CHIEF COMPLAINT: Right Arm Weakness

PRESENT ILLNESS: Mr. [**Known lastname 8494**] is a 53yo RH man with a PMHx significant only for
rare migraines who presents after a transient episode of right
arm weakness who was found to have a left ICA dissection.  He
had
been in his USOH until 3pm on the day of admission, when he
developed a mild migraine.  He reports that it was like his
typical migraine: dull and holocephalic with "flashing lights"
noted and blurred vision in the right > left eye.  His symptoms
improved with two advil, though still present.
     Approximately one hour later, he was playing tennis.  When
he raised his right arm to make an "amazing backhand", he
suddenly felt like he "lost power" in his right arm.  He notes
that it felt like "flabby", but denies any numbness or tingling.

MEDICAL HISTORY: 1.  Migraines:  Occurs every 6-12 months.  Managed with OTC
medications for abortive therapy.
2.  Tooth extraction 3 weeks ago [**3-19**] "multiple abscesses"

MEDICATION ON ADMISSION: 1.  Naproxen prn insomnia

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T: 98.2 BP: 152/108 HR: 64 RR: 15 O2: 99% on 2L NC
Genl: Awake, alert, friendly, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: NABS, soft, NTND abdomen

FAMILY HISTORY: HTN.  No hx of strokes or vascular dz in family.

SOCIAL HISTORY: Lives in [**Hospital1 2436**], MA with his wife and oldest
daughter.  [**Name (NI) **] two other children. Endorses EtOH use of two
drinks/day.  Denies alcohol or drug use.  Brother is head of ER
at [**Hospital1 18**] [**Name (NI) 620**].
Dissection of carotid artery,Unspecified transient cerebral ischemia,Unspecified essential hypertension,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other and unspecified hyperlipidemia
Dissect carotid artery,Trans cereb ischemia NOS,Hypertension NOS,Migrne unsp wo ntrc mgrn,Hyperlipidemia NEC/NOS
Admission Date:  [**2116-1-18**]              Discharge Date:   [**2116-1-20**]

Date of Birth:  [**2062-5-29**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Right Arm Weakness

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Mr. [**Known lastname 8494**] is a 53yo RH man with a PMHx significant only for
rare migraines who presents after a transient episode of right
arm weakness who was found to have a left ICA dissection.  He
had
been in his USOH until 3pm on the day of admission, when he
developed a mild migraine.  He reports that it was like his
typical migraine: dull and holocephalic with "flashing lights"
noted and blurred vision in the right > left eye.  His symptoms
improved with two advil, though still present.
     Approximately one hour later, he was playing tennis.  When
he raised his right arm to make an "amazing backhand", he
suddenly felt like he "lost power" in his right arm.  He notes
that it felt like "flabby", but denies any numbness or tingling.

He was able to control his arm, but felt like it was only 10% of
his normal functioning.  Over the next 10-15 minutes, his arm
regained strength to the point where he was able to drink
gatorade and start to play a few more sets of tennis.  However,
his arm then began to feel increasingly heavy over the next 20
minutes.  Concerned, he presented to [**Hospital1 18**] [**Location (un) 620**] for further
management.
     There, his BP was found to be 185/115.  He got a dose of
5mg
IV metoprolol.  He underwent an MRI/A, which showed a left ICA
dissection.  He was then started on a heparin gtt and was
transferred to [**Hospital1 **] for further management.


Past Medical History:
1.  Migraines:  Occurs every 6-12 months.  Managed with OTC
medications for abortive therapy.
2.  Tooth extraction 3 weeks ago [**3-19**] "multiple abscesses"


Social History:
Lives in [**Hospital1 2436**], MA with his wife and oldest
daughter.  [**Name (NI) **] two other children. Endorses EtOH use of two
drinks/day.  Denies alcohol or drug use.  Brother is head of ER
at [**Hospital1 18**] [**Name (NI) 620**].


Family History:
HTN.  No hx of strokes or vascular dz in family.


Physical Exam:
VS: T: 98.2 BP: 152/108 HR: 64 RR: 15 O2: 99% on 2L NC
Genl: Awake, alert, friendly, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: NABS, soft, NTND abdomen

Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
presidents backwards to [**Last Name (un) 38492**]. Speech is fluent with normal
comprehension and repetition; naming intact. No dysarthria.
Registers [**4-17**], recalls [**4-17**] in 5 minutes. No right-left
confusion.
No evidence of apraxia or neglect.

Cranial Nerves: Fundoscopic examination reveals sharp disc
margins. Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. No RAPD. Extraocular movements intact bilaterally
without nystagmus. Sensation intact V1-V3. Facial movement
symmetric. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. Sternocleidomastoid and trapezius full
strength bilaterally. Tongue midline, movements intact.

Motor: Normal bulk and tone bilaterally. No observed myoclonus,
asterixis, or tremor. Mild right pronator drift.
  [**Doctor First Name **] Tri [**Hospital1 **]  WE FE FF  IP  H  Q DF PF TE
R  5   5   5  5  5  5   5   5  5  5  5  5
L  5   5   5  5  5  5   5   5  5  5  5  5

Sensation: Intact to light touch, pinprick, temperature
throughout. No extinction to DSS.

Reflexes: 2+ and symmetric throughout. Toes downgoing
bilaterally.

Coordination: finger-nose-finger and [**Doctor First Name **] normal.

Gait: Narrow based, steady. Able to tandem.

Romberg negative.

DISCHARGE EXAM
T 98 P 66 BP 148/87
GEN: NAD, alert and interactive
HEENT: no visible trauma, non0icteric
CV: RRR, no murmurs
Pulm: CTABL
Ext: no edema, pulses full

Neuro
MS: alert and oriented x3, language intact, no apraxia, no
neglect
CN:
Fundoscopic examination reveals sharp disc
margins. Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. No RAPD. Extraocular movements intact bilaterally
without nystagmus. Sensation intact V1-V3. Facial movement
symmetric. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. Sternocleidomastoid and trapezius full
strength bilaterally. Tongue midline, movements intact.

Motor: no observable weakness in R upper or lower extremity,
full strength throughout

Reflexes: symmetric and normal throughout

Coordination: intact FNF b/l

Sensory: intact to pinprick b/l

Gait: normal stressed/tandem, good arm swing

Pertinent Results:
CTA: Findings indicating dissection in the left distal cervical
internal carotid artery.

MR ([**Location (un) 620**]): There is no acute infarct seen.  There is no mass
effect, midline shift or hydrocephalus identified.  Following
gadolinium, no abnormal enhancement is seen.

Lipids:
[**2116-1-18**] 03:43AM   TRIGLYCER-138 HDL CHOL-68 CHOL/HDL-4.0
LDL(CALC)-177* LDL([**Last Name (un) **])-205*

HgA1c:
pending

Brief Hospital Course:
Left Carotid Dissection w/ Transient Ischemic Attack

Patient presented to the hospital from [**Location (un) 620**] ED after an
episode of R arm weakness that resolved by day 2 of
hospitalization. His exam was initially notable for a right
pronator drift. On MRA and CTA he was found to have a dissection
of the left ICA distally. This was likely traumatic in origin
and could have occurred while exercising or during a recent
dental extraction. He had no evidence of a stroke on MRI. He was
started on coumadin on [**2116-1-19**] and Lovenox as bridging therapy.
We contact[**Name (NI) **] Dr. [**Last Name (STitle) **] who said he would be happy to monitor his
INR to a therapeutic level of [**3-20**].

Hypertension

The patient wa snoted to have elevated blood pressures to the
170s systolic on admission. He was started on amlodipine 5 mg
and lisinopril 20 mg daily and pressures improved to 130s-140s
systolic.

Hyperlipidemia

Patient had an LDL of 177. He was started on 20 mg of
atorvastatin.

He will follow-up in clinic w/ Dr. [**First Name (STitle) **] in 3 months and will
need a CTA of his head/neck prior to that appointment. His
outpatient PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] will try to arrange this study.

Medications on Admission:
1.  Naproxen prn insomnia


Discharge Medications:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. enoxaparin 100 mg/mL Syringe Sig: One (1) syringe
Subcutaneous [**Hospital1 **] (2 times a day) for 5 days.
Disp:*10 syringe* Refills:*0*
4. warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Left Internal Carotid Dissection
Transient Ischemic Attack
Hyperlipidemia
Hypertension


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the stroke service after you had a
transient episode of right arm weakness. On exam you had a
slight right pronator drift indicative of mild weakness that
improved during your hospitalization. Your imaging revealed a
left internal carotid dissection. There was no evidence of a
stroke on your MRI. You were started on coumadin (a blood
thinner) and lovenox which you will need to be on until your
coumadin has become therapeutic. In addition we started you on a
statin medication as your LDL cholesterol was high (177). We
also started you on blood pressure medications (lisinopril 20 mg
daily, and amlodipine 5 mg daily). Please have Dr. [**Last Name (STitle) **] check
your blood pressure to make sure the medications are adequate.

You will need to follow-up with Dr. [**Last Name (STitle) **] on Tuesday morning to
have your INR checked (coumadin level). He will be able to tell
you a schedule to have this medication monitored.

You will follow up with Dr. [**First Name (STitle) **] in neurology clinic in 3
months. Dr. [**First Name (STitle) **] in Neurology - [**2116-4-20**] at 1:00 pm, [**Hospital Ward Name 23**] [**Location (un) 6332**]
You will need a CT angiogram prior to your appointment. Dr. [**Last Name (STitle) **]
was contact[**Name (NI) **] and will set this exam up sometime in late
[**2116-3-17**].

Contact Registration - [**Telephone/Fax (1) 10676**] prior to your follow-up
appointment with Dr. [**First Name (STitle) **] to update your status

Medications changed:
1. Started Coumadin (warfarin) 5 mg every night w/ a goal INR
[**3-20**]
2. Lovenox 90 mg SC twice daily - until INR is therapeutic
3. Amlodipine 5 mg by mouth at night
4. Lisinopril 20 mg by mouth at night
5. Atorvastatin 20 mg by mouth at night

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2116-4-20**] 1:00

F/U with your PCP on Tuesday to have your INR checked.

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

Completed by:[**2116-1-20**]
{'Dissection of carotid artery,Unspecified transient cerebral ischemia,Unspecified essential hypertension,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other and unspecified hyperlipidemia'}


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 Weakness

PRESENT ILLNESS: Mr. [**Known lastname 8494**] is a 53yo RH man with a PMHx significant only for
rare migraines who presents after a transient episode of right
arm weakness who was found to have a left ICA dissection.  He
had
been in his USOH until 3pm on the day of admission, when he
developed a mild migraine.  He reports that it was like his
typical migraine: dull and holocephalic with "flashing lights"
noted and blurred vision in the right > left eye.  His symptoms
improved with two advil, though still present.
     Approximately one hour later, he was playing tennis.  When
he raised his right arm to make an "amazing backhand", he
suddenly felt like he "lost power" in his right arm.  He notes
that it felt like "flabby", but denies any numbness or tingling.

MEDICAL HISTORY: 1.  Migraines:  Occurs every 6-12 months.  Managed with OTC
medications for abortive therapy.
2.  Tooth extraction 3 weeks ago [**3-19**] "multiple abscesses"

MEDICATION ON ADMISSION: 1.  Naproxen prn insomnia

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T: 98.2 BP: 152/108 HR: 64 RR: 15 O2: 99% on 2L NC
Genl: Awake, alert, friendly, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: NABS, soft, NTND abdomen

FAMILY HISTORY: HTN.  No hx of strokes or vascular dz in family.

SOCIAL HISTORY: Lives in [**Hospital1 2436**], MA with his wife and oldest
daughter.  [**Name (NI) **] two other children. Endorses EtOH use of two
drinks/day.  Denies alcohol or drug use.  Brother is head of ER
at [**Hospital1 18**] [**Name (NI) 620**]. 

### Response:
{'Dissection of carotid artery,Unspecified transient cerebral ischemia,Unspecified essential hypertension,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other and unspecified hyperlipidemia'}
