CHIEF COMPLAINT: Headache, left sided numbness and left sided vision loss

PRESENT ILLNESS: Neurology at bedside for evaluation after code stroke activation
within: 1 minutes
Time (and date) the patient was last known well: 15:15 (24h
clock)
NIH Stroke Scale Score: 7
t-[**MD Number(3) 6360**]: Yes Time t-PA was given bolus;19:26 and
infusion;19:27(24h clock)
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.

MEDICAL HISTORY: HTN, aneurysm in [**2107**] s/p cliping

MEDICATION ON ADMISSION: Cozaar 50mg [**Hospital1 **]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam:
Vitals 97.3, pulse 98, resp 18, bp 191/87, o2 sat of 98%
: General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: Alert, oriented x 3.  Able to relate history
without difficulty.  Inattentive requring frequent redirection.
Language is fluent with intact repetition and comprehension.
Normal prosody.  There were no paraphasic errors.  Pt. had no
anomia if object placed in right visual field.   Able to read
right half of sentenses without difficulty.  Speech was not
dysarthric. Able to follow both midline and appendicular
commands.  +neglect to the left hemispace.

FAMILY HISTORY: no family history of strokes or aneurysms

SOCIAL HISTORY: lives alone, no children, smoke [**1-7**] pack per day,
drinks socially, no illict drug use.
Cerebral artery occlusion, unspecified with cerebral infarction,Unspecified essential hypertension,Tobacco use disorder,Homonymous bilateral field defects
Crbl art ocl NOS w infrc,Hypertension NOS,Tobacco use disorder,Homonymous hemianopsia
Admission Date:  [**2115-4-6**]              Discharge Date:   [**2115-4-9**]

Date of Birth:  [**2050-12-27**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Headache, left sided numbness and left sided vision loss

Major Surgical or Invasive Procedure:
Infusion of TPA

History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 1 minutes
Time (and date) the patient was last known well: 15:15 (24h
clock)
NIH Stroke Scale Score: 7
t-[**MD Number(3) 6360**]: Yes Time t-PA was given bolus;19:26 and
infusion;19:27(24h clock)
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.

NIH Stroke Scale score was 7:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 2
4. Facial palsy: 1
5a. Motor arm, left: 1
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 2

NEUROLOGY RESIDENT CONSULT NOTE

Reason for Consult:CODE STROKE

HPI: Mr [**Known lastname 47097**] is a 64 year old right handed man presenting as a
code stroke after sudden development of right eye pain and left
sided numbness.  He was playing solitaire today at 15:15, when
he
started having left sided visual problems and left sided
numbness.  He drove himself to [**Hospital3 26615**] hospital and was
having some pain behind his right eye.  He went to [**Hospital3 26615**]
hospital and his finger stick was 101, temp 97.3, pulse 98, resp
18, bp 191/87, o2 sat of 98%.  He got a bag of normal saline,
fentanyl, and zofran. He has a history of aneurysm s/p clipping
at [**Hospital1 2025**] in [**2107**] without subsequent problems.  [**Name (NI) **] was evaluated by
neurosurgery who did not feel an intervention or tpa was
currently indicated and was transferred to [**Hospital1 **].  While in
transit he got a bag of normal saline, fentanyl, and zofran.
Upon initial evaluation he had an NIHSS of 7 (2 for left visual
field loss, 1 for mild facial palsy, 1 for left pronator drift,
1
for mild hemisensory loss, and 2 for inattention to the left).
Currently he states he has a headache but is unaware of any
deficits or why things are occuring.

On ROS patient states he had nausea and vomiting and diarrhea
for
the past week, and went to the ED at [**Hospital3 26615**] this past
Wednesday but has been feeling better the past 2 days.  He
denies
any other weakness, numbness, dysarthria, or neurologic symptoms
just pain behind his right eye.  Besided the recent fevers,
nausea, vomiting, he denies any other SOB, CP, or other general
symptoms.


Past Medical History:
HTN, aneurysm in [**2107**] s/p cliping

Social History:
lives alone, no children, smoke [**1-7**] pack per day,
drinks socially, no illict drug use.


Family History:
no family history of strokes or aneurysms

Physical Exam:
Physical Exam:
Vitals 97.3, pulse 98, resp 18, bp 191/87, o2 sat of 98%
: General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: Alert, oriented x 3.  Able to relate history
without difficulty.  Inattentive requring frequent redirection.
Language is fluent with intact repetition and comprehension.
Normal prosody.  There were no paraphasic errors.  Pt. had no
anomia if object placed in right visual field.   Able to read
right half of sentenses without difficulty.  Speech was not
dysarthric. Able to follow both midline and appendicular
commands.  +neglect to the left hemispace.

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.  left hemianopsia, appears worse
in
the inferior quadrant
III, IV, VI: EOMI without nystagmus.  Normal saccades.
V: Facial sensation intact to light touch.
VII: mild left facial at time of presentation but resolved after
CT
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. initial left pronator
drift
that resolved after CT scan.
  Delt Bic Tri WrE FFl FE IP Quad Ham TA
L  5    5   5   5   5  5  5   5    5-  5-
R  5    5   5   5   5  5  5   5    5-  5-
.
-Sensory:left hemibody sensory deficit to pinprick.  left leg
completely desensitized to pinprick, left upperextremity can
feel
the pin but less than the right side.  He has agraphestesia in
the left hand.

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2  2    2    2   2
R  2  2    2    2   2
Plantar response was flexor bilaterally.
.
-Coordination: No dysmetria on FNF

.
-Gait: defferred


Pertinent Results:
Admission Labs:
[**2115-4-6**] 06:15PM BLOOD WBC-15.4* RBC-4.55* Hgb-14.5 Hct-44.3
MCV-97 MCH-31.9 MCHC-32.8 RDW-12.9 Plt Ct-428
[**2115-4-6**] 06:15PM BLOOD PT-10.6 PTT-25.8 INR(PT)-1.0
[**2115-4-6**] 06:15PM BLOOD Fibrino-252
[**2115-4-7**] 06:39AM BLOOD Glucose-94 UreaN-17 Creat-1.1 Na-140
K-4.4 Cl-111* HCO3-21* AnGap-12
[**2115-4-7**] 06:39AM BLOOD ALT-34 AST-18 LD(LDH)-165 CK(CPK)-31*
AlkPhos-53 TotBili-0.3
[**2115-4-6**] 06:15PM BLOOD cTropnT-<0.01
[**2115-4-7**] 06:39AM BLOOD CK-MB-1 cTropnT-<0.01
[**2115-4-7**] 06:39AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.8 Mg-2.7*
Cholest-137
[**2115-4-7**] 06:39AM BLOOD %HbA1c-5.5 eAG-111
[**2115-4-7**] 06:39AM BLOOD Triglyc-94 HDL-28 CHOL/HD-4.9 LDLcalc-90
[**2115-4-6**] 06:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2115-4-6**] 08:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2115-4-6**] 08:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.039*
[**2115-4-6**] 09:28PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2115-4-6**] 8:15 pm URINE
   URINE CULTURE (Final [**2115-4-8**]):    NO GROWTH.

Discharge Labs:
[**2115-4-9**] 04:50AM BLOOD WBC-12.0* RBC-4.41* Hgb-13.3* Hct-42.4
MCV-96 MCH-30.2 MCHC-31.4 RDW-12.6 Plt Ct-429
[**2115-4-9**] 04:50AM BLOOD Glucose-111* UreaN-19 Creat-1.2 Na-139
K-4.3 Cl-107 HCO3-25 AnGap-11
[**2115-4-9**] 04:50AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.4

Reports:
EKG: Baseline artifact. Non-specific ST-T wave change. Compared
to tracing #1 no diagnostic change.
Rate PR QRS QT/QTc P QRS T
72 202 92 358/379 57 12 18

Chest Film: Single AP portable view of the chest was obtained.
No focal
consolidation, pleural effusion, or pneumothorax is seen. The
cardiac
silhouette was not enlarged. The aortic knob is calcified. No
displaced
fracture is seen. IMPRESSION: No acute cardiopulmonary process.

CT/CTP/CTA Head/Neck: Increased mean transit time with decreased
cerebral blood volume and blood flow on the right occipital
lobe, consistent with infarction in the right posterior cerebral
artery vascular territory as described in detail above. The
patient is status post aneurysm clipping via left frontotemporal
craniotomy. There is no evidence of acute intracranial
hemorrhage or mass effect. Atherosclerotic calcifications are
visualized in the carotid cervical bifurcations, causing severe
narrowing at the origin of the right internal carotid artery.

Echo: The left atrium and right atrium are normal in cavity
size. No atrial septal defect or patent foramen ovale is seen by
2D, color Doppler or saline contrast with maneuvers. The
estimated right atrial pressure is 0-5 mmHg. The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is high normal. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION:Trace aortic regurgitation with mild aortic valve
sclerosis. No definite structural cardiac source of embolism
identified.

Carotid U/S: Right ICA 70-79% stenosis, Left ICA 60-69%
stenosis.

MRI Head: Subacute infarction in the right PCA territory without
evidence of hemorrhagic transformation with a possible
involvement of the choroidal anterior artery territory.


Brief Hospital Course:
Me. [**Known lastname 47097**] was examined emergently in the ED of [**Hospital1 18**] and was
found to have a dense left homonymous hemianopia. Preliminary
STAT CT imaging showed the presence of hypoperfusion in a right
PCA distribution. His case was discussed with the attending
Stroke Neurologist and informed consent was obtained for TPA
administration, for which there were no apparent
contraindications. TPA was administered without any acute
complications, and he was admitted to the ICU for post-TPA
monitoring with q1hr neuro checks, etc. As he remained
hemodynamically stable and with stable neurologic examinations,
he was transferred out of the ICU. His left visual field cut
became less dense over time, but at the time of discharge, he
still had quite a significant visual field cut.

Several studies were done to work up his stroke. We obtained the
make/model number of his aneurysm clips from [**Hospital1 2025**] (he has a
history of a left ICA and left ACOMM aneurysm clipped by [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 1128**] from [**Hospital1 2025**]), and with this information, we were able to
obtain an MRI of his head, which identified a single area of
restricted diffusion in the right PCA distribution. Several days
of telemetry monitoring did not identify any evidence of atrial
fibrillation. His CTA done on admission did identify scattered
atherosclerotic lesions in his intra and extracranial blood
vessels, including the internal carotid arteries. A carotid US
did show right ICA stenosis of 70-79% and left ICA stenosis of
60-69%. However, these bilateral stenoses were not the cause of
his posterior circulation infarct. These bilateral ICA stenoses
will need to be monitored for plaque progression in the future.

His LDL returned elevated and he was started on statin therapy,
and was of course also placed on a daily aspirin as secondary
prophylaxis against future strokes. He was counseled extensively
on the importance of quitting smoking cigarettes. An
echocardiogram was performed which did not reveal any obvious
embolic source and no obvious valvular pathology.

Given his left visual field cut, he was strictly advised NOT to
drive prior to having a formal OPHTHALMOLOGICAL examination with
visual field testing. In addition, he was given information
about the [**Hospital1 18**] Drivewise program, which is a comprehensive
evaluation of one's driving abilities following a variety
different physical and neurologic disabilities. At the time of
discharge, he was able to ambulate independently, had no focal
neurologic signs (other than a resolving left visual field
deficit) and was cognitively intact.

Transitional Issues:
- HOLTER MONITOR
- Neurology Follow Up
- Eye examination with formal visual field testing

Medications on Admission:
Cozaar 50mg [**Hospital1 **]

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for headache.
Disp:*20 Tablet(s)* Refills:*0*
3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*1*
5. Cozaar 50 mg Tablet Sig: One (1) Tablet PO twice a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Ischemic stroke
Hypertension
Tobacco Abuse
History of brain aneurysm s/p clipping


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

Discharge Neurological Examination: Slight anisocoria (L>R),
full EOM, left homonymous hemianopia with intact sensation and
strength throughout


Discharge Instructions:
Dear Mr. [**Known lastname 47097**],
  It was a pleasure taking care of you during this
hospitalization. You were admitted to the neuro-intensive care
unit and the neurology wards of the [**Hospital1 827**] for symptoms of headache, left sided numbness and
left sided visual loss that you experienced while playing
solitaire. Through a series of interviews, physical
examinations, laboratory tests and neuroimaging studies, we
determined that you sustained a stroke in the right OCCIPITAL
region of your brain. The cause of this stroke was likely
related to atherosclerosis or plaques in the arteries of your
brain that be caused by risk factors such as high blood
pressure, high cholesterol and smoking. As we were able to
identify your stroke relatively quickly, you received TPA or
tissue plasminogen activator therapy (a "Clotbusting"
medication) that at times can improve the symptoms of stroke.
- We have made some changes to your medications as listed below.
Please take your medications as prescribed, and do not hesitate
to contact us should you have any questions or concerns. We have
started on you a daily ASPIRIN and a CHOLESTEROL lowering
medication called ATORVASTATIN. For your headache, we have
prescribed you OXYCODONE. Oxycodone can sometimes cause
constipation, for which we have prescribed you a stool softener
called DOCUSATE. Continue to take COZAAR as you were previously
doing.
- We expect that your headache will get better over time. To
reduce the impact of these headaches, we ask that you stay well
hydrated, eat regular meals, have regular sleep cycles and avoid
pain medications on a daily basis.
- Some strokes, such as the one you sustained, can affect your
ability to drive. We have referred you to a program at [**Hospital1 18**]
called DRIVEWISE, which is a comprehensive assessment conducted
by skilled therapists who are able to certify your ability to
drive safely. Please be sure to follow up with them. Their phone
number is [**Telephone/Fax (1) 110357**], and they will contact you to set up an
appointment.
- Please come to the nearest ED should you have any of the below
listed unexplained symptoms.
- We have organized a follow up appointment for you to see Dr.
[**First Name (STitle) 5846**], who is your primary care physician. [**Name10 (NameIs) **] ask that you take
these records with you as well as ALL your current medications
at that time. We have asked Dr.[**Name (NI) 110358**] office to set up a
referral for you to see a neurologist closer to your home town.
Please be sure that this is set up at your next visit with Dr.
[**First Name (STitle) 5846**].
- Smoking is an important modifiable risk factor for strokes.
Please try to cut down or quit smoking. Your PCP can talk with
you further about tips or medications that can help with this.

Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 5846**], your primary care physician
[**Last Name (NamePattern4) **]: [**Telephone/Fax (1) 110359**]
Fax: [**Telephone/Fax (1) 110360**]
[**2115-4-19**], 3:45PM
[**Apartment Address(1) 110361**]
[**Location (un) 5028**], MA: [**Numeric Identifier **]



Completed by:[**2115-4-9**]
{'Cerebral artery occlusion, unspecified with cerebral infarction,Unspecified essential hypertension,Tobacco use disorder,Homonymous bilateral field defects'}


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: Headache, left sided numbness and left sided vision loss

PRESENT ILLNESS: Neurology at bedside for evaluation after code stroke activation
within: 1 minutes
Time (and date) the patient was last known well: 15:15 (24h
clock)
NIH Stroke Scale Score: 7
t-[**MD Number(3) 6360**]: Yes Time t-PA was given bolus;19:26 and
infusion;19:27(24h clock)
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.

MEDICAL HISTORY: HTN, aneurysm in [**2107**] s/p cliping

MEDICATION ON ADMISSION: Cozaar 50mg [**Hospital1 **]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam:
Vitals 97.3, pulse 98, resp 18, bp 191/87, o2 sat of 98%
: General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: Alert, oriented x 3.  Able to relate history
without difficulty.  Inattentive requring frequent redirection.
Language is fluent with intact repetition and comprehension.
Normal prosody.  There were no paraphasic errors.  Pt. had no
anomia if object placed in right visual field.   Able to read
right half of sentenses without difficulty.  Speech was not
dysarthric. Able to follow both midline and appendicular
commands.  +neglect to the left hemispace.

FAMILY HISTORY: no family history of strokes or aneurysms

SOCIAL HISTORY: lives alone, no children, smoke [**1-7**] pack per day,
drinks socially, no illict drug use. 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Unspecified essential hypertension,Tobacco use disorder,Homonymous bilateral field defects'}
