CHIEF COMPLAINT: intermittent chest pain -> code stroke

PRESENT ILLNESS: 74 year-old male w/ h/o CAD s/p MI and multiple PCIs with at
least 8 stents, diabetes, HTN, hypercholesterolemia, and + FH
who is admitted to cardiology service with unstable angina who
was having cardiac catheterization performed when at 3:15 (noted
to be at baseline neurologic function).  @3:30, noted to cough
and to not be moving his left side and to not be able to speak,
while
only intermittently following commands. Dr. [**First Name (STitle) **], stroke
fellow, was contact[**Name (NI) **] for code stroke.

MEDICAL HISTORY: 1. NIDDM (diet control)
2. CAD s/p MI x2
3. Cardiomyopathy
4. Gout
5. Hypertension
6. Hyperlipidemia
7. Severe lower Back pain
8. ? BPH
9. CRI - baseline ~1.3
10. unstable angina (admitted on [**2191-11-17**] after 4 episodes of
chest pain over a 2 day period with radiation to left arm).

MEDICATION ON ADMISSION: 1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID PRN ().
2. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times

ALLERGIES: Indocin / Lipitor / Plavix

PHYSICAL EXAM: VS - AF BP 128/54 RR17  HR 60  100% on 2LNC
Exam per Stroke Fellow
Gen: White elderly male in NAD. not speaking, but following
simple commands; head turn to right
HEENT: NCAT. MMM
CV: RRR, no m noted
Chest: CTAB
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. No femoral bruits.
Skin: No lesions noted

FAMILY HISTORY: F died MI at age 74, son had [**Name2 (NI) **] at age 48.

SOCIAL HISTORY: Tob 100 py. Quit 13 y ago. Denies extensive EtOH use. Leaves
with wife, has children and grandchildren, but no sick contacts.
Coronary atherosclerosis of native coronary artery,Cerebral embolism with cerebral infarction,Intermediate coronary syndrome,Iatrogenic cerebrovascular infarction or hemorrhage,Accidental puncture or laceration during a procedure, not elsewhere classified,Urinary tract infection, site not specified,Cellulitis and abscess of upper arm and forearm,Infection and inflammatory reaction due to other vascular device, implant, and graft,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Chronic kidney disease, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Gout, unspecified,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus
Crnry athrscl natve vssl,Crbl emblsm w infrct,Intermed coronary synd,Iatrogen CV infarc/hmrhg,Accidental op laceration,Urin tract infection NOS,Cellulitis of arm,React-oth vasc dev/graft,Abn react-cardiac cath,Chronic kidney dis NOS,BPH w/o urinary obs/LUTS,Status-post ptca,Old myocardial infarct,Hy kid NOS w cr kid I-IV,DMII wo cmp nt st uncntr,Pure hypercholesterolem,Gout NOS,Other staphylococcus
Admission Date:  [**2191-11-17**]              Discharge Date:   [**2191-11-25**]

Date of Birth:  [**2117-5-21**]             Sex:   M

Service: NEUROLOGY

Allergies:
Indocin / Lipitor / Plavix

Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
intermittent chest pain -> code stroke

Major Surgical or Invasive Procedure:
cardiac catheterization
angiogram
MERCI retrieval

History of Present Illness:
74 year-old male w/ h/o CAD s/p MI and multiple PCIs with at
least 8 stents, diabetes, HTN, hypercholesterolemia, and + FH
who is admitted to cardiology service with unstable angina who
was having cardiac catheterization performed when at 3:15 (noted
to be at baseline neurologic function).  @3:30, noted to cough
and to not be moving his left side and to not be able to speak,
while
only intermittently following commands. Dr. [**First Name (STitle) **], stroke
fellow, was contact[**Name (NI) **] for code stroke.

Upon his arrival, pt following simple commands. Pt noted to have
forced R gaze (couldn't move eyes past midline), L homonymous
hemianopsia, L facial droop, aphasia, [**1-31**] on UE and LE.

Code stroke was called at that time.  Pt brought to CT scanner
where no hemorrhage was noted. CTA demonstrated filling defect
in R MCA.   With history of previous cardiac cath/heparin and
integralin X 2, decision was made not to give IV tpa.  Pt
brought to neurointerventional suite. Angio demonstrated cut off
in superiof M2 branch on the right. Patient was given local IA
tPA and MERCI device was utilized with recovery of flow.  repeat
CT performed afterwards was without evidence of bleeding.

Pt was then admitted to SICU for post tPA care.

ROS: upon admission, pt denied associated SOB, N, V,
diaphoresis,
recent illness.


Past Medical History:
1. NIDDM (diet control)
2. CAD s/p MI x2
3. Cardiomyopathy
4. Gout
5. Hypertension
6. Hyperlipidemia
7. Severe lower Back pain
8. ? BPH
9. CRI - baseline ~1.3
10. unstable angina (admitted on [**2191-11-17**] after 4 episodes of
chest pain over a 2 day period with radiation to left arm).


Social History:
Tob 100 py. Quit 13 y ago. Denies extensive EtOH use. Leaves
with wife, has children and grandchildren, but no sick contacts.



Family History:
F died MI at age 74, son had [**Name2 (NI) **] at age 48.

Physical Exam:
VS - AF BP 128/54 RR17  HR 60  100% on 2LNC
Exam per Stroke Fellow
Gen: White elderly male in NAD. not speaking, but following
simple commands; head turn to right
HEENT: NCAT. MMM
CV: RRR, no m noted
Chest: CTAB
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. No femoral bruits.
Skin: No lesions noted

Neuro
NEUROLOGICAL
MS: 	
General: 	alert, following simple commands, head turn to right.

CN:
II,[**Name2 (NI) 1105**]: 	left homonymous hemianopsia, pupils R 3->2 mm; L
2->1.5.

[**Name2 (NI) 1105**],IV,V:	right gaze, not crossing midline.
VII: 	left facial palsy
VIII: 	grossly appears to hear
IX,X: 	palate elevates symmetrically
XII: 	tongue protrudes midline without atrophy or fasciculation

Motor:	normal bulk, no movement of LUE with some spontaneous
movement of LLE.
[**4-30**] in RUE and RLE.  0/5 on LUE. [**1-31**] in LLE flexors.

Reflex:		

  	[**Hospital1 **]	Tri	Bra	Pat	An	Plantar
	C5	C7	C6	L4	S1	CST
L	0	0	0	1	1	Flexor
R	1	1	1	1	1	Flexor

Sensation:  	intact to LT bilaterally. extinction on left side
Coordination:	unable on left side, no dysmetria on right
Gait:	not tested


Pertinent Results:
[**2191-11-17**] 07:05PM   CK(CPK)-72
[**2191-11-17**] 07:05PM   CK-MB-NotDone cTropnT-<0.01
[**2191-11-17**] 12:00PM   GLUCOSE-92 UREA N-21* CREAT-1.4* SODIUM-142
POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-23 ANION GAP-16
[**2191-11-17**] 12:00PM   CK(CPK)-95
[**2191-11-17**] 12:00PM   cTropnT-<0.01
[**2191-11-17**] 12:00PM   WBC-7.6 RBC-4.38* HGB-13.6* HCT-37.9* MCV-87
MCH-31.1 MCHC-35.9* RDW-13.8
[**2191-11-17**] 12:00PM   NEUTS-78.6* LYMPHS-12.9* MONOS-5.0 EOS-3.3
BASOS-0.4
[**2191-11-17**] 12:00PM   PT-13.4 PTT-21.7* INR(PT)-1.2*

Head CT: No evidence of intracranial hemorrhage or significant
mass effect. Mild loss of attenuation involving the right
insular ribbon likely represents early change from known right
MCA distribution infarct.

Cardiac Catheterization:
1. Two vessel coronary artery disease.
2. Normal diastolic left ventricular function

MR [**Name13 (STitle) **]: Large acute/subacute infarct involving the territory
of the superior branch of the right middle cerebral artery. No
significant mass effect or shift of the normally midline
structures.

TTE:
The left atrium is normal in size. The left ventricular cavity
is dilated. Left ventricular function is severely depressed with
septall and apical akinesis. Right ventricular chamber size and
free wall motion are normal. The aortic arch is mildly dilated.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**12-28**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
No definite apical thrombus seen (cannot definitively exclude);
apex is akinetic.
Compared with the prior study (images reviewed) of [**2191-2-4**],
left ventricular systolic function appears similar.
[**2191-11-23**] 01:18PM URINE RBC-3* WBC-51* Bacteri-NONE Yeast-NONE
Epi-0
[**2191-11-22**] 08:58AM URINE RBC-21-50* WBC-[**11-15**]* Bacteri-FEW
Yeast-NONE Epi-0 TransE-0-2
[**2191-11-22**] 08:58AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2191-11-23**] 01:18PM URINE Blood-SM  Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD

[**2191-11-22**] 8:58 am URINE
   URINE CULTURE (Preliminary):
      STAPH AUREUS COAG +.    10,000-100,000 ORGANISMS/ML..

[**2191-11-22**] 10:17 pm SWAB      Source: L antecubital iv site.

   GRAM STAIN (Final [**2191-11-23**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.

   WOUND CULTURE (Preliminary):
      GRAM POSITIVE BACTERIA.    SPARSE GROWTH.
         ? OF TWO COLONIAL MORPHOLOGIES.

BLOOD CX [**11-22**] & 28: NGTD

Brief Hospital Course:
Mr. [**Known lastname 42746**] was admitted to the hospital for management of
unstable angina. He was sent to cardiac cath when he developed
abrupt onset L sided weakness and a L facial droop. A code
stroke was called at 3:30. He further hospital course by problem
is as follows.

Unstable angina:
He was transferred from the cardiac cath as a code stroke. He
has not had chest pain or ECG changes since the procedure. He
was ruled out for an MI. His BP was treated aggressively with
metoprolol and his FLP was excellent with an LDL of 75. He was
continued on Tricor, Rosuvastatin and a full aspirin. He had a
TTE which showed apical akinesis and a severely depressed EF
(20-25%). This issue and the role of anticoagulation was
discussed with cardiology. As this defect was both old and
stable, cardiology did not feel that there would be added
benefit in anticoagulation, especially as he is already on 2
antiplatelet agents, which he needs for cardiac stents.

Stroke:
He was found to have occlusion of the R MCA likely an embolus
from the catheterization. As he had received Integrilin and
heparin for his cardiac cath, the decision was made not to give
IV tPA given the risk for bleeding. Therefore he was treated
with IA tPA and MERCI. He had good recovery of flow and no
bleeding afterwards. He was transferred to the ICU for post tPA
care and then to the floor for further management. His SBP was
maintained between 140-185 and the DBP was < 105. He was
maintained on Metoprolol 100 mg PO & Imdur ER 90. He was also
continued on ASA 325.

After his stroke, he remained expressively aphasic, however his
comprehension was good. He was evaluated by speech for possible
aspiration and started on a modified diet. Despite several
re-evaluations, he continued to be a significant aspiration
risk, therefore he was referred for rehab with 1:1 supervision
during meals.

ID:
He developed cellulitis prior to discharge at an IV site. He was
therefore treated with vancomycin and a PICC was placed. He will
complete a 10 day course. He also developed a UTI which grew
coag positive staph and will also be treated with the
vancomycin. Zosyn was added on the day of discharge for a
persistent WBC, however the site appeared to be improving.

Medications on Admission:
1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID PRN ().
2. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times

a day).
4. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).


Discharge Medications:
1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours) for 8 days.
9. Zosyn 2.25 gram Recon Soln Sig: One (1)  Intravenous three
times a day for 7 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]

Discharge Diagnosis:
1. NIDDM (diet control)
2. CAD s/p MI x2
3. Cardiomyopathy
4. Gout
5. Hypertension
6. Hyperlipidemia
7. Severe lower Back pain
8. ? BPH
9. CRI - baseline ~1.3
10. unstable angina (admitted on [**2191-11-17**] after 4 episodes of
chest pain over a 2 day period with radiation to left arm).
11. R MCA occlusion s/p MERCI/ IA TPA
12. Cellulitis
13. UTI


Discharge Condition:
Stable, dysarthria and dysphagia


Discharge Instructions:
1. Please call your doctor or come to the closest ED if you have
new symptoms
2. Please take all medications as prescribed
3. Please have your swallowing re-evaluated in [**1-29**] weeks, you
may need to schedule a video swallow study


Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2191-12-26**] 2:00


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
{'Coronary atherosclerosis of native coronary artery,Cerebral embolism with cerebral infarction,Intermediate coronary syndrome,Iatrogenic cerebrovascular infarction or hemorrhage,Accidental puncture or laceration during a procedure, not elsewhere classified,Urinary tract infection, site not specified,Cellulitis and abscess of upper arm and forearm,Infection and inflammatory reaction due to other vascular device, implant, and graft,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Chronic kidney disease, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Gout, unspecified,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus'}


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: intermittent chest pain -> code stroke

PRESENT ILLNESS: 74 year-old male w/ h/o CAD s/p MI and multiple PCIs with at
least 8 stents, diabetes, HTN, hypercholesterolemia, and + FH
who is admitted to cardiology service with unstable angina who
was having cardiac catheterization performed when at 3:15 (noted
to be at baseline neurologic function).  @3:30, noted to cough
and to not be moving his left side and to not be able to speak,
while
only intermittently following commands. Dr. [**First Name (STitle) **], stroke
fellow, was contact[**Name (NI) **] for code stroke.

MEDICAL HISTORY: 1. NIDDM (diet control)
2. CAD s/p MI x2
3. Cardiomyopathy
4. Gout
5. Hypertension
6. Hyperlipidemia
7. Severe lower Back pain
8. ? BPH
9. CRI - baseline ~1.3
10. unstable angina (admitted on [**2191-11-17**] after 4 episodes of
chest pain over a 2 day period with radiation to left arm).

MEDICATION ON ADMISSION: 1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID PRN ().
2. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times

ALLERGIES: Indocin / Lipitor / Plavix

PHYSICAL EXAM: VS - AF BP 128/54 RR17  HR 60  100% on 2LNC
Exam per Stroke Fellow
Gen: White elderly male in NAD. not speaking, but following
simple commands; head turn to right
HEENT: NCAT. MMM
CV: RRR, no m noted
Chest: CTAB
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. No femoral bruits.
Skin: No lesions noted

FAMILY HISTORY: F died MI at age 74, son had [**Name2 (NI) **] at age 48.

SOCIAL HISTORY: Tob 100 py. Quit 13 y ago. Denies extensive EtOH use. Leaves
with wife, has children and grandchildren, but no sick contacts. 

### Response:
{'Coronary atherosclerosis of native coronary artery,Cerebral embolism with cerebral infarction,Intermediate coronary syndrome,Iatrogenic cerebrovascular infarction or hemorrhage,Accidental puncture or laceration during a procedure, not elsewhere classified,Urinary tract infection, site not specified,Cellulitis and abscess of upper arm and forearm,Infection and inflammatory reaction due to other vascular device, implant, and graft,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Chronic kidney disease, unspecified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Gout, unspecified,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus'}
