CHIEF COMPLAINT: Transfer from OSH for Code Stroke

PRESENT ILLNESS: The patient is a 66 year old right-handed man with a history of
paroxysmal atrial fibrillation, vertebral artery dissection in
[**2105-10-5**] complicated by hemorrhage while on
anticoagulation, and hypertension, who presented from an OSH as
a transfer for stroke.

MEDICAL HISTORY: 1. Paroxysmal atrial fibrillation, reportedly scheduled for
ablation in [**8-6**]. Vertebral artery dissection complicated by hemorrhage in
setting of elevated INR, on coumadin, lovenox, ASA
3. Hypertension

MEDICATION ON ADMISSION: 1. Pravochol
2. propafenone 425 mg po bid
3. ASA 81mg po daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: Tc: 95.3 BP: 154/72 HR: 57  RR: 18 O2Sat.: 100%/RA
Gen: WD/WN, comfortable, NAD.
HEENT: Abrasion over left eye. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: Sinus bradycardia. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E. Abrasion over left
knee.

FAMILY HISTORY: No known family history of stroke or neurologic disease.

SOCIAL HISTORY: The pt is married and lives with wife. [**Name (NI) 1403**] as an emergency
room physician. [**Name10 (NameIs) **] tobacco, alcohol, drug use.
Cerebral embolism with cerebral infarction,Atrial fibrillation,Aphasia,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hypospadias,Urethral stricture, unspecified,Urinary incontinence, unspecified,Other specified disease of white blood cells
Crbl emblsm w infrct,Atrial fibrillation,Aphasia,Hypertension NOS,Hyperlipidemia NEC/NOS,Hypospadias,Urethral stricture NOS,Urinary incontinence NOS,Wbc disease NEC
Admission Date:  [**2106-6-17**]              Discharge Date:   [**2106-6-22**]

Date of Birth:  [**2040-5-31**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Transfer from OSH for Code Stroke

Major Surgical or Invasive Procedure:
Cerebral angiography

History of Present Illness:
The patient is a 66 year old right-handed man with a history of
paroxysmal atrial fibrillation, vertebral artery dissection in
[**2105-10-5**] complicated by hemorrhage while on
anticoagulation, and hypertension, who presented from an OSH as
a transfer for stroke.

He complained to his wife of having a prolonged period of
palpitations on Tuesday (2 days PTA) night into Wednesday (1 day
PTA) morning lasting about 16 hours.

On the morning of admission, he awoke in his usual state of
health. He went into bathroom around 8:30 am. When he didn't
return from bathroom, his wife went to check on him. She found
him at 8:45 am on the bathroom floor, unable to speak and not
moving his right side. Per wife, he did not seem to understand
commands. EMS was called at 9:03 am.

The pt arrived at [**Hospital **] Hospital at 9:44 am. Initial vitals
there were: T: 97.6, HR 52 and regular, RR 12, BP 132/79, 98%/RA
with finger stick glucose of 128. NIHSS on arrival to the OSH
was reportedly 24. Non contrast head CT was performed at 10:15
am at OSH. This study was reviewed a this facility. The official
report was: no hemorrhage, [**Doctor Last Name 352**] white changes, sulci effacement.
No intravenous tPA given due to history of previous hemorrhage.
[**Hospital1 18**] stroke team was contact[**Name (NI) **] and arrangements made for
transfer.

The pt arrived at [**Hospital1 18**] at 12:03 pm. Neurology paged at 12:25 pm
and was at bedside at same time. NIHSS per neurology was 19. The
patient was taken directly to MRI. MRI showed area of restricted
diffusion left MCA and area of clot on susceptability in left
MCA. The patient was transferred to interventional radiology for
IA tPA, where the clot was lysed.


Past Medical History:
1. Paroxysmal atrial fibrillation, reportedly scheduled for
ablation in [**8-6**]. Vertebral artery dissection complicated by hemorrhage in
setting of elevated INR, on coumadin, lovenox, ASA
3. Hypertension



Social History:
The pt is married and lives with wife. [**Name (NI) 1403**] as an emergency
room physician. [**Name10 (NameIs) **] tobacco, alcohol, drug use.


Family History:
No known family history of stroke or neurologic disease.

Physical Exam:
Vitals: Tc: 95.3 BP: 154/72 HR: 57  RR: 18 O2Sat.: 100%/RA
Gen: WD/WN, comfortable, NAD.
HEENT: Abrasion over left eye. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: Sinus bradycardia. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E. Abrasion over left
knee.

Neuro:
Mental status: Awake and alert, cooperative with exam. Attempts
to mouth words, but no verbal output. Able to follow simple
midline and appendicular commands like open and close eyes, open
mouth, give thumbs up and show me two fingers. Does acknowledge
right side. Nods appropriately to yes/no questions.

Cranial nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 4 to 3 mm
bilaterally. No blink to right threat.
III, IV, VI: Left gaze preference but will close midline and
look to right with full movments.
V, VII: Right facial droop.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone on left. Right arm and leg flaccid.
Full strength left arm and leg. No movement of right arm and leg
spontaneously and no movement to noxious stimuli.

Sensation: Tells me he can appreciate noxious stimuli on right
side. Full sensation to all modalities on left.

Reflexes: B T Br Pa Ac
Right 1 1 1 tr 1
Left 2 2 2 2 2
Right toe mute. Left is downgoing.

Coordination: Unable to perform.

Gait: Did not assess.

Pertinent Results:
Labs on admission:
-[**2106-6-17**] 12:21PM BLOOD WBC-13.9* RBC-5.30 Hgb-16.1 Hct-46.6
MCV-88 MCH-30.4 MCHC-34.7 RDW-12.8 Plt Ct-235
[**2106-6-17**] 12:21PM BLOOD Neuts-86.7* Bands-0 Lymphs-10.6*
Monos-2.2 Eos-0.4 Baso-0.3
[**2106-6-17**] 12:21PM BLOOD PT-12.1 PTT-22.4 INR(PT)-1.0
[**2106-6-17**] 12:21PM BLOOD Glucose-113* UreaN-16 Creat-1.1 Na-139
K-4.2 Cl-102 HCO3-26 AnGap-15
[**2106-6-17**] 12:21PM BLOOD ALT-40 AST-39 LD(LDH)-250 CK(CPK)-125
AlkPhos-47 Amylase-54 TotBili-0.7
[**2106-6-17**] 07:23PM BLOOD CK(CPK)-116
[**2106-6-18**] 03:13AM BLOOD CK(CPK)-110
[**2106-6-17**] 12:21PM BLOOD cTropnT-<0.01
[**2106-6-17**] 07:23PM BLOOD CK-MB-3 cTropnT-<0.01
[**2106-6-18**] 03:13AM BLOOD CK-MB-3 cTropnT-<0.01
[**2106-6-18**] 03:13AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.9 Cholest-112
[**2106-6-18**] 03:13AM BLOOD Triglyc-40 HDL-44 CHOL/HD-2.5 LDLcalc-60

MRI head:
[**Month/Day/Year **]: The diffusion images show a large area of elevated
signal within the left anterior temporal lobe, left insular
cortex, left basal ganglia region and which extends as far as
the wall of the left lateral ventricle. There is a probable tiny
additional area of restricted diffusion in the left parietal
subcortical white matter. [**Month/Day/Year **] are probably representative
of acute brain ischemia. The larger lesion correlates with the
MR [**First Name (Titles) 56928**] [**Last Name (Titles) 4493**] of occlusion of the left middle
cerebral artery approximately 1 cm from its origin. I cannot
identify the left vertebral artery. Supposedly, there is a
history of prior vertebral artery dissection, which might
correlate with this finding. As there are no preceding neural
imaging studies available at this time for comparison, perhaps
this was the site of the vertebral artery dissection stated in
the history.
Lastly, there is a 1cm area of susceptibility noted within the
region of the vallecula of the cerebellum. Apparently, after
discussion with Dr. [**Last Name (STitle) **], the neurologist caring for the
patient, there is a history of prior hemorrhage in this locale.
If this was the same site, the susceptibility could represent
hemosiderin residue.
CONCLUSION: Very limited study, curtailed in order to provide
emergency thrombolysis. [**Last Name (STitle) **] consistent with acute brain
ischemia involving the left temporal lobe anteriorly, left
insula, and basal ganglia regions, with occlusion of the
proximal left middle cerebral artery. Other [**Last Name (STitle) 4493**], as noted
above.

Cerebral angiogram:
[**Last Name (STitle) **]: The left common carotid injection demonstrated patent
bifurcation of the internal and external carotid arteries.
The selective injection of the left internal carotid artery
demonstrated an occluded M2 segment. The microcatheter was
placed across the M2 segment. A total of 20 mg of TPA were
infused as described in the technique section. Conclusion
angiography performed within the middle cerebral artery after
TPA administration demonstrated improvement in flow to the
distal MCA branches. However, the mid M2 occlusion remained.
IMPRESSION: Intra-arterial infusion of 20 mg of TPA into left
middle cerebral artery occlusion.

CT HEAD WITHOUT IV CONTRAST:
There is no evidence of intracranial hemorrhage, hydrocephalus,
or shift of normally midline structures. There are areas of
hypoattenuation within the anterior left temporal lobe and left
basal ganglia including the left putamen, caudate and corona
radiata consistent with subacute infarction.
IMPRESSION: Evolving infarction within the left middle cerebral
artery distribution. No evidence of intracranial hemorrhage
after tPA infusion.

TTE:
Conclusions:
1. The left atrium is normal in size.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular  cavity size is normal. Due to suboptimal technical
quality, a focal wall  motion abnormality cannot be fully
excluded. Overall left ventricular systolic  function is normal
(LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic root is mildly dilated. The aortic arch is mildly
dilated.
5.The aortic valve leaflets (3) appear structurally normal with
good leaflet  excursion and no aortic regurgitation. 6.The
mitral valve appears structurally  normal with trivial mitral
regurgitation.
7.There is no pericardial effusion.


Brief Hospital Course:
The pt is a 66 year-old right-handed male with a history of
paroxysmal atrial fibrillation, hypertension, history of
vertebral artery dissection complicated by hemorrhage in setting
of elevated INR, who presented with  acute brain ischemia
involving the left temporal lobe anteriorly, left insula, and
basal ganglia regions, with occlusion of the proximal left
middle cerebral artery. Given the pt's history of paroxysmal
atrial fibrillation, this event was most certainly cardioembolic
in origin. Pt's initial deficits included a right flaccid
hemiplegia and expressive aphasia.  He remained in the
neurologic ICU for one night after receiving intra-arterial tPA.
 A dobhoff tube was placed for tube feeds.  He was started on
warfarin as stroke was most certainly cardioembolic in origin
due to underlying atrial fibrillation.  He should remain on this
medication with a goal INR of [**1-7**].  He was also maintained on
81mg of ASA daily. He was also restarted on propafenone for
cardiac rhythm control.  In addition, he was maintained on
pravastatin for hyperlipidemia.  Follow-up CT scan one day after
intra-arterial tPA showed no evidence of hemorrhagic
transformation of the infarct.
Over the course of the hospital stay, the pt's expressive
aphasia markedly improved.  On admission, he was just able to
utter one word answers and at the time of discharge, he was able
to form [**4-9**] word sentences.  He was also able to repeat simple
[**3-9**] word sentences.  [**Location (un) **] and naming ability were also
intact. He did demonstrate comprehension of speech throughout
the course of the illness.  A speech and swallow evaluation was
performed on hospital day five which demonstrated that the pt.
was able to tolerate both solids and liquids without
restriction. At this time, tube feeds were discontinued and the
dobhoff tube was removed.  Regarding the right-sided flaccid
hemiplegia, this remained static without evidence of improvement
at the time of discharge.
It should be noted that the pt. did develop a white blood cell
count of 11.2 on the day of discharge.  He was afebrile and had
no symptoms suggestive of infection.  It is recommended that the
pt undergo work-up for possible infection should the elevated
white count persist or he develop symptoms.

Medications on Admission:
1. Pravochol
2. propafenone 425 mg po bid
3. ASA 81mg po daily

Discharge Medications:
 1. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Propafenone 150 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

8. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO once a
day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
-ischemic stroke in left middle cerebral artery distribution
-s/p intraarterial thrombolysis
-atrial fibrillation

Discharge Condition:
The pt. was able to form and repeat [**3-9**] word sentences
(transcortical motor aphasia), had resultant right-sided flaccid
hemiplegia.

Discharge Instructions:
Please continue all medications as prescribed.  Please attend
all follow-up appointments after discharge from rehab.  If you
experience worsening of symptoms or new concerning symptoms,
please call your primary care doctor, your neurologist, or come
to the emergency department for evaluation.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 1694**] Date/Time:[**2106-9-13**] 1:00

Please follow-up with your primary care doctor within 7-10 days
after discharge from rehab.


                             [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
{'Cerebral embolism with cerebral infarction,Atrial fibrillation,Aphasia,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hypospadias,Urethral stricture, unspecified,Urinary incontinence, unspecified,Other specified disease of white blood cells'}


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: Transfer from OSH for Code Stroke

PRESENT ILLNESS: The patient is a 66 year old right-handed man with a history of
paroxysmal atrial fibrillation, vertebral artery dissection in
[**2105-10-5**] complicated by hemorrhage while on
anticoagulation, and hypertension, who presented from an OSH as
a transfer for stroke.

MEDICAL HISTORY: 1. Paroxysmal atrial fibrillation, reportedly scheduled for
ablation in [**8-6**]. Vertebral artery dissection complicated by hemorrhage in
setting of elevated INR, on coumadin, lovenox, ASA
3. Hypertension

MEDICATION ON ADMISSION: 1. Pravochol
2. propafenone 425 mg po bid
3. ASA 81mg po daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: Tc: 95.3 BP: 154/72 HR: 57  RR: 18 O2Sat.: 100%/RA
Gen: WD/WN, comfortable, NAD.
HEENT: Abrasion over left eye. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: Sinus bradycardia. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E. Abrasion over left
knee.

FAMILY HISTORY: No known family history of stroke or neurologic disease.

SOCIAL HISTORY: The pt is married and lives with wife. [**Name (NI) 1403**] as an emergency
room physician. [**Name10 (NameIs) **] tobacco, alcohol, drug use. 

### Response:
{'Cerebral embolism with cerebral infarction,Atrial fibrillation,Aphasia,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hypospadias,Urethral stricture, unspecified,Urinary incontinence, unspecified,Other specified disease of white blood cells'}
