CHIEF COMPLAINT: Acute change in mental status and reported right sided facial
droop

PRESENT ILLNESS: On [**12-5**], she was at her nursing home, [**Hospital3 537**], when she
was
noted to be drowsy by nursing staff.  She was taking a shower
around 9:20-9:40AM when her aide noticed that the patient became
progressively weak.  She "slumped over" and was helped back to
bed.  She was reportedly falling to the right and had a right
facial droop.  She was minimally verbal and generally weak.  EMS
was called and found the patient with right facial droop,
slurred
speech, and weak right hand.

MEDICAL HISTORY: 1. HTN
2. History of colon polyp
3. Chronic renal insufficiency
4. Hypothyroidism

MEDICATION ON ADMISSION: 1. Atenolol 50 mg po qd
2. Synthroid 75 mcg po qd
3. Vitamin B12 SC qMonth

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: 98.6      BP:178/72      HR: 55
Vent AC 550x12, not overbreathing, with Fi02 50%, Sp02 100%.
Gen:  WD/WN, intubated, comfortable on vent, NAD.
HEENT:   Dried blood around nares, in oral cavity. Anicteric. MM
dry. +ETT.
Neck:  Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: Coarse breath sounds anterolaterally. No R/R/W.
Cardiac:  RRR. S1/S2. No M/R/G.
Abd:  Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.

FAMILY HISTORY: 

SOCIAL HISTORY: Lives in a NH.  She is married-her husband is in the Rehab
facility at [**Hospital3 537**] after being treated for PNA.  She has
one son who lives in [**Name (NI) 4565**].  At baseline, is alert and
mobile, but confused
Acute, but ill-defined, cerebrovascular disease,Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Anemia, unspecified,Unspecified disorder of kidney and ureter,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Gout, unspecified
Cva,Subendo infarct, initial,Pneumonia, organism NOS,Urin tract infection NOS,Anemia NOS,Renal & ureteral dis NOS,Hypothyroidism NOS,Hypertension NOS,Gout NOS
Admission Date:  [**2146-12-5**]              Discharge Date:   [**2146-12-9**]


Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Acute change in mental status and reported right sided facial
droop


Major Surgical or Invasive Procedure:
none


History of Present Illness:
On [**12-5**], she was at her nursing home, [**Hospital3 537**], when she
was
noted to be drowsy by nursing staff.  She was taking a shower
around 9:20-9:40AM when her aide noticed that the patient became
progressively weak.  She "slumped over" and was helped back to
bed.  She was reportedly falling to the right and had a right
facial droop.  She was minimally verbal and generally weak.  EMS
was called and found the patient with right facial droop,
slurred
speech, and weak right hand.

She arrived in the [**Hospital1 18**] ER on at 10:20AM.  Her vitals at that
time were: BP142/114, HR 64 RR12 O2Sat 99%. She was emergently
intubated, paralyzed and sedated for ariway protection.  On
intial evaluation by stroke fellow, she was unresponsive, not
moving extremities and had NIH stroke scale of 23. Her initial
head CT showed possible early infart signs in the left insular
cortex, but no hemorrhage.  She was given labetalol 15mg IVP x2
for BP control.  IV t-PA was administered at 11:30AM with 4.5mg
IV bolus and 40.5mg over one hour.  She also rec'd one unit of
PRBCs in the ER for a Hct of 27.8.


Past Medical History:
1. HTN
2. History of colon polyp
3. Chronic renal insufficiency
4. Hypothyroidism


Social History:
Lives in a NH.  She is married-her husband is in the Rehab
facility at [**Hospital3 537**] after being treated for PNA.  She has
one son who lives in [**Name (NI) 4565**].  At baseline, is alert and
mobile, but confused


Physical Exam:
T: 98.6      BP:178/72      HR: 55
Vent AC 550x12, not overbreathing, with Fi02 50%, Sp02 100%.
Gen:  WD/WN, intubated, comfortable on vent, NAD.
HEENT:   Dried blood around nares, in oral cavity. Anicteric. MM
dry. +ETT.
Neck:  Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: Coarse breath sounds anterolaterally. No R/R/W.
Cardiac:  RRR. S1/S2. No M/R/G.
Abd:  Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.

Neuro:
Mental status: Grimaces to noxious stimuli. Not following
commands.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1 mm
bilaterally. No blink to threat.
III, IV, VI: Oculocephalic reflex intact.
V, VII: Bilateral corneal reflexes intact.
VIII: Unable to assess.
IX, X: Gag reflex intact.
[**Doctor First Name 81**]: Unable to assess.
XII: Unable to assess with presence of ETT.

Motor: Postures RUE to noxious stimuli. Withdraws RLE, left
side to noxious stimuli.

Sensation: Postures RUE to noxious stimuli. Withdraws RLE, left
side to noxious stimuli.

Reflexes: Present and symmetric. Grasp reflex absent. Toes
downgoing bilaterally.

Coordination: Unable to assess.

Gait: Unable to assess

Pertinent Results:
[**2146-12-9**] 05:05AM BLOOD WBC-6.7 RBC-4.87 Hgb-12.8 Hct-39.7 MCV-82
MCH-26.2* MCHC-32.2 RDW-17.5* Plt Ct-126*
[**2146-12-5**] 10:50AM BLOOD WBC-6.2 RBC-3.68* Hgb-8.5*# Hct-27.8*#
MCV-76*# MCH-23.0*# MCHC-30.4*# RDW-14.7 Plt Ct-193
[**2146-12-9**] 05:05AM BLOOD Plt Ct-126*
[**2146-12-5**] 10:50AM BLOOD PT-13.2 PTT-23.6 INR(PT)-1.1
[**2146-12-5**] 10:50AM BLOOD Plt Ct-193
[**2146-12-9**] 05:05AM BLOOD Glucose-83 UreaN-35* Creat-1.5* Na-142
K-3.9 Cl-109* HCO3-23 AnGap-14
[**2146-12-5**] 10:50AM BLOOD Glucose-124* UreaN-39* Creat-1.4* Na-149*
K-4.1 Cl-112* HCO3-26 AnGap-15
[**2146-12-5**] 10:50AM BLOOD CK-MB-NotDone cTropnT-0.54*
[**2146-12-5**] 10:43PM BLOOD CK-MB-NotDone cTropnT-0.46*
[**2146-12-6**] 03:40AM BLOOD CK-MB-NotDone cTropnT-0.51*
[**2146-12-9**] 05:05AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.9
[**2146-12-6**] 03:40AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.6 Cholest-125
[**2146-12-8**] 04:45AM BLOOD calTIBC-283 Ferritn-74 TRF-218
[**2146-12-6**] 03:40AM BLOOD %HbA1c-6.2*
[**2146-12-6**] 03:40AM BLOOD Triglyc-77 HDL-42 CHOL/HD-3.0 LDLcalc-68

Brief Hospital Course:
1.  NEURO-
After IV t-PA was given, the patient was noted to be moving her
extremities left greater than right.  An MRI was done (although
no diffusion imaging could be obtained due to problem with MRI
machine) which did not show evidence of new stroke, but did
reveal periventricular T2 hyperintensities c/w chronic small
vessel disease.  An old, right cerebellar infarct was also seen.
Multiple areas of susceptibility were seen bilaterally in the
basal ganglia and thalami.  A repeat CT scan was done on [**12-6**]
which was negative for acute infarct or bleed.  Anti-platelets
were held due to fluctuations in Hct.  An EEG showed slow
background and occasional generalized theta and delta slowing
c/w
drowsiness or mild encephalopathy.  She had carotid US which
showed mild, <40% bilateral proximal ICA stenosis.  During her
course, her mental status improved.  Neuro exam has shown
decreased attention, dysarthria and mild right facial droop. She
was started on aspirin, lipitor and ACEI for secondary stroke
prevention.

2.  PULM:
Initially intubated and sedated, but extubated [**12-6**] without
complications.  CXR has shown mild CHF and LLL atelectasis vs
infiltrate. She was treated with Levofloxacin for PNA.  Rpt CXR
showed bilateral pleural effusions and mild CHF.  Her
respiratory status improved after lasix. She was started on
atrovent and albuterol nebs with resolution of wheezing and SOB.

3. CV:
Her inital EKG showed non-specific anterolateral ST changes.
Cardiac enzymes were positive with peak troponin of 0.54.  Echo
showed EF 35%, mildly dilated LA, mild left ventricular hypo
(inferior wall), mild-moderate AR, MR [**First Name (Titles) **] [**Last Name (Titles) **] HTN.  Cardiology
consult saw her and felt that the elevated troponin and
decreased
EF were likley indicative of CAD.  They recommended medical
management with beta blocker and anti-platelet (ASA).  If
patient
becomes symptomatic, they suggest evaluation with persantine
stress test.  Her lipid profile showed HDL 42, LDL 68, and TG
77.
She was started on a statin and ACEI.  She should have an
outpatient persantine stress test if she develops cardiac
symptoms.

4. GI:
Initially fed with NGT.  Now able to tolerate oral feeding per
swallow eval today.  Continue GI ppx.  Stool guiac has been
negative.

5. RENAL/LYTES:
Elevated BUN/Cre-do not know baseline Cre.  Now also with
hypernatremia-started on free water hydration today. Started on
ACEI-need to follow up lytes and BUN/Cre as an outpatient.

6. ID:
Pt had postitive UA on admission and was started on
Levofloxacin.  Also has LLL infiltrate on CXR.  Will cont abx
for 7 day course. She has been afebrile and her

7. Heme:
On admission, Hct was 27.8.  She rec'd 2 U PRBCs in the unit
with
poor Hct response.  Yesterday, rec'd an additional 2 U PRBCs,
Hct
rose to 40.  She was started on ASA 325mg as her Hct was stable
post transfusion.  She should have follow up iron studies and
B12 level as an outpatient.

8. Endocrine:
Her HbA1C was mildly elevated.  She should adhere to a diabetic
diet.  Synthroid was continued at pre-admission dose

9.  Rehab:
PT/OT evaluated the patient and she will be discharged for
continued PT.


Medications on Admission:
1. Atenolol 50 mg po qd
2. Synthroid 75 mcg po qd
3. Vitamin B12 SC qMonth

Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
as needed for insomnia.
10. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
13. Atrovent 0.02 % Solution Sig: One (1)  Inhalation every six
(6) hours.
14. Albuterol Sulfate 5 mg/mL Nebu Soln Sig: One (1)  Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 537**]- [**Location (un) 538**]

Discharge Diagnosis:
1. Acute stroke:  s/p IV t-PA
2. Non ST elevation MI
3. Chronic renal insufficiency
4. Anemia-s/p 4U PRBC transfusion
5. Pnuemonia


Discharge Condition:
Improved-mild right facial weakness and right UE weakness.

Discharge Instructions:
Please continue to take your medications as prescribed.  If you
develop chest pain, SOB, new weakness, numbness, dizziness,
difficulty with speech or swallowing, please return to the ER
for evaluation.

Followup Instructions:
1.  Dr. [**Last Name (STitle) 2903**]:  Friday [**12-16**] at 11:15AM.  Please have Dr.
[**Last Name (STitle) 2903**] check your BUN/Cre and potassium as you have just been
started on Lisinopril.  You should also have a PA and lateral
CXR to follow up on LLL pneumonia and bilateral pleural
effusions. Please have your liver function tests checked in one
month as you have been started on lipitor.

2.  Dr. [**Last Name (STitle) **]:  [**2146-2-6**] at 1:00pm [**Hospital 878**] Clinic [**Hospital Ward Name 23**] Bldg
[**Location (un) **].  [**Telephone/Fax (1) 657**]


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
{'Acute, but ill-defined, cerebrovascular disease,Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Anemia, unspecified,Unspecified disorder of kidney and ureter,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Gout, unspecified'}


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: Acute change in mental status and reported right sided facial
droop

PRESENT ILLNESS: On [**12-5**], she was at her nursing home, [**Hospital3 537**], when she
was
noted to be drowsy by nursing staff.  She was taking a shower
around 9:20-9:40AM when her aide noticed that the patient became
progressively weak.  She "slumped over" and was helped back to
bed.  She was reportedly falling to the right and had a right
facial droop.  She was minimally verbal and generally weak.  EMS
was called and found the patient with right facial droop,
slurred
speech, and weak right hand.

MEDICAL HISTORY: 1. HTN
2. History of colon polyp
3. Chronic renal insufficiency
4. Hypothyroidism

MEDICATION ON ADMISSION: 1. Atenolol 50 mg po qd
2. Synthroid 75 mcg po qd
3. Vitamin B12 SC qMonth

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: 98.6      BP:178/72      HR: 55
Vent AC 550x12, not overbreathing, with Fi02 50%, Sp02 100%.
Gen:  WD/WN, intubated, comfortable on vent, NAD.
HEENT:   Dried blood around nares, in oral cavity. Anicteric. MM
dry. +ETT.
Neck:  Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: Coarse breath sounds anterolaterally. No R/R/W.
Cardiac:  RRR. S1/S2. No M/R/G.
Abd:  Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.

FAMILY HISTORY: 

SOCIAL HISTORY: Lives in a NH.  She is married-her husband is in the Rehab
facility at [**Hospital3 537**] after being treated for PNA.  She has
one son who lives in [**Name (NI) 4565**].  At baseline, is alert and
mobile, but confused 

### Response:
{'Acute, but ill-defined, cerebrovascular disease,Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Anemia, unspecified,Unspecified disorder of kidney and ureter,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Gout, unspecified'}
