CHIEF COMPLAINT: new onset aphasia

PRESENT ILLNESS: 66F discharged [**5-17**] after having a 3mm Acom aneurysm rupture and
SAH. She was neurologically stable at that time without
deficits. She then presented to [**Hospital3 **] Hospital on [**5-19**] with
LBP and during that admission she developed expressive aphasia.
CT there showed no new hemorrhage.

MEDICAL HISTORY: HTN, SAH Acom aneurysm s/p coiling

MEDICATION ON ADMISSION: 1. Docusate Sodium 100 mg [**Hospital1 **]
2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablets PO Q4H
3. Valsartan 40 mg'
4. Aspirin 325 mg'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
BP:137/72     HR:94    RR:18       O2Sats 96
Gen: WD/WN, comfortable, NAD.
HEENT:Atraumatic Pupils:3->2   EOMs UTA due to assess inability
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, flat
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension however delayed
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: Hx of embolic stroke, no hx aneurysm

SOCIAL HISTORY: Quit smoking years ago, drinks glass wine/[**Doctor Last Name 6654**]/night
Cerebral artery occlusion, unspecified with cerebral infarction,Aphasia,Unspecified essential hypertension,Personal history of tobacco use,Other and unspecified complications of medical care, not elsewhere classified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Crbl art ocl NOS w infrc,Aphasia,Hypertension NOS,History of tobacco use,Complic med care NEC/NOS,Abn react-procedure NEC,Hx TIA/stroke w/o resid
Admission Date:  [**2175-5-21**]              Discharge Date:   [**2175-5-26**]

Date of Birth:  [**2108-8-30**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
new onset aphasia

Major Surgical or Invasive Procedure:
none


History of Present Illness:
66F discharged [**5-17**] after having a 3mm Acom aneurysm rupture and
SAH. She was neurologically stable at that time without
deficits. She then presented to [**Hospital3 **] Hospital on [**5-19**] with
LBP and during that admission she developed expressive aphasia.
CT there showed no new hemorrhage.


Past Medical History:
HTN, SAH Acom aneurysm s/p coiling

Social History:
Quit smoking years ago, drinks glass wine/[**Doctor Last Name 6654**]/night


Family History:
Hx of embolic stroke, no hx aneurysm


Physical Exam:
PHYSICAL EXAM:
BP:137/72     HR:94    RR:18       O2Sats 96
Gen: WD/WN, comfortable, NAD.
HEENT:Atraumatic Pupils:3->2   EOMs UTA due to assess inability
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, flat
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension however delayed
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-25**] throughout. No pronator drift

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Toes downgoing bilaterally

On Discharge:
Alert, oriented to person place and date. Full strength and
power throughout upper and lower extremities. No pronator drift.


Pertinent Results:
Labs on Admission:
[**2175-5-21**] 02:03AM   GLUCOSE-126* UREA N-14 CREAT-0.8 SODIUM-137
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
[**2175-5-21**] 02:03AM   CALCIUM-8.9 PHOSPHATE-4.3 MAGNESIUM-2.2
[**2175-5-21**] 02:03AM   WBC-14.5*# RBC-3.87* HGB-11.6* HCT-34.4*
MCV-89 MCH-29.9 MCHC-33.7 RDW-14.1
[**2175-5-21**] 02:03AM   PLT COUNT-664*#
[**2175-5-21**] 02:03AM   PT-13.2 PTT-24.1 INR(PT)-1.1
[**2175-5-21**] 06:07AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]->1.035
[**2175-5-21**] 06:07AM URINE  BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2175-5-21**] 06:07AM URINE  RBC-0-2 WBC-0-2 BACTERIA-0 YEAST-NONE
EPI-0

Labs on Admission:
[**2175-5-25**] 06:05AM BLOOD WBC-5.2 RBC-3.57* Hgb-10.6* Hct-32.4*
MCV-91 MCH-29.7 MCHC-32.8 RDW-13.9 Plt Ct-384
[**2175-5-24**] 03:25PM BLOOD PT-13.4 PTT-24.6 INR(PT)-1.2*
[**2175-5-25**] 06:05AM BLOOD Glucose-101 UreaN-12 Creat-0.7 Na-144
K-4.2 Cl-108 HCO3-25 AnGap-15
[**2175-5-25**] 06:05AM BLOOD Calcium-8.9 Phos-4.9* Mg-2.1
[**2175-5-21**] 02:03AM BLOOD CK(CPK)-17*
[**2175-5-21**] 02:03AM BLOOD CK-MB-NotDone cTropnT-<0.01

Imaging:
CTA [**5-21**]:
CT HEAD WITHOUT IV CONTRAST:
Patient is status post ACom coiling with metallic artifact seen
within this region. A large amount of streak artifact is
demonstrated overlying the brain parenchyma in this region,
precluding evaluation for subtle detail. There has been marked
interval decrease of scattered subarachnoid hemorrhage with a
small amount of residual subarachnoid hemorrhage within the
bilateral, left greater than right, sylvian fissures. There has
been interval development of two discrete hypodensities within
the left insula and right lentiform nucleus. There are also
multiple new ill- defined hypodensities within the bilateral
centrum semiovale. The ventricles
are stable in size. There is a 1.4 x 0.9 cm, minimally enhancing
mass within the right lateral intraconal space of the right
orbit, likely representing hemangioma or schwannoma. Osseous
structures are unremarkable.
CTA HEAD:
There is a large amount of venous opacification which decreases
sensitivity for evaluation of the arterial structures.
Accounting for this: There is mild- to- moderate narrowing of
the distal M1 segments of the right MCA with mild narrowing of
the M2 and more distal branches of the right MCA. There is a
mild to moderate narrowing at the proximal M2 branches of the
left MCA with mild narrowing of the more distal branches.
Accounting for the large amount of artifact surrounding the A1
and A2 segments of the ACA due to the coils from the ACom
aneurysm embolization, there is moderate narrowing of the
bilateral distal A1 segments of the ACA. The proximal A2
segments just distal to the ACom demonstrates a normal caliber,
however, more distal in the proximal/mid A2 segments there is
moderate narrowing. There is stable narrowing of the mid portion
of the basilar artery with a bulbous basilar tip with no
evidence for aneurysm. Otherwise, the remainder of the
vasculature is unchanged when compared to the prior examination.
No abnormal enhancement is identified. Within the brain
parenchyma. Bilateral cervical internal carotid arteries take a
medial course in the retropharyngeal region consistent also
known as "kissing arteries".
IMPRESSION:
1. Hypodensities in the bilateral centrum semiovale, when
correlated with
same day MRI head are consistent with acute infarcts.
2. Left insula and lentiform nuclei hypodensities, which when
correlated with the same day MRI head is most consistent with
subacute infarcts.
3. Mild to moderate narrowing of the distal M1 segment of the
right MCA and mild to moderate narrowing of the proximal M2
segments of the left MCA
consistent with vasospasm.
4. Moderate narrowing of the distal A1 segments of the bilateral
ACAs and
proximal A2 segments of the ACAs distal to the ACom.
5. Kissing artery configuration of the bilateral internal
carotid arteries in the retropharyngeal area.
6. Right intraconal mass. Differential diagnostic considerations
would
include hemangioma or schwannoma.

MRI/A Head [**5-21**]:
FINDINGS:
There are multiple FLAIR hyperintensities within the bilateral
centrum
semiovale with an associated corresponding high intensity on DWI
and low
intensity on ADC most consistent with acute infarcts. There is
another acute infarct in the posterior right frontal lobe. In
the right corona radiata, there is an area of high intensity on
DWI with associated isointensity on ADC maps consistent with
subacute infarct. There is another similar appearing lesion in
the left external capsule/posterior limb of the left internal
capsule most consistent with subacute infarct.
Scattered subarachnoid hemorrhage is seen within the bilateral,
left greater than right, sylvian fissures as well as bilateral,
left great than right, frontal sulci. There are multiple
nonspecific foci of FLAIR hyperintensity involving the bifrontal
subcortical white matter, centrum semiovale, corona radiata, and
periventricular regions likely representing chronic
microangiopathic small vessel ischemic changes in a patient of
this age. There is mild diffuse parenchymal volume loss with
associated proportional prominence of the sulci and enlargement
of the ventricles, likely age-related volume loss. The
ventricles are stable in size with no evidence of hydrocephalus.
Again demonstrated is the intraconal mass within the right
orbit. Orbital structures are otherwise unremarkable. There is a
left maxillary mucosal retention cyst and mucosal thickening of
the bilateral ethmoid air cells. There is some fluid within the
right mastoid air cells. Otherwise, the remainder of the
paranasal sinuses and left mastoid air cells are clear.
MRA HEAD:
There is moderate narrowing of the distal M1, MCA and moderate
stenosis of the proximal M2 segments of the left MCA. Moderate
stenosis of the bilateral distal A1 segments of the ACAs are
also demonstrated. The proximal A2 segment just distal to the
ACOM and coiled ACOM aneurysm demonstrates normal caliber;
however, just distal to this, there is moderate-to-severe
narrowing of the A2 segments with slightly increased caliber to
the callosomarginal and pericallosal artery more distally.
There is stable narrowing of the mid portion of the basilar
artery with a
bulbous tip and without evidence for aneurysm. The bilateral
vertebral arteries are codominant. The right vertebral artery
becomes slightly narrowed distal to the takeoff of the PICA,
normal variant.
IMPRESSION:
1. Moderate narrowing of the distal right M1 segment, proximal
left M2
segments, bilateral distal A1 segments, and mid/proximal A2
segments,
concerning for vasospasm.
2. Subarachnoid hemorrhage within the bilateral, left greater
than right
sylvian fissures and left greater than right frontal sulci.
3. Right frontal and bilateral centrum semiovale acute infarcts.

4. Subacute infarcts in the left corona radiata and left insula.


MRI L-Spine [**5-21**]:
FINDINGS:
The conus demonstrates normal signal intensity and terminates at
the level of L1. Alignment is normal. There is a T2
hyperintense, T1 hypointense 1.5 cm lesion within the posterior
T12 vertebral body likely representing a hemangioma versus focal
fat. Mixed [**Last Name (un) 13425**] type 2 degenerative changes are noted at the
T11 inferior endplate and T12 superior plate. Slight disc
desiccation is noted at this level as well. The bone marrow
otherwise demonstrates normal signal intensity. The
intervertebral disc spaces are maintained.
T11/T12: There is a posterior disc bulge causing mild deformity
to ventral
thecal sac and no evidence for spinal canal or neural foraminal
narrowing.
T12/L1 through and L1/L2, there is no evidence for posterior
disc bulge,
central canal or neural foraminal narrowing.
L2/L3: There is an asymmetric disc bulge to the right causing
minimal
deformity to ventral thecal sac and no evidence of spinal canal
or neural
foraminal narrowing.
L3/L4: There is an asymmetric disc bulge to the left causing no
significant spinal canal stenosis. This associated with
bilateral facet joint degenerative changes cause mild bilateral,
left greater than right, neural foraminal narrowing.
L4/L5: There is a diffuse disc bulge causing mild deformity to
ventral thecal sac. This associated with bilateral facet joint
degenerative changes and ligamentum flavum thickening causes
mild spinal canal narrowing. There is minimal bilateral
subarticular narrowing causing no encroachment on the descending
L5 nerve roots. These findings cause mild, right greater than
left, neural foraminal narrowing.
L5/S1: There is a diffuse disc bulge causing mild deformity to
ventral thecal sac. Bilateral facet joint degenerative changes
associated with this causes no right and mild-to-moderate left
neural foraminal narrowing. There is close abutment of the disc
against the foraminal/extra foraminal segment of the exiting L5
nerve root. The paraspinal musculature and soft tissue are
unremarkable.
IMPRESSION:
Multilevel degenerative changes as detailed above, most
prominent at the level of L5/S1 causing close abutment of the
exiting left L5 nerve root.

Cardiac Echo [**5-22**]:
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. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). 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
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal study. No definite structural cardiac source
of embolism identified.

CT Head [**5-24**]:
NON-CONTRAST HEAD CT: Patient is status post ACom coiling. There
is continued resolution of scattered subarachnoid hemorrhage.
There is no evidence of new hemorrhage or major vascular
territorial infarct. Small hypodensities in the left corona
radiata and left insula are unchanged and relate to foci of
infarction on MRI from [**2175-5-21**]. There is no hydrocephalus
or shift of normally midline structure. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. The paranasal sinuses and mastoid
air cells are normally aerated. Right intraconal mass is
unchanged and may represent a schwannoma or a hemangioma.
IMPRESSION:
1. Continued resolution of scattered subarachnoid hemorrhage. No
new
hemorhage.
2. Small hypodensities in the left insula and lentiform nuclei
which
correlates to infarcts on MRI from [**2175-5-21**].
3. Right intraconal mass. Differential consideration include
hemangioma or
schwannoma.
4. No new hemorrhage or evidence of major vascular territorial
infarct


Brief Hospital Course:
Pt was admitted to the neurosurgical service and monitored
closely in ICU.  She was started on triple H therapy. MRI done
showed left basal ganglia and temporal lacunar infarcts. On [**5-23**], a CTA of the head was done that revealed mild vasospasm of
the A1/A2 segments of the left anterior cerebral arteries. On
[**5-24**], she was transferred to the neurosurgical floor,
neurologically intact and without deficit. She also had
echocardiogram done during her hospitalization(results on prior
page).  She was seen and evaluated by PT/OT. She was discharged
to rehab on [**5-26**] with appropriate follow up arrangements.

Medications on Admission:
1. Docusate Sodium 100 mg [**Hospital1 **]
2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablets PO Q4H
3. Valsartan 40 mg'
4. Aspirin 325 mg'

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fioricet 50-325-40 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.


Discharge Disposition:
Extended Care

Facility:
alliance rehab

Discharge Diagnosis:
Right frontal and bilateral centrum semiovale acute infarcts.
Subacute infarcts in the left corona radiata and left insula.


Discharge Condition:
neurologically intact


Discharge Instructions:
General Instructions

??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
??????	You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion, lethargy or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.
??????	New onset of the loss of function, or decrease of function on
one whole side of your body.

Followup Instructions:
Follow-Up Appointment Instructions

??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.



Completed by:[**2175-5-26**]
{'Cerebral artery occlusion, unspecified with cerebral infarction,Aphasia,Unspecified essential hypertension,Personal history of tobacco use,Other and unspecified complications of medical care, not elsewhere classified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}


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: new onset aphasia

PRESENT ILLNESS: 66F discharged [**5-17**] after having a 3mm Acom aneurysm rupture and
SAH. She was neurologically stable at that time without
deficits. She then presented to [**Hospital3 **] Hospital on [**5-19**] with
LBP and during that admission she developed expressive aphasia.
CT there showed no new hemorrhage.

MEDICAL HISTORY: HTN, SAH Acom aneurysm s/p coiling

MEDICATION ON ADMISSION: 1. Docusate Sodium 100 mg [**Hospital1 **]
2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablets PO Q4H
3. Valsartan 40 mg'
4. Aspirin 325 mg'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
BP:137/72     HR:94    RR:18       O2Sats 96
Gen: WD/WN, comfortable, NAD.
HEENT:Atraumatic Pupils:3->2   EOMs UTA due to assess inability
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, flat
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension however delayed
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: Hx of embolic stroke, no hx aneurysm

SOCIAL HISTORY: Quit smoking years ago, drinks glass wine/[**Doctor Last Name 6654**]/night 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Aphasia,Unspecified essential hypertension,Personal history of tobacco use,Other and unspecified complications of medical care, not elsewhere classified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}
