CHIEF COMPLAINT: Acute Stroke, s/p IV t-PA

PRESENT ILLNESS: 74 year old man with hx of CAD (s/p MI, s/p CABG), HTN, Right
carotid stenosis (s/p carotid stent [**10-5**]), and arthritis who
presented to the ED on [**11-25**] complaining of left sided weakness.
 A code stroke was called and the stroke
fellow assessed the patient immediately (Please see Dr.[**Name (NI) 105059**]
note [**11-25**] for details of initial assessment).  He was initially
found to have an NIHSS of 9.  CT/CTA was done and was negative
for early signs of infarction, but did show a paucity of vessels
in the right MCA territory.  IV tPA was administered by Dr.
[**Last Name (STitle) **] at 8:53am.

MEDICAL HISTORY: 1. CAD- s/p MI and CABG [**63**] yrs ago with subsequent coronary
stenting
2. COPD
3. HTN
4. High cholesterol
5. PVD-s/p right leg stenting
6. Osteoarthritis

MEDICATION ON ADMISSION: Plavix
ASA 325
Lipitor
NTG
Fluticasone
Atneolol
Lisinopril
Folate
Elavil
Pletal
Folate
Temazepam

ALLERGIES: Shellfish

PHYSICAL EXAM: T-96.6 BP-155/103 HR-72 RR-20 O2Sat-100
Gen: Lying in bed, NAD
HEENT: NC/AT, facial rubor, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, no carotid bruits
CV: RRR, Nl S1 and S2, [**2-4**] HSM
Lung: Decreased breath sounds throughout
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect.  Oriented to person, place, and date.  He is attentive,
says [**Doctor Last Name 1841**] backwards.  Speech is fluent with normal comprehension
and repetition; naming intact. Moderate dysarthria. [**Location (un) **]
intact.  Registers [**2-1**], recalls [**2-1**] in 5 minutes.  No right left
confusion. He has left sided inattention, but does look at
examiner on the left.

FAMILY HISTORY: Brother - stroke
[**Name2 (NI) 6419**] parents had heart disease in their 60s.

SOCIAL HISTORY: Divorced, lives alone.  Used to work appraising properties for
the government.  60 pk yr smoking hx, quit 2 yrs ago.  Drinks
once per week.  No drugs.
Cerebral embolism with cerebral infarction,Chronic obstructive asthma, unspecified,Urinary tract infection, site not specified,Mitral valve disorders,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Old myocardial infarction,Aortocoronary bypass status
Crbl emblsm w infrct,Chronic obst asthma NOS,Urin tract infection NOS,Mitral valve disorder,Hypertension NOS,Periph vascular dis NOS,Old myocardial infarct,Aortocoronary bypass
Admission Date:  [**2159-11-26**]              Discharge Date:   [**2159-12-5**]

Date of Birth:  [**2085-6-2**]             Sex:   M

Service: NEUROLOGY

Allergies:
Shellfish

Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
Acute Stroke, s/p IV t-PA


Major Surgical or Invasive Procedure:
IV TPA

History of Present Illness:
74 year old man with hx of CAD (s/p MI, s/p CABG), HTN, Right
carotid stenosis (s/p carotid stent [**10-5**]), and arthritis who
presented to the ED on [**11-25**] complaining of left sided weakness.
 A code stroke was called and the stroke
fellow assessed the patient immediately (Please see Dr.[**Name (NI) 105059**]
note [**11-25**] for details of initial assessment).  He was initially
found to have an NIHSS of 9.  CT/CTA was done and was negative
for early signs of infarction, but did show a paucity of vessels
in the right MCA territory.  IV tPA was administered by Dr.
[**Last Name (STitle) **] at 8:53am.

I arrived at 9:00AM and obtained the following history.  Pt was
feeling well when he went to bed last night, [**11-24**]. He awoke in
his USOH on the morning of admission at 5am, watched the news,
then started to read a book. At that time, he was able to use
both hands to hold the book and had no difficulty turning the
pages.  Around 6-6:30am, he got out of bed to go to the
bathroom.  His left leg "gave out" and he slid to the floor.  He
thought that there might be something wrong with his heart so he
reached for his nitroglycerine tablets.  He noticed that he was
unable to grip the bottle with his left hand.  He crawled back
into bed and called EMS.  He was brought to the ED where he
arrived shortly after 8AM.  He was noted to have a left visual
field cut, dysarthria, left sided inattention, left facial
droop, left hemiplegia (arm>leg) and left hemisensory deficit.
He was given IV-tPA.  NIHSS=8 (see exam below).

He denies fever/chills, CP, SOB, palpitations, nausea/vomiting,
or dysuria.  He denies having similar symptoms in the past.

Past Medical History:
1. CAD- s/p MI and CABG [**63**] yrs ago with subsequent coronary
stenting
2. COPD
3. HTN
4. High cholesterol
5. PVD-s/p right leg stenting
6. Osteoarthritis


Social History:
Divorced, lives alone.  Used to work appraising properties for
the government.  60 pk yr smoking hx, quit 2 yrs ago.  Drinks
once per week.  No drugs.


Family History:
Brother - stroke
[**Name2 (NI) 6419**] parents had heart disease in their 60s.

Physical Exam:
T-96.6 BP-155/103 HR-72 RR-20 O2Sat-100
Gen: Lying in bed, NAD
HEENT: NC/AT, facial rubor, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, no carotid bruits
CV: RRR, Nl S1 and S2, [**2-4**] HSM
Lung: Decreased breath sounds throughout
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect.  Oriented to person, place, and date.  He is attentive,
says [**Doctor Last Name 1841**] backwards.  Speech is fluent with normal comprehension
and repetition; naming intact. Moderate dysarthria. [**Location (un) **]
intact.  Registers [**2-1**], recalls [**2-1**] in 5 minutes.  No right left
confusion. He has left sided inattention, but does look at
examiner on the left.

Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. No visual field cut, +extinction to visual DSS
III, IV, VI: Right gaze preference, but extraocular movements
full bilaterally, no nystagmus.
V: Sensation decreased to LT and pin on left V1-V3
VII: Left lower facial palsy, also some weakness of orbicularis
occuli on the left-though forehead moves symmetrically.
VIII: Hearing intact to finger rub bilaterally
IX, X: Palate elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid normal bilaterally.
XII: Tongue midline (when facial droop corrected), movements
intact

Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
Left drift

  [**Doctor First Name **] Tri [**Hospital1 **]  WF WE FE FF  IP  H  Q DF PF TE TF
R  5   5   5  5  5  5  5   5   5  5  5  5  5  4+
L  5-  5   5  3  2  1  2   5-  5  5  5  5  5  4+

Sensation: Intact to light touch, pinprick on right, decreased
by (?50%) on left.  Vibration and proprioception diminished to
shin/ankle bilaterally.  Decreased proprioception in left
fingers (intact on right).  +agraphesthesia on left.  +
extinction to DSS on left.

Reflexes:
+2 and symmetric throughout.
Toes upgoing bilaterally

Coordination: finger-nose-finger normal on left-ataxia in
proportion to weakness on left, heel to shin normal, Unable to
do RAMs on left.

Gait/Romberg: Unable to assess

Pertinent Results:
7.1>37.8<197  73N 17L 5E
Na 143  K 4.0  Cl 106  CO2 25  BUN 20  Cr 1.1  Glu 112
Ca 9.4  Mg 1.7  Ph 3.6
Lip 43
PT 12.8  PTT 23.3  INR 1.1
A1C 5.2
Chol 155  TG 110  HDL 69  LDL 64
U/A neg

Head CT [**11-25**] - Abrupt cut-off of the anterior division of the
right middle cerebral artery (M3), consistent with acute
occlusive thrombus or embolus. No intracranial hemorrhage or
mass effect.

Head CT [**11-26**] and [**12-3**] - Stable head CT with evidence of evolving
right middle cerebral artery territory infarct, without definite
hemorrhage.

MRI head [**11-25**] - Large area of restricted diffusion in the right
middle cerebral artery territory in the right frontal and
temporal lobes, consistent with acute infarct. MR [**First Name (Titles) 4058**] [**Last Name (Titles) 4579**]s significantly decreased flow in the right mid
cerebral artery branches

Transthoracic Echocardiogram [**11-26**] - Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%).

Carotid ultrasound [**11-28**] - Minimal plaque on the right with a
less than 40% carotid stenosis. On the left, there is moderate
plaque with a 40-59% stenosis.

Neck MRA [**11-27**] - Patent right internal carotid artery stent but
with apparent slow flow. Signal irregularity and apparent
diminutive flow through the stent could be secondary to magnetic
susceptibility from the stent, intimal hyperplasia, or a small
amount of thrombus.

Preliminarily transesophageal echocardiogram:  simple atheroma
in descending aorta

Brief Hospital Course:
74 year old man with hx of CAD, HTN, high cholesterol, smoking,
s/p recent right carotid stent, and family hx of stroke who
presents with acute onset of left sided weakness.  He is s/p IV
tPA 2.5hrs after symptom onset. Initial exam notable for left
sided inattention, dysarthria, left facial, left sided weakness
(primarily in arm with cortical hand), left sided sensory
deficit to all modalities, left sided cortical sensory loss.
Deficits localize to the right fronto-parietal region.  He was
admitted to the neuro ICU after receiving tPA; MRI/A showed M2
or M3 occlusion, no recannulization.

Neuro - Stroke was most likely related to embolism from stent
thrombus. Serial head CTs stable, but more dense weakness
beginning on HD#2. Pt was continued on aspirin and plavix for
stent. Patient was started on low dose coumadin 2.5 mg a day
with no load given that he is already on two antiplatelets.  The
target is for low INR around 2. Plan for Coumadin for 3 months,
re-image stent, if patent, discontinue Coumadin. Exam remains
most notable for dysarthria, L hemiplegia and L extinction to
double simultaneous stimulation.

CV - Ruled out for MI upon admission. Blood pressure was
initially allowed to autoregulate. HTN now controlled on
Metoprolol. No events on telemetry. TEE performed on [**12-5**] prelim
read: simple atheroma in descending aorta, moderately thick
aortic valve, no ASD or PFO (final report pending). Should
follow up with his outpatient Cardiologist, Dr. [**Last Name (STitle) 2912**],
[**Telephone/Fax (1) 25832**] after discharge from rehab. Should continue Plavix
for at least 6 months after stent placement; duration of therapy
to be guided directly by Pt's cardiologist.

FEN/GI - Pt failed initial swallow evaluations, requiring tube
feeds through [**12-3**]. Cleared by video swallow evaluation for soft
solids and thin liquids on [**12-4**].

Heme - Should start Coumadin 2.5mg QHS on [**12-5**], goal INR ~2 (low
therapeutic goal as Pt will also be on Aspirin and Plavix and
would be at high risk for bleeding with higher INR). Check INR
twice weekly.

ID - Being treated with Nitrofurantoin for UTI, course to be
complete on [**12-7**].

Tox - For significant alcohol history, Pt was started on
Thiamine, Folate.

Discharged to rehab on [**2159-12-5**] in stable condition.

Medications on Admission:
Plavix
ASA 325
Lipitor
NTG
Fluticasone
Atneolol
Lisinopril
Folate
Elavil
Pletal
Folate
Temazepam


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]

Discharge Diagnosis:
Right MCA stroke


Discharge Condition:
Stable


Discharge Instructions:
Please do not load with coumadin, just start coumadin gently and
allow inr to trend slowing to goal INR of 2.

Seek medical attention for worsened weakness, numbness,
difficulty speaking, sudden change in vision/hearing, severe
headache, seizure, or for other concerns.

Take all medications (including new ones) as prescribed.

Followup Instructions:
1. If you do not receive a call from Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office
(Neurology) in [**12-3**] weeks, please call her office at [**Telephone/Fax (1) 105060**]
for an appointment
2. Follow up with your primary care physician after discharge
from rehab.
{'Cerebral embolism with cerebral infarction,Chronic obstructive asthma, unspecified,Urinary tract infection, site not specified,Mitral valve disorders,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Old myocardial infarction,Aortocoronary bypass status'}


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: Acute Stroke, s/p IV t-PA

PRESENT ILLNESS: 74 year old man with hx of CAD (s/p MI, s/p CABG), HTN, Right
carotid stenosis (s/p carotid stent [**10-5**]), and arthritis who
presented to the ED on [**11-25**] complaining of left sided weakness.
 A code stroke was called and the stroke
fellow assessed the patient immediately (Please see Dr.[**Name (NI) 105059**]
note [**11-25**] for details of initial assessment).  He was initially
found to have an NIHSS of 9.  CT/CTA was done and was negative
for early signs of infarction, but did show a paucity of vessels
in the right MCA territory.  IV tPA was administered by Dr.
[**Last Name (STitle) **] at 8:53am.

MEDICAL HISTORY: 1. CAD- s/p MI and CABG [**63**] yrs ago with subsequent coronary
stenting
2. COPD
3. HTN
4. High cholesterol
5. PVD-s/p right leg stenting
6. Osteoarthritis

MEDICATION ON ADMISSION: Plavix
ASA 325
Lipitor
NTG
Fluticasone
Atneolol
Lisinopril
Folate
Elavil
Pletal
Folate
Temazepam

ALLERGIES: Shellfish

PHYSICAL EXAM: T-96.6 BP-155/103 HR-72 RR-20 O2Sat-100
Gen: Lying in bed, NAD
HEENT: NC/AT, facial rubor, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, no carotid bruits
CV: RRR, Nl S1 and S2, [**2-4**] HSM
Lung: Decreased breath sounds throughout
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect.  Oriented to person, place, and date.  He is attentive,
says [**Doctor Last Name 1841**] backwards.  Speech is fluent with normal comprehension
and repetition; naming intact. Moderate dysarthria. [**Location (un) **]
intact.  Registers [**2-1**], recalls [**2-1**] in 5 minutes.  No right left
confusion. He has left sided inattention, but does look at
examiner on the left.

FAMILY HISTORY: Brother - stroke
[**Name2 (NI) 6419**] parents had heart disease in their 60s.

SOCIAL HISTORY: Divorced, lives alone.  Used to work appraising properties for
the government.  60 pk yr smoking hx, quit 2 yrs ago.  Drinks
once per week.  No drugs. 

### Response:
{'Cerebral embolism with cerebral infarction,Chronic obstructive asthma, unspecified,Urinary tract infection, site not specified,Mitral valve disorders,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Old myocardial infarction,Aortocoronary bypass status'}
