CHIEF COMPLAINT: R arm, face, and leg weakness, and inability to speak

PRESENT ILLNESS: 79yo Cantonese-speaking woman with HTN, hyperlipidemia and
otherwise active and healthy who presented with acute onset of
right face, arm and leg weakness and global aphasia of known
onset at 6:30pm today while playing cards. Arrived at ER at
8:30pm drowsy with eyes closed, moving left limbs spontaneously
and no observed movement of right limbs to noxious stimuli.  She
was unresponsive to commands.
.
CT negative for acute bleed, ? hyperdense left MCA. Also showing
a calcified mass in the ventricle that was determined to be of
low bleeding risk by head of neuroradiology.
.
Pt without contraindications to tPA. Son consented and patient
received 6.8mg bolus, then drip of 61.2mg was started of
alteplase. Roughly 30min after infusion was started, pt was
noted to become bradycardic to 40s and repeat EKG showed IW MI.
Pt was intubated, as she was felt to have lost her gag reflex
and tPA was stopped.

MEDICAL HISTORY: HTN
Hyperlipidemia

MEDICATION ON ADMISSION: antihypertensive, antihyperlipidemia

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen Elderly woman drowsy in NAD
CV RRR
Pulm CTAb
Abd Benign
Ext no edema
.
Neuro
Mental status: Responds to voice by opening eyes and occasional
turn of head to the left. Spontaneously moving left limbs. No
spontaneous speech; unable to follow commands.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives independantly, family in the area
Cerebral artery occlusion, unspecified with cerebral infarction,Intracerebral hemorrhage,Unspecified essential hypertension,Pure hypercholesterolemia,Other chronic disease of tonsils and adenoids
Crbl art ocl NOS w infrc,Intracerebral hemorrhage,Hypertension NOS,Pure hypercholesterolem,Chr T & A dis NEC
Admission Date:  [**2102-7-30**]              Discharge Date:   [**2102-8-1**]

Date of Birth:  [**2022-9-29**]             Sex:   F

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
R arm, face, and leg weakness, and inability to speak

Major Surgical or Invasive Procedure:
tPA administration

History of Present Illness:
79yo Cantonese-speaking woman with HTN, hyperlipidemia and
otherwise active and healthy who presented with acute onset of
right face, arm and leg weakness and global aphasia of known
onset at 6:30pm today while playing cards. Arrived at ER at
8:30pm drowsy with eyes closed, moving left limbs spontaneously
and no observed movement of right limbs to noxious stimuli.  She
was unresponsive to commands.
.
CT negative for acute bleed, ? hyperdense left MCA. Also showing
a calcified mass in the ventricle that was determined to be of
low bleeding risk by head of neuroradiology.
.
Pt without contraindications to tPA. Son consented and patient
received 6.8mg bolus, then drip of 61.2mg was started of
alteplase. Roughly 30min after infusion was started, pt was
noted to become bradycardic to 40s and repeat EKG showed IW MI.
Pt was intubated, as she was felt to have lost her gag reflex
and tPA was stopped.


Past Medical History:
HTN
Hyperlipidemia

Social History:
Lives independantly, family in the area

Family History:
non-contributory

Physical Exam:
Gen Elderly woman drowsy in NAD
CV RRR
Pulm CTAb
Abd Benign
Ext no edema
.
Neuro
Mental status: Responds to voice by opening eyes and occasional
turn of head to the left. Spontaneously moving left limbs. No
spontaneous speech; unable to follow commands.

Motor: No movement to noxious stimuli on right side, spontaneous
movement of leg on left.

Sensory: no facial griamcing or other response to noxious
stimuli applied to the right side.  She withdraws left side to
stimulation.

Gait: unable to assess

Coordination: unable to assess on the right side.


Pertinent Results:
Admission Head CT:
FINDINGS:  No intracranial hemorrhage, mass effect, or shift of
normally
midline structures, or major vascular territorial infarct is
apparent.  There is slightly increased density in the left MCA.
If there is a clinical concern for a left MCA territory infarct
an MRI would be recommended.  There is a 1.2 x 1.7 cm calcified
lesion in the superior aspect of the right lateral ventricle.
The etiology of this could also be further evaluated with MRI.
Calcifications are seen within the basal ganglia bilaterally.
There also is a small punctate calcification in the right
temporal lobe and brainstem, which are likely vascular in
nature.  The bony structures are unremarkable.  The visualized
portions of the paranasal sinuses and mastoid air cells are well
aerated.  The surrounding soft tissue structures are
unremarkable.
.
IMPRESSION:
1.  No CT evidence of acute ischemia.
2.  Increased density in the left MCA.  If there is a clinical
concern for
left MCA territory infarct, an MRI would be recommended.
3.  Calcified lesion in the right lateral ventricle, which may
represent a
calcified A-V malformation, among other possibilities.  MRI
could help in
further workup.
.
NOTE ADDED AT ATTENDING REVIEW: Dr. [**Last Name (STitle) **] discussed this study
with Dr.
[**Last Name (STitle) **] at approximately 9 pm on [**2102-7-30**]. At that time, [**Doctor Last Name **]
offered the
following discussion: There are several intraventricular
calcifications, in addition to the mass near the foramen of
[**Last Name (un) 2044**]. The differential diagnosis included an intraventricular
neoplasm, such as a meninigioma, choroid plexus papilloma,
oligodendroglioma, neurocytoma or giant cell astrocytoma. Some
of these lesions arise from the choroid plexus, which is absent
in the frontal [**Doctor Last Name 534**]. Thus, if this is a choroid-origin lesion,
it may be pedunculated. There is also an abnormal calcification
extending inferiorly into the suprasellar cistern. Although a
craniopharyngioma may calcify and arise in the suprasellar
cistern, invagination into the frontal [**Doctor Last Name 534**] would be unusual.
The lesion does not appear to represent a neoplasm with a high
bleeding risk, such as a metastasis or malignant glioma. It does
not appear to be an arteriovenous malformation. MR [**First Name (Titles) **] [**Last Name (Titles) 15758**]
CT are much more sensitive than noncontrast CT for detecting
early ischemia or infarction, but there is no evidence of
hemorrhage. The slight increased density in the left MCA may
represent calcification or thrombus.
.
Repeat Head CT, [**7-30**], after tPA administration:
FINDINGS:  Compared to prior study two hours earlier, there is
now new right frontal subarachnoid hemorrhage.  There is no
significant associated mass effect or shift of normally midline
structures.  The ventricular system is stable in appearance.
Otherwise, there has been no significant short interval change.
.
IMPRESSION:  New right frontal subarachnoid hemorrhage.
.
NOTE ADDED AT ATTENDING REVIEW: There appears to be [**Last Name (un) 940**] of
[**Doctor Last Name 352**]/white
differentiation in the left MCA territory, suggesting early
infarction.
.
Head CT [**7-31**]:
FINDINGS:  Comparison is made to [**2102-7-30**].
.
There are multiple large intraparenchymal hematomas in the right
cerebral
hemisphere, the largest measuring approximately 6.7 x 5.4 cm.
These hematomas are causing extensive  right sided subfalcine,
uncal, transtentorial, and bilateral cerebellar tonsillar
herniations.
.
Hypodensity surrounding the hematomas were seen, consistent with
vasogenic
edema.
.
There is loss of the [**Doctor Last Name 352**]/white matter junction essentially
diffusely
throughout the brain, consistent with brain edema. There is a
suggestion of possible left middle cerebral artery territory
edema, which could indicate the clinically suspected evolving
infarct originally requiring treatment, but imaging of this
region is markedly limited by the marked generalized brain
edema, noted previously. A 1cm linear area of hyperdensity is
seen within the brain stem, which likely represents a Duret
hemorrhage. Some subarachnoid hemorrhage along the right
cerebral convexity surface is again noted.
.
No focal bony abnormalities are seen. The visualized orbits and
paranasal
sinuses are normal.
.
IMPRESSION:  Since [**2102-7-30**], new massive right cerebral
intraparenchymal
hematomas causing subfalcine, uncal, transtentorial, and
tonsillar herniation. Duret hemorrhage.


Brief Hospital Course:
The patient arrived to the ER within 3 hours of symptom onset.
The clinical presentation highly suggested that she had an acute
ischemic stroke of the left MCA territory and CT was showing
evidence for left MCA occlusion.  Given the additional findings
on CT, a discussion was held with the head of neuroradiology
prior to initiation of t-PA treatment.  Given a potentially
elevated risk from t-PA, the benefits versus risk of t-PA were
discussed with the patient's son who gave consent to proceed
with IV t-PA administered within three hours of symptom onset.
After tPA administration, the patient developed bradycardia and
respiratory distress, t-PA was discontinued and she was
intubated prior to admission to the SICU for further monitoring.
 A repeat head CT showed subarachnoid hemorraghe in the right
hemisphere without midline shift or parenchymal bleeding and
there was further evidence for left MCA territory ischemic
stroke.  The following morning, she had developed new neuro
findings concerning for brainstem damage (pinpoint, unreactive
pupils, mute reflexes, negative oculocephalic reflexes, cold
calorics, gag, and corneal reflexes) and the patient. was taken
for urgent head CT.  This showed evidence of known left MCA
infarction.  In the interim, the patient had also developed
massive R hemispheric hemorrhage with subfalcine, uncal,
transtentorial, and tonsillar herniation.  The situation was
discussed with the family including the patient's son from
[**State 3706**] who decided that they would like the patient to be
DNR/DNI.  She developed bradycardia, cardiac arrest and expired,
with family at the bedside.

Medications on Admission:
antihypertensive, antihyperlipidemia

Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
L MCA infarction
R hemispheric intracerebral hemorrhage with subfalcine, uncal,
transtentorial, and tonsillar herniation

Discharge Condition:
Expired

Discharge Instructions:
None

Followup Instructions:
None


Completed by:[**2102-8-2**]
{'Cerebral artery occlusion, unspecified with cerebral infarction,Intracerebral hemorrhage,Unspecified essential hypertension,Pure hypercholesterolemia,Other chronic disease of tonsils and adenoids'}


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: R arm, face, and leg weakness, and inability to speak

PRESENT ILLNESS: 79yo Cantonese-speaking woman with HTN, hyperlipidemia and
otherwise active and healthy who presented with acute onset of
right face, arm and leg weakness and global aphasia of known
onset at 6:30pm today while playing cards. Arrived at ER at
8:30pm drowsy with eyes closed, moving left limbs spontaneously
and no observed movement of right limbs to noxious stimuli.  She
was unresponsive to commands.
.
CT negative for acute bleed, ? hyperdense left MCA. Also showing
a calcified mass in the ventricle that was determined to be of
low bleeding risk by head of neuroradiology.
.
Pt without contraindications to tPA. Son consented and patient
received 6.8mg bolus, then drip of 61.2mg was started of
alteplase. Roughly 30min after infusion was started, pt was
noted to become bradycardic to 40s and repeat EKG showed IW MI.
Pt was intubated, as she was felt to have lost her gag reflex
and tPA was stopped.

MEDICAL HISTORY: HTN
Hyperlipidemia

MEDICATION ON ADMISSION: antihypertensive, antihyperlipidemia

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen Elderly woman drowsy in NAD
CV RRR
Pulm CTAb
Abd Benign
Ext no edema
.
Neuro
Mental status: Responds to voice by opening eyes and occasional
turn of head to the left. Spontaneously moving left limbs. No
spontaneous speech; unable to follow commands.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives independantly, family in the area 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Intracerebral hemorrhage,Unspecified essential hypertension,Pure hypercholesterolemia,Other chronic disease of tonsils and adenoids'}
