CHIEF COMPLAINT: nausea/vomiting, L arm weakness

PRESENT ILLNESS: Mr. [**Known lastname **] is a 83yo R handed man with HTN, [**Hospital **] transferred
from [**Hospital **] hospital with subacute L PICA infarction. He was
initially transferred to the Neurosurgery service out of a
concern for a possible hemorrhage, however on review of the
imaging, there is no evidence for hemorrhage or edema in need of
neurosurgerical intervention.

MEDICAL HISTORY: Hypertension
BPH
carpal tunnel- s/p L release

MEDICATION ON ADMISSION: Diltiazem Extended release 180mg daily
Aspirin 325mg daily
Nitroglycerin sublingual PRN (does not use)
Multivitamin

ALLERGIES: Penicillins / Novocain

PHYSICAL EXAM: PHYSICAL EXAM:
O: T: 98  BP: 130/80   HR: 66 R: 14    O2Sats: 100% 2LNC
Gen: WD/WN, comfortable, NAD.
HEENT: NCAT
Neck: Supple, focal L posterior neck tenderness. No carotid
bruits bilaterally.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT (NO RUQ TENDERNESS), BS+
Extrem: Warm and well-perfused. 2+ symmetric radial pulses.

FAMILY HISTORY: both parents lived "long lives" and died in old age.

SOCIAL HISTORY: Married, lives with his wife and daughter, he is a
retired computer engineer who worked on hardware for Compaq,
never smoker, rare ETOH, no illicit or IV drug use.
Cerebral artery occlusion, unspecified with cerebral infarction,Muscle weakness (generalized),Difficulty in walking,Lack of coordination,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Atherosclerosis of aorta,Chronic airway obstruction, not elsewhere classified,Diaphragmatic hernia without mention of obstruction or gangrene,Coronary atherosclerosis of native coronary artery,Nontoxic uninodular goiter,Other and unspecified hyperlipidemia,Elevated C-reactive protein (CRP),Abdominal pain, right upper quadrant,History of fall
Crbl art ocl NOS w infrc,Muscle weakness-general,Difficulty in walking,Lack of coordination,Hypertension NOS,BPH w/o urinary obs/LUTS,Aortic atherosclerosis,Chr airway obstruct NEC,Diaphragmatic hernia,Crnry athrscl natve vssl,Nontox uninodular goiter,Hyperlipidemia NEC/NOS,Elev C-reactive protein,Abdmnal pain rt upr quad,Personal history of fall
Admission Date:  [**2201-6-18**]              Discharge Date:   [**2201-6-24**]

Date of Birth:  [**2117-11-24**]             Sex:   M

Service: NEUROLOGY

Allergies:
Penicillins / Novocain

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
nausea/vomiting, L arm weakness


Major Surgical or Invasive Procedure:
none


History of Present Illness:
Mr. [**Known lastname **] is a 83yo R handed man with HTN, [**Hospital **] transferred
from [**Hospital **] hospital with subacute L PICA infarction. He was
initially transferred to the Neurosurgery service out of a
concern for a possible hemorrhage, however on review of the
imaging, there is no evidence for hemorrhage or edema in need of
neurosurgerical intervention.

As per the neurosurgery admission note, the patient patient
reports carrying his daughters dog into the car around 6pm 4
days
ago when he noted the sudden onset of intense nausea, "dry
heaves," as well as dizziness and feeling unsteady on his feet.
He sat down in his daughter's car and was unable to be moved and
he was then taken via EMS to [**Hospital **] Hospital. There he noted
his
left arm "felt numb." The patient was admitted to the hospital
for evaluation of mild RUQ pain. Abdominal CT revealed
cholithiasis and no cholecystitis. A mass at the bladder trigone
was noted. Given the pt's protracted N/V and left arm symptoms
an
MRI brain was performed today at 2pm. Study revealed subacute L
PICA infarct. MRA was degraded by motion, there is a R dominant
vertebral artery. L vert not visualized.

The patient notably reports focal left neck tenderness. He is
otherwise without diplopia, headache, difficulty producing or
comprehending speech. His gait is quite unsteady and he has not
been walking since admission to [**Hospital1 **] four days ago.

On gen ROS, denies fever, chills, night sweats or  weight loss.
He has continued nausea and poor appetite. He denies CP and SOB.
He does report L shoulder pain.


Past Medical History:
Hypertension
BPH
carpal tunnel- s/p L release


Social History:
Married, lives with his wife and daughter, he is a
retired computer engineer who worked on hardware for Compaq,
never smoker, rare ETOH, no illicit or IV drug use.


Family History:
both parents lived "long lives" and died in old age.


Physical Exam:
PHYSICAL EXAM:
O: T: 98  BP: 130/80   HR: 66 R: 14    O2Sats: 100% 2LNC
Gen: WD/WN, comfortable, NAD.
HEENT: NCAT
Neck: Supple, focal L posterior neck tenderness. No carotid
bruits bilaterally.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT (NO RUQ TENDERNESS), BS+
Extrem: Warm and well-perfused. 2+ symmetric radial pulses.

Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date. Names [**Doctor Last Name 1841**]
backwards without difficulty
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally, he has R
beating nystagmus with L gaze only.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. there is slight L
pronator drift, he has a L hemiparesis, weakness of L delt, Tri,
FE, FA [**3-30**]. Full strength biceps. L IP, H, TA [**3-30**]. Full at
Quadriceps. R side is [**4-29**] throughout.

Coordination: slow, clumsy L hand movements
(dysdiadochokinesia).
dysrhythmic L foot tapping. dysmetria on L FNF. No clear
abnormality with heel knee shin bilaterally.

Sensation: Intact to light touch. Does not fully cooperate with
propioception testing, but intact to gross movements. pinprick
intact.

Reflexes: B T Br Pa Ac
Right     0 0 0  0  0
Left      1 1 1  1  0

Toes downgoing bilaterally

Gait: deferred.


Pertinent Results:
[**2201-6-20**] 06:30AM BLOOD WBC-6.8 RBC-4.41* Hgb-12.8* Hct-38.7*
MCV-88 MCH-29.1 MCHC-33.1 RDW-13.2 Plt Ct-295
[**2201-6-19**] 12:29AM BLOOD WBC-9.4 RBC-4.33* Hgb-13.3* Hct-38.1*
MCV-88 MCH-30.7 MCHC-34.8 RDW-13.3 Plt Ct-261
[**2201-6-20**] 06:30AM BLOOD Neuts-79.9* Lymphs-13.9* Monos-3.5
Eos-2.4 Baso-0.3
[**2201-6-20**] 06:30AM BLOOD Plt Ct-295
[**2201-6-20**] 06:30AM BLOOD PT-12.5 PTT-30.2 INR(PT)-1.1
[**2201-6-19**] 11:45AM BLOOD ESR-87*
[**2201-6-21**] 01:30PM BLOOD ESR-80*
[**2201-6-20**] 06:30AM BLOOD Glucose-128* UreaN-24* Creat-1.4* Na-139
K-3.4 Cl-104 HCO3-27 AnGap-11
[**2201-6-22**] 01:10PM BLOOD Glucose-82 UreaN-28* Creat-1.3* Na-140
K-3.9 Cl-105 HCO3-23 AnGap-16
[**2201-6-22**] 01:10PM BLOOD TotProt-6.1* Albumin-3.7 Globuln-2.4
Calcium-8.7 Phos-3.8 Mg-2.0
[**2201-6-19**] 11:45AM BLOOD %HbA1c-5.6 eAG-114
[**2201-6-19**] 11:45AM BLOOD Triglyc-93 HDL-73 CHOL/HD-2.8 LDLcalc-114
[**2201-6-19**] 11:45AM BLOOD CRP-248.5*
[**2201-6-21**] 01:30PM BLOOD CRP-117.2*

UPEP/SPEP both normal
[**Doctor First Name **] positive with very low titer 1:80

Imaging:
Echo:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with mild hypokinesis of
the distal septum and apex. The remaining segments contract
normally (LVEF = 55%). No masses or thrombi are seen in the left
ventricle. Doppler parameters are most consistent with Grade I
(mild) left ventricular diastolic dysfunction. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.

IMPRESSION: No left ventricular thrombus seen. Mild regional
left ventricular systolic dysfunction, c/w CAD. Mild aortic and
mitral regurgitation. Dilated thoracic aorta.

TEE:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. The left ventricle is not
well seen. There are complex (>4mm) atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.

IMPRESSION: Suboptimal image quality secondary to hiatal hernia.
No LA/LAA thrombus seen. No PFO/ASD at rest or with maneuvers.
Complex (>4mm, nonmobile) atheroma in the aortic arch and simple
plaque in the descending aorta.
CXR:
The lungs are hyperinflated and the diaphragms are flattened,
consistent with
COPD. There is mild-to-moderate cardiomegaly. The aorta is
slightly
unfolded. There is a moderate-sized hiatal hernia. There are
small bilateral
pleural effusions seen on the lateral view posteriorly. No CHF.
Doubt focal
infiltrate. Minimal bibasilar atelectasis. Probable small
calcified
granuloma in the right mid zone measuring approximately 3.5 mm
and overlying
the right fifth anterior rib. Degenerative changes of the
thoracic spine are
noted. Possible minimal anterior wedging of several lower
thoracic vertebral
bodies is suggested, unlikely to be acute.

IMPRESSION:
1) Background COPD.
2) Small bilateral effusions posteriorly. Doubt acute
infiltrate.
3) Moderate- sized hiatal hernia.

Head CT/CTA:
HEAD CT: There is a hypodense lesion in the left cerebellar
hemisphere
causing effacement of the fourth ventricle, consistent with
acute left
cerebellar infarct with history of left PICA. There is no
evidence of
hemorrhage, edema, mass effect, elsewhere in the brain. The
ventricles and
sulci are normal in caliber and configuration. The basal
cisterns are patent.
Visualized paranasal sinuses and mastoid air cells are clear.

CTA:

Neck CTA: There is a normal three-vessel aortic arch. The
origins of both
common carotid and vertebral arteries are normal. The cervical
common carotid
arteries are normal. The right vertebral artery is dominant and
the left
vertebral artery is developmentally hypoplastic. The cervical
portion of the
internal carotid arteries and vertebral arteries are normal.

Head CTA: The hypoplastic left vertebral artery gives off the
left posterior
inferior cerebral artery, just before it enters the dura (3:194)
and appears
unremarkable. The attenuated left vertebral artery continues on
to form the
basilar artery. The right vertebral artery supplies the major
flow of the
basilar system. The basilar artery and the major intracranial
branches are
normal, without evidence of occlusion or flow-limiting stenosis
or aneurysm
formation. The intracranial portion of both internal carotid
arteries and
their major branches are normal in their course without evidence
of occlusion,
stenosis, or aneurysm formation.

The thyroid gland is enlarged, left lobe greater than right. The

hypoattenuating left lobe nodule measures 3.7 x 3.1 cm.

IMPRESSION:

1. Cerebellar infarct in the territory of left PICA, with mild
mass effect on
the fourth ventricle and effacement of the cerebellar folia. No
evidence of
herniation.

2. No vascular occlusion, significant flow limiting stenosis or
aneurysm
greater than 2 mm identified in the CTA.

3. Enlarged nodular thyroid gland, involving the left lobe
greater than right,
needs further evaluation with a thyroid ultrasound.

US abd/gall bladder:
FINDINGS: Note is made that this is a limited study due to the
patient's body
habitus. The liver shows no focal or textural abnormality. No
biliary
dilatation is seen and the common duct measures 0.2 cm. The
portal vein is
patent with hepatopetal flow. A small amount of sludge and
several small
gallstones are seen moving within the lumen of the gallbladder.
There is no
gallbladder wall thickening and no pericholecystic fluid is
identified. The
pancreas is obscured from view by overlying bowel. The spleen is
unremarkable
and measures 9.2 cm. There is no hydronephrosis. The right
kidney measures
9.2 cm and the left kidney measures 9.1 cm. A small parapelvic
cyst is seen
in the left kidney measuring 0.9 cm. No AAA is identified. No
ascites is
seen in the abdomen.

IMPRESSION: Small amount of sludge and several small gallstones
within the
gallbladder, but no son[**Name (NI) 493**] signs of cholecystitis.


Brief Hospital Course:
The patient was initially admitted with nausea, vertigo and
difficulty with gait.  He was also noted to have significant
difficulty coordinating the movement of your left arm.  You were
first sent to [**Hospital **] Hospital.  The patient was also
complainting of abdominal pain.  At the OSH he was evaluted for
mild RUQ pain -> an abdominal CT revealed no cholecystitis.
There was a question of a small mass in the bladder trigone
although it was not clear and he will need urology workup as an
outpatient.  Given the protracted symptoms of nausea and
vomiting he had an MRI which revealed a L SCA infarct.  As a
result of this he was transferred to the [**Hospital1 18**].  He was
initially transferred to the neurosurgery service, however based
on his findings he was sent to the neurology service.

At [**Hospital1 18**] we further evaluated the patient to find the underlying
cause of the stroke.  Based on a complaint of neck pain we
obtained a CTA to help evaluate possible dissection, however no
evidence of dissection was seen.  There was a enlarged nodular
thyriod gland, that will need a thyroid ultrasound as an
outpatient.  His thyroid function was normal.

We kept the patient on telemetry and did not notice any atrial
fibriliation. There was an echo cardiogram of his heart which
did not note any source of thrombus.  A TEE was obtained which
showed no LA/LAA thrombus seen. No PFO/ASD at rest or with
maneuvers. Complex (>4mm, NON-mobile) atheroma in the aortic
arch and simple plaque in the descending aorta.

The patient had  elevated inflammatory markers including an ESR
of 80 and a CRP as high as 250 which came down to 117.  It is
not clear why these are elevated, he did not appear to have an
underlying infection.  He had mutiple negative blood cultures,
and no fevers or evidence of underlying infectious processes.
He had a normal chest x-ray and a normal UA.  He had a normal
SPEP and UPEP.  He has a positive [**Doctor First Name **] but with a very low titer.
 He will need these inflammatory markers checked when he returns
to clinic.

The  secondary stroke risk factors were also checked.  The
hgba1c = 5.6. The LDL was 117 and he was started on a statin.

In addition based on his initial complaint of  abdominal pain he
had normal liver enzymes as well as a normal  ultrasound of the
liver and gall bladder.

Neuro
- given his intracranial stenosis and risk of stroke he will
maintain on plavix
- he will not be started on coumadin given his current falls
risk

CV
- c/w statin
- c/w Diltiazem Extended release 180mg daily

Urology
- will need f/u for question of a bladder mass as an outpatient
- the patient is not scheduled for any chemotherapy in the next
week, this area will need workup first

Thyroid
- normal TFTs, however abnormal enlargement of thyroid seen on
CT will need re-eval with thyroid U as an outpatient


Medications on Admission:
Diltiazem Extended release 180mg daily
Aspirin 325mg daily
Nitroglycerin sublingual PRN (does not use)
Multivitamin


Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Diltia XT 180 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Multivitamin     Capsule Sig: One (1) Capsule PO once a day.

5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
Cerebellar infarct - Left Superior Cerbellar Artery


Discharge Condition:
MS: awake, alert, interactive, axox3. Language intact, repition
intact, comprehension intact, recalls [**1-28**] at 5 min
CN: on left gaze left beating nystagmus, o/w EOMI, PERRL, face
symmetric, facial [**Last Name (un) 36**] intact
Motor: mild weakness at left deltoid, 5-/5 at hamstring
bilaterally.  Appears weaker on left but given coordination
problems does not often give full effort.
no drift
[**Last Name (un) **]: no deficits to LT, mild pinprick and vibration loss at
feet, slight 2 point discrimination on left hand
[**Last Name (un) **]: dysmetria on FNF and HKS on left side. Overshoot and
increased cerebellar rebound on L
Gait: unable to stand, needs two person assist to walk, very
unsteady.


Discharge Instructions:
You were transferred from an outside hospital after you were
found to have a sub-acute left sided stroke in an area of your
brain called the cerebellum.  This part of the brain is
responsible for coordination and balance and it has made it
dififcult to coordinate the use of your left hand as well as
walk.  A stroke in this area is often caused by a clot from
another area.  We attempted to find an underlying cause of your
stroke.  You were on telemetry and it did not show any irregular
rhythms.  You had a echo-cardiogram of your heart which did not
show any clots.  You had a trans-esophageal echo of your heart
which was also normal.   You also had elevated inflammatory
markers (they are called ESR and CRP).  While these can happen
after stroke they were higher than we usually see post stroke.
You did not have an underlying infection, no infections in the
urine or chest x-ray.  We checked an measure of proteins in your
blood called an SPEP/UPEP which were normal.  You secondary
stroke risk factors were also checked.  A test of your blood
sugar was normal (hgba1c = 5.6).  A test of your cholesterol was
slighlty high (LDL=117) and you were placed on a cholesterol
lowering medication.

In addition you had an initial complaint of abdominal pain.  You
had normal enzymes and an ultrasound of your liver and gall
bladder which was normal.  It was also noted that you have a
slighlty enlarged thyroid gland that should be followed as an
outpatient with an ultrasound.

Please take all medications as prescribed.  Please make all
follow up appointments.  If you have any acute worsening of your
symptoms or new symptoms (new weakness, difficulty with
language) please call your doctor or return to the nearest
emergency room.

Followup Instructions:
Please follow up with
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2201-9-1**] 2:00
[**Hospital1 18**] [**Hospital Ward Name **] - [**Hospital Ward Name **] 8.

Please follow up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 56498**]
upon discharged from rehab


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
{'Cerebral artery occlusion, unspecified with cerebral infarction,Muscle weakness (generalized),Difficulty in walking,Lack of coordination,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Atherosclerosis of aorta,Chronic airway obstruction, not elsewhere classified,Diaphragmatic hernia without mention of obstruction or gangrene,Coronary atherosclerosis of native coronary artery,Nontoxic uninodular goiter,Other and unspecified hyperlipidemia,Elevated C-reactive protein (CRP),Abdominal pain, right upper quadrant,History of fall'}


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: nausea/vomiting, L arm weakness

PRESENT ILLNESS: Mr. [**Known lastname **] is a 83yo R handed man with HTN, [**Hospital **] transferred
from [**Hospital **] hospital with subacute L PICA infarction. He was
initially transferred to the Neurosurgery service out of a
concern for a possible hemorrhage, however on review of the
imaging, there is no evidence for hemorrhage or edema in need of
neurosurgerical intervention.

MEDICAL HISTORY: Hypertension
BPH
carpal tunnel- s/p L release

MEDICATION ON ADMISSION: Diltiazem Extended release 180mg daily
Aspirin 325mg daily
Nitroglycerin sublingual PRN (does not use)
Multivitamin

ALLERGIES: Penicillins / Novocain

PHYSICAL EXAM: PHYSICAL EXAM:
O: T: 98  BP: 130/80   HR: 66 R: 14    O2Sats: 100% 2LNC
Gen: WD/WN, comfortable, NAD.
HEENT: NCAT
Neck: Supple, focal L posterior neck tenderness. No carotid
bruits bilaterally.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT (NO RUQ TENDERNESS), BS+
Extrem: Warm and well-perfused. 2+ symmetric radial pulses.

FAMILY HISTORY: both parents lived "long lives" and died in old age.

SOCIAL HISTORY: Married, lives with his wife and daughter, he is a
retired computer engineer who worked on hardware for Compaq,
never smoker, rare ETOH, no illicit or IV drug use. 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Muscle weakness (generalized),Difficulty in walking,Lack of coordination,Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Atherosclerosis of aorta,Chronic airway obstruction, not elsewhere classified,Diaphragmatic hernia without mention of obstruction or gangrene,Coronary atherosclerosis of native coronary artery,Nontoxic uninodular goiter,Other and unspecified hyperlipidemia,Elevated C-reactive protein (CRP),Abdominal pain, right upper quadrant,History of fall'}
