CHIEF COMPLAINT: Confusion, agitation

PRESENT ILLNESS: Mr. [**Known lastname 62864**] is intubated and sedated so unable to obtain history
from him. History obtained from his family and review of
transfer records.
.
Mr. [**Known lastname 62864**] is a 49 y/o man with a PMH significant for open heart
surgery at CHB in the [**2124**] for "2 holes in his heart" and a
left MCA stroke in [**6-/2158**] with resulting aphasia (both receptive
and expressive (though he was able to communicate) and right
hemiparesis (some movement R arm but not full and wore R leg
brace as well as had RLE tremors) who presented to OSH today
with altered mental status. According to his son, he was last
seen well at 5:45 PM, when he was watching tv and his son left
the house. Of note, prior to that he did ask his son how to cook
chicken, which was noted to be odd. His son came back home at
11:30 and found the the couch cushions and drawers on the floor
and the lights in the house on. The patient was found in the
bathroom, sitting on the toilet in the dark. He got up and told
his son to go away and then was pacing around the house and not
responding to his son's questions. His son called EMS, who found
him combative and there is a report that he bit one of the
paramedics. He was brought to OSH, where was intubated for
agitation and airway protection. He was found to have a reported
R MCA thrombus with infarct at OSH and was transferred to [**Hospital1 18**]
for further management. Of note, he was out of the time window
for intervention upon arrival to [**Hospital1 18**].
.
Of note, he had oral surgery last week, at which time his
Coumadin was held for 2 days. He was started on the Coumadin
after his first stroke in [**2158**], though the etiology of that
stroke is unknown as per the family. He has been taking the
Coumadin for the last few days as scheduled. Also of note, he
was found to have an egorged tic on his chest at OSH, which was
removed.
.
ROS: unable to obtain as he is intubated and sedated.

MEDICAL HISTORY: -open heart surgery at CHB [**2124**] for "2 holes in heart"
-L MCA stroke [**6-/2158**] with resulting aphasia and right
hemiparesis. Has been on Coumadin since the stroke.
-right leg tremor subsequent to infarct in [**2158**]
-bladder surgery this year (reason unknown)
-oral surgery last week
-HTN

MEDICATION ON ADMISSION: -HCTZ 25 mg daily
-Coumadin 2 mg tab (1 or 1.5 tabs daily)
-Atenolol 25 mg daily
-Potassium 40 mEQ daily
-Baclofen 15 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: T: 101 P: 69 BP: 150/98 vent CMV 550/12/5/100%

FAMILY HISTORY: Father 79 with Alzheimer's. Mother 78 with HTN. Maternal great
grandfather with strokes.

SOCIAL HISTORY: He lives with his son. [**Name (NI) **] smoking, drinking, or illicit drugs
per family.
Cerebral thrombosis with cerebral infarction,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Unspecified essential hypertension,Long-term (current) use of anticoagulants,Personal history of surgery to heart and great vessels, presenting hazards to health
Crbl thrmbs w infrct,Late ef-hemplga side NOS,Hypertension NOS,Long-term use anticoagul,Hx-major cardiovasc surg
Admission Date:  [**2165-5-22**]              Discharge Date:   [**2165-5-28**]

Date of Birth:  [**2115-8-6**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Confusion, agitation

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Mr. [**Known lastname 62864**] is intubated and sedated so unable to obtain history
from him. History obtained from his family and review of
transfer records.
.
Mr. [**Known lastname 62864**] is a 49 y/o man with a PMH significant for open heart
surgery at CHB in the [**2124**] for "2 holes in his heart" and a
left MCA stroke in [**6-/2158**] with resulting aphasia (both receptive
and expressive (though he was able to communicate) and right
hemiparesis (some movement R arm but not full and wore R leg
brace as well as had RLE tremors) who presented to OSH today
with altered mental status. According to his son, he was last
seen well at 5:45 PM, when he was watching tv and his son left
the house. Of note, prior to that he did ask his son how to cook
chicken, which was noted to be odd. His son came back home at
11:30 and found the the couch cushions and drawers on the floor
and the lights in the house on. The patient was found in the
bathroom, sitting on the toilet in the dark. He got up and told
his son to go away and then was pacing around the house and not
responding to his son's questions. His son called EMS, who found
him combative and there is a report that he bit one of the
paramedics. He was brought to OSH, where was intubated for
agitation and airway protection. He was found to have a reported
R MCA thrombus with infarct at OSH and was transferred to [**Hospital1 18**]
for further management. Of note, he was out of the time window
for intervention upon arrival to [**Hospital1 18**].
.
Of note, he had oral surgery last week, at which time his
Coumadin was held for 2 days. He was started on the Coumadin
after his first stroke in [**2158**], though the etiology of that
stroke is unknown as per the family. He has been taking the
Coumadin for the last few days as scheduled. Also of note, he
was found to have an egorged tic on his chest at OSH, which was
removed.
.
ROS: unable to obtain as he is intubated and sedated.

Past Medical History:
-open heart surgery at CHB [**2124**] for "2 holes in heart"
-L MCA stroke [**6-/2158**] with resulting aphasia and right
hemiparesis. Has been on Coumadin since the stroke.
-right leg tremor subsequent to infarct in [**2158**]
-bladder surgery this year (reason unknown)
-oral surgery last week
-HTN

Social History:
He lives with his son. [**Name (NI) **] smoking, drinking, or illicit drugs
per family.

Family History:
Father 79 with Alzheimer's. Mother 78 with HTN. Maternal great
grandfather with strokes.


Physical Exam:
Vitals: T: 101 P: 69 BP: 150/98 vent CMV 550/12/5/100%

General: intubated, sedated
HEENT: ET tube in place
chest: anterior lung fields cta b/l. there is well-healed
midline
sternotomy scar noted
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, ND, +BS
Extremities: no edema
Skin: multiple pustules on chest

Neurologic: no eye opening or commands. Pupils 3 mm b/l and
sluggishly reactive to light. + occulocephalics. + corneals b/l.
+ cough/gag. moving all 4 extremities spontaneously. Purposeful
withdrawal of all 4 extremities, though he seemed to withdraw
right lower extremity brisker than left. RLE tremulousness
noted.
Reflexes 3+ and symmetric throughout. Extensor planatar response
b/l.

Pertinent Results:
Labs on admission:
[**2165-5-22**] 06:19AM BLOOD WBC-11.2* RBC-4.46* Hgb-13.8* Hct-36.7*
MCV-82 MCH-31.0 MCHC-37.7* RDW-13.2 Plt Ct-246
[**2165-5-22**] 06:19AM BLOOD Neuts-84.9* Lymphs-11.5* Monos-3.0
Eos-0.4 Baso-0.2
[**2165-5-22**] 06:19AM BLOOD PT-18.4* PTT-24.5 INR(PT)-1.7*
[**2165-5-22**] 05:44AM BLOOD UreaN-13 Creat-0.8
[**2165-5-22**] 09:37AM BLOOD ALT-18 AST-43* AlkPhos-44 TotBili-0.6
[**2165-5-22**] 05:44AM BLOOD Lipase-36
[**2165-5-22**] 05:44AM BLOOD cTropnT-<0.01
[**2165-5-22**] 09:37AM BLOOD cTropnT-<0.01
[**2165-5-22**] 09:37AM BLOOD Albumin-4.0 Cholest-141
[**2165-5-23**] 02:09AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.7 Cholest-105
[**2165-5-22**] 09:37AM BLOOD %HbA1c-5.0 eAG-97
[**2165-5-22**] 09:37AM BLOOD Triglyc-[**2170**]* HDL-15 CHOL/HD-9.4
LDLmeas-LESS THAN
[**2165-5-23**] 02:09AM BLOOD Triglyc-154* HDL-25 CHOL/HD-4.2
LDLcalc-49
[**2165-5-23**] 02:09AM BLOOD TSH-0.92
[**2165-5-22**] 05:44AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2165-5-22**] 06:19AM BLOOD Type-ART Temp-37.9 Rates-/12 Tidal V-550
PEEP-5 FiO2-100 pO2-293* pCO2-37 pH-7.44 calTCO2-26 Base XS-1
AADO2-383 REQ O2-68 -ASSIST/CON Intubat-INTUBATED Comment-GREEN
TOP
[**2165-5-22**] 05:47AM BLOOD Glucose-118* Lactate-1.6 Na-139 K-4.2
Cl-104 calHCO3-24
[**2165-5-22**] 05:47AM BLOOD Hgb-13.9* calcHCT-42 O2 Sat-97 COHgb-2
MetHgb-0
[**2165-5-22**] 05:44AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.046*
[**2165-5-22**] 05:44AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2165-5-22**] 05:44AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
[**2165-5-22**] 09:35AM URINE Mucous-RARE
[**2165-5-22**] 05:44AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
Labs on discharge:
[**2165-5-26**] 06:40AM BLOOD WBC-6.1 RBC-4.11* Hgb-12.0* Hct-34.8*
MCV-85 MCH-29.1 MCHC-34.5 RDW-12.8 Plt Ct-173
[**2165-5-26**] 06:40AM BLOOD Neuts-73.5* Lymphs-17.5* Monos-4.2
Eos-4.6* Baso-0.2
[**2165-5-28**] 05:50AM BLOOD PT-26.9* PTT-27.9 INR(PT)-2.6*
[**2165-5-28**] 05:50AM BLOOD Glucose-84 UreaN-14 Creat-0.9 Na-142
K-3.5 Cl-107 HCO3-28 AnGap-11
[**2165-5-26**] 06:40AM BLOOD ALT-17 AST-22 AlkPhos-41 TotBili-0.5
[**2165-5-28**] 05:50AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.0
.
Micro:
[**2165-5-25**] BLOOD CULTURE-PENDING
[**2165-5-25**] BLOOD CULTURE-PENDING
[**2165-5-24**] BLOOD CULTURE-PENDING
[**2165-5-24**] BLOOD CULTURE-PENDING
[**2165-5-24**] URINE CULTURE-NEGATIVE
[**2165-5-22**] MRSA SCREEN-FINAL
.
Imaging:
[**2165-5-25**]   CHEST (PORTABLE AP):
Endotracheal tube and nasogastric tube have been removed. Heart
is
upper limits of normal in size. Improved aeration at left lung
base with
residual linear focus of atelectasis. New patchy right
infrahilar opacity
favors atelectasis but followup radiographs may be helpful to
exclude a
developing pneumonia in this region considering clinical
suspicion for this entity.

[**2165-5-23**]   CHEST (PORTABLE AP):
The tip of the endotracheal tube projects 2.3 cm above the
carina.
The course of the nasogastric tube is unremarkable, however, the
tube is
looped in the stomach and the tip points back towards the
gastroesophageal
junction. No central venous access line is seen.

No complications, notably no pneumothorax. No pleural effusions.
Normal size of the cardiac silhouette. No pneumonia.

[**2165-5-22**]   MR/A HEAD/NECK W/O CONTRAST:
1. Continued maturation of right MCA territory cortical infarct,
no evidence of hemorrhagic conversion.

2. Markedly decreased flow-related enhancement within the
inferior division of the right MCA. Focal narrowing of the right
M1 has improved somewhat compared to [**2165-3-22**] CTA.

3. No flow-limiting disease within the carotid arteries.

4. Chronic left MCA territory infarction, similar to prior.

[**2165-5-22**]   CHEST (PORTABLE AP):
1. Low lung volumes with atelectasis.

2. Intubation with the endotracheal tube 3.5 cm from the carina.
The NG tube is coiled in the stomach.

[**2165-5-22**]   CT HEAD W/O CONTRAST, PERFUSION:
1. No evidence of hemorrhage.
2. Evolving nonhemorrhagic right MCA infarct, particularly the
inferior MCA territory. Perfusion reveals matched defects
inferiorly within the right MCA territory with some preservation
of flow and volume along the superior aspect.
3. Occlusion of the inferior division of the right MCA.
4. Near occlusion of the superior division of the right MCA,
though with
patnet peripheral bramches.
5. Chronic left MCA infarct.
6. Scout films reveal contrast within the right forearm from
contrast
infiltration.

[**2165-5-22**]   ECHO:
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.

IMPRESSION: Suboptimal image quality due to patient's body
habitus. Left ventricular systolic function is probably normal,
a focal wall motion abnormality cannot be fully excluded. The
right ventricle is not well seen. No significant valvular
abnormality. Unable to assess pulmonary artery systolic
pressures.

[**2165-5-22**]   ECG:
Probable ectopic atrial rhythm. Right precordial lead T wave
changes.
Borderline prolonged/upper limits of normal QTc interval.
Findings are
non-specific but clinical correlation is suggested. No previous
tracing
available for comparison.

Rate PR  QRS QT/QTc   P   QRS T
66   130 94  436/446  -63 38  67

Brief Hospital Course:
Mr. [**Known lastname 62864**] is a 49 y/o man with a PMH significant for open heart
surgery at CHB in the [**2124**] for "2 holes in his heart" and a
left MCA stroke in [**6-/2158**] with resulting aphasia (both receptive
and expressive (though he was able to communicate) and right
hemiparesis (some movement R arm but not full and wore R leg
brace as well as had RLE tremors) who presented to OSH today
with altered mental status and agitation. Found to have a R MCA
infarct, intubated for agitation and transferred to [**Hospital1 18**] for
further care. On exam, he is intubated with no eye opening on
commands; has intact brainstem reflexes and is moving all
extremities spontaneously. Based on head CT, he presented with a
new R MCA infarct in addition to the old L MCA infarct. He was
out of the time window for intervention upon arrival to [**Hospital1 18**].
While the etiology of his primary stroke is unknown, he was
placed on Coumadin afterwards and initially his INR is
subtherapeutic at 1.6 at time of presentation, so this is likely
the explanation of the new infarct. However, pt was admitted for
full stroke work-up.  . Pt was initially admitted to the neuro
[**Hospital 2571**] transferred to the neuro medicine floor on [**2165-5-24**].
.
Neurologic: MRA brain revealed right MCA territory cortical
infarct, no evidence
of hemorrhagic conversion as well as chronic left MCA territory
infarction, similar to prior studies. Pt became disoriented and
agitated at times s/p extubation, responded well to olanzapine
prn. Difficult to complete full neurology exam due to poor
attention, pt with expressive aphasia. Observed to move all four
extremities spontaneously. Pt was restarted on coumadin and
started on ASA. INR initially 1.7 at time of presentation,
elevated 4.7 during admission; coumadin was held until morning
of discharge, INR 2.6 on day of discharge. Goal INR [**2-7**]. Stroke
risk factors were checked: LDL 49 (at goal, statin not started),
HgBA1c 5.0; TSH: 0.92. Echo study with suboptimal windows and
unable to perform bubble study, preserved EF, no comment on
thrombus or ASD; no VSD.
.
Pulmonary: Pt initially intubated for agitation, extubated in
neuro ICU without complications. No issues while on neuro
medicine floor service.
.
Gastrointestinal / Abdomen: No active issues, pt on bowel
regimen during admission.
.
Nutrition: Passed speech and swallow evaluation, pt tolerated
Cardiac/Heart healthy diet.
.
Renal: Electrolytes repleted as needed, being discharged with
home potassium repletion.
.
Hematology: Hct stable throughout admission, anticoagulation as
above. Discharging on coumadin 2mg daily, INR to be checked
daily and coumadin dosage to be adjusted as needed.
.
Endocrine: Placed on insulin sliding scale for goal BS < 150
during admission.
.
Infectious Disease: No active issues during admission.
.
Musculoskeletel: Pt had IV contrast extravasate into right
forearm on day of admission; evaluated by orthopedic surgery,
compartment pressures measured. Based on measured pressures and
clinical exam, pt did not have compartment syndrome.

Medications on Admission:
-HCTZ 25 mg daily
-Coumadin 2 mg tab (1 or 1.5 tabs daily)
-Atenolol 25 mg daily
-Potassium 40 mEQ daily
-Baclofen 15 mg daily

Discharge Medications:
1. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
2. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
3. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
4. baclofen 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day.
6. olanzapine 5 mg Tablet, Rapid Dissolve Sig: [**1-6**] Tablet, Rapid
Dissolves PO TID (3 times a day) as needed for agitation.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Acute right inferior middle cerebral artery stroke


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


Discharge Instructions:
Dear Mr. [**Known lastname 62864**],

You were admitted for a right inferior middle cerebral artery
stroke.  This is likely due to the fact that your INR was
subtherapeutic.  You were restarted on your coumadin and started
on aspirin for stroke protection.  Your stroke risk factors were
checked.  Your LDL cholesterol was 49.  You had a cardiac
echocardiogram which demonstrated no obvious cardioembolic
source.    You were checked for blood glucose control with a HgB
A1c.  The level was 5.0.  You need to continue your blood
pressure control.  You should not smoke.

You should continue to eat a low fat healthy diet, and follow up
with your primary care physician and stroke Neurology as noted
below.

It was a pleasure taking care of you.

Followup Instructions:
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 62081**], at
[**Telephone/Fax (1) 62865**] for an appointment 7-10 days after you are
discharged from your rehabilition center.

Department: NEUROLOGY
When: MONDAY [**2165-7-1**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
{'Cerebral thrombosis with cerebral infarction,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Unspecified essential hypertension,Long-term (current) use of anticoagulants,Personal history of surgery to heart and great vessels, presenting hazards to health'}


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: Confusion, agitation

PRESENT ILLNESS: Mr. [**Known lastname 62864**] is intubated and sedated so unable to obtain history
from him. History obtained from his family and review of
transfer records.
.
Mr. [**Known lastname 62864**] is a 49 y/o man with a PMH significant for open heart
surgery at CHB in the [**2124**] for "2 holes in his heart" and a
left MCA stroke in [**6-/2158**] with resulting aphasia (both receptive
and expressive (though he was able to communicate) and right
hemiparesis (some movement R arm but not full and wore R leg
brace as well as had RLE tremors) who presented to OSH today
with altered mental status. According to his son, he was last
seen well at 5:45 PM, when he was watching tv and his son left
the house. Of note, prior to that he did ask his son how to cook
chicken, which was noted to be odd. His son came back home at
11:30 and found the the couch cushions and drawers on the floor
and the lights in the house on. The patient was found in the
bathroom, sitting on the toilet in the dark. He got up and told
his son to go away and then was pacing around the house and not
responding to his son's questions. His son called EMS, who found
him combative and there is a report that he bit one of the
paramedics. He was brought to OSH, where was intubated for
agitation and airway protection. He was found to have a reported
R MCA thrombus with infarct at OSH and was transferred to [**Hospital1 18**]
for further management. Of note, he was out of the time window
for intervention upon arrival to [**Hospital1 18**].
.
Of note, he had oral surgery last week, at which time his
Coumadin was held for 2 days. He was started on the Coumadin
after his first stroke in [**2158**], though the etiology of that
stroke is unknown as per the family. He has been taking the
Coumadin for the last few days as scheduled. Also of note, he
was found to have an egorged tic on his chest at OSH, which was
removed.
.
ROS: unable to obtain as he is intubated and sedated.

MEDICAL HISTORY: -open heart surgery at CHB [**2124**] for "2 holes in heart"
-L MCA stroke [**6-/2158**] with resulting aphasia and right
hemiparesis. Has been on Coumadin since the stroke.
-right leg tremor subsequent to infarct in [**2158**]
-bladder surgery this year (reason unknown)
-oral surgery last week
-HTN

MEDICATION ON ADMISSION: -HCTZ 25 mg daily
-Coumadin 2 mg tab (1 or 1.5 tabs daily)
-Atenolol 25 mg daily
-Potassium 40 mEQ daily
-Baclofen 15 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: T: 101 P: 69 BP: 150/98 vent CMV 550/12/5/100%

FAMILY HISTORY: Father 79 with Alzheimer's. Mother 78 with HTN. Maternal great
grandfather with strokes.

SOCIAL HISTORY: He lives with his son. [**Name (NI) **] smoking, drinking, or illicit drugs
per family. 

### Response:
{'Cerebral thrombosis with cerebral infarction,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Unspecified essential hypertension,Long-term (current) use of anticoagulants,Personal history of surgery to heart and great vessels, presenting hazards to health'}
