CHIEF COMPLAINT: headache

PRESENT ILLNESS: Ms. [**Known lastname **] is a 62-year-old right-handed woman presenting with
Transfer with intraparenchymal hemorrhage.

MEDICAL HISTORY: - "Seizures", two years, on Keppra. In [**2117-10-7**], she had
hit her head on a cabinet and had headaches since that event. On
[**2115-10-12**] she noted some visual disturbance as she was
walking to her car. Later that day she was stopped by police
because she was noted to be driving erratically. There was a
report that she "briefly passed out behind the wheel." She had
no memory of the event in the car. She was admitted to [**Hospital1 4494**] in [**Location (un) 3844**]. EEG at [**Hospital1 **] showed "sharp and slow
wave activity." She was placed first on Dilantin, and was later
switched to Keppra at [**Hospital1 2025**]. She was transferred to [**Hospital1 2025**] on [**2117-10-16**]
because imaging had shown a left MCA 4mm aneurysm. MRI brain at
[**Hospital1 2025**] on [**2115-10-18**] showed two small subacute right occipital
infarcts and a subacute left superior frontal infarct. CTA
brain/neck showed left MCA aneurysm, atherosclerosis of the
right PCA, mild narrowing of the
left vertebral artery origin, mild bilateral narrowing of the
proximal ICA's. Holter monitoring did not show atrial
fibrillation. TTE in [**10-16**] showed EF 65%. No evidence of ASD of
PFO by bubble study. These infarcts were of different ages. She
was started on simvastatin 20mg qhs and aspirin 81mg daily.
- [**2116-1-21**], she underwent coiling of the left MCA aneurysm by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1128**]. No other vascular malformation was found.
- She has a history of melanoma resection from her chin.
- hyperlipidemia.
- Palpitations
- Hypertension, borderline, saw PCP two years ago
- Tonsillectomy, Dilatation and curettage.

MEDICATION ON ADMISSION: levetiracetam 750mg po bid
MVI

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At admission:
Vitals: 98.6 82 190/110 18 96% (BP to 150s at time of exam, on
nicardipine drip)

FAMILY HISTORY: Older brother, now deceased, had seizure and clotting disorders
(PE). Mother - d. HTN, stroke (unknown). Father - lung cancer -
was a smoker. [**Name (NI) **] brother is well.

SOCIAL HISTORY: Smoking: Yes - 1PPD, perhaps 30 years.
Alcohol: About two glasses wine with dinner, three to four times
per week.
Drugs: No.
Living Situation: Lives alone, with cat (brother is feeding,
[**Doctor First Name 110586**]).
Education and Language: English, college - accountant.
Functional Baseline: Independent.
Other: Office manager - colleagues likely wondering where she
is,
but brother will call them. Watches baseline, dines with
friends.
Intracerebral hemorrhage,Other amyloidosis,Homonymous bilateral field defects,Unspecified cerebrovascular disease,Unspecified essential hypertension,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of malignant melanoma of skin,Other and unspecified hyperlipidemia,Tobacco use disorder,Epilepsy, unspecified, without mention of intractable epilepsy,Alexia and dyslexia,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Essential thrombocythemia
Intracerebral hemorrhage,Amyloidosis NEC,Homonymous hemianopsia,Cerebrovasc disease NOS,Hypertension NOS,Hx TIA/stroke w/o resid,Hx-malig skin melanoma,Hyperlipidemia NEC/NOS,Tobacco use disorder,Epilep NOS w/o intr epil,Alexia and dyslexia,Ocl crtd art wo infrct,Essntial thrombocythemia
Admission Date:  [**2118-6-3**]              Discharge Date:   [**2118-6-7**]

Date of Birth:  [**2055-6-21**]             Sex:   F

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
headache

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Ms. [**Known lastname **] is a 62-year-old right-handed woman presenting with
Transfer with intraparenchymal hemorrhage.

Two days ago, on Wednesday night, she felt in her normal state
of
health watching television, perhaps the Red Socks when she
developed a sudden onset posterior headache. She thinks that she
may have been watching the Red Socks.

It did not radiate, sharp, constant without banging. Onset, as
above, was hyperacute, not even coming on over seconds, it was
9.5/10 in severity and then came down to about [**7-17**] that night,
remaining quite constant, but increased now to [**10-17**]. She took
aspirin and Tylenol on the night of onset which did not help.
Coughing made it worse.

She noticed that she had difficulty seeing her peripheral vision
on the right, which would wax and wane. It wasn't black nor were
there positive phenomena, it was simply that this part of her
vision wasn't there. She did not bump into anything, she did not
notice any difficulty with math, but says that she would
typically know the year but has trouble thinking of it.

She is "not a big one on medicine" and wanted to wait it out.
She
was misplacing things which she never does. She was very thirsty
and was probably peeing a little more than usual. Her walking
was
unsteady. She noted no numbness, but her right hand was clumsy.
She did not eat, not being hungry - she attributes this to pain.
She had difficulty sleeping, perhaps with naps of 20 minutes,
perhaps due to pain. Her sense of time was odd - she thought she
had slept for an hour or two, but it would only be 15 mins. She
was disoriented in time while awake also - time was passing much
more slowly. She didn't read or write. She was nervous and had
some palpitations.

She only told her brother a few hours ago after she was in the
hospital ([**Hospital3 2568**]) from whence she was transferred upon
finding
hypertension and a intraparenchymal hemorrhage. Her blood
pressure there was 180/90 and nicardipine was started.

She has a chronic intermittent morning cough which she
attributes
to smoking. Review of systems was negative except as above.


Past Medical History:
- "Seizures", two years, on Keppra. In [**2117-10-7**], she had
hit her head on a cabinet and had headaches since that event. On
[**2115-10-12**] she noted some visual disturbance as she was
walking to her car. Later that day she was stopped by police
because she was noted to be driving erratically. There was a
report that she "briefly passed out behind the wheel." She had
no memory of the event in the car. She was admitted to [**Hospital1 4494**] in [**Location (un) 3844**]. EEG at [**Hospital1 **] showed "sharp and slow
wave activity." She was placed first on Dilantin, and was later
switched to Keppra at [**Hospital1 2025**]. She was transferred to [**Hospital1 2025**] on [**2117-10-16**]
because imaging had shown a left MCA 4mm aneurysm. MRI brain at
[**Hospital1 2025**] on [**2115-10-18**] showed two small subacute right occipital
infarcts and a subacute left superior frontal infarct. CTA
brain/neck showed left MCA aneurysm, atherosclerosis of the
right PCA, mild narrowing of the
left vertebral artery origin, mild bilateral narrowing of the
proximal ICA's. Holter monitoring did not show atrial
fibrillation. TTE in [**10-16**] showed EF 65%. No evidence of ASD of
PFO by bubble study. These infarcts were of different ages. She
was started on simvastatin 20mg qhs and aspirin 81mg daily.
- [**2116-1-21**], she underwent coiling of the left MCA aneurysm by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1128**]. No other vascular malformation was found.
- She has a history of melanoma resection from her chin.
- hyperlipidemia.
- Palpitations
- Hypertension, borderline, saw PCP two years ago
- Tonsillectomy, Dilatation and curettage.


Social History:
Smoking: Yes - 1PPD, perhaps 30 years.
Alcohol: About two glasses wine with dinner, three to four times
per week.
Drugs: No.
Living Situation: Lives alone, with cat (brother is feeding,
[**Doctor First Name 110586**]).
Education and Language: English, college - accountant.
Functional Baseline: Independent.
Other: Office manager - colleagues likely wondering where she
is,
but brother will call them. Watches baseline, dines with
friends.


Family History:
Older brother, now deceased, had seizure and clotting disorders
(PE). Mother - d. HTN, stroke (unknown). Father - lung cancer -
was a smoker. [**Name (NI) **] brother is well.


Physical Exam:
At admission:
Vitals: 98.6 82 190/110 18 96% (BP to 150s at time of exam, on
nicardipine drip)

General Appearance: Comfortable, no apparent distress, lying on
bed, reasonable self-care.
HEENT: NC, OP clear, MMM.
Neck: Supple. No bruits. Reduced ROM.
Lungs: CTA bilaterally. Normal respiratory pattern.
Cardiac: Regular. Normal S1/S2. No M/R/G.
Abdominal: Soft, NT, BS+.
Extremities: No edema, warm, normal capillary refill. Peripheral
pulses normal.
Skin: Normal appearances.

Neurologic Examination:

Mental status:
Level of Arousal: Awake. Normal level of arousal and alertness.
Attentiveness: Attentive. Acalcuic for serial seven 100??????93
(given)??????37. Pays good attention.
Language: Normal fluency, comprehension, repetition, naming. No
paraphasic errors. Errors on naming colors and on naming finger
(eventually got them correct). Cannot read (spells out and makes
errors, but got 'specimen' correct on specimen bag), and errors
with writing:"[**Known firstname **] [**First Name8 (NamePattern2) **] [**Known lastname **]" - correct, "The [**Last Name (un) 110587**] Brown
Tax"
for the quick brown [**Doctor Last Name **] and then "the Gisk drown [**Doctor Last Name **]".
Orientation: Oriented to name, [**Hospital1 **], day/date/month/year (thought
[**2121**], then corrected to [**2118**]), context of presentation.
Memory: Recall good for recent and remote events, (did not test
hidden objects). Three words correct at 30 s and 5 mins.
Knowledge: Appropriate fund of knowledge - vocabulary and recent
events.
Praxis: Cannot copy linked fingers with hers, but can copy the
two hands individually. Right obviously clumsy, but can mime and
copy. Construction is impaired - draws form and not details of a
copied figure. Clock poorly planned with 1 at top and 12 at 10
position, line placed between 1 and 2 for 10 past 11. House has
not intelligible form, but consists of lines that might
conceivably be rearranged into house.
Proverbial Understanding: Not tested.
Attitude: Cooperatve, agonistic.
Mood and Affect: Euthymic, congruent, full-range.
Thought: Form - Normal. Content - Understandable level of
concern
about presentation.
Perception: No hallucinations/delusions.
Judgment and Insight: Preserved, within normal limits.

Cranial Nerves:
I: Not tested.
II: Pupils symmetric, round and reactive to light, 3 to 2 mm
bilaterally. Early cataracts. Visual fields are significant for
homonymous hemianopia on right. Fundi are normal (discs and
cups), but with pigmentary changes and increased tortuosity of
vessels.
III, IV, VI: Extraocular movements full, conjugate and without
nystagmus.
V, VII: Facial muscles symmetric and strong. Facial sensation
intact.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetric.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius are of normal bulk and
strength bilaterally.
XII: Tongue midline without fasciculations.

Posture and Movement:
Posture is normal, without truncal ataxia. No tremor or abnormal
movements.

Tone and Bulk:
Tone is normal throughout (arms, legs, neck). Muscle bulk is
normal.

Power:
   D  B  T  WE  FE  FF  FAb | IP  Q  H  AT  G/S  EDB  TF
R  4  5  5  5   4   5   5   | 5   5  5  5   5    4    5
L  5  5  5  5   4+  5   5   | 5   5  5  5   5    4+   5

Reflexes:
   B  T  Br Pa Ac
R  2  0  2  2  0
L  2  0  2  2  0
Toes downgoing on left, equivocal on right.

Sensation:
Intact to light touch, vibration, joint position, pinprick
bilaterally. No extinction to DSS, no agraphesthesia. Romberg
not
done.

Coordination and Cerebellar Function:
Normal finger nose, great toe finger, [**Doctor First Name 6361**] bilaterally.

Gait:
Deferred.
.
.
Discharge examination:
Alexia without agraphia, acalculia (significantly affected as
patient was an accountant), right homonymous hemianopia and no
focal limb weakness, sensory disturbance or other CN
abnormality. Colour naming errors and finger agnosia had
resolved at time of discharge.

Pertinent Results:
Laboratory investigations:
.
Admission labs:
[**2118-6-3**] 09:04AM BLOOD Neuts-86.4* Lymphs-9.6* Monos-3.5 Eos-0.2
Baso-0.3
[**2118-6-3**] 09:04AM BLOOD PT-10.4 PTT-30.1 INR(PT)-1.0
[**2118-6-3**] 09:04AM BLOOD Glucose-136* UreaN-9 Creat-0.5 Na-133
K-3.8 Cl-95* HCO3-25 AnGap-17
[**2118-6-3**] 09:04AM BLOOD Calcium-9.4 Phos-3.5 Mg-1.7
.
Other pertinent labs:
[**2118-6-3**] 09:13AM BLOOD Lactate-1.7
.
Discharge labs:
[**2118-6-7**] 05:00AM BLOOD WBC-10.5 RBC-4.27 Hgb-13.0 Hct-40.3
MCV-94 MCH-30.5 MCHC-32.3 RDW-13.3 Plt Ct-650*
[**2118-6-7**] 05:00AM BLOOD Glucose-97 UreaN-14 Creat-0.6 Na-137
K-4.6 Cl-99 HCO3-28 AnGap-15
[**2118-6-7**] 05:00AM BLOOD Calcium-9.4 Phos-3.5 Mg-2.1
.
.
Urine:
[**2118-6-3**] 09:10AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2118-6-3**] 09:10AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2118-6-3**] 09:10AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
[**2118-6-3**] 09:10AM URINE CastHy-1*
[**2118-6-3**] 09:10AM URINE Mucous-RARE
[**2118-6-6**] 02:03PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.004
[**2118-6-6**] 02:03PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
.
Microbiology:
[**2118-6-3**] 2:01 pm MRSA SCREEN      Source: Nasal swab.

                            **FINAL REPORT [**2118-6-5**]**

   MRSA SCREEN (Final [**2118-6-5**]):    No MRSA isolated.
.
[**2118-6-6**] 2:03 pm URINE      Source: CVS.

   URINE CULTURE (Pending):
.
.
Radiology:
CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Study Date of
[**2118-6-3**] 9:50 AM
FINDINGS: There is a large left occipitoparietal
intraparenchymal hemorrhage
measuring approximately 5.8 x 3.0 cm. A second hyperdense focus
is present
just lateral to this large hemorrhage and measures 7 mm (2, 14).
This may
reflect another region of intraparenchymal hemorrhage or a small
focal
subdural hematoma. Hemorrhagic hyperdense material is layering
along the
tentorium and falx suggesting a component of subdural hematoma.
There is
intraventricular extension with blood in the left lateral
ventricle. It is
predominantly in the posterior [**Doctor Last Name 534**] but a small amount is
present in the left
frontal [**Doctor Last Name 534**] (2, 14). A small amount of blood is likely also
present in the
third ventricle (2, 15). There is relative enlargement of the
right lateral
ventricle suggesting some component of compression. There is
minimal shift of
the normal midline structures to the right by 2 mm.

Metallic artifact is present in the region of the left MCA
suggesting prior
aneurysmal coiling. There is no evidence of acute or prior
infarction.
Periventricular white matter hypodensities are consistent with
small vessel
ischemic disease. The basal cisterns are patent. No fracture is
identified.
The visualized paranasal sinuses, mastoid air cells, and middle
ear cavities
are clear.

IMPRESSION:
1. Large left occipitoparietal intraparenchymal hemorrhage with
intraventricular extension, as above. 2 mm rightward midline
shift. Relative
enlargement of the right lateral ventricle suggesting component
of
compression.
2. Smaller second focus of hemorrhage in the left occipital lobe
may be a
second small intraparenchymal hemorrhage or focal subdural
hemorrhage.
3. Subdural hemorrhage layering along the left tentorium and
falx.
.
CTA HEAD/NECK W&W/OC & RECONS Study Date of [**2118-6-3**] 4:39 PM
FINDINGS: The study is compared with the NECT ([**Hospital3 **]), obtained
roughly 9 hours earlier.

Again demonstrated is the very large left parieto-occipital
"lobar"
hemorrhage, measuring up to 6.4 (AP) x 3.3 cm with surrounding
zone of
vasogenic edema, not significantly changed over the interval.
There is
associated mass effect with effacement of the overlying sulci
and relatively
mild rightward shift of the septum pellucidum, measuring up to 4
mm, also
unchanged. There is no definite "trapping" of the contralateral
lateral
ventricle or evidence of more central herniation. There is
associated
ventricular hemorrhage with clot occupying the atrium and
extending into the
occipital and temporal horns of the ipsilateral lateral
ventricle. There is
also overlying subarachnoid hemorrhage, as well as subdural
blood layering
along the dorsal aspect of the falx and over the left leaflet of
the
tentorium, all unchanged. No new hemorrhagic focus is
identified. Again
demonstrated is extensive metallic "star" artifact originating
from coils in
the region of the left MCA bifurcation, presumably related to
previous
treatment of an aneurysm at this site, limiting the evaluation
of adjacent
structures.

No definite peripheral or central CTA "spot sign" is identified
in association
with the large parenchymal hematoma to suggest extravasation
portending rapid
expansion. Allowing for the presence of the clot, there is no
evidence of
underlying arteriovenous malformation or other vascular anomaly.
No aneurysm
is identified in the region or elsewhere in the circle of
[**Location (un) 431**], with
evaluation of the region of the left MCA bifurcation, limited by
the metallic
artifact. There is normal, symmetric opacification of the major
dural venous
sinuses and principal deep cerebral veins with no evidence of
cerebral venous
thrombosis. There is no significant mural irregularity or
steno-occlusive
disease involving the cerebral vasculature.

There is only minimal calcific atherosclerotic plaque involving
the aortic
arch and great vessel origins, with no flow-limiting stenosis at
these sites.
There is also calcific more than soft plaque involving both
carotid bulbs and
proximal ICAs; however, again, there is no evidence of
flow-limiting stenosis
with the Dmin measurements, as follows: On the right, proximal,
6 mm, distal,
4.5 mm; on the left, proximal, 6 mm and distal, 4 mm. Similarly,
the
vertebral arteries are normal in course, caliber, contour and
enhancement from
their origins through the vertebrobasilar confluence; note that
the left
vertebral artery originates directly from the aortic arch, a
common normal
variant.

The remainder of the examination is notable for fairly severe
panlobular
emphysema at the lung apices, without discrete bulla formation.
There is also
biapical calcific pleuroparenchymal scarring, which may relate
to old
granulomatous disease. The thyroid gland is grossly unremarkable
and there is
no cervical lymphadenopathy. The [**Last Name (un) **]-, oro- and hypopharyngeal
mucosal
surfaces are grossly unremarkable. The included portions of the
paranasal
sinuses, mastoid air cells and middle ear cavities are clear.

There is multilevel, multifactorial degenerative disease
involving the
cervical spine, most marked at the C5-6 and C6-7 levels, where
there is both
central spinal canal and severe left neural foraminal narrowing
with possible
exiting neural impingement. Also, incidentally noted are DISH
involving the
imaged cervicothoracic spine, as well as a congenital fusion
anomaly involving
the posterior neural arch of C1.

IMPRESSION:
1. No significant short-interval change in the large left
parieto-occipital
"lobar" hemorrhage, as well as associated left intraventricular
and
subarachnoid and subdural hemorrhage; the overall appearance is
highly
suggestive of underlying cerebral amyloid angiopathy (CAA).
2. No CTA "spot sign" to indicate extravasation portending rapid
expansion of
the hematoma.
3. No evidence of underlying arteriovenous malformation,
aneurysm or other
vascular anomaly.
4. No evidence of cerebral venous thrombosis.
5. Status post apparent aneurysm coiling at the left MCA
bifurcation, with no
other aneurysm seen to involve the circle of [**Location (un) 431**].
6. Calcific atherosclerosis involving the both carotid
bifurcations and
proximal internal carotid arteries, without flow-limiting
stenosis.
.
CHEST (PA & LAT) Study Date of [**2118-6-3**] 4:57 PM
IMPRESSION:

1. Cardiac and mediastinal contours are within normal limits.
Streaky linear
opacities at left base likely reflect subsegmental atelectasis
given their
absence on the comparison study from earlier in the day. Lungs
are otherwise
clear without evidence of pleural effusions, focal airspace
consolidation or
pneumothorax. Overall, there are slightly less vascular markings
in the upper
lungs relative to the lower lungs which suggests a component of
underlying
emphysema given the patient's history of smoking. If a lung
primary remains
of clinical concern, further imaging evaluation with CT should
be considered.
.
MR HEAD W & W/O CONTRAST Study Date of [**2118-6-4**] 2:39 AM
FINDINGS: The study is compared with the CTA of the head and
neck, obtained
roughly 8 hours earlier. There is expected extensive "blooming"
susceptibility artifact associated with the large left
parieto-occipital
"lobar" hemorrhage. There is similar susceptibility artifact
related to the
transependymal dissection with significant left lateral
ventricular component,
as well as the overlying subarachnoid and subdural blood,
layering along the
left lateral aspect of the falx, posteriorly, as well as the
left leaflet of
the tentorium. However, apart from this finding, there are also
scattered
"micro-bleeds," largely peripherally-located at the [**Doctor Last Name 352**]-white
matter junction
of both cerebral hemispheres, posteriorly. No similar
microhemorrhage is
identified in the basal ganglia or other deep [**Doctor Last Name 352**] matter
structures. These
findings are consistent with underlying cerebral amyloid
angiopathy (CAA).

There is only faint vascular and, perhaps, early marginal
enhancement
involving the lobar hematoma, but no discrete peripheral or
central nodular or
mass-like enhancement to suggest an underlying space-occupying
lesion. There
is no pathologic parenchymal, leptomeningeal or dural focus of
enhancement,
elsewhere.

Apart from the expected zone of vasogenic edema surrounding the
large
parenchymal hematoma, not significantly changed from the CTA,
there is also
more diffuse sulcal FLAIR-hyperintensity suggestive of
subarachnoid
hemorrhage, also likely related to CAA. There are also scattered
punctate,
more ovoid and more confluent T2-/FLAIR-hyperintense foci in
bihemispheric
subcortical and periventricular, as well as central pontine
white matter,
likely the sequelae of chronic small vessel ischemic disease. In
the region
of the lobar hemorrhage, the DWI sequence is not interpretable;
however,
elsewhere, there is no focus of slow diffusion to suggest an
acute ischemic
event, and the principal intracranial vascular flow-voids,
including those of
dural venous sinuses are preserved, and these structures enhance
normally,
corresponding to the findings on the recent CTA.

Incidentally noted is minor mucosal thickening involving the
anterior
ethmoidal air cells.

IMPRESSION:
1. Expected marked susceptibility artifact associated with the
known left
parieto-occipital lobar hemorrhage and associated
intraventricular and
overlying subdural blood.
2. Diffuse sulcal FLAIR-hyperintensity, likely representing
subarachnoid
blood, more evident than on the recent CT (this is in a
non-aneurysmal
pattern).
3. Several "micro-bleeds" peripherally-located in the posterior
aspect of
both cerebral hemispheres. The overall constellation of findings
is highly
suggestive of underlying cerebral amyloid angiopathy (CAA) with
leptomeningeal
vascular involvement.
4. Only expected early enhancement of the evolving parenchymal
hematoma, with
no finding to suggest underlying mass lesion.
5. Normal opacification of the cerebral venous system with no
evidence of
thrombosis.
.
CT HEAD W/O CONTRAST Study Date of [**2118-6-5**] 2:16 AM
FINDINGS: There is a large left occipitoparietal parenchymal
hemorrhage
similar in size and appearance compared to [**2118-6-3**]. A
second
hyperdense focus is present just lateral to this (2, 13) which
may reflect
another area of parenchymal hemorrhage or a small focus of
subdural hematoma.
This is unchanged from the most recent prior examination of
[**2118-6-3**].
There is extension of hemorrhage into the left lateral ventricle
as well as
layering along the left tentorium falx suggesting subdural
hematoma, unchanged
from the prior examination. There is mild asymmetric enlargement
of the right
ventricle; however, the ventricle size appears similar to [**6-3**], [**2118**].
Minimal rightward shift of normally midline structures (2 mm
rightward shift)
is noted, unchanged from the prior examination. Artifact from
left MCA
aneurysm coiling is noted. There is no evidence of acute major
vascular
territory infarction. Periventricular and subcortical low
attenuating regions
appear consistent with sequelae of chronic small vessel ischemic
disease.

Bilateral mastoid air cells and visualized paranasal sinuses are
clear.
Globes are intact.

IMPRESSION:
1. Stable large left occipitoparietal parenchymal hemorrhage
with
intraventricular extension, 2 mm rightward midline shift,
unchanged from [**6-3**], [**2118**].
2. Stable asymmetric enlargement of the right lateral ventricle.

3. Subdural hemorrhage layering along the left tentorium and
falx, unchanged
from the prior examination.
4. A smaller second focus of hemorrhage in the left occipital
lobe may
represent second smaller parenchymal hemorrhage or focal
subdural hematoma,
unchanged from the prior examination.
5. No new acute foci of hemorrhage.
.
CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST [**2118-6-5**]
11:31 AM
FINDINGS:

CT OF THORAX: The thyroid gland is unremarkable and there is no
supraclavicular lymphadenopathy. The airways are patent to [**Doctor First Name 553**]
mental
level. No mediastinal, hilar, or axillary lymph node enlargement
by CT size
criteria is present. With the exception of mild coronary artery
calcifications, the heart, pericardium, and great vessels are
unremarkable.
There is no esophageal wall thickening or hiatal hernia.

Lung windows demonstrate moderate diffuse centrilobular
emphysema. No focal
opacities. Biapical consolidations likely represent age-related
changes.
Calcified pleural plaques are noted. There is no pleural
effusion or
pneumothorax.

CT OF THE ABDOMEN: The liver is normal in size without evidence
of an
intrahepatic biliary duct dilatation. Multiple calcifications
are noted in
segments 4A and B. A small focus of focal fatty infiltrate is
also noted in
segment [**Doctor First Name 690**]/b along the falciform ligament, likely related to
focal perfusion
abnormalities. The portal vein is patent and the gallbladder is
unremarkable.
The pancreas and spleen are unremarkable. The right adrenal
gland is within
normal limits while the left adrenal gland demonstrates a 7 mm
nodularity in
its posterior lymph (3:59), which has a average attenuation of
8.3 Hounsfield
units in the non-contrast CT, suggesting small adenoma. The
kidneys do not
demonstrate any focal lesions and show symmetric nephrograms and
excretion of
contrast. There are no perinephric abnormalities or fluid
collection.

The stomach, small bowel and colon are within normal limits
without evidence
of wall thickening or obstruction. The appendix is not
visualized, but there
is no evidence of appendicitis. There is extensive sigmoid
diverticulosis
without evidence of diverticulitis.

With the exception of atherosclerotic calcifications of the
aorta and main
abdominal vessels there is no evidence of aneurysm or any other
abdominal
vascular abnormality. There is no mesenteric or retroperitoneal
lymph node
enlargement by CT size criteria. No ascites, free air, abdominal
wall hernia
is present.

CT OF THE PELVIS: The urinary bladder, terminal ureters, uterus
and adnexa
are unremarkable. Two small calcified fibroids are noted in the
uterus.
There is no pelvic free fluid.

OSSEOUS STRUCTURES: Mild left convex scoliosis centered in the
upper lumbar
spine is noted. There are also degenerative changes at the
lumbar spine, more
prominent at the level of L2 on L3, but no lytic or blastic
lesions concerning
for malignancy. Small sclerotic focus in the body of L1 is
likely a bone
island.

Coronal and sagittal images were reviewed, confirming the axial
findings.

IMPRESSION:
1. No evidence of thoracic, abdominal or pelvic malignancy.
2. Multiple calcified foci in the liver likely represents
granulomas.
3. Chronic conditions including atherosclerotic vascular
calcifications,
clacified pleural plaques, centrilobular emphysema, degenerative
changes of
the spine, and diverticulosis are noted.
.
.
Cardiology:
TTE (Complete) Done [**2118-6-6**] at 10:22:32 AM      FINAL
Conclusions
The left atrium and right atrium are normal in cavity size. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is high normal. There is no
pericardial effusion.

IMPRESSION: Mild aortic regurgitation with mild valve sclerosis.
Mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function.

Brief Hospital Course:
62-year-old right-handed woman with a history of left MCA
aneurysm s/p coiling in [**2115**], prior right occipital infarcts and
a subacute left superior frontal infarcts on imaging in [**2115**]
with negative workup and started aspirin and simvastatin per OSH
records, borderline HTN, HLD and seizure disorder (with somewhat
unclear history - please see "additional history" for details)
who presented on [**2118-6-3**] as an OSH transfer with persistent
(initially sudden onset) posterior headache and  fluctuating
difficulties with right visual field which then became fixed. On
presentation to [**Hospital3 **], patient was hypertensive to 180/90
and IV nicardipine was started. On arrival at [**Hospital1 18**],
neurological exam was significant for right visual field
homonymous hemianopia, alexia without clear agraphia, finger
confusion, and color errors and acalculia. She was admitted to
the stroke service from [**2118-6-3**] to [**2118-6-7**].

CT showed a large left occipitoparietal intraparenchymal
hemorrhage with intraventricular extension and 2 mm rightward
midline shift as well as associated left intraventricular,
subarachnoid and subdural hemorrhage suggestive of amyloid
angiopathy. CTA showed no evidence of underlying arteriovenous
malformation, aneurysm or other vascular anomaly. CTV showed no
evidence of cerebral venous thrombosis. In addition, there was
calcific atherosclerosis involving the both carotid bifurcations
and proximal internal carotid arteries, without flow-limiting
stenosis. MRI showed several "micro-bleeds" peripherally-located
in the posterior aspect of both cerebral hemispheres with only
expected early enhancement of the evolving parenchymal hematoma,
with no finding to suggest underlying mass lesion. This was
again suggestive of underlying cerebral amyloid angiopathy with
leptomeningeal vascular involvement.

Patient was initially admitted to the ICU and transferred to the
floor on [**2118-6-4**]. Repeat CT was stable after worsening of
word-finding difficulties. She was monitored on telemetry and
her examination remained stable thereafter. Hypertension was
controlled with uptitrating lisinopril to 40mg qd on discharge
in addition to PRN IV hydralazine which was latterly not
required. Echo showed EF >55% and mild AR with mild valve
sclerosis, mild symmetric LVH with preserved global and regional
biventricular systolic function. HA was treated with standing
acetaminophen and we continue home levetiracetam 750mg po bid.
She had no seizures in house. Patient should discuss with PCP
regarding routine screening (colonoscopy, mammography and skin
checks etc) and should discuss regarding starting Chantix to aid
in smoking cessation. WBCs and platelets were mildly elevated
and UA and chest exam were unremarkable and were felt to be
likely reactive to her IPH.

The most likely aetiology was amyloid angiopathy given the
multiple bleeding sources and evidence of microbleeds and other
imaging findings suggestive of this. MRI did not show any clear
underlying lesion and she had a CT torso which showed no clear
evidence of malignancy (This was pursued especially in light of
a remote history of melanoma). She will have an interval MRI w
and w/o contrast in [**Month (only) **] to assess for underlying mass lesion
once the hemorrhage has resolved.

Colour naming and finger agnosia resolved and writing
(previously described as clumsy but not agraphia) had also
improved and patient could spell words but could often not read
directly and had striking acalculia (was able to only do one
serial seven and had difficulty with simple arithmetic) given
her job as an accountant. There were no limb impairments and she
was bright and alert while on the floor. She had persistent
headache treated with acetaminophen. OT assessed her and felt
that she could go home if she had 24 hour supervision, however
the patient lives at home alone and given this, she was deemed
more appropriate for rehab. Dr [**Last Name (STitle) **] was contact[**Name (NI) **] and we have
arranged for formal visual fields and neuro-ophthalmology review
as an outpatient to happen in [**2118-7-8**]. She was transferred to
rehab on [**2118-6-7**]. Patient was still hypertensive on discharge
with SBP 140s-160s and she will need uptitration of her
anti-hypertensives at rehab. She has stroke, neuro-ophthalmology
follow-up and repeat MRI booked.
.
TRANSITIONAL ISSUES:
- Patient will need uptitration of her anti-hypertensives with
goal BP <140/90
- Plt increase likely reactive and to be trended at rehab
- Patient awaits repeat MRI w and w/o contrast on [**2118-7-25**]
- Awaits neuro-ophthalmology review and formal visual fields in
[**2118-7-8**]
- Patient should discuss with PCP regarding cancer screening and
f/u (Mammogram, Colonoscopy, Pap etc) and Dermatologist follow
up due to history of melanoma
- Patient to discuss Chantix with PCP to aid in smoking
cessation
- Pt was counselled to please avoid aspirin and antiplatelet
agents

Medications on Admission:
levetiracetam 750mg po bid
MVI

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
5. lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).



Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
Primary Diagnosis:
Left Intraparenchymal Hemorrhage in the Parieto-Occipital Region
with intraventricular, subarachnoid and subdural extension
likely secondary to amyloid angiopathy but awaiting repeat MRI
to rule out underlying mass lesion
.
Secondary Diagnosis:
Hypertension


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
.
Neuro Exam at time of Discharge:
Alexia without agraphia, acalculia (significantly affected as
patient was an accountant), right homonymous hemianopia and no
focal limb weakness or other CN abnormality.


Discharge Instructions:
Dear Ms. [**Known lastname **],

It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
from an outside hospital after having a bleed on the left side
of the brain (in the parietal-occipital area) seen on CT and
MRI. This area of hemorrhage accounts for your headache,
difficulties [**Location (un) 1131**] and problems with your right visual field.
Due to the bleed in the brain you were admitted initially to the
intensive care unit but remained stable enough for discharge to
the floor. You examination remained stable and your MRI scan
showed evidence of "microbleeds" suggesting a diagnosis of
amyloid angiopathy (leaky blood vessels which can rupture and
cause small or large bleeds in the brain) although an underlying
lesion could not be definitievly ruled out. You had a CT scan of
the body which did not show any evidence of tumours. In
addition, you have been referred for a repeat MRI of the head in
[**Month (only) **] to have a better look after the blood has absorbed. You
have also been referred for formal visual fields to assess your
vision.

It will be important that you avoid certain medications now that
you have had a bleed in your brain. You should avoid medications
such as aspirin, ibuprofen and aleve. You can use tylenol as
needed for pain.

Also, we discussed the importance of smoking cessation with you.
We have recommended that you further discuss this with your
primary care provider, [**Name10 (NameIs) **] we have specifically recommended that
you may benefit from a medication known as Chantix to help you
quit.

Also, it is important for you to have important screenings to
check on your health. As you have not had a colonoscopy yet we
are recommending that you discuss this with your primary care
provider. [**Name10 (NameIs) **] addition, please be sure you are up to date with
your mammograms and colonoscopy. Also, as you have had a history
of melanoma we are recommending that you see Dermatology for a
skin check after you are discharged.

You were also asked whether you would be willing to participate
in a special patient presentation lecture which will occur at
[**Hospital Ward Name 121**] 11, [**Doctor First Name **]-[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Last Name (Titles) 517**] on Wed [**6-15**], at
11:45. Should you wish to participate we would be able to
reimburse you for transportation costs.

You blood pressure was still slightly high on discharge and your
blood pressure medications will likely need to be increased at
rehab. Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**]
([**Telephone/Fax (1) **]) after discharge from rehab. We have organised
stroke follow-up.

Medication changes:
We STARTED Lisinopril 40mg daily
Continue Keppra 750mg twice daily

Followup Instructions:
Please follow-up with your PCP on discharge from rehab.
.
We have arranged the following neurology follow-up:

Department: NEUROLOGY
When: WEDNESDAY [**2118-7-27**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

In addition we have arranged a repeat MRI as below:

Department: RADIOLOGY
When: MONDAY [**2118-7-25**] at 1:40 PM
With: XMR [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Hospital 1422**]
Campus: WEST    Best Parking: [**Street Address(1) 592**] Garage

We have arranged the following neuro-opthalmology appointment to
check your visual fields:

Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2118-7-12**] at 8:30 AM
With: [**Name6 (MD) 6131**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Intracerebral hemorrhage,Other amyloidosis,Homonymous bilateral field defects,Unspecified cerebrovascular disease,Unspecified essential hypertension,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of malignant melanoma of skin,Other and unspecified hyperlipidemia,Tobacco use disorder,Epilepsy, unspecified, without mention of intractable epilepsy,Alexia and dyslexia,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Essential thrombocythemia'}


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: headache

PRESENT ILLNESS: Ms. [**Known lastname **] is a 62-year-old right-handed woman presenting with
Transfer with intraparenchymal hemorrhage.

MEDICAL HISTORY: - "Seizures", two years, on Keppra. In [**2117-10-7**], she had
hit her head on a cabinet and had headaches since that event. On
[**2115-10-12**] she noted some visual disturbance as she was
walking to her car. Later that day she was stopped by police
because she was noted to be driving erratically. There was a
report that she "briefly passed out behind the wheel." She had
no memory of the event in the car. She was admitted to [**Hospital1 4494**] in [**Location (un) 3844**]. EEG at [**Hospital1 **] showed "sharp and slow
wave activity." She was placed first on Dilantin, and was later
switched to Keppra at [**Hospital1 2025**]. She was transferred to [**Hospital1 2025**] on [**2117-10-16**]
because imaging had shown a left MCA 4mm aneurysm. MRI brain at
[**Hospital1 2025**] on [**2115-10-18**] showed two small subacute right occipital
infarcts and a subacute left superior frontal infarct. CTA
brain/neck showed left MCA aneurysm, atherosclerosis of the
right PCA, mild narrowing of the
left vertebral artery origin, mild bilateral narrowing of the
proximal ICA's. Holter monitoring did not show atrial
fibrillation. TTE in [**10-16**] showed EF 65%. No evidence of ASD of
PFO by bubble study. These infarcts were of different ages. She
was started on simvastatin 20mg qhs and aspirin 81mg daily.
- [**2116-1-21**], she underwent coiling of the left MCA aneurysm by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1128**]. No other vascular malformation was found.
- She has a history of melanoma resection from her chin.
- hyperlipidemia.
- Palpitations
- Hypertension, borderline, saw PCP two years ago
- Tonsillectomy, Dilatation and curettage.

MEDICATION ON ADMISSION: levetiracetam 750mg po bid
MVI

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At admission:
Vitals: 98.6 82 190/110 18 96% (BP to 150s at time of exam, on
nicardipine drip)

FAMILY HISTORY: Older brother, now deceased, had seizure and clotting disorders
(PE). Mother - d. HTN, stroke (unknown). Father - lung cancer -
was a smoker. [**Name (NI) **] brother is well.

SOCIAL HISTORY: Smoking: Yes - 1PPD, perhaps 30 years.
Alcohol: About two glasses wine with dinner, three to four times
per week.
Drugs: No.
Living Situation: Lives alone, with cat (brother is feeding,
[**Doctor First Name 110586**]).
Education and Language: English, college - accountant.
Functional Baseline: Independent.
Other: Office manager - colleagues likely wondering where she
is,
but brother will call them. Watches baseline, dines with
friends. 

### Response:
{'Intracerebral hemorrhage,Other amyloidosis,Homonymous bilateral field defects,Unspecified cerebrovascular disease,Unspecified essential hypertension,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of malignant melanoma of skin,Other and unspecified hyperlipidemia,Tobacco use disorder,Epilepsy, unspecified, without mention of intractable epilepsy,Alexia and dyslexia,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Essential thrombocythemia'}
