CHIEF COMPLAINT: confusion and language problems

PRESENT ILLNESS: Pt is a 50 year old R handed man in his usual state of
health today when he left home at 12pm today for a bike ride on
a
new bike. Shortly before 2pm, he was found lying next to his
bike, confused, speaking, but not making sense. D-stick 98 at
the
scene. Brought to the ED, taken to head CT at 2pm due to
concerns
for head trauma vs stroke. Neurology paged, arrived to ED at
approximately 2:05pm, Pt in CT scanner. NIH stroke scale total
score at ~2:15 = 6. Clear deficits included fluent aphasia, R
lower facial droop, extinction on R c/w L MCA stroke. Labs sent
at 2:30pm. Hypertensive to 188/93; received Hydralazine 10mg x1
with good effect. tPA was pushed at 2:55pm (7mg push, 62mg over
1 hour). No significant change during re-examination towards end

MEDICAL HISTORY: Chronic low back pain, herniated discs
Decreased sensation in 1 leg at baseline (wife unsure of which)

MEDICATION ON ADMISSION: advil

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T Afeb HR 69 BP 156/78 Sat 100% on RA

FAMILY HISTORY: -Brother: MI at age 48 (died)
-brother: MI age 60
-mother: stroke at age 60; cancer

SOCIAL HISTORY: -married, lives with wife and son
-denies drugs
-tobacco: 2.5 packs/day
Cerebral artery occlusion, unspecified with cerebral infarction,Pure hypercholesterolemia,Unspecified essential hypertension,Other and unspecified alcohol dependence, continuous
Crbl art ocl NOS w infrc,Pure hypercholesterolem,Hypertension NOS,Alcoh dep NEC/NOS-contin
Admission Date:  [**2118-8-21**]              Discharge Date:   [**2118-8-24**]

Date of Birth:  [**2068-7-28**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
confusion and language problems

Major Surgical or Invasive Procedure:
i.v. t-PA
TEE


History of Present Illness:
Pt is a 50 year old R handed man in his usual state of
health today when he left home at 12pm today for a bike ride on
a
new bike. Shortly before 2pm, he was found lying next to his
bike, confused, speaking, but not making sense. D-stick 98 at
the
scene. Brought to the ED, taken to head CT at 2pm due to
concerns
for head trauma vs stroke. Neurology paged, arrived to ED at
approximately 2:05pm, Pt in CT scanner. NIH stroke scale total
score at ~2:15 = 6. Clear deficits included fluent aphasia, R
lower facial droop, extinction on R c/w L MCA stroke. Labs sent
at 2:30pm. Hypertensive to 188/93; received Hydralazine 10mg x1
with good effect. tPA was pushed at 2:55pm (7mg push, 62mg over
1 hour). No significant change during re-examination towards end

of tPA infusion. Admitted to ICU for further workup.


Past Medical History:
Chronic low back pain, herniated discs
Decreased sensation in 1 leg at baseline (wife unsure of which)


Social History:
-married, lives with wife and son
-denies drugs
-tobacco: 2.5 packs/day

Family History:
-Brother: MI at age 48 (died)
-brother: MI age 60
-mother: stroke at age 60; cancer

Physical Exam:
VS: T Afeb HR 69 BP 156/78 Sat 100% on RA

PE: GEN NAD
HEENT NCAT, MMM, OP clear
Neck supple, no [**Doctor First Name **], no bruits
Chest CTAB
CVS RRR, no m/r/g
ABD soft, NT, ND, +BS
EXT Superficial abrasions over LE bilaterally. no c/c/e, distal
pulses strong, no rash

Neuro
MS: Alert, oriented to person only. Interactive, appears
frustrated by deficits. Limited mental status exam d/t poor
comprehension.
Speech: Fluent speech, mostly non-sensical. Naming for low freq
objects impaired (pen, glasses). Says "tweeze" for most items.
Does not repeat, read, or write. Perseverates on "sorry".
L/R confusion: +L/R confusion - refers to the L side of the body

as right.
CN: I--not tested; II,III-PERRLA (3 to 2mm bilaterally), R
homonymous hemianopia, optic discs sharp; III,IV,VI-EOMI w/o
nystagmus, no ptosis; V--sensation intact to LT/PP, masseters
strong bilaterally; VII-flattened R nasolabial fold; VIII-turns
toward voices bilaterally; IX,X--voice normal; [**Doctor First Name 81**]--SCM/trapezii
[**5-5**]; XII--tongue protrudes midline, no atrophy or fasciculation
Motor: normal bulk and tone; no tremor, rigidity, or
bradykinesia. R arm drifts upward with eyes closed. Full
strength throughout, symmetric

|ShAb|[**Male First Name (un) **]|ElFl|ElEx|WrFl|WrEx|FgSp|HpFl|KnEx|KnFl|Dors|Plan|
L | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5
|
R | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5
|
Coord: Unable to complete d/t comprehension problems. [**Name (NI) **] ataxia
when reaching for objects or pointing to people.
Reflex:
|[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe |
L | 2 | 2 | 2 | 2 | 2 | mute |
R | 2 | 2 | 2 | 2 | 2 | mute |
[**Last Name (un) **]: Sensation grossly intact to pinprick throughout.
+extinction on R to double simultaneous stimulation.
Gait: Not tested.

NIHSS
Time of exam: 2:15pm Total score - 6
1a: Alert and responsive (0) 1b:Unable to state month and name
(1) 1c: Follows simple commands (0) 2: Normal EOM (0) 3: R
homonymous hemianopia (2) 4: Minor R lower facial paralysis,
flat
nasolabial fold (1) 5: No L arm drift (0) 6: R arm drift not
indicative of weakness (0)
7: No L leg drift (0) 8: No R leg drift (0) 9: No ataxia (0) 10:

Normal sensation to PP (0)
11: Moderate aphasia (1) 12: No dysarthria (0) 13: R sided
extinction (1)


Pertinent Results:
[**2118-8-21**] 02:30PM   WBC-11.2* RBC-4.30* HGB-13.8* HCT-38.4*
MCV-89 MCH-32.2* MCHC-36.1* RDW-12.3
[**2118-8-21**] 02:30PM   PLT COUNT-286
[**2118-8-21**] 02:30PM   PT-12.2 PTT-26.6 INR(PT)-1.0
[**2118-8-21**] 02:30PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
[**2118-8-21**] 02:30PM   GLUCOSE-90 UREA N-17 CREAT-1.0 SODIUM-139
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-21* ANION GAP-16
[**2118-8-21**] 02:30PM   ALT(SGPT)-25 AST(SGOT)-21 CK(CPK)-168
[**2118-8-21**] 02:30PM   CK-MB-3 cTropnT-<0.01
[**2118-8-21**] 09:34PM BLOOD CK-MB-3 cTropnT-<0.01
[**2118-8-22**] 03:58AM BLOOD CK-MB-2 cTropnT-<0.01
.
Cholest-259*
Triglyc-134 HDL-53 CHOL/HD-4.9 LDLcalc-179*
.
HbA1C: 5.3
.
CT brain without IV contrast ([**8-21**]):
No prior studies.
There is no acute intracranial hemorrhage, shift of normally
midline structures, or hydrocephalus. [**Doctor Last Name **]-white matter
differentiation is preserved. Soft tissues and osseous
structures are unremarkable. Minimal mucosal thickening is seen
within the ethmoid air cells.
IMPRESSION: No acute intracranial hemorrhage.
.
EEG ([**8-21**]):This is a possibly abnormal portable EEG obtained in
wakefulness and stage II sleep due to the presence of mildly
disorganized background and voltage reduction over the entire
left
hemisphere only in wakefulness. The significance of this finding
is
unclear. There were no epileptiform discharges seen.

.
Carotid series ([**8-21**]):Minimal plaque with bilateral less than
40% carotid stenosis. Of note, the left vertebral artery appears
occluded.
.
TEE ([**8-23**]):Possible transpulmonary shunt. No cardiac source of
embolism
identified.
.
LENI ([**8-23**]): No evidence of lower extremity deep vein
thrombosis, bilaterally.


Brief Hospital Course:
The patient was admitted to the neurology intensive care unit
for further monitoring after his t-PA administration.  He was
placed initially on cardiac telemetry and ruled out for an acute
myocardial infarction.  He was transferred from the ICU to a
regular floor bed on [**8-22**].  He had a transesophageal
echocardiogram that was only significant for a possible small
transpulmonary shunt.  A carotid US study was negative for
stenosis, and an ultrasound of the legs was negative.  His lipid
panel showed elevated cholesterol.  An EEG was performed that
showed no epileptiform activity.  His aphasia slowly improved
during the hospitalization.  His NIHSS score upon discharge was
2.  He was given instructions to arrange outpatient speech
therapy.  He was discharged with instructions to stop aspirin in
5 days while increasing aggrenox to [**Hospital1 **] permanently.  An
appointment was made to have the patient follow up in stroke
clinic in one month.


Medications on Admission:
advil

Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) for 4 days:
Please take for 4 days then stop.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Aggrenox 200-25 mg Cap, Multiphasic Release 12 HR Sig: One
(1) Cap, Multiphasic Release 12 HR PO twice a day.
Disp:*60 Cap, Multiphasic Release 12 HR(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
1. left MCA fronto-parietal infarct, cryptogenic
2. s/p intravenous thrombolysis
3. hyperlipidemia
4. hypertension
5. Transpulmonary shunt


Discharge Condition:
stable


Discharge Instructions:
Please take aggrenox once a day and aspirin for 5 days, then
increase aggrenox to one tablet twice a day and stop the aspirin


Followup Instructions:
1. Please follow up with your Primary care Physician in one
week.
.
2.Please follow up at the [**Hospital 878**] Clinic: Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **]
& [**Doctor Last Name 2781**] Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2118-9-28**] 2:00


                             [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
{'Cerebral artery occlusion, unspecified with cerebral infarction,Pure hypercholesterolemia,Unspecified essential hypertension,Other and unspecified alcohol dependence, continuous'}


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: confusion and language problems

PRESENT ILLNESS: Pt is a 50 year old R handed man in his usual state of
health today when he left home at 12pm today for a bike ride on
a
new bike. Shortly before 2pm, he was found lying next to his
bike, confused, speaking, but not making sense. D-stick 98 at
the
scene. Brought to the ED, taken to head CT at 2pm due to
concerns
for head trauma vs stroke. Neurology paged, arrived to ED at
approximately 2:05pm, Pt in CT scanner. NIH stroke scale total
score at ~2:15 = 6. Clear deficits included fluent aphasia, R
lower facial droop, extinction on R c/w L MCA stroke. Labs sent
at 2:30pm. Hypertensive to 188/93; received Hydralazine 10mg x1
with good effect. tPA was pushed at 2:55pm (7mg push, 62mg over
1 hour). No significant change during re-examination towards end

MEDICAL HISTORY: Chronic low back pain, herniated discs
Decreased sensation in 1 leg at baseline (wife unsure of which)

MEDICATION ON ADMISSION: advil

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T Afeb HR 69 BP 156/78 Sat 100% on RA

FAMILY HISTORY: -Brother: MI at age 48 (died)
-brother: MI age 60
-mother: stroke at age 60; cancer

SOCIAL HISTORY: -married, lives with wife and son
-denies drugs
-tobacco: 2.5 packs/day 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Pure hypercholesterolemia,Unspecified essential hypertension,Other and unspecified alcohol dependence, continuous'}
