CHIEF COMPLAINT: Right arm and leg weakness

PRESENT ILLNESS: Patient was admitted [**Date range (1) 19867**] to Neurology after presenting with
acute onset of R arm and leg weakness with significant
resolution of deficits. According to patient, he had full
strength at discharge.  During that admission, MRI revealed a
small acute stroke in the L anterior centrum semiovale and a
large old L frontal stroke. Carotid US showed 70-79% stenosis.
Echo showed no thrombus.  He was taking aspirin at time of
stroke and Plavix was added.  However, abnormal signal of the
clivus on MRI prompted a a bone scan which revealed multiple
foci of abnormal uptake in long bones.  This led to a torso CT
which showed B/L infiltrating renal masses.  His antiplatelets
were stopped in anticipation of a biopsy which was performed
[**5-11**], results of which are pending.  He has remained off any
aspirin or Plavix since.

MEDICAL HISTORY: 1) L centrum semiovale stroke [**4-2**]
2) L frontal stroke on MRI
3) HTN
4) Hypercholesterolemia
5) S/p CABG
6) Gout
7) DM
8) B/L 70-79% ICA stenosis
9) B/L renal masses

MEDICATION ON ADMISSION: 1) Iron 150mg QD 2) Allopurinol 150mg QD
3) Simvastatin 40mg QD 4) Atenolol 25mg QD 5) Lisinopril 10mg QD
6) Lasix 20mg QD 7) Metformin 850mg [**Hospital1 **] 8) Insulin (70/30) 28
units AM and 20 units PM

ALLERGIES: Nitroglycerin

PHYSICAL EXAM: Vitals 97.8 BP 119/56 P 67  R 19 O2 sat 99%

FAMILY HISTORY: 

SOCIAL HISTORY: Cab driver
Lives alone
Occassional ETOH (drinks [**12-1**] scotch every few months)
Hx of 50 pack year smoking, quit several years ago
Cerebral embolism with cerebral infarction,Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Personal history of other diseases of circulatory system,Unspecified essential hypertension,Pure hypercholesterolemia,Gout, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Ostium secundum type atrial septal defect,Unspecified disorder of kidney and ureter,Anemia, unspecified
Crbl emblsm w infrct,Ocl mlt bi art wo infrct,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Hx-circulatory dis NEC,Hypertension NOS,Pure hypercholesterolem,Gout NOS,DMII wo cmp nt st uncntr,Long-term use of insulin,Secundum atrial sept def,Renal & ureteral dis NOS,Anemia NOS
Admission Date:  [**2144-5-17**]              Discharge Date:   [**2144-5-21**]

Date of Birth:  [**2069-3-6**]             Sex:   M

Service: NEUROLOGY

Allergies:
Nitroglycerin

Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
Right arm and leg weakness

Major Surgical or Invasive Procedure:
MRI brain, MRA head and neck
CT head
CT C-spine
Carotid US

History of Present Illness:
Patient was admitted [**Date range (1) 19867**] to Neurology after presenting with
acute onset of R arm and leg weakness with significant
resolution of deficits. According to patient, he had full
strength at discharge.  During that admission, MRI revealed a
small acute stroke in the L anterior centrum semiovale and a
large old L frontal stroke. Carotid US showed 70-79% stenosis.
Echo showed no thrombus.  He was taking aspirin at time of
stroke and Plavix was added.  However, abnormal signal of the
clivus on MRI prompted a a bone scan which revealed multiple
foci of abnormal uptake in long bones.  This led to a torso CT
which showed B/L infiltrating renal masses.  His antiplatelets
were stopped in anticipation of a biopsy which was performed
[**5-11**], results of which are pending.  He has remained off any
aspirin or Plavix since.

He went to sleep at 1AM this morning with normal strength.  He
woke at 730AM and fell when trying to get out of bed, with R arm
and leg weakness.  After about 30 minutes, he was able to get
up, eat breakfast, and then drive his cab.  His details are
somewhat unclear based on his account, but he called 911 at some
point when his weakness was not improving.  He arrived at [**Hospital1 18**]
at 11AM code stroke page went out at 1116AM.  I arrived at
1120AM and he was in CT scanner.

When CT scan completed, he complained of R arm and leg weakness
and numbness but denied visual changes, facial weakness,
dysarthria, dysphagia, L sided symptoms, fever, SOB, CP,
palpitations, headache or neck pain.

Past Medical History:
1) L centrum semiovale stroke [**4-2**]
2) L frontal stroke on MRI
3) HTN
4) Hypercholesterolemia
5) S/p CABG
6) Gout
7) DM
8) B/L 70-79% ICA stenosis
9) B/L renal masses


Social History:
Cab driver
Lives alone
Occassional ETOH (drinks [**12-1**] scotch every few months)
Hx of 50 pack year smoking, quit several years ago


Physical Exam:
Vitals 97.8 BP 119/56 P 67  R 19 O2 sat 99%

General:  Well nourished, in no acute distress
HEENT: NCAT
Neck: supple, no carotid bruits
Lungs: Clear to auscultation
CV: Regular rate and rhythm. No m/g/r
BACK: Pinpoint scab at L renal biopsy site. No hematoma.

Neurologic Examination:
Mental Status:  Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, month, day, and date
Attention: Can say days of week backward with 1 self corrected
omission. Language: Fluent, no dysarthria, no paraphasic errors,
reptition and comprehension intact, names [**3-4**] items on stroke
card (not hammock or feather).  [**Location (un) **] intact.  Unable to write
due to weakness.

Cranial Nerves: Visual fields are full to confrontation.  Pupils
equally round and reactive to light, 3 to 2 mm bilaterally.
Extraocular movements intact, no nystagmus.  Facial sensation
and facial movement normal bilaterally. Hearing decreased to
finger rub bilaterally.  [**Location (un) **] midline, no fasciculations.
Sternocleidomastoid and trapezius normal bilaterally.

Motor:
Increased tone in legs bilaterally. No tremor.

        D  T  B  WF  WE  FiF  [**Last Name (un) **]  HF  HE  KF  KE  AF  AE  TF TE
Right   5- 5- 5  4   3    4    0   5-  5   5   5   5   5   5  5
Left    5  5  5  5   5    5    5   5   5   5   5   5   5   5  5

Right pronator drift

Sensation was intact to Light touch.  Stocking glove loss to pin
prick and temperature.  Absent vibration in toes.

Reflexes: B  T  Br  Pa  Pl
Right     2  2  2   1   tr
Left      1  1  1   1   tr

Toes were downgoing L, mute R

Coordination is normal on finger-nose-finger on L

Gait was not assessed


Pertinent Results:
[**2144-5-18**] 04:00AM BLOOD WBC-10.3 RBC-3.64* Hgb-8.8* Hct-28.7*
MCV-79* MCH-24.3* MCHC-30.7* RDW-22.0* Plt Ct-292
[**2144-5-18**] 04:00AM BLOOD Plt Ct-292
[**2144-5-18**] 04:00AM BLOOD PT-12.9 PTT-26.6 INR(PT)-1.1
[**2144-5-18**] 04:00AM BLOOD Glucose-90 UreaN-50* Creat-1.2 Na-141
K-5.3* Cl-114* HCO3-19* AnGap-13
[**2144-5-17**] 06:46PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2144-5-18**] 04:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2144-5-18**] 04:00AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.6 Cholest-88
[**2144-5-18**] 04:00AM BLOOD %HbA1c-5.9 [Hgb]-DONE [A1c]-DONE
[**2144-5-17**] 11:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2144-5-18**] 04:00AM BLOOD Triglyc-190* HDL-18 CHOL/HD-4.9
LDLcalc-32

CT:
Small areas of low attenuation visualized in the left centrum
semiovale. There is white matter area just anterior to the left
lateral ventricle and a small area in the left caudate nucleus.
These areas were not clearly visualized on the prior study.
However, they do not appear to be of acute nature. An old
infarct is also visualized in the left frontal cortex, unchanged
in appearance since the prior study. There is no evidence of
hydrocephalus, shift of normally midline structures or new acute
major territorial infarction. The surrounding soft tissue and
osseous structures appear unremarkable.

MRI
increased diffusion-weighted imaging sequence signal located in
the left parietal lobe, head of the putamen on the left side and
basal ganglia on the right side. These are consistent with acute
infarction. An area of increased FLAIR/T2 signal is visualized
in the left parietal lobe consistent with an old infarction,
unchanged in appearance since the prior study. An area of
increased DWI signal is also visualized in the left centrum
semiovale, unchanged since the prior study.

MRA
Severe stenosis at the origin of the right internal carotid
artery and a moderate stenosis at the left ICA origin. This
appearance has not changed since the previous study. There is a
stenosis of the A1 segment of the right anterior cerebral
artery. There are no other hemodynamically significant stenoses
of the visualized vasculature.

Carotid US:
Rt: 70-79%
Lt: 60-69%

TEE:
Small secundum atrial septal defect. Simple atheroma in the
descending aorta and aortic arch. Basal inferior left
ventricular
aneurysm/dyskinesis.


Brief Hospital Course:
75yo man recently admitted to stroke for acute R arm and leg
weakness found to have small L CSO stroke and made a full
recovery. Workup at that time showed B/L 70-90% carotid
stenoses, B/L renal masses of unclear etiology. ASA, Plavix held
for renal biopsy, done [**5-11**]. Presented with R arm and leg
weakness and fall. Had fluctuating deficits ranging from RUE
weakness (4+/5) to plegia.  MRI showed several small strokes
bilaterally (left>right). MRA showed carotid stenoses but
adequate distal flow.  There was intitial concern for
hypoperfusion in setting of carotid stenosis, although symptoms
not clearly BP dependent. He was admitted to ICU for q1hr
checks. Unable to achieve goal SBP of 130-150 with IVF. He was
started on neosynephrine briefly for waxing and [**Doctor Last Name 688**] deficits.
 No significant change.  He was started on anticoagulation with
IV heparin as the most likely etiology of his strokes was felt
to be cardioembolic +/- hypercoagulable state from unknown
malignancy.  He was transferred to the neurology step down unit
for close neuro observation. Throught the remainder of his
admission, his exam was stable.  He had a repeat carotid US
which showed: Rt ICA  60-79% Lt ICA 60-69% (no change from
previous).  He had a TEE which showed an ASD with ASA and mild
right to left shunt with valsalva.  He was transitioned to
Lovenox and Coumadin.  He should have his INR checked in several
days and dose should be adjusted for goal INR 2.0-3.0.

He ruled out for MI with negative cardiac enzymes x3. TEE was
done (results noted above). Cholesterol level was normal, HDL
was low.  Antihypertensives were held in setting of acute
stroke. He was continued on Lipitor.

He had a renal biopsy prior to admission ([**5-11**]) to evaluate for
possible lymphoma given multiple renal masses found on previous
admission.  Prelim path results suggest a reactive process/
inflammation (cells were polyclonal)

His blood sugars have been fairly well controlled on insulin
sliding scale; his HbA1C was 5.9. He was restarted on outpaient
dose of metformin prior to discharge


Medications on Admission:
1) Iron 150mg QD 2) Allopurinol 150mg QD
3) Simvastatin 40mg QD 4) Atenolol 25mg QD 5) Lisinopril 10mg QD
6) Lasix 20mg QD 7) Metformin 850mg [**Hospital1 **] 8) Insulin (70/30) 28
units AM and 20 units PM

Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
Disp:*20 syringe* Refills:*2*
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Metformin 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]

Discharge Diagnosis:
left-sided cerebral infarction


Discharge Condition:
strength in right arm improved

Discharge Instructions:
discharge to acute rehab

Followup Instructions:
1. Primary Care: Patient is to call insurance and change PCP
[**5-27**] at 2pm (Dr. [**Last Name (STitle) 19868**], preceptor [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **]...this is new
PCP)[**Telephone/Fax (1) 250**] [**Hospital Ward Name 23**] building south suite.
2. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2144-7-14**] 1:30
{'Cerebral embolism with cerebral infarction,Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Personal history of other diseases of circulatory system,Unspecified essential hypertension,Pure hypercholesterolemia,Gout, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Ostium secundum type atrial septal defect,Unspecified disorder of kidney and ureter,Anemia, unspecified'}


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 arm and leg weakness

PRESENT ILLNESS: Patient was admitted [**Date range (1) 19867**] to Neurology after presenting with
acute onset of R arm and leg weakness with significant
resolution of deficits. According to patient, he had full
strength at discharge.  During that admission, MRI revealed a
small acute stroke in the L anterior centrum semiovale and a
large old L frontal stroke. Carotid US showed 70-79% stenosis.
Echo showed no thrombus.  He was taking aspirin at time of
stroke and Plavix was added.  However, abnormal signal of the
clivus on MRI prompted a a bone scan which revealed multiple
foci of abnormal uptake in long bones.  This led to a torso CT
which showed B/L infiltrating renal masses.  His antiplatelets
were stopped in anticipation of a biopsy which was performed
[**5-11**], results of which are pending.  He has remained off any
aspirin or Plavix since.

MEDICAL HISTORY: 1) L centrum semiovale stroke [**4-2**]
2) L frontal stroke on MRI
3) HTN
4) Hypercholesterolemia
5) S/p CABG
6) Gout
7) DM
8) B/L 70-79% ICA stenosis
9) B/L renal masses

MEDICATION ON ADMISSION: 1) Iron 150mg QD 2) Allopurinol 150mg QD
3) Simvastatin 40mg QD 4) Atenolol 25mg QD 5) Lisinopril 10mg QD
6) Lasix 20mg QD 7) Metformin 850mg [**Hospital1 **] 8) Insulin (70/30) 28
units AM and 20 units PM

ALLERGIES: Nitroglycerin

PHYSICAL EXAM: Vitals 97.8 BP 119/56 P 67  R 19 O2 sat 99%

FAMILY HISTORY: 

SOCIAL HISTORY: Cab driver
Lives alone
Occassional ETOH (drinks [**12-1**] scotch every few months)
Hx of 50 pack year smoking, quit several years ago 

### Response:
{'Cerebral embolism with cerebral infarction,Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Personal history of other diseases of circulatory system,Unspecified essential hypertension,Pure hypercholesterolemia,Gout, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Ostium secundum type atrial septal defect,Unspecified disorder of kidney and ureter,Anemia, unspecified'}
