CHIEF COMPLAINT: Chest pain
Tuberculosis rule-out
Acute cerebral infarct
Headache
End Stage Renal Disease
Pulmonary Edema
Type II Diabetes Mellitus
Anxiety

PRESENT ILLNESS: 70 year old man with a history ESRD, on HD T-Th-Sat, DM, HTN,
CAD s/p IMI with DES in [**2136**] recent stress shows reversible
defect in inferior wall but overall improved per cardiologist.
Complained of cough and left sided chest pain, he was then
having a cough productive of [**Doctor Last Name 352**] and white sputum, he did have
drenching night sweats, unable to tell if he had weight loss.
Followed for latent TB infection by Dr. [**Last Name (STitle) 724**], had been treated
with INH, but while being treated was exposed to his son so
there was a question of whether he could be treated or not. Dr.
[**Last Name (STitle) **] did feel like he was adequetely treated for TB. The CP was
constant, sharp, and pleuritic, made worse with climbing stairs,
similar to angina, EKG showed LVH with early repol abnormality,
no signs of acute ischemia, was ruled out for MI. With cough,
night sweats, questionable history of TB, decided he needed to
be ruled out for TB. On CXR had a LLL infiltrate. Was in sbps in
180s upon arrival, gave his home meds because they didn't think
this was urgency and he was 160 systolic prior to HS. They were
going to start CTX/Azithro after HD the next morning. Around
[**9-16**] in AM at 8am, intern spoke with him via interpreter, said
his CP was improved, and his headache was improved (longstanding
and worse on HD days), and so at that time moving all his
extremities, no focal deficits, then had bedside HD after exam,
and nurse noted that he was moving his extremities, then came in
around 9:20 for AM rounds found to have flaccid LUE paralysis,
left nasal-labial fold flattening. CODE STROKE called, taken to
head CT, showed right MCA perfusion defect with "penumbra", but
no evidence of bleed. BP was 210 systolic. So he was admitted to
the NSICU and started TPA. Wheeled him to the MICU but was
turned away because no respiration bed. Gave 10 x 2 brought his
BP down to 177 systpolic, at 1115 pushed TPA on the floor, neuro
attending at bedside, pushed continuous infusion. By the time
back to room, still aphasic but starting to move his LUE before
starting TPA. Then confirmed FULL CODE with family, transferrred
to TSICU under neuro team. Remains aphasic and still has LUE
weakness, but is moving it, still has nasolabial fold flattening
on the left. They did see a R carotid stenosis. No a fib on EKG.

MEDICAL HISTORY: ESRD -CKD stage 5 on hemodialysis.
DM2
CAD s/p drug-eluting stent [**3-/2136**]
Hyperlipidemia
HTN
Anemia
Latent TB treated with INH [**3-/2136**]/[**2136**]
Chronic HA

MEDICATION ON ADMISSION: Medications (verified):
metoprolol 25mg po BID
renagel 800mg nine tablets po TID with meals
ASA 81mg po daily
vitamin B complex one tab daily
fluticasone proprionate one spray in each nostril daily
lidocaine cream, apply to fistula as directed prior to
hemodialysis
prozac _____ (unknown dose)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam:
V/S: 97.6F, 180/100, 80, 16, 92-93%/RA
Gen: NAD, lying in bed comfortably
Head/Neck: NC/AT, no scleral icterus, no oropharyngeal lesions,
neck supple
Cardiovascular: RRR, continuous systolic-diastolic murmur
Pulmonary: Equal air entry bilaterally
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, thrill at L upper arm AVF

FAMILY HISTORY: Sister died from diabetes complications
6 siblings alive with hypertension
8 living children with various problems including diabetes,
obesity, and fatty liver

SOCIAL HISTORY: Immigration from Bolivia in [**2134-12-1**]. Has completed high
school and is currently married. Quit drinking approximately 4
years ago, however, has history of some heavier alcohol abuse.
He is a nonsmoker and has no tattoos. Has 8 children, 6 of whom
live in the area and are heavily involved in patient's health
care.
Pulmonary congestion and hypostasis,Cerebral embolism with cerebral infarction,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hemiplegia, unspecified, affecting nondominant side,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anxiety state, unspecified,Renal dialysis status,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Personal history of tuberculosis,Dysarthria,Contact with or exposure to tuberculosis
Pulm congest/hypostasis,Crbl emblsm w infrct,End stage renal disease,Hyp kid NOS w cr kid V,Unsp hmiplga nondmnt sde,Hyperpotassemia,DMII wo cmp nt st uncntr,Anxiety state NOS,Renal dialysis status,Old myocardial infarct,Status-post ptca,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Prsnl hst tuberculosis,Dysarthria,Tuberculosis contact
Admission Date:  [**2139-9-15**]              Discharge Date:   [**2139-9-23**]

Date of Birth:  [**2069-5-4**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
Chest pain
Tuberculosis rule-out
Acute cerebral infarct
Headache
End Stage Renal Disease
Pulmonary Edema
Type II Diabetes Mellitus
Anxiety

Major Surgical or Invasive Procedure:
tPA adminsistration


History of Present Illness:
70 year old man with a history ESRD, on HD T-Th-Sat, DM, HTN,
CAD s/p IMI with DES in [**2136**] recent stress shows reversible
defect in inferior wall but overall improved per cardiologist.
Complained of cough and left sided chest pain, he was then
having a cough productive of [**Doctor Last Name 352**] and white sputum, he did have
drenching night sweats, unable to tell if he had weight loss.
Followed for latent TB infection by Dr. [**Last Name (STitle) 724**], had been treated
with INH, but while being treated was exposed to his son so
there was a question of whether he could be treated or not. Dr.
[**Last Name (STitle) **] did feel like he was adequetely treated for TB. The CP was
constant, sharp, and pleuritic, made worse with climbing stairs,
similar to angina, EKG showed LVH with early repol abnormality,
no signs of acute ischemia, was ruled out for MI. With cough,
night sweats, questionable history of TB, decided he needed to
be ruled out for TB. On CXR had a LLL infiltrate. Was in sbps in
180s upon arrival, gave his home meds because they didn't think
this was urgency and he was 160 systolic prior to HS. They were
going to start CTX/Azithro after HD the next morning. Around
[**9-16**] in AM at 8am, intern spoke with him via interpreter, said
his CP was improved, and his headache was improved (longstanding
and worse on HD days), and so at that time moving all his
extremities, no focal deficits, then had bedside HD after exam,
and nurse noted that he was moving his extremities, then came in
around 9:20 for AM rounds found to have flaccid LUE paralysis,
left nasal-labial fold flattening. CODE STROKE called, taken to
head CT, showed right MCA perfusion defect with "penumbra", but
no evidence of bleed. BP was 210 systolic. So he was admitted to
the NSICU and started TPA. Wheeled him to the MICU but was
turned away because no respiration bed. Gave 10 x 2 brought his
BP down to 177 systpolic, at 1115 pushed TPA on the floor, neuro
attending at bedside, pushed continuous infusion. By the time
back to room, still aphasic but starting to move his LUE before
starting TPA. Then confirmed FULL CODE with family, transferrred
to TSICU under neuro team. Remains aphasic and still has LUE
weakness, but is moving it, still has nasolabial fold flattening
on the left. They did see a R carotid stenosis. No a fib on EKG.

In Neuro ICU, patient started to speak slowly, so hopefully more
dysarthria as opposed to enunciating rather than true aphasia.
Put the order in for an MRI given his cypher stent, but he has
an unusual intracranial circulation, he is a vasculopath, has
all the risk factors for large vessel disease, ?embolic
phenomena, so getting a TTE with bubble study. But now anxious
and associating HD with stroke unfortunately, need to reiterate
that with him. Currently, 98  73  147/56 (required 10 of
labetolol and hydralazine IV this morning for 170s)  15  982L.
He did pass speech and swallow. He was transferred to the
medical floor for continued stabilization before discharge to
home with PT.

Past Medical History:
ESRD -CKD stage 5 on hemodialysis.
DM2
CAD s/p drug-eluting stent [**3-/2136**]
Hyperlipidemia
HTN
Anemia
Latent TB treated with INH [**3-/2136**]/[**2136**]
Chronic HA


Social History:
Immigration from Bolivia in [**2134-12-1**]. Has completed high
school and is currently married. Quit drinking approximately 4
years ago, however, has history of some heavier alcohol abuse.
He is a nonsmoker and has no tattoos. Has 8 children, 6 of whom
live in the area and are heavily involved in patient's health
care.

Family History:
Sister died from diabetes complications
6 siblings alive with hypertension
8 living children with various problems including diabetes,
obesity, and fatty liver

Physical Exam:
Admission Exam:
V/S: 97.6F, 180/100, 80, 16, 92-93%/RA
Gen: NAD, lying in bed comfortably
Head/Neck: NC/AT, no scleral icterus, no oropharyngeal lesions,
neck supple
Cardiovascular: RRR, continuous systolic-diastolic murmur
Pulmonary: Equal air entry bilaterally
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, thrill at L upper arm AVF

Discharge Exam:
VS: 97.0F, 167/64, 63, 18, 97%/RA
GENERAL: Comfortable, NAD
HEENT: NCAT, sclerae anicteric, PERRLA, MMM, OP clear, neck
supple
HEART: RRR, [**3-8**] continuous systolic-diastolic murmur, no rubs or
gallops.
LUNGS: CTAB, no r/r/w, good air movement, resp unlabored
ABDOMEN:  +BS, soft, NT/ND, no guarding
EXTREMITIES: WWP, thrill at LUE AV fistula, slightly more
swollen L arm without pitting edema or rubor/calor/dolor, no
c/c/e, 2+ peripheral pulses.
NEURO: Awake, speaking in short sentences, persistent left NLF
droop, smile asymmetric with drooping on L side, symmetric
eyebrow raise and palate elevation, Strength 4+/5 and equal b/l
and distally. LT intact bilaterally. [**Doctor First Name **] continues to be slowed
on left compared to right. Can ambulate to bathroom without
assistance.


Pertinent Results:
# CBC with Diff:
[**2139-9-15**] 11:00AM [**Month/Day/Year 3143**] WBC-7.5 RBC-3.45* Hgb-12.2* Hct-33.6*
MCV-98 MCH-35.3* MCHC-36.2* RDW-15.1 Plt Ct-219
[**2139-9-15**] 11:00AM [**Month/Day/Year 3143**] Neuts-78.3* Lymphs-13.9* Monos-4.6
Eos-2.2 Baso-1.0
[**2139-9-16**] 07:50AM [**Month/Day/Year 3143**] WBC-6.5 RBC-3.21* Hgb-10.9* Hct-32.4*
MCV-101* MCH-33.9* MCHC-33.6 RDW-14.9 Plt Ct-232
[**2139-9-16**] 02:13PM [**Month/Day/Year 3143**] WBC-6.2 RBC-3.17* Hgb-10.8* Hct-31.3*
MCV-99* MCH-34.0* MCHC-34.5 RDW-14.8 Plt Ct-218
[**2139-9-17**] 02:27AM [**Month/Day/Year 3143**] WBC-7.5 RBC-3.20* Hgb-11.1* Hct-32.0*
MCV-100* MCH-34.7* MCHC-34.8 RDW-14.8 Plt Ct-239
[**2139-9-18**] 07:35AM [**Month/Day/Year 3143**] WBC-4.6 RBC-3.29* Hgb-10.9* Hct-31.9*
MCV-97 MCH-33.1* MCHC-34.2 RDW-14.7 Plt Ct-188
[**2139-9-19**] 08:24AM [**Month/Day/Year 3143**] WBC-3.6* RBC-3.22* Hgb-11.0* Hct-30.9*
MCV-96 MCH-34.1* MCHC-35.5* RDW-14.5 Plt Ct-202
[**2139-9-20**] 07:35AM [**Month/Day/Year 3143**] WBC-3.7* RBC-3.27* Hgb-11.2* Hct-31.7*
MCV-97 MCH-34.2* MCHC-35.3* RDW-14.8 Plt Ct-180
[**2139-9-21**] 05:55AM [**Month/Day/Year 3143**] WBC-3.9* RBC-3.10* Hgb-10.6* Hct-30.1*
MCV-97 MCH-34.1* MCHC-35.2* RDW-14.8 Plt Ct-220
[**2139-9-22**] 07:47AM [**Month/Day/Year 3143**] WBC-4.3 RBC-3.31* Hgb-11.3* Hct-32.2*
MCV-97 MCH-34.1* MCHC-35.2* RDW-15.3 Plt Ct-224
[**2139-9-23**] 06:15AM [**Month/Day/Year 3143**] WBC-5.3 RBC-3.40* Hgb-11.8* Hct-33.5*
MCV-99* MCH-34.7* MCHC-35.2* RDW-15.4 Plt Ct-251

# [**Month/Day/Year **] Chemistry:
[**2139-9-15**] 11:00AM [**Month/Day/Year 3143**] Glucose-86 UreaN-59* Creat-10.2*# Na-143
K-5.0 Cl-97 HCO3-27 AnGap-24*
[**2139-9-15**] 11:00AM [**Month/Day/Year 3143**] Calcium-9.1 Phos-5.6* Mg-2.7*
[**2139-9-15**] 11:21AM [**Month/Day/Year 3143**] Lactate-1.2 K-4.7
[**2139-9-16**] 07:50AM [**Month/Day/Year 3143**] Glucose-130* UreaN-70* Creat-10.9* Na-140
K-5.2* Cl-95* HCO3-28 AnGap-22*
[**2139-9-16**] 07:50AM [**Month/Day/Year 3143**] Calcium-9.2 Phos-6.4* Mg-2.6
[**2139-9-16**] 02:13PM [**Month/Day/Year 3143**] Glucose-138* UreaN-53* Creat-9.4*# Na-138
K-4.5 Cl-93* HCO3-30 AnGap-20
[**2139-9-16**] 02:13PM [**Month/Day/Year 3143**] Calcium-8.7 Phos-5.3* Mg-2.3
[**2139-9-17**] 02:27AM [**Month/Day/Year 3143**] Glucose-98 UreaN-57* Creat-10.6*# Na-141
K-4.6 Cl-95* HCO3-26 AnGap-25*
[**2139-9-17**] 02:27AM [**Month/Day/Year 3143**] Albumin-4.3 Calcium-9.0 Phos-6.8* Mg-2.4
Cholest-158
[**2139-9-18**] 07:35AM [**Month/Day/Year 3143**] Glucose-73 UreaN-27* Creat-7.4*# Na-141
K-4.4 Cl-93* HCO3-37* AnGap-15
[**2139-9-18**] 07:35AM [**Month/Day/Year 3143**] Calcium-9.2 Phos-5.9* Mg-2.2
[**2139-9-19**] 08:24AM [**Month/Day/Year 3143**] Glucose-147* UreaN-39* Creat-9.7*# Na-137
K-4.0 Cl-91* HCO3-32 AnGap-18
[**2139-9-19**] 08:24AM [**Month/Day/Year 3143**] Calcium-9.1 Phos-6.7* Mg-2.3
[**2139-9-20**] 07:35AM [**Month/Day/Year 3143**] Glucose-85 UreaN-17 Creat-5.9*# Na-138
K-4.4 Cl-92* HCO3-35* AnGap-15
[**2139-9-20**] 07:35AM [**Month/Day/Year 3143**] Calcium-9.7 Phos-4.7*# Mg-2.1
[**2139-9-21**] 05:55AM [**Month/Day/Year 3143**] Glucose-79 UreaN-27* Creat-7.7*# Na-136
K-4.5 Cl-91* HCO3-35* AnGap-15
[**2139-9-21**] 05:55AM [**Month/Day/Year 3143**] Calcium-9.5 Phos-5.6* Mg-2.1
[**2139-9-22**] 07:47AM [**Month/Day/Year 3143**] Glucose-77 UreaN-39* Creat-9.7*# Na-136
K-5.0 Cl-91* HCO3-32 AnGap-18
[**2139-9-22**] 07:47AM [**Month/Day/Year 3143**] Calcium-9.2 Phos-6.3* Mg-2.3
[**2139-9-23**] 06:15AM [**Month/Day/Year 3143**] Glucose-83 UreaN-24* Creat-6.7*# Na-133
K-4.4 Cl-89* HCO3-34* AnGap-14
[**2139-9-23**] 06:15AM [**Month/Day/Year 3143**] Calcium-9.3 Phos-4.5# Mg-2.2

# Cardiac Biomarkers:
[**2139-9-15**] 11:00AM [**Month/Day/Year 3143**] CK-MB-2 cTropnT-0.04*
[**2139-9-15**] 06:45PM [**Month/Day/Year 3143**] CK-MB-2 cTropnT-0.04*
[**2139-9-16**] 07:50AM [**Month/Day/Year 3143**] CK-MB-2 cTropnT-0.04*
[**2139-9-16**] 02:13PM [**Month/Day/Year 3143**] CK-MB-2 cTropnT-0.04*
[**2139-9-17**] 02:27AM [**Month/Day/Year 3143**] CK-MB-2 cTropnT-0.05*

# Liver function tests:
[**2139-9-15**] 11:00AM [**Month/Day/Year 3143**] CK(CPK)-58
[**2139-9-15**] 06:45PM [**Month/Day/Year 3143**] CK(CPK)-52
[**2139-9-16**] 07:50AM [**Month/Day/Year 3143**] CK(CPK)-52
[**2139-9-16**] 02:13PM [**Month/Day/Year 3143**] CK(CPK)-57
[**2139-9-16**] 07:59PM [**Month/Day/Year 3143**] CK(CPK)-75
[**2139-9-17**] 02:27AM [**Month/Day/Year 3143**] ALT-14 AST-23 CK(CPK)-81 AlkPhos-93
TotBili-0.3
[**2139-9-17**] 02:27AM [**Month/Day/Year 3143**] Triglyc-101 HDL-43 CHOL/HD-3.7 LDLcalc-95

# U/A:
[**2139-9-15**] 01:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2139-9-15**] 01:00PM URINE [**Month/Day/Year **]-NEG Nitrite-NEG Protein->600
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-NEG
[**2139-9-15**] 01:00PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
TransE-<1

# Sputum studies:
[**2139-9-16**] 5:28 am SPUTUM      Source: Induced.

   GRAM STAIN (Final [**2139-9-16**]):
      [**11-24**] PMNs and >10 epithelial cells/100X field.
      Gram stain indicates extensive contamination with upper
respiratory
      secretions. Bacterial culture results are invalid.
      PLEASE SUBMIT ANOTHER SPECIMEN.

   RESPIRATORY CULTURE (Final [**2139-9-16**]):
      TEST CANCELLED, PATIENT CREDITED.

   ACID FAST SMEAR (Final [**2139-9-17**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.

[**2139-9-17**] 10:54 am SPUTUM      Source: Induced.

   GRAM STAIN (Final [**2139-9-17**]):
      <10 PMNs and >10 epithelial cells/100X field.
      Gram stain indicates extensive contamination with upper
respiratory
      secretions. Bacterial culture results are invalid.
      PLEASE SUBMIT ANOTHER SPECIMEN.

   RESPIRATORY CULTURE (Final [**2139-9-17**]):
      TEST CANCELLED, PATIENT CREDITED.

   ACID FAST SMEAR (Final [**2139-9-18**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.


Log-In Date/Time: [**2139-9-18**] 5:53 am
      SPUTUM      Source: Induced.

   GRAM STAIN (Final [**2139-9-18**]):
      >25 PMNs and >10 epithelial cells/100X field.
      Gram stain indicates extensive contamination with upper
respiratory
      secretions. Bacterial culture results are invalid.
      PLEASE SUBMIT ANOTHER SPECIMEN.

   RESPIRATORY CULTURE (Final [**2139-9-18**]):
      TEST CANCELLED, PATIENT CREDITED.

   ACID FAST SMEAR (Final [**2139-9-21**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Preliminary):

[**2139-9-19**] 8:55 am SPUTUM      Source: Induced.

   ACID FAST SMEAR (Final [**2139-9-21**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Preliminary):

# MRSA Screen:
[**2139-9-16**] 12:47 pm MRSA SCREEN      Source: Nasal swab.
   MRSA SCREEN (Final [**2139-9-18**]):    No MRSA isolated.

# [**Month/Day/Year **] Cultures:
[**2139-9-15**] 12:05 pm [**Month/Day/Year 3143**] CULTURE     Site: ARM      X2.

                            **FINAL REPORT [**2139-9-21**]**

   [**Month/Day/Year **] Culture, Routine (Final [**2139-9-21**]):    NO GROWTH.

# [**2139-9-15**] EKG:
Normal sinus rhythm at a rate of 80. Right bundle-branch block.
Mild
prolongation of the Q-T interval. Left ventricular hypertrophy.
There are
diffuse non-specific ST-T wave changes throughout. Clinical
correlation is
suggested.

# [**2139-9-15**] CXR:
IMPRESSION: Mild pulmonary edema with bilateral small pleural
effusions and atelectasis.

# [**2139-9-16**] EKG:
Normal sinus rhythm. Right bundle-branch block. Non-specific
ST-T wave
changes, all of which are unchanged compared with the previous
tracing.

# [**2139-9-16**] CT Brain Perfusion
IMPRESSION:
1. No acute intra- or extra-axial hemorrhage.
2. Relatively small geographic region of abnormally increased
mean transit
time, without definite corresponding decreased relative cerebral
[**Name2 (NI) **] volume,
in the superior right frontal lobe, representing acute ischemic
(penumbra) in
the superior division, right MCA territory; there is no similar
region
elsewhere.
3. Unremarkable intracranial circulation; specifically, no
stenosis or
occlusion of the right MCA and its branches or the right ICA
terminus.
4. Atherosclerotic disease, involving particularly the left
carotid bulb and
proximal ICA with at least 65% diameter stenosis at its origin.
5. Evidence of CHF with bilateral pleural effusions.

# [**2139-9-17**] TTE
Conclusion:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Doppler parameters
are indeterminate for left ventricular diastolic function. There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. 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. There is no mitral valve prolapse. The tricuspid
valve leaflets are mildly thickened. There is borderline
pulmonary artery systolic hypertension. There is a very small
pericardial effusion.

IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Indeterminate indices to assess diastolic dysfunction. No
pathologic valvular abnormality seen.

# [**2139-9-17**] CXR:
FINDINGS: In comparison with the study of [**9-15**], there is
increasing
opacification at both bases with poor definition of the
hemidiaphragms
consistent with pleural effusions and compressive atelectasis.
The degree of pulmonary vascular congestion is more prominent,
though some of this could reflect the AP supine rather than PA
technique.

# [**2139-9-17**] Non Con Head CT
IMPRESSION:
Residual IV contrast limits optimal evaluation for subtle
hemorrhage.
1. New focal hypodense area with loss of [**Doctor Last Name 352**]-white
differentiation in the
right frontal lobe corresponding to the previously seen
perfusion abnormality representing either evolving ischemia or
infarction.
2. No large area of hemorrhage in this area or elsewhere within
limitation of this study. No new edema, mass effect, or shift in
midline structures.

# [**2139-9-18**] TTE Bubble Study
Findings:
No evidence suggestive of an atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers.

# [**2139-9-18**] MRI Head
IMPRESSION:

1. Acute infarct in the right posterior frontal lobe involving
the precentral gyrus which is unchanged.

2. No evidence of acute intracranial hemorrhage or new infarct.

3. Changes of chronic small vessel ischemic disease.

4. Arachnoid cyst versus a prominent cisterna magna in the
posterior fossa.





Brief Hospital Course:
ASSESSMENT:  70 yo Spanish-speaking RHM with h/o ESRD, CAD s/p
drug-eluting stent placed [**3-/2136**], DM2, HTN, HL, and latent TB
initially presented on [**2139-9-15**] with c/o CP, productive cough and
night sweats, admitted for MI rule out hospital course c/b
right-sided acute cerebral infarct s/p tPA on [**9-16**], initially
with motor weakness, left sided facial droop and expressive
aphasia, now with symmetric strength and no facial droop but
persistent expressive aphasia.

# Acute Cerebral Infarct: While in dialysis on [**2139-9-16**] pt was
found around 09:20 to have new speech difficulty and LUE flaccid
weakness. A Code Stroke was called and CTA showed small
frontoparietal increased MTT/perfusion deficit. He was
administered tPA starting at approximately 11:15 on [**9-16**]. He was
then transfered to the TICU for frequent neuro checks given risk
of bleed post-tPA. Passed speech and swallow on [**2139-9-17**].
Continued to improve on the medical floor, with equal strength
and sensation distally. TTE showed no ASD or PFO. Cardiology had
low suspicion for any left atrial thrombus or appendage
abnormality, so TEE was recommended for outpatient. Neuro aware
of left ICA. LDL is 95, so started a statin to obtain less than
70. Followed daily by neurology. Antihypertensives were
uptitrated as necessary to bring BP within goal SBP 140-180.
Patient was placed on Aspirin 325 mg per neuro recs because they
felt plavix was not a good medication for him.
Treatment Course:
- Captopril 12.5 mg PO TID x1 day
- Captopril 37.5 mg PO TID x3 days
- Lisinopril 40 mg PO DAILY x2 days
- Metoprolol tartrate 25 mg PO BID x3 days
- Carvedilol 25 mg PO BID x3 days
- Hydralazine 10-15 mg IV Q6H PRN SBP>180
- Atorvastatin 80 mg daily x6 days
- Aspirin 325 mg PO/NG DAILY x7 days
- Frequent neuro checks with monitoring for headache as
indication of possible hemorrhagic conversion or cerebral edema
- Continuous monitoring by telemetry
- Maintained normothermia
- Risk Factor Assessment with Lipid panel

# Headache: pt has h/o chronic HA with HD along with dizziness
and ear ache. [**Month (only) 116**] have h/o migraine but due to language barrier
it is described simply as HA. Associated with nausea and
vomiting. Varies from [**3-12**] to [**10-10**] in severity.
- Acetaminophen dose to 1000 mg PO Q6H prn pain
- Ibuprofen 600 mg PO Q8H prn pain
- Odansetron 4 mg IV Q8H:PRN nausea/vomiting
- Elevated HOB to 30 degrees
- Monitored closely for concurrent neurological findings
- Pt sent with a prescription for Tramadol for break through
headache pain

# No TB infection, ruled out after neg AFBx3 and neg
concentrated smear. Has been followed for latent TB infection by
Dr. [**Last Name (STitle) 724**] and previously treated with INH. Resolved.

# ESRD: has a LUE fistula, after TPA did have more swelling of
his LUE ?less mobile, non pitting edema, so don't believe there
is a clot but something to monitor as an outpatient.  Dialysis
on T, Tr, Saturday.
- Monitored by daily Cr, urine output, electrolytes

# No current chest pain on discharge, ruled out for MI with flat
CK-MB and TpnT.  Resolved.

# Pulmonary Edema: Likely [**3-4**] fluid overload on admission CXR,
now resolved.  Sats stable, lung sounds clear.

# DM 2:
- Pt placed on Insulin SS with goal <150.  BG very well
controlled during this admission.

# Anxiety: Pt has increased anxiety following stroke, especially
around HD, now resolved.
- Pt given Lorazepam 0.5 mg IV PRN anxiety pre-HD.

# Consults:
- PT evaluations for walking stairs, showering without assitance
- Nutrition evaluations for poor PO intake, treated with
appetite stimulant Megace
- Social work consults for discharge home with services

Transitional Issues:
1. Pt still needs a TEE for a better look at possible atrial
pathology which may have caused this stroke.  Cardiology did not
feel that this procedure had to be done in house and that he was
very low risk for having anything that would change our
management.  For this reason he was set up with cardiology as an
outpatient to get this TEE.
2. Pt will need close neurology follow up to follow neuro
deficits and continue to reduce his risk of further stroke.
3. Pt will need close PCP follow up to follow up on new
medications, medication refills, ongoing neuro deficits, stroke
risk reduction etc.

Medications on Admission:
Medications (verified):
metoprolol 25mg po BID
renagel 800mg nine tablets po TID with meals
ASA 81mg po daily
vitamin B complex one tab daily
fluticasone proprionate one spray in each nostril daily
lidocaine cream, apply to fistula as directed prior to
hemodialysis
prozac _____ (unknown dose)

Discharge Medications:
1. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
5. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Megace Oral 400 mg/10 mL (40 mg/mL) Suspension Sig: Fifteen
(15) mL PO once a day.
Disp:*1 bottle* Refills:*0*
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
9. Outpatient Occupational Therapy
10. Outpatient Physical Therapy
11. Outpatient Speech/Swallowing Therapy
12. lidocaine 4 % Cream Sig: One (1) application Topical once a
day as needed for prior to dialysis: PRN for dialysis.
Disp:*1 tube* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Acute Cerebral Infarct
Headache
End Stage Renal Disease
Pulmonary Edema
Type II Diabetes Mellitus
Anxiety
Anemia
Hypertensive urgency


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 Mr. [**Known lastname 72838**],

You were admitted to the hospital with chest pain which has
resolved.  Unfortunately, while you were here you had a stroke
that affected the right side of your brain (and consequently the
left side of your body). You were given a medication that helps
to dissolve clots and helps people improve following a stroke.
Over the few days following the stroke you improved dramatically
and your motor muscle function appears to be back to baseline.
As we discussed, the reason for the stroke was secondary to
years of high cholesterol, diabetes, high [**Known lastname **] pressure, and
dialysis that lead to hardening of the arteries, leading to a
blockage. The key to your recovery lies in your new medications
including aspirin, atorvastatin, and new [**Known lastname **] pressure agents.
Further, you will benefit from outpatient physical therapy,
occupational therapy, and speech therapy. We have set you up
with primary care, cardiology and neurology appointments below.

Additionally, while you were here we tested you for tuberculosis
and all of our tests were negative, indicating that you do not
have this infection.

The following changes were made to your medications:
STOP Metoprolol
STOP Fluticasone
CHANGE Vitamin B complex vitamins to B complex with Vitamin C
and Folic Acid, 1 capsule by mouth daily
CHANGE Aspirin from 81 mg daily to 325 mg daily
START Atorvastatin 80 mg by mouth once daily
START Carvedilol 25 mg by mouth twice daily
START Lisinopril 20 mg by mouth twice daily
START Megace 600 mg by mouth once daily
START Tramadol 50 mg by mouth every 6 hours as needed for
headache

Thank you for allowing us to participate in your care.  We wish
you a speedy recovery.

Followup Instructions:
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23903**]
Location: [**Hospital6 28009**]
Address: [**Street Address(2) 33773**], [**Location (un) **],[**Numeric Identifier 4544**]
Phone: [**Telephone/Fax (1) 17826**]
Appointment: Friday [**2139-10-2**] 2:30pm

Department: CARDIAC SERVICES
When: MONDAY [**2139-10-12**] at 10:40 AM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**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: WEDNESDAY [**2139-11-18**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
***We are working on a sooner appt for you and the office will
call you at home when a sooner appt becomes available.***
{'Pulmonary congestion and hypostasis,Cerebral embolism with cerebral infarction,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hemiplegia, unspecified, affecting nondominant side,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anxiety state, unspecified,Renal dialysis status,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Personal history of tuberculosis,Dysarthria,Contact with or exposure to tuberculosis'}


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: Chest pain
Tuberculosis rule-out
Acute cerebral infarct
Headache
End Stage Renal Disease
Pulmonary Edema
Type II Diabetes Mellitus
Anxiety

PRESENT ILLNESS: 70 year old man with a history ESRD, on HD T-Th-Sat, DM, HTN,
CAD s/p IMI with DES in [**2136**] recent stress shows reversible
defect in inferior wall but overall improved per cardiologist.
Complained of cough and left sided chest pain, he was then
having a cough productive of [**Doctor Last Name 352**] and white sputum, he did have
drenching night sweats, unable to tell if he had weight loss.
Followed for latent TB infection by Dr. [**Last Name (STitle) 724**], had been treated
with INH, but while being treated was exposed to his son so
there was a question of whether he could be treated or not. Dr.
[**Last Name (STitle) **] did feel like he was adequetely treated for TB. The CP was
constant, sharp, and pleuritic, made worse with climbing stairs,
similar to angina, EKG showed LVH with early repol abnormality,
no signs of acute ischemia, was ruled out for MI. With cough,
night sweats, questionable history of TB, decided he needed to
be ruled out for TB. On CXR had a LLL infiltrate. Was in sbps in
180s upon arrival, gave his home meds because they didn't think
this was urgency and he was 160 systolic prior to HS. They were
going to start CTX/Azithro after HD the next morning. Around
[**9-16**] in AM at 8am, intern spoke with him via interpreter, said
his CP was improved, and his headache was improved (longstanding
and worse on HD days), and so at that time moving all his
extremities, no focal deficits, then had bedside HD after exam,
and nurse noted that he was moving his extremities, then came in
around 9:20 for AM rounds found to have flaccid LUE paralysis,
left nasal-labial fold flattening. CODE STROKE called, taken to
head CT, showed right MCA perfusion defect with "penumbra", but
no evidence of bleed. BP was 210 systolic. So he was admitted to
the NSICU and started TPA. Wheeled him to the MICU but was
turned away because no respiration bed. Gave 10 x 2 brought his
BP down to 177 systpolic, at 1115 pushed TPA on the floor, neuro
attending at bedside, pushed continuous infusion. By the time
back to room, still aphasic but starting to move his LUE before
starting TPA. Then confirmed FULL CODE with family, transferrred
to TSICU under neuro team. Remains aphasic and still has LUE
weakness, but is moving it, still has nasolabial fold flattening
on the left. They did see a R carotid stenosis. No a fib on EKG.

MEDICAL HISTORY: ESRD -CKD stage 5 on hemodialysis.
DM2
CAD s/p drug-eluting stent [**3-/2136**]
Hyperlipidemia
HTN
Anemia
Latent TB treated with INH [**3-/2136**]/[**2136**]
Chronic HA

MEDICATION ON ADMISSION: Medications (verified):
metoprolol 25mg po BID
renagel 800mg nine tablets po TID with meals
ASA 81mg po daily
vitamin B complex one tab daily
fluticasone proprionate one spray in each nostril daily
lidocaine cream, apply to fistula as directed prior to
hemodialysis
prozac _____ (unknown dose)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam:
V/S: 97.6F, 180/100, 80, 16, 92-93%/RA
Gen: NAD, lying in bed comfortably
Head/Neck: NC/AT, no scleral icterus, no oropharyngeal lesions,
neck supple
Cardiovascular: RRR, continuous systolic-diastolic murmur
Pulmonary: Equal air entry bilaterally
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, thrill at L upper arm AVF

FAMILY HISTORY: Sister died from diabetes complications
6 siblings alive with hypertension
8 living children with various problems including diabetes,
obesity, and fatty liver

SOCIAL HISTORY: Immigration from Bolivia in [**2134-12-1**]. Has completed high
school and is currently married. Quit drinking approximately 4
years ago, however, has history of some heavier alcohol abuse.
He is a nonsmoker and has no tattoos. Has 8 children, 6 of whom
live in the area and are heavily involved in patient's health
care. 

### Response:
{'Pulmonary congestion and hypostasis,Cerebral embolism with cerebral infarction,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hemiplegia, unspecified, affecting nondominant side,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anxiety state, unspecified,Renal dialysis status,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Personal history of tuberculosis,Dysarthria,Contact with or exposure to tuberculosis'}
