CHIEF COMPLAINT: Word finding difficulties, possible left facial droop

PRESENT ILLNESS: The patient is a 67 yo RHF with HTN, HLD, afib not on
anticoagulation without known contraindications, on ASA 325
Qday, presented to ED today after episode at 19h05 of
word-finding difficulties with possible reported L facial droop,
lasting 10-15 mins. The patient was having difficulty giving a
history due to her expressive aphasia and her husband, who was
present at the bedside, was not up to date as to her medical
history so information was obtained from the [**Hospital1 112**] where she is
followed. By the time she was evaluated in the ED these had
resolved, gluc was 114, BP was elevated at SBP 210/120 but then
normalized and found to be in afib. At 20h15 pm she had been
normally conversant and her RN was asking her to list her
medications and acutely she was noted to develop an expressive
aphasia, not able to respond verbally to the question.
Comprehension seemed intact. A code stroke was called and her
NIHSS at the time was 1. She was taken emergently for CTA and
CTP, revealing a L MCA clot. No headache, no chest
pain/palpitations/SOB. No recent illnesses. No surgeries since
TKR last year. A few weeks ago experienced transient episode of
lightheadedness. No prior known strokes. Wears glasses for
[**Location (un) 1131**].

MEDICAL HISTORY: -HTN
-HLD
-afib not on anticoagulation without known contraindication
-L total knee replaecment in [**2099-7-8**]
-obesity
-anxiety
-nephrectomy in [**2081**] for renal malignancy
-OA
-TAHSO

MEDICATION ON ADMISSION: -Nitro PRN
-Verapamil 240 mg Qday
-Nexium 40 mg
-Atenolol 12.5 mg Qday
-ASA 325 mg Qday
-HCTZ 25 Qday
-Simvastatin 80 mg Qday
-Percocet PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 1a LOC = 0
1b Orientation = 0
1c Commands = 0
2 Gaze = 0
3 Visual Fields = 0
4 Facial Paresis = 1
5a Motor Function R UE = 0
5b Motor Function L UE= 0
6a Motor Function R LE= 0
6b Motor Function L LE= (old weakness IP )
7 Limb Ataxia = 0
8 Sensory perception = 0
9 Language = 1 ( mild aphasia )
10 Dysarthria = 0
11 Extinction/Inattention = 0
TOTAL = 2

FAMILY HISTORY: No strokes

SOCIAL HISTORY: Lives with husband, works as a school cross-guard, remote
tobacco x 40 pack-year hx, quit in [**2081**], 2 children.
Cerebral embolism with cerebral infarction,Urinary tract infection, site not specified,Atrial fibrillation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of kidney,Obesity, unspecified,Knee joint replacement,Abnormal coagulation profile
Crbl emblsm w infrct,Urin tract infection NOS,Atrial fibrillation,Hypertension NOS,Hyperlipidemia NEC/NOS,Hx of kidney malignancy,Obesity NOS,Joint replaced knee,Abnrml coagultion prfile
Admission Date:  [**2100-10-14**]              Discharge Date:   [**2100-10-19**]

Date of Birth:  [**2033-3-30**]             Sex:   F

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Word finding difficulties, possible left facial droop

Major Surgical or Invasive Procedure:
None


History of Present Illness:
The patient is a 67 yo RHF with HTN, HLD, afib not on
anticoagulation without known contraindications, on ASA 325
Qday, presented to ED today after episode at 19h05 of
word-finding difficulties with possible reported L facial droop,
lasting 10-15 mins. The patient was having difficulty giving a
history due to her expressive aphasia and her husband, who was
present at the bedside, was not up to date as to her medical
history so information was obtained from the [**Hospital1 112**] where she is
followed. By the time she was evaluated in the ED these had
resolved, gluc was 114, BP was elevated at SBP 210/120 but then
normalized and found to be in afib. At 20h15 pm she had been
normally conversant and her RN was asking her to list her
medications and acutely she was noted to develop an expressive
aphasia, not able to respond verbally to the question.
Comprehension seemed intact. A code stroke was called and her
NIHSS at the time was 1. She was taken emergently for CTA and
CTP, revealing a L MCA clot. No headache, no chest
pain/palpitations/SOB. No recent illnesses. No surgeries since
TKR last year. A few weeks ago experienced transient episode of
lightheadedness. No prior known strokes. Wears glasses for
[**Location (un) 1131**].

ROS: denies any fever, chills, weight loss, visual changes,
hearing changes, headache, neckpain, nausea, vomiting,
dysphagia, weakness, tingling, numbness, bowel-bladder
dysfunction, chest pain, shortness of breath, abdominal pain,
dysuria, hematuria, or bright red blood per rectum, rash, muscle
aches, joint pains.

Past Medical History:
-HTN
-HLD
-afib not on anticoagulation without known contraindication
-L total knee replaecment in [**2099-7-8**]
-obesity
-anxiety
-nephrectomy in [**2081**] for renal malignancy
-OA
-TAHSO

Social History:
Lives with husband, works as a school cross-guard, remote
tobacco x 40 pack-year hx, quit in [**2081**], 2 children.


Family History:
No strokes


Physical Exam:
1a LOC = 0
1b Orientation = 0
1c Commands = 0
2 Gaze = 0
3 Visual Fields = 0
4 Facial Paresis = 1
5a Motor Function R UE = 0
5b Motor Function L UE= 0
6a Motor Function R LE= 0
6b Motor Function L LE= (old weakness IP )
7 Limb Ataxia = 0
8 Sensory perception = 0
9 Language = 1 ( mild aphasia )
10 Dysarthria = 0
11 Extinction/Inattention = 0
TOTAL = 2

VITALS: HR 97 afib BP 134/60 RR 22 sO2 99%RA
GEN: NAD
HEENT: mmm
NECK: no LAD; no carotid bruits; full range neck movements
LUNGS: Clear to auscultation bilaterally
HEART: irregular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema

MENTAL STATUS:
Awake and alert, cooperative with exam, normal affect.
Oriented to place, month, day, and date, person.
Attention: DOWbw.
Language: fluent; repetition: mildy impaired; anomia to
low-frequency objects; Comprehension intact; no dysarthria,
presence of paraphasic errors. Writing: intact.
[**Location (un) **]: intact
Prosody: normal
No Apraxia.  No Neglect. Some L-R confusion and acalculia.

CRANIAL NERVES:
II: Visual fields are full to confrontation, pupils equally
round and reactive to light both directly and consensually,
3-->2 mm bilaterally.
III, IV, VI: Extraocular movements intact without nystagmus. No
ptosis.
V: Facial sensation intact to light touch.
VII: Facial movement symmetrical; no clear facial droop but
possible mild flattening of R nasolabial fold.
VIII: Hearing intact to finger rub bilaterally.
IX: Palate elevates in midline.
XII: Tongue protrudes in midline, no fasciculations.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.

MOTOR SYSTEM: Normal bulk and tone bilaterally. No adventitious
movements, no tremor, no asterixis.
      D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 5 5 5 5  5  5   5   5   5 5 5 5   5 5  5
Left  5 5 5 5  5  5   5   4   5 5 5 5   5 5  5
No pronator drift. No rebound.

REFLEXES:
      B T Br Pa Pl
Right 1  1 1  0  1
Left  1  1 1  0  1
Planatr response withdrawal bilat.

SENSORY SYSTEM: Sensation intact to light touch and
proprioception in all extremities.

COORDINATION: Normal [**Last Name (LF) 11140**], [**First Name3 (LF) **]. No dysmetria or pastpointing.

GAIT: not evaluated

Pertinent Results:
LABS:
[**2100-10-14**] 08:00PM BLOOD WBC-7.9 RBC-4.71 Hgb-13.0 Hct-38.6 MCV-82
MCH-27.6 MCHC-33.7 RDW-14.3 Plt Ct-306
[**2100-10-19**] 06:55AM BLOOD WBC-6.4 RBC-4.41 Hgb-12.1 Hct-35.9*
MCV-82 MCH-27.4 MCHC-33.6 RDW-13.7 Plt Ct-274
[**2100-10-14**] 08:00PM BLOOD Neuts-55.8 Lymphs-35.0 Monos-5.8 Eos-2.6
Baso-0.7
[**2100-10-14**] 08:00PM BLOOD PT-13.1 PTT-29.5 INR(PT)-1.1
[**2100-10-19**] 06:55AM BLOOD PT-17.8* PTT-41.4* INR(PT)-1.6*
[**2100-10-14**] 08:00PM BLOOD Glucose-115* UreaN-25* Creat-1.2* Na-140
K-4.1 Cl-103 HCO3-26 AnGap-15
[**2100-10-19**] 06:55AM BLOOD Glucose-90 UreaN-17 Creat-1.4* Na-139
K-4.4 Cl-103 HCO3-27 AnGap-13
[**2100-10-14**] 08:00PM BLOOD CK(CPK)-75
[**2100-10-15**] 04:12AM BLOOD ALT-19 AST-14 CK(CPK)-59
[**2100-10-15**] 10:25AM BLOOD CK(CPK)-56
[**2100-10-14**] 08:00PM BLOOD cTropnT-<0.01
[**2100-10-15**] 04:12AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2100-10-15**] 04:12AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.0 Cholest-194
[**2100-10-15**] 04:12AM BLOOD Triglyc-90 HDL-66 CHOL/HD-2.9 LDLcalc-110
[**2100-10-15**] 04:12AM BLOOD %HbA1c-5.9
[**2100-10-15**] 04:12AM BLOOD TSH-2.4
[**2100-10-15**] 04:12AM BLOOD CRP-7.9*
[**2100-10-14**] 10:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.036*
[**2100-10-14**] 10:15PM URINE Blood-TR Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2100-10-14**] 10:15PM URINE RBC-0-2 WBC-3 Bacteri-MANY Yeast-NONE
Epi-0-2

MICRO:
Urine Cx ([**10-14**]): ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.
         SENSITIVITIES: MIC expressed in MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

IMAGING:
ECG ([**10-14**]): Atrial fibrillation with rapid ventricular response
at a rate of 93.

CT Head, CTA head/neck, CTP ([**10-14**]): IMPRESSION: Dense left MCA
with perfusion imaging demonstrating ischemic tissue in the left
MCA distribution. Filling defect within the distal M1 segment of
the left MCA compatible with acute clot. No evidence for
hemorrhage.

TTE ([**10-15**]): 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 global systolic function are normal (LVEF
50-55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. There appears to be
mild global left ventricular hypokinesis, which may be partially
explained by the markedly irregular rhythm (LVEF = 50%). 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. Trace aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: No PFO or ASD seen. Normal global and regional
biventricular systolic function.

CXR ([**10-15**]): IMPRESSION: Cardiomegaly with elevated pulmonary
venous pressure.

MRI/MRA Head ([**10-15**]):
MRI IMPRESSION: Tiny areas of increased signal on diffusion
images in the left frontal lobe and external capsule insular
region without definite corresponding abnormalities on ADC map.
This could be secondary to the small size of the signal changes
on the diffusion images or less likely due to T2 shine-through.
Mild-to-moderate changes of small vessel disease.
MRA IMPRESSION: No significant abnormalities on MRA of the head.
The filling defects and/or the narrowing seen in the left middle
cerebral artery on CT angiography is no longer visible.

Brief Hospital Course:
The patient is a 67 year old right handed woman with a history
of atrial fibrillation not on Coumadin, hypertension, and
hyperlipidemia who presented with a [**9-22**] minute episode of
word-finding difficulties with possible reported L facial droop,
and then had another episode of expressive aphasia while in the
ED. She was a Code Stroke in the ED, with blood pressure 210/120
on admission. CTA Head/Neck, CTP showed dense left MCA with
perfusion imaging demonstrating ischemic tissue in the left MCA
distribution, filling defect within the distal M1 segment of the
left MCA compatible with acute clot, and no evidence for
hemorrhage. MRI/MRA showed tiny areas of increased signal on
diffusion images in the left frontal lobe and external capsule
insular region, and no significant abnormalities on MRA of the
head. TTE showed LVEF 50-55%, no PFO or ASD, mild global left
ventricular hypokinesis, which may be partially explained by the
markedly irregular rhythm, mild (1+) mitral regurgitation.
Given that she had a mild aphasia and likely cardioembolic
source of stroke, thrombolysis was not given. CEs: CK 75-59-56,
TropT <0.01 x2, FLP Chol 194, TG 90, HDL 66, LDL 110, HgA1c
5.9%, TSH 2.4, CRP 7.9. She was started on a heparin gtt given
the partial opacification of the M2 segment of L MCA suggesting
intraarterial embolus. She was initially admitted to NeuroICU,
but transferred to the Neurology floor when stable. She was
continued on a heparin gtt for bridge to Coumadin 5 mg daily.
Her ASA was discontinued. She was discharged on Lovenox 100 [**Hospital1 **]
to finish the bridge to Coumadin, and her INR was 1.6 at the
time of discharge. Her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], will follow her INR as an
outpatient. Her blood pressure was initially allowed to
auto-regulate, but her home doses of Atenolol 12.5 mg daily,
Verapamil 240 daily, and HCTZ 25 daily were restarted at the
time of discharge. She was continued on Simvastatin 80 daily.
She will follow up with Dr. [**Last Name (STitle) **] in Neurology as an
outpatient.
Her UA showed neg leuk, pos nitr, 3 WBC, many bacteria. Urine
culture grew pan-sensitive E. coli, and she was started on
Bactrim DS [**Hospital1 **] to complete a 5 day course.

Medications on Admission:
-Nitro PRN
-Verapamil 240 mg Qday
-Nexium 40 mg
-Atenolol 12.5 mg Qday
-ASA 325 mg Qday
-HCTZ 25 Qday
-Simvastatin 80 mg Qday
-Percocet PRN

Discharge Medications:
1. Outpatient Lab Work
Please have your INR and creatinine checked on Wednesday, [**10-20**]
and Friday [**10-22**], and have the results called to Dr.[**Name (NI) 15301**]
office at [**Telephone/Fax (1) 93680**].
2. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 1 days.
Disp:*2 Tablet(s)* Refills:*0*
4. Enoxaparin 100 mg/mL Syringe Sig: One (1)  Subcutaneous [**Hospital1 **]
(2 times a day) for 3 days.
Disp:*6 syringes* Refills:*0*
5. Lovenox 100 mg/mL Syringe Sig: One (1)  Subcutaneous twice a
day for 3 days.
Disp:*6 syringes* Refills:*0*
6. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.

9. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
10. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.


Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY:
Stroke-Left MCA infarct, likely cardioembolic
Atrial Fibrillation
Urinary Tract Infection

SECONDARY:
Hypertension
Hyperlipidemia


Discharge Condition:
Stable, speech fluent


Discharge Instructions:
You were admitted to the hospital with word finding difficulties
and possible facial droop, and were found to have a mini-stroke.
The stroke is most likely due to your atrial fibrillation.

The following changes were made to your medications:
1. You were started on Coumadin.  You should take 5 mg once a
day, and should have blood work drawn so that we can check the
level.
2. You should take Lovenox twice a day until your Coumadin level
is therapeutic (INR [**1-10**]).  Dr. [**Last Name (STitle) **] will be watching your INR,
and you should call her office after you get your next INR check
to see if you can stop the Lovenox.

Your Aspirin was discontinued now that you are on Coumadin.

You were started on Bactrim for a urinary tract infection, and
should complete a 5 day course.

If you develop weakness or numbness, difficulty speaking or
swallowing, decreased vision or blurry vision, or any other
symptoms that concern you, call your PCP or return to the ED.

Followup Instructions:
You have a follow up appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **] in
Neurology ([**Telephone/Fax (1) 2574**]) on [**2100-11-23**] at 2:30 in the [**Hospital Ward Name 23**]
Center, [**Location (un) 858**].

Please call Dr.[**Name (NI) 15301**] office at [**Telephone/Fax (1) 93680**] to set up a
referral to their [**Hospital 197**] clinic, so that they can keep a close
eye on your INR.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
{'Cerebral embolism with cerebral infarction,Urinary tract infection, site not specified,Atrial fibrillation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of kidney,Obesity, unspecified,Knee joint replacement,Abnormal coagulation profile'}


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: Word finding difficulties, possible left facial droop

PRESENT ILLNESS: The patient is a 67 yo RHF with HTN, HLD, afib not on
anticoagulation without known contraindications, on ASA 325
Qday, presented to ED today after episode at 19h05 of
word-finding difficulties with possible reported L facial droop,
lasting 10-15 mins. The patient was having difficulty giving a
history due to her expressive aphasia and her husband, who was
present at the bedside, was not up to date as to her medical
history so information was obtained from the [**Hospital1 112**] where she is
followed. By the time she was evaluated in the ED these had
resolved, gluc was 114, BP was elevated at SBP 210/120 but then
normalized and found to be in afib. At 20h15 pm she had been
normally conversant and her RN was asking her to list her
medications and acutely she was noted to develop an expressive
aphasia, not able to respond verbally to the question.
Comprehension seemed intact. A code stroke was called and her
NIHSS at the time was 1. She was taken emergently for CTA and
CTP, revealing a L MCA clot. No headache, no chest
pain/palpitations/SOB. No recent illnesses. No surgeries since
TKR last year. A few weeks ago experienced transient episode of
lightheadedness. No prior known strokes. Wears glasses for
[**Location (un) 1131**].

MEDICAL HISTORY: -HTN
-HLD
-afib not on anticoagulation without known contraindication
-L total knee replaecment in [**2099-7-8**]
-obesity
-anxiety
-nephrectomy in [**2081**] for renal malignancy
-OA
-TAHSO

MEDICATION ON ADMISSION: -Nitro PRN
-Verapamil 240 mg Qday
-Nexium 40 mg
-Atenolol 12.5 mg Qday
-ASA 325 mg Qday
-HCTZ 25 Qday
-Simvastatin 80 mg Qday
-Percocet PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 1a LOC = 0
1b Orientation = 0
1c Commands = 0
2 Gaze = 0
3 Visual Fields = 0
4 Facial Paresis = 1
5a Motor Function R UE = 0
5b Motor Function L UE= 0
6a Motor Function R LE= 0
6b Motor Function L LE= (old weakness IP )
7 Limb Ataxia = 0
8 Sensory perception = 0
9 Language = 1 ( mild aphasia )
10 Dysarthria = 0
11 Extinction/Inattention = 0
TOTAL = 2

FAMILY HISTORY: No strokes

SOCIAL HISTORY: Lives with husband, works as a school cross-guard, remote
tobacco x 40 pack-year hx, quit in [**2081**], 2 children. 

### Response:
{'Cerebral embolism with cerebral infarction,Urinary tract infection, site not specified,Atrial fibrillation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of kidney,Obesity, unspecified,Knee joint replacement,Abnormal coagulation profile'}
