CHIEF COMPLAINT: aphasia

PRESENT ILLNESS: Reason for Consult: Called by Emergency Department to evaluate
for aphasia, transferred from OSH s/p tPA

MEDICAL HISTORY: -Alzheimer's Disease
-HTN
-GERD
-macular degeneration

MEDICATION ON ADMISSION: -ASA 81 mg daily
-Atenolol 50 mg daily
-Hudrocerin cream to skin on arms and legs at bedtime
-I-CAPS plus daily
-Lisinopril 20 mg daily
-Multivitamin
-Namenda 10 mg [**Hospital1 **]
-Ranitidine 150 mg daily
-Vitamin D 1000 units daily
-Loperamide 2 mg prn diarrhea

ALLERGIES: Penicillins

PHYSICAL EXAM: Physical Exam on Admission:

FAMILY HISTORY: Unable to obtain from patient

SOCIAL HISTORY: She lives in the memory impairment unit of an [**Hospital3 12272**] facility in [**Location (un) 5028**]. Distant smoking history, but not
believed to have smoked in over 40 years, per her daughter.
Cerebral embolism with cerebral infarction,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Other speech disturbance,Other musculoskeletal symptoms referable to limbs,Facial weakness,Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility,Unspecified essential hypertension,Macular degeneration (senile), unspecified,Esophageal reflux,Other generalized ischemic cerebrovascular disease
Crbl emblsm w infrct,Alzheimer's disease,Dementia w/o behav dist,Speech disturbance NEC,Muscskel sympt limb NEC,Facial weakness,TPA adm status 24 hr pta,Hypertension NOS,Macular degeneration NOS,Esophageal reflux,Ac cerebrovasc insuf NOS
Admission Date:  [**2194-12-11**]              Discharge Date:   [**2194-12-13**]


Service: NEUROLOGY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
aphasia

Major Surgical or Invasive Procedure:
IV tPA

History of Present Illness:
Reason for Consult: Called by Emergency Department to evaluate
for aphasia, transferred from OSH s/p tPA

Time Code Stroke called: 00:14
Time Neurology at bedside for evaluation: 00:15
Time (and date) the patient was last known well: [**2194-12-10**] 20:15
NIH Stroke Scale Score: 6
t-[**MD Number(3) 6360**]:   -x-- Yes     Time t-PA was given   22:52 (tpA
given
at OSH prior to transfer)
              --- No       Reason t-PA was not given or

I was present during the CT scanning and reviewed the images
within 20 minutes of their completion.


HPI:

  Ms. [**Known lastname 30674**] is a 87 year-old woman (likely right handed as she
took ppen to write with right hand) with PMH significant for
Alzheimer's Disease, HTN and macular degeneration who developed
acute onset aphasia, right facial droop (though daughter who was
present at bedside after eval. noted she never appreciated
facial
droop), right sided neglect and possbily right sided weakness
(no
clear documentation of this in transfer records). She was last
known well at 8:15 PM. Symptoms were noted at 8:45 PM. She
presented to [**Hospital3 26615**] with these symptoms and was given tPA
(bolus noted to be given at 10:52 PM). She was then transferred
to [**Hospital1 18**] for futher evaluation and management. Per EMS, she was
initially noted to be mute, but would shake head yes/no to
questions en route to [**Hospital1 18**]. Soon after arrival to [**Hospital1 18**], while
EMS was present, she was able to say her name and some other
words; EMS noted this to be signiciant improvement from earlier.

  Her daughter was present at bedside after initial evaluation
and was able to provide some history regarding baseline status.
She says that she lives in the memory impairment unit of an
[**Hospital3 **] facility in [**Location (un) 5028**]. She has Alzheimer's,
with dementia noted to be mild to moderate. She gets help with
ADLs at her facility. She knows her birthday, but at baseline
usually does not know her age or who is President. She is able
to
communicate. Of note, she was signing cards for her
grandchildren
earlier in the day today and her daughter noted she spelled one
of their names wrong, which she has never done before. She
ambulates with a cane at baseline.


ROS: unable to obtain from patient.

Past Medical History:
-Alzheimer's Disease
-HTN
-GERD
-macular degeneration


Social History:
She lives in the memory impairment unit of an [**Hospital3 12272**] facility in [**Location (un) 5028**]. Distant smoking history, but not
believed to have smoked in over 40 years, per her daughter.

Family History:
Unable to obtain from patient

Physical Exam:
Physical Exam on Admission:

Vitals: T: 97.7 P: 63 R: 14  BP: 131/53

General: Awake, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple
Pulmonary: scattered rhonci
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, NT/ND, +BS
Extremities: warm, well perfused

Neurologic:

NIH Stroke Scale score was: 6
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0 (blinks to threat b/l, difficult to perform
confrontation testing, number counting mistakes in RLQ, but this
is not definitive)
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 2
10. Dysarthria: 1
11. Extinction and Neglect: 1 (inconsistent with sensory and
visual extinction right; sometimes accurate, sometimes not,
possibly component of inattention, but when mistakes were made,
always on the right)

Mental Status: Awake, alert, oriented to person only.
Inattentive- able to name [**Doctor Last Name 1841**] forwards up until [**Month (only) 116**] and then got
stuck and was unable to proceed. She is perseverative. She is
able say the year she was born, but does not know her age. She
is
unable to name the POTUS. She is able to tell me the names of
her
daughter and son-in-law. [**Name (NI) **] to follow simple midline and
appendicular commands. No right-left confusion. No definitive
objective evidence of spatial neglect, but when given the
picture
to describe, she only seemed to be looking at left side of
picture when trying to say what she was seeing (her nonfluent
aphasia prevented her from saying anything meaningful though).
She does attend to people who are on her right side.

Language: nonfluent aphasia. The speech she did produce
initially
sounded dysarhtric, but this seemed to improve with time. She
never produced a fluent sentence of 7 grammatically correct
words. No spontaneous speech, but is able to respond to
questions. Was unable to describe what she saw in picture. Her
vocabulary and ability to respond to questions was improving
over
time. Anomia (she was unable to name anything). She is able to
repeat. She is able to follow simple 2 commands (point to
curtain
after pointing to ceiling and also point to ceiling and then
close your eyes). Occasional paraphasic errors. She was able to
read a 3 word sentence, but had difficulty [**Location (un) 1131**] longer
sentences. She was unable to write a sentence.

Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm. She blinked to threat bilaterally. Difficult
to perform visual field testing to confrontation due to her
inattention, but on finger counting in different quadrants,
there
is a possible right lower quadrantanopia (she would consistently
make mistakes in this quadrant, but not consistently in others,
though she did an occasional mistake in other quadrants).
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: There is possibly a slight right lower facial droop, but
the
NLF is symmetric. Her daughter does not note any asymmetry.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.

Motor: Normal bulk, tone throughout. No pronator drift on right,
though she did curl fingers on right. Formal strength testing
difficult due to inattention, but from what she was able to
participate in, strength appeared full and symmetric
bilaterally,
including at deltoids, biceps, triceps, FE, IP and hams.

Sensory: No deficits to light touch or noxious (pinching).
Pinprick deferred given recent tPA use. Proprioception attempted
but she was too inattentive to participate in this. She would
occasionally extinguish right on DSS testing, but would often
answer correctly.

DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  3  3    3    2   0
R  3  3    3    2   0
No clonus. Plantar response was extensor bilaterally.

Coordination: No intention tremor or dysmetria on finger-nose,
FNF.

Gait: deferred

=====================================

Physical Exam on Discharge:
VS: T 98.6, BP 120/60, HR 70, RR 18, 96% on RA
GEN: elderly woman sitting in chair, in NAD
HEENT: MMM
CV: RRR
PULM: CTA-B
ABD: soft, NT, ND
EXT: no edema

NEURO:
MS - doesn't know what she ate for breakfast, family reports
that she is back to baseline
CN - very mild R facial droop, EOMI
MOTOR - 5/5 strength throughout
SENSORY - intact to LT throughout
COORDINATION - can reach for examiner's hands bilaterally
GAIT - deferred


Pertinent Results:
From OSH:
WBC 8.4 Hb 12.7 HCT 37.8 Plt 257
Na 140 K 4.3 Cl 104 CO2 28 BUN 26 Cr 1.7 Glu 103

EKG: NSR @60, no ST changes

Radiologic Data:

NCHCT: no acute changes noted; there is diffuse cortical
atrophy.

CTA: left M2 inferior division cut-off with good collaterals and
good distal filling. No other flow limiting stenosis or
thrombosis noted.

CTP: left temporal hypoperfusion with prolonged MTT but no
CBF/CBV mismatch.

_
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_
_
_
_
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_
________________________________________________________________

ADMISSION LABS:

[**2194-12-11**] 11:30AM BLOOD WBC-7.7 RBC-4.09* Hgb-12.1 Hct-36.5
MCV-89 MCH-29.6 MCHC-33.2 RDW-12.9 Plt Ct-284
[**2194-12-12**] 08:10AM BLOOD PT-11.1 PTT-25.8 INR(PT)-1.0
[**2194-12-11**] 11:30AM BLOOD Glucose-95 UreaN-23* Creat-1.5* Na-141
K-4.5 Cl-108 HCO3-25 AnGap-13
[**2194-12-11**] 11:30AM BLOOD ALT-12 AST-20 AlkPhos-83 TotBili-0.3
[**2194-12-11**] 11:30AM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.6 Mg-2.0
Cholest-224*
[**2194-12-11**] 11:30AM BLOOD %HbA1c-5.4 eAG-108
[**2194-12-11**] 11:30AM BLOOD Triglyc-61 HDL-61 CHOL/HD-3.7
LDLcalc-151*

DISCHARGE LABS:

[**2194-12-13**] 04:35AM BLOOD WBC-7.4 RBC-4.00* Hgb-11.9* Hct-35.2*
MCV-88 MCH-29.7 MCHC-33.8 RDW-12.8 Plt Ct-259
[**2194-12-13**] 04:35AM BLOOD Glucose-81 UreaN-20 Creat-1.3* Na-142
K-4.0 Cl-110* HCO3-25 AnGap-11
[**2194-12-13**] 04:35AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.9

IMAGING:

ECHO [**2194-12-11**]:
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-5 mmHg. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal. The right ventricular cavity
is dilated with normal free wall contractility. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
number of aortic valve leaflets cannot be determined. There is
no aortic valve stenosis. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.

IMPRESSION: No intracardiac source of thromboembolism
identified.

CTA [**2194-12-11**]: IMPRESSION:
1. Occlusion of the anterior left M2 division with perfusion
abnormalities
suggesting acute infarct in the left anterior frontal lobe.
There is no
evidence of hemorrhagic transformation or mass effect.
2. Unclear area of increased perfusion and blood volume
involving the medial left frontal lobe (ACA territory). While
these changes may be related to old infarct or neoplasm, there
is no structural CT correlate and MRI should be performed for
further assessment.

CXR [**2194-12-11**]: IMPRESSION: No acute intrathoracic process.

MRI [**2194-12-11**]: IMPRESSION:
1. No evidence of vascular infarction, specifically in left MCA
distribution.
2. Multiple small areas of slow diffusion, with associated ADC
change, too
small to accurately characterize; scattered throughout the right
parietal and left temporal lobes, likely related to embolic
infarction.
3. Severe changes related to the sequelae of chronic small
vessel ischemic
disease.


Brief Hospital Course:
87 year-old right-handed woman with history of Alzheimer's
Disease, HTN, and macular degeneration who presented to OSH with
left hemispheric syndrome (aphasia, right facial droop and
questions of right hemiparesis). Last known well time was 8:15
PM and she was found at 8:45 PM. NIHSS unknown on arrival but
tPA was given at 10:52 PM and she was then transferred to [**Hospital1 18**]
for further management.
Upon arrival, her NIHSS here was 6, with deficits due to her
nonfluent aphasia/anomia and disorientation (though the
disorientation may be her baseline). She had no gross motor or
sensory deficits on exam (although somewhat limited by
inattention). NCHCT showed no acute process; CTA showed L
inferior division cut-off but with good collaterals with good
distal filling. There was decreased left
temporal MTT on CTP but no mismatch. No further intervention was
taken as risks believed to outweigh benefits at that time. She
was admitted to the neuro-ICU for post-tPA monitoring.
.
She was reportedly mute upon arrival at the OSH but her speech
significantly improved after receiving tPA. Upon arrival at
[**Hospital1 18**] she remained nonfluent with dense anomia although was able
to repeat, follow 2-step commands, and read short sentences. She
continued to improve, and the next morning [**Last Name (un) **] able to speak
fluently in complete sentences although still with some anomia
and paraphasic errors.
.
# Neuro:
She was maintained on close neuro and BP checks following tPA.
Her home antihypertensives were held and BP was allowed to
autoregulate with goal SBP 140-180 with hydralazine prn SBP >
180. Her home atenolol was restarted at half her home dose the
following day, then on the day of discharge was increased back
to her prior home dosing. MRI on [**12-11**] showed no evidence of
vascular infarction, specifically in left MCA distribution but
multiple small areas of slow diffusion, with associated ADC
change, too small to accurately characterize; scattered
throughout the right parietal and left temporal lobes, likely
related to embolic infarction as well as severe changes related
to the sequelae of chronic small vessel ischemic
disease.
.
# CVS:
Blood pressure was closely controlled as above. She was
maintained on telemetry monitoring throughout her admission. EKG
showed sinus rythym with atrial premature beats. Cardiac markers
were negative and echo was unremarkable with an EF of 55%.  She
was started on simvastatin 20mg QD for an elevated LDL and for
secondary stroke prevention.  While here her telemetry did not
show any afib.
.
# Renal
Cr was slightly increased at 1.7 on admission. She was
maintained on IVF @ 100cc/hr given elevated Cr and CTA. BUN/Cr
were monitored closely and on day of discharge her Cr was 1.3.
This will need to be monitored further to ensure that it
continues to decrease.
.
# Endo
She was maintained on fingersticks ACHS with insulin sliding
scale with a goal of euglycemia.  Her LDL was 151 so she was
started on simvastatin as above.
.
.
TRANSITIONAL CARE ISSUES
Patient will need her Cr monitored to ensure that it continues
to decrease.  We also recommend that she has a 30 day Holter
monitor set up through her PCP to further evaluate our suspicion
of paroxysmal atrial fibrillation.

Medications on Admission:
-ASA 81 mg daily
-Atenolol 50 mg daily
-Hudrocerin cream to skin on arms and legs at bedtime
-I-CAPS plus daily
-Lisinopril 20 mg daily
-Multivitamin
-Namenda 10 mg [**Hospital1 **]
-Ranitidine 150 mg daily
-Vitamin D 1000 units daily
-Loperamide 2 mg prn diarrhea

Discharge Medications:
1. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
4. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day.
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
9. loperamide 2 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for diarrhea.
10. ICaps     Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day.
11. hudrocerin  Sig: One (1) application  at bedtime.


Discharge Disposition:
Home With Service

Facility:
Excella VNA

Discharge Diagnosis:
Multiple embolic infarcts in right parietal and left temporal
lobes.


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).

NEURO EXAM: difficulty with short-term memory, 5/5 strength
throughout with v. mild R facial droop


Discharge Instructions:
Dear Ms. [**Known lastname 30674**],
You were seen in the hospital because of a left sided stroke.
While here we determined that the likely source of your stroke
was from your heart, but did not find any clots on our imaging.
However, because we suspect that your heart may be
intermittently going in and out of an irregular rythm (atrial
fibrillation), we recommend that your PCP arrange for your to
have a 30 day Holter monitor placed as an outpatient to monitor
your heart rhythm.

We made the following changes to your medications:
1) We STOPPED your ASPIRIN.
2) We STARTED you on SIMVASTATIN 20mg once a day.
3) We STARTED you on PLAVIX 75mg once a day.

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:
Please call your PCP to arrange for a follow-up appointment
within the next 1-2 weeks.

Department: NEUROLOGY
When: TUESDAY [**2195-2-3**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
{"Cerebral embolism with cerebral infarction,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Other speech disturbance,Other musculoskeletal symptoms referable to limbs,Facial weakness,Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility,Unspecified essential hypertension,Macular degeneration (senile), unspecified,Esophageal reflux,Other generalized ischemic cerebrovascular disease"}


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: Reason for Consult: Called by Emergency Department to evaluate
for aphasia, transferred from OSH s/p tPA

MEDICAL HISTORY: -Alzheimer's Disease
-HTN
-GERD
-macular degeneration

MEDICATION ON ADMISSION: -ASA 81 mg daily
-Atenolol 50 mg daily
-Hudrocerin cream to skin on arms and legs at bedtime
-I-CAPS plus daily
-Lisinopril 20 mg daily
-Multivitamin
-Namenda 10 mg [**Hospital1 **]
-Ranitidine 150 mg daily
-Vitamin D 1000 units daily
-Loperamide 2 mg prn diarrhea

ALLERGIES: Penicillins

PHYSICAL EXAM: Physical Exam on Admission:

FAMILY HISTORY: Unable to obtain from patient

SOCIAL HISTORY: She lives in the memory impairment unit of an [**Hospital3 12272**] facility in [**Location (un) 5028**]. Distant smoking history, but not
believed to have smoked in over 40 years, per her daughter. 

### Response:
{"Cerebral embolism with cerebral infarction,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Other speech disturbance,Other musculoskeletal symptoms referable to limbs,Facial weakness,Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility,Unspecified essential hypertension,Macular degeneration (senile), unspecified,Esophageal reflux,Other generalized ischemic cerebrovascular disease"}
