CHIEF COMPLAINT: Right arm weakness, slurred speech

PRESENT ILLNESS: Patient is an 84 year old female nursing home resident with PMH
of DVT [**3-4**], HTN, GERD, dermatitis.  She awoke this morning at
0540 with right arm weakness, slurred and inappropriate speech
and bladder/bowel incontinence.  She was noted to have said "I
think I'm having a stroke".  There was no associated fall or
trauma.  Was reportedly aphasic and weak in the right upper
extremity initially, but these deficits resolved at some point
as noted in the OSH records.  En route, she reportedly
desaturated to 88%, was put on face mask and improved, but
required CPR for some reason.  It is not known at this time if
she was receiving CPR for cardiac arrest or respiratory arrest.
.
CT at OSH showed Intracranial hemorhhage.  INR was found to be
6.4 (takes coumadin for h/o DVT this year).  She was given FFP
and transferred.
.
She was electively intubated at the OSH ([**Hospital3 628**]) and
arrived here to [**Hospital1 18**] intubated but not sedated.  On initial
evaluation by neurology ER resident, she was noted to be
unresponsive, moving all four extremities spontaneously (L>R),
with brain-stem reflexes intact and withdrawing X4 to pain.
Repeat INR here at [**Hospital1 18**] at 0830 showed INR of 3.2.  Patient was
given 2 vials of proplex.  3rd INR is pending at this time.
.

MEDICAL HISTORY: DVT [**3-4**], HTN, GERD, Bipolar, Dementia, chronic bladder issues,
OA, b/l knee pain with partial knee replacement in past.
Dermatitis. Undocumented, but according to son, has history of
"golf-ball sized" meningioma in the left part of brain.  Was
seen by a neurosurgeon last year who did not want to operate.
History from chart and partially from son who is unclear on some
details of PMH.

MEDICATION ON ADMISSION: MEDS at NH:
Erythromycin ointment to eyes QHS first 5 days of each month
Dulcolax Sup PRN
Coumadin 4mg PO Daily
Namenda 5mg PO Daily
MVI Daily
Remeron 45mg Daily
MOM 30cc daily prn
Tyelnol 650mg Daily prn

ALLERGIES: Penicillins

PHYSICAL EXAM: T-97.3  BP-118/78 HR-72 RR-12 (vented) O2Sat: 100%
Gen: Lying in bed, intubated, vented, sedated.  No spontaneous
movements.  Left arm slightly more flexed at elbow than right.
No posturing.
HEENT: NC/AT, moist oral mucosa.
Neck: In C-spine hard collar.
CV: Distant heart sounds.  RRR, Nl S1 and S2, no
murmurs/gallops/rubs
Lung: slight ronchi bilaterally.  no crackels/wheezes.
aBd: +BS soft, nontender.
ext: no edema.  no lesions.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: NH resident.  Son lives nearby.  Otherwise unknown.
Intracerebral hemorrhage,Anticoagulants causing adverse effects in therapeutic use,Other convulsions,Urinary tract infection, site not specified,Pneumonia due to other specified bacteria,Other iatrogenic hypotension,Benign neoplasm of cerebral meninges,Bipolar disorder, unspecified,Esophageal reflux,Personal history of venous thrombosis and embolism
Intracerebral hemorrhage,Adv eff anticoagulants,Convulsions NEC,Urin tract infection NOS,Pneumonia oth spcf bact,Iatrogenc hypotnsion NEC,Ben neo cerebr meninges,Bipolar disorder NOS,Esophageal reflux,Hx-ven thrombosis/embols
Admission Date:  [**2151-6-30**]              Discharge Date:   [**2151-7-15**]


Service: NEUROLOGY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Right arm weakness, slurred speech

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Patient is an 84 year old female nursing home resident with PMH
of DVT [**3-4**], HTN, GERD, dermatitis.  She awoke this morning at
0540 with right arm weakness, slurred and inappropriate speech
and bladder/bowel incontinence.  She was noted to have said "I
think I'm having a stroke".  There was no associated fall or
trauma.  Was reportedly aphasic and weak in the right upper
extremity initially, but these deficits resolved at some point
as noted in the OSH records.  En route, she reportedly
desaturated to 88%, was put on face mask and improved, but
required CPR for some reason.  It is not known at this time if
she was receiving CPR for cardiac arrest or respiratory arrest.
.
CT at OSH showed Intracranial hemorhhage.  INR was found to be
6.4 (takes coumadin for h/o DVT this year).  She was given FFP
and transferred.
.
She was electively intubated at the OSH ([**Hospital3 628**]) and
arrived here to [**Hospital1 18**] intubated but not sedated.  On initial
evaluation by neurology ER resident, she was noted to be
unresponsive, moving all four extremities spontaneously (L>R),
with brain-stem reflexes intact and withdrawing X4 to pain.
Repeat INR here at [**Hospital1 18**] at 0830 showed INR of 3.2.  Patient was
given 2 vials of proplex.  3rd INR is pending at this time.
.

Past Medical History:
DVT [**3-4**], HTN, GERD, Bipolar, Dementia, chronic bladder issues,
OA, b/l knee pain with partial knee replacement in past.
Dermatitis. Undocumented, but according to son, has history of
"golf-ball sized" meningioma in the left part of brain.  Was
seen by a neurosurgeon last year who did not want to operate.
History from chart and partially from son who is unclear on some
details of PMH.


Social History:
NH resident.  Son lives nearby.  Otherwise unknown.


Family History:
Unknown

Physical Exam:
T-97.3  BP-118/78 HR-72 RR-12 (vented) O2Sat: 100%
Gen: Lying in bed, intubated, vented, sedated.  No spontaneous
movements.  Left arm slightly more flexed at elbow than right.
No posturing.
HEENT: NC/AT, moist oral mucosa.
Neck: In C-spine hard collar.
CV: Distant heart sounds.  RRR, Nl S1 and S2, no
murmurs/gallops/rubs
Lung: slight ronchi bilaterally.  no crackels/wheezes.
aBd: +BS soft, nontender.
ext: no edema.  no lesions.

Neurologic examination:
Mental status: Intubated.  Off propofol, exam shows no response
to voice commands.  Withdraws all four extremities to pain (left
greater than right) but no localization of pain.  No spontaneous
movements.  PERRLA 2-->1 bilaterally.  Dolls eyes difficult to
assess as in hard collar.  Corneal reflexes present bilaterally.
 Tone moderately rigid in bilateral upper extremities.  Reflexes
2+ at brachrad/biceps/triceps/patella.  Plantar response
extensor on right, mute on left.
.
No Adventitious movements.
.

Pertinent Results:
Admission Labs:
[**2151-6-30**] 08:30AM URINE  RBC-0-2 WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-[**10-18**] RENAL EPI-0-2 URINE  HYALINE-0-2
[**2151-6-30**] 08:30AM URINE  BLOOD-SM NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2151-6-30**] 08:30AM URINE  COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2151-6-30**] 08:30AM   PT-30.5* PTT-33.8 INR(PT)-3.2*
[**2151-6-30**] 08:30AM   HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2151-6-30**] 08:30AM   NEUTS-84* BANDS-7* LYMPHS-6* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2151-6-30**] 08:30AM   WBC-14.5* RBC-3.82*# HGB-12.3# HCT-33.8*#
MCV-88# MCH-32.2* MCHC-36.5* RDW-13.7 PLT COUNT-276
[**2151-6-30**] 08:30AM   ACETONE-MODERATE
[**2151-6-30**] 08:30AM   CALCIUM-9.5 PHOSPHATE-1.4* MAGNESIUM-1.8
[**2151-6-30**] 08:30AM   CK-MB-NotDone   cTropnT-<0.01   CK(CPK)-42
[**2151-6-30**] 08:30AM   GLUCOSE-117* UREA N-25* CREAT-0.7 SODIUM-141
POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-20* ANION GAP-22*
[**2151-6-30**] 09:25AM   freeCa-1.19   LACTATE-0.9
[**2151-6-30**] 09:25AM   TYPE-ART PH-7.37 INTUBATED-INTUBATED
[**2151-6-30**] 12:00PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2151-6-30**] 12:00PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2151-6-30**] 12:30PM   PT-13.7* PTT-23.9 INR(PT)-1.2*
[**2151-6-30**] 12:30PM   ASA-NEG* ETHANOL-NEG ACETMNPHN-9.8
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2151-6-30**] 12:30PM   TSH-1.3   ALBUMIN-4.4
[**2151-6-30**] 12:30PM   CK-MB-4 cTropnT-<0.01
[**2151-6-30**] 12:30PM   ALT(SGPT)-22 AST(SGOT)-61* CK(CPK)-125 ALK
PHOS-81 TOT BILI-0.5
[**2151-6-30**] 05:33PM   PT-18.0* PTT-29.8 INR(PT)-1.7*
[**2151-6-30**] 10:14PM   PT-22.8* PTT-35.1* INR(PT)-2.3*
[**2151-6-30**] 10:14PM   CK-MB-NotDone cTropnT-<0.01   CK(CPK)-72
.
Admission CT Head:
CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST:  A large left
frontoparietal
intraparenchymal hemorrhage is again noted.  There is
questionable minimal
increase in prominence of the caudal portion of the hemorrhage
in comparison with the examination of several hours earlier.
The degree of hypodensity surrounding the inferior portion of
the hemorrhage also appears minimally increased, consistent with
slight increase in edema.  The degree of left to right
subfalcine herniation is unchanged.  There is no hydrocephalus
or evidence of transtentorial herniation.  Bilateral cerebral
periventricular white matter hypodensity is consistent with
chronic small vessel ischemic change. There is no evidence of
extra-axial hemorrhage.
.
Bone windows demonstrate no evidence of fracture within the
surrounding
osseous structures.  The mastoid air cells and visualized
portions of the
paranasal sinuses are normally pneumatized.
.
IMPRESSION:  Left frontoparietal intraparenchymal hemorrhage,
questionably
minimally increased along its caudal aspect, without change in
degree of mass effect.
.
CT C Spine:
1.  No fracture or malalignment seen.
2.  Extensive degenerative disc disease as well as multilevel
DJD.
.
[**7-1**] follow up CT: Stable left frontoparietal intraparenchymal
hemorrhage.  No change in degree of mass effect
.
EEG [**6-30**]:
ABNORMALITY #1: Throughout the recording there were frequent
bursts of
mixed frequency slowing with a generalized distribution. There
were
also occasional bursts of bitemporal mixed frequency slowing.
ABNORMALITY #2: Background rhythm was usually disorganized. It
was
often somewhat slow, in the [**6-5**] Hz range although there were
some faster
frequencies. The background did react to external stimuli with
some
apparent alerting.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Abnormal portable EEG due to the bursts of
generalized
slowing with additional bitemporal mixed frequency slowing.
These
findings suggest multifocal subcortical abnormalities. Vascular
disease
is a relatively common cause of such findings. In addition, the
background was disorganized and usually somewhat slow,
suggesting a
concomitant encephalopathy. There were no areas of prominent and

persistent focal slowing, and there were no clear epileptiform
features.
.
Bilateral LENIs:
1.  No evidence of acute DVT.
2.  Evidence of prior DVT of the left popliteal vein.
.
MRI/MRA Brain:
FINDINGS:  As noted on the prior CT, there is an acute 4 cm left

frontoparietal intraparenchymal hematoma.  There is a small
amount of subdural blood present over the anterior left temporal
lobe.  There is mass effect upon the atrium of the ipsilateral
lateral ventricle.  However, there is no significant midline
shift or herniation.  There are no additional foci of abnormal
magnetic susceptibility to indicate other microhemorrhages.
There are multiple T2 hyperintensities within the subcortical
white matter of both cerebral hemispheres due to chronic
microvascular infarct.
.
This study is slightly limited by patient motion artifact.
There is no slow diffusion to indicate an acute infarct.
.
IMPRESSION:  Large intraparenchymal left frontoparietal acute
hematoma with a tiny amount of subdural blood along the left
middle cranial fossa.
.
There is no evidence of other microhemorrhages.
.
No acute infarct.  Chronic microvascular infarct.
.
MRA: Normal brain MRA, but limited by motion.
.
EEG [**7-3**]:
TIME SAMPLES: Throughout the recording, there is continuous
slowing of
the left hemisphere in the mixed [**11-30**] Hz delta and [**3-3**] Hz theta
frequency
range. There were no clear epileptiform discharges seen
throughout the
recording.
BACKGROUND: Over the left hemisphere is more disorganized and
represented a lower voltage gradient. The right hemisphere is
mildly
disorganized but reaches normal alpha frequency ranges.
SLEEP: Normal transitions of the sleep architecture were not
seen.
CARDIAC MONITOR: Normal cardiac rhythm with a rate of 84 bpm.
There
was a continuous widespread QRS complex seen.
AUTOMATIC SEIZURE DETECTIONS: There were no entries in these
files.
AUTOMATIC SPIKE DETECTIONS: There were 103 entries in these
files. All
entries represent movement and muscle artifact.
PUSHBUTTON EVENTS: There was one pushbutton at the beginning of
the
recording which represented a system's test.
IMPRESSION: This is an abnormal discontinuous 24-hour long term
EEG
monitoring due to the presence of continuous slowing over the
mixed
delta and theta frequency range over the entire left hemisphere.
There
were no clear epileptiform discharges or seizure activity
recorded. A
widespread QRS complex was noted.
.
EEG [**7-4**]:
TIME SAMPLES: Throughout the recording, there is a persistent
moderate
voltage slowing in the [**11-30**] Hz delta frequency range and
intermittent
theta frequency slowing over the entire left hemisphere with
left
temporal emphasis. As the study progressed, there are initially
isolated sharp features over the left temporal region with phase

reversing around T3 and runs of semi-rhythmic 5 Hz theta
frequency
slowing in the left central region lasting up to 20 seconds.
Beginning
in the early evening of the recording, there are frequent
semi-rhythmic
sharp and slow wave and spike slow wave discharges seen phase
reversing
around F7 and T3, secondarily spreading over the entire left
hemisphere.
The frequency of these discharges vary between 1 and 2 Hz
lasting from 1
a.m. to the end of the recording at 10 a.m. on [**2151-7-4**].
AUTOMATIC SEIZURE DETECTIONS: There are three entries in these
files.
All events represent fast eye movements. There was no clear
seizure
activity recorded.
AUTOMATIC SPIKE DETECTIONS: There were 79 entries in these
files. The
majority of these entries represent muscle artifact. There were
also a
few sharp wave discharges over the left temporal region
captured.
Please see above.
PUSHBUTTONS: There were no entries in this file.
SLEEP: Normal transitions of the sleep architecture were not
seen.
CARDIAC MONITOR: There is a normal cardiac rhythm with a rate of
90
bpm. There are prolonged widespread QRS complexes alternating
with
normal QRS complexes seen.
IMPRESSION: This is an abnormal 24-hour discontinuous EEG
telemetry due
to the presence of prolonged epileptiform sharp and spike slow
wave
discharges seen over the left fronto-temporal region spreading
over the
entire left hemisphere. This finding was persistent for at least
nine
hours through the end of the recording. Additionally, there is
continuous delta frequency slowing over the entire left
hemisphere.
This finding suggests cortical and subcortical structural
abnormalities.
Over the 24-hour EEG recording, there are described discharges
over the
left hemisphere which became more frequent and persistent but
there were
no clear seizures recorded. Widespread QRS complexes alternating
with
normal QRS complexes were noted.
.
EEG [**7-8**]:
ABNORMALITY #1: Throughout the recording, there are intermittent

bicentral sharp slowing seen independently occasionally followed
by a
slow wave.
ABNORMALITY #2: There is increased voltage gradient over the
entire
left hemisphere with a diffuse mixed theta and delta frequency
slowing.
There is no clear anterior-posterior voltage gradient on both
hemispheres. The background is slow in the [**5-5**] Hz theta
frequency range
and disorganized. The superimposed fast activity in the beta
frequency
range is noted.
BACKGROUND: As above.
HYPERVENTILATION: Was not performed due to the patient's
clinical
condition.
INTERMITTENT PHOTIC STIMULATION: Was not performed because this
was a
portable study.
SLEEP: Normal transitions of the sleep architecture were not
seen.
CARDIAC MONITOR: Normal cardiac runs of widespread QRS complexes

followed by normal QRS complexes were seen.
IMPRESSION: This is an abnormal portable EEG due to the presence
of
intermittent, independent, bicentral sharp slowing and sharp
slow wave
discharges and due to slow and disorganized background rhythms
with
diffuse theta frequency slowing and increased voltage gradient
over the
entire left hemisphere. The background slowing suggests
cortical/
subcortical dysfunctions and a mild encephalopathy. Epileptiform

discharges represent most likely cortical dysfunction in central

parietal regions. Superimposed fast activity is most likely due
to
medication effect. Given the patient's clinical history and EEG
findings, EEG monitoring might be of benefit.
.
CT Head [**7-8**]:
Comparison with the prior study of [**2151-7-1**], reveals
reduction
in the density of the large hemorrhage, but negligible change in
its degree of mass effect or surrounding edema.  Once again,
there is considerable compression of the posterior aspect of the
body of the left lateral ventricle as well as the atrium.  The
minimal subfalcine herniation is unaltered.  No new area of
intracranial hemorrhage is identified.
.
There is moderate mucosal thickening within the posterior aspect
of the left ethmoid sinus, which has evolved since the prior
study.  The finding likely relates to the intubated status of
the patient.
.
TTE [**7-9**]:
The left atrium is mildly dilated. There is mild
(non-obstructive) focal
hypertrophy of the basal septum. The left ventricular cavity
size is normal.  There is mild to moderate regional left
ventricular systolic dysfunction with akinesis of the mid
antero-septum, distal LV and apex. No masses or thrombi are seen
in the left ventricle. Right ventricular chamber size and free
wall motion are normal. 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. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
.

Brief Hospital Course:
Pt. was admitted to the Neuro ICU.  Was intubated at the outside
hospital.  BP was initially maintained below 140 with Labetalol
IV, and repeat imaging showed stability of the hemorrhage.  INR
was corrected with FFP and proplex.  Over the first 24 hours,
her exam was felt to be out of proportion with findings on CT.
However, she did receive narcotics at the OSH and was found to
have UTI on admission both of which could account for a change
in neurological status.  Propofol was weaned and narcotics held.
 On day 2 she was noted to be much more awake and following
commands.  She was able to raise left arm and leg anti-gravity
and was noted to be moving all four extremities spontaneously
(L>R).  Her mental status continued to improve and she was
transferred to the floor [**7-4**].  Failed multiple bedside swallow
exams and was NPO with NG in place.
.
On the floor mental status continued to improve, although pt.
failed a repeat bedside swallow evaluation.  Aspirin was
restarted.  She finished a 7 day course of Levofloxacin for UTI.

.
On [**7-7**] had GTC seizure in the early morning hours.  Witnessed by
physician who reported as upper extremities and face
involvement.  Received 2mg IV ativan without any change.  After
another 1mg ativan converted to RUE and face only.  GTC portion
estimated to have been about 20 minutes.  After another 1+1
ativan she gradually slowed the RUE movement but facial
twitching continued.  Was loaded with 1 gram IV Dilantin and
movements ceased after about an hour.   Vitals were all
initially stable with tachycardia, but became hypotensive in
post-ictal period.  Patient received 5mg Ativan and 1gram
Dilantin in total.  She was not on seizure prophylaxis up until
this point.  Was not following any commands but withdrew all
four extremities to noxious stim.  Transferred back to ICU for
hypotension.  Dilantin discontinued as she had cyanotic
fingertips which was presumably as a reaction to the Dilantin
(purple glove syndrome).  Was loaded on Depakote and maintained
with IV doses QID.  Was following commands at 24 hours although
very somnolent.  After 48 hours was more awake and near
baseline.  Was transferred back to the floor [**7-9**].
.
On the floor Depakote was continued, and dose titrated up as
levels were low.  Depakote levels should be checked QOD at rehab
and dose titrated accordingly.  Pt. worked with PT and OT who
recommended acute rehab.  She failed another swallow evaluation.
 Her swallowing was discussed several times with her son and
HCP, [**Name (NI) **] [**Name (NI) 111356**], who felt that he did not want to subject his
mother to a PEG tube at this juncture, and was hopeful that with
more time she would pass a swallow evaluation.  We discussed
with him that there was a chance that she may not to regain her
swallowing abilities, which he understood, but he maintained
that he wanted to give her more time before making the decision
to proceed with PEG.  She should continue to be evaluated by
speech and swallow at rehab, and if she continues to fail PEG
tube will need to be readdressed with him.
.
Neuro exam on discharge was significant for diffuse mild L sided
weakness ([**3-3**] in all muscles groups), trace movement of R ankle
but 0/5 strength of all muscle groups on the right, and some
inattention and perseveration, as well as problems following
complex commands.
.
CVS:
Cardiovascularly ruled out for MI with serial enzymes.  No
significant events on Telemetry.  Was hypotensive to 80s/50s and
initially did not respond to fluid boluses (3 boluses of 500cc
NS each).  On arrival to ICU received additional 500 cc bolus
and pressures corrected to acceptable level.  Pressors not
initiated.  Ruled out again for MI with serial enzymes.  Had
echo (please see results section) which showed mild to moderate
regional left ventricular systolic dysfunction with akinesis of
the mid antero-septum, distal LV and apex, EF 35%.  She should
have a repeat TTE when she is more medically stable to f/u these
findings.  BP stable for several days with no IV boluses
required prior to discharge.
.
RESP:
Intubated at OSH.  Extubated after 48 hours without
complications.

HEME:
INR was initially corrected with FFP and proplex.  Serial INRs
were performed and she required a few additional units of FFP
over the first 48 hours.  She also received some vitamin K SC.
INR was stable at 1.0-1.2 after HOD #3.
.
GI: Failed multiple swallow evals and NG placed.  Received tube
feeds throughout hospitalization.  PPI for prophylaxis.
Decision for PEG
.
ID: Had UTI on admission which was treated with IV Levaquin for
7 days.
.
RENAL: No issues this admission.
.

Medications on Admission:
MEDS at NH:
Erythromycin ointment to eyes QHS first 5 days of each month
Dulcolax Sup PRN
Coumadin 4mg PO Daily
Namenda 5mg PO Daily
MVI Daily
Remeron 45mg Daily
MOM 30cc daily prn
Tyelnol 650mg Daily prn


Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): please administer prior to meals
per sliding scale attached.
2. Memantine 5 mg Tablet Sig: One (1) Tablet PO daily ().
3. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1)  PO DAILY (Daily).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Valproate Sodium 250 mg/5 mL Syrup Sig: 7.5 mL PO Q6H (every
6 hours).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
1) Left frontoparietal intraparenchymal hemorrhage
2) Generalized tonic-clonic seizure


Discharge Condition:
stable, tolerating medications


Discharge Instructions:
1) Please return for increasing weakness, trouble speaking,
inability to take medications, uncontrolled bleeding, vomiting
and fevers.
2) Please attend all appointments
3) Take all medications as prescribed.

Followup Instructions:
Your PCP will visit you at your nursing home.  Please have your
nursing home call upon your arrival.
.
Your have a neurology appointment with Dr. [**Last Name (STitle) **] and his fellow
(Dr. [**Last Name (STitle) 70597**] , Wed [**2151-9-8**] at 1pm.  [**Hospital3 **] hospital
[**Hospital Ward Name 23**] building [**Location (un) **].  For more details can call #
[**Telephone/Fax (1) 2574**].


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

Completed by:[**2151-7-15**]
{'Intracerebral hemorrhage,Anticoagulants causing adverse effects in therapeutic use,Other convulsions,Urinary tract infection, site not specified,Pneumonia due to other specified bacteria,Other iatrogenic hypotension,Benign neoplasm of cerebral meninges,Bipolar disorder, unspecified,Esophageal reflux,Personal history of venous thrombosis and embolism'}


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: Right arm weakness, slurred speech

PRESENT ILLNESS: Patient is an 84 year old female nursing home resident with PMH
of DVT [**3-4**], HTN, GERD, dermatitis.  She awoke this morning at
0540 with right arm weakness, slurred and inappropriate speech
and bladder/bowel incontinence.  She was noted to have said "I
think I'm having a stroke".  There was no associated fall or
trauma.  Was reportedly aphasic and weak in the right upper
extremity initially, but these deficits resolved at some point
as noted in the OSH records.  En route, she reportedly
desaturated to 88%, was put on face mask and improved, but
required CPR for some reason.  It is not known at this time if
she was receiving CPR for cardiac arrest or respiratory arrest.
.
CT at OSH showed Intracranial hemorhhage.  INR was found to be
6.4 (takes coumadin for h/o DVT this year).  She was given FFP
and transferred.
.
She was electively intubated at the OSH ([**Hospital3 628**]) and
arrived here to [**Hospital1 18**] intubated but not sedated.  On initial
evaluation by neurology ER resident, she was noted to be
unresponsive, moving all four extremities spontaneously (L>R),
with brain-stem reflexes intact and withdrawing X4 to pain.
Repeat INR here at [**Hospital1 18**] at 0830 showed INR of 3.2.  Patient was
given 2 vials of proplex.  3rd INR is pending at this time.
.

MEDICAL HISTORY: DVT [**3-4**], HTN, GERD, Bipolar, Dementia, chronic bladder issues,
OA, b/l knee pain with partial knee replacement in past.
Dermatitis. Undocumented, but according to son, has history of
"golf-ball sized" meningioma in the left part of brain.  Was
seen by a neurosurgeon last year who did not want to operate.
History from chart and partially from son who is unclear on some
details of PMH.

MEDICATION ON ADMISSION: MEDS at NH:
Erythromycin ointment to eyes QHS first 5 days of each month
Dulcolax Sup PRN
Coumadin 4mg PO Daily
Namenda 5mg PO Daily
MVI Daily
Remeron 45mg Daily
MOM 30cc daily prn
Tyelnol 650mg Daily prn

ALLERGIES: Penicillins

PHYSICAL EXAM: T-97.3  BP-118/78 HR-72 RR-12 (vented) O2Sat: 100%
Gen: Lying in bed, intubated, vented, sedated.  No spontaneous
movements.  Left arm slightly more flexed at elbow than right.
No posturing.
HEENT: NC/AT, moist oral mucosa.
Neck: In C-spine hard collar.
CV: Distant heart sounds.  RRR, Nl S1 and S2, no
murmurs/gallops/rubs
Lung: slight ronchi bilaterally.  no crackels/wheezes.
aBd: +BS soft, nontender.
ext: no edema.  no lesions.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: NH resident.  Son lives nearby.  Otherwise unknown. 

### Response:
{'Intracerebral hemorrhage,Anticoagulants causing adverse effects in therapeutic use,Other convulsions,Urinary tract infection, site not specified,Pneumonia due to other specified bacteria,Other iatrogenic hypotension,Benign neoplasm of cerebral meninges,Bipolar disorder, unspecified,Esophageal reflux,Personal history of venous thrombosis and embolism'}
