CHIEF COMPLAINT: Worsening language difficulties

PRESENT ILLNESS: This [**Age over 90 **] year-old right-handed woman with a history of
atrial fibrillation on warfarin in the setting of myocardial
infarction in [**2099-11-17**], also on ASA and Plaxix, with
hypertension, and breast cancer was transferred from [**Hospital **]
Hospital for an atraumatic intraparenchymal hemorrhage in the
left parietal region, after ~48 hours of worsening language
difficulties noted by friends and family.

MEDICAL HISTORY: -Atrial fibrillation, diagnosed in [**2099-11-17**] at time of MI
-Hypertension
-Dyslipidemia
-CAD s/p myocardial infarction, [**2099-11-17**]
-Peripheral vascular disease with AAA and claudication
-Hypothyroidism
-GERD
-COPD
-Breast cancer, diagnosed [**2087**] and received lumpectomy and
radiation; no known recurrence
-Osteoarthritis
-s/p left hip replacement, [**2098-6-17**]
-s/p cystocele repair in [**2095**]

MEDICATION ON ADMISSION: Medications (complete medication list from recent PCP [**Name Initial (PRE) **]
[**2100-6-18**]):
- Coumadin 2.5 mg daily, except for Wednesday, when she takes 5
mg
- Plavix 75 mg daily
- Aspirin 81 mg daily (? recently added [**6-18**])
- Lipitor 40 mg qhs
- Nexium 40 mg daily
- Klonopin 0.5 mg daily
- Levoxyl 175 mcg daily, except none on Sunday
- Lasix 20 mg daily
- Lisinopril 2.5 mg daily
- Imdur 30 mg daily
- Inspra 12.5 mg daily
- Toprol XL 25 mg daily
- Tylenol/codeine 300.30 [**11-18**] QID prn pain

ALLERGIES: Ciprofloxacin Hcl

PHYSICAL EXAM: Temp: 97.6; BP: 128/82; HR: 88; RR 12

FAMILY HISTORY: Brief Hospital Course:

SOCIAL HISTORY: Lives at home alone in [**Location (un) 12415**], family members, including son
lives near by.  She uses no ambulatory aids, and was managing
her
finances, and even driving as of this week.  Smoked [**11-18**] ppd for
50 years, but quit in [**2081**].  She drinks one glass of wine each
evening.  No history of drug use.  Worked in a loan office until
[**2031**].
Intracerebral hemorrhage,Pneumonia, organism unspecified,Unspecified essential hypertension,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Atherosclerosis of native arteries of the extremities with intermittent claudication,Abdominal aneurysm without mention of rupture,Unspecified acquired hypothyroidism,Esophageal reflux,Chronic airway obstruction, not elsewhere classified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Old myocardial infarction,Personal history of malignant neoplasm of breast,Hip joint replacement
Intracerebral hemorrhage,Pneumonia, organism NOS,Hypertension NOS,Atrial fibrillation,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Ath ext ntv at w claudct,Abdom aortic aneurysm,Hypothyroidism NOS,Esophageal reflux,Chr airway obstruct NEC,Osteoarthros NOS-unspec,Old myocardial infarct,Hx of breast malignancy,Joint replaced hip
Name:  [**Known lastname 12774**],[**Known firstname 1683**] E            Unit No:   [**Numeric Identifier 12775**]

Admission Date:  [**2100-7-16**]              Discharge Date:   [**2100-7-22**]

Date of Birth:  [**2009-3-1**]             Sex:   F

Service: NEUROLOGY

Allergies:
Ciprofloxacin Hcl

Attending:[**Last Name (NamePattern1) 4697**]
Addendum:
We discussed the results of the echocardiogram with the family
([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Last Name (un) **]). They do not want the patient to remain on
coumadin, despite the AF. In addition, once this decision was
made, we decided not to pursue a TEE.

Family History:

Brief Hospital Course:


Discharge Disposition:
Extended Care

Facility:
[**Hospital 12776**] Healthcare Center - [**Location (un) 12777**]

Discharge Condition:

                             [**First Name8 (NamePattern2) 77**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern4) 4698**] MD [**MD Number(2) 4699**]

Completed by:[**2100-7-22**]

Admission Date:  [**2100-7-16**]              Discharge Date:   [**2100-7-22**]


Service: NEUROLOGY

Allergies:
Ciprofloxacin Hcl

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Worsening language difficulties

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This [**Age over 90 **] year-old right-handed woman with a history of
atrial fibrillation on warfarin in the setting of myocardial
infarction in [**2099-11-17**], also on ASA and Plaxix, with
hypertension, and breast cancer was transferred from [**Hospital **]
Hospital for an atraumatic intraparenchymal hemorrhage in the
left parietal region, after ~48 hours of worsening language
difficulties noted by friends and family.

Her son, who is bedside, notes that she has had some difficulty
with naming (particularly proper names of people) since [**2100-4-18**].  However, on visiting his mother two days ago, he noted
that she was having troble naming common things like "car."  Her
speech was not slurred.  Yesterday, she was noted to have some
difficulty with memory according to another family member.
[**Name (NI) **]
in the day, her son noted that she signed a check without her
last name, then wrote a message in a card that made "no sense."
She made dinner for her family last evening, but her son became
increasingly concerned and brought her to [**Hospital **] Hospital this
morning at 6 am.

[**Hospital **] Hospital ER staff records additionally indicate that
there was some concern about "slurred speech" and "agnosia."
Her
blood pressure on arrival there was noted at 128/80.  She
received a CT scan of the head that revealed a 2.7 x 3.7 cm left
parietal hemorrhage with some mild surrounding edema.
Her INR was 3.5.  She received Vitamin K, 10 units SQ and 10
units IV.  She received FFP x 2 and Zofran.  Sodium was 133 and
creatinine 1.2; EKG revealed atrial fibrillation.  She was
medflighted to [**Hospital1 18**] for for further evaluation.

Review of Systems:
Denies headache, fevers, chills, chest pain, dyspnea, vision
change or loss, weakness, numbness, tingling, incoordination,
bumping into walls, weight loss, night sweats, cough, trauma.


Past Medical History:
-Atrial fibrillation, diagnosed in [**2099-11-17**] at time of MI
-Hypertension
-Dyslipidemia
-CAD s/p myocardial infarction, [**2099-11-17**]
-Peripheral vascular disease with AAA and claudication
-Hypothyroidism
-GERD
-COPD
-Breast cancer, diagnosed [**2087**] and received lumpectomy and
radiation; no known recurrence
-Osteoarthritis
-s/p left hip replacement, [**2098-6-17**]
-s/p cystocele repair in [**2095**]


Social History:
Lives at home alone in [**Location (un) 12415**], family members, including son
lives near by.  She uses no ambulatory aids, and was managing
her
finances, and even driving as of this week.  Smoked [**11-18**] ppd for
50 years, but quit in [**2081**].  She drinks one glass of wine each
evening.  No history of drug use.  Worked in a loan office until
[**2031**].

Family History:
No known family history of stroke, hemorrhage, or other disease


Physical Exam:
Temp: 97.6; BP: 128/82; HR: 88; RR 12

Gen: Alert elder woman, no apparent distress. MMM.
No meningismus.
No carotid bruits auscultated.
No thyromegaly.
Lungs clear bilaterally.
Heart irregularly irregular in rate.
Abd nontender, nondistended.  Bowel sounds heard throughout.

Neuro:

>>MS??????Alert. Speech fluent, not dysarthric.  Spontaneous speech
prosodic "I really don't know why I need to be here."  Cannont
name objects "blue" for watch and "yes" for hand.  Follows two
step commands.  Repeats "no if and buts".  Sings fluently.
Frustrated with speech difficulties and simple questions posed:
"I'm very smart".  Oriented to self, DOB.

>>CN??????Fundi w/ sharp discs. PERRL. No ptosis. VFIC. EOMI w/
smooth
pursuit. Facial sensation and pterygoid strength intact. Facial
mm intact. Hearing intact to finger rub. Palate elevates
midline.
SCMs intact. Tongue protrudes midline without fasciculations.

>>Motor??????R UE [**3-22**]. L UE [**3-22**]. R LE [**3-22**]. L LE [**3-22**]. No drift. Tone
normal.

>>Sensory??????Light touch, temp, pinprick and vibration intact.  No
DSSE.

>>DTRs??????L/R: bic [**12-20**], br [**12-19**], tri [**12-19**]; pat [**12-19**], Ach 0/0. Plantars
bilaterally flexor.

>>Coord/Gait??????No dysmetria. No dysdiadochokinesia. No tremor.



CT: my read 3x3x4 cm LEFT parietal intra parenchymal hemorrhage.

Mild associated edema.  No MLS.

Labs:

PT: 18.5  PTT: 28.8  INR: 1.7

134  99  28  94
4.4  27  1.1

CK: 77
Ca: 9.3 Mg: 2.2 P: 3.8
Serum ASA, EtOH, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
TSH:Pnd
Dig: 0.2

CBC:  6.7  11.0/33.1  314

PT: 19.6  PTT: 31.2  INR: 1.8



Pertinent Results:
[**2100-7-16**] 08:20AM   GLUCOSE-94 UREA N-28* CREAT-1.1 SODIUM-134
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-27 ANION GAP-12
[**2100-7-16**] 11:30AM   PT-18.5* PTT-28.8 INR(PT)-1.7*
[**2100-7-16**] 12:11PM   %HbA1c-5.5
[**2100-7-16**] 08:20AM   TSH-0.17*
[**2100-7-16**] 08:20AM   DIGOXIN-0.2*
[**2100-7-16**] 08:20AM   ASA-NEG ETHANOL-NEG ACETMNPHN-5.0
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2100-7-16**] 08:20AM   WBC-6.7 RBC-3.82* HGB-11.0* HCT-33.1* MCV-87
MCH-28.8 MCHC-33.3 RDW-13.3
[**2100-7-16**] 08:20AM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG

CT CNS: 08/ 29/ 08: Left parietotemporal parenchymal hemorrhage
is unchanged since 4 hours prior (at [**Hospital **] hospital).

MRI w/o contrast: 08/ 29/ 08:  While degraded by patient motion,
the FLAIR images are of  sufficient quality to re-demonstrate
the large hemorrhage within the left  posterior temporal lobe,
with extensive surrounding edema. There is  associated
effacement of the atrium of the left lateral ventricle.
There is extensive high T2 signal within the periventricular
white matter of both  cerebral hemispheres, which presumably
represents chronic small vessel infarction, given the patient's
very advanced age. There is at least one  probable chronic
lacunar infarct within the inferolateral aspect of the right
cerebellar hemisphere. There is no shift of normally midline
structures.
Given patient age, there are the expected diffuse involutional
changes of the  brain parenchyma.

MRA: 08/ 31/ 08: Redemonstration of left temporal lobe
hemorrhage, without
definite signs of underlying pathological enhancement or
abnormal vascularity.

Ct scan: 09/ 02/ 08: Multifocal pneumonia within the dependent
portions of the lung involving  the posterior right upper lobe
and lower lobes bilaterally is most suggestive  of aspiration
induced pneumonia. No reactive effusions or pericardial
effusions.

2. No focal mass lesions. Moderate centrilobular emphysema with
some
peripheral interstitial thickening and peripheral
bronchiolectasis, which
could relate to an underlying interstitial lung disease, NSIP
distribution.

3. Large type 3 hiatal hernia with no CT findings to suggest
gastric
volvulus.

4. Extensive atherosclerotic disease within the coronary tree
and
intrathoracic aorta which contains regions of ulcerating plaque.
Questionable thrombus in the left atrial appendage. Can
correlate with echo.


ECHO: 09/ 04/ 08 The left atrium is mildly dilated. The right
atrium is moderately dilated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. No masses or thrombi are
seen in the left ventricle. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. 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. An eccentric, posteriorly-directed jet of
mild to moderate ([**11-18**]+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.

IMPRESSION: Normal global biventricular systolic function. Mild
to moderate mitral regurgitation. Mild pulmonary hypertension.
No large left atrial thrombus seen, but transthoracic
echocardiography is inadequate for exclusion of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**].


Brief Hospital Course:
Ms [**Name13 (STitle) 38136**] has remained stable during her hospitalization. Her
bleed does not seem to relate to a mass or AVM (MRI/ MRA
negative plus CT torso negative for tumor). She was on ASA plus
plavix and coumadin (INR was 3.5 at [**Hospital **] Hospital prior to
transfer). Her bleed may have occurred because her INR was
supertherapeutic. There was no previous history of trauma. The
location of the bleed argued against a HTN etiology. She may
have amyloid angiopathy (though there is no lobar distribution
in her bleed).
Her deficits were Wernicke's aphasia and pseudobulbar symptoms .

In addition, though she remained asymptomatic and afebrile with
normal WBC and Na levels, a PNA was reported in the CT study.
She was started on a cephalosporin plus clindamicin. She needs
to complete a total of 10 days of therapy (day 3 currently).
The risks and benefits of restarting coumadin after a period of
two weeks to protect her against ischemic stroke was discussed
with her son [**Name (NI) **] (who is her health care proxy). The risk of
coumadin causing a recurrent intracranial hemorrhage was
discussed. [**Male First Name (un) **] said that he did not want his mother restarted on
Coumadin. She was
restarted on aspirin 81mg daily instead for secondary stroke
prevention. The plavix was not restarted (Her PMD Dr. [**Last Name (STitle) **]
said that prior to this hospitalization she had asked that the
Plavix be stopped).

Medications on Admission:
Medications (complete medication list from recent PCP [**Name Initial (PRE) **]
[**2100-6-18**]):
- Coumadin 2.5 mg daily, except for Wednesday, when she takes 5
mg
- Plavix 75 mg daily
- Aspirin 81 mg daily (? recently added [**6-18**])
- Lipitor 40 mg qhs
- Nexium 40 mg daily
- Klonopin 0.5 mg daily
- Levoxyl 175 mcg daily, except none on Sunday
- Lasix 20 mg daily
- Lisinopril 2.5 mg daily
- Imdur 30 mg daily
- Inspra 12.5 mg daily
- Toprol XL 25 mg daily
- Tylenol/codeine 300.30 [**11-18**] QID prn pain

Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.

2. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO 6X/WEEK
(MO,TU,WE,TH,FR,SA).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Eplerenone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Clindamycin HCl 150 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 8 days.
10. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 8 days.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).


Discharge Disposition:
Extended Care

Facility:
[**Hospital 12414**] Healthcare Center - [**Location (un) 12415**]

Discharge Diagnosis:
LEFT occipito-parietal henorrhagic stroke


Discharge Condition:
The exam evidences no deficits. However, she has pseudobulbar
findings.


Discharge Instructions:
You have been diagnosed with a hemorrhagic stroke. this means
you have had a bleed in your brain.

Followup Instructions:
We recommend you follow up with Dr. [**Last Name (STitle) **] at the [**Hospital 79251**] clinic.
Please, call [**Telephone/Fax (1) 2574**] to set up an appointment.
{'Intracerebral hemorrhage,Pneumonia, organism unspecified,Unspecified essential hypertension,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Atherosclerosis of native arteries of the extremities with intermittent claudication,Abdominal aneurysm without mention of rupture,Unspecified acquired hypothyroidism,Esophageal reflux,Chronic airway obstruction, not elsewhere classified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Old myocardial infarction,Personal history of malignant neoplasm of breast,Hip joint replacement'}


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: Worsening language difficulties

PRESENT ILLNESS: This [**Age over 90 **] year-old right-handed woman with a history of
atrial fibrillation on warfarin in the setting of myocardial
infarction in [**2099-11-17**], also on ASA and Plaxix, with
hypertension, and breast cancer was transferred from [**Hospital **]
Hospital for an atraumatic intraparenchymal hemorrhage in the
left parietal region, after ~48 hours of worsening language
difficulties noted by friends and family.

MEDICAL HISTORY: -Atrial fibrillation, diagnosed in [**2099-11-17**] at time of MI
-Hypertension
-Dyslipidemia
-CAD s/p myocardial infarction, [**2099-11-17**]
-Peripheral vascular disease with AAA and claudication
-Hypothyroidism
-GERD
-COPD
-Breast cancer, diagnosed [**2087**] and received lumpectomy and
radiation; no known recurrence
-Osteoarthritis
-s/p left hip replacement, [**2098-6-17**]
-s/p cystocele repair in [**2095**]

MEDICATION ON ADMISSION: Medications (complete medication list from recent PCP [**Name Initial (PRE) **]
[**2100-6-18**]):
- Coumadin 2.5 mg daily, except for Wednesday, when she takes 5
mg
- Plavix 75 mg daily
- Aspirin 81 mg daily (? recently added [**6-18**])
- Lipitor 40 mg qhs
- Nexium 40 mg daily
- Klonopin 0.5 mg daily
- Levoxyl 175 mcg daily, except none on Sunday
- Lasix 20 mg daily
- Lisinopril 2.5 mg daily
- Imdur 30 mg daily
- Inspra 12.5 mg daily
- Toprol XL 25 mg daily
- Tylenol/codeine 300.30 [**11-18**] QID prn pain

ALLERGIES: Ciprofloxacin Hcl

PHYSICAL EXAM: Temp: 97.6; BP: 128/82; HR: 88; RR 12

FAMILY HISTORY: Brief Hospital Course:

SOCIAL HISTORY: Lives at home alone in [**Location (un) 12415**], family members, including son
lives near by.  She uses no ambulatory aids, and was managing
her
finances, and even driving as of this week.  Smoked [**11-18**] ppd for
50 years, but quit in [**2081**].  She drinks one glass of wine each
evening.  No history of drug use.  Worked in a loan office until
[**2031**]. 

### Response:
{'Intracerebral hemorrhage,Pneumonia, organism unspecified,Unspecified essential hypertension,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Atherosclerosis of native arteries of the extremities with intermittent claudication,Abdominal aneurysm without mention of rupture,Unspecified acquired hypothyroidism,Esophageal reflux,Chronic airway obstruction, not elsewhere classified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Old myocardial infarction,Personal history of malignant neoplasm of breast,Hip joint replacement'}
