CHIEF COMPLAINT: aphasia

PRESENT ILLNESS: Ms. [**Known lastname 90885**] is a 65 year-old right-handed woman with a history
including tobacco use, arrhthymia s/p cardioversion, and left
MCA
stroke ([**6-/2111**]) with residual subtle comprehension deficits and
paraphasic errors who initially presented to [**Hospital3 **] with a
global aphasia and was transferred to the [**Hospital1 18**] following the
administration of t-PA.
.
The patient suffered a left MCA stroke in [**2111-6-17**] (presenting
syndrome included language deficits but is otherwise unclear).
[**Name2 (NI) **] daughter states that she since regained the ability to speak
in fluent, grammatical sentences.  However, she continues to
demonstrate paraphasic errors.  Her daughter thinks Ms.
[**Known lastname 90886**] comprehension is largely intact.  She can watch
television and engage meaningfully in conversations.  However,
the patient has trouble identifying the date and her birthdate
at
baseline.  She has no residual weakness.  Although she has been
living with her daughter, she is reportedly getting ready to
move
into independent housing.  She is independent in activities of
daily living.
.
She was in her usual state of health until about 11 am on the
day
of evaluation.  At around 11:05 am, the patient went downstairs
to find one of her relatives.  At that time, she could no longer
speak fluently; rather, she was "mumbling."  She seemed to be
able to understand to some degree and communicated a desire for
coffee.  Her family member took her to get coffee.  She was able
to walk independently with no incoordination.  No facial droop
or
non-language deficits were noted.  When the language impairments
did not improve, she was taken to [**Hospital3 **] for evaluation.
There an NIHSS score of 8 was given.  After a telemedicine
evaluation, she was given t-PA at about 1406.  She was then
transferred to the [**Hospital1 18**] for further evaluation and care.
.
A code stroke was called at the time of the patient's arrival.
NIHSS score following thrombolysis was 7 (for inability to
answer
loc questions 2, failure to follow some loc commands 1, slight
right facial palsy 1, severe aphasia 2, and slight dysarthria
1),
although her baseline is estimated to be about 3 (inability to
answer loc questions, slight aphasia).  A non-contrast CT of the
head performed at [**Hospital3 **] reveals a prior left MCA stroke
without clear evidence of new ischemic lesions; major
territorial
vessels appear patent without signifcant stenoses.  The
patient's
daughter thinks the patient's ability to produce speech has
improved since the t-PA was administered.
.
NEUROLOGICAL, GENERAL REVIEW OF SYSTEMS:
- Positive for: headaches (baseline), recent flu shot and cold
symptoms per her daughter
- otherwise unobtainable

MEDICAL HISTORY: - left MCA stroke as above ([**6-/2111**])
- hypothyroidism
- depression
- headache
- "arrhythmia" s/p what sounds like cardioversion

MEDICATION ON ADMISSION: - proAir Inh 2 puffs inh q6h prn SOB
- amitriptyline 25 mg po qhs (older rx)
- topamax 25 mg po bid
- levothyroxine 137 mcg po daily
- pravastatin 40 mg po qhs
- sertraline 100 mg po bid
- asa 325 mg po daily

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
VS: 97.7, 148/64, 53, 17, 97%RA
GEN: elderly woman lying in bed, struggling to communicate
HEENT: OP clear
PULM: CTA-B anteriorly
CV: RRR
ABD: soft, NT, ND
EXT: no peripheral edema
.
NEURO EXAM:
MS - able to follow some commands (show L thumb, squeeze hand,
let go of hand), but no more than 1-step commands, able to count
fingers, but unable to always answer appropriately, most answers
are "I dunno" or "no", which are intermittently appropriate
responses.  She nodded her head when asked if she was in a
hospital.
CN - PERRL, EOMI, mild R facial droop,  decreased blink to
threat in R eye
MOTOR - effort/comprehension dependent exam, pt unable to
cooperate with distal LE's
  delt  bic  tric  WrExt WrFlex IP  Quads  Ham
L 5      5     5     5      5    5    4+    4+
R 4-     5     5     5-    4+    4    4+    4
DTRs - 2 and symmetrical throughout, upgoing toe on R
SENSORY - intact to light touch throughout
COORDINATION - deferred
GAIT - deferred

FAMILY HISTORY: - positive for stroke (sister), migraine (daughter, etc), CAD

SOCIAL HISTORY: lives with daughter, previously worked in a factory, had a 6th
grade education, likes gambling, smokes [**2-19**] cigarettes/day but
previously [**1-18**] ppd for "most of her life", her daughter denies
alcohol or drug use.
Occlusion and stenosis of carotid artery with cerebral infarction,Tobacco use disorder,Aphasia,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Examination of participant in clinical trial
Ocl crtd art w infrct,Tobacco use disorder,Aphasia,Hypothyroidism NOS,Depressive disorder NEC,TPA adm status 24 hr pta,Hx TIA/stroke w/o resid,Exam-clincal trial
Admission Date:  [**2111-10-19**]              Discharge Date:   [**2111-10-27**]

Date of Birth:  [**2046-6-1**]             Sex:   F

Service: NEUROLOGY

Allergies:
Sulfa (Sulfonamide Antibiotics)

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
aphasia

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Ms. [**Known lastname 90885**] is a 65 year-old right-handed woman with a history
including tobacco use, arrhthymia s/p cardioversion, and left
MCA
stroke ([**6-/2111**]) with residual subtle comprehension deficits and
paraphasic errors who initially presented to [**Hospital3 **] with a
global aphasia and was transferred to the [**Hospital1 18**] following the
administration of t-PA.
.
The patient suffered a left MCA stroke in [**2111-6-17**] (presenting
syndrome included language deficits but is otherwise unclear).
[**Name2 (NI) **] daughter states that she since regained the ability to speak
in fluent, grammatical sentences.  However, she continues to
demonstrate paraphasic errors.  Her daughter thinks Ms.
[**Known lastname 90886**] comprehension is largely intact.  She can watch
television and engage meaningfully in conversations.  However,
the patient has trouble identifying the date and her birthdate
at
baseline.  She has no residual weakness.  Although she has been
living with her daughter, she is reportedly getting ready to
move
into independent housing.  She is independent in activities of
daily living.
.
She was in her usual state of health until about 11 am on the
day
of evaluation.  At around 11:05 am, the patient went downstairs
to find one of her relatives.  At that time, she could no longer
speak fluently; rather, she was "mumbling."  She seemed to be
able to understand to some degree and communicated a desire for
coffee.  Her family member took her to get coffee.  She was able
to walk independently with no incoordination.  No facial droop
or
non-language deficits were noted.  When the language impairments
did not improve, she was taken to [**Hospital3 **] for evaluation.
There an NIHSS score of 8 was given.  After a telemedicine
evaluation, she was given t-PA at about 1406.  She was then
transferred to the [**Hospital1 18**] for further evaluation and care.
.
A code stroke was called at the time of the patient's arrival.
NIHSS score following thrombolysis was 7 (for inability to
answer
loc questions 2, failure to follow some loc commands 1, slight
right facial palsy 1, severe aphasia 2, and slight dysarthria
1),
although her baseline is estimated to be about 3 (inability to
answer loc questions, slight aphasia).  A non-contrast CT of the
head performed at [**Hospital3 **] reveals a prior left MCA stroke
without clear evidence of new ischemic lesions; major
territorial
vessels appear patent without signifcant stenoses.  The
patient's
daughter thinks the patient's ability to produce speech has
improved since the t-PA was administered.
.
NEUROLOGICAL, GENERAL REVIEW OF SYSTEMS:
- Positive for: headaches (baseline), recent flu shot and cold
symptoms per her daughter
- otherwise unobtainable


Past Medical History:
- left MCA stroke as above ([**6-/2111**])
- hypothyroidism
- depression
- headache
- "arrhythmia" s/p what sounds like cardioversion


Social History:
lives with daughter, previously worked in a factory, had a 6th
grade education, likes gambling, smokes [**2-19**] cigarettes/day but
previously [**1-18**] ppd for "most of her life", her daughter denies
alcohol or drug use.

Family History:
- positive for stroke (sister), migraine (daughter, etc), CAD

Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
VS: 97.7, 148/64, 53, 17, 97%RA
GEN: elderly woman lying in bed, struggling to communicate
HEENT: OP clear
PULM: CTA-B anteriorly
CV: RRR
ABD: soft, NT, ND
EXT: no peripheral edema
.
NEURO EXAM:
MS - able to follow some commands (show L thumb, squeeze hand,
let go of hand), but no more than 1-step commands, able to count
fingers, but unable to always answer appropriately, most answers
are "I dunno" or "no", which are intermittently appropriate
responses.  She nodded her head when asked if she was in a
hospital.
CN - PERRL, EOMI, mild R facial droop,  decreased blink to
threat in R eye
MOTOR - effort/comprehension dependent exam, pt unable to
cooperate with distal LE's
  delt  bic  tric  WrExt WrFlex IP  Quads  Ham
L 5      5     5     5      5    5    4+    4+
R 4-     5     5     5-    4+    4    4+    4
DTRs - 2 and symmetrical throughout, upgoing toe on R
SENSORY - intact to light touch throughout
COORDINATION - deferred
GAIT - deferred

DISCHARGE PHYSICAL EXAM:
VS: 97.5 128/80 86 16 98% RA
GEN: awake and alert, sitting up in bed, NAD
HEENT: OP clear
PULM: CTAB
CV: RRR
ABD: soft, NT, ND
EXT: no peripheral edema
.
NEURO EXAM:
MS - awake and alert, able to state name. Repeats some simple
words (book) but not phrases. Comprehension intact for
questions, follows commands
CN - PERRL, EOMI, mild R facial droop,  decreased blink to
threat in R eye
MOTOR - slight R pronator drift
  delt  bic  tric  WrExt WrFlex IP  Quads  Ham
L 5      5     5     5      5    5    5    5
R 5      5     5     5      5    5    5    5
DTRs - 2 and symmetrical throughout, upgoing toe on R
SENSORY - intact to light touch throughout
COORDINATION - intact FNF
GAIT - ambulates steadily with assitance

Pertinent Results:
ADMISSION LABS:

[**2111-10-19**] 04:48PM BLOOD WBC-6.3 RBC-4.72 Hgb-14.0 Hct-42.5 MCV-90
MCH-29.7 MCHC-33.1 RDW-12.9 Plt Ct-195
[**2111-10-19**] 04:48PM BLOOD PT-11.4 PTT-23.8 INR(PT)-0.9
[**2111-10-19**] 04:48PM BLOOD Glucose-105* UreaN-20 Na-141 K-4.4 Cl-105
HCO3-25 AnGap-15
[**2111-10-20**] 03:00PM BLOOD ALT-15 AST-18 LD(LDH)-189 AlkPhos-76
TotBili-0.2
[**2111-10-19**] 04:48PM BLOOD CK-MB-2 cTropnT-<0.01
[**2111-10-20**] 03:00PM BLOOD CK-MB-2 cTropnT-<0.01
[**2111-10-19**] 04:48PM BLOOD Calcium-8.9 Phos-4.3 Mg-2.1
[**2111-10-19**] 04:48PM BLOOD %HbA1c-5.6 eAG-114
[**2111-10-19**] 04:48PM BLOOD TSH-0.030*
[**2111-10-19**] 04:48PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

IMAGING:
CXR [**2111-10-19**]: IMPRESSION: Ill-defined opacity projecting over the
posterolateral left eighth rib, difficult to discern whether
pulmonary. Recommend further evaluation with oblique views to
help localize and if finding persists, chest CT.

ECHO [**2111-10-22**]: Conclusions
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
5-10 mmHg. 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) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion. There is
an anterior space which most likely represents a prominent fat
pad.
No cardiac source of embolus seen.

CT HEAD [**2111-10-20**]: IMPRESSION: Acute left frontal lobe infarct in
the left MCA territory, similar to the preceding MRI. No acute
hemorrhage.

Carotid US [**2111-10-20**]:
IMPRESSION:
1. 60-69% stenosis in the bilateral internal carotid arteries.
2. Mid systolic decelerations in the left vertebral artery
consistent with
occult left subclavian steal syndrome.

CTA neck [**2111-10-23**]:

FINDINGS: There is calcified atherosclerotic plaque involving
both carotid
bulbs and proximal ICAs. The right cervical internal carotid
artery has
minimum diameters of 6.0 mm, proximally, and 4.5 mm, distally.
Within the
proximal right ICA, at the site of greatest narrowing due to
atherosclerotic
disease, the Dmin measures 3.5 mm.

The left cervical internal carotid artery demonstrates minimum
diameter of 4.0
mm, proximally, and 4.5 mm, distally. At the site of greatest
atherosclerotic
narrowing within the proximal left ICA, the Dmin measures 3 mm.
There is no
site of significant atherosclerotic disease seen more distally
in either
internal carotid artery.

The origin of the left vertebral artery demonstrates significant

circumferential plaque, with resultant high-grade stenosis;
there is slight
post-stenotic dilatation and resumption of caliber, distally.
The origin of
the right vertebral artery is widely patent. Otherwise, there is
no focal
stenosis involving the vertebral arteries. There appears to be a
right fetal
PCA intracranially, incompletely imaged. A fetal-equivalent left
PCA is also
likely present.

Visualized lung apices demonstrate mild paraseptal emphysema.
Mild-to-moderate degenerative changes are noted within the
cervical spine,
worst at C5-6, incompletely assessed.

IMPRESSION:
1. Calcified atherosclerotic disease within the carotid bulbs
and proximal
ICAs, bilaterally. However, there is no site of greater than 50%
diameter
stenosis.

2. Significant plaque at the origin of the left vertebral
artery, with
resultant high-grade stenosis.

MR:

MRI: Restriction of diffusion is seen in the left frontal and
insular lobe in
a cortical and subcortical distribution. There is associated T2
hyperintensity, suggesting an early subacute chronicity. Blood
products are
not identified, and there is no mass effect.

Extensive encephalomalacia is seen involving large portions of
the left
temporal lobe. Otherwise, the cerebral sulci, ventricles, and
extra-axial
CSF-containing spaces have normal size and configuration. There
is no shift
of the midline structures. The visualized paranasal sinuses and
mastoid air
cells are clear. The orbits and osseous structures are
unremarkable.

MRA: MRA studies are limited in image quality due to extensive
motion
artifacts. The left superior M2 branching artery is not well
visualized which
could be related to technical factors or represent extensive
narrowing or
embolic occlusion.
Otherwise, the intracranial internal carotid, vertebrobasilar,
and anterior,
middle, and posterior cerebral arteries appear patent. There is
a fetal origin
of the right posterior cerebral artery. Within the limits of
this study,
there is no evidence of aneurysm or arteriovenous malformation.

The origins of the common carotid arteries and vertebral
arteries are not
visualized due to technical limitations. The left vertebral
artery is
hypoplastic; within the limiations of this exam, the bilateral
cervcial
portions of the ICA and right vertebral artery do not
demonstrate significant
stenosis.

IMPRESSION:
1. Early subacute cortical and subcortical ischemic infarct
involving the left frontal and insular lobe. No evidence of
associated hemorrhage.

2. Extensive encephalomalacia of the left temporal lobe.

3. Failure to visualize the left superior M2 branching artery
which could be technically related or represent embolic or
atherosclerotic occlusion. If clinically indicated CTA should be
performed for definite diagnosis.

The study and the report were reviewed by the staff radiologist.



Brief Hospital Course:
[**Known firstname **] [**Known lastname 90885**] is a 65 yo RH woman w/ hx of tobacco use,
arrhythmia s/p cardioversion, and L MCA stroke in [**2111-6-17**]
with residual subtle comprehension deficits and paraphasic
errors who initally presented to [**Hospital3 **] with a global
apahasia and was transferred to [**Hospital1 18**] following tPA.
.
# NEURO: patient presented initially not following commands, but
by day 2 of her admission, she was following some simple
commands and responding somewhat appropriately to questions.
She was initially monitored in the ICU for 24 hrs s/p tPA.  Her
head CT 24 hrs s/p tPA showed no bleeding, so she was able to be
started on plavix 75mg QD and SQH at that time.  We continued
pt's home dose amitriptyline and topmax once she was able to
take PO's.

Carotid ultrasounds showed 60-69% stenosis of the ICA
bilaterally. Vascular surgery was consulted and recommended a
CTA neck, which showed an irregular extensive, likely ulcerated
plaque bilaterally at the carotid bulbs  and proximal ICAs,
worse on the left. Approximately 60% stenosis at worst level in
proximal left ICA. She was not felt to be a candidate for CEA at
this time. She was started on a heparin drip and bridged to
coumadin per vascular recs.

Her neurologic exam remained stable. She continued to have
significant nonfluent aphasia, able to say a few simple words
and few-word phrases. She had no weakness or other significant
deficits.  She will follow up in stroke clinic to determine
length of time of anticoagulation.

# CARDS: We got an echo that showed no source of stroke.  She
had a carotid duplex done that showed bilateral 60% stenosis of
ICA.  We continued pt's home dose pravastatin.  We allowed for
autoregulation of pt's BP, with goal of 140-180, and gave
hydralazine PRN SBP >180.  Patient was put on plavix 24 hrs s/p
tPA and her aspirin was not restarted. She was subsequently
changed over to a heparin drip and bridged to coumadin.

# PULM: we continued pt's proair inhaler. CXR was clear.

# ENDO: Her TSH was low at 0.03. T3 and T4 were normal. We
continued her levothyroxine at her home dose. She should follow
up with her primary care physician for further management of her
hypothyroidism.

# PSYCH: we continued her home dose sertraline at 100mg [**Hospital1 **]

# CODE/CONTACT: FULL; hcp is daughter [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 90887**]

TRANSITIONAL CARE ISSUES:
She will need rehab upon discharge with PT/OT and speech
therapy. She will need to be maintained on coumadin with goal
INR [**2-19**] due to her carotid disease. She has an INR on dicharge
of 1.9.

Medications on Admission:
- proAir Inh 2 puffs inh q6h prn SOB
- amitriptyline 25 mg po qhs (older rx)
- topamax 25 mg po bid
- levothyroxine 137 mcg po daily
- pravastatin 40 mg po qhs
- sertraline 100 mg po bid
- asa 325 mg po daily

Discharge Medications:
1. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. sertraline 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB,
wheezing.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, temp > 100.4.
7. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 8971**] Rehabilitation Center (at [**Hospital6 8972**])
- [**Location (un) 8973**]

Discharge Diagnosis:
Primary: Left frontal and insular infarct
Secondary: hx of stroke, depression


Discharge Condition:
Mental Status: Clear and coherent. +Aphasia.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Ms. [**Known lastname 90885**],
You were seen in the hospital for a stroke.  You were given tPA
(the clotbuster medication) before you arrived.  You were then
monitored in the ICU when you arrived here to ensure that you
did not have any bleeding complications from the tPA. You were
found to have narrowing of the carotid arteries which may be a
possible cause of your strokes. You were started on a blood
thinner called coumadin to help reduce your risk of future
strokes. An echocardiogram of your heart was normal.

We made the following changes to your medications:
Started on coumadin 5mg daily. You will need an INR checked
daily until your level is at goal of [**2-19**].

Please continue to take your other medications as previously
prescribed.

If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.

It was a pleasure taking care of you on this hospitalization.

Followup Instructions:
Department: NEUROLOGY
When: MONDAY [**2111-12-21**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Occlusion and stenosis of carotid artery with cerebral infarction,Tobacco use disorder,Aphasia,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Examination of participant in clinical trial'}


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: aphasia

PRESENT ILLNESS: Ms. [**Known lastname 90885**] is a 65 year-old right-handed woman with a history
including tobacco use, arrhthymia s/p cardioversion, and left
MCA
stroke ([**6-/2111**]) with residual subtle comprehension deficits and
paraphasic errors who initially presented to [**Hospital3 **] with a
global aphasia and was transferred to the [**Hospital1 18**] following the
administration of t-PA.
.
The patient suffered a left MCA stroke in [**2111-6-17**] (presenting
syndrome included language deficits but is otherwise unclear).
[**Name2 (NI) **] daughter states that she since regained the ability to speak
in fluent, grammatical sentences.  However, she continues to
demonstrate paraphasic errors.  Her daughter thinks Ms.
[**Known lastname 90886**] comprehension is largely intact.  She can watch
television and engage meaningfully in conversations.  However,
the patient has trouble identifying the date and her birthdate
at
baseline.  She has no residual weakness.  Although she has been
living with her daughter, she is reportedly getting ready to
move
into independent housing.  She is independent in activities of
daily living.
.
She was in her usual state of health until about 11 am on the
day
of evaluation.  At around 11:05 am, the patient went downstairs
to find one of her relatives.  At that time, she could no longer
speak fluently; rather, she was "mumbling."  She seemed to be
able to understand to some degree and communicated a desire for
coffee.  Her family member took her to get coffee.  She was able
to walk independently with no incoordination.  No facial droop
or
non-language deficits were noted.  When the language impairments
did not improve, she was taken to [**Hospital3 **] for evaluation.
There an NIHSS score of 8 was given.  After a telemedicine
evaluation, she was given t-PA at about 1406.  She was then
transferred to the [**Hospital1 18**] for further evaluation and care.
.
A code stroke was called at the time of the patient's arrival.
NIHSS score following thrombolysis was 7 (for inability to
answer
loc questions 2, failure to follow some loc commands 1, slight
right facial palsy 1, severe aphasia 2, and slight dysarthria
1),
although her baseline is estimated to be about 3 (inability to
answer loc questions, slight aphasia).  A non-contrast CT of the
head performed at [**Hospital3 **] reveals a prior left MCA stroke
without clear evidence of new ischemic lesions; major
territorial
vessels appear patent without signifcant stenoses.  The
patient's
daughter thinks the patient's ability to produce speech has
improved since the t-PA was administered.
.
NEUROLOGICAL, GENERAL REVIEW OF SYSTEMS:
- Positive for: headaches (baseline), recent flu shot and cold
symptoms per her daughter
- otherwise unobtainable

MEDICAL HISTORY: - left MCA stroke as above ([**6-/2111**])
- hypothyroidism
- depression
- headache
- "arrhythmia" s/p what sounds like cardioversion

MEDICATION ON ADMISSION: - proAir Inh 2 puffs inh q6h prn SOB
- amitriptyline 25 mg po qhs (older rx)
- topamax 25 mg po bid
- levothyroxine 137 mcg po daily
- pravastatin 40 mg po qhs
- sertraline 100 mg po bid
- asa 325 mg po daily

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
VS: 97.7, 148/64, 53, 17, 97%RA
GEN: elderly woman lying in bed, struggling to communicate
HEENT: OP clear
PULM: CTA-B anteriorly
CV: RRR
ABD: soft, NT, ND
EXT: no peripheral edema
.
NEURO EXAM:
MS - able to follow some commands (show L thumb, squeeze hand,
let go of hand), but no more than 1-step commands, able to count
fingers, but unable to always answer appropriately, most answers
are "I dunno" or "no", which are intermittently appropriate
responses.  She nodded her head when asked if she was in a
hospital.
CN - PERRL, EOMI, mild R facial droop,  decreased blink to
threat in R eye
MOTOR - effort/comprehension dependent exam, pt unable to
cooperate with distal LE's
  delt  bic  tric  WrExt WrFlex IP  Quads  Ham
L 5      5     5     5      5    5    4+    4+
R 4-     5     5     5-    4+    4    4+    4
DTRs - 2 and symmetrical throughout, upgoing toe on R
SENSORY - intact to light touch throughout
COORDINATION - deferred
GAIT - deferred

FAMILY HISTORY: - positive for stroke (sister), migraine (daughter, etc), CAD

SOCIAL HISTORY: lives with daughter, previously worked in a factory, had a 6th
grade education, likes gambling, smokes [**2-19**] cigarettes/day but
previously [**1-18**] ppd for "most of her life", her daughter denies
alcohol or drug use. 

### Response:
{'Occlusion and stenosis of carotid artery with cerebral infarction,Tobacco use disorder,Aphasia,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Examination of participant in clinical trial'}
