CHIEF COMPLAINT: right hand weakness

PRESENT ILLNESS: History is provided by the patient, his chart, EMS note and the
daughter, [**Name (NI) 24990**], [**Name (NI) 653**] at home (cell [**Telephone/Fax (1) 100539**])
.
HPI: 84yo RH M h/o Parkinson disease diagnosed 13yrs ago and
followed by Dr. [**Last Name (STitle) 10442**] with possible [**Last Name (un) 309**] body dementia as well,
HTN, hyperlipidemia BIB EMS after he was found lodged between
the toilet and the bathroom wall today. He had barricaded
himself inside the bathroom and was found with several skin
tears, on his right elbow and right shin, as well as with
multiple left-sided bruises. Per EMS note, on their arrival at
11pm yesterday, they found a "cluttered apartment with a
disheveled" patient. FSG was 110.
.
The patient's daughter reports that the patient has had
decreased use of his right hand for at least several days. Over
this time, the wrist has become contracted. She reports a prior
episode months ago where his left wrist was similarly involved.
He was evaluated at this time by Dr. [**Last Name (STitle) 10442**], who found L wrist
dystonia. MRI C-spine showed spondylosis at multiple levels and
MRI brain was normal.
.
Over this time period, the daughter feels that the patient's
walking has gotten slightly worse, from a baseline deterioration
over months. He has had a harder time getting up into his
walker. She says that he "slipped" today when she was trying to
get him into a wheelchair from the bed.
.
She has noted no other new complaints. No facial droop or other
weakness. She endorses several chronic problems, including
stuttering, dysarthric, hypophonic speech; drooling; decreased
appetite with requirement for soft foods; frequent falls. She
admits that he misses medications and attributes this to
insufficient help (gets 2hrs of VNA/day). He frequently is
"acting irrational", getting angry or sad all of a sudden and
his room is disorganized and messy. His wife is currently in
rehab.
.
When asked what brought him here, the patient states that he
"couldn't walk one step" and was "unstable" on his feet.
However, he says that this has been an ongoing problem, for
months. He says that he has been veering to the right for
"years" when walking and requires a walker. He feels that his
right arm is weak, but this too, he says has been going on for
months. When pressed about the right wrist posture, he says that
this too has been going on for that time  period. He feels that
his speech is worse today, in that "people cannot understand
what I'm saying" and he feels that it may be more slurred than
usual. This has not had a sudden onset but rather fluctuates
throughout the day, he feels. He complains of generalized
fatigue.
.
He reports blurry vision for one week or more, in both eyes and
all fields of vision. No diplopia. No vertigo. No numbness or
tingling. He feels his legs are stiff and have been so for over
a year, "slowly but surely" getting worse. Review of systems is
otherwise negative.
.
In the ED, he was found to be hypothermic to 93.5 and has been
in a warming blanket. He was given clindamycin 600mg IV x 1 and
vancomycin 1g IV x 1 for cellulitis, as well as 1L NS.

MEDICAL HISTORY: Parkinson disease with possible LBD
HTN
Hyperlipidemia
Hypothyroidism
s/p basal cell carcinoma
chronic venous stasis
Anemia

MEDICATION ON ADMISSION: 1. Polysaccharide Iron Complex 150 mg Capsule [**Month/Day (4) **]: One (1)
Capsule PO DAILY
2. Modafinil 100 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO daily
3. Trazodone 50 mg Tablet [**Month/Day (4) **]: 0.5 Tablet PO HS (at bedtime)
4. Cyanocobalamin 500 mcg Tablet [**Month/Day (4) **]: Two (2) Tablet PO DAILY
5. Donepezil 5 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO HS (at bedtime).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS 93.5 50 142/77 16 100%
Gen Awake, cooperative, NAD. Grossly cachectic.
HEENT NC/AT, no scleral icterus noted, dry mucous membranes, 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 3+ edema b/l to mid-shins. + venous stasis. Multiple ulcers.

FAMILY HISTORY: denies h/o neurologic disease

SOCIAL HISTORY: denies tob/etoh/drugs. Lives at home with his daughter and
requires assistance walking with a walker. See above for details
of living situation.
Paralysis agitans,Subdural hemorrhage,Subendocardial infarction, initial episode of care,Toxic encephalopathy,Cellulitis and abscess of leg, except foot,Pneumonitis due to inhalation of food or vomitus,Carbuncle and furuncle of leg, except foot,Hyposmolality and/or hyponatremia,Unspecified protein-calorie malnutrition,Methicillin susceptible pneumonia due to Staphylococcus aureus,Pressure ulcer, heel,Lesion of radial nerve,Dementia with lewy bodies,Dementia in conditions classified elsewhere with behavioral disturbance,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Iron deficiency anemia, unspecified,Venous (peripheral) insufficiency, unspecified,History of fall,Unspecified hereditary and idiopathic peripheral neuropathy,Abrasion or friction burn of hip, thigh, leg, and ankle, infected,Fall from other slipping, tripping, or stumbling,Abrasion or friction burn of elbow, forearm, and wrist, without mention of infection,Hypothermia,Accident due to excessive cold of unspecified origin
Paralysis agitans,Subdural hemorrhage,Subendo infarct, initial,Toxic encephalopathy,Cellulitis of leg,Food/vomit pneumonitis,Carbuncle of leg,Hyposmolality,Protein-cal malnutr NOS,Meth sus pneum d/t Staph,Pressure ulcer, heel,Radial nerve lesion,Dementia w Lewy bodies,Dementia w behavior dist,Hypertension NOS,Hypothyroidism NOS,Iron defic anemia NOS,Venous insufficiency NOS,Personal history of fall,Idio periph neurpthy NOS,Abrasion hip/leg-infect,Fall from slipping NEC,Abrasion forearm,Hypothermia,Excessive cold NOS
Admission Date:  [**2162-5-19**]              Discharge Date:   [**2162-6-16**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
right hand weakness


Major Surgical or Invasive Procedure:
Blood transfusion
PICC line placement
PEG/J-tube placement
Incision & drainage of right leg furuncle


History of Present Illness:
History is provided by the patient, his chart, EMS note and the
daughter, [**Name (NI) 24990**], [**Name (NI) 653**] at home (cell [**Telephone/Fax (1) 100539**])
.
HPI: 84yo RH M h/o Parkinson disease diagnosed 13yrs ago and
followed by Dr. [**Last Name (STitle) 10442**] with possible [**Last Name (un) 309**] body dementia as well,
HTN, hyperlipidemia BIB EMS after he was found lodged between
the toilet and the bathroom wall today. He had barricaded
himself inside the bathroom and was found with several skin
tears, on his right elbow and right shin, as well as with
multiple left-sided bruises. Per EMS note, on their arrival at
11pm yesterday, they found a "cluttered apartment with a
disheveled" patient. FSG was 110.
.
The patient's daughter reports that the patient has had
decreased use of his right hand for at least several days. Over
this time, the wrist has become contracted. She reports a prior
episode months ago where his left wrist was similarly involved.
He was evaluated at this time by Dr. [**Last Name (STitle) 10442**], who found L wrist
dystonia. MRI C-spine showed spondylosis at multiple levels and
MRI brain was normal.
.
Over this time period, the daughter feels that the patient's
walking has gotten slightly worse, from a baseline deterioration
over months. He has had a harder time getting up into his
walker. She says that he "slipped" today when she was trying to
get him into a wheelchair from the bed.
.
She has noted no other new complaints. No facial droop or other
weakness. She endorses several chronic problems, including
stuttering, dysarthric, hypophonic speech; drooling; decreased
appetite with requirement for soft foods; frequent falls. She
admits that he misses medications and attributes this to
insufficient help (gets 2hrs of VNA/day). He frequently is
"acting irrational", getting angry or sad all of a sudden and
his room is disorganized and messy. His wife is currently in
rehab.
.
When asked what brought him here, the patient states that he
"couldn't walk one step" and was "unstable" on his feet.
However, he says that this has been an ongoing problem, for
months. He says that he has been veering to the right for
"years" when walking and requires a walker. He feels that his
right arm is weak, but this too, he says has been going on for
months. When pressed about the right wrist posture, he says that
this too has been going on for that time  period. He feels that
his speech is worse today, in that "people cannot understand
what I'm saying" and he feels that it may be more slurred than
usual. This has not had a sudden onset but rather fluctuates
throughout the day, he feels. He complains of generalized
fatigue.
.
He reports blurry vision for one week or more, in both eyes and
all fields of vision. No diplopia. No vertigo. No numbness or
tingling. He feels his legs are stiff and have been so for over
a year, "slowly but surely" getting worse. Review of systems is
otherwise negative.
.
In the ED, he was found to be hypothermic to 93.5 and has been
in a warming blanket. He was given clindamycin 600mg IV x 1 and
vancomycin 1g IV x 1 for cellulitis, as well as 1L NS.

Past Medical History:
Parkinson disease with possible LBD
HTN
Hyperlipidemia
Hypothyroidism
s/p basal cell carcinoma
chronic venous stasis
Anemia


Social History:
denies tob/etoh/drugs. Lives at home with his daughter and
requires assistance walking with a walker. See above for details
of living situation.


Family History:
denies h/o neurologic disease


Physical Exam:
VS 93.5 50 142/77 16 100%
Gen Awake, cooperative, NAD. Grossly cachectic.
HEENT NC/AT, no scleral icterus noted, dry mucous membranes, 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 3+ edema b/l to mid-shins. + venous stasis. Multiple ulcers.

.
NEURO
MS Awake, alert. Cooperative with exam but prefers to keep his
eyes closed and requires prompting to complete his history.
Oriented to [**Hospital1 18**], says date is "[**2162-5-16**]". MOYF intact; MOYB:
skips [**Month (only) 205**] but otherwise persists in the task, which he
completes slowly. Registers [**3-13**] and recalls [**1-13**] without prompts,
[**3-13**] with them at 5min. Distant recall is intact. Speech is
fluent, with normal naming to high/low frequency items, [**Location (un) 1131**],
writing, comprehension (by two-step commands) and repetition.
However, speech is stuttering, hypophonic and difficult to
understand due to dysarthria. There were no paraphasic errors.
No neglect or apraxia. Masked facies.
.
CN
CN I: not tested
CN II: VFF to confrontation to a red object, no extinction.
Pupils 2->1.5 b/l. Fundi unable to be visualized
CN III, IV, VI: EOMI except for limited vertical gaze b/l. No
nystagmus or diplopia. +Square wave jerks b/l with dysmetric
saccades.
CN V: intact to LT/cold throughout
CN VII: +R NLF flattening. Full excursion and strength
CN VIII: hearing intact to FR b/l
CN IX, X: palate rises symmetrically
CN [**Doctor First Name 81**]: shrug [**5-15**] and symmetric
CN XII: tongue midline and agile
.
Motor
Diffusely decreased muscle bulk. No pronator drift. +b/l
asterixis. Tone is increased in both legs and in the right arm,
which has cogwheeling, moreso than in the left arm. The right
wrist and MCP joints are held in a dystonic, flexed position
(unable to extend). There is no observed resting tremor.
.
  D B T WE  FE  FF IP Q H  DF PF TE
L 5 5 5 5   5-  5  5  5 5  5  5  5
R 5 5 4 0   0   5  5  5 5  5  5  5
.
Sensory intact to LT, PP, JPS, vibration in both arms; LT, PP
are intact distally but vibration and JPS are impaired
symmetrically. No extinction.
.
Reflexes +jaw jerk, +[**Last Name (un) 100540**] sign, +snout. 3+ in right arm in
biceps, triceps, brachioradialis. 2 in the left arm throughout.
1+ at both knees and 0 at the achilles. Toes down b/l
.
Coordination FTN with slight dysmetria on the right; normal on
the left. [**Doctor First Name 6361**] slow b/l.
.
Gait Patient required assistance to rise to a seated position.
He was able to sit unassisted once upright. On repeated efforts
to stand, he rocked forward but could not initiate necessary leg
movements, even with a visual cue on the ground. Given his
hypothermia, further efforts to help him stand were deferred.

Pertinent Results:
Admission Labs:

[**2162-5-19**] 08:00AM   CK(CPK)-339* CK-MB-14* MB INDX-4.1
cTropnT-0.07*
[**2162-5-19**] 02:25AM URINE  COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2162-5-19**] 02:25AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2162-5-19**] 02:01AM   LACTATE-1.5
[**2162-5-19**] 01:30AM   GLUCOSE-104 UREA N-23* CREAT-0.8 SODIUM-138
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-27 ANION GAP-11
[**2162-5-19**] 01:30AM   ALT(SGPT)-11 AST(SGOT)-76* CK(CPK)-440* ALK
PHOS-90 AMYLASE-120* TOT BILI-0.3
[**2162-5-19**] 01:30AM   CK-MB-17* MB INDX-3.9 cTropnT-0.07*
[**2162-5-19**] 01:30AM   CALCIUM-8.8 PHOSPHATE-2.6* MAGNESIUM-2.3
[**2162-5-19**] 01:30AM   VIT B12-[**2079**]* FOLATE-GREATER TH
[**2162-5-19**] 01:30AM   TSH-6.0* T4-3.7* T3-46*
[**2162-5-19**] 01:30AM   WBC-8.0 RBC-2.63* HGB-9.6* HCT-27.9* MCV-106*
MCH-36.5* MCHC-34.4 RDW-15.5 PLT COUNT-299
[**2162-5-19**] 01:30AM   NEUTS-73.9* LYMPHS-21.4 MONOS-3.6 EOS-0.5
BASOS-0.6
[**2162-5-19**] 01:30AM   MACROCYT-3+
[**2162-5-19**] 01:30AM   PT-12.4 PTT-32.0 INR(PT)-1.1
.
X-Rays:
RIGHT LOWER EXTREMITY, FOUR VIEWS, TIBIA AND FIBULA:  There is
no evidence of fracture, dislocation, or bony destruction.
Vascular calcifications are noted.
.
LEFT LOWER EXTREMITY, TIBIA AND FIBULA, FOUR VIEWS:  No prior
studies
available for comparison.  Vascular calcifications are noted.
There is
chondrocalcinosis in the menisci as noted previously, also
present on the
right. There is no evidence of fracture, dislocation, or bony
destruction.
.
RIGHT ELBOW, AP, LATERAL AND OBLIQUE VIEWS:  There are no prior
studies
available for comparison.  There is no evidence of fracture,
dislocation, or bony destruction.  It is difficult to assess for
effusion.
.
RIGHT WRIST, AP, LATERAL AND OBLIQUE VIEWS:  No prior studies
are available for comparison.  There is no evidence of fracture,
dislocation, or bony destruction.  There is calcification of the
triangular fibrocartilage, which can be seen in
chondrocalcinosis.
.
MRI/MRA Head [**5-24**]:
FINDINGS:  On the left, there is a subdural hemorrhage unchanged
in size since [**2162-2-11**], but now demonstrating subacute or
acute blood products within it (low signal intensity on T1 and
heterogeneous signal intensity on FLAIR images).  The right
extra-axial fluid collection is old and has involuted into a
subdural hygroma. There is mild effacement of the adjacent sulci
in both hemispheres with minimal mass effect.  No shift of
normally midline structures or hydrocephalus.  No areas of
abnormal signal intensity on the FLAIR images to suggest
infarct, though diffusion- weighted imaging was not performed
due to claustrophobia.
.
IMPRESSION FOR MRI OF THE BRAIN:
1.  Left subdural hematoma with subacute or acute blood and
minimal mass
effect, not changed in size or effect since [**2162-5-19**].
2.  Right subdural hygroma, also unchanged compared to [**2162-5-19**]
and [**2162-2-26**].
3.  No evidence of infarct on FLAIR images, though DWI was not
performed due to patient claustrophobia.
.
FINDINGS:  No stenosis, aneurysm, or AV malformation is seen in
the anterior or posterior circulation.  The carotid arteries are
tortuous bilaterally, unchanged since prior exam.
.
IMPRESSION:  No significant abnormalities detected on MRA of the
head.
.
TTE:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. There
are focal calcifications in the aortic arch. The number of
aortic valve leaflets cannot be determined. The aortic valve
eaflets are mildly thickened. There is no aortic valve stenosis.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.


Brief Hospital Course:
Parkinson's Disease: On admission an NG tube was placed and pt.
was initially continued on his home dose of his sinemet (short
acting and CR) and Comtan.  His rigidity improved as his
medications were reintroduced, and eventually he was able to
take his own medications.  There was concern after a few days of
his full dose of Sinemet that he was confused and that this
could be a Sinemet side effect, so he was decreased to only CR
dosing TID.  On this regimen his rigidity was not adequately
controlled, so he was increased back to his home doses with no
recurrence of his confusion, which may have been toxic metabolic
and due to his cellulitis.  Mirapex was added for improved
symptomatic relief, and was titrated up to 0.5 mg TID.  He was
seen by PT and OT who felt that he would benefit from [**Hospital1 1501**]
placement.  On a video swallow eval after his NGT was pulled, he
was initially cleared for a diet of honey thick liquids and
ground solids.  However, he had a clinical aspiration event on
[**6-5**], so this his swallowing was readdressed with him and his
daughter.  A decision was made to place a PEG to decrease the
risk of aspiration.  This was placed under flouroscopy on
[**2162-6-8**].  He was kept NPO afterwards.  Sinamet, Mirapex, and
Comtan doses were adjusted to accommodate crushable forms prior
to discharge.  His swallowing should be re-evaluated at rehab,
and if it improves with continued aggressive treatment of his PD
his diet should be changed as appropriate.
.
Right Hand weakness:  Initially there was concern for stroke,
although exam was limited by rigidity.  MRI was performed and
showed no evidence of acute infarct.  As his rigidity improved
and a better strength exam was obtained his pattern of weakness
seemed more c/w a radial nerve palsy, likely from compression.
He was seen by OT and given a R wrist splint.  A stroke work up
showed FLP: Cholesterol:158 Triglyc: 62 HDL: 77 LDLcalc: 69, A1c
5.5%.  He was continued on ASA 325 and lipitor per his home
regimen.
.
SDH: On MRI pt. was found to have SDH, which on review was seen
on MRI from [**2-16**] admission.  It was stable in size, although
there was evidence of some acute blood products (see report
above).  Pt. had no deficits on exam from this, and there was no
evidence of mass effect or shift, so no intervention was made.
On [**6-15**] CT head was repeated which revealed SDH to be stable with
no evidence of acute bleed.
.
NSTEMI:  Patient had no EKG changes but had elevated cardiac
enzymes c/w NSTEMI.  These were stable when trended.  He was
started on Plavix and ASA and Statin were continued.  He had no
chest pain in house.  TTE showed EF 60%, normal wall motion (see
report above)
.
Cellulitis:  Patient was initially treated with Keflex.  Wound
care was consulted and gave recommendations to nursing about
wound care.  Blood cultures were negative (except 1/8 bottles +
for coag negative staph which was felt to be a contaminant).
Wound culture eventually came back + for MRSA, so pt. was
switched to Vancomycin, and treated with a 7 day course from
[**Date range (1) 100541**].
.
Aspiration PNA: He had a aspiration event on [**6-5**], and chest X
ray showed a left lower lobe infiltrate.  He was started on
Levofloxacin on [**6-5**] and should be continued through [**2162-6-14**] for
a 10 day course. On [**2162-6-11**] developed worsening dyspnea. He was
transferred to the MICU. CXR again showed LLL infiltrate with
increased pulmonary edema. Sputum gram stain showed 4+ GPC, he
was started on vancomycin while cultures pending (given recent
history of MRSA). He was also diuresed and respiratory status
improved after 1 L of fluid removed.  He will complete a 14-day
course of vancomycin from [**Date range (1) 100542**].  Vancomycin dose was reduced
prior to discharge, and trough should be check prior to evening
dose on [**6-17**].
.
Right leg furuncle:  Patient was noted to have a fluctuant,
warm, erythematous furuncle on right inner thigh, measuring
approximately 3 cm.  I&D was performed, which revealed this
lesion to be filled with clot-like material.  Gram stain showed
no organisms, no poly's.  Culture was pending at the time of
discharge.

Medications on Admission:
1. Polysaccharide Iron Complex 150 mg Capsule [**Month/Day (4) **]: One (1)
Capsule PO DAILY
2. Modafinil 100 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO daily
3. Trazodone 50 mg Tablet [**Month/Day (4) **]: 0.5 Tablet PO HS (at bedtime)
4. Cyanocobalamin 500 mcg Tablet [**Month/Day (4) **]: Two (2) Tablet PO DAILY
5. Donepezil 5 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO HS (at bedtime).

6. Multivitamin,Tx-Minerals     Tablet [**Month/Day (4) **]: One (1) Tablet PO
DAILY
7. Aspirin 81 mg Tablet, Chewable PO DAILY
8. Quetiapine 25 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO QHS
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Day (4) **]: Two (2)
Drop Ophthalmic TID (3 times a day).
10. Levothyroxine 75 mcg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY
11. Entacapone 200 mg One (1) Tablet PO q 8AM, 11AM, 2PM, 5PM,
8PM, 11PM
12. Carbidopa-Levodopa 25-250 mg Tablet PO Q 8AM, 11AM, 2PM,
5PM, 10PM
13. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release [**Month/Day (4) **]:
One (1) Tablet PO Q 8AM, 11AM, 2PM, 5PM, 11PM
14. Lipitor 20 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day.
15. Docusate Sodium 100 mg PO BID as needed for constipation.
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (4) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
17. Cepacol 2 mg Lozenge [**Month/Day (4) **]: One (1) Lozenge Mucous membrane
PRN (as needed).
18. Phenol-Phenolate Sodium 1.4 % Mouthwash [**Month/Day (4) **]: One (1) Spray
Mucous membrane Q4H (every 4 hours) as needed.
19. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Day (4) **]: Thirty
(30)ML PO Q6H (every 6 hours) as needed.

Discharge Medications:
1. [**Doctor Last Name **] brace
please apply to legs for contractures
2. Polysaccharide Iron Complex 150 mg Capsule [**Doctor Last Name **]: One (1)
Capsule PO DAILY (Daily).
3. Cyanocobalamin 100 mcg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY
(Daily).
4. Donepezil 10 mg Tablet, Rapid Dissolve [**Doctor Last Name **]: One (1) Tablet,
Rapid Dissolve PO at bedtime.
5. Atorvastatin 20 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO at bedtime.

6. Heparin (Porcine) 5,000 unit/mL Solution [**Doctor Last Name **]: One (1) mL
Injection TID (3 times a day).
7. Levothyroxine 100 mcg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY
(Daily).
8. Captopril 12.5 mg Tablet [**Doctor Last Name **]: 0.5 Tablet PO TID (3 times a
day).
9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Doctor Last Name **]: One (1)
capsule Inhalation Q4H (every 4 hours).
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Doctor Last Name **]: One (1)
capsule Inhalation Q2H (every 2 hours) as needed.
11. Aspirin 325 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY (Daily).

12. Clopidogrel 75 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY
(Daily).
13. Acetaminophen 325 mg Tablet [**Doctor Last Name **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
14. Carbidopa-Levodopa 25-250 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO
5X/D (5 times a day).
15. Pramipexole 0.25 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO 5x/day ().

16. Entacapone 200 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO 5x/day ().
17. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
18. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mL
PO BID (2 times a day) as needed.
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: [**1-12**]
Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed.
20. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) nebulizer
Inhalation Q6H (every 6 hours).
21. Vancomycin 500 mg Recon Soln [**Month/Day (2) **]: Seven [**Age over 90 1230**]y (750)
mg  Intravenous Q 12H (Every 12 Hours): End date [**6-25**].
22. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Year (2) **]: Two
(2) ML Intravenous DAILY (Daily) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Parkinson's Disease
Subdural hematoma
NSTEMI
Cellulitis
Aspiration pneumonia
Hyponatremia
Anemia
Hypothyroidism
Radial Nerve Palsy


Discharge Condition:
Stable


Discharge Instructions:
Take all medications as directed.  Do not stop or change any of
your medications without first speaking to your doctor.

Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16747**], M.D.
Department of Neurology
Phone: [**Telephone/Fax (1) 16748**]
Date/Time: [**2162-6-25**] 3:00 p.m.
{'Paralysis agitans,Subdural hemorrhage,Subendocardial infarction, initial episode of care,Toxic encephalopathy,Cellulitis and abscess of leg, except foot,Pneumonitis due to inhalation of food or vomitus,Carbuncle and furuncle of leg, except foot,Hyposmolality and/or hyponatremia,Unspecified protein-calorie malnutrition,Methicillin susceptible pneumonia due to Staphylococcus aureus,Pressure ulcer, heel,Lesion of radial nerve,Dementia with lewy bodies,Dementia in conditions classified elsewhere with behavioral disturbance,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Iron deficiency anemia, unspecified,Venous (peripheral) insufficiency, unspecified,History of fall,Unspecified hereditary and idiopathic peripheral neuropathy,Abrasion or friction burn of hip, thigh, leg, and ankle, infected,Fall from other slipping, tripping, or stumbling,Abrasion or friction burn of elbow, forearm, and wrist, without mention of infection,Hypothermia,Accident due to excessive cold of unspecified origin'}


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 hand weakness

PRESENT ILLNESS: History is provided by the patient, his chart, EMS note and the
daughter, [**Name (NI) 24990**], [**Name (NI) 653**] at home (cell [**Telephone/Fax (1) 100539**])
.
HPI: 84yo RH M h/o Parkinson disease diagnosed 13yrs ago and
followed by Dr. [**Last Name (STitle) 10442**] with possible [**Last Name (un) 309**] body dementia as well,
HTN, hyperlipidemia BIB EMS after he was found lodged between
the toilet and the bathroom wall today. He had barricaded
himself inside the bathroom and was found with several skin
tears, on his right elbow and right shin, as well as with
multiple left-sided bruises. Per EMS note, on their arrival at
11pm yesterday, they found a "cluttered apartment with a
disheveled" patient. FSG was 110.
.
The patient's daughter reports that the patient has had
decreased use of his right hand for at least several days. Over
this time, the wrist has become contracted. She reports a prior
episode months ago where his left wrist was similarly involved.
He was evaluated at this time by Dr. [**Last Name (STitle) 10442**], who found L wrist
dystonia. MRI C-spine showed spondylosis at multiple levels and
MRI brain was normal.
.
Over this time period, the daughter feels that the patient's
walking has gotten slightly worse, from a baseline deterioration
over months. He has had a harder time getting up into his
walker. She says that he "slipped" today when she was trying to
get him into a wheelchair from the bed.
.
She has noted no other new complaints. No facial droop or other
weakness. She endorses several chronic problems, including
stuttering, dysarthric, hypophonic speech; drooling; decreased
appetite with requirement for soft foods; frequent falls. She
admits that he misses medications and attributes this to
insufficient help (gets 2hrs of VNA/day). He frequently is
"acting irrational", getting angry or sad all of a sudden and
his room is disorganized and messy. His wife is currently in
rehab.
.
When asked what brought him here, the patient states that he
"couldn't walk one step" and was "unstable" on his feet.
However, he says that this has been an ongoing problem, for
months. He says that he has been veering to the right for
"years" when walking and requires a walker. He feels that his
right arm is weak, but this too, he says has been going on for
months. When pressed about the right wrist posture, he says that
this too has been going on for that time  period. He feels that
his speech is worse today, in that "people cannot understand
what I'm saying" and he feels that it may be more slurred than
usual. This has not had a sudden onset but rather fluctuates
throughout the day, he feels. He complains of generalized
fatigue.
.
He reports blurry vision for one week or more, in both eyes and
all fields of vision. No diplopia. No vertigo. No numbness or
tingling. He feels his legs are stiff and have been so for over
a year, "slowly but surely" getting worse. Review of systems is
otherwise negative.
.
In the ED, he was found to be hypothermic to 93.5 and has been
in a warming blanket. He was given clindamycin 600mg IV x 1 and
vancomycin 1g IV x 1 for cellulitis, as well as 1L NS.

MEDICAL HISTORY: Parkinson disease with possible LBD
HTN
Hyperlipidemia
Hypothyroidism
s/p basal cell carcinoma
chronic venous stasis
Anemia

MEDICATION ON ADMISSION: 1. Polysaccharide Iron Complex 150 mg Capsule [**Month/Day (4) **]: One (1)
Capsule PO DAILY
2. Modafinil 100 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO daily
3. Trazodone 50 mg Tablet [**Month/Day (4) **]: 0.5 Tablet PO HS (at bedtime)
4. Cyanocobalamin 500 mcg Tablet [**Month/Day (4) **]: Two (2) Tablet PO DAILY
5. Donepezil 5 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO HS (at bedtime).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS 93.5 50 142/77 16 100%
Gen Awake, cooperative, NAD. Grossly cachectic.
HEENT NC/AT, no scleral icterus noted, dry mucous membranes, 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 3+ edema b/l to mid-shins. + venous stasis. Multiple ulcers.

FAMILY HISTORY: denies h/o neurologic disease

SOCIAL HISTORY: denies tob/etoh/drugs. Lives at home with his daughter and
requires assistance walking with a walker. See above for details
of living situation. 

### Response:
{'Paralysis agitans,Subdural hemorrhage,Subendocardial infarction, initial episode of care,Toxic encephalopathy,Cellulitis and abscess of leg, except foot,Pneumonitis due to inhalation of food or vomitus,Carbuncle and furuncle of leg, except foot,Hyposmolality and/or hyponatremia,Unspecified protein-calorie malnutrition,Methicillin susceptible pneumonia due to Staphylococcus aureus,Pressure ulcer, heel,Lesion of radial nerve,Dementia with lewy bodies,Dementia in conditions classified elsewhere with behavioral disturbance,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Iron deficiency anemia, unspecified,Venous (peripheral) insufficiency, unspecified,History of fall,Unspecified hereditary and idiopathic peripheral neuropathy,Abrasion or friction burn of hip, thigh, leg, and ankle, infected,Fall from other slipping, tripping, or stumbling,Abrasion or friction burn of elbow, forearm, and wrist, without mention of infection,Hypothermia,Accident due to excessive cold of unspecified origin'}
