CHIEF COMPLAINT: left sided weakness

PRESENT ILLNESS: Mr. [**Known lastname 15360**] is a 50 yo RHM with h/o HTN, HL, RCC who presents
with acute onset L facial droop, L sided weakness and
dysarthria.
His wife was with him when she noticed a sudden L facial droop,
weak L arm/leg and slurred speech at 13:30. She gave him an
aspirin and called EMS. He arrived at [**Hospital1 18**] with fingerstick
70-80, and received D5. He had right gaze preference but could
cross midline, and L hemiparesis but leg was antigravity on
noxious stimulation. NIHSS 10.
He was 3.5 hours from event, and had no contraindications, so
was
given IV tPA. He has no significant improvement after 30
minutes,
so neuro IR was called. In IR suite, R MCA was occluded and
MERCI
clot retrieval attempted.  Multiple attempts at clot retrieval
were completed, however clot was large and well organized so
limited flow could be restored.

MEDICAL HISTORY: - HTN
- HL
- arrhythmia-  on stress testing [**3-/2145**], increased ectopy
including frequent APB's, couplets, triplets and several runs of
nonsustained wide complex tachycardia. Atrial
fibrillation/flutter was noted in recovery. Holter showed atrial
ectopy and a few runs of NSVT in the absence of symptoms.
- RCC s/p L nephrectomy, no chemo/XRT, in remission on annual
exams
- normal cardiac cath [**2144**]

MEDICATION ON ADMISSION: Toprol XL 25 mg Qday

ALLERGIES: Iodine / Morphine Sulfate

PHYSICAL EXAM: VS afeb  HR 60  BP 123/78  RR 18  02 95/RA
GEN: African American man, NAD
HEENT: sclera anicteric
CV: RRR, no m/r/g

FAMILY HISTORY: father had MI in 50s

SOCIAL HISTORY: lives with wife, has 2 children. Supervisor for [**Company 2318**]. No
tobacco, EtOH.
Cerebral embolism with cerebral infarction,Intracerebral hemorrhage,Urinary tract infection, site not specified,Hemiplegia, unspecified, affecting nondominant side,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of kidney,Atrial fibrillation
Crbl emblsm w infrct,Intracerebral hemorrhage,Urin tract infection NOS,Unsp hmiplga nondmnt sde,Hypertension NOS,Hyperlipidemia NEC/NOS,Hx of kidney malignancy,Atrial fibrillation
Admission Date:  [**2145-12-19**]              Discharge Date:   [**2145-12-23**]

Date of Birth:  [**2095-12-13**]             Sex:   M

Service: NEUROLOGY

Allergies:
Iodine / Morphine Sulfate

Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
left sided weakness

Major Surgical or Invasive Procedure:
Merci clot retrieval


History of Present Illness:
Mr. [**Known lastname 15360**] is a 50 yo RHM with h/o HTN, HL, RCC who presents
with acute onset L facial droop, L sided weakness and
dysarthria.
His wife was with him when she noticed a sudden L facial droop,
weak L arm/leg and slurred speech at 13:30. She gave him an
aspirin and called EMS. He arrived at [**Hospital1 18**] with fingerstick
70-80, and received D5. He had right gaze preference but could
cross midline, and L hemiparesis but leg was antigravity on
noxious stimulation. NIHSS 10.
He was 3.5 hours from event, and had no contraindications, so
was
given IV tPA. He has no significant improvement after 30
minutes,
so neuro IR was called. In IR suite, R MCA was occluded and
MERCI
clot retrieval attempted.  Multiple attempts at clot retrieval
were completed, however clot was large and well organized so
limited flow could be restored.


Past Medical History:
- HTN
- HL
- arrhythmia-  on stress testing [**3-/2145**], increased ectopy
including frequent APB's, couplets, triplets and several runs of
nonsustained wide complex tachycardia. Atrial
fibrillation/flutter was noted in recovery. Holter showed atrial
ectopy and a few runs of NSVT in the absence of symptoms.
- RCC s/p L nephrectomy, no chemo/XRT, in remission on annual
exams
- normal cardiac cath [**2144**]


Social History:
lives with wife, has 2 children. Supervisor for [**Company 2318**]. No
tobacco, EtOH.


Family History:
father had MI in 50s


Physical Exam:
VS afeb  HR 60  BP 123/78  RR 18  02 95/RA
GEN: African American man, NAD
HEENT: sclera anicteric
CV: RRR, no m/r/g

NEURO:
Mental status: eyes open, awake, alert, responsive to questions
and oriented x 3. Naming, repetition, comprehension intact.
Moderate dysarthria. Able to read.
CN: PERRL 4 to 2mm. R gaze preference, overcomes on command. No
nystagmus. L facial droop. Tongue midline.
MOTOR: normal bulk and tone. Strength 5/5 R delt, [**Hospital1 **], tri,
finger
flex, IP, ham, tib ant, gastroc. L side some proximal movement
at
shoulder not antigravity, lateral movement of leg to command,
antigravity flexion and withdrawal to pain.
[**Last Name (un) **]: intact to light touch and pain in all extremities.
Decreased sensation to light touch on L face V1-V3. Extinction
to
DSS on left.
DTR: 2+ and symmetric, toes withdraw bilaterally


Pertinent Results:
[**2145-12-21**] 06:35AM BLOOD WBC-11.0 RBC-3.93* Hgb-11.7* Hct-34.2*
MCV-87 MCH-29.7 MCHC-34.1 RDW-14.2 Plt Ct-136*
[**2145-12-22**] 06:05AM BLOOD PT-13.4 PTT-25.0 INR(PT)-1.1
[**2145-12-21**] 06:35AM BLOOD Glucose-100 UreaN-12 Creat-1.4* Na-137
K-4.6 Cl-106 HCO3-24 AnGap-12
[**2145-12-22**] 11:25AM BLOOD ALT-19 AST-23 AlkPhos-43 TotBili-0.5
[**2145-12-20**] 06:04AM BLOOD CK(CPK)-250
[**2145-12-20**] 06:04AM BLOOD CK-MB-4 cTropnT-<0.01
[**2145-12-20**] 02:38AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9 Cholest-190
[**2145-12-20**] 02:38AM BLOOD %HbA1c-6.0* eAG-126*
[**2145-12-20**] 02:38AM BLOOD Triglyc-161* HDL-36 CHOL/HD-5.3
LDLcalc-122

CT Head/CTA head and neck/CT perfusion head [**2145-12-19**]
NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage.
There is
hyperdensity in the distal M1 segment of the right middle
cerebral artery
(image 2:15), concerning for thrombus. There is a small focus of
cortical
hypodensity in the right frontal lobe (image 2:21), concerning
for developing
infarction. The ventricles are normal in size and configuration.
The imaged
bones appear unremarkable. There is a small focus of polypoid
mucosal
thickening in the inferior left maxillary sinus. There is fluid
in a single
left mastoid air cell.

CT PERFUSION: There is elevated mean transit time in the right
middle
cerebral artery territory. There is no evidence of blood volume
asymmetry in
the middle cerebral artery territory.

NECK CTA: There is a bovine configuration of the great vessel
origins. The
great vessel origins are tortuous. The cervical common carotid,
internal
carotid, and vertebral arteries are patent without evidence of
stenoses. The
right vertebral artery is dominant. The distal cervical right
internal
carotid artery measures 4.8 mm in diameter, and the distal
cervical left
internal carotid artery measures 5.5 mm in diameter.

Foci of gas in the veins of the neck and in the cavernous sinus
are likely
related to the intravenous contrast administration via a power
injector.
Evaluation of the imaged lung apices is limited by respiratory
motion, but no
obvious abnormalities are detected. Degenerative changes are
noted in the
cervical spine.

HEAD CTA: There is complete occlusion of the distal M1 segment
of the right
middle cerebral artery. There appears to be some reconstitution
of the more
distal right middle cerebral arterial branches, possibly via the
external
carotid branches. No atherosclerotic plaque is visualized in the
intracranial
circulation. There is fetal configuration of the left posterior
cerebral
artery. The intracranial portion of the nondominant left
vertebral artery is
hypoplastic distal to the low origin of the posterior inferior
cerebellar
artery. The left aspect of the anterior communicating artery is
wider than
the right, with an apparent small infundibulum at the junction
of the left
anterior cerebral artery with the anterior communicating artery.
No definite
aneurysm is seen.

IMPRESSION:

1. Occlusion of the M1 segment of the right middle cerebral
artery. In the
absence of atherosclerosis in other intracranial or cervical
vessel, a cardiac
or another embolic source should be considered.
2. CT perfusion demonstrates ischemia in the right middle
cerebral artery
territory, without evidence of a matching completed infarction
at the time of
the exam. A small focus of cortical edema in the right frontal
lobe on the
noncontrast CT suggests a developing acute infarction.
3. Apparent infundibulum of the left aspect of the anterior
communicating
artery.

MRI and MRA head and neck [**2145-12-20**]
MRI BRAIN WITHOUT IV CONTRAST: Edema and restricted diffusion in
the right
lenticulostriate arterial distribution, involving the putamen
and extending
into the body of the caudate, are consistent with acute
infarction as
suggested on non-contrast CT. There is susceptibility artifact
within the
putamen, corresponding to hyperdense area seen on overnight
non-contrast head
CT, which is consistent with hemorrhage. There are also tiny
distal cortical
foci of restricted diffusion in the right temporal and parietal
lobes.
Overall, findings are suggestive of initial M1 occlusion with
tiny distal
emboli. There is no shift of normally midline structures,
hydrocephalus nor
effacement of the basal cisterns. Normal vascular flow voids are
seen within
the major vessels of the circle of [**Location (un) 431**]. The soft tissues,
visualized
osseous structures, and orbits appear normal. Minimal fluid
signal is seen
within the mastoid air cells, as well as minimal mucosal
thickening in the
ethmoid and maxillary sinuses.

MRA HEAD: The major branches of the circle of [**Location (un) 431**] are patent,
with no
evidence of high-grade stenosis, occlusion, or aneurysm
formation. Fetal-type
circulation is noted on the left, with large patent left
posterior
communicating artery and hypoplastic P1 segment of the left PCA.
The
intracranial left vertebral artery is also noted to be
hypoplastic.

MRA NECK: The cervical common and internal carotid arteries as
well as the
vertebral arteries are patent. No high-grade stenosis or
occlusion is
demonstrated.

IMPRESSIONS:

1. Hemorrhagic infarction in the right lenticulostriate
distribution involves
the putamen and body of caudate, consistent with initial M1
occlusion as seen
on admission CTA. Additional tiny distal cortical foci of
infarction in the
right temporal and parietal lobes are consistent with tiny
distal emboli.

2. MRA shows patent circle of [**Location (un) 431**] and cervical carotid and
vertebral
arteries.

Surface Echo [**2145-12-20**]:
The left atrium is moderately dilated. No thrombus/mass is seen
in the body of the left atrium. The right atrium is moderately
dilated. No atrial septal defect or patent foramen ovale is seen
by 2D, color Doppler or saline contrast with maneuvers. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. Trivial mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.

Brief Hospital Course:
Pt received IV tPA and subsequently IA tPA and Merci clot
retrieval. After this, he spent 1 day in the Neuro ICU for
monitoring. His repeat NCHCT showed some area of hyperdensity
that was interpreted as hemorrhagic transformation vs contrast,
given that the CT was performed within hours of an arteriogram.
His strength continued to improve.
Cardiology was consulted. Given his history of heart
arrhyhtmias, he was started on Coumadin with an aspirin bridge.
HgbA1C was 6.0 and fasting lipid panel showed mildly elevated
TG's. He was started on simvastatin. His WBC count elevated
modestly and he was found to have a UTI, which was treated with
Ceftriaxone IV. He will complete course of cefpodoxime upon
discharge.
On discharge, his neurological exam was notable for full
strength when testing individual muscle groups, however, there
was still some slowness to movements on the left as compared to
the right, and his gait was still slightly unsteady with a
slightly externally rotated left leg.
He will receive home services for PT/OT and VNA for anticoag
follow up.
He will follow up with Drs. [**Last Name (STitle) 7741**] and [**Name5 (PTitle) **] in stroke clinic.


Medications on Admission:
Toprol XL 25 mg Qday

Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 7 days: Last
dose [**2145-12-27**]. .
4. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
6. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Outpatient Physical Therapy
evaluate and treat


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Right middle cerebral artery embolism with infarction


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted with a stroke that was the cause of your left
sided weakness. You received an intervention and medicine to
dissolve the offending clot, and your weakness improved. You
were started on a cholesterol-lowering medicine which you should
continue taking. You were also started on the blood thinner
coumadin. You will need to have your blood INR checked
regularly, with a goal INR between 2 and 3.

Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2146-1-14**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2146-6-8**] 5:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6575**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2146-6-8**]
5:00

Please follow up in Neurology with Drs. [**Last Name (STitle) 7741**] and [**Name5 (PTitle) **] on
[**2146-2-2**] at 1:30 pm in the [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **], [**Location (un) 86**], MA.


                             [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
{'Cerebral embolism with cerebral infarction,Intracerebral hemorrhage,Urinary tract infection, site not specified,Hemiplegia, unspecified, affecting nondominant side,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of kidney,Atrial fibrillation'}


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: left sided weakness

PRESENT ILLNESS: Mr. [**Known lastname 15360**] is a 50 yo RHM with h/o HTN, HL, RCC who presents
with acute onset L facial droop, L sided weakness and
dysarthria.
His wife was with him when she noticed a sudden L facial droop,
weak L arm/leg and slurred speech at 13:30. She gave him an
aspirin and called EMS. He arrived at [**Hospital1 18**] with fingerstick
70-80, and received D5. He had right gaze preference but could
cross midline, and L hemiparesis but leg was antigravity on
noxious stimulation. NIHSS 10.
He was 3.5 hours from event, and had no contraindications, so
was
given IV tPA. He has no significant improvement after 30
minutes,
so neuro IR was called. In IR suite, R MCA was occluded and
MERCI
clot retrieval attempted.  Multiple attempts at clot retrieval
were completed, however clot was large and well organized so
limited flow could be restored.

MEDICAL HISTORY: - HTN
- HL
- arrhythmia-  on stress testing [**3-/2145**], increased ectopy
including frequent APB's, couplets, triplets and several runs of
nonsustained wide complex tachycardia. Atrial
fibrillation/flutter was noted in recovery. Holter showed atrial
ectopy and a few runs of NSVT in the absence of symptoms.
- RCC s/p L nephrectomy, no chemo/XRT, in remission on annual
exams
- normal cardiac cath [**2144**]

MEDICATION ON ADMISSION: Toprol XL 25 mg Qday

ALLERGIES: Iodine / Morphine Sulfate

PHYSICAL EXAM: VS afeb  HR 60  BP 123/78  RR 18  02 95/RA
GEN: African American man, NAD
HEENT: sclera anicteric
CV: RRR, no m/r/g

FAMILY HISTORY: father had MI in 50s

SOCIAL HISTORY: lives with wife, has 2 children. Supervisor for [**Company 2318**]. No
tobacco, EtOH. 

### Response:
{'Cerebral embolism with cerebral infarction,Intracerebral hemorrhage,Urinary tract infection, site not specified,Hemiplegia, unspecified, affecting nondominant side,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of kidney,Atrial fibrillation'}
