CHIEF COMPLAINT: L sided weakness

PRESENT ILLNESS: HPI: 81 year old right handed woman hx atrial fibrillation (not
on Coumadin), bilateral CEA, HTN, who presented on [**2138-2-13**] with
left hemiparesis.
    She was last known normal at 2:15pm on [**2138-2-13**]. She and her
husband had just returned home from a restaurant. Her husband
left the room for a few minutes. When he returned at 2:30pm, she
was slumped over in her chair. She was slurring her words and
had
weakness of her left arm and leg. There was no evidence of
trauma.
    The husband called EMS. Per EMS, she had two episodes each
lasting one minute of rhythmic, high amplitude jerking of the
right arm. She did not follow instructions during these
episodes.
No eye deviation, tongue biting, or incontinence during these
episodes.

MEDICAL HISTORY: -Afib dx 1 month ago-declined coumadin because of frequent blood
draws
-HTN (not well controlled per daughter)
-CABG stent x5 (20 y ago)
-CAD
   patient had 3 stents placed. One stent was placed in [**2132**] and

MEDICATION ON ADMISSION: Cozaar 100mg qd
atenolol 50 mg [**Hospital1 **]
Adalat 30 mg qday
Lipitor 40 mg qd
Plavix 75 mg qday

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: VS:  BP 167/73       P 70       R 18      02 99%
Gen: WD/WN
Heent: supple neck, no carotid bruits, bilateral CEA scars, no
lymphadenopathy
Chest: sternotomy scar, ecchymosis over the upper sternum, lungs
clear to auscultation bilaterally, no wheezes, rales, or rhonchi
Heart: irregularly irregular, no murmurs,
Abd: soft, non-distended, non-tender, no mass, decreased bowel
sounds
Ext: no cyanosis, clubbing, or edema
Skin: no erythema
Neuro: MS: alert, able to answer month and age, able to repeat
with one mistake (missed transition word), follows simple
commands, decreased fluency, eyes open spontaneously
CN: incomplete left homonymous hemianopsia, pupils equal, round,
and reactive, extraocular movements intact, dense left lower
facial droop

FAMILY HISTORY: Had daughter who died of brain aneurysm

SOCIAL HISTORY: Married, has 2 daughters
Occlusion and stenosis of carotid artery with cerebral infarction,Cerebral thrombosis with cerebral infarction,Flaccid hemiplegia and hemiparesis affecting unspecified side,Peripheral vascular complications, not elsewhere classified,Urinary tract infection, site not specified,Coronary atherosclerosis of autologous vein bypass graft,Atrial fibrillation,Congestive heart failure, unspecified,Aphasia,Dysphagia, unspecified,Homonymous bilateral field defects,Other facial nerve disorders,Percutaneous transluminal coronary angioplasty status,Unspecified essential hypertension,Other otorrhea,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of malignant neoplasm of breast,Aneurysm of artery of lower extremity,Accidents occurring in residential institution
Ocl crtd art w infrct,Crbl thrmbs w infrct,Flccd hmiplga unspf side,Surg comp-peri vasc syst,Urin tract infection NOS,Crn ath atlg vn bps grft,Atrial fibrillation,CHF NOS,Aphasia,Dysphagia NOS,Homonymous hemianopsia,Facial nerve dis NEC,Status-post ptca,Hypertension NOS,Otorrhea NEC,Abn react-procedure NEC,Hx of breast malignancy,Lower extremity aneurysm,Accid in resident instit
Admission Date:  [**2138-2-13**]              Discharge Date:   [**2138-2-25**]

Date of Birth:  [**2056-6-15**]             Sex:   F

Service: NEUROLOGY

Allergies:
Penicillins / Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
L sided weakness

Major Surgical or Invasive Procedure:
IV TPA/angiogram

History of Present Illness:
HPI: 81 year old right handed woman hx atrial fibrillation (not
on Coumadin), bilateral CEA, HTN, who presented on [**2138-2-13**] with
left hemiparesis.
    She was last known normal at 2:15pm on [**2138-2-13**]. She and her
husband had just returned home from a restaurant. Her husband
left the room for a few minutes. When he returned at 2:30pm, she
was slumped over in her chair. She was slurring her words and
had
weakness of her left arm and leg. There was no evidence of
trauma.
    The husband called EMS. Per EMS, she had two episodes each
lasting one minute of rhythmic, high amplitude jerking of the
right arm. She did not follow instructions during these
episodes.
No eye deviation, tongue biting, or incontinence during these
episodes.

    Patient was taken to the [**Hospital1 18**] ED. Stroke code was called at
3:50pm. Stroke fellow was at bedside at 3:55pm.
    Her NIHSS was 16.
NIH SS:
1a. Level of Consciousness: 0
1b. LOC questions: 0
1c. LOC commands:0
2. Best gaze:1
3. Visual: 1 (left hemianopia vs extinction)
4. Facial palsy: 2
5a. Motor arm, left: 3
5b. Motor arm, right:0
6a. Motor leg, left: 3
6b. Motor leg, right: 0
7. Limb ataxia: 0
8. Sensory: 2
9. Best language: 1 ( missed one transition word during
repetition testing)
10. Dysarthria: 1
11. Extinction and inattention: 2 (left visual neglect and left
sensory neglect)

Patient was taken to CT head which showed dense right MCA sign.
No hypodensity appreciated on the right. No loss of [**Doctor Last Name 352**]-white
differentiation.
CTA brain showed intraluminal thrombus of the proximal right M1
artery and the bifurcation of the right ICA.
CT perfusion showed decreased blood volume in the right ACA and
increased MTT in the right ACA.

After Head CT, patient was given 6.1mg of TPA. She received an
infusion of 50mg iv TPA in the ED. She got an additional 10.4mg
of iv TPA in the Angio suite.

Once patient returned to the ED from the CT scanner, she
desaturated. Patient was emergently intubated. Her BP
transiently
increased to 200 systolic. Once she was given Propofol, her SBP
returned to 140-160's.

She was taken to the angio suite at 5:30pm. Conventional
angiogram showed revascularization of the proximal right MCA. No
thrombus was visible. No intra-arterial TPA or MERCI device was
utilized. During the procedure, she was given norephinephrine
prn
and nitroglycerin prn.

It was noted that she had a right femoral hematoma at the site
of
the catheter insertion. The catheter sheath was left in place.
Patient was given frequent groin checks. She also had a small
amount of bleeding from her external ear canals bilaterally.

Patient was admitted to the SICU. STAT Head CT was obtained at
7:50pm. There was no intracranial bleeding.

Past Medical History:
-Afib dx 1 month ago-declined coumadin because of frequent blood
draws
-HTN (not well controlled per daughter)
-CABG stent x5 (20 y ago)
-CAD
   patient had 3 stents placed. One stent was placed in [**2132**] and

   another stent was placed in [**2135**]
-breast mass diagnosed in [**2137-7-10**]
   [**2137-8-10**]- breast cancer was resected (lumpectomy) with
   negative, clear margins
   No chemo or radiation
-Bilateral CEA


Social History:
Married, has 2 daughters


Family History:
Had daughter who died of brain aneurysm


Physical Exam:
VS:  BP 167/73       P 70       R 18      02 99%
Gen: WD/WN
Heent: supple neck, no carotid bruits, bilateral CEA scars, no
lymphadenopathy
Chest: sternotomy scar, ecchymosis over the upper sternum, lungs
clear to auscultation bilaterally, no wheezes, rales, or rhonchi
Heart: irregularly irregular, no murmurs,
Abd: soft, non-distended, non-tender, no mass, decreased bowel
sounds
Ext: no cyanosis, clubbing, or edema
Skin: no erythema
Neuro: MS: alert, able to answer month and age, able to repeat
with one mistake (missed transition word), follows simple
commands, decreased fluency, eyes open spontaneously
CN: incomplete left homonymous hemianopsia, pupils equal, round,
and reactive, extraocular movements intact, dense left lower
facial droop

Motor: flaccid left arm and leg, normal tone of right arm and
leg
   left arm and leg did not move spontaneously
   right arm was 5/5 Strength, right leg was at least [**1-14**]
   Strength
Sensory: did not admit to feeling noxious applied to the left
arm
or leg
         did admit to noxious applied to right arm or leg
         withdrew to noxious with the left arm and leg
Reflex:  T     BR   B    K    A    toes
Left     0      0   0    0    0    mute
Right    0      0   0    0    0    mute
Coord: unable to assess
Gait: unable to assess


Pertinent Results:
[**2138-2-13**] 09:00PM   %HbA1c-6.1*
[**2138-2-13**] 09:13PM   TYPE-ART PO2-124* PCO2-35 PH-7.41 TOTAL
CO2-23 BASE XS--1
[**2138-2-13**] 09:13PM   LACTATE-1.4
[**2138-2-13**] 09:00PM   GLUCOSE-138* UREA N-26* CREAT-0.8 SODIUM-139
POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-22 ANION GAP-11
[**2138-2-13**] 09:00PM   ALT(SGPT)-17 AST(SGOT)-25 LD(LDH)-188
CK(CPK)-160* ALK PHOS-62 TOT BILI-0.5
[**2138-2-13**] 09:00PM   CK-MB-5 cTropnT-<0.01
[**2138-2-13**] 09:00PM   %HbA1c-6.1*
[**2138-2-13**] 09:00PM   HOMOCYSTN-9.7
[**2138-2-13**] 09:00PM   TSH-1.6
[**2138-2-13**] 09:00PM   WBC-9.4 RBC-2.72*# HGB-8.9* HCT-25.8*# MCV-95
MCH-32.8* MCHC-34.5 RDW-13.5
[**2138-2-13**] 09:00PM   PT-13.3 PTT-26.9 INR(PT)-1.1
[**2138-2-13**] 09:00PM   SED RATE-22*
[**2138-2-13**] 04:00PM   GLUCOSE-92 UREA N-28* CREAT-1.0 SODIUM-141
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13
[**2138-2-13**] 04:00PM   cTropnT-<0.01
[**2138-2-13**] 04:00PM   WBC-8.8 RBC-3.64* HGB-11.7* HCT-35.1* MCV-96
MCH-32.3* MCHC-33.5 RDW-13.3
[**2138-2-13**] 04:00PM   PT-12.5 PTT-22.2 INR(PT)-1.1

[**2-13**]: Head: CT/CTA/CTP:
1. Thrombus in the right internal carotid artery at the
bifurcation of the MCA and ACA, and involving the M1 segment of
the right MCA and A1 segment of the right ACA. Both MCA and ACA
demonstrate more distal filling.
2. Evidence of ischemia in the distribution of the right
anterior cerebral artery.

[**2-13**]: CTH: (After TPA) No evidence of hemorrhage after TPA
intravenous infusion.

[**2-14**]: CTH: prelim: no significant hemorrhage/infarction noted on
CTH

[**2-13**]: CXR: 1. The endotracheal tube lies too close to the carina
and can be moved up 2 cm. 2. Moderate CHF.

[**2-14**]: TTE: The left atrium is mildly dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.  IMPRESSION: Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. Mild aortic regurgitation. Moderate mitral
regurgitation. Mild pulmonary hypertertension.

MRA head: [**2-15**]:
1. Areas of narrowing in both middle cerebral arteries could be
due to occlusive atherosclerotic disease or due to emboli.
2. Probable partial occlusion of the A2 segment of the left
anterior cerebral artery.
3. Atherosclerotic disease in the posterior circulation as
described above.

MRI brain:: [**2-15**]: 1. Acute left frontal lobe infarct.
2. Small right middle cerebral artery infarcts in the basal
ganglia and right posterior temporal regions.
3. The left-sided infarct has lower ADC value than the
right-sided infarct and could be of more recent origin than the
right-sided infarcts.

CT abd/pelvis: [**2-15**]: 1. Right proximal anterior thigh
subcutaneous hematoma. No retroperitoneal hematoma identified.
2. Small bilateral pleural effusions with bibasilar atelectasis.
3. L5 spondylolysis. Grade I L4 on L5 anterolisthesis.
4. Mild pulmonary edema with small bilateral pleural effusions.

[**2-15**]: R groin u/s: Limited exam shows right groin hematoma with
internal flow demonstrating arterial waveforms suggestive of
pseudoaneurysm, less likely AV fistula. Repeat ultrasound or
contrast- enhanced CT is recommended for further evaluation.


Brief Hospital Course:
Neuro: pt received IV tPA with CT/CTA findings.  pt was brought
to the angio suite where RMCA appears to have been recanalized,
so no IA TPA was given.  pt with some bleeding from her ear
canals bilaterally - repeat CT without evidence of bleeding.
repeat CT at 24 hrs (after TPA) demonstrated:  no significant
bleeding. no evidence of infarction.  Pt with improving strength
of L side UE and LE.  However, noted on [**2-14**] to be moving L>R but
moving all 4 extremities spontaneously.  Pt after extubation
continued to be quite sedated.  Upon am of [**2-15**], pt noted to be
moving her L side spontaneously with minimal spontaneous
movement of her RUE. no movement of her RLE.  MRI revealed
bilatreal ACA infarcts with some R MCA territory infarctions.
MRA revealed clot in LACA with both ACAs deriving from her R
sided intracerebral circulation.  the patient continued not to
speak, was abullic, and had decreased spontaneous movement of
both sides with plegia of RLE.

Heme: pt with significant groin hematoma - improved by HD2.
However, HCT continued to decline and hematoma noted to be
greater in size.  CT abdomen/pelvis revealed R thigh hematoma. R
groin U/S revealed 2x2cm of pseudoaneurysm.  pt was transfused 3
units of pRBCs stable serial hematocrit thereafter.
Pseudoaneurysm was injected with thrombin by interventional
radiology on [**2138-2-17**].

Resp: pt remained intubated until HD 2 when she was extubated
without incident in am.  CXR demonstrating pulmonary edema -
given 20 mg lasix X 2 with pRBC transfusion.

CV: telemetry revealed A Fib throughout stay in ICU.  BPs well
controlled without medications during stay.  CE X 2 negative.
Echo revealed: no thrombus.  however, with dropping HCT, CE
increased and troponing rising to 1.[**Street Address(2) 56254**] depressions in
V2-V6.  cardiology consulted and recommended maximizing statin
and starting asa which was done.  repeat echo revealed:

Endo: normal TSH, A1c 6.1

COURSE ON [**Hospital1 **]:
remained abulic, R hemiparesis mildly improved, started on
Heparin drip for PEG tube which was inserted on [**2-24**]. There was
some bleeding during the procedure but her Hematocrit has
remained stable. Her R thigh size has been stable and her
peripheral pulses are being monitored by Doppler. Cardiology
recommended could add Lisinopril if needed for BP control.
Completed course of Cipro for UTI.

Medications on Admission:
Cozaar 100mg qd
atenolol 50 mg [**Hospital1 **]
Adalat 30 mg qday
Lipitor 40 mg qd
Plavix 75 mg qday


Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Insulin Regular Human 100 unit/mL Solution Sig: scale scale
Injection ASDIR (AS DIRECTED).
4. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed: max 4 g daily.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: 0.5 Tablet PO Q 8H
(Every 8 Hours).
7. Sodium Chloride 0.9%  Flush 3 mL IV DAILY:PRN
Peripheral IV - Inspect site every shift


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
R MCA and L ACA stroke s/p iv TPA

Discharge Condition:
abulic, R hemiparesis mildly improved, does not follow commands

Discharge Instructions:
You have had a stroke. You required a Percutaneous Gastrostomy
tube  for feeding. You should resume amticoagulation 48 hrs
after the surgery for your atrial fibrillation.

Followup Instructions:
[**Hospital 56255**] CLINIC: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 162**], MD
Date/Time: Tuesday [**2138-4-1**] 10:00
Phone:[**Telephone/Fax (1) 2574**]
Please call the above number prior to appointment to update your
hospital registration information.

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

Completed by:[**2138-2-25**]
{'Occlusion and stenosis of carotid artery with cerebral infarction,Cerebral thrombosis with cerebral infarction,Flaccid hemiplegia and hemiparesis affecting unspecified side,Peripheral vascular complications, not elsewhere classified,Urinary tract infection, site not specified,Coronary atherosclerosis of autologous vein bypass graft,Atrial fibrillation,Congestive heart failure, unspecified,Aphasia,Dysphagia, unspecified,Homonymous bilateral field defects,Other facial nerve disorders,Percutaneous transluminal coronary angioplasty status,Unspecified essential hypertension,Other otorrhea,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of malignant neoplasm of breast,Aneurysm of artery of lower extremity,Accidents occurring in residential institution'}


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: L sided weakness

PRESENT ILLNESS: HPI: 81 year old right handed woman hx atrial fibrillation (not
on Coumadin), bilateral CEA, HTN, who presented on [**2138-2-13**] with
left hemiparesis.
    She was last known normal at 2:15pm on [**2138-2-13**]. She and her
husband had just returned home from a restaurant. Her husband
left the room for a few minutes. When he returned at 2:30pm, she
was slumped over in her chair. She was slurring her words and
had
weakness of her left arm and leg. There was no evidence of
trauma.
    The husband called EMS. Per EMS, she had two episodes each
lasting one minute of rhythmic, high amplitude jerking of the
right arm. She did not follow instructions during these
episodes.
No eye deviation, tongue biting, or incontinence during these
episodes.

MEDICAL HISTORY: -Afib dx 1 month ago-declined coumadin because of frequent blood
draws
-HTN (not well controlled per daughter)
-CABG stent x5 (20 y ago)
-CAD
   patient had 3 stents placed. One stent was placed in [**2132**] and

MEDICATION ON ADMISSION: Cozaar 100mg qd
atenolol 50 mg [**Hospital1 **]
Adalat 30 mg qday
Lipitor 40 mg qd
Plavix 75 mg qday

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: VS:  BP 167/73       P 70       R 18      02 99%
Gen: WD/WN
Heent: supple neck, no carotid bruits, bilateral CEA scars, no
lymphadenopathy
Chest: sternotomy scar, ecchymosis over the upper sternum, lungs
clear to auscultation bilaterally, no wheezes, rales, or rhonchi
Heart: irregularly irregular, no murmurs,
Abd: soft, non-distended, non-tender, no mass, decreased bowel
sounds
Ext: no cyanosis, clubbing, or edema
Skin: no erythema
Neuro: MS: alert, able to answer month and age, able to repeat
with one mistake (missed transition word), follows simple
commands, decreased fluency, eyes open spontaneously
CN: incomplete left homonymous hemianopsia, pupils equal, round,
and reactive, extraocular movements intact, dense left lower
facial droop

FAMILY HISTORY: Had daughter who died of brain aneurysm

SOCIAL HISTORY: Married, has 2 daughters 

### Response:
{'Occlusion and stenosis of carotid artery with cerebral infarction,Cerebral thrombosis with cerebral infarction,Flaccid hemiplegia and hemiparesis affecting unspecified side,Peripheral vascular complications, not elsewhere classified,Urinary tract infection, site not specified,Coronary atherosclerosis of autologous vein bypass graft,Atrial fibrillation,Congestive heart failure, unspecified,Aphasia,Dysphagia, unspecified,Homonymous bilateral field defects,Other facial nerve disorders,Percutaneous transluminal coronary angioplasty status,Unspecified essential hypertension,Other otorrhea,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of malignant neoplasm of breast,Aneurysm of artery of lower extremity,Accidents occurring in residential institution'}
