
bilaterally.  Palate elevation symmetrical.  Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact

Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
  [**Doctor First Name **] Tri [**Hospital1 **]  WF WE FE FF  IP  H  Q DF PF TE TF
R  5   5   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  5  5

Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout. No extinction to DSS

Reflexes:
+2 and symmetric throughout.
Toes downgoing bilaterally

Coordination: finger-nose-finger normal, RAMs normal.

Gait: Narrow based, steady.

Romberg: Negative


Pertinent Results:
[**2138-4-28**] 07:20AM BLOOD WBC-9.6 RBC-3.75* Hgb-11.3* Hct-33.6*
MCV-90 MCH-30.1 MCHC-33.6 RDW-14.9 Plt Ct-289
[**2138-4-26**] 12:45AM BLOOD PT-12.9 PTT-30.0 INR(PT)-1.1
[**2138-4-28**] 07:20AM BLOOD Glucose-130* UreaN-9 Creat-0.5 Na-143
K-3.9 Cl-105 HCO3-29 AnGap-13
RADIOLOGY  Final Report

CHEST (PA & LAT)  [**2138-4-28**] 8:50 AM

CHEST (PA & LAT)

Reason: evaluate effusion

[**Hospital 93**] MEDICAL CONDITION:
66 year old woman s/p CABG
REASON FOR THIS EXAMINATION:
evaluate effusion

TWO VIEW CHEST Of [**2138-4-28**].

COMPARISON: [**2138-4-25**].

INDICATION: Status post coronary artery bypass surgery.

Left internal jugular catheter has been removed with no evidence
of pneumothorax. Cardiac and mediastinal contours are stable in
the postoperative period. Minor bibasilar atelectasis is present
adjacent to small bilateral pleural effusions.

On the lateral view, a small air-fluid level is present in the
retrosternal region. Trachea is deviated towards the left above
the thoracic inlet level with mild coronal narrowing without
change from the preoperative radiograph of [**2138-3-18**],
corresponding to enlargement of the right lobe of the thyroid
gland on interval CT.

IMPRESSION:
1. Small pleural effusions and minor basilar atelectasis.
2. Retrosternal air-fluid level, which can be a normal
postoperative finding in the early postoperative period in the
absence of clinical signs of infection.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2138-4-28**] 11:07 AM
Cardiology Report ECHO Study Date of [**2138-4-24**]



PATIENT/TEST INFORMATION:
Indication: Coronary artery disease. Left ventricular function.
Mitral valve disease. Preoperative assessment. Right ventricular
function.
Status: Inpatient
Date/Time: [**2138-4-24**] at 14:53
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW5-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate




REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **]

MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Ejection Fraction: 40% to 55% (nl >=55%)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)

INTERPRETATION:

Findings:

RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.


LEFT VENTRICLE: Mild symmetric LVH. Normal regional LV systolic
function.
Overall normal LVEF (>55%).

LV WALL MOTION: remaining LV segments contract normally.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma
in the
descending thoracic aorta.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
(1+) AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**11-19**]+)
MR. Eccentric MR jet.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.

GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure.

Conclusions:
PREBYPASS
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy.
Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function
is normal (LVEF>55%). The remaining left ventricular segments
contract
normally.
3. Right ventricular chamber size and free wall motion are
normal.
4. There are complex (>4mm) atheroma in the descending thoracic
aorta.
5. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. There is
prolapse of the A2
segment of the anterior leaflet (demonstarted on 3D
reconstruction) with
resultant mild to moderate ([**11-19**]+) eccentric mitral regurgitation
is seen.There
is a posteriorly-directed jet of MR.
7. An epiaortic scan was performed which demostrated no
significant
atheromatous disease in the portion of the ascending aorta
scanned.

POSTBYPASS: On infusion of phenylephrine. Preserved LV systolic
function post
cpb. MR is now 1+. AI is 1+. Normal aortic contour post
decannulation.

Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2138-4-24**] 18:06.







Brief Hospital Course:
The patient was transferred back to from [**Hospital6 **] and
had an intracranial stent angioplasty for tandem [**Country **] stenosis.
She was transferred to the neuro ICU and remained stable.  On
[**2138-4-24**] she underwent CABGx6(LIMA->LAD< SVG-.Diag, OM1, OM2, RCA,
PDA).  The cross clamp time was 100 mins., and total bypass time
was 121 mins.  She tolerated the procedure well and was
transferred to the CSRU in stable condition.
She was extubated on the post op day 1 and had her chest tubes
d/c'd and was transferred to the floor on POD#2.  Her epicardial
pacing wires were d/c'd on POD#3.  She continued to progress and
was discharged to home in stable condition.

Medications on Admission:
Tylenol 650 Q4H PRN Headache
ASA 325 QD
Lipitor 80 mg QD
Plavix 75 mg QD
Colace 100 [**Hospital1 **]
Lovenox 30 mg SC QD
NPH 18 U QAM, 6 U QPM
RISS
Maalox PRN
MOM PRN
Methimazole 15 mg QAM
Metoprolol 12.5 mg TID
NTG PRN chest pain
Omeprazole 20 mg QD


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Methimazole 5 mg Tablet Sig: Three (3) Tablet PO Q 24H (Every
24 Hours).
Disp:*90 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig:
Eighteen (18)  Subcutaneous q AM: 6 units q PM.
Disp:*8 vials* Refills:*2*
11. Lancets & Blood Glucose Strips     Combo Pack Sig: One (1)
Miscellaneous four times a day.
Disp:*1 pack* Refills:*2*
12. syringe
3cc insulin syringe
1 [**Hospital1 **]
dispense 60
2 refills


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
1. Right carotid extracranial and intracranial stenosis status
post extracranial angioplasty and intracranial stenting.
2. History of transient ischemic attacks and bilateral watershed
strokes
3. Coronary artery disease with three vessel disease with recent
NSTEMI
4. Diabetes #2
5. Hypertension
6. Hyperlipidemia
7. Iron deficiency anemia
8. Hyperthyroidism with history of multinodular goiter
9. Sciatica


Discharge Condition:
Good.


Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Do not use creams, lotions, or powders on wounds.
Shower daily, let water flow over wounds, pat dry with a towel.
Call our office for sternal drainage, temp>101.5.

Followup Instructions:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2138-6-4**] 1:30
Make an appointment with Dr. [**Last Name (STitle) 914**] for 4 weeks.
Make an appointment with Dr. [**First Name4 (NamePattern1) **] [**Telephone/Fax (1) 73124**]



Completed by:[**2138-4-29**]

Name:  [**Known lastname **],[**Known firstname 12161**]                     Unit No:   [**Numeric Identifier 12162**]

Admission Date:  [**2138-4-17**]              Discharge Date:   [**2138-5-5**]

Date of Birth:  [**2071-7-24**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1546**]
Addendum:
Patient developed LT sided weakness/TIA on [**2138-4-29**]. patient
remained in hospital until [**2138-5-5**]. See discharge summary from
[**Date range (1) 12163**] and [**Date range (1) 12164**].

Chief Complaint:
Left sided weakness on day of discharge (see previous summary
for events [**Date range (1) 12163**])

Major Surgical or Invasive Procedure:
Right carotid extracranial angioplasty and intracranial stent
placement [**2138-4-19**]
s/p CABGx6(LIMA->LAD, SVG->Diag, OM1, OM2, RCA, PDA) [**2138-4-24**]
Right carotid endarterectomy and Dacron patch
angioplasty [**2138-5-2**]


History of Present Illness:
Patient was being readied for D/C today after being asymptomatic

and tolerating walking up and down stairs with no problems over
last few days. Her dose of Lisinopril was increased this am. At
1:10 pm she had difficulty with raising the left hand while
sitting in bed eating lunch. She also noted L leg weakness
associated. No headache or other symptoms. Stroke team was
called and was at bedside within 5 minutes of being called. At
that time exam notable for L arm drift (strength in L arm 3-4/5,

weaker distally) and L leg drift (grade [**2-20**]). No other focal
findings on exam. BS normal. Bp was slightly lower at 110s/50s.
Started on IVF and head of bed kept down and taken to MRI. MRI
revealed scattered DWI lesions but most looked old with no clear

change on MRA. Upon coming out of MRI, pt had improved
considerably with very slight L arm drift only. Over the course
of the next 30 minutes patient had almost completely recovered
with no notable drift of arm or leg.

Taken for CTA head and neck to rule out thrombus around stent.
Dr
[**Last Name (STitle) 12165**] looked at these images and thought that there was no
clear vessel cutoff but that there was significant narrowing of
the R ICA at the bifurcation.

Scheduled for Right carotid endarterectomy and Dacron patch
angioplasty with Dr. [**Last Name (STitle) **]


Past Medical History:
1.  Diabetes type 2.
2.  Hypertension.
3.  Hyperlipidemia.
4.  h/o TIAs in [**2131**] and [**3-/2137**] with known carotid stenosis
5.  Iron deficiency anemia.
6.  Hyperthyroidism with h/o multinodular goiter
7.  Sciatica
8.  Coronary artery disease
9. NSTEMI MI ([**Hospital 15**] hospital)

Social History:
The patient is from [**Country 11955**] and speaks Hindi, lives with her
daughter's family. Activities of daily living: She is able to
cook, clean, and ambulate without difficulty. She denies any
alcohol, tobacco, or occasional drug use

Family History:
No family history of stroke or cardiovascular disease.

Physical Exam:
98, 89, 120/50 97%RA
GEN: NAD, RT neck incision-C/D/I, staples removed
CV: RRR, sternum incision stable
Lungs: CTA
Abd: soft, NT
Ext: warm, no edema, palpable pulses. Lt groin/thigh hematoma
stable

Pertinent Results:
[**2138-5-4**] 04:55AM BLOOD WBC-8.3 RBC-3.32* Hgb-9.9* Hct-30.1*
MCV-91 MCH-29.7 MCHC-32.8 RDW-15.3 Plt Ct-486*
[**2138-5-4**] 04:55AM BLOOD Glucose-88 UreaN-6 Creat-0.6 Na-137 K-4.5
Cl-102 HCO3-31 AnGap-9
[**2138-5-4**] 04:55AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1

[**2138-4-29**] CT ANGIOGRAPHY OF THE NECK AND HEAD

HISTORY: Rule out thrombus in region of intracranial stent.

TECHNIQUE: Preliminary noncontrast head CT scan.

COMPARISON STUDY: [**2138-4-29**] study, interpreted by Drs. [**Last Name (STitle) 12166**]
and [**Name5 (PTitle) 12167**] as revealing "resolution of previously identified
hypoattenuating lesions likely reflective of contrast blush
immediately post-procedure. Unchanged old watershed infarct at
left anterior cerebral and middle cerebral artery border zone".

FINDINGS: The present study has a number of scans degraded by
patient motion. Some of these were repeated.

Within these limitations, there is no definite sign for the
presence of interval appearance of an intracranial hemorrhage or
new area of brain infarction. No new osseous pathology is
identified. The radiopaque stent in the region of the cavernous
portion of the right internal carotid artery is demonstrated.

CT angiography of the neck and head was obtained.

COMPARISON STUDY: Conventional angiography from [**2138-4-19**].

FINDINGS: Comparison with the prior study, perhaps due to
modality differences, suggests that there is a high-grade (90+
percent) stenosis at the exact origin of the right internal
carotid artery. The lumen does rapidly expand to an area of
minor stenosis distal to this point, with adjacent heavy
atherosclerotic calcification along the posterior wall of the
right internal carotid artery seen. On the left side, there is
only minor stenosis of the origin of the left internal carotid
artery, but again there is heavy atherosclerotic calcification
along the posterior wall of this vessel. No other definite
vascular stenoses involving the cervical carotid systems are
appreciated.

Intracranially, there is clear contrast enhancement on either
side of the stent, but it is somewhat difficult to be certain of
the exact status of the lumen within the stent itself.
Certainly, there is contrast material seen within the
intracranial vasculature elsewhere, but it is to be acknowledged
that it is difficult to be certain as to the contribution of
collateral flow into the anterior circulation tributaries of the
right cavernous carotid artery. Certainly, transcranial Doppler
measurements might be useful in this regard. Intracranially,
there does appear to be a moderate stenosis of the proximal M1
segment of the right middle cerebral artery that was not as
clearly appreciated on the prior angiogram, but of course the
present study allows for multiplanar reconstructions. The axial
projection, particularly shows this stenosis to maximal extent.
The right callosalmarginal artery appears quite diminutive,
which was probably present on the prior angiographic study, as
well. The left vertebral artery distal to the origin of the left
posterior inferior cerebellar artery has an area of moderate
stenosis and there is a more severe stenosis involving the
distal right vertebral artery just proximal to its junction with
the basilar artery.

CONCLUSION: Studies raise the question of a high-grade stenosis
now seen at the origin of the right internal carotid artery with
additional multiple intracranial stenoses as noted above. It is
quite difficult to ascertain the stent patency, even with the
sub-mm sections employed for this CT angiogram.

These findings were discussed with the requesting stroke
neurologist, Dr. [**Last Name (STitle) 12168**], and the issue of a proximal
internal carotid stenosis was raised with the interventional
neurosurgeon, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 8374**] on [**4-29**], shortly after the
conclusion of the examination.

[**2138-5-1**] CAROTID SERIES COMPLETE

REASON: Stroke.

FINDINGS: Duplex evaluation was performed of both carotid
arteries. Significant plaque was identified on the right.

On the right, the internal carotid artery peak
systolic/diastolic velocity is 260/114. In the remainder of the
vessels, the peak systolic velocities are 81, 70 in the CCA, ECA
respectively. The ICA to CCA ratio is 3.3. This is consistent
with an 80-99% stenosis.

On the left, peak systolic velocities are 83, 85, and 103 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1. This
is consistent with a less than 40% stenosis.

There is antegrade flow in both vertebral arteries.

IMPRESSION: Significant right-sided plaque with an 80-99%
carotid stenosis. On the left, there is a less than 40% carotid
stenosis.

[**2138-4-29**] EMERGENCY MR SCAN OF THE BRAIN:

HISTORY: Right intracranial carotid stenosis and stent. Now
presents with acute left arm weakness. Rule out acute stroke.

TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging,
including the use of diffusion-weighted scans.

COMPARISON MR STUDY: None.

FINDINGS: The diffusion-weighted images disclose a 1-cm
wedge-shaped area of restricted diffusion that likely represents
a relatively acute area of brain ischemia superimposed on much
more extensive chronic small vessel infarction involving the
white matter of both cerebral hemispheres. There is no new major
vascular territorial infarction identified. There are no areas
of abnormal susceptibility in the brain seen to suggest an area
of hemorrhage.

CONCLUSION: 1-cm focus of restricted diffusion in the right
occipital lobe suspicious for an area of acute brain ischemia.

MR ANGIOGRAPHY OF THE CIRCLE OF [**Location (un) 243**] AND ITS TRIBUTARIES

TECHNIQUE: Three-dimensional time-of-flight imaging with
multiplanar reconstruction.

PREVIOUS STUDY FOR COMPARISON: Standard angiography of [**2138-4-19**].

FINDINGS: Since the previous angiogram, there has apparently
been placement of an intravascular carotid stent within the
cavernous portion of this vessel on the right side. Flows signal
through the stent appears to be somewhat reduced in caliber but
it is possible that some of this apparent reduction could
reflect susceptibility effects from the stent metallic content.
There does appear to be symmetric flow signal within both middle
cerebral arteries. As was noted on the standard angiogram, both
anterior cerebral arteries appear to derive flow from the left
carotid system.


Brief Hospital Course:
This 66-year-old woman, status post coronary bypass and
intracranial internal carotid artery stenting, scheduled for
discharge on [**2138-4-29**] and developed left sided weakness,
transient ischemic attack. Evaluated by stroke team and carotid
ultrasound and a CT angiogram showed progression of her previous
40% internal carotid artery stenosis to 80%-99%. Scheduled for
right carotid endarterectomy on [**2138-5-2**]. Continued on Neo for BP
support and Heparin.
Neurology closely following.
[**2138-5-2**]: weakness of LLE resolved. Underwent uneventful right
carotid endarterectomy. Extubated. Pain controlled.
[**Date range (3) 12169**] No overnight events, VSS. IV fluid HL, diet
advanced, foley d'ced. Neurologically intact. Lt thigh pain post
CABG/left greater saphenous vein harvesting is unchanged.
[**2138-5-5**] No overnight events, VSS. Tolerating regular diet.
Physical therapy evaluated and cleared patient for home. RT CEA
Staples discontinued. Will discharge to home with services. Home
diabetic medications resumed. CT surgery evaluated Lt
groin/thigh hematoma prior to discharge. Hematoma is stable.
recommendations include warm compress and elevation. Patient
understands all discharge instructions (reviewed with her RN who
speaks Hindi). Follow up appointment scheduled with primary care
next week. She will follow up with Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) **] in [**12-22**] weeks.


Medications on Admission:
Metformin 1000mg [**Hospital1 **], Glipizide 5mg TID, Lisinopril 10mg',
Lipitor 20mg', Methimazole 10mg', Aggrenox 25/200', Atenolol
12.5mg', Baby ASA

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Call primary care for [**Hospital1 **].
Disp:*60 Capsule(s)* [**Hospital1 **]:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* [**Hospital1 **]:*0*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* [**Hospital1 **]:*2*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Methimazole 5 mg Tablet Sig: Three (3) Tablet PO Q 24H (Every
24 Hours): Call primary care MD [**First Name (Titles) **] [**Last Name (Titles) 3906**].
Disp:*90 Tablet(s)* [**Last Name (Titles) **]:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Call primary care MD [**First Name (Titles) **] [**Last Name (Titles) **].
Disp:*60 Tablet(s)* [**Last Name (Titles) **]:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours):
Call primary care for [**Last Name (Titles) **].
Disp:*30 Tablet, Delayed Release (E.C.)(s)* [**Last Name (Titles) **]:*0*
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
11. Lancets & Blood Glucose Strips     Combo Pack Sig: Check
Blood sugar 4x per day  Miscellaneous four times a day: Call
primary care for [**Last Name (Titles) **].
Disp:*120 1* [**Last Name (Titles) **]:*2*
12. Glipizide 5 mg Tablet Sig: One (1) Tablet PO three times a
day.
13. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 136**] Homecare

Discharge Diagnosis:
1. Right carotid extracranial and intracranial stenosis status
post extracranial angioplasty and intracranial stenting and
carotid endarterectomy.
2. History of transient ischemic attacks and bilateral watershed
strokes
3. Coronary artery disease with three vessel disease with recent
NSTEMI
4. Diabetes #2
5. Hypertension
6. Hyperlipidemia
7. Iron deficiency anemia
8. Hyperthyroidism with history of multinodular goiter
9. Sciatica


Discharge Condition:
Good. Cr 0.6
HCT 30.1
Warm compress to left groin/thigh hematoma. Elevate LE when not
ambulating


Discharge Instructions:
Discharge instructions from CT surgery (S/P CABG)
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Do not use creams, lotions, or powders on wounds.
Shower daily, let water flow over wounds, pat dry with a towel.
Call our office/Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1477**]  for sternal drainage,
temp>101.5.

Division of Vascular and Endovascular Surgery
Carotid Stent Discharge Instructions

Medications:
??????	Take Aspirin 325mg (enteric coated) once daily
??????	Take Plavix (Clopidogrel) 75mg once daily
??????	Continue all other medications you were taking before surgery,
unless otherwise directed
??????	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 incision 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 1 week, you may resume sexual activity
??????	After 1 week, gradually increase your activities and distance
walked as you can tolerate
??????	No driving until you are no longer taking pain medications
??????	You should not have an MRI scan within the first 4 weeks after
carotid stenting
??????	Call and schedule an appointment to be seen in [**1-19**] weeks for
post procedure check and ultrasound

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
vascular office/[**Doctor Last Name **] at [**Telephone/Fax (1) 4749**]. If bleeding does not
stop, call 911 for transfer to closest Emergency Room.

Division of Vascular and Endovascular Surgery
Carotid Endarterectomy Surgery Discharge Instructions

What to expect when you go home:
1. Surgical Incision:
??????	It is normal to have some swelling and feel a firm ridge along
the incision
??????	Your incision may be slightly red and raised, it may feel
irritated from the staples

2. You may have a sore throat and/or mild hoarseness
??????	Try warm tea, throat lozenges or cool/cold beverages

3. You may have a mild headache, especially on the side of your
surgery
??????	Try ibuprofen, acetaminophen, or your discharge pain
medication
??????	If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeon??????s office

4. It is normal to feel tired, this will last for 4-6 weeks
??????	You should get up out of bed every day and gradually increase
your activity each day
??????	You may walk and you may go up and down stairs
??????	Increase your activities as you can tolerate- do not do too
much right away!

5. It is normal to have a decreased appetite, your appetite will
return with time
??????	You will probably lose your taste for food and lose some
weight
??????	Eat small frequent meals
??????	It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
??????	To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication

What activities you can and cannot do:
??????	No driving until post-op visit and you are no longer taking
pain medications
??????	No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
??????	You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
??????	Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
??????	Take all the medications you were taking before surgery,
unless otherwise directed
??????	Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
??????	Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal

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
??????	Temperature greater than 101.5F for 24 hours
??????	Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions


Followup Instructions:
F/U scheduled with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (primary care MD) on [**5-12**] at
910am. Office phone [**Telephone/Fax (1) 12170**]. Copy of discharge summary
faxed to office.
Call Dr.[**Name (NI) 12171**] office at [**Telephone/Fax (1) 5643**] to schedule post op
visit in [**12-22**] weeks.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1887**], MD, PHD[**MD Number(3) **]:[**Telephone/Fax (1) 12172**]
Date/Time:[**2138-6-4**] 1:30
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks [**Telephone/Fax (1) 1477**] .
Make an appointment with Dr. [**First Name4 (NamePattern1) **] [**Telephone/Fax (1) 12173**]


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]

Completed by:[**2138-5-5**]
{'Subendocardial infarction, initial episode of care,Occlusion and stenosis of carotid artery with cerebral infarction,Other nervous system complications,Coronary atherosclerosis of native coronary artery,Personal history of other diseases of circulatory system,Unspecified transient cerebral ischemia,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Iron deficiency anemia, unspecified'}


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: transferred for carotid stenting

PRESENT ILLNESS: Pt. is a 66 y/o Hindi-speaking female with a hx of HTN,
hyperlipidemia, DM2, recent TIA ([**3-18**]) with w/u that revealed RCA
stenosis, followed by an episode of chest pain ([**4-1**]), NSTEMI,
found to have 3VD on cardiac catheterization, who is transferred
here for carotid stenting.

MEDICAL HISTORY: 1.  Diabetes type 2.
2.  Hypertension.
3.  Hyperlipidemia.
4.  h/o TIAs in [**2131**] and [**3-/2137**] with known carotid stenosis
5.  Iron deficiency anemia.
6.  Hyperthyroidism with h/o multinodular goiter
7.  Sciatica
8.  Coronary artery disease

MEDICATION ON ADMISSION: Tylenol 650 Q4H PRN Headache
ASA 325 QD
Lipitor 80 mg QD
Plavix 75 mg QD
Colace 100 [**Hospital1 **]
Lovenox 30 mg SC QD
NPH 18 U QAM, 6 U QPM
RISS
Maalox PRN
MOM PRN
Methimazole 15 mg QAM
Metoprolol 12.5 mg TID
NTG PRN chest pain
Omeprazole 20 mg QD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T- 98.7 BP- 145/64 HR- 66 RR- 18 O2Sat- 100% on RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema

FAMILY HISTORY: No family history of stroke or cardiovascular disease.

SOCIAL HISTORY: The patient is from [**Country 11150**] and speaks Hindi, lives with her
daughter's family. Activities of daily living: She is able to
cook, clean, and ambulate without difficulty. She denies any
alcohol, tobacco, or occasional drug use. 

### Response:
{'Subendocardial infarction, initial episode of care,Occlusion and stenosis of carotid artery with cerebral infarction,Other nervous system complications,Coronary atherosclerosis of native coronary artery,Personal history of other diseases of circulatory system,Unspecified transient cerebral ischemia,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Iron deficiency anemia, unspecified'}
