CHIEF COMPLAINT: CODE STROKE: left arm weakness, left facial droop, inability to
speak

PRESENT ILLNESS: Mr [**Known lastname 111763**] is a 32 year old man with no significant PMH who
presented with left sided weakness and the inability to speak.
History is aided from his family friend [**Name (NI) 335**] at bedside and
over the phone while patient was being transported from [**Hospital1 34585**].
.
Patient was in a normal state of health at 11 am this morning
and was speaking with his friend. [**Name (NI) **] night and this morning he
also felt well, and was playing basketball with his friends.
.
At some point between 12-1pm today patient emerged from his room
and he was not able to speak yet he was still walking.  He wrote
on a piece of paper that he needed help and to go to the
hospital. He was then taken to [**Hospital6 **] where he
had an NIHSS of 13.  Initial vitals were 167/79, HR 115, Temp
97.7, 99% on RA. Decision was made to give IV t-PA. tPA was
given at 14:21 PM (6.8 mg IV push and 61 mg/hour). Patient was
then transferred to [**Hospital1 18**] for potential neuro-interventional
procedure.
.
On arrival to [**Hospital1 18**] ED patient was able to communicate only by
writing and was stating he had an [**9-9**] headache. Repeat NIHSS
was done and was given a 14.  A repeat NCHCT was significant for
extensive cerebral edema and decision was made to not persue an
intervention.
.
On general review of systems (obtained through his friends), the
pt had not complainted of reecent fever or chills.  No night
sweats or recent weight loss or gain. Denies cough, shortness of
breath.  Denies chest pain or tightness, palpitations.  Denies
nausea, vomiting, diarrhea, constipation or abdominal pain.  No
recent change in bowel or bladder habits.  No dysuria.  Denies
arthralgias or myalgias. Denies rash.

MEDICAL HISTORY: -none
-no history of sickle cell, cardiac disease, or any medical
problems this is his first time to a hospital ever.

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAM ON ADMISSION:
Vitals: T: 98  P:117  R: 25 BP:139/103  SaO2:97%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: sinus Abdomen: soft, NT/ND, no masses or organomegaly
noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: done by patient writing, he was alert, oriented
x 3. Attentive following midline and appendicular commands.
Language is fluent to writing but he remains mute with no
attempt to speak.  Pt. was able to name both high frequency
objects from stroke card by writing them out.  The pt. had good
knowledge of current events.  He appears to be neglecting the
left.   Calculation was intact (answers ("4+3 = 7" for seven
quarters in $1.75)
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.  left field cut vs heavy neglect
on the left, but extingushes to DSS.
III, IV, VI: EOMI without nystagmus.  Normal saccades.
V: Facial sensation intact to light touch.
VII: left facial droop
VIII: Hearing intact to voice
.
-Motor:
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L  3    0   0   0   0  0  0  5   5    5  5     5     5   5
R  5    5   5   5   5  5  5  5   5    5  5     5     5   5
.
-Sensory: he writes only "slight feeling on the left"

FAMILY HISTORY: Sister: 2 miscarriages
Father: possible stroke in his 20s with some paralysis--unclear
history

SOCIAL HISTORY: Patient is originally from [**Country **] but has lived in the US for
the past 6 years.  Was there several weeks back for a wedding.
Was living in [**Location (un) **] and was planing on moving back to
[**Country **]. He is currently staying with a family friend here in
[**Name (NI) 86**]. Recently graduated from a masters in architecture
program. Social etoh, no smoking, or illicit drug use.
Cerebral embolism with cerebral infarction,Cerebral edema,Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility,Aphonia,Monoplegia of upper limb affecting dominant side,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Facial weakness,Visual field defect, unspecified,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants,Family history of stroke (cerebrovascular)
Crbl emblsm w infrct,Cerebral edema,TPA adm status 24 hr pta,Aphonia,Monplga upr lmb dmnt sde,DMII wo cmp nt st uncntr,Facial weakness,Visual field defect NOS,Hyperlipidemia NEC/NOS,Long-term use anticoagul,Family hx-stroke
Admission Date:  [**2191-9-7**]              Discharge Date:   [**2191-9-23**]

Date of Birth:  [**2159-2-2**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
CODE STROKE: left arm weakness, left facial droop, inability to
speak

Major Surgical or Invasive Procedure:
Trans-esophageal echocardiogram


History of Present Illness:
Mr [**Known lastname 111763**] is a 32 year old man with no significant PMH who
presented with left sided weakness and the inability to speak.
History is aided from his family friend [**Name (NI) 335**] at bedside and
over the phone while patient was being transported from [**Hospital1 34585**].
.
Patient was in a normal state of health at 11 am this morning
and was speaking with his friend. [**Name (NI) **] night and this morning he
also felt well, and was playing basketball with his friends.
.
At some point between 12-1pm today patient emerged from his room
and he was not able to speak yet he was still walking.  He wrote
on a piece of paper that he needed help and to go to the
hospital. He was then taken to [**Hospital6 **] where he
had an NIHSS of 13.  Initial vitals were 167/79, HR 115, Temp
97.7, 99% on RA. Decision was made to give IV t-PA. tPA was
given at 14:21 PM (6.8 mg IV push and 61 mg/hour). Patient was
then transferred to [**Hospital1 18**] for potential neuro-interventional
procedure.
.
On arrival to [**Hospital1 18**] ED patient was able to communicate only by
writing and was stating he had an [**9-9**] headache. Repeat NIHSS
was done and was given a 14.  A repeat NCHCT was significant for
extensive cerebral edema and decision was made to not persue an
intervention.
.
On general review of systems (obtained through his friends), the
pt had not complainted of reecent fever or chills.  No night
sweats or recent weight loss or gain. Denies cough, shortness of
breath.  Denies chest pain or tightness, palpitations.  Denies
nausea, vomiting, diarrhea, constipation or abdominal pain.  No
recent change in bowel or bladder habits.  No dysuria.  Denies
arthralgias or myalgias. Denies rash.

Past Medical History:
-none
-no history of sickle cell, cardiac disease, or any medical
problems this is his first time to a hospital ever.


Social History:
Patient is originally from [**Country **] but has lived in the US for
the past 6 years.  Was there several weeks back for a wedding.
Was living in [**Location (un) **] and was planing on moving back to
[**Country **]. He is currently staying with a family friend here in
[**Name (NI) 86**]. Recently graduated from a masters in architecture
program. Social etoh, no smoking, or illicit drug use.


Family History:
Sister: 2 miscarriages
Father: possible stroke in his 20s with some paralysis--unclear
history

Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: T: 98  P:117  R: 25 BP:139/103  SaO2:97%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: sinus Abdomen: soft, NT/ND, no masses or organomegaly
noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: done by patient writing, he was alert, oriented
x 3. Attentive following midline and appendicular commands.
Language is fluent to writing but he remains mute with no
attempt to speak.  Pt. was able to name both high frequency
objects from stroke card by writing them out.  The pt. had good
knowledge of current events.  He appears to be neglecting the
left.   Calculation was intact (answers ("4+3 = 7" for seven
quarters in $1.75)
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.  left field cut vs heavy neglect
on the left, but extingushes to DSS.
III, IV, VI: EOMI without nystagmus.  Normal saccades.
V: Facial sensation intact to light touch.
VII: left facial droop
VIII: Hearing intact to voice
.
-Motor:
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L  3    0   0   0   0  0  0  5   5    5  5     5     5   5
R  5    5   5   5   5  5  5  5   5    5  5     5     5   5
.
-Sensory: he writes only "slight feeling on the left"

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2  2    2    2   1
R  2  2    2    2   1
Plantar response was mute
.
-Coordination: No intention tremor,on FNF on the right

===========================
PHYSICAL EXAM ON DISCHARGE:
Vitals: 98.2 110/75 62 18 100% RA
Neuro: Severe aphonia (difficulty producing speech) but
preserved comprehension and ability to communicate via written
language. +distal left arm weakness (3+/5 in left wrist and
finger extensors). Full strength in bilateral lower extremities
and right arm.

Pertinent Results:
LABS ON ADMISSION:
-WBC-6.4 RBC-5.43 Hgb-15.1 Hct-44.2 MCV-81* MCH-27.8 MCHC-34.2
RDW-13.5 Plt Ct-260
-PT-11.9 PTT-22.4* INR(PT)-1.1
-Glucose-170* UreaN-10 Creat-1.1 Na-139 K-3.9 Cl-100 HCO3-26
AnGap-17
-CK(CPK)-836*
-ALT-24 AST-23 LD(LDH)-198 AlkPhos-80 TotBili-0.4 Lipase-31
.
CARDIAC ENZYMES:
-[**2191-9-7**] 4PM: CK-MB-2 cTropnT-<0.01 CK(CPK)-836*
-[**2191-9-7**] 11:40PM: CK-MB-1 cTropnT-<0.01 CK(CPK)-706*
-[**2191-9-8**] 8:47AM: CK-MB-1 cTropnT-<0.01 CK(CPK)-574*
.
MODIFIABLE STROKE RISK FACTOR LABS:
-Cholest-218* Triglyc-68 HDL-78 CHOL/HD-2.8 LDLcalc-126
-%HbA1c-7.3* eAG-163*
.
HYPERCOAGULABILITY WORKUP LABS:
-Lupus-NEG
-ProtCFn-136
-ProtSFn-228* (high, normal is 50-150%)
-ACA IgG-1.6 ACA IgM-6.3
-AT-120
-ALPHA 2 ANTIPLASMIN-69% (low, normal is 80-150)
-PLASMINOGEN ACTIVITY-90% (normal)
-BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-<9% (normal)

-[**Doctor First Name **]-NEGATIVE
-HIV Ab-NEGATIVE
.
LABS ON DISCHARGE:
-WBC-3.7* RBC-4.79 Hgb-13.0* Hct-39.1* MCV-82 MCH-27.2 MCHC-33.2
RDW-13.8 Plt Ct-281
-PT-23.9* INR(PT)-2.3*
.
IMAGING:
.
NONCONTRAST HEAD CT ([**2191-9-7**]): There is a large region of
transcortical hypoattenuation in the right temporal lobe, with
some superior extension into the parietal lobe, consistent with
a right MCA distribution acute ischemic infarct, likely
predominantly involving its inferior division. No definite
"hyperdense" right MCA is appreciated. There is no intracranial
hemorrhage, mass effect, or shift of normally midline
structures. Apart from the site of infarction, the [**Doctor Last Name 352**]-white
matter differentiation is preserved. Ventricles are normal in
size and configuration. Mild sulcal effacement is seen in the
right temporal region. Suprasellar and basilar cisterns are
patent. Paranasal sinuses and mastoid air cells are well
aerated. Globes and orbits are preserved.
IMPRESSION:  Large acute right MCA distribution ischemic infarct
without
significant mass effect or intracranial hemorrhage.
.
NONCONTRAST MRI HEAD ([**2191-9-8**]):
1. Large acute-to-subacute right MCA stroke, with expected
parenchymal edema, but no midline shift.
2. No evidence of large amount of intracranial hemorrhage.
Small hypointense foci in the gradient echo images could
represent either flow voids or a small amount of hemorrhage.
.
TTE ([**2191-9-8**]): The left atrium and right atrium are normal in
cavity size. No atrial septal defect or patent foramen ovale is
seen by 2D, color Doppler or saline contrast with maneuvers.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). No masses or thrombi
are seen in the left ventricle. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion. IMPRESSION: No
ASD/PFO or cardiac source of embolism. Normal global and
regional biventricular systolic function.
.
TEE ([**2191-9-12**]): No cardiac source of embolism seen. Negative
bubble study. However, there was quite vigorous inflow from the
inferior vena cava which was baffled towards the septum by the
Eustachian valve. As a result the upper part of the right atrium
does not opacify well with bubbles, making less bubbles
available for potential shunting.
.
MRI brain w/o contrast ([**2191-9-12**]): Evolving right MCA territory
subacute infarct with hemorrhage.
.
BILATERAL LOWER EXTREMITY DOPPLERS ([**2191-9-13**]): No evidence of
deep vein thrombosis of either right or left lower extremity.
.


Brief Hospital Course:
Mr [**Known lastname 111763**] is a 32 year old man with no significant PMH who
presented with left sided weakness and the inability to speak.
.
# CRYPTOGENIC RIGHT MCA STROKE: Per HPI, patient received IV tPA
at OSH prior to transfer to [**Hospital1 18**]. On arrival to the ED, a
repeat NCHCT showed extensive cerebral edema so decision was
made not to pursue neuro-interventional procedure. Patient was
admitted to Neuro-ICU for close monitoring. On arrival to the
Neuro-ICU, strength had improved in the left lower extremity,
but patient remained plegic in left upper extremity and left
lower face and was neglecting the left side.  He also had a
severe headache not responsive to toradol, dilaudid, fentanyl or
Tylenol. Repeat head CT 24 hours post tPA was stable compared to
prior. CTA showed right MCA superior division cut-off, and MRI
confirmed large right MCA stroke. For first 2 days of
hospitalization he was quite lethargic and remained in ICU for
close neurologic monitoring given risk for herniation [**3-3**]
cerebral edema. His lethargy improved after this and he was
transferred to the regular neurology floor for further
monitoring.

Given presence of right MCA superior division cut-off on CTA
head, etiology of patient's stroke was felt most likely embolic.
Extensive workup for embolic stroke was pursued, none of which
was revealing. He had TTE which showed no PFO/ASD/atrial
thrombi. Follow-up TEE showed Eustachian valve (fetal remnant)
which caused artifact on study, but no clear PFO/ASD etc were
seen. Routine LENIs showed no DVT. Given family history of early
stroke (father) and sister with h/o 2 miscarriages,
hypercoagulable state was also considered so extensive lab panel
was sent including [**Doctor First Name **], lupus anticoagulant, Protein C/S
activity, anticardiolipin IgG/IgM, alpha 2 antiplasmin,
plasminogen antibody, and beta 2 migroglobulin IgA/IgG/IgM. All
of these studies were negative. HIV [**1-31**] antibody was also sent
(as HIV can cause increased propensity for thrombosis, presence
of anti-phospholipid antibodies, clotting factor abnormalities
and TTP-HUS). This too was negative. However, of note
ultra-sensitive HIV PCR was not sent. Ultimately,
.
Patient also had routine modifiable stroke risk factor labs sent
(A1C, full lipid panel) sent which revealed elevated A1C (7.3%)
and elevated LDL (126). He was started on atorvastatin 40mg
daily for secondary stroke prevention. Metformin 500mg PO BID
was initially started, then stopped as small vessel disease was
clearly not likely etiology of this stroke and diet/exercise
seemed more appropriate intervention.
.
For directed stroke treatment, patient was initially started on
ASA 325mg daily. However, as it was felt that etiology of this
stroke was likely embolic, the decision was made to empirically
start lifelong Coumadin for secondary stroke prophylaxis (day 1
= [**2191-9-13**]). Patient's INR remained stable between [**3-4**] on
Coumadin 2.5mg daily during hospitalization. He will follow up
with [**Hospital 191**] [**Hospital 197**] clinic for monitoring.
.
Clinically, patient's symptoms improved slowly during
hospitalization with the aid of extensive PT, OT and speech
therapy. His LLE strength quickly improved to full. His LUE
strength improved to full in the proximal extremity, although he
still has weakness in his distal LUE particularly in the wrist
and finger extensors. His difficulty speaking was of particular
interest to the neurology team, as aphemia (inability to
vocalize, with preserved comprehension and written language) is
almost always a left-sided brain lesion in right-handed
patients. Ultimately it was felt that he is probably genetically
co-dominant in terms of handedness.
.
For insurance reasons, patient was unable to be discharged to
rehab. With extensive help from PT, OT, speech therapy and case
management teams, plan was made for patient to be discharged to
friend's home in [**State 350**] with free care for outpatient
PT/OT/ST. He will follow up with Neurology (Dr. [**Last Name (STitle) **] in 2
months, at which point he will likely have repeat functional MRI
for prognostic purposes. He will also have new PCP appointment
within the next month: would advise rechecking HIV at this
point.
.
=====================
TRANSITIONS OF CARE:
- Contact info: mother [**Name (NI) **] ([**Telephone/Fax (1) 111764**]), [**Name2 (NI) **] (friend
he will be staying with upon discharge: [**Telephone/Fax (1) 111765**]). Patient's
cell phone # is [**Telephone/Fax (1) 111766**] but he is unable to speak.
- Should consider repeat HIV test in future
- Will follow up as outpatient with Dr. [**Last Name (STitle) **] in [**Hospital 878**]
clinic
====================

============================================================
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 126 ) - () No
5. Intensive statin therapy administered? (for LDL > 100) () Yes
- () No (if LDL >100, Reason Not Given: )
6. Smoking cessation counseling given? () Yes - () No (Reason
(x) non-smoker - () unable to participate)
7. Stroke education given? (x) Yes - () No
8. Assessment for rehabilitation? ()x Yes - () No
9. Discharged on statin therapy? () Yes - () No (if LDL >100,
Reason Not Given: )
10. Discharged on antithrombotic therapy? (x) Yes (Type: ()
Antiplatelet - () Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A

Medications on Admission:
None

Discharge Medications:
1. Outpatient Physical Therapy
2. Outpatient Occupational Therapy
3. Outpatient Speech/Swallowing Therapy
4. Warfarin 2.5 mg PO DAILY16
Start [**9-19**] in am
RX *warfarin [Coumadin] 1 mg 2.5 tablet(s) by mouth once a day
Disp #*100 Tablet Refills:*2
5. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2


Discharge Disposition:
Home

Discharge Diagnosis:
1. Right MCA stroke (likely embolic)
2. High cholesterol


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

Neuro exam: severe aphonia (difficulty producing speech) but
preserved comprehension and ability to communicate via written
language. +distal left arm weakness (3+/5 in left wrist and
finger extensors). Full strength in bilateral lower extremities
and right arm.


Discharge Instructions:
Dear Mr. [**Known lastname 111763**],

You were admitted to the hospital after developing sudden-onset
inability to speak and weakness in your left arm. You first went
to an outside hospital where you were found to have a stroke and
received IV tPA, a clot-busting medication. You were then
transferred to [**Hospital3 **] where you were initially monitored
closely in the ICU for brain swelling. We did an MRI which
showed that you had a large stroke on the right side of your
brain, likely caused by a blood clot (embolus). We searched
extensively for the cause of this clot, but could not find any
particular reason why you developed it. To prevent you from
having more strokes in the future, we started you on Coumadin, a
blood thinning medication to prevent clots from forming. We also
found you have high cholesterol, so we started you on a
cholesterol-lowering medication (atorvastatin) to help prevent
future strokes. During hospitalization you worked closely with
speech therapy, occupational therapy and physical therapy to
regain some of your speech and strength. You will continue doing
this as an outpatient.
.
Now that you are on Coumadin, you will need to have your blood
tested periodically to make sure the level (a.k.a. INR) stays
normal. You will be called by the [**Hospital3 **] [**Hospital 197**] Clinic on
[**Hospital 766**] to arrange your lab tests.
.
Please attend the outpatient appointments listed below with your
new Primary Care doctor ([**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **]), your Neurologist
([**Doctor First Name **] [**Doctor Last Name **]), and physical therapy.
.
We made the following changes to your medications:
1. STARTED Coumadin (Warfarin) 2.5mg by mouth daily
2. STARTED atorvastatin 40mg by mouth daily

Followup Instructions:
Department: NEUROLOGY
When: Tuesday, [**11-15**] at 5:30 pm
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. ([**Telephone/Fax (1) 2574**])
Building: [**Hospital6 29**], [**Location (un) **]
Campus: EAST    Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: THURSDAY [**2191-10-13**] at 3:15 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 75863**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

OCCUPATIONAL THERAPY APPOINTMENTS:

Department: REHABILITATION SERVICES
When: THURSDAY [**2191-10-13**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24924**], OTR/L [**Telephone/Fax (1) 44928**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: REHABILITATION SERVICES
When: TUESDAY [**2191-10-18**] at 1:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24924**], OTR/L [**Telephone/Fax (1) 44928**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: Speech Therapy
When: [**Last Name (LF) 766**], [**9-26**] at 8:30-9:90 am
When: Thursday, [**9-29**] at 2:00-3:00 pm
When: Thursday, [**10-6**] at 3:30-4:30 pm
Where: Span 106 (off enterance to [**Hospital Ward Name 121**] Building, [**Location (un) 453**])

Department: Rehabilitation Services - Physical Therapy
When: Thursday, [**10-6**] at 2:15pm
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 111767**]
Where: Span 106 (off enterance to [**Hospital Ward Name 121**] Building, [**Location (un) 453**])
Telephone: [**Telephone/Fax (1) 44928**]

                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
{'Cerebral embolism with cerebral infarction,Cerebral edema,Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility,Aphonia,Monoplegia of upper limb affecting dominant side,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Facial weakness,Visual field defect, unspecified,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants,Family history of stroke (cerebrovascular)'}


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: left arm weakness, left facial droop, inability to
speak

PRESENT ILLNESS: Mr [**Known lastname 111763**] is a 32 year old man with no significant PMH who
presented with left sided weakness and the inability to speak.
History is aided from his family friend [**Name (NI) 335**] at bedside and
over the phone while patient was being transported from [**Hospital1 34585**].
.
Patient was in a normal state of health at 11 am this morning
and was speaking with his friend. [**Name (NI) **] night and this morning he
also felt well, and was playing basketball with his friends.
.
At some point between 12-1pm today patient emerged from his room
and he was not able to speak yet he was still walking.  He wrote
on a piece of paper that he needed help and to go to the
hospital. He was then taken to [**Hospital6 **] where he
had an NIHSS of 13.  Initial vitals were 167/79, HR 115, Temp
97.7, 99% on RA. Decision was made to give IV t-PA. tPA was
given at 14:21 PM (6.8 mg IV push and 61 mg/hour). Patient was
then transferred to [**Hospital1 18**] for potential neuro-interventional
procedure.
.
On arrival to [**Hospital1 18**] ED patient was able to communicate only by
writing and was stating he had an [**9-9**] headache. Repeat NIHSS
was done and was given a 14.  A repeat NCHCT was significant for
extensive cerebral edema and decision was made to not persue an
intervention.
.
On general review of systems (obtained through his friends), the
pt had not complainted of reecent fever or chills.  No night
sweats or recent weight loss or gain. Denies cough, shortness of
breath.  Denies chest pain or tightness, palpitations.  Denies
nausea, vomiting, diarrhea, constipation or abdominal pain.  No
recent change in bowel or bladder habits.  No dysuria.  Denies
arthralgias or myalgias. Denies rash.

MEDICAL HISTORY: -none
-no history of sickle cell, cardiac disease, or any medical
problems this is his first time to a hospital ever.

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAM ON ADMISSION:
Vitals: T: 98  P:117  R: 25 BP:139/103  SaO2:97%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: sinus Abdomen: soft, NT/ND, no masses or organomegaly
noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: done by patient writing, he was alert, oriented
x 3. Attentive following midline and appendicular commands.
Language is fluent to writing but he remains mute with no
attempt to speak.  Pt. was able to name both high frequency
objects from stroke card by writing them out.  The pt. had good
knowledge of current events.  He appears to be neglecting the
left.   Calculation was intact (answers ("4+3 = 7" for seven
quarters in $1.75)
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.  left field cut vs heavy neglect
on the left, but extingushes to DSS.
III, IV, VI: EOMI without nystagmus.  Normal saccades.
V: Facial sensation intact to light touch.
VII: left facial droop
VIII: Hearing intact to voice
.
-Motor:
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L  3    0   0   0   0  0  0  5   5    5  5     5     5   5
R  5    5   5   5   5  5  5  5   5    5  5     5     5   5
.
-Sensory: he writes only "slight feeling on the left"

FAMILY HISTORY: Sister: 2 miscarriages
Father: possible stroke in his 20s with some paralysis--unclear
history

SOCIAL HISTORY: Patient is originally from [**Country **] but has lived in the US for
the past 6 years.  Was there several weeks back for a wedding.
Was living in [**Location (un) **] and was planing on moving back to
[**Country **]. He is currently staying with a family friend here in
[**Name (NI) 86**]. Recently graduated from a masters in architecture
program. Social etoh, no smoking, or illicit drug use. 

### Response:
{'Cerebral embolism with cerebral infarction,Cerebral edema,Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility,Aphonia,Monoplegia of upper limb affecting dominant side,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Facial weakness,Visual field defect, unspecified,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants,Family history of stroke (cerebrovascular)'}
