CHIEF COMPLAINT: Aphasia

PRESENT ILLNESS: 65 y/o M who presented last night with two episodes of
aphasia. Patient went to see his PCP when he suddenly became
mute. He was immediately transferred to the ED where code stroke
was called. Patient's head CT showed no acute hemorrhage or
infarct. His risk factors were high for stroke and he was given
TPA at 6:30pm. His speech cleared after TPA was given.
Overnight,
his speech became slurred and n/v presented. He was taken for a
stat head CT which revealed a L cerebellar hemorrhage.

MEDICAL HISTORY: * HTN
* DM2
* Diabetic retinopathy OU
* Cystoid macular edema OS
* Supertemporal
* back injury
* hx of exposure to asbestos
* hx of excision of a Lipoma on posterior neck [**2126**]
* MRI [**2126**] of head and neck showed mild generalized atrophy
inconsistent with his age,nonspecific white matter densities
* Paranoid psychosis (recently untreated, but with multiple
prior hospitalizations)

MEDICATION ON ADMISSION: ASA 81mg chewable qd
Metformin 1000 mg [**Hospital1 **]
Lisinopril 10mg qd
Lantus 100 units/ml 42 units qd
Toprol XL 50mg q 24 hrs
Novasc 10mg qd

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:
PHYSICAL EXAM:
 BP:159/84         HR: 74        O2Sats:100%
General: Awake,alert at times, 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: Brother w/ h/o admission to a psychiatric hospital.

SOCIAL HISTORY: Born and raised in [**Location (un) 669**], [**Location (un) 686**] and [**Location (un) 2268**] and as of
[**2126**] he had been homelesss for 9 years. He reports that he now
lives in [**Location 669**] in his own apt alone. He is single has never
married and does not have any children. Hx of heavy use of ETOH
but stopped drinking many years ago. H/o past use of marijuana
and cocaine; none recently. Previous tobacco history.
Cerebral artery occlusion, unspecified with cerebral infarction,Intracerebral hemorrhage,Cerebral edema,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Obstructive hydrocephalus,Delirium due to conditions classified elsewhere,Hyperosmolality and/or hypernatremia,Paralytic ileus,Paranoid type schizophrenia, chronic,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Other specified disorders of the teeth and supporting structures,Background diabetic retinopathy,Unspecified essential hypertension,Personal history of contact with and (suspected) exposure to asbestos,Physical restraints status
Crbl art ocl NOS w infrc,Intracerebral hemorrhage,Cerebral edema,Ac DVT/emb prox low ext,Obstructiv hydrocephalus,Delirium d/t other cond,Hyperosmolality,Paralytic ileus,Paranoid schizo-chronic,DMII ophth nt st uncntrl,Dental disorder NEC,Diabetic retinopathy NOS,Hypertension NOS,Hx-contct/expos asbestos,Physical restrain status
Admission Date:  [**2141-11-7**]              Discharge Date:   [**2141-11-30**]

Date of Birth:  [**2076-9-25**]             Sex:   M

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Aphasia

Major Surgical or Invasive Procedure:
[**2141-11-9**]: Posterior fossa craniotomy for clot evacuation
[**2141-11-9**]: Right EVD placement
[**2141-11-17**]: Right VPS placement
[**2141-11-23**]: extraction of teeth #7 & #8


History of Present Illness:
65 y/o M who presented last night with two episodes of
aphasia. Patient went to see his PCP when he suddenly became
mute. He was immediately transferred to the ED where code stroke
was called. Patient's head CT showed no acute hemorrhage or
infarct. His risk factors were high for stroke and he was given
TPA at 6:30pm. His speech cleared after TPA was given.
Overnight,
his speech became slurred and n/v presented. He was taken for a
stat head CT which revealed a L cerebellar hemorrhage.


Past Medical History:
* HTN
* DM2
* Diabetic retinopathy OU
* Cystoid macular edema OS
* Supertemporal
* back injury
* hx of exposure to asbestos
* hx of excision of a Lipoma on posterior neck [**2126**]
* MRI [**2126**] of head and neck showed mild generalized atrophy
inconsistent with his age,nonspecific white matter densities
* Paranoid psychosis (recently untreated, but with multiple
prior hospitalizations)


Social History:
Born and raised in [**Location (un) 669**], [**Location (un) 686**] and [**Location (un) 2268**] and as of
[**2126**] he had been homelesss for 9 years. He reports that he now
lives in [**Location 669**] in his own apt alone. He is single has never
married and does not have any children. Hx of heavy use of ETOH
but stopped drinking many years ago. H/o past use of marijuana
and cocaine; none recently. Previous tobacco history.


Family History:
Brother w/ h/o admission to a psychiatric hospital.


Physical Exam:
On admission:
PHYSICAL EXAM:
 BP:159/84         HR: 74        O2Sats:100%
General: Awake,alert at times, 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, awake.
Does not answer questions.  Follows commands.  Opens eyes,
squeezes hands , wiggles toes.  Communicates for visual field
testing by wiggling thumbs.
No evidence of neglect.

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.  VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus.  Normal saccades.
V: Facial sensation intact to light touch.
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.
Appears to move all 4 extremities symmetrically.

-Sensory: Withdraws to pain ful stimuli.
-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2  2    2    2   1
R  2  2    2    2   1
Plantar response was flexor bilaterally.

-Coordination: Appears intact upon observation.

-Gait: Unable to assess.

ON DISCHARGE:
Eyes opening spontaneously and verbalising but will sometime not
respond to questioning. A+O only to self. Good power in all 4
limbs but difficulties regarding cooperation. Pupils equal and
reactive and no dysarthria. Mild dysmetria perhaps worse on
left.
Wound clean with no erythema or drainage. VP shunt placement
good without irritation. Patient can be agitated.

Pertinent Results:
ADMISSION LABS:
[**2141-11-7**] 05:50PM BLOOD WBC-9.3 RBC-4.63 Hgb-14.3 Hct-39.8*
MCV-86 MCH-30.8 MCHC-35.8* RDW-13.9 Plt Ct-261
[**2141-11-7**] 05:50PM BLOOD Neuts-57.9 Lymphs-34.9 Monos-5.3 Eos-1.4
Baso-0.4
[**2141-11-7**] 05:50PM BLOOD PT-11.9 PTT-22.1 INR(PT)-1.0
[**2141-11-7**] 05:50PM BLOOD UreaN-14
[**2141-11-7**] 05:50PM BLOOD Creat-1.3*
[**2141-11-7**] 09:52PM BLOOD Glucose-203* UreaN-14 Creat-1.4* Na-142
K-3.8 Cl-101 HCO3-30 AnGap-15
[**2141-11-7**] 05:50PM BLOOD ALT-16 AST-13 AlkPhos-85 TotBili-0.8
[**2141-11-7**] 05:50PM BLOOD Albumin-4.2 Calcium-9.6 Phos-3.8 Mg-2.0
.
Other pertinent labs:
[**2141-11-7**] 09:52PM BLOOD CK-MB-2 cTropnT-<0.01
[**2141-11-8**] 03:55AM BLOOD CK-MB-2 cTropnT-<0.01
[**2141-11-7**] 05:50PM BLOOD Lipase-38
[**2141-11-16**] 03:22AM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.7 Mg-2.5
[**2141-11-7**] 09:53PM BLOOD %HbA1c-8.6* eAG-200*
[**2141-11-7**] 09:52PM BLOOD Triglyc-87 HDL-41 CHOL/HD-3.6 LDLcalc-88
[**2141-11-7**] 09:52PM BLOOD TSH-1.5
[**2141-11-8**] 03:55AM BLOOD TSH-0.49
[**2141-11-7**] 05:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
INR trend:
[**2141-11-7**] 05:50PM BLOOD PT-11.9 PTT-22.1 INR(PT)-1.0
[**2141-11-7**] 09:52PM BLOOD PT-14.6* PTT-32.5 INR(PT)-1.3*
[**2141-11-8**] 03:55AM BLOOD PT-14.3* PTT-25.3 INR(PT)-1.2*
[**2141-11-9**] 03:26AM BLOOD PT-13.3 PTT-22.3 INR(PT)-1.1
[**2141-11-9**] 03:17PM BLOOD PT-13.2 PTT-23.0 INR(PT)-1.1
[**2141-11-10**] 05:43AM BLOOD PT-15.0* PTT-28.4 INR(PT)-1.3*
[**2141-11-11**] 01:21AM BLOOD PT-13.5* PTT-25.8 INR(PT)-1.1
[**2141-11-16**] 02:36PM BLOOD PT-13.1 PTT-25.8 INR(PT)-1.1
[**2141-11-17**] 03:02AM BLOOD PT-13.5* PTT-26.5 INR(PT)-1.1
[**2141-11-18**] 01:56AM BLOOD PT-13.1 PTT-25.9 INR(PT)-1.1
[**2141-11-23**] 11:00AM BLOOD PT-13.4 PTT-33.8 INR(PT)-1.1
[**2141-11-25**] 04:30AM BLOOD PT-12.4 PTT-30.9 INR(PT)-1.0
[**2141-11-26**] 06:15AM BLOOD PT-12.6 PTT-30.4 INR(PT)-1.1
[**2141-11-27**] 10:50AM BLOOD PT-13.3 PTT-33.4 INR(PT)-1.1
[**2141-11-28**] 04:25AM BLOOD PT-14.3* PTT-29.8 INR(PT)-1.2*
[**2141-11-29**] 04:15AM BLOOD PT-16.3* PTT-29.2 INR(PT)-1.4*
[**2141-11-30**] 04:25AM BLOOD PT-19.2* PTT-33.7 INR(PT)-1.7*
.
Discharge labs:
[**2141-11-30**] 04:25AM BLOOD WBC-11.9* RBC-3.94* Hgb-11.7* Hct-36.0*
MCV-91 MCH-29.7 MCHC-32.5 RDW-13.4 Plt Ct-387
[**2141-11-30**] 04:25AM BLOOD PT-19.2* PTT-33.7 INR(PT)-1.7*
[**2141-11-29**] 04:15AM BLOOD Glucose-156* UreaN-17 Creat-0.9 Na-135
K-4.4 Cl-94* HCO3-33* AnGap-12
[**2141-11-16**] 03:22AM BLOOD ALT-13 AST-17 AlkPhos-84 TotBili-0.4
.
.
Urine:
[**2141-11-7**] 06:33PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.035
[**2141-11-7**] 06:33PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2141-11-9**] 10:01PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2141-11-9**] 10:01PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2141-11-9**] 10:01PM URINE RBC-18* WBC-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2141-11-10**] 09:31PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.034
[**2141-11-10**] 09:31PM URINE Blood-SM  Nitrite-NEG Protein-30
Glucose-150 Ketone-TR Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG
[**2141-11-16**] 02:36PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2141-11-16**] 02:36PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2141-11-16**] 02:36PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
[**2141-11-9**] 10:01PM URINE Mucous-RARE
[**2141-11-7**] 06:33PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
.
Microbiology:
[**2141-11-17**] 12:12 pm CSF;SPINAL FLUID     Site: SHUNT

                            **FINAL REPORT [**2141-11-23**]**

   GRAM STAIN (Final [**2141-11-17**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
      This is a concentrated smear made by cytospin method,
please refer to
      hematology for a quantitative white blood cell count..

   FLUID CULTURE (Final [**2141-11-23**]):    NO GROWTH.
.
[**2141-11-16**] URINE URINE CULTURE-NO GROWTH
[**2141-11-13**] MRSA SCREEN MRSA SCREEN-NOT DETECTED
[**2141-11-11**] BLOOD CULTURE Blood Culture, Routine-NO
GROWTH
[**2141-11-10**] URINE URINE CULTURE-NO GROWTH
[**2141-11-10**] BLOOD CULTURE Blood Culture, Routine-NO
GROWTH
[**2141-11-10**] MRSA SCREEN MRSA SCREEN-NOT DETECTED
[**2141-11-9**] BLOOD CULTURE Blood Culture, Routine-NO
GROWTH
[**2141-11-9**] BLOOD CULTURE Blood Culture, Routine-NO
GROWTH
[**2141-11-9**] URINE URINE CULTURE-NO GROWTH
[**2141-11-7**] MRSA SCREEN MRSA SCREEN-NOT DETECTED
[**2141-11-7**] BLOOD CULTURE Blood Culture, Routine-NO
GROWTH

[**2141-11-10**] 1:37 pm SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2141-11-10**]**

   GRAM STAIN (Final [**2141-11-10**]):
      [**12-5**] PMNs and >10 epithelial cells/100X field.
      Gram stain indicates extensive contamination with upper
respiratory
      secretions. Bacterial culture results are invalid.
.

CTA Head & Neck [**2141-11-7**]:
NON-CONTRAST CT HEAD: There is no evidence of acute intracranial
hemorrhage or territorial infarction. Focal and confluent
periventricular and subcortical hypodensities are noted in
bilateral cerebral hemispheres, which likely represent sequelae
of chronic small vessel ischemic disease.
Hypodensity is noted in the pons which likely represents a
lacunar infarct.  There is prominence of ventricles, extra-axial
CSF spaces and cortical sulci suggestive of mild generalized
cerebral atrophy. The visualized paranasal sinuses and mastoid
air cells are clear. The orbits are unremarkable. A fat density
lesion is noted in the subgaleal soft tissues in midline in the
frontal region which likely represents a lipoma. There is no
significant change as compared to the prior CT.

CTA NECK: The aortic arch is bovine-type with left common
carotid artery
arising from the brachiocephalic trunk. Atheromatous plaques are
noted in the aortic arch and at the origin of left subclavian
artery without significant stenosis. Bilateral common carotid
arteries, internal and external carotid arteries appear normal.
There is medialization of distal common carotid and internal
carotid arteries. There is no evidence of focal flow limiting
stenosis, occlusion or aneurysm greater than 3 mm. Bilateral
vertebral arteries are patent. The proximal and distal right
internal carotid arteries measure 6.5 and 5.5 mm respectively
and proximal and distal left internal carotid arteries measure
5.9 and 4.2 mm respectively. Degenerative changes are noted in
the cervical spine.

CTA HEAD: The arteries of anterior circulation including
bilateral
intracranial internal carotid arteries, anterior cerebral and
right middle
cerebral arteries appear normal. There is mild atherosclerotic
disease of
left middle cerebral artery. The arteries of the posterior
circulation
including bilateral vertebral arteries, basilar artery, and
posterior cerebral arteries appear normal. The P1 segment of
left posterior cerebral artery appears hypoplastic. There is no
evidence of focal flow-limiting stenosis, occlusion, or aneurysm
greater than 3 mm.

IMPRESSION:
1. No evidence of acute intracranial hemorrhage or territorial
infarction.
2. Changes of chronic small vessel ischemic disease and lacunar
infarct in
pons.
3. No evidence of focal flow-limiting stenosis, occlusion or
aneurysm greater than 3 mm in arteries of anterior and posterior
circulation of head.
4. No evidence of occlusion, focal flow-limiting stenosis or
aneurysm greater than 3 mm in arteries of neck.

ECHO [**2141-11-8**]:
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with cough. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The ascending 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 mildly thickened. No mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.

IMPRESSION: Suboptimal image quality. No intracardiac source of
embolism identified. Patient unable to cooperate with Valsalva
maneuver. Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.

CT Head [**2141-11-8**]:
IMPRESSION:
1. Acute large intraparenchymal hemorrhage centered at the left
cerebellum, likely represents hemorrhagic conversion of stroke.
2. Equivocal trace hyperdensity layering at the right lateral
ventricular
occipital [**Doctor Last Name 534**], could represent trace intraventricular
hemorrhage extension.
3. No evidence of developing hydrocephalus.

Repeat CT Head [**2141-11-8**]:
IMPRESSION:
1. No significant change in the size of the acute cerebellar
hemorrhage,
centered in the left cerebellar hemisphere. Associated tonsillar
herniation, upward transtentorial herniation, and effacement of
the fourth ventricle are not significantly changed. There is no
significant further ventricular dilatation or transependymal
migration of CSF to suggest acute obstructive hydrocephalus.
2. No significant change in the overall quantity of
bihemispheric
subarachnoid hemorrhage allowing for redistribution. Decreased
layering
hemorrhage within the bilateral occipital horns of the lateral
ventricles.

[**11-9**] CT head -
1. Interval increase in the amount of bilateral subarachnoid
hemorrhages with increased intraventricular blood.

2. Unchanged left cerebellar hemorrhage.

[**11-9**] CT head -
1. Expected post-operative changes status post evacuation of
cerebellar
hemorrhage via a suboccipital approach including residual blood
products and mild pneumocephalus.

2. Persistent effacement of the fourth ventricle, tonsillar
herniation, and likely upward transtentorial herniation.

3. No significant change in the size of the lateral ventricles
or third
ventricle status post placement of an external ventricular
drain, which
appears appropriately positioned.

4. Unchanged bihemispheric subarachnoid hemorrhage.
Intraventricular
hemorrhagic extension with increased hemorrhage layering in the
right
occipital [**Doctor Last Name 534**] and unchanged hemorrhage layering in the left
occipital [**Doctor Last Name 534**] of the lateral ventricles.

[**11-10**] Ct head - the mass effect on the fourth ventricle
appears to be slightly less. Postoperative changes again
identified with
hemorrhage in the left cerebellar hemisphere, pneumocephalus and
subarachnoid hemorrhage. Other findings as above including more
blood seen on the current study in the occipital [**Doctor Last Name 534**] of the
lateral ventricles.

[**11-11**] CXR - The ET tube tip is 5.5 cm above the carina. The right
internal jugular line tip is at the level of mid SVC.
Cardiomediastinal silhouette is unchanged.
There is interval improvement of left perihilar opacity but
still vascular
engorgement is present most likely consistent with mild volume
overload. No new consolidations are present. Minimal left basal
atelectasis is unchanged.

[**11-15**] CT Head

1. New bilateral subdural hygromas consistent with the clinical
history of
"over-shunting."
2. Overall unchanged extent of residual subarachnoid and
intraventricular
blood.

[**11-17**] CT Head

1. Interval increase of the mass effect in the posterior fossa
with now
complete effacement of the 4th ventricle and cerebral aqueduct
and concern for worsening ascending transtentorial herniation.
2. Similar or slightly decreased bifrontal subdural hygromas.
3. Unchanged ventricles

CT HEAD W/O CONTRAST [**2141-11-17**]
1. Interval increase of the mass effect in the posterior fossa
with now
complete effacement of the 4th ventricle and cerebral aqueduct
and concern for worsening ascending transtentorial herniation.
2. Similar or slightly decreased bifrontal subdural hygromas.
3. Unchanged ventricles.
4. Small foci of gelfoam material/ fat in the posterior fossa-
ucnhanged;
however, attention on followup. MRI can be considered if not
contra-indicated, when appropriate.

LE Dopplers [**2141-11-21**]:
DVT, with thrombus in the right peroneal and the left peroneal
and posterior tibial veins.

RUE Doppler: [**2141-11-22**]
FINDINGS:

The left and right subclavian veins demonstrate normal flow and
symmetric
waveforms. The right internal jugular, axillary, brachial,
basilic and
cephalic veins demonstrate normal compression, grayscale
appearance, color
flow and waveforms.

IMPRESSION:

No right upper extremity DVT.


[**2141-11-23**] CT maxilla / mandible
FINDINGS: The paranasal sinuses are normally aerated with no
mucosal
thickening or air-fluid levels. The ostiomeatal units are
patent. The
cribriform plates are intact. There is no nasal septal defect.
The lamina
papyracea is intact.

In terms of dentition, there is reabsorption around the root of
multiple
teeth, most significant in the right maxillary molar (#2). There
is also
reabsorption around the left maxillary canine and the right
maxillary
incisors. In particular, teeth #2, #7, #8, #9, #10, #11 are
affected by
reabsorption.

IMPRESSION:
1. Severe reabsorption around the root of the right second
maxillary molar.  Significant reabsorption around the root of
the left maxillary canine and right maxillary incisors.
2. Otherwise, unremarkable sinus CT.


[**2141-11-24**] LUE ULSTRASOUND
COMPARISON: Right arm ultrasound, [**2141-11-22**].

FINDINGS: Grayscale, color, and Doppler images were obtained of
the left IJ, subclavian, axillary, brachial, basilic, and
cephalic veins. Normal flow, compression, and augmentation is
seen in all of the vessels.

IMPRESSION: No evidence of deep vein thrombosis in the left arm.



[**2141-11-27**]  B/l LE U/S
FINDINGS:
There is normal grayscale appearance, compressibility,
waveforms, and response to augmentation in the left and right
common femoral, superficial femoral and popliteal veins.

LEFT CALF: One of the two posterior tibial veins on the left
demonstrates
echogenic clot and absent color flow consistent with thrombosis.
The left
peroneal vein is poorly visualized; however, there is no color
flow in the
expected location.

RIGHT CALF: Right posterior tibial veins demonstrate normal
color flow. The right peroneal vein demonstrates no color flow
consistent with deep venous thrombosis. There may be color flow
within the second peroneal vein which previously was thrombosed,
however, evaluation is limited by acoustic window.

IMPRESSION:
Essentially stable examination without propagation of known
bilateral calf
DVTs. DVT involves right peroneal, left peroneal and left
posterior tibial
veins.


CT HEAD W/O CONTRAST Study Date of [**2141-11-28**] 10:09 PM
IMPRESSION:
1. No acute hemorrhage.
2. Significant interval improvement in bihemispheric
subarachnoid and
intraventricular hemorrhage.
3. Ventricles are stable in size and configuration.
4. Moderate-sized extra-axial fluid collection in the posterior
fossa,
largely at or superficial to the suboccipital craniotomy site.
5. Post-surgical changes in the posterior fossa with persistent
mass effect.
.
.
Neurophysiology:
EEG Study Date of [**2141-11-8**]
IMPRESSION: This is an abnormal waking EEG because of slow alpha
rhythm
and bursts of frontal intermittent rhythmic delta activity.
These
findings are indicative of moderate diffuse cerebral
dysfunction. FIRDA
can be seen with increased intracerebral pressure, diffuse
hydrocephalus, and midline structural lesions and, less
commonly, with
brainstem dysfunction. In this case, the findings are likely
secondary
to increased intracranial pressure and/or hydrocephalus. These
results
were communicated to the neurology team at 6 p.m. on [**2141-11-8**].

EEG Study Date of [**2141-11-8**]
IMPRESSION: This telemetry captured no pushbutton activations.
The
background appeared to show wakefulness at the beginning and
then
encephalopathy later. The bursts of frontally predominant delta
slowing
(often called FIRDA, frontal intermittent rhythmic delta
activity)
lasted no more than a few seconds at a time. It indicates a
dysfunction
in midline structures, but it cannot be determined how severe
that
dysfunction is or what the etiology is from the tracing alone.
It can
come from raised pressure. There were no prominent focal
abnormalities,
but encephalopathies may obscure focal findings. The lower
voltage
record (and resolution of the tachycardia) in the middle of the
recording could represent more cortical dysfunction or more
likely,
sedating medication use, especially if the patient was agitated
and
received such medication. There were no clearly epileptiform
features
or electrographic seizures.

EEG Study Date of [**2141-11-9**]
IMPRESSION: Abnormal extended routine EEG due to a mildly slow
low
voltage background and due to the bursts of generalized slowing.
These
findings indicate a widespread encephalopathy. Medications,
metabolic
disturbances, and infection are among the most common causes.
Occasionally, the slowing or sharp features were more evident on
the
right side, but there was no dependably localized or focal
abnormality.
Encephalopathies may obscure focal findings. There were no
clearly
epileptiform features.
.
.
Pathology:
Cerebellar hematoma [**2141-11-9**]
H&E and trichrome stains show blood clot with minute fragments
of brain tissue containing vasculature with thickened vessel
walls, consistent with hypertensive changes. Beta-amyloid
immunolabelling is negative.
.
.
Cardiology:
ECG Study Date of [**2141-11-15**]  8:51:42 AM


Sinus arrhythmia. Moderate baseline artifact. Tendency toward
low voltage
in the standard leads. Compared to the previous tracing of
[**2141-11-12**] no
diagnostic interval change.


Read by: [**Last Name (LF) **],[**First Name3 (LF) 125**] M.

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
68 158 94 454/468 77 72 58

Brief Hospital Course:
65M with T2DM and schizophernia presented with sudden onset of
speech arrest and was assessed by neurology in the ED. Initial
CT head revealed no evidence of acute intracranial hemorrhage or
territorial infarction and he was treated with TPA for presumed
stroke and admitetd to the neuro ICU under neurology. Later in
the evening he was noted to have slurred speech and vomiting and
a STAT head CT at 0200 on [**2141-11-8**] showed a L cerebellar
hemorrhage with marked mass effect with effacement of the 4th
ventricle, but no definite evidence of obstructive hydrocephalus
and layering of blood in the lateral ventricles. Mannitol was
given and the decision was initially to treat with medical
therapy. On [**11-8**] AM his exam remained stable and a repeat Head
CT was stable. Overnight he was noted to be very agitated and
was sedated. On [**11-9**] he appeared more lethargic and was no
longer following commands. A repeat Head CT showed increase in
ventricle size. The patient was emergently taken to the OR for a
posterior fossa craniotomy for clot evacuation and right EVD
placement on [**2141-11-9**]. His post-op head CT remained stable with
expected post-op changes. His post-op exam remained unchanged
from pre-op. Mannitol was discontinued.

On POD1 [**11-10**] he was febrile and cultures were sent. He was also
seen to be tachycardic and was placed on a diltiazem gtt.
Additional staples were added to his incision. On [**11-11**], he was
extubated. Patient was seen have increased aggitation and was
given ativan and haldol in which he then became very sedated.
His SBP was also elevated. On [**11-12**], psych consult was called for
evaluation of aggitation and catatonic schizophrenia. They
recommended that we hold ativan and give haldol for aggitation.
His EVD was raised to 20cmH20. His exam was improved with some
speech and full strength.

On [**11-13**], patient was doing well. Some leakage from incision was
observed on patient's pillow. EVD was dropped to 10cmH20 as the
drainage may have been due to CSF leak.  His incision was
oversewn. On [**11-16**] his EVD was clamped in an attempt to wean. His
posterior surgical site began leaking clear fluid and his drain
was reopened and placed at 10cm above the tragus. He was taken
to the O.R on [**11-17**] for placement of R frontal VPS. He tolerated
this procedure well with no complications. Post operatively,
patient was sedated and intubated. Post op head CT was stable.
He was transferred to the step down unit for conitnued care. He
continued on with PT OT and ST evals.

On screening lower extremity ultrasounds on [**11-21**], the patient
was noted to have bilateral lower extremity DVTs. Upon
consulting with the vascular team it was recommended that we
repeat this study in [**6-17**] days and full anticoagulation for six
weeks which we started with enoxaparin as a bridge to Coumadin
on [**2141-11-22**]. Repeat doppler ultrasound was stable examination
without propagation of known bilateral calf  DVTs with DVT
involving the right peroneal, left peroneal and left posterior
tibial veins. INR on discharge was 1.7 and should be measured
regularly at rehab. Enoxaparin was stopped when the INR was >1.5
on [**11-30**] with a goal INR 1.5-2 given recent hemorrhage aiming at
the upper end of this range.

His front tooth was noted to be loose by ST. He was seen by
dental who recommended that he have all of his maxillary teeth
extracted.  In particular they felt that teeth #7 #8 were posing
an aspiration risk to the pt.  They recommended that oral
surgery pull the teeth.  OMFS was contact[**Name (NI) **] and they came to the
bedside and with gauze extraction, removed teeth #7 #8 on
[**2141-11-23**].  The pt tolerated this procedure well and was treated
with a week course of penicillin to finish on [**12-1**] and 2 weeks
of chlorhexadine oral rinse.

In the ICU he was noted to have possible sleep apnea and PCP
should consider sleep study to evaluate as an outpatient.

His PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was updated on his care. Patient will
be followed up by neurology and neurosurgery with repeat CT head
and patient will require dental follow-up regarding his teeth.

Transitional issues:
Patient was stable bilateral DVTs and enoxaparin was stopped on
[**11-30**]. He should aim for INR 1.5-2 given recent hemorrhage with
INR checks regularly at rehab.
Patient was treated with a week course of enicillin post dental
surgery to finish on [**12-1**].

Medications on Admission:
ASA 81mg chewable qd
Metformin 1000 mg [**Hospital1 **]
Lisinopril 10mg qd
Lantus 100 units/ml 42 units qd
Toprol XL 50mg q 24 hrs
Novasc 10mg qd


Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution Sig: [**2-12**]  PO Q6H (every
6 hours) as needed for pain.
2. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous once a day: At dinner.
3. insulin regular human 100 unit/mL Solution Sig: per sliding
scale per sliding scale Injection four times a day.
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) MG
PO BID (2 times a day): Hold for loose stools.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. penicillin V potassium 500 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) for 2 days: To finish on [**12-1**].
11. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day) for 8 days.
12. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day:
Please redose as appropriate daily based on INR.
13. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 86**]

Discharge Diagnosis:
Primary diagnoses:
Left cerebellar hemorrhage s/p TPA and s/p craniotomy and clot
evacuation and VP shunt
Bilateral deep vein thromboses
Dental extractions
.
Secondary diagnoses:
Possible sleep apnea
Schizophrenia
Type 2 diabetes


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mr [**Known lastname **],
You were seen in the hospital for inability to speak.  You were
given a clot [**Male First Name (un) 18701**] called alteplase (TPA) for a presumed
stroke.  Unfortunately, you had a complication from this and had
a bleed in your cerebellum (the base of your brain).  The bleed
rapidly incraesed in size and ended up necessitating an
operation to remove the blood.  You also had placement of a
ventriculoperitoneal shunt to decrease pressure as you had
exessive drainage from your wound.

During your stay you indicated that some of your upper front
teeth were loose.  You were seen by Dental and Oral maxilofacial
surgery who pulled two of your upper/front teeth for your safety
and were started on a 7 day course of antibiotics following this
and a chlorhexadine oral rinse for 14 days.

You were found to have blood clots in the veins of both of your
legs and you were started on a blood thinner called warfarin
which you will continue for likely 6 weeks. You were also
started on an additional blood thinner called enoxaprin until
your warfarin level was high enough. You will need to have
warfarin levels taken regularly at rehab.

You were agitated and risperidone was changed to olanzapine and
this dose was increased.

You were felt to have possible sleep apnea and your PCP [**Name9 (PRE) 97317**]
consider [**Name Initial (PRE) **] sleep study for evaluation as an outpatient.

You recovered well and were able to be sent to a rehab facility
to get stronger.

We made the following changes to your medications:
We STOPPED aspirin
We STOPPED metformin
We DECREASED lantus to 20 units at dinner
We INCREASED metoprolol to 50mg twice daily
We STARTED an insulin sliding scale
We STARTED laxatives
We STARTED penicillin V 500mg every 6 hours which you should
continue until [**12-1**] at night
We STARTED pantoprazole 40mg daily
We STARTED chlorhexadine rinse 15mg twice a day for 8 days
We STARTED warfarin 7.5mg daily and this dose should be adjusted
depending on INR
We STARTED olanzapine 5mg at night

Please continue to take your other medications as previously
prescribed.

It you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.

It was a pleasure taking care of you on this hospitalization.
Below you will find some general instructions on post-surgical
care:

General Instructions

??????	Check your incision daily for signs of infection.
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit.
??????	Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.

Followup Instructions:
Please have general follow-up with Dr [**First Name (STitle) **] in 4 weeks with a
Head CT w/o contrast. Please have rehab call [**Telephone/Fax (1) 4296**] to
make this appointment.

You will need to follow up with your dentist as you have several
teeth that our dental team felt you should have monitored and
that might need to be extracted.

You will need to follow up follow up with your PCP withing two
weeks of discharge to monitor and order your warfarin dosing and
also to re-evaluate the status of your DVTs and determine an end
date for anticoagulation. We recommended a total of 6 weeks.

You will also need a formal sleep study after you are discharged
- this can be arranged through your primary care physician.

YOU ALSO HAVE AN APPOINTMENT WITH THE NEUROLOGY TEAM / THEY WERE
TREATING YOU FOR YOUR STROKE

Department: NEUROLOGY
When: MONDAY [**2142-1-8**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 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
{'Cerebral artery occlusion, unspecified with cerebral infarction,Intracerebral hemorrhage,Cerebral edema,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Obstructive hydrocephalus,Delirium due to conditions classified elsewhere,Hyperosmolality and/or hypernatremia,Paralytic ileus,Paranoid type schizophrenia, chronic,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Other specified disorders of the teeth and supporting structures,Background diabetic retinopathy,Unspecified essential hypertension,Personal history of contact with and (suspected) exposure to asbestos,Physical restraints status'}


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: Aphasia

PRESENT ILLNESS: 65 y/o M who presented last night with two episodes of
aphasia. Patient went to see his PCP when he suddenly became
mute. He was immediately transferred to the ED where code stroke
was called. Patient's head CT showed no acute hemorrhage or
infarct. His risk factors were high for stroke and he was given
TPA at 6:30pm. His speech cleared after TPA was given.
Overnight,
his speech became slurred and n/v presented. He was taken for a
stat head CT which revealed a L cerebellar hemorrhage.

MEDICAL HISTORY: * HTN
* DM2
* Diabetic retinopathy OU
* Cystoid macular edema OS
* Supertemporal
* back injury
* hx of exposure to asbestos
* hx of excision of a Lipoma on posterior neck [**2126**]
* MRI [**2126**] of head and neck showed mild generalized atrophy
inconsistent with his age,nonspecific white matter densities
* Paranoid psychosis (recently untreated, but with multiple
prior hospitalizations)

MEDICATION ON ADMISSION: ASA 81mg chewable qd
Metformin 1000 mg [**Hospital1 **]
Lisinopril 10mg qd
Lantus 100 units/ml 42 units qd
Toprol XL 50mg q 24 hrs
Novasc 10mg qd

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:
PHYSICAL EXAM:
 BP:159/84         HR: 74        O2Sats:100%
General: Awake,alert at times, 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: Brother w/ h/o admission to a psychiatric hospital.

SOCIAL HISTORY: Born and raised in [**Location (un) 669**], [**Location (un) 686**] and [**Location (un) 2268**] and as of
[**2126**] he had been homelesss for 9 years. He reports that he now
lives in [**Location 669**] in his own apt alone. He is single has never
married and does not have any children. Hx of heavy use of ETOH
but stopped drinking many years ago. H/o past use of marijuana
and cocaine; none recently. Previous tobacco history. 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Intracerebral hemorrhage,Cerebral edema,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Obstructive hydrocephalus,Delirium due to conditions classified elsewhere,Hyperosmolality and/or hypernatremia,Paralytic ileus,Paranoid type schizophrenia, chronic,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Other specified disorders of the teeth and supporting structures,Background diabetic retinopathy,Unspecified essential hypertension,Personal history of contact with and (suspected) exposure to asbestos,Physical restraints status'}
