CHIEF COMPLAINT: hemiparesis and aphasia following angiography

PRESENT ILLNESS: The patient is a 75 year-old female who presented for elective
cerebral angiography for evaluation of dural arteriovenous
malformation.  Shortly after the procedure was begun, it was
noted that the she became mute, she was not following commands,
and she was plegic on the right arm and leg  The stroke team was
called to evaluate the patient.  Her initial NIHSS was 19.
Cerebral angiography revealed an occlusion of the M1 segment of
the left MCA.  After  consent was obtained from her husband,
[**Name (NI) **]-arterial t-PA was injected into the occluded artery.  She
developed respiratory distress and was intubated for a short
period of time.  Reportedly, her respiratory status improved and
she was quickly extubated.  In addition, she was noted to be
moving all extremities prior to transfer to the ICU.

MEDICAL HISTORY: -history of SAH and SDH after falling and hitting her
head([**6-11**]), at which time the question of a possible dural AVM
was discovered on imaging.  The etiology of the SAH was unclear.
-Hypertension
-Zoster L leg and foot, now with postherpetic neuralgia
-Chronic low back pain

MEDICATION ON ADMISSION: -metoprolol 25mg po bid

ALLERGIES: Benzodiazepines

PHYSICAL EXAM: Upon transfer from angio to the ICU:
.
Vitals: T: 98.5F P: 80 R: 16 BP: 143/86  SaO2: 98% RA
General: Lethargic, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
OP
Neck: supple, no JVD or carotid bruits. 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.
Extremities: No C/C/E bilaterally, 1+ radial, DP and PT pulses
b/l.
Skin: no rashes or lesions noted.

FAMILY HISTORY: -hypertension and diabetes mellitus (father).

SOCIAL HISTORY: -she lives at home with husband. Former yoga teacher.
-remote history of smoking (1 pack per week for 5 years).
-two to three glasses of wine per week.
-no drugs.
Iatrogenic cerebrovascular infarction or hemorrhage,Anomalies of cerebrovascular system,Anemia, unspecified,Unspecified essential hypertension,Encephalopathy, unspecified
Iatrogen CV infarc/hmrhg,Cerebrovascular anomaly,Anemia NOS,Hypertension NOS,Encephalopathy NOS
Admission Date:  [**2197-8-9**]              Discharge Date:   [**2197-8-14**]

Date of Birth:  [**2122-7-28**]             Sex:   F

Service: NEUROLOGY

Allergies:
Benzodiazepines

Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
hemiparesis and aphasia following angiography

Major Surgical or Invasive Procedure:
Angiography for dural AVM.


History of Present Illness:
The patient is a 75 year-old female who presented for elective
cerebral angiography for evaluation of dural arteriovenous
malformation.  Shortly after the procedure was begun, it was
noted that the she became mute, she was not following commands,
and she was plegic on the right arm and leg  The stroke team was
called to evaluate the patient.  Her initial NIHSS was 19.
Cerebral angiography revealed an occlusion of the M1 segment of
the left MCA.  After  consent was obtained from her husband,
[**Name (NI) **]-arterial t-PA was injected into the occluded artery.  She
developed respiratory distress and was intubated for a short
period of time.  Reportedly, her respiratory status improved and
she was quickly extubated.  In addition, she was noted to be
moving all extremities prior to transfer to the ICU.

In the ICU, the pt regained her strength, was talking and
following commands.  She denied pain.

Past Medical History:
-history of SAH and SDH after falling and hitting her
head([**6-11**]), at which time the question of a possible dural AVM
was discovered on imaging.  The etiology of the SAH was unclear.
-Hypertension
-Zoster L leg and foot, now with postherpetic neuralgia
-Chronic low back pain

Medications:
-metoprolol 25mg po bid

Allergies:
benzodiazepines

Social History:
-she lives at home with husband. Former yoga teacher.
-remote history of smoking (1 pack per week for 5 years).
-two to three glasses of wine per week.
-no drugs.


Family History:
-hypertension and diabetes mellitus (father).

Physical Exam:
Upon transfer from angio to the ICU:
.
Vitals: T: 98.5F P: 80 R: 16 BP: 143/86  SaO2: 98% RA
General: Lethargic, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
OP
Neck: supple, no JVD or carotid bruits. 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.
Extremities: No C/C/E bilaterally, 1+ radial, DP and PT pulses
b/l.
Skin: no rashes or lesions noted.

Neurologic:
-mental status: Lethargic but easily arousable to voice.  Speech
is fluent but incomprehensible.

-cranial nerves: PERRL 3 to 2mm and brisk.  VFF to threat. There
is no ptosis bilaterally. EOMI without nystagmus.  Sensation
[**Month/Year (2) 5235**] to light touch over face. No facial droop, facial
musculature symmetric. Palate elevates symmetrically in midline.
 5/5 strength in trapezii and SCM bilaterally. Tongue protrudes
in midline; no fasciculations.

-motor: normal bulk, tone throughout. No adventitious movements
noted.
Pt. moving all extremities symmetrically to command but will not
participate in formal strength testing.

-sensory: [**Month/Year (2) **] to light touch over all four extremities..

-DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+
ankle jerks bilaterally. Plantar response was equivocal
bilaterally.
.
.
Neurologic exam after transfer to the floor:
.
Mental status:
awake, alert, cooperative, oriented to place, not time
attention: able to do DOWbw; naming [**Month/Year (2) 5235**]; repetition poor;
language fluent, no dysarthria; [**Location (un) 1131**] [**Location (un) 5235**]; registration
[**3-9**]; recall 0/3; does not remember her physician's face;
comprehension [**Month/Day (4) 5235**]; knows body parts; no insight in her
illness.
.
Cranial Nerves: PERRL 3 to 2mm and brisk. There is no ptosis
bilaterally. EOMI without nystagmus.  Sensation [**Month/Day (4) 5235**] to light
touch and pinprick over face. No facial droop, facial
musculature symmetric. Palate elevates symmetrically in midline.
 5/5 strength in trapezii and SCM bilaterally. Tongue protrudes
in midline; no fasciculations.
.
-motor: normal bulk, tone throughout. No adventitious movements
noted.
Full strength throughout with formal strength testing
.
-sensory: [**Month/Day (4) **] to light touch, temperature (cold) over all
four extremities. [**Month/Day (4) **] vibration and proprioception sense.
.
-DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+
ankle jerks bilaterally. Plantar response downgoing bilaterally.
.
-Coordination: FNF slow bilaterally; [**Doctor First Name **] slower on the left than
right
.
-Gait: slow, mildy unsteady, no ataxia


Pertinent Results:
Laboratory Data upon admission:

Hgb:11.0
CalcHCT:33

Na:139
K:3.4
Cl:108
Glu:89
freeCa:1.13
.
TIBC: 316; retic. 1.5%;  vitB12 651; folate 14.4; haptoglobin
311; ferritin 85.
.
Radiologic Data:
CT head:
Note is made of hyperdense left frontal subdural fluid
collection,
which may represent acute subdural bleeding, or accumulation of
the contrast [**Doctor Last Name 360**] in this patient status post cerebral
angiography. Previously noted right frontal subdural hematoma
has resolved. Note is made of cortical and subarachnoid high
densities in left frontal, parietal, and occipital lobes as well
as left thalamus, which may represent hemorrhage or enhancement,
due to acute infarction in this patient with left middle
cerebral artery infarction noted during angiography. No mass
effect is seen. No shift of normally midline structure is seen.
Again note is made of arteriovenous the information in the right
frontal lobe, which was noted in the prior CTA study. The
surrounding osseous and soft tissue structures are unremarkable.

IMPRESSION:
1. High-density left frontal subdural fluid collection, which
may represent acute subdural hemorrhage versus accumulation of
the contrast [**Doctor Last Name 360**] in this patient status post cerebral
angiography. Previously noted right subdural hematoma has
resolved.
2. Cortical and subarachnoid high-density areas in left frontal,
parietal, and occipital lobes as well as left thalamus, which
represent either blood or enhancement due to acute infarction.
3. Arteriovenous malformation in the right frontal lobe, as
noted in the previous CTA
.
CXR: The lungs are clear. The heart and mediastinum are within
normal limit. Note is made of a small esophageal hiatus hernia.
IMPRESSION: No active lung disease. Small esophageal hiatus
hernia.
.
Repeat CT-scan [**8-12**]: no evidence for a post tPA-hemorrhage; the
reconstructions (to determine whether the blocked vessel had
re-canalized) are pending.
.
ABDOMINAL/PELVIC IMAGING:
CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: The visualized
lung bases demonstrate minuscule amount of pleural fluid and
adjacent atelectasis. Note is made of a hiatal hernia. The
unenhanced images of the liver, spleen, adrenals, pancreas and
unopacified loops of abdominal large and small bowel are
unremarkable. The kidneys demonstrate several bilateral low
attenuation lesions, most pronounced in the renal pelvis which
is most consistent with a parapelvic cyst. A tiny nonobstructing
1-2 mm stone is appreciated in the interval region of the right
kidney. Note is made of an IVC filter. There is vicarious
excretion of contrast in the gallbladder. There is no free air
or free fluid. There is no mesenteric or retroperitoneal
adenopathy. Small amount of atherosclerotic vascular
calcifications along the abdominal aorta is noted.
CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: Stranding is
noted in the right groin consistent with recent puncture site. A
Foley is present within the collapsed bladder. The rectum,
sigmoid, uterus and adnexa are within normal limits.
BONE WINDOWS: There are no suspicious lytic or sclerotic
lesions. Degenerative changes are noted in the visualized
vascular skeleton.
IMPRESSION: No evidence of retroperitoneal hematoma.


Brief Hospital Course:
The patient is a 75 year-old female who presented for elective
angiography for evaluation of a dural AVM, complicated by a
left-MCA stroke with right hemiparesis and aphasia. The stroke
was treated with [**Month/Day (4) **]-arterial t-PA and mechanical
thrombolysis.  The etiology of the stroke was likely embolic
from a dislodged plaque along the aortic arch.

1. Stroke:
The hemiparesis resolved with no residual weakness on formal
strength testing. However, her gait was unsteady and she
continued to have problems [**Name (NI) 94285**] new information. She had
some insight into her condition.  The patient was
encephalopathic immediately following the stroke. This slowly
resolved and an infectious metabolic workup to explain the
encephalopathy had been negative. A CXR did not show pathology
(other that small hiatal hernia). Her LFTs were within normal
limits and her amylase was elevated 205 but trending down
(lipase was not elevated). UA and repeat cultures were negative
at the time of this dictation. Her Hct was low, but no sources
of bleeding were found (see next paragraph).
For further stroke prevention she is receiving ASA 325mg and
lipitor 20mg (tc 208, ldl 122).  A repeat CT-scan [**8-12**] did not
show evidence for a post tPA-hemorrhage (there was some mild
contrast enhancement seen in the old frontal subdural hygroma
although this could have been fresh blood; the reconstructions
(to determine whether the blocked vessel had re-canalized) were
pending. Given her impressive rapid improvement, it is very
likely that the vessel re-canalized.  By the time of discharge,
her encephalopathy had substantially improved.

3. Anemia:
The patient's Hct has been low since admission (baseline low
30's per OMR); [**8-13**] 29.9; [**8-14**] 29.2. A CT abdomen/pelvis ruled-out
post t-PA hemorrhage.
Iron studies, B12, folate, and hemolysis labs did not point to
any specific pathology. Stools was guaiac negative.  Monitoring
of stools and frequent checks of Hct are recommended as
outpatient to make sure the Hct remains stable, which it was at
discharge.
.
4. Cardiovascular: Patient's blood pressure was monitored. For
tachycardia she was given lopressor 12.5mg [**Hospital1 **] after the acute
phase of the stroke.
.
5. FEN: She passed a speech and swallow evaluation and tolerated
a cardiac healthy diet.
.
6. PPX: A PPI was dosed [**Hospital1 **] to prevent gasterointestinal
bleeding post t-PA. Pneumoboots were in place when the patient
was in bed.
.
7. Disposition: Due to an unsteady gait which improved with
physical therapy in-house, the patient will need rehab. She
needs to be on fall precautions at all times.

Medications on Admission:
-metoprolol 25mg po bid

Discharge Medications:
1. Acyclovir 5 % Ointment Sig: One (1) Appl Topical  [**Hospital1 **] (2
times a day) as needed.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain or fever.
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).

7. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. lopressor 12.5mg  Sig: One (1) 12.5mg  twice a day: hold for
SBP<90.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
1. L-MCA stroke
2. dural AVM
3. Anemia


Discharge Condition:
Good; no residual weakness, unsteady gait, difficulties in
registration

Discharge Instructions:
Please continue your medications as instructed.
.
Please follow up with your Primary Care Physician and at the
[**Hospital 4038**] Clinic as indicated below.
.
Please have your rehab physician and PCP follow Hct.
.
If you experience symptoms of weakness, numbness, slurred
speech, or a new headache, please seek medical assistance
immediately

Followup Instructions:
Please follow up with your Primary Care Physician [**Name Initial (PRE) 176**] 1 week
after discharge from rehab.
.
Please have your the rehab physician and PCP follow Hct. Your
PCP will need to provide a referral for the [**Hospital 4038**] Clinic.
The appointment at the [**Hospital 4038**] Clinic, [**Hospital Ward Name 23**] Building has
already been scheduled:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name 2781**] Where: [**Hospital6 29**] NEUROLOGY
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2197-9-26**] 4:00
.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. NEUROSURGERY WEST Where: LM [**Hospital Unit Name **] NEUROSURGERY Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2197-8-22**]
11:00
.
Provider: [**Name10 (NameIs) **] SCAN Where: [**Hospital6 29**] RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2197-8-22**] 10:00



Completed by:[**2197-8-14**]
{'Iatrogenic cerebrovascular infarction or hemorrhage,Anomalies of cerebrovascular system,Anemia, unspecified,Unspecified essential hypertension,Encephalopathy, unspecified'}


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: hemiparesis and aphasia following angiography

PRESENT ILLNESS: The patient is a 75 year-old female who presented for elective
cerebral angiography for evaluation of dural arteriovenous
malformation.  Shortly after the procedure was begun, it was
noted that the she became mute, she was not following commands,
and she was plegic on the right arm and leg  The stroke team was
called to evaluate the patient.  Her initial NIHSS was 19.
Cerebral angiography revealed an occlusion of the M1 segment of
the left MCA.  After  consent was obtained from her husband,
[**Name (NI) **]-arterial t-PA was injected into the occluded artery.  She
developed respiratory distress and was intubated for a short
period of time.  Reportedly, her respiratory status improved and
she was quickly extubated.  In addition, she was noted to be
moving all extremities prior to transfer to the ICU.

MEDICAL HISTORY: -history of SAH and SDH after falling and hitting her
head([**6-11**]), at which time the question of a possible dural AVM
was discovered on imaging.  The etiology of the SAH was unclear.
-Hypertension
-Zoster L leg and foot, now with postherpetic neuralgia
-Chronic low back pain

MEDICATION ON ADMISSION: -metoprolol 25mg po bid

ALLERGIES: Benzodiazepines

PHYSICAL EXAM: Upon transfer from angio to the ICU:
.
Vitals: T: 98.5F P: 80 R: 16 BP: 143/86  SaO2: 98% RA
General: Lethargic, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
OP
Neck: supple, no JVD or carotid bruits. 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.
Extremities: No C/C/E bilaterally, 1+ radial, DP and PT pulses
b/l.
Skin: no rashes or lesions noted.

FAMILY HISTORY: -hypertension and diabetes mellitus (father).

SOCIAL HISTORY: -she lives at home with husband. Former yoga teacher.
-remote history of smoking (1 pack per week for 5 years).
-two to three glasses of wine per week.
-no drugs. 

### Response:
{'Iatrogenic cerebrovascular infarction or hemorrhage,Anomalies of cerebrovascular system,Anemia, unspecified,Unspecified essential hypertension,Encephalopathy, unspecified'}
