CHIEF COMPLAINT: Speech difficulty

PRESENT ILLNESS: Mr. [**Known lastname 105691**] (previous spelling incorrect as Rhineharist and a
new [**Hospital **] medical record was created) is an 80 year old right
handed male with complex medical history including prior TIA,
possible seizure disorder, now presenting with difficulty
speaking. The patient is unable to provide a complete history as
a result of his language deficit. He lives alone and cannot
provide a proxy at the moment. [**Name2 (NI) **] report intermittent difficulty
with balancing his checkbook over the last few days prior to
admission. He reported something was wrong on the day of
admission with sudden intermittent difficulty speaking
associated with right hand numbness and clumsiness. He was
brought to [**Hospital1 18**] ED where a head CT revealed question of a left
frontal lobe mass.

MEDICAL HISTORY: -Hypertension
-Peripheral [**Hospital1 1106**] disease, s/p distal aortic stenting
-Chronic renal insufficiency
-Multiple TIAs in [**2161**]. Then with right hand weakness in [**2164**]
and
now s/p L ICA stent in [**11-25**]
-Autonomic neuropathy, with evidence of both sympathetic and
parasympathetic dysfunction on autonomic testing
-Prostate cancer s/p brachytherapy
-Hyperlipidemia
-Gout
-Enhancing lesion, thought to be a meningioma in the anterior
cranial fossa
-? h/o Clivus lesion on MRI, bone scan negative

MEDICATION ON ADMISSION: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2
puffs(s) by mouth every four (4)  to six (6) hours as needed
ALLOPURINOL - 100 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
ASA - 325 MG  - ONE BY MOUTH EVERY DAY
ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth every day
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
CHLORPROMAZINE - 10 mg Tablet - 1 Tablet(s) by mouth [**Hospital1 **] prn
hiccups
CITALOPRAM [CELEXA] - 40 mg Tablet - 1 Tablet(s) by mouth once a
day
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once
a day
DARIFENACIN [ENABLEX] - 7.5 mg Tablet Sustained Release 24 hr -
1
Tablet(s) by mouth once a day
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays(s) both nares
every day
LEVETIRACETAM [KEPPRA] - 250 mg Tablet - 1 Tablet(s) by mouth
twice a day
OMEPRAZOLE - 20 mg Capsule daily
DOCUSATE SODIUM 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
FERROUS GLUCONATE -  (Prescribed by Other Provider) - 325 mg
Tablet - 1 Tablet(s) by mouth once a day
SODIUM CHLORIDE - 1,000 mg Tablet, Soluble - one tab po three
times a day for orthostatic hypotension

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: T 98.3, HR 64, BP 114/36, 16, 100% 2L NC
Gen- well appearing, comfortable, upright in bed, cooperative
with obvious speech deficit, NAD
HEENT: NCAT, OP clear, MMM, Anicteric sclera
Neck- no carotid bruits bilat. Left sided neck incision is c/d/i
with steri-strips in place
CV- RRR, no MRG
Pulm- diffuse, prominent expiratory wheezes
Abd- protuberant, soft, nd, nt, BS+
Extrem- no CCE

FAMILY HISTORY: No history of neurologic disease.

SOCIAL HISTORY: He lives alone in [**Location 1268**]. Widowed from his second
marriage, son lives in [**State 531**] City - [**Name (NI) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name 105692**]. He
has a sig other [**Doctor Last Name 636**] "[**Doctor First Name 7019**]" [**Location (un) **]. He is retired from a
medical supplier shipping business.  He has an 80-pack-year
smoking history; he quit 18 years ago. He denies any ETOH or
illicit drug use.
Mechanical complication of other vascular device, implant, and graft,Occlusion and stenosis of carotid artery with cerebral infarction,Asthma, unspecified type, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Mononeuritis of unspecified site,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places
Malfunc vasc device/graf,Ocl crtd art w infrct,Asthma NOS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Mononeuritis NOS,Abn react-anastom/graft,Accident in place NEC
Admission Date:  [**2169-4-14**]              Discharge Date:   [**2169-4-21**]

Date of Birth:  [**2088-5-12**]             Sex:   M

Service: SURGERY

Allergies:
Ace Inhibitors

Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Speech difficulty

Major Surgical or Invasive Procedure:
Left CEA per Dr. [**Last Name (STitle) 1391**] on [**2169-4-19**]

History of Present Illness:
Mr. [**Known lastname 105691**] (previous spelling incorrect as Rhineharist and a
new [**Hospital **] medical record was created) is an 80 year old right
handed male with complex medical history including prior TIA,
possible seizure disorder, now presenting with difficulty
speaking. The patient is unable to provide a complete history as
a result of his language deficit. He lives alone and cannot
provide a proxy at the moment. [**Name2 (NI) **] report intermittent difficulty
with balancing his checkbook over the last few days prior to
admission. He reported something was wrong on the day of
admission with sudden intermittent difficulty speaking
associated with right hand numbness and clumsiness. He was
brought to [**Hospital1 18**] ED where a head CT revealed question of a left
frontal lobe mass.

He was evaluated by neurosurgery and admitted for MRI. Two days
following his initial admission, MRI reveals subacute infarcts
in the inferior division of the L MCA. Neurology was then
consulted to evaluate the patient.

Upon my comparison of the patient's license in his wallet to his
current ID band there is a discrepancy in the spelling of his
last name. Revealing that the patient has an extensive previous
medical history here at this institution. The patient is able to
tell me that his PCP his here at [**Hospital1 18**].

MRI is without any vessel imaging. The patient was taking plavix
for coronary and carotid stents and this is currently being held
for unclear reasons. The patient is unable to offer any further
HPI. At present he denies any headache. He is well aware of his
difficulty in speech production. He reports difficulty with
handwriting, he is unable to hold a pen in his right hand
despite normal strength. He reports right hand diminished
sensation. No bowel or bladder
incontinence. He reports his gait has been unsteady for ? amount
of time.

ROS: denies any F/C/NS, + chronic cough and singultus, no chest
pain. no abdominal pain. no N/V, no diarrhea, no constipation.

Past Medical History:
-Hypertension
-Peripheral [**Hospital1 1106**] disease, s/p distal aortic stenting
-Chronic renal insufficiency
-Multiple TIAs in [**2161**]. Then with right hand weakness in [**2164**]
and
now s/p L ICA stent in [**11-25**]
-Autonomic neuropathy, with evidence of both sympathetic and
parasympathetic dysfunction on autonomic testing
-Prostate cancer s/p brachytherapy
-Hyperlipidemia
-Gout
-Enhancing lesion, thought to be a meningioma in the anterior
cranial fossa
-? h/o Clivus lesion on MRI, bone scan negative

Social History:
He lives alone in [**Location 1268**]. Widowed from his second
marriage, son lives in [**State 531**] City - [**Name (NI) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name 105692**]. He
has a sig other [**Doctor Last Name 636**] "[**Doctor First Name 7019**]" [**Location (un) **]. He is retired from a
medical supplier shipping business.  He has an 80-pack-year
smoking history; he quit 18 years ago. He denies any ETOH or
illicit drug use.


Family History:
No history of neurologic disease.

Physical Exam:
T 98.3, HR 64, BP 114/36, 16, 100% 2L NC
Gen- well appearing, comfortable, upright in bed, cooperative
with obvious speech deficit, NAD
HEENT: NCAT, OP clear, MMM, Anicteric sclera
Neck- no carotid bruits bilat. Left sided neck incision is c/d/i
with steri-strips in place
CV- RRR, no MRG
Pulm- diffuse, prominent expiratory wheezes
Abd- protuberant, soft, nd, nt, BS+
Extrem- no CCE

Neurologic Exam:
MS- alert, arouses easily to voice, attentive to examination,
speech is of variable fluency, largely nonfluent, his naming is
intact to high and low frequency objects, he makes some frequent
paraphasic errors with spontaneous speech, repitition is
impaired. He is able to read some simple phrases, but then
perseverates and does not read more complex sentences. He is
unable to write. No difficulty with praxis for combing hair,
brushing teeth. No neglect.

CN- PERRL 3-->2mm bilat, EOMI, no nystagmus, VFF to
confrontation, his facial musculature appears symmetric, full
facial strength, facial sensation diminished to pinprick R
V2,V3. hearing intact to FR, palate elevates symm, SCM and trap
are [**4-25**], tongue at midline.

Motor- increased tone in all extremities, no cogwheeling. no
adventitious movements. R pronator drift. Strength is full in
all muscles tested including delt, tri, [**Hospital1 **], WE, FE, FF, IP, Q,
H, TA, PF, [**Last Name (un) 938**].

Sensory- diminished PP, LT, temperature, prop on right hemibody
(face, arm, trunk, leg).

Reflexes- Absent [**Hospital1 **], tri, brachioradialis, 1+ patellars, absent
ankle jerks.

Coordination- intact FNF, slightly slowed [**Doctor First Name 6361**] bilaterally
(symmetrically).

Gait- poor initiation, shortened stride, unsteady.

Pertinent Results:
CT Head [**4-14**]:
IMPRESSION: 1.6 x 1.3 cm left frontal hyperdense brain mass. MRI
is
recommended for further evaluation.

MR [**Name13 (STitle) 430**] [**4-15**]:
IMPRESSION: Multiple foci of slow diffusion consistent with
acute infarction in the left MCA [**Month/Year (2) 1106**] distribution,
involving the subcortical white matter, likely consistent with
embolic disease. No mass lesion or abnormal enhancement is
identified at the site of hyperdensity seen on recent CT.
Multiple scattered FLAIR hyperintensity areas likely consistent
with chronic microvascular ischemic changes in the subcortical
white matter.

CTA Head and Neck [**4-16**]:
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or major
territorial
infarction. Small regions of embolic infarction within the left
MCA territory are better appreciated on the DWI sequence of
recent MRI.
2. Severe luminal stenosis involving the right internal carotid
artery just distal to its bifurcation, of at least 80%.
Significant stenosis is present involving the left internal
carotid artery at the cranial aspect of the [**Month/Year (2) 1106**] stent and a
short segment beyond with at least 60% stenosis.
3. Mild paraseptal emphysematous changes within the lung apices.

4. Moderate irregularly ulcerated plaque within the aortic arch
incidentally noted.

Carotid Series Complete [**4-17**]
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On the right there is significant heterogeneous plaque
in the carotid bulb/ICA. on the left there is a patent LT
ICA/CCA stent with some mild to moderate narrowing distal to
stent .

On the right systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are141/33, 160/43, 55/15,
cm/sec. CCA peak systolic velocity is 83 cm/sec. ECA peak
systolic velocity is 107 cm/sec. The ICA/CCA ratio is 1.9. These
findings are consistent with 60-69% stenosis.

On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 70/26, 119/43, 102/31, cm/sec. CCA peak
systolic
velocity is 72 cm/sec. ECA peak systolic velocity is 123 cm/sec.
The ICA/CCA ratio is 1.6. These findings are consistent with
40-59% stenosis.

There is antegrade right vertebral artery flow.
There is antegrade left vertebral artery flow.
Impression: Right ICA stenosis 60-69
Left ICA stenosis 40-59


Brief Hospital Course:
Patient is a 80 year old man admitted to Neurosurgery service on
[**4-14**] with difficulty speaking and now transferred to Neurology
for stroke workup. He has hx of TIA in [**2161**], two admissions for
TIA in [**2164**], first with aphasia and then subsequently for right
hand weakness, received left ICA stent in [**2164**]. He has been on
aspirin, Plavix, and Lipitor since the ICA stenting. He has
history of two amnestic episodes and multiple episodes of
left-sided weakness. He is being evaluated for possible simple
partial seizures and complex partial seizures. He has been on
Keppra since [**2167**]. Also hx of autonomic instability both
sympathetic and parasympathetic. Hyperlipidemia. PVD.

On [**4-14**], he had difficulty speaking. Also noted right hand
numbness and clumsiness. Patient was taken to [**Hospital1 18**] ED where
Head CT showed question of left frontal mass.
Admitted to Neurosurgery. MRI brain on [**4-15**] showed multiple
subacute infarcts in the inferior division of the left MCA. No
hemorrhages seen.

On exam, he has non-fluent aphasia, with alexia and agraphia,
right pronator drift, and mild sensory deficits on the right.
Etiology could be embolic due to possible restenosis of the left
ICA stent, intracranial embolus, or possibly cardioembolic
source. CTA showed critical stenosis of the L ICA just distal to
the prior stenting hence he was started on heparin gtt and
[**Month/Year (2) 1106**] consult was obtained.  Given the symptomatic and
critical stenosis, patient was taken for L CEA per Dr. [**Last Name (STitle) 1391**].

He tolerated the procedure well and was taken to the [**Last Name (STitle) 1106**]
ICU overnight. He was on a nitro drip to keep his systolic
pressures below 140 mmHg. This was discontinued on the same
night as surgery.

On POD 1 his staples were removed from his neck and steri-strips
were placed. He was seen and evaluated by PT and OT who
recommended rehab.

POD#2 stable. rehab screening in progress.

POD#3 d/c to rehab.


Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2
puffs(s) by mouth every four (4)  to six (6) hours as needed
ALLOPURINOL - 100 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
ASA - 325 MG  - ONE BY MOUTH EVERY DAY
ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth every day
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
CHLORPROMAZINE - 10 mg Tablet - 1 Tablet(s) by mouth [**Hospital1 **] prn
hiccups
CITALOPRAM [CELEXA] - 40 mg Tablet - 1 Tablet(s) by mouth once a
day
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once
a day
DARIFENACIN [ENABLEX] - 7.5 mg Tablet Sustained Release 24 hr -
1
Tablet(s) by mouth once a day
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays(s) both nares
every day
LEVETIRACETAM [KEPPRA] - 250 mg Tablet - 1 Tablet(s) by mouth
twice a day
OMEPRAZOLE - 20 mg Capsule daily
DOCUSATE SODIUM 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
FERROUS GLUCONATE -  (Prescribed by Other Provider) - 325 mg
Tablet - 1 Tablet(s) by mouth once a day
SODIUM CHLORIDE - 1,000 mg Tablet, Soluble - one tab po three
times a day for orthostatic hypotension


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Recurrent left carotid stenosis
history of HTn
history of aortic- descending stenosis, s/p thoracic stenting
history of chronic renal disease
history of recurrent TIA's, stroke-aphasic
history of carotid disease s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stenting [**11-25**]
history of prostatic Ca s/p brachythearphy
history of rt. ueretal stenting
history of autonomic neuropathy
history of dyslipdemia
history of gout


Discharge Condition:
Stable. Steri-strips over left neck incision.


Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or

back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Other:
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1391**] in 4 weeks. Call his office
at [**Telephone/Fax (1) 1393**] to schedule that appointment.

Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2169-4-25**]
1:00
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2169-4-25**]
2:00
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2169-4-25**]
2:30
followup Dr. [**Last Name (STitle) **] [**2169-5-10**] @ 1pm Neuro/stroke , if need to
change appointment call [**Telephone/Fax (1) 2574**]



Completed by:[**2169-4-21**]
{'Mechanical complication of other vascular device, implant, and graft,Occlusion and stenosis of carotid artery with cerebral infarction,Asthma, unspecified type, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Mononeuritis of unspecified site,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places'}


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: Speech difficulty

PRESENT ILLNESS: Mr. [**Known lastname 105691**] (previous spelling incorrect as Rhineharist and a
new [**Hospital **] medical record was created) is an 80 year old right
handed male with complex medical history including prior TIA,
possible seizure disorder, now presenting with difficulty
speaking. The patient is unable to provide a complete history as
a result of his language deficit. He lives alone and cannot
provide a proxy at the moment. [**Name2 (NI) **] report intermittent difficulty
with balancing his checkbook over the last few days prior to
admission. He reported something was wrong on the day of
admission with sudden intermittent difficulty speaking
associated with right hand numbness and clumsiness. He was
brought to [**Hospital1 18**] ED where a head CT revealed question of a left
frontal lobe mass.

MEDICAL HISTORY: -Hypertension
-Peripheral [**Hospital1 1106**] disease, s/p distal aortic stenting
-Chronic renal insufficiency
-Multiple TIAs in [**2161**]. Then with right hand weakness in [**2164**]
and
now s/p L ICA stent in [**11-25**]
-Autonomic neuropathy, with evidence of both sympathetic and
parasympathetic dysfunction on autonomic testing
-Prostate cancer s/p brachytherapy
-Hyperlipidemia
-Gout
-Enhancing lesion, thought to be a meningioma in the anterior
cranial fossa
-? h/o Clivus lesion on MRI, bone scan negative

MEDICATION ON ADMISSION: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2
puffs(s) by mouth every four (4)  to six (6) hours as needed
ALLOPURINOL - 100 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
ASA - 325 MG  - ONE BY MOUTH EVERY DAY
ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth every day
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
CHLORPROMAZINE - 10 mg Tablet - 1 Tablet(s) by mouth [**Hospital1 **] prn
hiccups
CITALOPRAM [CELEXA] - 40 mg Tablet - 1 Tablet(s) by mouth once a
day
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once
a day
DARIFENACIN [ENABLEX] - 7.5 mg Tablet Sustained Release 24 hr -
1
Tablet(s) by mouth once a day
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays(s) both nares
every day
LEVETIRACETAM [KEPPRA] - 250 mg Tablet - 1 Tablet(s) by mouth
twice a day
OMEPRAZOLE - 20 mg Capsule daily
DOCUSATE SODIUM 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
FERROUS GLUCONATE -  (Prescribed by Other Provider) - 325 mg
Tablet - 1 Tablet(s) by mouth once a day
SODIUM CHLORIDE - 1,000 mg Tablet, Soluble - one tab po three
times a day for orthostatic hypotension

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: T 98.3, HR 64, BP 114/36, 16, 100% 2L NC
Gen- well appearing, comfortable, upright in bed, cooperative
with obvious speech deficit, NAD
HEENT: NCAT, OP clear, MMM, Anicteric sclera
Neck- no carotid bruits bilat. Left sided neck incision is c/d/i
with steri-strips in place
CV- RRR, no MRG
Pulm- diffuse, prominent expiratory wheezes
Abd- protuberant, soft, nd, nt, BS+
Extrem- no CCE

FAMILY HISTORY: No history of neurologic disease.

SOCIAL HISTORY: He lives alone in [**Location 1268**]. Widowed from his second
marriage, son lives in [**State 531**] City - [**Name (NI) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name 105692**]. He
has a sig other [**Doctor Last Name 636**] "[**Doctor First Name 7019**]" [**Location (un) **]. He is retired from a
medical supplier shipping business.  He has an 80-pack-year
smoking history; he quit 18 years ago. He denies any ETOH or
illicit drug use. 

### Response:
{'Mechanical complication of other vascular device, implant, and graft,Occlusion and stenosis of carotid artery with cerebral infarction,Asthma, unspecified type, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Mononeuritis of unspecified site,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places'}
