CHIEF COMPLAINT: Slurred speech

PRESENT ILLNESS: 64yo RH M h/o HTN, frontal dysfunction who was last known well
at 1:30pm. At  6:10pm, he was seen to slump over by his son, who
was alarmed that his speech was markedly slurred and he was
difficult to arouse for 3-4 minutes. He wheeled him to the couch
and called EMS. On their arrival, their exam was notable for
"altered mental status", saying he was 29yo and also for mild
slurred speech and their screen for stroke was negative, with no
significant droop or lateralized weakness.

MEDICAL HISTORY: Atrial fibrillation, treated with flecainide, which caused
atrial
flutter; now s/p two ablations, first in [**2190**], another in [**2195**]
h/o migraines
Hyperlipidemia
h/o MVA with frontal lobe dysfunction: deficits of
attention/executive function on recent testing
h/o TGA
h/o 1mm MCA aneurysm
No h/o HTN, DM or CAD

MEDICATION ON ADMISSION: ASA 325
Lipitor 10
Flecanide 150mg [**Hospital1 **]
Cartia 120
Zoloft 100mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: CODE STROKE SCALE:
Neurologic (NIHSS): 5
1a. LOC: alert, responsive (0)
1b. LOC questions: knew age and name of month (0)
1c. LOC commands: closed eyes and gripped with **(nonparetic)
hand (0)
2. Best gaze: No gaze palsy (0)
3. Visual: left inferior quadrantanopsia (1)
4. Facial Palsy: left facial asymmetry (1)
5a. Left arm: mild drift (1)
5b. Right arm: no drift (0)
6a. Left leg: No drift (0)
6b. Right leg: no drift (0)
7. Limb ataxia: absent (0)
8. Sensory: left face/arm sensory loss (1)
9. Language: No aphasia, normal (0)
10. Dysarthria: None (0)
11. Extinction/inattention: extinguishes visual and tactile
stimuli (1)

FAMILY HISTORY: mother died at 86 of PNA, CHF. Father is unknown to him.

SOCIAL HISTORY: lives at home independently. No h/o tob/etoh/illicit drugs.
Former mortgage broker
Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Paralysis of vocal cords or larynx, unspecified,Dehydration,Urinary obstruction, not elsewhere classified,Hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (LUTS),Vascular disorders of kidney,Acute kidney failure, unspecified,Dissection of other artery,Chronic kidney disease, Stage III (moderate),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Facial weakness,Other dysphagia,Encephalopathy, unspecified,Aneurysm of artery of neck,Atrial fibrillation,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants
Crbl emblsm w infrct,Food/vomit pneumonitis,Other staphylococcus,Vocal cord paralysis NOS,Dehydration,Urinary obstruction NEC,BPH NOS w ur obs/LUTS,Renal vascular disorder,Acute kidney failure NOS,Dissection artery NEC,Chr kidney dis stage III,Hy kid NOS w cr kid I-IV,Facial weakness,Dysphagia NEC,Encephalopathy NOS,Aneurysm of neck,Atrial fibrillation,Migrne unsp wo ntrc mgrn,Hyperlipidemia NEC/NOS,Long-term use anticoagul
Admission Date:  [**2199-10-17**]              Discharge Date:   [**2199-11-1**]

Date of Birth:  [**2135-5-2**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Slurred speech


Major Surgical or Invasive Procedure:
endotracheal intubation
central venous line insertion
radial arterial line insertion

History of Present Illness:
64yo RH M h/o HTN, frontal dysfunction who was last known well
at 1:30pm. At  6:10pm, he was seen to slump over by his son, who
was alarmed that his speech was markedly slurred and he was
difficult to arouse for 3-4 minutes. He wheeled him to the couch
and called EMS. On their arrival, their exam was notable for
"altered mental status", saying he was 29yo and also for mild
slurred speech and their screen for stroke was negative, with no
significant droop or lateralized weakness.

Per the patient, he was "attacked by 4 naked women." On repeat
questioning about what happened, he said that his son became
alarmed that he had had a stroke.

At present, the patient denies all complaints. He says his
speech is now normal. He recalls the entire episode, which was
not preceeded by any prodrome of feeling faint, palpitations,
chest pain or alteration in his thinking. He denies vertigo,
diplopia or visual changes, weakness, tingling/numbness, gait
difficulty.

This morning, he reports that he had a "migraine". These are
preceeded by flashing white lights and followed by a
retroorbital, throbbing headache. They are a/w photophobia and
now occur 3-4 times a week. They first occurred in adolescence
then remitted until he was in an MVA a few years ago (with no
associated LOC).

ROS: On review of systems, the pt denied recent fever or chills.
 No night sweats or recent weight loss or gain. Denied cough,
shortness of breath.  Denied chest pain or tightness,
palpitations.  Denied nausea, vomiting, diarrhea, constipation
or abdominal pain.  No recent change in bowel or bladder habits.
 No dysuria.  Denied arthralgias or myalgias. Denied rash.


Past Medical History:
Atrial fibrillation, treated with flecainide, which caused
atrial
flutter; now s/p two ablations, first in [**2190**], another in [**2195**]
h/o migraines
Hyperlipidemia
h/o MVA with frontal lobe dysfunction: deficits of
attention/executive function on recent testing
h/o TGA
h/o 1mm MCA aneurysm
No h/o HTN, DM or CAD

PSH: s/p appendectomy


Social History:
lives at home independently. No h/o tob/etoh/illicit drugs.
Former mortgage broker


Family History:
mother died at 86 of PNA, CHF. Father is unknown to him.


Physical Exam:
CODE STROKE SCALE:
Neurologic (NIHSS): 5
1a. LOC: alert, responsive (0)
1b. LOC questions: knew age and name of month (0)
1c. LOC commands: closed eyes and gripped with **(nonparetic)
hand (0)
2. Best gaze: No gaze palsy (0)
3. Visual: left inferior quadrantanopsia (1)
4. Facial Palsy: left facial asymmetry (1)
5a. Left arm: mild drift (1)
5b. Right arm: no drift (0)
6a. Left leg: No drift (0)
6b. Right leg: no drift (0)
7. Limb ataxia: absent (0)
8. Sensory: left face/arm sensory loss (1)
9. Language: No aphasia, normal (0)
10. Dysarthria: None (0)
11. Extinction/inattention: extinguishes visual and tactile
stimuli (1)

PE
VS 97.9 64 134/82 12 98%
Gen Awake, cooperative, NAD
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no rashes or lesions noted

NEURO
MS Awake, alert. Fully oriented. Recites [**Doctor Last Name 1841**] forwards but only
two backwards then trails off. Disinhibited and reaches to poke
my eyes (like the three Stooges). Impaired luria sequencing.
Unable to perform go-no go properly. Speech fluent, with normal
naming, [**Location (un) 1131**], writing, comprehension and repetition. Normal
prosody. There were no paraphasic errors. Able to follow both
midline and appendicular commands. No apraxia. Interprets cookie
theft picture appropriately. No dysarthria.

CN
CN I: not tested
CN II: L inferior quadrantanopsia to confrontation, with
extinction on the left to DSS. Pupils 3->2 b/l. Fundi clear.
CN III, IV, VI: EOMI no nystagmus or diplopia
CN V: LT/PP decreased on the left
CN VII: mild L facial droop (not on prior neuro eval)
CN VIII: hearing intact to FR b/l
CN IX, X: palate rises symmetrically
CN [**Doctor First Name 81**]: shrug [**4-27**] and symmetric
CN XII: tongue midline and agile

Motor
Normal bulk and tone. No pronator drift
  D B T WE FE FF IP Q H DF PF TE

Sensory intact to LT, PP, JPS, vibration throughout the right
side; the left face and arm have decreased LT/PP.

Reflexes
   Br  [**Hospital1 **]  Tri  Pat  Ach  Toes
L  2+  2+  2+   2+   2+   down
R  2+  2+  2+   2+   2+   down

Coordination FFM, RAMs, FTN, HTS all normal

Gait deferred, due to need for CT


Pertinent Results:
Labs
[**2199-10-17**] 07:50PM   WBC-11.4* RBC-4.45* HGB-14.3 HCT-42.7 MCV-96
MCH-32.1* MCHC-33.5 RDW-14.4
[**2199-10-17**] 07:50PM   PLT COUNT-274
[**2199-10-17**] 07:50PM   GLUCOSE-109* UREA N-12 CREAT-1.2 SODIUM-141
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-28 ANION GAP-13
[**2199-10-17**] 10:05PM   PT-11.5 PTT-34.5 INR(PT)-1.010/26/07 06:05AM
BLOOD Triglyc-97 HDL-69 CHOL/HD-2.9 LDLcalc-114
[**2199-11-1**] 06:20AM BLOOD PT-24.7* PTT-41.9* INR(PT)-2.5*
EKG  [**2199-10-17**]:
Probable atrial fibrillation. Voltage changes and ST-T wave
abnormalities
are consistent with left ventricular hypertrophy. Clinical
correlation is
suggested. Compared to previous tracing the patient is now in
atrial
fibrillation.

Imaging

CT/CT-P/ CTA head and neck ([**2199-10-17**]):

HEAD CT:  There is no evidence of hemorrhage, mass, mass effect
or shift of
the normally midline structures. The [**Doctor Last Name 352**]- white differentiation
is
maintained.

CT PERFUSION:  There is decreased blood flow and increased
transit time in the
right temporal and right frontal regions in the distributions of
teh inferior
division of the right middle cerebral artery and the right
anterior cerebral
artery. There is moderate reduction of the blood volume in these
areas,
suggesting irreversible injury.

CT OF THE HEAD AND NECK:  Dental artifact limits visualization
of the cervical
portion of the carotid arteries and the cervical vessels, which
are apperently
irregular only in this area. Otherwise, the visualized portions
of the carotid
and vertebral arteries are unremarkable without evidence of
stenosis. The left
vertebral artery is hypoplasic. Scattered lymphadenopathy in the
anterior neck
is not enlarged by CT size criteria.

IMPRESSION: 1)  Ischemia in the territory of the inferior
division of the
right middle cerebral artery and the right anterior cerebral
artery. This
distribution is suggestive of embolic phenomenon. There is
moderate reduction
in blood volume in these regions, raising a concern that some of
the tissue
may be irreversibly injured.

2) limited evaluation of the vascular structures in the neck
without cervical
area

MRI ([**2199-10-19**]):
MRI OF THE BRAIN:  Diffusion abnormalities are noted in the
right MCA
territory consistent with acute/subacute stroke.  There is no
shift of
normally midline structures, intra- or extra-axial hemorrhage.
The orbits, paranasal sinuses and mastoid air cells  within
normal  limits

MRA OF THE CIRCLE OF [**Location (un) **]:  There is occlusion of the distal
branches of the
posterior right MCA. The previously demostrated 1 mm aneurysm in
the right M1
segment of the middle cerebral artery is again noted just
proximal to the
bifurcation and unchanged.

Multiple bilateral FLAIR hyperintensity foci likely represent
chronic
microvascular ischemic changes.

MRA OF THE CAROTIDS AND VERTEBRAL ARTERIES:  The carotids and
vertebral
arteries are visualized from the origins to the intracranial
courses.
Hypoplastic left vertebral artery.  No significant carotid
stenosis.

IMPRESSION:
1.  Occlusion of the distal branches of the right MCA with large
acute stroke.
2.  Unchanged 1 mm right M1 MCA aneurysm.

Transthoracic echocardiogram: [**2199-10-18**]
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. Very mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2195-2-16**],
the rhythm is now atrial fibrillation and mild mitral
regurgitation is now identified. The severity of aortic
regurgitation is similar.

CT OF THE PELVIS WITH INTRAVENOUS CONTRAST ([**2199-10-19**]):  The
rectum, sigmoid colon,
bladder, prostate, seminal vesicles, ureters are within normal
limits. The
bladder contains a foley balloon .

BONE WINDOWS:  No suspicious lytic or sclerotic lesion is
detected.
Degenerative changes are seen, most notably at L5-S1 endplates.

IMPRESSION:
1.  Bilateral lower lobe atelectasis/consolidation.
2.  Patchy areas of low attenuation within both kidneys, some of
which appear
wedge-shaped concerning for renal infarction.
3.  Linear opacity within the proximal SMA which is most
concerning for
dissection.*  No evidence of bowel ischemia at this time.
*  Was no borne out clinically on hospitalization


Brief Hospital Course:
Mr. [**Known lastname 95655**] is a 64 year old right handed gentleman with
history of atrial fibrillation on antiarrhythmic s/p ablation,
hyperlipidemia who had transient, severe dysarthria that
resolved. His Neuro exam at presentation, in addition to frontal
lobe dysfunction that appears to be chronic, was significant for
new onset left facial asymmetry, as well as either primary
visual field defects (left homonymous inferior quadrantanopsia)
and left face/arm sensory loss; or alternatively
neglect (although cookie jar picture interpretation at
presenation was intact).

1) Right inferior division MCA infarction-
The patient was found to have a R inferior division MCA infarct
by CT perfusion images. He presented out of the window for IV
tPA. IA tPA or merci retrieval was not justified due to the
nature of his deficits risks of the procedure. The etiology of
his infarct was likely embolic in the setting of recurrent
atrial fibrillation.

He was admitted to the stroke service where he was started on
heparin IV goal PTT 50-70 given suspected cardioembolic source
of the infarct. The morning following admission the patient
developed transient worsening of left facial droop and
dysarthria. Repeat head CT was stable in appearance. This
recurred later in the afternoon, and his PTT was noted to be
above therapeutic range at 97.5. Repeat head CT revealed stable
size of hyperdense R MCA parietal territory however [**12-25**]
microhemorrhages vs. hyperdense MCA sign consistent with vessel
occlusion. His blood pressures were noted to be SBP's 110's and
it was thought the infarct penumbra may be hypoperfused given
loss of cerebral blood autoregulation s/p infarction. He was
transferred to the ICU for tighter blood pressure regulation,
with goal SBP's > 140 and closer neurological monitoring given
concern for early hemorrhagic conversion.

In the ICU the patient underwent central line placement and
aterial line placement and was started on neosynephrine to
maintain SBP's > 140mmHg. The patient became markedly agitated
on ICU day #2 and required four point restraints, leading to
intubation. On HD #4 pressors were weaned and the patient was
intubated. He was started on vancomycin and zosyn on [**10-22**] for
fevers in setting of RML infiltrate by chest x ray for presumed
aspiration pneumonia; he completed a 10-day course of these
antibiotics. He was transferred to the neuroscience step-down
unit for further care.  Neurologically, his exam improved over
time: he had significant improvement of the strength and
attention to his left arm and by the time of discharge, the
facial droop was barely noticable.  His walking remained mildly
unsteady, thus physical therapy recommended rehab.  His course
in the stepdown unit was initially notable for agitation and
confusion at night (consistent with sundowning), sometimes with
hallucinations.  This was felt to be a combination of reversal
of his sleep-wake cycle, his underlying frontal lobe dysfunction
(chronic, question of frontotemporal dementia) and the new
stroke.  Initially he required medications for sleep and a 1:1
sitter.  This improved with time and with orientation via family
members involved in his care, and by the time of discharge he
was sleeping well at night.

Of note, Mr. [**Known lastname 95655**] was discovered to have vocal cord
paralysis and oropharyngeal paresis, likely a result of the
intubation in the ICU.  He worked with the speech pathologists
and should continue at rehab to work on vocalization exercises.
Initially he was unable to swallow safely due to incomplete
vocal cord closure and thus risk of poor cough.  He was
reassessed by the swallow specialists and approved for a
modified diet the week of discharge.  No further signs of
aspiration were seen, and the swallowing function was not felt
to have been damaged by the stroke.

Periodically he complained of mild, dull headaches and was
treated with tylenol, ibuprofen (discontinued after rising
creatinine), and fioricet.  The headaches responded to Percocet
at times.  There were no changes in his neuro exam or other
symptoms associated with these headaches.  Of note, he has R
frontal headaches at baseline and has so for many years, many
with visual scotomata, suggestive of migraines.  He had no
similar headaches in the last week of his hospital stay.

2) Atrial Fibrillation-
He had failed ablative therapy and pharmacotherapy on
flecainide, and had presented with this acute R MCA infarction.
He will require life long anticoagulation on coumadin for
secondary prevention of stroke. Metoprolol was started for rate
control, and eventually he was restarted on anticoagulation with
heparin and then coumadin.  On the day of discharge, his rhythm
was again normal sinus.  At the time.  In response to this,
cardiology recommended restarting his calcium channel blocker
and flecanide.  He should follow up with his cardiologist as an
outpatient following discharge.

Of note, cardiology had concerns about anticoagulation in this
patient, who was found incidentally to have a possible 1mm
aneurysm at the RMCA; however, the neurology service felt that
the benefits of prevention of further strokes outweighed the
minimal risks associated with a small vascular anomaly, and he
was anticoagulated after discussion with the family.

3) Renal infarcts and possible SMA occlusion-
The patient complained of abdominal pain on ICU day #2. He
underwent contrasted CT of the abdomen revealing concern for
wedge shaped renal infarcts and partial superior mesenteric
artery occlusion. Vascular surgery was consulted and did not
deem the SMA partial occlusion a surgical condition; further
imaging revealed this to be potentially artifactual. Renal
infarcts were felt to be likely embolic in nature relating to
afib and will require coumadin anticoagulation.  Further in his
hospital course on the floor, he developed an elevated
creatinine.  He was seen by the renal specialists for this
problem (below).

4) Renal failure-
He was found to have a rising creatinine and was seen by the
renal service for this while he was on the floor.  Though he had
been on some renally cleared medications and ibuprofen at time
for headaches, renal felt ultimately after checking urine
eosinophils (negative) and urine lytes (unremarkable) that the
most likely explanation was damage incurred with the renal
infarcts and possible dehydration.  Of note, his foley was
discontinued periodically with some difficulty urinating, likely
the result of prostate hypertrophy.  The day of discharge, he
had trouble voiding; nursing recommended timed voids attempted
with straight-catheterization if necessary every 6 hours once he
arrives at rehab.  He was hypernatremic to 147, then receiving
D5W over 2 days at 55 cc/hr to correct a free water deficit.  On
the day of discharge, his sodium was 146 and he received
addition free water, per renal recommendations.  His sodium
should be checked periodically at rehab.

5) FEN-
NG tube was attempted multiple times, in addition to assistance
from interventional radiology without initial success, but later
with success. He eventually was able to swallow following the
vocal cord paralysis (as above), and he resumed a modified diet.


6) ID-
His aspiration pneumonia was treated with ten days of
antibiotics (as above); on the day of discharge, his white blood
cell count was stably high (12-13,000 range) with no fevers and
no abnormal blood or urine cultures.


Medications on Admission:
ASA 325
Lipitor 10
Flecanide 150mg [**Hospital1 **]
Cartia 120
Zoloft 100mg [**Hospital1 **]


Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation
Q6H (every 6 hours) as needed.
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for headache.
8. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours).
9. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).


Discharge Disposition:
Extended Care

Facility:
[**Location (un) **]

Discharge Diagnosis:
-Right MCA stroke
-Atrial fibrillation
-Renal failure in the setting of bilateral renal infarcts
-Aspiration pneumonia
-Vocal cord paralysis and pharyngeal paresis possibly related to
intubation


Discharge Condition:
Good.  Neurologically, his exam improved over time: he had
significant improvement of the strength and attention to his
left arm and by the time of discharge, the facial droop was
barely noticable. His walking remained mildly unsteady.


Discharge Instructions:
Please take your medications as prescribed and follow up with
appointments as scheduled.  You are on warfarin to thin your
blood for stroke given your history of atrial fibrillation.  The
INR should be checked regularly (daily at first), with the
target range between [**1-26**].  Should you have any additional
concerning, worsening, or new symptoms, such as new visual
changes (loss), dysarthria, or weakness, then please contact Dr.
[**First Name8 (NamePattern2) 2530**] [**Name (STitle) 2531**] office ([**Telephone/Fax (1) 7394**] or the on-call [**Hospital3 **]
neurologist at ([**Telephone/Fax (1) 2529**].

Of note, the patient voided on the morning of hospitalization,
but not thereafter.  A straight-cath revealed 250cc of urine in
the afternoon.  If the patient does not urinate, he should be
bladder-scanned (and straight-cathed, if necessary) every 6
hours until he does so on his own.  Furthermore, his sodium was
mildly elevated on the day of discharge at 146; the sodium level
should be checked daily until it is stably within normal limits.
 The patient may require additional free water to correct this
hypernatremia.

Followup Instructions:
1)  Please call the office of Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] at ([**Telephone/Fax (1) 19129**] to set up an appointment with him in the neurology
stroke clinic in the next 2-4 weeks.

2)  You have the following appointment cardiologist in
approximately 4 weeks.  please call his office to determine if
he would like to see you sooner.
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2199-12-5**] 3:20

3)  Please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**] at
([**Telephone/Fax (1) 2941**], to arrange follow up after your hospitalization.
 He should be seen in the next 2-4 weeks, if possible.


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
{'Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Paralysis of vocal cords or larynx, unspecified,Dehydration,Urinary obstruction, not elsewhere classified,Hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (LUTS),Vascular disorders of kidney,Acute kidney failure, unspecified,Dissection of other artery,Chronic kidney disease, Stage III (moderate),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Facial weakness,Other dysphagia,Encephalopathy, unspecified,Aneurysm of artery of neck,Atrial fibrillation,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants'}


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: Slurred speech

PRESENT ILLNESS: 64yo RH M h/o HTN, frontal dysfunction who was last known well
at 1:30pm. At  6:10pm, he was seen to slump over by his son, who
was alarmed that his speech was markedly slurred and he was
difficult to arouse for 3-4 minutes. He wheeled him to the couch
and called EMS. On their arrival, their exam was notable for
"altered mental status", saying he was 29yo and also for mild
slurred speech and their screen for stroke was negative, with no
significant droop or lateralized weakness.

MEDICAL HISTORY: Atrial fibrillation, treated with flecainide, which caused
atrial
flutter; now s/p two ablations, first in [**2190**], another in [**2195**]
h/o migraines
Hyperlipidemia
h/o MVA with frontal lobe dysfunction: deficits of
attention/executive function on recent testing
h/o TGA
h/o 1mm MCA aneurysm
No h/o HTN, DM or CAD

MEDICATION ON ADMISSION: ASA 325
Lipitor 10
Flecanide 150mg [**Hospital1 **]
Cartia 120
Zoloft 100mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: CODE STROKE SCALE:
Neurologic (NIHSS): 5
1a. LOC: alert, responsive (0)
1b. LOC questions: knew age and name of month (0)
1c. LOC commands: closed eyes and gripped with **(nonparetic)
hand (0)
2. Best gaze: No gaze palsy (0)
3. Visual: left inferior quadrantanopsia (1)
4. Facial Palsy: left facial asymmetry (1)
5a. Left arm: mild drift (1)
5b. Right arm: no drift (0)
6a. Left leg: No drift (0)
6b. Right leg: no drift (0)
7. Limb ataxia: absent (0)
8. Sensory: left face/arm sensory loss (1)
9. Language: No aphasia, normal (0)
10. Dysarthria: None (0)
11. Extinction/inattention: extinguishes visual and tactile
stimuli (1)

FAMILY HISTORY: mother died at 86 of PNA, CHF. Father is unknown to him.

SOCIAL HISTORY: lives at home independently. No h/o tob/etoh/illicit drugs.
Former mortgage broker 

### Response:
{'Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Paralysis of vocal cords or larynx, unspecified,Dehydration,Urinary obstruction, not elsewhere classified,Hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (LUTS),Vascular disorders of kidney,Acute kidney failure, unspecified,Dissection of other artery,Chronic kidney disease, Stage III (moderate),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Facial weakness,Other dysphagia,Encephalopathy, unspecified,Aneurysm of artery of neck,Atrial fibrillation,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants'}
