CHIEF COMPLAINT: Right sided weakness and headache

PRESENT ILLNESS: The pt is a 56  year-old right-handed male with a past
medical history of stroke 9 years prior with transient left
sided
symptoms, HTN (and has not been taking medication for months
now)
who presents after vomiting and right sided weakness, and found
at OSH to have a left pontine bleed and transferred to [**Hospital1 18**].

MEDICAL HISTORY: - HTN
- history of old stroke with ? left sided symptoms (?numbness) 9
years prior
- pseudogout

MEDICATION ON ADMISSION: - not currently taking any of his prescribed medications

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION
Vitals: T: 98.2  P:70  R: 16  BP: 173/123 -> 128/92  SaO2: 100
General: Intubated, sedated,
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, intubated
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Mechanical breath sounds b/l
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

FAMILY HISTORY: Mother with stroke, Multiple family members with CAD
and HTN

SOCIAL HISTORY: Lives with wife and has adult children.  Currently
unemployed, has been out of work for some time, currently
without
insurance and as a result has not been taking his medication.
Occ etoh, no tob, no drugs Wife HCP:[**Telephone/Fax (3) 87833**]
mother: [**Telephone/Fax (1) 87834**]
Intracerebral hemorrhage,Acute kidney failure, unspecified,Hemiplegia, unspecified, affecting unspecified side,Unspecified essential hypertension,Personal history of noncompliance with medical treatment, presenting hazards to health,Facial weakness,Dysphagia, unspecified,Thrombocytopenia, unspecified,Dysarthria
Intracerebral hemorrhage,Acute kidney failure NOS,Unsp hemiplga unspf side,Hypertension NOS,Hx of past noncompliance,Facial weakness,Dysphagia NOS,Thrombocytopenia NOS,Dysarthria
Admission Date:  [**2133-11-23**]              Discharge Date:   [**2133-12-4**]

Date of Birth:  [**2077-1-10**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Right sided weakness and headache

Major Surgical or Invasive Procedure:
PEG tube placement
Endotracheal intubation


History of Present Illness:
The pt is a 56  year-old right-handed male with a past
medical history of stroke 9 years prior with transient left
sided
symptoms, HTN (and has not been taking medication for months
now)
who presents after vomiting and right sided weakness, and found
at OSH to have a left pontine bleed and transferred to [**Hospital1 18**].

(history obtained from notes/patient's wife)
The patient was a passenger in his car and was doing errands
with
his wife.  At one point she turned to him and thought he looked
grey.  He complained of severe nausea and she pulled over to the
side of the road.  She then noted a right facial droop and he
appeared to be having trouble with his right arm, possibly his
right leg.  As his wife is [**Name8 (MD) **] RN she thought he may be having a
stroke and called EMS who picked him up and transported him to
[**Hospital3 26615**].  At AJ he was noted to be significantly
hypertensive, with multiple BPs at 260/120s.  He had a head CT
and was noted to have a left sided pontine hemorrhage.  At the
time according to notes he was awake and could respond to
commands, was not using his right arm and right leg, and had a
right facial droop.  He could respond to commands with his left
side.  He was given labetalol for his BP and then transferred to
[**Hospital1 18**] for further eval.

Here he was initially seen by the ED and neurosurgery team.  On
initial exam they neurosurgeons felt he was able to say his
name,
had slurred speech, a right facial droop, they only elicited
upgaze.  He was able to follow commands with his left arm/leg,
and had no movement at the right.  He apparently was becoming
more sleepy as the interview progressed and he was sent to the
CT
scanner.  The CT demonstrated a stable bleed, with slightly more
edema than on the prior scan.  On return from the scanner the
patient was even more somnolent and he was intubated and sedated
out of concern for protecting his airway.  Neurosurgery at this
point recommended no surgical intervention and neurology was
called to evaluate the patient.

Of note per his wife the patient has long standing hypertension
however as he has been unemployed for some time and does not
have
health insurance.  He has not taken any of his antihypertensive
medications for many months now.

On neuro ROS and GROS largely unavailable, prior to presentation
the patient had nausea, clear dysarthria and weakness as
described above.
Per wife no recent fevers, no recent weight loss or gain. No
cough, shortness of breath. No recent change in bowel or bladder
habits.


Past Medical History:
- HTN
- history of old stroke with ? left sided symptoms (?numbness) 9
years prior
- pseudogout


Social History:
Lives with wife and has adult children.  Currently
unemployed, has been out of work for some time, currently
without
insurance and as a result has not been taking his medication.
Occ etoh, no tob, no drugs Wife HCP:[**Telephone/Fax (3) 87833**]
mother: [**Telephone/Fax (1) 87834**]


Family History:
Mother with stroke, Multiple family members with CAD
and HTN


Physical Exam:
ADMISSION
Vitals: T: 98.2  P:70  R: 16  BP: 173/123 -> 128/92  SaO2: 100
General: Intubated, sedated,
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, intubated
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Mechanical breath sounds b/l
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: Asleep and sedated, grimaces to pain but will
not
open eyes, does not follow commands, allowed ~30 minutes off
sedation and began to buck and fight vent so patient was re
sedated

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL right 3.5->2 , left 3mm->2mm,  does not blink to
threat.
III, IV, VI: Can get vertical dolls, can't get horizontal in
either direction
V, VII: corneal's intact bilaterally
IX, X: Gags and coughs

-Motor:
Right Upper Ext: no withdrawal to nox stim
R leg: triple flexes
LUE: occ spontaneous movements but does not withdraw to stim
LLE: makes purposeful movements with leg

-Sensory: Withdraws to nox at LE b/l, not reliably in either arm

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2  2    2    2   1
R  2  2    2    2   1
Plantar response was mute bilaterally
Clonus 5-7 beats in right leg, none in left

DISCHARGE
GEN: NAD, lying comfortably in bed
HEENT: atraumatic, bearded
CV: RRR, no murmurs
Pulm: CTABL
Abd: PEG in place c/d/i
Ext: no edema

NEURO:
MS: alert, oriented to [**Hospital1 18**], [**2133-12-4**], language dysarthric but
fluent, no paraphasia
CN: L eye fixed in midposition, R eye can ABduct but not ADDUCT
Motor: R arm was anti-gravity; L arm had D [**3-30**] B [**4-29**] T [**3-30**] FE
[**3-30**]
R leg anti-gravity; L leg IP [**3-30**] Q [**4-29**] H [**3-30**] TA [**3-30**]
Sensory: no gross deficits
Coordination: unable to test due to weakness
Reflexes: more brisk on right side
Gait: unable to assess


Pertinent Results:
CT (head) 1) Acute hemorrhage within the pons, extending into
the left middle cerebellar peduncle with possible slight
interval increase in the posterior component within the pons as
compared with exam performed 2 1/2 hours prior. Remainder of the
exam is stable.

2) Diffuse bilateral periventricular white matter hypodensity is
notable in a patient of this age. Findings are non-specific, and
while could relate tovchronic small vessel disease, although
other etiologies such as
demylenating/inflammatory processes are not excluded. Findings
could be
further evaluated on MRI, if no clinical contraindication.

Video Swallow:
Penetration with thickened honey consistencies. Silent
aspiration due to oral residue.


Brief Hospital Course:
HOSPITAL COURSE:

Neurologic:
He was first seen by the neurosurgery service who noted that he
was able to say his name and follow simple commands with the
left hand and leg. No movement at the right arm/leg.  Per their
exam he had upgaze, but difficulty with lateral eye movements.
He apparently was getting more somnolent and was sent to the
scanner, which showed the pontine bleed with some slightly worse
edema.  On return from the scanner he continued to be somnolent
and was intubated by the ED team out of concern for airway
protection.  When taken off sedation he will grimace to noxious
stimulation but will not open his eyes. He has intact corneals,
gag present, reactive pupils, has vertical VOR, but cannot get
horizontal.  No movement at the right arm, triple flexes right
leg, spontaneous movements of left leg, and purposeful
withdrawal.  Occasional spontaneous movements of left arm, but
no withdrawal to stimulation.  Given his recent non-compliance
with his anti-HTN medications, and elevated pressures, this is
likely a hypertensive bleed. Patient was admitted to the ICU for
further management.  Follow up Head CT on [**11-24**]- Stable left
pontine hemorrhage extending into the left middle cerebellar
peduncle, with stable mild surrounding edema and mild effacement
of the fourth ventricle. Unchanged extensive supratentorial
white matter hypoattenuation, notable for the patient's age,
which could indicate advanced chronic small vessel disease.
Patient was extubated on [**11-25**] and has been doing well since that
time.

He was transferred to the floor. He was unable to pass his
speech and swallow exam and received a PEG tube by surgery on
[**2133-12-2**]. The tube feeds were started without complication.

Cardiovascular: Patient was initially started on labetalol gtt
for a goal SBP 140-160 using an aline.  After extubation he was
switched off the gtt and started on amlodipine with PRN
Hydralazine as needed for control of his BP.

He was restarted on a home regimen of antihypertensives with
good blood pressure control.
1. Hydrochlorothiazide 25 mg GT daily
2. Lisinopril 20 mg GT daily
3. Atenolol 50 mg GT daily
4. Amlodipine 10 mg GT daily

Gastrointestinal / Abdomen:
- Was initially NPO while intubated.  After extubation the
patient was evaluated by speech and swallow and required a PEG
tube.

Endocrine:
- RISS  to keep Blood sugars low

Fluids: NS @ 100 mL/hr

Prophylaxis:  DVT: boots /Stress ulcer: famotidine


Medications on Admission:
- not currently taking any of his prescribed medications


Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

9. atenolol 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
10. lisinopril 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
QHS (once a day (at bedtime)).
12. verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)

Discharge Diagnosis:
Pontine hemorrhage


Discharge Condition:
Mental Status: Confused - sometimes. Very dysrathric, but
fluent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.


Discharge Instructions:
You were admitted to the neurology service after you became weak
on the right side of your body and had a headache. You were
found on CT to have a pontine hemorrhage. On examination you
were inititally minimally arousable and you were intubated for
airway protection and cared for in the neuro-ICU. You were
extubated and transferred to the neuro stepdown unit once your
blood pressure was adequately controlled. You did not pass
speech and swallow and required a PEG tube for enteral
nutrition. Physical therapy saw you and felt that you would
benefit from an acute rehab.

You will need to have an MRI prior to your follow-up with Dr.
[**Last Name (STitle) **]. One has been scheduled for you on [**2133-12-30**].
You will follow-up with Dr. [**Last Name (STitle) **] in neurology clinic on
[**2133-1-19**]

You were started on several medications to adequately control
your blood pressure. They are listed below.
1. Hydrochlorothiazide 25 mg GT daily
2. Lisinopril 20 mg GT daily
3. Atenolol 50 mg GT daily
4. Amlodipine 10 mg GT daily


Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2134-1-19**] 2:30


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

Completed by:[**2133-12-4**]
{'Intracerebral hemorrhage,Acute kidney failure, unspecified,Hemiplegia, unspecified, affecting unspecified side,Unspecified essential hypertension,Personal history of noncompliance with medical treatment, presenting hazards to health,Facial weakness,Dysphagia, unspecified,Thrombocytopenia, unspecified,Dysarthria'}


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: Right sided weakness and headache

PRESENT ILLNESS: The pt is a 56  year-old right-handed male with a past
medical history of stroke 9 years prior with transient left
sided
symptoms, HTN (and has not been taking medication for months
now)
who presents after vomiting and right sided weakness, and found
at OSH to have a left pontine bleed and transferred to [**Hospital1 18**].

MEDICAL HISTORY: - HTN
- history of old stroke with ? left sided symptoms (?numbness) 9
years prior
- pseudogout

MEDICATION ON ADMISSION: - not currently taking any of his prescribed medications

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION
Vitals: T: 98.2  P:70  R: 16  BP: 173/123 -> 128/92  SaO2: 100
General: Intubated, sedated,
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, intubated
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Mechanical breath sounds b/l
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

FAMILY HISTORY: Mother with stroke, Multiple family members with CAD
and HTN

SOCIAL HISTORY: Lives with wife and has adult children.  Currently
unemployed, has been out of work for some time, currently
without
insurance and as a result has not been taking his medication.
Occ etoh, no tob, no drugs Wife HCP:[**Telephone/Fax (3) 87833**]
mother: [**Telephone/Fax (1) 87834**] 

### Response:
{'Intracerebral hemorrhage,Acute kidney failure, unspecified,Hemiplegia, unspecified, affecting unspecified side,Unspecified essential hypertension,Personal history of noncompliance with medical treatment, presenting hazards to health,Facial weakness,Dysphagia, unspecified,Thrombocytopenia, unspecified,Dysarthria'}
