CHIEF COMPLAINT: Code stroke

PRESENT ILLNESS: Mr. F is a 57 year old right handed male with PVD, CAD, afib
presenting with dizziness, nausea and dysarthria. He awoke
feeling well. He developed symptoms around 1pm of dizziness
following taking insulin. He went to sleep and awoke ~5pm,
evaluated at OSH where noncontrast head CT revealed ? basilar
opacity. He was medflighted to [**Hospital1 18**] for evaluation. CODE STROKE
called upon arrival. NIHSS 6 for R facial droop, R pronator
drift, dysarthria.

MEDICAL HISTORY: Past Medical History: (incomplete)
PVD- Right foot ischemia s/p [**2-14**] digits amp [**2188-3-19**] in [**Male First Name (un) 36290**]
CAD s/p CABG
Afib
DM 2
HTN

MEDICATION ON ADMISSION: Aldactone 25mg daily
Coreg 25mg [**Hospital1 **]
Coumadin 5mg daily
Lasix 40mg [**Hospital1 **]
Vasotec 20mg [**Hospital1 **]
Amaryl 4mg [**Hospital1 **]
Lantus 6units daily
 Lipitor 10mg daily
Avelox ?? 400mg daily x 2 weeks
? pletal
gabapentin 300mg

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 98, BP 162/80, HR 72, R 18, 100% 2l
Gen: well appearing, cooperative, NAD
HEENT: slight R exopthalmos, no scleral icterus, OP clear, MMM
Neck: no carotid or vertebral bruits.
CV- irregularly irregular, 2/6 SEM at RUSB
Pulm- CTA B
Abd- obese, soft, NT, ND, BS+
Extrem- R toe [**2-14**] amputation, distal pulses 1+ bilat.

FAMILY HISTORY: prominent for DM2

SOCIAL HISTORY: not married. moved here from [**Male First Name (un) **] three days ago.
staying with his sister in-law. denies smoking.
Cerebral artery occlusion, unspecified with cerebral infarction,Pneumonia, organism unspecified,Acute respiratory failure,Hemiplegia, unspecified, affecting unspecified side,Dysphagia, unspecified,Unspecified essential hypertension,Atherosclerosis of native arteries of the extremities, unspecified,Atrial fibrillation,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Long-term (current) use of insulin,Other toe(s) amputation status
Crbl art ocl NOS w infrc,Pneumonia, organism NOS,Acute respiratry failure,Unsp hemiplga unspf side,Dysphagia NOS,Hypertension NOS,Athscl extrm ntv art NOS,Atrial fibrillation,Hyperpotassemia,DMII wo cmp nt st uncntr,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Long-term use of insulin,Status amput othr toe(s)
Admission Date:  [**2188-6-24**]              Discharge Date:   [**2188-6-28**]

Date of Birth:  [**2130-8-20**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Code stroke

Major Surgical or Invasive Procedure:
Intubation, bronchoscopy


History of Present Illness:
Mr. F is a 57 year old right handed male with PVD, CAD, afib
presenting with dizziness, nausea and dysarthria. He awoke
feeling well. He developed symptoms around 1pm of dizziness
following taking insulin. He went to sleep and awoke ~5pm,
evaluated at OSH where noncontrast head CT revealed ? basilar
opacity. He was medflighted to [**Hospital1 18**] for evaluation. CODE STROKE
called upon arrival. NIHSS 6 for R facial droop, R pronator
drift, dysarthria.

CT/CTA/CTP revealed extensive R vert occlusion and ? basilar
thrombus.

At present the patient denies headaches. Reports feeling "well."
He is aware of slurred speech. No sensory loss.

ROS, no recent, f/c, NS, CP, SOB, no abdominal pain.


Past Medical History:
Past Medical History: (incomplete)
PVD- Right foot ischemia s/p [**2-14**] digits amp [**2188-3-19**] in [**Male First Name (un) 36290**]
CAD s/p CABG
Afib
DM 2
HTN


Social History:
 not married. moved here from [**Male First Name (un) **] three days ago.
staying with his sister in-law. denies smoking.


Family History:
prominent for DM2


Physical Exam:
Vitals: T 98, BP 162/80, HR 72, R 18, 100% 2l
Gen: well appearing, cooperative, NAD
HEENT: slight R exopthalmos, no scleral icterus, OP clear, MMM
Neck: no carotid or vertebral bruits.
CV- irregularly irregular, 2/6 SEM at RUSB
Pulm- CTA B
Abd- obese, soft, NT, ND, BS+
Extrem- R toe [**2-14**] amputation, distal pulses 1+ bilat.

NEUROLOGIC EXAM: (with spanish interpretor)
MS- Alert, oriented to person, place time, attentive to
examination. Speech is severely dysarthric. Naming of high and
low frequency objects is intact. No visual neglect of NIHSS
picture.

CN- L pupil 6mm and unreactive to direct light, constricts to
5mm
via consensual response. R pupil 6mm reacts to 4mm directly. No
evidence for field cut. End-gaze nystagmus bilat, ? worse with
left gaze. There is appearance of baseline ocular misalignment.
Right UMN facial droop. weakness of R eye closure. Sensation
symmetric bilat. tongue protrudes in an irregular fashion. Able
to move bilaterally. Some debate about tongue being at midline.
SCM and Trap. full.

Motor- R pronator drift, holds arms and legs antigravity x 10
seconds intially, upon re-examination, right arm was barely
antigravity.

Sensory- no loss of LT, PP.

Plantar response, mute bilaterally.

Gait- unable to test.


Pertinent Results:
[**2188-6-24**] 06:00PM   GLUCOSE-210* UREA N-34* CREAT-1.3* SODIUM-139
POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16
[**2188-6-24**] 06:00PM   WBC-11.6* RBC-4.90 HGB-12.4* HCT-38.2*
MCV-78* MCH-25.3* MCHC-32.4 RDW-19.7*
[**2188-6-24**] 06:00PM   NEUTS-86.8* LYMPHS-10.0* MONOS-1.6* EOS-1.2
BASOS-0.5
[**2188-6-24**] 06:00PM   PT-16.4* PTT-26.0 INR(PT)-1.5*
[**2188-6-24**] 06:00PM   cTropnT-<0.01
[**2188-6-24**] 11:25PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2188-6-24**] 11:25PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG

[**2188-6-25**] 02:52AM BLOOD Triglyc-59 HDL-39 CHOL/HD-5.4
LDLcalc-160*
[**2188-6-26**] 01:16PM BLOOD Lactate-2.6*

[**6-24**] CT head: Findings concerning for basilar artery thrombosis
and acute
infarction of the right cerebellum.

[**6-24**] CT A/perfusion: Decreased blood flow and volume, increased
MTT in cerebellar hemispheres and vermis in matched distribution
compatible with infarction with no penumbra identified. Thrombus
in the basilar artery with possible extension to the left
vertebral artery. Right vertebral not visualized with extensive
clot throughout entire course.

[**6-25**] Echo: Biventricular cavity dilation with severe global
biventricular hypokinesis c/w diffuse process (toxin, metabolic,
multivessel CAD, etc.) Moderate pulmonary artery systolic
hypertension. No definite cardiac  ource of embolism identified.
Increased PCWP. Moderate mitral egurgitation. EF 25%.

[**6-24**]: Significant worsening of mass effect associated with
evolving right cerebellar infarction, causing effacement of the
fourth ventricle and perimesencephalic cisterns, interval
dilatation of the third and lateral ventricles, consistent with
acute obstruction. The dense appearance of the Basilar artery is
less obvious on the present study.


Brief Hospital Course:
Admission impression: 57year old male with severe PVD, CAD, now
presenting with
dizziness, nausea and dysarthria found to have vertebrobasilar
occlusion. His examination is notable for R gaze preference, low
vision in L eye, R pronator drift, dysmetria R > L. Etiology of
embolus is likely cardioembolic with subtherapeutic INR. Pt is
not a candidate for IV or IA tPA or MERCI retrieval given
presentation outside window for intervention, extent of thrombus
in the vessel presents risks of hemorrhage that outweigh
potential benefits.

ICU Course:
Neuro: [**Known firstname 11805**] was admitted to Neuro ICU and started on heparin
13units/kg, with goal PTT 50-70.  [**6-25**] he had increased right
sided weakness but has some movement, was alert, oriented,
dysarthric, and following commands.  In the late afternoon he
had an abrupt decompensation with decreased alterness, decreased
movement of the left side a more right sided weakness, along
with agonal breathing pattern.  CXR and ABG were ok at that
time.  He was intubated and taken for stat head CT which found
significant swelling of the right cerebellar stroke with
compression of the brainstem and development of hydrocephalus.
He was immediately started on hyperventillation and mannitol but
did not clinically improve.  Heparin drip was stopped and he
started a baby [**Name (NI) 17408**] the following day.  Neurosurgery was also
emergently consulted and did not feel he was a surgical
candidate.  Overnight his pupils became unresponsive and he lost
his right corneal reflex.  Overnight there were extensive
conversations with the family reguarding the severity of the
situation.  They decided to leave him full code while family was
traveling to see him.  He was determined braindead on [**6-28**].

CV: Pt was in a. fib with RVR requiring diltiazem drip on [**6-26**].
He had heart failure with EF 25%.

Resp: He was intubated for agonal breathing on [**6-25**].

FEN/GI: He remained NPO after failing swallow eval [**6-25**]

Endo: He was treated with insulin sliding scale and home po DM
agents were held.

Renal: Slight bump in Cr to 1.4 initially but then up to 2.4 in
the setting of herniation.

ID: Developed fever on [**6-26**] up to 103.


Medications on Admission:
Aldactone 25mg daily
Coreg 25mg [**Hospital1 **]
Coumadin 5mg daily
Lasix 40mg [**Hospital1 **]
Vasotec 20mg [**Hospital1 **]
Amaryl 4mg [**Hospital1 **]
Lantus 6units daily
 Lipitor 10mg daily
Avelox ?? 400mg daily x 2 weeks
? pletal
gabapentin 300mg


Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
stroke, posterior fossa herniation

Discharge Condition:
expired

Discharge Instructions:
None

Followup Instructions:
None

                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

Completed by:[**2188-8-15**]
{'Cerebral artery occlusion, unspecified with cerebral infarction,Pneumonia, organism unspecified,Acute respiratory failure,Hemiplegia, unspecified, affecting unspecified side,Dysphagia, unspecified,Unspecified essential hypertension,Atherosclerosis of native arteries of the extremities, unspecified,Atrial fibrillation,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Long-term (current) use of insulin,Other toe(s) amputation 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: Code stroke

PRESENT ILLNESS: Mr. F is a 57 year old right handed male with PVD, CAD, afib
presenting with dizziness, nausea and dysarthria. He awoke
feeling well. He developed symptoms around 1pm of dizziness
following taking insulin. He went to sleep and awoke ~5pm,
evaluated at OSH where noncontrast head CT revealed ? basilar
opacity. He was medflighted to [**Hospital1 18**] for evaluation. CODE STROKE
called upon arrival. NIHSS 6 for R facial droop, R pronator
drift, dysarthria.

MEDICAL HISTORY: Past Medical History: (incomplete)
PVD- Right foot ischemia s/p [**2-14**] digits amp [**2188-3-19**] in [**Male First Name (un) 36290**]
CAD s/p CABG
Afib
DM 2
HTN

MEDICATION ON ADMISSION: Aldactone 25mg daily
Coreg 25mg [**Hospital1 **]
Coumadin 5mg daily
Lasix 40mg [**Hospital1 **]
Vasotec 20mg [**Hospital1 **]
Amaryl 4mg [**Hospital1 **]
Lantus 6units daily
 Lipitor 10mg daily
Avelox ?? 400mg daily x 2 weeks
? pletal
gabapentin 300mg

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 98, BP 162/80, HR 72, R 18, 100% 2l
Gen: well appearing, cooperative, NAD
HEENT: slight R exopthalmos, no scleral icterus, OP clear, MMM
Neck: no carotid or vertebral bruits.
CV- irregularly irregular, 2/6 SEM at RUSB
Pulm- CTA B
Abd- obese, soft, NT, ND, BS+
Extrem- R toe [**2-14**] amputation, distal pulses 1+ bilat.

FAMILY HISTORY: prominent for DM2

SOCIAL HISTORY: not married. moved here from [**Male First Name (un) **] three days ago.
staying with his sister in-law. denies smoking. 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Pneumonia, organism unspecified,Acute respiratory failure,Hemiplegia, unspecified, affecting unspecified side,Dysphagia, unspecified,Unspecified essential hypertension,Atherosclerosis of native arteries of the extremities, unspecified,Atrial fibrillation,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Long-term (current) use of insulin,Other toe(s) amputation status'}
