CHIEF COMPLAINT: Left facial droop and left sided weakness.

PRESENT ILLNESS: Patient is a 56 year old male with past medical history of
gastroesophageal reflux disease and headaches with a postive
family history of stroke at young age who presented to [**Hospital1 18**] ED
on [**2125-3-18**] as a CODE STROKE.

MEDICAL HISTORY: 1. Gastroesophageal reflux disease
2. Headache

MEDICATION ON ADMISSION: 1. Levitra
2. Prilosec
3. Flonase

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General: Well developed, well nourished male, eyes closed,
somnolent.
HEENT: Anicteric.  Mucosa moist without lesions. Oropharynx
clear.
Neck: Supple. No lymphadenopathy, carotid bruits, thyromegaly.
Cards: Regular rate and rhythm with normal s1/s2. No murmurs,
rubs, gallops.
Lungs: Clear to ausculatation bilaterally.
Abd: Soft, non-tender, non-distended.
Ext: No clubbing, cyanosis, edema. Distal pulses intact.
Skin: No rashes, petechiae.

FAMILY HISTORY: Sister with stroke in her 40s. Mother with stroke in her 60s.

SOCIAL HISTORY: Married, lives with wife. Nonsmoker. [**Name2 (NI) **] alcohol use. Used
marijuana in the [**2079**]. Employed as a carpenter.
Cerebral embolism with cerebral infarction,Dissection of carotid artery,Esophageal reflux
Crbl emblsm w infrct,Dissect carotid artery,Esophageal reflux
Admission Date:  [**2125-3-18**]              Discharge Date:   [**2125-3-22**]

Date of Birth:  [**2068-7-25**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Left facial droop and left sided weakness.

Major Surgical or Invasive Procedure:
-Intraarterial tPA

History of Present Illness:
Patient is a 56 year old male with past medical history of
gastroesophageal reflux disease and headaches with a postive
family history of stroke at young age who presented to [**Hospital1 18**] ED
on [**2125-3-18**] as a CODE STROKE.

Patient was in his usual state of health until [**2125-3-17**] evening.
At that time, he developed a headache. Went to sleep and woke up
feeling well on morning of admission. He took a Levitra pill
around 10:30am. Then, around 11am, he had suddent onset of
"mumbled speech" as well as left facial droop and left arm
weakness. EMS was called and he was taken to [**Hospital3 7569**].
Reportedly, he normalized around 11:45 am and remained deficit
free until 2:25 pm. He was scheduled for transport to [**Hospital1 18**] for
neurological evaluation.

While he was being loaded into the ambulance to come to [**Hospital1 18**],
he had acute development of the left facial weakness, left arm
weakness, and slurred speech again.

He was brought to the [**Hospital1 18**] where a noncontrast head CT showed
dense R MCA. He taken to angio suite for acute stroke management
with IA thrombolysis. During procedure, angiography revealed
extensive R ICA dissection. Moreover attempts at thrombolysis
proved unsuccessful at establishing recannalization/restoration
of flow.  Patient was therefore admitted to the Neuro ICU
service for post-IA-tPA observation.

On review of systems, he denies fevers, chills, chest pain,
palpitations, nausea, vomiting, dysuria. No visual changes,
paresthesias.

Past Medical History:
1. Gastroesophageal reflux disease
2. Headache

Social History:
Married, lives with wife. Nonsmoker. [**Name2 (NI) **] alcohol use. Used
marijuana in the [**2079**]. Employed as a carpenter.

Family History:
Sister with stroke in her 40s. Mother with stroke in her 60s.

Physical Exam:
General: Well developed, well nourished male, eyes closed,
somnolent.
HEENT: Anicteric.  Mucosa moist without lesions. Oropharynx
clear.
Neck: Supple. No lymphadenopathy, carotid bruits, thyromegaly.
Cards: Regular rate and rhythm with normal s1/s2. No murmurs,
rubs, gallops.
Lungs: Clear to ausculatation bilaterally.
Abd: Soft, non-tender, non-distended.
Ext: No clubbing, cyanosis, edema. Distal pulses intact.
Skin: No rashes, petechiae.

Mental Status: Arouses to voice. Oriented to person, place, and
time. Keeps eyes closed during most of exam. Speech fluent but
mildly dysarthric. Able to name and repeat. No apraxia. Left
neglect.

Cranial nerves:
I: Not tested.
II,III: PERRL, VFF by threat on right, no blink to threat on
left. Eye opening apraxia.
III,IV,VI: EOMI, no ptosis, no nystagmus. Dyes midline at rest.
V: Sensation intact to LT, masseters strong symmetrically.
VII: Left facial weakness/asymmetry.
VIII: Hears finger rub bilaterally.
IX,X: Palate elevates symmetrically.
[**Doctor First Name 81**]: SCM/Trapezii [**4-26**] B bilaterally.
XII: Tongue protrudes midline, no atrophy or fasciculations.

Motor: Normal bulk and tone, no tremor, rigidity or
bradykinesia. Moves right side spontaneously and against
gravity. Left arm plegic [**12-27**]. Lifts left leg briefly off bed and
gives resistance at least [**3-27**].

DTRs: [**Name2 (NI) 2325**] toe upgoing. Right toe downgoing.

Sensory: Grimaced to pinch in all 4 extremities, otherwise
inattentive to exam.

Coordination: Unable to comply with exam.

Gait: Deferred.

Pertinent Results:
[**2125-3-18**] 03:45PM   WBC-5.9 RBC-5.37 HGB-15.5 HCT-44.3 MCV-83
MCH-28.9 MCHC-35.1* RDW-13.2
[**2125-3-18**] 03:45PM   PLT COUNT-273
[**2125-3-18**] 03:45PM   PT-12.4 PTT-23.5 INR(PT)-1.0
[**2125-3-18**] 03:45PM   GLUCOSE-111* UREA N-19 CREAT-0.9 SODIUM-143
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-27 ANION GAP-12
[**2125-3-18**] 03:45PM   ALT(SGPT)-20 AST(SGOT)-15 CK(CPK)-46 ALK
PHOS-68 AMYLASE-59 TOT BILI-1.4
[**2125-3-18**] 03:45PM   CK-MB-3
[**2125-3-18**] 03:45PM   cTropnT-<0.01
[**2125-3-18**] 03:45PM   ALBUMIN-4.3 CALCIUM-9.2 PHOSPHATE-4.0
MAGNESIUM-1.9
[**2125-3-18**] 03:45PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
-----
Noncontrast head CT [**2125-3-18**]: : A focal area of increased
density is seen within the right MCA branch in the sylvian
fissure, consistent with thrombus within this vessel.
Additionally, there is loss of [**Doctor Last Name 352**]-white differentiation within
the insular cortex. No shift of normally midline structures. The
ventricles are symmetric. No other focal areas of decreased
attenuation are identified within the brain parenchyma. No
intracranial hemorrhage. The soft tissue and osseous structures
are normal.
IMPRESSION: Findings suggestive of acute right MCA infarct
including dense right MCA within the sylvian fissure and loss of
the [**Doctor Last Name 352**]-white differentiation in the insular cortex on the
right.
-----
Post tPA noncontrast head CT [**2125-3-18**]: There is again seen a
dense middle cerebral artery on the right. Intra-arterial air is
present within the distribution of the right middle cerebral
artery. There is a focus of high attenuation within the right
basal ganglia immediately anterior to the posterior limb of the
internal capsule on the right. This focus of high attenuation
could reflect contrast from the patient's procedure or
alternatively hemorrhage. There is no shift of normally midline
structures. The ventricles and sulci are unchanged in size when
compared to the prior examination from the same day. The
differentiation of the [**Doctor Last Name 352**] and white matter appears preserved.
The patient's known carotid arterial dissection is not evaluated
on this examination. Bone windows show clear paranasal sinuses
with no evidence of fracture.
IMPRESSION:
1) Dense middle cerebral artery consistent with right middle
cerebral artery occlusion that is unchanged when compared to the
prior examination. Intra- arterial air is seen within the
distribution of the right middle cerebral artery. This finding
presumably reflects air related to the patient's recent
intra-arterial t-PA infusion.
2) Focus of high attenuation within the region of the posterior
basal ganglia on the right. This could reflect contrast from the
patient's recent procedure or alternatively could reflect a
focus of intraparenchymal hemorrhage.
-----
Noncontrast head CT [**2125-3-19**]: There is again seen a dense right
middle cerebral artery. Hypoattenuation is present within the
right basal ganglia, right frontal lobe, and right temporal lobe
in the distribution of the superior division of the right middle
cerebral artery. The previously described focus of high
attenuation within the posterior aspect of the right basal
ganglia has resolved indicating the resolution of contrast
material. The ventricles and sulci are unchanged in size. There
is no evidence of shift of normally midline structures. Air that
had been present within the right middle cerebral artery
branches has resolved compared to the previous study. The
patient's known right carotid arterial dissection is not imaged
on this examination.
IMPRESSION: 1) Unchanged dense right middle cerebral artery with
evolving infarction in the distribution of the superior division
of the right middle cerebral artery. High attenuation material
within the right basal ganglia seen on the prior examination has
resolved indicating this focus of high attenuation represented
retained contrast.
2) The patient's right carotid dissection is not imaged on
today's examination.


Brief Hospital Course:
The patient is a 56 year old male with no significant past
medical history who presented to [**Hospital1 18**] on [**2125-3-18**] for
evaluation of acute onset left sided facial droop and weakness.
Initial exam showed NIHSS of 11. Ct imaging demonstrated a dense
right MCA sign consistent with acute thrombosis. He was admitted
to the Neurology service and taken emergently for angiogram.
Angiogram demonstrated right carotid dissection with subsequent
right MCA clot/thrombus. Unfortunately, interventional
approaches and intraarterial tPA were unable to result in
recanulization of the afected vasculature. Etiology of the
dissection is unclear, but as the patient is a carpenter by
trade, this might suggest some extreme manipulation of his neck.

Post angiography/tPA the patient was admitted to the SICU for
further observation.  The patient remained stable in the SICU
with no acute events.  The patient had a repeat head CT scan
after 1 day in the SICU that showed and evolving infarction but
no hemorrhagic transformation. He was started on a heparin gtt
as bridge towards a therapeutic INR of [**1-25**] on coumadin. The
patient was then transferred to the floor where he remained
stable.  He should continue intravenous heparin until which
point INR is therapeutic on coumadin.

The patient was discharged to [**Hospital3 **] with
scheduled follow up in stroke clinic in ~ 2 months time.  At
time of discharge, he has residual dysarthria and left
hemiparesis with arm affected >leg.


Medications on Admission:
1. Levitra
2. Prilosec
3. Flonase


Discharge Medications:
1. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: 1200 (1200) units/hour Intravenous  ASDIR (AS DIRECTED):
Continue until Coumadin therapeutic.
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).



Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
1. Right carotid dissection
2. Right parietal infarct
3. GERD


Discharge Condition:
Fair. Hemodynamically stable. Neurologically, has left facial
droop. Has lateral motion of left arm side to side on bed. Able
to left lower extremity against gravity briefly.

Discharge Instructions:
Please call a physician if your experience neck pain, increasing
weakness in your arms or legs, worsened speech, difficulty
swallowing, blurred vision, numbness/tingling.

Followup Instructions:
Please make an appointment to see your primary care physician
within two weeks of getting discharged from rehabilitation.

The following appointment has already been scheduled:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) **]: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 657**] Date/Time:[**2125-5-16**] 1:00


                             [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
{'Cerebral embolism with cerebral infarction,Dissection of carotid artery,Esophageal reflux'}


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: Left facial droop and left sided weakness.

PRESENT ILLNESS: Patient is a 56 year old male with past medical history of
gastroesophageal reflux disease and headaches with a postive
family history of stroke at young age who presented to [**Hospital1 18**] ED
on [**2125-3-18**] as a CODE STROKE.

MEDICAL HISTORY: 1. Gastroesophageal reflux disease
2. Headache

MEDICATION ON ADMISSION: 1. Levitra
2. Prilosec
3. Flonase

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General: Well developed, well nourished male, eyes closed,
somnolent.
HEENT: Anicteric.  Mucosa moist without lesions. Oropharynx
clear.
Neck: Supple. No lymphadenopathy, carotid bruits, thyromegaly.
Cards: Regular rate and rhythm with normal s1/s2. No murmurs,
rubs, gallops.
Lungs: Clear to ausculatation bilaterally.
Abd: Soft, non-tender, non-distended.
Ext: No clubbing, cyanosis, edema. Distal pulses intact.
Skin: No rashes, petechiae.

FAMILY HISTORY: Sister with stroke in her 40s. Mother with stroke in her 60s.

SOCIAL HISTORY: Married, lives with wife. Nonsmoker. [**Name2 (NI) **] alcohol use. Used
marijuana in the [**2079**]. Employed as a carpenter. 

### Response:
{'Cerebral embolism with cerebral infarction,Dissection of carotid artery,Esophageal reflux'}
