CHIEF COMPLAINT: Left sided weakness

PRESENT ILLNESS: 64 yo RHM with h/o HTN, HL presents with headache, L sided
weakness and slurred speech.
The patient was golfing on Sunday when he suddenly developed a
severe headache between his eyes, [**10-30**] at onset. The pain was
non-throbbing, but caused light sensitivity. He also had blurry
vision in the R eye. He thinks he could see fine if he covered
the R eye.
10 minutes after the headache, he became "disoriented." He had
been golfing with 2 physicians, who called 911. The patient
remembers feeling like he could not stand, and was leaning
against a golf cart, and could not get in on his own. He
remembers being taken by ambulance to hospital. He did not try
speaking because he didn't know what was going on, but could
hear
and understand everything. When he did try speaking it was in
the
hospital and it was slurred.
He initially presented to [**Hospital **] Hospital. BP ws 138/80 and
NIHSS >10, EKG NSR. Initial documented exam at 3:15 pm showed
gaze prefence to RIGHT, L facial droop, L neglect and dense L
hemiparesis. He had a negative head CT and received tPA. Workup
then included carotid U/S which suggested R ICA high resistance,
and MRA showed distal R ICA occlusion versus stenosis. MRI brain
showed R ACA and MCA territory acute infarct with no hemorrhage.

MEDICAL HISTORY: HTN
HL
recent foot surgery for bone spur

MEDICATION ON ADMISSION: ASA 81 mg
lisinopril 20 mg
Lipitor 20 mg

ALLERGIES: Erythromycin Base / Augmentin

PHYSICAL EXAM: Vitals: T: afeb P: 65 R: 16  BP: 138/87  SaO2: 95/RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple. No nuchal rigidity.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.

FAMILY HISTORY: mother had migraines and MI at age 73, father had [**Name2 (NI) **] clots
post-knee surgery.

SOCIAL HISTORY: divorced, has stepchildren, lives alone. Owns Edible Arragments
franchise. No tobacco, social EtOH, no illicits.
Cerebral artery occlusion, unspecified with cerebral infarction,Dissection of carotid artery,Hemiplegia, unspecified, affecting unspecified side,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Dysarthria
Crbl art ocl NOS w infrc,Dissect carotid artery,Unsp hemiplga unspf side,Hypertension NOS,Hyperlipidemia NEC/NOS,Dysarthria
Name:  [**Known lastname **],[**Known firstname **]                    Unit No:   [**Numeric Identifier 14148**]

Admission Date:  [**2169-7-17**]              Discharge Date:   [**2169-7-21**]

Date of Birth:  [**2105-5-31**]             Sex:   M

Service: NEUROLOGY

Allergies:
Erythromycin Base / Augmentin

Attending:[**Last Name (NamePattern1) 4697**]
Addendum:
MRI Shoudler PRELIM READ:
1. High-grade undersurface partial tear of the supraspinatus,
with
tendinopathic thickening.
2. Calcific tendonitis at the infraspinatus.
3. Calcium deposit along the long head of the biceps tendon,
with
tendinopathy.
4. Anterior labral tear.
5. Marked AC and [**Hospital1 **] joint DJD.

The above report was discussed with the orthopedics consult
team.  They have recommended Physical therapy for immobilization
and treatment for the rotator cuff tear.  A follow-up
appointment should be scheduled with Dr. [**Last Name (STitle) 14149**] in the next
7-10 days.

[**Last Name (LF) **], [**First Name3 (LF) **]
Pager: Office Phone: ([**Telephone/Fax (1) 7848**]
Office Location: [**Hospital Ward Name **] 10 Department Orthopaedic Surgery

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 41**] - [**Location (un) 42**]

                             [**First Name8 (NamePattern2) 77**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern4) 4698**] MD [**MD Number(2) 4699**]

Completed by:[**2169-7-21**]

Admission Date:  [**2169-7-17**]              Discharge Date:   [**2169-7-21**]

Date of Birth:  [**2105-5-31**]             Sex:   M

Service: NEUROLOGY

Allergies:
Erythromycin Base / Augmentin

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Left sided weakness

Major Surgical or Invasive Procedure:
received IV tPA


History of Present Illness:
64 yo RHM with h/o HTN, HL presents with headache, L sided
weakness and slurred speech.
The patient was golfing on Sunday when he suddenly developed a
severe headache between his eyes, [**10-30**] at onset. The pain was
non-throbbing, but caused light sensitivity. He also had blurry
vision in the R eye. He thinks he could see fine if he covered
the R eye.
10 minutes after the headache, he became "disoriented." He had
been golfing with 2 physicians, who called 911. The patient
remembers feeling like he could not stand, and was leaning
against a golf cart, and could not get in on his own. He
remembers being taken by ambulance to hospital. He did not try
speaking because he didn't know what was going on, but could
hear
and understand everything. When he did try speaking it was in
the
hospital and it was slurred.
He initially presented to [**Hospital **] Hospital. BP ws 138/80 and
NIHSS >10, EKG NSR. Initial documented exam at 3:15 pm showed
gaze prefence to RIGHT, L facial droop, L neglect and dense L
hemiparesis. He had a negative head CT and received tPA. Workup
then included carotid U/S which suggested R ICA high resistance,
and MRA showed distal R ICA occlusion versus stenosis. MRI brain
showed R ACA and MCA territory acute infarct with no hemorrhage.

The patient was transferred to [**Hospital1 18**] for further evaluation and
treatment of R ICA.
During his hospital course, the patient has had constant frontal
headache that varies in severity, currently a [**5-30**] and
associated
with photophobia. His speech has been slurred without any
worsening or improvement. His R eye vision remained blurred
until
this morning. On questioning about his L side, he says he has to
look at it to move it, but can use his hand to type and can
walk.
He is also quite insistent that he is not at [**Hospital1 18**], but must be
on the [**Location (un) 1121**] because of how the ambulance drove here.
Of note, the patient had a similar acute onset headache 2 weeks
ago associated with R eye blurriness, that only lasted 5
minutes.
He has never had this type of headache or vision changes before.
He has never had migraines.


Past Medical History:
HTN
HL
recent foot surgery for bone spur


Social History:
divorced, has stepchildren, lives alone. Owns Edible Arragments
franchise. No tobacco, social EtOH, no illicits.


Family History:
mother had migraines and MI at age 73, father had [**Name2 (NI) **] clots
post-knee surgery.


Physical Exam:
Vitals: T: afeb P: 65 R: 16  BP: 138/87  SaO2: 95/RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple. No nuchal rigidity.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: Alert, oriented x 3 (knows hospital, though does
not think he is at [**Hospital1 18**]). Able to name [**Doctor Last Name 1841**] backwards but with
long pauses and requires cues. Language is fluent with
intact naming, repetition and comprehension.  Normal prosody.
There were no paraphasic errors.  Able to read without
difficulty.  Speech was mildly dysarthric. Able to follow both
midline and appendicular commands. Pt. was able to register 3
objects and recall [**3-23**] at 5 minutes.  The pt. had good knowledge
of current events.  There was no evidence of apraxia of R hand.

NEGLECT- patient able to cross midline (grabs left hand with his
right hand) and recognize own hand. His head and eyes are turned
preferentially to the right but can cross midline. He cannot
find
the TV in the room (which is on the left).

-Cranial Nerves:
PERRL 3 to 2mm and brisk. VFF to confrontation.
EOMI without nystagmus.  Normal saccades. Gaze preference and
head turned to the R but can cross midline.
Facial sensation intact to light touch.
L lower facial weakness
Tongue protrudes in midline but slow and clumsy movements.

-Motor:
LLE increased tone.
R postural tremor.
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L  0 throughout
R  5    5   5   5   5  5  5  5   5    5  5     5     5   5

-Sensory: intact light touch and pain, no extinction to DSS.

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2 2    2    2+  2 with clonus
R  2 2    2    2   1
Plantar response was flexor on R and extensor on L.


Pertinent Results:
[**2169-7-17**] 09:00PM   %HbA1c-5.5 eAG-111
[**2169-7-17**] 09:00PM   TSH-1.6
[**2169-7-17**] 09:00PM   TRIGLYCER-78 HDL CHOL-59 CHOL/HDL-3.0
LDL(CALC)-101

CAROTID U/S: R ICA high grade downstream stenosis or occlusion

MRA: short segment of occlusion of distal R ICA near skull base.

MRI: acute infarct R frontal lobe and R BG involving ACA and MCA
distributions. No ICH. Diminished flow in distal R ICA

ECHO:
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers.

MR HEAD W/O CONTRAST Study Date of [**2169-7-18**] 5:13 PM
IMPRESSION:
1. Acute stroke involving the right MCA and right ACA
territories which
appears to have progressed since the recent prior CTA and MRI.
2. Short segment dissection in the distal cervical course of the
right
internal carotid artery. Lack of flow-related enhancement in the
M2 segment
branches of the right MCA consistent with occlusion.

Right Shoulder X-ray:
Four views of the right shoulder, demonstrate moderate
acromioclavicular
osteoarthritis. Moderate glenohumeral osteoarthritis with mild
joint space
narrowing, osteophytes, subchondral cystic change. In addition,
there is
amorphous calcification projecting over the supraspinatus
tendon, consistent with calcific tendinopathy. Visualized right
upper lung zone is clear.

MRI Right shoulder: Report is pending at the time of discharge.



Brief Hospital Course:
Mr. [**Known lastname 2031**] is a 64 y/o RHM with PMH HTN, HLD who presented to
OSH with headache, L sided weakness and slurred speech, for
which he received IV tpA. He was found to have R ACA/MCA stroke
and R distal ICA occlusion vs stenosis.

Neuro:
He was transferred from [**Hospital **] Hospital after 24 hours
post-TPA. Neuro exam on presentation was significant for dense L
hemiparesis, L neglect and mild dysarthria. He was admitted to
the Neuro ICU. CTA showed severe stenosis of the distal right
cervical artery with a suggestion of a likely dissection without
convincing pseudoaneurysm. MRI/A with fat sats was then done and
this did confirm diagnosis of dissection. The patient was
started on heparin drip bridge to Coumadin for anticoagulation.
He was discharged on a lovenox bridge.  At the time of
discharge, the patient continued to have a left visual field
neglect.  He had flaccid paralysis of the left side, with only
1+/5 movement at the left IP.

He was seen by speech and swallow:
Evaluation on [**7-20**] with the following assessment:
Pt presents with isolated cough during today's evaluation which
may be his baseline dry cough/med associated or could have been
an isolated episode of aspiration.  Would recommend continuing
with current diet order of regular solids and nectar thick
liquids as primary source of PO intake.  Would also continue
medications whole with nectar or puree.  However, would
recommend
patient to begin a "[**Last Name (un) 6358**] Free Water Protocol" in which he's
allowed to drink thin liquid H2O between meals after aggressive
oral care.  Pt should be monitored closely for signs of negative
sequelae associated with possible intermittent/ occasional
aspiration such as worsening respiratory status, increased SOB,
etc.  If these occur, Free Water Protocol should be stopped.  We
will continue to follow during this admission to ensure diet
tolerance and consider further diet upgrades.  Pt will also
benefit from swallow dx/tx in rehab setting upon d/c to continue
to upgrade diet as Neurological issues resolve.
1. PO diet: regular solids, nectar thick liquids
2. PO meds whole with puree or nectar
3. [**Last Name (un) 6358**] Free Water Protocol:
   a) thin liquid H2O allowed between meals only
   b) provide aggressive oral care prior to H2O intake
4. Assist with meals as needed to maintain standard aspiration
precautions and assist with self-feeding.
5. Monitor closely for signs of aspiration above and cease Water
Protocol if they occur.
6. Continued swallow follow up here and in rehab setting upon
d/c
for further diet upgrades when medically appropriate.

Musculoskeletal:
The patient noted significant R shoulder pain that was worse
with laying flat and significantly limiting his range of motion.
A shoulder x-ray was obtained that noted moderate
acromioclavicular and glenohumeral osteoarthritis with mild
joint space narrowing, osteophytes, and subchondral cystic
change. In addition, there is amorphous calcification projecting
over the supraspinatus tendon, consistent with calcific
tendinopathy. An MRI was later obtained due to concern for
rotator cuff tear. While the formal read was pending at the time
of discharge****

Medications on Admission:
ASA 81 mg
lisinopril 20 mg
Lipitor 20 mg


Discharge Medications:
1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
2. Lovenox 100 mg/mL Syringe Sig: One (1)  Subcutaneous twice a
day: Until INR>2.
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
R ACA/MCA stroke
R ICA dissection


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neuro Defecits: L neglect (improving), L hemiplegia ([**1-25**] at left
IP)
Vitals on discharge: Temp 131/89 HR 57

Discharge Instructions:
You presented to the hospital after acute onset of headache and
disorientation with subseque nt slurred speech and left
hemiplegia. You received IV tpa and was admitted to the ICU at
an outside hospital, where a stroke on the right side of your
brain was noted. You were transferred to [**Hospital1 18**] for further
management. While here, you had further imaging, which showed
that there is a dissection in your right internal cartoid
artery. The dissection is beleived to be the source of the clot
causing the stroke. You were started on [**Hospital1 **] thinning
medication called Coumadin to help prevent future strokes. While
on this medication, you will need to have [**Hospital1 **] levels called
INR measured. Your PCP should monitor these levels after you ar
discharged from rehab.

Followup Instructions:
Department: NEUROLOGY
When: TUESDAY [**2169-10-3**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

PLEASE FOLLOW-UP WITH YOUR PCP.
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) **] MARK
Location: [**Hospital1 **] FAMILY PHYSICIANS
Address: [**Street Address(2) 89231**], [**Hospital1 **],[**Numeric Identifier 89232**]
Phone: [**Telephone/Fax (1) 39393**]
Fax: [**Telephone/Fax (1) 89233**]



Completed by:[**2169-7-21**]
{'Cerebral artery occlusion, unspecified with cerebral infarction,Dissection of carotid artery,Hemiplegia, unspecified, affecting unspecified side,Unspecified essential hypertension,Other and unspecified hyperlipidemia,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: Left sided weakness

PRESENT ILLNESS: 64 yo RHM with h/o HTN, HL presents with headache, L sided
weakness and slurred speech.
The patient was golfing on Sunday when he suddenly developed a
severe headache between his eyes, [**10-30**] at onset. The pain was
non-throbbing, but caused light sensitivity. He also had blurry
vision in the R eye. He thinks he could see fine if he covered
the R eye.
10 minutes after the headache, he became "disoriented." He had
been golfing with 2 physicians, who called 911. The patient
remembers feeling like he could not stand, and was leaning
against a golf cart, and could not get in on his own. He
remembers being taken by ambulance to hospital. He did not try
speaking because he didn't know what was going on, but could
hear
and understand everything. When he did try speaking it was in
the
hospital and it was slurred.
He initially presented to [**Hospital **] Hospital. BP ws 138/80 and
NIHSS >10, EKG NSR. Initial documented exam at 3:15 pm showed
gaze prefence to RIGHT, L facial droop, L neglect and dense L
hemiparesis. He had a negative head CT and received tPA. Workup
then included carotid U/S which suggested R ICA high resistance,
and MRA showed distal R ICA occlusion versus stenosis. MRI brain
showed R ACA and MCA territory acute infarct with no hemorrhage.

MEDICAL HISTORY: HTN
HL
recent foot surgery for bone spur

MEDICATION ON ADMISSION: ASA 81 mg
lisinopril 20 mg
Lipitor 20 mg

ALLERGIES: Erythromycin Base / Augmentin

PHYSICAL EXAM: Vitals: T: afeb P: 65 R: 16  BP: 138/87  SaO2: 95/RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple. No nuchal rigidity.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.

FAMILY HISTORY: mother had migraines and MI at age 73, father had [**Name2 (NI) **] clots
post-knee surgery.

SOCIAL HISTORY: divorced, has stepchildren, lives alone. Owns Edible Arragments
franchise. No tobacco, social EtOH, no illicits. 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Dissection of carotid artery,Hemiplegia, unspecified, affecting unspecified side,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Dysarthria'}
