CHIEF COMPLAINT: code stroke for L sided numbness and weakness

PRESENT ILLNESS: Mr. [**Known lastname **] is a 47 year old right-handed man with history of HTN,
HL, DM2, smoking presenting from [**Hospital6 3105**] after
acute onset of left foot and arm numbness and left hemiparesis.

MEDICAL HISTORY: Hypertension
hyperlipidemia
Diabetes -noninsulin dependent
Back pain with lumbar DJD, considering surgery for this
gout

MEDICATION ON ADMISSION: metformin 500 mg [**Hospital1 **]
simvastatin 20 mg daily
lisinopril 20 mg daily
meloxicam prn
fish oil
Vit D
oxycodone prn for back pain

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At admission:
VS T:afebrile  HR: 60s SBP: 140-160s/ RR: 14 SaO2: 100% RA

FAMILY HISTORY: No h/o stroke

SOCIAL HISTORY: +Tobacco (1 pack per day). Denies ETOH, or
illicit drug abuse. unemployed currently looking for work.
Dissection of carotid artery,Cerebral artery occlusion, unspecified with cerebral infarction,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Unspecified sinusitis (chronic),Lumbosacral spondylosis without myelopathy,Tobacco use disorder,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia
Dissect carotid artery,Crbl art ocl NOS w infrc,Late ef-hemplga side NOS,Chronic sinusitis NOS,Lumbosacral spondylosis,Tobacco use disorder,DMII wo cmp nt st uncntr,Hypertension NOS,Hyperlipidemia NEC/NOS
Admission Date:  [**2174-3-17**]              Discharge Date:   [**2174-3-21**]

Date of Birth:  [**2127-1-30**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
code stroke for L sided numbness and weakness


Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname **] is a 47 year old right-handed man with history of HTN,
HL, DM2, smoking presenting from [**Hospital6 3105**] after
acute onset of left foot and arm numbness and left hemiparesis.

According to patient and daughter (over the phone) he developed
acute onset of left foot and arm numbness at 9 AM. The patient
also remembers this beginning in both foot and arm at the same
time without clear spread. He rested for the morning, and his
family who was home with him did not notice anything else wrong
until 12:30. At this time, he had difficulty walking and walked
into the wall on the left side. He fell upon trying to stand up.
When his daughter returned home she noticed L sided weakness and
patient was brought to [**Hospital3 **]. At OSH a NCCT was
reportedly normal (no disc sent) but due to the extended time
window no tPA given. Patient was then transferred to [**Hospital1 18**] for
potential intervention. Despite repeat questioning the exact
time
of onset remained unclear.

Per the patient and his daughter, he was feeling well and
asymptomatic yesterday. He has never had an episode like this
before, and has never had a stroke or TIA.


Past Medical History:
Hypertension
hyperlipidemia
Diabetes -noninsulin dependent
Back pain with lumbar DJD, considering surgery for this
gout


Social History:
+Tobacco (1 pack per day). Denies ETOH, or
illicit drug abuse. unemployed currently looking for work.


Family History:
No h/o stroke


Physical Exam:
At admission:
VS T:afebrile  HR: 60s SBP: 140-160s/ RR: 14 SaO2: 100% RA

General: Awake, moderate distress, lying in bed.
Head: NC/AT, no scleral icterus, no oropharyngeal lesions, MMM
Neck: Supple, no nuchal rigidity, no bruits
Cardiovascular: RRR, no M/R/G
Pulmonary: CTAB
Abdomen: Soft, NT, ND, +BS
Extremities: Warm, no edema
Skin: No rashes or lesions

Neurologic Examination:

- Mental Status - Awake, alert, oriented x to date ([**2174-2-27**])
hospital in [**Location (un) 86**]. Can relate history but not great at
describing details. Attention intact.
Follows midline and appendicular commands. Language
fluent with intact repetition and verbal comprehension.
Normal prosody. No paraphasic errors. High and low frequency
naming intact. Mild to moderate dysarthria. No apraxia. Left
neglect to visual and tactile stimuli ([**Location (un) 1131**] only right half
of
sentences on the page, ignores left side of cookie theft
picture).

- Cranial Nerves
[II] PERRL 3->2 brisk. VF full to confrontation.
[III, IV, VI] EOMI, no nystagmus. No diplopia. Normal saccades.
[V] V1-V3 without deficits to light touch bilaterally
[VII] Left lower facial weakness with delayed and reduced
excurision on volitional expressions. Eye closure full strength.
[VIII] Hearing intact to finger rub bilaterally.
[IX, X] Palate elevation symmetric.
[[**Doctor First Name 81**]] SCM/Trapezius strength 5/5 bilaterally.
[XII] Tongue midline.

- Motor - Normal bulk, decreased tone in L side.
LUE- deltoid 3, tricep 4+, bicep 5, wrist ext 4, finger ext 4,
finger flex 5
LLE- IP 3, ham 3, quad 5, TA 5, [**Last Name (un) 938**] 5, gastroc 5
R side full strength in all above mentioned muscles

- Sensory - Decreased to light touch and pinprick on left but
can
feel pain and withdraws briskly. Extinction to DSS.

- Reflexes
 [Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2      2      2      2        1
R 2      2      2      2        1
Plantar response flexor bilaterally.

- Coordination - intact finger-to-nose testing.

- Gait - Deferred.
****

Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
.
Neuro Exam at Time of Discharge:
Mental Status:
* Degree of Alertness: Alert.
* Orientation: Oriented to person, place (hospital), day, month,
year
* Memory: Pt able to repeat 3 words immediately and recall [**1-29**]
unassisted at 30-seconds and 5-minutes.
* Language: Language is non-fluent and sparse with a latency.
Repetition is intact. Comprehension appears intact; pt able to
correctly follow midline and appendicular commands.
Pt able to name knuckles and thumb without difficulty. Able to
read "dining menu." Able to write "the welther..." in attempting
to write a sentence about the weather.
* Neglect: Exteniguishes left with double tactile simultaneous
stimulation; also attends to right visual field more than left;
able to identofy left arm as his own however.
* Praxis: No evidence of apraxia.
.
Cranial Nerves:
* I: Olfaction not evaluated.
* II: PERRL 4 to 2mm and brisk. Does not well attend to left
visual field.
* III, IV, VI: Crosses midline but does not completelty bury
sclera of either eye with extreme left lateral gaze. EOM
otherwise intact.
* V: Facial sensation decreased to pinprick, increased to cold
temp in left V1, V2, V3 distributions.
* VII: Left upper motor neuron facial.
* VIII: Hearing intact to voice.
* IX, X: Palate elevates symmetrically.
* [**Doctor First Name 81**]: 5/5 strength in right trapezii.
* XII: Tongue protrudes in midline.
.
Motor:
* Adventitious Movements: left upper extremity occasionally
twitches once at a time.
.
Strength:
* Left Upper Extremity: 0 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Right Upper Extremity: 5 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
.
* Left Lower Extremity: 0 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
* Right Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
.
Reflexes:
* Left: difficult to elicit at Biceps, Triceps, Patellar
* Right: 2 thoughout Biceps, Triceps, Patellar,
* Babinski: flexor R, extensor L
.
Sensation:
* Pinprick: decreased in left hemibody
* Temperature: increased to cold sensation in L hemibody
* Vibration: intact bilaterally at level of great toe
* Extinction: extinction on left to double simultaneous
stimulation


Pertinent Results:
LABS ON ADMISSION:
[**2174-3-17**] 04:20PM BLOOD WBC-8.5 RBC-5.55 Hgb-15.1 Hct-45.3 MCV-82
MCH-27.2 MCHC-33.3 RDW-14.2 Plt Ct-335
[**2174-3-17**] 04:20PM BLOOD PT-11.0 PTT-29.2 INR(PT)-1.0
[**2174-3-20**] 09:00PM BLOOD PT-12.0 PTT-55.6* INR(PT)-1.1
[**2174-3-21**] 05:30AM BLOOD PT-12.7* PTT-68.6* INR(PT)-1.2*
[**2174-3-18**] 12:34AM BLOOD Glucose-116* UreaN-13 Creat-0.8 Na-142
K-3.7 Cl-109* HCO3-23 AnGap-14
[**2174-3-18**] 12:34AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.6 Cholest-147
[**2174-3-20**] 06:30AM BLOOD %HbA1c-8.0* eAG-183*
[**2174-3-18**] 12:34AM BLOOD Triglyc-218* HDL-25 CHOL/HD-5.9
LDLcalc-78
[**2174-3-17**] 05:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2174-3-19**] 01:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
ECG:
Sinus rhythm. Within normal limits. No previous tracing
available for
comparison.
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
62 130 92 [**Telephone/Fax (2) 110490**]5
.
STROKE RISK FACTOR ASSESSMENT:
[**2174-3-20**] 06:30AM BLOOD %HbA1c-8.0* eAG-183*
[**2174-3-18**] 12:34AM BLOOD Triglyc-218* HDL-25 CHOL/HD-5.9
LDLcalc-78
.
Admission CTA Head and neck/CTP Brain:
Final Report
INDICATION: 47-year-old male with left upper extremity weakness
and left
lower extremity weakness along with facial droop, here to
evaluate for CVA.
.
COMPARISON: No prior studies available.
.
TECHNIQUE: CTA of the head and neck with perfusion was performed
with and
without intravenous contrast according to department protocol.
.
CT HEAD WITHOUT CONTRAST: A 15 x 12 mm roughly demarcated area
of
hypoattenuation is identified in the right parietal lobe
involving the right
centrum semiovale, which extends to the cortex. There is no
associated
hemorrhagic transformation or mass effect. Otherwise, the
[**Doctor Last Name 352**]-white matter
differentiation is well preserved, and there is no evidence of
additional
ischemic infarct. The cerebral sulci, ventricles, and
extra-axial CSF
containing spaces are normal in size and configuration. There is
no shift of
normally midline structures. The left maxillary sinus shows
mucosal thickening
with an air-fluid level. The remainder of the visualized
paranasal sinuses
and mastoid air cells are well aerated.
.
PERFUSION IMAGING: There is increased mean transit time
throughout the right
cerebral hemisphere with corresponding decreased blood flow but
no significant
blood volume abnormality, which is concerning for a large area
of penumbra.
.
CTA OF THE HEAD AND NECK: The right internal carotid artery
shows an acute
dissection extending from the upper pole of the right common
carotid artery
bifurcation to the level of the intracranial internal carotid
with an
associated filling defect in the right carotid canal. There is
loss of normal
enhancement in the right MCA distribution. The left intracranial
internal
carotid, vertebrobasilar and anterior, left middle, and
posterior cerebral
arteries are patent with normal contrast enhancement and
branching pattern.
There is no evidence of stenosis, occlusion, aneurysm or
arteriovenous
malformation.
.
The origin of the common carotid and vertebral arteries are
patent without
significant stenosis. The common, left internal and external
carotid arteries
are normal in appearance without evidence of hemodynamically
significant
stenosis or dissection. The cervical portions of the vertebral
arteries
demonstrate normal contrast opacification.
.
IMPRESSION:
1. Right internal carotid arterial dissection extending from the
origin of
the [**Country **] to the intracranial internal carotid.
2. Perfusion mismatch with increased mean transit time and
decreased blood
flow but normal blood volume throughout the right cerebral
hemisphere
concerning for a large area of penumbra.
3. Hypoattenuating lesion in the right parietal lobe and centrum
semiovale
may represent core infarct.
.
Findings were communicated by Dr. [**Last Name (STitle) **] to Dr. [**Last Name (STitle) 4281**] of the
emergency
medicine by phone at 5:25 p.m. on [**2174-3-17**] after the discovery of
findings at
5:10 p.m. The plan is for urgent neurointerventional radiology
consult.
.
Repeat CTA head and neck/CTP brain:
Final Report
INDICATION: 47-year-old male with right internal carotid artery
dissection
and concern for evolving CVA now with complete left hemiplegia,
here to
evaluate for interval changes.
.
COMPARISON: CT cerebral perfusion study last performed on
[**2174-3-17**] at 16:23
p.m.
.
TECHNIQUE: CTA of the head and neck with perfusion was performed
with and
without intravenous contrast according to department protocol.
.
CT HEAD WITHOUT CONTRAST: There is a persistent area of
hypoattenuation in
the right parietal lobe and centrum semiovale extending to the
cortex.
Several more conspicuous areas of hypoattenuation are now
scattered throughout
the right cerebral hemisphere, corresponding to multiple
arterial
distributions since [**2174-3-17**] including the right frontal lobe,
globus pallidus,
parietal lobe and periventricular white matter concerning for
thromboembolic
ischemic changes. There is no associated hemorrhagic
transformation or mass
effect. There is no shift of normally midline structures. The
[**Doctor Last Name 352**]-white
matter interface of the left cerebral hemisphere is preserved
without evidence
of acute major vascular territorial infarct. The cerebral sulci,
ventricles
and extra-axial CSF-containing spaces are normal in size and
configuration.
The left maxillary sinus again shows mucosal thickening with an
air-fluid
level. The remainder of the paranasal sinuses and mastoid air
cells are well
aerated.
.
PERFUSION IMAGING: There is a vague area of persistent slightly
increased
mean transit time in the right cerebral hemisphere when compared
to the left
hemisphere. The blood volume and blood flow appears symmetric
bilaterally.
.
CTA OF THE HEAD AND NECK: An intimal flap is again noted in the
right
internal carotid artery extending from the level of the right
common carotid
artery bifurcation to the terminus of the intracranial internal
carotid,
consistent with acute internal carotid dissection. There is an
increased
filling defect in the arterial wall of the right intracranial
internal carotid
artery within the carotid canal which is nearly complete with
only vague
enhancement. The terminus of the right intracranial internal
carotid artery
is completely occluded. The right middle cerebral artery
reconstitutes by
collateral arterial flow from the anterior communicating artery.
The right M1
segment is not visualized. There is normal enhancement in the
distribution of
the right MCA. The left intracranial internal carotid,
vertebrobasilar and
anterior, left middle and posterior cerebral arteries are also
patent with
normal contrast enhancement and branching pattern. No posterior
communicating
artery is identified.
.
The origin of the common carotid and vertebral arteries are
patent without
significant stenosis. The bilateral common, left internal and
bilateral
external carotid arteries are normal in appearance without
evidence of
hemodynamically significant stenosis or dissection. The cervical
portions of
the vertebral arteries demonstrate normal contrast
opacification.
.
The thyroid is unremarkable. Atheroma of the aortic arch is
incidentally
noted.
.
IMPRESSION:
1. Persistent dissection of the right internal carotid artery
extending from
the origin of the [**Country **] to the intracranial [**Country **].
2. Near complete filling defect within the arterial wall of the
intracranial
right internal carotid artery with complete occlusion at the
terminus of the
intracranial [**Country **].
3. Several patchy areas of hypoattenuation scattered throughout
the right
cerebral hemisphere corresponding to multiple arterial
distributions are
concerning for thromboembolic ischemic changes. No hemorrhagic
transformation
is seen.
4. Minimally improved cerebral perfusion with persistent
slightly increased
mean transit time in the right cerebral hemisphere but symmetric
blood volume
and flow as compared to the left hemisphere.
.
TTE:
Conclusions
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy with top normal cavity size. Regional
left ventricular systolic function is normal. Global left
ventricular systolic function is low normal (LVEF=55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta, arch, descending thoracic and abdominal aorta are mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with top
normal cavity size and normal regional/low normal global
systolic function. Dilated thoracic and abdominal aorta. Mild
mitral regurgitation with normal valve morphology. No patent
foramen ovale or atrial septal defect identified. No cardiac
source of embolism identified.
.
[**2174-3-18**] CXR:
There are low lung volumes. Cardiac size is top normal, is
accentuated by the low lung volumes. Bibasilar opacities larger
on the right side are consistent with atelectasis. There is no
pneumothorax or large pleural effusion.
.
LABS AT TIME OF DISCHARGE:
[**2174-3-21**] 05:30AM BLOOD WBC-8.2 RBC-5.65 Hgb-15.0 Hct-47.2 MCV-84
MCH-26.5* MCHC-31.7 RDW-14.7 Plt Ct-344
[**2174-3-21**] 05:30AM BLOOD Glucose-110* UreaN-12 Creat-0.8 Na-138
K-3.9 Cl-104 HCO3-21* AnGap-17
[**2174-3-21**] 05:30AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.9

Brief Hospital Course:
Mr. [**Known lastname **] is a 47 year old right-handed male with HTN, HL, DM2,
tobacco use, who presented with L hemisensory loss and
hemiparesis, with L neglect and extinction, found to have R
hemispheric stroke in the setting of R terminal ICA
occlusion/dissection.
.
#Right Internal Carotid Artery Dissection: The patient's history
is unfortunately not completely clear in terms of progression of
symptoms over time, and exact time of onset. Neurological exam
initially showed dysarthria and left neglect as well as left
hemibody sensory loss with visual and tactile extinction. The
patient's neuro motor exam worsened overnight while he was in
the ICU on the night of admission. Originally the exam was
significant for L face, arm and leg weakness in upper motor
neuron pattern but was still antigravity in proximal muscles and
full strength in the hand and ankle. Currently he is unable to
move L hand or ankle. Intial CTA/CTP (see full report above)
shows occlusion/dissection of terminal R ICA with reconstitution
at take-off of MCA from contralaterals through anterior circle
of [**Location (un) 431**]. The intial NCHCT shows small area of R parietal
hypodensity, and CT perfusion showed very large entire R MCA
territory penumbra. Repeat CTA/CTP (see full report above)
showed extension of the ICA dissection to involve most of the
intracranial R ICA. Discussion was held at his admission with
the neurointerventional team and it was felt that clot retrieval
attempt may be complicated by distal embolization of clot,
causing further infarction and worsening of his current
symptoms, and therefore risk outweighed the benefit.
.
The etiology of the dissection is not completely clear at
present.
.
The patient's blood pressure was maintained above SBP 140 with
IVF to avoid hypoperfusoin, at times the patient had SBP>180 so
he was given hydralazine 10mg IV PRN and responded well to this.
He was eventually started on lisinopril 10mg (which is half dose
of his home 20mg). The patient was placed on a heparin gtt with
goal PTT 50-70, and was eventually started on coumadin with goal
INR [**12-31**]. He is currently undergoing bridging therapy for his
anticoagulation.  The heparin should be continued until the INR
has been at goal for 24 hours.
.
His stroke risk factors were assessed, and HgbA1c was 8, TG 218,
HDL 25, LDL 78. Patient was placed on an ISS with good blood
sugar control while in the hospital. The metformin was also
restarted prior to discharge. The patient had a TTE (see full
report above) performed which did not demonstarte an ASD/PFO or
thrombus.  The patient was monitored on continous telemtry
throughout his stay without any clearly contributable cardiac
arrhythmias.
.
He was evaluated by physical and occupational therapy who has
recommended continued therapy, and therefore the patient will be
discharged to a rehabiliation facility.
.
#HTN: Patient is on home lisinopril 20mg, he was restarted on
half dose 10mg lisniopril with good effect. He will likely need
uptitration of this in the future.
.
#DM2: The patient was placed on an RISS while inpatient with
good blood sugar control. Of note his Hba1c was 8.0, and the
patient's home regimen is metformin 500 mg [**Hospital1 **]. We recommend
better glucose control, and patient will need f/u with PCP once
he is discharged from LTAC. We have continued him on a RISS and
restarted metformin prior to discharge.

#Nutrition: Initially patient was seen by speech and swallow
evaluation and was cleared for ground dysphagia diet and thin
liquids. On repeat evaluation the patient was cleared for
regular solids and thin liquids (cardiac/diabetic diet).
.
#Diarrhea: Patient had one large BM with some diarrhea on [**3-21**],
a CDiff PCR was sent and was negative. He was afebrile, without
an leukocytosis.

TRANSITIONAL ISSUES:
1) Restart full dose lisinopril 20mg QD when able
2) Patient will need uptitration of his metformin as he was on
500mg [**Hospital1 **]) and his HBa1c was at 8 (this will need to be
discussed with PCP)
3) Continued bridging with heparin gtt and Coumadin. INR was
subtherapeutic at 1.2 on last check, with dosing of 5 of
coumadin.
4) F/u with PCP after discharged from rehab re: Hypertension and
Diabetes Mellitus
5) F/U with neurologist Dr. [**First Name (STitle) **].

Medications on Admission:
metformin 500 mg [**Hospital1 **]
simvastatin 20 mg daily
lisinopril 20 mg daily
meloxicam prn
fish oil
Vit D
oxycodone prn for back pain


Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: see sliding
scale per scale Injection ASDIR (AS DIRECTED): please see flow
sheet.
2. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Fish Oil  Oral
6. Vitamin D3  Oral
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. docusate sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
9. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: 1400 (1400) units/hr Intravenous ASDIR (AS
DIRECTED): titrate to goal PTT 50-70. Will stop after 24 hours
of goal INR [**12-31**] when reached on Coumadin.
10. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.



Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
Primary Diagnosis: Right Internal Carotid Artery Dissection with
multiple infarcts in the Right Cerebral Hemisphere resulting in
Left Hemiparesis, Left-sided neglect
Secondary Diagnosis: Hypertension, Diabetes Mellitus Type II


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
.
Neuro Exam at Time of Discharge:
Mental Status:
* Degree of Alertness: Alert.
* Orientation: Oriented to person, place (hospital), day, month,
year
* Memory: Pt able to repeat 3 words immediately and recall [**1-29**]
unassisted at 30-seconds and 5-minutes.
* Language: Language is non-fluent and sparse with a latency.
Repetition is intact. Comprehension appears intact; pt able to
correctly follow midline and appendicular commands.
Pt able to name knuckles and thumb without difficulty. Able to
read "dining menu." Able to write "the welther..." in attempting
to write a sentence about the weather.
* Neglect: Exteniguishes left with double tactile simultaneous
stimulation; also attends to right visual field more than left;
able to identofy left arm as his own however.
* Praxis: No evidence of apraxia.
.
Cranial Nerves:
* I: Olfaction not evaluated.
* II: PERRL 4 to 2mm and brisk. Does not well attend to left
visual field.
* III, IV, VI: Crosses midline but does not completelty bury
sclera of either eye with extreme left lateral gaze. EOM
otherwise intact.
* V: Facial sensation decreased to pinprick, increased to cold
temp in left V1, V2, V3 distributions.
* VII: Left upper motor neuron facial.
* VIII: Hearing intact to voice.
* IX, X: Palate elevates symmetrically.
* [**Doctor First Name 81**]: 5/5 strength in right trapezii.
* XII: Tongue protrudes in midline.
.
Motor:
* Adventitious Movements: left upper extremity occasionally
twitches once at a time.
.
Strength:
* Left Upper Extremity: 0 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Right Upper Extremity: 5 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
.
* Left Lower Extremity: 0 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
* Right Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
.
Reflexes:
* Left: difficult to elicit at Biceps, Triceps, Patellar
* Right: 2 thoughout Biceps, Triceps, Patellar,
* Babinski: flexor R, extensor L
.
Sensation:
* Pinprick: decreased in left hemibody
* Temperature: increased to cold sensation in L hemibody
* Vibration: intact bilaterally at level of great toe
* Extinction: extinction on left to double simultaneous
stimulation


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

It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
due to weakness and sensory changes on your left side. You had
some imaging performed of your head which showed a stroke on the
right side of the brain due to damage to one of the arteries
suppling the brain. This artery had a dissection (tear in the
vessel wall), and is known as right internal carotid artery.

We evaluated several risk factors for stroke, and we found that
your blood sugar has not been optimally controlled. Please
discuss with your primary care provider the benefits of
increasing your metformin regimen when you are discharged from
your rehabiliation facility.

We made the following changes to your medications:
START Heparin IV (this will be dosed at your Long Term Care
Facility and discontinued after you are thereapeutic - with an
INR of [**12-31**] - on your coumadin for at least 24 hours)
START Coumadin (Warfarin) take 5mg tablet by mouth once daily at
4:00pm
START Senna 8.6mg tablet take one tablet by mouth up to two
times daily as needed for constipation
START Docusate 100mg take one tablet by mouth twice a day to
soften stool
DECREASED Lisinopril 10mg take one tablet by mouth daily
STOPPED Meloxicam
STOPPED Oxycodone

It was a pleasure taking care of you. You have a follow up
appointment with Dr. [**First Name (STitle) **] (Neurology), please see below.

Followup Instructions:
Please call your Primary Care Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name9 (PRE) 1022**] at
[**Telephone/Fax (1) 81482**] when you are discharged from your rehabilitation
facility to make a follow-up appintment. Please follow up
regarding your diabetes medications and your blood pressure
medications.
.
Department: NEUROLOGY
When: TUESDAY [**2174-5-17**] at 11:30 AM
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**]
{'Dissection of carotid artery,Cerebral artery occlusion, unspecified with cerebral infarction,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Unspecified sinusitis (chronic),Lumbosacral spondylosis without myelopathy,Tobacco use disorder,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}


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: code stroke for L sided numbness and weakness

PRESENT ILLNESS: Mr. [**Known lastname **] is a 47 year old right-handed man with history of HTN,
HL, DM2, smoking presenting from [**Hospital6 3105**] after
acute onset of left foot and arm numbness and left hemiparesis.

MEDICAL HISTORY: Hypertension
hyperlipidemia
Diabetes -noninsulin dependent
Back pain with lumbar DJD, considering surgery for this
gout

MEDICATION ON ADMISSION: metformin 500 mg [**Hospital1 **]
simvastatin 20 mg daily
lisinopril 20 mg daily
meloxicam prn
fish oil
Vit D
oxycodone prn for back pain

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At admission:
VS T:afebrile  HR: 60s SBP: 140-160s/ RR: 14 SaO2: 100% RA

FAMILY HISTORY: No h/o stroke

SOCIAL HISTORY: +Tobacco (1 pack per day). Denies ETOH, or
illicit drug abuse. unemployed currently looking for work. 

### Response:
{'Dissection of carotid artery,Cerebral artery occlusion, unspecified with cerebral infarction,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Unspecified sinusitis (chronic),Lumbosacral spondylosis without myelopathy,Tobacco use disorder,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}
