CHIEF COMPLAINT: Right sided weakness

PRESENT ILLNESS: HPI: [**Age over 90 **] year old Russian-speaking only woman with PMH HTN, DM,
dementia who was found on the floor at 11:30pm, non-verbal and
right sided weakness; found to have a L ICA and L MCA occlusion;
s/p IV tpa.

MEDICAL HISTORY: -HTN
-Alzheimer's dementia
-CAD

MEDICATION ON ADMISSION: -aspirin 81mg
-lorazepam 05mg Q6
-cholecalciferol
-glipizide 5mg
-HTCZ 12.5mg
-meclizine 25mg
-metoprolol 25mg
-nifedipine 60mg

ALLERGIES: Topamax / Ciprofloxacin

PHYSICAL EXAM: T-97.8 BP-138/44 HR-88 RR-20 97O2Sat
Gen: Lying in bed, non-verbal
HEENT: R subgalleal hematoma
Neck: C-collar
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient has dementia, she has lived at [**Hospital 100**] Rehab for the
past 4 years, she has needed increased care recently. At
baseline
she speaks Russian-only and is not oriented to time
Occlusion and stenosis of carotid artery with cerebral infarction,Subendocardial infarction, initial episode of care,Hemiplegia, unspecified, affecting dominant side,Urinary tract infection, site not specified,Aphasia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Coronary atherosclerosis of native coronary artery,Contusion of face, scalp, and neck except eye(s),Contusion of unspecified site,Unspecified fall
Ocl crtd art w infrct,Subendo infarct, initial,Unsp hemiplga domnt side,Urin tract infection NOS,Aphasia,Hypertension NOS,DMII wo cmp nt st uncntr,Alzheimer's disease,Dementia w/o behav dist,Crnry athrscl natve vssl,Contusion face/scalp/nck,Contusion NOS,Fall NOS
Admission Date:  [**2185-6-8**]              Discharge Date:   [**2185-6-10**]


Service: NEUROLOGY

Allergies:
Topamax / Ciprofloxacin

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Right sided weakness

Major Surgical or Invasive Procedure:
Administration of IV-tPa

History of Present Illness:
HPI: [**Age over 90 **] year old Russian-speaking only woman with PMH HTN, DM,
dementia who was found on the floor at 11:30pm, non-verbal and
right sided weakness; found to have a L ICA and L MCA occlusion;
s/p IV tpa.

Patient was last seen well at 11am, she has a diagnosis of
Alzheimer's disease (at baseline she speaks Russian only, not
oriented to time, needs care flor dressing; she lives in a
nursing home). At 11:30am she was found lying on the floor,
non-verbal, moving R side less and with a R facial weakness. Her
FS was 250 and BP 130/90. She was brought to [**Hospital1 18**] where BP
138/44 HR 88 RR 20 Sat 97%.
We called her son and confirmed that she has not had heart
attacks, history of brain hemorrhage, GI bleed or recent
surgeries. CTA showed proximal L MCA occlusion and L ICA
occlusion. As patient was within the time window for tpa, she
was
given a bolus 7.3mg at 1:54pm and she is undergoing an infusion
dose 65.5. We discussed the risks and benefits of intra-arterial
procedures with her son, who declined further procedures.

NIHSS: 20


Past Medical History:
-HTN
-Alzheimer's dementia
-CAD


Social History:
Patient has dementia, she has lived at [**Hospital 100**] Rehab for the
past 4 years, she has needed increased care recently. At
baseline
she speaks Russian-only and is not oriented to time

Family History:
NC

Physical Exam:
T-97.8 BP-138/44 HR-88 RR-20 97O2Sat
Gen: Lying in bed, non-verbal
HEENT: R subgalleal hematoma
Neck: C-collar
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema

Neurologic examination:
Mental status: Awake and alert, non-verbal, grimaces to noxious
stimuli. She does not follow any commands (not even with Russian
interepreter)


Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally; R facial weakness, no gaze preference, normal
doll's, tongue is midline

Motor:
She moves L side spontaneously; no spontaneous movement of R
side. She retracts R side on noxious stimuli.


Reflexes: B T Br Pa Pl
Right     2 1 2  2  0
Left      2 1 1  1  0
R upgoing toe


Coordination: unable to perform

Gait: unable to perform


Pertinent Results:
Admission Labs:

141 | 100 | 19
---------------< 199
3.8 |  25 | 1.0

CK: 128 CK-MB: 21 Trop: 0.28

      14.0
14.8 >-----< 330
      42.5

.
Imaging:
.
CT HEAD WITHOUT CONTRAST ([**2185-6-8**]):
There is no fracture or hemorrhage. There is a right frontal
subgaleal hematoma. The ventricles and sulci overall enlarged
consistent with parenchymal involutional change. There is also a
pattern of
small vessel ischemic change evidenced by periventricular white
matter
hypodensity. Although this is somewhat more prominent on the
left, there is no clear evidence of edema. There is no
hemorrhage. The visualized paranasal sinuses and soft tissues
appear unremarkable.
.
CTA HEAD AND NECK: The aortic arch demonstrates a normal
three-vessel
takeoff, but with significantly tortuous brachiocephalic
vasculature. There is a severe calcified and soft plaque of the
aortic arch. The vertebral arteries and common carotid arteries
are patent. However, there is a large amount of soft plaque and
calcified plaque at the left carotid bulb, and there is long
segment occlusion of the left ICA from its origin (3W:139). On
the right, there is carotid bulb calcified and soft plaque, and
the proximal right ICA measures 2 mm in its narrowest dimension
(3W:125), compared to 3.5 mm distally (3W:137) representing
approximately 40% stenosis.
.
There is reconstitution of the distal most supraclinoid left
ICA, with
retrograde flow from the A1 segment of the left ACA, which is
enlarged from collateral flow from the right circulation. The
anterior cerebral arteries are patent. However, the left MCA and
perisylvian branches are smaller in size and number than on the
right. The posterior circulation appears normal.
.
The right lobe of the thyroid gland is not visualized, and
tissue with thyroid density in appearance is seen in the right
paramedian anterior strap muscles, which may represent an
ectopic thyroid gland (3W:1A). There is expected degenerative
change, with somewhat exaggerated cervical lordosis and an
osteophyte posteriorly arising from C7 causing narrowing of the
canal (400B:31).
.
CT PERFUSION: Extensive left MCA territory increased mean
transit time and
decreased blood flow are seen. Although there is matched
distributionof
decreased cerebral blood volume, the degree of decreased blood
volume is not quite matched, especially in the temporal lobe
([**Numeric Identifier **]:30, 112).
.
IMPRESSION:
1. Largely completed left MCA territorial infarction, but
evidence of at-risk territory in the anterior left temporal
lobe.
2. Chronic-appearing long segmental left ICA occlusion from its
origin
through its supraclinoid portion; this may be a substrate for
so-called "stump embolus" syndrome.
3. Collateral flow in left anterior circulation but decreased
size of left
MCA, and size and number of its distal branches, especially in
the perisylvian region.
4. Incidentally noted likely ectopic and malrotated right lobe
of the thyroid gland.
.
CT Head without Contrast ([**6-9**]):
FINDINGS: Large area of increasing hypodensity is noted within
the left MCA territory, especially in the left basal ganglia and
insular ribbon, consistent with known left MCA territory
infarct. There is increased sulcal effacement of the left
frontal lobe, consistent with edema. However, there is no shift
of midline structures. The ventricles are stable in size and
configuration. There is no acute hemorrhage.
.
Since the previous study, the right frontal subgaleal hematoma
has markedly increased in size and extends inferiorly over the
right and left eyelid and laterally over the midline to the
left.
.
IMPRESSION:
1. Findings consistent with evolving left MCA infarct. No acute
hemorrhage.
2. Markedly enlarged frontal subgaleal hematoma, now extending
over to the
left and inferiorly over the eyelids bilaterally.
.
CXR ([**2185-6-8**]):
FINDINGS: Clips projecting over the left breast. Borderline size
of the
cardiac silhouette, no evidence of pleural effusions, no
pneumonia, no
pulmonary edema. No pneumothorax.


Brief Hospital Course:
Ms. [**Known firstname 103874**] [**Known lastname **] is a [**Age over 90 **] year old Russian-speaking only woman
with PMH HTN, DM, dementia who was found on the floor at
11:30pm, non-verbal and right sided weakness; found to have a
left internal carotid and left middle cerebral artery
occlusions.  She was admitted to the stroke service from [**2185-6-8**]
to [**2185-6-10**].
.
#Neuro: Given the significant ICA and MCA occlusions,
discussions were held with the patient's sons regarding the
risks and benefits of IV tPA, as well as possible intra-arterial
interventions.  The decision was made to attempt IV tPA, but
given her baseline dementia and overall prognosis, the family
declined any additional interventions beyond the therapy.  IV
tPA was given at 13:54, however she showed minimal improvement.
Futher discussion was held with the family on the following day,
and the decision was made to transition the goals of care from
cure to comfort.
.
#CV: On admission the patient was noted to have an elevated
troponin at 0.28, with TWIs in lateral leads.  It was unclear
whether this represented an NSTEMI.   Because of the risk of
hemorrhage from tPA, she was not started on anti-platelet
agents.  She was also noted to have significant episodes of
bradycardia, so was not started on a beta-blocker.
.
#ID: She was noted to have a UTI on admission.  She was
initially started on ciprofloxacin in the emergency department,
however developed erythema around the IV site.  She was then
switched to ceftriaxone to be continued through [**6-14**].
Antiobiotics were subsequently discontinued when the patient's
code status was changed to comfort measures only.
.
#FEN: On admission there was significant concern for aspiration,
so the patient was kept NPO.  Upon discussion with the family,
given her baseline dementia, and poor prognosis following the
stroke, the family opted to not place an NG tube or PEG.
.
# CODE STATUS:
As noted above, the team had discussions with both of the
patient's sons (one of whom is the health care proxy) regarding
the patient's wishes for goals of care.  In accordance with Ms.
[**Known lastname 103875**] wishes, her code status was transitioned to CMO.


Medications on Admission:
-aspirin 81mg
-lorazepam 05mg Q6
-cholecalciferol
-glipizide 5mg
-HTCZ 12.5mg
-meclizine 25mg
-metoprolol 25mg
-nifedipine 60mg


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]

Discharge Diagnosis:
- Stroke in the left middle cerebral artery territory in the
setting of a left internal artery occlusion
- NSTEMI
- Dementia


Discharge Condition:
Mental Staus: unresponsive to voice, touch.
Ambulatory Status: not assessed.


Discharge Instructions:
You were admitted to the [**Hospital1 18**] with inablity to speak and
right-sided weakness.  Neuroimaging revealed evidence of a large
stroke in the left middle cerebral artery territory in the
setting of a blocked left internal carotid artery.  A medicine
called t-Pa was administered with the hope of dissolving the
clots in the blood vessels.  Unfortunately, the [**Doctor Last Name 360**] had
minimal effect.  Given your baseline quality of life, and the
poor prognosis, goals of care were transitioned from cure to
comfort.


Followup Instructions:
* Please pursue comfort care.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
{"Occlusion and stenosis of carotid artery with cerebral infarction,Subendocardial infarction, initial episode of care,Hemiplegia, unspecified, affecting dominant side,Urinary tract infection, site not specified,Aphasia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Coronary atherosclerosis of native coronary artery,Contusion of face, scalp, and neck except eye(s),Contusion of unspecified site,Unspecified fall"}


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: Right sided weakness

PRESENT ILLNESS: HPI: [**Age over 90 **] year old Russian-speaking only woman with PMH HTN, DM,
dementia who was found on the floor at 11:30pm, non-verbal and
right sided weakness; found to have a L ICA and L MCA occlusion;
s/p IV tpa.

MEDICAL HISTORY: -HTN
-Alzheimer's dementia
-CAD

MEDICATION ON ADMISSION: -aspirin 81mg
-lorazepam 05mg Q6
-cholecalciferol
-glipizide 5mg
-HTCZ 12.5mg
-meclizine 25mg
-metoprolol 25mg
-nifedipine 60mg

ALLERGIES: Topamax / Ciprofloxacin

PHYSICAL EXAM: T-97.8 BP-138/44 HR-88 RR-20 97O2Sat
Gen: Lying in bed, non-verbal
HEENT: R subgalleal hematoma
Neck: C-collar
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient has dementia, she has lived at [**Hospital 100**] Rehab for the
past 4 years, she has needed increased care recently. At
baseline
she speaks Russian-only and is not oriented to time 

### Response:
{"Occlusion and stenosis of carotid artery with cerebral infarction,Subendocardial infarction, initial episode of care,Hemiplegia, unspecified, affecting dominant side,Urinary tract infection, site not specified,Aphasia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Coronary atherosclerosis of native coronary artery,Contusion of face, scalp, and neck except eye(s),Contusion of unspecified site,Unspecified fall"}
