CHIEF COMPLAINT: acute left hemiparesis

PRESENT ILLNESS: 77yo woman with PMH signficant for atrial fibrillation, CHF EF
35%, hemothorax s/p VATS 1mo ago, and TB with treatment
initiated [**9-20**] presents with acute left hemiparesis. She was
with her son in her usual state of health around 10:30am when
she had acute onset of left hemiparesis, witnessed by her son.
EMS
was called and she presented to [**Hospital1 18**] as a CODE STROKE at 11:07.
Neurology was at the bedside at 11:08am.

MEDICAL HISTORY: atrial fibrillation
hypertension
systolic CHF, EF 35% 9/21
tuberculosis on sputum culture x 2 ([**8-26**], [**8-27**]) but not on AFB
smears, started on multidrug therapy [**9-20**] w/ DPH
pleural effusion and hemothorax during recent hospitalization in
the setting of a supratherapeutic INR, with hct drop 28-22 and
VATS [**8-27**] with 750cc drained and chest tubes placed, evidence of
granulomatous inflammation
hyperlipidemia

MEDICATION ON ADMISSION: (Noted from recent discharge):
aspirin 81mg daily
pravastatin 20mg daily
toprol XL 200mg daily
lasix 40mg daily
coumadin 2mg qhs
lisinopril 5mg daily
Additional meds since [**09**]/30 per Dr. [**Last Name (STitle) 7443**] (ID):
PZA 1000mg
Ethambutol 1200mg
Rifamate 2 caps
Vit b6 50mg

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam at presentation:
General: lying on bed in NAD, appears comfortable
CV: irregularly irregular
Chest: CTAB anteriorly
Abd: soft, NTND, BS+
Ext: warm and dry

FAMILY HISTORY: Not elicited;

SOCIAL HISTORY: no tobacco, alcohol, or illicit drug use, lives w/ her son in
[**Name (NI) 669**], takes
care of herself at home
Cerebral artery occlusion, unspecified with cerebral infarction,Diverticulosis of colon with hemorrhage,Pulmonary tuberculosis, unspecified, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture,Systolic heart failure, unspecified,Hemiplegia, unspecified, affecting unspecified side,Atrial fibrillation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Facial weakness,Precipitous drop in hematocrit,Atrophic gastritis, without mention of hemorrhage,Helicobacter pylori [H. pylori],Other diseases of lung, not elsewhere classified,Encephalopathy, unspecified
Crbl art ocl NOS w infrc,Dvrtclo colon w hmrhg,Pulmon TB NOS-cult dx,Systolic hrt failure NOS,Unsp hemiplga unspf side,Atrial fibrillation,Hypertension NOS,Hyperlipidemia NEC/NOS,DMII wo cmp nt st uncntr,Facial weakness,Drop, hematocrit, precip,Atrph gastrtis w/o hmrhg,Helicobacter pylori,Other lung disease NEC,Encephalopathy NOS
Admission Date:  [**2107-9-26**]              Discharge Date:   [**2107-10-7**]

Date of Birth:  [**2030-4-12**]             Sex:   F

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
acute left hemiparesis

Major Surgical or Invasive Procedure:
Femoral arterial access for attempted Intra-arterial TPA
Endotracheal intubation
radial arterial line

History of Present Illness:
77yo woman with PMH signficant for atrial fibrillation, CHF EF
35%, hemothorax s/p VATS 1mo ago, and TB with treatment
initiated [**9-20**] presents with acute left hemiparesis. She was
with her son in her usual state of health around 10:30am when
she had acute onset of left hemiparesis, witnessed by her son.
EMS
was called and she presented to [**Hospital1 18**] as a CODE STROKE at 11:07.
Neurology was at the bedside at 11:08am.

On arrival, NIHSS was 21 (see below). HCT/CTA/CTP was performed,
showing a proximal right MCA occlusion. Interventional radiology
was called and she was brought immediately to the INR suite for
IA tPA. Of note, the thoracic surgeon was called regarding her
recent VATS procedure; he felt she was not at risk for recurrent
hemothorax or bleeding from the site given the procedure was 1
month ago. ID was also called, given her recent initiation of
RIPE therapy for TB, and did not feel she needed to be on
precautions as she had been taking the medications daily since
[**9-20**].


Past Medical History:
atrial fibrillation
hypertension
systolic CHF, EF 35% 9/21
tuberculosis on sputum culture x 2 ([**8-26**], [**8-27**]) but not on AFB
smears, started on multidrug therapy [**9-20**] w/ DPH
pleural effusion and hemothorax during recent hospitalization in
the setting of a supratherapeutic INR, with hct drop 28-22 and
VATS [**8-27**] with 750cc drained and chest tubes placed, evidence of
granulomatous inflammation
hyperlipidemia


Social History:
no tobacco, alcohol, or illicit drug use, lives w/ her son in
[**Name (NI) 669**], takes
care of herself at home

Family History:
Not elicited;

No family members with hx of TB

Physical Exam:
Exam at presentation:
General: lying on bed in NAD, appears comfortable
CV: irregularly irregular
Chest: CTAB anteriorly
Abd: soft, NTND, BS+
Ext: warm and dry

Neurologic examination:
NIHSS:
1a LOC: 0
1b LOC q's: 0
1c commands: 0
2 gaze: 2
3 visual field: 1
4 facial palsy: 2
5a RUE motor: 0
5b LUE motor: 4
6a RLE motor: 3
6b LLE motor: 4
7 ataxia: X
8 sensory: 1
9 language: 1
10 dysarthria: 1
11 neglect: 2

Mental status: awake, somnolent, able to follow commands when
given from the right side (not acknowledging questions/commands
from the left side), language dysarthric, but able to repeat.
Can
name thumb, nail, chair. Cannot read.

Cranial nerves: pupils very small, though equal and reactive,
?cataracts, decreased left visual field, right gaze preference
with inability to cross midline to the left, left facial droop

Motor: RUE lifts without drift x 10 seconds, and purposeful, LUE
flaccid w/o movement, RLE moves but is not antigravity, LLE
triple flexes

Sensory: responds to noxious in all extremities

DTRs, [**Name (NI) 14791**] and gait were not tested acutely.  When patient was
in ICU, no overt ataxia out of proportion to weakness.  Gait was
not assessed until PT working with patient on floor, and needed
assistance to walk due to left-sided weakness.


Pertinent Results:
Labs on admission-
142  100  20
------------< 149
3.1  32  0.9
estGFR: 61/73 (click for details)
6.5 > 31.6 < 243
PT: 16.4  PTT: 26.2  INR: 1.5

Imaging Studies-

CT BRAIN PERFUSION  [**2107-9-26**] 11:28 AM

CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS
FINDINGS: There is no sign for the presence of an intracranial
hemorrhage. However, a nearly 1 cm, heavily calcified probable
aneurysm is noted in the region of the supraclinoid portion of
the left internal carotid artery. There is atherosclerotic
calcification involving the distal cavernous portion of the
right internal carotid artery. While the images are degraded by
patient motion, there is no definite evidence for a major
vascular territorial infarct. However, there is slightly
diminished density, approximately 1 cm in dimension within the
anterior aspect of the right lentiform nucleus. This finding
could represent a subacute-to-chronic infarct. The surrounding
osseous and soft tissue structures do not display additional
abnormalities.

CONCLUSION: No intracranial hemorrhage. Other findings as noted
above.

CT perfusion study was obtained, including the CT angiography.

FINDINGS: There is prolongation of the mean transit time and
reduced blood flow within the right temporal lobe, frontal and
parietal lobes, within the territory of the right middle
cerebral artery. However, there does not appear to be visible
reduction in blood volume. This combination of findings suggests
the presence of acute brain ischemia, that may be reversible if
thrombolysis is promptly instituted (see below).

The CT angiogram does disclose a cutoff of flow within the right
middle cerebral artery just distal to its origin, most likely
due to an embolus. Additionally, there is confirmation of the
1-cm left supraclinoid internal carotid artery aneurysm.

No other definite vascular abnormalities are appreciated, aside
from heavy atherosclerotic calcification of the origin of the
left vertebral artery and to a minor degree involving the aortic
arch.

CONCLUSION: Right proximal middle cerebral artery occlusion and
reduced perfusion wtihin its territory. Left supraclinoid
internal carotid artery aneurysm.

CTA CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: ([**2107-9-29**] 12:54
PM)
There is an NG tube with the tip in the stomach. There are
several mediastinal lymph nodes with the largest measuring 19 x
11 mm in a right paratracheal location. There has been interval
decrease in the pleural fluid in the right hemithorax. There is
residual fluid and pleural thickening present at the right lung
base. There is multifocal consolidation present in the right
lung likely representing recent thoracic surgery.

There is a ground-glass subpleural nodule in the right upper
lobe, this is unchanged since the prior examination and may
represent infectious or inflammatory. A followup CT is
recommended to assess for resolution and to exclude the
possibility of a bronchoalveolar cell cancer.

The heart is grossly enlarged. The main pulmonary artery
measures 33 mm. The ascending aorta at the level of the right
main pulmonary artery measures 34 x 33 mm. The right coronary
artery arises from the normal expected anatomical location. The
left coronary artery arises from the left aortic cusp in a
posterior position than usual. There is no aortic dissection.

There are bilateral renal cortical low attenuation foci likely
representing cysts.

MUSCULOSKELETAL: There is thoracic kyphoscoliosis with
multilevel degenerative changes present in the spine.

CONCLUSION:

1. No aortic dissection or pulmonary embolism. The heart is
grossly enlarged, and the main pulmonary artery measures 33 mm
in maximum transverse diameter.

2. The left coronary artery arises from the left coronary cusp
in a position more posterior than usual. The right coronary
artery arises from the normal anatomical location.

3. Postoperative changes are present in the right hemithorax
with decreased pleural effusion and multifocal consolidations.
There are enlarged lymph nodes also present in the mediastinum
as described above.

4. 5 mm ground-glass subpleural nodule in the right upper lobe
is likely inflammatory in nature; however, a followup CT is
recommended in six months to assess for resolution and to
exclude a small focus of bronchoalveolar cell carcinoma.

Echocardiogram [**2107-9-29**]-
The left atrium is markedly dilated. The right atrium is
markedly dilated. The estimated right atrial pressure is [**3-31**]
mmHg. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity is mildly dilated. There is moderate to
severe global left ventricular hypokinesis (LVEF = 30 %).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). There is no ventricular septal defect.
Right ventricular chamber size is normal. Right ventricular
systolic function is borderline normal. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] The ascending aorta is
mildly 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. Moderate to severe (3+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The supporting structures of the tricuspid valve are
thickened/fibrotic. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.

EKG:Baseline artifact
Probable sinus rhythm with frequent atrial premature complexes -
possible
multifocal atrial rhythm
Delayed R wave progression - is nondiagnostic but consider prior
anterior
myocardial infarction
Nonspecific T wave abnormalities
Since previous tracing of the same date, atrial ectopy appears
more frequently

Antrum biopsy [**2107-10-3**]:
DIAGNOSIS:
Antrum, mucosal biopsy:

1.  Chronic active gastritis with focal intestinal metaplasia.

2.  Bacteria consistent with H. pylori are seen.

Clinical:  GI bleed, iron deficiency anemia.
Gross:
The specimen is received in one formalin container labeled with
the patient's name "[**Known firstname **] [**Known lastname 4249**]" and the medical record number
and "antrum" and consists of multiple soft tan yellow tissue
fragments measuring up to 0.3 cm which is entirely submitted in
A.


Brief Hospital Course:
Ms. [**Known lastname 4249**] is 77 year old woman with atrial fibrillation who
presented with history, exam, and imaging consistent with right
MCA infarct, likely due to atrial fibrillation.

1) Acute Right Inferior Middle Cerebral Artery Infarction-
Likely in setting of atrial fibrillation, she was subtherapeutic
on coumadin. She was intubated and taken emergently for
intra-arterial intervention. Her vascular anatomy did not allow
access to deep cerebral vessels for administration of IA TPA,
she was therefore given IV TPA just prior to the 3 hour window
in the onset of her symptoms after discussion of the risks and
benefits with her family. Repeat head CT s/p TPA did not reveal
hemorrhage. Following evaluation by thoracic surgery and
negative CTA for dissection, the patient was started on heparin
gtt without bolus for secondary stroke prevention. She was
transitioned to coumadin.  She was eventually transferred to the
stepdown unit from the ICU and worked with physical therapy and
occupational therapy, who recommended rehab.  She passed a
swallow evaluation for a modified diet, which she tolerated
without problems.  She was able to raise her arm and leg in the
air against gravity and provide resistance in the extensors [**2-24**]
proximally and [**1-24**] distally.  She could withdraw the leg to
stimulation as well as lift it slightly in the air.  She was
discharged on a heparin drip with q6 hour PTTs and coumadin,
with a goal PTT of 40-60 and a goal INR of [**12-25**].  The heparin
drip should be stopped when the INR is between 2 and 3.

2) GI bleed -
After starting IV heparin, the patient's hematocrit dropped and
she was noted to have bright red blood per rectum.  The heparin
drip was stopped (coumadin had not yet been started).  She
received packed red cells, with a rise in her hematocrit.  She
was seen by GI, who recommended endoscopy (EGD and colonoscopy);
this revealed mild gastritis (Bx done for H. pylori was later
positive, and patient started on triple-therapy); diverticulosis
was seen in the right and left colon.  Though there was no
active bleeding, this was felt to have possibly contributed (ie,
brief diverticular bleed).  She was restarted on the heparin
drip, with no evidence of active bleeding and a stable
hematocrit on discharge.

3) Tuberculosis + pleural fluid by culture-
Pt recent VATS procedure found AFB + cultures, smears negative.
She was started on RIPE therapy two weeks prior to her
presentation with this acute infarct. Given that the patient was
only culture positive (smear negative) and has been compliant
with full four drug therapy she did not require respiratory
isolation precautions (per discussion with infectious disease
and hospital infection control). She was continued on RIPE and
pyridoxine supplementation while in-house.

4) Paradoxic Respiratory pattern-
The patient developed elevated RR 29-35 with paradoxical
respiratory pattern ~12hrs s/p extubation. Her saturations
remained stable on room air and her JVP was 7cm. She was
diuresed with lasix IV given her history of CHF (EF 35%). CXR
revealed possible mediastinal widening. Thoracic surgery was
consulted given pt was s/p R sided VATS 1 month prior. Suggested
CT angiogram to rule out dissection and echocardiogram to rule
out pericardial effusion. Pt was given N-acetylcysteine prior to
the study, CTA was negative for dissection. Echocardiogram
revealed an enlarged heart with severe systolic dysfunction (EF
30%). Pulmonary consultation was also obtained and thought
respiratory pattern seemed related to slight volume overload.
This pattern continued on the floor, and improved slightly with
diuresis and use of an incentive spirometer.  She never
complained of shortness of breath, orthopnea, nor was she
tachycardic with elevated blood pressure or abnormal oxygen
saturations (thus home dose of lasix was continued). No evidence
of PE on CTA.

5) RUL pulmonary nodule-
CTA revealed 5 mm ground-glass subpleural nodule in the right
upper lobe that is likely inflammatory in nature; however, a
follow-up CT is recommended in six months to assess for
resolution and to exclude a small focus of bronchoalveolar cell
carcinoma.

6) FEN-
She passed repeat speech and swallow, and initially was not be
able to maintain full nutritional needs, required NGT for
supplementation.  Later on, she was able to eat more and sustain
her caloric needs, thus the NGT was discontinued.  Electrolytes
were monitored, as was renal function - all remained stable
during the hospital stay.

Medications on Admission:
(Noted from recent discharge):
aspirin 81mg daily
pravastatin 20mg daily
toprol XL 200mg daily
lasix 40mg daily
coumadin 2mg qhs
lisinopril 5mg daily
Additional meds since [**09**]/30 per Dr. [**Last Name (STitle) 7443**] (ID):
PZA 1000mg
Ethambutol 1200mg
Rifamate 2 caps
Vit b6 50mg


Discharge Medications:
1. Pyrazinamide 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Ethambutol 400 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Isoniazid 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
5. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
6. Pilocarpine HCl 4 % Gel Sig: One (1)  Ophthalmic QHS (once a
day (at bedtime)).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
12. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for temperature > 100 F.
13. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO q 12 hours ().
15. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
16. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO twice a day.
19. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: Eight [**Age over 90 1230**]y (850) units/hour Intravenous ASDIR (AS
DIRECTED): check PTT q6 hours; goal PTT is 40-60, adjust as
necessary; d/c when INR is between 2 and 3.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Acute stroke (RMCA, embolic)


Discharge Condition:
Stable - improved strength of L arm and leg, subtle dysarthria,
left field cut, no language deficit noted (repetition, fluency,
naming, comprehension normal).  Mildly inattentive.


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.

Please return to the ER if you are having new symptoms of stroke
(new weakness, sensory loss, trouble speaking or swallowing, new
visual changes).

Please check INR and monitor heparin drip at rehab - goal is
40-60 PTT; d/c drip when INR is between 2 and 3.

Followup Instructions:
Follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 3581**]), after discharge from rehab.

Follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] (neurology) after discharge
from rehab ([**Hospital1 69**]) - call for
appoinment ([**Telephone/Fax (1) 7394**].


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
{'Cerebral artery occlusion, unspecified with cerebral infarction,Diverticulosis of colon with hemorrhage,Pulmonary tuberculosis, unspecified, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture,Systolic heart failure, unspecified,Hemiplegia, unspecified, affecting unspecified side,Atrial fibrillation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Facial weakness,Precipitous drop in hematocrit,Atrophic gastritis, without mention of hemorrhage,Helicobacter pylori [H. pylori],Other diseases of lung, not elsewhere classified,Encephalopathy, 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: acute left hemiparesis

PRESENT ILLNESS: 77yo woman with PMH signficant for atrial fibrillation, CHF EF
35%, hemothorax s/p VATS 1mo ago, and TB with treatment
initiated [**9-20**] presents with acute left hemiparesis. She was
with her son in her usual state of health around 10:30am when
she had acute onset of left hemiparesis, witnessed by her son.
EMS
was called and she presented to [**Hospital1 18**] as a CODE STROKE at 11:07.
Neurology was at the bedside at 11:08am.

MEDICAL HISTORY: atrial fibrillation
hypertension
systolic CHF, EF 35% 9/21
tuberculosis on sputum culture x 2 ([**8-26**], [**8-27**]) but not on AFB
smears, started on multidrug therapy [**9-20**] w/ DPH
pleural effusion and hemothorax during recent hospitalization in
the setting of a supratherapeutic INR, with hct drop 28-22 and
VATS [**8-27**] with 750cc drained and chest tubes placed, evidence of
granulomatous inflammation
hyperlipidemia

MEDICATION ON ADMISSION: (Noted from recent discharge):
aspirin 81mg daily
pravastatin 20mg daily
toprol XL 200mg daily
lasix 40mg daily
coumadin 2mg qhs
lisinopril 5mg daily
Additional meds since [**09**]/30 per Dr. [**Last Name (STitle) 7443**] (ID):
PZA 1000mg
Ethambutol 1200mg
Rifamate 2 caps
Vit b6 50mg

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam at presentation:
General: lying on bed in NAD, appears comfortable
CV: irregularly irregular
Chest: CTAB anteriorly
Abd: soft, NTND, BS+
Ext: warm and dry

FAMILY HISTORY: Not elicited;

SOCIAL HISTORY: no tobacco, alcohol, or illicit drug use, lives w/ her son in
[**Name (NI) 669**], takes
care of herself at home 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Diverticulosis of colon with hemorrhage,Pulmonary tuberculosis, unspecified, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture,Systolic heart failure, unspecified,Hemiplegia, unspecified, affecting unspecified side,Atrial fibrillation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Facial weakness,Precipitous drop in hematocrit,Atrophic gastritis, without mention of hemorrhage,Helicobacter pylori [H. pylori],Other diseases of lung, not elsewhere classified,Encephalopathy, unspecified'}
