CHIEF COMPLAINT: Not being able to say what he wanted to say

PRESENT ILLNESS: [**Known firstname **] [**Known lastname **] is a 68 yo right handed man with a history of
atrial fibrillation who presents for evaluation of stroke. The
patient reports the he was feeling well upon waking last Monday
([**2143-10-14**]) and was planning on playing golf during the
afternoon. At approximately 2:45, he stopped by his friend's and
in while speaking to him he suddenly felt strange. His friend
continued to speak and then
asked him if he was feeling ok- the patient was unable to
respond, saying he could not speak a word.  His friend told him
to sit down and the patient's symptoms seemed to improve.  He
was able to get up and walk outside of the home when he again
was unable to speak.  It was at that point that his friend
called
EMS. He was initially brought to [**Hospital1 **] where his NIH Stroke
Scale was 4 (breakdown unavailable, but appears to have had
right arm and leg weakness as well as impaired language which
was worsening during the evaluation).  He was evaluated by
telemedicine. CT head was negative and tPA was given at 15:39
(Bolus 7.5mg, then additional 66.3 over 60minutes). The
patient's symptoms showed almost immediate improvement and was
trasferred to [**Hospital1 18**] for further eval.

MEDICAL HISTORY: - Afib x 10 years, s/p cardioversion x 3.
- venous disease of LE, s/p saphenous vein stripping
- Hyperlipidemia
- s/p Left Knee Meniscus surgery [**10-11**]
- s/p right ankle surgery secondary to torn tendons
- s/p left shoulder surgery
- s/p inguinal hernia repair [**2141**]

MEDICATION ON ADMISSION: - Flecanide 75mg [**Hospital1 **]
- ASA 81mg
- Simvastatin 20mg daily
- Atenolol 12.5mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At admission:

FAMILY HISTORY: Mother had stroke in her 80s
Brother with a pacer
Brother s/p MI at age 40

SOCIAL HISTORY: Married, retired. Had multiple jobs, most recently as a Caddy,
but previously a salesman. Avid in sports- has run 46 marathons.
Very remote smoking (as a teenager, quit at age 18). Drinks 15
drinks per week ([**1-3**] glasses of wine in evenings).
Cerebral artery occlusion, unspecified with cerebral infarction,Atrial fibrillation,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility
Crbl art ocl NOS w infrc,Atrial fibrillation,Hyperlipidemia NEC/NOS,Hypertension NOS,TPA adm status 24 hr pta
Admission Date:  [**2143-10-14**]              Discharge Date:   [**2143-10-16**]

Date of Birth:  [**2074-11-5**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Not being able to say what he wanted to say

Major Surgical or Invasive Procedure:
none


History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 68 yo right handed man with a history of
atrial fibrillation who presents for evaluation of stroke. The
patient reports the he was feeling well upon waking last Monday
([**2143-10-14**]) and was planning on playing golf during the
afternoon. At approximately 2:45, he stopped by his friend's and
in while speaking to him he suddenly felt strange. His friend
continued to speak and then
asked him if he was feeling ok- the patient was unable to
respond, saying he could not speak a word.  His friend told him
to sit down and the patient's symptoms seemed to improve.  He
was able to get up and walk outside of the home when he again
was unable to speak.  It was at that point that his friend
called
EMS. He was initially brought to [**Hospital1 **] where his NIH Stroke
Scale was 4 (breakdown unavailable, but appears to have had
right arm and leg weakness as well as impaired language which
was worsening during the evaluation).  He was evaluated by
telemedicine. CT head was negative and tPA was given at 15:39
(Bolus 7.5mg, then additional 66.3 over 60minutes). The
patient's symptoms showed almost immediate improvement and was
trasferred to [**Hospital1 18**] for further eval.

Here, the patient is able to relay his complete history.  He
denies any other symptoms at the time of his event, beyond the
above. He has never had anything like this before. Currently,
the
patient denies headache, loss of vision, blurred vision,
diplopia, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denied focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denied difficulty with gait.

On general review of systems, the patient denied recent fever or
chills. he has had a runny nose/sinus congestion x 3 days and
was
taking a homeopathic [**Doctor Last Name 360**] for this.  Denied shortness of
breath.
Denied chest pain or tightness, palpitations.  Denied nausea,
vomiting, diarrhea, constipation or abdominal pain.  No recent
change in bowel or bladder habits.  He states that he underwent
arthroscopy of the left knee 1.5 weeks ago for a torn meniscus;
he was off his aspirin for this procedure.

Past Medical History:
- Afib x 10 years, s/p cardioversion x 3.
- venous disease of LE, s/p saphenous vein stripping
- Hyperlipidemia
- s/p Left Knee Meniscus surgery [**10-11**]
- s/p right ankle surgery secondary to torn tendons
- s/p left shoulder surgery
- s/p inguinal hernia repair [**2141**]

Social History:
Married, retired. Had multiple jobs, most recently as a Caddy,
but previously a salesman. Avid in sports- has run 46 marathons.
Very remote smoking (as a teenager, quit at age 18). Drinks 15
drinks per week ([**1-3**] glasses of wine in evenings).


Family History:
Mother had stroke in her 80s
Brother with a pacer
Brother s/p MI at age 40


Physical Exam:
At admission:

T 98.9 BP 152/84 HR 76 RR 20  O2% 98 on 2L
General: Awake, cooperative, NAD.
Head and Neck: no cranial abnormalities, no scleral icterus
noted, mmm, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: regular rate and rhythm, No murmurs appreciated.
Abdomen: soft, non-tender, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: 2+ radial, DP pulses bilaterally.
Skin: + venous statsis/varicose veins b/l LE, left>right.

Neurologic:
-Mental Status: Alert, oriented x 3.  Able to relate history
without difficulty.  Attentive.  Language is fluent with intact
repetition and comprehension.  Normal prosody.  There were no
paraphasic errors.  Pt. was able to name both high and low
frequency objects.  Able to read and write without difficulty.
Speech was not dysarthric. The pt. had good knowledge of current
events.  There was no evidence of apraxia or neglect,
calculations intact. Registered [**3-4**] and recalled [**2-1**] at 5
minutes, [**3-4**] with catagory cue.

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk.  Visual fields full on bedside
testing. Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus.  Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid
bilaterally.

XII: Tongue protrudes in midline.

-Motor: Normal bulk, tone throughout. Mild right pronator drift.
No rigidity. No adventitious movements, such as tremors, noted.
No asterixis.

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

-Sensory: No deficits to light touch, vibratory sense 8 seconds
on right, 16 on left. Proprioception impaired to fine movements
of the 1rst toe bilaterally. No extinction to double
simultaneous stimuli.

-Deep tendon reflexes:
    [**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L   2   2    2    2   2
R   2   2    2    3   2
Plantar response was flexor bilaterally.

-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.

-Gait: deferred

At discharge:
T 97.3 BP 150/90 HR 72 RR 18  O2% 100 RA   Fingerstick glycemia:
111 mg/dL
No neurological deficit. Gait: normal stance and stride.
Symptoms completely recovered.

Pertinent Results:
Pertinent lab results:

[**2143-10-16**] 04:35AM BLOOD WBC-5.9 RBC-4.65 Hgb-13.8* Hct-39.3*
MCV-85 MCH-29.8 MCHC-35.2* RDW-12.6 Plt Ct-178
[**2143-10-16**] 04:35AM BLOOD Plt Ct-178
[**2143-10-16**] 04:35AM BLOOD PT-12.2 PTT-23.8 INR(PT)-1.0
[**2143-10-16**] 04:35AM BLOOD Glucose-100 UreaN-18 Creat-1.1 Na-141
K-3.9 Cl-107 HCO3-25 AnGap-13
[**2143-10-15**] 03:40AM BLOOD ALT-23 AST-21 LD(LDH)-164 CK(CPK)-86
AlkPhos-82 TotBili-0.9
[**2143-10-15**] 03:40AM BLOOD CK-MB-2 cTropnT-<0.01
[**2143-10-16**] 04:35AM BLOOD Albumin-4.2 Calcium-8.9 Phos-3.2 Mg-2.3
[**2143-10-15**] 03:40AM BLOOD %HbA1c-5.5 eAG-111
[**2143-10-15**] 03:40AM BLOOD Triglyc-138 HDL-56 CHOL/HD-4.0
LDLcalc-140*

Imaging:

MRI/MRA [**2143-10-15**]:
There is a focal, subcentimeter area in the subcortical white
matter of the left temporal lobe with increased signal on
diffusion-weighted and FLAIR sequences with decreased signal on
ADC (10:13). This is compatible
with a small area of ischemia. There is no evidence of large
territorial
ischemia or infarction. There is no evidence of hemorrhage.
There are areas of increased FLAIR signal in the periventricular
and subcortical white matter that likely represent changes from
chronic small vessel ischemic disease. The ventricles and sulci
are prominent consistent with age-related atrophy.
The intracranial vertebral and internal carotid arteries and
their major
branches appear normal without evidence of stenosis, occlusion,
or aneurysm formation.
IMPRESSION: Subcentimeter diffusion abnormality in the
subcortical white
matter of the left temporal lobe compatible with a small area of
ischemia.

Echo [**2143-10-15**]:
The left atrium is elongated. (Transthoracic echocardiography
not adequate to assess for atrial appendage thrombus). No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is mildly
depressed (LVEF= 50-55 %). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. 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. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.

No cardiac source of embolus identified other than atrial
fibrillation.


Brief Hospital Course:
68 year old right handed man with a history of paroxysmal atrial
fibrillation who presents for evaluation following acute speech
arrest. Initial evaluation at [**Hospital1 **] was concerning for
aphasia and right sided weakness. He was given tPA within 1 hour
and had rapid resolution of sx. Transfered to [**Hospital1 18**] where he had
a mild right pronator drift and a brisk patellar reflex, but
otherwise his neurologic exam was normal. CT head was without
evidence of prior infarct or small vessle disease. The patient
reports recently discontinuing his aspirin for a knee surgery.
It is possible that he was acutely hypercoaguable in the setting
of this medication change and recent surgery, this may also be
considered aspirin failure or due to his atrial fibrillatiojn.
Symptoms completely resolved. MRI/MRA showed subcentimeter
diffusion abnormality in the subcortical white matter of the
left temporal lobe compatible with a small area of ischemia and
nil on MRA. Echo showed mildly depressed LC function EF 5-0-55%
and mildly dilated ascending aorta, no source of embolus.
Transferred to floor [**10-15**]. Received physical therapy and was
asymptomatic during his admission.

Cardiologist (Dr. [**Last Name (STitle) 2293**] at [**Hospital1 112**]) was emailed in order to
determine preference of anticoagulation but unfortunately we
were unable to reach him. The patient refused coumadin
regardless so he was started on dabigatran.

Given his altered lipid profile Simvastatin dose was raised to
40 mg qd.

He will continue follow up with Dr. [**Last Name (STitle) **] (Neurology-Stroke).

Medications on Admission:
- Flecanide 75mg [**Hospital1 **]
- ASA 81mg
- Simvastatin 20mg daily
- Atenolol 12.5mg daily


Discharge Medications:
1. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. flecainide 50 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12
hours).
4. atenolol 25 mg Tablet Sig: 0.5 Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Left temporal subcortical infarct
hyperlipidemia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: no deficits


Discharge Instructions:
Dear Mr. O' [**Doctor Last Name 10321**],

It was a pleasure to take care of you at the [**Hospital1 18**]. You were
initially admited at [**Hospital1 **] because you had trouble to
express what you wanted to say. There it was noticed you also
had weakness on the right side of your body. A CT scan was
negative for bleeding so you received tPa to disolve the cloat
that was causing your stroke. This was successful since your
symptoms resolved in less than 2 hours. From [**Hospital1 **] you were
transfered to [**Hospital1 18**] to continue follow up. At admission you
still presented slight weakness on your right arm but this
resolved as well as your other symptoms.
Your MRI showed a small infarct (stroke) on the subcortical area
of the left temporal lobe. It is possible that this stroke was
due to your recent medication change and surgery or to your
atrial fibrillation.
You will continue follow up with Dr. [**Last Name (STitle) **] in Neurology-Stroke.
Your antiplatelet medication was modified to start Dabigatran
150mg by mouth twice a day. We attempted to confirm this choice
with your cardiologist prior to your discharge but was unable to
reach him in time. We will contact you if we hear differently
from him.
Your lipid profile is above desirable limits, so your
Simvastatin was increased to 40 mg per day.
If you present a similar event, weakness, sensation deficit or
any other neurological deficit you should consult at the
Emergency Department inmediately.

Followup Instructions:
You have a follow-up appointment with Dr. [**Last Name (STitle) **] on [**11-26**], [**2142**] at 3:30 pm. [**Hospital Ward Name 23**] Building, [**Location (un) **].
Phone:[**Telephone/Fax (1) 657**]


                             [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
{'Cerebral artery occlusion, unspecified with cerebral infarction,Atrial fibrillation,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility'}


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: Not being able to say what he wanted to say

PRESENT ILLNESS: [**Known firstname **] [**Known lastname **] is a 68 yo right handed man with a history of
atrial fibrillation who presents for evaluation of stroke. The
patient reports the he was feeling well upon waking last Monday
([**2143-10-14**]) and was planning on playing golf during the
afternoon. At approximately 2:45, he stopped by his friend's and
in while speaking to him he suddenly felt strange. His friend
continued to speak and then
asked him if he was feeling ok- the patient was unable to
respond, saying he could not speak a word.  His friend told him
to sit down and the patient's symptoms seemed to improve.  He
was able to get up and walk outside of the home when he again
was unable to speak.  It was at that point that his friend
called
EMS. He was initially brought to [**Hospital1 **] where his NIH Stroke
Scale was 4 (breakdown unavailable, but appears to have had
right arm and leg weakness as well as impaired language which
was worsening during the evaluation).  He was evaluated by
telemedicine. CT head was negative and tPA was given at 15:39
(Bolus 7.5mg, then additional 66.3 over 60minutes). The
patient's symptoms showed almost immediate improvement and was
trasferred to [**Hospital1 18**] for further eval.

MEDICAL HISTORY: - Afib x 10 years, s/p cardioversion x 3.
- venous disease of LE, s/p saphenous vein stripping
- Hyperlipidemia
- s/p Left Knee Meniscus surgery [**10-11**]
- s/p right ankle surgery secondary to torn tendons
- s/p left shoulder surgery
- s/p inguinal hernia repair [**2141**]

MEDICATION ON ADMISSION: - Flecanide 75mg [**Hospital1 **]
- ASA 81mg
- Simvastatin 20mg daily
- Atenolol 12.5mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At admission:

FAMILY HISTORY: Mother had stroke in her 80s
Brother with a pacer
Brother s/p MI at age 40

SOCIAL HISTORY: Married, retired. Had multiple jobs, most recently as a Caddy,
but previously a salesman. Avid in sports- has run 46 marathons.
Very remote smoking (as a teenager, quit at age 18). Drinks 15
drinks per week ([**1-3**] glasses of wine in evenings). 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Atrial fibrillation,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility'}
