CHIEF COMPLAINT: Consulted by ED for "ICH"

PRESENT ILLNESS: This is an 87 year-old woman with a history of HTN, AF with
pacer, who was found by her niece this AM on the floor of her
bathroom.  She was last known well Sunday evening, when her son
(who calls every night) spoke to her by phone.  He was unable to
reach her Monday evening and after failing to reach her this AM,
called his cousin to check in on her.  This cousin gained entry
into her appartment with the help of the local constabulary and
found Ms. [**Known lastname **] lying on her R. side, wedged between the toilet
and bathtub.  She was awake but non-verbal.  She moved her L.
arm with apparent full strength, L. leg with perhaps moderately
decreased strength, and did not move her R. side.  In her
niece's estimation she had been lying immobile for quite a while
-
perhaps > 24h.

MEDICAL HISTORY: - AFib with pacer, on coumadin
 - HTN
 - Breast CA, years ago, thought to be in remission

MEDICATION ON ADMISSION: Synthroid 50mg qDay
 Coumadin 5/7.5 alternanting qDay
 Digoxin 175 mcg qDay
 Lisinopril 5mg qDay
 Atenolol 100mg qDay
 KCl 20mg qDay
 HCTZ/CBRR 37.5/25 qDay
 Calcium/Vit D
 Multivitamin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: <<on admission:>>
- intubated and sedated, off Propofol x 20m:
VS: HR 82 RR 14  OS 100%  Riding vent, no spontaneous breaths
during ~10m eval.  BP upon arrival 121/85, progressively rising
with time off propofol, 161/84 at high.

FAMILY HISTORY: nc

SOCIAL HISTORY: The patient lives alone, and is retired.  She is functionally
independent and manages her own medical care and finances.  She
just returned from a solo trip to West Palm beach.
Cerebral artery occlusion, unspecified with cerebral infarction,Cerebral edema,Rhabdomyolysis,Hemiplegia, unspecified, affecting dominant side,Urinary tract infection, site not specified,Atrial fibrillation,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Unspecified essential hypertension,Personal history of malignant neoplasm of breast,Congestive heart failure, unspecified,Do not resuscitate status,Aphasia
Crbl art ocl NOS w infrc,Cerebral edema,Rhabdomyolysis,Unsp hemiplga domnt side,Urin tract infection NOS,Atrial fibrillation,Long-term use anticoagul,Status cardiac pacemaker,Hypertension NOS,Hx of breast malignancy,CHF NOS,Do not resusctate status,Aphasia
Admission Date:  [**2180-11-7**]              Discharge Date:   [**2180-11-16**]

Date of Birth:  [**2103-11-12**]             Sex:   F

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Consulted by ED for "ICH"

Major Surgical or Invasive Procedure:
none

History of Present Illness:
 This is an 87 year-old woman with a history of HTN, AF with
pacer, who was found by her niece this AM on the floor of her
bathroom.  She was last known well Sunday evening, when her son
(who calls every night) spoke to her by phone.  He was unable to
reach her Monday evening and after failing to reach her this AM,
called his cousin to check in on her.  This cousin gained entry
into her appartment with the help of the local constabulary and
found Ms. [**Known lastname **] lying on her R. side, wedged between the toilet
and bathtub.  She was awake but non-verbal.  She moved her L.
arm with apparent full strength, L. leg with perhaps moderately
decreased strength, and did not move her R. side.  In her
niece's estimation she had been lying immobile for quite a while
-
perhaps > 24h.

Ms. [**Known lastname **] was transported via EMS to [**Hospital 8641**] Hospital.  There her
CT head demonstrated a 1x3cm L. basal ganglia hemorrhage without
intraventricular or subarachnoid extension.  At [**Location (un) 8641**] she was
protecting her airway and maintaining consciousness.  However,
because of a hospital protocol mandating intuabation for
particular GCS scores, she was intubated, sedated, and
mediflight trasported to [**Hospital1 18**].

ROS: No known recent symptoms per family.

Past Medical History:
 - AFib with pacer, on coumadin
 - HTN
 - Breast CA, years ago, thought to be in remission


Social History:
The patient lives alone, and is retired.  She is functionally
independent and manages her own medical care and finances.  She
just returned from a solo trip to West Palm beach.

Family History:
nc

Physical Exam:
<<on admission:>>
- intubated and sedated, off Propofol x 20m:
VS: HR 82 RR 14  OS 100%  Riding vent, no spontaneous breaths
during ~10m eval.  BP upon arrival 121/85, progressively rising
with time off propofol, 161/84 at high.

General: 	
Appearance: Intubated and sedated, no spontaneous activity
Skin: Bruising in the R. axilla, R. calvarium, R. flank
HEENT: 	Intubated.  NCAT, MMM
Neck: 	Supple, No Thyromegaly, No LAD, No bruits
Chest: 	CTAB with good flow.	
CVS: 	RRR, Nl S1/S2. No M/G/R. No JVD.
Ext:	No CCE. DP 2+.

MS:
Gen: 	Non-responsive to voice.  Responds to sternal rub only
with
prolonged stim.  Withdraws to modest nailbed pressure in
bilateral toes, no asymmetry. Withdraws to strong L. nailbed
pressure, no response in R. hand.  With sternal rub she
localizes
with L. arm, no response on the R

CN:
I:  	Not tested.
II: 	Unable to test visual fields.  PERRL 2.5mm to 1.5mm, brisk.
No RAPD.
III,IV,VI No spontaneous eye movements, no aversive movements,
in
C-collar so can only do limited occulocephalic but that does
produce equal, slight lateral eye movement.	
V: 	Unable to assess.
VII: 	R. facial weakness, upper and lower - limited strength to
eye closure, limited grimace with nasal stim.
VIII: 	No response to shout or clap.
IX,X: 	Unable to assess
[**Doctor First Name 81**]: 	SCM and trapezii full.
XII: 	Unable to assess.

Motor: Normal bulk.  Increased tone in the R. hand.  Does not
support limbs against gravity.  Spontaneously grasps hand with
L.
hand, no response in R.  Withdraws bilateral limbs at least
against gravity

Reflex:	
  	[**Hospital1 **]	Tri	Bra	Pat	[**Doctor First Name **]	Toes
	C6	C7	C6	L4	S1	
R	1+	1	1+	-	-	up
L	2	1+	1+	-	-	up

[**Last Name (un) **]:  Responds to nailbed pressure in the bilateral toes, L.
hand, but not R. hand.  Responds to vigorous sternal rub.


Pertinent Results:
[**2180-11-7**] 02:52PM BLOOD WBC-17.2* RBC-4.76 Hgb-15.3 Hct-45.8
MCV-96 MCH-32.3* MCHC-33.5 RDW-13.8 Plt Ct-247
[**2180-11-16**] 06:40AM BLOOD WBC-8.9 RBC-3.70* Hgb-12.0 Hct-35.7*
MCV-97 MCH-32.5* MCHC-33.6 RDW-14.4 Plt Ct-210
[**2180-11-7**] 02:52PM BLOOD Neuts-91.4* Lymphs-4.0* Monos-3.7 Eos-0.3
Baso-0.5
[**2180-11-7**] 02:52PM BLOOD PT-26.4* PTT-25.8 INR(PT)-2.6*
[**2180-11-16**] 06:40AM BLOOD PT-14.6* PTT-25.1 INR(PT)-1.3*
[**2180-11-7**] 02:52PM BLOOD Glucose-130* UreaN-26* Creat-1.2* Na-143
K-4.4 Cl-106 HCO3-23 AnGap-18
[**2180-11-16**] 06:40AM BLOOD Glucose-86 UreaN-29* Creat-0.9 Na-140
K-3.9 Cl-105 HCO3-27 AnGap-12
[**2180-11-7**] 02:52PM BLOOD CK(CPK)-5055*
[**2180-11-7**] 07:44PM BLOOD CK(CPK)-3749*
[**2180-11-7**] 07:44PM BLOOD CK(CPK)-3613*
[**2180-11-8**] 03:02AM BLOOD CK(CPK)-2535*
[**2180-11-8**] 01:24PM BLOOD CK(CPK)-[**2141**]*
[**2180-11-9**] 02:26AM BLOOD CK(CPK)-1361*
[**2180-11-14**] 08:45AM BLOOD CK(CPK)-91
[**2180-11-7**] 02:52PM BLOOD cTropnT-<0.01
[**2180-11-7**] 07:44PM BLOOD CK-MB-33* MB Indx-0.9 cTropnT-<0.01
[**2180-11-7**] 07:44PM BLOOD CK-MB-33* MB Indx-0.9 cTropnT-<0.01
[**2180-11-7**] 07:44PM BLOOD Calcium-7.9* Phos-2.9 Mg-2.0
[**2180-11-16**] 06:40AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.1
[**2180-11-14**] 04:43PM BLOOD %HbA1c-6.4* eAG-137*
[**2180-11-9**] 02:26AM BLOOD Triglyc-133 HDL-42 CHOL/HD-3.4 LDLcalc-75

OSH CT C-spine:
IMPRESSION: No acute fracture or malalignment.
NCHCT on admission: (read as hemorrhagic infarct, but more
likely was hemorrhagic transformation of ischemic infacrt)
FINDINGS: There is a 3.2 x 1.1 cm focus of parenchymal
hemorrhage within the left basal ganglia, with surrounding
edema. There is mild mass effect on the adjacent lateral
ventricle. A second focus of parenchymal hemorrhage is seen in
the left occipital lobe which approximately measures 2.2 x 1.6
cm (2:15) with associated edema in a pattern suggesting
cytotoxic edema. There are additional areas of hypodensity in
the left occipital lobe, series 2 image 18, suggestive of acute
infarct. Overall, the findings as described are stable from the
outside hospital CT. There is a large right lateral scalp
subgaleal hematoma. No acute fracture is identified. The mastoid
air cells, the imaged paranasal sinuses are clear. Secretions
are seen in the nasopharynx. An endotracheal and nasogastric
tube are in place. There is coiling of the nasogastric tube in
the oropharynx.
  IMPRESSION:
1. Stable findings of left basal ganglia, and left occipital
parenchymal
hemorrhage with surrounding edema likely related to HTN and
hemorrhagic
infarction.
2. Right lateral scalp subgaleal hematoma.
3. Coiling of OGT in oropharynx. Please correlate clinically

CTA of the head and neck, [**11-8**]:
IMPRESSION:
1. Slightly increased size of the hyperdense hemorrhagic focus,
located
laterally within the left MCA infarct, without evidence of new
hemorrhagic
focus or active contrast extravasation ("spot sign") to suggest
impending
expansion.
2. Stable appearing left PCA infarct with internal hemorrhagic
conversion.
3. Left fetal PCA, which appears patent with increased distal
flow compared
to the right, possibly secondary to recruitment of flow to this
previously
ischemic territory.
4. Patent left MCA with M1 segment uniformly slightly reduced in
caliber
compared to the right but patent-appearing distal branches.
COMMENT: The overall appearance suggests embolism to the left
MCA and (fetal) PCA from a more central, perhaps cardiac source.
N.B. The cervical vessels were not included in this study. If
evaluation of the more proximal carotid and vertebral arteries
is clinically warranted, dedicated neck CTA is recommended.

ECG on admission:
Cardiology Report ECG Study Date of [**2180-11-7**]  2:50:46 PM
Atrial fibrillation. ST-T wave abnormalities are non-specific.
No previous tracing available for comparison.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 0 92 414/443 0 13 -29

Echo in ICU:
Conclusions
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thicknesses and cavity size are
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. The right
ventricular cavity is mildly dilated with borderline normal free
wall function. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. The mitral valve shows
characteristic rheumatic deformity. There is moderate thickening
of the mitral valve chordae. There is mild valvular mitral
stenosis (area 1.5-2.0cm2). Moderate (2+) mitral regurgitation
is seen. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Preserved left ventricular systolic function. Mildly
dilated right ventricle with borderline normal function. At
least moderate pulmonary hypertension. Moderate to severe
tricuspid regurgitation. Mild mitral stenosis which may be due
to rheumatic heart disease. Moderate mitral regurgitation.

Video swallow study [**11-14**]:
FINDINGS:
ORAL PHASE: Poor bolus control was demonstrated with delayed
swallowing.
Liquid barium material remained within the valleculae throughout
the oral
phase.
PHARYNGEAL PHASE: Intermittent aspiration was noted with liquid
administration. Moderate amount of penetration was also seen.
IMPRESSION:
1. Intermittent aspiration with liquids and penetration.
2. Moderate impairment during the oral phase, as demonstrated by
poor bolus control and delayed swallowing.


Brief Hospital Course:
76 yr RH WF with hx of a-fib on coumadin, htn was found down on
the floor with decreased mentation and right hemiplegia. She was
awake and arousable and followed simple commands. She had
bruises on her head, right shoulder/arm region and right
hip/lateral right upper leg. Brought to OSH. HCT showed
hypodensity and hyperdensity in left basal ganglia region. It
was first thought that she had a primrary hemorrhage. 10 mg of
Vit K was given and she was transferred to [**Hospital1 18**]. Here she
received 2 units of FFPs. Repeat imaging done. No further
increase in hemorrhage. However, evaluation of hCT by the
attending revealed that she has an ischemic stroke involving the
striatocpasular branches and some patchy lesions in the inferior
division of the MCA as well as the PCA. There was also a
hyperdense sign in the left MCA stem. Her examination in the
UNIT showed impairment in right gaze and dense right hemiparesis
with withdrawal to noxious stimuli in right arm and right foot.
She does have a right facial palsy too. Pupils are equal and
reactive. All brainstem reflexes present. She followed some
simple commands with her left hand. Multiple bruised areas on
her forehead, right shoulder/right arm, right hip. CT is most
consistent wiht an ischemic stroke with hemorrhagic
transformation. She probably has a fetal PCA which might explain
why she has a stroke in MCA and PCA at the same time. Multiple
emboli are possible as well. Hyperdense MCA stem suggests clot
in MCA stem. Her echocardiogram showed no evidence of
thrombosis. Her LDL was 75, total cholesterol was 144. Over the
next few days she became alert and would follow few simple
commands, still with global aphasia amd a dense right
hemiparesis. She was transferred to the floor. She was
re-started on coumadin on [**11-11**]. She started to take a puree
diet on [**11-15**].

Neuro: ischemic stroke involving the striatocpasular branches
and some patchy lesions in the inferior division of the MCA as
well as the PCA with hemorrhagic transformation. Re-started on
coumadin on [**11-11**]. Therapeutic INR goal [**12-22**]. No bridge is
necessary. Continue aspirin. Her LDL was 75, total cholesterol
was 144.

Card: atrial fibrillation; plan to anti-coagulate as above. HTN;
currently on lisinopril 10mg and atenolol 100mg; may titrate BP
medications. SBP should not be higher than 180; PRN hydralizine;
[**Last Name (un) **]

Pulm: no issues

Renal: no active issues

ID: no active issues

GI: currently on ground-solids/nectar-thick liq diet. Caloric
intake improved after d/c concurrent NGT feeds as anticipated.
Speech and Swallow consult service cleared the patient for d/c
on PO intake.

Proph: heparin SC until warfarin/INR therapeutic > 2.0


Medications on Admission:
 Synthroid 50mg qDay
 Coumadin 5/7.5 alternanting qDay
 Digoxin 175 mcg qDay
 Lisinopril 5mg qDay
 Atenolol 100mg qDay
 KCl 20mg qDay
 HCTZ/CBRR 37.5/25 qDay
 Calcium/Vit D
 Multivitamin

Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day) as needed for constipation.
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. warfarin 5 mg Tablet Sig: alternate 1.5 and 1.0 pills qod
(7.5/5.0 mg) Tablet PO DAILY (Daily).
8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): For DVT-ppx. Please discontinue
this medication once INR is >2.0.
9. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Primary diagnosis:
- Large Left-sided MCA+PCA-territory infarction (stroke) with
hemorrhagic conversion

Secondary diagnoses:
 - AFib with pacer, on coumadin
 - HTN
 - CHF
 - Breast CA, years ago, thought to be in remission


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted after you were found on the floor. You had a
stroke in two different areas of the left hemisphere of your
brain. You were in the ICU and then transferred to the floor.
After receiving food through [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube, you have been
able to eat a diet by mouth; this diet is specially formulated
to help you swallow without getting food into your lungs
(aspiration), which would cause an infection. You will need to
have close nutrition monitoring. You are being anti-coagulated
(taking a blood thinner called warfarin, aka Coumadin) because
you have atrial fibrillation and warfarin reduces your risk of a
stroke. The A/C was held initially because you had a little
bleeding into the stroke, but this was re-started to reduce the
chances of additional strokes in the future.

Followup Instructions:
1. With PCP

2. With [**Hospital 87680**] clinic: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD
Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2180-12-18**] 2:00


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

Completed by:[**2180-11-16**]
{'Cerebral artery occlusion, unspecified with cerebral infarction,Cerebral edema,Rhabdomyolysis,Hemiplegia, unspecified, affecting dominant side,Urinary tract infection, site not specified,Atrial fibrillation,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Unspecified essential hypertension,Personal history of malignant neoplasm of breast,Congestive heart failure, unspecified,Do not resuscitate status,Aphasia'}


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: Consulted by ED for "ICH"

PRESENT ILLNESS: This is an 87 year-old woman with a history of HTN, AF with
pacer, who was found by her niece this AM on the floor of her
bathroom.  She was last known well Sunday evening, when her son
(who calls every night) spoke to her by phone.  He was unable to
reach her Monday evening and after failing to reach her this AM,
called his cousin to check in on her.  This cousin gained entry
into her appartment with the help of the local constabulary and
found Ms. [**Known lastname **] lying on her R. side, wedged between the toilet
and bathtub.  She was awake but non-verbal.  She moved her L.
arm with apparent full strength, L. leg with perhaps moderately
decreased strength, and did not move her R. side.  In her
niece's estimation she had been lying immobile for quite a while
-
perhaps > 24h.

MEDICAL HISTORY: - AFib with pacer, on coumadin
 - HTN
 - Breast CA, years ago, thought to be in remission

MEDICATION ON ADMISSION: Synthroid 50mg qDay
 Coumadin 5/7.5 alternanting qDay
 Digoxin 175 mcg qDay
 Lisinopril 5mg qDay
 Atenolol 100mg qDay
 KCl 20mg qDay
 HCTZ/CBRR 37.5/25 qDay
 Calcium/Vit D
 Multivitamin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: <<on admission:>>
- intubated and sedated, off Propofol x 20m:
VS: HR 82 RR 14  OS 100%  Riding vent, no spontaneous breaths
during ~10m eval.  BP upon arrival 121/85, progressively rising
with time off propofol, 161/84 at high.

FAMILY HISTORY: nc

SOCIAL HISTORY: The patient lives alone, and is retired.  She is functionally
independent and manages her own medical care and finances.  She
just returned from a solo trip to West Palm beach. 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Cerebral edema,Rhabdomyolysis,Hemiplegia, unspecified, affecting dominant side,Urinary tract infection, site not specified,Atrial fibrillation,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Unspecified essential hypertension,Personal history of malignant neoplasm of breast,Congestive heart failure, unspecified,Do not resuscitate status,Aphasia'}
