CHIEF COMPLAINT: Episodes of Speech difficulty (dysarthria and non-fluency) and
left arm numbness

PRESENT ILLNESS: The pt is a 77yo RH male with PMHx of HTN, HL and NIDDM who
presents because of 2 episodes of L arm numbness with L facial
droop and 1 episode of slurred speech. The patient was at his
baseline until Wednesday [**4-5**], when at
noon her was at his grandson's lacrosse game when he noticed the
onset of L hand numbness over seconds.  He felt that the
numbness was mostly in his 4th and 5th digit, and that it didn't
feel like tingling, but rather "it was dead".  He rubbed his
hand and the sensation didn't go away.  Within 30 seconds he
noticed that his L face was drooping also and he also had a
numbness sensation around his mouth on the left side "that felt
like novocaine".  He felt that his speech was normal and that he
could produce and
comprehend speech without difficulty and without slurring of his
words.  His wife drove him to [**Hospital3 **] where
he was admitted and had an EKG notable for afib with RBBB, an
unremarkable NCHCT but a CTA that showed a likely pial AV
fistula in the R parietal [**Hospital3 3630**] measuring ~ 4.5cm.  He was
discharged home on [**4-7**] with plans to be seen as an outpatient
in their neurology clinic.

MEDICAL HISTORY: - HTN (average BP 160's)
- HL
- NIDDM
- ? silent MI (pt had a cardiac stress test "many years ago" for
chronic chest pain and palpitation, that was suggestive of a
prior MI)
- glaucoma
- cataracts s/p surgery bilaterally

MEDICATION ON ADMISSION: - amlodipine 10mg QD
- ASA 81mg QD
- atenolol 25mg QD
- lovastatin 20mg QHS
- metformin 500mg [**Hospital1 **]
- niacin 500mg [**Hospital1 **]
- fish oil 1,000mg QD
- travatan eye drops 1gtt QHS both eyes

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: **********
Physical Exam On Admission
Vitals: T: 97.7 P: 70 R: 18  BP: 166/90  SaO2: 98% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

FAMILY HISTORY: Mother died of CHF at age 64, dad died from stomach ca at 80,
sister died of lung ca (smoker) at 70, no hx of strokes, blood
clots or AVMs

SOCIAL HISTORY: Lives with wife, has 2 kids, smoked a ppd x40 yrs in addition to
cigars and pipes, quit 20 years ago, denies EtOH or illicits. Is
a part time hairdresser, was last full time 15 years ago.
Cerebral aneurysm, nonruptured,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of tobacco use,Dysarthria,Disturbance of skin sensation,Old myocardial infarction
Nonrupt cerebral aneurym,Atrial fibrillation,DMII wo cmp nt st uncntr,Hypertension NOS,Hyperlipidemia NEC/NOS,History of tobacco use,Dysarthria,Skin sensation disturb,Old myocardial infarct
Admission Date:  [**2147-4-8**]              Discharge Date:   [**2147-4-16**]

Date of Birth:  [**2069-5-24**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Episodes of Speech difficulty (dysarthria and non-fluency) and
left arm numbness

Major Surgical or Invasive Procedure:
-[**2147-4-11**] Cerebral Angiogram
-[**2147-4-14**] NeuroIntervnetional Embolization of Right Parietal AVM


History of Present Illness:
The pt is a 77yo RH male with PMHx of HTN, HL and NIDDM who
presents because of 2 episodes of L arm numbness with L facial
droop and 1 episode of slurred speech. The patient was at his
baseline until Wednesday [**4-5**], when at
noon her was at his grandson's lacrosse game when he noticed the
onset of L hand numbness over seconds.  He felt that the
numbness was mostly in his 4th and 5th digit, and that it didn't
feel like tingling, but rather "it was dead".  He rubbed his
hand and the sensation didn't go away.  Within 30 seconds he
noticed that his L face was drooping also and he also had a
numbness sensation around his mouth on the left side "that felt
like novocaine".  He felt that his speech was normal and that he
could produce and
comprehend speech without difficulty and without slurring of his
words.  His wife drove him to [**Hospital3 **] where
he was admitted and had an EKG notable for afib with RBBB, an
unremarkable NCHCT but a CTA that showed a likely pial AV
fistula in the R parietal [**Hospital3 3630**] measuring ~ 4.5cm.  He was
discharged home on [**4-7**] with plans to be seen as an outpatient
in their neurology clinic.

However, pt went home, ate pancakes, had coffee, but at around
6:30pm (~1hr after arriving home) he again noted numbness in his
L hand, mostly the 4th and 5gh digits.  He again had almost
immediate L facial drooping with L facial numbness most notable
around his mouth in addition to some mildly slurred speech.  He
reports that he had no difficulty with speech production or
comprehension and was answering questions appropriately, but his
speech was just "slurred".  No associated
weakness/tingling/HA/visual sx.  He was then taken back to
[**Hospital1 **], where they immediately sent him to [**Hospital1 18**] as
they felt he needed to see neurosurgery. While here in the [**Name (NI) **] pt
reported that while the slurred speech improved over the course
of 45 mins since onset (but hasn't entirely gone away), the hand
and face numbness has not gone away
and only very mildly improved. He was initially evaluated by
neurosurgery in the ED who felt that his presentation could be
c/w TIAs rather than the AV
fistula in his R parietal [**Last Name (LF) 3630**], [**First Name3 (LF) **] neurology was called to
evaluate the patient further.

On neuro ROS, the pt reports L hand and L face numbness.  Denies
headache, loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech.  Denies focal weakness, parasthesiae. No bowel or
bladder incontinence or retention. Denies difficulty with gait.

On general review of systems, the pt denies recent fever or
chills.  No night sweats or recent weight loss or gain. Denies
cough, shortness of breath.  Denies chest pain or tightness,
palpitations.  Denies nausea, vomiting, diarrhea, constipation
or abdominal pain.  No recent change in bowel or bladder habits.
 No dysuria.  Denies arthralgias or myalgias. Denies rash.

Past Medical History:
- HTN (average BP 160's)
- HL
- NIDDM
- ? silent MI (pt had a cardiac stress test "many years ago" for
chronic chest pain and palpitation, that was suggestive of a
prior MI)
- glaucoma
- cataracts s/p surgery bilaterally

Social History:
Lives with wife, has 2 kids, smoked a ppd x40 yrs in addition to
cigars and pipes, quit 20 years ago, denies EtOH or illicits. Is
a part time hairdresser, was last full time 15 years ago.


Family History:
Mother died of CHF at age 64, dad died from stomach ca at 80,
sister died of lung ca (smoker) at 70, no hx of strokes, blood
clots or AVMs


Physical Exam:
**********
Physical Exam On Admission
Vitals: T: 97.7 P: 70 R: 18  BP: 166/90  SaO2: 98% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

Neurologic:

-Mental Status: Alert, oriented x 3.  Able to relate history
without difficulty.  Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty.  Language is fluent with intact repetition and
comprehension.  Normal prosody.  There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects.  Able
to read without difficulty.  Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**1-20**] at 5 minutes.  The pt. had
good
knowledge of current events.  There was no evidence of apraxia
or
neglect.

-Cranial Nerves:
I: Olfaction not tested.
II: pupils post-surgical bilaterally.  VFF to confrontation.
Funduscopic exam chronic changes c/w known glaucoma.
III, IV, VI: EOMI without nystagmus.  Normal saccades.
V: Facial sensation intact to light touch and PP on R side, but
decreased to LT and PP on the L forehead, cheek and chin in a
V1,
V2 and V3 distribution.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.

-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L  5    5   5   5   5  5  5  5   5    5  5     5     5   5
R  5    5   5   5   5  5  5  5   5    5  5     5     5   5

-Sensory: Decreased PP in the L face, L arm and L leg, but not L
torso.  Decreased cold sensation to the knees bilaterally.
Otherwise, no deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2  2    2    1   0
R  2  2    2    1   0
Plantar response was flexor on the R and extensor on the L.

-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.

-Gait: Good initiation. Narrow-based, normal stride and arm
swing, but unsteady on feet and stumbled when turning.  Unable
to
walk in tandem without significant difficulty. Romberg positive
for sway.
.
*****
On Discharge:
Mental Status: Alert, Oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
Cranial Nerves; VFFTC, face symmetric, no dysarthria
Strength: full throughout
Sensation:
- pinprick sensation 100% on RUE and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face V2-V3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger

Pertinent Results:
LABS ON ADMISSION:
[**2147-4-8**] 09:00AM BLOOD WBC-8.3 RBC-5.13 Hgb-15.7 Hct-47.9 MCV-93
MCH-30.5 MCHC-32.7 RDW-13.6 Plt Ct-257
[**2147-4-8**] 09:00AM BLOOD PT-10.7 PTT-28.7 INR(PT)-1.0
[**2147-4-8**] 09:00AM BLOOD Glucose-167* UreaN-10 Creat-0.9 Na-146*
K-3.9 Cl-105 HCO3-31 AnGap-14
[**2147-4-8**] 09:00AM BLOOD ALT-21 AST-23 LD(LDH)-211 CK(CPK)-83
AlkPhos-84 TotBili-0.6
[**2147-4-8**] 09:00AM BLOOD Albumin-4.5 Calcium-9.7 Phos-4.0 Mg-2.0
Cholest-152
.
STROKE RISK FACTOR ASSESSMENT:
[**2147-4-8**] 09:00AM BLOOD Triglyc-129 HDL-52 CHOL/HD-2.9 LDLcalc-74
[**2147-4-8**] 09:00AM BLOOD %HbA1c-7.2* eAG-160*
[**2147-4-8**] 09:00AM BLOOD TSH-2.3
.
CARDIAC ENZYMES:
[**2147-4-8**] 09:00AM BLOOD CK-MB-1 cTropnT-<0.01
.
[**2147-4-8**] EEG:
FINDINGS:
ROUTINE SAMPLING: The background activity showed a symmetric 10
Hz
alpha rhythm which attenuated with eye opening.
SPIKE DETECTION PROGRAMS: There were 91 automated spike
detections
predominantly for electrode and movement artifact. There were no

epileptiform discharges.
SEIZURE DETECTION PROGRAMS: There was one automated seizure
detection
for electrode artifact. There were no electrographic seizures.
PUSHBUTTON ACTIVATIONS: There were no pushbutton activations.
SLEEP: The patient progressed from wakefulness to stage II, then
slow
wave sleep at appropriate times with no additional findings.
CARDIAC MONITOR: Showed an irregularly irregular rhythm with an
average
rate of 85-90 bpm.
IMPRESSION: This is a normal video EEG monitoring session with
no
pushbutton activations. Background activity was normal. There
were no
epileptiform discharges or electrographic seizures. A note was
made of
an irregularly irregular heart rhythm.
.
[**2147-4-8**] MRI HEAD:
FINDINGS:
There is no focus of slow diffusion in the brain parenchyma to
suggest an
acute infarct. Subtle increased signal intensity along the
cortex in the
parietal lobes on both sides is likely artifactual related to
the interface between the brain and the bone.
.
There are several FLAIR hyperintense foci, in the
periventricular and
subcortical locations in the frontal and the parietal lobes,
likely related to small vessel ischemic changes. There is
moderate dilation of the lateral and the third ventricles along
with a prominent cerebral aqueduct. This may relate to central
parenchymal volume loss with or without a component of
communicating hydrocephalus such as NPH. The bifrontal diameter
at the level of the foramen of [**Last Name (un) 2044**], measures 3.5 cm. Bowing of
the corpus callosum upward is noted.
.
The cerebral aqueduct is better seen on the prior CT angiogram
sagittal
reformations with ? minimal narrowing inferiorly. Foci of
negative
susceptibility are noted in the bilateral basal ganglia, left
more than right, which may relate to mineralization. Left
vertebral artery is dominant and indents the left side of the
cervicomedullary junction. The right is diminutive in size. The
major intracranial arteries and the known AV fistula/AVM, in the
right parietal [**Last Name (un) 3630**] are better assessed on the prior CT
angiogram study.
.
The ocular lenses are not seen. There is mild mucosal thickening
in the
ethmoid air cells on both sides.
.
IMPRESSION:
1. No focus of slow diffusion to suggest an acute infarct.
2. Mild to moderately dilated lateral ventricles and prominent
third
ventricle and cerebral aqueduct, which may relate to central
parenchymal
volume loss, with or without a component of normal pressure
hydrocephalus/
minimal aqueductal narrowing. Correlate clinically.
3. Please see the prior CT angiogram study for evaluation of the
major
intracranial arteries and the known right parietal [**Last Name (un) 3630**] AVM/AV
fistula.
.
[**2147-4-9**] EEG:
ROUTINE SAMPLING: The background activity showed a symmetric
9.5-10 Hz
alpha rhythm which attenuated with eye opening.
SPIKE DETECTION PROGRAMS: There were no automated spike
detections.
SEIZURE DETECTION PROGRAMS: There was one automated seizure
detection
for movement artifact. There were no electrographic seizures.
PUSHBUTTON ACTIVATIONS: There were no pushbutton activations.
SLEEP: The patient progressed from wakefulness to stage II, then
slow
wave sleep at appropriate times with no additional findings.
CARDIAC MONITOR: Showed an irregularly irregular rhythm with an
average
rate of 70 bpm.
IMPRESSION: This is a normal video EEG monitoring session with
no
pushbutton activation. Background activity was normal. There
were no
epileptiform discharges or electrographic seizures. A note was
made of
an irregularly irregular cardiac rhythm.
.
[**2147-4-10**] TTE:
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. The estimated
right atrial pressure is 5-10 mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The descending thoracic aorta is mildly dilated.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild to moderate
([**12-19**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function.
Mild-moderate mitral regurgitation. Mild pulmonary artery
hypertension. Dilated aorta..
.
[**2147-4-11**] CEREBRAL ANGIOGRAM:
PROCEDURE PERFORMED: Left vertebral artery arteriogram, left
external
carotid artery arteriogram, left internal carotid artery
arteriogram, right external carotid artery arteriogram, right
internal carotid artery
arteriogram, right common femoral artery arteriogram.
.
Anesthesia was moderate. Sedation was provided by administering
divided doses of fentanyl and Versed throughout the total
intraservice time of 54 minutes during which the patient's
hemodynamic parameters were continuously monitored.
.
INDICATION: The patient had presented with a dural AV fistula
and I had
performed this procedure in order to diagnose and possibly treat
this.
.
DETAILS OF PROCEDURE: The patient was brought to the angiography
suite. IV sedation was given. Following this, both groins were
prepped and draped in a sterile fashion. Access was gained to
the right common femoral artery using a Seldinger technique and
a 5 French vascular sheath was placed in the right common
femoral artery. We now catheterized the above-mentioned vessels
and AP, lateral filming was done. This revealed that an
arteriovenous fistula fed by both middle meningeal arteries with
draining veins primarily in the right sensory motor area and
draining down into the sylvian fissure.
.
Right common femoral artery arteriogram was done and manual
compression
applied for closure of the right common femoral artery puncture
site.
.
FINDINGS: Left internal carotid artery arteriogram shows filling
of the left internal carotid artery along the cervical, petrous,
cavernous and
supraclinoid portion. Both anterior and middle cerebral arteries
are seen
well. There is no evidence of supply to the fistula.
.
Left external carotid artery arteriogram shows supply to the
dural AV fistula from the left middle meningeal artery and
drainage into the right cortical veins.
.
Right external carotid artery arteriogram shows filling of the
right middle meningeal artery which is predominantly supplied to
fistula with drainage into the cortical vein which eventually
drains through a single vein down into the sensory motor area.
Right external carotid artery arteriogram also demonstrates
minimal filling from the right occipital artery.
.
The right internal carotid artery arteriogram shows no evidence
of supply to the AV fistula.
.
Left vertebral artery arteriogram shows filling of the left
vertebral artery with a prominent PCA on the left side. The PCA
on the right is hypoplastic.
.
Right vertebral artery arteriogram again demonstrates right
vertebral artery arteriogram again demonstrates filling of the
basilar artery and the PCAs with no evidence of supply to the AV
fistula.
.
[**First Name8 (NamePattern2) **] [**Known lastname **] underwent cerebral angiography which revealed a
dural AV
fistula in the midline frontoparietal area primarily fed by the
middle
meningeal arteries with some supply from the left occipital
artery. The
d raining vein is predominantly cortical draining into the
sensory motor area.
.
LABS AT TIME OF DISCHARGE:


Brief Hospital Course:
Mr. [**Known lastname **] 77 y.o. RH male with PMHx of HTN, HL and NIDDM who
presented because of 2 episodes of L arm numbness with L facial
droop and 1 episode of slurred speech.

#Right Parietal Arterio-Venous Malformation: Patient initially
had a neurological exam which revealed fluctating L sided
numbness and mild dysarthria concerning for an ongoing process
in the R hemisphere.  Seizure (secondary to an AVM previously
noted on imaging) was on the differential as the patient had 2
episodes while in the hospital with left hemisensory loss,
transient dysarthria and word-finding difficulties. These
episodes only lasted about 5 minutes in duration. The patient
was monitored with a continuous EEG for 48 hours but no
epiliptiform activity was recorded (of note he did not have any
of these presenting episodes while on monitoring). He initially
was started on Keppra 1000mg [**Hospital1 **] but had increased drowsiness
with this and was brought down to 750 [**Hospital1 **]. He tolerated this
well and did not have any other episodes while in the hospital.
.
Other imaging obtained included an MRI (see full report above)
which did not show any signs of acute infart. The patient had
his stroke risk factors evaluated and was noted that his Hba1c
7.2% , LDL 74.  We continued him on his home dose statin, and
have recommended uptitration of his metformin with PCP on
[**Name9 (PRE) 85433**] basis for better control of blood sugars. The patient
had a TTE performed without evidence of PFO/ASD and normal EF
(see full report above).
.
Of note the patient on a previous CTA from OSH had a R parietal
AVM.  The Neurosurgical team performed a cerebral angiogram on
[**2147-4-11**] with demonstrated a right parietal AV fistula with
middle meningeal artery with pial drainage, which was noted to
put the patient at an increased risk for intracranial bleed. The
patient was taken by Neurosurgery for an AVM embolization on
[**2147-4-14**], and he tolerated the procedure well. The patient's
symptoms (dysarthria, word-finding difficulties, left-sided
numbness) were though to to be secondary to his AVM and
significant associated venous congestion (rather than seizure).
We therefore decided to stop his Keppra. The patient will have a
f/u MRI/MRA in 4 weeks and will have a follow-up appointment
with Dr. [**First Name (STitle) **] of NSurg and Dr. [**First Name (STitle) **] of Neurology.
.
#Atrial Fibrillation: Patient has new onset atrial fibrillation
(never had previous episodes documented before). His CHADS2
score is 3, so patient was deemed a good candidate for
anticoagulation. Unfortunately as he has a known right parietal
AVM that it is at increased risk of bleed, so his
anticoagulation was deferred initially. He was continued on a
baby aspirin prior to his Neurosurgical intervention. The
patient was monitored on continuous telemetry without any
significant adverse events. Patient also had his cardiac enzymes
evaluated which were negative. The patient went for embolization
of his dural AVM on [**2147-4-14**]. Afterwards he was started on ASA
325 and coumadin (his last INR was 1.1 on day of discharge). He
will take the ASA 325 until he is therapeutic on his coumadin
(goal INR [**1-20**]) for at least 24 hours. The antiocoagulation is to
be monitored by his PCP.
.
#Hypertension: Patient had his home BP meds held initally for
the first day of being in the hospital as there was concern for
an ischemic event. He was restarted on his home amlodipine, and
atenolol and tolerated this well with good control of his blood
pressure.
.
#Hyperlipidemia: Patient had LDL of 74, he was continued on his
home dose of statin.
.
#Diabetes Mellitus Type II: Hba1c 7.2%, patient on metformin
500BID at home. This was held during the hospital stay, and he
was placed on a RISS with good control He will likely need
uptitration of his metformin on an outpatient basis.
.
TRANSITIONAL ISSUES:
1) Follow-up with PCP (scheudled day after discharge) re:
coumaadin and diabetes management
2) Patient started on Coumadin prior to discharge, INR was
subtherapeutic. Will take ASA 325 until he is thereapeutic (INR
[**1-20**]) on his coumadin.
3) Follow-up with Dr. [**First Name (STitle) **] of Neurology
4) Follow-up with Dr. [**First Name (STitle) **] of Neurosurgery in about 4 weeks
after having MRI/MRA perforemd at 4 weeks

Medications on Admission:
- amlodipine 10mg QD
- ASA 81mg QD
- atenolol 25mg QD
- lovastatin 20mg QHS
- metformin 500mg [**Hospital1 **]
- niacin 500mg [**Hospital1 **]
- fish oil 1,000mg QD
- travatan eye drops 1gtt QHS both eyes

Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
6. travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic QHS
(once a day (at bedtime)): 1 drop in each eye at bedtime.
7. niacin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.

9. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day: to
be taken at 4pm daily. Do not drink alcohol while taking. dosage
will be changed by your primary care provider.
[**Name Initial (NameIs) **]:*70 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis: Dural Arterio-Venous Malformation (Right
parietal area), Atrial Fibrillation
Secondary Diagnosis: Diabetes Mellitus Type II, Hypertension,
Hyperlipidemia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
.
Neuro Exam at time of Discharge:
Mental Status: Alert, Oritented, fluent speech, no paraphasic
errors, able to name several objects without any anomia
Cranial Nerves; VFFTC, face symmetric, no dysarthria
Strength: full throughout
Sensation:
- pinprick sensation 100% on RUE and decreased by 50% in lateral
aspect of left forearm (otherwise intact), decreased pinrpick
(75%) in left face V2-V3 distribtuion (otherwise intact in face
bilaterally); intact in lower extremities bilaterally
- temperature sensation 100% on right upper extremity and
decreased by 50% in the lateral aspect of the left forearm
(otherwise intact); intact in the lower extremities and face
- vibration sense intact  bilaterally at the great toes and
index finger
- propriception intact bilaterally at the great toes and index
finger


Discharge Instructions:
Dear Mr. [**Known lastname **],
.
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
with recurrent episodes of speech difficulties and numbness on
the left arm. We performed some imaging of your head and did not
see any signs of a stroke. In addition we performed electrical
studies of the brain, which showed no clear signs of seizure
activity(although you did not have episodes of symptoms while
you were connected to the EEG monitoring). Importantly, your
previous imaging from the outside hospital had identified a
malformation in the blood vessels in your brain known as an AVM
(Arterio-Venous Malformation). This is likely to have caused
some congestion and back pressure in the veins draining the
right side of the brain.  We think the secondary effects of this
"back pressure" phenomenon most likely account for the symptoms
that brought you to the hospital.
.
Neurosurgery performed a procedure to treat your arterio-venous
malformation (known as an embolization), and you tolerated this
procedure well. You subsequently shared that your speech has
returned to baseline and you have had no more epiosdes of
sensory disturbance.
.
Due to your underlying heart rhthym abnormarlity, you are at an
increased risk for stroke. Your irregular heart beat is known as
Atrial Fibrillation. Due to your increase risked of having a
clot form in the heart and go to the brain, we are recommending
that you take a blood thinning medication known as Coumadin
(warfarin). This medication causes your blood to be thin which
can be measured by a simple blood test known as an INR. The INR
gives us a good idea of how thin the blood is, and your blood
will be need to be tested frequently to make sure it is within
range (your goal INR will be between [**1-20**]). Before you reach that
range, it will be important for you to take Aspirin 325mg one
tablet daily.  The aspirin can be discontinued after the INR has
been in the 2-3 range for at least 24 hours.
.
The blood thinning medication known as Coumadin interacts with
several other mediations and can be affected by your diet. For
example, green vegetables such as spinach with a lot of Vitamin
K can make the coumadin less effective. Also, there are certain
medications such as antibiotics that can also affect the blood
thinning compenent and change your INR. Therefore it is
imperative that you talk with your primary care provider before
starting any new medications while on the coumadin. In addition
to this, alcohol also affects the coumadin, so you should be
particularly careful to avoid alcohol while taking coumadin.
.
We will work to contact your primary care provider [**Name Initial (PRE) 503**]
([**4-17**]) in order to setup the next time for you to get your blood
drawn and your INR checked.
.
We assessed your stroke risk factors, and found that your
cholesterol in a good range, but your blood sugars have not been
well controlled. Your hemoglobin A1c (a marker of your average
blood sugars over the past 3 months was eleavetd at 7.2%).
Therefore, we are recommending that you talk to your primary
care provider about increasing your metformin medication, or
considering other treatments to help control your blood sugars.
.
Also, Neurosurgery would like for you to have a repeat scan of
your head and its vessels(MRI/A). We have put in an order for
this, but you will need to call to setup your appointment
tomorrow. The number is: [**Telephone/Fax (1) 590**].  Both the neurosurgeon,
Dr. [**First Name (STitle) **], and the neurologist, Dr. [**First Name (STitle) **], would like to meet
with you over the next few months.  We have been able to
schedule some follow-up appointments for you, please see below.
.
We made the following changes to your medications:
-CHANGE Aspirin to 325mg tablet, take one tablet by mouth daily
until your blood is thin enough on the coumadin (goal INR [**1-20**])
-START Coumadin (warfarin) take 5mg (five 1mg tablets) by mouth
daily at 4pm (your blood levels will need to be checked with a
lab known as INR and your goal INR is [**1-20**])


Followup Instructions:
Please call [**Telephone/Fax (1) 590**] tomorrow to schedule the MRI/A of the
head with and without contrast for a time in four weeks from
now.
.
Also, please call to setup an appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
(Neurosurgery). You can schedule the appointment for a date that
is after your MRI scan. The number for his office is: ([**Telephone/Fax (1) 85434**]
.
--Please discuss with your primary care provider better blood
sugar control with your metformin as well as your blood thinning
medication--
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: MONDAY [**2147-4-17**] at 8:10 AM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site
.
Please meet with Dr. [**First Name (STitle) **]:
Department: NEUROLOGY
When: TUESDAY [**2147-5-30**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Cerebral aneurysm, nonruptured,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of tobacco use,Dysarthria,Disturbance of skin sensation,Old myocardial infarction'}


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: Episodes of Speech difficulty (dysarthria and non-fluency) and
left arm numbness

PRESENT ILLNESS: The pt is a 77yo RH male with PMHx of HTN, HL and NIDDM who
presents because of 2 episodes of L arm numbness with L facial
droop and 1 episode of slurred speech. The patient was at his
baseline until Wednesday [**4-5**], when at
noon her was at his grandson's lacrosse game when he noticed the
onset of L hand numbness over seconds.  He felt that the
numbness was mostly in his 4th and 5th digit, and that it didn't
feel like tingling, but rather "it was dead".  He rubbed his
hand and the sensation didn't go away.  Within 30 seconds he
noticed that his L face was drooping also and he also had a
numbness sensation around his mouth on the left side "that felt
like novocaine".  He felt that his speech was normal and that he
could produce and
comprehend speech without difficulty and without slurring of his
words.  His wife drove him to [**Hospital3 **] where
he was admitted and had an EKG notable for afib with RBBB, an
unremarkable NCHCT but a CTA that showed a likely pial AV
fistula in the R parietal [**Hospital3 3630**] measuring ~ 4.5cm.  He was
discharged home on [**4-7**] with plans to be seen as an outpatient
in their neurology clinic.

MEDICAL HISTORY: - HTN (average BP 160's)
- HL
- NIDDM
- ? silent MI (pt had a cardiac stress test "many years ago" for
chronic chest pain and palpitation, that was suggestive of a
prior MI)
- glaucoma
- cataracts s/p surgery bilaterally

MEDICATION ON ADMISSION: - amlodipine 10mg QD
- ASA 81mg QD
- atenolol 25mg QD
- lovastatin 20mg QHS
- metformin 500mg [**Hospital1 **]
- niacin 500mg [**Hospital1 **]
- fish oil 1,000mg QD
- travatan eye drops 1gtt QHS both eyes

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: **********
Physical Exam On Admission
Vitals: T: 97.7 P: 70 R: 18  BP: 166/90  SaO2: 98% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

FAMILY HISTORY: Mother died of CHF at age 64, dad died from stomach ca at 80,
sister died of lung ca (smoker) at 70, no hx of strokes, blood
clots or AVMs

SOCIAL HISTORY: Lives with wife, has 2 kids, smoked a ppd x40 yrs in addition to
cigars and pipes, quit 20 years ago, denies EtOH or illicits. Is
a part time hairdresser, was last full time 15 years ago. 

### Response:
{'Cerebral aneurysm, nonruptured,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of tobacco use,Dysarthria,Disturbance of skin sensation,Old myocardial infarction'}
