CHIEF COMPLAINT: Left-sided weakness.

PRESENT ILLNESS: The pt. is a 78 year-old right-handed woman who presented with
transient left arm weakness and numbness.

MEDICAL HISTORY: -prior strokes: Pt reports that roughly 10 years ago and again
in
[**2138-1-28**] she had strokes.  The first event started with
a
dull headache and was followed by transient (minutes-long) left
hand clumsiness. The next episode occurred when she was playing
cards and she transiently lost vision in the right half of
space.
Apparently, she was admitted to [**Hospital6 33**] and was
told
she had a stroke.  She remembers having an MRI and also other
studies.  She also noted that she was told she had "a hole in my
heart", and has been on warfarin since.
-migraine headaches: Since about the age of 30 years.  Headaches
consist of bifrontal dull aching and are preceded by aura of
scintillations and sometimes by right field cut.  She has
roughly
one headache per month.
-hypertension
-hyperlipidemia

MEDICATION ON ADMISSION: -lopressor
-warfarin
-lipitor
-HCTZ
-KCl

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98F P: 68 R: 16 BP: 177/64 SaO2: 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no JVD or carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
bilaterally.
Skin: no rashes or lesions noted.

FAMILY HISTORY: Notable for many female family members with migraine headache.

SOCIAL HISTORY: The pt lives at home alone.  She is a former clerical worker.
She smoked roughly [**12-29**] pack of cigarettes per day for twenty
years, but quit about 40 years ago.  She has an occasional glass
of wine with dinner. No history of IVDU.
Cerebral artery occlusion, unspecified with cerebral infarction,Atrial fibrillation,Iron deficiency anemia secondary to blood loss (chronic),Urinary tract infection, site not specified,Compression of brain
Crbl art ocl NOS w infrc,Atrial fibrillation,Chr blood loss anemia,Urin tract infection NOS,Compression of brain
Admission Date:  [**2139-6-7**]              Discharge Date:   [**2139-6-25**]

Date of Birth:  [**2061-4-30**]             Sex:   F

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
Left-sided weakness.

Major Surgical or Invasive Procedure:
Right hemicraniectomy.

History of Present Illness:
The pt. is a 78 year-old right-handed woman who presented with
transient left arm weakness and numbness.

The history is per the pt and her granddaughter who was present
for the events.  The pt has been in her usual state of health.
She went to the Red Sox game with her granddaughter this
afternoon.  At approximately 4:15pm, the pt felt as if her left
leg was going to "give out from under (her)".  She and her
granddaughter were concerned that it was due to all of the
walking they had done during the day. They were able to walk a
short distance and find a bench to sit down.  When they sat
down, her granddaughter gave the pt some water and she proceeded
to rub it on her wrists, which seemed odd to her granddaughter.
She told her granddaughter she thought she was having a stroke,
but wasn't sure, so they decided to go into the game.  They were
[**Hospital1 67677**] and the pt was walking up a ramp into the
stadium.  At that point, she noticed that she was having
difficulty holding on to the railing with her left hand, but did
not bring it to anyone's attention.

They got to their seats in the stadium and the pt noted that her
left hand felt "numb" and it was clumsy.  Her granddaughter
noted that she handed her a hot dog to eat and the pt dropped it
with her left hand.  The granddaughter also noted that her hand
appeared to be weak insofar as she didn't seem to be able to
extend the wrist.  She noted that the pt was able to squeeze her
hand, however.  At this point (which was roughly an hour after
the first symptom, which was when her left leg gave out), the
granddaughter became concerned and alerted EMS at [**Hospital1 778**].  The
pt was transferred to [**Hospital1 18**] as a Code Stroke.

The granddaughter noted that the pt did not appear to have any
facial asymmetry and that her speech was clear and articulate.
The pt had no difficulties producing or comprehending speech.
The only other symptom that the pt reported was a dull headache
which is located over the right frontal region and began about
30 minutes after the leg started to feel weak. The pt denied
loss of vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty.

Neurology was paged at 6:08 and was at bedside by 6:09. NIHSS
was completed by 6:16 and was 0.  CT scan was not ordered by the
ED and was ordered by this physician after completion of the
history and physical examination.  The pt stated that all of her
symptoms had completely resolved about 20 minutes prior to
presentation at [**Hospital1 18**].

On review of systems, the pt denied recent fever or chills.  No
night sweats or recent weight loss or gain. Denied cough,
shortness of breath.  Denied chest pain or tightness,
palpitations.  Denied nausea, vomiting, diarrhea, constipation
or abdominal pain.  No recent change in bowel or bladder habits.
 No dysuria.  Denied arthralgias or myalgias.

Past Medical History:
-prior strokes: Pt reports that roughly 10 years ago and again
in
[**2138-1-28**] she had strokes.  The first event started with
a
dull headache and was followed by transient (minutes-long) left
hand clumsiness. The next episode occurred when she was playing
cards and she transiently lost vision in the right half of
space.
Apparently, she was admitted to [**Hospital6 33**] and was
told
she had a stroke.  She remembers having an MRI and also other
studies.  She also noted that she was told she had "a hole in my
heart", and has been on warfarin since.
-migraine headaches: Since about the age of 30 years.  Headaches
consist of bifrontal dull aching and are preceded by aura of
scintillations and sometimes by right field cut.  She has
roughly
one headache per month.
-hypertension
-hyperlipidemia


Social History:
The pt lives at home alone.  She is a former clerical worker.
She smoked roughly [**12-29**] pack of cigarettes per day for twenty
years, but quit about 40 years ago.  She has an occasional glass
of wine with dinner. No history of IVDU.



Family History:
Notable for many female family members with migraine headache.


Physical Exam:
Vitals: T: 98F P: 68 R: 16 BP: 177/64 SaO2: 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no JVD or carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
bilaterally.
Skin: no rashes or lesions noted.

Neurologic:
-mental status: Alert, oriented x 3.  Attentive.  Language is
fluent with intact repetition and comprehension.  Normal
prosody. There were no paraphasic errors.  Pt. was able to name
both high and low frequency objects.  Able to read without
difficulty.  Speech was not dysarthric. Able to follow both
midline and appendicular commands. Pt. was able to register 3
objects and recalled [**1-30**] at 5 minutes.  The pt. had reasonable
knowledge of current events.  There was no apraxia or neglect.

-cranial nerves: Olfaction not tested.  PERRL 3.5 to 2mm and
brisk.  VFF to confrontation.  There is no ptosis bilaterally.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages. EOMI without nystagmus.  Normal saccades. Facial
sensation intact to pinprick. No facial droop, facial
musculature symmetric. Hearing intact to finger-rub bilaterally.
 Palate elevates symmetrically.  5/5 strength in trapezii and
SCM bilaterally. Tongue protrudes in midline.

-motor: Normal bulk throughout. Paratonic throughout. No
adventitious movements noted. No asterixis noted. No myoclonus
noted.
No pronator drift bilaterally.

  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L  5    5    5  5    5  4+ 5  5   5   5- 5    5     5
R  5    5    5  5    5  5  5  5   5   5  5    5     5

-sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense throughout. There is reduced JPS in the great
toes to small but not large amplitude movements. No extinction
to DSS.

-coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  3   3   3    3   1
R  3   3   3    3   1

Plantar response was flexor on the right, extensor on the left.

-gait: deferred.

Pertinent Results:
[**2139-6-7**] 06:36PM BLOOD WBC-6.2 RBC-4.05* Hgb-12.9 Hct-36.1
MCV-89 MCH-31.9 MCHC-35.8* RDW-12.6 Plt Ct-278
[**2139-6-7**] 06:36PM BLOOD PT-15.0* PTT-21.9* INR(PT)-1.3*
[**2139-6-7**] 06:36PM BLOOD Glucose-97 UreaN-20 Creat-0.8 Na-140
K-3.7 Cl-101 HCO3-27 AnGap-16
[**2139-6-7**] 06:36PM BLOOD CK(CPK)-125
[**2139-6-8**] 06:30AM BLOOD ALT-25 AST-32 LD(LDH)-251* CK(CPK)-95
AlkPhos-96 TotBili-1.3
[**2139-6-20**] 08:29AM BLOOD CK(CPK)-45
[**2139-6-7**] 06:36PM BLOOD CK-MB-6 cTropnT-<0.01
[**2139-6-8**] 06:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2139-6-20**] 08:29AM BLOOD cTropnT-<0.01
[**2139-6-8**] 06:30AM BLOOD Albumin-4.2 Calcium-9.1 Phos-3.5 Mg-1.9
Cholest-166
[**2139-6-8**] 06:30AM BLOOD Triglyc-120 HDL-50 CHOL/HD-3.3 LDLcalc-92
[**2139-6-8**] 06:30AM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE

MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST ([**2139-6-7**]):
MR BRAIN: High T2 signal in the left parietooccipital cortex
corresponds to hypodensity on CT scan indicating previous
infarctions or sequelae of previous contusion. There is a very
small 3 mm high signal focus within the left posterior frontal
lobe near the convexity that may represent a very small area of
acute ischemia, but no areas of territorial infarction are
identified. Low signal and diffusion-weighted imaging that
corresponds to area of the previous left parietooccipital
infarction. Hypodensities within the periventricular white
matter are the sequelae of chronic small vessel infarction.
Dilated perivascular spaces are also present. Abnormal high
signal within the right internal carotid on a FLAIR imaging
signifies no flow within the right internal carotid that is more
fully described on MRA.
MRA CIRCLE OF [**Location (un) **]: There is no 3D time-of-flight signal
within the right internal carotid artery throughout its
visualized course in the mid neck. Reconstitution of the right
MCA occurs at the circle of [**Location (un) 431**], presumably through
collateralization. The left internal carotid artery is patent
throughout its visualized course without evidence for aneurism
or marked stenosis. Both vertebral arteries are patent within
left dominant circulation with no marked obstruction of flow
within the basilar artery. All major branches of the circle of
[**Location (un) 431**] are patent.
IMPRESSION:
1) Small 3 mm high diffusion signal in left posterior frontal
lobe may indicate small focus of acute ischemia, but no
territorial ischemia is identified.
2) Occlusion of right internal carotid artery with
reconstitution of the right MCA presumed via the
collateralization.
3) Chronic left parietooccipital infarction.

[**2139-6-8**]:
MR HEAD W/O CONTRAST
FINDINGS: Multifocal restricted diffusion along the right
frontoparietal convexity indicates acute ischemia, not present
only thirteen hours earlier. In addition, a new very small 3 mm
high signal focus within the right occipital lobe may also
represent a very small focus of ischemia. The non-uniform,
multifocal distribution suggests embolic etiology. Previously
identified tiny focus in the left posterior frontal lobe still
present, but not as prominent.
IMPRESSION: Acute right frontoparietal and occipital ischemia,
likely embolic, within the right MCA territory.

[**2139-6-8**]:
CT HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage.
There is no mass effect or shift of normally midline structures.
The ventricles, cisterns, and sulci are mildly prominent,
secondary to involutional change. A hyperdensity within the left
parietoccipital lobe secondary to chronic infarction is
unchanged. The osseous structures and paranasal sinuses are
unchanged.

[**2139-6-8**]:
CT ANGIOGRAM OF THE CIRCLE OF [**Location (un) **]: The visualized portion of
the right internal carotid artery demonstrates total occlusion
to the level of its terminus. Flow is present within the right
MCA, presumed secondary to the anterior communicating
cross-filling. A thin filling defect is seen originating from
the distal internal carotid stem thrombus (or stump embolus)
extending into the proximal M1 segment of the right MCA. A
difference in the contour and location of the distal stem
thrombus when compared to MRA strongly suggests partial distal
migration with impaction of thrombus (or embolus). The left
internal carotid and its major branches are patent. The
vertebral, basilar and posterior circulation is patent without
evidence for stenosis or aneurysm.
CT ANGIOGRAM OF THE NECK: Distal to the right carotid
bifurcation, contrast opacification within the right internal
carotid dissipates to total occlusion at the level of the dens.
The left internal carotid is patent throughout its course
without evidence for stenosis. Both vertebral arteries are
patent without evidence for stenosis or occlusion. The apices of
the lungs are clear. No pathologic adenopathy is present within
the soft tissues of the neck. Visualized paranasal sinuses and
the mastoid air cells are clear.
IMPRESSION:
1. Complete occlusion of the distal cervical right internal
carotid artery, with flow into the right MCA via cross-filling
from patent anterior communicating artery.
2. However, the contour and location of thrombus at its distal
margin, compared to its appearance on very recent MRA, suggests
possible migration of and impaction of thrombus into the
proximal M1 segment of the right MCA, likely accounting for the
recent DWI findings.

TTE:
The left atrium is dilated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers (cannot definitively exclude). Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
Mild (1+) aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
moderate pulmonary artery systolic  hypertension. There is no
pericardial effusion.
No cardiac source of embolus identified (cannot definitively
exclude).


Brief Hospital Course:
1. Stroke: The pt was admitted to the Neurology-Stroke service.
Initial neurologic examination was notable for mild weakness of
the finger extensors and hamstrings on the left.  Initial MRI
did not demonstrate areas of restricted diffusion, but MRA did
reveal absence of signal from right carotid artery. On the
morning of the second hospital day, the pt was found to have a
left facial droop and was weak in the left arm in an upper motor
neuron pattern.  Stat repeat DWI sequence of MRI revealed areas
of restricted diffusion in the territory of the right MCA.  CTA
was then performed which demonstrated right carotid artery
occlusion.  The pt was started on a heparin gtt.  Her blood
pressure was in the 110-120's range and was difficult to
increase despite multiple boluses of intravenous fluid.
Therefore, she was transferred to the ICU overnight for
pressors.  By the next morning, her blood pressure had increased
without pressors into the 150-160 range and she was transferred
to the floor.  On the floor, she did well until hospital day
four, when she became progressively more somnolent.  A repeat CT
of the head demonstrated enlargement of the right hemisphere
infarct.  She rapidly deteriorated and after discussion with and
consent from her son, she was taken urgently to the OR for
right-sided hemicraniectomy for worsening edema and herniation.
Heparin was discontinued given the size of her infarct. Post-op
head CT did show an area of bleed in the left parietal lobe. She
was kept on mannitol for awhile post-op, but this was
successfully weaned off.  She had a difficult time waking up
after surgery, but eventually did so over the next several days.
She was successfully extubated. Serial CT scans of the head
demonstrated stability and no changes to the small amount of
hemorrhage in the left hemisphere. After 10 days in the ICU, she
was transferred to the floor.  Her neurologic examination
remained stable and was notable for eyelid apraxia, left-sided
neglect, autotopagnosia on the left, and left hemiparesis.  Her
son was happy that she underwent the surgical procedure and she
was interactive with her family at the time of her discharge.

2. Atrial fibrillation: The pt developed an episode of atrial
fibrillation with rapid ventricular rate unresponsive to
intravenous metoprolol or diltiazem on hospital day 14. She was
transferred to the CCU where intravenous amiodarone was started
with effect.  She was in the CCU for less than 24 hours and was
transferred back to the floor in normal sinus rhythm. She sould
be continued on metoprolol and amiodarone.

3. Hypertension: The pt was mildly hypertensive throughout the
hospital stay.  She was treated with successfully with
metoprolol.

4. Blood loss anemia: Towards the end of the hospital stay, the
pt began to develop a slowly dropping hematocrit.  Stool was
guaiac negative, but the nurses noted blood oozing from the pt's
vagina.  Gynecology was called and a pelvic ultrasound was
performed which demonstrated only small fibroids.  The bleeding
had ceased for 48 hours prior to discharge and the pt's
hematocrit steadily increased.  The pt should follow-up with a
gynecologist after discharge for further work-up.

5. UTI: The pt developed a UTI toward the end of the hospital
stay.  She was started on a seven day course of cipro.

6. GI: The pt failed repeated speech and swallow evaluations.
Therefore a PEG tube was placed.

Medications on Admission:
-lopressor
-warfarin
-lipitor
-HCTZ
-KCl


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain or fever.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
8. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 **]

Discharge Diagnosis:
-right MCA territory stroke
-atrial fibrillation
-hypertension


Discharge Condition:
Stable. Neurologic examination notable for eyelid apraxia,
left-sided neglect, autotopagnosia on the left, left
hemiparesis.

Discharge Instructions:
Please take all medications as prescribed. Please attend all
follow-up appointments.  If you experience worsening weakness,
visual or speech disturbances or other concerning symptoms,
please call your primary care doctor or return to the emergency
department for evaluation.

Followup Instructions:
Please follow-up with your primary care doctor 7-10 days after
discharge.

Neurology: Provider: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 33346**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2139-7-14**] 5:30

Neurosurgery: Please call [**Telephone/Fax (1) 2731**] to arrange for suture
removal in [**10-10**] days and for a follow up appointment to plan
replacement of bone flap.
{'Cerebral artery occlusion, unspecified with cerebral infarction,Atrial fibrillation,Iron deficiency anemia secondary to blood loss (chronic),Urinary tract infection, site not specified,Compression of brain'}


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-sided weakness.

PRESENT ILLNESS: The pt. is a 78 year-old right-handed woman who presented with
transient left arm weakness and numbness.

MEDICAL HISTORY: -prior strokes: Pt reports that roughly 10 years ago and again
in
[**2138-1-28**] she had strokes.  The first event started with
a
dull headache and was followed by transient (minutes-long) left
hand clumsiness. The next episode occurred when she was playing
cards and she transiently lost vision in the right half of
space.
Apparently, she was admitted to [**Hospital6 33**] and was
told
she had a stroke.  She remembers having an MRI and also other
studies.  She also noted that she was told she had "a hole in my
heart", and has been on warfarin since.
-migraine headaches: Since about the age of 30 years.  Headaches
consist of bifrontal dull aching and are preceded by aura of
scintillations and sometimes by right field cut.  She has
roughly
one headache per month.
-hypertension
-hyperlipidemia

MEDICATION ON ADMISSION: -lopressor
-warfarin
-lipitor
-HCTZ
-KCl

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98F P: 68 R: 16 BP: 177/64 SaO2: 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no JVD or carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
bilaterally.
Skin: no rashes or lesions noted.

FAMILY HISTORY: Notable for many female family members with migraine headache.

SOCIAL HISTORY: The pt lives at home alone.  She is a former clerical worker.
She smoked roughly [**12-29**] pack of cigarettes per day for twenty
years, but quit about 40 years ago.  She has an occasional glass
of wine with dinner. No history of IVDU. 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Atrial fibrillation,Iron deficiency anemia secondary to blood loss (chronic),Urinary tract infection, site not specified,Compression of brain'}
