CHIEF COMPLAINT: found down with right upper extremity shaking

PRESENT ILLNESS: The pt is a 35 year-old man with minimal PMH. He was
transferred to [**Hospital1 18**] ED, intubated, from an OSH. We were
consulted for seizure.

MEDICAL HISTORY: -Mood/"depression" per OSH notes. On BDZ
-GERD. On omeprazole.
-PE in [**2105-11-12**]
PT 20210G mutation NEG ([**2107**])
AT 3 activity 124 (NML)
Protein S 131
cardiolipin <6
Factor V Leiden 3.4
Protein C 92
ALL NORMAL off coumadin (1 month)

MEDICATION ON ADMISSION: Xanax ?mg tid
Nexium ?mg daily

ALLERGIES: Tramadol

PHYSICAL EXAM: ADMISSION EXAM
VSS in ED (see ED record in chart), afebrile, normotensive (SBP
130s), HR 80s, RR 14 SaO2 100% (intubated, on vent/suppl O2)

FAMILY HISTORY: unknown

SOCIAL HISTORY: h/o learning disability (per aunt/HCP), which is
why he has a HCP [**Doctor First Name **] [**Telephone/Fax (1) 88058**]). Special Ed, education
through 8th grade. Cannot read or write well per aunt (small
words only).
Cerebral thrombosis with cerebral infarction,Methicillin susceptible pneumonia due to Staphylococcus aureus,Dysphagia, unspecified,Hemiplegia, unspecified, affecting unspecified side,Primary hypercoagulable state,Unspecified protein-calorie malnutrition,Aphasia,Epilepsia partialis continua, without mention of intractable epilepsy,Esophageal reflux,Personal history of venous thrombosis and embolism,Facial weakness
Crbl thrmbs w infrct,Meth sus pneum d/t Staph,Dysphagia NOS,Unsp hemiplga unspf side,Prim hypercoagulable st,Protein-cal malnutr NOS,Aphasia,Epil par cont w/o int ep,Esophageal reflux,Hx-ven thrombosis/embols,Facial weakness
Admission Date:  [**2111-1-4**]              Discharge Date:   [**2111-1-20**]

Date of Birth:  [**2075-1-8**]             Sex:   M

Service: NEUROLOGY

Allergies:
Tramadol

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
found down with right upper extremity shaking

Major Surgical or Invasive Procedure:
PEG tube placement [**2111-1-18**].


History of Present Illness:
The pt is a 35 year-old man with minimal PMH. He was
transferred to [**Hospital1 18**] ED, intubated, from an OSH. We were
consulted for seizure.

By report, he had a trip-and-fall on his head yesterday (Sat
[**1-3**]), with no LOC and no known sequelae. He was reportedly
normal that evening and this morning ([**1-4**]), and went out with a
friend. On returning home in the afternoon he told the friend he
felt weak and sat down. When he did not get up hours later,
EMS was called and they took him to the [**Location (un) 47**] ED where he
was noted to have right-sided arm/leg weakness and expressive
aphasia. According to their notes, he was able to give
appropriate y/n head-nod/shake responses to questions and follow
commands. He denied any h/o stroke, seizure or illicit substance
abuse (he was MJ/THC+ on their Utox screen, however). He was
taking Nexium for GERD and Xanax tid for mood Sx (I confirmed
these Rx with [**Company 4916**], his pharmacy, and with his HCP/Aunt).
Then, he was noted to exhibit myoclonic jerks of his right arm
and leg. A Neurology assessment there was partial-complex
seizure. He was given a total of 12mg LZP and loaded with 1gm
PHT
to stop the shaking/jerking, and consequently intubated with
succ+etomidate for airway protection. He was bolused 200 of
propofol, self-extubated, given 2mg/h LZP gtt, 50mcg/h propofol
gtt, Phenobarbital 65mg IV, and then after re-intubation, was
given 4mg more of LZP on transport-EMS on the way here due to
Right-sided shaking.

He arrived intubated and sedated on a propofol gtt at 50. He was
again re-intubated on arrival (balloon above the vocal cords on
arrival). He exhibited shaking of his right arm, and a MDZ gtt
was started in the ED. A NCHCT here revealed a
left-insular/opercular/subcortical hypodense region (completed
infarct), and CTA revealed a left ICA large occlusion
(just proximal to bifurcation) and decreased # of distal MCA
branches on the Left. He has no known risk factors.

I spoke on the phone with his HCP/aunt [**Name (NI) **] [**Telephone/Fax (1) 88058**]. [**Name2 (NI) **]
was apparently in an OSH ED 5d PTA with cold Sx, normal CXR,
negative flu swab, sent home.


Past Medical History:
-Mood/"depression" per OSH notes. On BDZ
-GERD. On omeprazole.
-PE in [**2105-11-12**]
PT 20210G mutation NEG ([**2107**])
AT 3 activity 124 (NML)
Protein S 131
cardiolipin <6
Factor V Leiden 3.4
Protein C 92
ALL NORMAL off coumadin (1 month)

[**2107**] - drug seeking behavior
had stopped coumadin

Cardiomyopathy - Cardiologist ([**Doctor Last Name 6254**] [**Telephone/Fax (1) 6256**])
last seen - [**2108**] ([**Month (only) 958**]) Nonischemic CMY
ED [**2-19**] - chest pain

Pheochromocytoma [**2106-11-12**] - resected
@[**Hospital1 2025**] was having stomach pains


Social History:
h/o learning disability (per aunt/HCP), which is
why he has a HCP [**Doctor First Name **] [**Telephone/Fax (1) 88058**]). Special Ed, education
through 8th grade. Cannot read or write well per aunt (small
words only).


Family History:
unknown

Physical Exam:
ADMISSION EXAM
VSS in ED (see ED record in chart), afebrile, normotensive (SBP
130s), HR 80s, RR 14 SaO2 100% (intubated, on vent/suppl O2)

<<Exam was greatly limited by sedation not stopped [**1-14**] c/f sz.>>

General: Sedated, intubated.
HEENT: Intubated. Blood in ETT suction catheter after 3x
intubations. Normocephalic. Mild bruise on Lt forehead. No
scleral icterus. Mucous membranes are moist.
Neck: Supple, with full range of motion and no nuchal rigidity.
No carotid bruits appreciated, including specifically no bruit
over Left ICA (clot location seen on CTA). No lymphadenopathy
was
appreciated.
Pulmonary: Lungs CTA bilaterally. Non-labored breathing with
vent.
Cardiac: RRR, normal S1/S2, no M/R/G.
Abdomen: Mildly obese. Soft, non-tender, and non-distended, +
moderate bowel sounds. No masses or organomegaly were
appreciated.
Extremities: Warm and well-perfused, no clubbing, cyanosis, or
edema. 2+ radial, DP pulses bilaterally.
Skin: no rashes or lesions noted.

DISCHARGE EXAM
Eyes open, making eye contact, shakes head yes and no but not
appropriately to simple questions, and does not follow axial or
appendicular commands reliably or specifically.
Moves left side spontaneously with apparent full strength. Not
moving right side, but it withdraws purposefully to noxious
stimuli.

Pertinent Results:
[**2111-1-4**] 08:50PM BLOOD WBC-11.6* RBC-4.38* Hgb-13.0* Hct-38.0*
MCV-87 MCH-29.8 MCHC-34.3 RDW-13.5 Plt Ct-285
[**2111-1-5**] 05:58AM BLOOD Neuts-67.4 Lymphs-24.3 Monos-7.5 Eos-0.5
Baso-0.3
[**2111-1-4**] 08:50PM BLOOD PT-13.2 PTT-24.2 INR(PT)-1.1
[**2111-1-8**] 03:57AM BLOOD Thrombn-43.6*
[**2111-1-4**] 08:50PM BLOOD Fibrino-238
[**2111-1-8**] 03:57AM BLOOD ACA IgG-2.6 ACA IgM-4.6
[**2111-1-8**] 03:57AM BLOOD ProtCFn-101 ProtSFn-81
[**2111-1-5**] 05:58AM BLOOD Glucose-99 UreaN-8 Creat-0.7 Na-139 K-4.0
Cl-108 HCO3-23 AnGap-12
[**2111-1-5**] 05:58AM BLOOD ALT-53* AST-28 CK(CPK)-204 AlkPhos-50
TotBili-0.3
[**2111-1-14**] 06:43PM BLOOD Cholest-288*
[**2111-1-5**] 05:58AM BLOOD %HbA1c-6.2* eAG-131*
[**2111-1-14**] 06:43PM BLOOD Triglyc-158* HDL-27 CHOL/HD-10.7
LDLcalc-229*
[**2111-1-5**] 05:58AM BLOOD TSH-0.74

[**2111-1-4**] 08:50PM URINE bnzodzp-NEG barbitr-POS opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG marijua-PRESUMPTIV

MICRO:
SPUTUM CX:  STAPH AUREUS COAG +, PAN-SENSITIVE
BLOOD CX NGTD

EKG: Sinus rhythm. Left axis deviation may be due to left
anterior fascicular block. RSR' pattern with early precordial
QRS transition is non-specific. Consider posterolateral
myocardial infarction of indeterminate age, although is
non-diagnostic. ST-T wave abnormalities are non-specific but
cannot exclude myocardial ischemia. Clinical correlation is
suggested. No previous tracing available for comparison.

IMAGING:

CTA HEAD AND NECK
1. Nonocclusive filling defect within the proximal left internal
carotid
artery, with occlusion of the distal left M1 segment and
opercular and insular branches with a nonhemorrhagic infarct in
the left MCA distribution. The atherosclerotic disease elsewhere
is most compatible with a dissection of the proximal cervial
[**Doctor First Name 3098**] with embolization to the left MCA.

MRI BRAIN
Acute infarct of the left MCA territory, likely secondary to
dissection as proposed in the prior CTA - post-traumatic versus
collagen
vascular disease etiologies are diagnostic considerations.

ECHOCARDIOGRAM
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.

EEG [**1-6**]

This 16-hour recording showed only severe diffuse
encephalopathic changes with loss of background and irregular
high
voltage delta with a little preservation of fast rhythms
centrally in
the right. This could be anoxic, ischemic, or possibly secondary
to
medication. No seizure activity or paroxysmal epileptic
interictal
discharges identified.

EEG [**1-7**]

This EEG shows an evolving encephalopathy going from an
extremely severe marked attenuation of all activity which may
have
reflected drug effect to a still severe encephalopathy with
diffuse
delta activity and suppression of rhythms posteriorly but there
were no
ictal or interictal discharges identified.

EEG [**1-8**]

This EEG gives evidence for a severe diffuse encephalopathy
that improved minimally during the course of the 24 hours. Over
the
course of 24 hours, however, activity over the left frontal
central
regions appeared to be more prominent and suggests lateralized
difficulty superimposed upon the severe encephalopathy. No clear

sustained epileptic activity was identified although an isolated
left
temporal discharge was seen.

EEG [**1-9**]
This EEG continues to show a severe diffuse encephalopathy
that, as the record continued to the end, appeared to be
slightly more
abnormal broadly across the left hemisphere. Note is there is
very
poorly developed background rhythm in both hemispheres. No
epileptic
activity was identified.


Brief Hospital Course:
Left Middle Cerebral Artery Stroke
The patient was admitted after being found down in a hallway
with jerking movements of his right arm and an inability to
understand commands. He was initially taken to [**Hospital **]
hospital where he was given Ativan, Dilantin and Phenobarb which
failed to stop the seizures. He was then transferred to [**Hospital1 18**]
for further care. On arrival he was given Keppra, started on
Versed and propofol drips which aborted the seizure. On imaging
he was found to have a large thrombus v. dissection in his left
common carotid artery, and MRI imaging revealed ischemia of most
of the left MCA territiory. After careful review of his outside
records it was discovered that he had a pulmonary embolism in
[**2104**] and had been treated with coumadin until [**2107**]. In a
cardiology note it was documented that he was lupus
anticoagulant positive. It was unclear why he was taken off
anticoagulation. His exam on discharge was notable for being
alert, and attentive, globally aphasic and having a right
hemiparesis. He was restarted on coumadin in hospital and on
Lovenox 100 mg SubQ [**Hospital1 **] as bridge therapy until INR is between 2
and 3.

Methicillin sensitive pneumonia
The patient developed a culture positive (S. Aureus) pneumonia
and was intially treated with vancomycin and zosyn which were
switched when sensitivites returned. Antibiotics were started on
[**2111-1-8**] and he should receive a 14-day course (end date
[**2111-1-22**]).

Seizures
The patient was loaded with Keppra, Dilantin, Phenobarb as well
as Versed and Propofol to stop his focal right arm seizures. EEG
monitoring was performed which showed no epileptiform
discharges. His medications were reduced to Keppra 1000 mg [**Hospital1 **]
by time of discharge. no EPC noted on discharge form [**Hospital1 18**]

Nutrition
Patient was unable to tolerate PO intake and speech and swallow
evaluation was performed twice. He received tube feeds, but
required PEG tube placement on [**2111-1-18**]. The procedure was
uncomplicated and the patient was given dilaudid for pain.

Anticoagulation
The patient was on a heparin drip after being admitted and was
continued until after his PEG tube was placed. He was then
started on coumadin with a goal INR of 2.0 - 3.0 with Lovenox as
a bridge until this goal is reached.


Medications on Admission:
Xanax ?mg tid
Nexium ?mg daily


Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: [**12-14**]  PO BID (2 times a
day).
2. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever or pain.
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) as needed for GERD.
6. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush: heparin
flush 2ml IV PRN line flush PICC. Flush 10ml normal saline
followed by heparin PRN per lumen use.
7. levetiracetam 500 mg/5 mL Solution Sig: Two (2)  Intravenous
[**Hospital1 **] (2 times a day).
8. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q6H (every 6 hours) for 3 days.
9. insulin lispro 100 unit/mL Solution Sig: per protocol
Subcutaneous ASDIR (AS DIRECTED).
10. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. enoxaparin 100 mg/mL Syringe Sig: One (1) mg Subcutaneous
Q12 HRS (): 90mg SC Q12hrs until INR goal of [**1-15**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]

Discharge Diagnosis:
New
- Left MCA stroke
- Epilepsia partialis continua

OLD
- Lupus anticogulant positive
- HLD


Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - always.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted for a stroke and seizure. You had a stroke
involving the left side of your brain and that led to language
deficits. Because of this we have started you on coumadin to
prevent future strokes. You were also placed on Keppra for
seizure control. You had a PEG tube placed to ensure that you
get adequate feedings.

Followup Instructions:
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Location (un) **] of [**Hospital Ward Name **] center [**Hospital1 18**]. [**3-23**] at
2pm
Call [**Telephone/Fax (1) 10676**] to ensure paperwork is in place 3 weeks prior
to appointment. Please call ([**Telephone/Fax (1) 7394**] one week prior to
appointment to ensure place and time.


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

Completed by:[**2111-1-20**]
{'Cerebral thrombosis with cerebral infarction,Methicillin susceptible pneumonia due to Staphylococcus aureus,Dysphagia, unspecified,Hemiplegia, unspecified, affecting unspecified side,Primary hypercoagulable state,Unspecified protein-calorie malnutrition,Aphasia,Epilepsia partialis continua, without mention of intractable epilepsy,Esophageal reflux,Personal history of venous thrombosis and embolism,Facial weakness'}


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: found down with right upper extremity shaking

PRESENT ILLNESS: The pt is a 35 year-old man with minimal PMH. He was
transferred to [**Hospital1 18**] ED, intubated, from an OSH. We were
consulted for seizure.

MEDICAL HISTORY: -Mood/"depression" per OSH notes. On BDZ
-GERD. On omeprazole.
-PE in [**2105-11-12**]
PT 20210G mutation NEG ([**2107**])
AT 3 activity 124 (NML)
Protein S 131
cardiolipin <6
Factor V Leiden 3.4
Protein C 92
ALL NORMAL off coumadin (1 month)

MEDICATION ON ADMISSION: Xanax ?mg tid
Nexium ?mg daily

ALLERGIES: Tramadol

PHYSICAL EXAM: ADMISSION EXAM
VSS in ED (see ED record in chart), afebrile, normotensive (SBP
130s), HR 80s, RR 14 SaO2 100% (intubated, on vent/suppl O2)

FAMILY HISTORY: unknown

SOCIAL HISTORY: h/o learning disability (per aunt/HCP), which is
why he has a HCP [**Doctor First Name **] [**Telephone/Fax (1) 88058**]). Special Ed, education
through 8th grade. Cannot read or write well per aunt (small
words only). 

### Response:
{'Cerebral thrombosis with cerebral infarction,Methicillin susceptible pneumonia due to Staphylococcus aureus,Dysphagia, unspecified,Hemiplegia, unspecified, affecting unspecified side,Primary hypercoagulable state,Unspecified protein-calorie malnutrition,Aphasia,Epilepsia partialis continua, without mention of intractable epilepsy,Esophageal reflux,Personal history of venous thrombosis and embolism,Facial weakness'}
