CHIEF COMPLAINT: Right sided weakness, ?seizure

PRESENT ILLNESS: Mrs. [**Known lastname **] is a 62 year old woman with a history of a left cea
one week ago for an asymptomatic 90% stenosis. She was doing
well until yesterday afternoon when she had the sudden onset of
rt sided weakness and right sided "twitching" both in the arm
alone. By report she was responding normally when EMS arrived
but began to have slurred speech and declining alertness
enroute.  At OSH she had myoclonic jerks of the right arm and
was given 5mg  valium, 200mg PB, and 1gm PHT. She was
transferred to [**Hospital1 18**], paralyzed and intubated on propofol.
Overnight she was extubated and noted to be confused and unable
to speak.

MEDICAL HISTORY: Hypertension, coronary artery disease with an MI in [**2139**],
angioplasty with stent placement to the right coronary artery in
[**2139**], a second MI in [**2144**], with a re-stenting of the right
coronary artery at that time.

MEDICATION ON ADMISSION: protonix
[**Doctor First Name 130**]
xanax 0.5 prn
lescol 80
avapro 300

ALLERGIES: Aspirin / Cephalexin / Hydromorphone / Ativan

PHYSICAL EXAM: General Exam:
Vitals:  afebrile  BP: 150/70s   P: 90s    R: 12
Gen: obese, distraught
Head: NC/AT, non-icteric, MMM, equal pulses
Neck: supple, left CEA scar, no carotid bruits
CV: nl S1, S2  regular
Ext: no edema nor rashes

FAMILY HISTORY: N/C

SOCIAL HISTORY: +smoker, no hx of EtOH or drug use
Iatrogenic cerebrovascular infarction or hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Other convulsions,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Unspecified essential hypertension
Iatrogen CV infarc/hmrhg,Crbl art ocl NOS w infrc,Convulsions NEC,Int inf clstrdium dfcile,Urin tract infection NOS,Hypertension NOS
Admission Date:  [**2146-12-9**]              Discharge Date:   [**2146-12-13**]

Date of Birth:  [**2084-12-7**]             Sex:   F

Service: NEUROLOGY

Allergies:
Aspirin / Cephalexin / Hydromorphone / Ativan

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Right sided weakness, ?seizure

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Mrs. [**Known lastname **] is a 62 year old woman with a history of a left cea
one week ago for an asymptomatic 90% stenosis. She was doing
well until yesterday afternoon when she had the sudden onset of
rt sided weakness and right sided "twitching" both in the arm
alone. By report she was responding normally when EMS arrived
but began to have slurred speech and declining alertness
enroute.  At OSH she had myoclonic jerks of the right arm and
was given 5mg  valium, 200mg PB, and 1gm PHT. She was
transferred to [**Hospital1 18**], paralyzed and intubated on propofol.
Overnight she was extubated and noted to be confused and unable
to speak.


Past Medical History:
Hypertension, coronary artery disease with an MI in [**2139**],
angioplasty with stent placement to the right coronary artery in
[**2139**], a second MI in [**2144**], with a re-stenting of the right
coronary artery at that time.


Social History:
+smoker, no hx of EtOH or drug use

Family History:
N/C

Physical Exam:
General Exam:
Vitals:  afebrile  BP: 150/70s   P: 90s    R: 12
Gen: obese, distraught
Head: NC/AT, non-icteric, MMM, equal pulses
Neck: supple, left CEA scar, no carotid bruits
CV: nl S1, S2  regular
Ext: no edema nor rashes

Neurological Exam:
Mental Status:
   Awake, alert, and attentive. Non fluent aphasia with little
comprehension and impaired repetition that fits technical
criteria for global aphasia but with more comprehension than
usually.  Tries to repeat but unable.  Sparse output.
Perseverative.  Says "Scared" repeatedly. 50% midline commands,
<25% axial.

Cranial Nerves:
II. visual fields intact to threat. pupils normal, round and
reactive to light, no rAPD
III, IV, VI. Extraocular movements intact and without nystagmus,
V, VII. Normal facial sensation. No facial droop.  Strength full
and symmetric.
VIII. Hearing intact to voice bilaterally
IX, X, XII. Normal oropharyngeal movemement. Tongue midline
without fasciculations. Sternocleidomastoid and trapezius normal
bilaterally

Motor:
Left side with full strength but motor impersistance.
repeatedly extends left arm and hand toward examiner or railing
 and often lifts left leg in the process.
Left arm with 4 to 4+/5 range UMN weakness,
Left leg sustained antigravity
Appears to have either proprioceptive difficulty or motor
 planning problems.

Sensory: grossly intact

Reflexes:
       Tri    [**Hospital1 **]    Br    Pat    Ach    Toes
L      2      2     2     2      0      down
R      3      3     3     3      0      down


Pertinent Results:
[**2146-12-9**] 01:05PM BLOOD WBC-17.9*# RBC-4.47# Hgb-13.7 Hct-41.8#
MCV-93 MCH-30.7 MCHC-32.9 RDW-13.0 Plt Ct-434#
[**2146-12-13**] 04:45AM BLOOD WBC-11.8* RBC-4.15* Hgb-12.8 Hct-37.7
MCV-91 MCH-30.8 MCHC-33.9 RDW-13.4 Plt Ct-353
[**2146-12-9**] 01:05PM BLOOD PT-13.1 PTT-28.4 INR(PT)-1.1
[**2146-12-9**] 01:05PM BLOOD Glucose-237* UreaN-12 Creat-0.8 Na-142
K-3.8 Cl-99 HCO3-34* AnGap-13
[**2146-12-10**] 04:27AM BLOOD ALT-36 AST-22 LD(LDH)-264* AlkPhos-97
Amylase-69 TotBili-0.4
[**2146-12-10**] 04:27AM BLOOD Lipase-41
[**2146-12-10**] 04:27AM BLOOD %HbA1c-5.8
[**2146-12-10**] 04:27AM BLOOD Triglyc-115 HDL-68 CHOL/HD-2.9
LDLcalc-103
[**2146-12-13**] 04:45AM BLOOD Phenyto-11.5
[**2146-12-9**] 01:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Stool: positive for C. dif toxin
Urine Cx: positive for proteus and E. coli


Brief Hospital Course:
62 yo s/p endarterectomy last week for 90% stenosis of left ICA
who presents to the ED after acute right sided weakness followed
by accounts of shaking of the RUE. She was given large doses of
valium, phenobarb, and dilantin at an OSH and was intubated in
the [**Hospital1 18**] ER for airway protection. Was extubated, transfered to
floor [**12-10**]. Head CT showed evidence of subacute left frontal
infarct which likely served as the focus for her seizure.  CTA
demonstrated patent cervical and intracranial vasculature. EEG
showed intermittent low amplitude sharp activity seen over the
left centro-temporal region confirming an area of focal
irritability which may have led to her seizure. She was loaded
with dilantin and levels were therapeutic at the time of
discharge. Dilantin will be continued for the next six months.
She has remained seizure free during her hospitalization. She
was continued on Plavix for secondary stroke prevention (has asa
allergy).  She had a carotid duplex which showed less than 40%
stenosis right extracranial internal carotid artery, no
significant stenosis was seen in the left extracranial internal
carotid artery. Echocardiogram was done to r/o cardioembolic
source. It showed no cardiac source of embolus. On admission she
was noted to have an elevated WBC.  She was found to have a UTI
with cultures positive for both P. mirabilis and E. coli.  Her
stool was also positive for C. diff.  She was started on
Levofloxacin and Flagyl and will finish 7 and 14 day courses,
respectively, of these antibiotics.  Vascular surgery evaluated
her with regard to her recent CEA and felt that she was healing
well.
Her exam improved over the course of her admission, no aphasia,
mild right sided weakness and ataxia. She will be discharged
with primary care, vascular surgery and neurology follow up
appointments. She will also have outpatient PT/OT to improve
right UE mobility.

Medications on Admission:
protonix
[**Doctor First Name 130**]
xanax 0.5 prn
lescol 80
avapro 300

Discharge Medications:
1. Fluvastatin Sodium 20 mg Capsule Sig: Four (4) Capsule PO qd
().
Disp:*120 Capsule(s)* Refills:*2*
2. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO qd ().
Disp:*30 Tablet(s)* Refills:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*10 Tablet(s)* Refills:*0*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 12 days.
Disp:*90 Tablet(s)* Refills:*2*
9. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times a
day.
Disp:*90 Capsule(s)* Refills:*2*
10. Dilantin 30 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
11. Occupational Therapy  Sig: One (1)   as needed: S/P acute
stroke, please do OT to improve right upper extremity function.
Disp:*1 1* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 537**]- [**Location (un) 538**]

Discharge Diagnosis:
1. Seizure
2. Stroke -left frontal lobe infarct
3. HTN
4. C. diff colitis
5. Urinary tract infection-Proteus and E. coli


Discharge Condition:
Stable:  Right UE weakness and ataxia.

Discharge Instructions:
Please follow up with Dr. [**Last Name (STitle) **] next week.  Please take your
medication as directed.  You will need to be on dilantin for six
months for seizure prevention.  You cannot drive for the next
six months.  You will take two antibiotics: Levofloxacin and
Flagyl.  You should take the Levofloxacin for 4 more days (to
complete 7 days) and the Flagyl for 12 more days (to complete 14
days).

Followup Instructions:
1.  Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 42057**].  Have bloodwork done next week to
check dilantin level. The target dilantin level is [**1-20**].
Please have your blood pressure checked.  You will also need a
repeat UA and Urine culture after you have completed the course
of antibiotics.

2.  [**Hospital **] CLINIC:  Dr. [**Last Name (STitle) 7994**]/ Dr. [**Last Name (STitle) **].  ([**Telephone/Fax (1) 8951**] TIME: [**3-12**] at 1:00PM.  WHERE:  [**Hospital Ward Name 23**] Bldg

3. Outpatient Occupational Therapy


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
{'Iatrogenic cerebrovascular infarction or hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Other convulsions,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Unspecified essential hypertension'}


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 sided weakness, ?seizure

PRESENT ILLNESS: Mrs. [**Known lastname **] is a 62 year old woman with a history of a left cea
one week ago for an asymptomatic 90% stenosis. She was doing
well until yesterday afternoon when she had the sudden onset of
rt sided weakness and right sided "twitching" both in the arm
alone. By report she was responding normally when EMS arrived
but began to have slurred speech and declining alertness
enroute.  At OSH she had myoclonic jerks of the right arm and
was given 5mg  valium, 200mg PB, and 1gm PHT. She was
transferred to [**Hospital1 18**], paralyzed and intubated on propofol.
Overnight she was extubated and noted to be confused and unable
to speak.

MEDICAL HISTORY: Hypertension, coronary artery disease with an MI in [**2139**],
angioplasty with stent placement to the right coronary artery in
[**2139**], a second MI in [**2144**], with a re-stenting of the right
coronary artery at that time.

MEDICATION ON ADMISSION: protonix
[**Doctor First Name 130**]
xanax 0.5 prn
lescol 80
avapro 300

ALLERGIES: Aspirin / Cephalexin / Hydromorphone / Ativan

PHYSICAL EXAM: General Exam:
Vitals:  afebrile  BP: 150/70s   P: 90s    R: 12
Gen: obese, distraught
Head: NC/AT, non-icteric, MMM, equal pulses
Neck: supple, left CEA scar, no carotid bruits
CV: nl S1, S2  regular
Ext: no edema nor rashes

FAMILY HISTORY: N/C

SOCIAL HISTORY: +smoker, no hx of EtOH or drug use 

### Response:
{'Iatrogenic cerebrovascular infarction or hemorrhage,Cerebral artery occlusion, unspecified with cerebral infarction,Other convulsions,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Unspecified essential hypertension'}
