CHIEF COMPLAINT: unresponsive, ? seizure vs stroke

PRESENT ILLNESS: (on transfer to cardiology service)
Ms. [**Known lastname 110272**] is an 85-year-old female with a history of dementia,
hypertension who was found unresponsive on [**2192-3-15**] thought to be
due to seizure and has since been diagnosed with an acute
infarct in the right basal ganglia/insula and then devloped high
degree AV block after verapamil administration.

MEDICAL HISTORY: HTN
hx colon CA
family concerned for mild dementia signs
family reports "ablation" - although denies a-fib/flutter, PCP
unaware of this

MEDICATION ON ADMISSION: -amlodipine 5mg daily
-lisinopril 5mg daily
-verapamil 240mg daily
-tramadol
-advair

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At admission:
VS T: not measured HR: 83 BP: 150s/80s SaO2: 100% intubated
General: NAD, lying in bed comfortably. / Head: NC/AT, no
conjunctival icterus, no oropharyngeal lesions, no trauma /
Neck:
Supple, no nuchal rigidity, no meningismus / Cardiovascular:
RRR,
no M/R/G / Pulmonary: Equal air entry bilaterally though soft /
Abdomen: Soft, NT, ND, +BS, no guarding / Extremities: Warm /
Skin: No rashes or lesions

FAMILY HISTORY: no stroke/seizure

SOCIAL HISTORY: Smokes cigarettes - >100 pack year hx
No sig alcohol
Lives with her grandson who helps her with some ADLs
Cerebral embolism with cerebral infarction,Subendocardial infarction, initial episode of care,Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Atrial flutter,Unspecified essential hypertension,Hyperpotassemia,Chronic airway obstruction, not elsewhere classified,Do not resuscitate status,Tobacco use disorder,Atrioventricular block, unspecified,Coronary vasodilators causing adverse effects in therapeutic use
Crbl emblsm w infrct,Subendo infarct, initial,Ac/chr syst/dia hrt fail,Acute kidney failure NOS,Atrial flutter,Hypertension NOS,Hyperpotassemia,Chr airway obstruct NEC,Do not resusctate status,Tobacco use disorder,Atriovent block NOS,Adv eff coronary vasodil
Admission Date:  [**2192-3-16**]              Discharge Date:   [**2192-3-22**]

Date of Birth:  [**2106-9-30**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
unresponsive, ? seizure vs stroke


Major Surgical or Invasive Procedure:
intubated and extubated


History of Present Illness:
(on transfer to cardiology service)
Ms. [**Known lastname 110272**] is an 85-year-old female with a history of dementia,
hypertension who was found unresponsive on [**2192-3-15**] thought to be
due to seizure and has since been diagnosed with an acute
infarct in the right basal ganglia/insula and then devloped high
degree AV block after verapamil administration.

Please see admission note for full details. Briefly, she was
noted to be unresponsive with right leg movements on [**2192-3-15**] in
the evening. Initial blood pressure at at outside hospital was
200/120 mmHg, and she was intubated for airway protection. Head
CT showed no hemorrhage. She was transferred to [**Hospital1 18**], where MRI
brain showed an acute infarct in the right basal ganglia,
insula, and semiovale. She was started on aspirin 325mg daily
and atorvastatin 40mg daily. She was extubated over the weekend.


On [**3-19**], she was noted to have an episode of supraventricular
tachycardia at a rate of approximately 120 bpm (see below). She
was given 120mg PO verapamil. About 10 minutes later, she was
noted to have a junctional rhythm in the 50s. At 10:40 AM, about
30 minutes after this, she was noted to have three 7-second
pauses on telemetry; she was poorly responsive per the nursing
staff, and complained of chest pain. Her son notes that she
extended her arms as if she were sensing an electric shock. A
few minutes later, she had a noninvasive BP of 74/30 mmHg. She
then progressed toward a junctional rhythm in the 50s-60s. She
was given 2gm calcium gluconate to reverse the verapamil dosing.


On cardiac review of symptoms, she does not recall the details
of those events. She lives with her grandson, who does not
recall her having episodes of chest pain or tightness, dyspnea,
palpitations, or lightheadness or dizziness. All other ROS
negative.

Currently, patient feels well.  Denies sob, chest pain, abd
pain, light headedness.


Past Medical History:
HTN
hx colon CA
family concerned for mild dementia signs
family reports "ablation" - although denies a-fib/flutter, PCP
unaware of this


Social History:
Smokes cigarettes - >100 pack year hx
No sig alcohol
Lives with her grandson who helps her with some ADLs

Family History:
no stroke/seizure

Physical Exam:
At admission:
VS T: not measured HR: 83 BP: 150s/80s SaO2: 100% intubated
General: NAD, lying in bed comfortably. / Head: NC/AT, no
conjunctival icterus, no oropharyngeal lesions, no trauma /
Neck:
Supple, no nuchal rigidity, no meningismus / Cardiovascular:
RRR,
no M/R/G / Pulmonary: Equal air entry bilaterally though soft /
Abdomen: Soft, NT, ND, +BS, no guarding / Extremities: Warm /
Skin: No rashes or lesions

Neurologic Examination: 30 minutes off Propofol

- Mental Status - No arousal to voice, but spontaneously turning
head (non-rhythmically) spontaneously. Does not follow commands.
Intubated.

- Cranial Nerves - [II] PERRL 1.5->1 brisk. Resists eye opening
but does not appear to have consistent blink to threat. [III,
IV,
VI] No OCRs. [V] Grimaces to brow noxious stimulus. [VII]
Furrows
brows to pressure. [IX, X] Palate elevation symmetric. [[**Doctor First Name 81**]] Gag
present. [XII] Cough present.

- Motor - Withdraws all four extremities and furrows brow
bilaterally, but LUE withdrawal is less brisk and does not
sustain antigravity as does the other three limbs.

- Sensory - Withdrawal to noxious all four extremities and
grimace to eyebrow pressure bilaterally.

- Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2      2      2      2        1
R 2      2      2      2        1
Plantar response extensor bilaterally.

- Coordination - Unable to assess at the time of examination.

- Gait - Unable to assess at the time of examination.

At transfer out of Neuro ICU to Cardiology EP service:
Pt awake, alert, oriented to [**12-30**]. LUE weakness ([**3-1**] in
deltoid/ECR/finger extensors). No other clear deficits.
Physical Exam on Discharge:
Vitals: T 98 HR 76-108  BP 98-127/54-72 RR 20 O2 94 on 2L
tele: avg 105, up to 140s with walking
Gen: NAD, awake, alert
HEENT: No conjunctival pallor. No icterus
NECK: Supple, No LAD. JVP not elevated
CV: PMI in 5th intercostal space, mid clavicular line. regular
rhythm, no m/r/g
LUNGS: ctab
ABD: NABS. Soft, NT, ND. No HSM
EXT: no edema. Full distal pulses bilaterally
NEURO: A&Ox2, strength 5/5 in RUE, [**3-1**] in LUE, [**3-31**] in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/l
PSYCH: Mood was appropriate

Pertinent Results:
Labs:
[**2192-3-16**] 12:43AM BLOOD WBC-9.4 RBC-4.28 Hgb-13.9 Hct-43.5
MCV-102* MCH-32.4* MCHC-31.9 RDW-14.2 Plt Ct-161
[**2192-3-16**] 12:43AM BLOOD PT-11.7 PTT-27.4 INR(PT)-1.1
[**2192-3-16**] 12:43AM BLOOD Plt Ct-161
[**2192-3-16**] 12:43AM BLOOD Fibrino-277
[**2192-3-16**] 10:56AM BLOOD Glucose-109* UreaN-17 Creat-0.6 Na-140
K-3.9 Cl-107 HCO3-22 AnGap-15
[**2192-3-19**] 11:00AM BLOOD Glucose-207* UreaN-13 Creat-0.7 Na-143
K-5.5* Cl-110* HCO3-17* AnGap-22*
[**2192-3-20**] 04:03AM BLOOD Glucose-116* UreaN-12 Creat-0.5 Na-142
K-3.4 Cl-107 HCO3-20* AnGap-18
[**2192-3-16**] 12:43AM BLOOD ALT-18 AST-32 AlkPhos-56 TotBili-0.6
[**2192-3-16**] 10:56AM BLOOD CK(CPK)-612*
[**2192-3-16**] 04:17PM BLOOD CK(CPK)-358*
[**2192-3-19**] 11:00AM BLOOD CK(CPK)-239*
[**2192-3-19**] 02:07PM BLOOD CK(CPK)-163
[**2192-3-19**] 10:01PM BLOOD CK(CPK)-139
[**2192-3-20**] 04:03AM BLOOD CK(CPK)-145
[**2192-3-16**] 12:43AM BLOOD cTropnT-0.09*
[**2192-3-16**] 10:56AM BLOOD CK-MB-12* MB Indx-2.0 cTropnT-0.20*
[**2192-3-16**] 04:17PM BLOOD CK-MB-8 cTropnT-0.08*
[**2192-3-17**] 04:04AM BLOOD cTropnT-0.10*
[**2192-3-19**] 11:00AM BLOOD CK-MB-7
[**2192-3-19**] 11:00AM BLOOD cTropnT-0.02*
[**2192-3-19**] 02:07PM BLOOD CK-MB-6 cTropnT-0.02*
[**2192-3-20**] 04:03AM BLOOD CK-MB-6
[**2192-3-16**] 12:43AM BLOOD Albumin-4.4
[**2192-3-16**] 10:56AM BLOOD Calcium-8.1* Phos-1.9* Mg-2.0
[**2192-3-17**] 04:04AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.1 Cholest-163
[**2192-3-16**] 10:56AM BLOOD %HbA1c-5.7 eAG-117
[**2192-3-17**] 04:04AM BLOOD Triglyc-93 HDL-61 CHOL/HD-2.7 LDLcalc-83
[**2192-3-19**] 02:07PM BLOOD Osmolal-299
[**2192-3-16**] 10:56AM BLOOD TSH-0.48
[**2192-3-16**] 10:56AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2192-3-16**] 01:44AM BLOOD Type-ART Temp-36.3 Rates-18/ Tidal V-450
PEEP-5 FiO2-50 pO2-242* pCO2-40 pH-7.42 calTCO2-27 Base XS-1
Intubat-INTUBATED Vent-CONTROLLED
[**2192-3-19**] 08:46AM BLOOD Type-ART pO2-172* pCO2-29* pH-7.46*
calTCO2-21 Base XS--1
[**2192-3-19**] 12:22PM BLOOD Type-ART pO2-107* pCO2-26* pH-7.45
calTCO2-19* Base XS--3
[**2192-3-19**] 02:13PM BLOOD Type-ART pO2-79* pCO2-30* pH-7.40
calTCO2-19* Base XS--4
[**2192-3-16**] 12:48AM BLOOD Glucose-133* Lactate-1.6 Na-139 K-3.7
Cl-103 calHCO3-25
[**2192-3-19**] 12:22PM BLOOD Glucose-221* Lactate-1.8 Na-135 K-5.2*
Cl-115*
[**2192-3-19**] 02:13PM BLOOD Lactate-1.7
[**2192-3-16**] 12:45AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2192-3-16**] 12:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2192-3-17**] 01:19AM URINE RBC-13* WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
[**2192-3-19**] 12:16PM URINE Hours-RANDOM UreaN-319 Creat-111 Na-17
K-GREATER TH Cl-66 Calcium-3.9 Phos-268.0 Mg-4.4 HCO3-LESS THAN
[**2192-3-17**] 01:19AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2192-3-17**] 01:19AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017

Labs on Discharge:

[**2192-3-22**] 05:00AM BLOOD WBC-10.6 RBC-3.36* Hgb-10.9* Hct-33.8*
MCV-101* MCH-32.4* MCHC-32.2 RDW-14.1 Plt Ct-189
[**2192-3-22**] 05:00AM BLOOD PT-26.0* PTT-70.8* INR(PT)-2.5*
[**2192-3-22**] 05:00AM BLOOD Glucose-124* UreaN-35* Creat-0.6 Na-141
K-3.7 Cl-106 HCO3-25 AnGap-14

Microbiology:

[**2192-3-17**] 4:52 am SPUTUM      Source: Endotracheal.

   GRAM STAIN (Final [**2192-3-17**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CHAINS.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE ROD(S).

   RESPIRATORY CULTURE (Preliminary):
      MODERATE GROWTH Commensal Respiratory Flora.
      STREPTOCOCCUS PNEUMONIAE.    MODERATE GROWTH.

Blood Cx x 2 - no growth
Urine Cx - no growth

Imgaging/studies:

Routine EEG:
FINDINGS:
ABNORMALITY #1: With activation procedures (calling the
patient's name
out loud, performing a sternal rub) background activity was seen
to be
in the [**8-6**] Hz alpha frequency range, though it was not
well-organized.
ABNORMALITY #2: When the patient appeared to be resting (eyes
closed,
not responsive to vocal commands,) background activity was
somewhat
slower, in the [**7-5**] Hz alpha frequency range with interspersed, 1
second
bursts of beta frequency spindles.
BACKGROUND: As above.
HYPERVENTILATION: Could not be performed as the patient was
unable to
cooperate.
INTERMITTENT PHOTIC STIMULATION: Was not performed as the test
was
requested as a portable study.
SLEEP: There appeared to be two distinctive EEG patterns seen as

described above; however, neither appeared consistent with
normal sleep
patterns.
CARDIAC MONITOR: Revealed a generally regular rhythm with
average rate
of 72 bpm.
IMPRESSION: This EEG was without focal findings or epileptiform
activity. Two distinct patterns were seen, one associated with a
more
wakeful state and one associated with a less wakeful state. Both

demonstrate poor organization suggesting a mild encephalopathy
or
widespread areas of subcortical dysfunction. The presence of
spindles
in the less wakeful state may also be consistent with lingering
evidence
of sedatives such as barbiturates or benzodiazepines.

[**2192-3-16**] ECG:
Sinus rhythm. Left atrial abnormality. Possible remote
anteroseptal
myocardial infarction. No previous tracing available for
comparison.
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 160 88 444/463 81 -46 62

[**2192-3-16**] ECG:
Sinus rhythm bordering on sinus tachycardia. Probable biatrial
enlargement. Anteroseptal wall myocardial infarction, age
indeterminate. Left axis deviation consistent with left anterior
fascicular block. Non-specific inferior and anterolateral ST-T
wave changes. Compared to the previous tracing of [**2192-2-27**] the
rate is faster. Otherwise, no diagnostic interim change.
TRACING #1
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
97 134 84 358/422 81 -47 50

[**2192-3-19**] ECG:
Sinus rhythm with atrial premature beats. Compared with tracing
#1 previously
described abnormalities persist and P wave morphology has
changed. The rate is
also slower.
TRACING #2
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 132 90 406/441 66 -44 -29


CXR:
PORTABLE AP CHEST RADIOGRAPH: ET tube is approximately at the
carina just
proximal to the right mainstem bronchus and should be
repositioned.
Nasogastric tube passes below the diaphragm with side port
within the expected region of the stomach and tip not visualized
in the field of view provided. The cardiac, mediastinal and
hilar contours are unremarkable. Both lungs are clear with no
focal consolidation, pleural effusion or pneumothorax. Findings
were discussed with Dr. [**Last Name (STitle) 13162**] at 2:32 a.m. on [**2192-3-16**] via
telephone.

CTA Head and Neck:
IMPRESSION:

1. Sequela of small vessel ischemic disease as well as low
attenuation in the
left aspect of the pons that may be another manifestation of
small vessel
ischemia or represents a chronic infarct.

2. Marked paucity of branches within the right MCA candelanbra
which may
represent acute or chronic atheroembolic insult.

3. ETT at the level of the carina, just at the entrance of the
right main stem
bronchus (this was already communicated by the wet [**Location (un) 1131**]
resident
radiologist).

MRI brain with and without contrast:
IMPRESSION:
1. Restricted diffusion is identified on the right insular
region and right
basal ganglia as described in detail above, likely consistent
with
acute/subacute ischemic changes, with no evidence of hemorrhagic

transformation.

2. Confluent areas of high signal intensity noted on T2 and
FLAIR,
distributed in the subcortical white matter, both centrum
semiovale and in the
pons, representing small vessel disease/microangiopathic
changes.

3. Mild enhancement is noted in the right basal ganglia,
suggesting
hypeperfusion.

TTE:
Conclusions
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). A secundum
type atrial septal defect is suggested on color Doppler (clips
44, 81) but was not confirmed by intravenous saline injection at
rest. Left ventricular wall thicknesses and cavity size are
normal. There is moderate regional left ventricular systolic
dysfunction with severe hypo/akinesis of the septum and anterior
walls. The remaining segments contract normally (LVEF = 40 %).
No masses or thrombi are seen in the left ventricle. 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. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is a
very small pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD (LAD distribution). Mild mitral
regurgitation. Pulmonary artery hypertension. Possible small
secundum atrial septal defect.

Chest x-ray [**3-20**]:
A new left PICC ends in the mid SVC. No pneumothorax. Prominence

of the pulmonary vasculature remains. Left sided opacity again
concerning for PNA. Otherwise, unchanged examination from the
prior.




Brief Hospital Course:
85yoW h/o HTN and dementia p/w being found down on floor with
some movement of R leg concerning for seizure activity.
Neurological exam shows pt is now . CTA at admission showed no
major stenoses. MRI brain shows acute infarct in the right basal
ganglia/insula/semiovale. Hospital course complicated by cardiac
arrhythmia, electrolyte abnormalities, and brief concern for
oligouric acute renal failure.

# Right Basal ganglia stroke: found down with acute right right
basal ganglia/insula/semiovale stroke, etiology suspected to be
cardioembolic. Resultant deficit primarily limited to LUE
weakness. On admission started full strength aspirin and
atorvastatin 40, however heparin gtt started after cardiac
events and atrial fib/sick sinus syndrome [**3-19**]. Decreased
aspirin to 81mg for cardiac protection per discussion with
cardiology. From neurological perspective, anticoagulation alone
is sufficient for stroke ppx.   HgbA1c 5.7%, LDL 83, TTE shows
no ASD/PFO or thrombus but does show EF 40% with akinetic
septum/anterior walls.   On discharge, INR was therapeutic at
2.5 and heparin drip was stopped.  Patient will f/u with Dr.
[**First Name (STitle) **] in stroke clinic as scheduled. Patient was evaluated by
speech and swallow on day of d/c who recommended ground solids
and nectar thick liquid diet.  There was some concern for an
opacity on chest x-ray on [**3-20**], however, no leukocytosis,
afebrile, not coughing so no clinical concern for infection [**12-29**]
aspiration.  Should be re-evaluated by speech and swallow in
rehab.

# High grade AV block: Patient had 3 8second pauseas shortly
after administration of verapamil for tachycardia in the 130s.
At this time, blood pressure dropped and pt complained of chest
pain and was less responsive.  Initially, considered for
pacemaker placement.  However, after discontinuation of
verapamil, did not have any repeat pauses.  So, pacemaker was
deferred per discussion by EP with family and patient.  Should
AVOID Verapamil, but patient tolerating home dose amlodipine.

# Afib: New onset afib during the admission. Patient initially
was quite tachycardic to 140s.  She was started on metoprolol
12.5mg [**Hospital1 **] and tolerated this well so transitioned to metoprolol
XL 25mg daily.  Permissive heart rate monitoring to 120s.
Patient was bridged with heparin drip to coumadin and INR was
therapeutic at 2.5 on d/c.  Will f/u with cardiology as
scheduled.

# NSTEMI: Patient had trop leak during admission adn TTE with
evidence of anterior and septal wall motion abnormalities,
which, along with the delayed R wave progression on EKG,
suggests that she has had a myocardial infarction. Since she is
not symptomatic with exertion, and because she may not be a
candidate for surgical or even percutaneous revascularization
based on her goals of care, she does not require further risk
stratification or work-up for coronary artery disease.  Started
aspirin 81, atorvastatin 40mg as above per cardiology
recommendations while patient was on neurology service.

# HTN: Continued home amlodipine, lisinopril.  Held all calcium
channel blockers.

# Dementia: Patient's family concerned about dementia.  Will w/u
as outpatient with neurology.

# [**Last Name (un) **]: oligouric renal failure [**3-19**] with electrolyte
abnormalities.  Renal consulted, suspect pre-renal. UOP picked
up after IVF boluses. Hyperkalemia was likely due to unexpected
robust response from K replacement.  Cr decreased to baseline
0.5

TRANSITIONS OF CARE:
-please check INR on [**3-24**], goal [**12-30**]
-will f/u with Dr. [**First Name (STitle) **] in stroke clinic
-please f/u with Dr. [**First Name (STitle) **] in cardiology clinic
-patient will need to be re-evaluated by speech and swallow for
aspiration

Medications on Admission:
-amlodipine 5mg daily
-lisinopril 5mg daily
-verapamil 240mg daily
-tramadol
-advair

Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
7. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Primary:
Right basal ganglia stroke
Non-ST Elevation Myocardial Infarction
Atrial fibrillation

Secondary:
Hypertension


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Ms. [**Known lastname 110272**],

You were admitted to the hospital because of an episode of being
unresponsive.  An MRI of your brain showed that you had a
stroke.  During the admission, your heart rate started beating
very fast and irregularly (atrial fibrillation).  You received a
medicine to slow down your heart rate and that caused your heart
to beat too slowly.  Without any medicines, you continued to be
in atrial fibrillation.  We started you on a different medicine
called metoprolol to control your heart rate which worked well.
In addition to that, we also started you on a blood thinner
called Coumadin to prevent strokes in the future.

During the admission, you also had a small heart attack based on
blood work and an ultrasound of your heart.  To prevent future
heart attacks, we started you on aspirin and atorvastatin (for
cholesterol lowering effects).

The rehab doctor [**First Name (Titles) **] [**Last Name (Titles) 4656**] you, but you will also need to
follow up with cardiology and neurology (for stroke) as
scheduled below.

We have made the following changes to your medications:
-STOP Verapamil (do not EVER take this medicine again, as it
caused your heart to stop for 8 seconds)
-START Coumadin 3mg daily (goal INR [**12-30**])
-START Aspirin 81mg daily
-START Metoprolol XL 25mg daily (for heart rate control)
-START Atorvastatin 40mg daily (for cholesterol)
-START Nicotine patch

Please follow up with cardiology and neurology as scheduled
below.

It was a pleasure taking care of you, we wish you all the best!

Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2192-4-19**] at 11:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: NEUROLOGY
When: MONDAY [**2192-5-21**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]

Completed by:[**2192-3-22**]
{'Cerebral embolism with cerebral infarction,Subendocardial infarction, initial episode of care,Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Atrial flutter,Unspecified essential hypertension,Hyperpotassemia,Chronic airway obstruction, not elsewhere classified,Do not resuscitate status,Tobacco use disorder,Atrioventricular block, unspecified,Coronary vasodilators causing adverse effects in therapeutic use'}


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: unresponsive, ? seizure vs stroke

PRESENT ILLNESS: (on transfer to cardiology service)
Ms. [**Known lastname 110272**] is an 85-year-old female with a history of dementia,
hypertension who was found unresponsive on [**2192-3-15**] thought to be
due to seizure and has since been diagnosed with an acute
infarct in the right basal ganglia/insula and then devloped high
degree AV block after verapamil administration.

MEDICAL HISTORY: HTN
hx colon CA
family concerned for mild dementia signs
family reports "ablation" - although denies a-fib/flutter, PCP
unaware of this

MEDICATION ON ADMISSION: -amlodipine 5mg daily
-lisinopril 5mg daily
-verapamil 240mg daily
-tramadol
-advair

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At admission:
VS T: not measured HR: 83 BP: 150s/80s SaO2: 100% intubated
General: NAD, lying in bed comfortably. / Head: NC/AT, no
conjunctival icterus, no oropharyngeal lesions, no trauma /
Neck:
Supple, no nuchal rigidity, no meningismus / Cardiovascular:
RRR,
no M/R/G / Pulmonary: Equal air entry bilaterally though soft /
Abdomen: Soft, NT, ND, +BS, no guarding / Extremities: Warm /
Skin: No rashes or lesions

FAMILY HISTORY: no stroke/seizure

SOCIAL HISTORY: Smokes cigarettes - >100 pack year hx
No sig alcohol
Lives with her grandson who helps her with some ADLs 

### Response:
{'Cerebral embolism with cerebral infarction,Subendocardial infarction, initial episode of care,Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Atrial flutter,Unspecified essential hypertension,Hyperpotassemia,Chronic airway obstruction, not elsewhere classified,Do not resuscitate status,Tobacco use disorder,Atrioventricular block, unspecified,Coronary vasodilators causing adverse effects in therapeutic use'}
