CHIEF COMPLAINT: unsteady gait, slurred speech, headache, fall from bed

PRESENT ILLNESS: 77 yo W h/o DM2, HTN, hyperthyroidism admitted [**8-17**] and p/w
unsteady gait, slurred speech and HA on [**8-12**], fall out of bed on
[**8-13**] which prompted hospitalization, and further decompensation
on [**8-14**] with nonresponsiveness, likely due to R proximal MCA
occlusion causing completed R entire MCA infarction

MEDICAL HISTORY: Diabetes mellitus type 2
Hypertension
Hyperthyroidism
Colonic polyps
s/p appendectomy
s/p bilateral cataract surgeries

MEDICATION ON ADMISSION: ASA 325 mg
amiodarone 150 mg IV daily
enalapril 1.25 mg IV q8h
Lovenox 72.5 mg SC daily
hydralazine 10 mg q6
Keppra 250 mg q12
metoprolol tartrate 50 mg PO daily
Protonix

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At Admission:
General: Asleep, NAD, lying in bed comfortably.
Head: NC/AT, no scleral icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity
Cardiovascular: RRR, soft aortic murmur radiating to the
carotids
bilaterally
Pulmonary: Equal air entry bilateraly, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses

FAMILY HISTORY: Not known

SOCIAL HISTORY: Divorced, has two children. No tobacco or ETOH.
Cerebral embolism with cerebral infarction,Unspecified protein-calorie malnutrition,Hemiplegia, unspecified, affecting unspecified side,Unspecified pleural effusion,Neurologic neglect syndrome,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Atrial fibrillation,Homonymous bilateral field defects,Other fluid overload,Unspecified essential hypertension,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Other and unspecified hyperlipidemia,Dysphagia, unspecified,Dysarthria
Crbl emblsm w infrct,Protein-cal malnutr NOS,Unsp hemiplga unspf side,Pleural effusion NOS,Neurologic neglect syndr,DMII wo cmp uncntrld,Atrial fibrillation,Homonymous hemianopsia,Fluid overload NEC,Hypertension NOS,Thyrotox NOS no crisis,Hyperlipidemia NEC/NOS,Dysphagia NOS,Dysarthria
Admission Date:  [**2155-8-17**]              Discharge Date:   [**2155-8-25**]

Date of Birth:  [**2078-4-12**]             Sex:   F

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
unsteady gait, slurred speech, headache, fall from bed

Major Surgical or Invasive Procedure:
PEG placement


History of Present Illness:
77 yo W h/o DM2, HTN, hyperthyroidism admitted [**8-17**] and p/w
unsteady gait, slurred speech and HA on [**8-12**], fall out of bed on
[**8-13**] which prompted hospitalization, and further decompensation
on [**8-14**] with nonresponsiveness, likely due to R proximal MCA
occlusion causing completed R entire MCA infarction

Past Medical History:
Diabetes mellitus type 2
Hypertension
Hyperthyroidism
Colonic polyps
s/p appendectomy
s/p bilateral cataract surgeries

Social History:
Divorced, has two children. No tobacco or ETOH.

Family History:
Not known

Physical Exam:
At Admission:
General: Asleep, NAD, lying in bed comfortably.
Head: NC/AT, no scleral icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity
Cardiovascular: RRR, soft aortic murmur radiating to the
carotids
bilaterally
Pulmonary: Equal air entry bilateraly, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses

Neurologic Examination:
- Mental Status - Easily awakened, alert, oriented x 3.
Attention
attainable and maintainable through interview. Follows commands,
midline and appendicular. Language fluent with intact verbal
comprehension. + mild dysarthria.

- Cranial Nerves - [II] PERRL 2-1.5 brisk. [III, IV, VI] Eyes do
not cross midline to left. [VII] L NLF flattening. [IX, X]
Palate elevation symmetric. [XII] Tongue midline.

- Motor - Normal bulk and tone. No pronation, no drift. No
tremor
or asterixis.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[[**Last Name (un) 938**]]
  [C5]  [C5]  [C7]  [C6]  [T1] [L2]  [L3]  [L5]  [L4] [S1]  [L5]
L  1      1     1     X     X    2    2      2     X    X     X
R  5      5     5     5     5    5    5      5     5    5     5

- Sensory - Withdraws to pain in four extremities.

- Reflexes - Plantar response extensor bilaterally

- Coordination - No dysmetria with mirrored movements on R arm.

At discharge:
Vitals: T 97 BP 150-170/38-60s HR 70s RR 16 O2 sat: 92-93% on
2-3L NC O2
General: NAD, lying in bed comfortably.
Head: NC/AT, no scleral icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity
Cardiovascular: RRR, soft aortic murmur radiating to the
carotids
bilaterally
Pulmonary: Equal air entry bilaterally, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses

Neuro:
Easily arousable, oriented x 3, eye-opening apraxia, eyes cross
midline, left homonymous hemianopia,  L NLF flattening, RUE/RLE
full strength, Languge fluent wit intact repetition and
comprehension. No movement in LUE or LLE. Perceives light touch
stimuli on both left and right as "right". Recognizes left hand
as own.

Pertinent Results:
[**2155-8-17**] 09:20PM   WBC-11.2* RBC-3.57* HGB-10.6* HCT-30.5*
MCV-86 MCH-29.7 MCHC-34.7 RDW-14.5
[**2155-8-17**] 09:20PM   PT-12.4 PTT-26.9 INR(PT)-1.0
[**2155-8-17**] 09:20PM   CALCIUM-9.2 PHOSPHATE-3.3 MAGNESIUM-2.2
[**2155-8-17**] 09:20PM   CK-MB-3 cTropnT-0.03*
[**2155-8-17**] 09:20PM   GLUCOSE-152* UREA N-26* CREAT-1.2* SODIUM-134
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-21* ANION GAP-13

[**2155-8-13**] NHCHT negative, old L basal ganglia lacune

[**2155-8-13**] MRI/MRA Brain and MRA Neck - ?small right parietal
infarct, ?R proximal MCA narrowing

[**2155-8-16**] MRI Brain - R entire MCA territory infarction

[**2155-8-17**] EKG: Sinus rhythm. Normal tracing. No previous tracing
available for comparison.

[**2155-8-18**]: Routine EEG:
IMPRESSION: Abnormal EEG due to mild posterior background
slowing for
age suggestive of a mild diffuse encephalopathy with
superimposed right
posterior quadrant relative paucity of faster activities
consistent with
the clinical history of a right MCA stroke and to bursting
slowing
occurring in a bifrontally predominant but generalized
distribution with
some degree of semi-rhythmic and semi-rhythmic and sharp
activity seen
bifrontally. The record overall is consistent with a vascular
etiology
with the clearly defined right MCA but with the possibility of a
second
vascular process involving subcortical or deeper midline
structures with
some degree of increased irritability.

[**2155-8-18**] NCHCT
IMPRESSION:
1. Large right middle cerebral artery distribution infarct
involving the
frontal, temporal, occipital lobes as well as the caudate and
putamen. There is associated mild effacement of the right
lateral ventricle, without shift of the normally midline
structures.

[**2155-8-18**] Carotid US
Impression: Right ICA 60-69% stenosis.
Left ICA bo-69% stenosis.

[**2155-8-18**] CXR
FINDINGS: Cardiac silhouette is mildly enlarged and accompanied
by pulmonary vascular congestion. Minimal patchy opacities at
both bases probably reflect atelectasis, but aspiration is
additional consideration considering clinical suspicion for this
entity.

[**Date range (1) 9154**]/[**2155**] LTM EEG: Prelim read: right hemisphere slowing and
right T4 spikes intermittently, no apparent epileptiform
activity.

[**2155-8-21**] EKG:
Atrial fibrillation with rapid ventricular response. Delayed R
wave transition. Poor baseline. Compared to the previous tracing
of [**2155-8-19**] atrial fibrillation is new. Rate 128

Brief Hospital Course:
The patient is a 77 year old woman with a h/o DM2, HTN, and
hyperthyroidism
admitted to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital on [**8-13**] with complaints of
unsteady gait, slurred speech and headache that started during
the day on [**8-12**] and are likely the result of an acute ischemic
stroke. On the morning of [**8-13**], she fell out of her bed upon
waking which prompted her hospitalization. She had no neurologic
deficits documented on her admission exam. Her CT imaging was
unremarkable and her MRI showed the suggestion of a small right
parietal infarct. She was treated with a full dose aspirin. The
following day, she developed slurred speech, left sided face and
[**4-22**] arm weakness and was later found by the bedside
unresponsive. She was reimaged and was found to have an
extension of her initial infarct to cover the entire right MCA
territory. She was transferred to [**Hospital1 18**] for further care as well
as concern for potential seizure activity and midline shift. Her
exam had changed to include eye opening apraxia, left lower face
weakness, left upper extremity paraplegia, and left lower
extremity weakness with otherwise preserved mental status, right
sided motor function, and sensation. On route she received
mannitol x 1 for concern of midline shift.

Neuro: Right MCA ischemic infarct: The patient's exam and repeat
imaging at [**Hospital1 18**] on [**8-18**] showed stable  infarct without midline
shift.
- The patient was transferred on Levetiracetam 250 [**Hospital1 **] for
seizure prophylaxis although EEG negative. This was discontinued
as repeat routine EEG and then long term monitoring also proved
negative.
- Carotid US was done that showed right ICA 60-69% stenosis, eft
ICA bo-69% stenosis, and it was hypothesized that artery-artery
thromboembolus may have been the etiology of the infarct.
- During this admission, despite no previous history of atrial
fibrillation, the patient went into a-fib with RVR overnight.
Likely the patient has intermittent a-fib and was not on
anticoagulation, so this is also a possible etiology. She was
started on coumadin for anticogaulation on [**8-23**].

Cards: HTN and new diagnosis of intermittent atrial fibrillation
- The patient was hypertensive intermittently during her stay.
She is currently SBP 150-170s on amlodipine 10mg po daily,
enalapril 20mg po bid, metoprolol 37.5mg po tid, and HCTZ 25mg
po daily.
- Intermittent atrial fibrillation was seen on telemetry with
one episode of RVR that resolved with metoprolol. Currently the
patient is in normal sinus rhythm. Coumadin was started on [**8-23**].

GI: Impaired swallow ability on evaluation.
- PEG placed [**8-22**] while patient under goes rehabilitation.

Pulm: Patient received IVF and became volume overloaded per exam
and chest Xray that showed bilateral pleural effusions. She
responded well to 1-2 doses of IV furosemide.
- Currently the patient is requiring [**2-20**] liter nasal cannula O2
to maintain 93-94% saturation.

Endo: Patient has type 2 diabetes.
- The patient's blood sugar was monitored 4 times daily and
maintained on a regular insulin sliding scale.
- HgbA1c 6.8

Renal: No issues. Patient is at baseline, normal renal function.


Medications on Admission:
ASA 325 mg
amiodarone 150 mg IV daily
enalapril 1.25 mg IV q8h
Lovenox 72.5 mg SC daily
hydralazine 10 mg q6
Keppra 250 mg q12
metoprolol tartrate 50 mg PO daily
Protonix

Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. enalapril maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
6. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. ibuprofen 100 mg/5 mL Suspension Sig: Four Hundred (400) mg
PO Q8H (every 8 hours) as needed for muscle pain.
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing/SOB.
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
13. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please stop when INR is therapeutic (Goal [**2-20**]) on coumadin.
14. insulin regular human 100 unit/mL Solution Sig: Five (5)
units Injection ASDIR (AS DIRECTED): Please use insulin sliding
scale for blood sugar > 150.
15. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
16. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
R MCA ischemic infarct
intermittent atrial fibrillation
hyperlipidemia


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neuro: Drowsy but easily arousable, oriented x 3, eye-opening
apraxia, left homonymous hemianopia, eyes cross midline to left,
mild-moderate dysarthia, L NLF flattening, RUE/RLE full
strength, No movement of left side, sensation to pain and light
touch intact, DSS extinction on left.


Discharge Instructions:
You were admitted to the hospital for a stroke. This stroke
could have been caused due to carotid artery disease and or from
a clot from your heart, given you were found to intermittently
have a heart arrhythmia, atrial fibrillation. We have started
you on a cholesterol-lowering medicine, simvastatin to help
decrease your risk of artery disease and subsequent brain or
heart events in the future. Also, given the intermittent atrial
fibrillation, we recommend that you stay on a blood thinner,
warfarin (aka coumadin). This medicine requires frequent blood
work monitoring and will increase your risk of bleeding from
falls but it will decrease your risk of stroke in the future.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**Hospital 18**] [**Hospital 878**] Clinic on
Tuesday, [**11-11**] at 1pm. [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) **].
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]. Please
call if you need to reschedule.


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



Name:  [**Known lastname 4755**],[**Known firstname 9312**]                 Unit No:   [**Numeric Identifier 17302**]

Admission Date:  [**2155-8-17**]              Discharge Date:   [**2155-8-25**]

Date of Birth:  [**2078-4-12**]             Sex:   F

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 608**]
Addendum:
Clarification - During her stay, the patient had volume
overload. She did not have pulmonary edema.

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1933**]

                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**]

Completed by:[**2155-10-7**]

Name:  [**Known lastname 4755**],[**Known firstname 9312**]                 Unit No:   [**Numeric Identifier 17302**]

Admission Date:  [**2155-8-17**]              Discharge Date:   [**2155-8-25**]

Date of Birth:  [**2078-4-12**]             Sex:   F

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 608**]
Addendum:
atorvastatin dose decreased to 40mg po qHS prior to discharge.

Discharge Medications:
**atorvastatin decreased to 40mg po daily prior to discharge.

1. enalapril maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

3. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
4. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
5. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. ibuprofen 100 mg/5 mL Suspension Sig: Four Hundred (400) mg
PO Q8H (every 8 hours) as needed for muscle pain.
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing/SOB.
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please stop when INR is therapeutic (Goal [**2-20**]) on coumadin.
13. insulin regular human 100 unit/mL Solution Sig: Five (5)
units Injection ASDIR (AS DIRECTED): Please use insulin sliding
scale for blood sugar > 150.
14. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
15. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
16. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.



Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1933**]

                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**]

Completed by:[**2155-8-25**]
{'Cerebral embolism with cerebral infarction,Unspecified protein-calorie malnutrition,Hemiplegia, unspecified, affecting unspecified side,Unspecified pleural effusion,Neurologic neglect syndrome,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Atrial fibrillation,Homonymous bilateral field defects,Other fluid overload,Unspecified essential hypertension,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Other and unspecified hyperlipidemia,Dysphagia, unspecified,Dysarthria'}


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: unsteady gait, slurred speech, headache, fall from bed

PRESENT ILLNESS: 77 yo W h/o DM2, HTN, hyperthyroidism admitted [**8-17**] and p/w
unsteady gait, slurred speech and HA on [**8-12**], fall out of bed on
[**8-13**] which prompted hospitalization, and further decompensation
on [**8-14**] with nonresponsiveness, likely due to R proximal MCA
occlusion causing completed R entire MCA infarction

MEDICAL HISTORY: Diabetes mellitus type 2
Hypertension
Hyperthyroidism
Colonic polyps
s/p appendectomy
s/p bilateral cataract surgeries

MEDICATION ON ADMISSION: ASA 325 mg
amiodarone 150 mg IV daily
enalapril 1.25 mg IV q8h
Lovenox 72.5 mg SC daily
hydralazine 10 mg q6
Keppra 250 mg q12
metoprolol tartrate 50 mg PO daily
Protonix

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At Admission:
General: Asleep, NAD, lying in bed comfortably.
Head: NC/AT, no scleral icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity
Cardiovascular: RRR, soft aortic murmur radiating to the
carotids
bilaterally
Pulmonary: Equal air entry bilateraly, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses

FAMILY HISTORY: Not known

SOCIAL HISTORY: Divorced, has two children. No tobacco or ETOH. 

### Response:
{'Cerebral embolism with cerebral infarction,Unspecified protein-calorie malnutrition,Hemiplegia, unspecified, affecting unspecified side,Unspecified pleural effusion,Neurologic neglect syndrome,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Atrial fibrillation,Homonymous bilateral field defects,Other fluid overload,Unspecified essential hypertension,Thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm,Other and unspecified hyperlipidemia,Dysphagia, unspecified,Dysarthria'}
