CHIEF COMPLAINT: Left upper extremity numbness and weakness.

PRESENT ILLNESS: This is a 56-year-old male with
no significant past medical history who presented to
[**Hospital3 3834**] [**Hospital3 **] with acute onset of numbness and
weakness on the left upper extremity.  He initially noted
paresthesias in the left lateral shoulder while working on
his computer on the evening of admission.  Within 5-10
minutes of onset, his entire left upper extremity became numb
and paralyzed.  He immediately went to [**Hospital3 3834**],
where his left upper extremity was noted to be cold, pale,
and pulseless from the axilla distally.  He had no sensation
from the forearm to the fingers.  He was sent to [**Hospital1 346**] for insufficiency and Vascular
Surgery consult.

MEDICAL HISTORY: 1. Gout.
2. Left Bell's palsy 10 years resolved after one year.
3. Hernia repair as a child.
4. Sciatica.
5. Questionable hypertension.
6. No history of coronary disease or coagulopathies.

MEDICATION ON ADMISSION: 

ALLERGIES: None.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He has smoked for the past 40 years anywhere
from half to [**4-1**] of a pack per day.  He has episodically
tried to quit smoking.  He socially uses alcohol.  He has a
history of experiment drug use as a teenager which includes
marijuana, cocaine, and LSD, but no current experimental drug
use at this time.  He denies any IV drug use.  He works as a
computer engineer living at home with his three children.  He
recently separated from his wife and moved into the area.  He
is not sexually active.
Arterial embolism and thrombosis of upper extremity,Other pulmonary embolism and infarction,Dissection of aorta, abdominal,Pneumonia, organism unspecified,Atrial fibrillation,Ostium secundum type atrial septal defect,Disturbances of sulphur-bearing amino-acid metabolism
Upper extremity embolism,Pulm embol/infarct NEC,Dsct of abdominal aorta,Pneumonia, organism NOS,Atrial fibrillation,Secundum atrial sept def,Sulph amino-acid met dis
Admission Date:  [**2200-2-4**]       Discharge Date:  [**2200-2-14**]

Date of Birth:   [**2143-12-24**]       Sex:  M

Service:  [**Hospital1 212**]

CHIEF COMPLAINT:  Left upper extremity numbness and weakness.

HISTORY OF PRESENT ILLNESS:  This is a 56-year-old male with
no significant past medical history who presented to
[**Hospital3 3834**] [**Hospital3 **] with acute onset of numbness and
weakness on the left upper extremity.  He initially noted
paresthesias in the left lateral shoulder while working on
his computer on the evening of admission.  Within 5-10
minutes of onset, his entire left upper extremity became numb
and paralyzed.  He immediately went to [**Hospital3 3834**],
where his left upper extremity was noted to be cold, pale,
and pulseless from the axilla distally.  He had no sensation
from the forearm to the fingers.  He was sent to [**Hospital1 346**] for insufficiency and Vascular
Surgery consult.

On arrival to the Emergency Department, he subjectively noted
improvement in his symptoms, but persistent absent radial
pulse in the left upper extremity and no pulse in the
dorsalis pedis, posterior tibialis in the right lower
extremity.  His blood pressure was 183/141, and therefore he
was taken for a CTA to rule out aortic dissection.  He was
found to have very large bilateral pulmonary embolism,
splenic infarct, chronic infrarenal aortic and right common
iliac dissections.

He denied any trauma to the arm or shoulder.  He had a 10 day
history of dyspnea on exertion complaining of shortness of
breath with two flights of stairs.  He denies any chest pain,
nausea, vomiting, or diaphoresis.  There is no other weakness
or numbness elsewhere on his body.  He denies any bright red
blood per rectum, melena, or bleeding gums.  There is no
recent history of travel, plane flights or long car rides.
Again, he denies any fever, chills, night sweats, or weight
loss.

PAST MEDICAL HISTORY:
1. Gout.
2. Left Bell's palsy 10 years resolved after one year.
3. Hernia repair as a child.
4. Sciatica.
5. Questionable hypertension.
6. No history of coronary disease or coagulopathies.

SOCIAL HISTORY:  He has smoked for the past 40 years anywhere
from half to [**4-1**] of a pack per day.  He has episodically
tried to quit smoking.  He socially uses alcohol.  He has a
history of experiment drug use as a teenager which includes
marijuana, cocaine, and LSD, but no current experimental drug
use at this time.  He denies any IV drug use.  He works as a
computer engineer living at home with his three children.  He
recently separated from his wife and moved into the area.  He
is not sexually active.

FAMILY MEDICAL HISTORY:  Mother died of brain cancer at age
[**Age over 90 **].  Father with arrhythmia and died with a complication of a
hernia repair, no bleeding disorders.

ALLERGIES:  None.

OUTPATIENT MEDICATION: Indocin prn for gout, last use was a
month ago.

PHYSICAL EXAM UPON ADMISSION:  Temperature is 96.6, blood
pressure 175/128, pulse 92, respiratory rate 16, and 96% on
room air.  Generally, this is a pleasant male in no acute
distress who is resting comfortably in bed.  HEENT:  Mucous
membranes are moist and oropharynx is clear.  Jugular venous
pressure is not elevated.  The neck is supple and without
carotid bruits.  His sclerae is anicteric.  Chest was clear
to auscultation bilaterally.  Cardiovascular:  Regular, rate,
and rhythm.  Normal S1, S2, no murmurs or gallops noted.
Abdomen is soft, nontender, and nondistended with normoactive
bowel sounds.  No hepatosplenomegaly felt.  Extremities:
Pale left hand with capillary refill greater than three
seconds.  There is no radial pulse in the left upper
extremity.  There is presence of an ulnar pulse in the left
upper extremity.  There is also a presence of a dorsalis
pedis and posterior tibial pulses bilaterally.
Neurologically, the patient is alert and oriented times
three.  Cranial nerves II through XII intact except for the
left lower facial weakness.  The left is 4+/5 and left upper
extremity flexion and extension is 4+/5.  Right upper
extremity is [**6-2**].  Decreased sensation in the left hand and
forearm which have been improving.

White count 10.8, hematocrit 45.8, platelets 154, chloride
142, potassium 3.9, 105 for chloride, bicarb of 22, BUN of
11, creatinine 0.9, glucose 110.  Differential on the white
count was 82% neutrophils, 12% lymphocytes, 4% monocytes,
1.5% eosinophils.  PT is 13.6, PTT is 28.9, INR 1.2.

Chest x-ray showed no infiltrate or effusion.  CT scan showed
bilateral large pulmonary embolism, splenic infarct, and
chronic infrarenal, aortic, or right common iliac dissection.

ELECTROCARDIOGRAM:  Normal sinus rhythm at a rate of 84.
There is a right heart strain pattern in V2 through V4 with
T-wave inversion in III.  Right bundle branch is noted.

HOSPITAL COURSE:
1. Pulmonary system.  Pulmonary embolism.  Given that the
patient had bilateral pulmonary embolism discovered on CTA,
patient was put on Heparin for a PTT of 60-80.  Doppler of
the lower extremities showed a right popliteal deep venous
thrombosis, but no deep venous thrombosis on the left.
Patient was then sent for MRI of the pelvis which showed no
evidence of clot in the femoral vein or IVC.  Therefore, the
patient did not require any IVC filters at this time.

It is unusual why the patient would have pulmonary embolism
since there is no recent history of travel or long car rides.
His extensive smoking history may predispose him to neoplasm
hypercoagulable state.  Subsequent studies that his protein-C
was normal at 66, protein-S at 139, anticardiolipin IgG as
well as IgM were normal at 1.2 and 4.3 respectively.
However, he was found to have high levels of homocystine at
70.5, where the high range of normal is 12.4.  He was
therefore then started on vitamin B6, vitamin B12, and
folate.

His prothrombin gene mutation and factor-[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12843**] were still
pending.  He was then started on Coumadin 5 mg to reach an
INR between [**3-3**].  He eventually reached 2.2 on the day of
discharge with a regimen of Coumadin 5 and 7.5 mg alternating
days.

2. Vascular system.  Left subclavian artery clot status post
embolectomy.  Given the patient's symptoms of neurological
and vascular compromise in his left upper extremity, Vascular
Surgery was consulted.  They eventually took him for
embolectomy of a very large subclavian artery clot.  After
the embolectomy, neurological and vascular functions were
returned to the patient's left upper extremity.

3. Cardiovascular.  Patent foramen ovale status post
clam-shell placement.  Given that the patient had all of
these clots, thrombolysis was a consideration, therefore
Cardiology consult was called to do an echocardiogram.  The
echocardiogram actually revealed a patent foramen ovale with
a right-to-left shunt in light of a normal pulmonary pressure
with PR gradient of 17 mm Hg.  Also noted on the
echocardiogram was preserved left ventricular ejection
fraction, mild right ventricular dilation, mildly depressed
right ventricular function, and apical-septal aneurysm.

Given the right-to-left shunting and embolization without
elevated pulmonary artery pressure along with his known deep
venous thrombosis, it was felt that a PF closure with a
clam-shell would be best.  The clam-shell was placed without
complications.

However, on hospital day five, the patient did spike a fever
of 101.3.  He was given 48 hours of Vancomycin along with
other antibiotics which he was taking for his pneumonia until
blood cultures were clear for 48 hours.  The blood cultures
did remain negative for 48 hours, so the Vancomycin was
discontinued.  Given the clam-shell placement, the patient
should be on 75 mg of Plavix for the next three months.

4. Hematology.  Homocystinemia.  Given that the patient had
many clots in a situation, where he did not have many risk
factors that led to the tests that were mentioned above in
the course of finding the etiology of the pulmonary embolism.
It was discovered that he had elevated homocystine levels of
70.5.

At that time, Hematology recommended starting vitamin B6,
vitamin B12, and folate.  He is to remain on these cofactors
for breaking down the homocystine for life.  He is to be on
Coumadin with INR of 2.3 for at least six months.  At that
time, it should be reassessed whether the patient should be
on life-long Coumadin.  There is no literature mentioning
whether life-long anticoagulation would be called for in the
state of homocystinemia.

5. Infectious Disease.  Pneumonia.  When the patient spiked a
fever on hospital day five, a chest x-ray was obtained along
with blood and urine cultures.  The chest x-ray revealed a
left basilar infiltrate and left pleural effusion.  Patient
was empirically started on azithromycin for five days and
ceftriaxone for 14 days.  However, the course of ceftriaxone
was decreased down to seven days given that the fever may
also be due to the gout that the patient was having.

6. Rheumatology.  Gout.  In the middle of the hospital
course, the patient complained of right ankle and right first
metatarsal erythema, swelling, and pain.  He says that these
symptoms were similar to his gout flares, so he was given
Indomethacin.  The indomethacin helped resolve the symptoms
on the right foot, but then he started noticing pain,
swelling, and erythema with his left first metatarsal.  He
was continued on indomethacin until a day before discharge,
where his gout flare had resolved.

DISCHARGE DIAGNOSES:
1. Pulmonary embolism.
2. Patent foramen ovale status post clam-shell placement.
3. Homocystinemia.
4. Left subclavian artery clot status post embolectomy.
5. Pneumonia.
6. Gout.

DISCHARGE MEDICATIONS:
1. Protonix 40 mg po q day.
2. Indomethacin 25-75 mg po tid prn gout.
3. Folate 2 mg po q day.
4. Pyridoxine 50 mg po q day.
5. .................... 400 mcg po q day.
6. Thiamine 100 mg po q day.
7. Plavix 75 mg po q day.
8. Aspirin 81 mg po q day.
9. Lisinopril 5 mg po q day.
10. Atenolol 100 mg po q day.
11. Warfarin 5 and 7.5 mg po alternating.

DISCHARGE CONDITION:  Stable.

DISCHARGE STATUS:  Home.

FOLLOW-UP APPOINTMENT:  The patient is to followup with Dr.
[**First Name (STitle) **] [**Name (STitle) **] on [**2200-2-26**] for blood pressure and INR
check.




                            [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D.  [**MD Number(1) 3475**]

Dictated By:[**Last Name (NamePattern1) 4270**]
MEDQUIST36

D:  [**2200-2-21**]  03:41
T:  [**2200-2-21**]  05:18
JOB#:  [**Job Number 46529**]
{'Arterial embolism and thrombosis of upper extremity,Other pulmonary embolism and infarction,Dissection of aorta, abdominal,Pneumonia, organism unspecified,Atrial fibrillation,Ostium secundum type atrial septal defect,Disturbances of sulphur-bearing amino-acid metabolism'}


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: Left upper extremity numbness and weakness.

PRESENT ILLNESS: This is a 56-year-old male with
no significant past medical history who presented to
[**Hospital3 3834**] [**Hospital3 **] with acute onset of numbness and
weakness on the left upper extremity.  He initially noted
paresthesias in the left lateral shoulder while working on
his computer on the evening of admission.  Within 5-10
minutes of onset, his entire left upper extremity became numb
and paralyzed.  He immediately went to [**Hospital3 3834**],
where his left upper extremity was noted to be cold, pale,
and pulseless from the axilla distally.  He had no sensation
from the forearm to the fingers.  He was sent to [**Hospital1 346**] for insufficiency and Vascular
Surgery consult.

MEDICAL HISTORY: 1. Gout.
2. Left Bell's palsy 10 years resolved after one year.
3. Hernia repair as a child.
4. Sciatica.
5. Questionable hypertension.
6. No history of coronary disease or coagulopathies.

MEDICATION ON ADMISSION: 

ALLERGIES: None.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He has smoked for the past 40 years anywhere
from half to [**4-1**] of a pack per day.  He has episodically
tried to quit smoking.  He socially uses alcohol.  He has a
history of experiment drug use as a teenager which includes
marijuana, cocaine, and LSD, but no current experimental drug
use at this time.  He denies any IV drug use.  He works as a
computer engineer living at home with his three children.  He
recently separated from his wife and moved into the area.  He
is not sexually active. 

### Response:
{'Arterial embolism and thrombosis of upper extremity,Other pulmonary embolism and infarction,Dissection of aorta, abdominal,Pneumonia, organism unspecified,Atrial fibrillation,Ostium secundum type atrial septal defect,Disturbances of sulphur-bearing amino-acid metabolism'}
