CHIEF COMPLAINT: Code Stroke

PRESENT ILLNESS: Patient is a [**Age over 90 **] year old Russian speaking unknown handedness
woman with past medical history of TIA [**7-3**] with slurring of
speech, atrial fibrillation not on anticoagulation,
hypertension,
severe AS, glaucoma and cataracts with legal blindness who
presented to [**Hospital1 18**] ED on [**2117-10-1**] at 11:55 am as a "Code Stroke".

MEDICAL HISTORY: 1. TIA [**7-3**] with slurred speech
2. Atrial fibrillation not on coumadin
3. Hypertension
4. Severe Aortic Stenosis
5. Dyspnea
6. Leg swelling
7. Hearing loss
8. Glaucoma
9. Cataracts , legally blind

MEDICATION ON ADMISSION: 1. Alphagan
2. ECASA 325 mg po qd
3. Atenolol 50 mg po qd
4. Lasic 20 mg po qd
5. Levobunolol HCL 0.5% gtt
6. Lipitor 10 mg po qd
7. Xalatan 0.005%

ALLERGIES: Lipitor

PHYSICAL EXAM: Tc: BP: 194/122 HR: 125
RR: 18 O2Sat.: 100%/NRB
Finger stick 122
Gen: WD/WN elderly female, resisting examiners, agitated.
HEENT: NC/AT. Anicteric. Corneas clouded bilaterally.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: Tachycardic, irregularly irregular. S1/S2. Grade [**3-7**]
murmur at upper right sternal border, radiating to carotids.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro pre tPA:
Mental status: Awake and alert, nods to family if asked if she
is
in the hospital. Able to state name, but occasionally stuttering

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Social Hx: Lives alone. Moved here from [**Country 532**] 24 years ago.
Employed as a food engineer. No alcohol, tobacco, drug use.
Daughter lives next door. Proxies are her children [**Female First Name (un) **] and
[**Doctor First Name 2491**].
Cerebral embolism with cerebral infarction,Atrial fibrillation,Congestive heart failure, unspecified,Aortic valve disorders,Unspecified essential hypertension,Unspecified hearing loss,Unspecified glaucoma,Legal blindness, as defined in U.S.A.
Crbl emblsm w infrct,Atrial fibrillation,CHF NOS,Aortic valve disorder,Hypertension NOS,Hearing loss NOS,Glaucoma NOS,Legal blindness-usa def
Admission Date:  [**2117-10-1**]              Discharge Date:   [**2117-10-6**]


Service: NEUROLOGY

Allergies:
Lipitor

Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
Code Stroke


Major Surgical or Invasive Procedure:
IV tPA


History of Present Illness:
Patient is a [**Age over 90 **] year old Russian speaking unknown handedness
woman with past medical history of TIA [**7-3**] with slurring of
speech, atrial fibrillation not on anticoagulation,
hypertension,
severe AS, glaucoma and cataracts with legal blindness who
presented to [**Hospital1 18**] ED on [**2117-10-1**] at 11:55 am as a "Code Stroke".

Per information from her family and her home health aide,
patient
was well this morning. Her daughter, who lives next door, was
visiting. Patient ate normally and spent all morning playing
with
her great grandson [**Name (NI) 12130**]. [**Name2 (NI) **] daughter left around 10:15 am.
Around 11 or 11:15am, her home health aide [**Doctor First Name 38329**] arrived. Family

and I spoke to [**Doctor First Name 38329**] via telephone. Per [**Doctor First Name 38329**], patient was able

to open door to let [**Doctor First Name 38329**] in and was walking around the house
normally (in her usual fashion, which is holding onto the walls

because she is legally blind and refuses to use a walker). [**Doctor First Name 38329**]

and patient had conversation. Patient complained about the
weather, but did not endorse any neurologic complaints. Per
[**Doctor First Name 38329**], patient's speech was normal. Then, around 11:30 am, they

went into bathroom to get patient ready for bath. While in
bathroom, patient started to have slurring of speech, was
diaphoretic, and had left facial droop and difficulty using her

left side. [**Doctor First Name 38329**] called the patient's son [**Name (NI) 2491**] who then called

EMS.
She arrived at [**Hospital1 18**] ED at 11:55am. Code Stroke called at
11:57am. Neurology Resident on scene at 12:08pm; stroke fellow
had arrived several minutes earlier.
NIH stroke scale was performed and graded as follows:
1a LOC: Alert=0
1b LOC questions: Said name=1
1c Commands: Able to follow commands=0
2 Gaze: Fixed to right. Could not overcome with OCR=2
3 Vision: Blind per family. No consistent blink to threat=3
4. Facial: Left UMN palsy=2
[**6-4**]. Motor: Holds right arm and leg off bed with no drift. Left

arm and leg are plegic with no withdrawal to pain=3+0+3+0
7. Limb ataxia: Proportional to weakness=0
8. Sensory: Severe sensory loss on left arm/leg/face=2
9. Language: Limited by language barrier, but some
perseveration,
stuttering=1
10. Dysarthria: Speech slurred by family=1.
11. Neglect: Left hemineglect profound=2
Scored at 21. Noncontrast head CT showed no evidence of
hemorrhage. Discussed with Stroke Fellow, Attg Dr. [**Last Name (STitle) **], and
patient's family members. Risks/benefits of thrombolysis
reviewed. Contraindications reviewed with family and patient had

no absolute contraindications by history. Decision made to
proceed with thrombolysis with bolus 4.9 mg and infusion of
44.2mg. Bolus started at 1:30pm. While bolus was being infused,

patient noted to move left arm and to have resolution of her
right eye deviation. Post tPA bolus, BP elevated to 190s
systolic, so at 1:50pm, 5 mg IV Labetalol given per stroke
fellow. 10 mg IV Labetalol given at 2:15pm after BP goals
changed
to systolic of 140-160 after recanulization.
Per family, no recent fevers, chills, chest pain, palpitations,

nausea, vomiting, abdominal pain.


Past Medical History:
1. TIA [**7-3**] with slurred speech
2. Atrial fibrillation not on coumadin
3. Hypertension
4. Severe Aortic Stenosis
5. Dyspnea
6. Leg swelling
7. Hearing loss
8. Glaucoma
9. Cataracts , legally blind


Social History:
Social Hx: Lives alone. Moved here from [**Country 532**] 24 years ago.
Employed as a food engineer. No alcohol, tobacco, drug use.
Daughter lives next door. Proxies are her children [**Female First Name (un) **] and
[**Doctor First Name 2491**].


Family History:
Non-contributory

Physical Exam:
Tc: BP: 194/122 HR: 125
RR: 18 O2Sat.: 100%/NRB
Finger stick 122
Gen: WD/WN elderly female, resisting examiners, agitated.
HEENT: NC/AT. Anicteric. Corneas clouded bilaterally.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: Tachycardic, irregularly irregular. S1/S2. Grade [**3-7**]
murmur at upper right sternal border, radiating to carotids.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro pre tPA:
Mental status: Awake and alert, nods to family if asked if she
is
in the hospital. Able to state name, but occasionally stuttering

her speech and having word finding problems. [**Name (NI) **] to follow
commands to raise arm and leg, grip hand.
Cranial Nerves:
I: Not tested
II: Pupils irregular, post surgical. No blinks at all to left
threat. Inconsistent blink to threat on right.
III, IV, VI: Eyes fixed to right, could not overcome with
oculocephalic manuever.
V, VII: Left upper motor neuron pattern facial droop. Has brisk

bilateral corneal reflexes.
VIII: Hearing grossly intact.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Did not assess.
XII: Tongue midline without fasciculations.
Motor: Diffusely diminished bulk. Left upper extremity flaccid.

Tone in left lower extremity reduced as well. Holds right arm
and
leg off bed against gravity for several seconds without drift.
Unable to hold left arm or leg off bed; they immediately fall
back. No withdrawal in left arm or leg to nailbed or more
proximal pressure.
Sensation: Intact to light touch in right arm and leg.
Reflexes: B T Br Pa Ac
Right 1 1 1 0 0
Left 2 1 1 0 0
Exam limited by patient cooperation. Right arm depressed
compared
with left. Toes mute.
Coordination: Normal FNF on right. Unable to assess on left
secondary to weakness.
Gait: Did not assess.
.
At the time of discharge, the patient had recovered her speech
and was alert and oriented x 3.  She was moving all 4
extremities without difficulty.

Pertinent Results:
[**2117-10-1**] 10:17PM   CK(CPK)-71
[**2117-10-1**] 10:17PM   CK-MB-NotDone cTropnT-<0.01
[**2117-10-1**] 03:15PM URINE  HOURS-RANDOM
[**2117-10-1**] 03:15PM URINE  GR HOLD-HOLD
[**2117-10-1**] 03:15PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2117-10-1**] 03:15PM URINE  BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2117-10-1**] 03:15PM URINE  RBC-<1 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2117-10-1**] 03:15PM URINE  HYALINE-<1
[**2117-10-1**] 12:46PM   GLUCOSE-113* UREA N-17 CREAT-1.0 SODIUM-140
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-16
[**2117-10-1**] 12:46PM   CK(CPK)-144*
[**2117-10-1**] 12:46PM   CK-MB-1 cTropnT-<0.01
[**2117-10-1**] 12:46PM   WBC-9.8 RBC-4.23 HGB-11.8* HCT-36.0 MCV-85
MCH-27.8 MCHC-32.6 RDW-16.3*
[**2117-10-1**] 12:46PM   PLT COUNT-248
[**2117-10-1**] 12:46PM   PT-13.7* PTT-23.8 INR(PT)-1.3
.
[**2117-10-1**] CT head - 1. No acute intracranial hemorrhage.  2. Likely
subacute-to-chronic infarcts in the left parietal and right
frontoparietal distributions. It is difficult to exclude early
acute stroke given these findings, and if clinical suspicion
remains high, MRI is recommended.
.
ECG - Atrial flutter with 2:1 response.  Left anterior
fascicular block
Probable left ventricular hypertrophy with ST-T wave
abnormalities
The ST-T wave changes are nonspecific - clinical correlation is
suggested
.
CXR - Evidence of failure. No evidence for pneumonia.
.
[**2117-10-2**] CT head - 1. Stable appearance of right middle cerebral
artery area infarction. No evidence of interval intracranial
hemorrhage.
2. Stable appearance of left posterior parietal infarction.
.
Carotid US - report pending at time of d/c

Brief Hospital Course:
The patient was transferred to the ICU on cardiac telemetry
after administration of tPA.  She ruled out for an acute
myocardial infarction with three sets of negative cardiac
enzymes.  She had almost a total recovery from her symptoms
after 1 day in the ICU.  Her blood pressure was maintained in
the 140-160 systolic range.  After two days she was started on a
heparin drip.  She was eventually transferred to the floor after
four days.  Lisinopril was added for blood pressure control.
The patient was started on warfarin with a goal INR of 2.0-3.0.
She had several episodes of mild shortness of breath.  This
responded very well to light diuresis and atrovent nebulizers.
The patient had carotid US that were found to be negative for
significant disease.  The etiology of her stroke was felt to be
most consistent with a cardioembolic source secondary to atrial
fibrillation.  She was discharged to rehab with a follow up
appointment to be seen in the stroke clinic within six weeks.


Medications on Admission:
1. Alphagan
2. ECASA 325 mg po qd
3. Atenolol 50 mg po qd
4. Lasic 20 mg po qd
5. Levobunolol HCL 0.5% gtt
6. Lipitor 10 mg po qd
7. Xalatan 0.005%


Discharge Medications:
1. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: Seven Hundred (700) units Intravenous  per hour for until
coumadin therapeutic w/ INR of 2.0-3.0 days: goal PTT between
45-60.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop
Ophthalmic  [**Hospital1 **] (2 times a day).
4. Levobunolol 0.5 % Drops Sig: One (1) Drop Ophthalmic  DAILY
(Daily).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic  HS
(at bedtime).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Right MCA embolic stroke
Hypertension
Aortic Stenosis
CHF


Discharge Condition:
stable


Discharge Instructions:
Please call your primary care physcian or come to the emergency
room if you experience slurred speeh, facial droop, impaired
vision, difficulty swallowing, numbness, tingling, worsened
weakness above baseline, shortness of breath, chest pain.

Followup Instructions:
Please make an appointment to be seen in stroke clinic with Dr.
[**First Name8 (NamePattern2) 26055**] [**Name (STitle) **] ([**Telephone/Fax (1) 22692**] in 6 weeks.  You will need to call
to give your demographic information prior to making an
appointment.
{'Cerebral embolism with cerebral infarction,Atrial fibrillation,Congestive heart failure, unspecified,Aortic valve disorders,Unspecified essential hypertension,Unspecified hearing loss,Unspecified glaucoma,Legal blindness, as defined in U.S.A.'}


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: Code Stroke

PRESENT ILLNESS: Patient is a [**Age over 90 **] year old Russian speaking unknown handedness
woman with past medical history of TIA [**7-3**] with slurring of
speech, atrial fibrillation not on anticoagulation,
hypertension,
severe AS, glaucoma and cataracts with legal blindness who
presented to [**Hospital1 18**] ED on [**2117-10-1**] at 11:55 am as a "Code Stroke".

MEDICAL HISTORY: 1. TIA [**7-3**] with slurred speech
2. Atrial fibrillation not on coumadin
3. Hypertension
4. Severe Aortic Stenosis
5. Dyspnea
6. Leg swelling
7. Hearing loss
8. Glaucoma
9. Cataracts , legally blind

MEDICATION ON ADMISSION: 1. Alphagan
2. ECASA 325 mg po qd
3. Atenolol 50 mg po qd
4. Lasic 20 mg po qd
5. Levobunolol HCL 0.5% gtt
6. Lipitor 10 mg po qd
7. Xalatan 0.005%

ALLERGIES: Lipitor

PHYSICAL EXAM: Tc: BP: 194/122 HR: 125
RR: 18 O2Sat.: 100%/NRB
Finger stick 122
Gen: WD/WN elderly female, resisting examiners, agitated.
HEENT: NC/AT. Anicteric. Corneas clouded bilaterally.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: Tachycardic, irregularly irregular. S1/S2. Grade [**3-7**]
murmur at upper right sternal border, radiating to carotids.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro pre tPA:
Mental status: Awake and alert, nods to family if asked if she
is
in the hospital. Able to state name, but occasionally stuttering

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Social Hx: Lives alone. Moved here from [**Country 532**] 24 years ago.
Employed as a food engineer. No alcohol, tobacco, drug use.
Daughter lives next door. Proxies are her children [**Female First Name (un) **] and
[**Doctor First Name 2491**]. 

### Response:
{'Cerebral embolism with cerebral infarction,Atrial fibrillation,Congestive heart failure, unspecified,Aortic valve disorders,Unspecified essential hypertension,Unspecified hearing loss,Unspecified glaucoma,Legal blindness, as defined in U.S.A.'}
