CHIEF COMPLAINT: left frontal operculum stroke

PRESENT ILLNESS: This is a 70 yo woman with hx CAD, high chol, HTN, who presents
at 6:30PM to [**Hospital1 18**] after presenting at 1PM to [**Hospital **] Hospital
with global aphasia since last known well time of NOON, s/p IV
TPA and transferred to [**Hospital1 18**] for further post-TPA care.  Hx
provided by son in law, at bedside: pt had been feeling
"slightly
unwell" over wknd, had c/o leg cramps bilaterally.  Was last
seen
by husband to be well at noon - husband left house to take a
walk, and returned between 12:20 and 12:30 PM to find wife
staring straight ahead and not talking, not interacting well.
He
feels that she seemed to understand what he was saying to her;
he
asked her to get in the car, and she had no trouble walking to
car, and even locked door on the way out.  No obvious weakness
anywhere, or gait problems.  [**Name (NI) 4906**] brought pt by car to
[**Hospital **]
Hospital, where initial NIHSS score documented as 7 (2 for LOC
questions, 3 for mute/aphasic, and 2 for dysarthria "speech so
slurred or pt mute" - Dr. [**First Name (STitle) **]/neurology [**Name (NI) 653**], and after
head CT negative for ICH (or early signs of stroke), IV TPA
given
at 14:48 (6mg bolus for wt 150 lbs, followed by infusion of 55mg
over 1 hr, ended at 15:35).  BG at time was 121, but unknown
coags.  Per family's request (upon arrival of son in law and
daughter), pt was transferred to [**Hospital1 18**] for post-TPA care.  Of
note, following TPA administration, nursing note reads "Pt seems
to say 'yes' to all questions."  Initially in [**Hospital1 18**] ER, BP was
178/117 but was rechecked as 160/80 after no intervention.
There
is no difference in her exam, though her son in law feels that
she appears very fatigued.

MEDICAL HISTORY: PMH:
CAD s/p MI 5 yrs ago s/p stent (unknown details, osh)
High chol
HTN
"occasional headaches"
s/p basal cell ca resection 1 mo ago
GERD

MEDICATION ON ADMISSION: Atenolol 50 mg [**Hospital1 **]
Zetia 10 mg qd
Nexium 40 mg qd
Wellchol - not taking, per daughter, as bottle full
ASA 81 mg po qday

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Examination:
Afebrile, hr 60, bp initiall 178/117 upon arrival-> 160s/80s
with
no intervention when rechecked, RR 17, 97% 2L
General appearance: white female, appears younger than stated
age
HEENT: moist mucus membranes, clear oropharynx
Neck: supple, no bruits
Heart: regular rate and rhythm, no murmurs
Lungs: clear to auscultation bilaterally
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
No TTP along spine.

FAMILY HISTORY: Family History:
No known early strokes in family.

SOCIAL HISTORY: Social History:
Lives with husband, very physically active, takes care of 4
horses; no tob, etoh, drugs.  Has one son [**Doctor First Name **], one daughter.
Cerebral artery occlusion, unspecified with cerebral infarction,Rheumatic mitral insufficiency,Thoracic aneurysm without mention of rupture,Coronary atherosclerosis of native coronary artery,Pure hypercholesterolemia,Unspecified essential hypertension,Old myocardial infarction,Esophageal reflux,Personal history of other malignant neoplasm of skin,Facial weakness,Aphasia
Crbl art ocl NOS w infrc,Rheumatic mitral insuff,Thoracic aortic aneurysm,Crnry athrscl natve vssl,Pure hypercholesterolem,Hypertension NOS,Old myocardial infarct,Esophageal reflux,Hx-skin malignancy NEC,Facial weakness,Aphasia
Admission Date:  [**2141-6-12**]              Discharge Date:   [**2141-6-16**]

Date of Birth:  [**2070-7-11**]             Sex:   F

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
left frontal operculum stroke

Major Surgical or Invasive Procedure:
none


History of Present Illness:
This is a 70 yo woman with hx CAD, high chol, HTN, who presents
at 6:30PM to [**Hospital1 18**] after presenting at 1PM to [**Hospital **] Hospital
with global aphasia since last known well time of NOON, s/p IV
TPA and transferred to [**Hospital1 18**] for further post-TPA care.  Hx
provided by son in law, at bedside: pt had been feeling
"slightly
unwell" over wknd, had c/o leg cramps bilaterally.  Was last
seen
by husband to be well at noon - husband left house to take a
walk, and returned between 12:20 and 12:30 PM to find wife
staring straight ahead and not talking, not interacting well.
He
feels that she seemed to understand what he was saying to her;
he
asked her to get in the car, and she had no trouble walking to
car, and even locked door on the way out.  No obvious weakness
anywhere, or gait problems.  [**Name (NI) 4906**] brought pt by car to
[**Hospital **]
Hospital, where initial NIHSS score documented as 7 (2 for LOC
questions, 3 for mute/aphasic, and 2 for dysarthria "speech so
slurred or pt mute" - Dr. [**First Name (STitle) **]/neurology [**Name (NI) 653**], and after
head CT negative for ICH (or early signs of stroke), IV TPA
given
at 14:48 (6mg bolus for wt 150 lbs, followed by infusion of 55mg
over 1 hr, ended at 15:35).  BG at time was 121, but unknown
coags.  Per family's request (upon arrival of son in law and
daughter), pt was transferred to [**Hospital1 18**] for post-TPA care.  Of
note, following TPA administration, nursing note reads "Pt seems
to say 'yes' to all questions."  Initially in [**Hospital1 18**] ER, BP was
178/117 but was rechecked as 160/80 after no intervention.
There
is no difference in her exam, though her son in law feels that
she appears very fatigued.


Past Medical History:
PMH:
CAD s/p MI 5 yrs ago s/p stent (unknown details, osh)
High chol
HTN
"occasional headaches"
s/p basal cell ca resection 1 mo ago
GERD


Social History:
Social History:
Lives with husband, very physically active, takes care of 4
horses; no tob, etoh, drugs.  Has one son [**Doctor First Name **], one daughter.


Family History:
Family History:
No known early strokes in family.


Physical Exam:
Examination:
Afebrile, hr 60, bp initiall 178/117 upon arrival-> 160s/80s
with
no intervention when rechecked, RR 17, 97% 2L
General appearance: white female, appears younger than stated
age
HEENT: moist mucus membranes, clear oropharynx
Neck: supple, no bruits
Heart: regular rate and rhythm, no murmurs
Lungs: clear to auscultation bilaterally
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
No TTP along spine.

Mental Status: The patient is alert awake; could understand
command to "close eyes" and "open eyes" but did not understand
other verbal commands; could imitate with nonverbal cues, though
not 100% of time; did not make facial expressions, stick out
tongue, or close eyes "tighter."  No verbal output (completely
mute).  Occasionally closed eyes when not being spoken to, but
appeared alert, with somewhat poor eye contact when being
addressed directly.

Cranial Nerves: +blink to threat bilat. The optic discs are
normal in appearance. Eye movements are normal, with no
nystagmus.  Pupils react equally to light, both directly and
consensually.  +Corneals bilat.  Facial movements are
diminished,
with no volitional mvmt of facial mms, did not protrude tongue -
no obvious asymmetry. Hearing is intact to voice/commands.

Motor System: No obvious abnl bulk/tone, full strength at delt,
[**Hospital1 **], tri, wrist ext, finger ext, finger flex, IPs, hams, quads,
TAs, gastrocs, with no drift, no asterixis

Reflexes: The tendon reflexes are 2+ at [**Hospital1 **], [**Last Name (un) **], tri, knees,
ankles, with downgoing toes bilat

Sensory: W/d slightly to tickling x 4 ext, no obvious asymmetry;
no obvious unilateral neglect.

Coordination: There is no ataxia, with nl RAMs, nl f->n bilat

Gait:  deferred for now


Pertinent Results:
[**2141-6-15**] 06:15AM BLOOD WBC-6.2 RBC-3.79* Hgb-12.3 Hct-34.6*
MCV-91 MCH-32.5* MCHC-35.7* RDW-13.1 Plt Ct-222
[**2141-6-14**] 07:05AM BLOOD PT-12.1 PTT-22.1 INR(PT)-1.0
[**2141-6-15**] 06:15AM BLOOD Glucose-118* UreaN-12 Creat-0.7 Na-140
K-3.7 Cl-104 HCO3-27 AnGap-13
[**2141-6-12**] 08:10PM BLOOD ALT-22 AST-25 CK(CPK)-181* AlkPhos-92
Amylase-52 TotBili-0.5
[**2141-6-15**] 06:15AM BLOOD ALT-PND AST-PND CK(CPK)-58 Amylase-PND
TotBili-PND
[**2141-6-15**] 06:15AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.2
[**2141-6-13**] 03:25AM BLOOD Triglyc-70 HDL-71 CHOL/HD-3.0 LDLcalc-125
[**2141-6-12**] 08:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Studies:
MRI brain/MRA brain:  Acute infarct in the superior division of
the left MCA territory.The posterior circulation is patent with
no significant stenosis. In the superior division of the left
MCA is an abrupt cut off of signal on time-of-flight images,
suggesting stenosis from embolus to this vessel. The remaining
branches of the anterior circulation are patent. No evidence of
aneurysm.Loss of signal in the superior division of the left
MCA, likely from embolus to this vessel.

EEG: This is an abnormal EEG in the waking and drowsy states due

to the persistent left posterior quadrant slowing and left
temporal
rhythmic slowing. This suggests left posterior quadrant
subcortical
dysfunction, while rhythmic left temporal slowing suggests a
region of
cortical irritability. No epileptiform features were noted.

Surface echocardiogram:
 No PFO/ASD seen. Preserved global and regional biventricular
systolic function. Mild rheumatic mitral stenosis with moderate
mitral
regurgitation. Mild aortic regurgitation. Mild pulmonary
hypertension.
Moderately dilated ascending aorta.

carotid US: Less than 40% stenosis of the proximal internal
carotid arteries bilaterally. This is a baseline examination at
the [**Hospital1 18**].


Brief Hospital Course:
Neurology: Patient admitted for known left frontal operculum
stroke s/p IV TPA likely of cardioembolic etiology. She was in
the ICU x 24 hours on admission for post-IV TPA care. The
patient had an EEG because of first presentation of global
aphasia to rule out seizure (as outside CT scan showed no
evidence of stroke). Her EEg showed no epileptiform activity
that would be concerning for seizure but showed some slowing
over the area of the infarction site. The patient received a
work-up for stroke. Her labs are as following: HgbA1c 6%, LDL
121, HDL 71. Her suface echocardiogram showed the mitral valve
leaflets are mildly thickened, with
characteristic rheumatic deformity. She had mild left atrial
dialtion. No thrombus, vegetations or PFO noted. Family declined
trans-esophageal echocardiogram to visualize aorta. Patient was
kept on telemetry during her hospital stay with no arrhythmias
noted.

In terms of exam, it was clear patient had some dysfunction of
facial muscles from stroke site which limited facial expression
and ability to take oral foods. She initially failed her swallow
study but on follow-up testing with bedside swallow study and
video swallow study, she was cleared for regular diet and thin
fluids. She improved in terms of her ability to produce speech
but speaks with hypophonic voice, and has little spontaneous
speech output. She will work with outpatient speech therapy.
PT/OT cleared her for home discharge.

Upon further discussions with family, it was thought the patient
did take a baby aspirin at home so patient discharged on
Aggrenox. She has history of muscle aches with statins. CK
checked and was 58 and LFTS nml. She was started on Zetia 10 mg
po qday which will be monitored by her primary care doctor.


Medications on Admission:
Atenolol 50 mg [**Hospital1 **]
Zetia 10 mg qd
Nexium 40 mg qd
Wellchol - not taking, per daughter, as bottle full
ASA 81 mg po qday

Discharge Medications:
1. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO twice a day: you may start with one pill
qday x 3 days. If no headache, you may take 1 tab po twice
daily.
Disp:*60 Cap(s)* Refills:*2*
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Outpatient Speech/Swallowing Therapy
Speech therapy outpatient therapy


Discharge Disposition:
Home

Discharge Diagnosis:
stroke


Discharge Condition:
stable. MS: hypophonic voice, few spontaneous words. Does not
read. Follows midline and appendicular commands. Has mild right
facial droop. Mild right UMN pattern right arm weakness.


Discharge Instructions:
Please follow-up with appointments and take medications as
instructed.

Followup Instructions:
[**Hospital 4038**] Clinic. Neurology. [**Hospital1 18**] [**Hospital Ward Name 23**] [**Location (un) **]. [**Name6 (MD) 3688**] [**Name8 (MD) 72617**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2141-7-18**] 9:30 AM. YOU
MUST CALL TO CONFIRM THIS APPOINTMENT
{'Cerebral artery occlusion, unspecified with cerebral infarction,Rheumatic mitral insufficiency,Thoracic aneurysm without mention of rupture,Coronary atherosclerosis of native coronary artery,Pure hypercholesterolemia,Unspecified essential hypertension,Old myocardial infarction,Esophageal reflux,Personal history of other malignant neoplasm of skin,Facial weakness,Aphasia'}


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: left frontal operculum stroke

PRESENT ILLNESS: This is a 70 yo woman with hx CAD, high chol, HTN, who presents
at 6:30PM to [**Hospital1 18**] after presenting at 1PM to [**Hospital **] Hospital
with global aphasia since last known well time of NOON, s/p IV
TPA and transferred to [**Hospital1 18**] for further post-TPA care.  Hx
provided by son in law, at bedside: pt had been feeling
"slightly
unwell" over wknd, had c/o leg cramps bilaterally.  Was last
seen
by husband to be well at noon - husband left house to take a
walk, and returned between 12:20 and 12:30 PM to find wife
staring straight ahead and not talking, not interacting well.
He
feels that she seemed to understand what he was saying to her;
he
asked her to get in the car, and she had no trouble walking to
car, and even locked door on the way out.  No obvious weakness
anywhere, or gait problems.  [**Name (NI) 4906**] brought pt by car to
[**Hospital **]
Hospital, where initial NIHSS score documented as 7 (2 for LOC
questions, 3 for mute/aphasic, and 2 for dysarthria "speech so
slurred or pt mute" - Dr. [**First Name (STitle) **]/neurology [**Name (NI) 653**], and after
head CT negative for ICH (or early signs of stroke), IV TPA
given
at 14:48 (6mg bolus for wt 150 lbs, followed by infusion of 55mg
over 1 hr, ended at 15:35).  BG at time was 121, but unknown
coags.  Per family's request (upon arrival of son in law and
daughter), pt was transferred to [**Hospital1 18**] for post-TPA care.  Of
note, following TPA administration, nursing note reads "Pt seems
to say 'yes' to all questions."  Initially in [**Hospital1 18**] ER, BP was
178/117 but was rechecked as 160/80 after no intervention.
There
is no difference in her exam, though her son in law feels that
she appears very fatigued.

MEDICAL HISTORY: PMH:
CAD s/p MI 5 yrs ago s/p stent (unknown details, osh)
High chol
HTN
"occasional headaches"
s/p basal cell ca resection 1 mo ago
GERD

MEDICATION ON ADMISSION: Atenolol 50 mg [**Hospital1 **]
Zetia 10 mg qd
Nexium 40 mg qd
Wellchol - not taking, per daughter, as bottle full
ASA 81 mg po qday

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Examination:
Afebrile, hr 60, bp initiall 178/117 upon arrival-> 160s/80s
with
no intervention when rechecked, RR 17, 97% 2L
General appearance: white female, appears younger than stated
age
HEENT: moist mucus membranes, clear oropharynx
Neck: supple, no bruits
Heart: regular rate and rhythm, no murmurs
Lungs: clear to auscultation bilaterally
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
No TTP along spine.

FAMILY HISTORY: Family History:
No known early strokes in family.

SOCIAL HISTORY: Social History:
Lives with husband, very physically active, takes care of 4
horses; no tob, etoh, drugs.  Has one son [**Doctor First Name **], one daughter. 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Rheumatic mitral insufficiency,Thoracic aneurysm without mention of rupture,Coronary atherosclerosis of native coronary artery,Pure hypercholesterolemia,Unspecified essential hypertension,Old myocardial infarction,Esophageal reflux,Personal history of other malignant neoplasm of skin,Facial weakness,Aphasia'}
